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THK 


SCIENCE    AND    ART 


SURaERY. 


A  TREATISE  ON  SURGICAL  INJURIES,  DISEASES, 
AND  OPERATIONS. 


BY 

JOHN  ERIC  ERICHSEN,  F.R.S.,  LL.D.,  F.R.C.S., 

triSXOX    KXTRAOKOIIiAXr  to  bFx  MlJBBtT   TBI  QDBBH;   XX-PI1E8IDBRT  OF  THK  KOTAL  COLLBSl 

or  scMiKosB  OP  laai-AnD  akd  or  thx  rotal  vkdical  and  cHiRUBatcAL  bociktt; 
KM  rritcs  rRorusoR  or  scRacRT  aud  or  clikical  anRflSRr  in  UHiTiBSiTr 

CVLLKOB ;  COKBDLTIRO  SrHeKOH  TO  DHITBnsITr  COLLROK  ■OSriTAI., 
ARtl  TO  MARy  OTBRR  MRDICAL  CHARITIES. 

EIGHTH  EDITION. 

REVISKD   AND    EDITED  BY 

MARCUS  BECK,  M.S.  and  M.B.  Lond.,  F.E.C.S., 

»riiKKO!i  TO  iRivauiTT  COLLEGE  bospital;  and  propessor  or  clinical  suroert  in 

CSITRRtITT  COLLESE,  LONDON. 

H'/rW  .V/.V£  UVSDRED  ASD  EIGHTY-FOUR  ESGRAVINOS  ON  WOOD. 

VOL  n. 


PHILADELP  m  A: 

LEA    BROTHERS    &   CO. 

1885. 


"^They  be  the  best  ChintrgeoQS  tchtck  being  leametl  incline  to  the  tradition*  of 
experience,  or  beinif  empiriea  indine  to  the  methodx  of  learning" 

Bacor  vn  Ltarni-ng. 


rHII,ADKI.PHIA: 
WH.  J.  DOHNA!),  FXIMTRa, 

H28-«34  Fnb«rt  St. 


CONTENTS  OF  THE  SECOND  VOLUME. 


DIVISION  THIRD. 
SURGICAL    DISEASES. 

(COKTINDKD.) 

Chapter  XXXVII. — Suboical  Diseases  of  the  Skin  and  its 

Appendaoes. 

PAflB 

DisEAKO  or  THX  Appehdaoes  or  the  Skin — Diseases  of  the  K'ails — Onychia — 

Simple — Srphilitic — Ingrowing  of  theN^ail — Hypertrophy  of  Toe-nail  ,        88-86 

Di-EA»»  or  THE  Skim — Lupiu — Varieties — Lupus  Erythematosus — Lupus  Yul- 
Z^Ti*.  or  Lupus — Causea — Prognosis — Diagnosis — Treatment — Rodent  Ulcer — 
Symptoms— Diagaoa  is — Pathology — Treatment — Cancer  of  the  Skin — Primary 
Cancer — Secondary  Cancer — Sarcomata  of  the  Skin — Alveolar  Sarcoimi — 
Simple  Tumore  of  the  Skin — Fibroma — Keloid — False  Keloid— Oateomata 
— Aden^ima — Moles — Papillomata,  or  Warts— Corns — Perforating  Ulcer  of 
Foot 8&-48 

Chapter  XXXVIII. — Diseases  of  the  Nervous  System. 

NrtRiTi! — Symptoms — Treatment 48 

>.-i  tTii  A — Symptoms — Dia^nn^is — Treatment — Acupuncture — Stretching  the  Sci- 

al:o  Nerve 48-50 

Nk'  rvlgia — Symptoms — Situation  a— Causes — Diagnosis — Treatment — Stretching 

>■'.  tlu-  AtTvcted  Nenc — Secli.m  of  the  Affected  Xerve— Facial  Neuralgia       50-56 

Mr-Mi.\KTic — Clonic  Torticollis -t? 

Tkai  matic   Paraltsis — Kheumatic  Paralysis,  or  Paralysis  from    Exposure  to 

(-'■■IJ — Treatment 57— '>S 

Ni.<H<>u* — Structtire — Traumatic  Neuroma — Treatment  ....  68-60 
TcT  \M> — Causes — Period  of  Occurrence — Forms— Symptoms — State  of  Ner^-es — 

S..»i  of  Injurj- — Patholi>gical  Conditions  in  Spinal  Cord — Treatment  60-68 

Chapter  XXXIX — Diseases  of  the  Lymphatic  System. 

Im  i.-iMVATioj;  Of  THE  Ltmpuati''  Vesselh — Lymphangitis,  or  Angeiolcucitis — 

C.'aU'^-* — Morbid  Anatomy — Symptoms — Results — Diagnosis — Treatment        fi8-T0 
VAai\  i.r  THE  Lymphatic  Vehsklm — Occurrence — Treatment  .70 

Kui.rii  4>TiA»is  OF  TBE  Leos  A>'T»  ScROTCM — TroHtmcnt      ....         70-72 

Li  UPIIAI'KMTIM,    OR    IJIPLAMMATION     OK      LvMrilATIC     Gl.AM>S Pllth"lr>i.'icBl 

AnHt-iiiy — Sympt'>ms — Tremmcnt 7"2-76 

Li  Mi-iiAi'EXoUA — KetnovQl 71 


33203 


Tl  CONTENTS. 


Chapter  XL. — Diseases  of  Veins. 

PASK 

Vkmoub  THEOMBOflis—Cauaea— Process  of— Fate  of   the    Thrombuft— Effect*— 

Symptoms — Treatment . 77-88 

Pblebitib— Causes— Pathological  Anatomy — Symptoms — Treatment       .        .   88-86 
Yabicobk  Vkim8,  oe  Vaeix — Definition — Causes — Locality — Morbid  Anatomy — 
Appearances  and  Symptoms — Progress  and  Effects— Treatment — Obliteration 
of  Varicose  Veins 86-91 


Chapter  XLI. — Aneurism  by  Anastomobis,  and  Njevub — 
Hemorrhagic  Diathesis. 

AVKUBIKM  BY  AXA8T0H0BIS — Nature — Diagnosis — Treatment  ....   92-93 

Nmyvb — Capillary — Venous  or  Cavernous — Prognosis — Treatment — Operations — 

Obliteration — Nitric  Acid — Galvanic  Cautery — Galvano-puncture — Ligature 

— N.«Ti  IN  Special  Situatiosb — Scalp — Fontanell<i — Face — Eyelids — Nose 

— Cheeks — Lips — Tongue— Penis — Vulva — Extremities,  Neck,  and  Trunk — 

Nicvoid  Lipoma 98-106 

Heuosbuagic    Diathesis,    or    H.cmofhilia  —  Causes  —  Pathology  —  Treat- 
ment              105-108 


Chapter  XLII. — Diseases  of  Arteries. 

Abtieitis — Acute — TraumaUc — Arteritis  by  Extension — Embolic — Acute  Endar- 
teritis— Arteritis  Deformans,  or  Atheroma — Nature  and  Causes  of— Effects — 
Arteritis  Obliterans — Endarteritis  Proliferans — Periarteritis  108-1 1« 

pRilfABT  Degenkrations  Of  Artkbies — Fatty  DegeneraUon — Calcification — 
Ossification — E Sects  of  Disease — Ulceration — Spontaneous  Rupture — Con- 
traction and  Occlusion 116-1*21 


Chapter  XLIII. — Aneurism. 

Akeubism  defined— Caufes — Classification — Fusiform  or  Tubular  Aneurism — Sac- 
culated Aneurism — True — False — Dissecting  Aneurism — Formation  of  an 
Aneurism — Structure — Pressure-effects — Number — Duration — Symptoms  of 
External  Circumscribed  Aneurism;  of  Diffuse  Aneurism — Diagnosis — Termi- 
nations— Spontaneous  Cure — Causes  of  Death  fk>m  Aneurism — Constitutional 
or  Medical' Treatment — Local  Treatment 122-141 

SuROicAL  Tbeatment  ot  Aneurihh. — LioATUBE — Situation — Ligature  on  both 
Sides  of  Sac — Ligature  on  Cardiac  side  of  Aneurism — Distal  Ligature— I  ndi- 
catiuna  and  Contra- indications  of  Ligature — Accidents  after  Ligature — Secon- 
dary Hemorrhage — Continuance  or  Kctum  of  Pulsation — Secondary  Aneurism 
— Treatment  of  Recurrent  FuUation — Suppuration  and  Sloughing  of  Sac — 
Gangrene — Causes — Treatment. — Comtrkssiox  by  iNoTBUHENTa — Principle 
— Circumstances  influencing  Success — Application  of  Compressor — Effects — 
Durution  of  Treatment^  A  jiplicabi  lit  j' — Digital  Compression — Esmarcfa's 
E  lustic  Bandage — Flex  ion — Acu  pressure —  Man  i  pulation — Gal  vano-puncturo 
— Injei'tion  with  Perchloride  i)f  Inm — lIy(KK!erniic  Injection  of  Ergotin — 
Introduction  of  Foreign  Bodies — Acupuncture 141-171 

Artkrio-vknous  Ankurihm 172 


CONTKNTS.  Til 


Chapter  XLIV. — ANEmusus  op  the  Thorax,  Head  and 
Neck,  and  Upper  Extbehitt. 

PAOI 

Tboeacic   Aorta — Symptoma — Auscultatory   Signs — Pressure-effects — Pulsation 

And  Tumor— Tre&tmeat 178-160 

IvxoMUiATK  AbtsRT  —  Symptoms  —  Piesaure-effecU  —  Prognosis  —  Diagnosis — 
TreAttnent — Ligmture  of  Subclavian  only — Of  Carotid  only — Of  Subclavian 
and  Carotid — General  Bemarks  on  the  Operation  ....  lBO-188 
Cakotid  Astkbt — Aneurismsl  Varix  of  Carotid  Artery  and  Jugular  Vein — 
Spontaneous  Aneurism  of  Carotid — Symptoms  —  Diagnosis — Treatment — 
Digital  Compression — Ligature  of  Carotid — Effects  on  Brain — Table  of  Cases 
of  Ligature  of  both  Carotids — Effects  on  Lungs — Ligature  of  Carotid  on 
Di*tAl  Side— Table 188-200 

I5TEKXAL  Carotid  Abtirt — Extracranial  Aneurism — Treatment  .  200-201 

IrrKACKAXiAL  Akeubihh — Causes  Pathology — Pressure-effects — Symptoms — ■ 
Causes  of  Death— Treatment 201-206 

IxTAAORBiTAL  AsxiTBUM — Erroneoiu  Opinion  regarding — Causes — Symptoms — 
Prognosis — Patholc^y— Diagnosis — Treatment 206-210 

SrBTLATiA!*  Abtcrt — Symptoms — Diagnosis — Results — Treatment — Ligature  of 
Uie  Bntcfaio-cephalic  Artery — Table  of  Cases — Ligature  of  Subclavian  on 
Tracheal  Side — Table— Compression  of  Artery  on  Distal  Side — Distal  Liga- 
ture of  SubclavUn  beyond  the  Scaleni — Amputation  at  Shoulder-joint,  and 
Distal  Ligature— Ligature  of  Vertebral  Artery 210-221 

IziLLART  Artkbt — Symptoms — Diagnosis — Treatment — Ligature  of  the  Sub- 
clavian in  Third  Part  of  Course — Accidents  during  Ligature  of  the  Third 
Part  of  the  Subclavian — Ligature  behind  the  Scalenus  Anticus — Results  of 
Ligature  of  the  Subclavian — Suppuration  of  the  Sac — Secondary'  Hemorrhage 
— Gangrene  of  Hand  and  Arm — Treatment  of  Inflamed  Axillary  Aneurism 
thieatening  Suppuration — Ligature  of  AxilUiy  Artery  221-237 

Arm,  Forearh.  and  Ha»i> — Rarity  of  Spontaneous  Aneurism — Treatment — 
Litrature  of  the  Brachial  Artery — Ligature  of  Radial  and  Ulnar  Arteries    287-241 

Chapter  XLV. — Aneurisms  of  the  Abdomen  and  Lower 
Extremities. 

Aiit-'KiNAL  Aorta  and  its  Branches — Symptoms — Diagnosis — Treatment — 
(.'•■nipre^sion  of  Abdominal  Aorta 241-244 

l5t;t  i>AL  Akkurism — Symptom»^Diagnoais — Tr^tment — Ligature  of  External 
liiac  Artery — Abemethy's  Modified  Operation — Cooper's  Method — Results — 
Lieaiureuf  Common  Iliac — Results — The  Old  Operation — Treatment  by  Com- 
pre^ion — Ligature  of  Aorta — Aneurism  of  the  Internal  Iliac  and  its  Branches 
— Gluu^l  and  Sciatic  Aneurisms — Lig&ture  of  Intemnl  Iliac  244— S'li) 

Femoral  and  Popliteal  Akehrisuh — Aneurism  of  Deep  Femoral  Artery — 
Aneurism  of  the  Superficial  Femoral  and  Pupliteal  Arteries — Symptoms — 
Iti*L-nijsif — Treatment — Compression — Flexion — Ligature  of  Common  Femoral 
— <»f  Superficial  Femoral — Results — Accidents  attending;  Operation — Wound 
^'f  Fcm'-ml  Vein — .Secondar>-  Hemorrhage — Gangrene — Return  of  Pulsation 
in  ."^c — Secondary  Aneurism — Ligature  of  Femoral  Artery  in  the  Middle  of 
th^  Thiiih — Ligature  of  Kxtemal  Iliac  in  Poplitenl  Aneurism — Double  Pop- 
litml  Aneurism — Ififfused  Popliteal  Aneurism — Amputation  fur  Diffused 
P<-ptite«l  Aneurism 256-2ii8 


VIU  CONTENTS. 

Aneubisu  or  THX  Tibial  Artkries — Ligature  of  Popliteal  Art«ry — Of  Poste- 
rior Tibial— Of  Anterior  Tibial — Of  Arteria  DorsaliB  Pedia — Of  Peroneal 
Artery 2t>8-2TI 

Chapter  XLVI. — Inflammation  op  Bone  and  rra  Effects. 

OsvKRAL  pATHOLOQT  OF  iKri^MMATORT  ArFBCTiONs  OF  BoNC — Inflammatory 
Proceuee  in  the  Periosteum — Affecting  Compact  Ttisue — In  the  Medulla  of 

Long  Bones— In  the  Cancellous  Tissue 272-28S 

PiBiOBTiTis — Symptoms — Treatment 268-2S4 

Cbkohic  Osteitis  and  Periobtitis — Symptoms — Treatment — Linear  Osteo- 
tomy              284-286 

Osteitis  DxroRUAtra — Microscopic  Examination 285-286 

Obbokic  Abscess  of  Bone — Causes — Symptoms — Treatment   .  28G-289 

DiFrosK  Bkftjc  Ostiomyelitis — Symptoms — Treatment  28d-2dl 

Acute  Nkckosib  —  Symptoms  —  Pathology  —  Results  —  Diagnosis  —  Prognosis — 

Treatment 292-294 

Gabies  —  Definition  —  Causes— OenemI  Appeannces — Situation  —  Symptoms  — 

Treatment — Operations  on  Carious  Bone 294-300 

Kecbosis — Nature — Causes— Characten — Peripheral  and  Central — Sequestrum — 
Symptoms — Separation  of  the  Dead  Bone — Exfoliation — Reparative  Process 
— Treatment — Removal  of  the  Sequestrum — Instruments — Amputation — 
Resection— Necrosis  of  the  Sternum,  Scapula,  or  Pelvis— Cranial  Bones — 
Patella— Kibs 800-31 1 

Chapter  XL VII. — Steuctural  Changes  in  Bone  and 
Tumors  of  Bone. 

Htpbbtbopht  —  True    Hypertrophy  —  Inflammatory    Hypertrophy  —  Increased 

Length. — Atbopht — Arrested  tirowth 812-818 

Rickets — Causes — Symptoms — Prt^jess   and   Prognosis — Pathology — Treatment 

818-317 

Mollities  Ossidu  :  Osteomalacia- Nature — Cause — Seat  of  the  Disease — State 

of  Urine — Symptoms — Diagnosis — Treatment 817-819 

TuuoKS  OF  Bone — Exostosis — Varieties — Symptoms — Treatment — Enchondro- 
mata  or  Cartilaginous  Tumors — Fibroma— Cystic  Tumore — Structure — Treat- 
ment— Hydatids. — Sarcouata  of  Bone. — Priuabt  Malignant  Disease — 
Central  —  Peripheral — Situations — Symptoms —  Diagnosis — Treatment. — S«c- 
ONDABT  Sabcouata. — Trde  Canckb  OR  Cabcinoua — Epithelioma, — Put- 
SATiNO  Tumors — Situation — Symptoms — Treatment  ....        819-881 

Chapter  XLVIII. — Diseases  of  Joints. 

Synovitis — Cause* — Pathology — Symptoms — Acute  Synovitis — Chronic  Synovitis 

— Hydrarthrosis — Terminations — Treatment 382-886 

AcTTK  Artiiritii? — SituftiioHfl — Symptoms — Suppuration — Diagnosis — Pathology 
— Niituni  of  Changes  in  Cartilage — Destniclion  of  Cartilage  from  Synovial 
Discusi' — >'niiii   Disease  of  Bone — Causes  and  Varieties — Repair — Treatment 

386-848 

Chronic  STKUMors  Artiiriti:*,  or  WhitiSwki.i.ino — Synipti'ms — Pathological 

Change* — Treatment 848-868 


CONTENTS.  tX 

PAflM 

Chromic  RHRinu.Tic  Abthritib — Nature — Symptoms — Causes — Treatment — 
Chronic  Rheumatoid  Arthritis  of  Hip — Pathologfcal  Changes — Diagnosis — 
Chronic  Rheumatoid  Arthritii  of  Lover  Jaw — Of  Shoulder  358-358 

AxKTLOsis  OB  STirr  Joint — Incomplete  or  Fibrous  Ankylosis — Complete  or 
Osseous  Ankylosis — Treatment 858-861 

LoosR  UASTII.AOZB  IN  JotNTs — Waity  Condition  of  Synovial  Membrane — Loose 
Cartilages — Characters — Symptoms — Diagnosis — Treatment  .        S6 1-364 

yKCRALQiA  OP  JoisTs — Sj^mptoms — Causes — Treatment  ....        864-866 

Chapter  XLIX. — Excision  of  Jointb. 

HisTORT — Indications  for  Excision — Conditions  of  Success — Repair  after  Ex- 
cision— Instruments — Operation 866-878 

SzcnioKa  in  tbc  Upper  Extbsuitt. — Shodldrr-joint — For  Disease — Partial 
Excision — Complete  Excision — Result — Fur  Compound  and  Comminuted 
Fracture. — Scapui^ — Entire  —  Partial  —  Operation — Result. — Claticle. — 
Elbow-joikt — For  Strumous  Diseases-^For  Ankylosis — For  Compound 
Fracture  or  Dislocation — Operation — Results. — TJlna  or  Radius — Ole- 
cranon. — Wrist — Lister's  Operation. — Hand — Excision  of  Fingers  and 
Metacarpal  Bones 878-398 

COICSKBTATITI   SdbOBRT   07   THE     LOWRB     ExTRBllITT. — HiP-JOTMT. — £kEE — 

Operation — Selection  of  Cases  for  Excision — Resulte. — Bonks  or  the  Leo. — 
Foot — Progress  of  Conservative  Surgery — Conditions  demanding  Excision — 
Tarsal  Bones — Os  Calcis — Operation — Subperiosteal  Excision — History  and 
Results — Astragalus — Cuboid  Bone — Scaphoid — Cuneiform  Bones — Several 
Tarsal  Bones— U all eoli—MeUtarsal  Bones— Toes  ....  398-414 
Ahpctation  in  Joint  Diseasks — Circumstances  influencing  Mortality  .        414-416 

Chapter  L. — Diseases  of  the  Spine. 

Spina  BiriDA — Characters — Prognosis — Treatment  ....         416-419 

Caries  of  xar  Spine. — Angular  Curvature. — Pott's  Dihease — Pathology 
— Symptoms — Paraplegia — Pleuritic  Attacks — Abscess — Diagnosis  —  Prog- 
nosis—Treatment 419-485 

Disease  op  the  Certical  Spink — Diseases  of  the  Atlas,  Axis,  and  Occiput — 

Treatment 43r)-436 

Other  Diseases  of  the  Spine — Qummata — Rheumatoid  Arthritis — Tumors     .  487 

Chapter  LT. — Diseases  of  the  Sacro-iliac  Joist. 

ijACRO-iLiAC  Disease  —  Nature  —  Pathology  —  Symptoms  —  Pain — Swelling — 
Lameness — Alteration  in  Limb — Abscess — Prognosis — Diagnosis —  Treat- 
menl 437-442 

Chapter  LH. — Diseases  of  the  Hip-joint, 

Hip-joint  Dihease — Characters — Forms  of  the  Disease — General  Phenomena — 
Pain — Attitude — Limitation  of  Movement — Suppuration— Sinuses — Disloca- 
tion—  Ankylosis  —  Pathology  and  Symptoms  of  the  Various  Forms.— 
Arthritic  Coxaloia — Symptoms — Results. — Chronic  Strumous  Arth- 
ritis.— White  Swbllino. — Femoral  Coxaloia — Symptoms — Pathology 
— Acetarular  Coxaloia — Symptoms — Prognosis  of  Hip-joint  Disease — 
Life — Utility  of  the  Limb — Diagnosis  of  Coxalgia — Treatment  442-461 


X  CONTENTS. 

PAOK 

Excision  or  the  Head  of  the  Thiob-boke  and  ov  the  Hip-joimt — Ui«tiirj 
— Cases  requiring  Operation — In  Arthritic  Cozalgia — In  Femoral  CoxBlt;ia^ 
In  Acetabular  Cosalgia — Removal  nf  the  Diteaaed  Acetabulum  and  I'clvic 
Bones — Methods  or   Uperatini; — Results. — Diheabe  of   the   Great  Tho- 

CRANTEB. — AMPnTATION  IN  DiSEABE  OF  THE  HlP-JOINT    .  461-471 

Ankylosis  of  IIip-joint — Operation  for  Oueous  Angular  Ankylosis — Ctom  or 
Scissor- legged  Deformity 471-47& 

Chapter  LIII. — Dibeabes  of  Synovial  Membranes,  and  of  Muscles. 

Diseases  or  Bxjbsm — Situations  in  which  Biirsie  exist — Morbid  AUerHtionn. — 
DlBEASES  op  THE  BuRSA  pATKLLiS — InQammation — Suppuration — Diiieau 
of  the  Patella — Sloughing  of  the  Bursa  Patella — Enlargements — HouseniHid'a 
Knee — Treatment — Chronic  Enlargement — Solid  Tumors — Treatment — Dib- 
eabes OF  otbeb  Bvjiba. — BcNiON — Treatment  ....        4Tr>-48S 

Diseases  op  Sbeathb  or  Tendons — Ganglion — Simple  Ganglion — Treatment — 

Tenosynovitis — Treatment — Compound  Ganglion — Treatment  .        .        483-tS» 

Dibeabes  of  Muscles — Fatty  Degeneration — OssiBcation — Inflammatory  Affec- 
tions—Syphilitic Diaeasfr— Tumors— Treatment 48i>-488 

CHArTEB  LIV. — Defoemities. 

Latebal  Cortatube  or  the  Spihe — Nature — Mechanism — Kyphosis  and  Lor- 
doiis — Caufef — Signs  of  Lateral  Curvature — Treatment  of  Lateral  Curva- 
ture— Recumbent  Position — Mechanical  Contrivances — Treatment  of  P(»- 
terior  Escurvatton — Of  Posterior  Incurvation 489-49>'V 

Deforuitieb  op  the  Neck  and  Lihbs — Causes — Treatment — Tenotomy — 
Repair  in  Divided  Tendons 496-499 

Deformities  Apfectino  the  Face  and  Neck — Wry-neck — Nature — Causes 
—Treatment 490-.J01 

Deformities  or  the  Arm  and  Hani>— Contraction  of  the  Arm — Straight 
Ankylosis — Acquired  Contraction  of  Muscles  of  Forearm — Paralysis  of  Er- 
tensors  and  Supinators — Club-hand — Arthritis  Deformans  of  Hand — Con- 
traction of  the  Fingers — Pathology — Treatment — Congenital  Deformities  of 
Fingers  and  Hand 50l-o08 

Deformities  of  the  Leo  and  Foot — Knock-knee — Treatment — Antiseptic  Os- 
teotomy— Contraction  of  the  Knee-joint — Varieties — Causes — Contraction 
from  Nervous  Irritation — Treatment — Contraction  from  Inflammation  of 
Knee — Chronic  Contraction — Contraction  from  Ligamentous  Consolidation 
— Treatment — Contraction  of  Hamstrings — Division  of  Hamstring  Tendons 
— Contraction  with  Lateral  Displacement — Treatment — Osseous  Ankylosis 
of  Knee — Deformities  of  the  Bones  of  lower  Limb  fr^m  Rickets — Clul>>foot — 
Varieties — Pathulogicnl  Changes — Talipes  Equinus — Treatment — Talipes 
Calcaneus — Treatment — Talipes  Varus — Treatment — Talipes  Valgus — Treat- 
ment— Spurious  Talipes  Valgus — Hollow  Club-foot — Contraction  of  the 
Plantar  Fascia — Contraction  of  One  Toe — SupernumerHry  and  Webbed 
Toes— Congenital  Hypertrophy  of  Toes  and  Fool — Weak  Ankles  :i08-629 

CnAITEK   LV. — D[ftEA8E8  OF   THE   HeAD   AND   NeCK. 

ScAi.p  AND  Skull— Pachydermatous  Tumor  of  Scalp — Fungus  of  the  Dura 
Maler — Nature — Symptomii — Treatment — Fungus  of  the  Skull — Congenital 
lli^rnia  of  the  Membranes  of  the  Brain — Tapping  the  Head  .         LiS0-&S2 


XU  CONTENTS. 

Langenbeck's  and  Ollier's  Modifications — Fistulous  Openings  through  Nasal 
Bones — CTperation  for  I>epresBed  Nose r>9S-60i 

Plastic  Sdboebt  or  tbk  Lifb — Harelip — Single  and  Double — Median  Fissure- 
Age  for  Operation — Objects  of  Operation — Operation  for  Bingle  Harelip^ 
Operation  for  Double  Harelip — Treatment  by  Simple  Suture— Congeaital 
Transveree  Fissures  of  Cheeks — Cbeiloplasty — Buchanan's  Operation  for  Re- 
storing Lower  Lip 604-614 

Plastic  Sdrqekt  of  the  Palate — Age  for  Operation — Suphyloraphy — Fergus- 
son's  Operation — Pollock's  Operation — Uranoplasty — Perforation  of  the  Hard 
Palate 614-CI9 

Chapter  LVIII. — Diseases  op  the  Mouth  asd  Throat. 

TosocE — Tongue-tie — Hypertrophy  and  Prolapsus — Glossitis — Abecees — Chronic 
Superficial  Qlossitis — Psoriasis,  Leucoplakia — Prognosis — Treatment — Apbthse 
— Simple  Ulceration — Tuberoular  Ulcer — Syphilitic  Oummata — Tumors- 
Nevus  and  Aneurism  by  Anastomosis — Cancer  of  Tongue— Nature — Diagno- 
sis— Treatment — Division  of  Gustatory  Nerve — Ligature  of  Lingual  Artery^ 
Operations  on  the  Tongue — Excision  of  a  Small  Fart — Strangulation  by  Liga- 
ture— Excision  of  Whole  or  Lai^e  Portion — Application  of  £craseur — Sub- 
mental Operation — Excision  after  Division  of  Lower  Jaw — Hemorrhage 
During  Excision — After-treatment — Accidents  after  Operalion — Comparison 
of  Methods  of  Operating — Results — Effect  of  Removal  of  Tongue  on  Speech — 
CysU  in  Floor  of  Mouth— Salivary  Calculi 619-641 

Palate,  Uvula,  and  Tonsiib — Hard  Palate — Soft  Palate — Elongation  of  the 
Uvula — Tonsillitis  or  Quinsy — Treatment — Enlargement  of  the  Tonsils — Treat- 
ment— Excision  of  Tonsils — Malignant  Tumors 641-646 

Diseases  op  the  Phaktnx — Byphiliiic  Affections — Erj'sipelatous  Pharyngitis — 
Abscess— Treatment — Tumors 646-647 

Stricture  or  tue  (Ebophaqus — Conditions  producing  Dysphagia  without  Stric- 
ture—Forms of  Stricture — Hysterical  or  Spasmodic — Fibrous — Cancerous — 
Treatment — Gastrostomy 647-654 

Dihearks  or  the  Larynx — The  Laryngoscope — Laryngitis — Varieties — Acuta 
Catnrrfaal  Laryngitis — Symptoms — Treatment — Acute  (Edematous  Laryngitis 
— Symptoms — Diagnosis — Treatment — Chronic  Laryngitis — Varieties— Simple 
— Chronic — Treatment — LochI  Medication  of  Larynx — Syphilitic  Laryngitis 
— Diagnosis — Troiitment — Tubercular  Laryngitis —  Diagnosis  —  Treatment — 
Complications  of  Chronic  Laryugitis — Nervous  Affections  of  Larynx — In 
Children — In  Adults — Paralysis  of  the  Larynx — Tumors  of  Larynx — Thy- 
rotomy — Malignant  Tumors— Extirpation  of  Larynx  ....         664-668 

Chapter  LIX. — Operations  on  the  Air-tube  and  on  the  Chest. 

Lartnootomt  AM)  Traciieotomt — Conditions  requiring  Operation — Opening 
the  "Windpipe  in  Membranous  Laryngitis — In  other  Forms  of  Laryngeal  Ob- 
htniction — Necessity  fur  Promptitude— Operations — Conditions  requiring  Ope- 
ratiiin — Laryngolomy — Tracheotomy — DilHcultics — Ex|>09ing  the  Trachea — 
Heiii'irrtiiige — Opening  the  Tnichoii — Intn.>dMetii'n  of  Tube — Trachea-tubes — 
TrftcliRototiiy  In  Children — Com|>Brison  of  Liirynijotomy  and  Tracheotomy — 
After-treatment  of  Laryngotomy  and  Trite lii'otoniy      ....         669--668 

Sdroic.vi.  Oi'KRATioNs  ON  TUE  Chkst — Tttjiping  the  Pleural   Ciivity — Surgical 

Tn-HtTiicnt  of  Enipyenm 683-689 

Tappino  !'ri,M0NART  Cavities — Operation — Tnp]iini;  the  Pericardium  .        689-691 


CONTBNTd.  xiii 

Chapter  LX. — Diseases  op  the  Breast. 

PAfll 

DuxAsas  or  tbk  Bbeast — Ages  at  which  they  occur 692 

AiroMALiBB  or  DxTELoricXKT — Absence  of  Breast — Supemumerary  Breasts  and 

Xipplea 6B2-«98 

Xeuraloia — Symptoms — Diagnosis — Treatment 698 

HTPSRTKOFHT^^imple — Treatment 698-694 

ABNOufAL  CoMDiTiom  OT^TBi  Lactzal  Sscbstioh— Absence — Excessive  FIot 

— Lacteal  Tumor— Treatment 694-69& 

Implammatiom  or  the  Bbkast — ^Varieties — Of  Nipple  and  Areola — Treatment — 
Eczema  of  Nipple— Abscess  of  Areola — Milk-abrcesi — Inflammation  and 
Abscess  in  Subcutaneous  Areolar  Tissue — Inflammation  of  Mammary  Oland 
— Inflammation  in  AreolarTi»ue  between  the  Uamma  and  Pectoral  Muscle — 
Treatment — Chronic  Inflammation— Chronic  Inierstitial  Masiitis — Chronic 
Abscesf — Diffused — Treatment — Encysted — Diagnoei»— Treatment— Tubercle 

— Syphilitic  Disease  of  Mamma 69O-701 

TcruoRB  or  thk  Bbzabt 701 

SoK-UALioKAMT  TuMOBS — Retention — Serous — Hydatid  Cysts  —  Lipoma  — 
Fibroma — Chondroma  and  Osteoma — Adeno>fibroma — Adeno-sarcoma — 
Painful  Mammary  Tumor — Treatment  of  Adeno>flbroma  and  Adeno-sar- 
coma —  Cysto-iarcoma — Sarcomata  —  Diagnosis  —  Treatment — Sanguineous 

Cysts — Tumors  containing  Fcetal  Remains 701-712 

Cajtceb  or  THE  Ubbast — Varieties — Scirrhus — Symptoms — Implication  of  Skin 
— Pain — Retraction  nf  Nipple — Implication  of  Axillary  Glands  and  Ytscera 
— Constitutional  Cachexy — Duration  of  Disease — Structure  of  Scirrhus — 
Encepbaloid — Colloid — Duct-cancer — Causes  of  Cancer  of  Breast — Sex — 
Age — Injuries — Inflammation — Eczema  of  Nipple — Diagnoeis— Treatment^ 
Compression — Caustics — Operation — Question  of  Relapse — Prolongation  of 
Life  by  Operation — Cases  UnBt  for  Operation — Doubtful  Cases — Cases  Favor- 
able for  Operation — Return  of  Cancer  after  Operation — Amputation  of  the 
Breast — Mortality  after — Axil lo- mammary  Cancer     ....        712-732 

D19EA8E8  OF  THK  Male  Brbast — Scirrhous  Cancer 732-738 

AxiLLABT  TuuoKs — StrumouB  Disease  of  Axillary  Glands — Simple  Tumors — 

Lympbadenoma  of  Axillary  Glands — Fibromata — SarcomaUi    .        .         733-784 


Chapter  LXI. — Diseases  op  the  Abdomen. 

Iktroddct-ort  Remarks — Operative  Treatment  of  Diseases  of  the  Abdominal 
and  Pelvic  Viscera — Septic  Peritonitis  and  Septicatmia — Shock  after  Opera- 
tions— Hemorrhage       .         ■ 78  5- 739 

Hkbkia  defined  —  Structure — Sac — Neck — Body — Contents — Enterocele — Epi- 
plucele — Entero-epiplocele — Adhesions — Fluid — Hydrocele  of  Hernial  Sac — 
Loose  Foreign  Bodies  in  Sac — Signs  of  Hernia — Intestinal  Hernia — Omental 
Hernia — C«cal  Hernia — Hernia  of  Bladder,  or  Cyslocele — Exciting  Causes — 
Predisposing  Causes — Sex — Age — Occupation — Other  Causes — Conditions 
presented  by  Hernia 739-744 

RiDDCiBLE  Hernia — Definition — Application  of  Truss — Radical  Cure  of  Ilernia 
— "Wutzer's  0[>eration — "Wood's  Operation 744-7J1 

Irreducible  Hkbmia — Causes  of  Irreducibitity — Symptoms — Treatment — In- 
flamed  Irreducible   Hernia — Treatment — Incarcerated    Hernia — Treutuient 

701-753 


XIV 


CONTBNTS. 


StaakoolatKU  Drskia— Otflntlion— UeclianUtn  of  StrangulftUon— 8«mt  uf 
BirkUire — L<m.-«I  KffecU  of  Strang uluiit>a — InAamuftli'ti)  i>r  Uut  sfler  raliuf 
of  SmnguliLioii — Symptunij  —  Loeul  Slgiu — Clonitltutinnvl  Sytnptonf — 
MudtllcntloiiR  of  S^mptonif  —  l>iAgtiotit  —  TrtMiiaMiit  —  TxkU  — Auxiliary 
MaMurva— PentatOnce  t>f  Sj'nt|>luiui  KfUr  Rctluctioti^Trcalmont  ''ilV-7aS 

Opmiutiox  rox  •Stnakuvlatku  IfiCRMt^ — Uporniiou  in  wbich  lb*  Sac  it  opsned 
— Kspoture  of  ihe  H»c — Opening  iho  :^c— Uviiivn  «f  llie  Sulviun — R«duc- 
Uoa— TrMtswDt  of  thv  Sue — TmBtotont  of  tho  Wound — Aftvr-UMtoMnI — 
AoeldenU  and  Hodiflcation*  of  the  Uperallon — PftriiAnltIt— AouU  Catarrhal 
Inflaminalian — Managtinont  ofCongoUd  IntMtine— Of  Ti^htljr  CuntLriuied 
IdImUiiv — Of  Oaii(;Teu<fu>IiilMlJne— Uf  AdliaiunB-~Of  Uiii«Dtum— Woutuli 
of  line  iDtwiin*— Wowmli  of  Art«ri9* — ^lougbing  of  tli«  S»c — Artillclal  Aim* 
■nd  Focal  Fblulu — TreatineRi — Operailoa  witlii>ui  Opiinlnit  tb«  Sac — R«lu&- 
tioa  in  Maat — Cau*«i — Symptomi — Traalmonl — £Iydrucal>  of  ibe    Bernial 

H*o ;aa-7U 


CaATTiiU  LXII. — Sr&ciAL  Hbbnia 

IffOU JV aL  HKKHia  —  Varktin  —  Oblique  —  Co««riDgi  —  B«lalioikt  —  Dlj«el-> 
COTeringt — Botatioiu — lacumpli'iv  or  lotvntkuil — t>oubl« — In  Fvraalei, 
Signt — THagBftri? — ^Treatmeni— Ojieration — Seat  uf  Strlctur«i— llBrnla  con- 
talning  Cikuiii,  Sigmoid  Flexure  of  Colon,  or  Urinary  Bladdor— Ilernla  io 
TllliloaTaginiilii,  ur  Oon^iiilal  llernia — Stgiu  and  Diagnoait—CuRi plica* 
tlon  witb  UndiMoand«d  T««lii — Traatnivot — Enojrtlvd  Uenua  la  Timi«B 
Taslnalh,  or  lafimUle  Hernia 7U-79S 

FnioiuL  Hbbmu — Courw  —  Balalioiu — Cootenu — Sigat — Diacnoali — Tmsi- 
ment — Operalioa 708-1 

UMaiLifALlIicHai*— lu  Children — In  Adulti — Trcattnenl — Operation  . 

VKKTitAi.  lIcKMtA— Trealuicnt 802- 

pHLTir  IltaKtx — Obturator — ijyniptorai — Trsatment — Perineal- -Va|ina] — Po. 
dendai — ^luUi: 

Duu-BkAflUATlc  Ukrnia — CoDgeniul  Uefeot  of  Uiaphragtn— Traumatic  Dis> 
phrajpiiaiio  Hornia 8(U-807 


CuAVTER  LXIIL— Intebtktal  Ojmtbuctiox. 

AocTB  OnrrnoCTtov — Cau«ei — Syioplonu — Cusoxio  OumDcriOK — Symptoraa 
— InliiwuKepUon — STmptumi — IhagnoKiiofCaufMofUbatrucUan — Previous 
Uiitorjr — Mode  of  Invailon-^iieneral  Concitlon  uf  Patient — Character  of 
Pain— Vomiting — Duration  and  Uegree  uf  Conktipatiun — Phyiical  Kxaiui> 
nation  of  Beily,  of  Reutuin — (Janotlty  of  Urine — Trkatuext— Acute  UU- 
itruflioD — Inr«r*ionof  Patient — Puncture  of  IniMtmc — Operation — TnM- 
meat  of  Inttiuuu'eiition — Operation — Trsatment  uf  Chronic  ObstrueUon — 
Gaitructomy— Colotumy — Litlre's  Operation — Atnuaiat'a  Operation —Ooai> 
|iftri«>n  of  Litlre'*  and  AmuMat'a  Ujieration«  B07- 


CtlAKTEIt  LXIV. — TAPI'l.'iO   TOK   AUDOMKN. — OrSKAllUNS  ON   TKU 

Auik^minai.  VidCKKA. — Tiuoa-*  or  tui:  Groin. 


TAPrmn  THB  Aii»»i»K  .  .  .  . 
Rkmuval  or  PoRTioKa  or  rat  Iktbtisb 
Kxciaiox  or  tbk  Ptlobcs 


Kiism 


CONTENTS.  XT 

PASK 

Ofuatio!ts  as  the  Liteb —  Abscess  —  HyditJds —  Diseases  of  the  Gall- 
biadder 829-881 

KxTiKrATion  or  tdb  Spleen    ■ 881 

[tUEASB  or  THE  UvBiLiCDS — UlcenttioD — W&rt;  growth — Epithelioma — Um- 
bilical Fistube 882 

Trvi^Bs  or  tbb  Oboiit — Varieties — Diagnosis — Pulsating — Kon-pulsating — 
Kcducible — Irreducible — Fluid  Tumors—Solid  Tumors — Treatment— Re- 
moval  of  Cystic  or  Solid  Tumors 88S--S84 


Chapter  LXV. — Diseases  of  the  Large  Intestine  and  Anus. 

Cii^OD-iTAL  MALTOBHATioini — Narrowing  and  Partial  Closure  of  Anus — 
Completa  Closure  of  Anus — Occlusion  of  Rectum  above  Anus  by  Mem- 
bmnous  Septum — Complete  Absence  of  Anus — Treatment — Closure  of  Anus 
vith  Absence  of  Rectum — Treatment — Perineal  Incision — Iliac  Incision — 
—Lumbar  Incision — Abeence  of  Anus :  Opening  of  Rectum  into  other 
Canmli 83^^-837 

Stiktukb  :  SiupLE,  Stphilitio,  aso  Maliohant — Simple  or  Fibrous — Symp* 
tomi — Prepress — Treatment— Syphilitic  Stricture  of  Large  Intestine — Cancer 
ud  Malignant  Stricture — Symptoms — Treatment — Cancer  of  Anus — Sarco- 
maU  of  Rectum — PapiUomau — Polypi 887-840 

BiCTAL  Fistclj: — Recto-vesical  Fistula — Treatment — Entero- vaginal  Fistula — 
Kecto-TBgioal  Fistula— Treatment— Entero- vesical  Fistula  846-849 

Ultkb  axd  FustjKK  or  the  Ahus— Symptoms — Causes — Treatment — Spasmodic 
Contraction  of  Sphincter  Ani — Treatment — Atony  of  Rectum — Treatment 

849-851 

Akchb  axd  Fistula — Acute  Iscfaio-rectal  Abscess — Chronic  Abscess — Treat- 
ment— Anal  Abscess — Fistula  in  A  no — Extent — Yarietiee — Complete — In- 
complete or  Blind — Operation  for  Fistula  in  Ano        ....         851-857 

HuoKSHoiDS  OK  P1LB8 — Tarieties — Predisposing  Causes — Exciting  Causes — 
StTuctur»— External  Ilemorrhoida — Symptoms — Internal  Piles — Longitudi- 
nal or  Fleshy — Globular — Symptoms — Hemorrhage — Complications — Ter- 
minatioDS — Subsidence  —  Coagulation — Suppuration  — Sphacelus — Diagnosis 
—Of  Uemurrhoidal  Tumors — Of  Hemorrhoidal  Flux — Treatment — Consti- 
tDtional — Local — Operation — Excision — Ligature — Smith's  Operation — Gal- 
tanic  ^raseur — Crushing — Causticc — Dangers  attending  Operations  for 
Pile* — Uoist  Condition  of  Slcin  around  Anus — Pruritus  Ani  .  .  857-870 
PioLAFScs  Aki — Causes — Diagnosis — Treatmeni — Palliative — Curative — Liga- 
ture—Prolapsut  of  the  Rectum — Causes — Treatment — Protrusion  of  an 
OvariM  Cvet 870-874 


CiiAPTEB  LXVI. — Secondary    Diseases    of    the    Urinary  Organs 

ARISING      FROM     SURGICAl.    CAUSES. — Py.EMIA    AKD    SEPTICEMIA    IN 

UttiNAKY  Diseases. 

V  ibid  Conditions  of  the  Bladder — Diseased  CundilionB  of  the  Ureters  and  Pelvis 
..f  the  Kidney — Morbid  Conditions  of  the  Kidneys — Results  of  Pressure — 
Acute  Diffueo  Interstitial  Inflammation — Acute  Interstitial  Nephritis  with 
Scattered  Abscesses — Eflects  of  Former  Attacks  from  which  the  Patient  has 
Rccuvercd — Causes  of  Interstitial  I ntlammatiun— Tension — Keflex  IrriU lion 
of    Kidney — Septic  Matter  in    Pelvis  of  Kidney — Symptoms    of    Kidney 


OONTBMTS. 


DiMftw  In  Stirgkftl  Affactiont  Df  GttDito-uriniry  OrgKU — UnHbnil  Ftvar 
QT  Uniinic  Porer— Pit>gno«i*^Tr«atni«nU-Pya!Riiii  mini  8«)ilicMniia  in  I>i«- 
cM«i  of  lh«  ITrinary  Orgsiif BT&-S8B 


Cbaptek  LXVII. — Surgical  Opeiutioss  ok  the  Kidmey. 

Stosbisthe  Kidsit— Symptom*— TrvnimfDl—C»lc«ln««  PyellUf — TubofcuUr 
or  SororuloM  Kidn«.v — Syrnptonii — l'vone[jl)ri>«ii — Uydrun«|rhr<Mi»— Trcal' 
in«nt — Tuino»— Otrcinomii  and  Sumima — DiagDutiii  ur  lUiial  Tumon^ 
TmtDient  of  CarclDomn  or  Sarcoma — FiaiDloiji  Communtcationi — ytoatioi; 
Kidney 

OfKHATiojfs  OH  TllK  CiDNKT — Exploration — Aipintion — naphro-lilholontjr — 

Kephrolomy— NephKctomy — Abdominal  Xephreetomy — ItMolU      .         e9fi»8WS 


CnAPTER  LXVni.— UttI.VA.aT  CALCt'Ltm  and  LmiOTOMT. 

Vrisart  DspoeiTS  axd  Calvdu — Uric  or  LUIiic  Acid  I>epo«iu — Catcall— 
Tr«aun*nl— ItepMiu  of  OxalnU  of  Lime — Calculi— Treatmsnt—Phoipballc 
DepoiiU — Varietiea  of  I'hMphatM — Calculi — Trealm«nl— Cyiline — Xanlhinv 
or  Xanthic  Uxid»~('«rbdijal«  uf  Lime— ^bemical  Eiaminalion 
IthxrVK  tx  TUK  BLiUiDKii — ^titicturo  of  Calculi — Urifiii) — Number — Sponlaneoua 
Fracture— Pbyiloal  Cbarmaiert— Siae— W«lgkt— Baidnew — Sbapo— Potttion 
— Caiaes— A{«  —  flex  —  Geographical  l>islribulion — SymptotM— Pain — In. 
crMued  PrequAnoy  nf  Mii-turltion — Stoppa;;*  of  Flow  ■>f  I'rinc— ^tone  in 
Eldarly  M«o — Stone  in  Childron — Enc3>lm]  Calculut — Pfay^ical  Uingntjaia  of 
Ston 9— Sounding  Bladder — Erruis  in  Sounding— Rxami nation  by  Manipu- 
lation— Slone  IB  Womon — Palholugicutl  CbaDgTC  induced  by  Calctilua        OOo-l 

LiTBOTouy — IriiiruBiitnt« — PrcjiarBlioD  of  PattenL^LATiKAi.  Opkkatio]*^ 
Stage* — Portion  of  Knift^-Incbion  of  Protiaie— Gxtrscilon  of  8u>ne — 
LithotoiB*  for  L«l«r»l  Litbutotny— Afloralrdatmeiit  ff  Lithotomy — Lateral 
Lithotomy  in  iloy' — DifBotillioi  diirioK  Lithotomy — In  Findini;  S(on»— In 
£iitiinns  Bladder— In  Svisiiig  and  £Ktmcti»g  Sume — From  Foeltioo  of 
Stone — From  Fixtura  of  Sion* — From  Fibroid  Tumon  in  Pr«i«t»— From 
RioktU  of  Pelvii:  Boaet — From  Sbapa  and  Slu  nf  Stone— R«moral  of  Lmrgn 
Stone— Inciiion  of  Kif^hl  Side  of  Proiiate — Criuhing  Oalculuf  in  Bladdei^^ 
DittcuUy  tram  Fneiura  uf  Hton»— AccidenU  during  Litltotomy— Hemor- 
rhage— Wound  of  Bulb — Miuintc  tli«  L^ntbra — Wognd  of  Kwtum— Wound 
of  P«M«rlor  Part  of  Bladder— OiOlcultle*  In  Cbildrvn— Suutcai  of  Dangtr 
and  canMt  of  l>ft«ll)  after  Litliotomy — .^utiitioof  Moruiity— ladaenoAof 
Ag»— of  Shock — Stal#  of  Kidneyi — Prolonged  Operation— Homorrh age — 
Cyiliti* — UltftiM  IndammAtivn  of  Areolar  Tiuue  uf  Polvi*^Frum  Cutting 
beyond  Pruatate— From  UruUing  and  Ov«t-disteritiui^~PeriUiailie— Sktagb- 
Ing — Pyictnia  and  Scpticxmia — Oihvr  Metbodi  of  Performing  Lltbolomf . — 
Mbdun  LiTHoToyv—Qlilory— Operation— OoupariMn  botwesn  Uedtao 
and  Lateral  Oporationi — (jeneral  Kaw  and  Simplicity — Oemorrhag^— Wound 
of  Bulb— W^oond  uf  Rectum — Trealmonl  of  Pmntiiitt— Manipulalioo  of 
Fon;«i«i  and  Exiradion  of  Htone — Indication*  for  Median  Operation. — 
BiLATKIUL  LiTUOrUMT.  — UKblO-nil^iaiUL  OrKKATIUK. — Ubcto-vxucal 
LlTUvTOUT. — QlOUOR'SDnUrUDlC  UrXKATtuN  ....  9UU'B&& 


CONTENTS.  XVU 

Chapter  LXIX. — Urinaey  Calculus  (wntimted). 

rAam 

LiTBOTRiTT — IIi«u>rj- — Ltthotrit;  m  PnmtiBed  before  1878 — InstrumenU — Prepa- 
ntion  of  Patient — Annatbetio — Openition — IntroductioD  of  Lithotrite — 
Seizure  of  Slune — Braaking  Ston»— Litbotrity  subsequently  to  1878 — Bif(e- 
low'i  Opention — Accidents  in  Lithrotity — Impaction  of  Angular  Fragments 
in  Urethra — Chronic  Enlargement  of  Prostate — Dangers  in  Litbotrity — 
Cystitis — Atony  of  Bladder — Disease  of  Kidneys — Constitutional  Disturb- 
■nc* — Perineal  Litbotrity — Results — Applicability    ....        95&-97& 

CoMr^Eisox  BETWKKX  LtTHOTouT  A.SD  LiTHOTBiTT — SutUtics — Circumstances 
determining  Selection — Age — Size  and  Character  of  Stone — Conditions  of 
Vrinary  Ot^ns — Choice  of  Operation  of  Lithotom}' — Result  of  Operations 
fur  Stone — Recurrence  of  Calculus  after  Operation — Treatment  .        97&-988 

tuTBKAL  Caixulc« — Symptoms — Treatment — Impaction  of  Calculus  in 
Urethrm  of  Boys 988-985 

Pio»T4Tic  Calcclcs — Characters — Symptoms — Treatment  .        .        985-986 

CiUTLCK  in  TBK  Female — Statiatici — Symptoms — Removal — Lithectasy — Sim- 
ple Dilacatiun — Dilatation  with  Incision— Lithotomy — Suprapubic — Urethral 
-Vaginal— Litbotrity  in  the  Female 986-990 

Chapter  LXX. — Diseases  op  the  Bladder. 

CoieixiTAL    Malfoematiok— Extroversion— Treatment— Ay  re's    Operation — 

Wood's  Operation 990-998 

Cmms  —  AcuU  —  Termination  —  Treatment  —  Chronic  Cystitis— Pathological 
Changes — Symptoms  —  Trvatment  —  Irritable  Bladder— Cauces — Diagnosis — 
Trcmtment — Cystotomy — Irritable  Bladder  in  Boys — In  Women  998-1001 
Atojct  or  THE  Bladder — Retention  of  Urine — Symptoms — Diagnosis — Results 
—Treatment — Incontinence  of  Urine — Passive — Distention  of  Bladder  with 
'h-erflow — Active  Incontinence^Treatment — Hysterical  Retention  and  Incon- 
tinence— Painful  Conditions  of  the  Bladder 1001-1007 

TcBtECLE  or  THE  Bladder 1007 

$JC>:uLi  »r  TiiE  Bladder 1007-1008 

TcMORS  fr  THE  Bladder — Villous  Tumor  or  Papilloma — Mucous  Polypi  in 
CLiidren — Sarcoma  —  Symptoms  —  Diagnosis — Treatment  —  Cancer — Treat- 

Bifct 1008-1011 

Hahati  RiA  —  SitiRCs  —  Kidneys  —  Bladder  —  Prostate  —  Urethra  —  Treatment 

1011-1013 

Chapter  LXXI. — Diseases  op  the  Prostate. 

Pa<»T*riTl>-^Symptoiiw — Treatment — Prostatic  Abscess — Kitcntion  of  Urine — 
<.  l.ri'nii'  InflainniBtii'u  of  the  Prostate — Diagnusia — Treatment — Deep-seated 
».vi  vvrj'  Lhr-.nic  AU^-efcs 1013-1016 

Caa  '^n-  Enlaroemextok  the  Prohtatb — Chametets — Simple  Pn>static Tumors 
—  Min  hanical  Effects  on  Urinarj-  Organs- Moral  Elfects  of  £nlurged  Prostate 
— >_vni[.Hims— CuNiplete  Kelention  of  Urine— Diagnosis- Treatment—  Pnistatic 
t  a'.ti'-ttr — Treatment  iif  Complete  Retention — Puncture  of  Bladder  above 
I'.l'-— Punciure  tlin>ui;h  Reel  urn- Forcible  (.'atheterism  or  Tunnelling  the 
I*^-tate 1016-1026 

ToL.  It. — H 


XVIU 


0ONTBKT8. 


Otbbr   DiKKASxa    or   tub    Pkobtatk — Atrophy— ('xneor— Tubercle— Crite    or 
CBTitiM     ....  ...  '   1026-1037 


CUAPTBB   LXXII. — DiSKASte  OF  TUB  UOKTHRA. 

UBnaairdi— SympUHw— TrwiliMiii      .        .  ....        \<t27-lOQS 

GonoHRuau — Cmim — Cbusoter— Symptom*— Incut«lJviiStKg«— Acuta  or  Influn- 
niKtorjr  Stag«— Chruiic  ^^ugo- GI«ot— Tn>«tm«nl  i>f  Oonorriiow— TrvatfiKntuf 
OlMt— (.'ura|iluHtUHM— Influumalion  of  Lvinpliutict  of  Pniik— UbordM — 
AcuUi  snd  Clironlc  Prnatntitu— InflaminKtion  <if  ?ir<(;k  of  Kladdor— t\*liti»— 
Pftilttis  BiiJ  Sepbriiis— Helen  lion  of  Vrine— UcimirrbuKe  front  I'retlirB— 
DroUinl  or  rvriurvtlirol  AImccm— Soqueneecuf  GuiuirrlurA— AVnrU-iftrk-tiini 
— liidui»Ui<n  and  Tbickeniug- Oonotrhcml  Ept<]idymUi»— ConJuaitiTitts- 
TinUincnl — Sclcf-jtHi*— 'IVcftlittcnt— Indunmntion  of  Nom) — Oonorrbom  iif 
BfictuRi— HheumAtism— PyaemiM— <.!iitMieoui  Kniptiont- GonorrtaiM  In  Itn^ 
Fanftlo— Dbgnocb—Trattmiriil 1038-1043 

STKiOTOBioFTUxtTMCTiiRA — VarMtlec— S|MnnodieStrictut« — Ckusei— Sjrmptona 
— Trofttmenl — Congatti  vc  Stricture— C«iiM»—Symplom»—Tn»tmPB  I — Orgsithi 
Stricture— Ap«—S«il—l*ntliolop«J  App«*rancet— Amount  of  t'«mirictioD— 
Ihlataliun  of  ITrrlbni  behind  St Hctiin*— Chronic  Cjr*liti*  in  Illaddur— DiUtA- 
tioD  of  Vrvterc — 8yin)tt[init — Loral  Si|;u<— Kiamiiiation  of  J'alienL  for  Strtc^ 
tura— TraiUnum -(tniduul  >i«>chiinicnl  0!Uuitfo»— Introduction  of  Cnthno* 
—Gum-elastic  and  Molal  Jnitrumoou— lt««ulUof  Introduriionof  InBtnmienu 
— Accidenta  ■tt«adlng  Cfttltet^H&m— N(-r%-ons  Symptom*,  Kigor»,tind  Urrtliml 
Fever— TrutinaDt-^upprGMioiiof  Urine— UemoiTl)«g«—lnllararo»lion—KKlM 
fftmgB*— Uoulinuou*  DilalMlinn— Cauitin- Furviblu  Expaii«K>n  or  Kupturv 
^SUdins  Tubes— Kxp«nfion  by  Screw  Mechwiism- By  Wed|;e— Dimion  of 
Stricture— Internal  Urvtbrotumy— K(«ulu— Exlornil  Uretbrolomy- Op«r>tion 
for  Pennuble  Stricture — Perineal  auction— Result — tk.mp*rison  of  Method*  of 
TrrmUnnn I— Stricture  of  Unttfaral  Orillc — li[ipi>rtneiibli>Slnctiin>— t)permtions 
for  lmi*nneaW*  Stricture — Opt-rvtion  from  Ilebind — Openiliou  fn»m  Frwit— 
Gfincm)  Retulu  of  Treatment  of  Striolura lOia-lOTO 

C0UFLU-ATIDN8  AVD  Rsei'LTB  OP  Strictcrb — Rctetillufl  of  Urine — TteBtment— 
Foreibk  CethetoriMn— Upenine  Urrtbrx  bebind  und  through  KtHeium— Puncw 
ture  of  BUdder  tbMU^;h  Uectum — Puncture  Mbnvn  Pub^o — Employment  of 
Atpintor — 4*i>nditi<>n<i  rrquiring  Puncture  of  DIaddor — Extraviuuition  of  ITnne 
— L>K«1  Xfl'ectt— Onsiitutional  DUliirUnoe— Tmlmeot— Periamt  AbiecH — 
Chenutors — TrrjituK'ut — tTrinary  FijilulH — Tnatmont — UrvlfaroplHrty — Strio- 
lurcof  Female  Uretbm tOTO-IOdl 

UbO'Akt  Va<i1.sal  Fi.vriTL.K — Vurietiet — Vrethr^>-v«)piiAl--Vi»ico>v«eine)— lb«- 

nilu — Treatment — Simi't  and  lloECman'a  l)|i«r»liuiit  10BI-10M 

TuHOM  i)C  TUE  UtimiRi. — Polypt^d  Tumor — Trvalment — Kidn'm — Ligature 
— Cnmike— 0«uiery  .  10M-10M 


CHAPTRIt   LXXltl.— DDtRARIV  OF  THB  PBKIB   AND  StmOTUM. 

DnXAan  or  tuk  1'km»— Complete  Aneat  of  l>evelo|imonl  of  Male.^iiial  (lre»Ra 
— CuBgvniliil  .MAir<>nn»tii<n — Adhoaiun  of  Penii  to  .Scrotum— tlyp»tjudhi 
Timtiutuil —  Kpiipadtu —  PhuiiniU—Ctin|^ull«I —Aoqu  ired  —Treatment 
ntioiu— Uilalatlonor  Phimotit— tilitting-up  Prepuce — Ulrcumeiiioti  furCoA- 


CONTENTS.  Jtix 

PAflB 

geniul  Phimosis  in  Infanta— In  Boyi  or  Adults— Paraphimosis — Treatment 
—Balanitis  and  Posthitis — Treatmant — Horpos  of  Qlans  and  Prepuce — Byper- 
tii>[Ay  of  the  Prepuce — Warts — Uorny  Excrescences — Persistent  Priapism — 
Wart» — Gangrene  of  Penis — Fibrous  Tumor  of  Penis — Cancer  of  Penis — 
—Squamous    Epithelioma — Causes — Diagnosis — Treatment — Amputation    of 

Peni* — Nkvus  and  other  Tumors 1086-1097 

Dut4ses  or  toe  Scrotum — Inflammatory  (Edema — Treatment — Hypertrophy  or 
Elephantiasis — Treatment— Epilhclioma — Treatment  1097-1099 


Chapter  LXXIV. — Diseases  op  the  Testis  and  Cord. 

HtLrwiTinx  or  THK  Tkstib — Treatment 1099-1100 

Nicuuii.  OF  THE  TssTiti — Causes — Treatment 1100-1101 

bruMMATios  or  thk  Testih — Orehttis  and  Epididymitis— Acute  Inflammation 
—;*e»t— Symptoms — Atrophy  of  Testis — Subacute  Orchitis — Treatment — Of 
Acutely  Inflamed  Testicle — Of  Subacute  Orchitis — Strapping  the  Testis — 
Absceu — Inflammation   of   Testis    in    Inguinal    Canal — Inflammation    and 

AbMeu  of  Cord— Chronic  Orchitis 1101-1104 

Htdiocilb  and  H.KKATOCKLK — Hydrocele  of  Tunica  Vaginalis — Congenital 
ByCrucele — Symptoms — ^Treatment — Tapping — Injection  of  Iodine — Seton — 
AntiKptic  Method — Acupuncture — Encysted  Hydrocele — Hydrocele  of  Coid 
—Diffused  Hydrocele  of  Spermatic  Cord — Unmatocele — Characteia — Symp- 
toms— Diagnosis — Treatment — Hiematocele  of  Spermatic  Cord — Diagnosis-  - 

Treatment 1105-1116 

ViucocKLE — Cauaea — Symptoms — Diagnosis — ^Treatment— Radical  Cure  1116-1119 
Solid  EsfLAsaxuEKTS  or  Testis — Simple  Sareocele — Structure— Treatment — 
Tubercular  Testicle,  Scrofulous  Testicle,  or  Tubercular  Sareocele — Symptoms 
— Structure — Progaoaia — Treatment — Syphilitic  Orchitis  or  Syphilitic  Sareo- 
cele—Simple  Inflammatory  Form — Structure — Gummatous  Form — Structure 
-Prognosis — Treatment— Diagnosis  of  Simple,  Tubercular,  and  Syphilitic 
San.ix-tle — Cystic  Disease  or  Cystic  Sarcoma  of  Testis,  or  Cystic  Sareocele — 
Diuru'jfis — Sarcoma  of  the  Testicle — ^Enchondroma  of  Testicle — Cysts  con- 
tainini;  Colored  Matters— Cancer  of  the  Testicle,  or  Malignant  Sarcocele — 
Cbaraclen  —  Symptoms  —  Treatment  —  Structural    Disease    in    Undescended 

T^m  .       ' U19-1129 

Opeeitiun  of  Castration 1129-1131 

Ge>kkal     DlaONOais    of    Scrotal    Tduors — Ueducible    Tumors— Irreducible 

Tum.irt 1131-1133 

SrcKMAToaKlKKA  AND  IiiFOTENTE- Sexual  Melancholia- Tnie    Spermatorrhcea 
Diagiiiwi*— Treatment— Spasmodic  Sperma  torrhoea-Treatnienl— Impotence 
—A»c«-rmB— Sterility 1133-1137 


CiiAiTKR  LXXV. — Diseases  of  thk  Female  Genital  Organs. 

iKTrn'-Di'iTioN  or  Immtrcmests- Speculum  Vaginse— Female  Catheter  1137-1138 
HirEAKO  or  TOE  External  Oroash  and  Vaoina— Hypertrophy  of  Laliia — 
i'ondylomata  or  Vei Tuc» — Cystic  Tumors— Imperforate  Vagina — Imperforate 
Hymen— Absence  <)f  Uterus  and  Osaries- Hyp^'rtrophy  of  Clitoriii- Removal 
of  Clii'Tis — Vaginal  Tumors- Vaginal  llemorrhoidn- Prolapsus  of  Vagina— 
lUftocfle— Cyi-tiiele — Vaginal  Discharges— Treatment .  1138-1142 


XX  CONTENTS. 

TuMOBS  OF  TBI  TTtckus — Subperitoneal,  Intrftinural,  and  Submucous  Orowths 
—  Polypi  —  Malignant  Affection! :  Glandular  Carcinoma  —  Epitbeltoma 
(Cauliflower  Kicresoence) — Sarcoma 1142-1144 

TuuoBS  or  THK  Otabt — Diagnosia— Treatment — Medical  Means — Tapping — 
Inciaion  and  Drainage — Other  Means — Ovariotomy— Statistics — Preparation 
of  Patient^Operation— After-treatment. — Hkrnia  or  the  Otaby        1144-llfift 


APPENDIX. 

COBROSIVE  SUBLIMATE  A9  AN  ANTISEPTIC        .        .  Iliw-IIST 

INDEX  TO  VOLUME  II 1169 


LIST  OF  ILLUSTRATIONS  IN   VOL.  II. 


415  STphiliUc  Onvchift 

41fi  ilvpertrophy  of  Toe-nail    . 

4i:  lUent  Ulc«r  of  Back  of  Hand  . 

418  Rodent  Ulcer,  Perforatin);  Skull 

419  Kodrnt      Ulcer,     SecUon      of 

(Warren)        .... 
43)  CiDceroui  Ulcer  of  Leg    . 
421  N'eururoa,   with    nerve-fllament 
ipread  over  it  .        .        . 

421  Wnt  Indian  Elephantiacis 
4^  Ljmnbaiienoma  at  Root  of  Neck 
m  Utrelip  Pins  applied  to  yariooce 

Vein* 

^  ^irin^  for  Injecting  Neviu 
4^  Lipture  of  a  Nbvui  :  mode  of 
uiing  needles  .... 
^  IKigram  of  Nnvus  tied 
439  Diignm   of   Ligature  of   Flat 

anil  Elongated  Nsvui 
IS  Diaeram  o(  Plat  and  Elongated 
Nievus  tied      .... 
4)0  Narua  of  Lower  Lip:    Front 

Tiew 

<tl  Nvvut    of    Lower    Lip:     Side 

Tiew 

4Jl'  L«ree   X^vua  of   Upper   Lip: 
>'runt  view      .... 
tW  LaTK«    S»Tu»   of    Upper    Lip : 
.Side  view         .... 
*H  N»vu»  of  Tongue 
435  Aiberomatous    Material    under 
Mtcro#co[>e       .... 
43>{  .\the^■^)a  of  Aorta:  Section 
4-17  Annular  Calcification  of  Artery 
ti"  Tutiular  Calcification  of  Artery 
4-I1'  Thronibo«ii      of      Two     Large 
Branches  of  Abdominal  Aorta 
Ua   Kmb-dium    of  Axillary   Artery 
with  Secondary  Thrumbosis    . 
441    Large    Fusiform    Aneurism    of 
Ascending     Aorta,     bursting 
into  Pericardium 
44^  Sarrulated  .\neurism  of  Ascend- 
ing .\<irla         .         .         .         . 

443  Aiirta  laid  iijien,  thowinf;  Mouth 

"f  Sacculated  Aneurism 

444  I>M-««lini;  Aneiiriim  of  Aorta    . 

445  Larjfe  Atieuri<m    of  Ascending 

.\rTta,      Prtijocting     against 
nb. 

V.>L.   M. — K* 


PABB 

84 
86 
40 
40 

42 
44 

&9 
71 

77  j 

I 
91 

Ml 

98i 
98 

99; 

99 
102 
102 
102  I 

102  I 

103  I 

1121 
112 
117 
117 

120 

120' 


126 

12c 
1-J8 


130 


no.  PAflB 

446  PoslcriurTibialNerveFUttened 

by  Pressure  of  Aneurism        .     181 

447  Aneurism  of  Calf  Undergoing 

Spontaneous  Cure  .        .        .     186 

448  Aortic  Aneurism   opening  Into 

(Esophagus     .  .189 

449  Stellate  BuptureofAorticAneu- 

rism  into  Pericardium    .        .     189 

460  Diagram  of  Anel's  Operation     .     142 

461  Diagram  of  Hunter's  Operation     142 

462  Diagram  of  the  DisUl  Operation     142 

463  Femoral  Artery  tied  for  Aneu- 

rism ;  laid  open  from  Seat  of 
Ligature  to  Sac  146 

464  Popliteal  Aneurism  Compressing 

Vein:  Oangrene  of  Limb       .     154 

466  Sac  laid  open  :  Cured  by  Com- 

pression   156 

456  Sacof  Tubular  Aneurism,  Cured 

by  Compression       .  .      167 

467  Carte's  Compressor  for   Middle 

of  Tbigb  ■        ...     168 

458  Carte's  Compressor  for  Groin     .     158 

469  Two  Compressors  Applied  158 

460  P.  II.  WaUon's  Weight  Com- 

pressor     159 

461  Tuffnell's  Compressor         .        .     I6O 

462  Tuffnell's  Compressor  Applied  .     160 

463  Erosion  of  Intervertebral  Sub- 

stance by  a  Small  Aneurism   .     1T4 

464  Aneurism  of  Descending  Aorta, 

Eroding,  and  Traversing  Ver- 
tebra?        174 

465  Aneurism   of    Arch   of   Aorta, 

bursting  into  Left  Bronchus  .     175 

46ii  Aneurism  of  Innominate, 
Siretchine  Recurrent  Laryn- 
geal and  Displacing  Trachea  .     182 

467  Diagram  of  'Treatment  of  In- 
nominate Aneurism  by  Liga- 
ture of  Subclavian  184 

408  Diagram  of  Treatment  of  In- 
nominate Aneurism  by  Liga- 
ture of  Carotid  184 

4C9  Diagram  of  Treatment  of  In- 
nominate Aneurism  by  Liga- 
ture of  Subclavian  and  Carotid     184 

470  Aneurism    of  Arch    of    Aorta, 

Simulating  Carotid  Aneurism     189 

471  Incision  for  Ligature  of  Carotid     193 


xxu 


LtST    OF    ILLDSTKATIONS. 


47'i  Anatomy  of  Right  Ckrotid   «t 

Seal  uf  Lif[«iiire 
-ITS  Fueiforiii  Aritiumni  of  Biuitu-  . 
474  Anourittn      of      Lell      Internal 

CftrotitI  buriilD)t  Into  Ltttera] 

Ventricio         .... 
4Tfi  Anvurumnf  L«flIut«rn«1Csro< 

tid,  f««n  fritiii  hol»w        . 
in  Ugature  of  Vim   Part  of  6ub- 

clariBo 

4T7  Uciture    gf    Subi-Uviaii     dii<J 

Ciir»itd  fnr  Siibi-litvlun  Aiieu> 

ri«m 

478  Ug»iur«  of  Tbird  Part  of  &ah- 

clarlan 

470  Anatotny  of  Tliinl  Part  of  Sub. 

clavlan    ..... 

480  Anatomy  of  Thin]  Part  of  Sub- 

vlaviati 

481  Anatomy  nt  Fl»t  Part  of  Axil- 

lary .         .         ,         ,         . 

MS  Anatomy  of  Third  Partof  Axi  - 

lary 

468  InciiioD  fnr  LiKalurcof  Braclital 

at  Middle  or  Arm  . 
4M  Anatufny  of  Brachial  at  Mtddio 

of  Ann  ..... 
4H&  Anatumj  "f  Ulnar  at  VfHn     . 

486  Ini'tfliriii    fitr  l,|)|;aiiirfl  of  [tra- 

cliial  nt  ltwn>l  (if  RIbovr,  und 
lUdial  and  Ulbar  al  Middle 
of  Portarm  and  al  Wrlil 

487  AnaUicny   of   Radial  at   Middla 

of  Foreartp     .... 

488  Li^Utr«    ■'•f    Kxi«rnal     Iliac ; 

Alx-rn(ttliv'»  Ontrraliou   . 
480  FiMii'iral    V«in    Ob1ilcnt«d    by 
Inguinal  Anfuirium 

490  FuIh)  AnvuriBin  of  Pvrfonititig 

Artery 

491  Uk*'"'*  oI   SuparScial   F«ino 

nl 

493  Anatomy  of  Siifiorftflal  Femoral 

in  ix'tr^'a'*  Tnanglc 
4dft  Anatony  of  Fvm'jral  in  Hun- 

ur*!  Canal      .        .        .        . 
4M  Anatomy  of  P<>pltt«»l  Artorjir 
4V&  Anatomy    of    Putvrior    Tib' 

Artaf^y 

496  DilTuH)    0*(vom>«llti«    of   llo- 

m<>rui 

497  CaritHi*    Bone  from   Scrofulous 

Otlellis  of  Skull      . 

iSS  Scro(\ilMU  Vomica  in  Head  of 
TiUa 

48U  rtiront?  Rararartlva  OvtoitU  of 
Cancellous  Tiatue  of  Ilead  of 
TlUa 

fiOO  Ah«^«i  In  amd  of  Tibia  . 

COl    Bnn«  Trvphino  .... 

fiOS  3«olion  of  Tibia:  (.nironlc  Oa- 
teltlj  anil  Clrcum«cribed  Ab- 
M-iiiwa 

003  Sayre'»  Verlebmied  Probo 

004  Mar«hall'i  0M«otrlt4 


881 


Central   Ncoroiu :    Xew    Bona, 

Cloucie,  asd  Included  S«(|u«*- 

trum 

Reproduciioa    of    Ijowar    Jaw 

■Aer  Phaapboru»-nocr>i*i* 
Actito  yacroiii  of  Tibia  :  Dcfl- 

ct«Qt  Formation  ot  New  Buna 
Ouitinji;    Flier*    fur   Kemoving 

Nwn»ed  Bona 
Catting  Pli«r>  for  R«ino«fng  Ne> 

crowd  Bone    .... 
Cutting    Plkn    for    RcnKrvIng 

N«cro»cd  Bono 
Cvuffo  F'<r\-r|M  , 
Straight  Saw 

Nacrnwia  Forcc|»  ,         ,         , 

Bono  Forcepi     .        .       .        • 
Celk   from  Hpindle-c^Iled  SftN 

contaof  glca|>t>la 
Ouitytng    Spinfll(s«l!^     Sar- 

CORiH  'if  S<'a|iiiU  ;   K<-(;linn 
Cftlh    from  Svcoiid    R«curr«nc« 

of  al>r>ve  .... 

Uyeloid    Colli   fVnm    Tumor  of 

Low«>r  End  of  Femur 
Fu*if(>rm  ni'd  Oat-ntiati^  Cetta 

fWim  Myeloid  Tunn.r 
Secondary  Noduk  of  Calcified 

Sarcoma  in  Liinr:  Svciion     . 
"  Expaniinn  "  of  Lpwct  End  of 

Femur  by  Sarcoma 
Myeloid  Tumor  of  Law«r  Jaw 

Invading  Bona:  SrctiuB         . 
PoripliDrnl   Splndtc-roUiMl    Sar- 
coma of  Hhiitl  of  Fomur 
Pcriphfml    Spindlt^ci^lM    Har- 

comaof  Shnn  of  Fotnur:  Am- 
putation at  lIip»iKC-«<*«fiil 
Maliitnant  Growth  of  Head  of 

lliimftrui  .... 

M  icriaoopic     Hoctioa     through 

abovD  growth 
Aneurism    by    Anutomotia    of 

Pariftnl  Bona 
Interior  •.•f  Knt-e  daalroyed  by 

Aputf  Pvirmic  Arlhiitit 
Carict  of  Qmd  of  Tibia     ,         . 
Rheumatoid  Arthriiu  of  Hip: 

PutiRDt 

Secliou    of    Hip    affvcled    by 

Khcumatold  Artlirilii 
OMaoui  AnkyloiU  of  Dip 
Dutcbar''  Saw    .... 
Kxciiion  of  Shoulder:  Longita- 

dinnl  Incision 
SlK-uldor  Stump,  iifti>r  Amputa- 
tion by  Speoce'a  Meihud 
Kxeiiion  ofSboaldcr:  Klllptical 

Inriaton  .... 

KEt-iiiun    of    Klbow:    flawing 

Low«r  End  of  Uumarns 
Esdalon  of  Elbow :    T-*bap«d 

Incltioii  ..... 
Excision  of    Elbow:    T-thaped 

Indsioa :  Bones  Kipoaed 


804 
804 
806 
807 
807 

80? 

WT 
B07 

ao7 
«• 

a23 

«a 

sas 

tat 


tH 

SM 
ta 


S26 

836 

8«0 

841 
848 

sse 

8A7 

871 
876 
876 
870 
881 
804 
8M 


LIST   or   ILLUSTBATIONS. 


XXlll 


n«- 

640  Eicition   of   Elbow :    Longitu- 

diiul  Incuion 
541  Arm  after  Excition  of  Elbow    . 
0-42  Arm     after     Removat     of    lU- 

diui 

atZ  Radius  Removed 

544  Diaermm    of    Bonea    of    Wriit 

^Luter) 

Mi)  Diuram    of     Tendons     ibout 

Wriit  (Liaier) 
544  Lifter'*  Splint  for  Excision  of 

Wrist 

647  Hand   after  Excision  of  Wrist 

fixed  on  Litter's  Splint  . 

548  Thomas's  Knee-splint 

549  Tbonia»'s  Knee-splint  Applied   . 
650  EjLcifion  of  Knee  by  Elliptical 

Incision 

»S1  Application   of  Butcher's  Saw 

to  Head  of  Tibia    . 
552  Portions  of   Femur  and  Tibia 

removed  in  Excision  of  Knee 
65S  Pi-rtioDS  of    Femur  and  Tibia 

remoTcd  in  Excision  of  Knee 
554  LJmb  with  Kecroais  of  Fibula 
&>>5  Limb  after  Removal  of  Fibula  . 

556  Diagram    of    Synovial     Mem- 

branes of  Foot 

557  Foot  with  Diieve  of  Os  Calcis, 

Cuboid,  and  Calcaneo-Cuboid 
Joint 

558  Exci»toD  of  Ob  Calcis 

559  I>i»ease  of  Ob  Calcis :  Foot  be- 

fore and  after  Operation 
5>W  Disease  of  Astragalus 
S41  Limb  after  Excbion  of  Ankle- 

jcint 

562  ExciMon   of   Astragalus:    Foot 

l^fore  and  after  Operation 
rvijZ   Diiea^e  of  Cuneif(>nn  Bonea 
■VA  L>rt:<;  Spina  Bifida     . 
>-5  Angular    Curvature  of    Dorsal 

S|ine       

-»i  C»ri<-*  of  Lumbar  Spine:  no  re* 

r»>' 

>;T  Diagrams  of  Natural  Curves  of 
Spine 

»  Cbangeof  Curve  in  Early  Angu- 
lar Curvature 

->:i"  Change  of  Curve  in  Advanced 
Angular  Curvature 

^70  Ai'.itude  uf  Child  in  Advanced 
Angular  Curvature 

'.~l   S'ap[-jrt  in  Spinal  Cariea    . 

'~-  T«yl' Ti  Spinal  Suf'port 

'■T-;  Application  of  Sayre's  Platter 
Jacket     

-"4  Sayre's  Jacket  Applied 

'•'.'j  Satrf'i  Jat.'ket  with  Jury- 
n:a*t  ..... 

■'•>.  Early  Sacru-iliac  Disease — Sac- 
rum ..... 

'TT  Karh  Sacrn-iliac  Disease — Ilium 
■T-  Advanced  Sacro-iliac  Disease 


8891582 

389   588 

891 1  684 
686 
891 '686 
894' 
894 :  687 

897  j  588 

898  I  689 

398 

690 
898  :  691 
408; 
408  692 

405  598 

«7|694 
408| 

1695 
4081 
410 

I  596 
411 

412  '  697 
413. 
41"  698 

422  699 
42-2  600 

423  601 

4:i3  602 

423  I  (103 
1604 
425  I  606 
432' 

432  60C 

433  ■  607 
433  608 

609 
434 

610 
438  61 1 
438  612 
438    613 


Position  assumed  by  fLimb  on 
forcibly  dislending  Hip  with 
Fluid  (Barker)  .444 

Bonea  from  Acute  Disease  of 
Hip-joint  in  Adult 

Patient  with  Chronic  Hip  Dis- 
ease and  Sinuses  451 

Head  of  Femur  after  Excision, 
from  above  case  .    451 

Apparatus  for  Extension  by 
Weight  in  Hip  Disease  .  468 

Thomas's  Hip-splint .        .  459 

Thomas's  Hip-splint  applied  469 

Sayre's  Extending  Apparatus 
for  Hip-joint  Disease  460 

Acetabulum  perforated  in  Hip 
Disease 464 

Head  of  Femur  Carious :  from 
same  care        ....     464 

Patient,  Three  years  after  Exoi- 
sion  of  Head  of  Femur  and 
much  of  Hip-hone.  466 

Excision   in  femoral   Coxatgia    465 

Gowan's  Osteotome  applied  to 
Femur 467 

Splint  for  use  after  Excision  of 
Hip 468 

Incision  Exposing  Great  Tro- 
chanter for  Removal  of  Dis- 
eased Bone      ....    470 

Patient  with  Rectangular  Anky- 
lusii  of  Hip:  Spine  straight  .     472 

Same  Patient:  showing  Curve 
of  Spine  allowing  toes  to  toueh 
ground 472 

Lines  of  Section  of  Femur  in 
Sayre's  Operation  for  Anky- 
losis of  Hip     .  .    478 

Application  of  Chain-saw  in 
Sayre's  Operation   .  474 

Saw  used  in  Adams's  Operation 
for  ;\nkyl(ifis  of  Hip      ,        .     474 

Application  of  Adams's  Saw  to 
Neck  of  Femur      ,  474 

Crofs-legged  Deformity  (Lucas's 
case) 475 

Enlarged  Bursa  over  Olecra- 
non   477 

Toes  Distorted  by  Pressure: 
Bunion 488 

AppBrHtii.<>  for  above  Deformity    488 

Fibr< '-sarcoma  of  Sartorius  486 

BackView  of  and  Section  through 
above  Tumor  ....     487 

Back  View  of  and  Section 
through  above  Tumor  487 

Malignant  Tumor  in  Sole  .  488 

Section  through  above  Tumor    .     488 

Lateral  Curv»ture  and  Kotation 
of  Spine  ....     489 

Outline  of  Double  Lateral  Curve     489 

Outline  of  Quadruple  Curve      ,     489 

Outline  of  Kyphosis  .        .        .     490 

Outline  of  Ijuniosis    .        .        .     490 


XXIV 


LIST    or    ILLUSTRATIONS. 


I'Bliciii    with    Lai«ral     Cnrva- 

tur« 

34[i|>un  for  Laicrnl  Curvnture  . 
Sapjioit  for  PiMUrlor  Eiciirv*- 

««m 

417  Support  for  Poilorlor  Iiicurv»- 

Uon 

618  T«iMU>iny-knlfe 

4110  TcDotwntj'knlfc 

C'JO  Tenotomy -knife 

Ctil    Ui|5g'«  Anjianilu*  for  Wry-n»«k 

632  Cuniraction  of  Suplnktort  Kn<l 

Kxt«nM>r(  ftt  n&nd 
028  Conlniotlon  of  I'lexun  and  Fn>- 

DuUtn  of  Uanil 
Wit  Tluptivtren'i  Ci'iilrtctloni    Dli* 

leetioii  (AtlNmii) 
625  Su]i«rnumGrary  Tbumb 
Km  Appcn^nt  Kiiitnn  at  Iwo  H«ndt 
627  Arrwt  of  I>vv«l<.>prii<int  of  Fin- 

^n:  l^li  Mktia 
A28  Arr«tt  of  DevrUipmant  (if  Pin- 

K«n:    Kli;lii  IlHnd  . 
A29  I>iKtrrflmii*howlngOp«r«iiun  fur 

C80  Dliii:r>in*i)iowlriij;  Opomilon  fur 

Apiianltu  fur  Kn'iok-kn«o 

D4>n»  la  Kn<)ck>kno«:  LIna  of 
MiKwvren'B  And  Ogston'a  Ope- 
nttucu 

M«oeweti'«  CliiwI 

CohtfBclion  of  Knee:  Dlcplaocs- 
■ittTut  BackwKrda  of  Hewl  uf 
Tibia 

Kriuivjoint  dlraighl/>ned;  Bcftd 
I'f  Tibin  ThrowD  Backwardi  . 

ApDiratui  to  rcnied}'  above  Dis- 
■ilikccuicnt        .... 
087  Drill  for  Auk,Tl.«e(l  Kne«  . 
696  Drill  for  Ankj-loacd  Joint  . 

639  Talipes  Eqiiinui. 

MO  Tali|>M  KijiiiiiiH.   Bene*  in 

oil  Ap)MratU4  for  wic  after  divuioB 
of  Tcndo  AchilUt  for  Panljrlic 
KqutDu* 

042  Tatipu  Calcftooui 

«V43  TallpM  Varu»     . 

M4  THlipw  ^'arut:   Bone*  I u    . 

«16  Kdation  of  Tondona  divided  in 
Kqiliiio-vann  .         .         .         , 

640  AfflfltiB'*  Taliven 

647  Talifrtii  Vnlgu*    .        .        .         . 

MM   lli.llotr  (lH».f.tL>t 

A49  Appamlufc  fur  tnainUining  Kx- 

(f^iuiun  of  Toci  alter  Divbion 

■if  Tendoo*      .        .        .         . 
6aO  (-'■.npjiilt*!  HTTpertrophy  of  To« 

aiMl  Foot:   I'lnntiir  Ajpcnt 
C£l  Cutie^fittal  Svp«rtrjph}'  '.'f  To«i 

and  Foot :  t*ur<»l  .\iipect 
SfiZ  I'achytlonnaloiuTumur  of  Scalp 
<68  Mpoina  •'T  Svu*  Wfon  Opof»- 

tion 

KM  Snnw  Xum  afW  Oporation 


081 
082 


6I« 
684 


flSu 
68S 


4irj   6M) 

4M    057 

491, 
411.'.    imO 

im  flfii 

4»8 
4Uil   flA2 

fiC)t 

<t«8 
SOU 

664 
f.02 

(Hn) 

r«r> 

MM    000 
WW 

IM7 
tiOC 


,070 
507  671 
/rflB  (172 
078 


MO 

&09 


879 


614  6R0 
6l7'«f*l 
M7 

620  OSS 

I  CM 

621  ' 

&3)  \e»t> 

&22i 
«2-^   OM 

&£8,68; 
«34' 

&37 

OVO 
AM    Ot»l 

.01)2 
62&I 
680  098 

!g94 
fins  09r> 
68B- 


Xaanl  S|wciilutii.  .  .  . 
NaJinl  Sjimtlum  (Priuisal'*)  .  6W 
B<.'11>«.>)'*  Sotinii .  .  .  .  M4 
DiiL^nm  uf  I'lug^ng  Noatrll  by 

mpMiiii  iif  Hclloci]'*  i^iund  644 

NtuK>-<jH)iul  Tumor  .  .  .  M» 
Section  of  j^llhnlloraa  of  Faea  .  568 
Bit«iMiv«  Wartj  Bnithcliuma  of 

Up 864 

Llnet  of  IncUlon  for  nrnoring 

V-«li«pcd  Pirn  of  Up    .        .    CM 
£piUi«liun)nef  Lowvr  Lip:  LInca 

of  IncUlon       ....     fiM 
Lip  al\«r  Rvnioval  of    Epilli^ 

lioma fiM 

Rstoiulv^  Rplth^^lioma  of  Lip: 

Lintv  i>f  iMciniun  .         .     6(>6 

£p)tht-lioiua  uf    Lvwer  Lip  Ib- 

volTtns  Jaw  (IlMth)  .     5SA 

Tiini'fT  "f  Parotid,   loo  d«op1; 

ncnfd  fur  romoval  .  .     (UM 

SimiiloTumornf  Parutid:    Prunt 

Vm'w 687 

Simple  Tumor  of  Parotid:  Back 

View 667 

S«x>u*  Crrt  of  tbo  Tbyrold  .  698 
Epulia  of  Lower  Jaw  .     669 

^uliftiif  f^ppcr  Jaw  600 

Wood''  Cam  of  Pfao«pbora*<ne- 

oiwli  of  entire  Lower  Jaw  67S 

Anlrxitii-|>erforatur  674 

Antnini-i'orfomtor  674 

Aninim-pcrforator     .        .  674 

Oyitie  Tumur  of  Antrum  .  676 

Malignant    I>U«ue    of     Malar 

Bone 678 

UalijEQaiit  Tuniorof  Uppn  Jaw, 

larolTlnp  all  Bona  of  Face    .     679 
Jaw  Mw,  with  luovablo  back  680 

Li»«*  of  Inciiion  (Lialun'i)  fur 

Kxcislon  of  tapper  Jaw  .  680 

Trcad«lenbiii^'aTniclwa>Unipoa  6631 
ExcttioD  of  Upper  Jaw  (LlftonV 

Mothod) 688 

Line  of  Indflion  In  Eicfajon  of 


L'p|ter  Jaw  by  External  Flap . 
KiciJiun  of  l»wer  Jaw:    Boft 

part*  rabed       .... 
EsoiMtw  of  Lower  Jnw :    DImt^ 

tioulalion  of  Condyle 
Lirrn    of    IncLiion    in    IJurow'a 

Op«ra(lon         .... 
Opcmii'in  for   R«p«ir  of   Eve* 

lid      If)  UlidiOK.  (A]  Twiattno 

Method 

Lower      Eyelid     deformed     br 

Scar 

Lnw«*r  Eyfilid  after  OpenlJoa    . 

l>cl)rie»cy  of  Ala 

Diafjram  of  Flap  fmiB  Fowband 

in  '''■'  '     :■.- 

Dcj.:  .  .  .  . 

Now  .'.....    .irn  after OparatioB  . 

Pati«>iii  Iwforc  RbinupUstie  Ope> 

ralloti :  MoM  Oeatruyed  . 


684 
690 
601 

687 


6»7 

CM 
608 

tan 

000 

001 

oot 

OQS 


MST    OF    ILLU8THATI0NS. 


XXV 


ris- 
CM 

69T 
TUO 

:oi 

T02 
TliS 

TM 

7(V-, 

TC>6 

to: 
:ii 

'V2 

713 
714 
71". 


:-.'i 


ri-4 


7:> 


Satne  Pnticnt  tmiie  months  aft^r 

Ofxratirtn        .... 
t>p»-nine   'o*o   Antfriur   NHrvs: 

Cl-«ed  by  Operation 
Op^ninj!  into   Anlorior   Naref. 

Clns«^  by  Openttioii 
Single  Uarvlip    .... 
I>i»uble  H>Tvhp:  Front  View 
IV'uble  Harelip:  Side  View 
Bonesoont^^medin  UoubleUHrp- 

lip  mnd  Clefl  Palate 
Elaftic  Comprewor  on  Coronary 

Artery  of  Lip 
ApplioHtioD  of  Twisted  Suture  . 
Appliration  of  Pins  and  Sutuira 

in  Harelip 
Harelip:     Spring   Cheek    Com- 

(.rw*tir 

NeUton's  Operation  fur  Partial 

Harvlip:  TwoStagra 
Freshening    Edge    in     Double 

Harelip 

l><iiible  Harelip;  Intemiaxiliary 

IHirtion   fixed   to   Nuee:    Side 

View        ... 
I)<>uMe  llarvlip;  Intermaiillnr}- 

iMirtion  fixed  to  Nose:   Front 

View 

Cfaopart's  Of<eration  of  Cheilo- 

plasty;     Linen    of     Incision: 

Part*  appn)xiniated  by  Sutures 
Chi'part's  Operation  of  Cheilo- 

t>>a^ty;     Linea    of     Incision: 
*an»  approximated  by  futures 
Buchanan*  Operation   for   Re- 
storation of  Lower  Lip  . 
Buchanan's  Operation    for   Re- 

»t-ir«tioR  of  Lower  Lip  . 
B'ichanan'a   Operation    for    Re- 

^t•  ration  of  Li>wer  Lip  . 
S_\  ni(- 1  <.i|ier^tion  for  Restoration 

'  f  I^iwcr  Lip:    Lines  of  In- 

ci>i"n       ..... 
Sy:iif"»Operatifinfor  Restoration 

•  ■f  Lower  Lip:  Operation  Coin- 

[■>tfd 

B-'ne^  in   Fissure  of   Hard  and 

<"{t  I'alaie       .... 
W.nKi's  MudiScation  of  Smith's 

(JaiT  ..... 

S^-dill.i*  Operation  of  Staphy- 

Krniphy   .  .      " . 

S^-dill'fi  Operation  of  Staphy- 

loraj.hy 

S-'-dill.^is  Operation  of   StMphy- 

I'^r^phy 

IIvjMTtr  phy   and    Prolajieus   of 

"T-.m;'!!'    ..... 

N:»'Vti-  lif  Tonjiue 

Licturv  rif  Liniiual  Artorv 

Aj'l-liciiti.'ncif  Scn-w-iTHir.C'htt^k- 
Ptnicior,  tind  Whipcord  in 
'>["-nili'ins  I'll  Ti>ii;iic 

KT^iu—'n-  (jii:; 

\Vhit.-L<-»d  -  i;*:; 


TAOE 

PIO. 

729 

602 

730 

G04 

731 

004 

782 

t»5 

CO.'. 

783 

605 

734 

606 

736 

608 

736 

608 

737 

608 

738 

789 

609 

740 

741 

609 

742 

743 

610 

744 

746 

611 

740 

611 

747 

748 

749 

612 

750 

751 

612 

752 

7.')8 

61^ 

7.>4 

765 

013 

766 

767 

613 

7:"* 

7-VJ 

700 

014 

701 

702 

614 

763 

764 

014 

765 

015 

76 

Cl- 

707 

ou 

768 

017 

709 

020 

770 

024 

628 

771 

02fl 

772 

t;2fl 

773 

030 

PASB 

Cork  screw- needle        .        .        ,  680 
Application  of  Ligature  to  Cancer 

of  Anterior  part  of  Tongue    .  681 
Two  Erraeeiirs  applied  to  Cancer 

of  Tongue       ....  682 
'Wire-fcraseur   for    removal    of 

Tongue 688 

Galvanic  Ecraseur       .         ,         .  688 
Lines  of   Incision  in   Regnoli'a 

Operation        ....  C84 
Tongue  drawn  out  below  Jaw  in 

Operation        ....  684 
Removal  of  Tongue  by  division 

of  Jaw 686 

Raniila:  Introduction  of  Seton  .  640 

Vulsellum- scissors               .        .  642 

Forceps- scissors  ....  642 

Tonsil-guillntine  applied    .  644 

Tonsil-};ui]lotinc  shut                 .  644 

Tonsil-guil  lotine,  anoiher  pattern  644 
Removal  oT   Right  Tonsil  with 

LeA  Hand  .646 

Pharyngotome    ....  647 
Epithelioma    of    Phar\'QX    and 

Q^ophagus  causing  Stricture  .  661 
Modeof  usin^  the  Laryngoscope 

with  Reflector                              .  656 

ThroBt-mirror     ....  656 

(Edema  of  the  Glottis          .         .  669 
Pmbang  for  applying  Nitrate  of 

Silver  lo  the  Larynx                 .  660 

Laryngeal  Syrinire              .        .  661 

Endo-larjngeal  Forceps      ,  665 

Endii-laryngeal  Forceps               .  666 

Endii-l»ryngeal  Forceps               .  666 

Epithelioma  in  Larynx                 .  667 

Operation  of  Tracheotomy  674 

Parker's  Automatic  Retractor    .  676 

Trachea-hook  director                   .  077 

Cutting  Trachea-h(K)k  677 

Riv»Jve  TrHchca-tubo,  closed  678 
Bivalve  Trachca-tubc  with  Can- 

ulrt  intn>diiced  .  .  .  078 
Tmchon-dilator  -  .678 
Traciiea-tuhe:  Side  View  .  .  079 
Trachca-tubn:  Front  View  079 
LHryTisri'al-tuhc  ....  679 
Baker's  India-rubber  Trachea- 
lube          080 

Tapping  the  Chest  by  the  Bottle 

ui^pirator 684 

Pii^ton -trocar  for    Tapping    tlio 

Chest                           .        ";         .684 
Tapping  the  Chest   bv  Siphon- 
trocar       ..."..  686 
Trocar  for  Tupping  Pulmonar^- 

Cavities  .          .    ~     .         .        '.  COO 
Simple  Hypertrophy  of  Breast  in 

a  girl  flflecn  years  old  694 
Breast  laid  open,  showing  deep- 
ly sealed  Cysls,   mistaken  tor 

Scirrhus 704 

Cvslo-sarcoma  of  Breast  709 
Ulcenited  Cystic  TumorofIJroa»l, 

of  twenty  vears' dunition  710 


XXVi 


LIST   OF    ILLUSTRATIONS. 


774  UWrBl"d<'y«ii:Tiimitrwriir»'niH, 
six  monvli  Itilcr,  with  Kiinj^- 
inij  Samimnliiui  (jniwlli         .     710 

776  Ulnnilini;  Svirrbtit  v(  BrLtict  713 
770  PtMition  or  t'litit^iit  ftJT  Ampiiu- 

tM.li  ..f  Bnwt ....     728 

777  ItK.'iii';riiin><)iiitT>d  Tur  I  bo  roughly 

ClMirltii;  AwiU        .  .789 

778  Surrhii*  -f  M.ilx  llruatt  .  7fl2 
770  Fil>rr<u4    'I'timor    in    Azilte   of 

Womnn  .....  7Hi 
jm  Pil>roua    Tumor    in    Aitll*   of 

Wuinan,  rroitt  vi«w  .     734 

781   Lan;c  H«rGonift  \a    Axilla  of  « 

tUn 784 

7ft!  Larni  SHrcouM  in  Axillii  of  a 

Mun 784 

788  Diag^min  of  nvdmwlnnf  llirmial 

8»c.  .741 

7W  WuUw'i  Ap{wnlu«  for  Rutiml 

Cuiv  of  lli^mia       .  .747 

nh  Snc  laid  nptn :  StrirUirv  in  Nock  734 
780  OtMrnti'in  fi>r  litTniia:   Uivmon 

ofilw9kin      .  .704 

787  Oponilkm  for  licrnin:    Incision 

iirStitwermii  .\miliii  Tiwiii?     .     764 

788  Biuml   utid    Narruw    UnrnU-dl- 

ni'iiir       ■        .        .        ,        .     765 

780  Hnrnin-knifv  .  .  76fi 
7W>  Mtxieof  uiiuc:  B«miii-kni(b  780 

781  Itii/*unf,      OwigKnou*      from 

htrnn}!;iilrttion ....  770 
793  ]>uf)uytrun'K  EnUmtotne    .  777 

708  DujiuviKtn'*     Knt«rob>me     An- 

l.ii.n.! 777 

7M  DiiMcLiuii  of  I>(>tibk'  Direct  In- 

ruinal  tlitnita  .     786 

7M  nrncUon  of  Obliiuvund  Dinct 

Ui-mlw  on  <Ntii«  itd«  785 

790  Congniiitiil  Hernia  (diagratn)      .     71M] 

797  Infniiiilu  llvniiB(dtaj(niiii)         .     798 

798  DUjortlon  ^bowing  KclatloM  of 

Kpin'>rsil  Unmia 

799  IHtMviii'ii   "f   Fumorul    Hvriiitt 

turnlnr   upvrunl*    over    ft-o- 
(larl'i  l.i;u;ar(i>'nt 

800  Ui>lHti'>ii>i   of    Kciiiunil   Ucmin: 

(Ibtiirator  riaing  f^m  Kpigai- 

tric 

Mii    I'  -ii3(lc  llnniitl  of  Coitin 

W^    .  iil.iiniftii'n  fnim  In- 

liriiiil  lli-riiia  .... 
tOCt  Intliioii  I'l-r  Ltiiiib«r  Coloionijr 

andU«n'latt>>nio  l.tni<vir(.^Uiti 
MM  tncjii^n  iti  I>-fl  L>>iiil>nr  ICcgtun 

III  AniUkwii'x  upt-mtUm  . 
006  Colon '>)ir(ii>d  and  ktiU'faid  totikln 
8H  B«ctiim  riiln;  r  .... 
807  Can<  <  ■  )Min  of  Kn^urn  : 

V'  •  iiirtng    Ailmiiiia- 

Unr.    '.         I    ''■inn    .         .         .     842  it'  ' 

800  PiOi|n         i:..  iiirii.  with  Tall-  KAH   Kf. 

cU    in.ioi  iiiriJ,  twrvn  jr*>ni>ld     84&    fjAI  Sci 
006  Kaked-«Y«  Sn-tioo  Uirou^b  pi»-  &&6  An 

cadkng Mi>  i'.. 


794 


7M 


ria.  PM 

itIU  Anal  Uiinlt^r  .  ...  MM 
Bll  SMculuin  Ani    .  .        .819 

81'i  l*robi>nolnlMl  ititlHory  for  Ki^ 

tutH 88ft 

818  Opnvllnn  far  Pblula  in  A«o  .  865 
1*14  RiniC-fon-op-        .         .         .         .     W7 

815  Dmhi-'«  Nwiik'  fur  Applying 
Lii;atur«  to  rili-4  .  *      .    887 

816  Kinilir*  Catit"rv-(.'lainp  .     080 

817  Allirmliiim'' Ciamp    .  .    986 

818  ^?]H-culllm  Ani  889 
810  Oilt  Ulip  .....  8A0 
8^  FrolnjuuK  Ani  .  .871 
821  AoiiU:     InlcMltlnl      Nc|>hr(tU: 

Bi^atlvm)  A  Iwmaea.  M  icio- 
■CMpiti  :4«K'lioii  .     B80 

8SS  Acute  IntontJtlnl  »pbrttb: 
Condition  tif  I'^pitbi.'liunt.  Ui- 
ctTi*iMpic::i«ctian  .     881 

BSS  A.  Ornupnf  AlMc-eaMWonSurfaro 
of  Xiuney.  u.  Vuiiical  Sve- 
tion  nf  Mnio.     Nnkt-d  njra       .     881 

R-J4   (Trio  Acid  Cr^Mab     ...     900 

826  Umi«  of  Ammonia  and  Anor- 
phiHiK  U  ntt4»  ....    900 

828  One  Acid  C'kIcuUm    ...     SOI 

827  Cr)>ult  of  OiaUlQ  of  Llin«  .  908 
838  Very    Itnii;*)!   OiftlaU  of    LIniO 

Calculus  ....     909 

S20  Crv»uU  of  Ammonio-mi^uaabui 

l>bii>pbNli>  ....  DOS 
H«0  CrvHUl.  of  t,>«tin«  ...  904 
K81  Section  of  an  AlumaUng  Cal- 

ouliu 906 

K32  S^iHion  of  UxalH(«  of  Lima  Cal* 

culun  Incriutcd  with  Umtc*  .  905 
ess  Urio    A^-id  CalcMli    inatl«4  to. 

(nllier 997 

KS4  Calculi  with  Fatvti  ...  907 
HK't  Exterior  of  BUdd<v  caiit*iiilng 

an  Encviud  CahHilui  .     SOS 

8»t  Interior  of    llladdrr:    Showing 

SniKll  llrin<-0  ..r  Oral  .     900 

837  Sound  fir  rxatninine  Btad(l«r  .  912 
KM  Sounding  for  .Stone  behind  Pna- 

tnie  -         .         .     912 

889  Koondinic  for  Stono  abore  Pabo     918 

40  l[olI<.M'.S..iind    .  .        .Bit 

841  Sotiiiding  lor  Rmr<r*lt>d  Stone     .     914 

842  Lithoioinv  Scalpel  .917 
M.I  i'rol>o-pointnl  Liib.>(*>mv>knire,  917 
8-14  0(«n.blH(l«l  I  -'  i«  fll7 
M<y~^:^.   l-ninii'i                           'U- 

olotiiy  Ki.iii  [!•.  I  1.1  .nl  I  ..r- 
CV|M.  Sc<>i>{.  In  llMidU;,  Scoop, 
.Sun;  tv«r<'Upr  .     918 

861  LithnlottiT  Pmilton:  LimioflB- 
eulon  in  lliv  Lateral  Onvni- 
Uoa 919 

H63  TjatArat  Iiilbiriotnv?   FingMwnail 


:iU    Hlld 


brrp 


LIST    OF    ILLUSTRATIONS. 


XXVU 


86« 

«7 

808 

R5» 
S<0 

Wl 

863 

»«■) 
846 

867 

848 

WJ 
870 

>71 

872 

878 

8 
87s 

879 
8»> 

>^I 

lift! 

8M 

8*»*i 
Ri"7 

«*5 
«W 


Pt*iUi>n    of    Hand    »nd    Knife 

(Frriftut'OD)  .  .  .  . 
Pt»iti<>n    i)f   Hand    And    Knife 

(LiFton) 

PMition    of   Ilaud    and    Knife 

(Author)         .        .        .        . 
Ini-irii'n  in  Prostate   . 
Line  of  Traction  in  Extracting 

a  Stone 

Exinction  of  8tone  by  Finger 

and  Scoop  .... 
Smith't    Lithotomy    Staff   and 

Conductor  .... 
Smith's  Gorget  .... 
Tumor    of    Proetato,   Removed 

during  Lithotomy  . 
Cru'her  and  Drill  fur  Ijargc  Cal- 
culi in  Lithotomy  .  *      . 
Sledian  Operation  with  Rectang- 
ular Staff         .         .         .         . 
Line  of   Incision    in    Bilateml 

Lithotomy  (Dupuytren) 
Dupuytren't   Lithoiome  Cach^, 

opened  ..... 
Bilateral  Section  of  the  Prostate 
Line  of  Incision  in  Prostate  in 

Bilateral  Lithotomy ;  relations 

of  cut 

"Woode  Bilateral  Gorget     . 
Lithometer  Sound  (for  meaaur- 

ing  Sione)  .... 
\f  eiu's  old  Thumb-screw  Litbo- 

trite  for  breaking  Stone  . 

'77  Stfctionsof  Lithotrile-blades 
Ciriale's  Lithotrite  for  Crushing 

Fragments  .... 
Thompffon's  Improved  Lilhotrite 
Intn>duction  of  the  Lithotrite  . 
Bri'dte'f    Mode   of    Seizing   the 

Su>ne 

Clviale'fi    Mode  of    Seizing  the 

."^tone  behind  the  ProetMtc 
P-«iti--n  of  Lithotrite  in  Crush- 

int;  the  Stone  .... 
Pi«)tion  of  Hand  in  using  Cifi- 

al<;'R  Lilhotrite 
P-«itioQ    of    Hands     in     using 

Thumb-screw  Lithotrite 
Liihntrily  Catheter:  Eyes  at  Ei- 

Iremiiy  ..... 
Lith"lriiy     Catheter :     Eye     in 

Concavity  .... 
Litholrity    Catheters  i     Eye    in 

C'lnveiity  .... 
Clover'*     Lilhotrity    Injeclion- 

afinaratus'  .... 
Handle  of  Higelow'^  Lithnrite : 

fhul 

Handle  of  nii;cluw's  Lithotrite  : 

'>[*n 

Ja*«  "f    Bigc-low's   Lithotrite: 

fhui 

J»w*  of  Kigdow'B   Lithotrite  : 

"F-n 

Bicelfiw't  Evacttator  in  use 


PAflB 

rie. 

895 

922 

896 

897 

922 

898 

899 

928 

924 

900 

901 

926 

902 

926 

903 

928 

904 

928 

906 

906 

931 

907 

934 

945 

908 

960 

909 

951 

910 

9ol 

911 

912 

961 

962 

913 

966 

914 

956 

915 

957 

916 

967 

968 

917 

96t) 

918 

960 

919 

961 

920 

962 

921 

922 

962 

923 

902 

924 

925 

968 

926 

963 

927 

928 

963 

929 

964 

930 

931 

966 

932 

9GC 

!(33 

9C0 

•JM 

93'i 

•ifi« 

ya« 

'MM 

Bigeluw's  Cuthetor  :  Straight . 

Bigelow's  Calheter:  Curv«l    . 

Otis'a  Evacuator 

Thompson's  Early  Evacuator   . 

Thompson's  Improved  Evac- 
uator      

Urethral  Lithotrite  . 

Urethral  Forceps 

Urethral  Forceps  with  Alltga- 
tor-jaw  action 

Periiieal  Lilhotrity:  Introduc- 
tion of  Dilator  (Dolbeau) 

Extra-urethral  Calculus  . 

Pro>tai]c  Calculus    . 

Crusher  for  large  Calculus  in 
Female  Bladder 

"Wood's  0|>eration  for  Extro- 
verted Bladder.  Outline  of 
Incision  .... 

Wood's  Operation  :  Flaps  ap- 
plied       

Wood's  Operation  by  Lateral 
Revereea  Flaps 

"Wood's  Operation  by  Lateral 
Reversed  Flaps 

SaccuUis  in  wall  of  Bladder 

Cells  found  in  Urine  in  Catarrh 
of  Bhidder     .... 

Bladder  laid  open,  showing  En- 
largement of  Prostatic  Urethra 

Urinary  Organs  in  case  of  En- 
largei]  Prostate 

Elbowed  Catheter 

Enlarged  Middle  Lobe  of  Pros- 
tate arresting  progress  of 
Catheter         .... 

Puncture  of  Bladder  above 
I'ubes  and  thn>ugh  Rectum  . 

Teevan'a  Urethral  Injector 

Guyon's  Injector  for  nitrate  of 
silver 

Stricture  from  Consolidation  of 
Corpus  Spongiosum 

Bridle  Stricture 

Stricture  of  Anterior  Part  of 
Urethra         .... 

Conk'ul-hcadcd  Sound 

Olive-headed  Sound 

Olis's  Urelhronicter,  open  and 
cl(«e<l 

Conical  bulbous  Bougie    . 

Conicnl  bulbous  Ciitheler 

Catgut  Bougie  bent  to  Shape  of 
Stricture  .... 

Thompson's  Stricture  Expander 

Holfs  Dilator    .... 

Liincettrd  Stylet  for  Division  of 
Stricture         .... 

Otis's  Dilator  and  Urcthrometer 

Berkeley  Hill's  Diliiior  and 
I'reibnilome 

Civiiile's  Urethrotome 

Syinc'.'iStiiflTor  IVnn'nil  Section 

Civiale's  Uri-tliroicinic  for  Strict- 
ure of  tiio  Orifice  nioditied    . 


PAOB 

967 
967 
968 
969 

969 
970 
970 

970 

974 
984 
980 

989 


992 

992 

992 

992 
995 

995 

1018 

1019 
1022 

1028 

1026 
1084 

1034 

1047 
1047 

1047 
1050 
1050 

10.50 
1052 
1052 

1052 
105!) 
1059 


1060 
1061 

1062 
1063 
I0'>4 

]0fi6 


XXVlll 


LIST   OF    ILLUSTRATIONS. 


1080 

1080 
1082 
1088 
1088 
1083 
1083 

1064 

1084 
1086 

1090 

1090 


na.  I'Anis  '  via. 

986a.  Another  Form   of    Bistoiirie  963 

Citchde 1066 

987  Seat  of  Puncture  through  U&v-  964 

turn  in  case  of  Stricture  1072    965 

988  UrethroplHstjr :  N^lutou's  First 

Method  ....     1080:966 

989  Urethroplaijty  :  N^latun's  Sec 

ond  Method  ....     1080 

940  Urethroplasty :   Clark's  Opera 

tion:    First  Slai^o  . 

941  Urethroplasty:  Clark's  Opera 

tion  :  Second  Stage 

942  Duck-billed  Speculum      . 

943  Angiilnrly  Curved  Knife 

944  Angularly  Curved  Knife 
946  Hollow  Suture  Needle      . 

946  Sims's  Catheter 

947  Bozeraan's  Button  Suture:  Ap- 

plicution  of  Plate 

948  Bozeman's  Button  Suture:  Ap- 

plication of  Split  3hot  . 

949  IrriUted  Congenital  Phimosis 

960  Clover's  Circumcision  Tourni 

quet;  Open   . 

961  Clover's  Circumcision  Tourni 

quet:  Shut    . 

962  Instrumentforholding  thePre 

puce  in  Circumcision 

968  Circumcision  in  the  Adult 

964  Sloughing  of  Prepuce  and  Pro- 
trusion of  Olans    .  1091 

966  Reduction  of  Paraphimosis      .     1092 

966  Incision  in  Operation  for  Para' 

W>himoais         ....     1092 
arts  onOlansand  Inner  Sur 
faoe  of  Prepuce     .         .         .     1098 

958  Fibroid  Tumor  of  Penis  .        .     1094 

959  EpiiheliomH  of  Penis       .  1094 

960  Elephantiasis  of  the  Scrotum  ,     1098 

961  Double   Hydrocele    constricted 

oppoMte  oxtemal  abdominal 
nng,  and  thus  eimuluting  in- 
guinal hernia  1105 

962  Hydrocele  of  Tunica  Vaginalis, 

laid  open        ....     1107 


967 
968 
969 
970 

971 


972 
973 


974 
975 


1090 
1090  1  976 


977 
978 
979 


980 

981 
962 
988 
964 


DiiisoL'tion  of  a  Hydrocele,  to 
show  coverings       .  1107 

Tapping  in  Hydrocele  1108 

SperuiutoKa  from  Encyted  Hy- 
drotelo U12 

Haimatocele  with  thickened  Tu- 
nica Vaginalis  and  adherent 
Fibrin 1114 

Iron  pin  for  Treatment  of  Vari- 
cocele     1117 

Needle  threaded  with  Silver 
Wire  for  Varicocele  .     1118 

Vidal  's  Operation  forVaricocele, 
Needle  and  Wire  applied      .     1118 

Vidal's  Operation  for  Varico- 
cele: Wire  twisted;  and 
Veins  rolled  up  .        .     1118 

Vidal's  Operation:  appearance 
of  needle  and  wire  when  re* 
moved 1118 

Hernia  testis  (Benign  Fungus)     1120 

Tubercular  Testicle :  naked-eye 
section  through  Epididymis 
and  Body       ....     1121 

Tubercular  Testis:  Microscopic 
Structure  1123 

Syphilitic  Testicle  (Gumma- 
tous): naked-eye  section       .     1126 

Syphilitic  Testicle:  Microscopic 
Structure       ....     1125 

Cystic  Sarcoma  of  the  Testicle     1127 

DivisionoftheCordinCastration     1180 

Encephaloid  Testicle,  with  Hy- 
droceles of  Tunica  Vaginalis 
and  Cord  .1181 

Syringe- Catheter  for  applying 
Cuustio  to  Urethra  1136 

Cylindrical  Vaginal  Speculum     1188 

Branched  Vaginal  Speculum    .     1188 

Bivalve  Vaginal  Speculum       ,     1186 

Incisions  for:  Ligature  of  Ex- 
ternal Iliac  (Abemethy's  and 
Cooper's);  Abdominal  Ne- 
phrectomy ;  Ovariatomy  ; 
Gastrostomy  ....     1 160 


SCIENCE  AND  ART  OF  SURGERY. 

DIVISION   FOURTH. 
DISEASES  OF  TISSUES. 


CHAPTER  XXXVri. 

SURGICAL  DISEASES  OF  THE  SKIN  AND  ITS  APPENDAGES. 

The  rarious  specific  cutaneous  affections,  such  as  eczema,  scabies,  impetigo, 
acne,  lepra,  psoriasis,  etc.,  probably  fall  within  the  province  of  the  Surgeon, 
and  are  commonlT  treated  by  him  in  practice;  but,  as  the  consideration  of 
theae  diseases  would  necetearily  lead  into  the  whole  subject  of  Dermatology, 
the  limits  uf  this  work  would  not  allow  me  to  discuss  so  extensive  and  special 
a  branch  of  Surgery;  and  I  must  therefore  content  myself  with  the  con- 
sideration of  some  of  thoee  affections  of  the  skin,  which,  requiring  manual 
awi«taiice,  may  perhaps  be  more  properly  looked  upon  as  within  the  scope  of 
the  present  Treatise.  These  diseases  may  be  considered  under  the  several 
headji  of  Diseases  of  the  Skin  itself,  including  the  various  forms  of  uon- 
malienaut  ulceration,  and  the  malignant  ulcers  and  tumors,  and  Diseases  of 
the  Appendages  of  the  Skin,  as  the  nails.  We  have  already  in  Chapter  VI. 
<*■  n.-iilt?reti  the  ordinary  non-malignant  ulcers  of  the  skin,  and  in  Chapter 
XXXIV.  some  of  the  simple  tumor?)  that  occur  in  coimectinn  with  the  tissues; 
Mf-  f  hal  I  here,  therefore,  c<)n9ider  only  the  Diseases  of  the  Ap{)endages  of  the 
Skin  and  the  Malignant  Ulcers  and  Tumors. 

mSEASEJ'  OF  THE  APPESDACJKS  OF  THE  SKIN. 

DisEASii*  OF  THE  Naiij". — The  nails  may  become  diseased,  asthe  result 
■•{  m*-<-hanical  injury,  or  as  a  part  of  some  general  cutaneous  aflection;  they 
may  'Utft-r  from  inflammation  of  the  matrix,  or  may  grow  into  the  soft  tissue 
■  ■i  ibf  iiiej, 

A  vi'ilent  blow  or  pinch  oflen  partly  loosens  the  nail  and  causes  an  extrav* 
UA:i<iii  of  bliNwl  beneath  it.  It  then  becomes  black  in  color  and  slowly 
•rjiarati-i".  Xo  treatment  is  required  beyond  protecting  the  injured  part  by 
-jCDe  ctiuvenienl  covering. 

Id  w>me  broken  states  of  health,  and  especiallv  in  persons  suffering  from 
■^[iiamous  lUfezee  of  the  skin,  the  nails  occasionally  become  blackish  or  dark- 
bniwn  in  c>>l<>r,  are  ru^ed.  dry,  and  cracked,  scaling  ofl',  as  it  were,  without 
tay  apparent  affection  of  the  matrix.  This  condition,  of  which  I  have  seen 
•rveral  in«tADce«,  id  best  cured  by  a  course  of  alteratives  or  tonics,  the  dis- 
*»«  yiflrling  aa  the  general  health  Iwcomes  improved.  Arsenic  will  often 
>  f-^uoil  of  great  servicei  either  atone  or  with  mercury. 
v.jL  II  —a 


HI 


SUROICAL    l/ISKASSS    OF   TBB   SKIN. 


Onychia  h  odiiwtawof  the  nailtt  ilependent  ott  inflflnmialioD  of  tlie  r 
it  oceurc  under  two  foriiiH,  the  »itnp{e  and  the  epecljic, 

lu  Simple  Onychia  llierc  ar«  redness,  heat,  uiid  enelline.  ii»u»lly  do  one 
eidc  of  iht'  iiiiil,  itud  in  the  Hu^\e  ul'tho  tii>«uf>  in  wLich  it  is  iui[iliiuu-d  :  there 
ie  dinchargc  ot'  pus,  and  the  usil  gmdually  looseus,  becuiiiai  ilark-ctilortxl, 
somewhat  ehrivdlcd.  and  may  Qvcntuslly  bv  tiirown  off,  a  new  tiail  making 
iu  appearance  betuw,  which  vituniouly  Heauiues  a  samewliat  thickeood  and 
rugircd  shape.  This  disease  ueualiy  reujJig  fruii)  iligfat  de^refs  uf  violeaoc, 
an  tTie  running  of  thorns  and  epliuteni  into  the  fingera. 

The  treatment  cnnHiHts  In  cutting  away  any  part  uf  the  nail  thai  becnraes 
lorae,  (to  that  no  dischargw  may  nri'uniiilute  buneath  it.  Tht>  inAaraniatiun 
may  be  Buhduet]  by  hot  moist  appliralions.  In  >H)ine  eaant  ii  lotion  conipfjfled 
of  li<].  plumb,  snlmcetnlin  jw,  reiTCified  apiril  ,^j,  and  wiLlcr  to  one  pint,  will 
be  ffiiind  nioHl  pffit-aoious. 

Syphilitic  Onychia  is  a  more  serioui)  affection,  and  is  often  dependent  oo 
injiirii^  iiillictcd  on  the  fin^r  during  cntii'titutitinal  «y|ihili9.  In  it  a  iloKky- 
reil  or  livid  in  tin  munition  tnkpj  plncf  at  the  Rides  or  mot.  of  the  nail ;  ulcera- 
tion is  set  up.  ncrunipfliiieil  by  the  diiifharffe  of  tanioofl  and  very  Ji-iid  pus; 
nnd  large  lcx>w  gmnulaiiong  spring  up  at  its  r(»ot  and  «do«,  m  ihm  the  end 
of  the  toe  or  finger  that  is  affectM  (and  this  is  mn#t  cunmionly  either  the 
erewt  Ikk-,  the  thumb,  or  the  index  finger)  Wcomea  greiitlv  enliirged  and 
bulhuus  in  »hnpe.  The  nail  then  shrivels,  becomes  brown  or  Idack,  and  peels 
off  in  atrijw  ( Fig.  415} ;  after  its  separation,  thick  epidermic  mnme«,  forming 

abortive  attempt*  al  the  production  of  a  new 

^^^^^  nail,  may  dewlop  al  the  bn««  and  vidva.     In 

^^^^^^       ■.  I  the  TttainxKni,  both  local  and  cutt»tituti>Hial 

^^^B  1^       \         means  are  n-tiuired.     The  fi/st  and    moel 

^^^^m  ^DflB^^      esaeutial  )H)iut  is  to  Ttwmt  the  naii,  either  in 

^^^9  ^^S^^B      whole  or  purl,  fur  it  acts  as  a  fon-ign  body, 

jF      W  ^^^^V      and  prevents  the  healing  ai  the  surface  from 

nbicli  it  springs:  the  ulcvr  may  then  be 
trcutinJ  niih  ioiluform  or  well  rubh^l  with 
the  nitrate  iif  eilver.nnd  dreewd  with  black 
wash.  Coltes  reconimenils  fumigaliug  it  with  a  mercurial  candle,  maile  hy 
melting  a  drachm  of  cinnabar  and  two  ouoom  of  white  wax  t^igelher.  The 
coustitulwnaf  treatment  is  that  of  syphilis.  Sir  A.  Cooper  recommends  onlo 
mel  and  opium,  but  t  havi!  generally  found  bichluride  of  mercury,  irilh 
earsBpnrilla  or  rinchona.  the  most  useful  reme<ly. 

Ingrowing  of  the  Hail  is  an  extremely  painful  and  troublesome  aflection, 
principally  iK-ciirring  in  the  great  toe,  nnd  brought  about  hy  wearing  pointed 
shoes,  hy  which  the  siden  oi'  the  soft  'part  of  the  toe  arc  preaeed  u|^Hin,  and 
made  to  overlap  the  edge  of  the  nail.  An  ulcer  here  fornm,  the  liability  to 
which  is  greatly  increased  by  the  nail  being  cut  B<)uare,  so  that  the  tlesh 
preaaca  ofainst  a  sharp  and  pMJocting  corner  •*{  it;  thiri  ulcer  «ecrelca  a  fotid 
aanioua  discharge,  ami  large  granulations  are  thrown  up  by  It.  The  caiiae> 
r|uen(w  is  innhllity  to  walk  or  even  stand  with  omfort. 

TVcfilmrtil. — Id  thu  very  early  stage«  before  ulceration  has  taken  plaoe. 
further  (rouble  may  often  l>e  prevented  by  vcrnping  the  nail  ilown  along  ita 
middle  with  a  piece  of  l>rok<'i]  giam  or  a  knife,  till  it  is  atraut  as  thin  as  a  snevt 
of  note  paper.  At  the  enme  lime,  its  free  end  should  be  cut  short  id  the 
middle,  and  ita  coriien^  altoned  to  gn>w  well  beyond  the  matrix,  ao  that  tbt 
nalurni  edge  of  the  nail,  and  not  a  sharp  angle,  ahall  be  in  contact  with  tin 
9ofl  parts.  W'h«n  thv  tofi  parts  begin  to  overlap  the  nail  rarions  plana  hftva 
been  deviar^l  with  a  view  of  raising  the  edge  of  the  nail,  and  prcauitt  uicte 
the  aofl  stnioturea.     I  have  never,  however,  seen  much  pemuiuent  Iteoefil 


Fif.  416.— Sypbililitt  Onjrohia 


LUPUS — VABIBTIKS.  35 

muU  from  an^r  of  these  means ;  and  the  only  method  that  is,  I  think,  really 
servicvable  to  the  patient,  is  the  removal  of  the  whole  naii.  As  this  opera- 
tiiia  u  an  excessively  painfut  one,  the  patient  should  be  ansesthetized  with 
oitroQS  oxide,  or  the  matrix  should  be  rendered  insensitive  by  the  ether- 
sprmy.  The  Surgeon  holds  the  diseased  toe  in  bis  lett  hand,  ana  then,  run- 
ning  one  blade  of  a  strong,  sharp-pointed  pair  of  scissors 
uoder  the  nail  up  to  its  very  root,  he  cuts  through  its  whole 
length,  and,  removing  the  scissors,  seizes  first  one  half  and 
then  the  other  with  a  pair  of  dissecting  forceps,  and  twists 
tbem  away  frum  their  attachments.  The  surface  left  is  still 
covered  by  the  deeper  layer  of  the  epithelium,  and  becomes 
covered  with  a  dry  layer  of  cuticle  in  a  few  days.  The 
back  of  the  sciflBors  usually  wounds  the  matrix  in  the  mid- 
dle line,  and  here  granulations  may  form.  The  new  nail 
f-ows  straight  and  oeatttiy.  In  sonae  rar«  cases,  however, 
have  seen  a  fwulty  direction  assumed  by  it.  If  this  should 
happen  the  nail  must  be  again  removed,  and  the  matrix  Fig-  4ifl.~-Hjper- 
diasected  awmy.  Avulsion  of  the  toe-nail  is  usually  unat^  trophy  ^nd  De- 
tended  by  danger.  I  was,  however,  once  called  upon  to  rortnuj  or  To*- 
amputate  a  foot  for  gangrene,  which  had  followed  the  oper-  >>ftil. 
atiatii  performed  on  an  elderly  person. 

Htpertbophy  of  ToE-NAiL.^Occaeionally  from  neglect  the  toe-nail 
mar  become  enormously  hypertrophied  and  twisted,  looking  more  like  a 
bom  than  a  nail,  as  iu  the  accompanyiog  drawing  (Fig.  416),  taken  from  a 
pstieDt  in  whom  the  nail  had  been  allowed  to  grow  uucut  for  twenty  years, 
pffTtducing  complete  lameness.  I  removed  the  nail  whole  by  avulsion,  and  a 
soand  and  useful  foot  resulted. 

DIBEABES  OF  THE  SKIN. 

Ll'PUB- — Under  the  terra  fupiu  various  affectioDB  of  the  skin  were  formerly 
included,  having  but  little  in  common  with  each  other  beyond  running  a 
cbrvoic  course  and  leading  to  destruction  of  the  cutaneous  tissues,  with  or 
without  ulceration.  It  is  now  limited  to  two  diseases  which,  although  in- 
rludtd  under  the  common  name,  are  iu  reality  quite  distinct.  These  two 
auctions  are  distinguished  aa  Lupus  Erythematosus  and  Lupus  Vulgaris. 
When  the  terra  lupus  is  used  alone  it  is  applied  only  to  the  latter  disease. 

Lnpns  Erythematosnt. — This  disease  was  originally  described  as  a  disease 
of  the  sebaceuua  follicles.  Hebra,  in  1845,  gave  it  the  name  of  Seborrbcea 
CitDgestiva.  It  is  now  generally  known  by  the  name  of  Lupus  Erythema- 
Daiid.  It  consists  essentially  in  a  chronic  infiammation,  affecting  chiefly  the 
H-baceous  follicles  and  the  tissues  immediately  surrouudtng  them.  There  ie 
ID  increased  secretion  of  sebaceous  matter  from  the  follicle  by  which  the 
arini  of  the  gland  become  dilated  and  the  duct  widened.  The  parts  imme- 
diately surrounding  the  follicle  show  the  ordinary  signs  of  chronic  inflam- 
mation, the  capillaries  being  dilated  and  the  tissues  infiltrated  with  small 
piuod  celts.  The  disease  terminates  iu  destruction  of  the  follicles,  and  the 
rbp>nic  inflammatory  pnxlucts  partly  degenerate  and  are  absorbed,  and 
partly  become  developed  into  cicatricial  tissue. 

Tb«  dii>ease  commences  as  a  sharply  defined  red  patch,  the  color  of  which 
didppMirs  almost  entirely  on  pressure.  The  redness  is  most  marked  round 
the  orifices  of  the  follicles.  The  spots  may  be  isolated  or  in  groups,  and  vary 
in  ftiw  from  a  pin's  head  to  a  split-pea.  The  patch  soon  becomes  covered  by 
an  ailberent  scale,  which  is  greasy  to  the  touch.  If  this  be  removed,  it  is 
f'^und  to  be  continuous  with  the  plugs  of  altered  sebaceous  matter  filling  the 


M 


SCBOICAL   DI8BASK8   OF  THE  SKIt(. 


dilati^  dui-lK  nf  tlif.  fiAWcl^.  Tbe  patches  itch  eJightly,  but  are  not  nctualljr 
pniaful.  Aft  ih«  diecssc  Bilvnnvcs  the  8poi«  slowly  iacrrase  in  size  m  tb* 
cireuiDfereucf,  while  the  cciUrnI  tmrte  l>u»roe  paler,  fligbtlr  depresieO,  aod 
ciratricial — the  ihio  »PBr-(ucue  W-ing  drv  like  piircJiiiMDt  and  oUen  scmly. 
Tticru  it  uu  icDdcncy  to  iuppuratixii  or  iilcpmtion.  Another  and  leaa  oon- 
num  varietv  oi  the  iliHcafc  is  descrilK-d.in  «hii'b  it  ixnamences  as  numennia 
dincrctir  siiots,  and  tprcads  hy  the  apm-arauce  of  frvsh  patchw,  rothor  than 
by  extenmon  fmiii  a  single  ccuirr.  Lupus  cn*lhpmnii«u8  it  m<«t  eomnion 
no  the  elit-ekfi.  It  may  iiccur  ntsu  on  the  van,  lips,  sralp,  am)  ihp  Imclu  of 
the  hands.  The  dtaraae  rnns  an  exirvuifly  chrDoic  Limrae,  ofi<-o  lai^iing 
inaDy  years,  and  raiisiog  great  disfigure  men  t.  It  has  a  gn>ai  tcndi-ncy  to 
relapse  after  amtan^nt  cure.  Attarks  uf  errsipelas  are  ont  UDroinmon  during 
its  iirncn^m.  The  cause  is  unknown.  S'o  diatiuct  connection  has  been 
traced  uelweim  it  and  MTnirula  or  xyphilis,  and  it  is  not  brn^diinry  nor  ctm- 
laffions.  It  comnienccs  wually  in  youny  adult  l)f«  af^r  lh<>  rightrcnlb 
yenr.  and  is  nio>tL  ntmnion  in  wonjfD. 

TWntinf^il.  —  'Sn  drup  f  itertJi  aur  ipwlfie  itiflurnce  on  the  disease,  and  iho 
eomatilutional  treatment  consistit  therefore  merely  in  atteudini^  to  iho  ^'eneral 
health  on  ordinary  principles.  Locally,  Kaposi  states  that  be  has  fimiid  Lbe 
attplienti'in  of  Kmplastniin  Hrdrarfjyri  the  mn»t  efficient  mode  of  treatment. 
The  iurfacu  mnv  l)e  cleaned  bci'orc  it^  n])plicaiion  bv  being  tnieare<1  with  oil 
and  well  washed  with  soil  soap.  The  plosler  should  be  spread  ihiekly  on 
thin  linen,  and  changed  dally.  Strong  caiiatica  are  not  to  be  reconimcuded, 
and  the  results  oinnined  br  the  application  of  sajx'rticial  e«i'harolirs  have  nut 
been  very  encourn^inj;.  t*iiinting  with  iiMiiuc  als(>  has  been  recomnieuded. 
It  excitet>  a  certnin  dcf^rei?  of  intlitmniation  atU-r  u  tew  applications,  in  cun- 
se<^iien(-e  of  whivb  the  »i;bu('t-<)iia  plug»  in  the  ducts  itf  the  fullicleM  si>eiu  to 
bet-onie  softenwl  iin>l  discliiirgc*l,  thus  caiisinf;  tenifmrHry  ini|ir<ivemeiit. 

Ltqini  Vulgaris  or  Lupni:  Pathological  Appearances,  —  TIuh  diMease 
criiiiinem>^  in  llip  deep  lavor  ul"  tin'  Liilij'  vera.  In  its  carlicat  nta^e  circular 
accumulntimtsnf  tnmll  n*und  cells  are  seen  displacing  the  bundles  of  Hbroiis 
tUeue.  The  surrounding  vessels  ore  dilnti>d,  and  neir  capiliariia  exbl 
auiungst  the  cells,  nnd  ttins  the  mtdule  resembles  in  stnicturo  ordiuarr 
grauulation-linuc.  Tlicoe  circular  mn>«c«  of  cells  gradually  incr^nio  iu  Bite, 
and  by  their  preaenre  destroy  the  lisstiv  of  the  trne  skin  and  thus  approitrh 
tbe  surface,  until  at  Inst  the  papillary  layer  is  impltcnted  and  the  new  gruwtli 
is  covered  merely  by  the  epithelium.  Utiring  this  pntccw  ncigbburiug 
groups  of  cells  cidesce,  nnd  prucewes  of  eel!  infiltration  extend  along  the 
vesMTls  and  surround  the  hair  bulbs  and  fulliolM,  so  that  in  ita  fully  dcvelowHl 
itagc  a  lu|>t>id  tubercle  cmsisu  of  an  inSltrntion,  nnd  more  nr  1c»  complete 
d^^trurlton.  of  the  ntirnml  tissue  of  tbe  akin  from  the  papilla.'  lo  the  sub- 
cuuinf.>iis  fat.  On  exaniiuing  a  Bwlti»n  of  n  folly  developed  patch,  non- 
vascular uodulrs  c«rop<wed  of  a  giant  c«ll,eurn>unded  by  Inrger  "epithelioid" 
cells,  and  "gni"  hy  cnliunr)-  lymph<iirl  or  BniHli  round  cells,  will  alwa^'s  be 
met  with.  These  me  identical  iu  np|>enrniut  with  tbe  n'Klule?  of  gray  grann- 
Iatian.H,  a  fuel  wtiicli  has  Id  some  jmlhologiKis  to  regard  lupus  os  a  toral 
tnbcfculoais  of  the  akin  ;  hut  (bio  virtr  if;  not  generellT  accepted. 

After  a.  poteh  of  ti)pi>&  has  n.'ach«H)  its  full  devetopnipnt,  retrogresalT* 
chmiyi-s  take  place.  These  may  be  of  two  kinds.  In  the  fiwt,  some  of  tl»« 
icelU  mnv  become  cloudy  frjm  fatty  dcKcnrration,  brnik  up, and  be  ahsorbMl, 
while  a  development  of  cicatricial  fibrous  vame  takes  place  from  the  re< 
maindrr.  Thus,  tbe  prucen  comes  to  an  enil  without  ulceration,  nnd  a)thou)ch 
the  rpithelial  <-«iveniig  has  been  lhntui;hout  ininct.  a  scar  rraalu  rimilar  m 
aPiNrarnoce  ti>  ilial  caused  by  a  superficial  burn.  When  the  diaeaae  lakra 
curse.  It  is  described  as  non-u/ceraft'iK  tupu*,  Ivput  non-errdnu,  or  iujntt 


LUPUS — STHFTOUS    AND   CAUSES.  S7 

fxj-jliaticui  (Kaposi).  In  the  second  form  the  futtr  degeneration  afTects  the 
whole  v(  the  cellular  maaa,  which  then  softens,  the  cuticle  coveriog  it  U 
thrown  off,  and  the  disintegrated  caseous  mass  is  discharged,  leaving  an  ulcer 
whiL-h  may  slowly  extend.  The  disease  is  then  known  as  uieerattve  lupus, 
lupus  exedens,  or  lupus  exuleerans.  These  two  forms  are  therefore  mere  modi- 
ficatioDB  of  one  process;  the  fat«  of  the  new  growth,  whether  it  is  absorbed 
without  ulceratiou  or  whether  it  soflens  and  is  discharged,  being  due  to  acci- 
deDUi,  local,  or  constitutioosl  conditions,  the  nature  of  which  cannot  in  all 
CMies  be  deterniioed. 

SfjRpioms. — Lupus  cuinmences  iu  the  form  of  tubercles,  buried  iti  the  skin. 
Tb«r  are  separate  fn>m  each  other,  and  arranged  in  groups,  or  sometimes  in 
invjrular  circles.  At  first  they  form  red  or  reddish-brown  patches,  from  a 
Hoc  to  a  quarter  of  an  inch  in  diameter,  which  are  not  raised  above  the  sur- 
face. The  tubercles  continue  slowly  to  develop,  till  after  some  weeks  they 
become  slightly  elevated,  and  covered  by  a  fine  branny  epidermic  desquama- 
tioa.  Several  patches  may  coalesce,  forming  larger  tubercles,  and  at  the 
tame  time  new  patclies  appear,  so  that  all  stages  of  development  may  he 
obaerred  at  once  in  the  same  case.  At  this  point  the  two  forms  of  the  (liaease 
diver^^  In  Lupus  nov-exeden$,  the  tubercle  becomes  paler  in  color  and 
trraduallv  shrinks  and  disappears.  The  integument  which  has  been  atfected 
by  the  disease  may  he  in  one  of  two  states ;  it  may  either  continue  red,  irri- 
uble.  and  branny,  having  the  appearance  of  a  thin  cicatricial  tissue,  and  in 
this  way  the  greater  part  of  the  whole  of  the  face  may  be  affected ;  or  it 
may  leave  a  firm,  white,  smooth,  and  depressed  cicatrix,  exactly  resembling 
that  produced  by  a  burn,  along  the  margin  of  which  the  disease  slowly 
spreads,  in  the  f4irm  of  an  elevated  ridge  composed  of  soft  bluish-wbite  or 
rcwldtsh  tubercles. 

Id  lupu«  exedens,  instead  of  disappearing,  the  tubercles  become  pale  in 
Color  and  softened  ;  the  epithelial  covering  separates,  and  the  disintegrated 
rbecsy  mass  mixed  with  some  pus  is  discharged,  and  drying  on  the  surface 
t'-frms  a  scab.  This  process  may  be  accompanied  by  considerable  intlamraa- 
tioD  of  the  skin  surrounding  the  lupoid  patches,  with  heat,  swelling,  and 
TKtio.  When  the  scab  separates,  an  ulcer  is  seen  beneath.  It  is  sharply  de- 
rl:ie<l.  with  slightly  niiseil  edges,  and  usually  a  smooth  red  surface  which 
i>U-e<ls  readily.  This  sore  may  gradually  extend  both  superficially  and  in 
.ir[«ih.  and  when  seated  on  the  nose  often  leads  to  destruction  of  the  alje  and 
miumna.  Lupus  vulgaris  seldom,  however,  spresuls  very  deeply,  although 
iirz-!  art-as  of  skin  may  be  affected,  and  the  most  fiightful  delurmity  result. 

.<iUi'itlan. — Lupus  may  occur  on  any  part  of  the  body,  but  it  is  far  more 
.•..-omMnly  met  with  iu  the  lace  than  elsewhere.  The  nose  and  cheeks  are 
tiiv  pttrt.-  of  the  face  usually  attacked.  It  miiy  commence  un  mucous  mem- 
l<ntii««.  hut  most  commonly  reaches  them  by  extension  from  the  skin.  It  is, 
liowcver.  c.K'cn!iiiinally  met  with  as  a  primary  disease  in  the  pharynx  and 
larviix.  It  then  usually  assumes  the  ulcerative  form,  and  may  lead  to  ex- 
itii.-iv**  dt^trurtion  of  the  mucous  membrane. 

SrjT  -iii'l  Aiju. — Lupus  vulgaris  occurs  altnost  with  equal  frequency  in  the 
tK')  itxe*.  It  Ix-gins  m(«t  commonly  in  early  life,  "  rarely  before  the  third 
vf^r  and  slni'<st  never  af\er  puberty"  (Kaposi). 

i  •iMftlieatioM'. — Bevoud  the  deformity  caused  by  the  contracti<m  of  the 
tt-nrf.  the  di««ase  itself  causes  no  serious  cunsetpiences.  ^Vs  a  rule,  it  in  no 
"  IV  atf<-cts  the  general  health.  Erysipelas  not  unoomiiionty  attacks  the  <Us- 
tiiMfil  ourface,  and  cases  have  been  recorderl  in  which  epithelioma  has  arisen 
fr-m  the  scan'. 

CauM. — Until  recently  it  was  universally  assumed  that  lupus  owed  its 
-rijcin  t<>  a  scrofulous  taint  in  the  constitution,  and  possibly  sometimes  to 


88 


BCBOIOAT^   niBIASKS   OF   THE   9EIK. 


)uhi'rilv<l  syphilw;  but  at  the  preKtit  tira«  moat  autliuntiei  «re  uf^Tt-c-d  lliat 
ahlidugl)  Will  these  views  may  bu  irue  uf  siinie  CMes,  vvl  in  the  great  ma- 
jorily  iir)  eviilenre  ie  forthciimiDg  tu  justify  them.     Tbc  (liseoBe  a  not  bemli- 
tAry  nutl  is  nut  coiiimunicnhle. 

FrognosiB. — Lupus  is  cbaraclemed  by  its  alow  ctxiree,  ami  ito  t«ii(l«)rr 
Lu  relH|iw  after  appnrcut  arreet ;  it  is,  however,  never  directly  ratal. 

Diagnoiit. — Tlie  dingnoek  ie  not  always  easy,  the  cHmi^bbc  lieitig  especially 
apt  to  be  euiifouDde<]  with  etnue  fornis  of  Inipetigo,  with  Icrtiarv  ^vphilitlo 
ult'eralioDs,  with  nident  ulcer,  and  with  oaiu'er.     From  itnprlitjo  it  tnnv  ba 
distio^idied  br  the  nbAence  of  puetulr^,  an<i  of  the  iLirk  gummy  crtivtii 
charaeteriMic  of  that  aflecti'^n,  as  well  an  by  the  le«s  cxtctil  dC  «urfin."p  im- 
plicated,    from  trrtmiy  «t/phiUtic  ulrfmtionJ>,  r^ptf'mWy  from  <in)^fnin(;  cula- 
neous  guninmla,  it  i^  uAeu  very  difficult  to  distififjuiith  it.     The  hintury  of 
th«  disease,  the  age  of  the  pMt'ient  at  th«>  tlmo  of  inviuioii,  nod  the  more 
rapid  progress  of  the  flvphifttic  aflectiou  will  usually  ettnbli;  ihu  l^ur^von  to 
make  a  correct  diaf^nosU.     From  uptamotu  epilhe/ioma,  it  \«  UMially  ilititiR- 
gu*nhed  with  «a»e ;  io  lupus  the  tuherclec  are  nunien>uH,  and  there  are  luooy 
centrcv  of  ulcersttott,  Lhe  glandc  are  Kldom  enlarged,  and  the  disease  cooi- 
mencM  in  early  life;  iu  cancer  the  primary  dtwaae  is  single,  the  glands  ar« 
early  aSected,  the  discaw  commeuece  after  middle  life.     Id  lupus  the  uleer 
is  flat,  with  sharply  cut  ed>Ee« ;  in  cancer  it  is  rugged  and  irregular,  nith 
hard,  elevated,  and  everted  edges.     Tbe  diiguuna  from  rodent  difrrr  nill  be 
^iveii  with  thai  disease. 

Trmtmeat. — The  evm/iiutimuii  trfatmtnt  of  lupus  waa  formerly  considered 

of  much  inipiirtADce.     Cud-liver  oil,  the  iodides  of  potnpj^ium,  mercury,  um) 

Offcnic,  either  alouL'  ur  combined  wilh  various  other  uru};e.  have  bevii  cn'diUfl 

with  a  curative,  or  at  tvu^i  n  beneGcial  influence  on   the  diseniae.     At   the 

present  lime  when,  hy  more  extended  clinical  ol>ecrvatiuu,  simple  scnifuluun 

itvf  and  tertiary  Kvphiliiic  ulcerations  have  lieen  clearly  rii»!iiuguiithed  from 

lopuc,  ihe  efficary  of  dru;js  in   the  treatment  of  the  iliaciisi*  ha»  been 

found  to  b4-  mnrh  let-s  than  whs  once  supposed.     Kapi«i  slater  that  no  drue 

exi-rL«  any  deBnitr  itprcjfic  influence  un  the  progress  of  Uie  disaisc.     H(ill, 

IjM  lupii»  frtt|u<'4itly  oecurs  in  patients  who  are  in  feeble  lieolih,  nnnniic  or 

[^roful'tus,  constitutionnt  trrHtmeut   must  on  Do  aecuuut  Iw  neglected  ;  fur, 

»lth<HiKh  <\rugB  mayoxerl  no  9[)eeifiu  influcDce,  il  is  evident  tliut  by  improv- 

[tiiu  the  geuenil  hcnlih  th<^y  will   promote  the  henling  of  the  ulcent  and  so 

I  lend  to  diminish  (he  iirvfrttv  of  the  disea-ii--.     Tht-  dii-t  should   hf  carrfully 

F regulated  and  nulritiriufi,iiDd  general  hygienic  eondiiiimfl  must  be  atti-iulfd  |o. 

It    is  on    thi-  f'-riil  tTtttlmenl   that  we    have   chiefly  to   rely,  and    |hr  ouiy 

f^ftlcifnt  III  :ii(iM>  by  whirb  the  morbiil  groivth  in  4»ntpli-tely  dcytniyen. 

'In  the  mi  '.  mm-tdivrative  liipun,  or  Jupuit  notfexeilciis,  mii  iittemtit 

niftv  however  In*  nimh'  I"  iirrt^l  the  diwane  without  ki'IuhI  di>iilrurti.<t)  of  tue 

vrontli.     Ykt  this  iMifjKiMe  mercurial  pln^ler,  |)«iiiling  ivilh  tincture  of  iiidiiie, 

bor  with  a  stTvog  9olutii>u  of  nitmlc  of  viilvtr,  xnd  tlie  applienliou  nf  xinc  or 

.rt......!..  ..r  I.  ■.!  ojiiiineut  Imve  been  sometime*  fouml  etheactuuv.     Ixitions 

'ii>  an,'  caiwciiilly  useful  at  they  prevent  the  surface  fnmi 
>■•  »»'l  narsli.  If  the  di«caec  be  situatetl  on  the  fave,  care  must 
III  aruid  exposure  toculd  winds. dust. etc.  Volkinann  recommends 
pun.Miixrn  •I'ariflcation  by  means  of  an  instrument  coiuihvc*)  of  several 
snaJI  bladts  set  cl<»>t<ly  l4»gclher.  The  object  of  this  trv^tmeut  is  to  obliterate 
Uw  tfols  and  thus  nrreat  thegronlh  and  promote  ahsurniion  of  thr  morbid 
pmllwUk  Mhould  thr^e  methods  fail,  the  only  h<i|>e  of  arrest  ciuijiistii  iu 
'  «  dlfiisetl  ii.H>^ii{>,  If  it  be  liuiiteil  in  exti-iit,  the  ]uiieb  nmy  be 
4  anfrfqueuily  the  cicatrix  becomes  proniiiicul  and  irregular 


RODENT    ULCER.  S9 

from  a  fibruid  growth  reaembliag  keloid.  In  lupus  exedens  destruction  of 
the  growth  is  the  only  treatment  which  holds  out  any  prospect  of  success. 
In  <k»ng  this  the  means  adopted  must  be  eflScient.  Feeble  caustics  only 
irritate  the  parts  and  i^ravate  thedisease.  The  growth  may  be  completely 
removed  by  excision,  by  scrapiog,  by  caustics,  and  by  the  actual  cautery. 

£xcinon  is  applicable  only  to  small  isolated  patches,  and  is  seldom  prac- 
ticable. Scraping  has  lately  been  found  of  great  service.  It  is  done  by 
meansof  "sharp  spoons  "  (Fig.  95,  p.  258,  vol.  i.).  The  brittle  tissue  of  the 
growth  is  easily  removed,  and  the  sensation  given  by  the  denser  healthy 
timues  beneath  shows  when  the  operation  has  been  carried  far  enough.  The 
bleeding  it  very  free,  but  is  easily  arrested  by  pressure  with  dry  cotton-wool. 
It  is  wiser  to  apply  some  caustic  to  the  scraped  surface  to  insure  the  com- 
plete destruction  of  the  growth.  The  caustics  that  have  been  used  are 
various ;  solid  nitrate  of  silver,  chloride  of  zinc,  acid  nitrate  of  mercury,  and 
filming  nitric  acid  have  all  been  recommended,  and  are  equally  efficient. 
The  actual  cautery  is  easily  controlled,  and  can  often  be  used  when  other 
cmostics  are  inapplicable.  In  most  cases  Faquelin's  thermo-cautery  is  the 
best,  but  in  deep  cavities,  as  the  mouth  or  nose,  the  galvanic  cautery  ia  more 
eanly  applied. 

If  when  the  case  comes  under  observation  there  is  considerable  intlamma- 
tion  round  the  patch,  it  is  better  to  subdue  this  by  warm  moist  applications 
belure  adopting  any  of  the  above  modes  of  treatment. 

After  the  growth  has  been  destroyed  healthy  grauulationa  spring  up,  and 
iht  sore  must  be  treated  on  ordinary  principles.  Vaseline  and  iodoform 
oiDtment  often  seems  to  promote  the  healthy  healing  of  the  raw  surface. 

However  successful  the  treatment  may  appear  at  first,  relapses  are  very 
common,  but  in  a  large  number  of  cases  as  life  advances  the  disease  seems  to 
become  less  acute,  and  finally  ceases  to  reappear.  The  cicatrix  that  forms 
after  lupus  is  healed  is  thin,  and  readily  breaks  down,  giving  way  on  ex- 
posure to  cold,  or  on  the  occurrence  of  constitutional  derangement.  The 
pUteot  should  therefore,  for  some  length  of  time  after  recoverv,  be  careful 
not  to  expose  himself  to  any  such  influences.  The  scars  often  lead  to  great 
deformity,  drawing  down  the  eyelids,  distorting  the  mouth,  and  sometimes 
c]<«ing  the  nostrils.  Various  plastic  operations  are  sometimes  required  to 
remedy  these  defects. 

RoDEST  1'l<-er,  Xou-me-tangere,  or  Cancroid,  was  formerly  included 
under  lupus  exedens.    It  is  one  of  those  remarkable  afiections  that  stand 
midway  between  simple  and  malignant  diseases;  being,  so  far  as  constitu- 
tional  causes  or  secondary  complications  are  concerned,  apparently  of  a 
simple  nature,  while,  to  a  certain  extent,  in  regard  to  structural  condition 
and  entirely  in  respect  to  local  effects,  it  is  of  a  malignant  character.     The 
diMaae  consists  essentially  of  a  malignant  growth  of  very  feeble  vitality  and 
slight  activity  of  development.     This  invades  the  surrounding  structures  and 
deMroTs  them,  and  in  its  turn  breaks  down,  disintegrates,  and  is  thrown  off, 
thur  oaui'ing  a  pnigressive  destruction  of  tissue.     The  disease  is  especially 
characterizes]  by  lie  stow  ]>rogress,  by  its  eroding  nature,  and  by  the  impossi- 
bility uf  healing  it  by  all  ordinary  methods  nf  treatment.     It  ia  esseutlally  a 
dtaea.-^  of  advanced  age,  seldom  beginning  before  45  or  50.     Its  duration  is 
Ld  any  given  case  indefinite  ;  seldom  less  than  five  or  six  years,  occasionally 
est*-ndiD>;  to  twenty  or  thirty.     It  affects  individuals  uf  either  sex  iudiscrimi- 
naiely  ;  and  usually  occurs  in  persons  who  are  otherwise  perfectly  healthy. 
The  b*»Uh  also  ia  not  influenced  materially,  if  at  all,  by  its  long  duration. 
I  have  seen  persoos,  who  have  been  victims  to  it  for  more  tl\pn  twenty  years, 
lo  apparently  rubiist  health.     But  it  is  eventually  and  inevitably  fatal,  uuless 
rnuoved  by  operation. 


« 


SXTKOICJLL   PISCASX8  OP  TBK   SXIK. 


U»m4-   An|i«uilo&, 


It  lU-avB  rrimmMM>M  in  ih*  »kiB.  oauttlly  on  henJlhy  iDtcgunitfiit ;  liat 
occutoitallr  it  primsrilTBiivctaa  fmrt  wbidiit  tht^amtof  •omoell^lnic^hilD|re 

o("  rtnirtur*,  lu  «  moJr,  a  wiirt.  or  n  »cnr.  It 
iTUir»fliK4  MivfMirlAf  the  hra<l,  faci',  or  ttx- 
IrvmtltM.  Tiirr  f«c«  »  tt«  iVAt  of  plmion, 
nprctally  in  the  upper  fnrtA,  itiich  *»  thr 
fin-hraif,  tW  oidi-  of  tlif^  nn«e,  tkft  ittD«r 
•n^tv  iif  tbr  v\f,  .>r  lh<»  U»mple.  ft  iipr<Mdi 
•imftlr  hr  nHiliiniitr  uf  IlMue.  ttt'vet  hy 
(|i.'wmin>tv<t  I1H.11I  or  by  i«m>itdarr  ilffwrnla. 
It  n<«r  Hiradt!  uH  tiw>ii««;  th*"  fik>ti  pri- 
tiiarily.  the  cartiittuv  of  tl)«  «Mr.  the  Iklan 
»ti<l  erptom  of  liiv  at*v,  lh«  p«riti<)  t;l«ad. 
t)if-  ciiajiinrtivii,  anri  Ihr'  t^rlmll.  K  ill 
njHTinllr  ilcetntctire  tn  brmr  whru  rnii'^  it 
Mliack«  it.  It  cTixlra  sa<i  phLs  iiwiiv  tlie 
b'lne,  mtlinul  rmrits  or  ncrrwi*.  It  mar 
pmrtmtc  tii  lite  durm  mater,  aod  iovadc 
th«  hmia.  It  prorresws,  howevrr.  bjr  pre* 
fi-rporr  5ti[K>rtirtnny,  not  in  drplb  ;  faeoea 
it  15  wlHoni  mtuQiled  ity  bfrnorrhnfitr  i-veo 
in  the  more  advanced  etopv.  Tlic  Dci^b- 
liorin;:  lymplinlic  ^tandtt  dn  n>a  b«<»«ia 
iniplirutfd.  nml  Fivondary  %-i«(vral  depoaila 
arfr  ntvrr  met  witli.  A»  th<-  ulri'ratiiMi  ex- 
tenrip,  thpr«>  18  i)fti<n  a  iL*o<Ittiry  to  iraper- 
fibrt  rimtriuiioti  im  one  margin.  «rhili*t  tbc  diwaae  b  making'  pntgrew  at  ibe 
'  nibiT. 

Ssrmptoma. — In  wbutiver  ••itimtion  it  Iw^iim,  tt«  fir^t  apppantuoi!  Ih  in  the 
eliHpr  'if  a  mbrnrk'  or  hard  pimpln  of  u  brown iph-ntl  rulor.  This  mtK-ri'le 
utn;mt<r«  kIokIv;  and  then  tJbi'  [ti:^4!iLS«  rxti.-ndi'.  Monre,  to  whom  viv  are 
indi^biAJ  fur  a  toii^l  lucid  BL-tiiUDt  of  this  terrible  Rffr^ixD,  Inya  c^peeial 
amw  oD  ita  eoiunifiicf  luent  in  a  bnnj  wart,  and  its  <xiutiuu«d  ^xtntBioii  by  a 
hard  niargiu.  Tbi«  ulo^rated  tubercle  becuiiii*  (Vivpred  Iwaacab;  but^  aa 
tliD  pntccn  of  dmructive  uleemtiou  progn»tM.  tb«  futn  b<>cotiic«  too  larj^  u> 
be  eovntd  Id  tbla  way,  and  an  nlcvr  is  left.    Tbin  ulcer.  whiL'h  >.>oti«Utute»  * 

the  di«ca«e.  nod  is  the  true  "  Luptu,  or  "  Noli- 
ttf  lunger*"  of  ibr  oWer  authors,  prairnta 
the  fuliuwiD^  L'barAfttira.  It  iit  always  «in|il«, 
iind  spread*  solely  by  couiinuity  uf  ii»*>w. 
Il  ii  doprt««ed  «lit;litly  beiutv  ibe  «url'fl4-v,  W 
of  a  palo  pink  calur,  witb  a  Ibmiwed 
tban  a  ]>ranulaliot;  *urfaM>,  rMuahtli^ 
iCi  furrowed  amootbneu  an  irre({ular  lBy«r 
of  pink  wax.and  ia  UBualW  (>ainlcaa,ez<«pi 
wbrre  ricntricing.  Itx  eijgea  are  aligbtly 
mined,  the  de);rce  varying  iu  diHerenl  macs 
and  ilcficndine  00  Hie  eli>«cD«w  nilh  wliiRh 
the  ■Wtriirtiuu  of  the  new  growth  IoIIoms 
i\»  devfloputent.  In  »om«  i-aww  the  two 
follow  eacli  (ttlier  »o  closely  that  the  ulcer 
aiifirnr*  to  In>  a  dimple  Iom  of  tiMiic,  »oarrcly 
anv  ihickeninp  of  | lie  v*\\^  boio);  ri't-f^'Jii- 
alile.  luijicrfwt  uttcmpis  at  i-ii-atriiuitiua 
IJbrni  II  jiv<Hiliiir  fcRtori'  of  the  iiKt-r.  At  unc  pari  of  ita  rtinrutii  it  ctraMW  to 
IirKail,  and  a  liiin  bloc  line  >d'  L-pitiiclluiii  ht'giiia  to  uleud  ov«r  the  raw 


V 


}, 


\ 


uf  M«Umi<1  Ci|io*uf**[  Dan  M«t«r. 


PATHOLOGY    OF    RODENT   ULCEK.  41 

Mirfac«.  It  DCTer,  however,  idvances  far;  before  loog  the  spreading  re- 
oomnwnces  at  the  edge  of  the  apparently  unaltered  skin,  and  the  thin  layer 
of  epitheliura  speedily  disappears.  This  attempted  cicatrization  is  never 
accompanied  by  any  contraction  of  the  Bore.  The  want  of  contraction  is  a 
very  peculiar  feature  of  the  disease.  If  half  an  eyelid  is  destroyed,  the 
remaioiDg  half  retains  its  normal  position  unaltered.  Consequently  signs 
of  contraction  may  be  taken  during  treatment  to  indicate  that  the  growth 
has  been  succesafully  destroyed  in  part  at  least.  - 

The  courae  of  the  disease  is  always  progressive ;  more  rapid  in  the  skin, 
more  slow  in  the  bones  and  leas  vascular  tissues,  as  those  of  a  cartilaginous 
and  fibroid  character — the  pinna  of  the  ear,  the  sclerotic,  and  the  septum  of 
the  ti««e,  for  instance.  When  it  attacks  bones,  it  penetrates  them,  and  sinks 
deeply  into  their  softer  parts.  Moore  has  noticed  that  the  morbid  growth  iu 
front  of  the  advancing  disease  is  always  most  clearly  marked  in  cancellated 
bone — in  the  diploe,  for  instance.  The  soft  parts  immediately  contiguous  to 
the  disease  are  perfectly  healthy  and  uninfiltrated  ;  and  there  is  never,  even 
after  many  years^jf  progress,  any  sign  of  secondary  affection  of  the  lymphatic 
glaoda.  Unless  the  progress  of  this  ulcer  be  arrested  by  treatment,  it  is 
never  interrupted,  but  will  terminate  in  the  death  of  the  patient.  This  fatal 
tennination  may,  however,  be  long  delayed.  The  accompanying  Fig.  418  is 
from  a  patient  of  mine  who  had  suffered  from  the  disease  for  nearly  thirty 
yeare,  but  who  was  to  alt  appearance  in  perfect  health,  although  the  skull  was 
perforated,  the  dura  mater  exposed,  and  the  pulsations  of  the  brain  distinctly 
visible. 

Sugnosis. — The  diagnosis  has  to  be  made  from  Epithelioma,  Syphilis,  and 
Lupu?.  The  distinction  from  ordinanr  epithelioma  is  oilen  at  first  difficult; 
but  in  the  later  stages  the  absence  of  glandular  affection,  the  small  amount  of 
growth  compared  to  the  ulceration,  and  the  prolonged  course  of  the  case, 
render  the  diagnosis  easy.  From  faWtary  typhilis  it  is  clearly  distiuguished 
by  the  duration  of  the  case  ;  in  syphilitic  ulceration  "  the  rate  of  destruction 
is  n>easured  by  weeks ;  in  rodent  cancer,  by  years."  There  is  also  an  absence 
of  all  other  signs  of  constitutional  syphilis.  From  ordinary  lupvs  it  is  die- 
tinguishei]  by  the  age  and  healthy  constitutional  state  of  the  patient,  by  the 
^inglenes^  of  the  ulcer,  and  the  absence  of  the  pink,  scaly,  or  cerlematous  skin 
fn-a^iitrutly  found  around  lupus.  Lupus  may  cicatrize  and  cease  at  any  time; 
raleiit  ulcer  never  does.  Lupus  rarely  causes  death;  rodent  ulcer  is  always 
eventually  latal.  if  unrelieved  by  treatment. 

Pathology. — The  micn>ecopic  characters  of  the  solid  infiltrating  substance 
havf  been  examined  by  Moore,  Hulke,  and  C  Warren,  all  of  whom  have 
f  lund  some  parts  which  presented  appearances  identical  with  ppilhelioma. 
MiK-n:  found  this  in  the  diploe  of  the  frontal  hone,  and  Hulke  in  a  part  of 
the  ::I'ibe  tif  theeye  implicated  in  the  disease.  The  greater  part  of  the  growth 
presents  rliaraclers  diBering  but  little  from  those  of  ordinary  granulation- 
tivut-.     M<»ore  was  of  opinion  that  the  growth  commenced  in  all  cnECS  in  a 

ftimple  identical  in  structure  with  epithelioma,  hut  that  this  chanicter  was 
i»t  a.-  the  growth  extended,  hut  could  be  readily  assumed  again  iu  "certain 
»ituati--n»'  or  in  coui'enient  textures." 

Thv  nmctusions  at  which  Dr.  Collins  Wnrren  arrives  as  the  result  of  his 

f»>w«rehw.  are.  that  rodent  ulcer  is  a  form  of  epithelial  cancer;  and  that  it 

differs  friim  the  more  ordinary  forms  of  epithelioma  in  the  small  size  of  the 

cc-lU.     The  arrangement  of  these  epithelial  cells  mav  be  tubular  and  alveolar 

Fiji.  4iy^. 

l^tiT  obeervations  by  T.  C.  Fox,  Thin,  and  others,  have  generally  con- 
firmed the  observations  of  Moore,  Hulke,  and  Warren ;  but  these  observers 


TBBATXEHT   OF    RODENT   ULCER.  48 

Imoi;  covered  with  a  piece  of  water-drening  udUI  the  grayish  slough  that 

has  been  prodaced  haa  separated,  when  the  caustic  may  oe  reapplied  as  often 

M  Deeeasary.     Berides  the  chloride  of  ziuc,  various  other  caustics  may  be 

had  recouree  to,  each  of  which  poaaeMes  Bome  peculiar  advantages.     Nitric 

acid  is  asefiil,  if  the  action  required  is  not  to  be  very  deep ;  for,  as  it  hardens 

and  coagulates  the  tissues  to  which  it  is  applied,  it  does  not  extend  so  far  as 

the  chloride.    The  acid  nitrate  of  mercury  presents  the  same  advantage  as 

the  nitric  acid,  and  other  fiuid  cau8tic» — that  it  can  be  applied  into  the 

teures  and  hollows  of  the  part  into  which  the  more  solid  caustics  do  not 

penetrate.     The  potassa  fiisa  and  Vienna  paste  are  useful,  so  far  as  their 

dcMfuctive  properties  are  concerned,  but  are  somewhat  uocoDtrollable,  and 

tpt  to  spread.     The  most  convenient  mode  of  applying  them  le  to  cut  in  a 

ptwe  of  plaster  a  hole  of  the  exact  size  and  shape  oi  the  ulcer,  to  apply  this 

uoand  its  borders,  then  to  cover  the  sore  with  a  layer  of  potassa  cum  calce, 

ODe  lioe  in  thickness,  and  over  this  to  lay  on  another  piece  of  plaster.    In 

Aw  vty  a  considerable  amount  of  caustic  action  may  be  induced,  which  will 

bt  limiied  exactly  to  the  surface  to  which  it  haa  been  applied.    Of  all  these 

ochtrutics,  the  preference  is  to  be  given  to  the  chloride  of  zinc;  its  action 

ii  more  continuous  and  more  controllable,  and  it  appears  to  give  a  healthy 

ttimoliis  to  the  subjacent  structures. 

2.  Excision  of  the  whole  of  the  ulcer  may  often  be  very  advantageously 

Eised,  especially  when  it  is  situated  on  the  cheek,  eyelid,  eye,  or  fore- 
;  sod  the  gap  left  may  be  filled  in  by  some  of  those  plastic  processes 
1^  wilt  be  descrined  when  we  come  to  epeek  of  the  Plastic  Surgery  of  the 
Fite. 

3.  When  the  ulcer  has  attained  a  large  size,  when  it  is  complicated  in  its 
ootlioe,  and  irregular  in  its  depth,  the  Question  arises  whether  surgery  offers 
uy  resource,  or  whether  the  patient  should  be  left  slowly  and  miserably 
to  die. 

In  these  extreme  cases,  even,  something  may  be  done  to  prolong  life  and 
lo  relieve  suffering,  even  if  no  cure  be  ultimately  expected.  Moore  proved 
thMt,  unless  the  brain  be  implicated,  or  some  large  vessel  involved,  something 
eso  usually  be  done  at  least  to  arrest  the  rapidity  of  the  growth.  The 
■ethod  which  he  adopted  was  a  combined  use  of  the  knife  and  of  chloride  of 
tine.  By  these  means  he  removed  in  some  cases  the  whole  of  the  affected 
parts,  leaving  a  huge  chasra  in  the  face,  and  even  in  one  case  exposing  the 
dnra  matrr  for  a  considerable  extent  over  the  roof  of  the  orbit.  The  opera- 
tions were  done  on  no  regular  plan,  the  incisions  being  directed  solely  by  the 
shsfM-  of  the  growth,  and  no  attempt  being  made  to  repair  the  deformity  left. 
Hie  results  of  these  operations  were,  on  the  whole,  favorable.  Out  of  six 
caws  three  recovered,  and  three  others  received  decided  benefit,  but  were  not 
permanently  cured.  In  all  the  cases  in  which  the  chloride  of  zinc  came 
mtu  actual  contact  with  the  dura  mater,  epileptiform  fits  occurred,  but  only 
of  a  temporary  character. 

When  the  disease  is  situated  in  an  extremity,  and  the  caucellous  end  of  a 
bftoe  esperially  is  involved,  as  when  it  dips  into  and  erodes  the  head  of  the 
tibia  or  the  lower  end  of  the  radius,  amputation  would  be  the  proper  and 
ooIt  advantageous  procedure. 

When  the  disease  is  so  extensive,  or  so  situated,  that  absolutely  nothing  in 
MO  •>perative  way  can  be  done,  the  Surgeon  must  content  himself  by  covering 
op  tiie  raw  surface  with  lint  snaked  in  glycerine  and  water,  and  protected  by 
mted  ftilk.  Iodoform,  either  dusted  on  or  applied  as  an  ointment,  composed 
of  one  drachm  of  the  powder  to  an  ounce  of  vaseline  to  which  a  small 
quantity  of  eucalvplus  oil  may  be  added,  will  usually  be  found  the  best 
applicmtion. 


44 


SCKOICAL  DISEASRS   OP   THE    SKIN. 


/:33, 


ftf.  UV.— CMW*niM  UlMc  nf  Ika  Lt%, 


Cx'scr-R  OF  niK  Skp*  id«t  be  either  priiiinry  or  eecomliirv.  Primaiy 
Cancer,  il"  wo  nclutic  the  K<xirot  Ulcer,  nlwnvs  nwuiui-s  the  iorni  »(  iiin 

Si]iinni')U^  Epilhelioiiii).    Thf  struriun' 

iiiiH  liiMory  .if  iJiis  Imve  uln-miy  Ikvo 

described.     Ii  i«  tuuulty  MAict]  nlxiut 

ihc  lipe.  fnoe,  anil  scrotum,  aud  ai  the 

oriflds  of  the  raaoitus  caimU.     Il  lomr 

lu    rare   casta    arise    frmii    itinli|;ii9tic 

Irauflforinitliiin  of  nu  atb«rrinmti>U9  cytt 

1  p.  034,  Viil.  i.  >.    Kpitheliut  iiiutTr  may 

■irijtltititv  alw)  iu  nti  nlil  D<^^ir  )>r  tikM!r. 

In  lhi«  wxy  il  mtir  ■>(;i-iir  ugiou  nlitioat 

WMv  |>itr1  oTtlie  ivtfly  ;   I  liiiveeci'tl  it  on 

thi*  tifti>k,  lirrff  ■   hntiil,  ihi^h,  tiuil  wiU-  of  the  f">t.     It  ihni  ("(•mis  a 

luui  uli-rr,  (111-  ."  liirh  i»  j;riiy  or^tUHi^hy.ntiil  ttneti  oivi-roti  with  large 

wnrty  itrntiulati.nt-   nti'l  pnHulwraiil   mnww*.      Thi*  Imi»«-'  i»  iiidiinilfd.  the 

f\\p.v  rniwtl  iiii'l  I'vi-nnl,  Kiiil  idlru  {xiitillnrv  iu  sLructurv  t  Ki^r-  -I'Ju  i.     Thr 

di»i'hHrgr  is  thiu  aud   toaittv.  aail  udWm  the  sors  is  treated  by  atitue|itiD 

nrndirAiiitiiK  i(  lHHt)iiii«  burribly  alT)>u«i\*r. 

BecoDdiU7  Cancer  of  Um  Skin  rtiny  artH^  Trom  direct  extetuiion  from  a 
[iriiiiiirv  tintwih  >ir  tritii  a  n>cniHlnr>- };laadular  tunmr.  Tb«  inmt  marked 
cxi>ni)if<L«  an  oiattiumW  um  with  in  cancer  i>f  tht>  bfintat.  Iu  thla  dtsMue, 
nfliT  ihr  priaiNry  (umur  haf  rcarhtsl  the  surface,  nunii'roii*  Hm<xith,  rlcvai^d 
tulKTi-lca  iif  a  duitky  rwl  .ir  bnmni.-ih  iidor.  niav  a)»iN'ttr  ilntied  in  the  akin 
fitr  iiinuy  iuohca  <tr.tiiitil  tiw  [uri  fir^i  im|)Iii-nt<-iV  Kiu:h  nf  these  i»  a  amftll 
snirrhou^  cnutvr  idfiili'-nl  in  ^tructurt*  with  the  jiritnary  growth  in  the  mam* 
mary  ^land. 

In  Ktbfr  ciUM.  fitrtuunlrlr  rare,  ibe  akio  corering  the  tide  of  the  chest  ia 
wiifrlv  iiilillr:tti-^l  hv  tlic  iiinlijnmni  in^'Wlh.  It  ltccnnu'9smifnth,or  a  hroiriK 
iiih-ml  i-.iliii,  niid  liatti  and  riaid,  like  a  piece  of  leather,  from  which  it  baa 
rci-i-ivril  thi>  tiiiiiir  •>('  lhi>  canci>n)ua  futrasa. 

Sarcomata  of  the  Skin. — \'nriiuis  f^irms  of  rarcoma  are  met  with  in  the 
•kit).  .Sm-.r.  .vV/fW  and  vvui'l  rrlirti  mtrcimn  are  seen  here  a»  in  all 
othfr  tiltfxu*  mrMcUin*.  Tw  ftirms,  hnwrver.  »how  a  ^terisl  pmlilection 
f<»r  tho  #kia— tb«  mftanolic,  and  ihr  akeolar,  Mrlannlie  tnrrt^ma  oftvo  com- 
tti9Ucc«  in  •••mo  ptjiiicnlol  sihiLfuch  as  a  mnlr.  It  fi<rni*  a  ntun<leH  limxir. 
■mimtb  t>n  the  •urt'ac*'.  and  dnrk  bnmn  or  hUck  in  v*Avr.  It  is  iDlcowty 
IK  '<■■•.  atiil  h-i«VT«r  carl;  it  roar  hv  remove*!,  it  is  v^rr  ant  to  return 
I  V  and  in  ialcmal  fincatia.     If  not  removed,  it  grndimlly  iucroam 

lud  ai  ',A*i  itli'cratf-*.  I>  '  ihli  takca  place  it  nftca  reaches  a  o^naider* 

ibic  iiti-.     1  havi>  lurt  v^  .uataooaaof  late  of  th'ta  dbeaae,  ona  iia  tha 

ftiot,  tho  oilier  on  th«  baud,  oi  Indies  both  abot'e  ecvcnty  yean  of  an 
fianw  time  ntWr  n-moral  in  both  oaaea.  browoi»h-black  palclics  looklof;  like 
atainn  «iih   Indian  Ink  appeared  oa  the  tkin  in  the  neiKhburlHitHt  of  tbt* 

Iettmirix.  TI>i-»«  eradually  daTalo|Md  into  new  tumora.  In  one  euebun- 
An^U  ikf  ilo^o  f.>rii>i<d  up  tbe  kg,  varrioK  in  iiae  frum  a  pen  to  a  filbert. 
Tl>.'>'  .L.-ii  •:!  . '  .inl  ami  lift  viaa dca(roy«l,  probably  hy  aecondary  growth 
11  A  t>cniid  of  about  four  yean  from  the  priuiary  mauifea- 

Alvi^'>l*c  Suoama  *4  thf  »kin  is  rare.  In  tiiructurc  and  fpuenU  cbarac- 
Irt  ^  nMtv  •t>'wrib«tl  ( p.  966,  vol.  i  ).     It  it  pruhablv  this  tunurj 

lk  b^   '-'•TtriM  as  the  "M?irrhoiu  wan."  as  from  its  hardnt 

L  pHtrtal  mati|[naQcy  It  usually  manifests,  it  dusely  rc*ein< 

I  if  a  malijciMUit  tumor  uf  the  akin,  whether  a  cancer  or 


SIMPLE   TUMORS.  45 

ttrtroma,  consists  in  its  ezcistoo  or  m  amputation  of  the  limb  affected.  Its 
mnoval  by  excision  should  be  effected  as  soon  as  its  true  characters  have 
declared  themselves;  provided  it  be  of  such  a  size,  and  bo  situated,  that  it 
cmo  be  freelv  removed  with  a  sufficient  stratum  of  subjacent  healthy  parts, 
and  a  wide  border  of  surrounding  skin.  Should  it  be  so  situated  that  its 
excision  through  surrouoding  healthy  tissue  is  not  practicable,  tbe  limb  must 
be  ampuuted,  as  was  done  in  the  case  depicted  iu  Fig.  420.  In  such  cir- 
cumstances the  limb  may  be  removed  at  no  great  distance  above  the  dis- 
ease ;  it  not  beiug  necessary,  as  in  cases  of  cancer  of  the  extremities  in 
whicb  tbe  bones  are  affected,  to  allow  a  joint  to  intervene  between  the  seat 
of  opermtion  and  the  malignant  growth. 

Simple  Tcmobs  of  the  Skin. — 

Fitoomft. — Circumscribed  fibrous  tumors  are  occaBionally  met  with  in  the 
skin,  but  are  not  cummon. 

Keloid  is  a  fibroid  growth  not  encapsuled,  but  fusing  with  the  healthy  skin 
at  its  edges.  It  forms  a  flat  tumor,  raised  about  a  line  above  the  surruund- 
ing  healthy  skin.  It  is  oval,  rounded,  or  irregular,  and  branching  or  radiat- 
ing in  form.  The  surface  is  smooth,  and  white  or  pink  in  tint.  It  is  firm 
■Oil  elastic  iu  cuoustence.  It  arises  without  known  cause  and  roost  fre< 
qoeotly  upon  the  trunk  or  extremities  in  persons  otherwise  healthy.  It  is 
seldom  painful,  but  may  give  rise  tu  itching  and  burning  sensations.  It  ex- 
tend)'  slowly,  and  although  covering  a  wider  area  sometimes  seems  to  have 
uDilerguoe  a  process  of  contraction  like  a  scar,  the  surrounding  skin  being 
ilnwn  in  and  wrinkled  ur  puckered.  After  reaching  a  certain  size  it  ceases 
In  gn>w.  It  has  no  tendency  to  ulcerate  or  to  degenerative  changes.  The 
Trmtment  is  merely  to  allay  uneasy  sensations  by  sedative  applications.  If 
excised,  it  almost  certainly  returns  in  the  scar. 

Closely  allied  to  true  keloid  are  those  fibroid  growths  that  have  a  ten- 
dency tospmut  up  io  scars,  constituting  Palse  Keloid.  It  was  described 
als««  by  :^ir  Cxmt  Hawkins  under  Warty  Tumors  of  CloatriMs. 

This  morbid  condition  appears  to  be  simply  an  abnormal  increase  in  the 
activity  of  the  development  of  the  cicatricial  tissue,  which  spriugs  up  with 
grvat  luxuriance.  They  are  wpecially  apt  to  follow  the  irregular  eicatriza- 
ii-  n  "t'  l»um,s  more  particularly  iu  children.  I  have,  however,  seen  them  in 
ihf  a.iuk.  occacioned  both  io  this  way  and  by  the  irritation  of  a  blister.  The 
warty  cicatricial  tissue  develo[»  chiefly  on  the  chest  and  neck,  and  13  com- 
mxnly  attended  by  much  itching  and  tingling,  ofYen  of  a  most  distressing 
ehameler.  It  is  very  vascular,  blee<ling  freely  when  incised.  The  Treat- 
iHtiii  lit'  th«^  prowihg  is  not  satisfactory.  As  a  rule,  they  may  safely  be  let 
sl-m**.  if  thoy  cause  any  aiiuoyance,  the  only  treatment  is  to  remove  them 
by  thf  knife  it'  they  are  so  situated  as  tu  make  this  possible,  but  most  com- 
monly the  new  scar  assumes  the  same  unhealthy  condition. 

The  disease  known  as  Kolltucam  Fibrosom,  in  which  enormous  pendu- 
louH  tumor?  coniixned  of  hypertrophied  skin  and  subcutaneous  tissue,  has 
«lr«idy  been  <iescribed  ( n.  944,  vol.  i.). 

Otteomata  of  the  Skin  have  been  described.  They  are  always  atheroma- 
t>>u'  ry>t^,  the  walls  of  which  have  undergone  calcificatioo.aud  occasionally 
true  ■**iti(.-atinn  in  [Mirts  (p.  933,  vol.  i.). 

Adenoma  of  the  Skin,  arising  both  from  the  sweat-glands  and  sebaceous 
f  .iiu-U*.  have  Imwo  occasionally  met  with.  They  are,  however,  very  rare, 
\\  iitii  uriain^  in  cimnecti<m  with  the  sebaceous  follicles,  they  form  lobulated 
Qia.-**-*  <.f  wmie  size,  which  alter  i^rowing  for  many  years  may  ulcerate  and 
rv— -mi.ie  e(»iiheli<mia  in  apiK-arance.  Oo  microscopic  exarainiition,  they  are 
fxutKi  iM  be  L'DmpijHed  of  a  structure  resembling  a  number  of  greatly  en- 
largM  follicles  bound  together  by  a  vascular  connective  tissue. 


46 


SPKOICAL   DISKASE5    OP  TBE   SKIX. 


i 


Atheroiutow  and  other  CytCi  bare  alradjr  bem  dcKribBd  (p.  dSl, 

L^.  and  VsTt  mil  be  dt»crib«d  in  ■  nbanjusDl  «fa«pt«r  mtli  INmmi  oC  lb« 
Blood  vow  Is. 

HoIm  are  pigmcDted  patcbca  of  variable  iise  ta  thm  ikia,  and  alwaya  of 
coogcfiiial  cfigia-  Th«v  are  nAcn  raind  abi>ve  Uie  larfiwa  of  Un  awTMsd* 
ia^  iktn  and  curered  wiib  hair.  loiDfdiutv  luug  and  eoana.  Tbejr  caawit. 
Im  pry)\tt:r\y  rlaaed  ai  tumon,  as  tbey  ehuw  oo  trndeaer  la  gnm  oat  uf  pro- 
portiim  Uj  llie  rot  of  tbe  body.  In  later  life,  buwvver,  a  mole  out  iuib«- 
qaeotly  farru  the  ctftrtiag-puiut  of  a  lunior.  It  mar  gradually  iacreaw 
in  uae.  becoming  coore  and  more  pnitnioent,  and  auaetinm  peduaciilamd. 
It  ma;  tbu»  form  a  tumor,  usually  loliiibiled  or  papUlarr,  and  nnira  or  Imi 
darkly  pi^nt^ntrd.  Finally,  fn)ni  tbe  frininn  uf  tbe  cloOica  it  nay  uleerale 
and  lievufue  vary  truublewmie.  A  mole  alio  iioi  uoooaiinoatr  fonaa  iks 
of  origin  of  a  aarcuma,  or  more  rarely  of  a  equamuus  epilbdioma.  A 
requires  nu  ireaimeot  unleaa  it  become  affected  by  ooe  uf  tbfe  eomplieatl 
•bora  maatioued,  wben  it  must  be  at  once  exri»ed.     The  ^r|^D  la 

oananlled  as  lo  the  pnatihilitv  of  removing  a  divticuriDf;  uoie  tri>m  tbe 

There  u  no  metbod  by  wbinh  ibis  ran  be  ikwe  inlbout  Ifnrinif  a  sear  in  Itl 
place,  but  if  the  patient  prefer  this  to  the  pigmented  palrb.the  uole  may  be 
deatrored  by  caustics.  Nitric  acid  and  potaaga  fuM  are  the  two  tiu«t  efficient 
apptieatioos,  but  they  shouM  nnt  he  applied  in  tuclt  quantity  as  lo  deatroy 
the  wbrile  »kin,  othrrrise  a  puckered  and  rijitid  ciealrix  will  reanlL 

FapUlomaU  of  the  Skin,  or  Waits,  con<>ie«  j>f  elonnted  papill«.  corered 
by  strata,  of  thickened  ao'l  hardened  cuticle,  u^uaiiv  situated  ab<)ot  the 
bands  and  face,  and  chiefly  affectio);  youn^  peiiple ;  tbey  appear  in  many 
case*  U>  be  simple  overfrruwtbs  uf  tbe  cutaneous  structures,  cuming  aud  f^>tng 
withciui  xny  evident  cAu»e.  lo  other  cases  they  are  m^jre  permanonti  becum* 
tug  harde4ied  and  dark  to  color,  and  continuing  perhaps  thruuifh  life. 

riie  Trrahnrnt  •jfwartsis  osuaJly  sufficieullr  simple.  Tlicy  way  bcnmdily 
destroyed!  by  the  application  of  caustics  ur  a»(rioL'«nu :  aniuU);  Lhi<  moat  use* 
ful  of  these  1  hnw  fuund  tbe  concentrated  acvtic  acid  aod  tbe  tincture  of 
lh«  ■eaqulobluriile  of  iron.  Bnidie  rvciimmeods  a  solution  of  a  dracbm  nf 
ttrseaious  acid  ia  half  an  ounca  of  nitric  acid.  In  some  casta  they  may  be 
ligatured  or  snipped  off*  with  advantage. 

Ooms  consist  of  thickened  iiMBSa  of  epitbelium  accniuulaied  on  tboso 
poiolB  on  which  undue  prmeure  or  friction  has  been  ejtervieed.  Tbey  reeolt 
from  an  overgrowth  of  the  epiibelium.  cuoaN|uent  upon  tht  abnoraui  ctimu- 
lalion  to  which  tbe  part  is  exposed.  This  is  accompanied  by  some  ealaree- 
ment  of  the  |wpilla*.  The  man  of  epithelium  ts  hard,  dry,  and  ecaly.  In 
the  central  parts  it  may  lead  to  snme  atrophy  of  the  papillae  fnim  preaanre, 
aad  00Bee()uently  the  homy  manaasump^  a  conical  furm.  with  itsapex  down- 
wanls,  preaung  on  the  anuitive  cuib  beneath,  ami  thus  eauung  coDsiderBfale 
pain.  Wlien  tbe  com  is  situnled  in  places  where  the  seoretioiis  nf  the  skia 
accumulule  and  keep  it  moist,  a»  between  the  toe^i.  (hf  excefeiv'^  ''  '  ira 
fornix  a  •«»l\  pulpy  maaa  which  is  easily  removed,  nod  the  enlarg> .  :  he 

papilla!  is  then  very  evident. 

Under  fill  and  ven-  thickened  corns,  it  is  stntnl  by  Brodie  that  a  small 
burva  ii>  occasionally  fuund;  this  bursa  may  Buppurate,  aod  beoone  very 
|iainftil.  ComH  are  at  all  times  euflicieotly  painful,  but  become  espiKnally 
so  if  inftammntioo  or  suppuration  take  place  beneath  them  ;  tbe  ncciimula- 
latlun  of  It  umall  drop  of  pus  under  the  thickened  cuticle,  which  prevt-nttf  its 
Mcape.  giving  riao  to  very  intense  agony,  and  causing  o^ema  and  redneos 
extending  from  tbe  toe  to  tbe  foot,  and  sometimes  up  tbe  !«);.  There  ia  a 
•pecial  form  of  warty  corn  that  I  have  seen  only  in  tbe  sole  of  the  foot,  and 
which  may  become  tbe  source  of  tbe  grentcai  jrassible  pain  and  inomvenienoe 


PEBFOBATING  ULCER  OF  THE  FOOT.  47 

to  the  pstient,  preventiDg  his  walking,  and  in  l»ct  completely  crippling  him. 
This  Cum  is  usually  of  small  size  and  circular  iu  shape,  the  Deighboriog 
cuticle  being  always  greatly  thickened  and  hardened.  It  is  extremely  sen- 
Htive  ti>  the  touch,  the  patient  shrinking  when  it  is  pressed  upon,  as  if  an 
cxpoeed  nerve  had  been  injured.  On  slicing  it  down  with  a  scalpel,  it  will 
be  found  to  be  cumpoeed  of  soft,  tough,  and  white  epidermis,  arranged  in 
tufts  or  small  columns,  in  the  centre  of  each  of  which  a  minute  black  dot  is 
perceptible.  Each  tuft  appears  to  be  an  elongated  and  thickened  papilla, 
and  the  black  speck  is  a  small  point  of  coagulated  hlood  which  has  been 
effused  into  iL  Around  the  depression  in  which  each  of  these  corns  is  seated, 
the  bmrdeDed  cuticle  forms  a  kind  of  wall. 

The  Treatment  of  ordinary  corns  consists  in  shaving  or  rasping  them  down 
to  as  to  prevent  the  deep  layers  of  cuticle,  retained  by  the  indurated  super- 
ficial ones,  from  giving  rise  to  pain  by  pressure  on  the  papillae  of  the  cutis. 
rbe  ciiticle  may  be  previously  softened  by  dressing  the  toe  with  wet  lint 
corered  with  gutta-percha  tissue.  Relief  may  he  afforded  also  by  removing 
■Jl  presure  from  baring  upon  the  com,  by  attention  to  the  shape  of  the  shoe, 
and  by  wearing  a  piece  of  soft  leather  or  of  amadou,  having  a  hole  cut  in 
the  centre  into  which  the  com  projects.  A  soft  corn  between  the  toes  is  best 
treated  by  the  application  of  tincture  of  belladonna  after  clearing  away  the 
sodden  epithelium  with  soap  and  water.  It  is  well  to  avoid  the  application 
of  caustics  to  ordinary  corns;  injurious  consequences  being  often  produced 
by  these  agents,  especially  in  elderly  people,  in  whom  fatal  gangrenous  in- 
flammation may  be  excited  by  their  action. 

The  painful  papillated  com  of  the  sole  of  the  foot  is  the  only  form  to 
which  an  escbarotic  can  be  applied,  and  in  this  no  other  treatment  is  of  any 
oae.  I  have  found  the  application  of  either  fuming  nitric  acid  or  potaesa 
fnsa,  so  as  to  destroy  it  thoroughly,  to  be  the  best  and  speediest  remedy  ;  and 
a*  this  com  always  occurs  in  young  people  no  danger  attends  their  use. 

If  a  com  suppurate,  it  must  be  softened  by  water  dressing  and  shaved 
down,  and  the  drop  of  pus  let  out  by  puncture  with  a  lancet,  when  immediate 
relief  from  pain  will  result.  If  the  pus  is  not  thus  let  out,  it  is  unable  to 
point  through  the  indurated  cuticle,  and  may  burrow  beneath  the  skin  for 
some  distance  before  finding  an  exit.  In  such  case  a  troublesome  sinus  is 
left  which  can  sometimes  be  closed  by  the  injection  of  stimulating  lotions,  or 
bv  passing  a  dctoo  of  two  silk  threads  through  it,  but  more  often  laying  it 
open  is  the  only  efficient  treatment. 

PEitFORATiso  Ulcer  of  the  Foot. — This,  though  not  in  reality  a 
dbeaee  of  the  skin,  is  perhaps  most  conveniently  considered  here.  The 
disease  seems  usually  to  commence  by  a  corn  situated  on  the  sole  of  the  foot 
opposite  the  head  of  one  of  the  metatarsal  bones,  usually  the  first.  Thi^,  in 
some  cai>ee  apparently  as  the  result  of  some  injury,  becomes  inflamed  and 
suppurates,  and  a  sinus  is  left  opening  through  the  thickened  cuticle.  If  a 
pn>he  be  fKU»ed  into  this,  it  will  be  found  to  lead  to  dry  and  bare  bone  on 
one  of  the  phalangeal  or  metatarsal  bones.  The  discharge  is  scanty  and 
•carcely  purulent.  The  ulceration  may  extend,  forming  a  sore  an  inch  or 
m-tre  in  diameter.  This  is  covered  by  feeble  or  unhealthy  granulations. 
The  disease  in  painless,  and  on  further  examination  the  foot  will  be  found  to 
be  mnre  or  low  widely  anaesthetic.  The  anKsthesia  may  extend  up  the  leg, 
but  it  is  never  associated  with  motor  paralysis.  The  tendency  of  the  disease 
i*  sltfwly  to  pxtend,  causing  further  destruction  of  the  bouea  and  possibly 
c.>inplcifly  perfi)rating  the  foot.  The  foot  is  cold,  and  in  most  cases  is  prone 
to  e«eat  pnifusely,  the  perspiration  being  very  offensive.  Both  feet  may  be 
afl«ct«d.  and  ■  similar  disease  has  been  seen  in  the  hand. 

Michaud,  .Sonnenburg,  Duplay,  and  more  lately  Savory  and  Butlin,  have 


48 


DISXASKS   Oy    TUB    NERVOUS   STSTKU. 


piiintetl  (HI I  (liH*  tlie  ()neiu«  Is  lUBociatL'd  iu  many  cases  with  tbickeiiiagof  tfae 
-eutloiieuriutii  mid  aLn)|)liy  of  ihc  Hlirt'f)  of  the  nrrveo  lending  tn  the  aflectod 
BtKiU  Biiviiry  Htitl  Hiitlii)  liBVi'  hnm^lit  t'lirM-nnl  evidence  ti>  show  nl»<>  that 
lliip  seimory  libri.ii  am  cliii'fly,  if  uti(  tiijIpIy.iiffVcte*!.  .Similar  ulwratiMns  bm 
met  ttidi  in  Home  oi.-^-e  "f  liK-titiKilrtr  iilaxy.  It  mar  therefore  he  conclntitd 
ihut  ihu  i>riniHry  caum;  of  the  diseiisp  is  iiiipnirment  of  Dulritioo  coobctjueiit 
upoo  degeiienilive  chiitif^  taking  nlnre  either  iti  the  nerves  lefldlDg  to  the 
ftUbotei)  narts  or  in  that  portiou  ut'  the  wiisory  oolunina  of  tho  cord  that  u  in 
^oommiiniPAtioD  with  the  fmt.  Iu  some  reepcdfi  it  rcseioblei  the  discan 
known  M,  aiiieslhetic  leprosy. 

The  IVojImenl  consists  in  nmputati'm  of  the  aflectcd  parL  In  order  that 
thisoperntion  may  be  effective,  it  ihonld  be  done  above  toe  area  of  aiiBithaHa 
in  the  fout  or  log. 


OUAPTEK    XXXVIII. 

lilSKASES  OF  TIIK  NERVOl'S  STSTZSf. 

InfiammaiioD  of  tbe  Nerre^  or  rather  of  the  Xeurilcmma,  la  not  of  very 
iinfrv|iii'rit  llccll^rt-nl^t■,  being  i»tially  the  n»ult  of  rhc-umalism,  of  wunoda, 
or  of  utmimi.  When  Xeuritti  is  rheumatic,  it  aifcctA  prioeipally  the  uerv«8 
of  the  fat-c  «nil  the  lower  extremity, 

ftvMPTOMt*. — ThMO  c»in»i*i  of  iPiidemeM  on  preaiure  along  the  coarse  of 
thf  nerve,  und  severe  eonttQuooft  puios  running  down  it*  trunk  ond  ruriiify- 
ing  along  ittt  limnehe<\  with  o(.'ea9iunal  rioleoi  exncerbatioiip,  esjiecially  on 
moving  or  touching  the  part,  and  at  night.  In  very  rare  cases  the  ditfeavo 
luav  aiHimv  an  acute  form,  with  tome  sH-ctlirig  ali.>ag  th^courveof  the  nerve, 
and  slight  pyrvxia.  Ordinarilv  the  aftectiuu  is  chronic.  It  is  one  of  the 
caUK*  of  neuralgia.  On  examiniitioD  aAer  deiith  in  Hcute  caset  th*  sbwUl 
of  the  nerve  wilt  bo  found  iujeete<l  and  swollea  from  inBammat^nr  oxoda- 
tiun.  In  chrtjiiiu  cuss  tbe  netirilemma  may  be  fonnd  iodaratcd  and  iocr«aMd 
ID  ([uanlity,  the  nerve  fibre*  boiDg  more  or  leas  txtnipnaed  by  the  new  libroid 
tlMue.     Traumatic  neuritii  has  mqo  alraflr  fully  deacribed  (vol.  i.  {>.  477). 

T^tattNrnt.—iu  acut*  casea  this  oouaista  in  the  empiovmcnt  of  antiphlogistic 
means :  cupuing  or  the  applicutiuu  of  leedMi,  aoourdine  to  the  fiiuniion.  and 
poppy  ur  beiladoana  tumi'ntations.  In  diruatc  casea  blisleriug  or  the  ajipli- 
caiiuu  of  mustard  phulcn  altrng  the  lioe  of  the  nerve  usually  gives  rdiof. 
Tbe  part  in  which  the  a&ewl  iterv«>  \»  tituatcd  muit,  if  poniblc,  bo  kept  at 
peHbct  rc»t.  When  cbeaAiKitkm  ii  rheumutie. ulioylatooftodaisftvqaeiitly 
of  great  use :  in  some  eases  the  acetous  extract  of  eulcbicura  is  the  best  rtmcdy ; 
when  it  is  morv  cbrxmic,  ami  the  pain  ii  chiefly  nueitirual,  iodide  ut  potasaiun 
a*lvantageuusly  h«  givro. 


iCUTlCA. 


The  ehanelefiBtio  feature  of  aolalica  it>  pain  of  a  nenralfpe  characlrf  Is 
the  ctuine  of  the  great  •cislic  nerve.  Tht^  all'eetiun  is  b«Uaved  Id  ibe  grval 
majurily  vf  caaoa  to  be  due  to  chronic  rbrumatia  intUmskalion  of  tbe  tbeatb 


NKUBITIS — DIAGNOSIS   AND   TBEATUENT.  49 

of  tbe  Derve,  and  some  thickening  of  the  neurilemma  has  been  recognized 
afk«r  death  in  a  few  cases.  In  other  cases  pain  of  a  similar  character  may 
be  the  result  of  pressure  on  the  nerve  by  tumors  in  the  pelvis  or  gluteal 
region,  or  oocaeionally  firoro  affection  of  the  cord  or  disease  of  the  spine  in 
the  lower  lumbar  or  sacral  region.  Sciatica  is  most  common  in  young  adults, 
and  frequently  arises  from  exposure  to  cold  or  damp. 

The  liymptoms  of  sciaUca  are  pain  in  the  buttock,  back  of  the  thigh,  and 
the  leg  below  the  knee.  The  pain  may  amount  merely  to  uneasinras,  or  be 
iotense  and  paroxysmal.  It  is  usually  aggravated  by  movement,  often  to 
Mich  an  extent  as  to  render  locomotion  impossible.  When  the  pain  extends 
to  the  foot  it  is  fett  chiefly  on  the  outer  side,  the  inner  being  supplied  by  the 
toDg  sapheouus  nerve  from  the  lumbar  plexus.  By  pressing  with  the  point 
of  the  tinger.  t«ndemes8  will  be  found  m  the  course  of  the  nerve.  This  is 
most  marked  in  the  hollow  between  the  trochanter  and  the  tuberosity  of  the 
ischium,  and  down  the  back  of  the  thigh.  The  external  popliteal  nerve  is 
alao  sumetinies  acutely  tender  where  it  winds  round  the  upper  end  of  the 
fibula.  When  the  patient  is  lying  on  his  back,  if  the  limn  be  raised  with 
the  knee  extended,  acute  pain  is  felt  in  the  buttock  as  soon  as  the  sciatic 
oerve  becomes  tense.  If  now  the  knee  be  flexed  so  as  to  relax  the  nerve, 
flexion  \){  the  hip  can  be  carried  considerably  further  without  pain.  Numb- 
Dees  in  st>nie  of  the  jwrts  supplied  by  the  nerve  is  not  uncommou,  especially 
on  the  outer  side  of  the  toot.  Motor  paralysis  never  results  from  simple 
sciatica,  but  there  may  be  some  weakness  or  even  wasting  of  the  limb  from 
want  of  use.  The  affection  is  very  chronic,  uflen  lasting  many  weeks  or 
even  months. 

The  DittgHosis  of  sciatica  is  made  by  attention  to  the  above  symptoms.  It 
is  motfl  fretjueotly  confounded  with  strumous  disease  or  chronic  rheumatic 
arthritis  uf  the  hip.  The  distinction  is  in  muet  cases  easily  made  by  observ- 
log  that  tlie  movements  of  the  hip-joint  are  free  and  unaccompanied  by 

Ein,  nolens  flexion  is  carried  to  such  an  extent  as  to  render  the  nerve  tense. 
rheumatoid  arthritis  the  grating  telt  in  the  joint  on  movement  will  usually 
indicate  the  nature  of  the  disease;  with  the  "lightning  pains"  of  locomotor 
ataxy  it  must  not  be  confounded.  In  all  cases  of  sciatica  n  careful  exami- 
nation ot  the  buttock  must  l>e  made  for  a  tumor  in  that  region ;  the  lower 
part  of  ihe  spine  must  be  examined  for  signs  of  caries,  and  the  tiuger  might 
be  passed  into  the  rectum  to  feel  for  a  pelvic  tumor,  as  in  these  conditions 
local  treatment  directed  to  the  course  of  the  nerve  could  be  of  but  little  use. 

Trratmeut. — The  constitutional  treatment  already  described  for  rheumatic 
neuriti)!  m\in  be  adopted.  The  limb  must  be  wrapped  in  flannel.  Counter- 
irritation  along  the  line  of  the  nerve  in  the  early  stages  by  mustard-plasters, 
and  lattT  on  by  liiislere,  is  most  useful.  Hot  baths  usually  give  considerable 
relief.  Stimulating  applications,  as  the  ammonia  or  compound  camphor 
linimout,  may  be  of  use  ;  and  sedatives,  as  the  opium  or  belladonna  liniment, 
aiay  ea?e  the  pain,  but  they  do  little  to  cure.  Hypodermic  injections  of 
morphia  should  be  resorted  to  only  when  the  patient  is  suffering  from  want 
(^  »lt:\{>  due  to  tlie  pain.     They  exert  no  curative  influence. 

If  the  conslitutiunaj  treatment  and  external  applications  fail,  as  lliey'  very 
frpqut-nily  iln,  two  modes  of  treatment  may  be  adopted — acupuncture  and 
■<rre-ffi  ret  oh  iiig, 

Aeapimctiire  is  thus  performed.  The  patient  is  laid  on  his  face,  and  the 
trader  [Miinb*  nf  the  nerve  found  by  pressure.  Long  fine  needles  are  then 
thrust  ill  *•>  as.  if  possible,  to  puncture  the  nerve.  When  the  needle  touches 
the  n«Tve,  the  paiient  complains  of  a  sudden  pain  down  the  thigh.  The 
nombc-r  mI  thf  iitHlles  used  should  not  exceed  eix.  They  nmy  be  leJt  in  for 
'  ***  niiniiie*.    This  treatment  sometimes  gives  permanent  reliel'. 


DISEASES    or   THE   KCBTOUS   SYSTKIC. 


Our  last  rcBoaroc  is,  hoire vcr,  Stretching  tlie  Sciatic  Verre.  This  open- 
ttnu  hn»  been  more  eiiccfsaful  in  Mi-iuLicft  than  in  uttr  otbi^r  painful  alTrctiiHi 
for  which  it  haft  brcn  uuderluken.  Nnrht  hsa  collvcletl  34  caavi :  of  thece 
16  wi'n*  quiclilv,  A  chiwly,  relieved,  in  'i  the  operation  fnile^l,  and  1  ilied, 
Marvhall  Guds  ihtt  itf  9c8see  which  ocvurreH  in  University  College  Htxpital, 
4  were  lievidetlly  iniurove<l.  4  parlintiv  cured,  and  I  faileo. 

The  oiwmtinii  is  tiuiA  perfurnie<l.  The  pstient  is  laid  upon  bit  face,  anil 
n  vertical  incisiou,  nhout  three  iuchw  in  length,  m  nnide  n  liUte  above  the 
middle  <*(  the  back  of  (he  thigh.  Tlie  deep  faecin  is  opened,  aod  the  ooa- 
tiguuua  borders  of  the  t«nii-t«ndiQoeu8  and  biccpf  an*  Mparaied  with  the 
tiuger.  The  wound  being  now  held  open  by  copper  apatulie,  (he  Bciatio 
nervo  txtmes  into  view  nnd  is  railed  out  of  the  wound  by  piu<$ing  the  finger 
buDfiBth  it.  the  knee  beJn^  Sexed  to  relieve  it  from  tension.  It  is  then  pulTol 
forcibly  in  both  directions.  Murshall  has  denionstrau'd  that  any  furoo 
which  can  be  applied  while  holding  the  nervo  between  the  finger  and  thumb 
niav  Mifely  bo  used.  The  Bxpcrimenls  of  Johntun,  Trombetia,  CVeuhorvUit 
and  others,  have  shown  thac  the  breaking  strain  of  a  healthy  nerve  is  uever 
under  eighty  pounds.  The  wound  after  the  operation  must  bo  carefuUj 
drained  and  dreeeed  by  some  antiacpda  niotbod,  and  it  is  better  to  apply  an 
anterior  splint  for  a  week  or  ten  days. 

Borne  i^urgeom  prefer  exposing  the  nerve  at  a  higher  poiot,  below  the 
lower  border  of  the  gluteus  niaximua.  If  tbo  opcraiiou  be  performed  ac  tbia 
point,  the  whole  of  the  hamslring  museled  muil  be  drawn  together  to  the 
inner  Aide  of  the  wound,  and  (he  nerve  Miujiht  for  external  tu  th«m.  If 
aec«e«ary,  the  lower  fibres  of  the  gluteus  may  be  divided.  Tliere  U  do  mi^ 
tieular  advantage  in  thij  mode  of  operating,  and  the  rtMilting  wouDd  ta 
deeper  and  more  difficult  to  treat,  owing  to  iiH  situation. 

Trombetia  and  Uillroth  bav«  ■UBgettte^l  fitrei<.'hiii^  (he  nerve  by  lueaus  of 
forcible  flexion  of  the  hip  with  the  Knee  extended  and  the  fout  tlexeil.    That 
A  very  great  itrain  can  be  put  upon  the  nerve  in  thia  way  io  wideot, 
the  ntt'thod  might  very  well  be  tried  before  proceeding  to' the  mom  « 
o|>em(ii>n  just  u«ecribed.     It  is  beat  done  by  ffexing  the  thigh  fully 
the  abdomen  with  the  knee  bent,  and  then,  while  the  thigh  u  hxetl,  cxteod- 


OQ 


lug  the  leg. 
Tl 


he  ino<Je  of  action  of  nenre-stretching  in  Kiatioa  u  uncerlaiu.  The  coo- 
iluclivity  of  the  eciatic  nerve  ia  not  affected  at  all,  or  only  tu  a  very  alight 
degree-,  by  the  force  used  in  the  operation.  It  ha«  been  sui/^ratt^l  that  it  acta 
by  breaking  down  adhesion*  either  imiongct  the  fibrea  or  lieiivten  the  nbenth 
and  ■ummnding  slruuturea.  Manhall  believee  it  acts  by  tttrutobing  or  even 
rupturing  the  emiiiU  uervi  tiervurum  ramifying:  in  the  ueurileniiim  luid  in  Uie 
epiueuriuiii,  uhicb  must  be  more  or  lese  implicnleil  and  pressed  u|H>n  by  : 
inflammatory  growth  or  exudation  iu  chronic  neuritis. 


Henralgia  frrnueutly  occurs  in  surgical  practice,  either oamplirating  nt 

tl'w**e*.  or  on  a  diHttnct  affcetion  simulating  cloaety  variona  organic  MnoU, 
more  p»ppcially  of  joint*  and  bimee. 

BvMi-roMit.'-Tht.-  pain  in  neuralgia  is  the  eaaentia)  synipUim.  It  mar  be 
of  two  kindi< :  either  f<dlowing  analomically  the  eoarve  of  a  acrve  utui  the 
dEaiributlon  of  its  (ilam*-nt« ;  or  uffbcting  a  cimsidemble  p^iriinn  of  th« 
sarflic*  with(»ul  referwnci'  lii  any  cfiecial  nerve.  It  b  nf  all  di'gr<T«  of 
aeverity.  sonictinit^  moderate,  niinK'timi«  unbearable,  cvm  by  tiuMe 
posHw*  the  grcateiti  fortitude;  when  severe,  it  usually  come*  itn  »uiU 

a  kind  of  abock,  and  continuea  of  a  sharp,  darting,  or  bearing  ohsiV 


_E  J 


NEUBALGIA — SITUATIONS    AND   CAUSES.  51 

acter,  couning  along  the  trunk  or  rami6catioDB  of  the  affected  nerve,  the 
(li»tributioD  of  vhion  may  ofleu  be  diatiuctly  iudicuted  by  the  direction  the 
fiaiii  takes.  It  a  often  accompanied  by  other  aeneatione,  auch  as  a  tickling, 
Mtmrting,  or  creeping  feeling  on  the  aflected  surface ;  it  is  in  some  iustaooes 
relieved  by  pressure,  in  others  increased  by  the  slightest  touch  or  movement 
••f  tlie  (tart  Occasionally  there  is  spasm  in  the  muscles  supplied  by  the 
atftvted  nerve ;  in  other  cases,  there  are  heat  and  redness  of  the  aurface,  with 
increase«t  secretion  from  the  neighboring  organs,  as  a  flow  of  saliva  or  tears 
«heii  the  nervea  of  the  jaw  or  eye  are  implicated.  The  duration  of  an  at- 
tack may  vary  irom  a  tew  moments  to  many  days  or  months.  The  pain  is 
imist  commonly  intermittent  or  remittent;  it  is  often  irregularly  so,  but  in 
some  iustaiices  the  periodicity  is  well  D)arke<l. 

SiTUATioxa. — This  disease  may  affect  almost  any  part  of  the  body;  it  is 
tatnn  commonly  seated  distinctly  in  tbe  trunk  and  branches  of  a  nerve.  The 
(liviMooa  of  the  fifth  pair  are  the  most  frequent  seat  of  neuralgia;  the  pain 
oiay  extend  to  the  whole  of  the  branches  of  this  nerve  on  one  side  of  the 
bead  and  lace,  but  more  commonly  it  is  confined  to  one  of  its  principal  divi- 
»iuf»,  Buch  as  the  infraorbital,  which  is  especially  liable  to  be  affected  ;  in 
maur  instances  it  is  seated  in  the  temporal  and  dental  nervea.  Not  unfre- 
quently  aome  uf  the  termiual  twigs  aloue  of  one  of  these  nerves  become  the 
seat  of  intense  pain ;  thus  occasionally  the  afiectiou  is  found  limited  to  a 
patch  on  the  cheek,  brow,  or  temple,  from  which  it  scarcely  ever  ehifts.  The 
pusierior  branches  of  the  dorsal  spinal  nerves,  and  the  intercostals,  are  also 
very  commonly  affected,  though  not  to  the  same  extent  as  the  fifth  pair.  In 
otbt^r  cases  the  whole  of  an  organ,  or  part,  becomes  the  seat  of  neuralgia, 
though  no  uue  nerve  may  appear  to  be  distinctly  implicated  ;  thus  the  testes, 
tbc  breast,  the  uterine  organs,  or  one  of  the  larger  joints,  as  the  hip  or  knee, 
are  oocasioDally  the  seats  of  severe  suffering  of  this  kind.  Extreme  cuta- 
neuus  senaibUity  is  a  marked  feature  in  some  cases  ;  the  patient  wincing  and 
Buffering  severely  whenever  the  skin  is  pinched  or  touched,  however  lightly. 

CaL'SEs. — The  causes  of  this  painful  affection  are  very  various ;  they  may 
he  cunatitutiooal  or  local.  It  seldom  occurs  in  strong  and  healthy  individuals, 
)»ut  is  almtjst  invariably  associated  with  want  of  power,  unless  it  be  occa- 
-iun<^l  by  some  local  mechanical  cause.  Depretting  influences  of  all  kinds 
are  t^pecially  apt  to  produce  it ;  thus,  debilitating  diseases,  mental  depression, 
and  particularly  ex[)oeure  to  malaria,  are  common  occasioning  causes ;  those 
t'i'rni*  of  the  disease  that  arise  from  malarial  infiueuces,  or  from  exposure  to 
"iniplt:  cold  and  wet,  usually  assume  a  very  intermitting  or  periodical  char- 
it-icr.  and  are  commonly  seated  in  the  nerves  of  the  head.  The  hysterical 
••mj^rnment  very  frequently  disposes  to  the  spinal  and  articular  tornis  of 
nt- uraturia.  There  is  no  constitutional  condition  with  which  neuralgia  is  more 
irtr-|Utrntly  a»iociated  than  with  antcmia;  hence  its  frequency  in  females.  Aa 
K-imlHTg  somewhat  poetically  says,  "  Neuralgia  is  the  prayer  of  the  nerve 
i'..r  tit-alihy  bl(K)d."  Various  sources  of  peripheral  irritation,aB  loaded  bowels, 
;b«  irritation  uf  worms,  carious  teeth,  uterine  diseases,  and  calculus,  may  be 
rt^>i;rDize«l  aa  pnxlucing  some  of  the  more  olwcure  varieties  of  the  disease. 

Neuralgia  may  arise  also  from  any  compression  exercised  upon  the  trunk 
<il  a  uervc ;  and  in  this  way,  indeed,  some  of  the  more  intractable  forms  of 
ih*r  BtfW'tion  have  their  ongin.  Thus,  thickening  of  the  ueurilemma,  the 
prtwure  of  a  tumor  of  any  kintl,  or  of  a  piece  of  dead  bone,  may  give  rise 
VI  tbe  moot  intense  pain  in  the  part  supplied  by  the  irritated  nerve ;  and  it 
IS  not  improbable  that,  in  many  of  the  cases  of  neuralgia  in  the  branches  of  the 
fifth  nerve,  pain  may  be  owing  to  periosteal  intlanuuatiun,  or  to  some  other 
di«ea^  of  the  oMeous  canals  through  which  the  divisions  of  the  nerve  pasti. 


I118KA8IN   Of  TBI    KIBTOPi    STSTIM. 


.—Tti-  dinffn'M  of  BenrmlEpa,  ikuugb  ummII^  itbtttA  «>llwct 
^'iSieah*,  »  io  «'««  *■""  »  "•''«  einl-rrm-uig.  t»  ik*  tarn  Mf  «>» 
"T-l-^t«ti.  tlist  of  nrptuic ducjw of  ioHadidisuub  of  lb» |«rt.  FhMi 
-*-'  I^  Jiim^e  of  Ihff  i-fflrt  i^i"'  »  l^i^  «*•*  "*"  »«*"!«•  ■■*^  ■•  '^  *^  •^ 
r^rTfc.  ifMia  or  the  brwut.  (h«  dieew*  iii«¥  wtnJIjr  b«  ifainaiAwl  by 
S^J^kMoc  '.f  iKicfiu'ft**!  cutwieoM  •MuabUUr,  Um  oiMnw  of  tW 

''J^ir-i-:J  o(  Biniclure  io  ihe  fMUl  RfleciwJ.  Fmoi  n^nailiM  IW 
*!*^?  ji  gpually  wffictrnilj  e«y.  by  ftuendiug  u»  tbe  iDtimillMl  afaar- 
^?!/ihe  o«Jrtl)?ip  pain,  lo  'it«  inxurrtiiM  in  hjrattrif  1  Ueapewiifi,  — d 
*^^**.^^  ^,f  the  fowltiuliotial  avniptonu  of  taflaai malign.  Bat  •«>- 
*^i*^jLn  local  iiiflan""«>'iry  imuuoa  in  conjoioed  with  the 
*^^V'      •    j,  diffleull.      Here  the  praienM  «il  ctiiaaeoUB  hyi 

J   i^jlllRrf  of  Uie  pain  liy  fir™  prwaarc  will  inriicau  Detmlgia;  w 
^y  ^Saa  there  if  no  l«ndenia»  of  Mirface,  hot  the  snllbring  ii  HC*' 

«*■■  %^^^ —TbK  rr«atm*nt  of  aearalgia  mn«  hare  reference  le  its  cao»f. 

T*^  i!L  iseceaftil  or  aol  nwnrdioK  a«  thia  may  be  more  or  las  readity 

**  *"i     n„  1^,,  ID  (be  coo*litiuB9  ihat  primarily  occuKion  tbe  diaeMe  Mb- 

«^*P~'^    ji  lik^lr  to  roniiauf,  aoJ  it'  iheae  conHitJoiw  be  incflDorabfe, 

•^■^•^     _l^  l.^.kul  iii"'i>it»DeceBMirilv  iururahle,  thougli  til'       "       5 
^*fT^i]^«ittr*i  bv  »|)pn'iirin(e  moun.      U'ht-n  it  artsn  from  ;  .^1 

•■T       ^Jfcctjc"    i^f"*  "''^y  ^  '*■'"  "^  ^'"^  ultimate  occurrence  of  UWam 

■  *^^g/lvpc,  mcb  n*  cpilepiy.  insanity,  etc. 

k  Mcnn'  **  ^^'^  viro«^)U*nc<  of  aijinuia,  or  in  the  hyaterical  tem- 
.L-  ..iminiMratiMD  of  the  more  (tinmlBline  an 


^* 


'ih«  adminiRtratiMn  of  the  more  ^tiniulBlmg  and  Mntnger  prrpara* 
.Tina  ■0'^*'  ■*  '***  »itil|>h«tt  or  the  ptrt-hloridp,  or  lh«"  mi*iun»  frrri 
I'itL^Mttr  slofie  or  in  curiihiiialion  with  (|uitiin«,  with  Btt«^i!nii  1     i!i* 
'jr^!#  bnw«U  uu'i  of  ihe  uterine  function*,  and  a  neneraJ  1 

^T^^-wihted  t«>  br%w  mi'l  improve  tbo  general  health,  »iifh  a««r^ i.^, 

^•^v"rjj^t  or  LNiId  »pt>njfiug.  will  tw  of  ewcnita)  Krvice.  In  »nnt  «f 
**JT^  tbe  c«»mhinauoii«  of  zinc,  eepedally  the  valoriaDale,  with  the 
^^  "^  ^1  remove  llie  disease  when  iron  dow  mn  influeocc  il  much. 
^^t^Z^  timt,  ih'"  applicntioii  of  bflladoutiH  or  aoonite  plasterB,  or  lfa« 
Al  l**.^~J  1^^^  liDiiiifutH  limy  bf  of  scrric*.     When  the  ovuralffia  »  dta- 


'^"iT'lLirio'Wl**-  quiiii'tg  i"  full  doM*.  or  Ihe  lit|uor  aneoi*.'nll»,  *iill  uwially 
•■*? '"Jl^tan?.  Wli€U  it  i»  rbvumalic.  wcurring  in  dchititaiod  eub- 
<•■*  *v^|^<d  bv  itiatinct  nocturnal  ejtiici*rbiiliDn»  of  paiu,  110  rcowdy 
-^*'  ""^  It  an  uitprweioii  opou  it  a«  ihv  iixlide  of  potaaiiiim,  i^prcially 

^___     "  in  cjinhiotttion  wilii  quiniiit.     In  the  mort-  severe  and 
'^m^af  llw  diwase.  ri'licr  iiiny  Iw  ocoasi-mally  oblaiiifti  by  at- 
"^  ifcr  <***  ^^  *'"^  "*'*'"  "'"^  tliywlivc  orgaus,  by  a  counw;  of  aonie 
*    ^^  por^'v*-*  tiiioeral  niitcD-,  and  by  the  ovL-uHooaJ  adniiotMration 
^  -^  AiJFo**^!  by  tonif  reHiL-diw. 

V'TrrpphealiiJiii'  "f  n  (*dative  kind,  such  aa  cblorofurni,  WlladnnQm. 
j^\,p,mn.  i-lc.are  oAeu  uwful  Bdjuncls  to  conatitutional  Lreatmeni.  Bv 

l^f,-;,        'ie  of  atliirdiug  rvlit-f  liicftlly  is  the  hyp<idermic  injectioo. 

'^^n  I  4in«-tiiKlh  to  a  quarter  of  a  grain  of  morjibia  should  at 

ibsuK^l  nt  -'V  itiiie,  aut)  the  nrlioii  uf  ihi»Hn;a)l  dowisouen  Terypowvr- 

)|>-r^  than  this,  it  is  iitiKafe  to  lM>^in  with :  but  the  quantity  may  be  atmr- 

<-d.     1  hare  had  a  pntifiil  who,  to  relieve  the  {wina  Httending 

.  •  >-tum  and  atiu-n.  rt 'jinrfil  no  Imi  than  aix  gmina  to  bo  itiJL-<-tr>d 

irellili  hour,  for  M-verai  mouth%.     In  w>me  cuK*  a  Finglr  iigtction  has 

Ktinilgia  which   had  resjateil  nil  oilier  means,     iteru^f  may  nl'wn  b« 

'  bv  ta«  use  of  oleclricity  iu  the  form  of  the  continuous  current.     Th» 


NEURALGIA — OPERATIVE   TREATMENT.  53 

pocitive  tpoage  must  be  applied  to  soine  conTenteot  place  near  the  eeat  of 
paiD.  while  t^  oeurslgic  spot  is  gentljr  rubbed  with  the  negative  until  the 
skin  is  reddened.     Id  exceptional  cases  the  relief  is  permanent. 

In  tomaj  cases  all  these  means,  however,  are  unfortunately  unavailing,  and 
the  i^aflerer  is  doomed  to  an  existence  of  almost  constant  pain,  except  at  times 
when  the  disease  appears  to  cease  of  itself,  or  has  its  intensity  blunted  by  the 
admiotstration  of  the  more  powerful  sedatives,  such  as  morphia  hypoder- 
mically,  or  veratria,  aconite,  or  atropine  externally.  In  these  distressing 
cases  Che  sufferer  is  ready  to  grasp  at  any  means  of  relief  that  is  held  out  to 
him ;  and  atntduu;  of  the  ueeted  nerVe  is  now  frequently  undertakeu  in 
the  hope  of  relieving,  if  not  completely  removing  the  afftHstion.  This  opera- 
tion has  already  been  deiicribed  (p.  477,  vol.  i.).  It  was  there  pointed  out 
that  the  effect  produced  difTera  considerably,  according  to  the  size  of  the  nerve 
operated  on.  In  small  nerves,  such  as  those  of  the  face,  the  conductivity  of 
the  nerve  is  abolished  as  completely  as  if  it  had  been  divided,  but  as  its  con- 
tinuity is  not  interrupted,  repair  always  takes  place,  and  after  a  time  its 
function  is  restored.  In  the  larger  nerves,  even  when  considerable  force  is 
osed,  the  otnductivity  is  not  completely  abolished,  although  it  may  be  modi- 
fied for  a  time.  It  is  only  when  great  force  is  used  that  the  breaklDg  up  of 
the  medullary  sheath  observed  by  Leuterman  and  Horsley  takes  place.  We 
have  seen  that  in  sciatica,  in  which  the  disease  is  seated  in  the  actual  trunk 
of  the  nerve,  great  benefit  is  usually  derived  from  nerve^t retching,  and 
probably  the  same  result  may  be  hoped  for  when  a  similar  condition  exists 
in  other  nerves.  In  the  majority  of  cases  of  neuralgia,  however,  the  cause 
is  either  some  peripheral  irritation  of  the  terminal  branches  or  some  central 
diseaie,  and  in  these  but  little  is  to  be  expected  from  the  operation.  In  the 
former  case  there  might  be  temporary  relief  until  repair  of  the  nerve  was 
accomplished  ;  and  in  the  latter,  although  experience  has  shown  that  there  is 
sometimes  some  improvement,  this  is  onlv  of  the  most  temporary  character. 

When  stretching  has  fiiiled,  section  of  ue  affected  nerve  is  not  unfrequently 
recommended  as  a  last  chance  of  the  removal  of  the  disease.  Simple  section 
of  the  smaller  nerves  is  now  replaced  by  stretching,  which,  sb  has  just  been 
stated,  temporarily  abolishes  their  conductivity.  Division  is  undertaken  with 
th«  intention  of  permanently  destroyiug  the  continuity  of  the  nerve,  and  to 
insure  this  about  a  third  or  half  an  inch  of  the  trunk  must  be  cut  away.  As 
with  stretching,  however,  it  is  clear  that  the  operation,  though  wcasionally 
productive  of  temporary  relief,  cannot  in  most  cases  be  expected  to  benefit 
the  patient  permanently;  fur  by  It  the  cause  of  the  neuralgia  Is  not  removed, 
and  it  can  consequently  be  uf  service  only  when  the  pain  is  peripheral,  occa- 
Hoot^l  by  some  local  irritation  existing  between  the  part  cut  and  the  terminal 
branches  of  the  nerve.  If  the  neuralgia  depend  on  any  central  cause,  or 
OD  Itical  irritation  existing  higher  up  than  the  point  divided,  the  operation 
mu6t  trveuttially  be  useless.  Thus,  if  the  source  of  irritati<m  exist  in  the 
lermiosl  branches  of  the  infraorbital  nerve,  the  division  of  this  trunk  might 
be  useful;  but  if  the  pain  be  occasioned  by  any  pressure  to  which  this  nerve 
may  be  subjected  in  its  passage  through  its  canal  by  a  carious  state  of  the 
bifD««.  or  by  disease  of  the  periosteum,  it  would  be  unavailing;  though  it  is 
a  remarkable  fact,  that  it  not  unfrequently  happens  that  there  is  after  thf^se 
uptraiions  a  temporary  cessation  of  pain  fur  u  few  weeks  or  months.  In 
Bi>m*-  of  these  cases,  however,  the  pain  shifU  its  seat  from  the  branch  operated 
■•u  u*  another  division  of  the  same  trunk  ;  thus,  if  the  infraorbital  have  been 
dividnl.  the  inferior  dental  or  submental  nerve  Itecomes  the  scat  of  pain.  Or 
thi-  may  ascend,  as  it  were,  to  the  point  at  which  the  nerve  was  divide<i;  thus, 
after  amputaiion  for  neuralgia  of  the  knee,  the  pain  may  return  in  the  stump, 
and  again  when  this  is  removed  a  second  or  even  a  third  time. 


I>ISEA9ES   or   THE    KERTOUS   STSTBK. 


DiAiJKiH^iA. — The  diiif^oeiB  of  neurnlf2:ia,  though  usualty  eflTvclod  without 
nuy  HitKcully,  ig  in  Mime  CRses  a  little  i-iiiliArrnmiiig,  »t  the  iiaia  nwj  oc>cft- 
Btotiiilly  Miiiiiilflt^  thftt  of  organic  diM'tiiio  or  inttaminHlifii)  nt  (he  pnrt.  From 
or^nie  tlisetisf  nf  tho  part  itiai  i»  tlio  seat  of  HtiflrriDg,  sitch  iih  the  hip,  the 
kne«,  th«  ivfttis,  or  the  breut,  this  tli»ea»«  iiin^-  usually  be  dtalinguifhed  b^ 
the  covxisteDce  of  heightened  tutnoeoui  M-uoibiltty,  the  existcDce  of  lfa« 
hyrterical  tcni[MTHmOi)t,  and  ihn  absonce  of  lite  other  Btgn*  that  would  Kc- 
oorupanv  k-sitm  of  structure  in  the  part   iiHWctefi.      I'rmii   i'   "  "ri   ibfl 

diignniiiii  ia  Dsually  BuUicietillv  ener,  br  attemlitig  to  llie  ii::  i  ehar- 

acter  Iff  thu  neuralgic  paia,  to  ilB  occurrence  iu  hysterical  ti-miM-fanRUt^,  Bod 
to  the  absence  of  the  coustitulioaal  evniptomn  of  iu  flam  mat  ion.  But  ucca- 
gionully,  when  local  ioflHrnmntory  irritation  is  conjnioed  with  the  neomlgia. 
the  iliiignniits  ta  difficult.  Here  the  pmeoce  mI  cutaneous  bvpemlheaift 
MDd  the  relief  of  the  pain  by  6rm  pre»iure  will  inrlicaie  neuralgu  ;  irfaerou, 
in  inHammation,  there  is  do  teaderaeas  of  surfaoe,  but  the  eulTeriilg  U  aggra- 
rated  br  deep  pre»ure. 

Tkeatuettt. — The  treatment  of  neuralgia  tnnet  have  reference  to  its  cauae, 
and  will  be  aucceeaful  or  not  necordine  aa  this  may  be  more  or  Ins  readily 
removed.  So  lone  ns  the  couditiona  that  prininrily  oeca^ion  the  diaeue  aub- 
»\tt,  the  pain  is  likely  to  eontiDue;  and  if  ihem  condition!  be  irremovable, 
the  iliM-B^  may  be  lt>i>kcd  upon  as  neceHUirilr  incurable,  though  the  duUerliw 
may  bi-  alleviated  by  appropriate  meaiiB.  \Vhtn  ii  arises  fmni  nny  «^^itlnd 
nervous  ufTeclion,  lliere  mny  be  fear  of  tho  ultimate  occurrence  of  dtsentc 
of  ft  more  nerious  type,  wich  aa  epilepsy,  insanity,  ete. 

When  it  occurs  aa  the  coD«e<]ueoc«  of  anvmia,  or  in  the  hyiitericjil  tern- 
I)«ram*-iit,  the  adininifttraiion  of  the  more  ctimulating  and  titninger  prf|uro- 
liona  of  iron,  aueh  aa  the  sulphate  or  the  perehloriiltf,  ur  the  mi-ilura  ferri 
compwnla,  either  atone  or  iu  cotubitiation  with  quinine,  with  attention  tir  th« 
Plate  "f  the  boweU  and  of  the  uterine  fuoetiooa,  and  a  geuerat  liuiie  rr^ri* 
men  calculated  to  hrace  and  improve  the  general  health,  audi  aaaen-hathing, 
the  cold  douche  or  cold  spongiog.  will  be  of  eawnlial  »er«'ice.  In  tiymv  of 
these  CMCS  the  eombinacioits  of  zinc,  especially  the  valerianate,  with  the 
fetid  gums,  will  remove  the  dii>ease  when  iron  does  not  influence  it  much. 
At  the  vittue  time,  the  application  of  belladonua  or  aconite  plailers,  or  the 
inuoeti'iu  \jf  thmt.-  linimcntx  mar  be  of  service.  When  the  neuralgia  is  ijb- 
linctly  ]ierio<lical,  ijuiuine  in  lull  doaes,  or  the  liquor  an>eni<-ali»,  Mill  uaually 
effect  a  spui'dy  cure.  When  it  i«  rheumatic,  occurring  in  debililaird  mb- 
jeclB.  anil  attondeil  by  di»lioet  nocturnal  exacerbations  of  paiu,  nu  remedy 
rxer^isei'  mi  great  nii  impris^ion  ii|niu  it  m  the  iixlide  of  jiotasiiim,  eaprdally 
when  admininlcrrd  in  romhinaliuu  wiih  quiniut;.  In  the  nmrc  scvi^re  and 
pr*itrai'[ed  forms  id'  the  iliwa^f,  ri'licf  may  be  nccasinnally  obinincd  by  at- 
tention to  the  Btate  nf  the  liver  aud  digestive  orgati^,  hy  n  t^Hirse  of  atme 
of  the  niort-  pur>^tive  mlaeral  waters,  and  by  the  occasional  ndminisiration 
of  aluelicM.  fitllowed  by  titnir  remediea. 

Local  applications  of  a  sedative  kind,  such  at  rhlomfbrm,  bnltadotins, 
aconite,  npium,  et<^.,  are  nften  uacful  adjuncts  toconsiilntioital  treatment.  By 
far  the  readleat  mode  of  afibrding  relief  locally  is  the  hypodermic  injection. 
Not  more  than  fn>m  oDe-aizih  to  a  i|uarler  of  a  grain  of  morphia  ahould  at 
fiist  be  Med  at  one  time,  and  the  action  of  thb  small  done  io  often  very  )i»M'cr< 
All.  More  than  ihiit,  it  is  unaafe  tii  begin  with ;  but  the  quantity  may  he  ctior- 
mouety  increaiie<l.  I  have  had  a  patient  whn,  to  n-lievc  the  patM  aUendiun 
cancor  of  the  rectum  and  aiiua,  required  no  le»  than  nts  graitts  to  be  ioject<4 
iwerr  twelUh  hour,  for  several  innntliH.  In  home  caaea  a  Mngle  iujection  I; 
onreu  neuralcta  which  has  re«iste>l  nil  other  meant.  Relief  may  ulWa 
obtained  by  the  uvc  of  elect  ricity  iu  the  form  of  the  conUnuous  current. 


I 


^^ 


HXURALaiA — OPEBATIVE    TBEATUENT.  53 

poeitive  Bponge  muat  be  applied  to  sonie  coovenient  place  near  the  seat  of 
paia,  while  the  neuralgic  spot  18  gently  rubbed  with  the  negative  until  the 
skin  is  reddened.     Id  exceptional  caaee  the  relief  is  peroianent 

In  many  cases  all  these  means,  however,  are  unfortunately  unavailing,  and 
the  cofferer  is  doomed  to  an  existence  of  almost  coDstant  pain,  except  at  timefl 
when  the  disease  appears  to  cease  of  itself,  or  baa  its  intensity  blunted  by  the 
admin istrmtion  of  the  more  powerful  sedatives,  such  as  morphia  bypoder- 
mically,  or  veratria,  acooite,  or  atropine  externally.  In  these  distressing 
eases  tne  sufferer  is  ready  to  grasp  at  any  means  of  relief  that  is  held  out  to 
bim ;  and  itntdung  of  the  aSbeted  neire  is  now  frequently  undertaken  in 
the  hope  of  relieving,  if  not  completely  removing  the  affection.  This  opera- 
tioo  haa  already  been  dewribed  (p.  477,  vol.  L).  It  was  there  pointed  out 
Uiat  the  effect  produced  differs  considerably,  according  to  the  size  of  the  nerve 
operated  on.  In  small  nerves,  such  as  those  of  the  face,  the  conductivity  of 
ibe  nerve  is  abolished  as  completely  as  if  it  had  been  divided,  but  as  its  con- 
tiouitv  is  not  interrupted,  repair  always  takes  place,  and  after  a  time  its 
Aioetioo  is  restored.  Id  the  larger  nerves,  even  when  considerable  force  is 
Dsed.  the  Oi>nductivity  is  not  completely  abolished,  although  it  may  be  modi- 
fied for  a  time.  It  is  only  when  great  force  is  used  that  the  breaking  up  of 
the  medullary  iheath  observed  by  Leuterman  and  Horsley  takes  place.  We 
have  seen  that  in  sciatica,  in  which  the  disease  is  seated  in  the  actual  trunk 
of  the  nerve,  great  ben^t  is  usually  derived  from  nerve-stretching,  and 
probably  the  same  result  may  be  hoped  for  when  a  similar  condition  exists 
m  other  nerves.  In  the  majority  of  cases  of  neuralgia,  however,  the  cause 
11  either  some  peripheral  irritatioo  of  the  terminal  branches  or  some  central 
diseaae,  and  in  these  but  little  is  to  be  expected  from  the  operation.  In  the 
former  case  there  might  be  temporary  relief  until  repair  of  the  nerve  was 
accomplished  ;  and  in  the  latter,  although  experience  has  shown  that  there  is 
sometimes  some  improvement,  this  is  only  of  the  most  temporary  character. 

When  stretching  has  &iled,  aaetion  of  the  affected  nerre  is  not  unfrequently 
recomoteoded  as  a  last  chance  of  the  removal  of  the  disease.  Simple  section 
of  the  smaller  nerves  is  now  replaced  by  stretching,  which,  as  has  just  been 
sutcd,  temporarily  abolishes  their  conductivity.  Division  is  undertaken  with 
tb«  inlentiuu  of  permanently  destroyiug  the  continuity  of  the  nerve,  and  to 
insure  this  about  a  third  or  half  au  inch  of  the  trunk  must  be  cut  away.  As 
with  stretching,  however,  it  is  clear  that  the  operation,  though  occasionally 
pnMJuctive  of  temporary  relief,  cannot  in  most  cases  be  expected  to  benefit 
thv  patient  permanently;  for  by  it  the  cause  of  the  neuralgia  is  not  removed, 
«D<t  it  (."an  consequently  be  of  service  only  when  the  pain  is  peripheral,  occa- 
Hooetl  by  some  local  irritation  existing  between  the  part  cut  and  the  terminal 
braucbes  of  the  nerve.  If  the  neuralgia  depend  on  any  central  cause,  or 
on  local  irritation  existing  higher  up  than  the  point  divided,  the  operation 
must  eventually  be  useless.  Thus,  if  the  source  of  irritation  exist  in  the 
terminal  hninches  of  the  infraorbital  nerve,  the  divisinn  of  this  trunk  might 
be  useful;  but  if  the  pain  be  occasioned  by  any  pressure  to  which  this  nerve 
nay  be  subjected  in  its  passHge  through  its  canal  by  a  carious  state  of  the 
bones,  or  by  disease  of  the  periosteum,  it  would  be  unavailing;  though  it  is 
a  remarkable  fact,  that  it  not  unfrequently  happens  that  there  is  after  ihcae 
upfraliont  a  temporary  cessation  of  paiu  fur  ii  few  weeks  or  months.  In 
sum*-  of  these  cases,  however,  the  pain  shifU  its  seat  from  the  branch  operated 
••u  Ut  another  division  of  the  same  trunk ;  thus,  if  the  infraorbital  have  been 
Hirided,  the  inferior  dental  or  submental  uerve  becomes  the  seat  of  pain.  Or 
thL-  iiisy  ascend,  as  it  were,  to  the  point  at  which  the  nerve  was  diviile<l ;  thut>, 
liter  aniputalicin  for  neuralgia  of  the  knee,  the  pain  may  return  in  the  stump, 
and  again  when  this  is  removed  a  second  or  even  a  third  time. 


I>ISRA3BS    OF   THE    NERVOUS   SY»TCX. 

Facial  Heonilgia  in  the  nioet  <v)nintnn  form  of  thp  diACfiAe.  It  nifty  afT-rt 
any  one  of  ihn  braiioheii  of  tlip  fifth,  or  in  e«iremc  caw*  almoKt  every  iinrt  al 
thf  RBme  time.  The  VArinun  Hivisinns  of  l.hi»  nerv#  Imve,  therefonr.  Iieen 
mmt  frcnucntly  stn-lohed  or  iiivirl.>il  for  rieiimlRta.And  it  is  necoMarr  hrwfly 
t«i  ^ItH'crilM'  the  o|KTAliv«^  nnx-f-iliire  rfiininx)  in  tho  CM»tt  of  each  ner»*. 

Pint  or  Ophthalmic  Dtrision  of  the  Fifth.— It  w  evident  thnt  ilir  frontal 
hrancji  of  llii<t  xifrvf  in  iIk^  only  pari  ilmi  can  In*  eitln.T  i»ln>tclirtl  or  diviilwJ. 
Tho  frontAl  fliviil<^  til»niil  tUe.  middle  of  I  he  orbit  inlo  the  eiifiralmidiliar  »nd 
StipmnrbilN)  hrftn<-he«.  TIte  Rii|tnitroeh)i>iir  is  ttxi  erniill,  and,  ua  n  rule.  Uni 
much  bnilcen  u|i  into  lirauolie«  to  Iw  iMt|Kie<l  nnil  atrelchvd.  The  iitj|>ni- 
orl>ilill,oa  (he  other  hnnd,  leavc«  the  orbit  nKiiiilly  n»  a  single  trunk,  and  I'lin 
be  imilnted  without  itiflieuky.  The  iHntitiQii  of  lite  nerve  ie  n-eojiitiixeil  br 
fpfling  for  the  Bupraorbila!  noteh.  through  whieh  il  jiasM-s.  The  ucr^e  may 
be  atrelcbei)  eiibetitHneoiiely  by  itiaking  »  email  puncture  with  n  tenotome 
alvDut  D  (juarlerof  un  iiieli  ou  iiiie  side  of  ibe  nnteh.  A  blunt  hook  is  inserted 
through  this  aod  forciblv  Mraned  along  (he  bono  until  its  point  hae  pniweil 
the  line  of  iha  nerve.  The  ekin  of  the  foruhirud  niunl  be  nulleil  upMarda  ao 
ae  to  make  it  tenae,  and  there  will  then  be  un  diffieully  in  aii(TrtAiniD|>  bj 
the  sen^  nf  resialance  whether  the  uer\'e  haa  been  honked  nr  nuU  If  it  be 
fell  npiin  the  hook,  the  akin  of  ibo  furcheod  being  pulle«l  fnrcibly  upwnnls. 
the  nerve  may  be  firmly  Blreu-hetl. 

Hectiun  of  the  supralnK'hlear  and  auprnorbilal  brunehes  can  be  ihrne  pnb- 
cutaneoiiely  by  inserting  a  tenotome  about  half  an  inrh  external  lo  the  line 
of  the  latter  nerve,  and  ptiRsing  il  inwiinlx  nearly  In  the  root  nf  the  nose.  Id 
withdrawing  it  a  firm  ineifinn  niuM  l»e  made  along  ihe  margin  of  thr>  orbit, 
keeping  slightly  to  the  fronlul  ^ide  in  order  In  avoid  wounding  the  polpehral 
ligamont.  whirn  might  he  followeri  by  cnofiiderable  extravneation  of  blood 
into  the  l<Hi^  tlwue  of  the  nrbit. 

To  expose  the  fupraorbitat  nerve  the  akin  of  the  foreheod  must  be  drown 
Qp  and  the  evelid  driwn,  and  a  rnrved  inri^tinn  niMint  three  quarters  of  an 
inch  in  length  mitst  be  made  parallel  lo  ihe  crehrow  nod  a  little  hclow  it, 
the  centre  of  the  wound  being  npiMioile  the  noleh.  The  fihren  of  ihe  orbicti- 
lariit  )>alpebrarum  may  then  he  *enarnte>)  bv  a  bliinl  in»lruni«Dt.  and  the 
nerve  expn»e<l  k»  il  learea  the  orbit  lying  e)n»ely  upon  iho  bone.  It  mar 
then  be  siretehed.  or  a  piece  cut  out  na  do.«!red.  Cnre  must  l»e  taken  not  t>) 
wound  the  |Hiii>t'bm)  l>i;aiiient,  olherwiM;  blond  may  be  exIravtiMiled  into  the 
orbit  and  cupouratioM  follow. 

Th«  SacQU  or  Superior  Maxillary  Branch  of  the  Fifth. — Thi»  nerre, 
after  cmwiog  the  Bi'hrno-niaxillnry  i''i»wi,  loit-rB  n  cinial  in  ihe  fl'xir  of  the 
orbit,  and  appears  on  the  fm-e  thntuyb  ihf  iufniorbitui  foramen.  The  nerve 
haa  bei'n  divided  a*  il  Imves  the  fominen,  in  llu-  camd,  aud  in  the  fphenn- 
maxillarr  f-xwfl.  The  situation  of  the  infnmrbtlnl  lornnien  i»  f'<iind  bv 
drawii:g'ii  line  fr-uii  the  supraorbilnl  noteb  lo  Ihe  inlerrsil  Iwlwevti  (he  two 
bieu8t>ld  teeth  nf  the  lower  jnw.  This  line  er'ifc'e*  the  infraorbital  foramen, 
and,  if  pnilonged.  will  show  the  |>tM<>it>on  al»c>  <>f  (be  nienlal  f-ramen.  The 
infranrbital  fommrn  ia  eitunlet]  ittmut  half  an  inch  WInw  the  lower  ninrgtn 
of  the  orbit.  The  nerve  lie«  rather  deeply,  but  ean  beatretehed  xnbciitane- 
ottaly  in  the  mnu<  way  as  the  supraurtntal,  by  punelnring  (he  rktii  with  a 
tenntnme  and  gmj>pliiig  f<>r  the  nerve  with  a  binnt  hook,  the  (Miiiit  of  which 
il  made  lo  »em[>e  alimg  (he  bone  l>elow  the  furanien.  When  stretehing  it, 
the  upper  lip  and  cheek  niutit  lie  drawn  forcibly  downwnntH.  Hubeutaneoita 
aection  can  lie  done  in  the  same  situation  with  a  lenotonie.  To  expter  the 
orrvr  a  rurvc^l  inrirton,  arranged  m>  as  to  fall  into  the  lines  of  the  fnvr.  and 
ihoul  one  inch  in  length,  ahituhl  be  made  with  its  mid-point  over  the  font- 
■ten.      After  dividing  the  akin  the  levator  labii  superioria  must  be  cut 


NKURALGIA — OPBKATIVK    THBATHKNT.  6S 

tkroaph,  mud  the  aerve  then  comes  into  view,  and  when  the  bleeding  hiu 
been  Brrested,  can  be  exposed  clearly  and  stretched  or  a  piece  cut  out.  This 
operation,  however,  can  be  of  little  use  when  the  teeth  are  the  seat  of  the 
Bcurmlgic  paaa,  as  the  anterior  dental  nerve  is  not  affected  by  it.  To  divide 
this,  it  is  recommended  by  Maleaigne  to  make  the  incision  parallel  to  the 
margin  of  the  orbit  and  immediately  below  it.  A  few  fibres  of  the  orbicu- 
laris palpebrarum  are  cut  through,  the  origin  of  the  levator  labii  superioris 
turned  down,  and  the  nerve  thus  exposed  at  the  foramen.  The  palpebral 
ligament  is  then  separated  from  the  margin  of  the  orbit,  and  pushed  upwards 
wtth  the  fiit  and  tlte  eyeball  su  as  to  expose  the  floor  of  the  orbit.  The  nerve 
is  next  cut  through  as  it  lies  in  the  canal  in  the  floor  of  the  orbit,  with  a 
■troDK  tenotome,  which  is  made  to  penetrate  the  antrum,  and  the  terminal 
branch  being  seized  in  a  pair  of  forceps  at  the  infraorbital  foramen,  it  is 
forciblv  draped  out  of  the  canal  by  which  the  anterior  deutal  branches  are 
raptured.  The  free  part  is  then  cut  off.  This  operation  is  apt  to  be  followed 
by  suppuration  in  the  antrum  and  orbit.  liiDgenbeck  and  HQter  have 
rccomnaeDded  that  instead  of  opening  up  the  orbit,  the  nerve  should  be 
divided  subcutaneously  just  before  it  enters  the  canal.  To  do  this  a  punc- 
tare  is  made  in  the  skin  immediately  below  the  outer  commissure  of  the  lids, 
and  a  blunt  tenotome  is  pushed  backwards  and  downwards  till  its  point  is 
felt  to  be  in  the  spheun- maxillary  fissure.  The  nerve  is  then  pulled  forcibly 
where  it  has  been  exposed  at  the  infraorbital  foramen,  while  the  tenotome  is 
nade  to  shave  along  the  maxillary  border  of  the  fissure.  As  soon  as  the 
traok  is  divided,  it  will  pull  out  of  the  canal. 

Lastly,  Bruns,  Liicke,  Loasen,  and  others,  have  exposed  and  divided  the 
Dcrve  in  the  spheno-maxillary  fossa.  In  order  to  do  this,  an  incision  is 
commeDced  just  behind  the  middle  of  the  outer  margin  of  the  orbit,  and  car* 
ried  dnwDwards  to  a  point  opposite  the  last  uppec  molar.  From  the  upper 
end  of  this  another  is  carried  backwards  to  the  root  of  the  zygoma.  The 
malar  bone  and  zygoma  are  cut  through,  and  the  arch  turned  down  with  the 
manor trr  attached.  The  fat  beneath  is  then  pushed  back,  and,  if  necessary, 
some  of  the  fibres  of  the  temporal  muscle  which  are  inserted  into  the  pos* 
terior  part  of  the  coronoid  process  of  the  jaw  are  divided.  The  posterior 
part  m  the  superior  maxilla  is  then  rec(^nized  and  followed  upwards  and 
ttackwanls  to  the  spheno-maxillary  fossa.  The  nerve  is  then  raised  with  a 
blunt  h(»ok  and  divided,  as  large  a  piece  as  possible  being  removed.  As  the 
interna!  maxillary  artery  and  a  plexus  of  veins  which  He  in  the  fat  may 
cause  trouble»>me  hemorrhage,  the  dissection  should  be  carried  out  with  a 
blunt  instrument.  After  the  operation  the  malar  bune  is  replaced  and  secured 
by  sutures.  In  some  of  the  cases  in  which  the  operation  has  been  performed 
considerable  stiffness  of  the  jaw  has  been  lefl. 

Other  methods,  also,  including  partial  resection  and  replacement  of  the 
upper  jaw.  have  been  recommended. 

Third  or  Inferior  ICaxillary  SiTision  of  the  Fifth. — The  three  chief 
division.'  of  this  nerve,  the  lingual,  inferior  dental,  and  auriciilo-temporal, 
have  all  been  submitted  to  operative  treatment  in  neuralgia.  The  lingtutl  is 
earily  reached  from  within  the  mouth.  It  runs  obliquely  forwards  to  the 
#ide  of  the  t4>ngue  from  a  point  immediately  internal  to  the  last  molar  tooth. 
It  v  cDvered  cmly  by  the  mucous  membrane,  and  forms  a  distinct  ridge  if 
the  t'^ngue  be  pulled  forcibly  outwards  and  to  the  opposite  aide.  In  this 
sitoation,  the  nerve  can  readily  be  seized  and  stretched  by  means  of  a  blunt 
Ivtok  forced  through  the  mucjus  membrane,  the  tongue  being  forcibly  drawn 
to  the-  oppiisite  side  while  the  nerve  is  being  pulled  upon.  Section  can  be 
made  by  putting  the  nerve  on  the  stretch,  and  passing  a  curved  bistoury  to 
the  inner  side  of  it  opposite  the  last  molar  tooth,  and  then  cutting  towards 


fiA 


DlBEASCa  OP   THE    KKKVOCS   &T8TKM. 


itteJAW.  Ta  ivmove  a  pit>ce,  a  lontfitudioal  inctnoo  tbonld  be  made  ihnw^ 
tbe  muoou>  merobreQe  in  the  liue  of  the  DerT«,  wbidi  may  tbcii  be  dravD  out 
with  a  blunt  book. 

The  menlai  bmndt  ef  tkt  titfmoT  denial  m  awlj  reaclied,  a*  it  enutrgd 

\from  the  dental  caott].  Thu  forameii  is  tituated  diradlf  below  tbe  luterral 
betweeo  tbe  bicuspid  leetb.  The  oervc  can  be  streiebcd  HibcutaociHialjr  hy 
ntakwg  a  poucture  io  tbe  skin  oppccitc  tbe  fint  bieuspid  al  aucb  a  lenl  at 
not  to  penetrate  tb«  mouth.  A  Muot  book  it  inserted  thruuirfa  this,  and 
forciblr  scra|ied  alnnc  ibf  luine  acmn  tha  line  of  the  ttrrvr.  Th*  ]ip  and 
diin  naH  bu  poIM  bwards  white  tbe  nerv«  b  ctretcbed.    Tbe  ocrre  way 

|klM>  be  expoaed.aiKl  a  piece  cut  out  ifderired  bjr  a  anall  ineiunn  in  the  i 

Tbe  MOM  tnmk  a^  (Ac  taflerwr  dmUat  »enm  baa.  in  eomc  oun  of  in  >■■■■■  , 
and  penteieot  neuralgia,  bcoi  dirided  by  djaeeieling  up  a  flap  over  tbe  nwi^^^l 
of  toe  lower  jaw,  applyine  a  trephine  to  (be  booe  ao  expeaed.  and  cultii^lH 
I  oat  a  piirtinn  of  it  over  that  part  where  tbe  oerre  MHoa  the  dental  eaiHu^ 
which  iM  thns  laid  bare ;  when  a  portion  of  the  mtv*  any  be  eseieed,  bjr 
beta?  raised  on  a  director,  and  •nipped  avar  with  tciaaon. 

The  Auriehlo'Umponl  S'trM  ran  be  rpachinl  oolj  where  fl  irota  the  rwel 
of  ibe  rrframa  after  emerging  from  ab>)ve  the  parotid  gbad.  It  liea  immfr- 
diateW  SwiAd  tbe  temporal  arterr.  In  ibiii  nioation  it  can  be  expoeed  bf 
a  tmall  indiMe  parallel  to  iucaur»e,an<limmediatelT  in  fmni  o^tbetngna. 
t*n  being  taken  to  avoid  ihf  artery.  fNibcntaikeoaa  •trcicbiog  had  beucr 
faoc  be  attempted!  for  fear  f<f  injuring  tbe  temponl  Bftm-. 

The  value  of  tlieM>  uperatiuoa  t»  Milt  •umewhat  doublfal.     Mnay  caMi  of 

perutaufol  curv  have  beeu  rerorded.  sod  temporary  relief  latttag  fiir  weeka 

t^r  mootba  vary  ooomunly  rceulta,     Ko  bawiatioo  need  ibcrefor*  be  bit  itt 

[iwdcnakini;  the  leaa  aerioui  prucwediast,  eoeb  aa  MibontaBooiia  ilnubing  cr 

[•xpcaure  and  divtsioo  of  tbe  lermiual  bcancbea.    Tb«  mora  «XttMiTe  oo«c»> 

lioo«.«ucl>  at  expoatu^  tbe  (uperiMf  nuudllary  in  t^  MbciKHMUtiUary  MMft, 

or  tlic  inferior  dt^nial  iti  the  oanal.ahould  bareacrvad  Ibr  very  extraow  caaea 

in  which  all  miid^r  pruceediog*  ktr*  fiuletL    Woodf  of  Xcw  York,  baeano- 

[•MifBUy  dirided  tbe  luperior  marillary  aarrw  atar  tba  fimnoi  mmdaiB. 

ooe  caM  uf  lii>  wbieb  1  bare  aac*.  a  cwnplMa  care  waa  tftalaJ ;  tba 

,  a  haaltky  mao.  beinf  catirdy  frea  frnai  the  Deiuwigta  ooe  yaar  and 

half  after  tha  opetaliuB. 

Tbvre  ia  eoe  forai  of  Mttfalgta  of  the  dcatal  acrfai  that  it  to  wrare  and 
pentwent  ia  iia  gencrai  duratiaa.  aw)  to  |«iuiji— I  in  iu  attadu.  that 
aoneiitalMatnie  Ko.    Thit  iWMilfia  may  aftal  tttWr  jaw.    I  haTe  BMat 
r  net  with  it  in  iha  hnrtr.  aad  aotw  eoniiiMty  m  wowif  thaa  ia 
ocenn  in  people  who  ban  hat  taalh :  aad  tha  paia,  wUeh  a  aaaaa 
ively  acnia  aad  paimjaaal.  aeiBBWBM  ia  aad  dana  ana  lha  oeairBdcd 
IreoU  and  the  coofltBted  and  iadanUod  gam  aovtring  ihaai.    It  aniean  to 
!  owiaB  ta  tbe  aMaptMita  of  tha  Mfaaaal  hnaehta  of  ihn  dntaf  aartM 
the  aoatradiaa  apoa  tiMn  of  tha  ipty  ahaalL    TWac  thia  via*  of 
paiholocy  of  ihia  iatB  of  aaaialgia,  I  aaw  tnalad  it  bj  ua  rcMoval  of 
prwii<ui  ofUM  iadaialed  alvwolar  bnrdcr  and  gam.    Boia  Tcan  ^o  1  did 
%tt  io  m  paiimi  of  Dnan't.  reiMreias  a  V-^haped  pieee  of  the  Mae  by  lara at 
Hey*  taw;  aad  mon  reeeatn,  I  Imtc  ia  additioa  cfippad  away  the 
■Hv  br  lacaa*  of  eoOiiw  pGaiL    iMnm.  who  baa  fifceied  anoatiuA  i^  thit 

'.<rara^in.  wa  ue  pUen  ooly  far  tha  t— nral  of  lha  aftcted 
I  :<«■  it  u  aeocHtfy  io  cat  iafiB,  faai  ae&  Ato^h,  tha  body  of  tbe 

t£it>  indakm.  the  denial  obmI  bw  he  opeaad  ia  the  body  ct  the 
tlte  narrt  dfatroyed  by  aeana  of'^ihe  fuvaaie  caaucy. 


TBAUHATIC    PABALTSIS.  57 


HUBCDLAR  TIC. 

MuBcular  tic  of  the  &ce  or  "hUtriouic  spasm"  coDsists  of  almoet  constaot 
tvitcfaJDg  nf  the  muscles  of  the  face,  sometimes  so  severe  as  to  interfere  with 
sleep,  aod  always  causing  most  serious  annoyaoce  and  discomfort  to  the 
patient.  During  the  last  few  years,  the  facial  nerve  has  been  stretched  for 
relief  of  this  affection  in  several  cases.  Godlee  has  collected  thirteen,  inctud- 
iog  two  of  hia  own.  Of  the  13  cases,  6  were  unrelieved,  the  spasm  returning 
asfoon  as  the  paralysis  caused  by  the  operation  passed  off:  and  in  5  the 
■pMmfl  returned,  but  with  less  severity ;  in  one  only,  under  the  care  of 
Sootham,  was  the  cure  permanent  One  patient  was  lost  sight  of.  The 
opermtioQ  is  performed  by  making  a  slightly  curved  incision  immediately 
behind  the  ear,  reaching  from  the  root  of  the  mastoid  process  to  nearly 
the  level  of  the  angle  of  the  jaw.  The  anterior  border  of  the  process 
and  the  edge  of  the  tendon  of  insertion  of  the  stern o-mastoid  are  carefully 
deaned.  and  the  parotid  turned  forwards.  The  upper  border  of  the  digastric 
i*  next  found,  crossing  the  wound  nearly  transversely.  The  nerve  is  parallel 
to  this,  and  according  to  Godlee  it  will  be  found  emerging  from  under  the 
middle  of  that  part  of  the  mastoid  process  which  is  exposed  in  the  wound. 
After  the  digastric  is  exposed,  the  dissection  must  be  carried  out  with  a 
director  and  forceps  as  the  deep  parts  of  the  wound  approach  the  internal 
JQgular  vein.  When  the  nerve  is  found  and  cleaned,  it  must  be  firmly 
■tretcbed  with  two  blunt  hooks.  Complete  paralysis  of  the  face  should  re- 
mit if  sufficient  force  is  used. 

In  elonie  torticoUii  the  spinal  accessory  nerve  has  been  divided  in  one 
(a«e  by  Tilleaux,  and  stretched  by  Nicoladoni,  at  its  entrance  into  the  steroo- 
nastoid.  The  division  gave  some  relief,  but  the  stretching  only  exa^erated 
the  spasms. 

TRAUMATIC   PARALYSIS. 

Traumatic  paralysis  is  referable  to  three  distinct  sets  of  causes.  First,  it 
niay  arise  from  Injury  to,  or  Cbmpremon  of  the  Brain  giving  rise  to  localized 
paralysii  when  the  cortical  motor  centres  are  injured,  or  to  hemiplegia  or 
toon  general  paralysis  when  the  deep  centres  are  implicated,  or  pressure  is 
exerteil  on  the  braiu-eubstance  generally.  These  conditions  have  already 
been  fully  describe*!  in  the  chapter  on  the  Injuries  of  the  Head  i  pp.  683 
and  72^1.  vol,  i,/.     Secondly,  it  may  arise  from  Injury  of  the  Spitifil  Cbrd, 

Cng  rise  primarily  or  secondarily  to  lesion  of  the  substance,  either  by 
ration,  compression,  or  ultimate  disintegration.  The  effects  produced 
will  vary  with  the  extent  and  seat  of  the  injury  from  complete  [>araplegia, 
wiih  l<"ir«i  of  sensation  in  the  paralyze*!  parts,  to  irregular  impairment  of 
wneati'iD  and  motion.  (See  Wounds  of  the  Spinal  Cord,  p.  763,  and  Secon- 
dary KlTecl*  of  Omcussion  of  the  Cord,  p.  750,  vol.  i.).  Thirdly.  Injury  to 
Ike  .V*Trf^  at  any  part  of  their  couree,  from  the  roots  to  the  terminal  8ul>- 
divisions  of  their  trunks,  may  occasion  paralysis  of  the  pnrts  supplied  by 
them.  The  effect  produced  may  be  immediate,  as  from  Section  of  a  Nerve 
<«*  p.  471.  vol,  i,> ;  or  more  gradual,  from  Pressure  (sec  p.  470,  vul.  i.) ;  or 
it  may  iK-cur  hd  the  result  of  Chronic  Neuritis  following  a  strain,  or  other 
injury    »ee  p.  47S,  vol.  i.). 

ThfTS'-  conditions  having  been  already  fully  described,  it  remains  to  notice 
here  only  a  form  of  paralysis  that  is  occasionally  confounded  with  the 
traumatic  varieties;  viz.,  that  arising  from  exposure  to  cold,  or  rheumatic 
paralytic. 


58 


niSKASBS  OF   THK   V8BT0US   STSTEH. 


BlieQiDBtic  Paralysis.  orPftralysis  from  Expoiore  to  Cold  i  Dui-licuoc), 
is  R  I'ltriu  uf  .Hsea^u  rin>rc  frcqaitDtly  spoken  about  than  mtt  with — that  k  to 
say,  if  wtf  apply  the  t«nn  paral}'8»  to  Ium  of  ncrvoui  power  itnlepcnilently 
of  iaabilitr  t«  use  tbe  limb  from  iniucular  wcakneMS,  rigidity,  nr  (Miin,  or 
from  eimifnr  ccmiiiliooA  c^nncotcd  with  the  joints.  Ofnuiiio  rheumatic 
paraln.t«  from  affectinn  n(  the  n«rve«  ilors,  however,  exbt  Durhcnne  nuUoi 
that  l^e  has  met  with  it  in  mcwt  of  the  nerve*  of  the  limbs,  and  it  b  far  from 
uneotnmon  In  the  fneinl  nerve,  [i  most  oTDmnnly  ariwa  from  exp-rtiire  uf 
the  atfeeteH  juirt  to  a  draught  nr  proloof^l  chilt  while  the  body  tf>  «weating. 
It  Uk  dilfiriili  to  Hjisii^n  A  dUlinct  pnthol'^nical  ("auno  fur  it :  ihitt  it  ixlui-  Lu  an 
actual  inflaniniAlion  of  the  iicrve.n  neuritis,  may  beaf«uni««l  Trotn  ibe  ayotp- 
lorai,  «ud  the  )i9irA)Yi>i»  lo  prithably  the  result  <>f  oompremioii  nf  the  Ht>r«a  of 
the  Dorve  frum  e(1Vif)ion  into  it«i>beatl).  Tbe  parAlysis  inHynrite  in  twu  w»iyiu 
In  the  firat  varietr  there  \»  pruIooK«d  evideuce  of  neuriti*  tvefun:  ibr  |i>«  of 
power  appeatK.  The  fimt  tiympt'imH  when  a  cutnpoiiud  nerve  ix  atfttcted  is 
pain  along  iu  course,  ^ntduitlly  increausg  in  Kverify,  ttahbiug  or  violently 
aching  in  character.  With  tlui  there  may  be  variuui  oiodiijoatioiu  uf  md- 
satinu  to  t))c  parU  eupplie*!  by  tb«  nerre.  as  aambncH,  tui{[liii^,  or  hypenBB< 
theeta.  These  symptumK  are  iocreaaed  by  movameoL  AiVer  lantini;  eaoie 
time,  ovea  for  wcclcs  ur  luiiDtlis.  tbe  pains  oeaae,  mad  the  muftcla  aupuiied  by 
the  nerve  t>ocamc  paralvicd,  and  after  a  time  waste,  aod  tbcn  electrical 
irritability  bcoumes  impaired. 

In  theM>con<i  variety  the  preliminary  «ympfaHiuofoeurilis  arc  wau(iu);,ib« 
paratysi.-!  n|t|>'Hrin^  immedi»ti-Iy  al\er  cxpaeura  to  culd.  Tbie  tA  t-oninKmly 
observed  in  lhi<  farinj  nLTW.  or  in  tbe  museolo^piml  and  uveaaioually  in 
other  nerrcfi.  Dur-lnMinu  has  collected  orer.  100  caaes  of  ttuddta  paralyxuof 
the  latter  oerve  twrurrinjraAer  exposurs  to  oold,  uaoally  fmm  »le<^ping  with 
the  nrm.'i  expnned  In  n  dmujchL  The  aymptoma  of  paralysia  of  the  musoulo- 
apirai  have  already  breu  ()e«crtbet1  (p.  56.5,  vol.  i.).  Durbenoe  iital«s  that 
ID  paralysis  fn>m  expneure  to  cold  tbe  whole  of  the  part»  Mipplieil  hy  the 
norre  io  the  forearm  arc  paralried,  whereas  in  wrUt-'lmp  fmm  lead-palay 
tbe  floptnalnr  loa^o«  ««capes.  la  paraJyw*  nocurrinK  in  lhi«  »udden  way 
from  pnld  the  rlertricat  trritability  of  the  muscles  n^maing  nurinal,  tbe  facial 
|»ef^-e  «lone  forniiDi;  an  exreption  tii  this  rule.  Ttm  i»  explained  hy  sup- 
p<«iin-;  that  thi»  nrrre  U  expand  to  more  severe  preHUr*  when  it  •wells,  Itl 
«OR«eqiienee  of  its  c<>ur«p  hetoe  through  a  lung  caJaal. 

It  i*  important  Uy  difttiDi;ut»b  these  formi  nf  paralysis  from  that  arimng 
from  other  cMUsni — more  i«afticoIarly  from  ihf  Iraumalie  foniw.  This  may 
tnoally  be  d<Mio  by  ulteniline  to  tbe  pn*liniiii»ry  hislitrr  of  neuriUa  iu  the 
6nt  f'^rm,  ill  which  then.-  i#  nliui  frt-iiiti-utly  n  cotfti^trot  or  aiUecedeflt  rfaen* 
mxlic  stfeotion  of  tbe  joints  or  inu»cte«,  aod  in  the  sccimd  form  by  the  main- 
teuanee  <>f  the  aonBal  irritnhility  of  the  muiKrles,  remembering,  howerer, 
that  fneial  paralyms  fVom  odd  form*  %n  exception  to  the  rule. 

The  TVfttm^nt  in  the  curly  »ta)f«s  ti>  that  of  aeuritts.  free  cmoter^irritaUoD 
aad  PBsL  wtlb  the  ad  mi  nt«t  ration  nf  saticyltc  add  if  there  are  any  eeoerml 
li§,m  of  rheumstism.  ^Iien  paralysb  ■■  clearly  derelopfd,  faradixation 
must  be  Mnptoycd  to  pnveot  waattag  of  th«  moadca.  By  tbeae  mcaM  a  cure 
b  always  eAeted.  altoough  the  Pworsry  is  oA«a  vary  uom. 


I 


MKraoxiu 

By  Vanroaa  is  arant  a  lumor  eooneeted  with  a  Derre.    Tha 
neuroma  i>  a  dbroma  spriapng  A«n  tha  nettrilmaaB.    idee,  aba.  p 
ruL  I)     It  is  computed  of  dove  white  Abnas  tataa^  aad  as  a  rvU  tha 


TRAUMATIC   NE0BOUA. 


59 


t>f  the  nerve  are  stretched  over  it  or  pass  aloDg  one  side,  seldom  being 
involved  in  the  mass. 

This  tumor  may  vary  from  the  size  of  a  roillet-seed  to  that  of  a  melon ;  it 
i>  itfually  solid,  but  when  it  attains  a  large  bulk,  a  cavity  may  form  in  it, 
containiog  a  yellowish  or  brownish  serous-looking  fluid,  apparently  owing  to 
tiie  dtsiDtcfrration  of  the  central  portions  of  the  mass.  In  shape  it  is  usually 
ovml  or  oblong,  the  long  axis  correfipnuding  to  the  course  of  the  nerve  (Fig. 
421) :  it  grows  slowly,  and  is  movable  transversely,  but  not  in  the  direction 
vi  the  nervous  trunk  on  which  it  is  seated ;  it  has  do 
Appearance  of  maUgnancy,  and,  however  lai^  it  be- 
cornea,  it  never  contracts  adhesions  to  the  iategument 
nor  iDTolves  its  stractnre.  Neuroma  ooramonly  affects 
only  the  nerves  of  the  cerebro-spinal  system ;  but  B^rard 
hjiiS  met  with  one  case  of  the  disease  on  a  ganglionic 
nerve.  The  nerves  of  special  sense  are  but  very  rarely 
the  ae«t  of  this  disease.  Indeed,  the  only  recorded  case 
with  which  I  am  acquainted  of  a  neuroma  connected 
with  one  of  these  nerves,  is  one  described  by  Lideil,  of 
Xew  York,  of  a  neuroma  of  the  optic  nerve  filling  up 
tbe  orbit.  Battening  and  protruding  the  eye,  and  extir- 
pnted.  together  with  the  contents  of  the  orbit,  by  that 
burgeon. 

Most  commonly  the  tumor  is  single,  and  is  usually 
paialen.  As  it  increases  in  size  it  may  become  the  seat 
of  severe  lancinating  or  neuralgic  pain,  which  extends, 
however,  only  to  the  parts  below  the  tumor,  and  is  com- 
■Kwly  panixyBmal.  The  motor  function  of  the  nerve  is 
very  seldom  affected.  The  pain  is  evidently  owing  to 
tbe  stretching  of  the  nervous  twigs  as  they  pass  over  the 
tumor.  A  single  neuroma  is  sometimes  not  only  paio- 
fnl,  but  acutely  tender  when  touched  ;  but  when  many 
tuoior*  are  present  it  is  a  singular  fact  that  they  are 
alwav»  fiaintose  and  unattended  by  any  inconvenience 
except  »U(-h  a<>  arises  from  their  numbers  and  bulk.  Tbe 
number  nf  such  tumors  is  sometimes  amazingly  great; 
ihu?.  in  one  <>f  R.  W,  •'■mith's  cases,  described  in  a  monograph  which  con- 
tains the  fullest  and  most  accurate  account  of  this  disease,  he  counted  in  tliu 
two  lower  extremities  alone  more  than  250  of  these  tumors,  besides  those  in 
other  r*rts  nf  the  body.  In  another  ctise  related  by  him,  there  were  upwards 
•■f  *>Kl  small  neuromata  scattered  over  tbe  sides  of  the  chest  and  abdonirn. 
■I5«t  iin  the  right  lower  extremity,  and  upwards  of  300  on  the  left;  altogetln-r 
prohahly  not  less  than  2000  of  these  growths  in  "  this  unprecedented  com  ." 

Other  tuniorK  besides  fibromata  are  occasionally  met  with  in  cimiiectinn 
with  nerves.  Myxomata  are,  perhaps,  the  most  frequent.  In  1870  I  aiii|)u- 
tatHJ  the  leg  lor  a  spindle- eel  led  sarcoma  of  considerable  size,  whirh  was 
fuund  i>n  dissection  to  have  sprung  from  the  posterior  tibial  nerve. 

The  jtaiiifvl  ntbeutaneout  tubercle  (see  p.  947,  vol.  i.)  is  probably- alsn  a 
tibn>n>a  connected  with  a  nervous  twig. 

Tzmamatic  Henromata  may  arise  from  the  wound  or  partial  division  <>f  a 
n^rve.  The  central  end  of  every  divided  nerve  becomes  more  or  less  bulb- 
ous, the  eolar}>omeDt  being  composed  partly  of  dense  fibrous  \\s?.\\e  und 
Crtly  of  newly  formed  nerve-fibres.  As  a  rule  this  condition,  which  must 
rfgard«i  as  normal,  is  unattended  by  any  pain  or  discomfort.  Occasion- 
allr,  however,  the  enlargement  reaches  the  size  of  a  nut  or  pigeon's  egg,  uud 


Fig.  421.— Neuroinn 
wUh  Nervoui  Filn- 
mentt  fjiread  out 
□  Ter  Tuiiiiir, 


1^5 


— X>  ■ntTMB*  AooU  be  iuarfcrwl  witli  n»lei*  it  u  caaiii^ 

by  1^  (MIS  il  ciTct  viae  («  or  fa^  tai  balk.     If  it  beeooMi 

U>  nli«T«  ibe  paUMl.  ezcMMi  of  ibe  (um<ir  t«  lbs 

rftrwlMaii.    la  iiliifihii  ■iwi—ra  ilii  iriinnit  iniut 

■^■■iie-  Wf  aatioM  dMKcOott.  towwrg  Un  tOBor  rnm  the  nene 

_.  Uib  MfiML    Thii  eM  be  dooe  n  iMfll  cmm  mjth>Mt  difl- 

^  it  »  iwHiMilito  to  mm  tbe  «bok  HaA,  «  fcw  fiMflieuli  may 

W  ■nKTwo,  vbieb  irill  mamtaia  tbe  eAatinaitv  «r  th«  nrrvr  noJ 

■■Mfimit  icMimtiiHi.    Tf  caanplete  itivWoa  a  iiaavnt.lnMf,  nn 

be  Bade  ta  Mtan  tbe  dividad  cad*  altar  rdaxiai:  -^  u 

—  fwiftli  by  pgwdoa.    Ewa  if  ihw  ftnl.  nnimriiia  of  i  oiar 

Mkaplaee. 

BearooMta  of  atamp*  are  treated  br  cxewon. 


TTTASTK 

M  a  diiean  eosrietlBr  eeeeoitallT  io  aa  exetlad  atata  of  tbe  sfaaal 
tbe  medulia  obloosata — in  bet,  of  tbe  whole  tnu  apiaal  ■JAeel^ 
to  painful  aod  onniiniied  vpaams  of  tbe  Tolastary  faoBclea  atiil  tba 
alternating  Kitb  iucnntplete  relaxatioa,  and  OMiallT  teraioatiag 


Caowb  or  Trta  vi'H. — This,  wbtcb  ib  one  of  the  moat  eerimiB  and  dittr 

tn  vhirh  the  nrrvnas  arsleiii  if  liable,  is  in  the  great  jnnjnritr  n( 
Af  Traaoutio  nri^n.  imag  the  enaaegoenee  of  aome  wmind  that 
I  or  iiritatnn  a  piirtinn  nf  the  periphemi  oervooi  sjntem  :  the  local 
produced  being  pmpA^ted  in  the  nerrnns  oeotrcs,  the  exdtatioa 
af  wbieh  beoomes  penistent,  and  conttDUffl  after  the  local  cause  haa  baea 
lesoTrd.  indaeiair  reflex  mtucular  movefuenia  in  viirioa»  parte  nt  the  body. 
neirritatioQ  of  theoerrouafyBtem.  hAwever,  that  in<1uo«>i  trtAnuK,  may  arin 
from  other  Nturce*  beeide*  surRical  wouods,  oocanooini;  tht*  Idiopathic  form  ^ 
•f  tbe  disease ;  tbuB.  for  ioBtaace,  tbe  preaeiKe  of  wnrnw  tu  thr  inrr^tinal  H 
taaal,  expnmire  t<j  cold  and  wet.  the  timiture  of  tbe  ambtlioal  rord  in  iofaD(«,  ^ 
■A>)  rwn  the  uterine  irritation  fullowint;  abortion,  biive  been  kn'^wn  to  occa- 
awa  it.     These  causes,  however,  rarely  inv«  rive  to  it  in  this  counlry. 

Tetanus  raay  occur  at  all  ny^x.  from  the  t^arliest  infancy  to  an  advancad 
period  of  life.     In  hot  climate*  It  is  omnxm  Brixinunl  newly  bt-rn  Infiints.  in 
tbe  lurtn  of  TVumu'  AVonofenun.     In  this  country  It  rarelr  o^-cun  at  this' 
Tcrr  early  period  of  life,  but  is  comnion  iu  yoiinK  adults.     Whave  ni«9t  fre-j 
ttnenllT  ohaerved  it  between  the  a^ea  of  IG  and  'i-').  and  aAer  that  in  old' 
people;  but  It  may  neciir  at  any  period  of  life.     It  is  far   more  common 
aninnitat  mo/m  than  femaica— io  the  proportion  of  about  four  tu  one.     Seiuan 
mfthe  yrar  tieemtt  to  exercise  little  influence  over  iL     It  occur*  lu  all  stalra  of 
(be  almivphtTR,  and  at  all  periods  nfthe  rear:  but  is  certainly  m<«t  cntooMa 
rhi>n  the  Wfeihrr  is  tttiddenly  chan^enlile — altemsting  fn>m  hcnt  tn  culd. 
Iff  .  ^    ''■':!*  exposure  to  cold  and  wet,  more  parliculariy  after  the  b-Mlr  has 
',  is  thn  most  cnmmun  r&uae  of  tetanus  when  it  nccure  indepen- 
iwv  '■[  fiurf^eal  injury,  and  is  a  iVequent  prediapoeing  caiae  to  penuui 
who  havf  IxTO  woiindi-d. 

'Tins  mav  \m'  occasioned  by  injuries  that  do  not  pTO  rfae  in  brendi  of 

:  thua  1  hav^  known  it  to  occur  in  a  child  who  was  ffoddenljr  tbrown 

its  back  by  anoihi-r  at  plav.  in  a  pr!  from  a  boy  jnmpine  im  Ui 

in  a  ImI  by  anolhi-'r  fttriking  him  on  liic  buck  by  running  a 

wt  him;  aod  Ueid  mentions  a  caae  produced  by  the  stroke  of  a 


1 


TETANUS — CAUSES.  61 

vhip ;  but  ID  tbe  great  majority  of  cases,  it  is  directly  occasioned  by  a  toound 
uf  suDie  kiod.  G^Derally  a  oerTous  twig  lias  been  lacerated,  divided,  or 
iaflaiDcd ;  and  this  seems  to  have  been  the  startiDg-point  of  that  disturbance 
uf  tbe  spiDa]  system  of  nerves  which  leads  to  the  tetanic  spasms. 

Tbe  kirtd  of  wound,  as  well  as  its  situation,  doubtless  influences  materially 
tbe  occurrence  of  the  disease.  Though  it  certainly  more  frequently  follows 
punctured,  torn,  and  lacerated,  than  clean-cut  wounds,  yet  it  occoBtonally 
eDiDpliotes  these,  even  when  they  are  made  in  surgical  iiperations;  thus,  it 
has  been  known  to  follow  the  removal  of  the  breast,  amputation,  the  liga- 
ture of  the  larger  arteries,  and  the  operation  for  hernia.  1  he  minor  surgical 
operations  also  are  not  fi«e  from  the  potsibility  of  this  dangerous  complica- 
tMQ.  It  has  been  observed  after  the  operation  for  fistula  in  ano,  the  ligature 
of  piles  and  varicocele,  the  removal  of  natal  polypi ;  and  I  have  seen  a  fatal 
ease  resulting  e%'en  from  the  introduction  of  an  issue.  Burns  are  peculiarly 
liable  tu  be  toltowed  by  tetanus.  It  is  the  common  belief,  both  in  tLe  pro- 
l»iun  and  out  of  it,  that  wounds  of  the  hands  and  feet,  and  more  especially 
of  ibe  ball  of  the  thumb  and  of  the  great  toe,  are  more  likely  to  be  followed 
by  tetanus  than  those  in  other  situations.  I  think  the  truth  of  this  opinion 
nay  be  doubted ;  though  it  is  not  improbable  that  tetanus  may  occur  more 
frcqoeotly  after  injuries  of  these  regions  than  of  other  parts  of  tbe  body, 
■Dpiy  because  punctured  and  lacerated  wounds  are  more  common  here  than 
elaewbere.  It  cannot  well  be  supposed  to  be  owing  to  the  tendons  and  fasciae 
that  abound  here,  as  Hunter  imagined ;  fur  it  is  seldom,  if  ever,  met  with 
after  operations  for  tenotomy,  which  are  so  commonly  practised  on  tbe  feet. 

Tbe  statistics  of  the  American  Civil  War  are  very  complete  on  this  point. 
Of  oOo  cases,  21  followed  wounds  of  the  head  or  neck,  55  of  the  trunk,  137 
of  tbe  upper  extremity,  and  292  of  the  lower.  Of  the  137  wounds  of  the 
■pper  limb  which  were  followed  by  tetanus,  all  but  4  were  above  the  wrist ; 
aad  of  tbe  292  of  the  lower  extremity,  only  57  were  of  the  foot.  These 
siuifltics  do  not  therefore  justify  the  popular  belief  that  wounds  of  the  hand 
mmd  foot  are  particularly  prone  to  be  followed  by  this  affection. 

TelADUs  may  occur  in  all  conatitutiotu — in  the  strong  and  robust,  and  in 
tbe  feeble  and  emaciated.  It  is  especially  apt,  however,  to  occur  in  feeble 
aod  debilitated  individuals,  and,  indeed,  may  be  looked  upon  as  a  disease  of 
debility:  hence  auy  condition  that  lowers  the  tone  of  the  nervous  system  is 
especially  likely  to  occasion  iL  When  it  occurs  in  persnos  who  are  other- 
wise stmtig  and  in  the  prime  of  life,  it  will  be  found  that  they  have  been 
expD«e<i  tu  causes  of  depression  influencing  the  nervous  system.  It  is  lose  of 
nervous  tone,  and  not  muscular  weakness,  that  di8j>oBe8to  this  disease.  Thus, 
in  tr>>pical  clinrates,  as  in  some  of  the  West  India  Islands,  and  amoDget  the 
iBai%h««  of  Cayenne,  it  occurs  with  peculiar  frequency,  the  most  trifling 
tcratcbes  or  punctures  being  followed  by  the  disease.  Polaud,  who  has 
esbaU5ted  the  statistica  of  tetanus,  states  that  the  mortality  from  it  is  in  Lod- 
<kia  .*X£-\  whereas  in  Bombay  it  causes  2.5  per  cent,  of  the  total  deaths.  It 
it  intere^itiDg  to  observe,  that  the  natives  of  hot  climates  are  far  more  liable 
tu  this  disease  than  Europeans  resident  there.  In  the  American  Civil  War, 
'4.1  per  cent,  uf  the  cases  occurred  amongst  the  negro  troops,  who  furnished 
only  -.7  per  cent,  of  the  b>tal  number  at'  wounds. 

lu  miiit'iry  praetiee  tetanus  is  of  common  occurrence.  Its  frequency  varies 
much  in  dittervut  cam]>aigos  and  uuder  different  circumstances,  aeauon,  and 
dimate.  In  the  Peninsular  War,  it  was  estimated  to  occur  iu  the  proportion 
■jf  aitirtit  one  case  in  every  200  wounded ;  in  the  Schleswig-Holstein  war  of 
I»4!*.  accunling  to  Stromeyer,  once  in  about  liaU  cases.  In  the  Crimea  it 
^»pvar«  to  have  been  of  rare  occurrence.  Alcock'a  estimate  of  ime  to  every 
TV  wounded  is  evidently  too  high.     In  the  American  war  it  occurred  in  0.2 


DtBSABEB   OP   THE    NERVOUS   SYSTEM. 


oenL  u(  ibp  wouihImI.  A  ftcr  naval  eoKagemeDta,  however,  tho  nmrUlity 
utVri  b«*n  high,  ntort-  particularly  it"  Un-y  hnve  lalccii  placf  tu  tr<>[iu-ftl 
rliniiitrs.  8ir  G.  Blune  state*  that,  alier  limloeyB  a«lii>u  iu  tliv  Wcvl  liiiUe*, 
nut  ut'  ^10  ntiuiuleil  'Jft  were  aitackeii  with  (eUiniiB,  beio);  ornf  iit  4U-  All 
Kiirri)iettti  Army  Siirt^euii?  are  ngrei^l,  thtit  Mjd'icn  vhaogvs  I'runi  hcnt  lo  ruld 
are  aiii(>n};»L  tli>^  nii«t  t'reqiieutruui^iMi  uf  teUnu*  MinoDg»l  (h«  wouixJed.  Thua 
Larrvy  slali?»  that,  slier  the  hattle  *>f  Mmkuwu,  iillliou^li  thr  ttuiiibrr  itf 
wuiinaeil  wn«  immense,  there  were  few  c«w«  uf  telsuus.  Ili«  heiil  being  rery 
jitreal  and  coutiouDue ;  whilut  afUr  Bautxeu.  where  the  wuuud(;4  wens  JeJl  ua 
ibv  lJel<i  all  oi^Ul  ex|KM«<l  to  ncvvre  culd.  mure  thou  100  had  tvtuniie  ;  Rod 
alter  the  butllc  ut'  Drcadeo,  when  great  lieMt  was  Julluwed  by  tuiicb  wet  awl 
ci'ttl.  the  wouuiled  euHeritl  muat  severely.  Ho,  alter  buiiil-  uf  the  Imlian 
baltle«,  «e  Chiliauwallnh  and  Feruzej^vre,  wherv  the  wuuiitled  lay  vxpuoetl 
to  cmM  nights  tiller  very  ln^t  days  iMacleud),  teuuua  was  tif  very  rre4iiet)l 
oceurreoee.  The  caee  a(>|>e«rB  to  have  Iteeii  difTereut  in  America,  when 
letuuua  duea  nut  Reeni  to  have  aritfen  I'ruiii  ex|io9ure  ut'  the  w-'uuded  tu  culil 
antl  ni)^ht-air.  ('hishulin  staleti  thai  aUhuu]i;li,  from  the  vvtxxleil  nature  of 
llie  Country  in  which  the  balties  wer«  ul'ten  lought.  wuiiniled  luen  werv  not 
unlrefinently  left  for  two  or  ihree  days  uu  thi*  gruuud,  lelanui;.  did  not  appear 
to  h«<  ninni  fre^iuent  aniou>rHt  ihent  than  in  th(«e  immediau-iy  <-areil  fur. 
Hennt-u  Hiulea  ilial  u  draught  uf  air,  wbellier  but  or  culii,  direuil^  bluwiag 
on  the  |iatient,  is  the  ni<»c  Ji^rtile  cause  of  tetanuB. 

Ttif  iri>queui7  with  which  tenaaua  ocrura  varies  much.  It  oflca  happens 
that  mil  one  cane  octrurs  in  a  hije|iical  fur  HOine  years,  ami  then  several  an 
riiLT  with  in  clow  BUccceaioit  or  iiiniultaoeouAly. 

I*i:hioi>  up  0(xt;KKKNCN. — Tetanus  mar  tiike  place  at  any  jieriod  after 
the  inrtictiun  of  the  wnund  that  ocuaeknu  iL  In  ont  climates  especially,  it 
umy  oeciir  very  r|>e«dily ;  thus,  liobinaon  relaten  ibe  case  nf  a  negro  serraot 
in  the  West  Iiiditw.  who  mnitobed  bis  finger  with  a  bntkeu  plaie,  niid  died 
lit'  tetanuit  in  n  ipiarier  ot*  an  hiMir.  U  ia  very  Mldom,  Imwever.  in  tetuper-j 
ute  clinintrtt.  that  it  enitervenea  be/ore  the  fourth  or  fil^b  lUy.  uaually  ^^40^1 
thai  to  the  tenth  day.  I^arrey,  who  had  great  es[MTienire  uf  tbb  diaMH^ 
(luring  NHiKt](>^>n'«  campaign!  iu  F'g>'pt,  met  with  it  ni<«t  fre<iiientlY  between 
the  tilth  unii  litteenth  dayo  alter  the  inHiotiou  of*  the  wound.  At/cordiog 
to  ibf  experienw  ut'  the  Snrgeonn  of  the  Peninsular  War,  under  wbu«e  ob- 
wrvnlioii  iiiHiiy  hundred  auea  came,  the  tliiteaiie  does  not  i>>h>iw  it««lf  alter 
the  twenty •iM-cinid  day ;  but,  though  tbi»  may  be  the  general  rule.  Sir  G. 
Blune  ha»  ndiiied  a  raw  in  which  it  took  place  M  late  n»  a.  month  after  lite 
intliclion  of  the  wound.  It  ia  Ntated  that  il  may  take  place  after  the 
cicnlriyjitiiin  of  a  wound  h  completed  ;  when  thin  liappena,  the  diaeiuw  niuat 
rather  be  lo<>ke«l  u[kiii  an  Itring  idio)iaihtc,  accidentally  occurnng  tn  a  {ler- 
sun  who  luiH  l)^n  recently  injured. 

In  Ibe  American  War  uut  *<(  dlST  caaes  in  which  the  day  of  appearmiic« 
nf  the  dixeai^  »  not4-<l,  it  lollowc<)  secondary  amputation*  iu  iwenly-ou«caMa 
during  Ibe  lintt  day  alter  the  o|M-ruti<»i ;  and  in  nix  it  appeai'oil  m  llie  firat 
tweniv -fKiir  luxir*  alV<r  the  original  Wound.  Aller  tbui  but  few  case*  ap- 
praru«'l  till  tlic  tilth  dnv,  when  I!^  arc  reo^rdcd.  The  highest  number  waa  3(, 
on  the  eighth  day,  nmf  by  the  litteenth  day  ibr  number  leil  to  G.  tieveo  raann 
occurml  between  thr  '.*t>th  and  '<ii*lh  dayn,  nud  )iZ  after  the  end  uf  ibv  nuotb. 

Futuia. — Tetanus  may  l>evlr«(<«or  ('Aronir;  being  in  foiue  inatauca  fatal 
in  the  ctHirvc  ot  a  lew  houm,  but  uaunlJy  lusting  lor  three  or  fotir  daya.  Po- 
land fiiaiea  that  at  (.luy*  6l  (ler  rent,  ot  Ihr  caaes  were  fatal  liefure  tb«  fiiUi 
duv  alter  iavn^inn.  In  llie  AtucHran  War,  out  ol  -i^t*  cnset,  1  rrcorcred  and 
61*  dad  during  (he  hrvl  day;  I  recoverrtl  and  ^3  died  on  Ihvpecotid  day; 
•If  da-d  00  Lbo  third;  31  on  the  lourtb ;  'JU  *m  th«  filth;  19  ua  tb« aixtk. 


TETANUS — STHPTOHS.  68 

uid  14  OD  the  seveotfa,  and  7  od  the  eighth  day.  Thus  of  the  acute  cases 
2,  evidently  slight  in  character,  recovered,  and  294  died  before  the  eod  of 
the  ei^th  dar,  and  ia  203,  or  more  than  half,  the  disease  did  uot  exceed 
ibree  days  in  duration.  From  the  ninth  to  the  nineteenth  day  inclusive,  36 
died  and  6  recovered ;  from  the  twentieth  to  the  twenty- seventh  inclusive, 
7  died  and  7  recovered,  and  6  survived  beyond  the  twenty-seventh  day  and 
SoallT  recovered.  The  longest  period  during  which  tlie  disease  la^ited  was 
fortT'nine  days.  These  interesting  statistics  coiitirm  the  view  that  the  mora 
cfantoic  the  disease  becomes  the  better  is  the  diance  uf  recovery  ;  indeed,  if 
the  patient  survive  the  tenth  day,  the  prospect  of  a  favorable  issue  to  the 
case  ia  materially  increased.  As  a  general  rule,  those  cases  are  the  most- 
&tal  which  are  most  active  in  their  syniptonis ;  danger  being  in  the  ratio  of 
the  acuteness  of  the  attack,  both  as  to  severity  and  also  as  to  rapidity  of  in- 
vasion after  injury. 

Symptoms. — ^The  invasion  of  the  disease  is  sometimes  preceded  by  a  gen- 
eral uneasiness  on  the  part  of  the  patient,  a  feeling  of  illnese  or  weakness, 
or  a  sense  of  im[>ending  mischief.     Abemethy  was  of  opinion  that  tetanus 
was  usually  ushered  in  by  a  disturbed  state  of  the  digestive  organs,  the  stools 
being  offensive  and  indicative  of  much  gastric  irritation.     When  the  disease 
sets  in  gradually,  it  may  be  somewhat  difficult  of  recognition  in  its  early 
Maga ;  if  it  come  on  suddenly,  its  nature  is  immediately  evident.     It  is  a 
reiuarkable  fact  that  the  cramps  do  not  begin  in  the   part  injured ;   but, 
wherever  this  may  be  situated,  they  are  always  first  noticed  in  the  muscles 
of  mastication,  of  the  face,  and  upper  part  of  the  neck ;  and,  throughout, 
these  aod  the  muscles  of  respiration  are  principally  affected.     In  tetanus, 
the  circle  of  nervous  disturbance  is  at  first  very  limited.     It  is  confined  to 
the  muscles  supplied  by  the  motor  branch  of  the  fifth,  by  the  portio  dura 
of  the  seventh,  and   by  the  spinal  accessory.     These  nerves  appear  to  be 
alone  afected  ;  the  sensory  division  of  the  fifth  is  never  influenced  through- 
oat  the  disease.     The  spasm  may  be  confined  to  the  muscles  supplied  by 
these  oerres,  as  is  the  case  in  trismus ;  but  it  soon  spreads  to  the  true  spinal 
aerres,  being,  however,  confined  to  their  motor  divisions.     The  first  symp- 
toms uiiually  consist  in  the  patient  feeling  a  stiffness  or  soreness  about  the 
iaw^  aud   throat,  being  unable  to  open  his  mouth  widely,  to  take  food  or 
drink,  the  muscles  about  the  temples,  jaw,  and  neck  feeling  stiff  and  rigid  ; 
(ht»  o-'Ddition  has  given  to  the  disease  the  popular  term  uf  lock-jaw    Aa  the 
aflectii>n  advances,  the  countenance  assumes  a  peculiar  expression  uf  pain 
and  anguish,  the  features  are  fixed  or  convulsed  from  time  lo  time,  and  the 
ugl*%  of  the  mouth  drawn  up,  constituting  the  appearance  called  risua  »ar- 
lionin^.     When  fairly  set  in,  the  disease  is  marked  by  spasms  of  the  volun- 
tary ntuivles  of  the  most  violent  character,  with  much  pain  and  only  partial 
retois^ions.     The  pain  is  of  that  kind  that  attends  ordinary  cramp  in  the 
Riuscl*^.  as  of  the  legs,  and  is  usually  very  severe.     The  spasms  are  of^eu 
jr-rkiug.  the  patient  being  suddenly  thrown  up  or  twisted  on  one  side ;  the 
breath  is  drawn  with  a  loud  sobbing  catch  from  spasm  of  the  diaphragm, 
ud  fjn>m   the  iwme  cause  there  is  usually  violent  pain  experienced  in  the 
epigastric  region,  darting  across  to  the  spine.     Tbe  muscles  uf  the  trunk  are 
tteually  affected  next  in  order  of  frequency  to  those  of  the  head  and  oeck, 
th«  b<Wy  being  bent  backwards  so  as  to  form  a  complete  arch  I  Opisthotonoe)  ; 
m->r¥  rarely  it  is  drawn  forwards  ( Emproetholonoe) ;  and  slitl  less  frequently 
Ui  one  fcide  {MeurotthotoHOg).     In  some  cases  the  body  becomes   perfectly 
rizi'l,  like  a  piece  of  woo*i,  the  belly  being  drawn  in,  an<l  the  cheet  expanded. 
It  u  oaid  that  in  severe  cases  the  spasms  have  been  so  violent  that  muscles 
bave  been  ruptured,  teeth  broken,  and  the  tongue  lacerated.     In  the  num- 
truus  cases  of  tetanus  that  I  have  unfortunately  witnessed,  it  has  rarely  fallen 


64 


UIBKASBS   or   THE    KEnVOCS   SYSTKK. 


to  mv  l<jt  to  tee  any  rtTecU  of  tliw  kiii*l  |>ru«iticc<J ;  ttic  epasms,  iudccil.  t>ciD^ 
in  geueni  uot  verjr  viulcot,  ibuugli  cutiuuuoua  aitd  very  paiulul.  The  uoljr 
nuHclea  thai  I  liavc  aceu  luru  faavb  been  ttie  recti  of  the  alxlomcri. 

Tii«  iotcJleutual  facultits  arc  not  tliBiurbtiil,  anil  ttie  niiuti  cfjiitinuc*  c\eu 
tu  tbe  last.  Ca«ee  uf  tetuiu«  ucuaaiuaally  prove  &t«l  wjlliuut  auy  elevatioa 
of  icmpcruture ;  but  id  iuuhc  iti«taai.-vs  ttiere  are  grt'at  lieut  of  surfatv,  firth 
fuK' awfubs  Biifl  quickutiBBof  jtulae;  uutsoniuch  from  any  febrile  (ItsLurliaiicr, 
but  u[)pur«iilly  I'runi  tbe  vmleuce  ui'  the  muscular  cuotractiuna.  In  muet 
van-n  UiiH  fljiupUiiu  is  peculiarly  uiarktnJ,  ee]iecially  towards  the  end  nf  ihn 


ca»(?.  when  Lbc  lemperatnre 


<  may  rspiillv  rise  to  extraurdlnary  herehls. 
a  case  in  which  it  reached  l)2.'>&''  r'ahr.  i 


Tbns. 


dialflv  In  ti.r.'  .leaih.  It  may  riw  u  lew  lonthauf  a  degrw"  bigluT  after  death 
ill  lUt.'f  i\.-t'-.  The  jimlon/ation  ul'life  appears  to  depend  ^Tt^Atly  ii|H>n  the 
ioleuaily  oj'tlie  convulsive  luoveineots:  the  more  aerere  thfse  art',  the  (tomer 
does  death  result  The  fatal  termination  oocurs  not  so  much  from  any  ^reat 
phynical  li'siitti,  or  disturhaui-e  of  imiiortaut  porta,  as  {rom  exhausliun  ooo- 
acauetii  on  the  freouency  of  the  teimiic  spaftnu. 

PATnoEXKiv. — 'Ihere  in  surely  nothing  more  reiiuirknbl«  in  lite  wbol* 
liisiory  of  dtaease  than  that,  in  c<»ise(jueocie  of  a  trivial  wouu'l  inHictexi  on  a 
distant  part  of  oite  »t'  tbe  extreiuitie«  of  tlie  body,  an  uthirrwim  apfiarf-utly 
healthy  nian  should  be  seised  with  a  spa8mo<iic  arfecttoii  of  the  muM'lva  of 
the  jatrs;  that  this  apasm  should  extend  to  the  trunk  ;  and  that  after  a  few 
hour*  it  fliiould  1m*  tallowed  by  general  conTuUive  lunvemenls  which  will,  in 
tiie  ([real  majority  xf  instances,  speedily  end  in  death.  It  might  reaiMiuably 
be  ex^H-rtt^l  ihxL  xueh  a  train  of  pheooiueua  would  leave  the  niovt  unrai*- 
takablv  fviduiR-en  of  the  conditions  that  bad  given  risp  to  theiii  ;  and  that 
IJHili<>li>t|;ietil  HUMluiiiy  would  »l  onoe,  ao<l  in  tbe  cleAreat  inuitnvr,  tenable  us 
l»  iinnivel  thf  myrtlirious  liouds  that  connect  a  graxi.*  of  thv  fuoi  with  a 
Mtnnni  of  the  uiuMrle*  uf  the  neck  itnd  jaw.  But  in  tbia  mv  ebiill  tte  f;rievouely 
uiM(p[M>i tiled  ;  for  tliv  morbid  appearances  found  alUr  death  from  tetanus 
thn>n'  but  little  light  on  Ui«  real  nature  of  tbU  atfection, — «o  little,  iude^, 
that  it  bas  been  Irequently  described  as  a  "  funcliuunl  dieetuuL"  But  in 
anyiug  that  this  ur  any  other  disease  b  fuuctioual.  we  express  only  our  ignor- 
ance of  ita  real  cause.  There  is  no  lunetiou  without  au  organ  to  perform 
it ;  and  there  can  b«  no  darangetucut  of  a  tunctiuu  without  a  corrvHponding 
and  cuucuumant  disorder  of  tbe  organ  that  produces  it.  iDvery  Tunclioiuu 
diaaaM  must,  therefore,  at  last  be  reterrod  to  an  organic  lesiuu.  Tbe  term 
"Ibnctiuual"  la  employed  only  when  we  are  not  acquainted  with  tlie  true 
nuturu  of  tiK?  dipt'iue.  As  le«  n  knowrn  of  tbe  real  physiulaffy  and  paLhulogy 
of  liif  bruin  and  ttpinal  cord  liMn  of  other  organt  of  [he  thMlr.  we  have  oiura 
"  futii'ttonul "  dti^'iuiee  uf  the  nervous  sy»tcni  than  of  the  circutatory  ur  re- 
ajiiraiory.  But,  as  pathological  nnatumy  becomes  more  atudit'd,  and  ■■ 
intnutu  luvCKtigatioU!)  into  structure  are  eutored  upOB.so  the  chias  uf  so-eallad 
"  funcliuiial "  diseates  bccoiua  narrower.  We  do  not  •}>eak  of  "  funottan^  " 
ouuiu,  because  we  can  appreciate  the  didercnt  conditions  thai  occauoa  oo»- 
prabiiui  of  ibe  brniu  ;  but  w«  siill  sometimea  apeak  ul  lunrtional  cuoTaliiva 
atHaiMs  and  of  functional  amaureaia.  The  opblbalniusc^ipe.  however,  has 
shown  thai  "  lunotional"  amaurwdt  does  one  eotiel,  but  thai  the  &ilure  of 
visual  power  b  always  dependfnt  on  eume  change  of  simciuro  in  the  interior 
of  ihv  eye;  and  advances  in  pathology  nill  doubtless  show  that  other  m^ 
called  funeuunal  disesuea  uf  the  nervous  f^stem  are  in  realitv  dcpendeai  oa 
Mirurturwl  Iftiona. 

Sutc  of  the  VoTTM  At  tht  Smt  of  I^|vy.— There  is  one  morbid  ooikH*^ 
Ltun  t]iaL  will,  I  tliiuk.  invariably  be   foond  in  tetanus,  vIl.  a  marked 
IfCBtioo  and  inflaoimatioa  of  the  narv*  «onn«cied  with,  and  l««ding  froea. 


TETANUB — FATHOLOOICAL    CHANGES    IN    CORD.  65 

tbc  woand  that  bu  occanooed  the  diseaee.  Tbis  morbid  state  I  have  never 
found  wantiDg.  In  all  cases  of  &tal  tetanus  that  I  have  seen  in  which  a 
careful  dissection  has  been  made,  the  Bigos  of  infiammation  of  a  nerve 
eonuBunicmttng  with  the  wound  have  been  found;  and  the  vascularity, 
which  is  often  very  intense,  may  be  traced  up  the  neurilemma,  often  to  a 
OKiriderable  distance.  In  a  case  of  tetanus  following  a  wound  of  the  knee, 
in  a  pfttient  who  died  in  University  College  Hospital,  a  small  branch  of  the 
internal  cutaneous  nerve  was  found  to  have  been  injured,  and  was  inflamed. 
In  another  patient  who  died  of  tetanus  about  sixteen  days  aiter  treading  on 
a  rusty  nail,  a  black  speck  was  found  on  the  internal  plantar  nerve,  wnere 
H  bad  been  wounded  by  the  nail.  In  a  man  who  died  of  acute  tetanus  a 
week  after  receiving  a  lacerated  wound  of  the  dorsum  of  the  foot,  the  digital 
nerves  were  found  to  be  sloughy,  and  evidences  of  inflammatory  irritation 
extended  some  distance  up  the  musculo-cutaneous  nerve.  In  another  case 
under  my  care,  in  which  tetanus  resulted  from  a  bruise  of  the  back,  and 
terminated  in  death,  the  injured  nerve  (a  dorsal  branch)  was  found  lying 
bare  and  reddened  in  the  wound ;  and,  on  tracing  it  up  to  the  spinal  cord, 
iu  sheath  was  found  to  be  much  injured  and  eccfaymosed.  In  another  in- 
stance, in  which  tetanus  followed  a  wound  of  the  wrist,  the  external  cutaneous 
nerve  was  found  in  a  similar  inflamed  state. 

Tlie  Pathological  Conditions  found  in  the  Spinal  Cord  in  cases  of  tetanus 
have  been  studied  by  Rokitansky,  Lockhart  Clarke,  Dickinson,  and  Allbutt. 
Bokitansky  described  them  as  consisting  chiefly  of  a  proliferous  development 
of  connective  tissue,  composed  of  young  celts.  Billroth  doubts  the  correct- 
new  of  this  observation ;  and  many  competent  observers  have  failed  to 
discover  anything  more  positive  than  ecchymosed  patches  and  interspaces  in 
the  spinal  medulla.  Lockhart  Clarke  has  in  at  least  six  cases  ooserved 
lesions  of  structure  in  the  spinal  cord,  consisting  of  disintegration  and  soften- 
ing of  a  portion  of  the  gray  substance  of  the  cord,  which  appeared  in  certain 
parts  to  be  in  a  state  of  solution.  The  fluid  thus  formed  was  in  some  parts 
granular,  holding  in  suspension  the  fragments  and  particles  of  the  disinte- 
grated tissue,  but  in  many  places  it  was  perfectly  pellucid.  He  considers 
ihb  due  to  hypersmia  of  the  cord,  accompanied  by  exudation  and  disinte- 
gration. Dickinson  has  described  intense  hypenemia  with  a  structureless 
exudation  poured  out  around  the  vessels  in  many  parts  of  the  gray  matter, 
breaking  down  the  surrounding  tissue.  He  observed  also  some  hemorrhages 
in  the  «rbite  columns.  These  observations  have  been  confirmed  by  Clifford 
Allbutt,  but  the  exact  significance  of  the  changes  observed  is  still  uncertain. 

The  absence  of  any  constant  and  distinct  patnol(^ical  lesion  has  led  to  the 
hypothesis  of  tetanus  being  dependent  primarily  on  blood-poisoning,  and  not 
•iO  a  lesion  of  the  nerve-centres.  Billroth,  who  inclines  to  this  idea,  admits 
that  it  is  a  mere  hypothesis.  This  theory  of  blood-poisoning  being  the  pri- 
mary cause  of  tetanus  is  based  on  the  following  line  of  argument.  A 
chemical  substance,  capable  of  producing  convulsive  moveraeuts  when  it  is 
abii>rbed  into  the  blooa  by  its  action  on  the  nervous  centres — of  acting,  in 
fisct,  like  strychnia — may  be  supposed  to  be  generated  in  certain  circum- 
Kaoces,  whether  due  to  some  individual  predisposition,  or  to  some  peculiar 
fermentative  process  in  the  discharges  of  the  wound  or  at  the  seat  of  injury. 
We  have  the  analogy  of  hydrophobia  in  support  of  the  idea  that,  in  certain 
circumstances,  such  an  agent  may  be  generated  in  the  system,  rendering  the 
fluids — blood  and  saliva — poisonous  to  others,  and  capable  of  developing  a 
courulsive  disease  in  the  animal  affected.  We  have,  bowever,  no  evidence 
as  yet  that  the  blood  or  any  one  of  the  secretions  of  a  tetanic  patient  is 
capable,  when  inoculated,  of  producing  a  similar  disease  in  a  healthy  animal. 

There  ia  one  objection  to  this  theory  which  appears  to  me  too  serious  to 

VOL.   II. — 5 


w 


DISEASES   or   THE    XEBVOfS   STSTBJI. 


be  overlooked,  viz.,  thai  tetanus  hu  been  arrested,  if  not  curnl.  h^  Uk 
diraion  of  the  principfll  iiervuug  trunk  lesdinj^  from  the  seat  of  injury,  M 
tbe  pOAterior  tibial  nervi-  in  caM»  of  tetanus  arbiuv  fn>ai  wouml  of  ibe  «•■!« 
of  tllQ  foot.  Tbiii  fact  a|)[)eAiB  to  m«  to  jxiiiit  ratlipr  to  »  primary  uervout 
IcAioti  than  to  bliMMl-pittimiiiii];  a»  tht  exciting chusv  of  tliv  tHtanic  cuiivtilnioOA. 

TltEATMKST. — Tbe  trcatiiit>i>t  of  U'lnniis  if  of  a  l»cai  aud  of  a  tMinfttltU" 
tioim]  c!iamrt<T.  The  Local  Treatment  ha^  tor  ita  object  the  remuval  of  the 
irritatioD  that  liaa  imluced  the  lutanic  conditiuD.  It  is  true  that,  whvn  oitor 
tetJUUC  excitement  htu  be«u  »et  up  in  tb«  I'onl,  il  has  a  tvndencv  t«i  c"a- 
tione,  and  to  be  iucapiablL*  uf  removal  bj  tbe  mere  abftmolion  or  tfcsaattoa 
of  tliu  local  irrltnliou  which  gave  rise  to  it  in  the  6tvt  ta»taace.  Il  iv. 
buwevu',  odIv  reaaonaUIe  to  BUppoee  that  other  treatueoL  will  succeed  beet 
if  local  irritation  be  removed  ;  and,  indeed,  »o  long  as  Chis  continues  to  keep 
up  the  centric  uej^'ous  diBlurbance,  no  general  means  cau  be  expected  to 
niccced  ;  aa  they  n-ill  have  not  only  to  combat  already  exiitiog  diaeaae.  but 
also  to  overcome  the  continuous  excitement  maintaiuod  by  thelooiil  dbtoHt- 
aaoe.  Hence  il  in  of  ini)>>>ruincc  tu  bring  tbe  wound  into  as  heallby  a  state 
as  pceafale,  and  to  see  that  il  is  cleoii,  free  from  torc'T?ii  bodiea.  and  dbI 
inflamed.  In  order  effectually  to  remove  all  local  disturbance,  rMoum  hai 
beeo  bad  to  anipiitntion;  but  though  ihig  may  have  succeeded  in  chockioe 
some  of  the  more  chronic  forniD  of  [he  dieeiieo,  yet  oilier  and  milder  local 
moana  have  sufficed  equally  well,  and  in  iho  majority  of  coat*  it  ha^  had  ae 
efl^t,  and  henoe  bo  severe  oo  operation  can  scarcely  be  recommended  for 
adoption.  The  division  of  the  truak  of  the  injured  nerve,  at  some  di»tanoe 
above  the  wound,  if  there  be  one  that  bae  becu  punctured  or  taoerated,  ha* 
occaaonatly  proved  8uecca§ful.  Thuii,  iu  a  caae  of  tetanus  following  iojurv 
of  the  guprnorbital  nerve,  Larrey  cut  ihi«  at-roea,  and  ihe  patient  recovered. 
lo  a  midshipman,  id  whom  tetanus  came  on  the  day  after  the  eole  of  the  foot 
had  been  wounded  by  ireadiog  on  a  rustvuail,  Murray  divided  the  posterior 
tibial  nerve,  and  ihe  patient  f^ot  well,  to  ilio«c  case*  in  which  no  special 
nerre  appears  lo  hav*;  iax-u  injured,  Lijtio)i'!i  n-coiumendaiion  of  making  a 
y\-aluipe<l  incision  down  to  the  bout.-,  and  above  ibe  part,  »«•  as  to  iiuulale  il 
compk'Iely,  may  be  advantageously  followe«i.  After  the  nerve  ba»  Iweo 
divided,  or  the  i>an  pniperly  insulated,  gome  solution  of  atropine  inuy  be 
carefully  apjilied  to  it,  so  as  stilt  further  t^)  leeeen  local  irrJtalion.  lu!>t«ad 
uf  dividing  the  nerve  leading  from  the  source  of  irritatioo,  it  has  l>een  »ug- 
geited  thai  Uie  ofteration  of  stretching  should  be  performed.  This  baft  been 
done  in  a  conniderahle  number  of  cases,  and  as  with  every  other  of  the  voora 
uf  reme^liefl,  lucal  tuid  consLilntioiial.  that  have  been  recommended  for 
tetanus,  recovvriuef  have  taken  place  after  its  employmeni.  On  Lbe  other 
hand,  in  acute  oues  it  has  proved  us  impoteot  as  the  rest. 

In  tlie  OoDsUtatiODal  Treatment  of  the  disejise.  it  is  neceaury  to  bear  In 
mind  that  teUtnuM  is  an  affection  of  dchilily,  the  violence  of  the  spasmodic 
poruxyamfl  giving  an  appearance  of  false  strength  to  tbe  patient;  and  that 
the  pnnoipal  source  of  danger  aoti  death  is  the  exhaustion  induced  by  the 
enrtrio'  of  the  muscular  muvcments.  The  mmnti  adopted  should.  ibetvJore, 
have  for  ihuir  object  tlte  removal  of  irrilfition  aud  the  support  of  the  patient's 
strength,  so  as  to  enable  him  to  hold  up  against,  the  dbeaae. 

Nothing  can  be  more  unMati«factorv  than  the  ireatmeiit  of  tbe  Atmie  form 
uf  traumnlic  tt'tnnus.  In  it.  nil  medicines  are  ueeleM  as  curnUre  agent*. 
Hut.  though  meijicim's  are  of  no  avail  us  means  of  cure,  they  may  act  as 
palliativ{«,  and  sHonl  relief  to  the  jiatieai;  and  much  may  be  douu  by  the 
£>urgeoi).  by  removing  all  sourceti  of  eilenial  irriuition,  ti>  mitigate  bis  aulfer' 
[Sngi,  and  to  place  him  In  a  favonthli'  condition  to  withstand  tlie  cKhauniion, 
and  |o  Ifwien  tbe  lonure  of  the  ftpiunn.     With  this  view,  th<'  first  thing  lo 


I 
1 


TETANUS  — TREATMENT.  67 

be  done  U  to  clear  the  bowels  out  well  with  an  aperient  dose;  aided,  if 
oecw— ry,  by  a  turpeotioe  enema.  The  patieDt  should  theu  be  kept  perfectly 
i^uiet  ID  ■  room  by  himself,  a  ecreeo  or  muslin  curtains,  as  recommended  by 
Marshall  Hall,  being  drawn  round  the  bed,  as  noise  or  movement  of  any 
kind  iocreaaes  the  spasms  greatly.  In  order  to  allay  the  spinal  irritation, 
the  moat  efiectual  means  consists,  perhaps,  in  the  plan  recommended  by 
T'^dd,  of  applying  ice  along  the  whole  length  of  the  spine;  this  is  best  done 
by  a  caoDtcnouc  spine-bag.  This  is  a  powerful  depressing  agent,  and,  unless 
care  be  taken,  may  lower  the  heart's  action  too  much,  or,  indeed,  completely 
extiDguisb  iL  It  may,  however,  be  applied  with  safety  for  six  or  eight 
hours,  the  condition  of  the  patient  being  looked  to  in  the  meanwhile.  Seda- 
tive or  antispasmodic  agents  are  of  no  use  whatever  in  acute  traumatic 
tetaniu.  I  have  seen  many  drugs  of  this  kind  employed  without  producing 
any  e&ct  in  lessening  the  violence  of  the  convulsions.  In  most  cases, 
however,  the  inhalation  of  chloroform,  or  the  administration  of  chloral, 
materially  lessens  their  severity,  and  gives  the  patient  at  least  temporary 


In  the  Subacute  or  Chronic  form  of  the  disease,  recovery  is  much  more 
likely  to  take  place ;  and  it  is  only  in  these  cases  that  antispasmodics  and 
aedatives  bare  been  of  use,  and  in  these  also  chloroform  and  chloral  are  far 
iu<>re  beneficial  than  in  the  acute  cases.  There  is  a  kind  of  trismus  occur- 
ring in  females,  often  of  a  hysterical  nature,  which  is  at  once  removed  by 
the  inhalation  of  chloroform.  Almost  every  drug  in  the  pharmacopoeia  of 
m  tonic,  sedative,  or  antispasmodic  nature,  has  been  employed  in  tetanus ; 
aod  the  recovery  which  has  occasionally  resulted  has  been  perhaps  over- 
haetilv  attribute  to  the  remedy,  rather  than  to  the  employment  of  those 
dietetic  and  hvgienic  means  which  are  of  the  6rst  importance,  by  enabling 
the  patteot  to  live  on  until  the  disease  wears  itself  out.  Tunics,  especially 
irai  and  quinine,  have  been  employed  by  some.  Elliotsou  was  strongly 
imprened  with  the  value  of  the  carbonate  of  inm,  Sedatives  in  nil  forms — 
oonium,  belladmina,  opium,  and  their  alkaloids — have  been  largely  and  most 
ineflectoally  employed.  Miller  speaks  highly  of  cannabis  indica  pushed  to 
narcotism,  three  grains  of  the  extract,  or  thirty  minims  of  the  tincture,  being 
pveo  every  half-hour  or  hour;  and  Ilaughtoii  has  employed  nicotine  in 
one-^lrop  duses,  administered  every  second  hour,  with  complete  success  in 
severe  cases  of  traumatic  tetanus. 

The  (.'alabar  bean  (^Phi/gogtigma)  is  the  remedy  that,  perhaps,  deserves 
physiologically  the  most  attention ;  for  as  it  is  nearly,  if  not  quite,  antago- 
nistic to  the  tetanic  spasms  of  strychnia,  it  was  hoped  that  it  would  be  tound 
t-qually  useful  as  a  sedative  to  the  spinal  cord  In  those  arisiug  from  traumatic 
causes.  In  K.  Watson's  bands,  very  successful  results  followed  its  adininis- 
tration.  Vet  it  is  far  from  being  a  specific.  I  have  tried  it  in  several  cases, 
with  no  appreciable  good  effect.  It  may  be  given  by  the  mouth,  hypoder- 
micallv.  ur  ptr  antim;  in  the  form  of  a  solution  ur  a  tincture  of  the  extract 
in  half-grain  doses,  by  the  mouth;  hvpodermically,  iu  doses  of  one-sixth  of 
a  grain :  per  anum,  in  grain  doses.  The  dose  should  be  given  at  least  every 
?«c'>Dd  hour,  until  complete  contraction  of  the  pupil  occurs,  ^^tiniutunts,  as 
brandy,  should  at  the  same  time  be  given  to  counteract  the  depression  that 
will  result  from  the  use  of  the  drug.  At  the  same  time  th:it  recourse  is  had 
!•>  «uch  measures  as  these,  it  must  not  be  furgotton  that  the  <lisease  is  one  of 
i;rc«t  exhaustion  and  that  the  patient  wilt  die  worn  out,  unles.~  he  he  sup- 
j.!ie*l  with  plenty  of  nourishment.  Beef-tea  auri  wine  should,  theretore,  be 
administered  by  the  mouth,  as  long  as  the  )>alient  can  swallow,  nnd  nutritious 
"nirmata  by  the  rectum;  and  iu  this  way  the  pnvers  of  life  may  be  sup|iiirted 
until  ibe  violence  of  the  disease  exiwnds  itself.     I  am,  however,  disposed  to 


DISSASSB   OF    THE    LVMi'UATIC    STSTKU. 

think  that  ev«u  in  tbeee  chronic  ca»c«,  much  more  may  be  don«  b;  fiinple 
than  by  irpecJfJc  Irvatroeni.  Clearing  out  the  howcU  by  a  turpentine  eoenia. 
brt^alciu^  the  violence  of  the  spaanu  and  gtviog  the  patient  rwt  and  «rk  by 
chloroform  inhalations  or  bv  chloral  eneoiBta,  and  Iceeping  up  tb«  |>ou'vra  «f 
tbeiyvtetu  by  injectiout  of  D«ef-tea,  egu.  and  brandy  into  the  rectum,  till  Ihe 
doeaae  weiue  itself  out,  appear  most  likely  to  be  (bllowed  by  a  c«tl»ractury 
K«ult,  wheD  u^  in  flddilivo  to  the  hygienic  tseaaures  recunioiended  in  the 
acute  fonii  of  the  diaense.  It  is  certainly  more  ratiooal  lo  employ  tuch 
meaeur(-8  as  these,  than  iu  the  vniu  hope  ot  finding  a  specific  fur  letaiiuf,  to 
be  constftntly  recurring  lo  ftntiepB&modic  and  Bcdatircs,  which  n-pesUil 
experience  htti  proved  to  be  uaeleu  as  curative  agents. 


CHAPTER  XXXIX. 

DISBA8E8  OP  THB  LTMPHATIC  SYSTEM. 


INPLAMUATIUN  OP  TUK  LYUrilATIC  VEMKL^ 

Lymphangitii,  or,  aa  it  was  formerly  called.  Angeiolettcitia,  la  n  diffuse- 
inflanimalittn  of  the  )ytn]iLutic  vesaeU. 

Cai'SF*.— Id  ihe  va*t  majority  of  eaaes  it  arlHea  from  the  irritation  caund 
by  the  prvsence  witlitn  the  vessels  of  the  product*  of  an  infective  Inflamma- 
tion aflecling  tlic  tiMuea  from  nhicb  they  derive  their  lymph.  It  thuk  foriii« 
rather  a  conipliraliuti  of  these  indamuations  thtin  an  inde|>endent  diaeaae. 
Moet  couinionh'  it  is  atMiociated  HJib  cutaneous  eryci^elas,  but  it  ia  alto  nwC 
with  in  other  forini>  of  infective  inflanmiation :  thus  it  ie  a  frequent  result  of 
the  iuoculatiou  of  virulent  matter  from  dead  hodiett,  and  is  occusionallv  aeen 
in  the  lymphatics  leading  from  a  aoft  chancre.  Iti  moct  caeea,  (hcreJbre.  a 
wound  or  nbrasion  servca  as  ihc  starting-point  uf  the  inflaminaiiuD.  It  is 
very  rarely,  indeed,  thnt  lymphangitis  occurs  %(ithuui  some  such  exlarnat 
cause :  yet  we  arc  certainly  warranted  iu  eousidi.-nn)'  it  aa  of  idiopathic  ori^ 
in  auiiiu  iuetiLuctf.  I  have  at  least  seen  casejt  tu  which  Lwreful  examinauou 
hna  failed  iu  detecting  any  breach  of  surface  or  cvideiic-e  of  local  infcctiuu. 
The  iliwase  is  predisposed  to  by  Ihe  same  camwa  that  favur  the  dc%'elupmeui 
of  erysipelas,  aa  by  atniijepheric  vicii«itudeB,  by  particularseawitu  of  the  year, 
more  ospecially  the  early  spring,  ami  by  epidemic  influences.  Broken  health 
and  the  ueglret  uf  hygiunic  precautioike  uIm)  Lend  to  induce  it. 

MoKniD  Anatomy. — The  wulln  of  the  inflamed  ve»els  becnme  swollen, 
■oftetieil,  An<l  iufittraii^d  with  small  niiind  eel b.  and  the  endothelium  dea- 
quamates.  Tfwier  Btates  that  ihe  lymph  coagulates,  forming  a  rosy  clf»t 
which  plugs  the  ve«.<^l.  The  inflammation,  thbii^'h  oommmring  from  irrita- 
tiou  within  the  ve>iicl,9iion  extend.*  beyond  its  wall*,  the  !-urronnding  areolar 
tissue  becomes  fiwolh'n  and  infillratcd  with  inllahiniatory  produelii,  and  toin^ 
times  suppuralioD  may  take  place  nrnund  the  inflamed  lympbntic. 

SvMi-roMs.— During  the  progress  of  au  ordinary  injury,  the  |>atieDt  ta 
eeiu-*!  with  chills  or  nj;on>,  with  considerable  elevation  ot  ten|>erature  reach- 
ing 102°  F.  or  103°  r,,  attended,  perhaps, by  vomiting  or  diarrh<«a.  These 
syuptvtns  mny  precede  by  twelve  or  fourteen  houra  the  local  signs  of  the  dtt* 


LTUPHAKOITIS — DIAGNOSIS    AND   TREATMENT.  69 


■  tmaty  bat.inore  commoDly  accornpanr  them.     On  examining  the  part  it  will, 

■  if  snperficial,  be  Been  to  be  covered  07  a  number  of  fine  rea  streaka,  at  Brat 
^      icattered,  but  graduallT  approximating  to  one  another  so  as  to  form  a  distinct 

baad,  about  an  inch  in  breadth,  running  from  the  part  affected  along  the  in- 
side of  the  limb  to  the  neighboring  lymphatic  glande,  which  will  be  felt  to  be 
enlarged  and  tender.  The  band  itself  feels  somewhat  doughy  and  thickened. 
Sometimes  one  lymphatic  can  be  felt  hard  and  isolated  like  a  piece  of  whip- 
cmi.    There  is  usually  more  or  less  oedema  of  the  limb,  from  the  implication 

•  •f  the  deeper  lymphatic  Teasels  and  their  obstruction  by  the  inflammation. 
Along  the  course  of  the  inflamed  lymphatics,  erysipelatoua-looking  patches  not 
unfrequentlr  appear,  and  coalesce  until  they  assume  a  considerable  size,  and 
onstttute  a  distinct  variety  as  it  were  of  erysipelas.  In  some  cases  the  glands 
are  atfected  before  any  other  local  signs  manifest  themselves,  owing  probably 
!■•  the  deeper  seated  lymphatics  having  been  first  implicated ;  or  possibly  to 
the  direct  absorption  of  and  deposit  in  them  of  some  infective  matter  that 
o»nstitute8  the  primary  source  of  the  inflammation.  Not  uncommonly 
throuiifaout  the  disease  the  inflammation  continues  to  be  confined  principally 
t't  tbii  set  of  vessels,  giving  rise  to  great  and  brawny  swelling  of  the  limb, 
but  without  much  if  any  superficial  redness.  The  constitutional  disturb- 
aoce.  at  firet  of  the  active  inflammatory  type,  may  gradually  subside  into 
the  asthenic  form. 

R»^^■LTs. — The  disease  usually  terminates  in  resolution  at  the  end  of  eight 
or  ten  days;  not  uncommonly  it  runs  on  to  erysipelas;  and  in  other  cases, 
azAin.  localized  suppuration  may  take  place,  sometimes  in  the  form  of 
•>ae  large  deep-seated  abscess  in  the  iliac  fossa  or  in  the  thigh  if  the  lower 
c-xtreroitT,  or  under  the  pectorals  and  in  the  axilla  if  the  upper  extremity 
tw'  the  seat  of  irritation  ;  or  a  chain  of  abscesses  may  form  along  the  course 
"f  the  inflamed  lymphatics  and  in  the  glands  to  which  they  lead.  In  some 
ia^tanoes,  after  the  disappearance  of  the  disease,  a  state  of  chronic  and  rather 
f-Aid  oedema  of  the  part  may  be  lefl,  giving  rise  indeed  to  a  species  of  false 
hvpertropby,  and  constituting  a  troublesome  consequence.  More  rarely 
death  results,  either  from  general  blood-poisoning,  or  as  the  effect  of  exhaus- 
tion fmm  prolonged  suppuration  of  deep-seated  abscesses. 

The  Di.vGNOi^if)  of  inflammation  of  the  lymphatics  has  to  be  made  in  its 
•^^rly  stages  from  phlebitis  and  erysipelas,  and  of  the  abscesses  in  later  stages 
I'r-im  th'»e  of  py»mia.  From  phlebitis  it  is  easily  distinguished  by  thesuper- 
ri<'ia!  redness  of  Ivraphangitis,  and  the  absence  of  the  cord-like  plugged  vein. 
Fmm  erysipelas  it  is  distinguished  by  the  want  of  a  defined  margin  to  the 
reilnese,  and  by  its  extending  in  the  line  of  the  lymphatic  vessels  only  ;  but 
the  affection  in  most  cases  is  closely  allied  to  erysipelas,  and  in  others  merges 
into  it.  and  consequently  the  distinction  is  often  of  little  consequence.  The 
scute  lymphatic  abscess  is  usuallv  distinguished  without  difficulty  from  the 
pv:t>mic;  the  lymphatic  abscess  Wing,  if  deep,  solitary;  if  superficial  and 
Hjaltiple.  confined  to  the  tract  of  the  previoualy  inflamed  absorbents;  in 
.--iiher  case  being  always  between  the  starting-point  of  the  primary  source 
■•I  irritation,  or  wound,  and  the  glands ;  in  the  calf,  thigh,  or  iliac  fi>ssa,  if 
I  be  primary  irritation  be  in  the  lower  extremity,  in  the  axilla  if  in  the  upper. 
The  fever  is  moreover  more  continued,  and  the  severe  rigors  and  sweatings 

•  ■!'  pyemia  are  wanting. 

Ti:l.vtmknt. — In  superficial  lymphatic  inflammation  of  the  skin  and  in- 
t.-jum<*ntal  structures,  the  local  application  of  belladonna,  as  recommended 
t'V  C.  Heath,  is  the  most  efiicient  agent  in  subduing  the  local  process;  a 
\-3fie  of  equal  parts  of  the  extract  and  of  glycerine  should  be  thickly  smeared 
■Ter  all  the  inflamed  parts,  and  covered  with  a  thick  layer  of  cotton-wool ; 
the  limb  at  the  same  time  being  kept  elevated.     As  a  substitute  treatment, 


70 


X»IS£A&B8   OF   THE    UYMPHATIi:   SVaTKV. 


^fhougli  of  Inferior  value,  hot  popjiy-iiiiKt-nlfitiMiw  remj  be  hwU.  If  afttr  th* 
ibtial  of  the  acute  inHfttntnntion  niucli  chronic  indunitioa  and  iiHleioa  occur. 
IwtiHagiiig,  su  D*  lo  c(>mpre»ij  the  limb,  nod  njeliiodical  friclioo  will  b«  of 
wn'ice.  If  nbsc«tB«»  form,  ihey  »hi.'uld  be  optiied  early  and  trvaled  oo  or* 
dinary  principle*. 

The  coaHtiluliooal  trestnieot  is  Ihe  mluic  bb  lor  cry8i|ielas.  No  ilcpletiuu 
b  ever  ju»liGnbt«,  oud  etinttilanU  are  ofleo  retjuired  iu  consiilerable  ijuaiiti- 
dcB,  nitfa  abuQiJaot  liquid  food  of  a  Dourialiiug  kind.  Perchluride  of  ima 
and  (|uiaiDe  are  oHea  uteful. 


VARIX   UV  TBK    I.TMrilATH'    VlBgErA 

Tarix  of  the  Lymphatics  has  been  occasionally  n>et  with,  boib  in  the 
auperlicial  and  deep  nciworks  and  iu  ihc  lymphatic  Irunka.  The  pan  moK 
commonly  found  ofTectcd  tms  been  t|io  ioDcrsiJcof  theihigh  ;  but  tncdIaeMe 
hae  been  seen  also  in  the  Anterior  wall  of  the  abdomen,  about  the  ankle  and 
ellKiw-joiu(«.  and  DO  the  prcpuci^.  Iu  tbe  ^fupt^rficial  lyinpliatii.'fi.  the  varix 
fin>t  a|>))i^tini  in  (he  form  of  »ii)hII  ti'lvvations.  giving  tbt?  vkiu  an  ap|iearaDc« 
which  has  been  coiupaired  to  Ihe  riud  «f  an  orange;  It  flubsefjuenlly  lakes 
the  form  of  tiltle  vesiclts  covered  with  a  ihio  layer  of  epiderniin.  Varii 
nf  tlie  larger  lymphatic  trunks  frequently  accumpauie^  the  cuudilion  ji»( 
dewribed.  The  vevselB  may  either  be  dilati^j  cyliudricnlly  into  round  beaded 
eiiliir^icnieiiti!,  often  Kmi-traneparcrnl,  Had  but  •lightly  ct'mprt-wible:  or 
atnpultie  tuay  be  formed  on  them,  giving  rise  (o  more  or  lets  tofl  swelliag*. 
Sucttifiting  under  the  lin(.'er.  There  is  some  a-dema,  nUributable  either  Ut 
iil>«trttiiit>n  of  the  lymphatics  or  to  the  impede<l  flow  of  the  lymph. 

Iu  't1  uut  of  oo  recortled  ca^s,  u  discharge  uf  lyotph  (LympboiThiBa)  Una 
l»eeu  obeerved.  Tbh^  ban  been  i^een  to  occurnlso  without  varix,n«  the  result 
of  wound.  In  the  latter  en^e  I  he  flow  iscouiiuuouH;  while  iu  the  lynitihorrIi<t« 
nhich  Htteiida  varis,  is  is  lo  «ome  extent  iulermiltent.  The  iilentitv  of  iho 
flui<l  difchnrgtHl  with  lymph  hn»  been  e^iabliithed  by  chemical  nnd  micro- 
Bcopic  exuitiinntion.  An  excessive  discharge  of  the  fluid  h  liable  tn  produce 
ttvmptoms  of  general  debility,  of  the  tame  kind  aa  tboau  induced  by  hemor* 
rtiBge. 

TiitMTiir-vT. — SpoDtnnooiu  cure  of  lymphatic  varix  ham  been  ol)iser\-e<l  iu 
ra»ea  where  the  penin  waa  nfiected.the  discuse  being  the  remit  nf  the  obfttrur- 
tion  10  the  How  of  lymph  cnut>ed  by  buboe«.  In  other  inatniices,  varioaa 
plane  of  ireniment  have  been  tried,  with  apparently  indifferent  mull. 
CaitMics  have  been  u»ed  by  aevernl  Surgeons,  but,  aa  the  dii-eaw  is  otten 
deeply  »ea(ed  as  well  »a  superticial,  with  but  little  result.  Beau  treated 
three  ease*  nuci-eHfulIy  by  intriKJucing  a  seton  into  the  ililatcd  lymphatic 
Vef>)ielt>.  and  ev<-itiug  HHhei<ive  iollAmntation.  B.  Bell  advise*  ligature  of  the 
lymplmUe  vexee),  from  nhieh  the  discharge  of  Huid  takes  plni.-<<.  I.'umpre*> 
aion  by  meaiM  of  a  tiandagv  ha»  been  recotninetide*!  by  Niilatun. 


I 


EtKpnjiynAris  of  tob  legs  a>u  spnoTtTi. 

Elephantiasis  Aiabum,  or,  as  it  is  often  callc^l,  iho  Barbadoes  Le^.  is  an 
atfociiuji  tbul  ib  t^x<mmon  in  miiny  tmpicjil  coualrieH.  in  the  VVec<t  Indino 
Islands  and  in  Bonth  America  more  iiarticulurly.  U  ix  met  with,  tboueh 
cumparalivolv  rarely,  in  J-Jirope.  Ttie  di£«aite  usually  afTecta  one  of  toe 
lower  extremllicB  (seldom  bulb ',  the  scrotum,  or  the  Inhia,  which  may  be> 
«otike  enormoiialy  enlarged  and  hypcrtrophictl.  In  the  &ce  it  ia  often  mtt, 
I  with ;  [n  the  upper  exiremitiea  rarely. 

It  ii not  my  iDtentioD  toenter  intoaoaccoantof  thabatory,  thasyraptt: 


■  LSPHAyTIASIS    OF    THJ!    LEGS    AND    SCROTUM. 


71 


or  the  caoMa  of  this  remarkable  malady.  It  is  Bu£Bcieat  for  my  purpose  here 
to  wmj,  that  it  appeara  to  consiit  in  disease  primarily  seated  in  the  lymphatics. 
The  f^aodB,  as  Virchow  and  RindfleiBch  suppose,  become  impervious  to  the 
trmnsmiHtOD  of  lymph,  and  the  hyperplastic  deposits  that  characterize  the 
diseue  are,  together  with  the  general  stretching  and  hypertrophy  of  the  in- 
t^amental  structure,  the  consequence  of  the  plastic  efifusion  into  the  areolar 
ti»ae. 

Trextuest. — When   this  disease  attacks  the  face,  little,  if  anything, 
avails  in  the  way  of  treatment.     When  it  affects  the  labia  and  scrotum,  the 


Fig.  432.— Weit  Indiao  Blepfaantiasis. 

enlarge*]  and  diseased  part  must  be  removed  (see  Diseases  of  Penis  and 
!*crototn  I.  But  wheu  the  leg  is  affected,  surgery  can  effect  much  iu  the  way 
of  cure.  In  the  slighter  cases  much  may  be  done  by  elevation  of  the  limb, 
mdhndica!  bandaging,  and  perhaps,  as  Kayer  anil  Lisfranc  recommend,  the 
effiploymeot  of  scariHcation.  But  in  the  more  severe  cases,  where  the  limb 
ha«  swollen  to  a  monstrous  size,  and  has  become  shapeless  from  the  groin  to 
the  ankle,  the  skin  sallow,  covered  with  nixlulea  and'overlnid  by  branny 
d««<:(uamation,  with  a  tendency  to  unhealthy  and  incurable  ulcerations — in 
thff!^  aiivanced  and  serious  cases,  more  active  measures  are  necessary. 

Ihifour  seems  to  have  been  the  first  to  propose  diminution  of  the  supply 
of  anerial  blood  to  the  limb  as  a  cure  for  this  disease.  This  he  effected  by 
compre««ing  the  femoral  artery  by  means  of  a  kind  of  truss,  and  was  suc- 
cecvt'ul  in  four  cases.  This  practice  of  compression  has  since  been  succes.v 
fiillv  followed  by  Hill,  Cockle,  Vanzetti,  and  others. 

To  4 'amoeban  is  due  the  merit  of  having  recommended  the  ligature  of 
the  femoral  artery  as  a  means  of  cure  in  these  cases;  and,  in  whatever  way 
it  «<^.  there  can  be  no  doubt  of  the  excellent  effects  that  have  followed  this 
metho']  of  treatment,  little  as  it  can  be  explained  by  the  received  patbologi- 


72 


tllSKASXS    OK    TIIK    ItYMPUATIC    SYSTEM, 


cftl  views  of  the  iHikhw.  Iu  oome  iuBtances,  aa  by  BryauL,  Bucfaaoaa,  and 
Simon  fof  Hvitlclbeiyt,  tim  ext«riial  iliac  has  be«n  advantageously  tied. 
The  0|>erHtiun  «ii  this  arl«n'  has  tht>  recnmineiitlNlion  not  only  of  b«ing  coot* 
pletvly  aUivtf  the  liniits  of  the  disease,  and  consequently  in  parts  thai  are 
quit«  healthy,  but  also  of  more  completely  controlling  the  nutrition  of  the 
limb  than  cati  b«  done  by  ligature  of  the  superficial  femoral. 

Eppner,  in  1881,  collected  the  records  of  49  catH»  of  elepbaatiasia  treated 
by  ligature  of  the  main  nrtery  leading  to  the  diseased  part.  In  40  of  these 
the  femoral  was  tied ;  in  b,  the  external  iliac;  io  2,  the  popliteal:  in  1.  tbe 
anterior  tibial ;  and  iu  1,  the  brachial.  Of  these  31  are  reported  to  bare 
been  cured,  3  relieved,  1  unrelieved,  and  &  died.  Of  the  cases  reported  as 
cured  9  8ul»ec)ueDtly  relapsed.  The  result  of  tbe  operations  appears  to  hare 
been  fairly  cucuuragiug,  although  in  a  certain  number  of  coses  it  is  evident 
that  little,  if  any,  improvement  ttxik  place. 

LYUrUADENnUi,  OK  INPLAM.'tlATION    OF  THE  LYUPRATIO  OiaKSe. 

Acute  loflammation  of  ths  Lymphatic  Olanda  almost  invariably  results 
from  the  irritation  of  srime  noxious  material  conveyed  to  them  by  the  lym- 
phatic vesneU.  The  lytnphaticj  through  which  it  passes  on  its  war  to  tbe 
glandft  may  thenuiei ves  he  inflamed,  hut  more  trequcntly  they  escape.  Thb 
fact  would  ^em  to  indicate  that  in  the  majorilT  of  co^es  the  irritating  mat^ 
ter  is  particulate  and  not  in  solution :  as  we  know  from  experiment  that 
solid  particles  pass  readily  through  the  lymphatic  vessels  without  lodging, 
but  are  arrested  in  the  lymphatic  glands.  In  every  acute  inflammation  the 
quantity  of  lymph  passing  through  the  glands  in  connection  with  the  af- 
fected area  is  greatly  incrcoiic'd.  In  simple  ittflammations  in  a  healthy  sub- 
ject tliis  causes  slight  swelling,  which  sulfides  m  so<»n  as  the  cause  is  re- 
moved :  but  In  itcrofulous  subjects,  as  heforu  pointed  out,  there  is  a  peculiar 
tendency  to  tnilummation  uf  the  tymphutic  glands  from  slight  causes,  and  in 
them  the  swelling  may  jwrsist,  and  may  jiiuis  on  to  suppuration  or  chronic  in- 
flamroatiun.  In  infective  in  Sam  mat  ions  the  iuHammutory  products  cuutuin 
thespecial  virus  Vi  which  the  iutlammutioa  is  due,  and  this  being  carried  by 
tbe  lymph-slream  to  tbe  glands  may  excite  a.  similar  process  in  Uiem.  Many 
specific  intlammattons  are  accompanied  by  the  presence  of  microscopic  orgao- 
istos  of  a  definite  form  in  the  exudations,  and  In  such  cases  the  organisms  caa 
frequently  be  demonstrated  by  the  uiieroscope  after  death  iu  the  lymphatic 
glands  Dearest  to  the  :wnt  of  the  disease.  As  a  rule,  tbe  secondary  iuflam- 
mation  in  the  glands  closely  resembles  in  character  that  at  tbe  primary  seat 
of  dieenH?. 

Thus,  iu  cutaneous  erysipelas,  the  glands  are  invariably  swollen  and  ten* 
der,  but  seldom  suppurate;  in  soft  chancres,  suppuration  commonly  takee 
place:  and  in  diphtheria,  the  glands  are  always  enlarged  and  painful,  but 
pus  mroly  forms,  while  in  scarlet  fever  suppuration  is  oAen  vcr^'  trouble* 
some.  In  syphilis,  the  change  that  takes  place  in  the  lymphatic  glands  ia 
identioid  with  that  occurring  at  the  «>at  of  inoculation;  and  the  same  is 
the  ctuH^  in  Mcondanr  tuberculosis. 

Some  infective  inSammalions,  as  hospital  gangrene  and  phlegmonoue  ery- 
sipolas,  have  hut  little  tendency  to  infect  the  glands.  This  is  possibly  due 
t*i  coagulation  of  the  lymph  in  the  spaces  of  the  inflamed  orca.  [ 

In  the  nmjoritv  of  cases  there  is  no  difficulty  iu  discovering  the  source  of 
the  irritation  whrch  has  caused  the  glands  to  inflame.    In  sororulous  subjects, 
howe%'er,  the  effect  may  be  produced  bv  causes  so  comparatively  slight  thai  ' 
llifir  detection  becomes  proportionally  difficult.     In  some  eases  it  appears  to 
arise  simply  in  consequence  of  a  strain,  as  in  over^valking.     In  children,  the 


LTMFHADBNITI8 — PATHOLOGICAL    ANATOMY.  73 

^lauds  are  more  prone  to  suppurate  from  slight  sources  of  irritation  during 
cuDvmlesceoce  from  measles  or  some  other  acute  specitic  disease. 

Pathokigieal  Anatomy. — Inflammation  of  the  lymphatic  glands  may  be 
a<:ute,  subacute,  or  chronic.  In  the  acute  form  the  gland  is  swollen,  and  at 
tii^t  piok  in  color  and  soft.  At  a  later  stage  yellow  points  of  commencing 
tfuppuratioD  will  be  observed,  both  in  the  medullary  and  cortical  part.  At 
a  still  later  period  the  greater  part  of  the  gland  may  be  hollowed  out  into  a 
cavity  filled  with  pus.  The  appearances  of  subacute  ioflaramation  are  much 
the  same  as  in  the  acute.  The  microscope  shows  the  usual  changes  observed 
ID  all  inflammations;  the  vewels  are  distended,  and  the  gland  is  crowded 
everywhere  with  multitudes  of  small  round  cells.  These  very  early  choke 
the  lymph-sinuses.  As  these  cells  exactly  resemble  the  normal  corpuscles 
uf  the  gland,  it  is  impossible  to  determine  whether  they  are  formed  by  mul- 
tiplication of  the  normal  lymphoid  cells,  or  have  been  brought  to  the  gland 
with  the  lymph  from  the  inflamed  area,  or  have  migrated  from  the  vesEels. 
The  capsule  and  trabeculse  are  similarly  infiltrated  with  small  cells.  The 
formation  of  pus  takes  place  in  the  same  way  as  in  other  parts.  In  the  less 
acute  forms  larger  cells  are  found,  formed  by  proliferation  of  the  flattened 
Lvrpuscles  that  cover  the  trabeculse  and  the  inner  aspect  of  the  capsule.  In 
the  more  acute  forms  the  surrounding  tissues  are  early  implicated  in  the 
inflammation. 

(.'Anmic  Inflammation  of  the  lAfmphatie  Glands  is  regarded  as  the  most 
characteristic  feature  of  scrofula.  In  it  the  gland  is  enlarged  often  to  many 
times  it«  normal  size.  In  the  early  stages,  it  is  usually  more  opaque  than 
natural,  and  of  a  gray  or  dull  pink  color.  At  a  later  period,  yellow  points 
appear,  due  to  caseation.  These  points  gradually  increase  in  size,  and  coalesce 
till  the  whole  gland  becomes  a  uniform  casenus  mass  still  enclosed  In  the 
capsule,  which  is  often  considerably  thickened.  The  caseation  may  terminate 
the  proce«,  the  cheesy  mass  remaining  dry  and  encapsuled  without  further 
change.  In  other  cases  it  is  followed  by  deposit  of  lime  salts,  and  the  dis- 
eased glaad  forms  a  hard  calcareous  mass.  These  formations  most  commonly 
occur  m  the  glands  of  the  abdomen  and  thorax.  In  superficial  glands  the 
caseation  is  more  commonly  followed  by  softening  of  the  cheesy  mass,  which 
break.-  down  into  a  thick  fluid  not  unlike  clotted  cream.  The  softening  is 
accompanied  by  inflammation,  and  the  stow  formation  of  pus  in  the  tissues 
r.'und  the  gland,  the  capsule  gives  way  at  the  most  superflcial  part,  and  the 
fluid  gradually  approaches  the  surface.  The  chronic  abscess  thus  formed  is 
vrry  slow  in  perforating  the  skin,  often  undermining  it  for  some  distance 
>>ef<.>re  finding  an  exit.  Microscopic  examination  of  these  glaods  shows  in 
the  early  stages  a  great  increase  in  the  lymphoid  corpuscles,  not  only  in  the 
f't!]icl«>  of  the  gland,  but  also  choking  the  lymph -sin  uses.  Amongst  the  new 
4i'rpu^-lt:«  lai^r  cells  are  found  many  times  the  size  of  a  lymph-corpuscle, 
aod  apparently  developed  from  them,  as  all  intermediate  varieties  are  found 
Ixrtwtr^n  the  two  forme.  The  flattened  cells  covering  the  trabeculie,  and 
lying  on  the  meshes  of  the  reticulum  of  the  gland,  proliferate,  and  may 
r-mtftin>e*  be  recognized  forming  a  coarse  network  amongst  the  lymphoid 
•-•rpuscles.  At  first  the  gland  is  more  vascular  than  natural,  but  from  the 
{■reri#ure  of  the  accumulated  cells  the  vessels  soon  become  obliterated,  and 
D*-D-vai>cular  areas  are  formed.  At  this  stage,  in  a  very  large  proportion  of 
f-  roiulous  glands,  giant-cells  surrounded  by  a  zone  of  larger  cells,  and  again 
by  Ivmphoid  corpuscles,  forming  thus  the  anatomical  structure  of  a  tubercle 
n->iule.  are  met  with  in  the  non-vascular  patches.  The  caseation  commences 
in  the  non-vascular  Bp<its,  and  gradually  extends.  The  trabecuhe  disappear 
la#t  in  the  caseating  process.  In  a  large  proportion  of  cases  examined  up  to 
the  present  time,  the  tubercle  bacillus  has  been  found  in  the  cheesy  glands. 


74 


niSEASBS   OF   THE    LYMPHATIC   SY8TSM. 


Ill  the  pr<wi)t  stnle  of  uiir  knonleil;;?,  U  u  not  pooeidle  to  define  nccurawTi 
tlif  retniion  of  tiil>»rclft  M  chronic  grlHticluUr  inflnmnmlinn.  In  ihoae  nt»» 
in  whicli  iheglftiitliilnr  (liH«^^  ij*  W'C4>iidi»ry  in  «.  iiibcrciilar  aflV-rtion  of  tbr 
rejjion  JWini  wliicli  ihcv  rfc»?ive  their  Ivnijih,  |li*y  ore  pruUnldy  titbfrrulAr 
from  the  tre^inniiij;.  it\  i>lh«r  vtavn  thi-  ihniiiir  iollnmnintiuii  mny  be  ante- 
Ci'itent  to  mill  ii  pn-ili0|Hi!>ing  (.'anHV  of  the  ileviplupiiiviil.  of  lutirrclr ;  ami  ag>in 
it  18  |>r<)bii)il»f  llint  ghn-Dic  intlniiimatiou  followwl  by  c«#*i»ti"i>  ninH  •oftcniti^ 
rtifly  lake  lAatx  without  tin;  prvWM  beiug  at  «uy  tiiiiu  tul)«r(.-ulnr.  Tb«  »oll- 
etie«1  cHsvuus  pro<luct  of  clironic  iaflnmiiiatton  uf  tbv  lympbattc  glanrla  hm* 
betu  bt'licvtrd  fur  maov  jeare  to  be  a  toutcl'  of  jtein'ml  tubercular  infectiuD. 
the  fioc  trmnulnr  tlibris  entering  the  circulation  and  bMlsing  in  distaat  pari*. 
and  there  causing  the  growth  <d'  tubercle.  ISince  Kocli's  divcovery  of  th* 
badlluB  of  tubercle,  this  organism  hns  been  believed  to  be  the  actual  infectire 
iiiiileriiil  ia  ^iieh  cnses.  This  ]j;eneral  infection  vrbcn  it  lioes  occur  it,  how* 
ever,  merely  an  at.*c)dcninl  occurrence,  the  vnHt  majority  of  patients  who  raflbr 
from  oueating  lyniphaiic  glands  escnpiog  with  nothing'  more  than  the  tuoal 
disease. 

Indumtion  of  the  gland,  duo  to  thickening  of  tbu  trabocuW  and  capaatv. 
and  of  ihe  meshes  of  iht  rctiforni  connective  tt«8ue,  is  not  tin  uncommon 
neult  of  slight  degrees  of  chronic  inflanimaiion. 

tn  whatever  wiiy  occurring,  intlAminnlion  of  the  lymphatic  gliutd«  alwan 
causes  obstruction  to  the  flow  of  lymph  thn)Ugh  them,  and  if  the  whole  or 
greater  part  of  the  g1and«  of  a  limb  be  affected,  rrdema,  often  of  u  solid  char- 
acter, may  occur  in  the  parts  from  which  they  receive  iheir  afferent  lymphatic 
VG«Bebi. 

.S\'MPTOMiL — In  Acnte  Lymphadenitis  there  are  pain,  twelling,  t*ndt!ifc 
n«w,  and  Mtiffnn*))  about  the  a)feoti-d  ijlande,  vtith  a  dull  heavy  MtiMtiou  in 
them.  The  otilline  of  the  swollen  ylncid  i»  at  firitt  cl«irly  detiueiH,  but 
••"•II  beo^iiie*  concenled  by  the  tnt^aiii  inn  lion  extending  to  the  miiligMuu* 
|irei>tar  tiwue,  Before  luug  rfhicw,  n-'ic-nia,  ami  the  olhi-r  »igr>«  "f  acut«^ 
»bMMI  innke  their  Hp)^M.-ii,r»ui.-e.  In  Bnbacnte  Lymphadftnitii  the  glnntU 
btonMBKullen.  t'ulnrged.und  lender,  and  un.-  inaltitl  logeiber  by  inltanima- 
tory  exudation  inu>  ihu  nurroumliny  tiKeurs.  If  abeceas  rnrni,  t't  fretjueniJy 
commences  in  the  alnieturetj  arotiiiil  the  glands:  and  ihoaw  are,  i>erbapi<, 
eventually  expueed  at  the  bottom  nf  thi-  cavity  that  reeultc.  Thb  is  espe- 
cinlly  apt  to  hapjK'n  in  riiL-bei>li<ianJ  strumous  |K>rRou(i  fntm  t>tighi  sources  of 
irritation.  Very  conmioQly  in  hucIi  HilijeetN  llit.-  inflnmniation  of  the  ^flatids 
runs  into  a  chronic  elate.  Chronie  Lymphadenitis  ur  Stntraons  Eolarg*- 
ment  of  the  Lymphatic  Glands  may  ari^e  m  n  He<|uence  of  eiibaeute  inHani- 
mntiim.  but  tiKirt' commonly  the  glands  gradually  enlargr-  without  marked 
pain  or  lendi-rnes^  in  con9ei|Uence  of  chronic  irritation  tit'  some  kind.  U  is 
not  possible  to  make  any  accurate  distinrtion  rlinically  between  nmple 
dlKHtio  inflammation,  strumous  enlargement,  and  tnlM-reuIar  dtseasft. 
Chrwnic  inllmnmation  if  the  glands  i^  commonly  bmktHl  up<  n  aa  thv  nioal 
marke^l  churncti-riatic  of  the  »truniiiU8  dinthf«il^,  and  ihe  ri-lntion  of  the  pro* 
cesA  to  tnbi'rrle  has  been  nlremly  sufficiently  discussed.  TbeM  i-hnnge*  twcur 
princi[uilly  in  children  and  young  people,  and  moot  freijiiently  in  the  neck, 
c-|>oci»lty  in  thv  Hubmaxillary  gtamh  Mini  the  KlNnduln^  ctjncatennttf,  ami 
••■metimeB  in  the  axillary  and  in^fuinnl  glnndit.  The  glands  nlowty  increnae 
in  the,  at  firrt  remaining  clearly  defined  an<t  distinrt  from  i*ach  Mher.  Thty 
may  after  a  time  cease  to  enlarge,  and  remidn  ixTninnentty  without  further 
chango ;  but  more  commonly,  aftvr  continuing  in  this  itntv  for  months  or 
Venn*,  thry  soften.  The  inttnmmntion  then  extends  to  tbo  surrounding 
itimurs,  nnd  the  glnmlif  become  adhf'rent  to  neighboring  parts,  and  Rnnlly  to 
the  skin.    .Several  glands  may  thus  become  fused  together,  forming  a  large 


LYHPU  ADENITIS — TREATMENT.  76 

intlurmted  and  nodulated  tumor.  Suppuration  takes  place  slowly,  and  the 
?kiD  becomes  thin,  blue,  and  uoderniined.  FiDalty,  it  gives  way  by  a  small 
opening,  and  curdy,  uohealthy  pus  is  discharged,  mixed  with  the  debris 
from  tne  soAeued  cheesy  matter  from  the  gland.  The  discharge  may  con- 
tinue fur  weeks  or  moDtns,  being  kept  up  partly  by  the  gradual  expulsion  of 
the  remains  of  the  degenerated  gland,  and  partly  by  the  thinned  and 
undermined  akin  being  too  feeble  to  take  any  part  in  healthy  repair.  The 
■opening  may  close  for  a  time,  bursting  open  and  discharging  again  at 
ioten'als.  In  other  cases  the  thinned  skin  perishes,  and  the  remains  of  the 
gland  may  be  exposed  as  a  reddish-gray  or  fleshy  mass  protruding  in  the 
midst  of  the  sore.  Wben  these  sores  finally  hea),  they  leave  thin,  blue 
cicatrices,  finally  forming  irregular  puckered  scars. 

Treatment. — ^The  local  treatment  of  inflamed  lymphatic  glands  varies 
according  tu  the  variety  of  the  process.  In  all  forms  tne  local  irritation  to 
which  the  inflammation  is  due  must  be  removed  if  possible.  In  acute  lytii' 
pkadfnUi*  the  application  of  glycerine  and  extract  of  belladonna  in  equal 
parts,  and  hot  fomentations  may  prevent  suppuration.  In  the  ntbacute  con- 
dition, spirit  lotions  containing  iodide  of  potassium  will  sometimes  subdue 
the  inBammation  and  take  down  the  swelling.  If  an  abscess  form,  it  must 
be  freely  opened  and  the  part  dressed  with  some  antiseptic  application.  The 
sinuses  which  are  often  left  when  the  abscess  is  imperfectly  opened,  or  allowed 
to  dischai^  by  itself,  require  to  be  treated  by  stimulating  applications, 
especially  the  nitrate  of  silver ;  but  very  commonly  they  will  not  heal  unless 
thiey  are  laid  open  and  dressed  from  the  bottom. 

'.'AroRi'c  or  Sarofulout  Jnjtammation  of  the  Lymphatic  Glands  requires  to  be 
treated  on  different  principles.  When  there  is  merely  chronic  enlargement, 
without  irritation,  methodical  friction  with  iodine  or  iodide  of  lead  ointment 
will  sometimes  produce  absorption  of  the  inflammatory  products,  constituting 
the  bulk  of  the  enlargement;  and  this  in  some  instances  may  remove  the 
tnmor  entirely.  In  other  cases,  painting  the  part  with  tincture  of  iodine, 
and  improvement  of  the  general  health,  will  cause  the  removal  of  the  disease. 
When  the  gland  has  softened  and  is  becoming  adherent  to  the  surrounding 
part^,  it  becomes  an  important  question,  at  what  period  it  should  be  opened, 
ft.'  a?  to  insure  the  speediest  recovery  and  the  feast  scarring.  It  was  for- 
merly advised  by  many  Surgeons  to  leave  the  gland  until  it  becnme  distinctly 
adherent  to  the  skin,  and  until  it  was  so  complctety  softened  that  the  whole 
of  the  chevsy  matter  might  be  discharged  at  the  time  of  opening.  The  result 
of  this  plan  was  usually  to  leave  a  deep  puckered  scar,  and  healing  was 
jieidoDi  complete  for  some  weeks  or  even  months.  These  unpleasant  consc- 
•jurnct*  can  frequently  be  to  a  great  exterit  averte<l  by  early  opening,  and 
Ire*  ^craping  with  a  sharp  spoon  (Fig.  95,  vol.  i.).  As  soon  as  the  pland  is 
evidently  softening,  the  operation  may  be  performed.  The  gland  is  steadied 
between  the  finger  and  thumb  of  the  left  hand,  and  a  puncture  made  into  it 
with  a  scalpel  about  a  quarter  of  an  inch  in  width.  A  probe  may  then  be 
{xui^tl  ailing  the  scalpel,  so  aa  to  serve  as  a  guide  to  the  opening  in  tlie  cap- 
•nle.  The  scal|)el  is  then  withdrawn,  and  a  small  sharp  spoon  |)assed  along 
thf  pp-br  into  the  gland.  By  forcibly  S(|ueczing  the  gland  and  scraping 
with  the  s|>oon,  the  whole  of  its  caseous  contents  can  usually  be  removed 
without  difficulty.  A  very  fine  drainage-tube  may  then  be  inserted  for  a 
few  days,  after  which  healing  will  probably  take  place  without  difficulty. 
Thf  rc#ult«  of  this  little  operation  are  very  much  better  if  strict  antiseptic 
prf  cautions  are  observed;  for  if  the  cavity  Ijccomes  filled  with  decomposing 
dM-harge^,  troublesome  diffuse  suppuration  may  follow  in  the  areolar  tis-fuc. 
I'--i>rf..rm  iir  salicylic  wool  forms  the  best  dressing  in  most  cases.  If  several 
slaod?  lie  cliise  together,  it  is  sometimes  possilile  to  scraj*  more  than  one 


Ttt 


UlSEASKS   or   THE    UYHPUJkTlC   SYSTEM. 


frviiii  a  single  opeuing.  Th«  scan  leil  after  this  mode  of  treatmcDt  arc  vtrf 
•li^ltt. 

Il'»t>  npcrture  alrcaily  exisu  leading  dowD  tn  an  indarated  niaae,  th<>iiiitM 
limy  Ik>  freeir  Kraped  in  the  mme  way.  aod  huliag  is  often  basteoed  by  tbe 
iuwrtikiD  vfa  amaU  -luantity  ol'  iodof»rm  into  the  track  left  afler  the  opera- 
tion, tr  uftcr  an  abacces  has  fornied  and  been  opened,  an  irregular  cavity 
i*  li-ft  with  nintfoa  of  degeoemtiDg  gland-tissue  projecting  into  it.  thew  mar 
hv  »ti'upcd  away  by  a  iborp  spixin,  or  destroyed  by  potASM  ftua.  In  apply- 
ipg  ibc  cnustic  potash,  care  mual  be  takeu  thai  ita  actioD  doea  Dot  spread  too 
widely ;  ihU  may  usuallv  bo  avuidcd  by  cuating  the  iurrouadiDg  inte^- 
incotH  with  oollodton.  U'hc  blue  undermined  iMtio  left  after  i<poolanenua 
l)ur»iing  uf  a  scrufuloua  nbaeew  of  the  glnods  delays  bealiDg,  and  is  uselea 
itaolf  fur  any  purpoaca  of  repair.  It  niiiitt.  tbcrofore,  be  deau-oyed,  however 
large  the  reaultiug  aorc  may  at  lirvt  appiwr  to  be.  This  may  be  done  by 
OMKOS  of  polana  fiua,  but  nulling  it  with  Kcistnra  in  a  uamber  of  linei 
radiating  from  the  central  onoiiing  will  u-'^ually  make  it  in  great  part  melt 
uwuy.  oud,  al  the  same  lime,  is  free  ffim  the  ri.4k  of  destroying  more  than  is 
neceaaary. 

Extirpntiuti  of  chronically  infltimed  and  ciueatin^  lymphatic  gtunda  haa 
been  reconimendtMl,  with  the  view  uf  pn> venting  general  tunercu tar  iofc<ctioo; 
i>ut,  for  this  rpfl.4<)u  nlone,  it  is  not  to  be  recommended.  It  is  impoasible,  id 
the  vast  majority  of  cases,  to  remove  all  or  ne-arly  all  the  aflected  glands, 
nnd,  if  undertakeii,  it  may  lend  U*  more  serious  and  extensive  dtHecliooB 
ihnn  might  at  first  appear  requisite;  for  a  chaio  of  disposed  glauda  oftea 
extends  a  considerable  dUtsuce,  aud  after  one  has  been  removed  othen 
come  into  sigbu  Cas«i«,  however,  ••ccastoually  occur,  in  which  such  a  pro* 
c«dure  may  be  deemed  advignble.  the  utfecled  gluuds  being  large  and  inda- 
rated, and  the  diseiuie  of  many  years'  standiui.' ;  their  exiirpalion  may  then 
be  pruper,  and  I  biive  iftit  unfrequvully  bad  occnsiuu  in  such  cirimmnUnoei 
to  remove  llieni  from  the  axilla,  from  the  submaxillary  region,  and  from  the 
poslerior  triangle  'if  the  neck. 

Tile  coiistitutiuiifil  treatment  of  chronic  atrumoua  diaeBse  of  the  glauds  is 
fully  described  in  the  chafiCer  on  .Scrofula  and  Tubercle,  vol.  i.  p.  1022. 

I.YMPnADENOUA. 

This  diMuse  has  been  already  dncrihed  in  the  chapter  on  Tumon  (tqL  L 

fi.  9o4 ),  and  hut  little  remains  to  be  said  concerning  iL     When  the  diaeue  is 
imited  to  the  lymphatic  glands,  the  question  uf  their  removal  often  oomea 
before  the  .Surgeon. 

If  the  tumor  be  large  and  single,  or  oompoted  of  an  agglomeratiuo  uf 
muliijile  niiis4>i-)i.  luid  fo  situatt-d  tnnt  it  can  be  tAken  out  with  safety,  its 
removal  i*  [>ri<i><-r.  nndahimld  be  practised.  I  have  several  times  removed 
lv(  mttla  from  the  nxilla  nnd  upper  ]»nrt  of  lh«  neck  with  great 

I.  J  when  the  itisea«?  is  mulltplc,  single  large  masses  (hut  are 

ipt  -]  >      ■    I      ililc  should  be  dissected  out.     In  one  such  case  a  tumor, 
rn*  i<-   i:i>^'    '"*  *  '^^>  ^'^  removes),  in  Luivenity  College  Hospital, 
■le  axilla.     The  patient,  a  delicate  woman,  had  n  group  of  similar 
t  in  ihe  neck,  which  had  remained  stationiiry  for  twenty  years. 
')"  r.Kion  sh<7uld  nut  be  undertaken  when  the  patient  is  very  weak  or 
■■:■■■■' especially  when  there  is  perHsteut  elevation  of  temperature. 
viog  figure  (Fig.  423),  Irom  a  pntieot  under  the  caro  ot 
.>'trn([    ii'aili.  is  a  good  .illustration  of  the  appearances  produced  hj 
when  aH'octing  the  glands  at  the  root  of  the  neck. 


VENOUS    THROMBOSIS. 


77 


With  the  exception  of  lympbadenoma,  the  lymphatic  glanda  are  siagularly 
czempc  from  the  growth  of  primary  tumore.  Rouod-cell  sarcoma  is  said 
occauooally  to  be  met  with,  but  It  is  probable  that  some  of  the  tumors 
fbrmcrly  described  under  that  name  would  now  be  classed  as  lyrophadeno- 


Fi(.  423.— Lympb adenoma  of  GUndt  at  Root  of  tbe  Keck. 

Bita.  Secondarr  tumors  are,  however,  extremely  common.  All  forms  of 
tuctt  tend  to  affect  the  glands  at  an  early  period  of  their  growth.  Round- 
fttled  ind  melanotic  sarcomata  also  frequently  give  rise  to  secondary  tumors 
in  the  glands. 


CHAPTEK    XL. 

DISEASES   OF   VEINS. 


VESOUS   THROMBOSIS. 

ThnmboiiJ,  or  coagulation  of  the  blood  iu  the  vessels  during  life,  is  very 
(oiDDUiD  in  the  veine. 

f'lutu. — The  views  generally  entertaioed  at  the  present  time  with  regard 
to  cuaKulation  are  that  fibrin  does  not  exist  as  such  in  the  blood,  but  is 
fum«d  by  the  union  of  two  substances,  fibriaogeu  aud  paraglobuliu,  uuder 
tbt  iofluenoe  of  a  third  body  of  the  nature  of  a  ferment,  kno'un  as  the  6briu- 
fcnnenl.  The  fibrinogen  is  always  normally  present  in  the  blood-plasma  and 
ihe  paraglobulin  is  supposed  to  be  contained  chietiy  iu  tlie  white  corpuscles. 
Tlw  fibrin-terment  is  not  supposed  to  be  present  in  a  free  state  in  the  blood 


76 


UISBASKS  OP    VEIVfl. 


■i  H  arealatM  n  tbt  bodr,  bat  b  Ubcnied  from  tk«  white  coipuaelM  note 
ooiaia  cwMJitiow.  Blood,  in  coatact  vitli  At  w«11b  of  Tend*,  vhtck.  Co  IM 
Calnhifai'a  •spraiioa,  are  id  ■  eute  of "  pbysiol«giaU  iau^ritjr,"  riiova  M 
KBdiaty  to  eoagvliitc,  but  when  ii  is  bno^i  in  eoMMS  witb  diead  nvllar 
dooiag  ukn  pbcc.  la  the  mme  wtr.  if  Ut«  iiitc«ritT  of  the  t— tin  k 
duemgai  hj  d'mtase  or  iojury  fibris  beoMiw^  dcpoaitea  at  the  dunaged  ifmt. 
The  pmcnee  of  fne  A»meat  io  the  bliRxl  loaj  atoo  eauae  eoacrilaiiaii  in  Ui« 
HrEn^  hod)r.  KAUer  has  ihoira  thai  if  a  sufficient  quaotttj'  oi  fibria-fennait 
be  experinuotally  introdoced  into  the  bl(Kid-»ti«aui,  rafod  coagulation  will 
lake  pUc«,  even  iu  contact  with  h^lthv  vf>«»eU-  If  m  Mualler  quanthj  ji 
injwtMl  therv  ia  tevetu  febrile  iltyturlmiict^,  but  ihrnmboni  doM  not  lake 
|>l*ce,  the  iullu<!ric«!  iif  the  bt«]thy  wallfi  i.if  lli«  vefkwU  brin^  iheu  *appuMd 
I'l  be  Mufbcieut  (>JBrrC9^t  c»a;riilat)gu  until  lh<-  ferrafnt  U  eliinitialiMl  frani  tba 
Mwh].  RctarilnlJou,  nr  nrn^t  nf  the  tikmd-^trt^ni,  mcl»  a*  a  powerfal  pfe- 
t]»p(i»iii^  c»u*^  of  thnimlM^U.  Thc«c  OQiiitiuiis  NJ>plv  tw)ually  to  all  veiielft, 
vr hither  art«ri(*,  cA|iillnriisit,  or  veitit,  but  we  have  to  coiHider  them  here  in 
reference  to  the  veiiia  utilv. 
The  cauaee  of  veaous  tliromboaii  ma^r  thus  lj«  clasified  : 

1.  Otanges  in  ibc  cuudition  of  the  wall  of  the  reaeel  due  to  ia)  injury; 
(.&)  tnflauiuiBtiuu  ;  <e»  degeaeratioii. 

2.  Altered  c<>ndition«  of  the  blutxt  io  which  there  ia  cnppaaeil  to  bea 
liburatjou  uf  the  feriut^uL 

•I.  Retardation  ur  urmt of  the  blood-etream;  due  toCo)  diminished  ruta 
terga;  (b)  prcmure  on  the  veaael ;  Tr^)  tiil^irruptiiip  uf  its  rutitjiiuiir ;  (if) 
obetniction  by  a  thrombus  due  to  an;  of  the  preceding  rau^e. 

1.  Changes  in  Ote  wall  of  OitvemeL 

a.  Injvry, — The  elfect  of  any  ftpvere  injury  to  the  coats  of  a  rein  b 
either  to  exlin^iah,  or  wj  hir  to  dinitotsh,  tlu'  vitality  of  the  injurec]  fwrt, 
that  it  hfhavee  towards  ihe  blc»od  as  a  fnrei^  body,  aodsooa>'uluin  i>  formed 
on  ihe  (laniaged  part  juat  as  it  would  be  on  a  pieoe  of  wire  ioiroduivd  into 
iJie  vein,  Vfia"  are  noeasionally  (leneirat^i  by  foreign  hodicn,  as  when  a 
nature  is  Accidentally  pasMd  tnroagh  a  vein  in  ligaturing  a  contiguoiu 
artery.  Under  tbeae  circumfttanoe?  a  clot  will  ()uicklr  form  upon  tbc  furei^ 
body. 

h.  TnJltmmatioM. — tt  liss  already  been  pointed  out  in  the  chapter  ou  In- 
dammation  thai  the  mnsl  eaaentiaJ  feature  of  the  proceea  is  a  diiufnisbed 
vitaiily  of  thr  aftWotod  part  to  a  de^^rec  gbort  of  actual  death.  If  the  io- 
tlarnoiation  in  NulHriently  intense  the  wall  of  an  inHamed  vein  behaTes  to- 
wants  the  contained  bliKMl  ai*  if  it  were  dead  niatl4>r,  and  CKAftulation  coo- 
seqiientlv  taketi  place.  TbroinboBiii  tbuo  forma  a  inarkeii  feature  of  all 
forma  of  phlebitis.  The  catiua  of  iiillttromnlinn  of  veins  will  be  d«»cnbeil 
later  on  (see  I'Klebitisy. 

r.  Dtgenemtitrn. — Out(*^erAtioQ  of  the  cfiat*  b  leas  marked  In  the  reins 
tliaii  ill  the  »r1<'rif«.  In  vitririute  veiuH,  the  middle  coat  in  greatly  ihii-ken«t) 
by  thn  growUi  of  Hbroid  ti»Miie,  am)  cali-areotie  plates  are  «uRH<titiir«  tuet  with 
in  it;  but  the  endothelial  lining  ih  untially  intaet,  and  con»r>iji]enlly  thmm- 
bulb  oontparatively  rarely  take*  place  as  a  consequence  of  this  alone. 

2.  Altered  (vndii!ont  oj  the  btood. — The  exact  nature  of  the  Ganges  of  the 
blood  that  prodisposc  to  thrombosis  Ji  very  imperfectly  known.  Tbsexperi- 
uenls  before  alluded  to  show  that  no  excess  ot  free  lermeot  in  the  blood  may 
act  as  a  powerful  pradiapoaing  cause,  or  even  Uie  8dI«  oanae  of  ooagulation. 
In  sepiicajmia.  pymnia,  and  many  other  acute  febrile  dbeaiM,  then  b  con- 

aole  d«struDtioa  of  the  corpusclea,  ami  very  probably  id  this  way  fer- 
,il  libtfBted.  and  it  is  well  Known  that  thrombmis  \a  ronimou  tti  tbeae 
Jons.    The  mere  exeen  o\'  whit«  corpotdleB,  aach  aa  is  obaerved  in  leu- 


THE    PROCESS    OF    THROMBOSIS.  79 

owrtluemia,  does  not  Beero  to  prediapose  in  any  great  degree  to  thromboBis. 
Kttch  hu  obserred,  in  pyaamia  experimentally  induced  in  animals,  throm- 
b<_«i8  of  unall  Teseels  apparently  originatiDg  in  the  plugging  of  the  channel 
br  microicopic  organtsma,  and  powibly  eome  auch  condition  may  be  con- 
cerned ID  lome  casea  of  venous  tbromboeia. 

3.  RtAardaiion  oj  the  blood-ttream. — Perfect  rest  of  the  blood  when  with- 
drawn from  the  body  delays  coagulation,  end  free  movement  hastens  it  It 
ia  imnoMible,  therefore,  to  auppo«e  that  retardation  or  arrest  of  the  flow  can 
act  directlT  as  a  cause  of  thrombosis.  Nothing,  however,  is  more  certain 
than  that  it  does  form  one  of  the  most  important  causes  of  coagulation  in 
the  Hring  veaieU.  It  may  act  in  various  ways.  First,  if  the  arrest  of  the 
circulation  be  complete  and  of  sufficient  duration,  the  vitality  of  the  part 
will  »utrer  until  the  vessels  come  to  act  as  foreign  bodies  and  coagulation  takes 
place.  Secoodlv,  if  a  part  of  the  vein  is  already  diseased  or  injured  the 
retardation  of  ttie  bloou-stream  will  iavor  the  adhesion  of  the  white  curpus- 
oie«  to  ihe  unhealthy  sur&ce,  which  is  the  Brst  step  in  thrombosis  when  the 
bl-ywi  \i  still  moving.  Thirdly,  if  the  blood  stagnate  tor  a  sufficient  time 
the  white  corpuscles  may  perish  from  want  of  oxygen  and  disintegrate,  thus 
libermting  the  ferment  and  inducing  coagulation.  Lastly,  it  is  possible  that 
the  nutrition  of  the  endothelium  may  suffer  from  arrest  of  the  now  of  blood 
thntugh  the  vessel  even  when  the  circulation  through  the  surrounding  tissues 
i^  sufficiently  active  to  maintain  their  vitality. 

Ketardation  or  arrest  of  the  blood-stream  may  arise  (a)  from  diminished 
rit  a  trtgo.  This  may  be  due  to  want  of  power  in  the  heart  from  old  age, 
hatl  nourishment,  exhausting  fevers,  or  from  shock,  loss  of  blood  from  injury 
vr  operation.  Interruption  to  the  proper  distribution  of  the  force  through 
want  of  elasticity  in  the  arteries  acts  in  the  same  way.  Obstruction  of  the 
main  artery  of  a  limb  or  arrest  of  the  capillary  circulation  from  which  a 
vein  derives  its  blood,  will  in  tike  manner  retard  the  venous  flow.  Another 
Terr  common  cause  of  retardation  or  arrest  of  the  blood-stream  in  the  veins 
i#  tte  obetructioQ  caused  by  the  preaence  of  a  tumor,  or  the  contraction  fol- 
lowing chronic  inflammation  of  the  connective  tissue  of  an  organ  ;  examples 
'-■f  tb^  conditions  may  be  frequently  seen  in  the  iliac  veins  pressed  upon  by 
■  prfgnant  uterus,  or  an  ovarian  tumor,  and  in  the  vessels  of  a  cirrhotic 
iivtrr:  and  it  must  be  remembered  that  h  tight  bandnge  may  act  in  the  sftme 
way. 

When  a  vela  is  divided  in  a  surgical  operation,  it  empties  itself  and  be 
i-'-mee  colla|i3ed  as  far  as  the  next  pair  of  valves,  but  above  these  it  may 
remain  full  of  Htagnant  blood  up  to  the  point  at  which  another  vein  enters 
:b«-  trunk.     When  a  vein  is  ligatured  in  its  continuity  there  will  be,  iu  addi- 
li<<D.  stagnation  of  blood  below  as  far  as  the  next  collateral  branch. 

When  the  circulation  is  too  feeble  to  press  the  valves  back  against  the 
«alU  of  the  vessel,  or  when  in  consequence  of  diliitation  they  are  never  pn>- 
I*rly  closed,  but  project  into  the  lumen  of  the  veiu,  it  not  uncommonly  hap- 
fieiis  that  stagnation  takes  place  in  the  sinuses  of  the  valves,  and  small 
tbr-'nibi  may  thus  form,  which  finally  project  into  the  lumen  of  the  vessel, 
and  by  (cradual  increase  may  at  last  close  it  completely. 

The  ProeaM  of  Thromboaii. — Thrombosis  may  take  place  while  the  blood 
i*  mnviujc,  the  lumen  of  the  vein  becoming  gradually  tilled  with  the  coagu- 
luDi.  or  while  the  blood  is  at  rest. 

The  appearance  of  the  thrombus  varies  with  the  conditions  under  which 
tl  \i  forraetl,  much  as  the  coagulura  obtained  by  whipping  blood  diHers  from 
That  f'lniK-d  when  freshly  shed  blood  is  allowe<l  to  coagulate  undisturbed  in 
a  vQCfl.  The  process  of  thrombc»is  has  been  observed  experimentajly  by 
/aho  iu  the  veins  of  the  mesentery  and  ti'UgiU'  of  the  fro^^.     A  large  vein 


80 


DIBKASBS    or    VEINS. 


being  cli(W«n,  its  wiili^  w»e  injured  hy  placiDii;  a  cmuU  of  oitnaioi 
Dtair  or  directly  uver  it.  On  wntchiog  the  injunii  fput.  the  white  corpaicin 
of  tbe  passing  bluoii  were  seen  to  adhere  to  it  until  thev  were  beapol  op, 
aoai«tiui(«  to  such  nu  extent  as  to  obstnict  compleU'ly  the  veio.  If  ihf 
mastic  uciiou  of  Uie  mlt  had  not  been  very  Kvero,  they  might  bnmk  loott 
wain  sod  puaa  away  into  the  blood-stream ;  if  it  had  been  more  powerAil, 
the  oorpiuclcfl  remained  udhereut.  After  some  hours  ihcy  were  k«ii  to  an- 
dergo  a  marktKl  change.  Tlio  greater  part  dtaintfgnited,  their  outlioo  being 
lost  Bud  their  oaclei  uo  longer  being  rucngnizablp,  and  a  fine  granular  ma*. 
bftTiDg  the  appearance  of  freKbly  furnietl  Ulirin,  apptrurei)  in  tbe  place  they 
formerly  occupied.  This  nbeervation  u  in  hurmony  with  the  view  that  the 
libemtjon  of  the  fermenl  by  disintegration  of  the  white  corpaaclea  pUyv  «n 
iniptirtADl  part  in  the  procejw  of  coagrdatinn.  The  thromouB  thun  formed 
wai  in  KilDc  cnM«  pure  white  in  color,  out  mor^^  commonly  a  few  red  cnrpiw- 
cIh  were  entangled  nmongst  the  white.  The  more  rapidly  the  plugging  of 
the  veael  took  place  tbe  more  red  corpuades  were  entsneled  in  thv  throm- 
btu.  Wh«n  coagulalioD  takes  plAc«  in  a  veaael  in  whtcTi  thf  tlow  i»  com- 
pletely arreal«d  tbe  clot  differs  in  no  rctpect  from  thnt  formod  in  hiood 
drawn  from  the  body.  It  entangles  in  its  roesbesall  thv  corpusokit.  both  r«^ 
and  whit«,  and  pre«cnt«  the  tamilittr  dark  red  color. 

These  ubservatiouB  explain  the  different  appearancev  of  the  thrombus  nr 
the  diff«reut  circumstaocee  in  which  thrombi<aui  takev  place.  The  clot  formed 
above  an  injury  which  completely  obittxuctj)  a  vein,  as  when  it  is  divided  or 
tie<),  19  uniform  in  structure,  dark  red  in  color,  and  nl  6n)t  but  IoomIj  ad- 
herent  to  the  inner  coat  o(  the  veaael.  At  a  later  period,  as  in  tbe  ewe  of 
a  IigBture<l  artery,  it  bec^imes  denser  in  coo»i."t«oce  from  i>^utratrtioo,  and 
more  firmly  adhervut,  and  loseit  it^  color  in  consequence  of  dtuntegration  of 
the  red  corpUBclea.  A  Ihniuibus  formed  by  gradual  deposit  from  tbe  circu- 
iaiing  blood  upon  the  unhmlthy  walls  of  a  vein  is  cither  white  or  mixed  in 
tint,  ucconling  to  the  rapidity  with  which  il  t^  formod.  It  i«  lirmly  udhereut 
to  the  inner  coat  of  the  vein  aud  laminated  in  Hructure.  Mtcrot^oopic  ex- 
amitiatioii  shows  il  to  contain  n  few  red  di^ks,  but  numerous  white  eornusrles 
which  have  esciipod  dieiutegmtion  are  uaunllv  lound  between  the  lamioie. 

As  a  rule,  the  thrombi  urtsiug  in  cases  in  which  an  altered  condition  of  the 
blood  is  supposed  to  be  the  cause  of  coagulation  are  white  or  mixed,  tbe 
librin  being  dejioeited  gradually  on  the  walls  of  the  vein,  startiug  I'rora  aome 
|H>iiit  where  from  diaeaec  or  iujurv*  the  endothelium  is  domognl. 

Whi-D  a  vein  is  completely  ubiiieruted  by  a  white  thrombus,  the  stagsont 
blood  on  each  side  coagulates,  forming  a  red  clot  adherent  to  the  white 
After  death  a  further  cxtennion  of  thb  red  dot  takes  place.  TbeK  poat- 
mortem  clots  are  reoogniuMi  by  tht-ir  softQess  and  by  their  floating  fre«  in 
tbe  veaael. 

Corail  and  Rauvier  have  supposed  that  in  many  case*  at  leant  the  central 
portion  of  a  laminated  clot,  and  not  its  periphfra]  layers,  nre  the  oldciil,  tbe 
fibrin  bavitig  been  fint  depoinied  on  the  wall  of  the  vein  and  tbrn  M-pamted 
from  it  by  cuntraction,  though  prevented  from  p«tsalng  on  toward*  the  heart 
by  the  prolongations  extending  into  the  collateral  branches.  This  view, 
however,  seems  far  from  probable.  The  only  appearance  soggMtiag  lucb  ■ 
process  is  met  with  in  the  clotx  exlendine  irom  the  boan  intoUi« puuDonary 
artenr  in  cases  of  oirdinc  thromboeis.  Theoe  are  commonly  fuuoJ  to  fill  th* 
voMed  incompletely,  and  often  present  perfect  easts  of  the  pulmonary  TaJraa. 
In  thoN  Dlnce»,  however,  tho  coagulation  lakes  place  immediately  before 
death,  and  vt-rr  probably  tho  contracliuu  is  poet-morlem. 

TUv  Fate  of  tae  Thronboi  varies  aceonling  lo  tlie  clrcumstanoes  in  which 
K  is  plnoed  and  the  cnuwa  of  its  formation.    Thrombi  arising  from  injurr 


4 


i 
I 


EFFECTS   OF   THBOKBOSIS.  81 

uojergo  the  same  changei  as  those  forming  in  arteries  under  similar  circum- 
Kaaces  (vol.  i.  p.  308).  The  restoration  of  the  channel  through  a  vein, 
when  the  cuotinuity  of  its  walls  has  not  been  interrupted,  takes  place  more 
rcsdily  than  in  similar  conditions  in  the  arteries.  It  is  pitssible  that  in  some 
cases  this  mar  result  from  disintegration  of  the  clot,  the  debris  being  carried 
•war  and  lodged  in  the  lungs,  where,  if  non-infective  in  character,  thej 
vuuld  cause  DO  serious  symptoms.  The  normal  process  of  restoration,  how- 
ever. U  effected  by  the  clot  becoming  infiltrated  by  new  cells  proceeding 
from  the  wall  of  the  vessel,  as  in  the  permanent  closure  of  a  divided  vein. 
Xew  veaaeU  afterwards  penetrate  amongst  these  cells,  and  by  means  of  these 
»  commuQicatioD  is  established  between  the  permeable  portions  of  the  vein 
above  mod  below  the  clot.  The  channel,  at  first  small,  gradually  enlarges 
by  absorption  of  new  tissue  through  which  it  passes,  and  thus,  at  last,  the 
full  calibre  of  the  vein  is  restored. 

Sojfiesattg  and  DinrUegnxtion  are  common  changes  when  the  thrombus  has 
been  formed  in  consequence  of  inflammation  of  the  vein,  or  as  a  result  of 
those  altered  conditions  of  the  blood  which  accompany  septictemia  or  malig- 
uaot  fevers.  It  is  a  very  frequent  occurrence  when  the  affected  vein  leads 
frum  a  wound,  the  discharges  of  which  are  in  a  septic  state,  or  from  an  area 
afltfcled  with  some  infective  inflammation,  as  in  acute  necrosis  of  bone. 

S»ftening  most  commonly  takes  place  in  white  or  mixed  thrombi.  It  com- 
mences in  the  centre  of  the  clot  at  the  part  furthest  removed  from  the  walls 
of  the  vein.  The  clot  if  mixed  becomes  completely  decolorized,  and  grad- 
oally  breaks  down  into  a  creamy  fluid  resembling  pus  in  appearance. 
Mtcrofcopic  examination,  however,  shows  that  it  is  not  pure  pus.  In  some 
cases  it  is  composed  merely  of  granular  debris,  no  corpuscles  of  any  kind 
being  recognizaole ;  in  others  a  certain  number  of  pus  cells  may  he  mixed 
siih  the  debris.  These  are  white  corpuscles,  which  were  either  contained  in 
tbe  clot  and  have  escaped  disintegration,  or  have  wandered  into  it  from  the 
samMinding  parts.  In  most  cases  in  which  softening  takes  place,  micrococci 
are  found  io  abuDdance  In  the  puriform  fluid.  The  effects  of  the  process  of 
tuftening  will  be  discussed  immediately. 

GdeiScUion  of  a  ThTombua  is  of  rare  occurrence.  It  occurs  chiefly  in  the 
fmall  clots  that  form  in  varicose  veins  in  the  pouches  behind  the  valves. 
TaiSK  calcified  clots  form  small  rounded  bodies,  varying  in  size  from  a 
multard  seed  to  a  pea,  aud  are  known  bv  the  name  of  phleboliths. 

Effects  of  Thrombosii. — The  first  etfect  of  thrombosis  when  not  arising 
from  '.betruction  is  necessarily  to  arrest  the  flow  of  bhwd  through  the  vein. 
If  a  single  superficial  vein  is  obstructed,  this  may  cause  uo  marked  symp- 
t' ■m.T' :  but  when  the  clot  is  situated  in  a  main  trunk,  as  in  the  femoral  at  the 
ifOfin.  great  lederaa  of  the  parts  below  results.  This  is  commonly  seen  in 
the  to-callcd  "while-leg,"  which  occurs  after  labor.  If, the  vein  remains 
pc-rmant-ntly  obstructe<l,  the  ledema  may  subside  after  some  weeks  or  months, 
in«  oillattrral  veins  gradually  dilating,  and  the  free  return  of  the  blood  being 
thus  r^-tablisheit.  In  other  cases  the  ccdeina  diminishes,  but  does  not  com- 
p!<rtc-ly  dtiimppear,  the  limb  swelling  considerably  when  in  a  dependent  posi- 
ti  -n.  Wht-n  this  occurs,  the  areolar  tissue  is  indur8le<i,  the  oe.lemft  becoming 
ID  .re  *'«  ilid  ■■  as  time  goes  on.  The  nutrition  of  the  parts  is  interfered  with, 
ao'l  c)in*nic  eczema  or  ulceration  of  the  skin  from  slight  causes  is  not  aa- 
c>*mu'>n. 

Tbc  relation  of  thntmlxtsis  to  inflammation  of  the  vein  is  a  subject  on 
R&icn  there  has  been  conitiderable  difference  of  opinion.  Patholo;rists  in  the 
••r:v  pari  of  the  century  regarded  the  presence  of  a  thrombus  iu  :i  vein, 
ri-vpi  when  obviously  due  to  mechanical  causes  arresting  the  flow  of  blood, 
■•  evt<lfnce  of  previous  inflammation  of  the  coats  of  the  vessel.  Some  later 
VOL.  II. — 6 


DISEASES   OP    VBIKS. 


paifaulngists,  OD  the  other  hnn<l,  have  maiutaine<l  that  when  thrombfletti  i» 
lounil  JiKtoclated  with  iuduminutinti  of  the  coatti  of  a  vein,  the  latter  cnndi- 
ticiD  18  lilwnys  secondary  to  the  former.  The  tmih  pmhably  lien  l>eiwcen 
the  two  views,  A  vein  may  become  inttamed  as  the  resiitt  nf  niechaRical 
viulvDci',  ur  of  being  laiil  bare  in  an  operation,  and  subftequentiy  expoAed  to 
the  contact  of  decomp4iiiing  diftcbargeft,  or  by  being  implicated  in  iinbealthy 
ulceration  of  the  surrounding  itructures.  In  other  cases  difluse  iDdamnaa- 
tioD  may  spread  frnm  a  ^ejiiic  wound  in  the  looM  areolar  tisfu«  surrounding 
the  <rcin.  lu  all  tbcM-  cniiditioo^  the  phlebitis  prec^lfH  the  thr<inilKN>i«. 
The  opjKiiiite  cnnditiun  may  be  met  uith  when  &  vtrin  hai)  been  wounded, 
and  its  divided  end  filled  with  a  clot  ia  eX]j<>8ed  in  a  wptic  wound.  Tlio 
clot  then  becomes  inipre^naleil  with  septic  matter,  Hml  fn*h  c^iag^latiuu 
takes  |>lace  Lipoii  itN  pn^ximal  extremity;  septic  disicttep-ation  of  th«  vh)C 
iol]iiwii,  »nd  tlie  coals  of  the  vein  beeoiDe  inllnnjed  fruiu  the  contact  of  th« 
irritating  products  of  ttie  process.  Thus  a  spreading  throiiibo)>i»,  follower) 
bv  diginlegraiiun  of  ttie  clot  and  inOanimaiioiL  of  tlie  vein,  niiiy  be  iwl  up. 
UhiB  is  a  condition  tri-i:|iit.-Mtly  met  witli  in  pvii-riiia,  and  is  especinlly  common 
iu  llio  inicelivc  inllammation  of  buuc  known  us  acute  necrosis,  in  »ome 
casus  of  pyieuiia,  tbrumboRie,  with  aoliening  of  the  ihmmbtiB  and  inHamma* 
Lion  of  Ltie  cnala  of  the  veiu,  ta  [net  with  in  {inrla  having  no  connection  with 
tbtf  iirigiual  wound.  Here  also  it  t»  only  reuKouablc  to  suppine  thai  the 
irritating  pn^pertieu  ol  the  throiiibiuj  uru  duu  to  the  presence  uf  the  infective 
material  in  llie  blond  from  wliic^h  it  ia  fnrmetl.  iijimjile  coagulation  of  healthy 
bIwHl  in  a  vein  doea  nut  eauiH!  acute  inflaniumtion  of  the  cinite  of  llic  vessel. 
Ailer  the  operation  liir  varix  the  %'ein  can  oltcn  lie  dearly  felt  on  each  side 
of  the  iibiiterutedfiput  us  a  solid  cord,  but  uune  uf  the  dgns  ol  phlebitis  are 
present. 

The  moet  eertoiiB  c<msu<]iience  of  venoti»  thrombwiH  ia  Embolism,  or  the 
wparalioo  of  a  clot,  and  its  entry  into  the  circulation.  When  the  formatioil 
of  the  thrombus  has  been  due  Ui  mechanical  injury,  this  compHcnlion  rarely 
takes  place.  Occa^iunnlly,  however,  alter  a  surgirnl  operation  or  parturi- 
tion, a  Inrge  clot  may  he  dislodged  and  cause  sudden  denth  by  obatrueliug 
the  pulmonar)'  artery.  If  the  clot  is  not  large  enough  lu  obstruct  the  main 
trunk  of  the  artery,  it  may  lodge  in  a  smaller  brunch.  A  typical  caM  of 
this  kind  occurred  not  long  ago  in  University  College  Hospital.  The  (latieAkt 
had  been  coufined  to  bed  lor  sonic  weeks  with  a  compound  distocfltioo  of  the 
ankle ;  the  wound  was  nearly  healed,  and  be  vaa  apparently  in  good  health. 
He  suddenly  woke  from  aleep  with  a  violent  paio,  which  scem«d  to  shtiot  up 
from  his  leg  to  his  che^t.  There  was  immcdintcly  intense  sense  of  dyspnera, 
althcMigh  the  air  entervd  the  lungs  freely  ;  the  pulee  roiM)  to  120,  and  the 
action  of  the  heart  wa«  violent  and  irregular.  The  eymptoiiit  gradually 
lubaided.  and  on  ^he  third  day  after  the  attack  he  expectorateil  a  »nialJ 
quantity  of  bloo<l.  Within  a  few  hours  of  the  attack,  the  symptoms  of 
obstruction  of  the  fenmral  vein  manifested  themselvet*.  It  whs  alightlv 
tender,  and  could  be  f«lt  as  a  hard  cord,  and  great  i^ema  of  the  limb 
apjieared.  li>i>iue  weeks  after,  the  veins  of  the  opposite  limb  became  plugged 
in  the  same  way,  but  no  embolism  tixik  plai.-e. 

Embolism  19  more  commonly  the  reHiilt  of  sollening  and  disintegration  of 
the  clot.  It  is  possible  that  a  heallby  clot  may  iu  this  way  be  removed 
without  giving  rise  to  any  deliuite  symptoms.  When  the  softening  »  due  to 
Kptic  duinges  in  Lbe  thrunibua,  or  when  the  clot  is  impregnated  with  the 
priHlucii«  of  an  infective  inflammation  of  any  kind,  the  virulent  fragmctita 
set  up  inflammation  wherever  tbev  lodi'e,  giving  rise  to  the  form  of  general 
infection  known  as  embolic  pytcnna.  The  pathological  cirects  of  simple  and 
iDfective  embolisni  have  been  already  described  (^see  FyKiuia,  vul.  i.). 


PHLEBITIS — CAUSES.  $8 

A  aofteiuag  thrombus  does  not  oecessarlly  give  rise  to  embolism.  Id  the 
common  form  uf  so-calied  idiopathic  phlebitis,  suppuratioo  frequeutly  takes 
place  itMiod  tb«  thrombosed  veia,  the  middle  part  of  the  thrombus  is  softened, 
the  walls  of  the  veio  give  way,  and  the  debris  of  the  clot  are  discharged  with 
tbe  piM  of  the  abscess.  In  these  cases  a  portion  of  the  thrombus  on  each  side 
lemaiiM  uoaoftened,  aod  undergoes  the  ordinary  changes  observed  in  closure 
of  a  divided  TesHel. 

The  SyjtPTOMS  of  thrombosis  are  merely  those  of  obstruction  of  the  vein. 
If  superficial,  the  vein  can  be  felt  as  a  hard  cord,  with  knot-tike  projections 
ai  the  situaUona  of  the  valves.  If  a  deep  vein  id  affected,  there  is  oedema  of 
the  part  from  which  it  comes,  olten  with  dilatation  uf  the  superficial  veins. 
The  awolleo  parts  are  white,  and  pit  deeply  on  pressure.  When  the  coats 
of  the  vein  are  infiamed,  the  symptoms  of  phlebitis  to  be  presently  described 
will  be  manifest. 

The  Trbatmekt  depends  entirely  on  the  cause.     When  it  is  a  part  of  the 

Ejxauc  process,  it  is  that  of  pytemia ;  when  associated  with  phlebitis,  it  must 
e  treated  as  described  under  that  disease.  CEdema  must  be  treated  by 
eteratioD  of  the  limb  and  careful  bandaging  with  an  elastic  or  stocking 
bandage.  In  all  cases  perfect  rest  of  the  part  must  be  maintained,  in  order 
to  (Aviate  as  far  as  poesible  the  risk  of  embolism. 

PHLEBITIB. 

/jt^aauNofton  o/*  the  Veins,  originally  studied  by  Hunter,  has  in  later  years 
utracCed  the  attention  of  many  distinguished  Continental  and  British 
paxboloffistB,  amongst  whom  may  be  specially  mentioned  Breschet,  Velpeau, 
Cruveilfaier,  Amott,  Henry  L#ee,  Tessier,  and  Virchow. 

Causes. — Phlebitis  may  arise  from  injury  of  the  coats  of  the  vein,  from 
inAaoiiiiati<Hi  of  the  tissue  surrounding  it,  periphlebitis,  or  from  the  forma- 
tion of  an  unhealthy  thrombus  within  it.  Each  of  these  causes  may  occur 
separately,  but  frequently  more  than  one  are  concerned  in  the  process.  In 
mber  cases  phlebitis  is  said  to  be  idiopathic,  which  means  that  the  cause 
eanooc  be  accurately  ascertained. 

Traumatic  phlebitis  may  be  simple  aud  localized,  or  septic  and  spreading. 
Th«  t-tjata  of  a  vein,  in  the  same  way  as  any  other  tissue,  become  inflamed  if 
cubmitted  to  any  injury  of  suflicient  intensity,  whether  it  be  the  application 
•>f  a  ligature  in  a  surgical  operation,  accidental  mechanical  violence,  or  the 
action  of  caustics.  A^  the  result  of  the  injury,  a  clot  forms  within  the  vein, 
adherent  tu  the  damaged  spot.  If  this  completely  occludes  the  vessel,  it 
«xu-D<b  upwards  and  downwards  as  far  oa  the  vein  contains  stagnant  blood. 
Tbt:  inflammation  is,  however,  limited  to  the  injured  spot,  and  shows  no 
tmdency  to  extend.  Ultimately  the  clot  may  become  absorbed,  and  the 
rbanoel  of  the  vein  restored,  or  the  vessel  may  become  permanently  obliter- 
al«il  by  the  processes  already  described  as  occurring  in  arteries  under 
fimilar  circumstances. 

Traumatic  phlebitis  does  not,  however,  always  run  this  simple  course. 
When  the  discharges  of  the  wound  through  which  the  vein  has  been  injured 
are  in  a  septic  condition,  and  the  plugged  vein  is  exposed  to  the  direct  con- 
tact of  putrid  matter,  the  thrombus  may  become  infected.  It  then  softens 
and  decomposes,  and  thus  excites  inflammation  in  the  coats  of  the  vein, 
Mtn-ading  beyond  the  part  originally  injured.  Fresh  clot,  which  in  its  turn 
•MO'inpiMs,  forms  in  the  vein  as  far  as  the  inflammation  extends;  and  so 
ifae  pnicesB  mar  spread  until  some  part  is  reached  at  which  a  large  vein 
>tittf  the  afl'ected  trunk,  when  fragments  of  the  softeuing  clot  are  washed  on, 
(iving  rise  to  the  dissemination   of  septic  emboli  and  pyxmia.     It  ia  this 


M 


DI*SA»a  or   TKIS*. 


TWtu4«r 


■liPCkM 


•Tibsi 


(Mspitml  pcB«d«3>. 
iua  of  tbt  Tcio  M 
;  cl»s  it  ■  nmiij  do* 


■■  mmr  txuoA  'mta 
ifcadrt  li  I  Ml 

I  oTlfca 


tfa 


it  frOM 


:r 


wkfa  tfc«  iafce* 
m  tbeae  jnrt 


tha  lali— i  aivB  or  thnioil 
mad  TCBvicL  la  dibcr  bh 
im  mMtrrnl,  aad 

la  aoaa  eaH>  ef  pyaaih  or  aifMaeaiBM,  tfawhwh  aw  •eeor,  a*  bai  ban 
alnadr  peioud  oat,  m  pam  dkuat  froa  tfae  «at  ef  jafctJog,  aad  ia  tboa 
warn*  H  aoAo*  aad  caaaa  iah»a«ioa  of  tfae  caata  af  thm  wuml.  ll 
MMlUa  ■■y**»*iin»  of  liiia  pheaaawaaa  Umi  ifca  hlaod  caaiaiaa  hafcft  i 
latioBiBBi  Boxioas  amerial,  wkkk  eamm  tba  aab^^aMt  ■dfaaiag'  i 
Ipnytkat.  Ia  wappon  at  this  iheoiy  ia  tka  flua  ibat  ■iefBeaeci  arc  fband 
abatidaailT  ia  ibe  d«bri»  cf  ih«  bnika-<Ian  dflL 

DlffuM  wflamaHttan  ipnadiag  frooi  aa  aalteal  tby  waaad  along  tbe  areolar 
iMMu  Mrrouadiag a  veia  aHy^ia  inair  ranri.giTf  riM  to  iaflaauaaiioii  of  iu 

Id  ulditiuu  Ui  the  abave  fernn  of  tbe  divaae,  pblebtti»  is  fm^oendv  met  with 
wilbout  our  bdog  ahle  deflniicljr  ia  exptoin  iu  mode  of  oriitiD,  and  it  baa 
tiM^rvfore  bees  aaid  to  be  idiopalbie.  TWta  form  almoat  invariablv  afl^da 
Mic  of  tbe  large  vHna  of  lh«  lower  extreBhjr,  osuatlr  tb«  aapbena,  b'al  occa- 
viouBll)'  tbc  p^liteal.  fcaiunU,  or  Utae.  Moat  fumtnanly  Ibe  vein  attacked 
bi»  \"D^  iuHered  l>»iu  varix.  It  aeeaia  to  be  araat  fretjoent  when  erraipaJaa 
i»  epidemic,  but  the  relatioo  betweeo  ibe  two  alR-ctioiu  m  oot  proved.  The 
iftuaimaliou  ex.teod«  to  the  aurrooDdiM  are«)Ur  tiaaue.  and  mar  oecaaioD- 
ally,  but  rarely,  end  in  cuppDraliao.  lae  dot  then  diaioiegratea,  the  wklb 
of  tbe  vein  give  way,  aod  the  dCbria  mix  with  tbe  aurrounding  pua ;  but  even 
wlirii  Lliia  bappeoa,  there  ia  but  little  lendaioy  to  ealeikakui  of  tbe  ntiachiftf, 
tliu  dwiiiiegrating  clot  Iwiog  eliut  otf  oa  each  aide  by  an  adherent  aaaofteitrd 
tlirotiibuii.  Wbeo  suppuration  do«s  doC  follow  the  risk  of  dtsiotegrBlinn  and 
csiboltNiD  ia  very  Bliglit.  but  ii  does  8u<D«timn  octmr  and  cauae  death. 

Hir  Jamea  Paget  baa  pointed  out  that  "idiupalbic"  pblebitia  connaaaly 
afleoUug  tbe  long  aapbesooa,  hut  occaaionally  tlic  deeper  vt^ina,  ia  not  ooeom- 
ojoD  In  gouty  Mibjecta.  It  may  occur  in  di^rent  (utrts  of  the  same  vein  at 
the  Minw  lime,  and  is  very  liable  to  relapses.  He  baa  tt^riued  the  aflectioa 
"  K"*>Ly  phlebitia,"  and  beiievea  that  it  commenctrs  aa  a  gouty  iuBatomaiion 
ol  the  ouats  of  the  vein, 

pATimuHiicAi.  Anatomy. — Tbe  cjals  of  an  indamed  vein  are  awollen  and 
ritcid.  and  of  a  redder  tiul  than  natural  from  injection  of  the  reaKla  of  the 
uuivr  i-oat.  Tbv  flurruuiiiliii>;  ttwieit  are  usually  o-dematoua.  Id  arptic  or 
iiilt'clive  phlebitifl  tbe  wnll*  of  the  vein  are  aoUened,  and  often  ^ire  vay 
op]i<j«ilt'  tlif  disiiili'tirtitiii^'  |)orttoiis  of  the  clot :  ami  wherever  thta  bappeiM 
a  DoUevtiou  of  pus  Jorniii  ouittd^*  the  vessel.  Tbv  (.xinditiona  of  tbe  throiubi 
m  luSanied  vrina  have  already  beeu  tuffieiently  di-acribed  (see  Venoua- 
Tlir"nitK)«ta'j.  Micruscopir  i-xnnjinntiou  ehoHe  tlir  ronis  of  the  vein  to  b« 
ii)filltatv<l  with  Ninall  rotiti<l  uells ;  the  t-ndoiheliinii  ii  at  tirsl  twullen,  and  if 
•otlcjiioi;  of  Lhf  llironihua  takes  place  is  luet  in  the  cliHtntegraling  clot. 

HYMi'ioMf,  —  hi  idiopathic  or  |Cou(y  phlebitis  of  n  superficial  veJu  tbe 
Bjm|>i<iiii«  arc  very  cvi4lent.     The  patient  Iiub  ueuiilly  sufTen-d  from  farit!caw 
L-iiiH  hdloru  the  ntlack.     TIte  inflsiiininlinii  )»  localized,  usually  aflecting  a 
inchi*  of  tliu  veaaci,  and  s«;nieLitiii-s  two  or  Diorc  (mrta  at  the  same  time. 
<  win  brvouira  bard.swollen,  knobbed, and  painful,  ibe  knoba coaatitating 


i 
\ 


SYMPTOMS  AKD  TREATHKNT  OF  PHLEBITIS.       85 

distinct  ealargements  opposite  the  valves,  or  in  the  poucfa-like  dilatatioaa  of 
the  variciiae  vein.  The  skin  covering  it  aBsumea  a  i^dish-purple  color,  and 
there  nuj  be  stifiheM,  or  iDability  to  move  the  limb.  There  may,  perbape, 
be  DO  pain  when  the  limb  is  at  rest,  but  ia  some  cases  there  are  severe  shocKS 
of  pain,  resembling  neuralgia,  darting  through  the  limb.  Id  all  cases  there 
M  acut«  tendemesB  over  the  course  of  the  vessel.  There  is  always  some 
vdema  aroond  the  inflamed  vein,  but  if  a  single  superficial  vein  is  affected 
tbere  is  but  little  swelling  of  the  parts  that  supply  it  with  blood,  owing  to 
its  free  oommunicatioDs  with  the  deep  veins. 

When  thedeep  veins  are  affected  the  most  marked  signs  are  deep-seated  acute 
pain  and  teoderness,  with  marked  cedema  uf  the  parts  from  which  the  vein 
derive!  its  blood.  This  aedematous  condition  of  the  limh  is  a  most  important 
diagnostic  sign  of  deep-seated  phlebitis  when  the  vein  cannot  be  felt  (as  in 
the  pelvis,  for  instance),  and  mEiy  be  the  first  symptom  observed,  coming  on 
cither  suddenly  or  gradually.  The  oedema  may  give  rise  to  a  hard,  white, 
tense  condition  of  the  limb,  which  pits  on  pressure,  though  in  some  cases  the 
hardoeas  is  too  great  for  this,  such  as  is  seen  in  the  ordinary  "white  leg"  of 
the  aoooucheurs.  Occasionally  in  deep  phlebitis  the  lirab  may  suddenly 
•well  to  a  considerable  size  without  there  being  any  subcutaneous  (Bdenia. 
In  phlebitis  of  the  deep  veins  of  the  leg  and  thigh,  the  calf  of  the  affected 
limn  may  suddenly  enlarge,  with  great  pain  and  much  distention  of  the  super- 
ficial veins  with  fluid  blood,  but.  without  any  subcutaneous  oedema.  As  the 
inflammation  subsides  the  pain  and  tenderness  disappear;  and  if  superficial, 
the  distended  vein,  with  its  solid  contents,  hecomes  more  clearly  defined.  In 
varicuee  veins  complete  obUteratioD  of  the  vessel  may  take  place,  the  hard 
eord  gradually  diminishing  in  size  till  it  is  no  longer  perceptible.  If  the 
deep  seated  veins  are  affected,  the  oedema  continues  long  after  the  signs  of 
tnflanimation  have  disappeared,  perhaps  for  many  months,  till  either  the 
channel  of  the  vein  has  been  restored,  or  the  superficial  veins  have  enlarged 
sufficiently  to  carry  back  the  blood  without  difficulty.  If  suppuration  takes 
place  in  phlebitis  of  a  superficial  vein,  the  symptoms  are  those  of  an  ordi- 
nary acute  abscess.  When  the  deep  veins  are  affected,  the  symptoms  are 
Um  clear  until  the  accumulation  becomes  of  sufficient  size  to  give  a  distinct 
eeoiw  of  fluctuation.  In  these  cases  there  is  but  little  fear  of  pyiemia.  as  the 
vein  is  closed  by  a  firm  adherent  clot  on  each  side  of  the  part  in  which  sup- 
puration is  taking  place.  After  the  resulting  abscess  has  been  opened, 
buwever,  spreading  septic  phlebitis,  followed  by  pyiemia,  is  very  apt  to  occur 
unleM  proper  antiseptic  precautions  are  taken  to  prevent  it.  The  constitu- 
ti*»nal  disturbance  in  this  form  of  phlebitis  is  not  severe  unless  suppuration 
takt«  place,  and  even  then  it  speetlily  subsides  as  soon  as  the  pus  is  evacuated. 

The  symptoms  of  spreading  teptie  phlebUis  of  the  deep  veins  are  less  evi- 
df'Dt.  being  concealed  more  or  less  completely  at  first  by  the  unhealthy 
inflammation  taking  place  in  the  part  from  which  the  mischief  has  started, 
and  later  on  by  the  grave  constitutional  symptoms  of  pysemia  which  speedily 
manifivt  themselves.  Pain  and  tenderness  in  the  line  of  the  vein,  with 
conM'lerable  u*  lenia  rapidly  coming  on,  would  lead  to  a  suspicion  of  its 
occurrence.  The  superficial  veins  are  less  commnnly  affected,  but  should  it 
happen,  the  symptoms  are  those  just  described  of  superfioial  phlebitis,  differ- 
ioz  only  in  the  steady  extension  of  the  redness  and  pain  up  the  course  of 
the  vein,  and  in  the  presence  of  the  general  symptoms  of  blood-poisoning. 

Tbkatmext. — The  first  point  to  be  attende<l  to  in  the  treatment  of  phle- 
biii^  i*  ahwdute  rest  of  the  limb  in  an  elevated  position.  The  importance 
"f  nsdl  in  these  cases  is  twofold  ;  first,  to  prevent  pain  and  increase  of  the 
local  mischief;  and,  secondly,  to  guard  against  the  danger  that  may  result 
fr>m  the  detachment  of  the  thrombus,  which,  carried  into  the  circulation, 


niSKASKS   or.  TEINB. 


iDny  occaeion  siiddeu  tit^aili  l>y  plugging  ur  the  pulmooary  artery,  or 
remotely,  in  oases  nf  aeinic  phleniits,  by  nya-inia. 

In  simple  or  gouiy  pnlebUiB.  nmch  1(h*b1  ivmfurt  is  (Jerivtvl  from  ihe  anpli- 
ralirm  of  extract  or  w>!la«liintm  ami  t^lyceririe.  in  filial  pans.  r*jvereil  t»y  « 
thick  layer  of  (:iiltuii-wiM)l  aiiH  a  bumlage.  .^huuM  l>iiii  applicatinn  nol  he 
at  haixl,  hot  rumrtilatioaa  will  aflonl  greut  relief.  The  Cfinatilutinnal  trrat- 
metit  moat  he  conrlurted  on  ordinary  nteflical  principles  in  Bn'onlancv  with 
the  age  and  strength  of  the  ttalient,  alwnye  avoiding  depletory  meamirrt. 
which  are  not  well  home,  an*)  early  having  reeonrae  to  a  tonic  or  stinnlat- 
ing  plan.  The  hardnem  that  i^  often  leA  fitter  ooheidenre  of  the  itifltinima- 
tion  may  be  removed  hy  salt  and  nitre  pouhicca,  as  rc-coni mender!  by  BasKam. 
If  a>dema  of  the  limb  eontioue,  the  preaaare  of  an  elastic  roller  nill  remtive 
il>  But  if  the  a-dema  has  been  extennrt  and  chronic  the  limb  rarely,  if 
ever,  completely  recuver«  its  nattirni  sixe. 

If  absceaees  form  they  must  bo  treated  by  free  and  early  incbioDS,  and 
the  mo»t  flcrupu)ouAntt«rnlion  being  paid  to  the  prevention  of  decomp<i«>ilino. 

In  Bpreading  aeptic  phlebitis  treatment  is  of  little  avail.  If  a  Bujierficial 
vein  id  affected,  it  vould  he  justifiable  to  expose  the  vein  above  the  affected 
part  and  remove  a  wirtion  of  it  to  armt  the  progreas  of  the  disease.  If 
the  deep  veine  are  affected  and  the  diagnoeis  can  Iw  clearly  mtabliflhed,  and 
especially  if  rignrs  and  other  aymptomB  of  bloo<l-poi!inning  are  prefeni,  aro- 
putnlion  may  give  the  patient  a  last  chance.  Tbiit  form  uf  pblebitia  ia, 
nowever,  almo«l  certainly  preventable  by  any  efficient  antiacptio  motle  of 
treating  n-ounda. 

In  thc«e  casea  in  which  q  similar  condition  is  aet  up  in  the  vein  leading 
fmtnan  arm  of  infective  inflRmniati«n.  not  eeptic  in  chnracler.  as  in  acute 
necroeta  of  the  bone  the  diagnosis  ii  atmoet  imposrible  till  it  ia  too  lata  for 
Bmpuiation  ti>  be  of  any  service. 


I 

I 


I 


VARICOSE  VmVS,  OR   VABtX- 

Ry  Taricose  Veins,  or  Varix,  ia  meant  a  pennanent  dilatation  of  ^he.  veina 
with  thickening  nf  their  wtilltt.  U  rautt  be  dietlogaished  fVom  .itmple  diU- 
tation  or  phleheelaais  Buch  a*  arises  from  acute  ohatnirttoQ  to  the  return  of 
hlood,  or  from  the  pKsaure  of  a  tumor  or  aneurism.  tStmple  dilatation  aub* 
aides  aa«nnn  aii  the  Cfluae  ia  removed,  and  it  is  not  aivompanied  hy  any  defi- 
nite change  in  the  structure  of  the  walla  of  the  vein  ;  varix  ia  {MTiiiantrnt, 
and  ia  alwaya  aaactcieted  with  degenerative  changea  in  the  cootc  of  the  af- 
fected veMsel. 

Cxv»w». — The  CflkHtec  of  rarix  are  generally  »ueh  eondilionn  a*  imlvcr  mora 
or  lest  jmrmantni  or  frequently  rtptated  diiteittiau  uj  ihe  v^nt.  Thus,  for  in- 
filauce,  Mrainii  anil  habiiual  itvi-rexorlioD  itf  iho  limb,  by  driving  the  hlood 
from  the  deep  iuin  the  »iilM.Hitam>uus  veins,  may  give  rise  to  their  distention; 
»<>  alw>  aedeniary  nceu{>ali-ms  and  prolonged  standing  lend  to  finvor  accuniu- 
latiiin  uf  bl'KMl  in  the  veins  of  the  lower  extremities.  Any  otNtijicle  to  the 
return  of  blood  from  a  vein  (aa  the  preMure  uf  a  light  garter  below  the 
liuec,  or  of  a  tumor  upfin  one  uf  the  large  venous  trunka).  may  give  rt*e  to 
jiermaDent  distention  if  it  net  for  a  sufficient  length  uf  time.  When  the 
vein  has  become  sufficiently  dilated  to  render  ita  valves  inct)m{ieu-til.  Ihe 
tou«ioQ  of  tlie  walls  of  the  vein*  I-*  greatly  increased  by  the  weight  of  the 
UDbrokeo  column  of  hliMxl,  and  the  condition  thus  becomes  aggravated,  la 
all  eaaea  io  which  the  li»ura  are  cimgeated  fn>in  anv  obtlniction  to  the  re- 
turn of  bliK>d  t«  the  heart,  the  wnllft  uf  the  veitu  nider  with  the  other  jiarta. 
aiid  thus  are  rendervl  more  pnmi.'  to  undergo  degenerative  changea. 

Ia  aome  caaee  the  afTcctluu.  or  Uie  diapositiua  to  it,  appears  to  be  hrredi- 


TABIC08K    TKINB — MORBID   AHATOHT.  87 

tary;  aod  in  many  instancM  it  is  difficult  to  KGOgaizjo  aoy  cause  except  an 
mjeebied  and  relaxed  tiate  of  the  vtaiU  of  the  Teeael,  such  as  is  met  with  ia 
tall,  debilitated,  and  phlegmatic  people.  Age  infiuencee  materially  the  occur- 
rence of  the  disease,  which,  rare  in  the  earlier  periods  of  life,  gradually  ia- 
creasM  in  frequency  as  the  individual  advances  in  years  up  to  the  middle 
period  of  life  when  the  tendency  ceases.  In  women,  especially,  the  affection 
H  common ;  in  ooosequence,  partly,  of  natural  debility,  but  more  frequently 
frum  the  preaaure  of  the  enlai^ed  uterus  during  pregnancy. 

LucAUTT. — The  veins  of  the  skin  and  the  mucous  membranes  are  those 
that  are  must  liable  to  varix.  It  is  most  commonly  met  with  in  the  legs, 
and  more  particularly  in  the  trunk  of  the  iDternal  aaphena.  Simple  dilar 
tation  may  be  met  with  in  any  of  the  superficial  veins,  as  of  the  chest,  arms, 
head.  Deck,  bypogartrium,  or  thorax,  but  true  varix  in  these  situations  is 
rare.  The  veins  of  the  anus  and  lower  part  of  the  rectum  are  especially 
liable  to  varix,  as  they  are  but  loosely  supported  by  the  surrounding  parts, 
and  are  liable  to  over^distention  from  any  cause  that  obstructs  the  hepatic 
circulatitm,  such  as  a  cirrhosis  of  the  liver.  The  spermatic  veins  also  oflen 
becwme  enlarged,  constituting  varicocele. 

True  varix  is  infinitely  more  common  in  the  lower  than  in  the  upper  part 
of  the  body,  owing  evidently  to  the  influence  of  gravity  in  causing  tension 
in  ibe  more  dependent  vessels.  Dilatation  of  the  veins  at  any  point  above 
tbe  pelvis  arises  in  most  cases  from  the  pressure  of  a  tumor  of  some  kind 
npoD  the  lai^  venous  trunks,  the  superficial  veins  being  enlarged  to  take 
the  place  of  the  deeper  vessels  that  are  obstructed.  This  condition  may  end 
io  true  varix,  but  if  the  enlargement  is  sufficient  to  enable  the  vein  to  carry 
tbe  required  quantity  of  blood  easily  there  will  be  none  of  those  changes  of 
tbe  cnats  which  constitute  true  varix  and  are  the  result  of  abnormal  tension. 
Tbe  deep-seated  veins  that  are  principally  affected  are  the  iuternal  jugulars, 
xfae  vena  azygos,  and  the  veins  of  the  prostate. 

MoBBiD  AxATOMY. — Veins  that  are  simply  dilated  difiTer  from  true  vari- 
cose veinii  in  being  merely  increased  in  size,  without  any  alteration  in  struc- 
ture. Their  walls  are  thin  and  soft,  and  they  collapse  readily.  A  varicose 
vein  is  increased  in  diameter  and  elongated,  forming  curves  and  bending 
back  on  itself.  Sometimes  the  enlai^mentsat  particular  points  appear  mul- 
lil><cular,  the  vein  forming  a  series  of  curves  and  lying  closely  packed  to- 
gether. The  coats  of  the  vein  are  opaque,  and  thickened  often  to  such  an 
extent  that  the  divided  vessel  stands  open  like  an  artery.  Occasionally  cal- 
careous plates  are  met  with  in  the  thickened  walls.  On  opening  the  vein  the 
valves  are  always  found  to  be  insufficient ;  sometimes  they  have  disappeared 
all->s^ther,  and  in  other  cases  they  form  small  ridges  or  bands  projecting 
frim  the  wall.  When  the  vein  has  been  cut  up,  it  will  be  seen  that  in  some 
'•{  the  p>iuch-like  dilatations  the  wall  has  become  greatly  thinned.  The 
inner  c-ut  of  the  vein  appears  smooth  and  but  little  altered,  beyund  being 
ntwa  marked  by  longitudinal  strife.  When  the  vein  is  subcutaneous,  the 
tmall  branches  entering  the  trunk  from  the  skin  are  often  dilated,  and  this 
o>jB-iiti<in  may  sometimes  be  traced  here  and  there  into  the  cutis,  which  is 
thinned  over  the  dilated  vessel.  In  the  wall  of  the  vein  and  in  its  sheath 
•mall  dilated  veins  belonging  to  tbe  vasa  vasorum  are  very  commonly 
whM-rveii. 

Micr>iM»)pic  examination  shows  that  the  thickening  of  the  vein  is  chiefly 
■iue  to  a  development  of  dense  fibroid  tissue  in  the  middle  cont.  The  mus- 
rular  fibre-cells  are  somewhat  increased  in  number,  but  are  separated  widely 
fr^ni  each  other  by  the  fibroid  tissue.  The  outer  coat  is  also  thickened  ;  the 
iaat^r  shows  but  little  change.  In  the  thinned  pouches,  the  middle  coat  is 
atp>phied,  and  may  have  completely  disappeared. 


DISEASES  or  rsiKS. 


Aptkakanceb  xvd  Symitoui;. — Varicoee  veioB  are  tortuous,  dilated,  nod 
sacculated ;  ttiey  are  serpeDtioe  iu  tbcir  course,  and  feel  thick  under  the 
finger.  When  superficial,  the  disease  '\m  olteu  liniiled  to  ooe  of  the  larger 
TNKHiB  trunks,  the  aaialler  branches  ool  being  ciigat.'cd.  This  wo  cotnmoalT 
Ke  in  the  inieruul  0U|ilieiui.  The  poucli-likc-  dilulatiuns  njar  ol\ea  appnMui 
very  clusely  [o  the  surface,  the  skiu  boin^  thinne«l  ovt-r  ihctn,  nud  the  blut 
tint  of  the  skin  bcia^  readily  ))eri-t.-piibl«.  When  the  patient  ih  erect,  the 
vein  beconiPd  mi>rc  pmuiiuetit  and  teii^c  In  uther  ca^OH  the  t^riiall  girjicriidal 
TciuB  are  ufl'uL-tcd.  iip;M_<arin^  in  the  skin  aa  a  cKwe  network  of  a  purnlii^h-blue 
eolor,  oauKJiig  nnu^h  dtstrnlorutioD  (if  the  parlifi.  Both  iH!lii  of  vit'twlt'  nuiv  he 
inplicated.  In  oontMN^ucnce  nf  the  incompeteni'v  of  the  valvt^,  an  impulse 
ean  uAeu  be  felt  even  below  the  knee  wlifn  the  (uilient  ii«  made  in  rough. 
Varix  tff  till!  dt-ep  veins  is  lew  common,  aa  the  veiwelH  an;  better  nupported 
by  tiie  t^itrroundinp  fmrlA.  They  ^i re  rute  to  nn  apjiearanre  nrhic-h  ran  t>e 
KCOgni«*d  during  life.  N'arir^iHe  veins  cause  a  fteiise  of  tendon  and  weight. 
often  with  t-oiiaiderahle  f<marttng  or  prirking  pnin  in  the  purtH  from  which 
they  return  the  blood.  tSometimefl  they  niay  caii-te  nund)n(>s8,  iliffirulty  of 
movement,  or  even  some  kiea  of  jKiwer  in  the  aflected  limb.  Tliese  symp- 
toms aic  tt^ravnted  by  exertion.  In  dc«{>«>ated  varix,  these  «yniptom«  are 
often  very  marked. 

PlWMiREM  AND  Effects: — Varicose  vein*  never  uttder^  spfuitancowt 
cure;  when  once  formed,  the  condition  in  permanent,  unleM  the  vci»el 
I  become  pluggt^l  by  coagnlum,  when  it  may  bv  oblitt^ruted.  The  current  nf 
blood  i»  then  diverted  int<^  other  chnnneU.  8i)d,R«  ii  rule,  lh<?»e  in  their  turn 
becnnie  vnrt(.'««e.  The  mnin  evil  that  roulu  fmm  vuriLxwc  veins  in  the  lem*. 
is  the  change  (hat  h  slowly  induced  in  the  nutrition  of  the  »kiii,  and  >>iibcu- 
taneous  areolar  tituiie,  by  (be  relArdation  of  the  circulation,  ami  the  inter* 
fereocc  with  the  due  return  of  blood.  The  pMrtu  frfim  which  the  vein 
derivte  its  blood  are  nflvti  edightly  (edematous.  Atler  a  time  the  subcuta- 
neous  fat  becoinefl  iuilurated,  and  the  skin  loses  its  elasticity,  becomoj  rigid, 
and  often  darkly  pigmented  iu  places*.  In  coneetjuence  of  the  imperlect 
jiulritiuu  of  the  parts  ulceration  frequently  takes  place,  especially  below  the 
middle  of  the  leg.  The  ulcer  has  a  great  tendency  to  assume  the  chronic  or 
callous  form.  Chronic  eczema  is  a  nrcaoeDl  consequence  of  the  congestion 
of  the  skin  rauaed  by  varicose  veins.  There  is  another  accident  that  may 
occur  as  the  remit  of  varicose  veins  of  the  legs,  vie.,  that  the  varix  umy  give 
way,  the  vein  may  "  bur^t  "  ss  is  generally  said.  In  these  cases,  the  word 
"  burst  "  ii>  scarcely  correct.  The  varix  docs  not  give  waysolely  by  pressure 
from  within,  but  a  process  of  ulceration  goes  on  from  without  by  which  its 
ooals  become  weakened,  so  thiit  at  Inst  a  pinhole  nperinre  fornis,  giving  riw 
tlo  profuse  heninrrhage.  Tlic  blee<ling  ia  oHcn  so  profuse  ea  lo  iniluce  faiuU 
,  and  wmelimes  even  death  in  a  few  minuter.  This  bleeding  lakes  place 
in  a  different  way  from  ordinary  venous  hcrnorrhnge,  the  blood  coming 
chiefly  fn>m  the  cardiac  and  not  the  dii^lal  side,  the  inconii)CteDt  valves  not 
presenting  the  ordinary  obstacle  lo  the  downward  flow  of  niood.  It  is  this 
that  causes  its  extraiinliuarv  cnpiousnc-ss.  In  most  coses  this  so-called 
**  bursting  "  is  not  so  sudden  but  tlint  a  Surgeon  may  for&«cc  the  probability 
of  its  occurrence,  as  tt  most  commonly  tBkc«  place  cither  iju  the  surface  of 
an  ulcer,  or  is  preceded  by  induration,  reddening,  nnd  thinning  of  the 
iDtegunienta  covering  the  diseased  vein.  In  some  catcs,  however,  the  warn- 
ings  may  be  very  slight.  A  few  year*  ago  a  man  was  brought  into  University 
Cullcge  Hospital  who  had  died  in  a  few  minuter  from  hemorrhage  from  n 
varicose  vein.  There  was  nothing  to  be  sc«n  on  the  body  but  a  minut« 
hole, surrounded  by  apparently  lientthy  skin.  Water  inj<-cted  into  the  vena 
cava  readily  flowed  out  through  the  aperture    On  injecting  thcapccinicu 


i^-.    a^f^  ^  I  •*«  ^-aa 


OPIRATIVE   TREATUENT   OF    VABIX.  89 

laddimecting  it,  a  large  mass  of  tortuoua  veins  was  found,  but  the  hemor- 
Ai|e  had  coTTie  from  a  amall  cutaneous  vein  which  joined  the  dilated  trunk. 
ItMd  been  dilated  to  the  size  of  a  crow-quill,  and  the  cutis  covering  it  was 
teied.  Varicose  veins  are  very  prone  to  suffer  from  iaflammation  and 
flnaibosts.  The  symptoms  are  those  of  phlebitis,  already  described.  The 
■JMBmatioo  is  always  localized.  Suppuration  occasionally  takes  place, 
kit  ipreading  phlebitis  and  eoibolism  are  rare  complications.  After  an 
•tti^  of  phlebitis  the  vein  is  often  obliterated,  and  the  patient  cured  of  his 
Sttaae. 

Tbeatmfvt — This  must  be  conducted  on  two  principles — to  palliate  and 
to  are.  The  PftUiatiTe  Treatment  consists  in  moderate  compression  exer- 
ond  apon  the  vewel,  so  as  to  support  its  weakened  and  dilated  coats,  and 
tkoi  prevent  its  further  distention  and  the  pain  occasioned  by  this,  as  well 
■  tbe  other  consequences — such  as  cedema,  induration,  and  ulceration.  The 
prarare  must  be  applied  very  smoothly  and  evenly,  lest  it  irritate  the  skin, 
udcaow  ulceration,  or  produce  distention  of  the  vein  below  the  part  com- 
pUMil.  For  the  purpose  of  compression,  bandages  and  elastic  stockings 
■R  commonly  employed.  The  soft  "stocking  bandage"  is  one  of  the  most 
eonfi^able.  If  an  elastic  stocking  be  used,  care  must  be  taken  that  it 
wHt  fits  evenly.  They  are  often  made  too  tight  at  the  upper  part. 
MutiD's  India-rubber  bandage,  applied  in  the  same  way  as  in  the  treatment 
rftke  chronic  ulcer  (vol.  i,  p.  278),  is  a  most  efficient  and  comfortable  mode 
tf  tmtment  if  tbe  patient  can  wear  it  without  its  causing  eczema.  Elastic 
pnsare  by  means  of  a  vulcanized  India-rubber  band  or  garter  applied 
■naod  tbe  limb,  so  a9  to  simulate  the  action  of  the  valves  of  the  vein,  and 
^iticnmpreseion  to  cut  off  the  weight  of  the  column  of  blood  from  tbe 
tonnioal  branches,  has  been  recommended ;  and  Colles  advised  the  applica- 
lu  of  1  truss  to  the  upper  part  of  the  sapbena  vein ;  but,  as  a  rule,  these 
■"l«of  treatment  only  aggravate  the  symptoms. 

If  1  vein  burst,  the  hemorrhage  is  easily  arrested  by  placing  the  patient  on 
Ui  btck  with  the  leg  elevated  and  applying  a  compress  and  bandage.  When 
iptiient  is  in  danger  of  hemorrhage,  he  should  be  advised  to  have  the  vein 
■•once  obliterated;  and  if  this  cannot  be  done,  he  should  be  warned  and 
Kwibst  if  bleeding  comes  on  he  has  nothing  to  fear,  if  he  lies  on  his  hack 
•ad  fltvates  liis  leg  against  some  convenient  object  nearly  to  a  right  angle 
»iUi  bis  body,  till  afislstance  can  be  obtained.  The  application  of  a  finger  to 
tfce  bleeilin;:  !ii>ot  would  immediately  arrest  the  hemorrhage.  When  death 
tik«  place,  it  is  while  the  patient  is  foolishly  running  about  to  seek  assistance, 
Ae  bleeding  coming  from  above,  not  from  below  the  opening. 

In  certain  ri rcu metances,  it  becomes  necessary  to  change  the  palliative  for 
a  CKrative  plan.  This  is  especially  requisite  in  the  following  three  con- 
ditions :  Lit'  the  varix  be  so  large  as  to  pro<Juce  much  inconvenience,  or  to 
jive  ri>e  to  -ievere  pain  by  its  pressure  on  the  nerves  in  its  neighborhood ;  2, 
if  a  varicose  vein  have  burst,  or  be  on  the  point  of  giving  way ;  or,  3,  if  an 
BJcer  dependent  on  its  existence  will  not  heal.  Various  plans  of  curative 
treatment  have  been  recommended  ;  most  of  which  have  for  their  object  the 
obliteratinn  <>f  the  vein  at  one  point  by  exciting  inflammation  there,  and 
tbofl  causing  it  to  be  filled  by  a  thrombus  which  will  extend  as  far  as  the 
Mzi  branch  on  each  side.  Finally,  the  vein  becomes  obliterated  and  reduced 
to  a  6bp'iU!«  cord.  As  the  treatment  involves  the  artificial  excitation  of  phle- 
bitia  and  thrnmbneis,  there  is  necessarily  some  little  risk  of  its  assumint;  a 
ipmt'ling  fi-rni  with  softening  of  the  clot  and  eubm^quent  pyiiniia.  This, 
bowever,  cold  iiccur  only  if  septic  inflammation  were  set  up  round  the  vein 
M  a  ccn^^juence  of  the  wound  made  in  the  operation,  or  if  the  patient 
U  the  time  of  the  operation  was  suffering  from  some  serious  general  dts- 


90  DISEASES    OF    TBIXS. 

eaic.    Bt  ft  little  cEotioo,  therefore,  Micb  accideots  can  ftlmnst  certainly  be 
preveDted. 

By  these  means  the  trunk  of  a  Taricwae  veio  and  the  larger  nuuMs  of  varix 
may  be  occluded.  Bat  can  the  diflea«e  be  cured  by  the  local  obliteraUun  of 
the  raD?  To  this  question,  I  have  do  hesitaiion  in  answeriog  iu  the  nega- 
tiT&  Though  the  tniitk  be  obliterated,  a  collateral  renoof  circulation  is  set 
up,  which  is  very  apt  in  the  course  of  a  few  iDoaths  to  take  on  a  varicose 
oonditi<»i.  and  thus  to  cause  a  return  of  the  disease.  Bat,  though  the  cure  be 
not  radical,  much  benefit  may  often  beeffeded  by  removiDgTaricosekDnts  that 
oceasicMi  pain  or  inconvenience,  by  enabling  an  ulcer  tocicatrize. or  by  occlud- 
ing a  vein  firom  which  hemorrb^e  has  occurred  or  is  threatening  to  occur. 
Various  plans  for  obliterating  the  veins  have  been  recommended.  They 
resolve  themselves  into  five  principal  beads  of  treatmoit. 

1.  Diriium  cf  tke  Vam  has  bera  done  by  a  subcutaneous  incision  followed 
by  the  application  of  a  compress  and  bandage.  Kxcisinn  of  a  portion  of  the 
vein  between  two  ligatures  is  a  most  efficient  mode  oi  treatment,  and  can  be 
safely  nndertaken  if  any  efficient  mode  of  antisepde  treatment  be  adopted  id 
the  treatment  of  the  wound.  Without  thic.  it  is  not  unalieoiled  by  danger 
of  septic  changes  in  the  thtombu*  followed  by  pyemia.  It  i«  convenientlr 
d<«e  by  makiag  a  small  iMintudinal  wound  about  one  inch  long,  in  which 
the  rein  may  m  exposed.  Two  ligatures  either  of  prepared  catgut  or  car- 
bt^ized  sUk  may  tbeo  be  applied,  and  the  [Hece  of  veu  between  them  cut 
out  with  sciators. 

2.  It  has  be^i  reoommended  by  Mayo,  Seu(in.BoDneC,andothers,toeie»(« 
imflammaiiom  in  tMe  vein  by  producing  a  series  <^  deep  eschars  or  issues  in  the 
■kin,  covering  it  by  the  application  ^  a  caustic,  but  such  treatment  has,  very 
pniperly,  been  long  abandoned. 

3.  Cwgulation  of  the  blood  in  the  vein  by  eiertnfyut  has  also  been  recom- 
mended. .\  harelip  pin  is  passed  under  the  vein.and  a  twisted  suture  applied 
over  it.  Two  insulated  needles  are  then  passed  into  the  dilated  vein  below 
the  pin.  and  a  galvanic  cunvni  of  sufficient  strength  passed  through  them. 
The  v«n  »iioD  becomes  filled  with  clot,  and  hard,  .\tter  a  ^w  hi>ui«,  when 
the  danger  of  embolism  is  past,  the  pin  may  be  removed.  This  plan  has 
been  trie<l  at  Cniverniy  College  Hospital,  but  seemed  to  preseut  no  special 
advanta^R*. 

4.  InJ^iom  cf  tke  nrnr  Ajr  a  few  dr«^  M  q  toiutitm  #r*  Ou  ptrtMaride  of  inm^ 
as  r«o>mmeoded  by  Pravai.  is  a  very  ed^tual  method  of  pHMruriog  coagula- 
tion of  the  cvMitained  blood  and  ci>nsolidati->n  of  the  varii.  moK  particularly 
if  it  be  very  large  and  sacculated.  In  employing  this  meaui«.  it  is  essential 
to  c«.»mpre«  the  vein  by  oKans  \.4  a  tourniquet  applied  above  the  \mrix,  which 
must  U'.K  be  removed  ult  half  an  hour  at  least  aiier  (he  operati'Xi.  for  fear  of 
embolism:  the  $t^lution  »  then  i>^  he  in}ecte«i  in  very  small  quantity — not 
m-ire  than  three  <>r  four  di\>p» — by  means  of  the  frringe  Tif-.  423)  into  the 
diUteil  veins.  C\>aLtcula{i<^D  oi  the  bIo»d  immediately  tafce»  place.  The 
patient  m-jst  he  o>xifiDed  to  his  bed  for  a  few  tiar;  «ith  the  limb  raised,  and 
a  baudaze  sh<.>uld  be  applied  befi^rv  he  is  allowed  u*  walk  al>->uL  This  mode 
of  tr^atm^Eii  is  very  ed^ual  in  large  varix.  and  may  in  such  cases  be  advan- 
tageiHisiy  ..vD'-uied  with  Ibe  oext  nieth<Lxl — the  pins  bein^  used  under  the 
venous  trunks,  and  the  s^'^iutioo  iotrvxiukvd  ioto  the  dilatni  ma^we  of  the 
varix.  Bji  it  i<  not  devoid  of  daa^r :  a<.V)*.ita:^  such  as  Uh'aI  suppuration 
and  si'.>U£bio^.  pyemic  symptom:',  aovi  even  tsial  emWibm.  have  followed 
its  us^. 

■>.  Tr.<r  r.i-«t  convenient  and  s»:es;  wsy  v^f  obliterating  the  vein  in  my 
a^pioi.-.t: .  An-\  that  which  I  always  ec:ploy,  cousbKs  in  «9m.^rvt*iny  tkt  vtMei  at 
ttT<:  -il yAnu.  by  paaeuig  a  harelip  pin  un<.iemeath  it.  Uyii^  a  piece  of  wax 


OPEBATITS  TBEATMBNT  OP  VABII.  91 

bougie  over  it,  and  then  applying  the  twisted  suture  around  the  pin  and  over 
the  bougie  (Fig.  424).     In  this  way  the  vessel  gradually  ulcerates  by  the 

Enure  that  is  exercised  upon  it,  and  the  presence  of  the  bougie  prevents  the 
^ure  from  injuring  the  skin.     In  performing  this  operation,  care  must  be 
eo  that  the  vein  be  not  transfixed,  but  that  the  pin  be  pushed,  or  rather 
dipped  underneath  it ;  the  ligature  should  nut  be  too  tbio,  and  must  be  applied 


I  I    a 


Fig.  434. — ApptioKtion  of  Harelip  Pioa  to  Vftriooae  Vain*. 

tigfatlv  over  the  bougie ;  several  pins,  as  many  as  eight  or  ten,  if  necessary, 
i^Mil^  be  introduced  along  the  course  of  the  same  vessel,  at  distances  of  about 
three^uarters  of  an  inch  from  one  another  (Fig.  424) ;  those  highest  up  should 
be  put  in  first,  and  they  should  be  left  in  fur  at  least  a  week  or  ten  days,  by 
which  time  the  obliteration  of  the  vessel  will  have  taken  place.  I  believe 
that  all  the  danger  of  the  operation  coDsiets  in  the  transfixion  of  the  vein  by 
the  pin ;  the  operator  may  always  know  when  he  has  done  this  by  the  escape 
of  a  few  drops  of  venous  blood ;  when  the  pin  is  properly  passed  under  and 
dear  of  the  vein,  the  operation  is  a  perfectly  bloodless  one.  If  the  vein  be 
tiBosfixed,  the  pin  should  immediately  be  withdrawn  and  passed  at  another 
point :  if  it  be  allowed  to  remain  in  the  vein,  it  wilt  act  as  a  foreign  body, 
and  septic  changes  in  the  thrombus  may  ensue.  When  the  vein  is  properly 
cumpreased  between  the  pin  below  and  the  bougie  above,  it  becomes  safelv 
obliterated  at  the  point  of  pressure.  By  attention  to  these  circumstances  1 
have  never  met  with  any  ilVcooeequeoces,  either  from  phlebitis  or  pyamia, 
in  any  of  the  cases  in  which  I  have  performed  this  operation,  which  are 
several  hundreds  in  number. 

In  addition  to  the  application  of  the  pins  in  the  usual  way,  H.  Lee  has 
recrimmended  the  subcutaneous  division  of  that  portion  of  the  vein  which  ia 
iacluded  batween  them,  afler  coagulation  of  the  blood  has  taken  place. 
This  I  have  found  to  be  a  useful  addition  to  the  ordinary  treatment,  and  to 
ioMire  the  obliteration  of  the  vessel. 

The  poinu  of  the  pins  may  be  prevented  from  pressing  injuriously  upon 
the  ekin,  by  putting  smalt  pieces  of  adhesive  piaster  under  them.  "Whilst 
the  pios  are  in,  the  patient  must  not  be  allowed  to  move  about,  and  after 
they  have  been  taken  out,  the  limb  should  be  bandaged  for  some  time.  In 
gentrral,  no  ulceration  takes  place  about  the  pinhole  apertures;  but  occa- 
tionally.  in  debilitated  constitutions,  a  sure  forms,  which  requires  to  be  treated 
on  onlinary  principles. 


AmutUib  by  ADMtomoiU  is  a  diMaM  of  the  arteries  in  whicli  the  voaeU 
Wc'MW  vscoiiTvIy  «li>D]f]ite(I,  turtiiouH,  hihI  MTiteitLiue;  •omttiiiMt  th<>r 
•MUOMR  vaHeow  nmtlitiou,  being  dilutv^  iuUi  email  itinUMB,UKlaf«aIwar« 
wry  ttiiD  walled,  nvrmblint;  retlivr  vi-itis  tlimi  artL-m-e  to  atroeture.  Thii 
kiu>l  i>i  ^ilstatioo  of  the  rcaels  givoH  rtiw  lo  [mUatiu};  tumon,  often  of  oon- 
•idflnUv  uiCi  and  of  a  wrr  urtive  ami  iliiii)!cr<iiia  crharacler.  Tbmf  nay  b* 
•tlualMt  in  alnioat  any  li.tsiiir  or  <jr):uii  uf  tliu  bixly.  but  uru  generally  Mtirttad 
lu  lh«>  Biibmiiuuus  «n<l  subcuuiui-oua  ureiilar  li»)Ut%  aud  mnet  freqMntljr  in 
i\w  u|i|tor  pari  of  the  b^xly,  ui|it.>t!iallv  ubtml  (he  ai-nlp,  orbit,  li)»,  and  mod; 
bul  infv  bavp  brro  luet  with  in  otlier  siiuali<>i»,  Huch  m  \hv  toiijiue,  aod 
«v<«H  iu  inl<>rnal  orgmiA,  a»  the  livor;  Hud  1  have  »een  very  ntnive  f^nivtha 
i\(  tlti*  liad  on  t)io  sidi*  of  ihu  ch<«l,  natr^,  nnd  faau  It  will  geDerally  be 
Ktuiitl  iliHt  thi>  arti^Tirs  Itmling  u>  uii  utii'uriKm  by  anaeliimnsiit,  ihnugh  at  a 
tsiitwiilfrubbf  diHtiinc«i  fnim  it,  are  t<ir(ui»tiii  and  cnlargpd,  with  thin  and  «z- 
|i4tii<l«>l  iHini«.  and  piiltuilif  it<-livt-lv:  in  fiirt,  cmiiititucing  tbatcnnilitioa  which 
^tm  by  thi>  nnmo  of  Cirwtd  Dilatation  of  the  renela. 

AiU'OrUm  by  anauUimfNiiH  furnmtumon  of  varying  mit^iriidennd  tnvgular 

•hntN< ;  tbvv  ari<  unually  of  a  bluish  onhtr,  Imve  n  f>piin)>v  fe*-!,  an-  readily 

)<itni|ir»^*ibli<,  not  circumscribed,  an<l    linvi*  liirf*n  tor(n<>ii9  ve^wU  runnliiii; 

intti  Mtnl  rmni  thrill  on  ditTcront  side^.     Tbt^ir  tetii)K>raturo  U  [^-nrrally  ntiovr 

Ibm   of  urtKhboriiii;  (WrU;  and  a  vihrattiry  or  piirrini;  thrill,  willi   dinliiirt 

putoiiliiin  ntny  be  f<-lt  in  thcni.     Thi*  (luliiaiiiin  or  thrill  is  »yncbronoiu  wiUi 

tlw  boart'ii  Ittwt,  riiiiy  boitrr««t«d  by  conipr^fwinv  the  tumor  or  the  art«ri«> 

^hi«ulli>lt  lo  it,  ind  returns  with  an   ex|ianMV(>.  lieut  on  tb»  r^niovsl  of  tbv 

HMtwuri',     Tlio  bruit  in  often  loud  and  Imrsh.  but  at  other  ttnics  of  a  mfi  and 

^^MnwinK  rbunicler.     The*H  (jrowths  mrely  uwur  in  infancy,  bat  pioerally 

mukit  llivir  uji|K>iinino«in  youn(r  adult»,  th'untrh  tbey  may  b«  met  with  at  all 

klieriicle  (if  life,  often  ai*  the  cunsfijiienw  of  injury. 
I>i4<iyu<>iB. — It  in  of  iiujiorlancv  ^t  etlcct  the  diuKnaeiB  between  onlinary 
ujifttrum  and  that  by  anwtocnu«t».     In  innny  ca«re  Ibv  Hiluattou  of  thetiiinur 
at  H  iliatiini'e  from  any  large  trunk.  a»  <in  the  scalp,  the  nul«ide  of  the  tliigb. 
iir  the  kIuU-uI  region,  will  determine  this.     Again,  the  mitiine  uf  the  gr^wtb 
!■  Inwiltntinrt  than  in  true  ant'uriitn  :  and  turtuoua  v^fnela  will  Im<  felt  leadiu)^ 
V  It  from  ililfi-rt>nl  direotimiB.     The  nwelliiiff  niao  ia  doiij;hy  und  vt.'rT  ruro- 
ruauilile ;  but.  when  the  preMunt  in  reinove<l,  the  blootl  eiitent  It  with  a  whix 
ml  thrill,  riot  with  the  dwtintit  pnl&»ting  ntnike  that  i»  foiiiiil  in  aneurism. 
he  pulantion,  not  w>  (broihleia  in  aneurism,  ia  mure  heaving  nnd  expansile, 
faa  bnitt  ia  hiuder.  and  more  nujierficial.  Kimetimea  having  a  o«xiin};  tone. 
■lire  on  the  urterira  lesdinif  Iu  the  tumor  tbeM  sigtiB  are  muially  not 
jrnited,  though  diminittht'd  in  fore«,  the  blo«Ml  entering  It  from  th« 
ig  partA,  und  in  a  lesa  direct  way. 


NAvus.  98 

Treatment. — ^The  treatment  of  aoeurism  by  anaatomoeis  tnuat  depend 
upoD  tbe  siie  and  situauoQ  of  the  growth.  When  it  ia  bo  placed  that  it  can 
be  liyatitred  or  erdeed,  aa  on  the  lip,  or  when  email,  about  the  neck,  face,  or 
scaip,  trunk,  or  extremities,  it  ahould  be  removed.  I  always  prefer  the  liga- 
ture, applied  as  will  immediately  be  described,  as  being  the  safest,  and  upon 
tfae  whole  the  readiest  mode  of  removing  such  a  tumor.  If  excision  be 
practised,  it  ia  ncceaaaiy  to  be  very  careful  to  cut  widely  of  the  disease ;  if 
it  be  cut  into,  feariul  hemorrhage  may  ensue,  which  can  only  be  arrested 
by  preaHure,  and  which  in  several  instances  has  proved  fatal. 

If  the  disease  be  very  large  and  extended,  aa  is  commonly  seen  on  the 
scaJp,or  if  deeply  seated,  as  in  the  orbit,  neither  ligature  nor  excision  of  the 
tumor  can  be  practised,  and  it  becomes  necessary  to  starve  it  by  cutting  off 
ita  supply  of  blood.  Ihis  may  be  done  either  by  ligaturing  the  principal 
branehtm  leading  to  it,  or  the  main  trunk  of  the  limb  or  part. 

Simple  ligature  of  tbe  arterial  branehea  leading  to  the  turner  has  never,  I 
believe,  been  followed  by  success  ;  at  least,  iu  ten  recorded  instances  in  which 
it  has  been  had  recourse  to,  the  disease  has  not  in  one  instance  been  cured. 
It  has,  however,  been  aucGeaafutly  conjoined  by  Gibson,  in  two  cases  of  aneu- 
nam  by  anastomoeia  of  the  acalp,  with  incisions  made  round  the  tumor  at  in- 
tervals between  the  principal  teeding  arteries,  which  at  the  same  time  were 
tied. 

Tbe  wunn  trunk  leading  to  tbe  tumor  has  been  ligatured  in  a  considerable 
■Dmber  of  cases.  The  brachial  and  femoral  arteries  have  been  tied  for  disease 
of  this  kind  situated  on  the  extremities,  and  in  some  instancea  with  succesa; 
but  tbe  carotid  is  the  vessel  that  has  been  most  frequently  deligated,  in  con- 
sequence of  the  tumor  being  commonly  situated  on  the  scalp  and  in  the 
urbit.  Wyeth  baa  collected  98  cases  in  which  the  carotid  was  ligatured  for 
vascular  growths  above  the  clavicle,  and  excluding  caaes  of  "intraorbital 
aneunaai."  The  results  bave  not  been  encouraging ;  in  73  cases  in  which  the 
common  carotid  was  tied,  almost  30  per  cent,  died  directly  from  the  opera- 
tiMi.  and  about  50  per  cent,  only  of  those  that  recovered  derived  any  benefit 
frum  the  operation.  Both  common  carotid  arteries  were  tied  at  varying  in- 
tervals in  9  cases,  of  these  2  died,  1  was  cured,  2  improved,  and  the  rest 
recovered,  but  derived  no  benefit  from  the  operation. 

Id  many  of  the  caaes  in  which  one  carotid  alone  was  tied,  the  disease,  being 
!<ste<l  upon  the  scalp,  was  not  cured  ;  and  it  was  afterwards  found  neces* 
sanr  to  bave  recourse  to  ligature  of  the  tumor,  to  excision,  and  to  other  means 
uf  removal ;  indeed,  when  seated  upon  the  scalp,  this  disease  appears  to  be 
more  iutracuble  than  in  any  other  part  of  the  body,  owing  pn)bably  to  the 
freedom  of  tbe  arterial  supply  from  the  numerous  vessels  that  ramify  in  this 
region.  Here,  however,  much  benefit  might  be  derived  afler  ligature  of  the 
carvtid,  by  adopting  the  plan  suggested  by  Gibson  of  tying  the  feeding 
arteries,  and  making  incisions  between  them  down  to  the  bone.  The  liga- 
ture of  the  carotid  has  answered  better  for  pulsating  tumors  in  the  orbit, 
but  few  of  these  are  true  cirsoid  aneurisms.     (See  Intraorbital  Aneurisms.) 

S.KVUS. 

Thia  di«eaK-,  under  which  are  included  those  vnrious  affections  termed 
MoIMt'i  Martu,  Erectile  Tumorg,  and  Vaicular  Growths,  conatitutt'S  an  ira- 
[■•■rtant  and  interesting  section  of  surgical  affcctiuiis. 

Natvi  an  i-itnimonly  divided  into  two  chief  varieties,  capillary  or  cuta- 
tiirM<ji>.  and  vviious,  cavernous,  or  subcutaneous.  Aueurisru  by  aiin:4lnmo»ls 
«a«  f-irnit-rty  included  under  the  name  of  arterial  nuivus.  The  simple  capil- 
lary nxv\  are  composed  merely  of  the  capillary  vetwels  of  the  akin  greatly 


M 


DISSAflKS    or    BLOODTESSBLS. 


ineiCMed  is  liie  sod  DQmber:  the  cause  of  their  growth  b  quite  aokoova. 
Vbbow  ur  eaveniniM  drtI  are  usunlly  definitely  circumBcribed  tunuirv.  cam- 
paMd  of  ifiaccs  lined  with  an  endothelium  Hinilir  to  that  of  the  reuu  SAil 
DoinKled  by  a  tliin  wall.  The  wbute  maie  ia  bouod  tag^hcr  br  a  delicaie 
ucolar  tueue.  The  Bpacea  are  filled  with  dark  veoooa  Blood.  The  arterial 
Hipply  is  uaually  Bioall,  the  arlerie«  opeo  dirL-t^tly  into  the  space*,  withuut 
the  int^rveiittoa  of  capillaries.  These  okt!  are  Mtnctiniea  purely  rabcuu- 
■eout,  but  more  comaooly  implicate  the  skin.  The  moat  common  eooditioD 
b  to  tind  the  two  furms  of  Dxvut  conjoined,  the  diaean  aMoming  the  captU 
lary  form  iu  the  tkin  and  the  reooua  bcDcath.  lu  aonie  cam*  the  uibcuta- 
neoua  tiaevus  is  not  clearly  defined,  but  consist*  of  a  mass  of  tortuoQ*.  thin- 
walled  veins,  surrounded  by  a  considerable  quaBtity  at  areolar  tisane, 
sometimes  eontaining  fat.  Id  fact,  the  structure  uf  the  various  nsToitd 
growths  differs  coosiaerably  in  different  caae*,  and  the  various  forma  merge 
into  each  other.     (See  also  Angiomata,  vol.  t.  p.  Ho3.) 

Xxri  are  almost  always,  if  not  invariably,  congenital.  Caveraoos  nari 
occaiiooally  seem  to  appear  in  young  adult  life,  but  it  ii  probable  that  Urns 
were  origiDalty  of  ooageoital  origin,  and  oomoMaosd  active  crowth  at  an 
unusually  late  period.  Nievi  are  not  associated,  aooapt  aceideDtally,  with 
any  "iher  congenital  defect. 

Capillary  Veeri  appear  as  slightly  elevated  but  flat  spots  on  the  akio.of  a 
brifbt  red  or  purplish  tint,  and  having  occuumallr  pfaanlar  or  papillated 
•levatioDs,  with  some  larger  vnsels  ramifyiog  on  their  aarftoe.  They  often 
spread  luperficiallr  to  d  cnusidenible  extent;  they  are  usually  situated  «a 
the  &CC,  head,  oeck,  or  arms,  but  occasionallv,  though  more  rarely,  on  the 
back,  tbe  nates,  liie  organs  of  geoeraiion,  and  the  lower  extremitiea.  They 
are  often  at  birth  very  small,  not  larger  than  a  pin's  heftd,  from  which  they 
may  spread  in  the  course  of  a  few  weeks  or  months  to  patches  an  inch  ur 
two  in  diameter.  In  many  cases  no  inooovaniencc  reeula  from  thb  dtseass^ 
except  the  deformity  it  causes;  but  ooeirioaaUy,  mare  especially  when  tha 
gruwih  is  at  all  prominent,  there  u  m  great  dtsposiiion  to  unhealthy  ulcera* 
tioD,  When  bleeding  oeoan  fh>m  a  wound  of  the  mevuld  structure  it  is 
iiauallr  in  a  trickling  scnam,  and  without  any  degree  of  force. 

Tenotu  or  Cavenuras  Vsvi  are  of  a  dark  purple  or  reddish  oolnr,  asnaUy 
Very  jirnminent.  and  often  forming  distinct  tumors  of  ooikeiderable  rite, 
which  may  either  be  smooth  and  ovoid,  or  somewhat  Lobulated.  On  eaos* 
prcMLUg  a  gmwth  of  this  kind,  it  subsides  to  a  certain  extent,  feeling  doogliy, 
•i>ft,aod  inelastic;  and  on  the  removal  of  the  prtMiire  fills  again.  In  some 
cases,  when  consolidated  by  inflammation,  or  cimtaining  cysts,  thev  cannot 
be  lesseuetl  in  bulk  by  pressure.  These  nsevi  are  usually  of  about  the  site  of 
half  a  walnut,  but  sometimes  much  larger.  I  have  removed  from  the  nates 
and  tli«  bock,  some  quite  as  large  as  au  orange.  They  occur  leas  frequently 
upou  the  head  and  face  than  the  capillary  form  of  the  disease;  most  of  tKe 
instaocea  that  I  have  seen  have  been  met  with  in  the  tower  part  of  the  body, 
about  the  uatee,  back,  lower  extremities,  and  organs  of  generation. 

When  a  venous  nevus  is  porelv  subcutaneous,  tl  forms  n  sot^,  doughy 
tumor,  uftun  clearly  de6ned  in  outliite.  Its  must  chnracterietic  feature  m 
that  it  can  be  diraintihed  by  pressure,  on  tbe  remot'al  of  which  it  slowly  Alb 
out  again  to  as  large  a  siie  as  before ;  it  also  becomes  dbteoded  when  the 
ebild  aoreams  or  straggles.  It  is  usunlly  oval,  smooth,  and  uniform  in  oul- 
llos.    Occasiooally  the  surrounding  veins  arc  bluish  and  enlarged. 

Cysta  art  tooMtimca  found  in  naivi  ouuiainiug  a  dark  fluid.  They  result 
jVon  oblilcratioD  of  the  oommuntcation  between  some  uf  tbe  spaces  of  the 
nwrua  »od  the  Tassels  which  carry  nff  tbe  blood.    Tbe  tumoia  once  auppoMd 


I 


\ 


ytxYVs — pRoayosis — trbatmsnt.  95 

to  he  conaolidated  nsevi,  with  cysts  scattered  through  them  containing  clear 
fluid,  are  now  rnmrded  aa  of  lymphatic  origin. 

Pbogxoais. — The  natural  biatory  of  Doevi  has  yet  to  be  learnt — we  have 
Tct  to  ascertain  what  becomes  uf  them  when  lefl  to  themselves.  They  are  so 
commoDly  removed  by  operation,  that  hitherto  Surgeons  have  had  hut  few 
opp>rtuDitie8  of  determining  this.  I  have,  however,  seen  several  cases  in 
which  from  various  circumstances  no  operation  had  been  performed,  and  I 
have  been  struck  with  the  tendency  that  there  is  in  the  cutaneous  ocevus  to 
disappear.  If  left  untouched,  or  subjected  to  continuous  pressure,  islands 
or  patches  of  white  skin  will  gradually  appear  on  the  reddened  surface. 
These  will  slowly  increase  ana  <k)ale8ce,  and  then  the  asevup,  becoming 
gradually  lesa  vascular,  may  tn  time  disappear.  Subcutaneous  venous  nievi 
will  sometimes  gradually  shrink,  but  the  active  erectile  neevus  is  progres- 
sive. 

There  is  usually  a  fear  expressed  of  nsevi,  if  lefl  without  surgical  inter- 
ference, leading  to  dangerous  or  even  fatal  hemorrhage.  This  I  have  never 
seen  ;  indeed,  if  the  nievus  ulcerates  its  tissue  hardens,  and  the  vessels  become 
blocked  up  by  coagulum,  and  hence  less  disposed  to  bleed. 

Trratmext. — In  the  treatment  of  nsevus,  the  first  point  to  be  determined 
is  whether  the  case  should  be  left  to  nature,  or  whether  operative  measures 
should  be  had  recourse  to.  In  deciding  this  point  we  must  be  guided  by  the 
site,  situation,  and  character  of  the  morbid  growth.  If  this  be  small,  cuta- 
neous, and  superficial,  so  situated  that  it  occasions  little  or  no  disfigurement, 
and  if  it  show  no  tendeucy  to  increase,  it  may  be  lefl  without  interference; 
when,  as  just  stated,  it  may  eventually  shrivel  and  disappear,  or  become 
Converted  into  a  kind  of  mole.  In  some  cases  this  process  may  be  hastened 
by  the  application  of  tincture  of  iodine  or  liquor  plumbi.  In  other  cases, 
again,  the  nsevus,  though  cutaneous  and  superficial,  is  so  widely  diffused 
over  the  sur&oe,  that  no  attempt  at  its  removal  or  destruction  can  be  enter- 
tained with  prudeuce.  But,  if  the  ufevus  be  large,  if  it  be  Buhcutaneous,  or 
if  it  increase  in  sixe,  or  if  it  be  so  situated  as  to  occasion  disfigurement,  means 
muft  then  be  adopted  for  its  removal  by  operative  procedure. 

Optratioju  for  the  removal  of  nsevi  may  be  conducted  on  six  principles  : 
I.  ti>  excite  adhesive  inflammation  in  them,  and  so  to  produce  plugging  and 
obiiteratitin  uf  the  vascular  tissue  of  which  they  are  composed  ;  2,  to  dt-stroy 
the  pn'wth  by  caustics;  3,  to  remove  it  by  the  cautery;  4,  to  cousolidate  it 
by  elet-inilysis ;  5,  to  remove  it  with  llic  kuife ;  or,  6,  to  remove  it  bv  liga- 
xuTv.  lilach  of  these  different  plans  of  treatment  is  peculiarly  applicable 
when  the  disease  assumes  certain  forms  and  atfucts  certain  situations. 

1.  When  the  nxvus  is  of  small  sice,  aud  occurs  in  such  situations  that  its 
destruction  by  caustics,  or  removal  by  knife  or  ligature,  would  be  attended 
by  ?eri'iu8  dpformity,  as  when  it  ia  seated  about  the  eyelids,  upon  the  tip  of 
thr  iiiM^,  at  the  inner  anjrle  between  the  eye  and  the  nuse,  or  about  the 
rfimtrs  of  the  mouth,  it  is  best  to  endeavor  (o  procure  obtiteration,  by  exniing 
iajtiimm'ition  in  ii.  This  may  be  done  in  various  ways.  If  smalt,  the  iia-vus 
may  be  vaccinated.  If  it  be  larger,  the  most  convenient  plan  consii<tB, 
pf-rbap^.  in  jtassiug  a  number  of  fine  silk  threads  across  the  tumor  in  diHereut 
•iirt^tion*.  and  leaving  them  in  for  a  week  or  two  at  a  time,  until  they  have 
pn-luced  sufficient  inflammation  along  their  tracks,  then  withdrawing  them 
and  fias^iii^  similar  threads  into  other  parts  of  the  tumor.  In  this  way  its 
c>-DHiliilati(in  may  gradually  be  effected.  Another  very  useful  plan  is  to 
bn-aL  up  the  cubs'tance  of  the  growth  subcutancoualy  by  mean?  of  a  calaract- 
oeciU-,  or  tenotome,  and,  in  the  intervals  between  the  different  introductions 
••f  xWi*  instrument,  to  keep  up  pressure  upon  the  tumor.     In  other  cases. 


M&SASKS   or    BLOOUVESBSLS. 


■gaio,  tlie  rcfjuisiie  amuuiu  of  oooHolidatinn  will  be  induced  bj  paaHog 

ECUiiuocture-iiecdIeB  ioui  the  dil-vui,  and  ihcu  iKuiiug  tlieui  by  nieaob  tif  ■ 

ftfirii'lanip.     rcrtiops  tbe  mu^t  elticitot  way  ut'  ottniuiii};  tbia  object  U  br 

iiijvi^LiiiK  tbe  percliluride  of  iron  by  meana  of  a  email  ^luf«  Dyrioj^'  with  a 
MKW-puton  riHl  niid  u  fine,  eharpiy  poiuLcd  plutitiiitu  ui>ule 
^Fig. -J2&;.  Ill  doing  ibis,  cari:  iiiu«t  bv  taliL-u  ihut  but  a 
vi^ry  small  i|UuotiLy  ur'  tbi>  doiutiun,  duI  more  tbuu  two  ur 
tliri-L'  dru})B,  be  iujemc*!  al  uiiu  time.  Tbe  porcliluridu  uf  iruo 
[luiai'MM  ejLLrauraiuary  power  of  iitiagulaiiug  lUa  blood ;  and, 
if  tuure  than  ba>  juat  been  meotiouixl  bv  throw  u  in,  the  tlaaue 
of  lliC'  iiiuvuA  mity  c-itbtr  bavu  iu  vitaltiy  dfairLi^ixl.  uod 
viough,  ur  coaguluUuii  ul  ibu  blood  in  liic  vuiacU  bvyuud  the 
liifvuo  fiiity  uc-cur,  Hliii  a  daugc-rous  ur  even  Inlai  cmbuli«tu 
ciikud  from  ibv  ciinguloiii  ihua  Joroiud  btdug  Kuahcd  lutit  the 
currvut  uf  Lbt>  i^irculatioo.  Iu  order  tu  |iruvciiL  tiiiit  laltvr 
avcidcut,  a  UiUroiijuet  ahuuM  be  placed  un  u  limb  if  ii  Iw  th* 
«vii(  of  the  UIUVU8.  Xl'  ibe  iiuivun  is  svated  uu  auy  olhcr  fuui, 
it  ia  bvllvr  to  [ww  two  harelip  piutf  U'lieaifa  il,  aud  n[i|ily  a 
Cciiipurary  ligiuure  btoeath  tJiu  (liiiv  duriug  tbe  i;p«.raiiua; 
ihin  uuu  sttftrly  li(j  n-muved  alter  uboul  a  quarter  i^t  an  b'vur. 
If  |irclt.'rn.'d,  tuiiuic  acid  dissolved  iu  uaier  iu  thu  )iro[)(.>ruuti 
of  ^  to  ^,  a»  rt'U>>iuiueud«l  by  Biyant,  or  a  k'w  ilrojw  uf  a 
atroii):  Milutiuu  uf  cbluride  of  xiuc,  may  bt:  iujct:lc*d  IU«UM<1  uf 
liir  |N>rrhloride  of  truu. 

2.  Wbru  ttiv  luuvuB  is  soiall.  very  aupcrfiditl,  of  iIm  capU- 
Inry  clmmctur,  with  au  vxcwijiugly  thin  covering  uf  cuticle. 
aud  HO  aitualtid,  at  uftou  ihu  urui,  uuck,  or  liark.  that  a 
modsnUti  aniuunl  uf  scarriug  a  uf  little  ciiu«4!(|UtfU<%-,  it  mar 
niuHixutvutitntlv  be  ruuovcd  by  ike/rce  ofipUcaUvn  of  nitne 
mdd,  Tbia  aliould  Ik:  well  rubbed  uo  by  iiitiuitJt  uf  a  yieoe  of 
slick.  Thr  skiu  n>uud  the  uu,-vu8  way  be  grcajfod  Uj  prevent 
ila  bt'iug  acridrutaily  tnuchcd  by  the  acid;  uid  a^  auun  ai 
\ht  caiulic  has  brvii  vuificieutly  rubbrd  in,  it  may  be  D«u- 
traliictl  with  aonic  carboiiatn  ul  soda.  Alter  ibe  •rpanuion 
of  the  flouiib,  il«  Bpplicalton  most  be  r*-pr»t<tl  i  ~  ■  h» 
thfr^  U  any  a]>pt-amti<Y  of  prouitu'ut  granulation-    .     ----i-^ 

<       '  '      '  gccii*i<itiany  baj<(M)tta  at  one  augic  of  the  wound,  and  iiMli<4U**  a 

r>  >  V  of  the  vaM-ulnr  growth. 

3.  Tba  mftwot  tatdm$  baa  mm  htrgtdy  ubnI  in  th*  irauaMat  uf  tuevi,  aad 

b  Ntimpalr  c««ivcoi«Bt  aad  eikacigiw  la  naay  cawsa.    It  b  Bvet  applicable 

lo  mix^  70l»m'<>u«  and  MiboulaMetta  tutxi.     It  iwty  be  uaod  a^  tim  ^klvanio 

raulrry  ur  ai  IS>)i>>-lo>'>  iK<>riii,.^-aiib'ry.     The  hratcd  platinuiu  wirv  ur  tbv 

pointM  caati^nr  U' 

ivuimI  ita  niarinn,  t> 

pwn\7tHna.     kacb  - 

t«aior.    A  nuHW' 

MBlnl  part*  can  t' 

•hNflu    la  tluB  way  a  iar^- 1 

tlttla  tw  of  akia.  a  aiaugdi  >• 

nfaai  llw  afantiaa  MMiw  t;> 

wetatiua  bvaek  •«•»!  otai. 


laflcthr  li^Ht* 


tiiu  »  tnad«  to  puuviiirv  th«  gruwth 

■•r-'-,if  an  io'-l  —'"■-,()  the  Mparabe 

the  auU  -   purttuo  uf  ib« 

■I  tu  OMtk*  too  maay.  lt»t  the  wbulo  maai 

u  be  dwuuj  wi  with  eaiB|Mmtiv«ly 

!■«  left.     U  ■  eftaa  naonaarj  (u 

care  ie  rfbcud.    Alter  tbe 

.  vr  aiaple  dnsiag  ouiat  tie 

*ant.  i»  b«|  adafAnl  to  Iboee 
MMvd  airri  m  whx6  elkev  tViatiwi  m  diCnak.  «r  |»  Uaae  eo  i 
nmk»  tt  UBptftaat,  if  friUe  fei  mvt  iW  afcaa.    TW  vfefatka  it  poftirnwtl 


w« 


( 


N^VOS — LIGATION — EXCISION.  97 

by  punag  into  the  oievus  two  needtea,  insulated  except  for  the  last  quarter 
of  an  inch,  by  a  coatiog  of  copal  varuiah,  and  then  counecting  them  with  a 
galvanic  current  of  moderate  streugth  from  one  of  the  ordinary  medical  bat- 
teries. The  current  should  be  gradually  increased  and  the  effect  watched. 
The  tumor  becomes  hard  somewhat  suddenly,  and  assumes  a  pale  or  almost 
white  tint ;  this  is  a  sign  that  enough  has  been  done.  The  moment  the 
earliest  sign  of  hardening  appears  the  needles  should  be  disconnected,  and 
ctmnected  with  the  opposite  p<)les  of  the  battery,  so  that  the  needle  which  was 
negative  becomes  positive.  By  doing  this  hemorrhage  is  prevented  when  the 
needles  are  witbdrawn,  as  the  salts  of  iron  formed  by  solution  of  the  end  of 
the  positive  needle  serve  aa  an  efficient  hsemostatic.  If  gas  bubbles  out 
alnngride  the  needles  it  is  a  sign  that  the  current  is  too  strong,  and  some 
cells  should  be  taken  oS*,  or  sloughing  may  result.  In  deep-seated  ncevi  the 
etfect  can  be  judged  uf  only  by  the  hardening  of  the  tumor.  The  operation 
has  often  to  be  repeated  several  times  before  the  dxvub  is  finally  cured. 

5.  When  the  neevus  is  large,  constituting  a  more  or  less  distinct  tumor, 
and  is  of  a  somewhat  venous  character,  it  may  occasionally  be  excised, 
Fridgin  Teale  has  shown  that  some  nsevi  which  are  distiDctly  encapsuled 
mar  readily  be  dissected  out.  Should  the  nsevus,  however,  be  diffused,  with- 
out aor  distinct  limiting  capsule,  care  should  be  taken  to  cut  wide  of  the 
disease ;  and  no  operation  with  the  knife  should  be  undertaken  unless  the 
gruwth  be  either  so  situated,  as  upon  the  lip,  that  the  parts  may  readily  be 
brought  or  compressed  together,  or  upon  the  nates  or  thigh,  where  it  is  un- 
connected  with  lai^  bloodvessels,  and  is  also  very  indolent  and  venous. 
It  is  especially  when  the  nsevus  is  lipomatous  or  cystic,  or  is  distinctly  en- 
capsuled,  that  excision  may  be  advantageously  practised. 

A.  As  a  general  rule,  it  is  far  safer  and  more  convenient  to  extirpate  the 
growth  with  the  ligature;  and  this,  indeed,  is  the  mode  of  treatment  that  is 
most  genenlly  applicable  to  tumors  of  this  kind  in  whatever  situations  they 
may  occur,  as  it  effectually  removes  them  without  risk  of  hemorrhage,  and 
leaves  a  sore  that  very  readily  cicatrizes. 

The  ligature  requires  to  be  applied  in  different  ways,  according  to  the  size 
and  situation  of  the  tumor.  In  all  cases,  the  best  material  is  6rm,  round, 
(.-■•niprt-ssed  whip-cord.  This  should  be  tied  as  tightly  as  possible,  and 
kn-'tt«ii  securely,  so  that  there  may  be  no  chance  of  any  part  of  the  tumor 
e!*«iping  complete  and  immediate  Btrangulation.  It  is  well,  if  posi^ible.  not 
t**i  inclu<li-  in  the  niKiee  any  healthy  skin,  but  to  snip  across  with  a  pair  of 
s<.'i.-w'n«  that  portion  of  integument  which  intervenes  between  the  cords  that 
arc  tied  together ;  at  the  same  time,  care  must  he  taken  to  pass  the  ligatures 
wi-II  hcTtind  the  limits  of  the  disease. 

When  the  tumor  is  small,  an  ordinary  double  ligature  may  he  passed 
a'.T>>Ni  it^  base,  by  means  of  a  commim  suturo-neodlo ;  and,  tlie  noose  being 
cut  »im1  the  thread  tied  on  each  side,  strftiif^'iilatioD  will  be  efloc-tcd.  When 
it  i!<  I'f  larger  size,  and  of  round  ehape.  tli<;  must  convenient  plan  of  strangu- 
latini;  the  tumor  is  that  recommended  by  Li.-'t'm,  It  consists  in  passing,  by 
mKiD>>  of  long  ntevus-ncedles,  fixed  in  won<ipii  liundlcs,  and  having  thoir  eves 
Dear  llieir  points, double  whip-cord  lignturosin  opposite  directions  across  the 
tumor;  th('U  cutting  thmogh  the  nooses,  and  tying  together  the  contiguous 
t-ndsof  the  ligatures  until  the  whole  of  the  growth  it<  encircled  ami  strangled 
by  them.  In  <ioing  this  a  few  precautions  arc  necessary :  thus,  the  first 
nievus-needle  should  be  passed  across  the  tumor  uniinned  (Fig,  426  i,  and 
u*-<i  to  mij*  up  the  gmwtli  somewhat  from  tlic  subjawnt  parts.  Tiie  second 
nf-"lle.  arme<l  as  representol  in  the  diagram  (Fig.  4'2(>\  carrying  the  whip- 
cord ligature  by  means  of  a  piece  of  suture-silk,  should  be  pussL'<l  across  tiie 
tumor  in  the  opixieite  direction  to,  but  underneath,  the  first  needle;  the 
voi_  iL— 7 


98 


DISEASES    OF    BLOODVESSELS. 


armed  needle  being  withdrawn,  the  ligature  is  carried  acroM;  and  the  6™t 
one,  having  been  armed  in  the  eame  way,  carries  its  nooee  through  the  tumor 
as  it  is  dniwn  out.  The  two  nooses  having  then  been  cut,  an  assistant  must 
seize,  but  nut  draw  u|>ou,  six  of  the  ligature  ends  ;  the  Surgeon  then,  having 


Ftg.  42ii.— DUnram  of  tti«  Ap|<>iniii>a  of  NifTnt-oecJlH. 


Fi(.  437.— DiBfrmm  of 
Nuera*  tied. 


divided  the  intervening  bridge  of  skin,  ties  rather  tightly,  in  a  reef-knot,  thfl 
two  ends  that  are  teA  hanging  out ;  as  »>oa  as  he  has  dune  this,  he  proceeds 
to  the  next  two.  and  so  on  to  the  last  vFig.  42T).  When  he  ties  tfaeee,  he 
must  do  so  with  all  his  fonv,  espoi>ial  ly  if  the  tumor  be  large,  as  by  drawing 
on  them  he  tightens  all  the  other  nix^es.  and  drags  the  knots  towards  the 
centre  *>(  the  gniwth.  whieh  is  thus  cBW-lually  strangled.  He  then  cuts  off 
the  tails  of  the  ligature.  The  straugulate<l  na^vus  mar  be  punctured  Co 
diminish  the  size  of  the  sloughing  niasis,  and  then  pi.>wJered  «ith  iodoform 
and  dn'sseil  with  dry  cvtlon-wt.Ht!,  the  dre^iog  being  letl  on  till  the  slough 
separates  Atler  the  tumor  has  sloughetl  away,  whioh  happens  in  a  few  day*, 
if  it  In*  pmjvrly  and  tiirhily  strsrigieil.  the  wound  is  treated  on  onlioary 
prineiple^.  If  the  na'viis  l>e  altogether  subeutaiiev>us.  the  skin  covering  it 
should  n<>t  tv  saoritiiT'il.  but.  b^'iiig  divide\l  by  a  crucial  incision,  may  be 
turneil  d^^nn  in  Ev'iir  ll.-ijts.  and  the  liiiature  then  tied  as  directed. 

In  jnMne  v'as<<s.  the  na>vus  i^  so  Am  and  eiougatevl  that  the  application  of 
the  quailruple  HintiunL*.  a:>  alv^ve  dos<.'rilK\l.  caunol  include  the  whole  of  iL 
In  those  i-i roil msiAn(\<s.  I  have  t'ound  the  liiir^turv  alvui  lo  be  described  emi- 
uentiv  us«'t'i:i.  haviui;  sui\t-S!i:ully  emplivtsi  it  in  a  iirt'ai  number  of  instance*. 
Its  grt-ai  advantage-  is  that.  «hi!i.'  it  ovanpli-ieiy  and  very  readily  strangles 
the  ttiin'r.  i:  d>x<s  u.n  enc^^M^  au  undue  ijuaniiiy  of  iDtegumeni,  and  (bus 
di«es  not  pr.^iutv  a  larger  ciia:rix  than  is  ne\>es»ary  K-r  the  eradication  of  the 
grv'wth.  1:  is  app'i«>i  in  th»  tMii^wiiij:  way:  A  long  iriangular  needle  is 
thrva.itAi  .11  ;ho  iv.i.idlv  -i:'  a  i-ievt  •  f  wi.iiwrii  alv-u;  i.-.ree  var\is  in  length; 
o«*^ha'.:"  .':"  I!^i^  is  >:,ii!u\i  tvs.-k  »i:h  ink.  ihv  ■  trxr  half  is  left  uocolored. 
The  ^l>:^i^  :*  -.r.xrit'i  ;:-.r.^-,:4:r. :( :">!ii  ■ :  ::;»  s  ;;:i-i  sk:i:.ab.'>u:  a  quarter  of  an 
inch  l'r.r.i  •  ;■,<  ir.i  ■  :  x'v.i-  ;.;ii-.r,  Ar.d  i.-ar.jvt  rs* '.y  t>  :ht  axis  vf  the  same. 
It  is  ihtv.  >-,-;rriiii  x'v.t  -.-.c'-i.  v.v\:l.  a  >;  ■.;;>!<  :a:!.  a:  .last  six  inihes  in  lengtli.  is 
lert  hs'.i^:;:;:  !'r.';r.  ;;:i-  :-.■:;!:  *:  whivh  :;  <r.:t  r*\i :  i:  is  uix:  carried  acroas  ibe 
b«M>  \i  it.<  tuni'T.  iniiriui:  aiui  {>aN>;r.;    .::  ~Oiyi.-u..i  il?  laural  limits,  so  as  lo 


N^TUS — TBEATMENT   BY   LIGATURE. 


99 


l«aTe  a  series  of  double  loops  about  oiae  inches  in  length  on  each  aide  (Fig. 
428 f.  Every  one  of  theae  loope  should  be  made  about  three-quarters  of  an 
incfa  apart,  including  that  space  of  the  tumor;  and  the  last  loop  should  be 
brought  out  through  a  fold  of  healthy  integument  beyond  the  tumor.  In 
this  way  we  have  a  series  of  double  loops,  oue  white,  and  the  other  black,  ou 
each  side  ( Fig.  428).  All  the  white  loope  should  now  be  cut  on  one  side,  and 
the  biadt  loops  on  the  other,  leaving  hanging  ends  of  thread  of  corresponding 
colore.     The  tumor  may  now  be  strangulated  by  drawing  down  and  knotting 


v.— Diagram  of  Fkt  and  Elongated 
Swu*  tied. 


Fiy.  4S8. — Diacramof  Ligatnreor  Flat  and  Elongated  Hictur. 

firmly  each  pair  of  while  threads  on  oce  side,  and  each  pair  of  black  ones  on 
the  other.  In  this  way  the  tumor  is  divided  into  segments,  each  of  which 
is  straogulated  by  a  noose  and  a  knot;  by  black  nooses  and  whiie  knots  on 
one  ude,  by  white  nooses  and  black  knots  on  the  other  (Fig.  429). 

The  cicatrix  resulting  from  the  removal  of  a  nievus  is  usually  firm  and 
healthy;  but,  ia  some  instances,  I  have  seen  it  degenerate  iuto  a  hard  warty 
maflB  requiring  subsequent  excision.  The  ligature  may  be  used  successfully 
at  all  ages.  I  have  repeatedly  tied  large  active  uoivi  in  infants  a  month  or 
t«<>  old  without  meetiug  with  any  accident. 

In  some  situations  in  which  it  is  very  desirable  to  save  the  skin,  the  nsevus 
may  often  be  cured  by  »iJ>cutaneou8  ligature.  This  is  done  by  passing  a 
curved  D^evus-needle  armed  with  a  struug  silk  ligature  as  far  as  possible 
n>und  the  growth,  immediately  beneath  tlie  skin;  on  the  eye  emerging  the 
thread  is  secured  and  the  needle  withdrawn.  The  needle  is  then  passed  un- 
armed so  as  to  include  the  other  half  of  the  tumor;  as  soon  as  its  eye  appears 
ri  is  threaded  with  the  end  of  the  ligature  and  drawn  back.  The  ligature  is 
then  tighlened,  and  the  n.-evu8  thus  strangulated  subcutanenusly.  If  pre- 
f(Tr«),  the  operation  can  be  done  with  a  common  suture  needle,  which  can  be 
withdrawo  and  reinserted  where  necessary  without  being  rethreaded.  The 
elk  ligature  separates  by  suppuration  after  a  week  or  ten  days. 

Attempts  have  been  made  to  apply  subcutaneous  ligatures  of  carbolizcd 
Alk  or  catgut,  and  then  to  push  the  knot  iti  at  the  needle- puncture,  leaving 
the  thread  to  be  absorbed.  This  method  has  not,  however,  been  very  suc- 
etaftful,  as  either  the  ligature  excited  suppuration  and  was  finally  expelled, 
or  after  its  absorption  a  return  of  the  growth  took  place. 

Widely  diffused  capillary  nievi  admit  of  but  litile  treatment.  Various 
attempts  have  been  made  to  diminish  the  dis6}rurement  l>y  the  application 
of  fuper6cial  caustics,  but  the  lesults  of  this  treatment  are  not  satisfactory. 

BalmanDo  Squire  has  recommended  scarification  of  the  surface  with  an  in- 


100 


DISSASK8   or    BLOODTSa8BL». 


fill  Till  oompatti  tt  ■  Baaibtr  n(  vf  rr  fine  koife  bUda  aet  dowly  to^tli* 
maA  ttou  tkb  M««  b«fMtl  hM  raulud. 

?»xvi  n<  Sraciju.  ^jtvxtiovb. — Smi  «f  tk»  Bmlp  aro  mora  fraqnnit 
than  ill  BBV  uUmt  HtualioD.  excvpt.  pBffc»p».  ihm  Sue.  Wbeo  occurrio^  on 
thoK  putt  ifamt  an  eorend  hj  hair,  tbijr  an  alnoai  inrariably  pronuacnt 
asd  nbcBtaaaoui ;  whoo  mtad  on  tbo  limbaHl.  or  on  the  bare  tlnn  bchtod 
the  can,  ibcT  are  oficn  cataaeouL  Tba  ordinary  cubcuianeoiH  dwvui  of  the 
acalp  is  nmdil;  raaoitd  bj  the  ipalicalkMa  of  the  mmtiinqtie  iiyaturr.  Car* 
nwt  be  taken  in  p— ing  iha  Dcvdfoe  ant  to  iaclutle  the  icaduo  of  ibe  oed* 
pito-frnotalts,  or  trottblaKMne  aillulttu  an>l.  perhaps,  atppuraiion  may  ooeur 
pcaeath  thai  meoibnuie.  In  general,  it  is  better  not  to  attempi  the  prrwirva' 
tioa  of  any  of  the  iniegntnent  covering  the  growth.  It  is  inii'  tiiBt,  when 
leroored,  a  clean  white  ricatrix  i»  leA  which  nerer  ooren  it»-U'  with  hair; 
bat  thia  cao£nirt&,  and  in  aftrr-lito  beeooKB  bat  Ultla  Tisible.  The  alicmpi 
to  ditci  dAwn  the  akia  that  raren  the  Mieraa  u  not  oolr  tmiibleaone,  hot 
H  attended  br  Tery  onondemble.  and  preihiy  daDgrriMiiit  hemorrhain.  Thnee 
Sal  naevi  thai  are  ntoaled  behind  the  mr  an>  best  treated  by  the  free  appli- 
caliuo  of  fuiiiio^  niirii-  ariil.  ur  Paqueltu'a  cautery. 

Vena  of  the  gontanelle  »  the  raoet  imimrtant  rariety  of  the  Halp* 
B»ru»,  and  oon«btute»a  tittncwhai  t'oniiidabte  dtseaue.  A  laTM  tmr|tl<'  tumor 
u  situated  over  the  anterior  I'natanrlle,  rising  and  falling  with  the  ptiUatioBa 
of  the  brain  cnmmunicaleil  to  it,  and  becumiDg  dtttettHtd  and  teoM  when 
the  child  cries.  The  tumor  is  erid«itly  c)i«e  upon  the  niembraoc*  of  the 
brain,  and  this  often  detera  pntctitiuDen  from  ioterferitii;  with  it :  and  I  bar* 
But  uufn^uentJy  Been  caMe  in  which  the  parents  of  the  child  have  b«eD 
oouoMllud  iiut  to  allow  any  operation  to  be  practtKd,  lest  death  ahoald  re- 
■■It.  Ytft  thia  tumor,  00  formidable  in  appearanee,  and  m  deeply  seated  and 
doae  upon  the  brain,  may  be  remored  mtn  perfcct  adeCy  by  ibe  lijfotvre,  I 
hmn  aAen  tied  oKvi  in  this  eituatii-n.  and  bare  oerer  ae«n  any  iII-o>DBi^ 
qiienea.  nut  even  «  convulsive  St,  occur.  The  daugv.  then,  frttm  the  mere 
BtranpiIatioD  tif  the  tumur  in  thta  Bitualioo  eaunot  be  gnat :  but  there  la 
anriLher  and  a  epecial  danger,  vit.,  the  risk  of  woondinir  th«r  uembraao  of 
th«  bnrin  m  pawin^j  the  ligaturai  nnder  the  baae  of  the  tiiBor.  If  uem*- 
aeadlea  or  anrp-puiated  inacmiiieats  of  any  kind  be  oaed.  thi*  accident  will 
be  Tery  likely  to  occur;  aud.  if  this  «ere  to  happen,  inevitably  fatal  ciinae- 
aamees  will  ciwoe.  ThiB  accident  may  always  be  avoided  by  operating  [a 
UUi  Ibllowiag  war.  A  punctare  '»  made  in  front  of  the  tumor  throng  ihe 
henltbr  aoalp.  An  eyed  probe^  armed  with  a  double  li^tun-,  i^  then  puahrd 
through  thta  openio;;  acrma  ih«  have  of  the  lunmr,  ami  lU  end  i«  made  to 
project  on  the  oepoMia  aide  beyond  it ;  here  aii<tthrr  puncture  >*  madtr,  and 
the  probe  and  Inlare  togellier  arc  dmun  through.  The  same-  procedure  t* 
adopted  anw  the  tnmor  sKlciiay*.  In  lht#  nay.  a  quadruple  ligature  k 
pMped  acroga-the  tomor  in  two  >^ppi«it«r  dirrctioint ;  the  rnde  an  then  dtaro* 
gam),  and  the  ligature  i«  tightened  in  the  ordinari-  way. 

mmri  of  tlte  Ftee  ere  of  very  mcumon  occurrront,  and  uaually  cauae 
nuch  dts^ufemrtit.  Tht-  [n-atinrnt  to  be  adopted  DeceMarily  varic*  grratly, 
•ce^irdiBg  to  the  nature  of  ihtf  nicvui,  whether  cnUneoacfobculaDeous,  or 
both;  bihI  vprcially  accoidhig  to  its  ntoalioa.  Tbe  aaioe  plan,  which  ia 
■dvantattwuitr  adoptnl  '>i>  •>»«  piu^  nay  be  altogetbar  ioapplioible  in  ai^ 
olhor.     Wr   ehall.  a<'.  ivaei^tvr   the  tRalmeol   of  tfaene  raacular 

fniwiiff.  a«  thry  afTrct  i..-  ■    ■  ■■'*.*,  the  iHwc,  tlie  chewkB.  and  the  lipa. 

Vcnu  of  the  Eyelidi  i*  usually  cutaaeotu,  coarating  of  ■  diMoloratiDo 
or  aiaiainj;,  ■»  it  mvtx,  of  the  lid.  without  any  tnatcnal  twelling.  Such  a 
ilinMe  ia.  I  ihink,  betlvr  tdl  aotoached ;  it  cannot,  af  ooDr^*.  be  remnred 
«iibar  by  tha  knih  or  bf  eawtin.  withooi  produdi^  wane  ranilte ;  and,  aa 


K^VI    IN    SPECIAL    SITUATIONS.  101 

the  skin  is  always  deeply  involved,  milder  means  are  inoperative,  or  possibly 
equally  destructive.  I  nave  heard  of  slouj^hing  of  the  eyelid  being  occa- 
siooed  by  the  use  of  aatrioeent  iojectiona  ;  though,  if  the  nicvus  were  subcu- 
taaeous  and  constituted  a  aistioct  tumor,  passing  perhaps  into  the  orbit,  de- 
BtructioQ  of  the  growth  by  electrolysis  is  the  safeBt  and  most  efficient  mode 
of  tn«taieDt. 

'SmwvM  of  the  Hoh  may  occur  in  two  situations — at  the  root,  or  towards 
the  al»  and  apex.  'When  seated  at  the  root  of  the  nose,  upon  the  bridge, 
or  at  the  lower  part  of  the  forehead,  between  and  perhaps  extending  above 
the  eyebrows,  it  is  often  subcutaneous,  and  may  attain  a  very  considerable 
magnitude.  lo  cases  of  this  kind,  I  have  found  the  quadruple  ligature  the 
readi«8t  means  of  removal ;  and  although  the  part  included  may  be  of  large 
Hie.  the  resulting  cicatrix  is  wonderfully  small  and  narrow,  usually  becom- 
ing borizootal,  BO  as  to  fall  into  the  folds  of  the  skin  naturally  existing  in 
that  situation.  In  the  case  of  a  little  girl  about  three  years  of  age,  under 
my  care  some  few  years  ago,  I  removed  a  mevus  that  was  cutaneous  as  well 
mi  subcutaneous,  and  as  large  as  a  walnut,  from  this  situation,  by  means  of 
the  quadruple  ligature,  with  the  most  satisfactory  result,  the  resulting  cica- 
trix being  remarkably  small;  and  in  another  little  girl,  from  the  bridge  of 
whose  nose  I  removed,  some  years  ago,  a  mevus  as  large  as  a  marble,  very 
little  scarring  or  deformity  resulted.  In  both  these  cases,  the  ntevus  was 
cutaneuu5  as  well  as  subcutaneous.  If  the  skin  be  not  affected,  the  applica- 
tioo  of  a  temporary  ligature  followed  by  injection  of  perchloride  of  iron 
may  be  advantageously  employed,  or  the  growth  may  be  destroyed  by  elec- 
trolysis. When  the  tip  and  alts  of  the  nose  are  affected,  the  nsevus  being 
cataneous,  we  can  seldom  do  much  to  improve  the  appearance  of  the  patient. 
In  such  cases.  I  have  tried  breaking  down  the  ntevus,  and  the  galvanic  cau- 
tery, without  any  material  benefit ;  the  destruction  of  the  tissues  soon  afler- 
vmrds  leading  to  deformity.  When  the  nsevus  is  subcutaneous,  occupying 
the  tip,  ala;,  and  columna  nasi,  galvano-puncture,  or  injection  with  perchloride 
of  inm,  are  the  only  means  that  I  have  found  of  real  service.  If  the  per- 
chloride be  injectecl,  care  must  be  taken  not  to  throw  in  too  much  of  the 
li'iuid,  lest  sloughing  ur  sudden  death  result. 

JTstI  of  the  Cheeks  may  occur  in  three  distinct  forms.  1.  There  may  be 
a  -tniple  cutaneous  mevua,  a  mere  staining  of  the  skin,  a  "  mother's  mark." 
Thb  ailmits  of  no  satisfactory'  treatment  in  most  cases  ;  and  the  subject  of  it 
mu&t  submit  to  ctmtinue  through  life  to  exhibit  the  cliaracteristie  discolora- 
ti>-n.  2.  The  elevated  cutaneous  mevus  may  be  raised  above  the  surface, 
bt^ing  I'f  a  deep  purplish-red  or  plum-color,  and  covered  with  a  very  thin 
iDte^ument.  In  this  form  of  the  disease,  I  think  that  the  application  of 
c>>Qfeni rated  nitric  acid  is  the  best  means  of  extirpiition.  By  one  or  two  free 
spplioatiun."  of  the  cau.4tic.  the  growth  is  remnvcil,  and  a  dense  white  cioa- 
irix.  prvstnting  little  disfigurement,  is  left,  in  iUs  place.  3.  The  ikcvus  may 
inv'-lve  the  whole  thickness  of  the  cheek,  being  scarcely,  if  at  all,  culanemis. 
>';»-vi  of  this  kind  cannot,  of  course,  be  extirpated,  either  by  the  knife,  liga- 
t'ir»*.  or  caustif!*,  le^t  the  cheek  be  perforated,  and  the  most  serious  distijrure- 
Dient  ennue.  In  such  cases  we  must  endeavor  to  obliterate  the  structure  of 
irir  narvu!"  by  galvano-puncture,  by  exciting  inHamtnntiou  in  it  by  setons,  or 
itv  breaking  <liiwn  the  structure  of  the  growth  witti  cfttanict-iicedli'sor  a  fine 
i'-D'>ti>me.  la  a  caw  which  I  attentled  sume  years  jigo,  I  nirfd  a  Uir^c  and 
.:r?>-ply  «eate<l  mevus,  which  occupied  ()ne  check,  by  |)nsffin;.r  a  iiiiiiiber  of 
r.ut^  -ilk  threads  acro«>s  it  in  different  directimis,  ami  gradually  breaking  it 
•l-.»u  pi*H"e  by  piece,  with  a  cataract-needle;  no  iiisfigiirenient  whatever  being 

Irfl, 


IflS 


DI8KASKS   OF    BtOOPTBSSBLS. 


ViDvi  of  the  Lips  rroutre  (liflrreot  trfntrnrnt.  ficcordinj^  ns  tlirr  ueuip^ 
the  margin  or  Itiivt- irivolvttl  tlic  ttlioleciiUdiiJce  of  llifse  ptrla.  Wlit-n  mM 
Bt  (he  maririD.us  prcjcotiug  Mud  i^onifwhul  pcudnloUBgroKtiiK.  they  may  vtry 
readilr  be  rcmuvttl  bv  a  double  or  qtisdtuple  ltf:titurc'.  arc«rdiiif(  l<>  tbeiriuze. 
This  was  the  practice  (luniued  in  thecii««  Iroui  «hich  theRCCutii|iHi>y)nfidraw- 
iDgR  U*')gs-'*30,  4iil)  were  taken,  where  a  nioet  vxcelltjit  result  was  obtained 
bv  the  UBe  of  the  ligature,  followed  at  a  later  i>eriud  by  it 


Vyg.  4.<tfi.— Nttvu*  ol  Lower  Lip : 
From  Vl««. 


fill  reFuii  wnsoDiaiPM]     ^ 
by  iDJcctinn  orjwrchlo-    fl 

tip:  8i<l>l'l»-. 


ride  of  iron  intOflomeof  Ihemore  widtly  diffunpd  parts  of  the  growth.  When 
the  niVTus  iuvolves  tht:-  whol*^  lliictincra  of  th«  lip,  micIi  nH-deurrfc  arc  not  al> 
ways  available,  in  lhv*v  ca*^  jralvano-punclure,  r«f(»cated  at  inter^'aU  of 
ahout  a  wwk  till  the  whole  growth  is  conHoHiJutwl.  is  p^rhap  the  wlrtt  aod 
beat  treutDieut.  The  iojectiuu  of  perch luride  itf  inm,  intiuicacid  S(>lutitiD,<?r 
chloride  of  zioc,  may  eflect  u  cure  in  mtwl  cum-s;  but  n  lemporsry  li^atttre 
should  always  be  applied,  aod  left  on  tor  about  a  quarter  of  nti  hour,  to 
prevent  uoy  accident  arinin^r  from  the  direct  entrance  of  the  elyplic  fluid 
into  the  bl'xvl-slreani. 

When  the  whole  «tibt>lnnpp  of  the  lip  is  inrolvefl.  inclusion  and  Klmngnla- 
tion  of  the  morbid  ma«  by  mcaos  of  ligature  arc  seldom  availablo ;  the 


Flf.  -is;.— t*r(*  Nirrw  of  Uppar  l.<|t: 
I'mnl  Vliiw. 


PI(.  US.— Ur(«II»rMart;| 


amount  of  sk)U(rhing  being  very  great,  and  tho  child,  abwtrbingthfputrfwCTit 
nmUere  from  the  sloughing  mn»  which  rc<»olt*.  incurring  iht  danger  of  being 
poboned  from  this  sonrce.  In  nn  infant  with  n  very  Inrge  nivvus,  including 
om  half  of  the  Up,  which  I  lignlarcd  at  the  Iloepital  some  ytiua  mgo,  dvatn 


I 


VMVl   or   THK   ORQAXS  OF   OBITKR ATIOIT. 


to  mull  fntiti  ib\g  cau)«.     One  uf  (be  iiioH  rurinidiihlc  canes  nf 

th«  lip  iKnt  I  hikvts  ever  had  lo  do  wtlh,  iitid  in  it«  rt-Aiilui  iho.  most 

Httaikclunr,  wr«  miui  to  mo  Mvcrul  jrcuni  agtt,  by  Budd,  of  Barnstapt<>.     Tlift 

p«li"-»    -  little  girl  five  year*  old,  wn*  (lotitvd  nt  birth  lo  harr  a  rt-d  strealc 

«Mi  i!  -idd  ol'  the  up|)or  lip;  this  rapidir  developed  into  a  lar^^  tumid 

|Mrp>r  ujL-\un,  which,  when  thr  ca»c  ramo  under  my  observation,  wad  nbout 

Um  mm  of  a  larfn-  walnut,  inriilvinj^  tbc  whole  of  the  «tnictur«i  of  the  lip, 

fran     '  \i»  ti>  thr  roucouM  fiiirfa<*f«  ;  it  wma  of  a  deep  mulberry  color, 

•»<  :<>  the  median   liii«  of  the  lip  to  the  aoule  of  th«  mouth 

;.;,;.     Thin  inltyumentD  covtrinij  (his  j;rowtb  were  exi.*ediiij;ly 

.  ■  ■  Himor  itwif  ws»  in   the  hi^litiit  dcKr***  vascular  «ml  active. 

I  lo  b«  out  of  th«- i|U<-«Liuii ;  tlia  ligature  presented  litlle  to 

ijiM-tiunft  with  th^  |ien-hluride  of  in^u  and  lh«  iulro<luc'lioa 

itf  M-uMi*  »erp  »ucc\-*MivRlY  (ri<^l,  but  ueltberuf  (hei^v  roeAn»  produced  any 

rfStwl  na  tbrr  tunmr,  which  c<>mineiii!e<l  to  t-xlend  upward))  into  the  uuetril. 

I  »cn»rdiMglr  d«t*rminBd  on  usiu^  cBurtirs.     Nitric  acid  w»a  fin»t  emphn-cNl ; 

but,  AA  tfatii  did  uut  pn^lucv  sulGueutly  ducp  ifupm»lun  un  the  gruwin.  I  had 

i«ODUT«c  t«>  tba  potaaHL  cu»i  cahx.     £ty  inuius  uf  thia,  tha  tumor  was  grad- 

tmilj  neaMfcd  :  ihe  bemurrhagc  which  occasionally  resuitiKl  bein}^  rvstrainecl 

br  prtaura.     Xutwithslaiidiug  thu  amount  of  titaue  dtstlnived,  ihu  resulting 

oralrJT  irar  rninll.  r-r-m'-lin;:  tliiitof  a  Iwdiy  unilfil  hHrelip.     Three  yeara 

■Airwarda  tfai*  child  vtae  bmu^hi  to  me  afniiu,  aud  1  nas  uuich  struck  by  the 

'Waaderfal  imjirowmeut  that  had  taken  place  since  the  removal  of  th«  iiievuB. 

The  Hp  wn*  «ni>»oth,  the  cicatrii  iii  a  jzreat  degree  worn  otit,  and  oompara- 

.tin-!  dicfintrement  was  left  in   the  countenance  of  an  exi^eedingly 

prvt:  ,  <  ongiBg  child.     Finding,  however,  that  the  lip  wna  atill  drawn 

>ar  tucked  in  uj  a  venr  dense  band  of 

-«iaBXnci«l  tiwue,  whten  earned  a  deep 

of  the  ala  of  the  nose,  on 

wit.  I  divided  Lhia,  and  the  reanlt 

«■■  ntcM  latia&ctctrr. 

It  baa  htm  recummradod  when  the 
rruwtb  invade*  the  Bubstaoce  of  the 
up  <tecply  for  a  limited  extent,  to  re- 
muTii  It  by  an  ••[iC'ratioii  aumewhal 
■iailsr  Ut  that  for  the  rviuovul  of  au 
•fH^diuaM;  th«wboleaub»tauceof  the 
Itp  being  cut  ihroiitrb  widely  on  each 
aiaa,  ana  the  fu\v»  »f  the  wound 
bi«D|{ht  loftrlber  with  hureiip  piu^ 
8nah  opMmlioiM  arc,  however,  not  ad> 
tjmMi,  m  Bfan  frum  the  danj^r  of 
haaorrbaite,  ihe  discaftc  van  nlwaya  be 
caml    by   pomr  of  the   meanx   above 

dcacribnl,  without  lmt[n|{  the  auiuunt  of  deformity  Ibat  would  reault  frum 
in  fwnaivaJ  by  the  ktiiAL 

Vvru  of  the  Ton^oe  is  of  rare  uccorrence.  1  have,  however,  sucoeasfully 
•i|i»r»tMl  by  mi-nni  of  thr  ^cmeeur  in  one  ease,  in  which  the  whole  uf  the 
flnv  cKCnmitT  of  the  nrinio  was  involved  (Pig.  i^-i  >.  The  psrticuiara  will 
k  And  iB  Chapter  [.IX. 

Iiavi  af  tlw  Orfvu  of  OcQeratioaareuccttflonally  met  with  in  ihe  female, 
b«t  rmn>)v  in  the  mati-.  Thr  only  inalanorof  yrrmtf  of  the  Pfnia  with  which 
I  fcA*«  oaal  u«eamd  in  ihe  cn*^  >\\'  n  gi-nilemnn  thirty-two  veareof  age,  who 
vaaoUcd  moiiMM  yearM  a^'»  l>ir  »  gmwth  i>f  (bin  kind,  a«  fai^  as  a  walnut, 
t*lrn*H  ssder  the  rrflexioo  of  the  preputial  mucau«  membrane.     li  had 


Vig.  4X1. — Kairas  o(  TonxiiB. 


104 


DISEASES  or    BI.OODTBS6BLfi. 


uated  for  manr  ycwi  witiMal  giving  mit  aaaoTBBoe.  bUL  m  U  Hul  or  laic 

in  to  enlargf.  slid  nfc—JrwlW  b>  bleed,  be  ra  deifavai  of  baring  It 

tuviid.     Thii  I  did  bT  spplria^  tb«  <{uadniple  I^atafe^  after  baviai;  dk- 

dic  miioHJf)  meinbnuie  doirn. 
Variof  the  VolTa  ue  bjr  bo  meaoatinrreqaeBt.  We  bare  bad  aBTefiU  ia- 
Maac«oftbfckUi<liatheHwpha]oflaleyaai«.  Tbe]rai«w«all7TeiioaH,oft0a 
attaio  a  large  nze.  mad  tnajr  aooMiteMi  invalTa  tbe  mUgaPK,aUl  Arudani 
on  the  inside  of  tb«  tbigfa,  or  oo  tba  periftanm,  m  «cU  at  tbe  Tulva.  Wbca 
the  growth  i»  coofiaed  to  the  rulra,  b  i*  but  Kmaved  bf  tbe  ligaiBni  Soaie 
time  ago,  I  r«;raoT<id  id  this  aav  B  large  pcsdaloM  waoat  aMnia,  ai  lame 
UM  two  ur  liiree  flatt«itiil  walautft,  from  tbe  left  labtan  «t  a  little  rlri  Mr 
ytu%  of  age.  In  tbU  caae,  I  found  it  inoM  coaveaiant  to  etoploy  Inn  cna- 
tiDtwot  ligature.  Tbe  fame  nieaitiMcr^  hod  recoaraslo  ia  order  lo  extirpate 
large  onvm  from  tbe  labium  of  a  cbihi  ihrrc  n'ranaf  age;  l^iit  in  thi*  ttutt 
tie  nueaee  exteaded  to  the  iDt<-cum«^[«  of  tiiv  fwriaetua  and  Inner  #i<)r  of 
'  tbe  thigb.  and  wm  here  rtmovca  b_v  tbe  apfiticattoa  oi  ftroag  nitric  acid, 
after  tbe  Inrir^^r  irroKth  had  wparated. 

Od  the  Extreautiea.  Veek,  aad  Tmak  everr  posible  Tariety  of  twrua 

ocoufB.     WLl'u  tbe  diceaw  u  Oai,  oiiuutiDg  ratbcr  of  itataiag  of  tbe  ikia 

tban  of  an<r  actual  tumor,  it  lua;  coiomoiilT  be  tivaied  KKGoafullT  bv  tba 

appUcatioQ  of  the  atnmg  tiocture  of  ic<dine :  or  kbuuld  it  be  tbouf&l  Amir- 

t-able  to  reiDOTe  it.  thia  may  be  aflbetcd  br  rubbine  it  witb  rtnog  nitric  add. 

[If  tfa«  owoa  avume  tbe  Ibrm  of  a  tumor,  it  will  almoeC  inrariablv  be  of  a 

'venoofl  diaracter,  aad  tben  nfumval  br  cxi-iBioB  br  BiMUia  nf  tbe  ligawre 

habould  baalRcted.     If  tbe  groinb  be  niund.th^ordiuarTquailnijile  lij^tan 

'may  be  emplojrad;  if  flat  ur  elongated,  ibv  Itingitudioal  eoniiuuotu  ligaturv 

ia  prelerable:. 

N.KTorD  Lii>oHA. — Thia  a  a  fnrm  of  ncrua  wbirb  I  hare  occasiaoallT 
8e«n,  but  wbtob  doei  ni>t  aniwar  tu  bare  aitrartral  much  milirr,  ahbnugb 
N^latfrD  apealcs  nf  h,  aad  Killmth  aye  that  in  lij>i>ma  be  bae  «.>vrral  times 
met  with  ravcmouH  diUtaliiin  of  llie  veiiw.  It  ik  a  tumor  in  which  the 
nnvtiid  Htrurture  is  ouioiucd  with  a  fattjr  growth  uttuallv  more  fibrouii  tban 
an  onlinary  lipoma.  Thui  dtneMP  in  inTariuhlT  •'vied  npno  the  naua,  luck, 
or  thi;(h.  It  oix'un  ta  a  nmouth,  doughy,  indnlent  tumor,  incompreMibte, 
not  varying  tii  mun  or  ahapp-,  without  heal,  tltrill,  or  pulMtion  u(  any  kind, 
|Mi«»ihly  hnvirijr  m  ff?w  v^inn  rnmifyiog  over  its  surfacf,  hut  no  di»tinct  va^ 
culiir  npiwiimure.  It  in  u»umlly  conj^nitnl,  or  has  been  nolired  in  early 
childbcKKl ;  Mrid  it  cmlinufv  without  any  \-ery  miilerial  chatij:e  in  shape, 
BiMi,  or  aji|wamii(xi,  until  ihw  incjuveuieoce  «r  def'Ttnity  ««c-c)i*ioned  by  il 
rt-quiriw  it«  rvmitrsl.  Thio  Is  beet  eObcled  by  the  knife.  After  removal,  tbe 
turner  will  he  found  to  hi.'  wmpoeod  of  a  tnaw  <>f  librous  fat.  having  a  Iar;;e 
uumlx?r  "fveim  rntiiiryini:  tlipjUfih  il,  eo  us  tu  oustitute  n  dbtioct  raacaiar 
riemeol,  uflen  c>iiimiiiiicAtiii|;  uith  small  cysts  eoutaiuiug  a  blo«>dy  fluid. 
Tbe  tumor  lias  'K-t'iui'^nally  a  leudenvy  to  recur  after  removal.  In  one  oaae 
I  have  o]>erute<l  tbre«  times  tor  the  removal  of  a  large  growth  of  this  docrip- 
lion.  Biluat(.*d  on  the  bult<ick,  and  extendini^  forward  ti)wanU  the  perineum. 
^^The  flm  "{tfrnliori  was  performed  in  IHol ;  tbe  aei'und  iu  1S5A.  and  tbe 
IMtient.  ill'  II  I'inhttwn  years  of  ace.  apaiu  preaeiilP<l  himself  in  1M3  with  a 
iK-c  Mt  the  growth  in  an  uln'raied  iilale.  in  the  ricairix  of  the  former 
«p,  The  situation  in  which  I  have  fie«-n  mieb  tuniors  occur,  where 
n  ri«'  to  m«»t  inconvenifnoe.  and  wher«  their  remi'val  hu  requlrvd 
Most  <■««•,  biw  (wen  the  iitiliTtor  part  of  the  thi>:li.  just  below  Pou. 
•r  [toll  iitid  nliiKwi  in  eniineetion  with  the  femnral 

,        ,|iti'(i],  uhich  was  »ent  to  me  by  Gdwanb>,  of  A 
enllKiiMiu  of  that  island,  bad  «uflerei((  for  some  yean 


HEMOPHILIA.  106 

duoDic  solid  <edems  of  ooe  of  his  I^,  appareotly  dependent  upon  the  preg* 
tare  exercised  upon  the  saphena  and  femoral  veins  by  an  elongated  indolent 
tDiDor  just  below  Poupart's  ligament,  and  over  the  course  of  these  vessels. 
This  tumor  had  existed  from  childhood,  and  presented  the  signs  that  have 
JDCt  been  given  as  characteristic  of  the  disease  under  consideration.  It  was 
lemoved  by  an  incision  parallel  to  Poupart's  ligament,  some  careful  dissec- 
tion being  required  to  separate  it  from  the  femoral  sheath,  more  particularly 
towards  the  inner  side,  where  a  prolongation  of  the  tumor  dipped  down  by 
the  side  of  the  femoral  vein,  compressing  that  vessel,  and  thus  causing  the 
sdema  of  the  limb.  After  removal,  the  tumor  was  found  to  consist  of  a 
nas  of  dense  adipoee  tissue,  with  much  vascular  structure  intermixed,  and 
lome  small  cysts.  The  cedema  gradually  subsided  ;  and  when  the  patient 
left  England,  about  three  months  afler  the  operation,  the  limb  had  nearly 
regained  its  normal  size,  being  but  little  larger  than  the  sound  one. 

HEMORRHAGIC  DIATHESIS,  OR  HEMOPHILIA. 

In  connection  with  diseases  of  the  bloodvessels  it  may  be  stated  that  in 
lome  constitutional  conditions  it  is  found,  though  fortunately  very  rarely, 
that  there  is  a  great  tendency  to  very  troublesome,  indeed  almost  uncon- 
trollable bleeding,  from  slight  wounds.    An  abnormal  tendency  to  bleed  is 
Ktmetimes  observed  in  persons  who  are  "  out  of  condition,"  and  whose  tissues 
ire  soft  and  flaccid.     They  bleed  freely  from  slight  wounds  and  bruise 
utmeively  from  trivial  blows.    In  these  cases  the  bleeding  appears  to  be 
Buistained  by  the  laxity  of  fibre  preventing  the  proper  contraction  of  the 
diTided  or  torn  vessels;  and  the  tendency  to  hemorrh^e  will  vary  at  different 
times  in  the  same  person  according  as  the  state  of  his  health  improves  or 
deteriorates.     In  other  cases  abnormal  bleeding  may  be  due  to  a  diminution 
in  the  normal  coagulability  of  the  blood.     This  state  is  sometimes  met  with 
ID  Kurvy,  chronic  jaundice,  and  albuminuria.      The   disease   known    as 
Hsnophilia  or  Hemorrhagic  Diathesis  is  quite  independent  of  such  condi- 
ttQUis  these.     It  is  a  peculiar  constitutional  state,  always  congenital,  and 
onn  frequently  hereditary,  especially  in  the  male  line.     In  some  families 
the  males  only  have  been  affected,  and  the  diathesis  has  been  transmitted  in 
(te second  or  third  generation  through  females;  who,  themselves  being  uii- 
■fected  by  it,  have  had  male  children  who  were  the  subjects  of  the  disease. 
A  ven-  remarkable  genealogical  account  of  such  a  family  has  beeu  drawn 
up  b_v  C.  Heath.    The  diathesis  occurs  in  persons  without  any  other  apparent 
d'rtDgement  of  health  or  morbid  condition,  innate  or  acquired,  to  account 
^rit.    In  such  cases  the  family  peculiarity  is  usually  recognized,  and  well 
konK-n  to  those  liable  to  it. 

The  ontr  constant  sign  of  the  diathesis  is  the  free  and  often  almost  uncon- 
troliablt;  bleeding  that  takes  place  from  trivial  wounds;  life  being  put  in 
jmpaniy  and  even  lost  by  the  hemorrhage  resulting  from  the  extraction  of 
•  liviih,  the  opening  of  an  abscess,  lancing  of  the  gums,  or  some  equally  slight 
oniiDpurtant  surgical  procedure.  The  blood  docs  not  flow  in  a  jet,  but 
CTfliinura  to  trickle  in  an  oozing  stream,  apparently  from  the  capillaries 
fsther  than  from  the  larger  vessels  of  the  part.  In  these  ca»e.a,  also,  there  is 
*  freat  tcmlency  to  inordinate  ecchyraosis  from  very  slight  contusiun. 

In  thwe  families  of  bleeders,  it  is  scarcely  necessary  to  say  that  it  is 
imperative  to  l>e  careful  to  make  no  surgical  wounds,  evt-n  of  the  most  trivial 
ffaaracUT,  if  they  can  [lossibly  be  avoided.  Above  all.  the  extract  ion  of  teeth 
muM  be  avoiijetl.  It  is  afler  this  slight  oporation  that  the  most  iMu-iiiitnil- 
iahlcand  fatal  hemorrhages  have  occurrefi.  Tlio  lic>m<irrhages,thougli  usually 
tnatuatic,  may  be  spontaneous;  they  then  usually  proceed  from  the  nose. 


v. 


HEMOPHILIA — TRKATMKNT.  107 

Tr£4T1ik>'t. — In  true  hsemophiUa  no  remediee  appear  to  exercise  the 
•lightest  influence  over  the  diathe&is.  At  the  same  time,  it  would  be  wise 
tbat  the  subject  of  this  unfortunate  condition  should  attend  tu  those  ordinary 
rulec  of  health,  the  neglect  of  which,  by  lowering  "his  condition,"  might 
fivor  the  tendency  to  bleed.  Legg  especially  reconimends  the  use  of  cold 
baths  of  plain,  sea,  or  chalybeate  waters,  residence  in  a  dry  air,  and  the  use 
of  warm  clothing.  The  preparations  of  iron  are  usually  given  in  a  routine 
way,  but  it  is  doubtful  if  they  have  ever  been  of  service  in  preventing  the 
heruorrhages,  certainly  never  in  arresting  ihem,  though  they  may  be  of  use 
in  removing  the  aniemic  state  left  after  a  copious  bleeding.  Ergot  has  been 
given  during  the  bleeding  in  many  cases,  but  without  evident  effect. 

The  Loetu  Treatment  is  that  on  which  most  dependence  will  necessarily  be 
placed.  It  consists  in  the  use  of  three  means,  viz.,  Pressure,  Styptics,  and 
CoiH. 

PreMon  is  to  be  relied  on  only  in  one  form  of  hsemophilic  bleeding — viz., 
the  continuous  hemorrhage  from  the  socket  of  a  tooth  after  extraction.  In 
these  cases  the  cavity  should  be  cleared  out  and  carefully  plugged  from  the 
bottom  by  means  of  lint  or  agaric,  the  whole  retained  by  means  of  a  piece  of 
cork  and  a  gutta-percha  cap  to  fit  over  the  neighboring  teeth,  and  compressed 
by  a  bandage  applied  under  the  chin  against  those  in  the  sound  jaw.  When 
the  hemorrhage  occurs  from  the  soft  parts,  pressure  must  be  used  with  great 
caution  lest  sloughing  occur;  the  integuments  being  extremely  liable  to  give 
way  eitenaively  under  very  moderate  pressure,  large  subcutaneous  extravasa- 
tion developing  at  the  same  time,  and  thus  increasing  materially  the  danger 
of  the  case  and  the  local  mischief. 

Compression  of  the  main  artery  of  the  limb  is  useless  and  liable  to  the 
objection  of  the  development  of  ecchymoses  and  subcutaneous  hemorrhages. 

Styptic*  of  all  kinds  have  been  used  as  a  matter  of  course,  and  the  per- 
chloride  of  iron  has  enjoyed  especial  favor.  I  have  used  and  seen  it  used 
frequently,  and  can  safely  say  that  I  have  never  seen  any  permanent  benefit 
from  its  application,  or  that  of  any  other  styptic,  in  these  cases.  Indeed, 
great  evil  nas  often  resulted  from  the  inflammation  excited  by  the  applica- 
tion of  styptics  of  any  kind.  The  parts  become  swollen,  fall  into  slough,  and 
a?  they  sej>arate  the  oozing  may  recommence  from  the  raw  surface,  and  the 
same  process  has  to  l>e  gone  through  again. 

The  actaal  Cautery  presents  the  same  inconveniences  as  ordinary  styptics. 
It  may  arrest  temporarily  the  bleeding,  but  inflammation  is  set  up  in  the 
pans  Ifcyond  the  limit  of  the  eschar,  and  this  on  separating  leaves  an  ex- 
ten<le<l  ulcemting  surface  which  bleeds  again,  and  perhaps  more  freely  than 
b^f.-re. 

Th*"  continued  application  of  Cold  appears  to  arrest  hiemnphilic  bleeding 
more  effectually  than  any  other  means,  and  this  circumstance  would  lead  to 
the  belief  that  the  hemorrhage  is  due  to  want  of  contractility  in  the  smaller 
arteries  rather  than  to  want  of  coagulability  in  (he  blood.  The  cold  may  be 
appliei]  by  means  of  irrigation  of  iced  water,  ns  has  been  done  successfully 
by  Marvhatl,  or  by  the  application  of  ice  either  directlv  to  the  part  or  laid 
ap<>n  a  sjxtnge  covering  it,  as  has  been  done  in  some  nf  the  cases  of  h:eiito< 
philia  (X'curing  at  Uni%'ersity  College  Hospital.  Simple  water  may  be  uec<l, 
or  a  w«ik  antiseptic  solution  of  boracic  acid.  If  the  bleeding  wound  be  in 
the  extremities,  the  limb  should  be  elevated  and  ke|)t  at  rest  on  a  splint. 

The  Surfreon  has  already  been  cautioned  as  to  the  inexpediency  of  per- 
fomiinc  any  operation,  except  under  circumstances  of  the  most  urgent  neces- 
•iiy,  on  any  member  of  a  family  of  bleeiier!",  or  on  an  individual  known  to 
be  the  subject  of  hiemophilia.  Should  an  operative  procedure  become  neces- 
lar^-.  it  should,  if  possible,  be  undertaken  with   Paquclin's  thermo-cautery. 


108 


OtSEASES   OP   ARTKRIBS. 


if  it  In-  (Iwiri'tl  to  make  a  simple  iacuioo ;  br  ihe  j^lvauic  ^cruwur.  if  it  be 
tiXfMtlirin  til  romuvc  a  part  or  Vj  (lerturin  u  iimall  miiiHiUiti'io.  In  tbe  event 
of  Uio  ifalvanic  4cnaeur  uiA  btrin^  at  bund,  the  etastte  Ugalnre  would  be  the 
bvtcsulielituu.-. 


CHAPTER    XLII. 

IJISEAKES  OK   ARTRltlES. 

Am'RRiiM  am  lisblf!  ti>  num«rt)UB  diwoMS  which  deriro  grmt  imptirtMDoc 
from  iht^  rdt'ClK  thBV  produce,  lh){h  upon  iJic  vtwacle  tbcnuwlvca  hiuI  up<m  the 
ptirlM  to  which  they  carry  the  blood.  AiiioiigsC  the  nioat  im|>ortAiit  Are  ibe 
vuriotiA  forinit  of  infliimnintion  or  nrtt-riliti.  'flie  intianimaKiry  H0ectiua»  of 
itrli-rti>4  nre  divided  lirat  into  tm>  clnss^a,  vik.,  thuoe  raiiiUing  tntm  injury, 
mid  those  tirt»iiii;  from  ;;i-ncrut  or  Incut  cnuftes  not  of  a  tntumiitic  nature. 
Iritlciiiimatioii  of  the  nrt4-rie«  ut  divided  also  into  endart«-ritt4,  in  which  it 
alti:-<'tA  Drimarily  or  chictly  tlie  internal  roat,  and  pcri-arteritii^,  in  whirh  tbe 
pntcf**  coniniPHce*  in  lh«  outer  ci>at  or  sheath.  The-  term  mes-art^ritin  has 
uleu  bevu  iru^jn^^tcd  fi>r  iiitlunimnttoii  of  the  middle  coMt,  but  it  is  of  little 
tl»e,  a«  liu  truu  iiillHmtn»lJ>ry  ntfcvtiim  commences  in  that  part  of  the  ve«»el. 
Sumo  forms  of  arteritis  nre  unmed  frum  (he  caowrof  the  duense,  as  syphilitic 
or  cinl)olic.  A»  id  other  «lruetiirr«,  the  inflammatory  proc««a  may  be  acute 
or  cbronic.  In  addition  to  the  «bi>ve  diseases,  arteries  suffer  fr)m  variotia 
detfvncrativu  chauuvi-,  some  of  which  ar«  pninary,  allt'ctiug  the  original 
ttraiies  of  the  vessels,  oth^TS  are  secjodary,  tbe  deigeiieratiuu  taking  place 
L-hii'lly  in  the  products  iii  a  c-bronio  iuflaniruatory  proce&s.  The»e  varioua 
pr'Hve»i-8  are  slill  further  complieuteil  by  eeetmdary  effecle.  fuvh  as  tht;  furin- 
Btiou  of  ani-urisui.  from  the  tlis^-nitiHl  wall;  of  iXw  artery  yreldini;  liefore  the 
pri'Mun*  of  the  bIwKl,  and  thnimbii«i»  of  the  atfivteil  vceeel  folkiwod  by  its 
oblitt'raliiin,  and  stimutimee  by  embolism  uud  ^aii^'rfue. 

lu  di.iciiiv<in^  the  dlseast's  nfnrti-riua,  it  « ill  be  mwt  cunvcDient  10  coDsIder 
timi  the  vari'His  forms  of  inflammation;  luvuiiilly.  the  degeaeratioas ;  and 
Itutly,  tbe  reiiioter  eflevte  of  these  ebautjix. 

ARTEIilTtS. 

AOQt«  Artentii  of  idiojiathic  oriifiit,  ttiat  in  to  Miy,  ariiiin^  as  an  indepeo*' 
dent  nHVi'tioii  liir  wliieli  no  t-videut  cniiHe  i-aii  he  totiint.  win*  formerly  ltelicvf.>d 
to  be  a  iMmpnnitiYely  I'onimon  nllW'tioti.  It  wax  ntlppiHeal  ti>  atfrrl  thr  inner 
cufflt,  sprt*adiut:  ulonii  lb<>  vi*<«ifl  in  the  dir^^i'tion  of  the  otrculatioti,  rikI  fn>m 
this  fact  it  HAS  )i|»ik**n  of  as  tliHutt'  or  erviiipelaloUiii.  [l  'm  now  kuonn,  bow- 
ever,  thai  nofiueh  aHVelion  really  exi-u.  and  that  the  errxjr  ar\«e  partly  from 
avamio;?  tbnt  thnmibusb  ii  iuvariublv  erideooe  of  previous  inHauima'tioa  tif 
the  allrctrd  vemi'l.aud  |nnly  from  oi'islakiogfur  tbereilaeMof  luflanimatiim 
tbe  staining:  of  the  iniima,  so  ofleu  ohMrved  as  tb«  mult  of  obaU)C>-R  in  tbe 
bl'hM)  with  •lisinte^ration  of  iliL>  red  rorpuwles,  ooeurriag  eiliier  durtD^  life 
in  acute  fomis  of  u|iHtd-poiN»iiintf  suc^i  as  sepuettmia  or  Bftliguaat  fuvsn,  or 
after  death  as  tho  result  of  putrvfaclion. 

Truunatio  Artaritii.. — Simp)'-  artite  imumatio  iaflannitatiao  limited  to 
tho  part  iDJur«d  and  showing  no  tendency  to  BXianaioa,  is  ^miliar  tu  orury 


I 


YABIKTIES    OF    ARTERITIS.  109 

Surgeon  in  coDoection  with  contUBJon,  laceration,  wound,  or  ligature  of 
art«n«s;  for  in  the  early  period  of  repair  ailer  any  of  theae  injuries,  inflam- 
matorr  exudation  from  tne  vaBa-vasorum  forms  an  essential  part  of  the 
pruceas.  For  a  deacription  of  this  condition,  the  reader  ie  referred  to  vol.  i. 
chap.  xiv. 

Arteritu  by  Extension,  from  infective  inflammation  or  ulceration  of  the 
tiMiues  surrounding  the  vessel,  has  already  been  described  as  one  of  the 
daoctTb  acciimpanying  these  processes.  In  inflammation  affecting  an  artery 
io  thia  way,  the  process  is  the  same  as  in  other  tissues.  The  vessels  of  the 
uuler  coal  are  dilated,  inflammatory  exudation  with  migration  of  corpuscles 
take:)  place,  and  the  wbndering  cells  infiltrate  the  coats  of  the  artery,  which 
become  swollen  and  softened.  The  process  spreatls  from  the  outer  to  the 
inner  coat,  the  endothelium  desquamates,  and  fibrin  le  deposited  upon  the 
di0«-a«e<l  surface.  In  the  smaller  arteries  complete  thrombosis  takes  place, 
and  the  clot  extends  upwards  to  the  nearest  branch  beyond  the  inflamed 
part  of  the  vessel,  and  may  then  undergo  the  changes  already  described  as 
tNTcurring  in  the  permanent  closure  of  an  artery  (vol.  i.,  Wouncfs  of  Arteries), 
and  hemorrhage  is  thus  prevented.  In  arteries  above  the  size  of  the  radial, 
however,  the  closure  of  the  vessel  is  frequently  not  accomplished  before  the 
crata  are  so  far  softened  as  to  give  way  before  the  pressure  of  the  blood,  and 
thus  fatal  hemorrhage  may  result.  This  is  all  the  more  likely  to  occur 
when  the  inflammation  and  subsequent  ulceration  affect  a  limited  portion  of 
ooe  side  only  of  the  artery,  as  in  those  cases  in  which  it  is  due  to  the  con- 
tact of  an  irritating  foreign  body,  such  as  a  sequestrum.  In  the  larger 
arteries  complete  thrombosis  occurs  much  less  readily  than  in  smaller 
Tcnels  or  in  veins,  the  rapidity  of  the  flow  of  the  blood  being  unfavorable 
to  the  adhesion  of  the  white  corpuscles,  which  is  the  first  step  in  thrombosis. 
In  arteries  which  have  been  divided  and  secured  by  ligature  or  otherwise, 
the  extension  of  unhealthy  inflammation  from  the  wound  to  the  exposed  end 
of  the  vessel,  followed  by  softening  of  its  coats,  and  disintegration  of  the 
eootained  clot,  is  the  commonest  cause  of  secondary  hemorrhage. 

Bnbolie  Artaritt*. — Moxou  has  pointed  out  that  a  form  of  acute  arteritis, 

resulting  in  softening  and  swelling  of  the  arterial  wall,  thus  leading  to  the 

fitnuati>>n  of  an  aneurism  or  to  rupture  of  the  vessel,  is  in  rare  cases  the 

rvauit  of  the  Iwigenit-nt  of  an  embolus.     A  simple  fibrinous  embolus  lodging 

in  an  artery  merely  obliterates  the  vessel  without  causing  softening  of  its 

oKiL'.     In  order  that  inflammatory  softening  may  occur,  it  is  necessary  that 

the  trmlHilus  should  l»e  derive<i  from  a  part  which  is  the  seat  of  some  infective 

inflamiiiaiion,  and  that  it  should  carry  with  it  the  unhealthy  prmlucts  of  the 

pp-ctT^-.     Kmlxilic  arteritis  is  most  likely  to  occur  in  the  somewhat  rare 

aiTi-cli'in  kntiwn  at>  ulcerative  or  infective  endocardilift,  hut  it  has  also  been 

ku<i«n  t'l  fullow  embolism  during  the  course  of  an  ordinary  cnso  of  acute 

rheumatism.     Localized  arteritis  arising  in  this  way  is  believed  to  l>e  the 

m'»?t  citmmon.  if  not  the  sole  cause  of  spontaneous  aneurisms  in  children, 

acil  in  the  smaller  vessels  of  the  extremities  in  adults.     Husliton  Parker  has 

Ttc-tpieti  a  case  which  well  illustrates  this  form  of  disease.     A  boy,  aged  14, 

during  an  attack  of  acute  rheumatism  was  suddenly  seiziHi  with  pain  in  the 

f'trvarni,  toiloweil  by  swelling  of  the  limb.     The  general  swelling  soon  snli- 

*ide<l.  leaving  a  <leeply  seated  circumscribed  tumor,  which  steadily  increased 

in  r'iue  for  the  next  four  mtmths.    On  laving  this  o]>en,  a  cavity  was  exposi-d 

o  tiuinin;;  more  than  a  pound  of  dark  clotted  blood,  and  tlie  anterinr  inter- 

riNiroui'  artery  was  found  to  i-oumiunicate  with  it  by  an  ojiening  ii  quarter  of 

an  inch  in  length.     The  vessel  was  sucit'ssfully  ligatured  ubi>ve  and  below 

ill):'  ofK'ning,  and  the  l>oy  rec(»vercd.    At  the  time  of  the  o]>eratton  there  was 

a  hwd  double  aortic  murmur. 


no 


msBASKs  or  aktkkies. 


Aoate  Endarteritii. — Comil  hikI  Unnviur  ilesiTriW  un'lvr  this  iMni«i 
iiirt'cii"!!  nl  (liH  ititirr  riNit,  iiitt  with  rhiflly  iti  thr  utirta,  but  (Kvasioni  ^ 
wAf^>  ill  BiiinllvT  voflwls,  ra))ccially  tu>ar  witiittilvi.  It  is  [rjiiirnftprir^il,  Lo  tbe 
nnkciJ  ryo,  hy  |inimiiienl  [lalciu'-i  fnnnetl  by  a  nwcliiiij;  of  ihc  iiitiiiin.  They 
aro  circulur  ur  nval  in  ontliiu*,  iiiul  tielftniii  exrpi^d  hull'  an  inch  in  dtatntWr, 
though  both  their  tbrm  and  eize  may  lie  alcerecl  by  the  (.xiale»«*t)ce  of  neigh- 
bnring  patohw.  They  are  pale  pint  in  on\»r,  and  si!mi-trani<pnr«nt  or 
opalnoant;  in  oonsistence,  they  nra  »ilt  and  eia«(ic,  almost  ^latinuus.  The 
ioteraal  surAice  bu  often  lt«t  its  pnliah,  in  oonneqiience  of  the  Irregularity 
of  the  ■welling,  but  it«  endothelial  covering  is  usually  intacL  The  middle 
orwt  bencnth  the  patch  appears  usually  to  he  aomowhat  fiwollen,  and  thie 
cunditiim  is  more  marked  in  theodventitia.  ^Ticr'»copic  examination  ohowa 
lliflL  the  svrelliiij;  is  due  to  nn  accnmuliition  of  ?mnll  pgII^,  cither  round  or 
aUghlly  jrre|a:ular  in  outline,  between  the  tibre^  of  the  i*ub-endothe1ioE  co»* 
neoijvc  tiuuo  and  the  elastic  layers  of  the  inner  coal.  These  eoll»  have  a 
dialiitct  DUcli>us  surrounded  bv  a  small  quantity  of  protoplaam,  and  fthnw 
ll\^^xn  iif  ac'livo  (ircwlh.  Oornil  mid  Rnnrier  Wlieve  they  are  pr..ducfd  by 
pruliiVralion  uf  the  originitl  cell*  of  the  part.  The  swelling  of  the  exierua) 
coat  is  CouDil  to  be  due  U>  the  preaeuce  of  numerous  celU  id  new  f<irmalioQ 
aauanilinji;  lliu  fibres  of  the  counecli%'c  tta;j>ue. 

The  uouditiiios  under  which  aciit«  eudarterilU  occur  are  not  clearly  d«ter- 
niine^l,  but  aa  every  intermedixte  condittoo  between  it  and  the  chn>nic  form 
t<j  be  iniiuvil lately  deacribed,  is  to  he  met  with,  Boroetimee  even  in  the  aame 
veiael,  it  wenia  Co  be  nothing  more  than  the  same  prooeaa  iocreaaecl  in 
inii'ncity. 

Chrome  Eadarteritia,  Arteritis  Beformaas,  Atheroma. — Thb  is  by  for 
the  mimt  ctiiiHiKiu  diseaae  to  Hliich  arl<.'n<.'!»  are  liable;  id  fuel,  il  is  very  rarv 
alU-r  middle  life  to  find  it  cwni|ilelely  abs'.'nl  Ju  the  larger  vvsm-'U.  It  ocearn 
Id  ita  nit»i  marked  fonn  tu  the  aorta  ami  the  large  arteriea  of  the  uvck, 
■bdomen,  ihv  upfier  |varta  of  (he  limb«.  itod  the  base  of  the  brain.  It  im  leai 
eoiuBHMly  iH.'vn  in  the  smaller  veHScla,  in  whidi  the  muscular  cuut  is  niure 
ftillr  devt'lojied. 

Chrmto  eiidarieritis  Urat  appeam  aa  pale  yellowith  i»tchea  or  etreake, 
amooth.  slightly  elevated  above  the  anrfiwe,  and  eefdeotly  seated  in  the 
drnjier  layers  of  the  inner  ciiat.  They  are  Irregular  in  uolline.  ihuir  long 
diami'itT  is  uauallv  in  tlic  line  of  the  vcMel's  ooarw.  but  they  abow  a  sperial 
prwililrctioa  tor  tfif  moutha  of  the  bnoebeB  tearing  the  mala  trunk,  round 
wlitrhihnv  form  annular  eleratiuna.  TbeiroutliuebeeoaeanjbaeqDeoitymore 
trrvgular  liy  theooaleeccDceuf  neigbboriDgpatebeft.  Aa  tbe  dheine  arU-aocea, 
ih*  palehe*  betMme  more  elevated,  often  reaehiag  a  tine  or  more  in  thicknw. 
At  tbi«  stairs'  thcr  arv  gray.  M>m)-tran«p«reDl  or  ufialeKeat,  and  inelastic, 
artilagioooa in  appearaaee aaij  wimjiwec.  Tht^omditino 
y  followed.  bcCire  the  patehia  bare  reacAH  mort- than  half 
ail  I  iiuctrr,  by  a  ehauge  to  aaopaqae  ydlewcfdMr,  ebe  altrratVm  io 

tiui  '   ing  in  ihf  ceatraf  |iarta.    TMa  CMti^  is  due  Ut  fiitty  degenera- 

lk)ii,asdt>  aocttnimnicdbyaeawloaiof  tougboeaa.  The  farther prograae uar 
ba  In  one  of  two  dirpotione;  tbe  growib  amy  •ofteo  ami  bnab  «)«ira.  or  it 
BBT  oalmfir.  When  BoAeaiog  lakea  plaee  IM  paldi  beooaea  ootivartad  into 
a  pttltaemn  or  cbeasr  aMia,  aod  eveo  awwietlMM  «D<<a<yea  ootapMe  Im|1>»- 
lactkKi  into  a  yellow  crvatay  fluid,  which  has  been  miatakcti  for  true  pot. 
and  lenocd  aa  **  mA^rmm^tom*  9^tn<m."  It  ia  thia  chaaE*  that  led  to  the  term 
nlbawia  ^xin^  applied  tn  the  dwaae.  the  ptvdocia  of  tbe  aoAnniBqi  of  the 
peablmg  tbe  oMtenIa  of  aa  athwuwaioM  nn(  of  tba  Am.  The 
aw  eAm  artanJeJ  In  all  ifgii  of  elinak  egjarierilia. 
iba  mnem  naebaa  tba  am  nJi—uwl  aMnitbaau 


Wb« 


middle  euat  Ea 


ABTSBITIS    DEFORHANS,  OB    ATHEROMA.  Ill 

aflected,  fint  hj  chrooic  inflaniinatioD,  and  subsequently  by  eoftening.  At 
UkeNiaiettiDe  eooaidemble  thickeaiDg  of  the  external  coat  takes  place  by 
tbe  fbnnatioii  of  dense  fibroid  tiaeue  which  is  not  prone  to  fatty  degeneration 
■wl  Mdcoiog.  Up  to  this  stage  the  fatty  patch  is  covered  by  the  most  !□- 
terual  laren  of  the  iotima  ana  the  endothelium,  which  are  not  affected  by 
Uteriirooic  inflammatory  process,  but  after  complete  softening  these  give  way, 
ml  Uie  atheromatous  fluid  is  discharged  into  the  circulation,  leaving  the  re- 
mtin  of  the  patch  exposed  to  the  blood-stream.  The  raw  surface  thus 
fbnDrd  is  called  "  an  ataeromatoug  ulcer."  The  debris  which  enter  the  circu- 
ktioD  are  carried  on  and  lodge  in  the  capillaries,  but  not  possessiog  any  irri- 
tuiog  properties  they  give  rise  to  no  evil  consequences.  Although  on  the 
fcraatittt  of  ao  atheromatous  ulcer  a  considerable  part  of  the  inner  and 
■Diddle  coats  are  lost,  perforation  or  rupture  of  the  artery  rarely  takes  place, 
aad  it  ii  only  in  exceptional  cases  that  the  blood  forces  its  way  amongst  the 
emit  of  the  diseased  vessel.  This  is  due  to  the  fact  that  at  the  margins  of  the 
pallet,  the  chronic  inflammatory  process  baa  led  to  firm  matting  together  of 
tbccoatiof  the  artery.  At  the  same  time  the  thickening  and  induration  of 
tbeextemal  coat  prevent  perforation.  It  is  especially  opposite  the  deeper 
ud  Dure  eroded  atheromatous  patches  that  this  consolidation  of  the  exter- 
Btleist  takes  place.  The  change,  although  described  as  a  chronic  inflam- 
Bitioo,  is  strictly  conservative  in  character.  The  new  growth  of  fibroid 
timeic  not  confined  to  the  external  coat,  but  extends  to  the  sheath  of  the 
T«el,  and,  by  soldering  it  to  the  contained  artery,  greatly  adds  to  the 
(tRogth  of  the  vascular  wall. 

Akbough  perforation  is  thus  prevented,  the  new  tissue  but  imperfectly 
rqiraeDtJ!  the  normal  structures  of  the  coats  of  an  artery,  as  it  is  entirely 
noting  in  elasticity.  Consequently  it  is  very  apt  to  yield  slowly  to  the 
pRSMire  of  the  blood,  and  thus  lead  to  the  formation  of  a  sacculated  aneu* 
fixn.  the  mouth  of  which  will  correspond  to  the  damaged  portion  of  the  wall 
<i  the  vessel. 

Complete  softening,  with  the  formation  of  an  atheromatous  ulcer,  is  not 
ir  toj  means  a  necessary  consequence  of  fatty  degoeration  of  the  patches 
ntalting  from  chronic  endarteritis.     In  many  cases  the  new  tissue,  after  de- 
^oerating,  remains  as  a  firm,  yellow,  opaque  mass,  and  may  undergo  no 
^rther  change,  but  meet  commonly  lime  salts  are  deposited  in  it«  and  it 
^ndually  becomes  converted  into  a  hard  calcareous  plate,  over  which  the 
tuperficial   layers  of  the  inner  coat  with  the  endothelium  may  remain  un- 
broken.     Sometimes,  however,  these  seem  to  wear  away  and  the  calcareous 
plate  comes  in  direct  contact  with  the  blood-etream.     This  change  was  for- 
merly described  as  "' otsification  of  the  arteries,"  but  it  need  not  be  said  that 
no  true  bone  is  formed.     From  the  arrangement  of  the  calcareous  matter  in 
plates  corresponding  to  the  atheromatous  patches  in  which  the  lime  salts 
tkave  been  deposited,  this  change  has  also  received  the  name  of  laminar  cal- 
tiieatioju 

MieroMopic  examination  of  an  atheromatous  artery  in  the  early  stage  of 
the  disease  shows  that  the  morbid  change  commences  in  the  deeper  layers 
of  the  inner  coat  by  a  proliferation  of  the  flattened  cells  that  lie  between 
th*-  laminae  uf  connective  tissue  of  which  it  \a  chierty  composed.  The  new 
*elU  are  arranged  in  lines  between  the  laminir.  With  the  proliferation  of 
ibe  cells  there  is  a  growth  of  new  laminae  of  connective  tissue  closely  resem- 
bling that  of  the  healthy  inner  coat,  both  in  ap|)earancc  and  in  arrnnge- 
Bcni.  The  change  is  therefore  a  true  overgrowth  of  the  deeper  layers  of 
the  intima.  The  relative  amount  of  cells  and  fibrous  inlercellular  snbstiiDce 
varies  in  different  cases,  but  the  chief  bulk  of  the  new  tissue  is  always  com- 
fioeed  of  the  latter.     The  cells  are  small,  rounded  or  slightly  flattened,  and 


IM 


MSEASes   OF    BLOOOVKS8EL8. 


exisU>4l  for  many  yeani  witlioiit  ^vin^  aii%-  annoyance,  but,  as  H  b&d  of  lite 
b«)j;un  to  «Dlai'^c,  and  occa»iun»lly  to  bleeil,  lie  yttta  desiroui  of  having  it 
reniuved.  Tbi«  I  did  by  applying  tbe  tjuadruple  ligature,  al\er  linviog  di»- 
8ec'l4><l  the  mucoiH  memoraue  down. 

Kevi  of  the  Volva  are  by  no  meuBa  uDfrcquenU  We  Lave  hod  sevirnl  id- 
etaiiLHXofthu kind iuUiuHoapitaloflate yean.  T)ieyarcueiiiiIlyretiou8,4fleii 
Bttaiu  a  largn  size,  and  may  vometinics  iuvdItc  the  iuti'jiumcnUil  siruciura 
on  the  inside  of  liie  tUigb.  or  ou  Lbo  pcrinvum,  as  well  iu>  the  vulva.  Wtieo 
tbe  growUi  i»  oon^ucil  Ui  the  vulva,  it  ii^  bcbt  ttriuuved  by  tl)«  ligature.  Sutm 
time  ago,  1  removeil  in  this  way  a  largo  p«nduli>uti  wunus  uirvus,  as  Utre 
as  two  or  three  UatteniHl  walanis,  from  Uie  !i-fl  labium  of  a  little  girl  six 
jeara  of  age.  Id  thia  case,  I  fuuml  it  luml  ooovenienl  to  omplor  thn  con- 
tinuous ligature.  The  same  means  were  liiid  reonurse  to  in  ordrr  in  rxur[iati) 
a  Urge  dictob  fntm  the  labium  id*  n  child  threo  yenrn  of  age;  but  in  thin  caaB 
the  ofiMoae  e:i1<'udi>'l  tn  the  inleguinenljs  of  tin*  |ierineiim  und  inner  mde  ot 
the  thigh,  and  was  here  removed  liy  the  apidiRatiim  nf  strong  nitric  acid, 
aller  thn  lnrg«>r  j^rowth  had  nepamted. 

On  the  Extremitios,  TSeck.  aad  Trtiiik  every  poMible  variety  of  niemt 
ocoura.  When  tiie  di>^ii.te  i»  Hat,  rnnsltitiag  rather  nt'  «taintBg  of  the  akio 
than  of  any  actual  tumor,  it  may  commonly  he  treateil  auiTceiwftitly  bv  tbe 
apblicalion  of  tbe  strong  tincture  of  iodine ;  or  should  it  bo  thought  Jc«ir- 
Bule  to  remove  it,  thia  may  be  effected  by  rubbing  it  with  »Lron{;  nitric  acid. 
If  the  nievuB  assume  the  form  of  a  ttiniur,  it  will  nlniot<t  invariably  bo  of  a 
venous  character,  and  then  reiuuval  by  excision  by  nic-anM  of  the  ligaturo 
should  bv  efl'ectad.  If  the  growth  hv  ruund,  the  ordiuurv  (jundruplv  ligaturv 
may  he  umpluyed  ;  if  Uut  or  elongated,  the  lungiLudiual  continuous  ligature 
is  prelerubie. 

N.KVOtD  Lii^MA. — This  is  a  form  of  ntevus  which  1  have  uceasionallr 
Been,  but  which  docs  not  api>ear  to  have  attracted)  much  notice,  ullhougb 
Nilattm  vpeuks  of  it,  and  Billroth  buvs  that  in  Iip4)nia  he  has  several  tima 
met  with  cavernous  dilatation  of  the  veins.  It  la  a  tumor  in  which  the 
sievaid  vtructuro  ii*  comuined  with  a  fatty  growth  uttiiatly  more  fihrnus  than 
an  ordinary  lipoma.  This  disease  i»  invarinblyse-nted  upon  the  oatefi.  back, 
or  thigh.  It  occura  »a  n  smooth,  doughy,  indolent  tumor,  incomprRwible. 
not  varying  in  eize  or  shape,  without  heat,  thrill,  or  pubation  of  any  kind, 
pn«ibly  having  a  few  veins  ramifying  over  its  surface,  but  no  distinct  vb»- 
cular  appenmnce.  It  is  ueuiilly  conv;euilul.  or  has  been  noticed  in  early 
obildhooa;  and  it  conlinuF«  without  any  very  material  change  in  shape. 
aiz«,  or  appearaDco,  until  the  incunvcuicnco  or  deformity  occasioned  by  it 
requires  its  removal.  Thi«  is  best  effected  by  the  knife.  After  removal,  the 
tumor  will  be  found  to  be  compoaed  of  a  naas  of  fibrous  fat.  having  a  targt 
□umhor  nf  voiua  rauiifyin):  through  it,  ao  as  to  ooosiituto  a  dlMJaot  vaWDlar 
element.  oAen  oommunicKiing  with  amall  oyvts  couiainiDg  a  bloody  fluid. 
The  tumor  baa  occasionally  a  teodcDcy  to  recur  after  removal.  In  Mte  com 
I  have  operated  three  times  for  the  removal  of  a  large  growth  of  tbt*  de«eri|^ 
tion,  .-tiluated  on  the  buttock,  and  extending  forward  towards  the  perineum. 
The  6nt  ojienttion  was  perfonned  in  1851;  the  second  io  )H-'>o.  and  the 
patient,  then  eighteen  y*-un  of  age,  again  prevented  himself  in  IS^Vt  with  ■ 
recurrence  uf  the  growth  in  an  ulcemtetl  slate,  io  the  ci^trix  of  the  former 
operationv.  The  eiluation  in  which  I  huvc  seen  such  tumon  'Kvur,  where 
toey  gave  rtse  to  motrt  inconvenience,  nn<l  where  their  removal  bns  ret^uirvd 
the  greatest  care,  has  been  the  anterior  piirt  of  the  thigh,  just  below  I'ou* 

1>arl »  Hgamenl,  cIom*  ujMin  niid  nluio«t  iu  c<Jum>etton  with  the  iVnioral  vr^rls. 
n  a  atao  ot'ilii^  dt^vrriptiou.  which  wa)>  ^iil  to  me  hv  ^^lwa^I^  of  Antigua, 
tbe  patient,  a  gentleman  uf  that  ialaud,  hod  suflareif  for  some  yeata  from  • 


HJEMOrniLtA. 


105 


(bwCMlid  ctdcmn  nf  onfi  nf  hia  Ipp,  appnrftitly  dependent  upon  tlie  pr«- 

.-•T-  *T-f-if«e<l  upon  the  saph^'nn  ana  frnmral  T<^in9  by  an  clnnptl^d  itxiolent 

:  below  Pouparts  liRflnifnt,  and  over  tlift  cfninw.  of  these  vessels. 

r  had  existpd  from  childhow).  and  presented  the  signs  that  liave 

.iveu  a»  cftnractfriettc  of  the  di*«'a»e  under  coneideratioo.     It  "wiuj 

,  au  iiici«on  pnrallel  to  Pooparl'ij  lignmeiu,  »ume  careful  dJssoc- 

reauirc*!  (o  iK-p«ri>te  it  from  [lir  reinumi  sliealh,  more  [MirticuUrly 

■■  iDuur  side,  wlivrf  »  pnilon^jntioii  of  tin?  tumor  dijiped  dowu  by 

■     ;  the  ft'inoml  vein,  cuiri[iri*>*iiijr  that  vewsel,  and  ibus  oaueiujj  tli« 

!■  J. II  vl"  Ibf  limb.     AClvr  rcirioval,  tbe  Uimor  w«8  fuund  lo  couswt  of  a 

L  -  .if  .[^n^'  adipope  liwuv,  with  mnch  vusvular  structure  iutermisviJ,  nud 

Tbt'  a-doma  gradually  Bubsidcd  ;  and  wbi-u  the  palieiit 

..  .„  ;_i  _.  .J>out  lliree  moutbe  »Itvr  tli«  opernliuu,  tin.*  limb  bad  uwirly 

Rfitned  its  Doroial  &iz«,  beiug  but  little  larger  tbau  tfa«  Bound  oue, 

nEUORKUAGIC  DtATUEBlS,  OR  USMOVniLU. 

lb  cnnnection  Willi  diseases  of  the  bloorlvcsscla  it  may  Iw  Rlalnl  that  tn 

MWDC  miiiiKtitutinnal  conditions  it  t<i  found,  tbougb  fortunately  very  rarely, 

iW  tliere  t>  a  great  tendency  to  very  troublesome,  indeed  almnttt  uncon- 

tnillfll)le  blei!dinf;,  from  iili^bt  vtnundit.     An  Abnormal  tendency  to  bleed  is 

murlimM  i)b>ier%'r-d  in  |>er»oiii^  who  are  "  out  of  condition, "  and  whoiu>  tisAUcs 

Mift  Hod  tlaecid.     Thi-y  bloed  freely  from  slight  wounds  and  bniise 

trii»iv<.'ly  from  trivial  blows.     In  these  case*  the  ble«?<linp  appears  to  be 

nvd  by  tb*  laxity  itf  fibre  preventing  the  proper  rontraction  of  the 

or  lorn  vessels ;  and  tlie  tendency  to  bemorrhflge  will  vary  at  dilferent 

io  tbe  same  person  aocordlug  a«  the  ^tatc  of  bis  liealtb  improve*  or 

deteiioraUa.     Id  otner  cases  abnormal  bl«cdiu^  may  be  duc>  to  »  diminulioa 

io  the  oormol  ooogulability  of  the  blood.     This  state  is  suiuvtimes  met  wilb 

in  icur\-y.  chronic  jaundice,  and  aibumiuuria.      The   diitenev   known    aa 

Uamupbilia  or  Hutuorrbaf^ic  Diathestti  is  quite  indt^pL'ndeut  of  such  condi- 

Uooaw  these.     It  ia  a  peculiar  consliluttonal  etate,  alwa^'s  congenital,  and 

noM  &i!i|DenUy  hcredibu-y,  e^liecially  in  the  male  line.     lu  some  families 

the  malsB  only  have  been  ailected.  and  the  diBlhesis  has  been  tnuuniilted  in 

tbeseeood  or  third  generaiion  through  females;  who,  ihemsalvcs  being  un- 

iftded  by  it,  have  bad  male  children  who  were  the  subjects  of  the  disease. 

■A.terT  remnrkablu  |;t>iicalo^lcat  account  of  euch  a  family  has  been  druno 

up  by  CL  Heath.    The  dinthti'is  occu  ra  in  persons  withoui  any  other  ap|Mirent 

wfaagrtoient  of  health  or  morbid  condition,  innate  or  acquired,  to  account 

'xr  it.     Id  such  cbh:*  the  family  poculiariiy  is  usually  rccoguised,  and  well 

Ur'on  to  those  liable  to  it. 

The  only  cotun.int  sif-n  of  the  diotbesis  is  the  free  and  often  almost  uncon- 
tnllablK  bleeding  that  takes  place  from  trivial  vounds;  life  li«iiig  put  in 
joi^rdy  and  even  lost  by  the  hemorrhage  resulting  from  the  extraction  r»f 
^^  tooth,  the  opening  nf  an  abso^M,  lancing  of  the  gums,  or  some  equally  slight 
^Bjmportant  surgical  procedure.  The  blood  does  not  flow  in  a  jet.  but 
^Kntion€«  to  trickle  in  nn  oorJng  stream,  apparently  from  the  cDpillaries 
^Hlh<>r  than  from  the  larger  ve«ela  of  the  |iftrt.  In  tficse  cnacs.  alao.  there  is 
^Kgrmt  Cctutcticy  to  inordinnte  ecchymosis  trom  very  slight  contusion. 
|Blo  tlwM  famiiint  of  blirt-ders,  it  is  scarcely  n«ccitsury  to  say  that  it  is 
^nipsraliv«  to  be  imrefut  to  nnike  no  surgical  wounds,  even  of  the  most  irixial 
[  thtnv^tr,  \*  tbi-y  can  |K»j*?.iblv  be  avoided.  Above  all,  the  extraction  of  teeth 
^■^^^^hMde«I.  It  ill  nllf  r  this  i^li;;lit  o|iera(ioBi  that  the  most  uncfintrol- 
^^^^^^■Ual  btimorrbugtvbavt'uix'urred.  Tho  hemorrhages, though  usually 
'    tnujajaticroofty  be  apooiauL-oiM;  tbey  then  usually  proceed  frtrtn  the  suae, 


106 


IIKMORRIIAOIC    DIATHESIS. 


I 

i 


bowel,  kiiluvv.  or  stiUcutanenus  conneclive  liseuc.  In  women  ther  UWBW 
tbo  L-)iiirA<rter  of  profiiiw  and  uncontrollable  nienurrhiigin.  The  hctiiorfbagM 
are  KecuiupuniRd  by  ttie  ^vrnpuinis  de^cribt'd  at  page  •iOA,  vol.  i.,  m  ohftnc- 
teriziug  L'X(-(!i^iv(!  liittt*  of  bl<.M)d  ;  and  after  their  ocp^utioii  tbo  pnlit^nt  rctnAiiiH 
niiiL-mii;  ti.nually  for  nmiiy  weeks  ur  months.  The  quiuilitv  of  blood  lost  is 
often  cnurniouB,  ainountiog  io  some  caam  to  Bevcmi  paunds  in  ibe  twcnlf-four 
liuurs. 

The  lendeocy  to  bloediiig  is  chiefly  from  recent  woundt  or  be«liJiy  niuoooft 
mombrunea.iiDd  sumetimca  does  not  occur  from  diseased  surfacct  from  vbtdl 
it  preauninbly  would  h«  likely  to  happen.  Thus  a  member  of  one  of  tbc  thrve 
faiDJtles  of  blcedeis,  nho  have  been  fre^juenlly  iunialex  of  Uuiveriity  CoIIcm 
Hnspilitl.  iiii-<l  iululy  of  pbthiHi!*,  u-itb  larf^  cavilienin  ibe  )uU|p.  Afcwwe^sEft 
before  htA  death  ho  Imd  nearly  died  <>|'  |ieiuorrlia>;e  aO«r  tbe  t^xtraciiuu  of  a 
tooth,  but  be  bad  never  «ii[fered  from  iwriuiiit  hivmuplyt^in.  Io  another  «aae 
the  patient  paxMed  ihroiii^h  an  altHck  of  lyphi^id  fever  without  BtTiuiia  bemor- 
rboge.  Io  another  a  lar^e  «luii};b  formed  iu  the  ekin  nller  thi.-  applii-altun 
of  perchloride  of  iron,  cold,  anil  pressure  to  urreot  heiuorrhnge  from  n  puDc- 
tured  Wound  of  tbe  Iv^.  yet  tbe  slough  EepnruUHj,  utid  the  Urge  grattuUttiDg 
Btire  healed  without  auy  recurreocB  of  the  bleeding. 

tVrnierlvit  wasauppiKed  that  fecniilcs  were  exempt  fnira  biemuphilin.  But 
Wickhnm  Legg.  tu  whom  we  are  iudebleil  for  an  excelleul  mouogmpb  on  tliia 
coaditiuu.  slatea  that  thiit  assumption  can  no  longer  be  tnaintaiueU,  altliougb 
women  ant  far  leas  dit<pi«ed  to  ilie  diRease  tban  men;  thuc  they  praent  few 
instaacw  of  the  more  typiml  forms  of  tlie  diseaiie ;  and  thai  it  u  Uob  fiual 
in  them  than  in  men.  Most  of  the  fatal  m»e«  in  women  have  occurred  by 
hemurrlia^'e  from  the  genital  nrgatis.  and  Lopiir  quotes  a  eaae  from  Wadt-  , 
emutb.  "where  the  rupture  of  the  hymen  on  tbe  marriage  night  caused  ^^HH 
death  of  the  bride  from  hemorrhnf;e."  ^^^^ 

A  frequent  symptom  Hccompanying  this  dinlheiis  iR  a  painful  and  sudjni  ' 
swelling  of  one  or  more  ii>int«  cither  oeeurring  sponlnneously.  or  as  the  mult 
of  aome  slight  injury.  The  sivelling  u  the  result  of  nn  etTu-sion  of  hinod  and 
aVDOVia  into  the  synovial  m«m)>rane.  It  is  ueuully  accom|)anied  by  mmo* 
slight  febrile  disturbance.  It  may  last  only  a  few  days  or  may  endure  for 
nionlhs.  The  joint  b  olUo  permaneotiy  weakened,  and  relapMa  are  fr»quei)t 
during  the  core. 

Pathoijdgy. — LilUe  if  anything  a  known  with  certainty  about  the  nature 
of  thi#  pttculiar  aflection.  It  has  been  itatetl  that  in  some  case*  the  inner 
coat  nf  the  arteries  has  been  found  aboornially  Ihin.and  degeneralive  cbangea 
have  been  observed  io  the  endothelium,  but  tbe  observat)<'UB  are  not  suffi- 
ciently numerous  or  uniform  for  any  theory  to  be  founded  upon  them.  Fmm 
the  inlluence  exert<xl  by  cold  iu  the  nrreet  of  the  bleeding,  it  may  be  n-owia- 
ably  susnertexl  that  a  want  of  proper  conlrnctilily  in  the  arteries  nmy  have 
tuimv  influence  io  causing  the  bleeding.  With  i-egard  to  the  <<ondition  tif  tbe 
blood,  rnrying  sialcnonta  have  been  made:  it  has  bem  laid  to  be  watpry, 
deficient  in  eorpuacles, Bod  uneim»;ulablL-.  In  the  caaea,  however,  which  have 
been  admitted  into  iroiven^ity  Colle^'e  Hoapiiul.tbe  blood  in  the  earlier  stani 
of  the  bcmorrlia;:e  coaguluted  healthily  and  was  of  good  color,  tliongb  luiar 
grttat  loss  tbe  lint  became  puler  and  (he  coagulum  less  firm.  Accurate  anal- 
ysea  of  the  blood  from  blcc^lcrs  are  atill  wanting.  It  boa  been  cuggeetcd  aa 
another  explamitiou  of  the  diM-ase  that  its  real  uiuee  Ia  an  execs  of  blood, 
but  of  this  al«<i  there  is  no  deftnite  evidence.  It  would  appear  then  that  the 
only  facts  of  iuipurtamre  thai  we  at  preaeni  possess  to  throw  light  on  tbe  cnuie 
of  htriiiophiliaarR.  rbat  it  t*  horrdiury ;  that  it  u  fur  more  freaucnt  in  mnlea 
than  in  femalt^  ;  anil  that  it  is  ifxij^enitiil,  and  may  occur  in  all  race*  and  In 
nil  couutries. 


IIJ[H01*UII.IA — TBBATXENT. 


^^■■■mIKM'. — In  tnie  hipmnphilia  oo  rcnivtlive  apiKrar  U>  t;x<;rt*itii  ihe 
^VqBBFnitiufDce  ovenlie  <liatheais.  At  the  9»me  lime,  il  would  liu  wi»e 
liiil  tb«  aubjcct  of*  thU  uDlurtiiDnte  c^'udilion  sliouM  attend  Ut  tliuM^  urdinary 
tula  I'f  health,  the  neeletl  uf  whicb.  by  loiivering  "Wte  eoiuliliuii,"  might 
brarilie  teDdcDCy  to  bleeU.  Lfgg  especially  reeuninifiids  iJie  u»«  iif  cold 
bubs  of  plain,  fipa,  or  chalybeoic  watei-e.  remdencc  in  a  dry  uir,  and  the  ufe 
vtwm  i'lothiQf>-  Thf  prt'paraiion*  of  iron  are  uaually  (livun  in  a  routine 
WT.  but  it  is  doubtful  if  lltey  have  ever  been  of  serviL-*  ju  |ircvontiiijr  the 
Miorrhagca,  certainly  never  in  urrcsting  then),  though  they  may  Ih^  of  uKe 
ID  imoTing  the  sua'iuic  state  Icjl  after  »  copious  bleciltng.  Kr^tit  hua  bei^n 
firCD  doriDg  the  bleeding  in  many  cuses.  but  witlioiit  evident  etfitnt. 

Tlie  Loftu  TVeatmait  is  that  on  whicli  most  dt-pondcnce  will  nce(»»arily  )k 
ftlan-d.     It  couBUte  iu  the  use  uf  three  nieiin».  viz.,  Prer»urL',  Styiitica,  and 

?MlilTe  18  to  be  rt-Iied  uu  only  in  oik-  form  of  hxmophilit!  bliHHJing — vix., 

tbcufiliDUOUei  hemorrhngi;  fmm  the  ftieket  of  n  tixith  ul\er  i:;xlra(rtioii.     In 

AeBt  cftjkj  the  cavity  shnulii  be  ctearett  out  and  carefully  plugged  fmin  the 

betioni  by  moans  of  lint  or  agaric,  the  whole  remined  by  meanH  of  a  piece  of 

torlLiuda  gultn-pereha  cap  to  Bt  over  I  he  neijfhbnring  teeth,  and  coniprewicd 

byabandaijie  ap|)lied  under  the  chin  n^insc  tlii)»«  in  the  oound  Jan.     When 

le  hcRiorrlmt^'  oeeurs  from  the  9of)  part^,  prr«siirc  must  he  iiited  with  j^rent 

ulha  im  »ti>ttj;hing  occur;  the  iocegiinienl?  being  extremely  liable  to  give 

ir  eiiefisivi'ly  under  very  nxidemte  jirewiore,  larye  aubeiitaiieouji  extravasin- 

ioD  developiug  flt  the  Fame  time,  and  thus  iucreH^iiig  niaterinlly  the  danger 

the  ciue  and  the  toml  mischief. 

Compression  of  the  main  urlery  of  the  limb  is  iweleM  and  liable  to  the 
ibjiTlinn  of  the  develtj|imeiit  of  eochymuseiii  and  subcuHuie'nis  hemorrhages. 
Styptics  of  all  kinds  have  been  uyed  as  a  matter  uf  couree,  aud  the  pt>r- 
Wide  of  in)n  baa  enjoyed  CBpeciai  favor.     I  have  used  uud  seen  it  used 
^ifuenlly,  and  can  safely  say  that  I  have  never  seen  any  perumneul  benefit 
i^iu  it£  application,  or  that  of  any  other  styptic,  in  theite  cases.     Indeed, 
»tevil  has  ufiea  resulted  fmm  ihe  indamtnatioQ  excited  by  Uie  applica- 
0  of  ityptics  of  any  kind.    Th&  {mrts  become  swollen,  fall  into  slough,  and 
tf  separate  the  oozing  may  recommence  from  the  raw  surface,  aud  the 
pmecfiB  has  to  be  gone  tlirough  again. 
Tbe  actual  Catitery  presents  the  «imc  ineonveniences  as  ordinary  gtypties. 
It  may  arrest  tcmpnnirily  the  bleediug.  but  intlammatiun  i»  set  up  in  the 
]«r;»  beyond  the  limit  of  the  est'har,  and  this  on  eeparaling  leaves  an  ex- 
tended ulet-nittng  surface  which  blct^^s  again,  and  perhaps  more  freely  than 
before. 

The  continued  application  of  Cold  appears  to  nrrert  hicmophilic  bleeding 
more  ellci-tunlly  than  any  other  means,  and  this  clrcumstanoe  would  lend  tu 
the  belief  that  the  hemorrhage  is  due  lo  want  of  contractility  in  the  smaller 
arvn'es  rather  than  to  want  of  cnagulabilitv  In  the  blood.  The  cold  mny  be 
applied  by  means  of  irrigation  of  iced  water,  as  has  been  done  eucee.'«fuliy 
l^  Mareball.  or  by  the  application  of  ice  either  directly  to  the  part  or  laid 
apnn  a  aponpc  covering  it,  aa  haa  been  done  in  some  of  the  cbbps  of  hiemo- 
philia  occunng;  at  University  College  Hospital.  Simple  warer  may  be  uw<l, 
or  a  weak  antuwptic  solution  of  boracic  acid.  If  Ihe  bleeding  wound  be  in 
^ihe  exir«*mitita,  the  limb  nhoiild  be  elevated  and  kept  at  rest  nn  a  splint. 
Hk  Th«>  .burgeon  ban  already  lieeii  canlioned  a*  to  the  inexpediency  of  per- 
^Bbro'ioi:  tiny  op^-nilion.  except  un<ler  circtim»tanee«of  the  mo3t  urgent  necea- 

^v  I-  of  ft  fnriiilv  'if  bleedprs.  i>r  on  an  individual  known  to 

i- mophilia.     f?hoiil<l  an  operative  [iroeedure  become  neees- 

wry.  it  abuuid,  it  punible,  be  undertaken  with  Paquclin's  t  her  mo-cautery, 


li 


108 


^ISSASBS   or    ABTSRIKS. 


if  it  be  doaireil  tf>  ninke  a  niinplA  incision  ;  by  tlit-  jralvanic  ^cnuctir,  if  it 
expedient  to  rum-ive  a  part  or  to  pertWui  a  euinU  siui>uUHtou,     In  tbo  cv< 
of  the  gmlvBitic  ^rawur  nut  t)eiug  at  band,  the  dvutic  liytture  vuutd  bo  the 
beatoubatitutf. 


CHAPTER    XLII. 

PlSEAtiES  OF  AKTEKIES. 

AitTEuiB?  nro  liable  to  numerous  diseases  wbicb  derivo  great  imponuoM 
from  tbi*  pMW-Ls  they  pntducr,  both  up<>a  tfae  vcMels  thvmftelvce  and  upon  ibo 
pnrts  to  which  ihcy  carry  th<>  bhiud.  Amongst  the  must  iiupartaot  are  the 
various  fitrms  of  inflaimiiutiun  or  arieride.  The  intininmatory  afiirctioiid  of 
nrterioe  ar«  divided  first  into  two  cla^ws.  viz.,  those  reaultiug  from  injarj, 
■ad  those  nrisint;  from  gonoral  or  local  causes  not  of  a  iraimiatic  nature. 
Inflammadon  of  tlic  aru-ri«  i«  divided  also  Into  I'ndartt-'rittft,  in  which  it 
admits  prininrily  or  chtctly  iho  internal  mat.  and jueri-arier ilia,  in  which  the 
proc«M  coininpiK-cs  in  ihn  oniiT  C'tiit  or  sheath.  The  term  mw-Rrttrritis  has 
alw)  been  au^f;<<9>tei)  lor  iDHniDrnation  uf  the  middle  coat,  but  it  is  of  little 
UM,  oi  no  iruK  iiiKHtninutiii-y  alffctiKO  cuniiMUCM  iu  thai  part  of  th»  va»d. 
Somt!  foriiH  (if  art^ritii*  nn-  uamed  frurii  the  cause  of  the  dtttettM!,  aa  ityphititic 
or  embolic.  Aa  in  lUhcr  HtructurM,  the  iiillAmmatory  proceas  may  Xm  acute 
or  chronic.  In  nd<liti»n  lo  the  ahove  dith'OAeii,  nrieriei  snller  from  vnriuu* 
degenerative  clinn|f<#,  »<ime  of  which  are  primary,  nfTecling  the  uri^oal 
ti.'tsuea  of  the  vesiwrls.  olhem  aro  necimilary,  the  dejrenerutioo  taking  place 
chietly  in  the  pro<)iicU  of  a  chronic  inHniumatory  procnc.  TheM>  vari<ru& 
pruciaaca  arc  sliU  furth«r  complicated  by  aecuudury  effects,  «ueh  at  the  furm- 
atiod  of  aneurtam,  from  the  dtsen^eil  waits  of  the  artery  yielding  b<Mt>ra  the 
pressure  uf  the  hlwid,  and  ibromboeis  of  the  iilfi-L-tcd  veeaol  folKtwiMl  by  its 
ohlitcmriim.  and  tiiiniciimes  by  embolism  and  gungrooc. 

In  discuGding  the  tliMntKea  uf  arlfries,  it  will  be  most  coDveuient  to  ronsidrr 
firat  the  vari'ius  formal  i)f  inllumiiiation ;  aecoodly,  tliu  dcgeuuratiuiu:  and 
lastly,  the  remoter  eflecls  uf  tliesL'  ebauges. 

AKTCRITtS. 

AODtt  Arteritis  nf  idiopnthic  origin,  thai  ix  Uf  ^mv,  ariatn;;  as  an  indepeo- 
dent  nlleetiiiri  for  which  no  cviih-iil.  eatim.-  can  be  tounti,  was  formerly  believed 
to  be  a  com  ]>u  rati  vely  nmimon  nlleclioti.  1 1  wasriifipos*^!  to  alledt  the  inner 
coal,  spreailinji  aioniz  the  veMt>l  in  (he  direclioii  uf  the  circulalion.  and  fr>m 
this  faet  it  ViU6  »{i<ikcn  of  ns  ilitliise  or  erysipelatous.  It  is  now  known,  hot*- 
ever,  tlxat  ni>AUvh  nlfoction  n-ally  exi^li*,  nod  that  the  error  anwe  partly  fnm 
Mwnning  that  thromhogis  in  inviiriably  evidence  of  previous  inttnminnlinn  of 
the  atTorted  vi'aeel,a)iH  partly  from  miHtakingfor  tlic  redniSHof  inllnmnialiott 
the  Btaiuing  of  the  inlima,  Ki  often  nliwrveil  as  the  rrauitof  ehangnu  in  the 
hloiMl  with  disintcgrntioa  of  the  ml  enrpuscleti,  nocitrring  either  duriog  life 
iu  acute  forms  of  ulnod-poiaoning  such  as  aepLiciemin  or  maligoaot  fevers,  or 
aiW  death  as  the  rcHjlt  of  |>utrefacLion. 

Trauutio  Arteritis.. — Simple  acute  trnumntic  inflammattoD  limitnl  to 
the  part  iujured  and  showing  no  tendency  to  extennon,  is  fiimtliar  to  every 


VARIETIES    OF    ARTERITIS.  109 

Surgeon  id  coDoectioD  with  cootuaioD,  laceration,  wound,  or  ligature  of 
BTtenee  ;  for  in  tbe  early  period  of  repair  ailer  any  of  these  injuries,  inflHrn- 
nuitorv  exudation  from  the  vasa-vasorum  forma  an  essential  part  of  the 
prucc«&  For  a  description  of  this  condition,  the  reader  is  reterred  to  vol.  i, 
chap.  xiv. 

Arteritis  by  Ezteiuion,  from  infective  iuflammation  or  ulceration  of  the 

ti^utre  surrounding  the  vessel,  has  already  been  described  as  one  of  the 

dani^eni  accompanying  these  processes.     In  inflammation  affecting  an  artery 

La  this  war.  the  prncees  la  the  same  as  in  other  tissues.     The  vessels  of  the 

outer  coat  are  dilated,  inflammatory  exudation  with  migration  of  corpuscles 

takes  place,  and  the  wlmdering  cells  in61trate  the  coats  of  the  artery,  which 

bei-^ime  swollen  and  softened.     The  process  spreads  from  the  outer  to  the 

inner  coat,  the  endothelium  desquamates,  and  iibrin  is  deposited  upon  the 

dteeaseil  surface.     In  the  smaller  arteries  complete  thrombosis  takes  place, 

ujd  the  clot  extends  upwards  to  the  nearest  branch  beyond  the  inflamed 

part  of  the  vessel,  and  may  then  undergo  the  changes  already  described  as 

occurring  in  the  permanent  closure  of  an  artery  (vol.  i.,  Wounds  of  Arteries), 

and  hemorrhage  is  thus  prevented.     In  arteries  above  the  size  of  the  radial, 

however,  the  closure  of  the  vessel  is  frequently  not  accomplished  before  the 

mats  are  so  &r  softened  as  to  give  way  before  the  pressure  of  the  blood,  and 

thus  fatal  hemorrhage  may  result.     This  is  all  the  more  likely  to  occur 

when  the  inflammation  and  subsequent  ulceration  affect  a  limited  portion  of 

one  ude  only  of  the  artery,  as  in  those  cases  in  which  it  is  due  to  the  con* 

tact  of  an  irritating  foreign  body,  such  as  a  sequestrum.     In  the  latter 

arteries  complete  thrombosis    occurs    much  less    readily  than   in  smaller 

TeseeU  or  in  veins,  the  rapidity  of  the  flow  of  the  blood  being  unfavorable 

to  the  adhesion  of  the  white  corpuscles,  which  is  the  Brst  step  in  thrombosis. 

lo  arteries  which  have  been  divided  and  secured  by  ligature  or  otherwise, 

the  extension  of  unhealthy  inflammation  from  the  wound  to  the  exposed  end 

of  the  vessel,  followed  by  softening  of  its  coats,  and  disintegration  of  the 

ooDtaiued  clot,  is  tbe  commonest  cause  of  secondary  hemorrhage. 

Embolic  Arteritii. — Moxon  has  pointed  out  that  a  form  of  acute  arteritis, 

resulting  in  s^iflening  and  swelling  of  the  arterial  wall,  thus  leading  to  the 

ffrmaii'in  of  an  aneurism  or  to  rupture  of  the  vessel,  is  in  rare  cases  the 

rrtult  of  the  lodgement  of  an  embolus.     A  simple  fibrinous  emboius  lodging 

in  an  artery  merely  obliterates  the  vessel  with<iut  causing  softening  of  its 

caiff.     In  onler  that  inflammatory  softening  may  occur,  it  is  necessary  that 

tW  i'diIkiIus  should  l)e  derived  from  a  part  which  is  the  sent  of  some  infective 

influmniatiiin,  and  that  it  should  carry  with  it  the  unhealthy  products  of  the 

l'^'^.f>s.     Kiuholic  arteritis  is  most  likely  to  occur  in  the  .somewhat  rare 

a^i.-ii<>n  known  as  ulcerative  or  infective  endocarditis,  hut  it  has  also  been 

iLiiiiwn  to  fiillow  embolism  during  the  course  of  an  ordiuiiry  ca-^e  of  acute 

rheumatism.     Localized  arteritis  arisinjr  in  this  way  is  believed  to  be  the 

^■fi  common,  if  not  the  sole  cause  of  spontaucoud  aneurisms  in  cliildn-n, 

U'l  in  tlio  smaller  vessels  of  the  extremities  in  adults.     Kusliton  Piirkcr  has 

rn-'iriicd  a  case  which  well  illustrates  this  form  of  disease.     A  boy,  uged  14, 

iluriii):  an  attack  <if  acute  rheumatism  was  suddenly  seized  with  piiin  in  the 

I'^rwirm,  fullowotl  by  swelling  of  the  limb.     The  general  swelling  soon  suh- 

fiiif  1,  leaving  a  dee)>ly  seated  circumscribed  tumor,  which  steadily  increased 

iD»iu  t'lr  the  next  four  months.    On  laying  this  o]>en,  a  cavity  whs  exposid 

'"■ntaiDiu^r  more  than  a  pound  of  dark  clotted  I)1o(h1,  and  the  anterior  intcr- 

'•*e..uii  artery  was  found  to  communicate  with  it  l\y  an  opening  u  quarter  of 

1'  inch  in  length.     The  vessel  was  successfully  ligatured  above  and  below 

tltf  'iitcnini:.  and  the  hoy  recfivered.    At  the  time  of  the  o])eration  there  was 

*  Iftuil  di^uble  aortic  murmur. 


110 


DISBASKS    or    AKTEHIES. 


Acate  EndarteritU. — Comil  «n'l  Ritnvi^r  deevrilii^  utidf-r  ihienam^M 
ulllH^Liitii  ul'  till-  iuiier  coal,  met  wilh  cliietly  in  lliv  hufIu.  IiuL  Murjmiojmlljr 
ulwi  ill  aiuKller  vcsm-'U,  oniwcially  iic*Hr  Moiiixle.  It  is  cliiinictfrked.  tn  tbe 
nakvii  eyv,  by  )in)rniu<;iit  (mtclicri  r<iniiuil  l>y  a  t^nellin^  iiftlie  intimii.  They 
are  cimiilar  nr  i>vnl  in  outline,  tinil  Stildoiti  i.-\i!t-tfti  hiilt'  iiii  iiirh  in  (lianicrUT, 
though  both  their  ttirrii  and  Kiu-  muy  btt  uIutflhI  by  ibe  cobIkkwik;*-'  of  uetg^- 
bnring  patchiia  They  are  jnilu  pink  in  ctilor,  uml  kc in i-tntn^ parent  or 
opalescent ;  in  ounsist«nce,  ihi^y  uro  Botl  nml  tOaKlic,  almmt  gelnttnoiifi.  The 
internal  surface  has  often  Itwl  it^r  polJFh,  in  tmnsetiuence  of  tbv  irre^uliiriLr 
of  the  swettinf^,  but  it«  endnLheliiil  (tu-vring  is  lutually  iotacl.  The  middle 
coat  hcneAth  the  patch  appeHTM  iMually  U*  be  mmewliat  swollen,  and  this 
c4>nHitioii  ismnremnrkt>d  in  theuHvenli'tia.  Micrwcopic  einmination  shnvs 
thai  the  swelling  U  duo  in  an  nccitmnlaUon  of  5innll  cel)^,  either  round  or 
slightly  irroiiular  in  onrlinc,  between  the  fibrw  of  the  euh-enffolhelinl  con- 
nective tissue  luid  the  einetic  layers  of  the  inner  coHt.  These  cell?  have  ■ 
distinct  nucleus  surrounded  br  ii  small  qunntity  of  protoplasm,  and  fthow 
oigiis  of  active  iiriiM'ih.  LWnil  and  Rauvier  believe  they  arc  prixlmx-*!  by 
pruliferHtimi  of  the  uri^iiiikl  <^^l|g  of  the  jiart.  The  ««i.'lling  of  the  <:'\IernAl 
coat  i»  found  to  be  due  U>  the  presence  of  nuuieroiw  cells  of  n«w  f..rroalioo 
aeparatiug  Ibe  iibresof  llie  connective  tissue. 

The  oonJilions  under  which  acute  endarleritia  occur  are  not  clearly  d«t«r- 
minetl,  but  aa  every  intenuedinte  condition  between  It  and  the  chronic  forn 
t<i  be  imniediiilvly  de»cribeil,  u  to  be  met  with,  eometintes  even  in  the  ■&»« 
vesel.  it  »tH!iua  to  be  nuthing  mora  than  the  wme  prooeaa  iuct«a«ed  io 
iutcntiity. 

Chronic  Endarteritis,  Arteritis  Deformatu,  Atheroma. — This  is  by  Ihr 
the  inoflt  comni-iu  diwase  to  which  arteries  are  liable;  in  taot,  it  is  very  rare 
nlWr  middle  life  to  find  il  completely  absent  in  the  larger  veasela.  It  occurs 
in  its  must  marked  form  in  the  aorta  and  the  hirge  iirluriu  of  the  twck^ 
abdomen,  the  upiwr  parts  of  ihe  liiul»,  uud  the  base  of  the  brain.  It  is  leas 
commouly  eoen  in  tne  tjmaller  veasels,  in  whiuli  the  musculur  coHt  is  more 
fully  developed. 

Chronic  endarterlttii  iir<t  iip|)pan<  as  pole  yellowish  patches  or  streaks, 
smooth,  slightly  elevated  above  the  surTacK,  and  evidently  -wHte^l  in  the 
deeper  layers  uf  the  inner  coat.  They  are  irregular  in  outline,  their  long 
diameter  U  usually  in  the  line  of  the  Teasel'a  oourie,  but  they  sliow  a  special 
prcdilectioQ  for  tbe  mouths  of  the  branches  leaving  tbe  main  trunk,  mund 
which  thcv  form  annular  elevations.  Their  outline  becomes  aubaequcntly  more 
irregular  by  the  coalescence  of  neighboring  palchea.  Aitbe  ducnseadvancMa, 
tbe  patches  become  more  clevnted,  often  reaching  a  lino  or  more  in  tbickn^MH 
At  this  stage  they  are  gray,  Kcmi-traitsparent  or  opalescent,  and  inrisj^^H 
sometimea  almost  cartiluginouA  iit  appearance  and  consistence.  This  (Niinlittoa 
in.  however,  speedily  fnllowwl.  bLlnrc  the  patches  have  reached  more  than  half 
HD  inch  in  diameter,  by  a  ehnuge  to  an  opnijue  yellow  color,  the  »lt4>ral>on  in 
tint  c»mmenctn}{  in  the  central  parts.  Thi^  change  is  due  to  tiilty  degenera- 
tion, and  is  accompanieil  by  srmie  InMof  tougbnen.  The  furtberprograssmar 
be  in  000  of  two  directions;  tbe  growth  may  aoften  and  break  down,  or  u 
may  calcify.  When  soOening  takes  place  thi  patch  becoroea  converted  iatn 
n  pultaoeous  or  oheeay  mass,  and  even  sometimes  undergoea  complete  lique- 
faction into  a  yellow  creamy  Quid,  which  has  been  mistaken  for  true  put, 
and  termed  an  "  atftemivitotu  abuxsa."  It  is  this  change  that  led  to  tha  lam 
atheroma  beint[  applied  to  the  disciuc.  the  prodocta  of  the  aoAcDin^  nf  Un 
patch  reaambling  ibe  oontenta  of  an  atheromatous  rvst  of  tbe  skin.  Tha 
term  is  now  oftaa  aitandad  to  all  stages  of  chronic  endarteritift. 

Wbea  the  proous  raaebea  tbe  more  advanced  stages  the  middle  cuat  is 


ABTSBITIS   DEFORMANS,  OR   ATHEROMA.  Ill 

■Sected,  fint  hj  chrome  inflanimation,  aod  subsequently  by  softening.  At 
Uwrnne  time  considerable  thickening  of  the  external  coat  takes  place  by 
ibe  formatioD  of  dense  fibroid  tissue  which  is  not  prone  to  fatty  degeneration 
asd  tofleoiDg.  Up  to  this  BtH&;e  the  fatty  patch  ia  covered  by  the  most  in- 
tfrtal  layers  of  the  intima  and  the  endothelium,  which  are  not  affected  by 
tbecbronic  iaflammatory  process,  but  afler  complete  softening  these  give  way, 
aad  tbe  atheromatous  fluid  is  discharged  into  the  circulation,  leaving  the  re- 
attiui  of  the  patch  exposed  to  the  blood-stream.  The  raw  surlace  thus 
fenwd  is  callra  "  an  atneromaUme  ulcer."  The  debris  which  enter  tbe  circu- 
ktioo  are  carried  on  and  lodge  in  the  capillaries,  but  not  possessing  any  irri* 
tatiog  properties  they  give  rise  to  do  evil  consequences.  Although  on  the 
fenatioo  of  an  atheromatous  ulcer  a  considerable  part  of  the  inner  and 
middle  coats  are  lost,  perforation  or  rupture  of  the  artery  rarely  takes  place, 
aad  it  ie  only  in  exceptional  cases  that  the  blood  forces  its  way  aniongst  the 
tnu  of  the  diseased  vessel.  This  is  due  to  the  fact  that  at  the  margins  of  the 
ptk-b,  die  chronic  inflammatory  process  has  led  to  firm  matting  together  of 
tbe  coats  of  the  artery.  At  the  same  time  the  thickening  and  induration  of 
ibt  externa)  coat  prevent  perforation.  It  is  especially  opposite  the  deeper 
and  more  eroded  atheromatous  patches  that  this  cunsulidation  of  the  exter- 
nal coat  takes  place.  The  chan^,  although  described  as  a  chronic  inflam- 
BtUoo.  is  strictly  conservative  in  character.  The  new  growth  of  fibroid 
QMe  is  not  confined  to  the  external  coat,  but  extends  to  the  sheath  of  the 
vokI,  and,  by  soldering  it  to  the  contained  artery,  greatly  adds  to  the 
Anngtb  of  the  vascular  wall. 

Although  perforation  is  thus  prevented,  the  new  tissue  but  imperfectly 
nproeots  the  normal  structures  of  the  coats  of  an  artery,  as  it  is  entirely 
noting  in  elasticity.  G)n8equently  it  is  very  apt  to  yield  slowly  to  the 
pnnire  of  tbe  blood,  and  thus  lead  to  the  formation  of  a  sacculated  aneu- 
na.  the  mouth  of  which  will  correspond  to  the  damaged  portion  of  the  wall 
of  the  vesKl. 

Complete  softening,  with  the  formation  of  an  atheromatous  ulcer,  is  not 
hr  uy  means  a  necessary  consequence  of  fatty  degneration  of  the  patches 
Rniltug  from  chronic  endarteritis.  In  many  cases  the  new  tissue,  afler  de- 
gntenting,  remains  as  a  firm,  yellow,  opaque  mass,  and  may  undergo  no 
Airther  change,  but  most  commonly  lime  salts  are  deposited  in  it,  and  it 
pidually  becomes  converted  into  a  hard  calcareous  plate,  over  which  the 
Nperficial  layers  of  the  inner  coat  with  the  endothelium  may  remain  un- 
broken- S«)metimes,  however,  these  seem  to  wear  away  and  the  calcareous 
piste  comes  in  direct  contact  with  the  blood-stream.  This  change  was  fiir- 
Berly  described  as  '* o$tification  of  ihe  arteries"  but  it  need  nut  be  said  that 
nutrue  bone  is  formed.  From  the  arrangement  of  the  calcareous  matter  in 
plates  corresponding  to  the  atheromatous  patches  in  which  the  lime  salts 
Bare  been  deposited,  this  change  has  also  received  the  name  of  laminar  eat- 
aieation. 

Micracopic  examination  of  an  atheromatous  artery  in  the  early  stage  of 
the  disease  shows  that  the  morbid  change  commences  in  the  deeper  layers 
of  the  inner  coat  by  a  proliferation  of  the  flattened  cells  thnt  lie  between 
ih^  laminie  of  connective  tissue  of  which  it  is  cliiofly  cumpused.  The  new 
«lls  are  arranged  in  lines  between  the  lamina'.  With  the  proliferation  of 
ike  cells  there  is  a  growth  of  new  lamina:  of  connective  tissue  clusety  reaeiii- 
btioir  that  of  the  healthy  inner  coat,  both  in  Hp|>eanince  and  in  urrunge- 
Btat.  The  change  is  therefore  a  true  overprowlh  of  the  deeper  layers  of 
the  intima.  The  relative  amount  of  cells  and  fibrous  intercellular  giibstitiice 
Ttrie*  in  diflerent  cases,  but  the  chief  bulk  of  the  new  tissue  is  always  com- 
jnwd  of  the  latter.     The  cells  are  smalt,  rounded  or  slightly  flattened,  and 


112 


DISEASES    or    ABTEKIKS. 


;v*, 


'•  »: 


'^- 


«Oo- 


contain  a  nitcUus  of  coniii(l«rabte  size,  round  which  it  is  oft«n  ilifficutkj 
recxi^uizc  aii>'  proUipliMii.     Xu  vesBela  pviiclrate  tb«  uew  Iimup  Kml 
({uciilly  nlu'i)  iL  r*iii:bit<  u  ct-Tbiiu  eU^  of  dcveiopuieut  the  a-utral  i^uU; 
but  iniiHTlK-lly  iiDuri^heil,  uud  J(.-ut>uer«tioa  ocMnmeaces.    Th<-  wU»  b 
Hhrivutlcil  aixl  i^rauulur,  ami  futty  ]eriiuuli-«  ah"  ip{n-ar  lu  the  intrrurllu 
8ubsUuic'v.     At  u    luler  atagu   uuIvuiuihik  };rauukw    muy  bIimp    lUMkc    their 

upitratHiice.     ir  wiltunjog    Lakus    (iluef,  the   &t- 
gninulcs  increaee  iii  <iunuui)',  ami  «>luliiia  of  the 
inlt-ni'Ilular  substance  iultuwa.  If  ooni|iIeti-  li' 
luction  takes  place,  ibeathnromiiuiaa  fltiiii  i»  it 
under  the  inii;ro6c«)pe  to  be  Cximpoaeil  chlpflj  nt 
tiitly  debris  and  oil-globulea,  and  very  Irciiueotly 
it  ennlainB  plates  of  obolCBteriDe  {Vig.  -i'Ab). 

The  aorompaDjing  drawing  C^'ig-  -^''^^)  illu»- 
trat«8  the  alnioture  of  an  utheromatutia  jiatcb 
very  well. 

"the  chants  in  the  middle  and  out«r  ooata  r»- 
qiiire  but  little  notice.  The  middle  cnat  iu  tb» 
Iftter  stages  h  oflco  iitvaileil  by  a  gntwih  Bimilar 
ill  eharacler  aud  8tniclure  tt>  that  xhich  origin- 
ally «LurtC<]  in  ibe  inner  cnat.  In  tact,  it  ^efiun  to  be  an  cxieiivion  nf  th» 
aame  gruwth,  the  true  vtructiirm  •>(  thv  middle  cnat  l>eing  atri)|ibi«tl  fnim 
prewure.  The  uuter  cuat  ehows  a  gn>wth  oT  new  libruus  tlnuu  eootittning  a 
number  of  small  runod,  or  elon({al«<l  cella. 


^^j 


He.  tSA.— AUierMM,  wUh 
tboadMil  Ckol«it«rtDr. 


fff^JS^ 


M         t 


rif.  IM.— AtlMriMM  «r  Aorta.    '.  tlulla  IftnlMK ;  m.  Bl4dU  egkt ;  t,  InUrSkl  sMt ;  /,  tka  aw 
fttiHh  aa<l«rc«tn|t  bUty  ilifMMrMino. 

Hatarfl  and  Cautet. — ^Thc  views  as  to  (he  nature  of  Ihti  dlKaao  have  nn- 
dergniir  vnriiiua  ehuugca,  but  at  the  present  time  it  is  ainiuft  univrmUly  re- 
garde^l  as  n  chr>uic  ioflaniuuitary  prvceaa,  eharacterized  bv  over^iwtb  of 
the  ttttect<-<l  ti»uo  followed  by  rleg^neration.  Gulliver  Kaa  long  ago  inclined 
tu  this  opinion,  and  it  has  been  e8|iMnally  inaislcil  uu  by  Vircbow,  Killrnth, 
and  Moxon.  That  It  belongs  tu  the  cIom  of  morbid  procoBBes  almost  uni- 
venally  sjMtken  of  an  chronic  inHammattnns,  may  be  aaid  now  to  be  geaer^ 


NATUBE    AND    CAUSES    OF    ATHEROMA.  US 

sIIt  accepted,  but  the  difference  between  these  and  acute  inflainination  is 
■o  marked  that  probably,  with  the  advance  of  pathological  knowledge,  a 
eoaplete  aeparatioD  will  be  made  between  them. 

The  moat  important  cause  of  chronic  endarteritis  ia  mechanical  strain. 
Thifl  maj  be  constant,  as  the  result  of  abnormal  resistance  in  the  capillaries 
or  smaller  arteries,  or  intermittent,  such  as  occurs  during  violent  exertion, 
io  which,  while  the  heart  is  beating  forcibly,  the  resistance  to  the  circulation 
m  increased  by  the  contraction  of  the  muscles.  Moxon  has  bniught  forward 
abaodant  evidence  in  proof  of  this  theory.  He  points  out  that  atheroma 
occura  more  constantly  and  at  an  earlier  period  in  males  than  in  females, 
and  that  when  extensive  atheroma  is  met  with  in  women,  it  will  usually  be 
fuaod  that  they  have  been  engaged  in  hard  manual  labor.  In  men,  the  most 
marked  examples  are  met  with  in  those  whose  occupations  have  involved 
rioleat  physical  exertion.  In  wasting  diseases,  in  which  the  quantity  of 
blood  is  diminished  and  the  arterial  tension  reduced,  atheroma  is  seldom  met 
with,  mod  in  the  pulmonary  arteries,  in  which  the  pressure  is  greatly  less 
than  in  the  systemic  vessels,  chronic  endarteritis  is  rare,  being  observed  only 
io  those  cases  in  which  the  right  heart  is  hypertrophied  in  consequence  of 
efaroDic  bronchitis  and  emphysema,  or  obstruction  at  the  mitral  orifice.  The 
earliest  patches  of  atheroma  are  moreover  situated  in  the  parts  exposed  to 
the  greatest  strain,  as  in  the  arch  of  the  aorta,  and  at  the  points  at  which 
taive  branches  are  given  off  or  a  trunk  bifurcates.  It  is  common  also  to 
find  the  disease  more  advanced  in  those  situations  in  which  the  artery  ia 
placed  in  close  proximity  to  a  bone,  as  in  the  femoral  at  the  brim  of  the 
pelvis.  The  fact  that  chronic  endarteritis  is  always  more  marked  in  the 
vessels  of  the  lower  limb  than  in  those  of  the  upper  may  also  be  explained 
by  the  pressure  being  greater  in  the  most  dependent  parts  while  the  Dody  is 
in  the  erect  position. 

Among  the  constitutional  affections  which  predispose  most  powerfully  to 
the  develttpment  of  atheroma  is  chronic  Bright's  disease,  with  the  granular 
contracted  kidney.  Gull  and  Sutton  have  demonstrated  that  this  disease  is 
asanciated  with  a  general  change  in  the  smaller  arteries  and  capillaries  to 
which  they  have  given  the  name  of  arterio-capillary  fibrosis.  It  is  charac- 
terized by  a  fibroid  thickening  of  the  external  coat  of  the  smaller  arteries. 
In  the  diseased  kidney,  Johnson  has  described  a  thickening  of  the  walls  of 
the  smaller  arteries,  which  he  believes  to  be  due  chiefly  to  the  hypertrophy 
•t(  the  muscular  coat.  The  nature  of  these  changes  and  their  extent  is  still 
a  matter  of  dispute  ;  but  whatever  the  exact  pathological  change  may  be,  it 
if  beyond  a  doubt  that  it  caui^es  considerable  ob^ttruction  to  the  circulation, 
a  (act  which  is  made  evident  by  the  hypertrophy  of  the  heart  that  accora- 

ries  the  disease  and  the  evidence  of  increased  arterial  tension  aa  indicated 
the  sphygmograph.  The  granular  contracted  kidney  and  the  general 
vascular  changes  asaociated  with  it  are  very  commonly  the  result  uf  (/out, 
K- much  so  that  this  form  of  Bright's  disease  is  often  termed  the  "  gouty 
kidney."  Gout  is  usually  the  result  of  an  abuse  nf  alcoholic  stimulants,  and 
thu«  habitual  alcoholic  excess  comes  indirectly  to  be  an  important  cause  of 
ehr>oi<'  endarteritis. 

The  influence  of  typhilis  in  the  causation  of  atheroma  is  a  more  doubtful 
p'-iot.  Aitken  attaches  great  importance  to  it.  The  effect  of  syphilis  in 
eau*iug  disease  of  the  smaller  arteries,  and  fibroid  induration  of  organs  and 
ti«u«-».  ha^  already  been  [xnuted  out  (see  Syphilis,  vol.  i,"),  and  it  in  evident 
that  tht-se  changes  would  tend  to  obstruct  the  eirculati<)n  iind  thus  cause 
inrrt«j>e<i  arterial  tension.  Whether  it  acts  more  directly  as  a  cause  of 
athtroms  is  uncertain. 

The  m(»t  important  predisposing  cause  of  chronic  endarteritis  is  old  age. 

VOL.  II. — H 


114 


UlliBAfiKS    OK    AHTKKIE8. 


After  R  rerlniii  perirxi  of  life  tht-  nricrieis  in  ctuniiioti  Mitli  olher  (i»»»ti« 
impaired  iu  etructure.  This  iiiuuitdilM  itecll'  chit-Uy  by  r  (Jittiiuutiuu 
□oniiHl  elasticity  of  tin'  coals,  so  tliuL  ilicy  becumo  leu  capable  of  witli 
iag  auy  i^train  lu  wbicli  thur  iimy  Im;  ux]K«(!d.  So  lV»)ueut.  oud  ludeeit 
cuDHiaul  Hi'c  t]ie«Q  irauafurtuatiuQs  ol'  tiio  arterial  uoau  duriuii;  llie  lit^clioe  ul 
Uf«,  that  tliuy  way  he  uoDsidonHl  tlic  natural  ri«ult  ul'  ihi*  tlimiuutiou  of  ititf 
DuLrioot  activity  muscqueut  upun  ndvnuce  in  yean.  Guielia  lias  I'uuDd  that 
them  is  a  |iri>grcasive  iiicrcuie  in  lliv  curlliy  iiiiilli'-n!  cmitaintHl  iu  Lbe  ccmuI 
of  lieallliy  urtvrius  a«  llic  tudividuul  udviiiiceii  in  lifu.  Thus  b«  aacettWoed 
that  Ihi!  a»h  uf  the  arlerim  of  a  newly  born  child  yiclila  t),ii^  per  cMit.  «u 
phiuphutii  of'  limn;  ihcr  hpallhy  urtcricK  of  un  adiiU  l.'lii;  and  liioae  of  aa 
old  mnn  2.77  of  thr  tiHtnc  Katl;  whtlot  I  he  ciilcitie<l  Hrterie^  of  aii  age<l  man 
contain  4.01.  There  Im  no  precim*  period  of  life  iit  wliirh  thcne  chaoen  «e( 
in  ;  old  age  \n  a  relative  term,  ami,  stt  soan  a.^  the  sv-Htt^ni  haa  paased  lU  full 
maturity,  iii  whHteve r  year  of  lifV'  this  mnv  happen,  there  ts  a  tiindency  for 
tiwae  def^nerntlve  «han>(es  to  tiike  pince.  The  lendeocy  to  enrlj  d«gmumi 
iioD  of  arteries  h  fre.|iieiitly  hereditary.  i 

Effects  of  Chronic  End  arteritis.^  A#  n  coii^quenre  of  the  htw>  of  rlai^ 
ticily  rifiilliii;;  iVorn  tlu-  clironio  inflnnimiitury  and  dejjenemtivv  chaiit;;v»  ia 
tho  cuul«  of  the  arterv,  it  usually  yichU  mure  or  \es»  before  th?  tli»(i<»din( 
fore**  of  tlie  heart.  Tim  change  in  ni<«it  marked  in  the  aorta  and  it»  [iritnarjr 
dirixtons,  but  i»  occasionally  wen  in  tho  femoral  and  hmehiiil  art^riea.  Tfat 
dilatation  may  be  regular,  or  pouch-like  projections  may  form  h«re  and  there. 
At  the  Miue  titue  the  vckkI  is  uAcn  somewhat  eWugated  »o  as  to  aasuoie  t 
tortuous  furiu.  il  is  in  couseiiueucc  of  lhe«e  chao^fev  that  tho  name  arteritit 
liefvmuiiu,  was  )pvvn  to  this  disease  by  Virchuw.  The  interior  uf  the  dilatiid 
VMBol  is  rough  and  irregular  iu  couBei^ueiice  uf  tht:  projecliou  of  the  iitbero* 
matous  patulie» :  when  sifrteuiug  has  Uiken  place,  "  titlivrunialuUB  ulcvrv" 
may  be  scattered  here  uud  there  uver  the  surtk<;e.  and  in  other  cases  it  may 
he  paved  witli  cl<.«.ely  »et  ealcareuuK  plates.  When  the  dilataliuu  readies  a 
certain  dv|;ree  and  is  limited  lo  a  deiinile  area,  the  eutnliliuii  is  deecribeil  nc 
a  Ibsiliirm  aueuriBm.  the  distinction  between  tliat  aud  simple  dilatatiua  I>ein2 
oiilv  one  of  dvj^rce  (see  Aiieurism  i. 

The  lues  of  elasticity  in  the  coals  seriitut^ly  interferes  vitb  the  drcuhuina 
through  distant  partt<.  us  the  natural  etora^  ufthe  heart's  force  in  thcelastia 
mills  of  the  larf^er  vessels  by  which  tlie  oonUnuous  flow  between  each  systoU 
is  muiniuincJ,  is  no  hin^^r  po^ible.  The  circulation  in  tho  exlremitim  tl 
therefore  usually  feeble,  and  the  nutritioo  of  tJia  jiarts  correspond Uigly  im* 
perfect. 

Narrowing  or  Oeebaion  of  Ihe  Brancha  leaving  the  Atharomatoui  TVvnl  i* 
hj  DO  means  uncommon.  As  bet^tre  ^tawd.  the  oriAoea  of  tbe  brmachrs  from 
tlifr  main  trunk  are  common  etnti  of  thcearl]«8Calheromutou»  |tatchc».  The 
thickcnins  of  the  intinia  may  take  place  iu  a  ring  rc>utid  the  mouth  of  tb« 
veasel  andthuH  gnidually  uitrrow  it.  The  coincident  thickening  of  the  out«r 
coat  may  still  further  coiilrnct  the  urifice.  When  ct>mptfle  obtiteratioa 
oocun  the  6nal  obstruction  probably  takes  place  by  the  fornmtion  of  a  throoh 
bus  in  tho  diseased  artery  immediately  above  the  niirrou-e<l  orjticv.  CvDipUu 
obliternlion  \»  m>.>stcommun  in  those  cases  io  which  theililstation  of  the  Dialn 
trunk  hits  reached  such  a  decree  a»  to  merit  the  uameuf  a  fusiform  aueurisu. 
la  a  ease  in  University  College  Hospital  a  few  years  ago,  in  which  tlie  left 
carotid  was  tie*)  lor  oneurifm  r.4'  the  innominate  artery  and  the  arch  of  tba 
aorta  with  nu  immpdiately  fatal  result,  it  wae  found  that  tbe  right  suMavian 
wu  obliterated  «b«re  it  left  the  dilated  innutniniite.the  right  earutid  waBpvr* 
moablo,  but  prcMed  on  by  the  aneurism,  and  the  aortic  openilig  of  the 


SS3ULTS   OF    ATBEROUA.  115 

rabdarian  wu  completely  closed,  thus  the  artery  which  was  tied  was  the  only 
KBwl  carrying  blood  to  the  brain. 

Xarrowing  of  the  coronary  arteries  by  an  atheromatous  ring  at  their  orifices 
it  %  common  cause  of  fatty  heart. 

Tkivmbo$U  is  an  occasional  consequence  of  atheroma.  So  long  as  the  patch 
ii  cohered  by  an  unbroken  layer  of  the  inner  coat  with  its  endothelial  cover- 
ing, there  is  no  tendency  for  coagulation  to  take  place  upon  it.  When,  how- 
errr.  tbe  patch  has  softened  and  discharged  into  the  circulation,  leaving  an 
"atheromatous  ulcer/'  or  when  the  thin  covering  over  a  calcareous  plate  has 
been  worn  away,  the  diseased  structures  come  into  direct  contact  with  tbe 
bloud.  If  the  surface  is  tolerably  smooth,  the  rush  of  blo<id  past  the  dis- 
eawd  patch  is  so  rapid  that  adhesion  of  the  corpuscles  is  barely  possible  and 
Consequently  no  thromboeis  results;  but  in  pouch-like  dilatations  it  readily 
takes  place.  In  the  same  way  it  may  occur  in  a  very  dilated  vessel  if  the 
heart's  action  is  unusually  feeble.  A  clot  thus  formed  may  gradually  Increase 
in  nize  till  it  fills  the  whole  vessel,  but  more  commonly  after  reaching  a  cer- 
tain bulk  it  is  washed  away  and  carried  on  as  an  embolus  to  some  distant 
part.  If  it  be  of  sufficient  size  to  obstruct  a  main  artery  of  one  of  the  limbs 
at  iu  bifurcation,  gangrene  will  frequently  result.  Smaller  fragments  lodg- 
ing in  the  extremities  usually  produce  no  important  effects,  the  anastomosing 
circulation  )>eing  sufficient  to  take  the  place  of  the  obstructed  vessel.  If 
lodging  in  one  of  the  solid  viscera,  it  gives  rise  to  a  hemorrhagic  infarct  (see 
ToL  L  p.  904).  but  does  not  as  a  rule  cause  any  serious  consequences. 

Sypoilitio  Endarteritis  has  already  been  det*crll>e<l  <  vol.  i.  p.  1048). 

Artmtii  Obliterans  or  ObUteratiTe  Arteritis  (Friedlander).  Endar- 
ttritis  Proliftnuis  or  Hyperplastic  Endarteritis  ( V.  Winiwarter). — Under 
these  names  have  been  described  certain  rare  cases  in  which  obliteration  of 
arteries  takes  place  as  the  result  of  infiammatory  changes  in  their  coats,  not 
erideotir  dependent  on  syphilis,  embolism,  or  injury.  The  disease  runs  a 
dimnic  course,  and  may  cause  spontaneous  gangrene  of  the  parts  supplied 
bv  the  affected  vessel.  The  symptoms  will  perhaps  be  best  illustrated  by 
qaoting  a  tvpical  case  latelv  recorded  by  Pearce  Goutd.  Tbe  patient  was  a 
brickmaker,  aged  l!l.  In  May,  18S3,  the  fingers  of  his  right  band  became 
congested  and  sometimes  dead  white,  with  much  sickening  pain.  Afler  a 
&w  weeks'  re:it  he  improved,  but  soon  relapsed  on  returning  to  work.  Afler 
»>me  months  the  pain  extended  into  the  fUrearm,  and  completely  iucapaci- 
laled  him  fmra  working.  He  came  under  Gould's  observation  in  October, 
l'"^3.  At  that  time  the  right  forearm  and  hand  were  cold  and  somewhat 
waftei).  and  he  sufforcti  much  pain,  especially  at  night.  The  brachial  artery 
wa^  hanler  than  natural,  and  pulsated  more  feebly  than  that  on  the  opposite 
li-ie.  The  radial  could  be  felt  as  a  solid  cord.  There  was  dry  gangrene  of 
the  tip*  of  three  fingers.  >'o  constitutional  affection  was  found  to  account 
fir  the  condition.  Two  weeks  af\erwania  (he  pain  increased  till  it  became 
aertnizing,  requiring  hvpoiiermic  injections  of  morphia  for  its  relief.  At  this 
time  there  was  slight  eles-ation  of  tem p(f nitu re.  The  brachial  artery  then 
became  i*<mverted  into  a  pulseless  cord  to  witliiu  one  inch  of  the  teres  major. 
!>>m  after,  the  subclavian  artery  was  found  to  be  prominent.  In  December 
the  pain  graduallv  subsided,  and  one  mcmth  atier  he  was  apparently  well. 
The  brachial  arterv  remained  a  (tolid  coni,  nnd  the  tirst  joint  of  the  thumb 
and  <if  the  index  finger  separated  after  beciimin<r  uiummified  n'i(/c  Trans. 
Clin.  Sk'.  I'"?4'.  a  rtoniewhat  ^fimiiar  ciwe  occurring  in  a  female,  aged  ;J5, 
it  rec<jrded  bv  W.  It.  Hadden  in  the  same  volume.  The  pathology  and 
aiu»«  iif  thi->'rare  alTection  are  still  uncertain.  It  commonly  occurs  about 
middle  life,  Gould's  case  being  the  youngiwt  rocitrded. 

The  disease  <lc«cribed  by  V.  Winiwarter  un<ier  the  name  of  endarteritis 


116 


DISEASES   or    ARTKRll£a. 


prolifcnins  ii>  prohnhlr  of  the  same  mtturc.  lit.-  Atntfo  Oiat  it  ooi-unt 
auna  apj'tirtutlv  licnllhy  ia  otber  respects,  and  give?  rwe  tu  frp<iti(nut.'<>iui' 
gsmgreui-  usually  of  ihc  tout.  Id  one  cum*  in  which  llie  v^ewlfi  wef«  exaaiiovd 
aficr  ai»{>u(nti<Jii  vt'  tbe  limb  tlie  •jblit^rnliifti  wus  louod  tu  be  tlir  rt-c>uU  of  a 
greai  pruliteratiou  of  the  cudothelJuii).  with  oarruwing  of  tbe  luruifu  of  tha 
vetsel,  Uie  linal  ublitcriitioD  being  brought  about  hy  ihrombuBiii.  New  voavls 
were  rouuil  pcuelruiiug  I'roai  tho  outer  coat  into  (he  pruliJerating  eoduUielium, 
whiuh  with  the  ihtoiubus  nus  fbuud  in  the  older  pane  lo  bv  uudurguitig 
changci^  einiilar  to  th(.<e  already  dtrtcribi'd  un  (»ccurtii)g  iu  closure  uf  aa 
artery  alter  tigaturc.  Biilri>lh  siutiK  that  the  dieeusf  is  pruredcd  by  fMbJr- 
neKnfcirculatJou,aud  obscure  puin,ofLeii  luHLiDg  Tor  moutlmoryi'en.  Therv 
is  no  drltiiiU'  trt'utnient  liir  thetM^  (■om-s. 

PeriBTteritis.— By  [M-riurlt'riliii  ie  meant  an  iiiBainniulidD  citmtiienciDg  bi 
the  outer  cual  or  j^ht-utli  of  the  iirtery.  It'  we  exclude  urteritit*  by  extetudon 
from  eurrounditi^  tieMui-s  and  iratjiuatic  arterilis,  periitrU'ritis  in  a  rare  dis- 
ease. Charcot  and  liouehurd  havi^  deiicribe<)  Biieh  an  nflectiun  in  the  veaaeU 
of  the  brain,  commencing;  an  an  iicctinmlation  <it'  fmall  nnind  cells  in  the 
perivflscMilnr  Dhealli!!;  ihfge  penelmt*?  the  coat»  from  withimt  nnd  lead  ti> 
SoAening,  frequently  fitlioned  by  the  formntiou  uf  minule  aneurtant^  and 
final  rupture.  It  is  a  senile  disease,  and  according  to  Charcot  »  conimoii. 
cauw  uf  aimplexy. 

Ad  aHectioD  of  the  arteries  of  an  uncertain  nature  not  causing  obliteration 
has  been  observed,  which,  from  its  giving  rise  to  aeute  pain  and  tenderness 
with  Auiue  fiwelHng  in  the  line  of  the  veseel,  mutil  be  eupp)j#«tl  to  be  iuflani- 
matory.  A  eaee  of  this  kind  bns  been  recorded  by  J.  H.  Morgnti,  in  the 
Transactions  of  the  Cliuicat  S<.K.'ivty  for  IStJl.  The  patienl,  a  oiau  aged  4ti, 
was  ailael(ed  with  severe  paiu  iu  the  line  of  the  right  femoral  artery  ;  the 
veael  was  acutely  tender,  but  tb^Te  uas  do  redness  of  the  tkiu  covering  it. 
The  oiudiliou  was  at  lint  limited  to  a  few  inches  uf  the  artery  near  the 
groin,  but  gradually  exleuded  to  tlie  iMtplitenl  space  and  leg.  Slight  tedeoia 
mod  aume  awelling  of  tbe  lymphatic  glands  became  apparent  when  the 
dlwoH  reuclii'd  the  leg.  The  vessel  pulbatv^l  forcibly  and  ihtre  was  qo 
thrunibnsis.  Hu  hud  boriie  years  nreviously  suffered  from  a  einiilar  aflecti^ui 
of  the  opposite  leg,  and.  while  still  under  obeervatiun,  the  right  brachial  aiid 
carotid  were  suceemively  al)e<^'led.  Altogether  the  second  attack  laste^l  over 
live  months.  It  was  nut  apparently  due  to  syphilis,  guut,  or  rheumaliam. 
From  the  alm'nve  of  tlirunilMwis,  it  would  seem  probAole  that  the  disease 
ira«  ft  periarteritis. 


PRIXARV  DBDRNERATIOm  OF  AKTKKIH!. 


roT^fS 


Fatty  Degeneration. — Fntty  degenrmtion,  except  as  a  part  of 
«DdiirtvritiD,  in  not  a  |>Mrti<.;iilArly  iW-^ioeiil  <>r  im(K>rtiini  chaoge  io  arteries. 
Ill  the  aurta.even  iu  young  wutijecu, yellnw  patrht*  of  Dmall  siie  and  irregu- 
lar liirni,  and  very  »li)>htly  if  at  all  vlevaied  aUive  the  nurinnt  surlaee  uf  the 
iotinia.  are  not  unci>niiiit>n.  If  uue  of  these  be  peel«d  olT  and  examined 
tuicmscupically  it  will  be  found  t»  present  stellate  patches  of  fat-granules  in 
tbe  most  superficial  layen  of  the  iuiima,  immediately  beneath  tbe  endothe- 
liucD.  These  are  the  result  of  laity  degeueratioD  of  the  braucbetl  cells  thai 
are  normally  present  in  this  part.'  The  afleotioo  seems  of  no  importanoa, 
and  its  cause  ii  not  known. 

In  later  life,  liitty  degeneration  afTectisg  tho  intima  more  deeply  issomih 
limes  met  with  unaccompanied  by  any  of  the  signs  of  nihcruina.  The 
degeoemtion  may  cxtvud  to  the  cmlothelium,  which  then  dieinlegratrs  and 
ii  cast  off,  leaving  a  rough  surface  exiHiseil.    This  condition  boa  been  do- 


CALCAREOUS   DEOENEBATION. 


117 


fcribed  u  fatttf  erofion.  It  is  most  coinnion  id  the  arch  of  the  aorta. 
Thruugh  such  a  surface  the  blood  may  force  its  way  into  the  middle  coat, 
toil  thus  give  rise  to  the  coDdition  to  be  aubsequently  described  as  "  dissecting 
at^ttrism." 

Fattj  granules  are  not  uncommonly  found  iu  old  age  in  the  external 
ooats  of  the  smaller  arteries,  but  they  are  of  no  pathological  importance. 

Calcification  or  Calcareom  Degeneration. — We  hnve  already  seen  that 

the  calcareous  plates  so  common  in  the  aorta  and  its  primary  branches  are 

the  result  of  the  calcification  of  the  products  of  chronic  endarteritis.    In  the 

HDsller  arteries,  principally  in  those  of  the  third  and  fourth  magnitudes,  as 

the  popliteal,  the  tibials,  the  brachial,  radial,  and  ulnar,  primary  calcification 

i*  c-tmmunly  wet  with.     It  commences  by  the  deposit  of  lime  salts,  in  a 

fTtnular  form,  arranged  in  lines  running  transversely  tu  the  axis  of  the 

ve«fl ;  these  lines  gradually  increase  in  breadth  until  they  coalesce  laterally, 

tk  iotert-ening  spaces  being  filled  up  and  the  vei*sel  converted  into  a  rigid 

tobe.    In  the  early  stages  while  the  calcareous  matter  is  arranged  so  as. to 

fono  lines  round  the  vesEel.  the  condition  is  termed  annvlar  caleijicatioji 

■  Tii.  437  K    When  these  lines  have  coalesced,  it  is  often  called  tubular  ealei' 

fintm  (Fig.  438). 

When  this  pnK«&s  has  reached  its  highest  stage,  if  the  artery  be  removed 
fmm  the  bttdy  and  drawn  through  the  fingers,  a  small  rigid  tube,  composed 
of  the  calcified  middle  coat  still  lined  by  the  inner  coat,  can  be  squeezed  out, 
IttTiDg  the  external  coat  apparently  healthy.     In  fact,  the  toughness  of  the 


Fif.  -l-iT. — AoDular  (^leiGestion. 


Fig.  4^3.— Tubuliir  Caloifieation. 


fiti-rital  r.iat  is  so  little  impaireil  that  sucli  vessels  can  be  tied,  and  even 
t»i*:(ii,  almtto'l  us  safely  as  a  healthy  artery.  Annuliir  and  tubulur  cnlclfi- 
faii.o  mrv  almost  invariably  associated  with  clinniic  eudurteritis,  and  its 
•n^-n-lary  dfgtneratinns  in  the  larper  vessels,  and  in  the  inter  mediate 
in'-ru-^.  such  as  the  axillarv  or  popliteal,  and  snnierinic-s  even  as  low  as  the 
tjiial',  h'lh  conilitionn  are  observea  side  by  side. 

Tht-  <'xi*tfnce  of  this  degenerative  chanjre  i:-  upniilly  recopnized  without 
■iilfi<-ully  liuring  life  in  any  artery  that  can  be  e.xainined  with  the  finger. 
The  v»"n(W'l  fecU  hard  and  less  compressible  than  natural.     Its  longitudinal 


118 


DT8BASE»    or    ARTEHIBB. 


vlaaticilv  U  ]vf!«di'iJ.  ho  tbat  ii  w  Uirowu  inui  a  wnvy  lino  when  ivlax«d 
IcDjeiluuinnllv  bv  fifxinii  tif  tlii>  limb. 

Tiie  [ui>rbi<l  c(iti<litit)ii  cutisists  eaH-iilialW  ul'  a  dej>OMt  of  limu  mlu  to  the 
mupoiilar  fibre-wIlB  tiflhe  middle  i^i*!.  Wo  iIiub  inily  nn-vl  wHIi  it  in  tb«wi 
\-ct«>el8  ill  wliifh  thi<  uiusrulnr  ti»ue  is  well  deTeln|>ed.  In  llio  largvr  anrrin 
lliv  niusculHr  ivUb  arc  so  i<<.itut,v  urn)  &>  tnt  ctniceaM  by  the  elastic  linue 
tlial  if  i\u»  change  dura  occur  in  ihtm  it  is  diffic-ult  Up  reruitoiw.  Tbt;  inner 
coat  in  the  larger  vcwiOF  usually  ^liowrs  tlii-  urdinary  &i]jiia  ol  ciirinln 
endartcritiii.  Id  the  #nmllcr  it  may  nt  tin^t  lie  healthy,  l)ul  later  nn  cal- 
careitue  pUtc«  may  form  in  it.  It  liae  bet-n  iHiinled  unt  by  fiiua  that  the 
flvninietry  of  the  arrangement  of  tho9C  morbid  H|i{)4-itrnnrt«  in  the  cof- 
mponding  veuela  on  xppnsile  sides  of  the  br^ly  '\»  rcmiirkably  prt-ni,  the 
arteries  of  one  Itmb  being  ofltn  the  exact  counlerpiirt  in  I  liia  respttt  Uj  ihuae 
of  the  other. 

The  caascs  of  ealoification  of  the  muscular  flbre-cells  of  the  iniddlc  c«AI 
are  unknown  beyond  that  it  is  alwayj>  a  senile  change. 

The  eflevU  of  nnnular  valcifivatiun  arc  lo  rvuder  the  venwl  ■  rigid  tube  ou 
longer  capable  of  regulating  the  flow  of  blou<l  to  Ihe  parte  it  suppliv*.  At 
the  same  lime  its  calibre  ts  alwH>'B  diminislipd,  and  the  nutrition  of  Ihv  pArta 
beyond  is  seriouuly  impftired.  Thus  in  the  limbs  vre  have  idl  the  signs  of 
dcleclire  circulation,  coldneeeof  the  fret,  cnim|>»  and  Hpspmsofthe  muscles ; 
whilst,  in  orguns,  softening  of  ti^ue,  fatly  degeneration,  und  other  evidencoi 
of  wnul  of  a  proper  supply  of  blood  are  observed.  SpuntHneous  aneurisim 
rarely  result  I'rtim  this  t-hange,  the  coals  of  the  artery  being  tnorr  resisting 
than  naturnl ;  moreover,  primary  cnlcificnlion  is  met  wiin  in  the  Tcfltela 
below  the  axilla  and  knee,  and  sponlnneoua  aneurisms  beyond  thn^  jwiints 
are  amongst  the  curiosities  of  surgery.  Thronibti^is  is  occnsionnlly  met  with, 
bat  is  not  coinnjon,  as  the  endolhclial  lining  i^aflected  only  in  exirt-me  rasfs 
and  late  in  ibv  diseui^t.-.  The  lodgement  of  a  small  fibrinous  embolus  cajTifd 
from  alberuniatoiw  urieriea  above  is  an  oconsioual  occurrence,  and  is  Terr 
likely  t(i  cautfo  gangrene  even  when  only  one  vessel  is  bloeket],  as  the  c'>l- 
lateral  arteries  arc  no  longer  capable  of  enlarging  to  carry  on  the  cireulntion. 
Oceluaion  of  the  ralcilied  nrltries  by  thromb.isU  or  onibolism  Is  the  ci>mmoii 
cause  of  the  dry  form  of  senile  gangrene.  The  moi!^t  form  arisrs  fnmi  in- 
flammation taking  place  in  ii««ue^,  the  vitality  of  which  has  brru  grrntly 
lowered,  tri  oon»e<pienee  of  thr  diminished  supply  of  blood  whieh  6ud9  its 
way  ihmngli  thf  narrowed  vessels. 

Ouiflcation  of  Arteries.— The  formation  of  true  bone  in  the  coats  of  an 
nrtery  \»  nn  extrt-nu-ly  rnre  ix-ciirrenit.  I  am  aci)U)iinteil  with  only  one 
nutheiitic  mrv  of  thie  elmnge.  The  lipcciraen  w«a  pxhil>i|ed  at  tbf  J^utbolo- 
gicnl  .Stcirly  of  London,  by  II.  G.  IIoww,  in  1877.  The  patient  whb  a  maa 
Bge<l,  'M.  who  was  run  over  by  n  csrt,  the  wheel  piiwing  over  his  shoulder 
iTie  axillary  artery  was  mplnred.  nnd  dealli  oct-nrred  t>e  a  result  of  the  acci- 
dent about  a  moulli  ollerwiirrls.  A  ntnall  plate  of  cancvlluu.i  bone  was  ftiUDil 
in  the  injure<l  vi-atwl,  apparently  developed  in  the  middle  and  outer  custs. 
Its  greKl<.-»t  ihiekneu  was  about  a  tjunrter  of  un  inch. 

Efi-'wi>  or  I)jfii:Ahi>  oe  niE  Aktkkies. — The  various  eflfects  nrdlsrue* 
of  the  arteries  have  already  been  mentioned  with  the  afU'clions  to  whieh  they 
an  due.  Iwit  it  may  U-ad  in  a  clearer  conijirehenBionof  the  suhjivt  if  tliry  are 
amin  referred  lo.  as  ihe  same  effect  may  riTsull  fnim  more  ihtin  one  cam*. 
TIh'  nio.-!  im|>ortant  efTet-lc  of  arterial  diwase  are  Ulcernlion  of  the  CVutta  of 
the  Arlery ;  .S(»onlHm,'oii»  Hupture  :  Contraction  or  Occliijuion  of  the  Vesael, 
and.  lastly,  I)iliiiatii>n  into  tiome  of  the  various  forms  of  Aneurism. 

Dloeratioii  of  Arteries. —  Lij»»  of  subslann^  in  the  inner  coat  results  fruto 
Bttperflcial  falty  ilegen^ralioufp,  116  k,  and  from  softening  of  an  atheromntuui 


EFFKCT8    OF    ARTERIAL    DISEASE.  119 

pitch' p.  110"!.  Neither  of  these  processes  is  a  true  ulceration.  Genuine 
ultfnttifio  of  the  inner  coat  is  in  reality  scarcely  ever  met  with.  When  true 
ulwntioD  of  an  artery  takes  place,  it  is  theresult  of  causes  acting  from  with- 
out, uucking  first  the  external  coat,  ae  iu  the  case  of  a  sloughing  sore  open- 
iBgimiiD  artery,  or  the  pressure  of  a  sequestrum  in  the  popliteal  space 
^iBt  the  vessel. 

SpOOttDMIU  Snptore  of  an  artery  is  rare,  and  never  happens  without 
pRTimis  disease  of  its  coats.  Experiments  made  by  Peacock,  which  I  have 
r^MiUd.  aod  theaccuracy  of  which  I  can  fully  conKrm,  prove  that  a  healthy 
inerr  will  sustain  a  very  great  pressure  from  water  injected  into  it,  without 
iu  lilUgiving  way.  But,  if  these  have  been  softened  or  weakened  by  disease, 
tbrr  DMT  be  unable  to  resist  even  the  ordinary  impulse  of  the  blood  ;  and  if 
Hiu  be  iJriveD  on  by  any  unusually  forcible  action  of  the  heart,  as  under  the 
influeoce  of  sudden  violent  strain  or  exertion,  they  may  give  way.  This 
ocnrrence  would  be  much  more  frequent  than  it  is  in  atheromatous  and  cal- 
etreHu  patches,  were  it  nut  for  the  inflammatory  consolidation  of  the  external 
ciatofthe  vessel  supplying  that  resistance  which  has  been  lost  by  thesofteu- 
iop  or  destruction  of  the  internal  and  middle  tunics.  Hence  this  rupture  is 
■Mt  trequeot  id  thuse  vessels  the  outer  coat  of  which  is  thinnest,  and  in 
vMdi,  consequently,  it  can  least  supply  the  place  of  the  others,  as  in  the 
utfrieiof  the  brain  and  in  the  intra  pericardial  portion  of  the  aorta.  The 
liibility  to  rupture  of  a  diseased  artery  by  the  distensile  force  of  the  blood 
inpelleil  into  it,  is  greatly  increased  by  the  exis^tence  of  an  obstacle  to  the 
frnflow  of  the  blood  out  of  its  terminal  branches  in  consequence  of  a  con- 
P*ted,  infiltrated,  or  chronically  thickened  state  of  the  organ  or  part  supplied 
brit 

Cntraetion  and  Occlusion  of  arteries  are  by  no  means  rare  sequences  of 

Ittiom  of  these  vessels.     Narrowing  of  an  artery  may  take  place  in  various 

*>n;  the  orifice  of  a  branch  leaving  an  atheromatous  trunk  is  often  narrowed 

^ibe  formation  of  a  ring-shaped  tnickening  of  the  inner  coat  (p.  114),  and 

iDecalibre  is  diminished  in  calcification  of  the  middle  coat  (p.  117),  syphilitic 

irieriti«  'vut.  i.  p.  1048),  and  endarteritis  proliferans  (p.  115).     Causes  acting 

ftom  without,  as  pressure,  or  contraction  of  chronic  inflammatory  or  cicatricial 

tkme  in  the  immediate  neighborhood  of  the  artery,  lead  to  ii  mirrt)wiiig  of 

iu  lumen.     Id  this  way  the  axillary,  the  iliac,  aiui  even  the  aorta,  have  been 

ooeIu-]trd.     Tiedemann  reconls  from  various  smirces  n()  fewer  than  eight  cases 

in  ffhich  the  abdominal  aorta  wa.s  coni|)letelY  closed,  in  all  of  which  so  full 

U'l  ftiicit-nt  a  collateral  circulation  had  been  set  up,  that  the  vitality  of  the 

iiivrr  part  t>i'  the  IxmIv  wa.^  ]>ertectly  maintained,  and  in  most  the   mtirbid 

■uii'  w.i«  not  9n-i[)octcil  during  lifo.     Besides  those  chains  he  states  that  there 

iTe  iin  reci-rd  twelve  instances  of  great  uarrowinp  of  the  uorta,  at  that  point 

wbt-n- ihe  ductus  arteriosus  is  implauled  into  it  in  f.rtal  life.     Thesewould 

apfiear  in  sorat-  way  connected  with  the  closure  of  the  duct  ;  as  in  every  case 

tiu  indentation  wa.-<  greatest  on  tlie  convex  part  of  the  aorta,  which  had  been 

dnvn  in  towards  the  mouth  of  the  duct. 

The  final  oblitenition  of  a  diseased  artery  is  most  comrnoTily  tlie  result  of 
tbnmtxRti.^.  Thrnmbosis  takes  place  in  arteries  under  much  the  same  coniii- 
ti>n-  as  in  the  veins.  Whenever  the  iioriiial  eiidotlielial  lining  of  the  vessel 
is  1-wt  "r  iu  ■■  pliy>iidiigical  integrity"  impaired  by  degenerative  changes, 
tbf  bl'nnl  tends  to  coagulate  upon  tlie  <iiseased  surfice.  The  rapidity  of  the 
arterial  flow,  by  preventing  the  adliosion  of  the  white  corpuscles,  coiniteracts 
thin  tendency  to  a  c«Ttain  extent,  hut  when  the  hluod-streain  beeuiiies 
iUckfnr<l  either  by  great  dilatation  of  a  large  trunk,  or  hy  iiari-.iwing  of  the 
orifij«  of  u  lirauch,  or  feebleness  of  the  heart's  action,  a  deposit  of  lihriri  very 


lao 


IflSEASES    or    ARTERIBS. 


rendily  laVc*  pliare.  An  artery  of  the  second  i»r  third  nmunilude  rua^ttiiM 
W  i4ili(vrnl(^.  Wht^u  n  thrombuii  bns  formed  in  a  bniiR-li  it  may  c-xl«n<l  by 
fresb  >it:poeit  iDU<  Ihe  main  iruok  aad  form  n  mnas  of  fibrin  pnijcrtiuif  into 
ita  lumen  (Fig.  -439).  ThromboeiB  uf  ihe  diseased  artery  ')»  jirobublr  in  a 
cotuiderable  Dumber  of  cases  the  fiual  dotermiiiing  cause  of  drjr  gaogreiK  ia 
old  people. 


\ 

¥it'  <»■— Throat  botli  «r  Iwo  <4  lh« 
rhUf  branobe*  af  th«  Ab<1«iBlii«| 
AiMt* :  fttiijvellon  «t  ibi  Throabw 
tMg  llio  Duln  truKb. 


rig.  440.— Bn.b«l(«ia  at  tbi 
Axillary  ArlHji  with 
Tlinioibn*t»t.(  lln  BimdtU 
hr  Mtmt*  dtaUKc*  b«hi*r 
Iba  Enbnlai.  I.  Subol*- 
vlan;  3.Aill)Br;  Art«rj  i 
3.  SBbacB^ulu  and  l>oK- 
tlroitniilti  AtIwI**:  i, 
flrBrhUI. 


Complete  ohi iteration  of  an  artery  u  in  laauv  i!a«««  thcrtsultof  embolkm. 
The  emuulue  is  usually  coaip>iaed  of  a  nmn  uf  fibriu  which  hn«  bn:o  depiMtl«d 
on  Kxmv  tlibeoDnl  part  uf  tlie  larger  vixmUs,  and  eui>sn[)urotly  washed  awnjr 
by  thf  hlood-stnam  and  loilgod  in  eumc  pout  at  which  the  irunk  auddetdjr 


OBLITBBATIOy    OF    ARTERIES.  121 

auTHWi  wheo  bifurcating  or  giving  off  a  large  trunk.  The  source  of  the 
rabiiluin  may  be  the  vegetatioDS  furmed  upon  the  valves  of  the  heart  in 
aoite  rbeuma'tUm  or  ulcerative  endocarditis,  the  fibrin  deposited  in  a  pouch 
of  t<iilited  aorta,  or  on  a  projecting  calcareous  plate,  or  a  fragment  of  a 
dot  |ir>jectiog  into  the  main  trunk  from  a  thrombosed  branch,  as  iu  Fig.  439. 
Tbeeflects  pnxiuced  vary  with  the  nature  uf  the  embolus  and  its  size.  When 
itmfi  fmni  the  vegetations  uu  the  valves  in  ulcerative  endocarditis  it  may 
p^t  rile  to  inflammation  and  soAeuing  of  the  cnat  of  the  artery  at  the  point 
tlihich  it  lodges  (see  Embolic  Arteritis,  p.  109),  more  commonly  it  leada 
nwrelv  to  obliteration  of  the  artery  by  tlie  ordinary  processes  already  de- 
Kribeil.  If  it  lodge  in  a  small  artery  in  a  part  in  which  the  anastomosing 
cin-uliiinn  is  free,  it  produces  no  effect  beyond  the  permanent  closure  of  the 
Tmel:  if  it  lodges  in  a  terminal  artery,  as  in  one  of  the  abdominal  viscera, 
il  give*  rise  to  the  formation  of  a  hemorrhagic  infarct  (vol.  i.  p.  904)  followed 
bj  ihe  subsequent  degeneration,  and  shrinking  of  the  affected  area.  These 
old  iorarcls,  forming  wedged-shaped  buffcolored  patches  of  considerable 
u>U|;hiif68,  are  commonly  met  with  in  the  spleen  and  kidneys  in  cases  of 
•dvanped  atheroma  or  fusiform  aneurism  of  the  aorta.  When  the  embolus 
Wlire«and  lodges  in  a  main  trunk,  as  in  the  popliteal  at  its  bifurcation,  or 
in  lb«  axillary,  spontaneous  gangrene  may  result.  This  is  the  cunimon 
fMneof  gangrene  in  young  people,  and  is  probably  the  immediate  cause  of 
icertiin  proportion  of  cases  of  senile  gangrene,  the  embolus  in  the  latter 
Ott  beiog  derived  from  the  diseased  surface  of  an  atheromatous  aorta.  The 
CM*  frvm  which  the  accompanying  drawing  (Fig.  440)  was  taken  was  that 
of  1  wnruan  ^y^  years  of  age,  admitted  for  spontaneous  gangrene  of  the  lefl 
■nn;  the  embolus  lodged  in  the  axillary  artery  had  caused  gangrene  of  the 
linib.  The  6gure  Illustrates  also  the  thrombosis  of  the  vessel  below  the  part 
Uvbich  the  embolus  has  lodged,  which  frequently  aids  in  the  production  of 
pQgfeDe. 

Ondual  narrowing  of  an  artery,  ending  perhaps  in  complete  obliteration, 
aoKs  few  or  no  symptoms  when  the  area  affected  is  limited  in  extent  and 
ibe  collateml  circulation  is  sufHciently  active  to  keep  up  the  supply  of  blood 
tiiht  [tarts  In-yond  the  obstruction.  The  gradual  narrowing  of  a  consider- 
•blr  rjit-nl  of  the  main  vessels  of  the  limb,  such  as  is  seen  frequently  frona 
ctlrarnius  dcgeneraliun  t)f  the  tibial  arteries,  gives  rise  to  more  or  less  defi- 
ninrtTects,  such  as  cold  feet,  cramps,  numbness,  and  weakness  of  the  legs. 
^Ulh  ^TnlI.tllms  are  often  tlie  premonitory  signs  of  gangrene  (see  vol.  i. 
^*4'^.aIl.l  are  au  iniMratiuu  that  care  must  be  taken  to  keep  the  parts 
*»mi  hy  appropriate  clothing  and  to  avoid  any  injury.  Tlie  symptoms  of 
^nibi'lism  of  a  large  trunk  have  been  described  already  (vol.  i,  p.  8oO>, 


122 


AKEUItlflM. 


CIIATTKU   XLIII. 


ANEDRISM. 

Bv  Aneurism  is  meant  &  lumor,  Ksuliioff  from  ditatauoo  of  the  nliot«  or. 
n  porijui)  iif  ttic  coou  of  an  artery  cauiied  by  tbii  jireMure  of  tlic  cooiAtnod 
binikd.  nod  otmruunicfllinjL'  with  the  iutvrior  uf  the  vi-Jwel. 

Tniuiunlif  AticuriamM  have  lk-4.'ii  nIrDHiIy  dcsiTilfctl  >  vul.  i.  p.  44G>.  !Mi»a> 
tADCOiisaDfUriaiiiit,  nri^iug  from  dbeasic  <>I  the  l-uuLs  ul'  thv  nrti-ry,  mrv  olitnn 
eonsidt-retl  in  the  prtw^iit  chHpter. 

Cai'm^x — The  cause!)  of  aneurism  are  divisible  Into  thnee  tbat  predufiive 
t'>,  Bud  those  Lliat  excite  the  dieeuee.  Alieuriitu)  i«  Frediapowd  tn  liy  anr 
aSeclioi)  of  iliu  arterial  cu»t«  lliat  luweos  llic  elutie  revilivncy  it{  thv  vtiavi, 
and  at  the  eaaio  ciuio  vreiikeua  iu  rcftistiug  {jower.  Whvit  au  nrlery  baa 
uodergoue  any  of  the  rbaiiifi^  d«»orilx.-d  iu  (he  last  ebupter  by  wliich  tho 
oatunil  elasticity  of  the  walls  is  diniiui^bed,  it  beeontes  lets  able  to  uoutract 
OD  its  ftntciila.  aud  U>  recover  duriug  the  diai^tulc  fDui  the  distentioa  occur- 
ring (luring  lliu  systolic  itnpulsc.  nnil  ibuH  eitlit^r  t-iiinpleto  or  imrtial  diliua- 
tiou  of  tlie  cavity  takett  place.  I  Ik-Huvc  tbal  this  Iws  uf  claelii'ity  aud  oi 
jHiu'or  of  corilnic'ting  on  iu  omteiKit,  which  evciiiuatly  nwull>  in  the  dilatk 
tion  nf  iho  vo)ss(i|,  never  occun^  except  as  the  rfsult  uf  pn'vioun  ilbtdaae  of  the; 
oonu.  Tn  the  very  nunieruns  Hpeciiiii'ii»<)t'diliile<l  arteries  that  [  linve  exain- 
iiied.  1  have  never  found  niie  tliHt  hn.«  nut  uiidiT^nni'  falir  degr'iicrHiion,  ur 
aibehimaloLiH  buflening.  Calcification  prevpnis  rather  tban  favors  dilata- 
tion of  the  artery,  by  lianlenin^  the  tMHts  Hud  convt-riing  ibeni  into  ri^fid 
ineUiitic  tnbei> ;  but  atheroma  aoAcne  them,  and  caii«ei>  yieldin^c  of  tbat  wir- 
tion  of  the  veese]  nllt'«ted  by  it.  I  have  fmjuemly  oW nrcd  tlmt  the  wnul* 
of  an  artery  might  be  healthy  except  at  one  part,  wburu  there  vraii  au  athercH; 
niatou«  |>nlch,  and  where  the  vi-«)«i;l  was  ililnltftl ;  or  that  the  whole  of  iVt 
Ctnitt  might  Ih)  caloifitfl  exc«pt  at  one  spot,  nberv  •oftcniog  had  lakco  placSi 
and  where  coitiwquently  thry  bad  yielded  undur  the  outwHpI  pretwuru  of  th« 
conlaiiieil  bioiHl.  I 

Ak  aneurism,  tbcrurorc,  raay  be  looked  upon  as  one  of  the  Bequenco  ofl 
atheroma,  the  prcdi!)|Mising  causes  of  the  one  conditiun  must  necewarilv  b* 
tbv  tniuv  lis  those  of  the  other.  Hence  we  tiod  tbat  age,  gout,  and  svphilia 
intluencv  the  •>ccurren<.'c  of  the  aaeurismal  diaeuM  by  laying  ita  foundnlioD* 
in  the  develi'pracnt  of  ntheroma. 

Ag«  exercises  n  powerfully  predi^poetng  influence  on  the  occurrence  of 
nneiiriem.  It  t»  during  ttio  nnddle  period  of  life,  about  the  agn  of  thirty 
oud  forir.  that  aneuriiims  arc  niuei  frtqiieutly  met  with ;  nt  thuee  age«, 
indeed,  when  tbu  arteries  have  olreadj  oommeiieed  to  lose  their  elusticttjr, 
in  eoosequence  of  def^ncralive  clinogee,  whilat,  at  the  same  time,  the  htiuC 
bna  nut  logt  any  of  its  impuUive  force,  or  the  genernl  muscular  srstem  h4 
ooairaeiile  vigor;  and  when  the  enfeebled  and  inelastic  veaiels,  beci>miujc 
exp'Micd  to  powerful  cpum?9  of  dUletition,  mar  readily  give  way  or  Ik  ex- 
patidttl  at  some  one  weakeneil  poinL  This  diaease  is  cxeesaiTcly  rare  bvfi»ra 
puberty,  yet  ia  occasionally  met  with  at  early  p^riotls  of  life :  thn»  Sym« 
mentinua  a  case  uf  popllival  aneurism  iu  a  boy  of  «>vcu.  Ilodgtun  had* 
preparation  of  a  carotid  aoeurism  lit  a  |jirl  of  ten,  aod  Hehniidt  a  osar  of 


CAUSES   OF   ANEURISM.  123 

ipHitiD«0U8  ftDeuriBin  of  the  radial  artery  ia  aD  infant  eight  weeks  old. 

K.  \V.  Parker,  in  a  inoet  valuable  paper  on  aneurisms  in  young  subjects 

mtl  before  the  Medico-Chirurgical  Society  in  1883,  states,  that  after  a  careful 

mrch  io  medical  literature,  he  has  found  only  fifteen  cases  of  spontaneous 

UMimm  reconletl  as  occurring  under  the  age  of  twenty,  including  a  case  of 

bi^iinn  of  inguinal  aneurism  in  a  boy  aged  twelve  years  and  eight  months. 

Id  fight  i)f  (he  fifteen  cases  there  was  disease  of  the  valves  of  the  heart,  in 

fiH  ih€  state  f)f  the  heart  was  not  recorded,  and  in  two  only  was  it  healthy. 

A  forcible,  imgnlar,  and  occasionally  greatly  increased  action  of  tne 

hmtti  the  immediate  cause  of  the  over-distention  and  dilatation  of  the 

tmkU,  ind  thus  of  the  production  of  aneurism.     Hence  we  find  that  this 

dittiw  is  especially  apt  to  be  induced  in  those  individuals  in  whom   the 

vsHular  system  is  called  upon  to  make  sudden,  violent,  and  intermittent 

exertiotu;  as,  for  instance,  in  men  who  habituallr  lead  soruewhat  sedentary 

Um,  but  occasionally  and  suddenly  change  their  habits,  and  indulge  in 

^>rtf,  Mich  a»  hunting,  rowing,  or  a  long  day's  shooting,  which  they  might 

■itbout  ri«k  have  practised  in  early  life,  but  which  cannot  be  taken  up  with 

iniNiDitT  at  an  age  when  the  arteries,  having  become  weakened,  are  unable 

uiWr  the  same  strain  upon  their  coata  as  heretofore.     I  agree  with  Porter, 

is  thioking  that  continuous,  steady,  laborious  employments  do  not  predis* 

p>Etn  aneurism,  as  this  disease  is  seldom  met  with  amongst  those  of  the 

*'>rking  clti<>a  who  labor  hard  and  uninterruptedly  ;  but  it  occurs  rather  in 

tif^  «ho,  after  long  periods  of  comparative  inaction,  are  occasionally  and 

iwWfDly  called  upon  to  make  very  violent  muscular  efforts,  disproportioued 

to  their  Mreogth,  or,  at  all  events,  to  their  previous  habits.    It  is  in  this  way 

(hit  nldiera,  sailors,  and  members  of  the  wealthier  classes  in  society,  are 

nnlered  peculiarly  liable  to  aneurism.     As  violent  muscular  strain  and 

amioD  predispoae  to  this  disease,  we  should  necessarily  expect  to  meet  with 

itnnn  fire«iueDtly  among  men  than  in  women  ;  and  accordingly  Crisp  finds 

tilt, of  .551  cases  of  aneurism  of  all  kinds,  more  than  seven-eighths  occurred 

■  dko.     It  is  important,  however,  to  observe  that  different  kinds  of  aneu- 

rim  occur  with  varying  degrees  of  frequency  in  the  sexen ;  thus,  this  affec- 

ttrto  U  mot  with  in  the  carotid  artery  about  as  often  in  women   as  in  men, 

•hilet  the  other  external  aneurisms  occur  in  tlie  proportion  of  thirteen  cases 

10  males  to  every  one  among  females.     It  is  remarkable,  hinvever,  that  in 

ibe  di#*ectin?  aneurism  the  proportions  are  reversed  ;  for  every  one  case  in 

ifcn,  twn  i>cour  in  women. 

Clioate  exercises  an  important  influence  on  the  occurrence  of  aneurism, 
»hich  is  far  more  fre<tuent  In  cold  than  in  hot  countries.  It  is  not,  hnwi'vor, 
tl*  p-<igra[ihical  ptisition  or  the  meteorological  state  c)f  a  country  that  exer- 
fWs  anv  direct  influence  over  the  occurrence  of  this  disease.  It  is  in  reality 
tin?  hahit.'i  of  the  peo]>Ie  that  dispose  to  it,  and  that  rojrulate  its  prcvnlcnrt' ; 
»iH  it  is  in  the  mnn-  energetic  nature  and  the  more  active  physical  habits 
'if  the  norihi-rn  nations  that  we  must  loi>k  for  an  explanation  of  its  greater 

Ertralence  amongst  them,  than  in  itie  mure  indolent  inliabitnnts  of  the  South. 
r»c  may  judge  of  the  prevalence  of  aneurism  in  a  country  by  the  number 
ff  [tublished  reports  of  cases,  I  should  suy  that  it  is  of  more  cnninion  orciir- 
Mice  in  '^irent  Britain  an'l  Ireland  than  ('Isewlu-re:  indeed,  lioux  states 
tUt  it  is  U-r^  fwrjupiil  in  France  than  in  Eii^'lainl.  In  America,  it  is  also 
''f  fn^iut-ni  oi-ourrence ;  liut  in  the  Kast  Indifs  it  is  comparatively  rare. 

Cachexy  induced  by  any  cause,  sucti  as  syphilis,  ehninic  gout,  or  rlieunm- 
ti»Bi.  the  abuse  of  mercury,  etc.,  has  a  tendency  to  occasion  disease  nf  the 
"•Ik  iif  the  arteries,  and  thus  to  predispose  to  aneurism.  Rut,  though  nier- 
mrr  snd  ^vphilis  are  conunonlv  said  to  tend  specially  t(»  the  production  of 
tki»  dii«aiie,  I  am  not  aware  that  we  are  in  p»ssessiou  of  any  definite  facts 


124 


ANKUniSM. 


that  would  wnrntnt  us  iu  coming  in  tliis  concliimuu  ;  llmugli  it  is  probable 
that  llie  caclipxy  thuti  imliicod  riiiiy  c)i«|t(jee  It)  it  aa  aiiirli  tis  any  (itlier  cause. 
It  is  rcriiHrkablb  tliat  phlhlsis  is  Hiit»t?>tiii9lic  to  uneiirHiii ;  ihou^b  pnibably 
this  may  arhi}  fmm  (lie  fucl^  tlmt  the  henrtV  Hinion  \.^  fueb)«  io  tliut  <liwii9ti, 
anil  that,  violent  muscular  exertion  is  seldutn  utiilertaken  by  those  taborlog 
umler  it. 

Any  obstacle  to  the  hee  flow  of  blood  through  »n  organ  or  ibe  capilla' 
riesot  »  purt,  cxorci^e^  :iii  iiiiporlniit  influence  in  ili^pix^ing  to  aneurism,  u 
it  tbrowa  nn  incrcaiif'  i>f  prc'isure  on  the  interior  of  ihe  nrtery.  Chevers  be- 
lieves that  nbt)Lriicti<m  in  ttie  Abdominnl  urgnns  rretpiently  occnsiona  aneu* 
risnis  nf  the  nbtli>minal  »rt<^ric«.  i^potitnneou^  nueurl^nis  of  the  anialler 
arteries,  us  the  riKlial,  ulnar,  or  tibials,  are  believed  in  the  great  tnajority  of 
cases  to  be  due  t>>  the  impnction  of  an  embolus  wnsbed  ou  }Vom  a  diieascd 
heart ;  but  in  these  cas&t  the  obstruction  to  the  flow  nf  blood  plays  but  4 
secondary  part  in  the  process,  the  most  important  clement  being  the  soAen- 
ing  of  ibe  cunts  of  the  vessel  consecpienc  upon  the  irritating  Jiatureof  th« 
ttiftterial  of  which  the  embulus  is  composed.  There  !a  no  reason  to  beliera 
that  a  tinipiti  emlwjiis  ever  cauK-s  aneurism  f pee  p.  109). 

The  only  Exciting  or  Direct  Occasioning  Caoseg  of  aneurism  are  btowa, 
violent  atruius,  and  wnunds  of  an  artery.  When  an  ntberomatous  artery  ii 
cvncu^ed  hy  a  biou\  the  lining  nienibraue  covering  the  soflened  patch  may 
be  niptured,  the  atheron>a  beiu};  poured  out  into  the  interior  of  the  venel; 
and  ifie  external  cout,  M'itb  perhaj^s  a  p'irtion  of  the  middle  adherent  to  Jt^ 
beeomini:  thuK  exposed  to  the  pressure  of  the  contained  blood  licfore  it  ha* 
been  fully  coneolidntetl  bv  chronic  intinnimation  and  the  fi>rmalion  of  new 
fibroid  liisue,  the  fuuudatron  of  an  aneurism  msT  readily  be  laid.  In  reir 
forcibJe  muscular  eflbrts,  it  is  easy  to  understand}  bow  aa  already  weakened 
porlitiu  of  tiiR  vessel  inny  betronie  diluted  by  the  increased  preasun;  (hat  is 
thrown  upon  its  intHrior;  ni;casi(in»lly  even  the  vessel  maybe  eumpletely 
tnrn  arros^  by  »  violent  strain.  M'owuh  iniplieaiing  arteries  are  common 
causes  of  tbf>5e  vnrions  formt)  of  anennitm  that  have  alrvu<]y  been  diHcusseil 
iu  confiderinp  Injuries  iif  Arteritat  (vol.  i.  p.  44t)).  / 

Classification. — Aneurism  nmy  he  i-tn^ilied  as  follovi'S: 

1.  Fif.siroKSi.— True. 

2.  SACCtrLATEU. —  if'  t/y*"'     (a.  Circ'iiniscrlbed. 

1.  Faaiform  or  Tubular  Aneurism.— This  h  a  preternatural  dilatation 
an  ftrltTv.  nil  tli«  iwMn  of  whi^'l:  ai*e  equally  expnnded  thnmyh  tlic  wholo 
circumference  of  tlie  vessel.  It  occurs  most  fre<|iieritJy  in  (lie  aorlu,  and 
may,  though  rarely,  be  iiiel.  with  elsewhpre.  The  lusifurm  uneurism  is  uoi 
a  mere  dilatation  of  the  %"v*sel,  for  th(^re  are  eloiijrntion.  thickening,  and  de- 
generation of  its  walls  «»  well.  The  elorigwlion  of  the  iirtery  in  tht-  fusiform 
aueuri^ni  is  n^  ninrked  ns  il«  dilidatiotL,  nnd  is  iilways  very  considerable. 
Thus  the  arch  of  llie  aortii  mav  be  ini-rerised  in  length  by  souie  inches,  with 
ft  considerable  sjKice  l>etween  the  origins  of  the  iniximiiiate,  the  carotid,  aod 
tl)e  subclavian,  at  the  same  time  lh:U  iti*  walls  ni^  greatly  thickened,  nodu- 
lated, and  rugged.  Sometimes  several  tubular  or  fusiform  aneurisms  are  met 
with  iu  Ibe  same  ve«tH?l,  with  henhliy  portions  of  the  artery  between  them. 
From  these  dilalatiuns,  sacculated  aneurisms  not  uncommonly  spring. 

On  examiniug  theetructure  of  a  fusii'oriii  iincurisiu,  it  will  be  found  that 
it  ie  composed  of  an  expHueion  and  outgrowth  of  the  ofmts  of  the  uriery. 
The  thiekneKS  of  the  ivall  ie  iiiniut.-iiiied  Ijy  growth  from  Ihe  inner  and  outer 
ouats,  the  middle  cvat  being  stretched  and  atrophied  in  proportion  tu  the 


SACCULATKP    AKEmiSM. 


125 


Tlit>  tuner  coat  preti^nUl)iechaiig<!«nlr«)i(ly  detcribed 

'  trti?ntu:  it  U  tUff,  rufig^,  and  tubvrculatcd  from  the 

ii«  patches.  Riid    frei]uently  calciireoiu  pUt«8  nre 

mwi  v,\-  Tli«  outer  coat  is  thickened  mid  oompofled  of 

ifilvoid  uhuv.     UicroMopic  exainiuacioii  shows  thut  tbc  luiildle  coat  is 

1  la  {Mvpfinioti  lu  the  Ue|;reG  of  dilataliou.    If  the  niieuri>-ui  iaul'aav 

biMbbIiIi.  >ik.  /nt>«  are  Tuund  liere  sod  there  in  which  the  middle  i-oal  u 

«iBtia|,  ihe  (lijcaum  iuavr  mat  cuming  ioto  direct  ci>Dtact  with  the  thick- 

mdmaaamt.    N'l  cuagula  uru  fouud  id  Oie  diUt^iliuu,  but  a  few  lilainen- 

aijtbnd*  of  fibrin  an*  (KTBijioiiiilly  neon  to  be  atlachexl  to  the  inner  wall. 

TWifttrim  that  iin^  usiinllv  the  wnt^  of  ftuifurm  aueurtsm  are  the  arch  of 

ibiKtii'PiK.  -141  \  the  ilnu'A,  ihp  fenio- 

aii,iD4ocea«ionully thcnxillirirs.  Thid 

iniealar  form  of  an('ijn.>ini  vicciirs  mi^i^t 

WnUj  m  rcncli  in  which  the  vi?ll<>w 

iUc  eaat  ia  tar^geljr  de\v|o|)ecl.  and 

kaft  ii  rarvljr    nicl   with    in   nrleric« 

taaBtt  tbao    thv    f«Tui>riiI ;    it  <K-cun'. 

kvtnt,  io  the   btteilnr  artery  of  the 

TW  fiBifurm  diUtxtirtn,  <»]>«rtnlly 
<ltt  waled  io  th«  arch  of  the  a»rln, 
■VUlaio  a  tery  cotiBitlemblv  magni- 
1m,  twl  iDBjr  oiDBe<iueiitly  exerciff« 
^  Mornnu  preosure  uu  coutigUKue 
p»ni,lsiii  pniductDg  great  distress  aud 
^aprof  lifr.  It  i^  usually  extreuiely 
(krwie.  inrreaaio^  very  hIowIv.  and 
Ik^  ir>jni|Mt)ble  with  e-xiittvuee  for 
Xi/  7«ar»  ;  but  It  uiunlly  ilts^troys  the 
fUicM  ai  last,  and  iniiv  "cviisiou  deuth 
Uatfifal  wars.  Thii5.  if  it  l>e  ftUial^^'d 
IB iW aorta  timth  ma v  take  )iIii<.iMr<im 
■noBfc  Tbia  mar  Ge  raiiiM^i  by  the 
■ihftof  thf  inrhulic  anrta  t»  fill  the 

ommtrr  arUTie^  diirinjfihc  diastole  of  the  heart,  or  from  imperfect  iitipply 

'4  UhmJ  u>  tiif  brain.     Then,  again,  death  may  mult  from  prt-^mirc  on  ([»• 

fvtaat  partii,  hj  on  the  bronchi  or  irsophagug.     When,  however,  a  tuhiitar 

lofthfi  arch  of  the  norta  oO'Upint  the  Intrapcricnrdial  portion  of  the 

Bi.t  unl're<)iH'nlly  lutppetw  that,  owiny  Io  the  absence  of  a  »lieHth  in 

ii.>n    ihr  nrt«-rv  mnv  ruptun^.      It   ittimt  conitiiuuly  bapfteiix   (hat  a 

_  it  «>urfe  of  diKcnitit'orl,  but  not 

•>ea«ct  ■prinK*  Inim  it»  i^ide;  and 

iiK  iii»r«  turmttlubi*;  ulivctiuti,  may  destroy  life  in  tome 

(.1  it. 

t  SMcalal*d  Aaanriim. — By  the  >accu)at<od  aneuri*ni  itt  meant  a  tumor 

I      *pi^iic  fruin  tin  aide  of  an  artery  or  uf  a  lubuUtr  aneuriani.  with  the  iate* 

twtif  •kieh  il  coiuoiunicaita  by  a  narrow  aperture,  called  the  mouth  of  the 

^^^^By.  ii'l).     It  M>  ^neraily  divided  into  the  True  and  Fattr  varieties. 

^^^^^Saccuiatml  AaearifiB,— By  thi«  ia  meuat  a  partial  dilatation  of  all 

^^^Bt-     -  — '      !'-  -\tjiteiicu  has  bveo  deaiml ;  thus  Scarpa  doubta 

lU^v  'L*,  and  Bixut  seems  disp««ed  to  coincide  with 

k*«.  jidla.howei'er.Icauuotagree;  and  though 

!«■*>.  1  the  so-cnlltid  "  true"  aaeuruuta  are  not 

■•  ni  ra^iu^,  yet  i  catmui  iluultt.  Irom  repeutiid  obeervntiuD,  thai  Hodgson  ia 


V\g.  KI. —  Large  Puiirniai  AkAdrWlB  of 
A*c«fl>l<ag  AoiU  hur«liii(  knt>  P«tlt.-M- 
iliium. 


k 


12« 


ANEUBItiU. 


riglit  ID  «ayiiigtlmt  in  their  early  gla^p*  twccuUted  aneurifliMliro  on*  ni 
qui^'Uiiy  ut  llie  truu  kinJ.  Ttius.  w«  ocuaiiouully  tiiirt.iu  iVitock  Iiob  fHiiiiif*] 
uut,  BOiitll  (iigiial  jMiuclif*  Bitriiifjiutr  from  Uic  walls  uf  wrnic  of  ihr  lurErr 
nrteriea,  Ihrou^^li  tin-  wlioio  lA'  ishirb  the  oxteruui.  iipiddlc,  and  inlemal  c<«W 
oin  bv  <l<^titiitiptniu<il  liy  iiian^raliou  to  c-xi^t;  nutl  in  tliuK  anvurisan  whidi 
lire  rormetl  by  ilie  <iilii(»tii>ii  of  a  (?i>iii|)arHtivQly  lurge  portion  of  tli«  ■rlrrial 
wall,  it  not  unfrequ^utly  liu[ipc'iis  that  ibe  tumor  remaitu  uf  tbe  true  kiad 


Fig.  44Z.— £MmiUl*d  AneMriiiu  Af  Ai««nillii( 


Flf.   443,— l|<|>«r   ).iirl   vt    IV 
Aoila  Iki'l  0|i«n,  fbavlng  ikm 
of  ih*  (MC  of  lui  AniiKiUtn.    TlM 
eu«i  rimiiiJ  ihi  u|.«dIo(  I*  Imfiter 
frOBi  [valiiha*  ol  ■tbarana  khU 
«(  Ahtlu. 


for  BOtoe  time,  as  I  have  avcertaioed  by  careful  diMectioD.  But  afW  an 
Mieorisni  baB  attaioed  a  c^rtnin  size,  its  coats  beconie  »o  fu»cd  tofivtber,  and 
to  oIomIv  incorporated  with  the  ut-isbburiui;  tieeuea,  that  tbeir  picciec  struo- 
turo  cannut  be  made  out.  ludeed,  for  a  aaoculated  aueuriiin  tu  be  uf  the 
true  kind.  I  believe  that  two  couditiotu  ore  ueceesary;  1.  tbat  tiiv  tumor 
it«elt'  be  Biimll ;  and,  2,  that  the  nioulh  uf  the  £U0  be  uf  tuWablj  largo  diiueo- 
aiuufe.  Furter  aaya  that  he  hoM  ucvcr  iiivl  with  u  true  uneuri^ni  larger  than  a 
small  orange :  and.  eenarnly  nuue  uf  tluioe  that  I  Jmve  necn,  provided  ihey 
were  xf  the  eacculatcd  kind,  haw  exrecdod  this  itiui.  lu  tru«  uccubiteil 
oneumius,  also,  it  ia  oeccesarv  thai  the  luoiuh  of  th«  sack,  ur  tbut  piirLiua  uf 
it  whieh  coramuoicates  with  tne  interior  id*  the  artery,  should  be  uf  j^Nid  kisc, 
and  not  hear  um  great  a  dinpnipnrlioti  to  tltK  wall  of  the  tumor.  I  cannot 
conceive  a  l&r^  sac  with  u  ^mall  mdiilh  to  be  n  inic  luieiirism.  But  io  all 
casc«  of  true  nneuriBm,  howi^vrr  Bmall  they  mny  be,  the  »ik-  oI'  the  kul'  greatly 
cxive-lH  tbnt  of  its  mouth.  It  iii  thorefore  elenr  ibm  there  muBt  have  bt«a 
not  imly  L-xpanuon,  but  u  dc^riw  ot'hyjWTtruphy  mxl  «vorKr<'Wth  of  the  wall 
uf  the  vea94>l.  jufit  lu  in  the  lubitlnr  aneurism,  nlhi^rwi:ie  titc  mc  would  be 
ihiuDod  io  the  exact  pniporlion  nf  lUt  ex)kau»iun.  ThisoviTt;nmth  Lakes  place 
t?biefly  fp>m  the  outer  ciHit,  imd,  in  n  Icnit  decree  from  the  inner  and  uol  at 
all  from  the  middle.  When  the  sac  tit  very  small  tlio  expande«l  middle  Ciul 
can  Ik  traced  tbrouf(hout  it;  when  «oraewnal  lar^r,  |Mil<:hc«  of  the  txii<]dltt 
coal  can  be  recogutited  with  wi<l«  jjafis  between  them;  but  when  it  rcacUe* 
any  couaidonble  aitm  the  ({reiiter  |»iirt  ti  composed  of  dense  fibrmd  li8iu«  in 


UISSECTINO    ANEURISM.  127 

«Wb  none  of  the  proper  structure  of  the  middle  coat,  and  in  most  cases  of 
the  iDDer  also  can  be  demoDst rated. 

TbIm  SftMolated  AnetuiBm  is  that  variety  of  the  diBease  in  which  the 

'muraal.  ur  the  inteniai  and  middle,  coats  have  beeu  ruptured,  and  are  con- 

Mqai-ntlr  deBcient.     This  is  by  far  the  most  frequent  form  of  sacculated 

uturisDi,  and  is  that  which  is  met  with  of  so  great  a  size.     In  by  far  the 

mtjority  of  caaes,  the  internal  coat,  and  the  innermost  layers  of  the  middle 

w«,  hive  been  dealroyed  by  atheromatous  degeneration,  leaving  an  erosion 

«iieprea§ioo  in  the  interior  of  the  artery,  with  weakness  of  the  corresjiond- 

iDgpiiniiHi  of  its  wall,  which  becomes  expanded  by  the  outward  pressure  of 

ihv  blood.     In  these  cases  the  sac  is  formed  principally  by  the  outer  coat,  in 

vhich  «ome  remains  of  the  middle  may  still  be  recognized.     That  the  sac  is 

fiimied  by  inflammatory  new  growth  in  the  external  coat  and  not  merely  by 

HptuioD,  is  evident  by  its  being  tliicker  than  the  corresponding  coat  of  a 

bnlthy  artery.     The  thickness  of  the  sac  is  increased  when  it  reaches  any 

C'D^idtrable  site  also  by  adhesion  of  neighboring  parts  to  it,  which  become 

fuKil  into  its  structure  as  a  consequence  of  the  chronic  inflammatory  process 

KtupruuDd  the  aneurism  from  the  pressure  it  exerts  on  the  surrounding 

itnjdures.     The  formation  of  an  aneurism  by  the  hernial  protrueiun  of  the 

loterul  and  middle  coats  through  an  ulcerated  aperture  in  tlie  external  coat 

^  been  described  ;  but,  though  there  is  a  preparatiim  in  the  Museum  of  the 

i'ollegr  of  Surgeons,  that  is  supposed  to  illustrate  this  fact,  I  doubt  the  exist- 

toce  iif  such  a  ft)rn]  of  the  disease,  and  after  careful  examination  think  that 

ibF  preparation  in  4]ue8tion  represents  rather  an  artificial  dissection  than  a 

Inie  rupture  of  this  dense  and  resisting  structure. 

A  &lse  aneurism  may  always  be  readily  distinguished  from  a  true  one,  by 

tlie  greater  magnitude  that  it  attains,  by  the  size  of  the  sac  being  out  of  all 

})n)f»ntoD  to  that  of  its  mouth,  and,  ou  a  section  of  this  being  made,  by  the 

niddle  coat  being  seen  to  terminate  abruptly  in  a  thick  and  dense  ring,  imme- 

diaietr  around  the  mouth  and  neck  of  the  sac.    A  false  aneurism  may  either 

fce  *>  from  the  very  first,  the  internal  and  middle  coats  having  been  destroyed 

braofteniDg  and  erosion,  and  the  external  expanded  and  hypertrophied  iuto 

•  sac;  or  it  may  originally  have  been  a  true  aneurism, and  have  been  converted 

into  the  false  variety  of  the  disease  by  the  giving  way  or  atrophy  of  some  of 

its  OtAtS. 

Surg»>n3  generally  recognize  two  varieties  of  false  aneurism — the  dreum- 
tcribfd  and  the  diffiued.  By  the  Circum'^cribed  False  Aneuriem  is  meant 
tliAL  form  of  the  disease  in  which  the  blood  is  still  contained  within  a  sac, 
formed  by  at  least  one  of  the  arterial  coals,  however  expanded  and  altered 
in  its  structure  this  may  be.  The  term  Diffused  Fake  Aneuriem  includes 
two  distinct  varieties  of  the  disease.  In  one  case  there  is  rupture  of  the  sac, 
with  general  and  widely  spread  extravasation  of  blood  into  the  areolar  tissue 
of  ibe  limb  or  part.  In  the  other  case  it  happens  that  the  sac  formed  by 
tbe  dilatation  and  hypertrophy  of  the  outer  coat  of  the  artery  is  ruptured, 
and  tbe  blood,  although  effused  beyond  this,  is  still  cimfined  in  a  sac  of 
oiodeneed  hreolar  tissue,  formed  by  that  of  the  iitructuri'8  into  which  the 
bhMid  has  been  efi'used,  matted  together  with  coagnlum  and  iuflummatory 
exudation. 

3.  BisMCtiii^  Anenrllin  is  a  remarkable  form  of  the  disease,  originally 
dcfcribed  by  Shekelton,  in  which  the  sue  is  situated  in  the  wall  of  the  artery 
betwe«a  its  coats.  It  originates  in  consequence  of  tlie  internal  coat  of  the 
T«Mel  l>ect>ming  enHJed,  and  givii'g  way  heturc  any  of  tliat  adhesion  and 
nulling  together  of  the  tissues  around  tlie  patch  ha^  taken  place,  which  pre- 
xtnVk  the  blood  from  Iteing  forced  between  the  diH'crent  tunics  of  the  artery. 
Tbe  ruptur«,  although  originating  in    the    internal  coat,  always  extends 


128 


AMKURISU. 


between  the  layore  nf  tlie  mttldlo  ane,  splitting  this  up  into  two  laminte,  and 
in  Bome  CHses  it  ■eparotea  alao  the  middle  fi-uin  the  external  luiiic  of  the 
vPAtel.  On  examining  the  arter)'  in  a  caee  of  di3i<ectiug  aneurigni.  its  coata 
will  nUvays  be  found  to  be  etieiiy  EvpHnihls  from  one  aDuthcr,  and  to  be  verjr 
taccrable,  often  appearing  sofl  and  ttoddeu  aa  if  macerated.  For  ibc  pro- 
duelion  of  tbis  diseaae,  indeed,  two  conditions  art  nco«*8iiry :  1.  That  tbere 
be  atheromatous  dlaeaae  of  the  artery,  deatroj-ing  n  portion  of  the  inU^nial 
and  uf  the  iDiierraost  Itiyere  of  the  middle  coal;  and,  2.  That  there  be  alM 
a  general  softening  of  the  tissue  of  the  middle  coat,  with  waut  of  c<ihe»ioa 
between  the  different  tunics  of  ihe  artcrv  ;  this,  indcwl,  may  be  considered 
as  the  essential  condition  disposing  to  tlic  farniati^ju  of  n  dtooeling  aueu- 
rum,  and  causing  the  di«enee  to  assume  this  rHlher  than  ihcBai^uliileil  form. 
The  rupture  constituting  di^dt-etingaDCurltm  nlwaja  takm  placf  longitudi- 
nally along  the  middle  coat,  and  may  olli^n  ext^'iid  tn  a  very  <^>nHiderabIe 
distance.  Thus  It  may  reach  from  the-  arch  nt  the  aorta  to  the  iliacc,  or 
from  the  ^aniu  part  to  the  bifurcation  of  the  carolidn.  The  disease  occun, 
however,  only  in  the  aorta  and  its  principal  branches — in  thoiw  arterie*, 
indeed,  in  which  yellow  elaaltc  tissue  is  abtindanl  in  the  middle  ooaL 

Cluies. — Dimectiug  aneurisms  arrange  ibeiuselves  into  three  distinct 
elasHis:  1.  In  one  class,  the  blmtd,  aflcr  having  passed  for  a  distauce  of 
uvcral  inches,  ur  even  more,  through  the  subeiauee  of  the  middle  coat, 
buKts  through  the  external  coat,  and  becomes  eifused  intti  the  areolar  tissue 

ouLsidf  the  vee«cl  tmd  amuud  the  seat 
of  rupture,  or  into  the  neigbboriag 
cavities  (Fig.  444).  lu  these  case*, 
which  couHiitutc  the  moet  comtuoa 
variety  uf  the  disease,  detilh  usually 
uceurs  rapidly,  the  |)ulieut  fueling  in- 
teune  pain  along  the  line  of  rupture, 
and  falling  into  a  ttule  of  syncope 
2.  The  external  coat  may  resist  the  im- 
pulse nf  the  blood,  which  consequently 
continued  to  pan  between  the  layers 
of  the  middle  coat  until  it  meets  a 
softened  and  atheromatous  patch,  and 
then  again  burats  into  the  canal  of  the 
artery.  In  this  form  of  the  disease. 
the  {Mitient  may  live  for  years  after  the 
occurreuee  of  the  rupture;  the  new 
channel  that  the  blood  hns  taken  be- 
coming lined  with  a  denae,  smooth 
nieinlirane,  and  reetfrnbling  closely  the 
interior  of  t he  artery ,  from  which, 
however,  it  is  Bepanitfl  by  a  kind  of 
septum.  The  apjfnriince  brre  pre- 
seuled  by  the  veeael  has  occnsioiially 
been  erroneously  described  as  coiitiLi* 
tuling  a  dnubti<  anrls.  H.  The  blood 
may  hod  its  way  between  the  Inminie 
of  the  middle  eont.  but  does  not  escape 
further  by  rupture  of  the  external,  or 
by  the  giving  WHV  of  the  lining  mom- 
brane  of  the  vc-wel.  A  eae  is  cuuse- 
quenlly  fVirmed  in  ihe  substance  of 
the  middle  coat,  which  may  become  oaronic,  but  which  will  at  last  rupture 
externiilly. 


.fcfM 


-t^ 


^.s 


Fif.  441. — RtitilarBof  l.lnlni(  M«Hilir>n«  of 
Aoru,  gliini:  (>*•  to*  UljiaDiIng  Antu- 
rinn  ohinh  bnul  iaio  PeiianrJinut.  AaitB 
m»eb  dilatad  aatl  cotersit  wltli  C«lc*r*<mi 
PUt«»,  e3c*|>l  mbtn  tlit  Anenrffpi  ca- 
euri«il ;  Itiere  It  >*<  atli«r«uialuii<. 


STBUCTURE.  129 

pRWEW  OF  Formation  of  an  Aneurism. — The  progression  of  the 
cfcangm  leadinc  to  the  formation  of  an  aneurism  is  brieny  as  follows.  The 
artery  having  been  aflected  with  chronic  endarteritis,  a  patch  of  athero- 
mat'Mu  sijflening  forms,  and  the  lining  membrane  covering  it,  perhaps  with 
a  portion  of  the  inner  layers  of  the  middle  coat,  becomes  eroded ;  or  the 
vmlU  of  the  vessel  may  be  weakened  at  this  point  without  any  destruction  of 
their  ooat«.  Cohesion,  however,  takes  place  between  the  tissues  of  the  vessel 
at  the  eroded  or  weakened  spot ;  and  the  outer  coat  becomes  strengthened 
MBtd  thickened  by  the  formation  of  dense  fibroid  tissue.  Dilatatiou  next 
takes  place  at  this  point ;  if  of  the  entire  coats,  a  true  aneurism  is  formed  ; 
if  of  the  eroded  tunics,  a  falne  aneurism  occurs ;  but  if  do  cohesion  have 
previously  taken  place  between  the  different  coats  of  the  vessel,  the  blood  be- 
eotoes  etfused  into  and  between  them,  thus  constituting  a.diasecting  aneurism. 

^"TKi'CTfRK  OF  AN  Anecbism. — An  aneuristoal  sac,  if  it  be  composed  of  a 
dilatation  of  all  (he  coats  of  an  artery,  may  be  recognized  on  dissection  by 
tbe  atheromatous  and  calcareous  patches  which  are  met  with  in  the  tissues  of 
which  it  is  composed.  If  it  be  a  false  aneurism,  it  will  be  found  that  there 
b  little,  if  any,  of  these  deposits  in  the  walls  of  the  sac  ;  that  the  middle  coat 
QMjally  terminates  abruptly  at  its  mouth,  and  that  the  external  coat  is  greatly 
tbickened  and  strengthened  by  newly  formed  fibroid  tissue.  An  aneurism^ 
MC  may  vary  in  size  from  a  tumor  not  larger  than  a  cherry  to  a  growth  of 
the  ma^itude  of  a  cocoanut  or  large  melon.  The  mouth,  which  is  oval  or 
roaod  in  shape,  varies  greatly  in  size,  being  always  very  small  in  proportion 
to  tbe  sac  Usually  the  interior  of  an  aueurismal  sac  contains  a  quantity  of 
cnlorless  fibrin,  arranged  in  concentric  laminie  of  but  moderate  thickness; 
tbcMf  lamtn»  of  fibrin  are  of  a  pale-buff*  color,  dry,  and  somewhat  brittle 
wherp  they  are  most  closely  applied  to  the  wall  of  the  sac ;  the  more  external 
were  fir»t  deposited,  and  occasionally  are  found  to  have  undergone  a  kind  of 
fcttr  degeneration  ;  as  we  approach  the  interior  of  the  vessel,  they  become 
softer  and  more  colored,  and  at  last,  in  the  central  portions,  dark  masses  of 
coa^lum  are  often  met  with. 

This  colorless  laminated  fibrin  was  termed  by  Broca  the  aetive  clot,  as  it  is 
deptvited  only  when  the  blood  is  in  motion  in  the  sac  of  the  aneurism.  It  is 
f<>rme<l  in  the  same  way  as  a  colorless  thrombus  iu  a  diseased  vein  (see  p.  80), 
thv  limit  i^tep  in  the  pnicess  being  the  adhesion  of  a  layer  of  white  corpuscles 
to  the  diseased  surface  of  the  aneurisnml  sac.  The.-'e  disintegrate,  and  thus 
del^rmiiie  the  formation  of  a  layer  of  fibrin.  The  mioniscopic  examination  of 
r*c*Dl  laminated  clot  shows  the  presence  of  numerous  white  corpuscles  which 
bavf-  <-»cape<i  disintegration  l)etween  the  layers  of  fibrin.  It  is  thought  by 
*'me  phy?i<>lii);idts  that  possibly  these  are  of  a  different  nature  to  those  which 
lake  part  in  the  proeem  of  coagulation.  In  the  older  layers  of  clot  no  cor- 
puM-U«  are  recognizable,  but  much  fatty  and  granular  matter  is  always  found, 
■  hich  may  have  rwiulietl  from  their  disinte^'ration.  The  part  played  by  the 
aiihi-^ion  of  the  cor[)ucles  in  tlie  I'urmntiou  of  lamiuiite<i  fibrin  explain.-*  the 
ioduence  of  retardation  of  t!ie  blood-streuin  ou  its  fnriiiati<m.  In  fusiform 
aofuri^ms  in  which  the  flow  of  bloixl  is  rapid  ihrougliout  the  dilated  vf)>(>el, 
atihM'-n  takes  place  with  difficulty,  and  no  clot  isi  usuitlly  found,  while  in 
eacvulateil  aneurii'ms  in  which  the  movement  of  the  blood  is  nceessarily 
mu<'h  !il>iwer.  laminated  fibrin  it>  always  abun<lantly  ilepo^'itcd.  It  will  be 
aturaanl-  ?wn  that  th<we  mmlts  of  treatiiu'nt  by  wliiih  the  flow  of  blood 
ihr-.ugh  the  sac  i.-»  retarded,  exert  the  nio.it  powerful  influence  in  determining 
ih*  dri*«"it  of  lavers  <if  clot.  The  color  of  the  tlot  viirios  in  ditfereut  ciu-ies  ; 
the  nior*  rapid  llie  flow  of  blood,  the  fewer  re<l  (.■orpiisclcs  will  be  entangled 
ID  th»f  ci»;tguluni,  the  shtwer  it  is  the  darker  the  clot  will  be.  Compk'te  arrest 
of  the  circulation  leads  to  the  formation  of  an  ordinary  dark  blood-clot, 
»yL.  11— 9 


130 


ANEURISM. 


Ftg.  m. — 1.*rgf>  Ativuritin  n/  Atocndlng 
Aorta,  ]>rnJ«o()a|t  B^ioat  {•ml  f-rnlrudlDK 
outnard*^  the  rib*.  laMjrEn  of  lid  mill  Bled 
Fibrio  %tr»mfti  in  (lio  JIiocIIdd  oI  ttas 
Cufr«Dt  uf  tbe  II1i>o<l. 


exactly  like  that  pn)duce<i  whcu  Llood.  wilhdrawa  Iron)  the  body,  is  nllowcd 
to  ooagulBte.     Clot  nf  tttis  kind  U  always  I'uuud  poec-mortem  in  (be  mid<ll« 

oi'tlic  eac«jrtheani-urtBiii,  and  is  lliea 
formed  probably  ini mediately  befura 
or  alter  <ieaih.  Those  modea  of  treat- 
tiieut  Mhich  completely  arrest  the  fltiw 
of  blmid  into  the  aae  cause  the  furoia- 
lion  cifa  similar  cougultim.  It  is  tin 
paesiii!  clot  of  Broca. 

The  Iuyer«  of  librin  id  the  laminated 
riot  arn  more  or  Itt^  conrenlricnllj 
arranffi'd,  hut  un  t^inylc-  lauiina  reacbe* 
over  the  whuU*  itac.  The  older  layert 
bfar  bvideniK;  ol'  liuviiig  betn  formed 
whrn  the  isar  was  eiualU-r  and  aulH 
ee4]iipntly  tlatieiiK]  otitagainKt  the  eo 
Iflr};f>d  walls  of  lliit  mc  'Vi^,  445). 
The  deptMit  of  kminaled  fibrin  exertK 
a  pnwerfiil  iiiiliir'tioe  in  preventing  tba 
too  mpid  increase  of  the  titmor.  Thft 
linini;  nf  llie  walln  of  the  sac  with 
eiK'h  a  toit^fh  and  eliistic  material  as 
the  (Stratified  fibrin,  most  jjreatly 
tend  lo  deaden  and  hroAk  the  force  of 
the  wave  of  blood  that  ia  projected  against  wlmt  would  otherwise  be  an  UD- 
pn>t4^eted  mettibraoe.  Another  ^reni  jHirpoite  it  serves  is  to  lessen  the  ca|mciC]r 
of  the  MC.  and  thus  to  diiiiinHh  Ihe  prciwuro  on  surroundinj;  pnrls,  the  dia* 
tending  force  of  the  anetirism  bciug  pruportiuual  lo  the  area  of  the  sac  tj 
well  H»  Ut  the  force  with  vtbieb  the  blond  is  driven  into  it.  lu  tboae  caaesin* 
whieh  tbe  lumiuuted  iihriu  u  griuH  in  c|imnLity  or  altogether  deficient,  the 
aneuristiotl  tumor  rajiidly  iucreaeeti  nith  u  forcible  pulfiatiou  that  it)  not  met 
with  io  wther  eircumatanees.  The  dark  eoaguluw  or  puaive  cint  of  Broca  is 
a  leas  eftlcieul  support  to  tbe  wall  of  an  aneurism  than  Ihecolorleas  or  active 
clnt.  It  is  much  eofler  in  coo&iHleiice,  and  at  lir»t  eoutniun  a  comsidcrable 
ami>unt  of  serum  :  thij)  gmduallr  si^ueezes  out  a»  the  clot  contnict«  and  thus 
it  becomes  eoiiEiderably  diminished  in  bulk.  If  the  clot  completely  filla  tbe 
sac  this  contractiou  may  ])<it«ih]y  be  fidbmed  by  tbe  reestabliehnieot  of  a 
cavity,  but  the  experience  vf  some  of  the  miwlern  modes  of  treatment  ahowa 
that  it  is  not  very  likely  to  ocvtir,  the  eonlraetion  of  the  clot  being  accompanied' 
by  a  oirresponilin^  diminution  in  the  size  of  the  bhc,  chiefly  due  to  the  pres- 
sure of  the  snrrnnnilin^  slruclures.  The  clot  further  diminishes  fnmi  the 
disintegration  of  the  red  corpusclca  whieb  form  the  chief  part  of  its  bulk. 
Ah  this  lakes  place  il  becomes  decolorized,  and  thus,  if  the  sac  is  only  partlj^ 
filled  by  a  dark  clot,  this  b«oamcs  flutiencil  out  and  tinally  forms  a  layer  in- 
distin[;iiis<bi(b!<>  from  tho  laminic  of  colorless  fibrin. 

PniBure  effects. -~A«  ibo  sac  of  an  aneurism  enlarges,  it  eierta  iniurioua 
ood  often  fatal  cfl'ccla  by  ila  urcasuro  upon  ointiguous  parts.  These  preeaure- 
effi^ts  deserve  attentive  stuny,  as  they  constitute  an  impurtant  and.  in  some 
tustances,  the  sole  element  in  the  diagnosis  of  aneurism.  The  pressure  oa 
the  surroundinjr  parts  inereaaea  with  the  size  of  iho  aac.  Dr.  W.  H.  Stnoo 
thus  dc«crib(ii  the  inlluenee  of  incr<>aM  in  size  on  pressure.  "The  hydrnstatia 
force  rises  rapidly  as  I  he  .hac  ettlaree*;  in  fact  in  a  modified  (^metrical  ratio 
as  against  a  itimple  arilhmelical  ini-rea(>e  of  the  heart's  impulse.  We  ara 
thus  from  the  fir»t  I'^mlng  grouml,  nnd  the  iiinlailr  is  (fining  on  us  acc4>rdin) 
to  some  simple  fuoclionof  the  funditmenlal  law  of  e<|UHlity  of  pressure  In  al 
directions.     naught4^m  estimates  tbe  bKmostatic  pressure  of  tbe  blood  in  tbe 


PRE3SURE-KFFECTS. 


181 


huniBD  arteries  as  equal  to  a  column  of  9.923  feet  Takiog  the  aneurism  asof 
3  iocbes  in  diameter,  its  internal  surface  wil)  be  28.27  square  inches,  which 
^vca  a  tension  of  12.24  pounds.  If  the  sac  rises  to  4  inches  diameter,  this 
increasefl  to  50.26  inches  of  surface  and  to  a  tension  of  nearly  25  pounds." 

One  of  the  inoet  common  pressure^ffects  of  aneurism  is  the  occurrence  of 
oedema  of  the  Hmb  or  part,  owing  to  the  compression  exercised  by  the  tumor 
DpoD  the  large  and  deep  venoua  trunks  in  its  vicinity.  The  consequent  ob- 
structtuD  to  the  venous  circulation  in  the  interior  of  the  limb  may  give  rise 
also  to  a  distended  or  varicose  condition  of  the  subcutaneous  vessels,  and  id 
■oue  instances  it  may  even  go  on  to  the  production  of  gangrene.  The  pres- 
sure of  the  sac,  also,  on  neighboring  arteries,  or  even  on  the  upper  part  of 
the  very  vessel  from  which  it  springs,  and  its  interference  with  the  general 
capillary  circulation  of  a  part,  is  commonly  associated  with  compression  of 
the  veins,  and  may  considerably  increase  the  ill-consequences  resulting  from 
iL  The  pressure  upon  a  neighboring  artery  may  go  on  to  perforation  of  the 
Teasel  by  the  sac,  and  so  a  communication  between  the  two  may  be  set  up ; 
thus  aneurism  of  the  aorta  has  been  known  to  perforate  and  communicate 
with  the  pulmonary  artery.  By  its  pressure  upon  neighboring  nerve«,  an 
mneunsmal  sac  may  give  rise  either  to  great  pain  io  the  part  supplied  by 
them,  or  to  disturbance  of  their  function  ;  the  nerves  themselves  becoming 
in  some  cases,  expanded  or  flattened  out,  and  ribbon-like  (Fig.  446),  and 
in  other  iostaacee  tort;ious  and  wavy,  being  considerably  elongated.  The 
pain  in  the  nerves  is  often  one  of  the  earliest  signs  of  the  existence  of  an 
uieurism.  The  pain  is  usually  of  two  kinds :  it  is  either  lancinating  and 
radiating  along  the  course  of  the  nerve  that  is  compressed;  or,  when  the 
tnmur  presses  severely  upon  neighboring  parts  and  tissues,  more  especially 
if  it  give  rise  to  erosion  of  the  bouea  (as  in  Fig.  445),  an  aching,  burning, 
teariBg.  or  boring  seosatioD  is  often  experienced  in  the 
part  subjected  to  the  pressure.  la  other  cases,  again, 
important  modifications  in  the  function  of  parts  take 
place,  in  consequence  of  the  pressure  that  is  exercised 
apuD  their  nerves.  Thus,  for  instance,  the  compression 
of  the  recurrent  laryngeal  nerve  will  occasion  hoarse- 
•eoess  of  voice  and  difficulty  of  breathing,  dept^ndiiig 
on  >pasm  or  paralysis  of  the  abductors  of  tlie  vocal 
e«irri».  On  the  bonejs  an  aneurism  may  produce  very 
impi>rtaDt  eflecw  by  its  pressure,  often  eroding  deeply 
the  oeseus  tissue.  If  the  bone  be  a  flat  oue,  as  the 
surroum,  the  aneurism  moy  perforate  it  by  making  as 
eai->>th  and  round  a  hole  in  it  as  if  this  had  been 
worked  by  the  trephine.  Glandular  organs  nnd  their 
dttfU  in  the  neighborhood  of  aneurisms  sutfer  the  most 
injurious  effects  from  the  pressure  of  these  tumors, 
their  functions  being  arrested,  and  the  parage  of  their 
secretiitQS  interfere<l  with  ;  so,  also,  by  the  pressure 
exercised  on  the  trachea  and  cuophagus,  respiration  nnd 
dciflutitiim  may  be  seriously  impeded. 

Xl'MBLB. — Aneurism8,though  usually  single,  are  not 
Tf-rr  unfrequently  multiple.  There  may  be  more  than 
one  tumor  of  this  kind  in  the  same  limb;  thus  the 
iliac  and  femoral  arteries  on  the  same  side  may  both 
be  affected.  In  other  cases,  corresponding  arterit.>s  in 
(^prjsite  limbs  are  the  seat  of  aneurism  ;  thu:^  the  two 
popliteals  are  not  unfrequently  found  t*)  be  the  seat  of 
this  disease,  and  occasionally  an  aneurism  may  exist  in 


Fig.  4J(1.  —  Klutlening 
itnil  Mrctcbiaif  of  Poi' 
tehurTILilal  Nene  bj 
pre»aure  oT  ftn  Aneu- 
ritm  of  tb«  Cftif, 


132 


AtTKUKISH. 


<^  llic  limbd,  and  trthen  id  the  arterirc  uf  ilie  iaterior  of  tlnfaody* 
nnefouK  aaeoriuBal  tamnni  are  at  times  in«t  with  in  the  H«w  pMaoaj 
u,  P^lletan  MOnrda  a  case  in  which  do  fever  than  stztj-flv*  ««re  uh- 
ved. 

DcKATinK. — Tht--  dnration  of  an  anearism  x»ne»  rerjr  greatly.  In  fnaog 
^1bll-UoiMl«d  persoDt  it  often  osakes  prugras  with  threat  rapidity ;  whrr*«9  in 
elderly  people  of  leeble  oonstitatiooa,  in  whoni  it  io  acc<>ntpat)i<4]  witli  mnn 
or  \em  cffttilitv  of  Lbe  beart'ft  aotioD,  the  dtitf^w  may  amurk'  a  very  rlintTiic 
fcriu;  ibus.  llodgson  relat««  the  ra^c  of  ati  nn<*un«m  of  the  ffn)<>ml  dru<ry 
of  twenty  yvan  dumtioo.  Much  aIjH<  nill  de|M-iid  oo  the  siiimtinii  of  tho 
anruriam,  the  »ize  uf  the  iiiuuth  ot  thv  sac,  and  tli«  n-latiuii  of  the  rac  to  the 
impube  uf  [he  hluod  tutu  it;  the  laq^r  and  nmrv  iltn-ot  thi"  nmuth  of  th« 
tumur,  the  more  rvadily  will  the  blood  be  pnijcctcd  in  it  at  each  imjiulM  tif 
be»n,  add  the  mure  qnicklv  will  the  tumor  expand. 
Symi'I'OMk. — The  symptofna  uf  an  aoeoriem  are  uf  two  kinds:  I.  Those 
that  are  peculiar  to  this  disenae;  and  2.  Tbuee  that  are  eiraply  ilf|w^id«>nl 
on  the  presence  of  the  tumnr  oncasitinfd  by  the  pnlan*iuf[  hhc.  The  pe<ni- 
liar  *\r  pathognoraooio  signi  are  those  that  nre  dp|Kiidi-nt  no  thu  (■oiiiniuoi- 
nuiim  of  the  sac  with  the  artery;  they  nmsist  of  aigiK  nttunJed  by  the 
[maoual  and  aosoiltjitory  ezaminaii'm  of  the  tumor;  thtwe  that  are  de- 
leot  OD  the  mere  elte  of  the  growth  are  the  prewnre-etl(H:tR.  It  !•  of 
ine  only  in  ext^mnl  aneurisms  that  thoee  signs  which  are  ascenHioablc 
maoual  czaminatiun  of  the  tumor  can  usunlly  be  rpco^niiied.  In  iolemal 
^MwarutDs,  in  the  majority  of  cft««,  the  a^cultatory  signs  and  the  preasure- 
eflects  afford  the  best  iDdicatioDs  of  the  presence  and  nntiire  of  the  wmor: 
thoagb,  when  this  approaches  the  surfiwe.  mach  information  can  h«  gained 
by  fialpati'iD. 

'  Bymptams  of  External  Circumscribed  ABearitm. — ^The  tumor  is  osually 

round  or  oval,  didiinctiy  circumscribed,  and  situated  upon  and  in  riose  am- 

nectioo  with  some  large  artery.    It  is  at  fint  somewhat  roniprenibic,  hut 

afterwards  bec-^roc»  more  and  more  solid  as  flbrin  is  dcpo«iic«l  in  if.    The 

moot  marked  sign  la.  perhaps,  the  puliation  that  lb  felt  in  it  fmra  the  very 

[first.     This  is  of  a  dinleosile,  eccvntric,  and  exjiau<liug  character,  se|>arating 

the  hands  when   laid  u[m)u  ettch  side  of  the  tumor,  hy  a  divlinvl  Impu' 

from  within  outwards.     The  puWlion  is  most  foreiblv  in  an  uiieuriMn 

which  there  10  but  little  laiuinati-d  hbnn ;  and  a*  tht»  increaw-B  in  quantil', 

the  pulsation  ^ruduully  hiwn  its  len«f. expanding  chamcter.  bein^  cunverted 

Lintoadea«l   fAud,  and  in  some  cHsea  vetuing  entirely.     When   ptilsation  is 

jt^bscure,  tile  comprvs^ion  uf  the  arterv  below  the  («c  will  cause  it  lo  iH-oume 

^urv  distinct,  ur  it  may  he  Increa^eil  lu  dislinilnesa  by  i-levaiinir  the  limb  or 

tirt  utTeirled.  When  the  artery  aNivc  the  «iL*  iit  eomprc»ie<l,  (hf  flow  of 
Iou4J  into  the  tumor  a  neceaRarily  arrested,  and  a  eonitiderable  <]unn(ity  of 
it«  more  Quid  ci)nteol»  may  be  ^pioczL'd  out  by  gentle  prewure.  If  the 
baDds  be  then  laid  upon  each  «ide  of  the-  tumor,  and  the  prpaenre  imddt-nly 
taken  off*  the  artery,  the  blood  wilt  be  found  in  rush  into  and  db'tcnd  Uue 
sac  by  a  Huddvn  »tnike,  separating  the  hands  from  one  another.  This  Bay 
be  l(M)l(e<l  u[>on  as  one  of  the  moat  rharnctcristic  ^gns  nf  aneurigm. 

The  bruil  or  tound  emiiuvl  by  the  blood  in  its  passage  thnmgh  an  aoea* 

lismal  sac  was  fint  notif-H  hy  Ambrose  Part.     It  varies  much  in  i-harucit-r. 

Ibeing  uaiiHlly  loud,  mitpiiig  or  sawing — loudntt  and  nmghcsL  in  loldur  anru. 

riims.     Occasionally  tlic  hniit  u  double,  and  if  so,  it  clearly  InrlimiiiA  the 

sacculated  naiunt  of  the  aneurism.     It  is  p>iMih]e.  Imwcver.  thai  whm  ttrrul 

iiSnrlio  regurgitation  is  present,  the  biirkward  nirrent  of  hlood  in  the  large 

^Ycssels  might  give  rise  to  a  feeble  dimlolic  murmur  in  a  fuiiitorm  aui^uritm. 

lo  many  cutti-A  it  ts  altogether  absent ;  this  especially  happein  lo  saoenhlled 


SYMPTOMS    OF    DIFFUSED    ANEURISM.  183 

aDeurismfl  with  small  mouths,  or  id  those  that  are  much  distended  with  coagula 
and  bluvid.  The  absence  of  sound,  therefore,  iu  a  tumor  must  not  be  taken 
a«  a  proof  that  it  is  nut  an  aneurism.  The  sound  ia  usually  beat  beard  in 
aneurisms  that  are  not  too  fully  distended  with  blood ;  indeed,  it  is  usually 
mi»t  distinct  when  the  sac  is  partially  emptied.  Thus,  fur  instance,  it  not 
uofrequentlv  happens  that,  in  an  aneurism  of  the  ham  or  thigh  no  bruit,  or 
but  a  very  Jaint  one,  is  audible  so  lung  as  the  patient  is  standing ;  but  if  he 
lie  diiwo,  and  elevate  the  limb  eo  as  partly  to  empty  the  sac,  then  it  may  be 
distinctly  heard.  Another  sign  of  considerable  importance  consists  in  the 
dimmtUion  in  the  sue  of  the  tumor,  and  the  cemation  of  thepuUation  and  bruit 
ou  eompreMtnd  the  vetael  leading  to  the  eac,  and  the  immediate  and  sudden 
return  of  these  signs  on  removing  the  pressure  from  the  artery. 

Many  of  the  symptoms  that  have  just  been  described  are  peculiar  to  and 
their  combination  is  characteristic  of  aneurism,  being  dependent  on  the  com- 
munication that  exists  between  the  artery  and  the  sac.  Those  that  result 
frx>m  the  pressure  of  the  sac  upon  neighboring  parts  are  common  to  aneurism 
and  to  any  other  kind  of  tumor  ;  but,  thougn  not  of  so  special  a  character 
Mi  those  that  have  just  been  described,  they  are  of  considerable  importance 
in  determining  the  nature  of  the  disease  when  taken  in  conjunction  with  the 
other  symptoms. 

SymptOBU  of  Diffiued  Anettrism.  —  When  a  sacculated  circumscribed 
aneurism  becomes  diffused,  the  sac  having  given  way,  but  the  blood  being 
Hill  bounded  by  the  tissues  of  the  limb,  the  patient  experiences  a  sudden 
mod  acute  [Mtin  in  the  part,  and  usually  becomes  pale,  cold,  and  faint.  On 
examination,  it  will  be  found  that  the  tumor  has  suddenly  and  greatly 
iocreased  in  size,  at  the  same  time  that  it  has  lost  its  circumscribed  and  dis- 
tinct outline.  The  pulsation  and  bruit  become  materially  diminished  in 
force  and  in  distinctness,  having  receded  an  it  were  from  the  surface,  and 
may  disappear  altogether.  The  limb  may  also  become  (edematous,  or  may 
mifkr  in  oth«r  ways  from  the  diffused  effects  of  the  pressure  of  the  aneurismal 
vwelling  up<m  the  neighboring  veins  and  tissues.  At  the  same  time,  the 
circulation  in  it  being  greatly  obstructed,  the  limb  may  become  cold  and 
livid,  and  a  sensation  of  weight  and  general  inutility  will  be  ex{>erienced  in 
it.  In  these  circumstances  the  aneurismal  swelling  usually  becomes  harder, 
in  com^juence  of  the  coagulattuu  of  the  bluod  iu  the  areolar  tissue  around 
the  ^Ac ;  by  which,  indeed,  the  further  extension  of  the  discuse  is  arrested, 
and  a  I'resh  boundary  is  often  formed,  so  as  to  tiinit  the  cxtravasated  blood. 
If  it  hv  left  to  itself,  the  tumor  will  now  usually  increase  rapidly  in  size, 
••jmt-tinies  without,  sometimes  with  nmcli  pulsiUion,  so  that  at  Ijist  it  may  so 
■jwiruct  the  circulation  throutrh  the  limb  sis  to  occasion  gangrene.  The 
tension  cau^eil  by  the  rapid  iucrease  of  the  tumor  excites  more  or  less  acute 
inflammation  ii)  thesurrounding  structures.  As  it  advances  towards  the 
Furfa<.t:.  the  skin  covering  it  becomes  tliinncil  and  reddened,  the  tumor  be- 
•Muie^  9*>ft  and  eemi-fluctuatiug,  owing  to  the  ooagulum  breaking  down,  and 
evfDtually  external  rupture  will  ensue. 

In  ^-mi-  cas4>:i  it  happens  that,  when  rupture  of  the  sac  takes  [ilace,  the 
«ffud«d  hI'Hjd,  iusteud  of  being  limited  by  the  surrounding  areolar  tissue, 
V-ri-iirae!'  suddenly  and  widely  extravasated  into  the  substance  of  the  limb. 
Wht-n  this  untowartl  accident  l)ap]M>ns,  the  shock  and  local  disturbance  are 
r--ry  great,  and  the  patient  is  suddenly  seized  with  ii  very  severe  lancinating 
and  nunibin^r  |iaii]  in  the  part.  Tho  pain  is  must  severe  in  thof<e  ciuses  in 
whit-li  the  rupture  take^  place  under  the  deep  fasciie,  by  which  tlie  elfiised 
U.mifl  ii  tightly  biKind  down  ;  ami  it  may  be  so  severe  as  to  occasion  syncope. 
In  'ither  in-itances,  faintness  occurs  from  tlie  sudden  escape  of  blood  from 
the  current  of  the  circulation  into  the  substance  of  the  part,  being  moat 


184 


AKECTBISU. 


mHrkcd  in  thoM-  IntiLanoefl  in  nMcli  ihe  lilofxl  ts  aorldcniy  ami  Inr._   ' 
into  l)ie  areolar  |tf«tit?.     It'  th&  extrnvn^nlion  hnppf-n  in  h  limb,  r  •'^ 

OOnie  grvnily  swollen,  h:in),  hmwny,  hikI  iiilr).  TIk*  s'lpi-rlit-iiil  vi  tii>  an 
OOOgetted,  aud  tliu  circulaliun  in  th«>  li>w«fr  [uirle  nt*  ihti  mciiilM'r  '»  soon  r<>ni- 
pl«ieljr  Brr«stnl  by  tlie  pr«wtire  of  ihu  extrtivMBBleii  »tu\  KmiTfiagtilntrfl 
blood  upon  its  V4-*vpls,  more  purliviilarly  llie  large  vvnous  triinkv.  In 
ooostquenceof  tlit».gtio)£rvni!  ot  a  nn/ut  kind  uvualty  makes  ita  appcaraitnt 
Uld  speedily  dealrovB  the  patipnt'e  life. 

DiAtiMOHi!!. — Tbc  diagnosia  of  nnenriera  may  in  many  ca»M  be  eflecl<4 
vith  llie  greatest  pr^sible  cece  by  a  etudent  in  eurfrery  ;  in  other  inittaiieee  it 
requin'B  B  vnst  oniounl  of  care,  sod  llie  nioet  experieneed  JudtrmeDt.  to  warn 
lu  11  correet  conclusion  a»  to  tbc  nature  of  the  lumnr.  Thia  is  easily  doa* 
wbeo  the  SDeurif  m  is  guperficial,  recent,  and  circurn^ribed,  ihc  blood  in  it 
betni;  fluid,  und  nil  the  i^i^n^  of  the  diwii^e  well  mnrkei).  The  diagnoeia  i> 
uftt'ii  replete  M'itli  difiieiiliy  when  the  aneurism  Ib  deeply  Heated,  or,  if  us* 
terniil,  ulien  it  ie  ohl  and  filled  nilb  n^aguln  ;  alHi,  if  acute  inflamniaiiaa  nr 
Huppuration  have  Inkeii  place  about  it.  or  if  it  hiiTo  become  diffused. 

In  rflcciing  the  dia(;uofcis  ol'anfuri^m  we  have,  in  the  lirM  place,  to  ascer- 
tain ihp  exlilenre  or  Hb^-ncc  of  a  tumor:  nud.  after  this  has  been  done,  to 
fiiicerlnin  whether  it  he  nnciirinnial  or  of  *onie  other  cliaructer.  Bulh  poiuta, 
the  latter  esperially,  are  difficult  to  detfrmine  in  inliTnal  aneuri'-ni.*  ;  in  tbe 
exlernal,  the  douht  in  not  a»  to  the  prrwnrc  of  a  tumor,  but  as  to  it»  ualure. 
Th<^  tumor*  with  which  aneuri^rnit  may  bo  oonfoundetl  may  conveuirutly  ba 
divided  into  two  elnMca — thoise  that  do  and  tho^  that  do  not  pul.onte. 

£v«rf  pnliating  tttmor  it  not  an  anetiriim.  Thuh  thpre  may  Ite  pulsation 
in  vnrioori  kindx  of  ntri-jihuiniti  iunmr  or  '1'/^  mtrcomn,  or  in  (fnnrlfi*  rampNWtl 
of  mrvoul  timU:  In  «ieli  lase*  as  ihew^  iiinny  of  Ihe  s-ign*  of  niieori»ni  »r» 
prtpeul;  thus  the  size  of  the  hinior  iii«y  he  diminiiihed  by  conijirei-jiivn,  and 
the  distinct  inBux  of  bltHKl  into  it  may  he  felt  on  the  removal  of  the  pre^ 
Dure,  tbv  tumor  retuniinj;  to  ila  original  eiite  witli  a  »>>i\  twvW'n)^  piilMlinn; 
there  may  also  be  a  bruit,  often  of  a  loud  and  distinct  chiinieler,  Hat 
theae  tumors  may  generally  he  diatinuuisbed  from  ancurinrnp  in  not  Ireiug 

Suite  so  diHtinrtly  circume<Tit>eil — iu  being  soft, spongy,  and  elostte,  wilhoat 
leMnsBlion  of  lluiil  that  is  met  with  in  stHiio  forms  of  am-urism.  or  of  eailid 
ooaguin  that  occurs  in  others.  A)^in.  the  hruit  ie  either  Mift,  hloaing,  and 
more  pr«)lunged,  or  eW  oharp  and  suprrficial ;  Ihe  nulsalinn,  also,  is  Dot  ao 
iliatinct.  and  is  mure  of  ihe  nature  of  a  general  Bwellinf;  and  heaving  of  tba 
tumor  than  uf  a  distinct  thump.  Much  lieht  is  (H-caaionally  thronn  upoo 
lhe?4*  anVctiiiRS  by  iheir  beinif  met  with  in  oiiuaiions  where  iint-urism  cannot 
occur.  fr(»m  the  abcence  of  any  artrritH  of  sufficient  rite  to  (live  riw  to  it,  aa, 
for  iimtance.on  the  head  of  the  lihia  or  the  sidoof  the  pelv'w:  hut  if  a  tumor 
of  thiH  kind  he  siuiatcd  ufKin  or  under  n  larjfe  artery  in  the  usonl  sit*  <.f  an 
uoeurtsiii.  tlifii  the  dineuoiai.-^  h  cerlninly  rcplelf  wilh  tlifficully.  and  cannot 
indeed  in  nmoy  case's  Iw  made.  Several  instances  hnve  i>cetirr«I,  in  which 
SurfTfuiw  ftf  ihe  jrreiUe«t  -kill  and  ex[>erietice  (a^Guihrie  and  Siiuileyl  lisva 
ligntureil  arteries  on  the  sup|M<!iit>on  llmt  they  had  to  do  wiiK  am-iirism, 
when  ill  n-nlity  it  waj«  one  of  the  puUiiliiig  tnniors  just  luentionnl  that  rlnxvly 
simulntiHl  jt. 

PulMilion  may  be  communicat<>(i  to  a  tnmor  of  a  fluid  chttrofUr  wated 
upon  nn  artery;  here  the  diagnosis,  though  oHen  dtmcull.  is  more  rmdilj 
madr  than  in  the  la^t  raiw.  All«-ntinn  to  the  history  of  the  cnv*.  to  th« 
imfMwiibility  of  dimiiiixhiog  the  tumor  by  prvRiure,  cither  directly  up«ni  it 
or  oi)  the  artery  leading  to  it,  its  fliictunti'^n,  and  want  of  circumscnptinn, 
will  usually  miint  out  \u  nnture.  E»j>ccinl  attention  should  likewise  be  paid 
to  the  fa*.-!*  tnat  Ilia  pultaition  isadistinct  heaving  up  and  down  of  tbe tumor* 


pfjLOiroBia  frum  non-pulsatino  tithors. 


185 


'BOCiwr  fccrtilric  nor  ilistcnaik,  and  that  the  swelliDg  may  nOrn  be 
"f  or  partly  fojtBratcd,  by  niii?inp  it  up,  frinn  ihc  nrifry  lying  Ijcnealh 
H.  Br  mttrDtMB  lo  tbcw  puiiiU.  absc«f#e»  in  ilie  Axilla,  iinilrr  \\\c  jM>ctt>rH)D, 
■I  lliv  root  of  Uw  DOok,  BOii  ID  other  8iliiiit)'>i)A  whi^re  pulsulion  mny  n>n«lily 
b»  eawirnicftled  to  the  fluid  moss,  en n  tx'  di»liiii;iii!t|ii-d  frvini  anenrUm^; 
jnivmn  in  disgDoais  hare  bappfDcd,  aod  uill  continue  to  dnwi,  frum  the 
MtrinBic  difficulty  of  the^  caae»,  and  from  do  whdl  of  nltill  nr  rare  on  the 
part  ut  il»«  Sar)^iu ;  and  tbuae  will  be  tnoet  charilablr  in  iheir  criUcisms  of 
tk«  uiMftkcs  of  others,  who  hare  OMiat 
tife^iMBtJy  had  o«caaioQ  to  vxperieoee 
thfM  4iABalllea  in  their  nwu  firat'tit'c 
TsBon  tkat  4»  oot  pcUate,  either  by 

iWif  \mn  VfMfel*  or  by  tbuwo  tliat  Vw  be- 
■Mkk  thfOi,  an  ucit  •<«  ruailily  tMul'<iiiiiil(>d 
with  aartirixii  n*  lb«  t-Iuu  of  aKWirliimtt 
tkaf  bas  ju*t  t>eeu  desert Ix^it.  Yet  it  tuutt 
ba  boroe  in  mioil,  tJiut  in  eoiuc  in»taiR-v« 
Mwurifina  du  uut  puUal^*,  or  hut 
iodbtiovtly  M,  having  bi'oxiic  filled 
wilh  ■  iivn««t  and  tinri  cuaKulutn.  Tliu 
■aa  paliUng  tumors  that  rhietly  require 
9t3mv6tKamnyhmdmlarKtTthtjrou.igv!fliiHtf». 
wmtaA  tnrr  Ibv  camtid  artery  at  the  roiii 
rf  iba  Dwelt,  ur  in  the  |io]iliipal  n\iUM. 
If  iImw  be  iif  a  fluid  rhnraclrr.  thoir  Muo- 
liua,  uoraryinir  oiKr.  nnd  the  want  of 
>Uno  in  tb«m,  pnfticienLly  indicate 
tiKT  are  not  cuanecti^  with  the 
fpini  which  they  may  alai  frr:- 
natlv  h^  «r;>Bnilp.l.  nnd  ufKiii  which 
la*T  '  moved.     If  siilid, 

„  I  ur  and  uodiilnt^l 
nnil  vnii  freiiiienllT  Im  di^ 

iinj;irr<>  )ivin){  pasM><l  nnd?r- 

thrcn  and  rai^in^  thcni  fmtii  the 
mhj»'^"'  " — '■'.  TbMc  is  much  daufier 
«r   tr.  a   consiilidateil    anetirism 

wkieb   w  i]i)<ifT|i[i^ing  or  has  undergone 
«■  cun>,  ami  in  which  thvro  is 
itljr   no   pulmtion.  for   n   solid 
of  anowkind.     1  have  known  one  instance  In  whirh  the  thtj*h  was 
for  m  very  painful   solid   tumor  «f  ihv   ]vi>|i]itfal  npncp.  which 
m  dHMQlHa  to  be  n  consolidated  nniiiiri^m  jirpiwing  upon  the   im)^ 

tibklMnra(rig.  *^~  ■ 

II,  more  parlJL-ularly  those  thai  anMlifTuMNl,  have  not  iinfrpc|uentlf 
MbUkm  (iyr  abterua;  aud  it  ti>  no  very  unriimnKin  thin^  for  a  8ur- 
10  be  caiied  io  an  aneurism  which,  under  Lbis  >>upp>Miiiiiin,  him  hn-n 
lUr  poultieed,  or  paiaml  with  t-Mlinr.  I  have  twice  liptture<l  the  ex- 
iltae  ftir  Mwurnau  of  ihft  fnna  that  had  been  mi*tnken  f^>r  nbtwnMe*. 
OwgionsllT.  ibe  nvin  fatal  vrrnr  hmt  )>een  fyirumitted  nf  ptmcturii));  the 
r  -"■*  *V?  view  of  leltin(*  out  pu*,  when  n'»ne  appeared,  and,  either 
r  after  a  lapMc  of  n  fiw  h^iurs,  prufu^c  nrlerinl  henifirrhn^ 
'  -  aix*ii)t-ttl  Diny  artw  frcni  the  inlriiiAic  dttfteiiltien  nt'  (he 
Jl^fD  '-    rn>ni  the  t'»ii   thiit  il  hns  hMp|«.'ned  l>>  ^iicb  HurKr"!)*  us 

DklBttll,  i'ciU-Uu,  UufmytrvD,  l'iri>);iitr,  and  many  other*.     I  have  uncvH-ca 


Amy 
OO  th. 

ttcbr. 


V\g.  4IT. — S«Mt(iQ  af  .tneniUia  «(  Catf, 

latoa  tor  Tuwor.  I.tnili  ■■■|>ulal«al. 
(u)  ItUok  tVMiit  Caaniiluia  Ijinx  (n 
eeftlrv  of  Lantiniitcd  FibHo.  (A)  Pm- 
iMiOT  IMital  N«rt«  Vlratnhtnl, 


ISO 


ANEDRISU. 


thin  «cci«lenl  ocour  to  a  Surgeon  of  oonsiHcrabIc  cxiioricnco,  wlift.  mirtaVing 
a  ditluwl  pu|i|iii-al  aoeurisni  lor  an  aiHoeas,  Of>eiie«i  it  witli  a  bistmirv.  liin 

pfiadinj^  no  put,  applied  a  poultice;  »larniing  hemorrhage  eosued  in  about 

'forty  hours,  aod  1  auijuitated  the  tiiigh  on  the  itecoiid  day  nfler  lhi»  unto- 
ward occurrence. 

Tb«  difficuliv  in  dUgDoait  is  eapeciallv  apt  to  occur  id  thoae  aoearinn 
wbicti,  having  Vecoinc  (liS\]8ed,  havo  ceased  to  puliate,  have  do  bruit,  an 
elastic,  auneued,  aud  ditHueut  to  the  feel,  and  iu  which  the  ikin  ba«  bccinia 
rcddvncd  aud  iuflaiucd  by  prra^u  re  from  withio.  It  is  only  by  careful  attcv- 
lion  ui  Uiu  bi«tury  nf  the  cose,  and  by  ekilful  maDipiilatioQ.  that  the  traa 
nature  of  the  tiiinor  can  be  made  out.  But  an  oueurbm  may  actually  b»- 
onme  assoriatod  with  an  nUoe^  in  one  of  two  waya.  Thue  it  may  euppura 
tbe  in  flam  mat  inn  takinj;  pliu-o  in  the  areolar  tisuic  aniniid  it,  with  awelli 
redneas,  a>d«ma,  anil  h<;iil  of  thu  iiueguoi<!Qlal  Mructurea,  iocrrase  at  aiae 
tlw  tumor,  iind  pn>tuthly  Hiliilitimiion  of  it.     It'  tbie  abecMB  be  opeood  or 

rjallowed  to  hunt, 'lark  grnnniuA  hum  u til  ettoaiK-,  followed  by  coeguln  and 

^wnnnro  of  broken-down  decnlorir^il  tibrin,  and  ennierJmes  nocomponied,  but 
more  uftunlly  followed  atVer  n  lapso'  of  some  hours,  by  a  free  and  perbapa 
Ht%\  di*cbarue  nf  fl..rid  bUmd. 

Another  form  of  combination  tketwirti  ab9ic«s»pi>  and  aneurinm  ootuiata  ia 
the  opening  of  an  artery  by  nlwration  into  the  cavity  of  an  abscets,  no  that 
the  hlootl  is  pp>jecte<l  directly  into  thi»  from  the  opened  vetael.  In  catra  of 
ihi«  kiod — of  which  the  instance  that  occurred  to  Liston  is  a  ^ood  example 
— wi^  have  the  ordinary  ei^'us  of  abM««,  usually  of  a  cbntnic  cbnractfr,  to 
which  thoiH!  of  an  nn«uri8m  are  geu«ra)ly  superadded  suddenly,  with  tnvat 
iocreaee  in  the  hulk  of  tb«  tumor.  This  accident  hna  been  ohwerv«^l  chiHly 
in  absceBSw  <>f  (lie  neck,  opi^nios:  up  a  ci>miMUDioalion  with  tbe  cttn>ti<I  nrlory. 
With  rheonuitiim  and  neuralgia  it  «<jukl  at  liret  ap|MTir  to  be  diffiaOt  to 
confound  nn  aiieuriain,  but  in   practice  it  if  not  so.     1  have  kuuwn  seTerml 

!  cases  iu  which  lliv  laucinutiug  {mius  of  aneurism,  more  especially  wbca  1^ 
tnmur  woe  internal,  have  bvvu  niislakeu  and  treated  for  rheumatic  or  oea- 
ralgio  afiectiuns ;  and  I  hav<>  even  known  tbe  naio  oocssionctl  by  the  pr«»- 

jeaoe  of  a  large  aneurism  of  the  ihi^h  treati^  ftir  tteveral  weeka  as  rbcuma- 
tiam.  In  a  larpe  proportion  of  piiplttea]  aneurixmn  the  ftatient  tint  pKBento 
hiniM'lf  complaining  of  rheumatic  ]m\m  iu  the  kne« ;  in  fact  bo  frequeatly 
Is  tbie  tbe  case  that  it  is  a  good  rule  whenever  a  patient  cnmplatna  of  ob- 
icnre  pain  in  that  joint,  to  examine  the  ham  fur  an  aneurism  n»  li>e  first 
aiep  io  making  a  diitgnoeii<.  In  such  cnsea  an  ibcee,  it  is  of  (>>un»e  obvious 
that  a  litltc  care  and  proper  examination  will  nsually  serve  to  enable  tbe 
Surgeon  to  avoid  an  error.  The  anenrianial  may  be  distinguished  fmm  the 
rheumatic  pain  by  its  having  a  twofold  charaflcr— being  oolh  lancinating 
and  intermittent,  OS  well  ba  continuous,  aching,  and  burning.  When  thb 
kind  of  pain  i:i  pcrsintont,  etipecially  about  the  hack,  the  sine  of  the  head 
and  neck,  or  arm,  it  ought  always  to  muse  the  Surgmn '4  attention  to  be 
dir«cicd  to  tlte  condition  of  the  neighboring  large  vessels. 

TERMlXATlo^ift.— Spontaneons  Care  .>f  an  aneurism  is  of  very  rare  occur- 
reooe.  Tbe  ronon«r  in  which  it  hiippens  has  been  espccinlly  and  ably  studied 
by  HodgND,  and  more  recently  by  Ucllingham ;  and  the  pathology  of  thb 
prooen  is  ofcousiderablD  interest.  I'roui  its  bearing  npon  theourtof  loediaciM 

I  Dy  surgical  operation.  The  spontaoenus  euro  may  Bcoidentally.  though  very 
rarely.occur  by  inflammation  of  tbe  aneurism  and  consequent  oblitenuaoB  of 
tbe  art/;ry  iscc  Suppuration  of  Shc)j  but  nio^l  fre<)uenlly  it  is  by  thejtradiial 
deposition  of  Inmiuated  fibrin  in  the  interior  of  Uie  aac  that  it  is  filled  Dp 
completely.  Thia  pDccKt  usually  takes  place  io  nneurisuu  oifecting  arierim 
di  too  aeooDd  or  third  magnitude,  rarely  in  tbuae  of  the  aorta,  though  both 


DO- 


TERMINATIONS — SPONTAXKODS  CDBE — SUPPURATION.     187 

HimIesod  and  Bmca  have  met  with  instances;  and  it  can  happen  ooly  in 
ncrulated  aneuriams,  the  fusiform  not  admitting  of  it,  it  being  necessary  that 
the  blood  flowing  through  the  sac  be  somewhat  retarded  in  its  pasdage,  eo 
ta  to  favor  the  deposit  of  its  fibrin  upon  the  interior  of  the  tumor.     This 

Erncen,  wfaicb  is  a  very  different  one  from  the  sinipie  coagulation  of  the 
lotid,  is  the  increase  of  a  natural  condition  always  going  on  in  the  sac.     In 
all  cases  of  sacculated  aneurism,  there  is  a  tendency  to  the  production  of  a 

rDUneous  cure,  though  this  is  rarely  accomplished.  The  tendency  to  it  is 
WD  by  a  coDtractiou  and  partial  occlusion  of  the  artery  below  the  enc,  and 
the  ooDsequently  diminished  force  of  the  circulation  through  it,  by  which  the 
depocitioD  of  fibrin  is  greatly  increased,  at  the  same  time  that  the  collateral 
Tecsels  given  off  cibove  the  sac  often  enlarge  to  h  considerable  extent,  and 
thus  divert  from  it  blood  which  would  otherwise  have  passed  through  it. 
This  cunditioo  of  the  vessel  below  the  sac  may  be  looked  upon  as  the  first 
mod  rntwt  important  step  towards  the  consolidation  of  the  tumor.  The  process 
is  also  roatenally  assisted  by  the  mouth  of  the  sac  being  small,  and  so  situated 
that  the  blood  cannot  be  directly  driven  into  it. 

For  spontaneous  cure  to  take  place,  it  is  by  no  means  necessary  that  the 
whole  current  of  blood  should  be  suddenly  arrested.  If  such  an  accident 
occur,  the  aneurismal  sac  becomes  filled  with  a  large  dark  sofl  clot,  which 
may  yield,  if  from  any  cause  a  pulsating  stream  of  blood  be  again  admitted, 
but  which  under  favorable  circumstances  may  lead  to  a  complete  cure.  If 
bloud  continue  to  circulate  through  the  sac,  deposit  of  laminated  fibrin  will 
take  place  if  the  impetus  with  which  this  fiuid  is  sent  into  the  tumor  be  con- 
siderably diminished.  This  may  happen  from  the  occurrence,  in  the  distal 
portion  of  the  artery  or  the  mouth  of  the  sac,  of  some  one  or  other  of  those 
conditions  that  have  already  been  described.  So,  also,  it  has  been  found  that 
in  those  ca«e8  in  which  two  aneurisms  are  situated  upon  one  artery,  the  distal 
cne  is  very  apt  to  undergo  partial  or  even  complete  consolidation,  the  blood 
losing  its  impetus  in  its  passage  through  the  first  sac.  Any  constitutional 
cause  or  condition  also,  by  which  the  impulse  of  the  heart  is  lessened,  and 
the  force  of  the  flow  of  blood  through  the  sac  diminished  (as  the  occurrence 
of  phthisis),  will  greatly  favor  the  deposit  of  laminated  fibrin  and  the  con- 
sijlidatiiin  of  the  tumor. 

A?  the  aneurism  undergoes  spontaneous  cure,  the  pulsation  in  it  gradually 
becomes  more  and  more  feeble,  until  it  ceases  entirely;  the  bruit  pniportion- 
ately  lessens,  the  tumor  becomes  harder,  and  at  Uuit  completely  cousolidated  ; 
al  the  same  time,  the  anastomosing  circulation  is  somL'tinies  found  to  be 
established  in  some  of  the  collateral  vessels  of  the  limh.  Eventually,  the 
f'lidified  tumor  shrinks  in  size,  undergoing  gradual  absorption,  with  ultimate 
C"Uv*-r<i'iD  into  a  small  mass  of  fibroid  tissue. 

Suppnimtion  with  sloaghing  of  nn  aneurismal  sue  in  not  of  very  frequent 
occur ri-nce,  but  is  especially  flpt  to  hapi>€n  in  those  casv.s  in  wiiich  the  tumor 
h**  increased  rapidly,  or  has  suddenly  become  diffused,  and  thus  is  exerting 
great  pre:wure  and  causing  severe  tension  of  the  surrounding  parts.  The 
accid*-nt  is  not  uncommon,  also,  after  operations  undertaken  for  the  cure  of 
ant-urism  in  which  the  wound  coniei^  in  close  proximity  to  tlie  siic.  The 
inflammation  is  then  merely  an  extension  from  ihnt  in  the  wound,  nnd  is 
Usually  de)>endent  uprm  septic  contaniinution.  Thoufrh  the  process  is  usually 
■|ir>keo  of  as  suppuration  of  the  s:ic,  tht'  intiammHtioii  cornmenecs  in  the 
tia-ues  i<urri>iiniling  the  aneurism,  the  slou^liing  of  the  sao  itself  being  a 
•eoiodary  prowss  dejK'ndent  upon  its  nutrition  being  cut  off  by  the  pus  that 
fjrms  around  it.  Suppuration  is  peculiiirly  liable  t<>  happen  nrniiml  tumors 
of  a  large  size  that  have  become  partly  diffused,  that  are  tilled  with  masses 
of  decolurized  fibrin,  and  that  are  situated  in  plates  where  the  areolar  tissue 


ANEURISM. 


tbumlani  antl  lax,  as  in  the  axillai.  The  8Yu.[it[iii»  of  ihls  roQ(titii>D  Im- 
Bildiii>c  aru  ftw«lliu(;,  teiiaiun  Miih  licat,  llirubliini;,  nn-i  n-<lui7>n  ul'  lliv  imltu 

oiiiiil  tilt!  liiniur;  the  inu-Kumeuift  cuvi^rini;  il  pit  uti  preaMiM,  oud  Are  ef(- 
ly  (itt'iily  tiiflAmetl.  at  ttit.-  xatm!  liiuv  lliut  (hin.-  is  a  good  deal  of  f«ver 
auil  gcucnil  eotiHlituUuiiftt  ilinliirluiiK^e.  Aa  ibu  SU|ipurulum  uilvancrs,  ihit 
oriliiiiiry  tiitcjia  of  ucutu  ub«rcM  in-ciir;  the  nkiii  cruVL-ririj^  the  tumor  bcmmat 
n-«l  aud  livid  UL  oiic  pan,  where  |MiiiiliDj[  tjikc^  plut-c;  and  if  Lht>  Suf^ntn 
make  an  iDcinitm  into  it,  or  if  the  tumor  hunti  (as  aMuredly  it  will  if  lult  tu 
flself  \  B  t|i)aiitity  of  pun  mixofi  with  Inr^e  iim9se«  of  bnikcn-duwti  cuHKula 
will  Iw  let  iniU  The  diiH-harKe  "f  the  «'tinl**nl8  cif  the  aiifuriiiiiiU  mic,  nmy 
be  fullowt^l  hy  ftij  jirufufi:  n  gii<>h  ufartcrinl  hliuxl  thnt  ihtf  jmtieiit  i»  »udil<-iily 
«xhnii«led. 

Ocniiiiiiiiiilly.  however,  m*  a  coitoetjuence  of  the  iuflaniinntiMii  iff  thn  tar^ 
p>iMiiliut;  tisMii",  tlivnrtery  becunii-v  lirnily  plii^Kcd  liy  h  ihruitihinnUivaand 
beliiw  ihv  (.iiH-iitii^  iut<.>  the  aut-iiriBrti  Ixd'uru  the  enc  ^ivcD  uny,  and  Lbut 
itwniurrlm^^e  tuny  Ix-  prewult^l  iiud  u  »]»>iiIiiiivoiib  curu  rmult,  lIiv  cavity 
clii^iii)^  like  ati  nnliiiary  iiliFi:i%s  after  iht*  Hhiui^iia  and  tlie  bruketi-ditwn  cluU 
havi;  Jnfii  ilischarL'^^ii. 

Catues  of  Death  from  AoeiiriillL — An  aiteurtHm  may  pnve  fatal  in  varioui 
ways.     It  iUtea  aa  when  inti'rnni,  iiuml  fretjiieutly  by  prrMvre  on  |inrU9  uf  im- 

tnrlauceiu  ile  vicinity,  I  he  patient  heinj;  iletttroyeil  by  ihi:  exhaustion  induenl 
y  interference  with  iheir  lunclions;  this  is  tiMiully  the  wuy  in  wliicli  aupu- 
risniH  of  the  aorta  occnaion  death.  In  other  cawH  the  tiac  bumtji  into  tb« 
perioanliiim,  pleura,  or  peritoneum,  and  Binlden  death  may  occur  from  \nm 
of  hlood;  ortisphyxia  may  result  from  ita  giving;  way  into  the  lra«h<«  Tbett, 
B^in,  death  niiiy  rf^ult  by  the  occurrenc-e  of  ayncope,  iDore  ecperiallv  if  the 
aneurism  be  of  large  8ii«,  and  siluatAd  near  the  rwit  of  the  aortjk.  hitiboiUm 
of  the  oerobral  arteriea  may  occcur  in  couaequenee  of  the  detaohiuent  of  a 
clot.  Kxtcmnl  nneuriam  most  commonly  proves  fatal  by  mpture  of  tht  aoe; 
this  may  eiihtT  take  place  into  the  interior  of  u  limb,  giving  riac  lo  «»  cw 
Other  of"  the  diflused  (orms  of  aneuriam,  jiud  t#rmiuot<  fatally  by  th«  indue- 
tton  of  ayncopc  or  gangrene;  nr  an  aneuriom  may  kill  by  rupture  oocurriog 
externally,  on  one  of  the  surfaces  of  the  bodv. 

The  rupture  of  nn  aoeurtsm  is  not  always  iromediAlely  fatal,  the  apcrtare 
in  the  sac  being  plugged  up  by  a  maea  of  coagulum,  as  happened  in  the  can 
abown  in  Fig.  444 ;  ou  the  gradual  detactinient  of  the  deeper  purtiotu  of  which 
the  bleediug  may  recur  in  siuall  quantities  at  intervals,  and  more  or  lea 
speedily  carry  off  the  palieot.  On  the  mucous  surfacoa,  as  of  the  (Eeophsgvi 
or  traclica,  rupture  occurs  in  a  similar  manner  (Pig.  448).  On  the  mtam 
irliues,  as  into  the  pleura  or  pericardium,  the  aneurism  may  bunt  by  a 
iro  or  hy  a  titellale  opening  (Fig.  44Ul  funning  in  the  membraoe.  An 
ineuriam  has  beeu  known  to  give  way  nnd  <IWhurge  hlood  for  aome  ndn 
Jure  it  proved  fnlnl ;  and  it  may  even  han|M'n  thul,  nfUr  the  rupture  has 
irred,  uo  hemnrrlioge  may  talte  place,  nut  'leuili  may  raeulc  I'ruui  tba 
lure  of  the  Luinor.  Thut.  in  the  case  of  IjkIi'U,  the  aar  a{  the  uueurbm 
rbich  caused  \\w  denlli  of  that  great  Hurgeim,  hud  actually  given  wav,  a 
DHH  of  co4tgutuni  proicding  from  it  into  the  tnu'hea;  yet  lU-atb  reMllnd 
from  thct  irritation  imluoed  by  prvwiure  upon  th*  inferior  laryngeal  nenra, 
and  not  fmm  heinnrrhoge. 

TitE-vTMKXT. — Th«  tnratment  of  aneuriMn  is  of  two  kinds — cunsiitutionak 
and  to(«l.  In  many  ruK-ii.  ad  in  thu  various  fnrnis  of  inlcmnt  anruri«in,  far 
inmaunc,  the  constilntionid  tr>-ntment  can  alon<^'  lwrnipl>i}icd  ;  and  in  all  niM« 
of  rslernal  aneurinm  it  tiitonid  Iw  had  recuurwi  to  as  an  ioapoitaDt  wljunct 
tu  any  Iim'aI  im-ajiiireM  that  are  adii|it<xl. 
In  the  ConstitDtionai  or  Medical  Treatment  of  aDcuriam.the  §reat  object 


tJTDICATIOKS    OF    LIGATDHK. 


B.  Sitlml  Xifatnre. — Id  sume  ciwee  id  which  the  ti^ture  cAnnot,  for  nnit- 
iMBtrml  tTUuo*,  be  applied  ua  the  proxiniul  »uh  of  the-  ancumm,  at.  id  the 
mrtmn  ftlmat  the  rtMit  of  the  Deck,  il  wu  recommcDded  by  Brn»dur,  ft 
Fraacb  f^awjpoa.  nbnut  the  middle  of  the  Ia»t  centunr, 
t^Bl  tht  w^amr]  shiiuld  be  tied  on  iu  ditiat  tttde.  This 
■y»f»iJoB.  tiriptnnllr  propoM>d  hy  Brusdnr.  was  first  pcr- 
tmrnni   by  IW-hnmpe   in   ITKO  at  la  CharitC  in   PariA  to 

■  ama  »il  fimDral  ADfuri^ni.  Id  prinojplc,  it  re»pn)bli« 
tba  HitlitcriftB    opemtioa,  the  object  hein;;  to  nrre«t  »o 

ni  tW  flow  ipf  bItMMJ  thri>u(th  the  »nc  tlial  the  cnn- 
lioo  (if  thi«  nmy  take  place  io  the  ukuhI  whv.  by  the 
tt(  laminatM  librin.  In  thf  Ilunterian  opera- 
liitt,  tilt*  i»  rtK-clt^rl  by  ilefKwtt  from  the  lt>«f^riied  qunnlity 
af  bitud  thai  ttnwA  thri'iiKb  tht^  Mtr:  in  the  distal  n)iera- 
tiMk,  it  pi  KNight  v>  be  acx-<>nipli^he«l  in  th«  twme  way,  and 
iW  ■UKI3—  tif  lb*  operation  niiiflt  DeoeeMrtly  de[>end,  in  a 
ifv.  upDD  Uw  extent  to  which  iho  tiow  oj'  blood 
tbtt  Hc  u  ioteriiand  with.  This  uperaiioa,  liow- 
r.  «  nudy  vuocobAiI;  for,  indcpendcully  of  ih«  ordi- 
wuy  daaacrt  rtsultioK  trurn  tli«  appliciitinn  of  the  li^'U- 
ai>«  bo  ■  «rp  tchbI,  the  eae  willcuntinuc  tolwdieieudtxl 
vith,  aad  lo  netiVB  the  dired  impulse  of,  llie  blond  that 

■  drivea  idIo  it.  Tho  oatural  reiitilt  nf  the  ligature 
wlii  be.  iliervibre,  to  increase  the  tenidnn  nf  the  tmc, 
bu,  ■•  Uoliniv  pointH  nul,  the  entar^menl  of  the  eoU 
iMArml  eirculatioo  opeui^,  ub  il  were,  ".><iili>'Hhiices"  to  re- 
Srtc  diii  pranture,  and  cnnHiHiueritly  aftt^r  a  few  honrs  or 
dm  ibm  «c  k  iMually  found  to  be  less  t^-n^e  thnn  before 
iba  npuatioa.  HeDce  the  progreae  of  the  aneuriFm  may 
bt  Twlwi  for  a  time,  but  it  will  often  speedily  inrreaae 
■fftiB,  and  may  perhaps  ereolunllr  destroy  the  patieotby 
4Dp(«irmttAb  and  nhxi^hinif.  Of  ^  CA«e«  io  which  this 
•prratiuD  KB*  pn*.-tL*r<l  on  llie  carotid  arlery.  in  US  io- 
^  :-  -.-•  a  iaial  rrsuU  tiior*  or  )ms  Bpe«dily  folloiwd    the 

•Mrti  :  in  the    tr-inaiuioj;   13  caaw  tb«    palienU  sur- 
mcil  the  ffffcU  of  Ibe  ligature  of  the  artery,  Ihoiigli  in 
(««  if  any  rmtm  were  they  cured  of  the  dtveaw  for 
ictised.     This  o|>erfttion  will 
H  in  speaking  of  the  parlicu- 
"lioi'ii  il  ha-  Uerii  i-nn'tis*.-*!  {ride  Chnp.  xliv. |. 
-Jits  aod  Contra-indicaUoiu  of  Ligattire. — Lie- 
<i  artery  lor  aneurifiui.  by  the  llunteriiin  method, 
•  ■eal  in  ihtiite  caM«  iu  which  tlie  tumor  ie  uirvuni- 
oi  Di  -  ,'e.  »low  in  iia  growth,  having  a 

try  to  0.1 — 4.,...ui'a,  and  nnaecompanied  by  much 
of  tba  Qmb.  When  the  antnriiim  is  undorgoing 
acvOi  mrt.  no  »argical  iDterfert.'uce  should  l>e  em- 
rrd.  b«t  tbe  cftM  lefl  to  nature.  In  this  way  it  ue<ra- 
li  happeni,  daring  thi-  prt-pamtory  treauuent  of  the 
that  tiit  atieuri^ni  bt-omitnt  conAolirlaled. 
Beiorv  tbe  Sar;g«uo  proceeds  lo  cut  down  upon  an  nr- 
ifry  with  tbe  Tlinr  of  tying  it,  be  shotild,  ns  tor  an  prac- 
tinblc.  Hcrrtatn  hy  n  cnrftiil  «-xnrninntiT<n  of  it,  ubether  il  Bppeare  to  he 
bft  bottilby  awl  wiuml  atnlc,  at  the  pi>int  at  which  he  is  about  lo  tie  it.  He 
AhwM  U*i  aJiiDg  its  coufM  to  a»c«ruia  if  it  be  tnuMiih,  eaaily  compresAihle. 
'ot.  II  —10 


Pig.  <ss.- 
Art«r/ 


llsal«r*d 


fw  I\>|iUt«*l  Aa«a- 
riam.  obltt*nt*4 
•1  «,  tba  lit*  »( 
lb*  Licftlvt*,  an  4 
■t     &.    what*     Uia 

TlUBI>T  llft<  kaCVBM 

euiKvliilulwl  «ud 
■tMorbail;  b«t«aaD 
ihcie  i)«lnU  Uia 
Artarjriiujiiii.aad 
MllaUralbfuidiM 
wn  talk  If  ail. 


140 


ANEURISM. 


B  gradual  and  careful  inimuer.sn  that  the  t^ntlency  to  tbo  d«poiitaf  laminattd 
fibrin  mif^hl  be-  iiicr<>afied.     ^'al5alvn  eotJiiivorefl  to  carfjr  out  the  first  of 

then«  iibjecu  by  suhjecting  the  patieut  u>  ainall  and  rapoAtM  bt»o'liDgs,  and 
by  gradufttly  reducing  the  qiiHtitity  of  food  that  wil»  daily  taltPD,  until  it  waa 
lowered  to  nulf  u  pound  of  puddiu^  in  ihe  iiioruiiig,  nod  a  quarter  of  s  poand 
in  theeTeniog.  lii  this  way  ihc  parK^ut'DStreDgLh  wa:i  reduced  antil  beoosld 
scarcely  be  raised  up  in  bed  wiihuuc  faintiug ;  the  quaotiir  c(  fuod  ma  then 

?raduallv  augmented,  so  that  the  pioatieiiy  of  the  bloud  luigbl  be  rcscund. 
t  is  Mlaom  that  SurgeoDft  carry  (»ut  Valsalva'^  plan  of  Lr«alin*?nt  in  the 
preciM  manner  indicated  by  him ;  it  is  generally  fuuud  ti>  be  more  cuvcuimiI 
to  modify  it  somewhat  according  to  the  circa ituOau cm  of  the  ca^>,  Ibutigh 
the  principles  on  which  it  in  conduclm)  are  eateotially  the  nanii!. 

In  aduptiii)^  aay  ciiii-ilitutiiiiiiil  irmttiieiit  in  caaea  of  nueurtmii.lhe  6rst  and 
moot  e>Kntinl  {loiiit  to  be  atlf;iidcd  to  U,  to  lc«ep  th«i  patiKnt  [H>rfiH'tly  <|uiet  in 
bed  and  free  from  all  mental,  emotioiiH).  or  convenMitionnl  excilritx-iit.  Tlw 
diet  should  at  the  ^aiiie  lime  be  very  carefully  re^ni latnl ,  Ininit  umdualty 
reduced  in  rjuaniity,  aud  being  made  to  consist  priucipnlly  uf  fnriiiai'euua 
food,  with  but  a  very  email  ([uuutity  of  nicul,  but  little  lii{uiil.  niid  a  total 
abeeuec  of  uU  stimulauta.  Perbu|M  tfaf  beat  regimen  is  tliac  ruconimsodsd 
by  Bvlliugham,  uon!>Lstjng  of  two  uuiiciw  uf  bread  nud  bull*tr  f<ir  broakfaal, 
two  ounces  uf  bread  and  the  same  ijunutily  of  meat  for  dinner,  and  two 
tiuuotie  of  bread  fur  supper,  with  alhmt  two  ounces  of  tntllc  or  water  with 
each  meat,  or  ocr-asioniilly  sippiKl  in  nmall  quNiititiea.  At  the  saicu  Ume 
purgtttivts  should  bo  admiiiiBtered,  eB|wciHtly  such  ii£  give  rise  t^i  wsl 
stoi)la,  and  remove  obMructtoiiif  of  the  p'lrUil  bysteni :  with  this  view  a  8nru| 
of  tbe  oorapound  jalap  powder  may  W  given  twice  a  we«k.  In  some  et 
if  the  heart's  action  be  narticularly  strong,  reoounie  may  adnkatagooiudy 
had  Ut  small  bleedings  irom  time  tu  time. 

Iodide  of  potassium,  in  doses  vnrying  fniiii  five  to  thirty  grains  three  t!l 
a  day,  has  been  tnrgoly  used  in  onaesof  ititrrithnmcicniidnlHlomioAl  aneat 
especially  by  Chuokerbntly,  G.  W.  Biilfoiir,  ami  W.  RolM-rts.  and  Its  ^ 
tmtcts  lend  sitme  vvei(;ht  to  ihe  8op|H)m^l  syphiltlic  nrijiin  of  many  Aneuriflf 
In  a  large  propiirtion  of  the  casts  tliue  treale<l,  tin-  i<uH^'riiigp  of  the  pativQta 
have  been  relieved  ;  there  has  been  diminotioa  of  the  size  of  the  ttw,  and  in 
several  instances  the  cure  has  been  apparently  perfect.  Tbe  enfori^^^ment  of 
the  recumbent  posture  is,  us  Balfour  rightly  iosints,  of  high  im[H>rtnnce  as  aa 
adjuvant  in  thii*  treatment.  There  oertainly  appears  tube  suffioirnt  «?Tid<njOB 
to  wammt  a  trial  of  the  i'jdide  in  the  cjustitutioiml  treatment  of  noeurtsm. 

By  judieiouitly  carrying  ou^  thiwc  plans  of  trcntmeot  aud  modifying  thvfB 
aeconling  to  the  eircunisUinoQa  of  the  case,  ooDsolidatkm  of  the  aoeurisi;'"'^ 
tumor  may  ocoa»ionally  be  produced  ;  or,  if  this  be  not  attained,  tbe  | 
of  the  di&eaM>  will  bv  very  materially  rclanled. 

When  aneurism  occurs  in  old./eMc  eadieetie,  or  antBmif  permms,  a  lower- 
ing; plan  of  treatment  is  ultirgetber  iiiaduiLBsible ;  here,  the  b1<.KHl  being 
dftieient  in  tibrin,  and  the  system  in  au  irriuible  slate  fruni  debility,  the  bast 
resului  follow  each  a  course  aa  will  iniumve  the  plasticity  of  the  blood,  and 
regulate  tbo  action  of  the  heart.  Witn  this  view,  cumplcte  reet,  tbe  admin- 
istration of  ihe  preparations  of  iron,  n  dry  but  nourishing  meat  diet,  aad 
the  ocrasitiuttl  employment  uf  upintm  to  relieve  paiu  and  to  quiet  the  syUeo^ 
will  be  atti?ndt-il  by  ihc  U-st  rcMulu.  In  aneurism  occurring  in  etderlv  people 
and  nniongM  the  [Mwrer  claiaea,  this  plan  is,  perhaps,  more  suecett^ul  ibao 
any  other. 

In  tilt*  LdosI  Treatment  of  auf^urism  but  little  ran  b«  done  with  the  view 
of  checking  itji  prog rr.-<)ii,  except  hy  lite  em|>loyni<-ut  uf  <limrt  Rilrgicnl  means. 
Tbe  application  of  ico  to  Ihe  surfbce  of  the  tumor  is  Mid  tu  have  avUal 


i 


ACCIDKXTS  JLFTKR    TitOATCKE. 


H7 


i-nds  that  llie  lignliin>  ehrmid  be  applied 


ob 


IT  Uk 


botirvrr,  mtitn 

K  I  cannnt  but  (l<iubl  the  pr«priely  01  mu  auvioe.      niiea  m- 
Iku  bren  aol  up  io  the  oae.  with  a  temlency  in  Huppuration  of  the 
;  it  ii  a  drbatshle  quMtii^n  whether  the  liigntiiro  should  be  applied  or 
Ib  ibne  outM  I  antte  with  H<(dK»<>n,  that  Iht-  artery  ah(>uld  be  tied : 
fcr  tvmn  Ulht  uc  eveaiually  »ippitnit^,  there  will  )h<  lew  risk  to  the  patieot 
if  tUt  vVBlit  f)r<.'ur  after  tlib  Ajiplieation  uf  ihe  lignture,  than  if  It  hap[>eQ 
r  leailinj;  iiilti  ihi-  Itimur  i*  pvr\-ioiiv.     IT  puppnmtiou  have 
;ilac«  aniuud  thv  sac,  the  upplieatioo  uf  the  lit^ture  ahovo  the 
-  nn  the  piiint  uf  bursting  wuuld   be  worse  than  useleaa.     Io 
_  ineiil'  pmvttce  must  be  deteriuined  by  the  seat  of  the  aneuriem. 

If  Ibtt  bv  m  the  axilla,  groiu,  or  oeck,  it  shuuhl  be  laid  freely  open,  the 
eoagula  MMopcil  out,  and  the  artery  tied  above  and  below  the  mouth  of  tJie 
a»e-— A  iBa»t  formiilnbte  and  doubtful  operatioa.  but  the  only  ooe  that  Imlds 
o«t  m  obmnce  n(  tucoeoB.  If  the  aneurism  be  iu  the  bam  or  calf.aiuputatioD 
«n«ld  pnthably  be  thv  beit  course  to  pursue. 

Io  aooie  ioaUDon,  there  w  do  resource  Icfl  to  the  Surgeon  but  to  amputate. 
1.  Ampatatioa  cnuet  be  performed  when  the  uDcuriBm  is  ai«»ciaiea  with 
^WMoa  bcuM  or  a  diseased  joiot,  as  wheo  a  popliteal  aucurism  haa  produced 
dUHractaon  of  the  knee.  2.  If  the  aneuriitiu  \iave  attained  ao  great  u  mugni- 
nim  Uiat  it  has  already  interfered  seriuusly  with  the  circulation  through  the 
Kaib,  mt  iudii^ted  by  eoandcrable  (Bdeiiia,  Hvidit)*,  and  cotdne&i  of  the  part, 
vitll  diatCDtiua  of  the  superficial  veioA,  it  is  a  question  whether  the  uppliea- 
lifla  of  ciw  linture  may  not  immediately  induce  ganffrene,  and  whether  the 
WDoM  not  have  the  bmt  cfaanee  of  recoverv  by  Kubtuiltiti;r  to  ampu* 
aioooe;  this  i«  more  particularly  the  ca«e  when  the  aix^urism,  whether 
preTiuosly  \if£i  or  «mall,  ha.s  become  difiuDe^I  with  impending  K^^'^IIi^^e, 
«Sea  Muuvaliiftlie  limb  nimil  nut  Im!  delayed.  U.  If  gangrene  haveactiinlly 
*  -i,  and  the  patient's  Btren^^h  be  sufficient  to  hear  the  ofieratiuu, 

»_.. ;.mu   »hi^uld    DC   done  without   delay.      4.  If  a  dilfuseil  aneurism, 

■bcthrr  suppurating  ur  Dot,  in  the  lower  extremity,  hare  been  opened  by 
■vtak-K  fur  an  al*HTm,  there  tit  no  rvsource  tcfl  hut  immediate  amputation. 

Tbv  niMrlalilv  aHer  ligniure«  of  the  largvr  arteries  fur  aueurism  is  very 
aoosidermlttv-  ^bu»,  in  I06  caam  of  ligature  of  the  larger  arteries  fur 
amamntia,  mWc'tni  nml  tabulated  by  Crifip,  it  would  apt>car  thai  the  mor- 
tKlity  -   '  ii  2'i  per  cent.     And  Porta  tiniU  thal.amoug  600 

asfs  I  >»  fiir  diseftsesanJ  injuring  of  all  kimU,  the  mortality 

•auu.  iviiL,     It  muAt  he  btirne  in  mind,  tluU  Lbfwe  are  ivdlec- 

boM  ,  >-<«.  and  that,  iftlie  unrecorded  cases  could  be  got  at,  Uie 

tait«<«fdaith  would,  io  all  prubabilityjH!  fituod  lo  be  much  higher  even  than 
that  alx^re  •uicd. 

^FTKB  Ln»ATt"iti:  poit  AsBlTKiflM. — The  aecideuts  tliHt  may 

:  iMi^n  (if  the  lt)falure  in  a  f-ascnf  aneurism. are:  I,  Secondary 

I  -rr'-  :.npi»*^iii  of  ligature;  2,  the  CuiitiuuHnoe  or  the  Reiiirauf 

-ill  .:i    .1.   ...T  .■>«o ;  3,  the  oecurrenee  of  Suppuraliou  and  Sloughing  of 

Ti:ii..ir,  with  or  without  Hemorrhage   from  it ;  and  4,  Gangrene  of  the 

1.  SMOoduT  RemarrlMS^  from  the  seat  of  ligature  presenU  ooihing 
[.  -     ind  has  already  Iwiii  i)!hi-ii»("I  111  vt    i.  p,  ■•04. 

CmtiMUtuu*  or  Return  of  Pahation  iu  nn  aneuriamal  sac  after 
lb*  li^s^J-in  of  the  iirti'ry  I>-iidiiii;  to  it,  is  nn  intorcMliig  phen»meni>n,  and 
€■•  thai  dtwrrvfw  murh  attfnM->n.  When  the  Iliiuterian  o|>vriiticm  is  Mic- 
OMfally  pfrfortDinl,  th<-itgh  the  puliation  in  the  sac  be  entirely  arretted,  a 
^Ptaia  quantity  of  hl'xid  contioues  to  be  conveyeil  into  and  through  it  b^ 
'  g  ebaMwla,uid  it  la  from  this  that  the  lamiuated  fibrin  is 


( 
H 

P. 

■h. 


142 


ANBURISH, 


betwceo  ibv  eac  aud  Ibu  livart,  the  lying  the  ynmel  vttm  nu  lunger  the  oalj 
how  uf  cure  iu  tliU  fomtiilahlt!  Hitfeat^e. 

But  tlie  ireatniunt  of  Kiieiirism  woe  dfslioed  bi  lie  sltll  further  ^hnplified, 
whua  VanzeUi  sliuwetl  ttiBt,  hy  dis'wnlinf;  ull  itulrunietib  u»l  br  the  Hiruple 
presiure  of  the  fin^r  on  the  feeding;  Krlery,  a  oon^lum  mi^hl  be  funned, 
on  the  priMlucLion  of  which  in  the  8ac  the  uurv  uf  the  Biipurixn  eeseatialljr 
(lej)eD(l8.  Aud  in  ndililion  to  thi^,  the  fnct  was  ettEnblii^eil,  that  in  aame 
caeea  adequnie  oiapre-'^ioQ  of  the  tcam;!  and  enc  might  be  efftK^t^Hl  br  aimple 
flexion  of  the  lifiib.  ThuK,  iheii,  we  have  h»d  n  continuous  and  pntgrvMiTe 
proooa  of  siniplilioalioa  in  thu  tr^atmeut  of  iiuc-urinru,  u  it  hiia  Im^^ti  proved 
thmt  itt»trum<-ntal  cuniprcMioo  raiiy  bi\  submit iiut^.'d  for  the  li?atur«,  tbu 
prtiMure  with  the  fitigor  or  Ilexi'in  of  tht-  limb  nufficw  for  the  (reposition  of 
thai  ooflgulum  on  whit->h  the  cuiv  of  the  diseuM!  Hcptynda;  nnd,  lilill  morti 
^•ct■ntly.  the  «[)ln'rt'  of  tht-  ap|ilirabilitr  of  ooraprtssion  hu  been  gn«tly 
extfodtNi  by  conducting  it  <luriug  prolong<7«i  anmlhcitia. 

Anotbcr  »ub)iirliary  m^^o*  of  treatnmnt  in  the  management  of  touM  of  th«' 
Di<>r«  iijtrnctable  tbrinsofaneurifin,  is  eleclro-puocture,  by  which,  m  CiniMlti 
and  others  have  sbowo,  partial  consolidation  of  the  content*  of  no  aneunwD 
may  be  effected  to  as  to  retard  the  progreea  of  tbe  dueaie.  if  not  to  oorv  U 
radicully. 

We  will  now  proceed  to  oonaider  in  detail  thne  various  method*  of  trat- 
mciil.  They  are  as  follows:  1.  Laying  open  tbe  hic;  '2.  Linrature  of  the 
artery  on  the  cardiac  nide;  !i.  Ligtilnre  of  liie  artery  on  the  diDlal  side:  4. 
CompreBftion  by  iu^trumenla;  6.  Di>;itAl  <'ipm|irceeiiin :  t!.  Compreaaina  by 
tbeelneiio  tourniquet;  7.  Flexion  of  the  liinh;  )*,  Acupressure;  *.K  Mitnipula- 
tinn;  lU.  Galvano-puuclure;  H.  lujeotioa  of  the  sac  with  coaguliuiii^'fluida. 
All  tbt!$e  varioua  methods  of  treatment,  howcvf^r  tticy  may  diOvr  ia  their 
deutils,  have,  with  tbe  exception  of  the  firsl.  the  »iriiiL-  great  priuciiik*  in  view, 
vii.,  tbe  coQH'iliiialiou  of  tno  aneurisinHl  tumor  by  tbe  depuuit  ot  L»agulum 
within  iu  When  the  prooem  adunttil  in  of  aurb  a  nature  a»  to  load  to  the 
sluw  depueit  of  enagtilum,  ihia  will  bp  found  to  br  pale,  firm,  and  laminated, 
the  oeLtM  clot  of  Hnicn.  Wbeu  the  deposit  in  rapid,  it  will  tie  dark,  soft,  and 
hotnngeneouti,  the  pftMive  cJoL 

LtOAniRF. — Til*?  application  of  the  Itfrature  to  tbe  feeding  nrU^ry  on  the 
canliac  Eiido  of  the  Hueuritim,  was  nhiuwt  tbe  only  rocthml  adopted  by  Sar> 

geoiiit  fur  the  cure  of  ttie  oiaeafla 
up  to  n  recent  dale.  The  maboaf 
in  \t-hirb  tbe  ligature  jihould  be 
upplietl,  uiid  tbe  vnrioui*  cautinu 
rc«|»ecliug  it«  U9e,  have  l)««u  ati^ 
ficieully  dJscuwed  (vol.  i.  p,  414 
ttffij.i.  The  (|UB!ti'»«  as  to  tbe 
part  of  tbe  v««vl  ^l  which  it 
should  be  apftUed  in  aneurum. 
remains  for  consideration:  and 
this  invoWw  some  important 
|x>int». 

Situation.— There  are  thn* 
Bituationa  in  which  the  Itgatun 
may  be  npplied:  1 .  above  9nd  b&- 
low  (he  Mr,  by  the  idd  ojieratioa; 
2,  on  tbe  wniiar  firie  of  the  iao, 
by  Aoi'lV  f  Kig.  -150  mr  tlanter'a 
(Pig.  451 )  operation ;  3.  on  the  dutat  tide  of"  the  sac,  by  Bnuiilur's  «)r  War- 
drop's  operation  ( Fig.  -152). 


i  h 


rif.  i».— Anel'*  Pif.  U1  —linn-   Pl|r.  l&S.— M>. 
Op«talli>U.  Ur'i  Opvfatinn.      lal  Opwratlon. 


SBCOKUAHY    ANEURISM.  149 

artkinlf  of  mora  oornnino  occurrence  alVr  tuieratioas  for  cnn^tM  aoourUm 
fcr  wBT  oth«r  form  of  the  dUeaw.     Tliiw,  of  ;il  caw*  in  which  tbe 


lerr  WM  lifil  for  aneurism,  I  floil  that  ptilMlioQ  in  iht*  tiim<>r  cou- 

!  1  returnt^I  ill  9  ioMancM ;  irhereaa  of  92  caaes  of  iii;{uitial  uueuriam, 

la  «UK-It  tlic>  rxu-rual  iliac  artery  was  ligatur^H.  the  puUation  recunvd  ia  6 

rAK*  oqIt  ;  am)  iu  Mveral  of  lbr««  it  is  int«re«tiii^  to  iiot«  tliut  there  were 

tvi>  ftOT^rL-raal  sacs  iu  the Mrite  limb — one  in  Hu- ^min,  llio  uther  ia  the  ham; 

xn  i  iliat  til*'  {>i]l«atiuD,  tliuiigh  jiennaiiently  Hmvl^*'!  iu  the  poplit^^iil,  recurred 

'-  in^tnal  aticurUm.     (n  ihc  ham  anil  axilla,  pulautina  occasionally 

--.  v-ry  rart^iy  mcure.    This  dilTcrviice  iu  tbe  frequency  of  the  recurrence 

.  u  in  ili0urvtit  aueuristus,  is  evideutly  uwiug  to  the  ditTcreut  degrees 

II)  of  [xtinmuDtcation  that  vxtst  between  the  sno  and  the  collateral 

la  rariiias  forms  uf  the  discaae;  thus  in  a  carotid  aneurism,  the  im- 

.'I  tbe  heart  may  at  once  Iw  brought  to  bear  upon  the  ooatents  of  the 

:  tinugli  the  medium  of  tbe  circle  of  Willis.    UuL,  in  the  cose  of  inguiuul, 

T  fopliicaJ  aneurism,  tlu'  luiustomosos,  consi&iiii;^    rather  of  tbe 

<  nfof  irrmiQal  branches  than  ofotieu  cummuuiaili>jiid  betwot^n  laree 

'  liable  to  irunsmit  tbe  blooiJ  in  a  pulsatory  stream.     Fur  the 

Ttic  Treat  fre«dom  of  the  communieitlioti  between  tbe  vcaecUof 

[lulMlion  hfu  more  frequently  been  found  to  continue 

u  ,        ..     ii-l  tllstinctly,  though  reduced  in  force,  after  the  ligature  of 

i^  artery  iu  carotid  ancurisma.  chan  in  thoM  In  any  other  utuation.    Tb« 

Mhieh  it  return*)  aft^r  the  oewation  of  a  few  hours  only  arc  perhaps 

-it  iu  the  groin  and  ham,  a*  in  the  neclt.     In  thuoe  inatanceo  in 

MP  puUalion  retumi  within  tbe  first  twenty-four  houre  after  the  li^a- 

',  it  UMially  i-raMM  a^in  in  a  few  day*,  though  it  sonielimeH  continue*  a 

or  two.     Whtui  it  recunt  at  a  later  |)«rio<l,  it  U  apt  Ut  la^t  soioewliat 

Compreiwtion  niitecetlent  to  the  li^ture  may  m  eniarj^^  the  collateral 

»"  ii  t-'inttouance  or  return  of  pulsiLtion.     I  have  once  known 

iW  palaa*  iiiir,  thuotfh  rery  nincb   tessvufd,  iu  a  pojvlitt^l  aueuriflm, 

■ftir  tiglUurti  vf  ibe  MJfierficial  fvmornl,  iu  a  ca«o  iu  which  treatiitvul  by 

biwl  unavoilingly  becu  triud  for  nearly  three  mouths.    In  another 


in  which  I  lied  iheexiprnal  iliac  artery  fur  popli(4>ul  Hu^urittn.  uwiug 
lo  iIm  fopcrfictal  femoral  beiu};  too  diseased  to  admit  of  u  lijiature,  the  pul- 
hUuo  ccMed  complftf  ly  for  a  time  as  I  nas  tij^bteuing  tlio  lifralure,  but  then 
nSawmed,  ajid  bocame  vtry  marked  iu  a  few  b<iurs.  Iu  this  caae  cumpiriBsiun 
hmi  bam  unavailiu^ly  eiupUiyeti  before  tliv  artery  was  tied. 

Tbe  jinyiWMtf  of  tbe»e  castM  is  on  tbe  whole  favorable,  but  few  of  ihem 
baring  evctttually  pmvnt  falal.  Of  26  patients  iu  whom  puliuilion  occurrtNl, 
I  tttd  tbai  thnw  die<]:  ttnd  in  all  of  thea*!  the  fatal  Ksult  was  uccosiuued  by 
taflsmatatiiin  and  •h'ii[:hing  of  the  sue  In  all  of  the  three  in»tuuces,  the 
pahMitMi  murn^l  Mithin  the  lir»t  twenty-four  honrs.  When  it  returns  at  a 
awM  ailrannnl  itcri'vl,  thfro  ii  litil«  risk  to  the  patient,  us  it  is  usually 
rtaililr  amMiablf  la  progwr  trcutment. 

A  .Vf^nrffiry  Aitrurlnt  i«  of  esirL-mely  rare  occurrence  ;  indeed  I  believe 
thcr>  twit  mirnuiv>><-al  in»tanrefl  of  lliis  nrtoction  upon  record,  both 

mt '*-  h'ncr  in  the  bam;  the  original  tunmr  having  ilisapprnred 

mMi  ition.  the  TCixiudary  diM«w  maile  ita  appeantuoe  after  a 

lifBL     .  ^   .  '—in  onu  unae,  and  iu  thr  other  aller  tour  years.     It  i«  of 

ta|MirtMic«  t"  i^b  bfliween  a  looondnry  aueuriam  and  aecondary  or 

noamait  pulfo..- ..  ..•  an  UMurLsmat  sac.  The  t«rni  " secondary  aMiirisin" 
i^ool  J  b«  rennirled  to  thow  cmh  only  iu  wbicb  an  aoeurismn)  tumor  ap- 
famn  In  xim  *Ua  of  n  former  one,  which  hai  uuderjronu  consolidation  and 
■bsnrpboo.  The  tjueatiou  ouy  be  raieetl,  whuiber  nncuriMms  of  thin  kind  are 
1b  realtty  leenadary  iir  wbethtu-  they  may  not  originate  in  the  dilatation  of 


lAO 


ANSDBISM, 


'  "  of  ihr  nrlery  coDligunus  tx*  tie  tent  of  a  fiirmtrr  AitemM:     It  (■ 
^  iKil  verr  vnny  to  uniJc»tKi]il  how  ao  HDCuntfiiiil  hic  (liat  liait  orm 
■v  toiuolidutiun  mid  nlieorpti'Jii  caii  bijoid  bccornv  tjilnlctl  inio  s 
J  iij  hiiiiur;  and  I  tliiuk  it  ainel  probable  Lfaot,  althouuli  the  c<'OHrcv* 

ltTi<  MtK'iirixRi  inny  hv  liiuiid  in  the  «anTu  iiur):icijl  regi<'u  ax  the  primarjr  um. 
it  ill  renlily  takt-s  tie  ■>ri^tu  fruiii  a  slightly  higher  part  of  thv  arierr.  wbtn 
the  ^iinie  Mnictunil  chntige  may  have  bvfn  in  protrrcM  that  dctcrmtDed  tfao 
diivaee  jii  the  limt  intlunt^'  at  a  tuwcr  piihiL  DiiuBle  aoeuriiDi  thuaariaiog 
is.  imiecd,  neciiniouBlly  mt-t  with  in  the  ham  uh  u  priiunry  djteafe.  1  ban 
•ceil  a  rnoe  in  which  mi  uubiirioiiml  tiinmr  wuh  eiiiiutfd  ia  the  ham,  mnd 
annlher  at  or  imtnr<lialely  iilmve  the  aperture  in  the  adductor  tniterle:  if  i1m 
artcnr  in  such  a  cnse  ns  thin  had  hecn  tied  hel'nre  iht*  Brntnd  tumor  had 
atlaiufd  any  mngnitudp,  we  can  easily  understand  hnw.  whpn  ihii;  beoima 
dilated,  it  might  have  been  etinsidered  to  Iw  a  new  rnlurjr»-mi'ni  of  tb« 
ori|tiual  site,  wnerena.  in  ffnltty,  it  vas  nothing  more  thiin  »  new  nneuritoi 
forming  in  the  chiao  vicinitv  of  the  old  one. 

Eniarfffwettt  ofun  nntunnrml  mc  uithmit  ptifMiti(m,»f\trlhp  Jipittirr  nfthe 
artery  Uadini;  t'>  it.  i»  hh  intere»ttny  phemmieuon,  and  ime  that  (i  -•• 

thtf  true  nnlurv  <if  the  tumor  t-i  he  fiiiBuniiorBi>>ix|,  as  it  ct'jwly  r>  -  m 

it»  &h>w  nod  gradual  increat**^  the  gruivlh  uf  »  malignanl  liiiiinr.  it  is  ocra- 
aittned  by  the  diMcution  nf  the  sac  hy  regurgitant  bhtiid  hniugbl  iotu  jl 
tbruugh  the  dii^tal  end  of  the  venel,  withuut  snffieient  l<jrc«  to  cau^e  duIh- 
tion,  thoujih  with  nuflicieol  (irCMure  to  occHMua  a  gnidual  increaw  in  Ui« 
Kiie  of  the  swelling. 

Treatmetit  of  Itecumnt  I'uUation.  —  In  by  far  (he  majority  of  csves  of 
ee<»ndary  pulimlion,  this  pheuouienoii  censes  of  itself  In  the  Lv^urse  of  a  few 
days  or  weeks  from  consolidation  of  the  hic,  in  the  same  way  ne  after  liga- 
ture of  the  artery,  by  the  deposition  of  laiQelliitrd  fibrin.  T}iii>  lendenrr  to 
ouQsolidntion  of  the  tumor  may  be  much  nisifiled  by  means  oiloulsled  to 
leSKn  the  fVjrec  of  the  tRipulM>  of  the  blood  into  the  hic,  such  as  eum|>re»tna 
of  the  artery  nbove  the  point  lignturetl,  rest,  the  elevated  piwilion,  and  the 
cautious  application  of  cold  to  the  part;  cold,  however,  must  be  carcfuIlT 
applied,  left,  the  vilfllity  of  ihc  limb  being  diminithed,  gangrene  be  inHuwd. 
At  the  snme  time,  direct  prefigure  may  be  exereiited  upon  the  nic,  so  ai  to 
modomtr  the  flow  of  hlond  into  It  j  ihifl  hnB  in  many  ctat*  tiuceeeded  in  pro- 
curing conaolidalion  of  the  tumor,  and  may  tnoat  conveniently  be  nppliea  by 
mean!)  of  a  comprera  and  nnrr^iw  roller.  This  plan  is  e«peeiAlly  adaptrd  to 
popliteal  and  inguinal  nneuni>mfl,  but  cannot  so  well  be  fxcrrii^ed  upon  ihoa* 
•itunted  in  the  neck.  Care  must  be  taken  that  the  preMure  be  not  at  fim 
too  powerful,  ie»t  gangrene  re«iilt ;  the  object  is  not  mi  much  to  force  out  the 
coQienii  of  the  tumor,  <ir  to  etliic«  tliiv.  »h  Minply  to  re«tmin  ami  modnntc 
•omewliat  the  flow  of  blood  into  it.  Should  the  niieurivm  \w  ii.o  (•itiiHti^l  that 
pnMuro  cnn  Ih*  exerci»e<l  upon  the  arlery  nhovc  [lie  point  ligntured,  Lhia 
•hould  he  had  recoiiree  li>  eitlicr  hy  the  finger  or  by  iiiHtruioenl,  and  will  be 
both  safer  and  more  likely  to  be  eflectual  than  direct  pressure.  1  succrrded 
[n  lhi«  way  in  coring  a  very  renmrknblr  cmm.'  of  recurrent  pulNition  in  a 
popliteal  nneuriKm.  The  patient,  a  mtm  alHiut  thirty-live  yenm  of  ngr,  was 
ailniittcil  into  I'nivenitty  College  Hot^pilal  for  an  anetiriem,  nlxiut  the  f\u>  of 
an  omnge.  in  the  right  ham.  Treatment  by  com|»re$«)on  wii.<)  employed, 
witlioiii  any  etfcrl  being  pn>duerd  in  the.  tumor,  fur  three  months.  During 
this  period  compn-wiim  wan  employed  in  all  formB — bv  Carte'i  inrtrurnvnt, 
ibc  weight,  the  finger,  and  llcxl»n.  I  then  ligiitured  tfie  superficial  femoral 
artery  in  Henrpa'is  triangle.  The  puUntinn  was  armied  in  the  tumor  when 
the  ligature  vap  lied,  hut  returned  in  n  slight  degree  In  about  an  honr.  and 
■lowly  inere&fted,  never  beroming  at  nil  forcible,  but  being  very  diatineL 


TBXATMENT  OF  RECURRENT  FULSATION.        151 

The  ligature  wparated  od  the  fourteenth  day.  The  limb  was  bandaged,  and 
s  pad  applied  over  the  aDeurisni  without  any  effect;  and  the  limb  was 
laised,  but  still  the  pulsation  continued.  Carte's  compressor  was  again  ap- 
plied to  the  commoD  femoral  artery,  and  used  fur  about  three  hours  in  an 
iDtenuiltent  manner,  when  the  pulsation  finally  ceased. 

In  the  event  of  the  pulsation  not  disappearing  under  the  influence  of  pres- 
•nre.  CDDJuined  with  rest,  dietetic  means,  and  the  local  application  of  cold, 
ibere  are  three  courses  open  to  the  Surgeon  :  1,  To  ligature  the  vessel  higher 
op;  2,  to  perform  the  old  operation  of  opening  the  sac  ;  and,  3,  to  amputate, 
if  the  aoeurism  be  situated  in  a  limb. 

With  r^^ard  to  ligaturing  the  artery  at  a  higher  point,  I  am  not  acquainted 
with  any  cases  that  throw  much  light  on  the  probable  success  of  such  an 
operatim.  We  know  that  the  ligature  of  an  artery  high  up  for  secondary 
betnorrhage,  after  previous  deligation  of  it,  is  a  most  disastrous  procedure. 
But  here  the  cooditions  are  by  no  means  identical  with,  or  even  similar  to, 
tbuae  that  accompany  recurrent  pulsation.  In  the  case  of  secondary  hemor- 
rhage, there  has  usually  not  been  time  for  the  full  development  of  the  coi- 
Ikleral  circulation ;  whereas,  in  the  case  of  recurrent  pulsation,  many  weeks 
woold  probably  have  elapsed  before  the  second  operation  would  become 
■eoessary,  so  that  ample  time  would  be  given  for  the  enlargement  of  the 
mnaatoiDaees ;  and,  besides  this,  the  very  occurrence  of  the  return  of  pulsation 
Bay  be  taken  as  evidence  of  an  unusually  free  anastomosing  circulation.  I 
think,  therefore,  that  if  such  a  case  were  by  any  possibility  to  occur,  in 
vhich  recurrent  pulsatioD  could  not  be  checked  by  the  application  of  pres- 
■nre,  digital  or  instrumental,  to  the  artery  above  the  point  originally  liga- 
tared.  aided  by  the  other  appropriate  local  and  constitutional  means  that 
have  been  mentioned  above,  the  Surgeon  would  adopt  the  proper  course  by 
luatDriDg  the  artery  higher  up — tx.  gr.,  the  common  femoral  or  external 
ihac,  if  the  superficial  femoral  had  been  the  one  previously  tied.  In  the 
errat  of  this  not  being  thought  advisable,  he  must  choose  between  one  or 
other  of  the  two  remaining  operations,  viz.,  amputation,  or  opening  the  sac. 
Of  these  measures,  I  shoula  certainly  prefer  amputation,  as  offering  the 
■est  &Torable  chance  to  the  patienL  The  operation  of  opening  the  sac, 
taming  out  its  contents,  and  ligaturing  the  vt-ssel  supplying  it,  is  in  any 
drcumstances  a  procedure  fraught  with  the  greatest  danger  to  the  patient, 
and  full  of  difficulty  to  the  Surgeon,  even  when  he  knows  in  what  situation 
to  8e«k  the  feeding  vessel.  How  much  greater  then  must  the  difficulty  be, 
•h«D  he  is  in  uncertainty  as  to  the  point  at  wh»ch  the  artery  enters  the  sac, 
and  cannot  know  whether  there  be  more  than  one  arterial  branch  leading 
iatu  it.  In  the  event,  therefore,  of  all  other  means  failing,  and  of  the  pulsa- 
tion in  the  tumor  continuing,  amputation  is  the  only  resource  left  to  the 
SorgeoD. 

In  those  situations  in  which  this  is  impossible,  the  Burgeon  may  occasion- 
ally attempt  the  old  operation.  Siiiythe,  of  New  Orleans,  as  a  last  resource, 
laid  open  a  subclavian  aneurism, for  which  he  had  successfully  lied  theinnomi- 
■ate  sume  years  before,  but  faile<l  to  secure  the  artery,  and  the  patient  died. 
Morrie.  however,  has  successfully  adopted  thia  proceeding  in  a  case  of  carotid 
aneurism  after  ligature  of  the  comnion  trunk  htui  failed  ;  and  Berkeley  Hill 
is  a  rase  of  axillary  aneurism  after  ligature  of  the  subclavian. 

^ncv  the  intn>durtion  of  absorbable  ligatures  into  surgical  practice,  a 
return  of  pulsation  has  in  a  few  cases  l>een  due  to  a  restoration  of  the  lumen  of 
the  artery  after  (he  disappearance  of  tlic  ligature.  This  is  reeopiiized  by  the 
pmeD4-e  of  pulsation  in  the  vessel  at  the  point  nt  which  it  whs  tied.  These 
belong  to  a  different  class  to  those  in  which  the  vessel  has  been  per- 
Jtly  occluded,  and  require  different  treatment.      The  artery  may  be 


144 


AKEUniBK. 


BTtery  boing  mora  rcmdily  secured  sl)i>ul(l  niiv  such  arcMrnt  happen.  The 
fi>rc«uf  the  circulHliuu  Iwii))^  llius  l»k<fii  I'll  Irniii  lliv  Htiviirivrnal  aac  tb* 
cauae  of  the  diM-ase  wouM.  in  Mr.  Huntvrs  uj>iutoii,  tw  rt-movtHl;  and  bt 
thought  it  hiKhly  |irobabl«  th»t,  it'  the  parlo  were  left  to  lh«niM<We0.  lh«  sac, 
with  the  Dosgulalwt  blood  cuulained  iu  it,  might  be  abutibed.  and  thv  uholv 
of  the  tuiDur  remov«il  by  the  actiun  uf  th«  auirual  ecuai^my,  wbicb  would 
coDve(]ueiilly  render  any  upeniog  iuto  the  mc  uuiiecfuwiry." 

IluDter's  linit  uperatiou  waa  iterfuriiKxl  in  Ducerabvr,  17fS5.  in  a  can  of 
popliteal  aneurism.  The  femtirnt  art«ry  waa  ligatured  rather  b«low  the  mid- 
ale  of  the  thigh,  uiidercieatli  the  Mirtunu.-*  iiiu8i*le;  an<l  from  thiil  time  bii 
method  was  almiift  cxclueivcty  eni|ii<iyed  bv  •Surgt>«)ns  in  the  treatxueot  of 
■Mturism,  tiiilil  iho  iiuriHlut^tion  of  votu|>r'es»i'<ri  in  1412. 

The  EffisctB  produced  upoa  an  aoeurLBmal  tamor  by  the  ligature  nf  the 
artery,  accunlilig  to  the  llunicrian  [netliod,  <l('M;rve  furvt'ul  atlvntion.  The 
iramudinto  ofTect,  on  <lriiwiug  the  lit^uiru  ligbi,  ronsii^u  in  a  oi'^aliou  uf  pul* 
«atii>n  and  bruit  in  tho  tumor,  n-hich  al  tlic  aami:  timu  gul)«tdc»,  beoi>tning 
partially  e mptic«l  of  iu  bl»od.  Tho  supply  of  blnofl  to  the  limb  being  in  a 
great  meiuun:;  cut  ott',  it  becomoo  numb  and  cold,  with  n  diminuihm  of  inaa~ 
cular  puwer.  Tho  more  remote  cSi^cu  cnuaist  in  an  increase  of  tho  Acliviir 
of  the  collateral  circulation,  by  which  the  vitality  of  the  timh  is  mainuinv<i. 
At  the  Mime  time,  and,  indeed,  in  eiinAe(|uence  of  this,  tho  temperature  of 
the  limh  often  riiios,  until  it  becomes  hi}(h<\r  (ban  that  of  its  fellow. 

Tb«  oonaolidation  of  the  aneiirumnl  tumor  beginu  M  toon  as  the  ligature 
is  applied,  and  i*  uanally  completed  in  a  few  daya.  by  chang«a  tAlcitig  place 
within  it  simitar  to  ib<)»e  thut  Mccur  iu  the  apontaououa  cure  of  lUc  ili>Mk». 
Thin  itii|iortanl  clmiige  \»  ed'tvted  by  the  gmdual  dvpoait  of  KlratiHed  librin 
iu  cuuL-eutric  layers  within  the  mlc,  anil  iH;c'H)<ii>nn)ly  by  the  auddea  coagula- 
tion gf  it*  c<int**ut«.  For  the  uure  to  Iw  aucoinpliitbe'l  by  the  deposit  of 
laiiiitiated  librin,  it  ia  oeoeBaary  that,  th'iugh  the  direct  flow  of  bliKxl  Ibroagb 
the  tumor  lie  arrt»ted  by  the  ligiiLuru  of  the  ninin  trunk,  »4jme  should  yH 
be  carried  into  it  by  collat«ral  vhnniicU.  This  is  a  condlli'in  very  favorable 
tu  the  Buccvaa  of  the  ligature ;  for,  if  it  happeus  that  all  the  flow  uf  blood 
through  the  tumor  ia  arretted,  coagulation  of  that  which  happens  to  be  (xui- 
lainea  i»  it  will  eiuue,  »ud  a  ixifl  yifihling  clot  Ix;  formed,  which  ia  mors 
likely  to  lead  to  uufuvomhle  reaulta  than  the  firm  productJ!  of  slow  coa^u- 
luti»n.  It  is  of  importaucu  to  tibaenri;,  thut  ihc  |ini))«r  conmdtdatioa  of  tba 
aneurinmni  tumor,  by  thu  df|Mwit  of  lamt»ut»l  fibrin,  will  occur  even  thuugb 
A  very  coiuideralik  i]unntity  of  btiHid  continue  to  tiuw  through  it.  la  thm 
Muaeuni  of  University  College  there  ia  an  excetxlingly  intrreming  prepanh- 
tiim  that  illuKtnites  ibin  point.  It  U  one  in  which  Srt'harles  RoU  ligatured 
the  femornl  nru-ry  for  popliteal  aneurism.  The  [Mitlcnt  di^d  a  wt^k  after 
the  operation,  from  erysipelas  ;  on  examination,  it  was  (oiind.  and  is  ehown 
by  the  prtjuralion,  that  the  femoral  artery  was  double,  and  that,  though 
only  one  pt>rti(>n  of  the  vessel  had  been  ligatured,  the  tumor,  wbirb  cod- 
tiaued  to  be  supplied  bv  the  other  branen,  was  completely  ciinsolidated. 
Ueooe  it  would  appear  tfmt,  if  one  half  imly  of  the  influx  of  bloml  be  ar- 
retted, obliteratiun  of  the  sac  by  depoeition  of  laminated  fibrin  may  be  ex- 
pected Vi  occur.  AAer  the  aueuriamal  mc  has  been  thus  occlude*!,  it  pro- 
fnssively  dinitnishce  in  siw,  and  is  at  last  converte<l  into  a  small  maa»  of 
brvid  tinue.  The  artery  that  has  bwn  ligaturvd  becomes  clmeil  si  two 
poinU — nl  the  part  deligati-d  i  Fit;.  453,  oi,  and  where  it  communionlM  with 
Uu>  aae  (Kig.  453.  b).  In  iMith  iIk^m;  siluaUons,  it  will  be  f  lund  tu  lie  n»n- 
vertefl  inti>  fibroid  tiuuv;  while  between  thiMU  (here  ta  an  open  space, 
tluvugh  thu  mediuju  of  whiuli  the  oullaivral  uirculatiuD  ia  freely  curried  oib 


i 

I 

I 


ACOIDXNTS   AFTKR   T.IOATDRE. 


147 


ialiMdi 


,  however,  reo'imniends  thnt  the  ligature  should  be  appliec)   in  Buch 

lh«.iigh  1  cADH'tt  but  doubt  the  propriety  of  tbU  adviiw.     When  in- 

fluDSHtioa  hat  be«D  Kt  up  Id  the  wc,  with  a  teodeoc)'  m  Hii|)|iunitioii  of  the 

iSHor.  U  Ua  debatable  question  whether  the  ligature  shouUl  hv:  applied  or 

mC    In  Ume  cases  I  *grm  with  Hiidg84jn,  thai  the  arlvry  eiuiuld  he  tied  ; 

erea  if  the  sac  eventualt;r  suppuraie,  there  will  he  Ivixt  rii^k  to  the  patient 

this  event  on-ur  at'icr  the  appticatioo  of  the  li)^turi>,  tliaii  If  it  hapjveo 

faitc  the  artery  Icadinf;  iuUi  the  tumor  is  perviuui^.     Il' Huppunilion  have 

It  lakeu  place  anmnd  th<-  mc,  the  applloation  of  tlit->  llguiure  ahovu  the 

bflinwd  lumiir  on  the  piiiiiL  of  bunititig  would   Ih<  wonut  than  useless.     In 

■ek  ca8eB,the  lineof  pruirtict-  muxt  Iw  df.-Lvriiiin(Nl  by  the  Heat  of  the  aneuristn. 

Iflbit  be  in  the  axilla,  gruiii,  or  nerk,  it  should  be  laid  freely  open,  the 

nagula  aoDU|>ed  out,  ami  the  artury  lied  abitve  and  below  th<>  mouth  of  the 

■r— •  moet  Ibrinithtble  and  doubtful  o[K-ration,  but  the.  uuly  one  ihuc  hulds 

aal  a  chanee  of  sacoess.     Jf  ihe  aneurism  be  in  the  ham  or  calf,anipuuitioQ 

vwuld  prvihably  be  the  l>eat  ciiurse  to  pursue. 

lu  »ome  inslauces,  there  u  no  resource  left  to  the  8urgefta  but  to  amputate. 
1.  Ainpulatton  must  be  performed  when  the  aneurism  is  a»fu>ciAte<l  with 
eariuu*  iKwie  or  a  dUeaded  joint,  m  when  a  {Kipliteal  aneurism  has  produceid 
({(4tni(-t)on  of  the  knee.  ^.  If  the  aaeurism  have  attained  so  great  a  niiij^ni- 
lodff  that  it  )tai  niready  interfered  fieriout>ly  with  the  cirrtilatirm  through  the 
limli,  a*  iu'tictitfd  br  considerable  iHtleuia,  lividity,  and  coldne^  of  the  part, 

Iviih  ilUb'ntion  of  the  superficial  veius,  it  tan  ({uetttiuu  whctlier  the  appiica* 
liint  •>}'  ciK^  ligature  may  uut  immediately  iuduLv  gaiigrt':ue,  and  whether  the 
paiifnt  Houid  nut  havt-  the  Ijeot  chance  uf  recovery  by  aubmitting  to  ampu- 
(itiuo  at  once ;  tbin  ia  more  jKirticularly  (he  case  wbeu  the  aneurism,  whether 
pTBriously  large  or  small,  bait  become  diSuaed  with  impending  gangrene, 
vh«a  removal  uf  the  tinibmui-L  not  be  delayed,  '■i.  If  gangrene  have  actually 
MfierveiKd,  and  the  patient's  strength  he  ^iBcient  to  benr  the  operation, 
•npatauoQ  should  oe  done  without  delay.  4,  If  n  diffuecd  aneurism, 
vbcihu*  euppurmtiog  or  not,  iu  the  lower  extremity,  have  been  opened  by 
oiiftake  fur  «u  absoeeti,  there  is  uo  resource  leJl  but  immiidiaLe  ampuiatioij. 

The  m»rlalitran«r  ligatures  of  the  larger  arteries  fur  aneuri^ni  i«  very 
eoDaiderable.  Thus,  lu  '1-^G  caan  of  ligature  of  the  larger  arteries  for 
•Muriain.  eollcctnl  and  tabuldti-d  by  CriKp,  it  would  appear  that  the  inor- 
taJrty  MnouDted  t<)  about  '22  per  cent.  And  Porta  fiuds  that,  nmoug  GOO 
<aca  of  ligature  of  arl<'rioe  for  diseases  ami  injuries-  of  all  kiiuU,  the  niortaUly 
wumoicd  u>  27  per  cent.  It  must  Iw  borne  in  mind,  that  ihcve  are  collec- 
riftM  of  reported  caftes,  and  that,  if  the  unrecorded  ca&rs  could  be  got  at,  the 
Mr  of  death  would,  in  all  probability,  be  found  to  be  much  higher  even  than 
dtal  »h<>vf  iitate«). 

ArctDEVTs  fcFTRR  Tjifj.vTt^BK  FOR  ANKfiii-HM. — The  accident"  that  may 
fdl'jw  tbe  application  of  the  ligature  in  a  Ciueiif'aneurifim,arc  :  I,  Secondary 
Bemi^rrliftge  from  the  eeal  of  ligature;  2,  the-  Continuance  or  the  Itcturti  of 
Pulaatina  in  tbe  Sac;  3,  the  t-KXsurreuoe  of  Suppuration  and  Sloughing  of 
the  Tumor,  with  ur  without  Hemorrhage  from  it :  and  4,  Gangrene  of  the 
Lhnb. 

1.  8e«ondar7  Heioorrhage  from  the  #eat  of  ligature  presenta  nothlug 
|«culiiir,  niid  lia§  iiln-ady  been  discui«e<1  in  vol.  i.  p.  40-1. 

2.  TSl  Continaance  or  Ketarn  of  Pulsation  in  an  aneuHnmal  nac  aflcr 
the  ligation  uC  the  artery  leiwliiig  to  it,  is  an  interesting  phenomenon,  and 
One  that  dcscrvex  much  attention.  When  the  Huuterian  operation  is  suc- 
tMsfully  performed,  though  the  puliation  in  the  sac  be  entirely  arrested,  a 
ovcain  ijuunlily  of  blood  couiinuea  to  be  conveyed  into  and  through  it  hy 
lk«  aaaatooiosiiig  ohanaels,  and  it  is  from  this  that  the  laminated  fibrin  is 


J 


146 


ANSUKiaH. 


and  naturnl  to  the  feel ;  if  it  be  hard,  iDComprcMible,  indicative  of  caLcifieatioB ; 
if  it  Ic-i^l  lirouiliT  than  iiutural :  if  a.  bruit  be  beard  i»  it  on  applyioe  Uie 
■telhcBCOpe;  if,  in  fine,  there  b«  ovidvnee  of  dc};«iicratii>ii  or  ditutiiUoa  of 
fu  coaU,  grtni  cautiun  jhouhi  bo  uu*l  in  uttfini[>ting  to  li^piiure.  Should 
the  deliffatiou  of  a  diMiued  artery  become  iiuuvoiiluble,  the  ADiiftopUe  cat- 
gut, or  the  ux-auna  Uguturf,  would  pmbubly  be  the  beat  mattirial  for  the 
purpose.  The  ends  being  cut  short,  and  the  wound  eloaed  over  them,  ibe 
cbanoe  nf  iih»ucbiiig  and  of  unhealthy  ulceratiou  of  the  Teasel  would  be 
greatly  lessened. 

It  has  occa«ir>nally,  perhaps  more  frequently  than  the  profeswitK)  knowt 
happeiie<l  to  Surgeons  tlial  {hey  have  cut  douu  upon  nn  artery  with  the  to- 
teutum  of  tyin>;  it,  and  found  it  in  »o  dii»ea»ed  a  state  tiiat  the  applicalinn  of 
the  lit!»ture  was  irupraeticable,  and  that  it  became  oeceesary  to  close  lb* 
Wound  without  winpieliugtbe  op«rat)on.  Listou  and  Aston  Key  have  both 
bad  the  caudur  to  n-<:vni  suc-h  cases.  In  one  case  that  hupi>entr<l  to  me  in 
which  it  WHe  thoiifjbt  uocewary  to  tie  the  suiiernciul  femoral  lor  popliteal 
Bneurism,  I  found,  on  cutting  ch)wuun  the  artery,  that  tliemuae  ii»mall  autru- 
lifimal  ililataiioi)  just  Iwluw  tlie  giving  off  of  the  profundu,  and  a  tubular 
dilatation  of  the  arLerv  IkIow  tliis,  rendering  the  applirAtiou  of  ligature 
utterly  imiiniclii-able.  1  aflerunrds  tied  the  external  iliae,  but  unsurcearulljr. 
It  must  be  remembered  that,  lu  such  cases  as  tbeee,  ooi  only  are  the  Hrterial 
coftts  Boflened  and  incapable  of  beariug  the  strain  of  the  ligature,  but  the 
vein  is  usually  adherent,  and  cuDsequeuily  liable  to  pttrforHiion  in  pasaiog 
the  nnfunsni-ntcdle  belweou  it  and  tlic  artery.  And  evea  could  the  act  m 
deligHlion  be  practised,  secondary  heniorrhngc  wtmhl  undoubtedly  occur  at 
an  early  period  in  an  artery  that  ts  incapable  of  healthy  ohUtirration. 

All  operation  should  be  avoide<l  when  there  is  any  si-rious  iliMase  of  the 
heart,  snd  in  cases  of  multiple  aneurism  where  the  second  tutrntr  is  situated 
internally;  but  it  has  happt'neit  that  two  aneuriitnis  in  one  limb,  ss  of  the 
popliteal  and  femoral  arteries,  Itnvc  been  cnrcid  by  one  ligature  applied  ta 
the  external  iliac.  Two  aneurisms  soAte^l  in  corrcapunding  parts  of  oppo^te 
limbs,  affecting,  for  iustance,  the  two  popliteal  arteries,  may  be  sucoasfuUy 
operated  upon.  But,  if  two  aneurisms  be  seated  on  dilTereut  part*  of  toa 
body.  n«  the  axilla  and  groin  for  instance,  at  the  same  lime,  extensive  disease 
of  tne  arteries  would  be  indicated,  and  it  certainly  would  not  b«  expedient 
to  operate. 

In  certain  cases,  the  Hunterian  operation  seldom  succeeds.  This  happens 
in  thoee  ioataooei  in  which  it  is  necessary  to  apply  the  ligature  very  close  to 
tlM  MO,  to  oa  iodeed  rather  lo  perforin  Anel's  operation,  as  here  there  is  Uw 
double  dnngor  of  inflaming  or  wounding  the  sac,  and  of  interfering  with  tha 
eiillaieral  eirculatiou  of  the  litub.  Those  coses,  utst),  iu  which  the  aoeurism 
is  %*ery  acute  in  il»  progreBS.iocreaiing  rapidly  with  forcible  pulsation,  bavior 
rery  iluid  e<>nteuts,  and  a  largo  mouth  lo  Uie  sue,  into  which  the  bluod  ■ 
oome()ueiitly  drivea  at  a  full  wave  at  each  pulsiiiinu  of  ibe  heart,  are  rartJy 
fitvorablc  for  the  use  of  the  ligature,  inosinurb  m  stnititir'atiou  tieldoui  oceura. 
When  the  aneuriaui  U  situateil  iu  the  midu  of  Iimkw  and  very  yielding  tissues, 
as  In  the  axilla,  where  it  readily  expanthi  to  a  large  size,  not  being  bonod 
down  bv  the  surrounding  parts,  suppuration  and  sloughing  of  the  asc  are 
esp«>i;lally  apt  to  occur  after  ligature.  When  it  is  ditfustxl  widely  through 
the  limb,  with  coldiicu  and  a  lendem^y  to  incipient  gangrene,  the  circulation 
of  blixid  through  the  part  ie  so  much  choked  that  deligatioQ  of  the  veatfl  will 
iu  all  probnbility  nrrc«t  it  entin-ly,  und  thus  prixluce  nmrttlicntinn.  When 
artcricA  ran  be  lelt  to  be  calciHed,  it  \»  a  i^uestion  wht^ther  ihor  <^sn  Iw  safety 
Itgatureil.  as  in  all  probability  they  will  be  cut  or  broken  ttirougb  by  the 
noose,  and  the  changes  mcessary  fur  their  occlusion  will  not  take  plaoe. 


t 


I 

I 


i 


more  cnniiiit)a  iK:currenc«  after  operations  for  oamtiJ  anpiimm 

»y  filb(!r  tVirrii  of  the  disease.     'Ihus,  of  8]  c&sea  in  which  the 

silery  vas  tied  for  itiieuri.sm,  [  Hud  thnt  pulaatiou  in  the  Liinior  cou- 

6a9»i  or  returned  in  9  iustauc«t<;  whereiuof  til  luisc^  uf  tuguiniil  an«>iirisna, 

!■  wbieb  the  external  iliac  artery  was  Manured,  the  pubukli-m  recurred  in  6 

amoDlT;  and  in  ^veral  of  thc^e  it  ia  iutero«tiiig  to  ante  tbnt  then?  w^r« 

n»  aiMiirtjniukl  sacs  in  the  same  lirnh — ouc  in  the  t^roiu,  the-  other  in  tli«  hum ; 

udtluillM  pulutioD,  though  pcriooneatly  arrested  iu  the  popliteal,  reeurrvii 

m  Iba  inguinal  aneurum.     Iq  the  ham  and  axilla,  pulButtuii  oecuMimally 

Ihourb  v«f7  rarely  recuNL    This  differenoe  in  the  fr«queary  of  the  recurreuce 

of  piiWlioQ  in  diflurent  aneurisms,  i»  evidently  uwiug  to  the  different  degrees 

of  GmoImd  of  communication  that  ex\*t  between  the  sac  and  (he  colIat«ntl 

,        bcaovhtt  io  variou*  forms  of  the  disease;  thiia  in  a  carotid  aiietiri^in,  tlie  iiu- 

palwuf  the  heart  nuiy  iit  ouce  be  broiiglit  fi  bear  upon  the  contents  of  the 

ue,  tiirougb  the  iiiediuiii  of  the  circle  ui  Willis.    Hut,  in  the  cM»e  of  inguiual, 

Jsmonil,  or  poplite.al  aneurism,    ihe  anaiitomo9«*i,  coniii^liiiif    rulher  of    the 

iiMieuUtioQsofieriuiual  hrauehes  tbuu  of  opeu  ootuiuuuiuutiMUe  lieiwi:eii  lurj^e 

truiilu.are  leas  liable  tu  truusuiit  the  bhfou  iu  a  pulisutory  litreuiu.     Fur  the 

•uw  Kasou — the  great  freedom  of  tlie  comiuunicatiou  bfcwi-mi  ihu  veiuels  of 

oppMiM  sides — the  pulsatiou  has  more  frequoutly  l>ui->n  found  to  continue 

unaterruptedly  and  diitioctly.  though  redueud  iu  furtv,  after  the  ligature  of 

Un  artery  iu  carotid  ancurbms.  thau  in  thiuc  iu  any  olher  Hituatiou.     The 

caw  in  which  it  returns  uIUt  the  cessation  <d'  a  lew  hoiiro  only  are  perlm|)e 

u  frvqueat  in  the  groin  and  ham,  an  iu  llie  neck.     In  those  instaucee  tn 

^B  *l>icb  the  pulsatiou  recunu  wtlhin  the  first  twenty-four  hours  after  the  liga- 

^Bturc,  it  usually  oeasea  again  iu  u  few  daya.  though  it  tupmetime»  contitiues  a 

^■ttdt  or  two.     \Ybeii  it  recurH  at  a  later  periml,  it  is  apt  to  last  aoruewhnt 

^B  loof^.    Coninreasion  antecedent  to  the  ligature  may  so  enlarge  the  cotlat^-Tal 

I      naiels  a^  to  favor  h  continuance  or  return  nf  puliation.    I  have  once  known 

Uw  pulsation  continue,  lliough  very  much  Ics^ued,  in  a  po])1iteal  aneuriiim, 

■Aer  ligature  of  the  superficial  femoral,  in  n  ctuio  in  which  treatment  liy 

tompreasion  had  uunvailiogly  been  tried  for  nearly  three  inontha.    In  another 

ease,  Jo  whioh  I  liwi  the  cxtenial  iliac  artery  for  popliteal  aneurijtrn,  owing 

Iu  the  supcrticial  femordl  btiug  too  diseased  to  admit  of  a  ligature,  the  yaU 

lfttU>a  oeaaed  com|iletely  for  a  time  a*  I  uaa  li(;hlening  the  ligature,  but  then 

muriMfl.  and  became  very  marked  in  a  few  hourb.    In  thi<i  aute  cumjireasion 

Wl  been  unavailiugly  employed  l>efore  the  artery  was  lied. 

Tb«  ptognatU  of  these  CMcit  is  on  the  whole  favorable,  but   few  of  them 

eveucually  proved  fatai.    Of  26  patieuts  in  wlioni  puUation  occurred, 

three  died :  and  in  all  of  these  the  fatal  result  was  occaajouud  by 

n  and  ifloiighiug  of  the  sac.     In  nil  of  the  three  inBtaucije,  the 

ioo  recurre<i  »itlim  the  first  twenty -four  hours.     Wheu  it  n:lurue  al  u 

mure  advanced  peri-^l.  there  \s  liule  risk  to  the  jmtiecit,  us  it  is  usually 

nadily  ameuable  to  jiroper  treatment. 

A  Seenndary  Aneuritm  is  of  exiremely  rare  oucurrcuce  ;  indued  I  believe 

tliar«Ar«  ooly  two  uueiiuivoeat  in^tauebs  of  this  allecliou  upon  record,  both 

of  wiiich  took  place  in  the  ham:  the  original  tumor  having  disapiH^ared 

enlirely  after  operation,  the  Kecnudary  dtH-ase  mudi'  i\*  apjiearancc  alter  a 

uf  six  monthe  tu  one  (uur,  anil  in  the  other  after  liiiir  yeans.     It  is  uf 

poruitice  to  dii^tiuguitih  between  a  ttecimdary  aiieurthrii  and  Ki^condary  or 

nl  pulAution  in  an  aneuri^^mal  hac.     The  term  " iter-tmdary  anniriMn" 

Im  reatrictei)  to  thnw  caeca  only  in  which  an  nneurismul  lunuir  up- 

in  the  site  of  a  former  one,  which  hnf<  undergone  ciuiaoliduLiou  and 

abaorption.    The  qufation  may  be  raised,  whether  Hneurism»  of  tbiH  kind  are 

is  reality  secondary  or  whether  they  mny  not  originate  in  the  dilataiiuu  uf 


148  AKEUBIBH. 

deposited  by  which  the  oonsoJidalion  of  the  tumor  b  ultimately  *fl<vted. 
This  ulrturu  of  blood  iurntslied  by  regurpilation,  or  by  tniitfiniseion  tlin>ugb 
th«  enialler  colliil«ral  chaoDeU.  i»  cuDlinunu^,  kd<I  Dot  pulMtor^;  occmsino- 
ally,  huwever,  it  »  trausinitled  iu  gufficieot  qiinDtity  oy  tome  mure  tiiui 
wimlty  direct  and  opeu  iiDBtiumociog  branch,  and  thus  gives  rhv  to  a  dod- 
tiouKDCe  or  lu  n  return  of  the  pulsation.  It  is  ioterestiDK'  t^  observe  thai,  io 
tome  of  the  ca«eB  iu  i^bicb  ibis  has  faappeaed,  there  has  htvu  a  rvturo  nf  Uir 
bruit,  but  in  the  miiJuriLy  uo  sound  appears  to  havo  bccu  cmitlnl. 

Tbe  period  uf  the  rvlum  uf  the  puleatimi  iii  the  sac  aller  the  ligature  of 
the  artery  varit«  greatly.  In  by  fur  the  miijuriiy  iil'  cases,  at  least  two- 
thirds  of  thoee  in  which'  it  ban  hRpppnp<l,  u  rerlaiti  rlejrree  of  thrill  or  of 
iiidi^tioel  pulKutiiin  han  been  ritiind  in  the  sac  shrtrtly  nftrr  the  application  of 
the  liguLure:  at  all  e%'enls,  niihin  the  fin^'t  twenty-four  hinirs,  Thin  niav  be 
lodkwl  upon  as  l»eing  rather  a  favoriiblp  pign  than  oiIn'rwiH'.  a»  i(  ifl  inaic«- 
tive  of  the  free  state  of  the  collateral  cimilnttoii,  and  ^i-niraMy  !UH>n  diaappean 
BpoDtaneoUBty,  the  sac  undergoing  cmisolidatioti.  Next  in  onier  u(  fre<|ueDcy 
are  tho«»  eases  in  which  the  pnleution  returns  in  iibout  a  m<intb  or  «ix  we^lu 
afWr  tlie  ligature  of  the  artprr,  the  collateral  circulation  having  been  ftllly 
established,  and,  after  continuing  fur  Minte  lengtb  of  time,  grndually  oeMC*. 
It  more  rarely  hapjiena  that  the  pulsation  n-tiinis  Wtweeu  ihew  two  per»ida: 
that  is  to  say,  about  ten  dH)-9  or  a  fortnight  aHer  the  application  of  the  liga- 
ture; thongh  io  some  instaucea  tbe  slight  vibratory  thrill,  scarcely  amount- 
ing to  a  pulsation,  which  perhaps  is  perceptible  a  lew  hours  aller  an  artery 
has  been  tied,  grHdiially  litreDgthens  at  ihe  end  of  a  week  or  ten  days  iatv  ai 
distinct  and  forcible  a  bi-at  as  had  beea  noticed  before  tbe  operation.  In 
some  rare  Instance*  the  pulsation  bas  reappeared  aAer  the  lapse  of  aoDW 
months,  the  aDcurisinal  tumor  having  in  tnc  meanwhile  undergone  absorp- 
tion;  liien,  indeed,  it  may  »ilh  jii^iice  be  looked  upon  as  constituting  a 
tecondary  annrruna,  and  a^  indicntiug  a  recurrence  of  tbe  complaint. 

Tbe  cavM  of  tlie  eontinuauct^  or  uf  the  reitirn  of  the  pulsation  in  an 
aneorismal  sac,  luuet  he  looked  for  in  too  great  a  freedom  of  the  collateral 
drcolation.  Indeed,  it  is  an  e^ventinl  reqatsiie  for  the  manifestation  of  this 
[Aennmennn,  thai  there  Hhould  be  so  free  and  direct  a  eoDiniuDicalion  hetwern 
the  artery  on  the  proximal  side  of  the  ligature,  and  that  jMirtJon  of  the  Tend 
situated  between  the  lignttirc  and  the  isar.  or  the  sae  itself,  as  to  enable  tka 
impulse  of  the  heart  to  be  tran^iinlted  in  a  puleatory  manner  into  tbe 
tumor.  Ko  regurgitant  blood  i-oming  upwards  from  that  portion  of  llw 
artery  which  in  distal  lothe  sac,  however  free  U  may  be,  ran  communicate  en 
itnjiiilfie,  ni>  ii.  uevcr  flows  j>rr  ftitvm  except  in  the  fijM'cial  case  of  a  cooiino* 
ou»  circle  of  Inrgc  annstouioertf,  euch  us  are  met  with  between  the  arteries 
within  the  ekull.  or  iu  the  palmar  and  plantar  archen.  If  any  "f  tbv  direct 
cjllaleral  or  feeding  vewelis  liap|«en  to  Iw  eofBcittitly  large  at  the  time  i>f  iha 
operntion  to  Iranemit  the  wave  of  blm<d.  tbe  puli<N(i<.>n  in  the  »ac  will  Im^  cod* 
tinuous,  or  will  return  almost  immediately  after  the  applicalioii  of  tho  Iik.>«- 
lure.  If  they  be  at  first  Uw  small  for  tliiB.  they  may  Itecome  eulNrgrd  aa 
part  of  the  anasli>n)<.«ing  circulation,  and  then  tho  pulsation  wilt  return  ho 
soon  as  their  calibre  ia  stifficient  to  transmit  the  heart's  impulee.  Btsidec 
these  cfmdilions  in  ibesiie  snd  dii^tribntion  nf  the  veeeels  of  the  [mrt.  it  is  not 
improbable,  as  has  been  ^iinpinie^l  by  Porter,  that  certain  atalea  of  tbe  blood  iu 
some  iodividuala  may,  from  enuiw^  with  which  we  are  unaccguainted,  render 
it  less  tinblfi  to  Coagulate  than  uxiinl,  nnd  thup  diHpot^  to  a  retunt  of  tbe  pul- 
sation iti  ihr  Mac.  which  remains  tilled  with  Buid  blood. 

The  phenomenon  under  coneidcralion  bns  been  noticed  lo  all  pnrla  of  the 
b*Kly  after  the  |>('rf<>miance  ol  the  Ilnntorian  ojieration,  though  it  occurs  with 
ditI«reot  degret^  of  fn^'juency  afUr  tite  ligature  of  diAniit  arteriea,  an<l  is 


SBCONDAKY    ANEl'KISM. 


149 


t:  '  '••'TTt  cnminnn  oecurreDce  after  operatJonf  for  carutid  uueurism 

.    ..ibvr  furiii  ul'  ibe  dit^aite.     That,  of  31  caaas  iu  whirh  tbe 

tiil  amuf  was  tied  for  sneurisai.  I  BoH  that  pulsatioo  iu  ttie  Lutiior  cnii- 
tioaad  nrntmiKd  in  9  instaocei;  wherea«of  92  caecs  of  iuj^uiual  uiiii(iri.stn, 
u  vhJeh  tlie  cxieraaJ  iliac  artery  H-aa  li^tured,  tbo  pubali'iu  n^rurnHt  Iu  6 
CBMBoalT;  and  iu  soveral  of  tlK'»«  it  is  luteresiiDg  lu  auui  lUat  tUum  were 
tvu  aoetLmioal  aac*  io  tbecaiae  limb — onoiti  tb«  groiu,  tbeolliur  in  the  bam; 
and  that  tbe  jJuUauuu.  ihougb  perinau«Qt.Iy  arretted  iu  tbe  puiilitiml,  recurred 
in  tke  iDguiiud  aucurt^u.  !o  tbi>  ham  aud  axilla,  pulsBlitiu  oc(^i>nully 
tiidcirii  vcrv  ran-ir  nvure.  Tbie  ditrvrvnuo  iu  the  fnHjuvQoy  uf  the  rBOtirreooe 
nf  paWliua  in  different  uiMiiriiiiii^,  iH  evidoolly  owiug  ti)  the  difieretit  degrees 
af  fraadiiai  i>f  commuutcatiuu  tbut  cx'in  biitweuti  Lhe  enc  aud  the  ci)llalcrnt 
fanadwi  ia  VKrious  fortna  of  the  diaeanv ;  thus  in  a  <'un>tid  aneurism,  the  im- 
polaa  of  (be  beait  may  at  unci!  I>e  brou^rbt  to  iH-ar  upim  the  cunlitnu  of  the 

thrangfa  ih*  medium  nf  the  circle  i}t'  Willia  Hut.  in  the  caseof  in|;uinal, 
~,  or  popliteal  aneuriflin,  the  aniutommeioK,  conHitilin^  rather  of  tbe 
f  u 


loi  t«TiiiinKl  hraiieiies  than  of  open  oonimuniuationa  Iwtween  lar|>;e 

OUttlBlimre  lew  liable  to  trnn^mit  the  hlooti  in  a  pnl^iitory  stream.  For  tli6 
Mac  rsMOO — thr  i;r«at  free<lo[ii  of  the  coniinunicatioii  helwt-en  tbe  vesaels  of 
4MMn|e  vdM — the  pulaatioo  ha«  more  frtiqueally  been  found  U*  coolinue 
oaiaUtmiptedly  aD<l  diatitictly,  thout^h  reduced  iu  force,  afler  the  ligatui-e  of 
ibe  artery*  in  carotid  aoeurUnis.  thati  in  tboM  iu  any  oth«r  gituation.  The 
eiB  in  which  it  rvturntt  afWr  tbu  ceaaatiou  of  a  few  hm\rs  only  are  perhaps 
a»  fn^atal  in  the  gmin  and  ham,  as  in  tbe  neck.  In  tbow  instances  in 
vlucii  the  pulaatiuo  returns  nitbiu  tbe  first  tweuty-fuur  hours  atW  the  liga- 
Vac  it  uaually  cvmam  again  iu  a  fuw  days,  tbou^^b  it  someCimes  eootiuuea  a 
«Mk  or  two.  When  it  recurs  at  u  later  periwl,  it  is  apt  to  last  soraewbat 
laopf.  CompreMtuQ  autectNient  to  the  ii^ture  may  so  enlarge  tlie  collatJ^ral 
fwariv  M  to  faror  a  uuotiuuauce  or  return  of  pulsation.  I  have  once  bnuwa 
iIm  palMOioB  cunliatw.  tbou>!b  very  much  lewened.  iu  a  popliteal  aucurism, 
*Jkv  Upuan:  of  tiie  tuperficial  femoral,  in  a  case  in  which  treatiutut  hy 
vmfrmAa  bad  unarailiot^ly  been  tribd  for  nearly  three,  months.  In  another 
can,  ID  wbirb  I  titil  the  external  iliuc  artery  for  popliteal  aneurisro,  owtoe 
ta  tbt  lupiTfirial  fcmi)ral  being  imt  dt»ea«ed  to  admit  of  a  ligature,  the  pui- 
■ttiiia  t^Mucd  completely  for  a  time  a^  I  was  tightening  the  ligature,  but  then 
ntaracd.  and  '*■■  ■■"•—•  very  markird  in  a  lew  boun.  In  tliis  com compre«ton 
kad  bvwn  unn  -  'Oi ployed  before  the  artery  vraA  tied, 

Tbt  pr^jfui'tM   M  \t»-M'  CHAM  ia  on  tbe  whole  fa%'orable,  but  few  of  them 
kaviDf  wvutimlly  |iri*ved  fatal.    Of  i!6  |Miiieni«  In  nhum  pulwtion  occurred, 


I  6ad  ibal  tbm« 
iDflammaiiiio  unit 
paU>' 


'■  iu  all  of  tbwe  tbe  futnl  result  wiu  iK-o:i»iMued  by 

_-  of  tlie  sac.     In  all  of  tbe  three  innlaiici^,  tbe 

li  the  t)r»L  twentr-f<iur  houhi.     When  it  returu.'^  xt  a 

then.'  ti>  little  risk  to  tbn  patient,  »»  it  a  iMuutly 

'\rvT  ln'«t!iiftn, 

]  on  a  nf  i-xirt-iiiely  rare  occurrence;  indeed  1  betie?e 

'  '  two  uiiNjuiviN-ul  inatauce^  of  this  alfectiou  upon  ri-cord.  both 

'.    ulncK  in  the  bam;  tbe  originai  tumor  having  dlftap^ieared 

"I  ..  ration,  the  iwoundary  di»euM<  made  it«  apjwanuice  afU<r  ft 

lk|»i-.  ■ .  ..i.  i....i..Ut  itt  one  caae,  and  in  the  other  alter  iour  yeura.     It  in  of 

UBportancv  Xi\  dtttiafatsh  between  a  sec^mdary  aneurifm  and  Httcoudary  ur 

iweunrot  pDlHUioo  10  an  natarbmal  sac     The  \Mrm  " lerandaiy  anettriam" 

afcaald  be  mtricled  l»  tbotse  caMe  only  in  whieh  an  nneuri^jmal  tumor  ap- 

pwn  in  ibe  rite  of  a  former  one,  wliich  has  undergone  cousolidalion  aud 

•fcaorptioo.    Tbe  qn«alion  may  b«  rai«e<l,  whether  aneuriams  of  r.hi»  kind  are 

»  Malhy  •eciMAarr  or  whether  ihcj  luay  not  originate  in  the  dilatation  uf 


ISO 


A.'f  BURISM. 


B  p^irtion  nf  (h«  nrtery  contijfuotin  to  the  BPat  of  »  furnier  ilturKW'.  Il  U 
certi'tnly  Dot  very  oaisy  to  umlt-rHtaud  linw  «u  niieumniHl  cue  itiut  liie  i«Dce 
uiiik'i-p<na  confioltdiilii>n  nii<l  nL>»orpti^>n  can  again  bvwme  dilated  into  ■ 
piiUndnK  tumor ;  and  1  think  it  nj<<M  prubable  thai,  altbuucb  tlic  cvuaero* 
live  Riicuii^ui  niny  bt^  tuuntl  in  the  »nnjc  t^ur^iriil  rt'^iiiii  »»  llie  primary  one, 
it  in  reality  titki-v  il8  itiigiu  fW>m  a  slightly  iii};lier  |>iirt  of  the  artery,  where 
the  suni(>  i>iriictiinil  rhnnge  njuy  liuvv  bei-ii  iu  iintLTCM)  that  deterniiued  tbc 
diacaec  iu  the  tinsl  inelunt*e  at  a  luwer  poiiil.    IXiuVile  aneurism  thua  ari>iDg 

~'l,  indeed,  oecusioiially  iiit?t  with  in  thu  ham  ajt  a  primary  dieesse.  I  buva 
■een  a  eitMi  in  nhirh  an  anpurifnml  liinior  wan  t>tiuult*d  in  thci  ham,  and 
uioiher  »t  iir  tmmcdintely  nl>nve  the  Hpcrinre  In  ihenddiirtormiisrle:  iflbe 
artery  in  ttiich  ii  ciise  as  ihiK  had  he^n  tied  hcfiiro  the  arcoiid  itimor  had 
attHined  Hny  mnfrnitudo,  ve.  ran  eflsily  nnderstand  how,  whfn  this  h<Mama 
dilatfil.  it  might  have  been   constderrd  to  be  n  new  cnlarpenient    of  tb« 

'ori^'inal  911c,  whereas,  in  rcftlity.  It  was  nothing  more  thiin  n  new  niieuri^m 
forming  in  the  cinw  vicliuiy  of  the  old  one, 

Euhryrmrnt  uj  an  tnxuri'tiiol  tac  withovi  ptilfaiion,  after  the  ligature  of  ibt 

Plirtery  Ivadinj;  in  il,  is  an  inter«»tiiig  pheuonM-non.nnd  one  that  might  caoM 
the  lni»"  nature  of  tho  tunmr  to  be  iHisiiiidFttiltKxI.  as  il  rlo«plr  resemble*  in 
its  »tow  and  gradunl  incretun:'  the  growth  of  a  iiinlignniil  tumor.  Il  w  ocra- 
eioneil  by  tlit-  dintt>utiou  of  lh«  sac  by  regurgilutit  bjiHHl  brought  into  it 
Uirutigh  the  di^uil  end  of  lh«  vesKl,  without  autlidcnt  foree  lo  cau^e  pulsa- 
tion, iliotigh  with  Huffitiienc  preMur«  to  occasion  a  gradual  incrvaae  in  tb« 
nze  of  the  Bwelliug. 

TreaUneht  0/  lientmnt  FitUQUim.  ~~  In  by  far  the  majority  of  oiMs  of 
8c<.*ondary  pul»>ation,  this  phenomenon  ee«s«s  of  itself  in  the  eoune  ofa  few 
days  or  week)*  fn>ni  itinttolidation  of  the  Mie,  in  the  BBme  way  an  after  liga* 
ture  of  the  artery,  by  llic  deposition  nf  Inmellated  tibrin.     Thi^  leudi-ncr  to 

l,iooittolidnllijii  of  the  tumor  may  Ito  mueh  fiwi)>le<]  by  means  calculated  to 
leaieo  the  fon-v  of  the  impulse  of  the  bloiHl  into  the  tae,  eueh  as  comprcwinn 
of  th«  arlery  nhov«  the  (xiint  ligatured,  rest,  the  elevated  position,  and  ike 
caiiiioua  appiioition  of  cold  to  the  part:  colil.  however,  murt  he  careAillr 
applied,  let>t,  the  vitality  of  the  limb  beine  dimiuifhcd,  gangrene  be  induced. 
At  the  name  lime,  direct  pro^^nre  may  be  exercised  upon  the  f»c,  so  aa  lo 
moderale  the  flow  of  bliMwl  into  it ;  tbia  haa  in  many  fatie*  miceeeiled  in  nm- 
ctiring  ronaolidation  of  the  tumor,  and  mar  most  mnvcniently  be  applied  by 
meanfl  of  a  comprem  and  nnrrow  ndler.  Yhis  plan  is  especially  adapted  lo 
popliteal  and  inguinal  aneuri«m».  but  cannot  bo  well  be  ei*Tciitpd  ujion  tboM 
ailiiated  in  the  neck.  Care  must  be  taken  that  the  pre>«ure  be  not  at  tint 
too  powerful,  test  gHugreue  result ;  the  object  in  not  no  nuu-h  Ui  force  out  tb« 
oontente  of  the  tuuior,  or  to  elbco  tlii»,  an  ximply  to  rentrain  and  nMHlerato 
ettntewhnt  thu  Dow  of  bbKtd  into  it.  Sb<>u]<l  the  Aiieiiri»ni  be  no  «itun(eil  that 
prtMuru  can  be  exercised  upon  the  artery  nhove  the  |Miint  ligHlun.-<(,  Ihia 

,'ahould  be  had  rocouroe  li>  either  by  the  firi^'er  or  by  inetnuiieiit,  and  will  be 
both  Mtfer  and  more  likely  to  be  ctlVclunI  thao  direct  pr«i«ure.  I  succeeded 
in  this  way  in  ciiring  a  very  rL-mnrknlde  c»«v  of  rectirrenl  puUtillon  in  a 
popliteal  aneurism.  The  patient,  u  man  almul  lliirty-li\i*  yeani  nf  age.  wai 
admitted  into  University  ColIc;re  H>utpitni  for  nn  nneuriKm.  ab<ml  the  stan  of 
an  orange,  in  the  right  ham.  Tnmtnient  by  cotiiprcfflion  ivnt<  emplojnl. 
without  any  elTeec  being  produced  in  the  tumor,  for  three  month?.  During 
this  period  eompri-asion  was  employed  in  all  forms — bv  (.'arte's  tn^trumcnt, 
the  weight,  the  finger,  and  flexion.  I  then  ligatured  (he  snperlieial  femonU 
arierv  in  Scnrpti'it  triangle.  The  i>ul«fltion  was  arnsted  in  the  tumor  when 
the  ligature  wa*  lied,  but  returned  in  a  alight  degree  in  aboat  an  hour,  and 
iluwiy  tncrcaaed,  never  boooming  at  all  forcible,  but  being  very  dticiooi. 


TRKATHENT  OF  RECURRENT  PULSATION.        151 

Tfa«  ligalDre  separated  on  the  fourteenth  day.  The  limb  was  bandaged,  and 
>  imd  applied  over  the  aneurism  without  any  effect;  and  the  limb  was 
raiMd,  but  still  the  pulsation  continued.  Carte's  cunipressor  was  again  ap- 
plied to  the  commoD  femoral  artery,  and  used  for  about  three  hours  in  an 
intemiitteDt  niauoer,  when  the  pulsation  tinaliy  ceased. 

In  the  event  of  the  pulsation  not  disap|tearing  under  the  influence  of  prea- 
■are,  ooojoJDed  with  rest,  dietetic  means,  and  the  local  application  of  cold, 
there  are  three  courses  open  to  the  Surgeon  :  1,  To  ligature  the  vc^el  higher 
ap ;  2.  to  perform  the  old  operation  of  opening  the  sac  ;  and,  3,  to  amputate, 
if  the  aneurism  be  situated  in  a  limb. 

With  r^ard  to  ligaturing  the  artery  at  a  higher  point,  I  am  not  acquainted 
with  aoT  cases  that  throw  much  light  on  the  probable  euccees  of  such  an 
operatioD.  We  know  that  the  ligature  of  an  artery  high  up  for  secondary 
hcoiorThage,  afler  previous  deligation  of  it,  is  a  most  disastrous  procedure. 
But  here  the  conditions  are  by  no  means  identical  with,  or  even  similar  to, 
tbiiae  that  accompany  recurrent  pulsation.  In  the  case  of  secondary  hemor- 
rha^.  there  has  usually  not  been  time  for  the  full  development  of  the  col- 
lateral circulation  ;  whereas,  in  the  case  of  recurrent  pulsation,  many  weeks 
woald  probably  have  elapsed  before  the  second  operation  would  become 
■ecesaary,  so  that  ample  time  would  be  given  for  the  enlargement  of  the 
■Dasbimoees ;  and,  besides  this,  the  very  occurrence  of  the  return  of  pulsation 
Bay  be  taken  as  evidence  of  an  unusually  free  an»9tum(»ing  circulation.  I 
think,  therefore,  that  if  such  a  case  were  by  any  possibility  to  occur,  in 
which  recurrent  pulsation  could  not  be  checked  by  the  application  of  pres- 
•are,  digital  or  instrumental,  to  the  artery  above  the  point  originally  liga- 
tored,  aided  by  the  other  appropriate  local  and  constitutional  means  that 
have  been  mentioned  above,  the  Surgeon  would  adopt  the  proper  course  by 
Ueataring  the  artery  higher  up — tx.  gr.,  the  common  femoral  or  external 
iliac,  if  the  superficial  femoral  had  been  the  one  previously  tied.  In  the 
ev<eDt  of  this  not  being  thought  advisable,  he  must  choose  between  one  or 
other  of  the  two  remaining  operations,  viz.,  amputation,  or  opening  the  sac. 
Of  these  measures,  I  shoula  certainly  prefer  amputation,  as  offering  the 
OHM  favorable  chance  to  the  patient.  The  operation  of  opening  the  sac, 
turning  out  its  contents,  and  ligaturing  the  vessel  supplying  it,  is  in  any 
circumstances  a  procedure  fraught  with  the  ^'reatest  diingcr  to  the  patient, 
and  full  of  difficulty  to  the  Surgeon,  even  when  he  knows  in  what  situation 
to  seek  the  feeding  vessel.  How  much  greater  then  must  the  difficulty  be, 
wbeo  he  is  in  uncertainty  as  to  the  point  at  wh'ch  the  artery  enters  the  sac, 
and  cannot  know  whether  there  be  more  than  one  arterial  branch  leading 
intti  it.  In  the  event,  therefore,  of  all  other  means  fitiliug,  and  of  the  pulsa- 
tiua  io  the  tumor  continuing,  amputation  is  the  only  resource  left  to  the 
Surgeon. 

Id  th««e  situations  in  which  this  is  impossible,  the  Surgeon  may  occasion- 
ally attempt  the  old  operation.  Siiivthe,  i)f  New  Orleans,  as  a  last  resource, 
laid  open  a  subclavian  aneurism,  for  which  he  ha<l  successfully  lied  theinnomi- 
■ate  M>me  years  before,  but  failed  to  secure  the  artery,  and  the  patient  died. 
Morris,  however,  has  successfully  adopte<l  this  proceeding  in  a  case  of  carotid 
atteuri«m  after  ligature  of  the  common  trunk  hail  fulled  ;  and  Berkeley  Hill 
in  a  case  of  axillary  aneurism  after  ligature  of  the  subclavian. 

Since  the  iutnKluction  of  abstirbable  ligmures  into  surgical  priicticc,  a 
rHum  ■>f  pulsation  has  in  a  few  cases  been  due  to  a  restoration  of  the  lumen  tif 
the  artt-ry  after  the  clisappearance  of  the  ligature.  This  is  reeojriiizetl  by  the 
prvsenr*'  of  puiratlon  in  the  vessel  at  the  point  at  which  it  wits  tied.  These 
eases  belont;  to  a  different  claifs  to  those  in  which  the  vessel  ha.s  been  jwr- 
BancDtly  occluded,  and  require  (lifferent  treatment.      The  artery  may  be 


162 


ANSLTKISH. 


ligatured  ugaio  at  or  near  tb«  eamo  sp^it  or  at  some  other  poinl.  la  a  out 
of  tills  kiiiil  tiiat  iKHTurrvd  uudvr  llie  v&tk  uf  CliruUi|tber  H«utfa  io  Uuivenity 
Cjltfj^f  H<ii«|)ilal,  lilt!  ffiotiral  vaa  wivxuxBi'uUy  Lied  in  lluiiler's  canal  aAar 
liLmturt'  orihf  Hrtt-ry  in  Scarpa '»  triaiiffte  liad  Ikili^d.  The  cauMB  of  failnn 
ol  tlie  lij,'!itiin'  Imvi?  iitrt'aity  hfcii  dt-mTilici  (vipI,  i.  |>,  421 1. 

3.  SapparatioD  and  Sloughing  of  the  Sac— Wbfti,  after  the  lif^iture  of 

^ita  eu|i[ilving  artery,  kii  aiieuri^ui  ii^  ahuul  to  8iJ|i|><iriit>>.  )ii»iii>ud  t>t'  diniinUb- 

fing  iu  hvie,  it  incn.iu<«i^.  with  )ieat,  paiii,  pul»ntii>ii,  iiml  some  iiifluniiiiai'ir^ 

^diMSilurutiou  of  the  tdiin  I'overing  it.  This  gradually  lMH'tiiii<«  ihintic^l,  aud 
at  liut  gives  wny;  tho  contents  of  the  tumor,  e<ifU:Q4--d  and  br<tk<'n  down  bjr 
iu&aininatioD  and  the  admixture  of  pii8.  are  dJAcbarged  through  the  upcrtur« 
in  ita  vra]l,  in  the  form  of  a  dark  purpligb-bruwn  or  plum-culortril  and  oAea 
fetid  fluid,  intermixed  with  raamea  of  a  »ufl  dark  coagula,  or  n(  th«<  drier 
laminated  fibriu,  which  mav  not  iuaptlv  be  compared  ia  appearaooe  to  por- 
tioiM  id'  raisin*  or  dales.  The  e^oapc  of^tbcse  tnatten,  variouaty  altered,  tnar 
be  acoompanied  or  followed  by  the  escape  of  florid  arlfiial  Mood.  Thu 
iemorrbajre,  which  is  the  great  eoiurce  of  danger  in  the  sutipuratiou  of  an 
aueurisDial  sac,  may  oerur  in  a  sudden  violent  gush,  by  woich  thi*  patient 
juay  at  once  be  deatn^>ye<i,  at  the  time  of  the  rupture  of  the  tumor ;  or  it 

iiua/  cuotiuue  io  email  i{UHntitie«.  which,  alter  ceasing,  recur  from  time  to 
tinM,  ihuH  gradually  exliautiting  the  patient.  It  is  thii  (recurrence  of  see* 
uudary  heiuurrhage  that  constituiea  the  principal  danger  oAer  suppuratioo 
of  aneurieoi,  which  ottierwieo  ii  not  a  source  of  any  ver/  wrious  riak  to  tba 
patient;  ab<iut  ooc-fourtb  only  of  the  cases  in  which  the  sac  hasauppuraud 
naving  had  a  fatal  termination,  and  atmuU  all  tlinee  in  wbtt-h  tiealh  resullad 
having  proved  faul  by  licmorrbagc.  Tbe  naiienta  in  a  few  reiuuining  in- 
8taac«)  have  been  carrietl  utt'  by  tiome  special  iiocidL-iit^,  iiucb  as  tbv  preasun 
of  tbeaac  on  the  pharynx  ur  uwiphaguti,  or  thu  dtft(diargi>  of  ibe  n»nli.>ata  of 
the  tumor  into  ibu  pleura  or  bnmcbial  lubea.  Heraorrbage  vt  mun'  liable  to 
occur  when  tiuppuration  lukex  plB<*e  a  few  Treeks  after  the  ligature  i if  the 
artery,  than  wben  a  longer  interval  haa  elapmxl.  That  hemorrhagt<  dnes  not 
happen  more  fret^uenllr  after  ^uppurutian  of  the  «ar  i«  very  renmrkahle,  and 
must  be  owing  pithrr  to  the  sealing  by  ndhntion  or  plug;;i[ig  by  tvuigultim  of 
tbe  mouth  of  tbe  nneiirii<ii),  where  it  onmmnnicates  niili  [be  interior  itf  tba 

{■-artary.  It  \*  owing  to  tbi*  plugging,  also,  that  in  many  (-aM9  tbe  lutal  bleed- 
tng  doM  not  occur  at  the  moment  of  rupture,  but  only  after  a  l«|w«  of  aoine 
days,  or  even  week*,  aixl  then  ni'»t  ii«ually  under  tbe  influencf  of  Mime 
incautious  movemcut  »{  the  patient,  by  which  tbe  cimgulum  or  adhrfiitn  is 
auddeuly  dintiirlied.  Th'jse  eavvs  are  most  dangerous  in  which  pulMlion  has 
returned  in  tbe  oac  alWr  the  ligature  of  Uie  vessel,  but  before  the  superveo- 
tioo  of  Buppuratiou;  as  in  thcev  the  tumor  i»  mi  freely  supplied  wiili  bluod 
ibat,  if  it  burst,  fatal  hemorrhage  will  with  certainty  supervene. 

Thi«  uccidcut  is  luucb  more  frfi^uvut  iu  some  eituulious  thau  iu  otbere,  mud 
ii  uorc  liable  Ui  occur  in  aneurisms  of  tbe  axilla  or  groin,  than  id  those  of 
the  ham  or  of  the  neck.  The  pruximity  of  the  ligature  and  tbe  neocsHUT' 
iuierfureuei;  with  ibt>  »ac  iu  iis  appHcuiiuu,  es|>eciully  in  largv  axillarj' or 
inguinal  atK^uriHtns.  in  undoubtedly  a  trnfuent  crum'  of  it.     The  large  aia_ 

;|mm  tumura  rapidly  attain,  in  couMMjuence  of  the  laxity  td'  their  areolar  < 
UMtiom.  also  favura  it.  Until  retn-uily  it  was  helievi^l  that  the  occui 
of  simple  coagulation,  inxkud  of  gradual  deposit  of  laminated  tibrin,  wa«  an 
important  factor  in  the  pnxlui'tion  id'  !<iippuratioti  of  tbe  aac;  but  uur  lale 
fiX)terieni'e  of  tbe  treatment  of  aneuritun  hy  rapid  compreseiuu  cleaHy  shova 
that  the  ilangor  baa  Im-n  greatly  exaggcratiii.     In  other  cast's  it  would  ap- 

ipaar  that  the  fibrin,  though  pnifMrly  dep««ited,  acts  as  a  fort-ign  body,  and 
l^vet  riac  to  inflanimatiuu  and  suppuration  in  tbe  wall  of  the  sac  and  tae  aur* 


fttrP^VHATION    or    &XC — TRBATHRNT. 


153 


artohu-  tOBtte.     Beaidev  tbiB,  il  has  been  Tory  justly  roraarked  hf 

tbe  excneive  hmidling  and  fr^Ufot  cs&iuiDaLlou  to  wbivh  an 

Itiaior  oooirrinK  in  a  hoepitnl  patieat  i«  usually  aubjceted.  may 

TW  Mrwd  at  which  suppuration  of  tlio  mc  may  occur  after  the  ligature. 

mm  a  few  dayii  to  as  ninny  months.     In  tbe  majority  of  iiwtaiicea.  it 

lid  appear  to  take  place  bftweon  iht!  thini  and  t^ixfath  weeks ;  later  than 

'  il  «Ndom  happens,  thou^b  it  may  do  i>u  after  the  Upse  of  several  inoulbs, 

■  a  eaie  recorded  by  Hir  A.  Cuuper,  iii  which  a  carotid  nneurtsm  sup- 

■TBicd  al  the  eisbtb  month. 

Tra^Mcat. — >\h^D  an  anvuri«m  is  suppuratinfc,  and  is  on  the  poiat  of 
pTiBg  way,  H  will  be  better  lo  make  An  ittcintuti  into  it  with  aniiMptic 
aneaMMiA,  so  m  to  let  out  the  brokeuMlnwn  coiitcnta  at  once.  It  muat  iKeit 
M  treated  like  an  unlinury  absoeaa,  witli  a  view  ti>  ilji  filling  up  by  gronula- 
tiOB;  whirh,  hiiwcvcr.  will  neceMorily  be  a  hIow  proceiw,  in  consequence  of 
great  t'lw  and  deptli  uf  the  op^nint;.  Durini^  the  wlmk  of  thja  time  a 
init<|Det  iihimid  be  kept  looeely  applied  ujhiu  ibe  artery  above  llie  sac.  so 
M  to  be  Ujfhtaaed  at  aoy  moment  it'  blevUiug  take  place.  If  hemorrhage 
hmva  alnady  wperveaed,  the  cose  is  atti-oded  with  immixliate  danger.  In 
iodt  a  cmm  as  this,  the  firal  iudicutioa  is  cliiirly  u>  arrest  the  flow  uf  blood, 
ill  pnrvtDt  thu  pattrot  from  dyiug  si  uucc.  This  can  beet  be  accom- 
by  tumiog  out  tbe  cimgula  tiud  plui^tug  (he  sue  with  Hot  or  com- 
apooga.  retaiued  in  situ  by  a  firm  graduated  compress,  and  well' 
ix»Ibr.  The  hemurrhacr  having  thus  been  arrived  for  a  time,  the 
ritoutd  takn  into  coneTderatioo  what  8t«]iH  should  be  adopted  per- 
Ij  ta  RBtrain  it.  In  some  cases,  indeed,  though  these  ar«  exrcpiiunal, 
plog  a«d  ronpreflft  may  be  sufficient  to  prevent  a  reeurrenceufibi' bleed- 
iar :  bat  b  geuenl  it  will  not  do  to  trust  tt>  these  meaas,  unteaa  the  anau>mi- 
caT  nrfarinw  af  the  part  be  audi  aa  tu  preclude  the  poaubility  of  adopting 
amy  ■»»  aetire  maaMirfe. 

plana  suMEcai  theimelres  to  the  Surveon  for  th<-  permanent  sup- 
win  at  tht  bleMioK-    The  sac  may  he  laid  open,  and  nn  attempt  maae 
-  that  portion  of  ihf  artery  fn>tn  which  the  blood  iMiies.     But  this 
Ir  (..  i-vi.M-tnl  lofuccc^.ati,  ill  the  majority  of  the  cased,  the  roats 
:ii-ncd  and  pulpy,  there  would  be  tittle  praepe«t  of  itJ 
11  if  it  were  pamiblv  to  cx[>o«e  it  twfore  the  pnttent 
Indi'ol,  ihoagh  this  plan  has  been  s^vral  times 
im  D>>>  :t«:tr>'  ihat  hy  it  the  8tirf^eoa  has  ever  sucoeeded  in  arresting 
l^laaJiag  fn;Di  »  »iippurating  ani-uricmid  sac. 

itioQ  of  tbe  actual  cauter>'  t<i  Ihi'  bleedtufr  orifice  would,  I  think, 
'-ttar  nbaocv.  more  particularly  if  (he  hicod  were  puurvd  out 
oeUaMfri  rowel  of  a  small  size;  In  this  way,  ^[l>rri9ou,  of  Monte 
MBaaailiJ  ia  arroatin^  the  bleeding  of  no  aneurism  io  the  gruia  that 
!  ■opparatod.  Should  this  mcoM.  however,  not  lufii'.'e  (and  it  is  the  only 
!■■  Inal  GUI  ba  applied  in  many  eituuiioos,  ne  in  the  groin  and  axilla), 
ttHW  ii  BO  wwn  leu  but,  in  lhc«e  Biiuatii>ns  in  which  it  can  be  done,  either 
•a  GfMOf*  the  aitery  bigher  up  or  to  amputate.  The  application  of  n  llga- 
tam  aaarwr  the  ttotn  of  the  cirruiation,  oven  though  praoticnble,  appears 
to  Be  lo  be  0/  vrrr  doubtful  utility ;  for  tlie  probability  \s,  that  the  circnla- 
tim  ikracigb  the  llnb,  embarraoaid  as  it  must  have  boen  hy^the  first  lignlare, 
aad  by  the  aahiKiueut  distention  and  suppuration  of  the  imlc.  will  be  so  mocb 
■Itffcffid  with  when  tbe  arti'rv  ia  tied  a  SM-ond  time,  that  gangreDo  will 
l«BiiIi;oreW     '  ..-otlaierul  circulation,  if  auffioiontly  aetive  to  mainlaui 

tW  ftiallt*  i'<  :  will  al«o  knsp  up  the  hemorrhage  from  the  opening 

ID  tb«  artvT  o.iiiiuuiuc»iing  with  tlic  «ic.     In  tbeae  eireumBtaneea,  ika  oolj 


Ti 


I 


164 


AN'KCniSM. 


coitrep  Ipfl  to  thn  Siirfft^n  in  amixiiatiirti  of  tli<?  limb  when  the  onenriMD  hm 
BJltinUtl  iliai  il  can  in  thj?  nay  lie  rr-miivt^l. 

4,  GaDgrene  of  the  Limb. — Tins  ^ticiivrnl  wiliji-ct  of  gniipT^'nc  i»f  a  limb, 
fullowiii;;  iiijiiry  ami  li^iilnre  of  iIr-  niniii  arU'rv.  Iium  ulrfuily  liec'U  ilvscribvd 
( vol,  i.  [>.  44^1)  ;  Hiid  we  huvt-  at  |>riwi>r.  t4i  cunsiilvr  iiiily  those  c— <■  in  wfaidi 
it  ucccum  after  the  upemtion  fur  HneunHm. 

Oji>k#. —  If  ibe  BDeummftl  sac  have  attaineH  a  laTgf>  aizc  «it)i  )pT«t 
rapidity,  it  may,  by  its  preairure  on  the  collateral  ve«»el»,  or  no  the  vcim  in 
ito  vicinity  (Fig.  V)4),  produce  such  an  araijunt  of  diiilurbaDc«  in  th*  cirm* 
lotiou  of  tti«  tiinb,  preveutiDg  the  iuSux  of  arterini  or  obftnjcting  the  cfflox 

nf  venous  bl'.Kxl,  iis  to  uccasioD  n  great  liabUit; 
to  the  occurrence  fif  ^nngrenp.  Uut  perbapa  tw 
prltK'ipn)  Hource  of  duiij^r  conaiBts  in  IM  imanrfwi 
bfmmuit;  tuddenfy  md  loidafy  diffut^,  more  pw- 
ticiilarly  in  tboae  oun  m  wfaich  the  auatumical 
rolnliutu  of  the  collaicral  ves^U  are  Hucti.  u  in 
tho  haul,  ihiit  ihey  may  rcaililv  and  auiromlr 
hccoiai}ci>m|)r«f«o<l  by  tHeeffiiM^f  blood.  In  than 
casfif  ihc  additional  vmbarraseinieut  induoMl  in  the 
circulatioit  of  the  limb  by  the  li^iiuireof  it*  main 
artery  will  readily  induce  gangrciie;  and  hence  It 
is  that,  in  difitiae  aneurism  of  the  lower  cxtremitj, 
ligature  of  the  artery  ia  so  commonly  followed  1^ 
inortiti  cation. 

Ix>M  of  Uood,*ttix«r  in  conaequenceof  Mcoudary 
heniorrhnge,  or  in  any  otber  wav  befortt  or  aA«r 
th«  application  of  the  ligature,  u  very  npt  lo  bt 
((tllowed  by  gangrene  i  the  more  to,  if  it  have  bMB    ^ 
nece«Mry  to  apply  a  ligature  to  a  higher  point  i^^fl 
the  trunk  of  itie  veswlthau  had  previ>.>u9ly  b«^^| 
tii-d.     Tliis  Bocvadary  liiivture  of  »  Urge  artery 
iucasesof  aoeurisni  ha£,  I  believe,  been  invariably 
folluwod  by  gangrene  of  the  limb,  when  dtme  io 
tho  lower  extremity  ;    the  interference  with  the 
collateraJ  circulation  by  the  second  li^ture  Iwing 
(IO  great,  that  the  Titaliiy  of  the  part  cannot  be 
luainlHtned. 
BraMes  these  cauaei!.  the  ot-curretiL-e  of  rrynfpeiaa.  exposure  of  tbe  limb  lo 
coid,  or  U)  an  undue  ilegree  of  heat,  or  aubjcrting  it  to  tbe  ampreatien  of  a 
bAndage.  mav  lie  attended  by  conaequeocen  fatal  to  its  vitality. 

Thc;)mW  (lyn/iirrwnfMnnf  gHOsmMof  the  limb  is  uenallv  from  the  third 
to  the  t<-nth  dav ;  it  seldom  oocun  bef>ire  this  peritKl,  anieaa  inoiptt^iit  miirti' 
Scati'tn  have  nfready  set  in  before  the  nrtery  was  linl.  Gangrt-ne  ustialljr 
follows  tbe  ligature  of  the  external  iliac  al  an  earlier  pori>>d  than  that  of  any 
other  artery.  In  c'4i»es  of  anuurtsm,  the  gangrene  it  always  of  the  dark  and 
oiotst  variety,  owing  to  its  being  coninioitly  depeudenl  on  prcasure  upoa  the 
l&rjce  vcnrkUD  trunks  by  the  sMeurisniHl  tumor. 

IVrrttmenL—'thii  gi,'ueral  preventive  trentmvnt  of  gangrene  followinr  the 
ligaliirc  nf  the  artery  for  aneuriam  must  be  conductetl  on  the  same  princtnls 
■a  when  it  nrioes  after  ligature  of  arteriev  nnerally  irol.  i.  p.  44.%).  But 
•QiDfl  apecini  mod ificat ions  of  it  arc  require*!,  so  far  as  the  ancuriaoi  is  oath' 
MTned.  When  the  gangrene  occun  fnim  the  preasura  of  the  aao  npoa  tke 
■ocom  pa  Dying  vein,  it  has  been  proposed  to  lay  the  tumor  open,  and  to  torn 
oat  its  coulents,  thus  removing  the  compression  exercised  by  iL  The  danger 
of  tucb  a  pmeevdiDg  oonsista  in  the  probability  of  lb*  ocewnno*  of ' 


Vtf.  IM.— Po|rhlMl  Apflari*qi 
S*ai|««Mla(  thu  Vain,  Kad 
ttin*  wnrlni  UHinna  of 
tht  Limb;  a,  Ariarj ;  i. 
Vajti  iMi«npr«M«d  »t  •!•,  r, 
Aaaurlaai. 


VBBATllByT    BV    INSTRUMENTAL    COMPABSfllON.         155 

'fton  tht  OMOiDtc  matl?  into  Ifae  ii»c,  and  in  the  risk  atf^ndinct  »uppu> 
up  in  Umc  fc;  yi-t  it  wouM  iippcur  thnUiii  two  CASce  iu  which  tliU 
few  bvcii  aditpU'iJ,  DO  bad  Ktulta  fuMuMed.  Tbufi,  L^iwroiice  liiu 
CMMof  JiffiiHiliinciiri?>m  of  the  p^>])li[eHl  artery,  in  which  ibtH  plna 
wwm  Ia4  HMWini  Co  witii  the  bwi  reautta ;  aa<l  Benza  has  rcvordetl  a  cas«  uf 
paipKtiKl  UMtuiam  in  which  the  aame  practice  wae  adopted  iu  twatequeuve 
•f  gnat  odemm  anit  incipient  gaograoe  of  tlic  ftxit;  aAcr  the  extniutiou  <ir 
aymntity  of  fleili-Uke  nbrin  frum  the  »ac.  the  pntieut  iiiad«  uti  ext-vtlenl 
nui«u,i.  Thtaa  eaaaa  wuuld  cwrtaliily  iuKtifv  the  Surgeon  in  adopting  hucH 
■  evon*  ■(■«»  the  dnoiivr  of  pinj^rone  its  iiiimincut,  and  <lL'pciid<'iit  <m  thg 
■w  mai  pnaMurw  tif  the  tumor.  Hhouhl,  hnwcvur,  thu  gaiign-iiH  tihow  any 
AlpMMtlini  In  axtend,  orshnnlfl  them  he  h«mnrrhHg«  fniiii  ihe  ni<-  Hl\cr  it  has 
drat  tMHB  laid  open,  the  Hiii'S'eon  must  hold  himiti>lf  in  reiulinrHH  to  Minpulati^ 
■khiMt  cMmt.  When  ^n^Trne  has  onre  fairly  set  in.  there  is  no  rpn^inulile 
prMMci  fif  mvinf!  ihf  liinh;  and  the  s^nnner  nin(>iiialion  is  drtne,  the  better. 
Thtt limb  mtua  alvay^  ht-  rrnioved  hiffh  up  above  the  ear,  and  if  pnaaible, 
■ol  only  Ml  <nni^  r!i.<titir«  from  the  pnii»  that  have  niortifief),  hut  also  above 
thepmrt  t<  ':>'  t^-riMiK  iiitiltnttiou  that   precedes  mortifirntior)  hns  ex* 

iMMini.       i  "T  L'Xirvinily  iiUD't  };envnilly  be  removed  nl  llic  i^houJder- 

jflinc ;  lh«<  lowrr  nbore  Uiv  middle  of  the  thi^h.  Id  th<^^«e  ca»e«  there  will 
ily  be  a  c'>n4iJemble  aoiuunt  id'  henjorrhage,  and  many  veseela  will 
Uk  be  ti«<d  ID  the  atuiup.  in  ootttequence  uf  tbe  eolargemeDt  of  Ihe 
'  rirrulalion. 
Lonpitw*t'.'X  uT  iMTRintEyi*. — Id  consequenee  of  the  dangers  and  diffi- 
alteudaol  u[>ui]  the  use  of  the  ligature,  Surguuiu  have  eodeavured  to 
BBvantm  by  omi|ire»iou.  The  employmeal  of  direct  preraurv  uu  the 
■•  TCtt  aimoM  uatumlly  5ugpesied  as  a  mesDa  to  counteract  the  ex> 
of  the  dlMue  by  the  prewure  of  the  b)o<>d  from  within,  and  bas 
Illy  been  applied  from  a  very  eiirly  [wriod  in  tlie  treatment  of  the 
Thb  plaa  uf  treatment  was  first  employed  by  Boiirdelot  at  Iho 
of  the  •eveateeiitfa  century;  afterwards  by  Gen(rn,  Hei&ter,  Guattani, 
aad  ollwnk  These  ^urg:eoDs  made  the  prcs^un.'  directly  upon  the  sac;  and 
Gaaltaai  ukI  Klajani  rtdnte  several  imres  thiii  they  effected  in  this  ivny ; 
Wu  llie  mrtluMl  wis  >»  uncertain  tn  itit  results,  and  so  dangerous,  fnttn  irri- 
tatise  and  inlUtiitng  the  lae,  ihut  it  fell  into  disuTc.  The  French  Surgeons 
falf«aoerd  a  oi'wliliratiou  of  the  pressure  plan,  by  laying  opt->n  the  sac,  clear- 
tajc  uat  iu  contents,  and  applying  the  pressure  dircelTy  over  the  opening 
iuo  tbe  Tnarl.  r>rsebamii«  cxprMcd  the  artery  leading  to  the  sac,  and  coni- 
mrmti  this  arith  an  ttutninient  which  he  teWcd  the  "  nreiue-arttre."  These 
larlMrvM  modes  of  trrnlment,  however,  wt-re  entirely  M-t  a-iide  by  the 
fceJHiy  aail  enaifamlivn  fiucrew  <-f  the  Iluaieriaii  o[kfmlion;  nn<l  t-uinpres- 
tiii*  in  an*  <*  rspr'ly  prHctuteil  hy  ^^ur^'t^)nM  alter  the  great  step  made 

IrJWta  ll  ;h^  trt-stuifnl  of  iImk  diHej^w.     Vet  we  hm)  that  Juho 

Hnalar  biiu»i<i  l-l  it. I.  ami  Freer  nttemplvd.  though  without  >iuccei«,  to 
ail*  tbisduea*"  i'<  j<i'u-ure  on  the  arlery  landing  to  the  sac.  Pelletan  nud 
Itebnia  apfwar  to  have  been  the  fin<t  who  sitccratfully  applied  pn-vsorv  to 
Iba  artarr  abiivr  the  aar.  inslrad  of  to  the  nueuriein  il«elf ;  this  was  in  l?tlO. 
After  Uua  period,  ▼ari«Ds  attempts  were  made  methodically  to  treat  uncu- 
n^  ia  tUa  way ;  but  tbe  merit  of  having  iiilnMluLvd  the  practice  of  mni- 
•raaaoB  to  tbe  tnalmcot  of  aueurt»m  into  modem  surgery,  of  hiiving  given 
■I  B  defioiUi  pifice  in  our  an.  and  ni'  having  pitiahliHhe*!  the  true  principles 
rhicfa  it  ads,  iDctintnilahty  lielongs  m  the  Dublin  Surgnms;  amongst 
tbo  aames  uf  Hutloo,  Hellingham,  TufocU,  and  (.'-arte  dnerve  especial 


fkiDdpla  of  CoBpTMiieiL — In  the  early  iriaU  of  the  cure  of  ■oeurisin 
fej  aawpf— tng  the  artery  on  the  cardiac  side  uf  the  tumor,  the  Surgeons 


156 


AKEUBI3M. 


who  employed  this  method  nctod  od  rd  erroneous  theory:  and,  the  prindpie 

not  being  UD<lcrt)U>od.  the  practice  uii«  bad.     It  was  eupp<Mcd  ihM  it  wh 

ii«c««Mry,  in  urd^^r  thut  a  ourv  might  tiik«  pluce.  (hat  tlii.'  whole  flow  of  bUxii 

through  the  art«ry  slioul'l  b«  arretted ;  that  inflarniiiHtiitn  uf  the  veMcl  at 

the  piiint  cumpreoevd  sliuiild  be  set  up;  and  tlmt  the  cixiB-ili-latioo  uf  |h« 

aa«umti)  depended  upuii  the  oltslructiuii  vf  the  vessel  <:'uuiK'|ueiit  ufxto  thii 

intlaiiiiiiutiuM.     ThU  l««l    to  the   titnplnyiiieiit   uf  i^uvh   violent  and  f'-rt-iblf 

cumpri^fum,  with  the  view  of  excitiDK  in6Aiiiiiiatton  in  tb«  artery,  thnt  tli« 

pHtieiil  oiild  eelduiii  b«ur  it  tor  a  Hufhcit-nt  len^'th  of  time  to  «fl<«t  k  cure; 

iflou^hing  <jf  th«  »kin  coiuiuuoly  rtsullin^  fn»in  the  severity  uf  tbe  preaaurv 

to  vrhiuh  it  nag  eiihjected.     To  [he  Dublin  Surgeuns  b<;k>ii|^  thts  very  graal 

merit  not  only  of  having  pointed  out  the  emir  of  this  doctrine,  but  having 

diatinotly  laicl  down  as  tlio  principle  of  the  pmcticc,  that,  iu  the  loajority  n 

coset),  iho  auisuriem  wan  cured,  when  tbe  urtery  leudin):  to  it  waii  conipn^aod, 

in  precisely  thv  same  way  it^  whi'U  a  sjKiubioetiue  eiiru  tak«i^  place,  or  wbcB 

the  Iluotertau  operuti>m   is  iMTformed— vii:.,  br  the  dopueii  of  ^iraiified 

Bbrin  in  the  hac,  iiud  by  the  t^niiU'quem  uonitoltdiiLion  nf  this  {,¥\g.  4>')d), 

aided  by  the  contraction  f>f  the  walh  tit'  the  sac ;  and  thst.  aji  in  the  onie  nf 

ligature  of  the  v^>»«el,  it  was  not  ocrcMury  that  the  vrhult 

of  the  eirrnlation  through  the  artery  i^hnuld  Im<  entiralj 

and  ncrmnnenlly  nrrf^ted.  but  merely  tlmt  it  *hiiuld  be  !«• 

Denen  in  iiuanlity  and  f'ln-e  to  such  tin  exii-nt  a*  to  be  oota- 

[inliiile  MJ[h  the  defnwiciiin  of  laminated  tihrio  in  the  me; 

and  it  WHB  clearly  nfiown  by  examination  after  death  tltal. 

if  tlie  preMure  w«ra  properly  conducted,  the  artery  waa  lo 

no  way  injured  or  oi.-ctuded  at  the  part  t-omprevevl.     Tb« 

reeojfnition  of  the  true  principlea  on  which  compreaMoa  uf 

the  artery  leading  ti>  the  eac  cure*  tbe  aneori»ra,  has  lad  lo 

iiiiptirtaut  re»mlt* ;  for  a»  the  severe  premuru  that  waa  ft*- 

merly  considered   necefcjary  n  now  known  not  only  (o  b# 

unuecewary,  but  oReu  to  be  absolutely  iujurious,  no  amouol 

<»f  comprmeiun  la  exercised  beyond  what  is  re(iui«itij  to  n- 

atraiii  and  nuNivrate  tbe  flow  nf  hliKxi  into  the  Kac :  no  a^ 

tempt  living  miule  lo  cninprvAK  the  artery  bo  severely  aa  to 

VIg.  <»i.^»M  of     l*^'l  '"  i^  obiiLeruttiin  by  inflammation. 

AnaarlnaMrW        I^u'-  although,  where   the  pn»iure  is  raixlenite  or  tiw 

by      CvtapTM.     anaiilomoi'ing  circulation  free,  the  cone^ilidation  of  the  ooo- 

tiem:     t>*|io*it     leata  of  the  ^ac  taket<  plnce  in  the  way  thnt  has  just  bem 

of     LauiiMud     dmcrilwd,  it  would  be  an  error  to  euppoee  that  tbia  is  tb« 

niMin.  process  hy  which  tbe  aneurism  beeoniM  cured  in  all  OMn 

in  which  recnarse  ts  had  to  compreeaioo.    There  can  ba  no 

doubt  that  in  .lomr  cnflea,  where  cunmlidation  has  taken  place  in  a  few  hoan 

after  tbe  employment  of  pressure,  coajtulalion  of  the  contents  of  the  aac  has 

suddenly  occurreil;  and  this  sudden  ctjofnilotion,  which  at  one  time  was 

drpiulod  hy  .Surj^eons,  ha^  been  found  by  inerMMd  experience  to  be  in  the 

highest  degree  advantageous,  as  loading  to  a  more  rapid  and  equally  oertaia 

cure  of  ihe  Riieoritin). 

In  iIr'  (ubulHr  f<irm  of  nneuri»oi.  which  ia  far  less  fre<^iient  than  llie  mc- 
culKti>l  in  llie  extmiiiliev,  (he  cure  ai{>|>e«ra  t"  lake  place,  if  it  ucuun  at  all, 
ralbvr  hv  tlie  i^mdual  cKiitriii'iioii  of  the  |mrtiHlly  emptied  aao  Uuui  eitber 
by  the  olow  di'iiwit  of  lamiiiHU'*!  liliriii,  or  by  the  rapid  and  alrawt  Mdden 
Ooaguliition  of  ittt  ci>nlenl«.  The  »ac  graiinally  Bhrinkit.  nud  eilmil*  >>f  fibrin 
only  are  f^>und  adlierent  lo  iIm  aide*.  13ul  altbuuxli  I  Ix-lieve  tiial  llie  cod- 
dilion  of  the  aneurism,  whether  peculated  or  tubular,  lias  a  oiuniiU'rablfr 
iDfluenct!  upon  the  mode  in  which  comprc»ion  tu'tn  in  rfrcL-tinji:  a  rare,  and 
also  ujMiu  tilt!  time  that  u  >x:oupiud  in  tlie  irvutment,  thta  being  much  shorter 


TKKATIIEST    BY    IKSTRUUENTAI.   OOMPRESSIOK^         151 


ralatiHi  thnu  iu  1I113  tubular  furiu  of  (lio  tli8t;ii.^;  vet  then  can  he 
loubi  Uist  lliiB  t6  malL'rially  iiiQiienccti  uleo  by  two  other  circutD«tjuice« 
'  '.,  the  ouDflitKBi  uf  ibe  blund  within  the  nc,  aud  the  corapkteiieM  of  the 

WiMO  the  a»c  B  filled  with  flulil  htoud,  aod  the  compreseion  ia  not  uoia- 
iptodly  oumplt-tti,  the  sue  appears  to  empty  it«elf  to  a  oon^identble  ex- 
■ow,  aftd  eventually  to  txmaolKlate  hv  the  ilopcwtt  of  Uininat«-<t  Hbria. 
Bu.  U*  tbe  wc  already  cfminio  some  solidified  Urern,  and  (li«  cuni[irv«eicia 
be  PoaliaatNH  aod  coinplele.  the  ouagulutjou  or  t)ie  rt'inaininK  lt*iid  part  of 
km  blood  t«  apt  Lo  lake  place  rnth^^r  AiKliienly.  But  iu  all  c«m-»  tlie  cuutrac- 
tftw  vt  iht  Mc,  oiHurquf  Dt  upoti  the  nrre»t  or  re«lniiiiL  vf  Uiv  current  nf 
blood  Ittio  it,  la  an  iiii[Mtrlnul  t-U-nit-nt  iu  lh«  cure.  llluKtriUivv  of  this  mode 
of  ciif«,  thrrv  u  a  preparatiuu  iu  tbu  Muxeuni  of  Uuiveraity  CVIIege  (Fig. 

Fnwa  all  tliiai  then,  it  would  appear  that  the  consolidatioa  aaj  care  of  an 
aaMrWD  bj  euiuprMsi«n  may  uke  plac«  io  thre«  diHereot  ways:  1.  by  the 
■Itf*  tWn»it  nf  lamttialed  hbriu:  2,  by  rapid  coagu- 
labuo  (j(  thr  coDt«nt«  of  the  sac ;  S,  by  cootractiou  of 
lla  aae.  The  paitioular  inude  of  cure  will  depend 
tbe  ootnpleteDeM  of  the  comprUBioD  aod  the 
or  len  parftct  armtof  the  blood  iu  tbe  sac,  the 
ibtlity  of  that  blood,  and  the  shape  of  the 


..<^ 


nmiitiiii  III  Indaencuig  Succeai.— The  success 
tf  cIm  traaiment  by  c>imprv»»i<ia  depeuda  vreatlv  u\kh\ 
a  SDVpsloafl  atti'DtiuD  Vt  a  oumbt^r  of  inioor  circutii- 
■aaOB,  which,  ihoujrh  oarh  be  triding  in  ilM'lf,  he- 
osaa  of  imp-irtaocQ  whpii  takeu  a^  a  whole.  Duriu); 
Ifcc  wbcile  of  the  treatlDMlt.  also,  the  pati<?iit>  ccncnil 
faaalth  ahuald  be  atteoded  lo  in  accordsncv  with  thiisi- 
dietetle  and  medical  principles  that  have  ulri'sdy 
Kms  laid  duwu  io  speakioff  uf  the  coustitutionul 
malAeiu  uf  the  disuue.  The  irritahility  of  the 
heart  luutt  aWt  be  subdued,  and  the  irritatino  of  the 
^«etti  Irarupd.  by  thv  u*e  of  optAt£«  nr  of  chloral ; 
Mid  the  potirul  ih'auld  he  put  into  a  comfortable  bed, 
«ith  Ar™  and  well'SMured  pillows  and  mattreoses,  so 
tWih.. 

^. 

■a  w  lo  rw" 
b— iagii  « 

thoa  be  cnt 
4f  Um  NCC 


Pic.  4MU-«u  of  TuVulv 

AlMUrliM       o«rai)      bj 

CompraatioD ;  Cmitrao* 

iIab  of  S««,  aad  Irrvgw* 

lar  D»|.o«lt  of  FibriD. 

may  nut  be  changpd.     As  it  is  prin- 

ii*ni  uf  ihf  l.iwtT  extremity  that  cotuprewiun  can  be  em- 

-.Mrt-f-nl  to  ■ItT'cribf  the  tuulhoU  vf  iltj  Hpplicatiun  here. 

:  the  Compreasor. — Tlio  llii;.'h  should,  if  ntttwary.  l>e  ^liaved. 

lir.     The  elciu  t^hnuld  tbiru  be  powdcreil,  and  the  limb 

r<'II':r  :  ii  fwd  U-iug  Inid  on  the  tumor.     Pillows  must 

:  und<:<r  it,  lh«  knee  being  isemiflexed.     Much 

^utwill  depeud  u)mid  the  kind  of  inatrumeot 

The  ordioary  (KtricahDe,  or  Si^noriui'ii  tourniquet,  was  the  one  first 

.,  BCd  ihia  will,  in  many  cauv,  amwer  tbe  purpose  perfectly  well ; 

ta  ii  VMBowhat  difficult  to  rt-fnilale  the  pnwure  with  this  itHtrunicnt, 

fe  ii  ool  uorreqaently  exen-tsftl  too  [Mwerf\illy,  it  has  eenerallr  piven 

at  tbe  pmeat  <faiy  U>  the  very  inj^i'niouii  aii|HiratU5  of  Cnrte.  wfiicli,  ss 

IhtI  '■■  cloMic  force  derivi>4l  from  vulcnnizMl  India-rubber  bnads 

thi-  -ag  preanire  of  tbe  ncrew.  nctiimuKMlntes  itwif  blotter  to  the 

ar»l  w  l*aii  itKfly  t<>  pnwluiv  iiijuriotifi  comprewion.     Thi^  ioiitniment, 

ell  m»  ihr  <fthi-r  iH)ttiriviiiicea  whirb  have  at  TBriotiB  times  hern  invented 

iri»tia*Dl  of  aneurism  by  comprettino,  are  dcacribed  by  Belliogharo 


168 


I8M. 


mill  TuHnell,  tn  their  works  <m  this  uibject,  to  wbic)>  I  must  r«/er  for  t 
fViller  awnmnl  tlma  I  cap  hen'  give. 

[  |Io  applviiig  tbc  cumprcseur,  especial  core  tiiurt  be  takeu  that  it  u  »p1I 
paiMotI  ja  every  part,  so  tut  uot  to  gall  the  ekin.  lo  «oiue  uf  tbv  early  caaei 
ID  which  I  Euw  eoinpresaion  erupluyed  in  Loodoa  by  menus  of  tbe  horauhoa 
tiiuniii]Ui>t,  uiueli  iiiiMuvenience  nwullcd  from  uaut  of  attentitm  tn  thia  p«r- 
Ucutar.  The  (eiiiK'nry  to  fretting  of  ihe  skiu  is  mtieb  letwene«l  by  ptmdpring 
tbe  iiiiib;  aaii  tbe  reiuoval  of  the  bairs  by  sbaving  rliniiiiiitbea  matenally 


Vlg.  U7'— C««|>r«r«ar  lor  ih*  MI4d1i>  af 
lb*  thigk. 


tig.  tM.— CWBprwMr  fnr  Ik*  Urola. 


the  irritation  produced  by  the  instrument.  In  order  to  keep  up  continuoufl 
preasure,  and  at  tbe  sniue  Ume  Ln  prevent  nor  one  part  o(  the  skiu  fron 
Deiop  injuriously  galled,  it  is  of  very  great  coaK-(|uence  ttiat  two  iastrumesla 
alioufd  be  used  at  tbe  same  time,  w  tbat  when  ooe  is  screwed  down  tb«  olfair 

may  be  loose;  Iheee  iiutramiisli 
O  need   not   be    placed   cloaelv   ti>- 

gclher.  If  Uie  nneuriam  m  ia 
tbe  ham,  it  will  be  sufficient  for 
one  (.f>^-  4AS)  lo  bo  applied  lo 
the  gruin.  whilst  tbe  other  (Fig. 
4&7 )  is  put  u  pen  tbe  middle  of  tu 
thigh  (Fig.  459).  In  using  tba 
instrument,  tbe  great  point.  ■• 
Tiifluell  niiMft  pn>)i<.-rlr  ncmarhi^ 
id  1^)  rnotrol  the  circulation  irilh 
tbe  minimum  of  prvMure.  lo 
onler  tn  do  this,  the  fimt  iiutrtl- 
mrnl  Hhnuld  be  screwed  down  le 
tbat  all  pultnlion  cea^eA  in  the 
tiinxir,  but  i4till  not  8>i  ti^htlv  aa 
comnleletv  ti>  nrmt  all  the  ^»« 
of  blood  Uirougb  it.  As  tbe  pr«SMire  exercised  by  tins  become*  painful,  tbe 
•eoond  one  must  be  screwed  tight,  aod  tbeo  tbe  firat  comprovor  may  b« 


W\$.  4*9.— Two  r«in|inMfDr*  ajiplM  far  Pantvrv- 
puplilnl  AnosrinB. 


70BMS    or  COHPHXSSORS. 


159 


la  Udl  w»^  ao  nlKroatioD  of  presauro  can  be  kept  up  without 
or  iBcoavenienM!.  Ifpimiblc',  (he  putit^nt  sbiiuld  be  (aiicbt  how 
BUikAx*^  the  ittsuiiiDCUt  hiiiisL'If.  and  will  uft^'n  find  t»ccuptition  und  amuae- 
st  in  duing  lo.  If,  htiwcvcr,  it  vxctten  much  pain  nt  irritnlion,  as  it  does 
la  mKue  wibjcctA,  it  may  be  neccMary  to  give  opiatcfl  or  chloral  hydrate. 
^w  prvBAure  !«huu1d,  if  pAMible,  1>cooutinued  duriiifi;  sleep;  bill  if  ic  prevent 
tKr  [Aiirnl  fnttii  taking  )i'h  tiaCural  re«t,  the  augf^tton  made  by  TulTndl,  of 
voMivwiog  the  iii»trutupjit  sli|;htly,  and,  when  the  patient  t«  asleep,  ifently 
tWfct— litiif  it  again  vrithont  awnkening  him,  may  advnntageou.iTy  be 
MofMcd ;  it  b  indved  Burpri«iag  how  very  little  iioecrewin};  will  relieve  tJie 
■ua  uf  ibe  cijiupre^iiiiu.  A  lar^e  rradle  should  be  placed  over  ibe  jMttent's 
oody.  o  that  the  weight  of  the  bed-clothes  inny  be  l«l(eu  off  the  HpjnLralue, 
sod  thai  the  ivtieuc  may  mauaL'e  It  without  risk  of  dti^turbance.  Should 
tlMT*  ■till  b«  inoch  uueuintws,  the  iiMtrunicut  might  be  tukeii  oU*  for  ii  lew 
boon,  and  oanpnwiuti  kept  ut>  iu  an  iuttfriuitlcul  ninnuer.  Evvn  in  etich 
areaBHteOflea  w  tbcae,  consul idatiou  of  the  site  luny  ennue. 

la  aoaw  c—c  in  which,  from  thr  situation  of  the  aneurism,  devp  and 
itm  pfMBUn  it  rei|tiirfd  to  rontrol  the  rirrulatioii,  the  pain  hccomts  to 
BBBadafaUe  that  the  patient  caimot  niibmit  to  the 
tnaUaeat  •uHIdenlly  long  for  a  gooil  elTecl  to  tie 
pf-^'-— '  In  aiichi-aaes  opium  or  chloral  liydrale 
r.  '  ^D  with  advantage,  so  as  tn  enable  the 

^Lirai  in  bear  the  prearare.  But  in  eome  iQ- 
MuflB  more  rorapk-te  narcotism  is  necessary  for 
kha  tn  eadure  tt.  In  these  circiimsljuicei.  cfalo' 
ndarm  heAi>mf»  a  m<Hit  useful  adjunct;  nnd  by 
■aia::  -    'icatuestbesia  for  several  hours,  the 

aaooi  Uiratlun  of  pressure  requisite   to 

iAkx  -ire  ntny  be  maintained.     In  tbta 

way  N\  I ,  of  XewoiAtli'-on'Trne — t'l  whom 

ii  dtt*  tar  merit  nf  employing  prolonrred  NU»a- 
tfaMa  aa  an  adjunct  to  c»nipr(;Mtou — cured  an 
aaaariiai  of  thv  ntxhiminal  aorta  by  keepiug  up 
pnaair*  on  that  vevtel  for  6ve  hoars  under 
cUunCiirai.  Heath,  of  the  tumt  Viwn,  cured  on 
■— liiiii  of  tlie  extVTDal  ilinc  by  comprcninK 
IfaaalMlQauial  aorta  fiirMvctrhoure  under  chluro- 
fcna;  llapotb«r.nf  Dublin,  treated  on  ili>.^femoral 
aaiariRBneoa*futly  by  coni|>res8ing  therominon 
Biaffantrf7f<irroarand  a  half  hours;  and  Lawsoo 
Inalad  an  tnniioal  aneurism  Bucceaifutly  by  prw- 
mn  oa  the  suominal  aorU  fur  four  houre.  Iu 
ttm  anan  of  popliteal  aoeuriani  I  kept  up  com- 
ly   obrtnctiug    prewure   tm   the   common 

arterr.  under  chlumform,  fur  twelve  hours.  By  the»e  means  the 
•eri-MU  obiectioa  to  tbu  employment  of  pn^eeeure,  and  the  mmt  common 
of  Iu  failure,  may  be  prevented ;  and  it  is  clear  that,  under  chI«ro- 
ftaa,  praaauK  may  be  applied  to  artcrie«,  such  oa  tlie  subclavian  and  camlid, 
Ml  wilieti  k  could  not  olherwlie  be  niKd.  The  employment  of  a  Htlffht  may 
— irtiairj  be  advantajjetiu^ly  !tubHtttnted  for  the  clamp,  and  oflen  oci^aaionB 
ima  di>lr«aa  Ui  the  patient  For  this  purpo«e  the  upparatua  (Fig.  4fl0)  will 
b»  (ittod  xtry  uflefbl. 

A  ntfy  smpU*  cnmpreMKir  in  TuffnellV  represented  in  Figs.  4fil,  402.  It 
f^MMto  »t(  littl*  mnm  than  a  truM  )*i>rin^,  tvilh  a  pad  to  c«)nipreMi  the  artery, 
mmd  ateap*  U*  Rx  it  to  it*  place,  aud  increaw,  by  bising  lightened,  the  force  of 
iha  coaipuMiiin. 


Fig.  *flO.  —  P-  n.  W«t»no'» 
Wrifht  Comprvator.  Tk| 
eircnlAT  doUeil  lins  ibooi  tit* 
pMltJoB  of  lb*  II tub. 


X»0RAT]ON    OF    COUPRessION— TREATMENT. 

1.  tbe  aoattumotiog  Tetsels  enlarge,  with  a  gotKl  denl  of  burolDg  pain 
ia  the  limb  gmenlly,  utd  arterial  puUatiuuB  in  siluuLiuoe  ftlit-ic  uhualh 
wmm  an  felt.  Tbo  aboormal  pulpstioQ,  in  theee  catei.  ia  alwajB  fouud  to 
is  [Davli  the  aane  litantioDe,  the  saoe  veR!e)s  appeario^  to  undergo 
Thtu  Tufnell  hoii  made  a  reuiark.  which  1  have  had  aivte  than 
•■•  opportunity^  of  Tcritring,  that,  iD  the  ireatiueDt  of  popliteal  uueiimm  hy 
CBMpnwoa,  tarte  irlerurs  will  he  fbuod  to  be  eQlarced.  oii«  of  which  pifsca 
•vcr  Uw  centre  of  the  luiaor,  another  over  the  beau  of  the  fibula,  and  the 
ikinl  aioMit  the  uiDer  ed^e  of  the  patella ;  he  states  aUo  that  the  severe  burn- 
tttg  piin  vhich  u  felt  in  dieae  caeca  ia  oHiog  to  the  artery  aceompeDviD^  the 
c— Biupicii*  pcruuei  nerve  being  ealarged.  After  contplele  sol idlfiva Lion 
of  the  tuuur  baa  takeu  place,  ibc  comprcgsiou  ought  to  be  coDtioued  for  at 
kaat  Ibrtj-eisbl  boun>,  m  as  to  aceure  agaiusl  tbe  occurrence  of  a  relapse. 

TSa  Intrauoii  of  tbe  Treatment  varir«i  vory  greatly.     In  eomc  caee»,  as 

mbore  atatrd.  ihr  tuuior  hua  U-rntue  aoltdificd  in  n  ft^w  hours,  or  in  two  or 

ibrcc  ilayai.     In  olhi-r  inhlanriii,  thi>  tnalineot  hae  n-quired  tu  be  pnttrarted 

ior  toon  ibao  thret:  HKintha  l»efnr<>.  a  rur^^  has  resulled.    Of  '2ti  cam  of  fi-uiural 

or  pnplitcal  aneurism  rtired  hy  conipresaion  in  the  Ijondon  hwpitats,  tbo 

«Tcr«fr  tituf,  atrcnrdinK  to  FTulchinaon,  was  nineteen  days.     Barvell  has  col- 

Urtf  r1  frttta  American,  Rritiiih,  and   Continental  jnunmU  all  the  recorded 

rsMra  of  fioiiliteal  aneuriiitu  cured  iv  comprefwinn  in  the  ten  yearn  1A70  to 

indtuife,  and  be  ^ive«  tbe  followinfr  statistics  of  the  duration  of  the 

,       ,^.-;^urDt.     For  iDStru mental  cumpre«sioQ  the  longest  period  waa  7  weeks,  the 

I     tbortai  'i4  houra,  the  nieao  of  19  caaes  in  which  the  lime  was  recorded,  12 

'      ^"--  -.  for  diuital  cunipre«*ion,  the  longwt  period  was  2X  days,  the  shortest 

ura.  and  the  nieau  of  13  ca:»e«  0}  daya ;  for  combined  iiislrutoentnl  and 

nipreeaioD  the  loogcat  period  was  fix  months,  the  shortest  44  hours, 

I  I  nm  of  1*2  caacfl  44i  days.     Much,  of  counte,  wilt  depend,  in  this 

'  '  >   cvn-titutiou  of  ihv  patient,  and  ou  ihecouditiuu  of  the  tumor; 

.-•ncva  wliiL'h  are  most  favorable  to  the  Bpontaueous  cure  of  the 

LdOi  HiU  al&o  inilueucc  the  rapidilv  of  the  euro  by  Ci>m{in>aiion.     There 

uduubtedlr,  ivrtain  cuuditioua  ul  the  bltHxl  in  which  it  is  little  dis- 

|D  oo^u^le,  and  in  tbese  caaes  tbe  duration  of  tbe  treatment  will 

ily  be  prolonged.    So  alau,  wbeo  the  aneurism  ia  tubular,  we  must 

opcct  tbat  tbe  bl<NMl  which  paatieti  freely  through  it  in  tlie  direct  current  of 

iha  drcalatioo  will  be  alower  in  undergoing  those  changes  tbat  lead  to  ita 

■■■aiiliilaliiiii  than  when  the  diseaae  h  aaeculated,  and  thus  contains  a  re^ 

•idaaoi  of  blood  tbat  ia  not  ao  directly  inBuenced  by  the  curn>nt  through  tbe 

mc.      lo  tbe  early  daya  of  the  com preaaion- treatment  there  was  an   indi»- 

pcattiao  on  tbe  pan  of  Surgeons  to  apply  it  very  effectually  and  firmly,  and 

a  Uager  ttma  waa  exj^eoded  over  it  tnan  is  now  generally  the  case  ;  and  the 

cSMDple  ael  by  Murray,  with  regard  to  abdominal  aneuri^im,  has  been  fol* 

li«ca  vitb  snccrai  in  respeei  to  the  femnral,  popHti-al,  and  other  forms  of  tbe 

Jfaaaa,  lb«  comprtMor  being  screwed  down  tight  on  the  artery  ao  aa  com- 

flMdy  Itt  ■rrat  for  the  time  all  circulation  through  tbe  aac,  tbe  patient  kept 

■Bder  cUoRkTorm,  and  tbe  cure  t-lTected  in  a  fo w  houra. 

AjpUMbOl^.— Of  the  great  valui;  of  compression  in  the  treatment  of  aneu- 
niB,  tbcrv  can  b*  do  doobt;  more  apecially  when  the  tumor  is  situated  in 
ftbaaitanea  of  lb«  lower  txt/emily  below  tbe  middle  of  tbe  thigh.  In  uneu- 
nam  oecarriDg  in  ibo  vidniCy  of  tbe  trunk,  aa  lu  the  iliac,  tbe  carotid,  sub- 
daTtaa.  and  axillary  arteriea,  it  is  generally  not  ao  applicable;  although,  as 
vt  bavt  abrcady  hcd,  aneuriama  in  the  groin  bare  been  cured  by  compree- 
mtn  m(  lb«  abaaaioal  aorta,  or  of  the  iliac  artery.  Spontaneous  aneuriuo 
iaeiAfviDcIy  ran  in  tbe  upper  extremity;  and.  as  llie  traumatic  forme  of  the 
bJcb  oerar  b«re  gcDcrally  require  tbat  tbe  aac  tboald  be  laid  open, 
tvt.-  II— 1< 


16S 


ANBUKISH. 


it  u  Beldom  fuund  ncceaiary  to  ksve  raeouree  to  U  in  IhU  nart  of  Uie  bodj. 
though  it  may  be  nod  lias  been  Biioeceafblly  applii^d  ui  the  uruchiul  nrt«ry. 

The  great  qucatluu  with  regiinl  In  coruprL-seioii  nppeare,  afite  nil,  Ut  be 
whether  it  pue««0e8  any  ^jtecinl  udvantac;bs  ov«r  thfr  ligAtiiR>,  in  thu  truatmeat 
of  th<«e  nncuri^nia  in  which  its  omplornictit  is  pructieable.  The  friutipti 
obj<K!tiuufl  that  hnv<;  hocn  ur^'d  aj^uinM  <Mniiir(^£8ioti  are,  that  tU  em^ojnncM 
is  more  painful  and  tedious  than  the  u.4cof  the  tip^atiiro;  and  thnt  thnaa  emm 
that  are  unpronmiiij;  to  the  ligature,  or  that  rrquire  amputation  rather  than 
[delijration  of  the  artery,  n re  equally  iinfnvorable  to  corapreaaion,  and  cannot 
be  Haveti  by  itn  employment. 

Tothene  objections  it  may  with  justice  be  anawered  thnt  the  pain  attendant 
on  the  employment  of  compiviMioD  depetidi  very  j|{r«atly  upon  thf  nkjll  and 
care  with  which  the  apparatus  is  applied  and  mnna^rei)  thmiiKhoul,  m  well  aa 
upon  tbe  kind  of  inetruraent  u»kI.  hein^  certainly  much  diiniQittbe>^  when 
Ckrte's  «la«tic  cr>Dipre#«or  is  employ«<) ;  and  that,  nx  han  already  iK'on  fthown, 
the  pain  may  be  uvercume  by  lhi<  use  uf  an»-«th^aic8.  With  regard  to  tba 
relative  Lcdioueuees  uf  the  treatment  under  the  two  plans,  it  wuuld  apEHiU 
that  in  reality  tliere  ie  but  little  difTereuce ;  fur  althim^rh  Bi>me  t'.aMe,  In  wn 
oomprcnion  la  u»od,  are  prulungcd  over  a  runsidenil)]!-  »4|«cc  of  tima,  yai 
do  out  occupy  mure  ihan  is  nflen  iMinHumuil  nhnn  acidenta  of  varioi 
follow  the  UAC  of  the  ligature;  and  it  not  unfreiguently  happens  in  com, 
■ion,  hut  can  never  o(^•*ur  aller  the  employmrnt  of  the  ligature,  that  ih* 
patient  is  cured  of  hia  diKease  in  a  lew  huura  or  day.'!.  Taking,  however,  the 
ftvemges,  we  find  that  in  tbe  Dublin  pai>efl  the  treatment  lanted  twenty-fira 
dam  and  in  the  Lunilon  caaes  collected  by  Hulchiu9>in  but  nineteen,  and 
thw  is  nnt  verj*  different  to  what  formerly  hsppeocd  when  nilk  Ugatnn*8  weje 
applied  so  as  to  cut  through  the  artery  and  he  finally  wtthdrnwn  from  the 
wound  :  for  of  fifly-four  cases  recorded  by  Crisp  in  which  the  femornl  artery 
was  tied,  tbe  averaffo  time  for  separation  of  the  ligature  waa  eightei^n  dnva. 
and  if  to  this  a  week  more  were  added  for  tJio  closure  of  the  woanil.  and  tnr 
.the  treatment  of  the  various  iiccidcmj)  thai  ofU>D  accompanied  and  followed 
I  ligature,  we  should  probably  Ih>  within  ibe  mark,  and  yet  "nly  brinj;  thedura- 
>tJOD  of  the  treatment  by  the  two  loetbudei  to  the  same  level.  In  the  nretent 
|day,  however,  ligatureti  which  areeither  abaorbable.or  are  inleud«d  to  uecoroe 
iMcloeed  in  the  wound,  are  almoet  unlveranlly  eniploved ;  and,  as  ««ilh  tb« 
improved  methods  of  trealinj:  wounds,  union  by  first  intention,  or  within  ten 
days,  is  tbe  rule,  the  treatment  by  ligature  han  oorae  to  be  the  more  apeedy 
mode  of  cure. 

Surgeons  will,  however,  be  eventually  guided  in  tlieir  entimate  of  the  value 
of  these  two  plans,  not  bo  much  by  the  question  of  Hubmitting  their  |>atiuotB 
to  ■  slightly  mure  painful  or  tedious  treatment,  as  bv  the  com[uLmtive  risk 
of  lift  attendant  upon  one  or  other  method,  llpc^n  tfils  point  suttHtta  have 
yet  to  be  made;  jrartly  because  the  uiisucoeesful  came  of  iif^ture  have  not  been 
[Saoomroouly  nubUsbed  as  the  succenfui  ones,  and  partly  because  mifficiestt 
>tinie  has  hitnlly  yet  elapsed  since  the  general  adoption  of  nbetirbable  Uga- 
turcfl  and  of  antiseptic  treotnienl  to  enaole  us  to  form  a  current  eoncluaJoBH 
to  the  diminution  in  the  dealh-rnle  that  may  be  rfTecfeil  by  their  use.  Tla* 
folloa-ingstatiatios,  however,  mar  bo  quoted  aa  showing  the  average  results 
of  compression  as  oomimred  with  li^ure  aihI  tbe  steady  improvement  that 
has  taken  pbicc  in  the  latter  operauon. 

In  1851,  Bellingham  published  the  results  of  32  «im»  of  femoral  and 
ponUt«al  aneurism  treated  by  comprmition  in  Dublin  { Mfd.-tKir.  TVoaa., 
Tot.  34),  which  may  be  contruted  with  18K  cases  of  ligature  of  the  feroiuvl 
for  tbe  same  disBBse  collected  by  Norris  in  1949.  Of  the  32  compreMiioa 
cases  26  were  cnred;  inl  the  ligature  was  applied  after  prtasura  had  failed; 


RESULTS    OF    INSTKUUEXTAL    COMPRESSION.  163 

iD  2,  smpntation  was  performed;  in  1,  death  occurred  from  erysipelas  ;  in  1 
irom  cfaest-diaease ;  and  in  1  case  the  pressure  wns  discontiDuea.  Thus  it 
vould  appear  that  6  out  of  the  32  failed,  being  in  the  proportion  of  1  to  5.3 
cases,  aod  2  died,  being  in  the  ratio  of  1  to  16.  Of  the  188  cases  in  which 
tne  artery  was  ligatured,  142  were  cured,  46  died,  6  were  amputated,  in  10 
the  sac  suppurated,  and  in  2  gangrene  of  the  foot  occurred.  Thus  the 
deaths  after  ligature  were  in  the  proportion  of  1  to  4,  and  the  failures  or 
serious  accidents  in  that  of  1  to  3,  showing  clearly  a  very  considerable  pre- 
|>ODderaDce  in  favor  of  the  treatment  by  compression.  Besides  this,  in 
many  patients  who  recovered  after  the  ligature,  various  accidents,  such  as 
gangrene,  erysipelas,  secondary  hemorrhage,  etc.,  resulted  as  the  direct  con- 
sequences of  the  treatment ;  and  these  do  not  happen  when  pressure  is  em- 
plured. 

The  perfect  safety  of  the  treatment  hy  compression  was  fully  confirmed  by 
the  statistics  collected  by  Holmes,  and  published  in  his  lectures  on  the 
Surgical  Treatment  of  Aneurism  in  1874  ;  but  the  proportion  of  success  ia 
not  so  great  aa  in  BcUingham's  cases.  Of  124  cases  of  compression  for 
p>)plitear  aneurism  collected  from  the  records  of  British  hospitals  for  a  period 
(if  10  years,  t>6  succeeded  and  o8  failed.  None  died  directly  from  the  con- 
sequences of  the  operation.  Of  the  58  failures,  44  underwent  ligature  of  the 
femoral,  in  8  amputation  was  performed,  one  died  of  pleurisy,  and  the  subse- 
quent history  of  the  remainder  was  uncertain.  The  failures  were,  therefore, 
1  in  2.1.  On  the  other  hand,  of  77  cases  in  which  the  femoral  was  tied 
directly,  11  died,  or  1  in  7.  In  1  gangrene  occurred,  butthe  patient  recovered, 
and  in  1  seccmdary  hemorrhage  was  successfully  treated.  The  11  deaths 
were  caused  as  follows :  pyaemia,  3  ;  wound  of  vein  and  phlebitis,  2  ;  second- 
ary hemorrhage,  2;  gangrene,  I;  smallpox  and  disease  of  the  kidneys,  1 
each,  and  I  was  uncertain. 

Lastly,  in  1888,  Harwell,  in  hia  admirable  article  on  Aneurism,  in  the 
ItUemational  Eneyeiopxdta  of  Surgery,  has  collected  148  cases  of  popliteal 
aneurism  treated  by  compression  between  1870  and  1880.  Of  these,  68  were 
successful,  while  80' ended  in  failure.  Of  the  unsucces.'^ful  cases.  57  submitted 
to  li:;ature,  9  went  away  unrelieved,  4  sufl'cred  amputation,  and  6  rlied.  Of 
the  t>  deaths,  2  i»ccurred  from  rupture  of  the  sac,  2  fnim  "  thrombosis,"  1  from 
^n::rene,  and  in  one  the  cause  was  not  stated.  Durin<;  the  same  period, 
'■>7  \-a^aof  ligature  occurred  in  six  of  the  chief  Lr)iiilun  Ilnspitals.  Of  these, 
Indie*).  If  these  are  further  subdivided,  it  will  be  found  that  out  of  32  cases 
which  occurrefl  in  the  first  half  of  the  decade,  7  died  and  2  underwent  subse- 
•{Uf-ni  amputation ;  while  from  1873  to  18TH  inclusive, -So  cases  occurred, 
wiih  ;>  deaths  aud  no  amputations.  W'hetlicr  this  great  ini|»rovement  is 
merely  accidental,  <ir  13  the  result  of  the  improvement  in  the  material  used 
a^  the  ligature  and  in  the  treatment  of  the  wound,  remains  to  be  seen,  but 
(hfrp  i.->  great  reason  to  believe  the  hitter  is  the  true  explanalion. 

If  omipreA^ion  fail,  ligature  may  often  be  advantngcously  applied  ;  in  some 
rue*  with  a  lx.-tter  pnwpect  of  success  than  if  C'lmpressioii  had  not  proviou.-»ly 
l>wD  Iricnl.  that  treatment  having  caused  the  collateral  circulation  to  enlarge, 
aad  thu.-  lesM-ned  the  tendency  to  gangrene.  If,  liowever,  we  take  tlie  general 
averairc  nf  thfiee  cases  tiiat  have  been  i-ubmitted  to  ligature  after  the  failure 
"f  ctHiprejfsion.  we  shall  find  that  the  result  is  not  so  satisfactory  as  when  the 
ligature  ha^  iR-en  employed  as  the  primary  method  of  treatment.  Thus  I  tind 
thai,  out  of  -U)  coBi'S  in  which  the  ligature  wa,-  employed  after  compresi-ion 
bad  failfl,  there  were  lt>  deaths.  This  is  probably  not  so  nmeh  due  to  the 
preTJiiu?  employment  of  comjiression,  as  to  tbe  same  caii.ses  interfering  with 
ihe  consul idation  of  the  tumor  after  the  ligature  that  had  prevented  the  sue- 
of  the  compression -treatment.     With  regard  to  the  facility  of  ligaturing 


164 


ANKUBISK. 


uterysach  ai  Uio  femoral,  iilWconipn«Hi«n  hna  been  tried  and  fklled,  it 

itut  be  admitted  tbiit  tht-  i)i6Scu)tiM  are  iocreueed.    The  aheath  of  tbeveHel* 

Ph  apt  to  become  tbick«Ded,  lafiltnited,  and  tlie  nrt«ry  and  vein  perbapa  Icae 

leasilT  arpiirable  tbun  whea  prewure  tiai  out  previousljr  been  eniplovea.     la 

fact,  it  must  be  said,  tbat  ia  sucb  cases  tb«  Surgeon  bai  Dot  to  uo  with  a 

TirKJu  artery. 

It  should  bIs^'  out  be  forgotten  that  io  some  cases,  as  nbeD  ancuriiBl  it 
ODuplicHlcd  with  heart  diaeute.  or  occurs  iu  a  very  brokeu  nud  uiihealUi^ 
confitituliou,  in  v^hicU  the  operation  oecesear;  for  ligature  would  scarce!]'  or 
not  at  all  bo  odmiseible,  compnvsion  may  be  safely  employed. 

Aflcr  carefully  ooDBideriDg  the  relative  merita  of  iho  two  plans  of  tresl- 
nient,  I  think  ve  may  eouclude  diat,  though  iu  some  few  caaea  neither  ligatiuv 
tipr  comprewiim  can  be  adopted,  and  ampoiatioii  is  the  aole  reaource,  yet  in 
others  I'Drnpri'SMOQ  can  be  employeii  wbeu  it  would  not  be  safe  to  have 
recourse  Io  the  ute  of  thclignturc  ;  and  that,  in  nil  ordluar)'  cam.ii  of  frmnrml 
and  poplih'al  ant-urism  c^itecially,  compniwion  should  h«  prui'iTri'd  to  tbc 
ligittiirf,  inniimnf-h  as  it  is  not  a  more  lc<li<jU9.  and  is  nn  infinitely  safer 
method  of  cure.  At  the  name  lime,  it  must  not  be  forgotlcn  that  its  Miccena 
depends  very  greatly  on  tho  continuous  care  bestowed  up<in  the  ca*e  during 
the  proprew  of  the  treatment. 

Digital  CoMPRi>i*ioN. — .Shortly  after  (he  introduction  of  the  treatment 
of  nneiirum  by  inntrumental  compression,  the  fingers  wert^  used  as  an  nrljtinct 
to  lb«  mochanira)  means  in  ueo.  Thus  Grentrex,iu  iMri,  directed  a  pntimt 
to  keep  up  comorenioD  by  means  of  the  fingers,  where  ihc  tourniquet  had 
been  used,  atiit  reijuired  to  be  looeencd.  In  tbe  fi.>llowing  year  1 1K4S> 
Vanutli,  Iheu  Profei>wr  of  Burgvry  at  Charkoff,  tried,  lui  uueuccesefully.  to 
cure  a  lar].'e  popliti;al  iiucuri«in  by  compreesiou  of  the  femomi  »i(b  the 
fingers  only,  ^-outiiiuod  for  two  day».  It  was  nut  until  seven  years  later. 
«liL>u  I*rulL'»)H>r  at  PaUuu,  that  Vanzetli  had  an  oi)[Kirt unity  of  putting  ihia 
method  Buccitefulty  into  prBrtict\  and  to  establish  it  as  a  ilistiuet  meaaa  of 
curing  aoeurienis.  liul  allhungh  tliia  merit  is  undoubtedly  dut;  to  Vonxetti. 
we  roust  cTi'dit  Knight,  uf  New  Haven  (U.  R  A.  >,  with  the  firvl  sucreseful 
cane — he  having,  in  IMX.  curtd  a  very  large  popliteal  anearigm  by  digital 
e«mpret>Mon,  maintaineil  for  forty  houre. 

In  thiii  plan  nf  treating  aneuritmis,  no  appiiratup  uf  any  kind  is  used  ;  but 
the  circulation  through  Uie  artery  leading  to  the  luntor  lit  controlled  by  tbe 
preffiure  of  the  finger.  In  order  to  carry  tt  out  rffieientlv,  there  must  be 
relays  uf  ni^t&tanls,  each  uf  w  hom  comprewee  the  vessel  for  about  ten  minutra 
at  a  time.  The  preseiire  should  be  applied  in  the  way  that  is  rcprf»ented  in 
Fig.  1ft,  vol.  i.  p.  78.  The  fatigue  may  he  very  malfrialty  leascned  by 
placing  a  6  or  8  lb.  veight  on  the  t.*ompr(-«siDg  finger.  'With  Hucb  aid  each 
aaaislant  may  readily  keep  op  ibe  prewure  for  half  an  hour  at  a  time.  So 
■oon  as  bis  fingera  become  fatigued,  but  before  ho  reln.\cs  tbe  prrmure. 
mnolher  assistant  compresses  the  vessel ;  and  thus  the  eirculiition  through  it 
may  be  uninterruptedly  controlled.  In  this  way  aneurisms  of  the  {Kiptiteal 
artery,  in  the  orbit,  at  the  bend  of  ihe  arm,  and  in  tbe  groin,  have  been 
■uccecafully  treated— thtr  tumor  hnving  in  aomc  inetances  become  consolidated 
in  a  lew  hour?.  The  effect  of  digital  compression,  and  the  rapidity  uf  cura, 
vould  be  increaicd  by  the  application  of  direct  prtsfure  to  the  tumor,  or  by 
[iikaoipulatioD  and  by  tbe  previouo  employment  of  proper  eunelitutiuoal 
tsMUis;  it  mi^ht  he  very  adviinlagcously  conjoined  with  the  irealment  by 
I'Basioo.  Ilut  Its  great  aaranttpgc  seems  to  he,  that  it  is  applicable  to  arteriis, 
ta  IhoK  at  (be  root  of  the  neck,  to  wbiob  it  might  be  dtfficdt  to  apply  any 
kind  oi'  compresor,  and  can  be  employed  generally  when  no  apparatus  la 
obtainable. 


eshabch's  clastic  bandage.  165 

Esxabch's  Elastic  Bandaqe  has  been  used  with  a  certain  amount  of 
cueoett  in  the  treatmeut  of  external  aneuriBms.  It  was  Brat  employed  in 
these  caees  by  Staff-Surgeon  Walter  Reid.  Pearce  Gould,  who  has  investi- 
^ted  carefully  thia  method  of  treatmeut,  has  collected  the  details  of  72  cases 
in  which  it  has  been  employed.  Of  these  he  finds  that  35  were  cured,  in  30 
the  treatment  was  unsuccessful,  in  5  death  resulted,  and  in  the  remaining  2 
the  result  was  douhtful. 

The  treatment  has  been  applied  chiefly  to  aneurisms  of  the  popliteal  artery, 
hot  in  a  few  cases  it  has  been  successfully  employed  in  other  aittiations.  The 
objects  in  view  are,  first,  to  empty  the  whole  limb  of  blood  as  far  as  possible, 
with  the  exception  of  the  sac  and  the  part  of  the  artery  in  immediate  con- 
nection with  It ;  secondly,  to  keep  the  blood  distending  the  sac  at  perfect 
rest  until  coagulation  has  taken  place;  and,  thirdly,  to  protect  the  soft  clot 
thus  formed  irom  the  influence  of  the  arterial  current  until  it  has  become 
Hifficiently  tough  and  solid  to  resist  it,  by  compression  of  the  trunk  leading 
to  the  aneurism.  In  the  case  of  a  popliteal  aneurism,  the  treatment  is  thus 
carried  out:  The  elastic  bandage  is  first  applied  from  the  toes  to  the  ham 
with  sufficient  force  to  render  the  limb  bloodless;  it  is  then  carried  loosely 
over  the  tumor,  so  as  not  to  empty  the  sac,  and  again  applied  firmly  as  hi^ 
as  tbe  middle  of  the  thigh  ;  the  elastic  tourniquet  is  then  put  on  with  suffi- 
cient force  to  arrest  the  circulation  completely.  The  bandage  is  better  left 
on  tilt  the  tourniquet  is  removed.  The  average  time  required  for  the  appli- 
cation of  the  bandage  is  one  hour  and  a  half.  The  time  during  which  the 
limb  may  be  kept  bloodless  with  impunity  is  uncertain.  Heath  has  kept 
ihe  tourniquet  on  in  one  case  for  three  hours,  and  in  another  for  three 
and  a  quarter,  without  evil  consequences ;  and  Barwell  in  one  case  retained 
tt  for  five  hours.  The  limb  must  be  wrapped  in  cotton<wool,  and,  if  neces- 
aaiT,  warm  bottles,  at  a  temperature  of  about  100°  F.,  may  be  applied.  The 
prenare  causes  severe  pain,  which  may  require  the  use  of  hypodermic  injeo- 
tioQS  of  morphia  ;  but  if  tbe  treatment  is  continued  for  more  than  one  hour, 
il  M  usually  necessary  to  administer  an  anaesthetic.  Before  the  bandage  is 
removed,  a  Carte's  compressor  may  be  applied,  or  arrangements  made  for 
keeping  up  digital  compression,  and  this  must  be  maintained  for  from  two  to 
six  hours,  even  if  all  pulsation  has  ceased  when  the  tourniquet  is  taken  ofi*. 

The  mode  by  which  the  elastic  bandage  effects  a  cure  is  by  causing  stasis 
of  the  blood  in  the  aneurism  and  the  adjoining  part  of  the  artery.  This 
stagnant  blood  coagulates,  the  clot  being  formed  first  in  the  aneurismal  sac, 
and  then  spreading  to  the  artery.  Gould  is  of  opinion  that  the  permanent 
■rure  of  the  aneurism  is  effected  cliiefiy  by  means  of  the  portion  of  coagulum 
extending  into  the  artery.  This  being  in  contact  with  the  comparatively 
healthy  walls  of  the  vessel,  undergoes  the  changes  described  in  the  chapter 
on  Wounds  of  Arteries  ("vol.  i.  p.  401);  the  vessel  is  thus  permanently 
occluded.  The  clot  in  the  aneurism,  on  the  other  hand,  being  in  contact 
with  the  unhealthy  walls  of  the  sac,  or  with  layers  of  laminated  fibrin, 
nndergoes  no  process  of  organization,  but  tends  to  become  friable,  and  to 
yield  before  the  pressure  of  the  blood,  unlesa  protected  by  the  thrombus  in 
the  artery.  If,  however,  the  vessel  he  safely  occluded,  the  sac  and  its  con- 
tents gradually  shrivel  and  are  absorbed.  Failure  has  in  some  cases  appa- 
rently been  due  to  the  bandage  having  hoen  applied  too  tightly  over  the 
tumor,  so  that  the  sac  was  but  partly  fille<l  by  the  coagulum.  In  other 
cases  it  may  have  been  due  to  a  want  of  coagulability  in  the  blood,  and  in 
order  l«  avoid  the  |>ossihility  of  this  it  is  well  to  submit  the  paticct  to  a 
course  of  medical  treatment  and  diet  (p.  lH!h  befurc  applying  the  bandage. 

If,  on  removal  of  the  bandage,  there  is  still  distinct  pulsation  to  be  felt, 


I 


I 

I 

i 

I 


altliMUgh  tti«  liiniKr  tK-^iii»  pnrtinlly  o'iit»)Ii<lnto<l,ti  ctim  may  oftm  bvoflfcctvl 
bjr  cli^ititl  <ir  iiislruiitc-utiil  ctiiii[-ri:Miou  to  a  iv<x  huun. 

Tbe  clitof  dnngvr  to  bo  Bpim-litoded  ewmt  to  be  tpinsrcnr,  which  has 
oocarreil  ill  luurc  tbaii  uiie  case.  Jl  a[»i>enr8  to  Imrc  lirvii  due  in  thruttibotu 
lakiog  |ilarc  in  Lbe  vein,  and  powibty  kImi  in  ibc  rapillMrics  of  the  patia  In 
the  DcighborbfHid  of  tbe  aiieurUiii  fnttii  whirb  th«  uIuimI  bad  not  been  ex- 
pelled, TbiF,  nitb  ibc  friuuiltaneuua  ucrluFiou  uf  ihc  arirry,  wuuld  offvr  au 
MDouui  i>f  utifilniPliou  lo  tbc  ciri-ulatiuii  ubich  auuld  alnxat  certainly  end 
in  gan^rcnei  The  only  mraits  nf  avoiding  it  srpnis  U)  lie  by  ratryjni;  I  hi 
baoiloge  ligbllr  nvi>r  ibc  tumor,  by  wliiob  Tbe  veins  may  be  eiuptieil  «bil& 
ihe  ftiloesB  of  ihe  sac  i«  unt  inlerfi-rMl  with.  The  eX|mIfiion  of  90  larte  au 
amount  nf  blood  fruni  iht-  limb  uvccEsarily  rai.trs  tbe  nnvrial  tentlon  la  r* 
rest  of  the  bixly  ;  contH-^iuiiilly  the  ti<ie  »f  the  elastic  bandage  itt  nol  la 
recommendtHl  in  paiirnt.t  nflicK'd  milh  nn  inleinal  aneurism  which  mil 
rupture  Dndcr  (he  etrnin.  I-'or  tbc  eaine  reason  it  should  be  avoided  wncs 
there  is  a  9li5|Mci(in  of  fatly  benrt. 

Tht?  eluvttc  bandn^i^  h  nio»t  lil<cly  Co  incceed  in  eSecting  a  cure  in  aneu* 
ri8iD»  that  are  Iteginnini;  lo  undergo  con«'>lidati(in.  It  i*  of  little  une  in 
aneuriemg  that  are  large,  rapidly  iucrcavitig,  with  Ihia  'niJIa  and  fluid 
coDtenta. 

Flkxiov. — Tbe  treatment  of  aueurisra  by  flexioo  of  the  contiguoui  jotni 
is  a  methiiKl  that  u  scarcely  iipfilicnblf  lo  any  othrr  form  of  tbe  dueBHthiKB' 
tbe  pLiplilcal.  Tbe  history  ot  this  )il»n  ui'  treating  aneurismi  ia  iutoraitilif, 
aa  no  illustration  of  the  grndunl  ?te)>s  by  which  Surgery  umally  arrives  at  ila 
ultimutt.'  results.  It  bnd  been  long  known  to  .Surgeon*  that  tbe  pulse  at  lbe 
wriht  luigbl  be  arretted  by  the  forcible  Bexi'^n  of  the  forearm  on  the  arm;  and 
Matgaigue  and  Kichet  had  rccomn)cnde<l  tbiii  means  for  the  itrn!»t  of  henior- 
rhago  from  the  bmehiiLl  arlory  and  Ihc  nncrJE*  ot  the  forearm  when  n ounded. 
I'ifurv — a  <ltl^liugui^hed  Frtnch  mival  Surgeon — baring  succeeded  in  ouri 
a  wound  of  tbc  brachial  artery  by  foroe^l  flexion  of  the  elbuw,  aided 
direct  rompn«Hiun,  and  one  of  the  radial  by  flexion  of  ibo  wrist,  publish, 
in  1846  a  memoir,  in  uhich  he  slated,  as  a  conclusion  from  hia  ohservattoiM, 
that  auv  aneurism  of  tbe  forenriu  ur  leg  might  be  treated  by  moatu  of  flextuo 
of  the  limb  in  which  it  was  situated.  To  A.  Tbierrv  is  due  tlie  honor  of 
having  been  tbe  Urn  in  curta  trautuatio  aucurisni  of  ite  bend  of  the  nrm  by 
fleximi  of  the  limb.  This  was  in  lH.'i2  i  Uiehet,  Diet  de  MM.  rt  de  CMnayit^ 
vol.  ii,  p.  ^I^^).  In  1^ri7,  Munnoir,  of  (tcnova,  applicil  tlie  flexi<>D>tn» 
meut  t'>  a  Inrge  anonrlsm  of  the  hnm.  Forced  flexion  could  not  bi>  Iwtrneoa 
account  of  the  pniti  it  uccn^ionnl,  and  tbe  pdtient  v.-a».  tbcrefore.  nUowod  U>' 
walk  ou  crntcbcv  with  the  le^  tHoI,  and  supported  in  a  kind  of  elirnip 
attaebed  to  Lbe  op[Mj!>ite  shoulder.  In  less  tlmu  three  we^^k*)  lbe  cure  wiu 
eSlKletl.  which  Maimoir  liiund  a  year  aftcrwiinbi  to  be  {wrmaaeDt.  In  th« 
following  year,  Ib.li'!',  Mart  npplici)  tbiu  tnelhod  of  treatment  vucocwfully  ia 
a  cii«c  of  popliteal  aneurism,  and  to  him  is  due  tbc  luerit  of  having  been  tbe 
lii»t  Ut  iutroUui-e  it  into  this  country. 

Flexion  is  iiecewarily  applicable  only  to  arlcritw  situated  at  the  bend  uf 
joints,  aa  the  elbow  or  ham.  in  which  the  circulation  mn  be  directly  cno- 
tmlled  by  Wnding  ihe  limb,  or  in  tmuntalic  ancurtcnid  in  the  limbs  below 
ihetM!  jnintA.  In  which  tiio  flow  of  bhxKl  through  lbe  fei-fUng  artery  eao 
be  stopp«sl  in  the  rame  way.  Its  a[>plicalioD  ia,  therefore,  snmewhat  limiir>ilf 
and  its  use  is  still  lurtber  n't^tricled  by  ihe  [win  and  tnt>uppon»M'  ■  rinrt 

occasiomil  in  many  raM*s  by  forced  llexion  of  tbe  limb,  nece.-  .is  in 

Mnnnoir's  rn.«e,  a  relnYiitinn  of  the  method,  which,  hnwc-ver,  vim  Milt  e 


Uv«  in  eunng  tlir  uneurisin. 


TBKATUEXT    BY    » ANIPrLATION. 


167 


JiotkinE  cnn  be  uraplvr  Lhau  tbe  details  of  this  ptui.  It  conaute,  in  the 
ki«*r  limb,  in  applyiDg  a  bnndagi;  us  high  as  the  Knee  and  then  gradually 
flcxiac  thr  k>i;  upcm  tno  thieh,  m  that  thp  brat  is  bmuf^hl  up  towards  the 
bwnock,  when  it  is  retained  liy  a  etnip  i.ir  handiigt;.  Ths  patient  ta  at  the 
■xtt  tine  ooBBntd  to  bfd,  and  put  iiiuler  pm[wr  cotixtitutionnl  treatment. 
Bf  thii  Btani,  the  popliteal  artery  being  lient  at  an  acute  angle,  the  circula- 
tiga  tkrosell  it  ts  DMrlT.  if  not  completelv  arresled :  and  the  oheiacte  to  tho 
lav  of  faiood  it  still  further  increased  hv  the  comprft^ion  of  the  tumor 
hrtWHa  dM  notterior  flat  surlaee  of  the  femur  and  the  upper  part  nf  the  calf. 
!■  tUa  vmy  the  aneurism  i^  moat  favorably  itituale<1  for  the  c-onM-lidntion  of 
ilM  floattnta,  which,  in  the  recorded  caaes,  has  ofU-n  taken  place  at  ao  early 
peiiod. 

Tbe  prtoeipJe  on  ahich  tho  eure  is  tfTected  in  these  caaea  appcare  to  be, 
tlkftt  liT  flenoa  tbe  ancry  leading  to  and  from  the  eac,  and  the  aneuritm 
kactf,  mm  an  comprrwed  that  nit&rdalioD  of  the  (Hrculation  euaues,  and  depo- 
wiotm  uf  lamioaivd  fibrin  iako«  place  in  the  usaal  way. 

Tbe  couiproHioii  by  flexion,  like  every  other  nietliod  of  Creating  aneurisnu, 
OceMHlsaUy  faili'.  It  Ib  nioet  likely  to  be  atteuded  by  succeed  in  those  CSM* 
Id  wUeh  the  aneuriBm  is  small,  flitiiHted  low  in  the  popliteal  space,  and  in  a 
j«il»H  or  tuiddle-a{:ed  subject,  who  cnn  bear  the  continued  tiexioD  without 
■Bocfa  ioooorenieDoe. 

WImb  flexioo  ia  nut  vufiicieDt  of  itself  to  cure  au  aneurum,  it  may  very 
ilmifglillMlj  be  had  recourse  to  in  addition  to  other  methods  of  treatment, 
■on  Mpacially  with  that  by  digital  eomprea^ion. 

TW  sCMiatics  of  the  trvalmeut  by  Hexiou  retfuire  ti)  be  carried  down  to  the 
pfMit  tiac  TfaoMS  pablished  by  Fischer  in  1^70.  coraprit>ed  -'>7  cases.  Of 
tiMvB  Sft  wer*  cum) — 20  being  by  flexion  alone;  and  in  29  the  melliod 

Tbe  TmriouK  methode  nf  employing  cumpreexion,  viz.,  by  clamps,  by  weight, 
by  flexiuB.  and  by  the  finger,  may  often  m  advnniugnously  combinod  iu  the 
wmme  ea*t>.  Wbro  the  patit^nt  tires  of  one,  auother  may  Ih.-  tiuhdtitutcd  for  it; 
■ttd  tboa  tbe  good  HiectK  rontiuuounly  kept  up  with  le«e  fatigue  and  irritation 
Ibftk  woald  oCherwiM  be  experientW.  .Si  alvi  various  moditictttions  of  th^ae 
dUNwftt  methods  may  be  practised  to  suit  thf-  requiremenlji  of  any  particular 
liut  for  thme  no  special  directions  can  be  given ;  the  ingenuity  of  the 
BiiiBt  supply  tbe  want  in  each  fa>^. 

io!c  RV  ActTPRGBRVRR  uf  the  main  artery  leading  to  the  sac  !e  a 

that.  I  think,  mi^'hi  in  certain  csaea  he  lemporarily  employed  with  ad- 

aud  lh«-  droMtlidntiou  of  the  Arieurieii)  thus  obtatneil  iu  eases  wher4 

tiion  liT  thworditiury  methods,  digital  or  instrumental,  is  not  prao> 
Ic.  With  this  view  a  long  and  otMng  curvetl  needle,  such  nn  the  slilet 
■fa  ndtiiD-trocar,  might  be  dipped  dreply  under  the  artery  and  vein — e.g^ 
tbt  oonoMra  femoral,  and  (he  artery  cumprusw*il  agaiuet  thia  by  means  of  a 
•Hk  sml  twiste«l  suture  kr  sevvnU  faoure — the  vein  iH'ing  lell  free.  The 
palicM  OHgfat  bs  kept  under  chloroform,  if  necessary.  When  cooKolidation 
■f  thm  moUota  of  tbe  «c  was  ublainetl,  the  cimiprestiing  means  might 
henniBtid*  Socb  a  method  of  treatment  might  |K»«iltty  be  advuntagmu^ly 
MMbbwrf  ID  certain  extreme  and  exceptiotiHl  caaet'.  with  tlie  itijectiun  of  tiio 
•ae  witb  tbe  perchloride  nf  iron,  or  the  use  of  eleotrn-poncture. 

HasiPt' LATius. — Hir  W.  Kergnwon  firoposed  to  treat  some  aneurisms  by 
■  praoBdim  which  he  termed  manipiUation.  This  couisU  in  squeesing  the 
aaaanMial  taoor  in  such  a  way  us  to  detach  a  portion  of  the  congulum 
witbin  it,  whieb,  being  carried  on  with  the  current  of  hlood  into  the  distjU 
artery,  obstructs  this;  and  thus,  by  impeding  ibe  drculatioo 


163 


tRlSM , 


through  the  tae,  may  lead  to  the  gradufti  coiuoHdatioii  of  the  tumor:  and  U 
htt  aUo  been  suggested  b^  Oliver  Peiuberton  that  the  atteratiun  nf  the  rela- 
tions of  the  lainiuated  fibrio  ia  the  cavity  of  the  aocumm  may  bring  aboat 
a  further  depoettion  of  fibrin  on  tho  dbplaccd  laiuimc.  This  pmcednre  Imu 
as  ret  bceu  cin^tloyed  to  loo  limited  an  extent  to  enable  us  lo  form  aa 
estimate  of  its  value,  and  can  scarcely  be  coDBidered.  uur  is  it  intended  lo  be. 
of  very  gvDcral  applicatiun.  Tu  aoeurisms,  however,  that  are  duI  ameoaUt 
toordinsry  surKicul  treatnieuL,  and  thai  raust  necessarilv  jjruve  fatal  if  tt-ft, 
•a  thoae  situatuid  ai  the  niol  of  the  neck,  murv  pftrticulany  of  the  snU'Iavian 
artery,  it  might  pdaoibly  be  advaniageoitaly  applied.  It  u  sooroely  neoe*- 
sary,  hnwevcr,  Ui  point  out  the  obvious  danger  of  rupture  of  the  sac,  or  of 
the  diffusion  of  the  aneurUra  from  the  weakening  of  its  walls  by  the  sepai»' 
liun  iif  the  coaj^lura.  to  make  Siir^ins  adopt  due  caution  in  carrying  out 
this  method  of  treatment.  There  is  another  daogerabo  Mpedallv  attendaat 
on  tlii»  procedure,  when  applied  f  *  aiieurisnia  about  the  seek ;  viz.,  that  the 
detached  euiasulum  may  be  carried  by  the  circulation  into  the  cerebral 
arteri«e,  and  oy  obstructtDi;  them  occasion  the  (Ame  kind  of  cerebral  dti- 
turhance  that  occurs  when  Ineae  venels  become  occluded  by  (Jbrinous  plugi — 
embula.  That  this  danger  is  a  real  and  A  great  one,  is  evident  from  the  faot 
that,  in  some  cases  in  which  manipulation  of  subclavian  and  carotid  anco- 
risrae  has  been  tried,  the  patient  has  beeu  suddenly  seite<I  with  svooopa 
aud  hemiplegia.  Teale  has  successfully  cuujoined  manipulation  with  com- 
presaioo  in  a  case  of  poplitoal  unuurism,  in  which  the  pressure  od  Ibe  artery 
was  slow  in  consolidating  the  tuumr;  the  detachment  o^a  portion  of  the 
ooaffulum  almost  at  once  Ted  to  the  coosolidatioa  of  the  tumnr.  Sjmewhmt 
analogous  to  this  method  is  one  recommeodod  in  164:2  by  Blake,  who  pro- 
posed, by  the  ineroductiou  of  a  cataract-needle  into  the  sac,  to  deiadi  at  '^ 
of  the  laminated  Qbrin.  which  might  then  be  washed  against,  and  ood 
the  aperture  of  exit. 

Galvako  ri'.Ncri'Bii. — The  attempt  to  procure  the  conaolidntiun  of  ao 
aoeuriamal  sac  by  the  employment  oi  electricity  ifl  of  oomparaiively  recent 
date.  It  appears  to  have  been  Srat  practiaod  hy  B.  Phillips,  abuut  the  year 
1832.  Little  attention,  however,  was  given  to  this  mode  of  treatment  until 
a  few  years  back,  when  it  was  revived  by  aorac  of  the  French  and  linlisn 
Surwons,  especially  Ptiitrcquin,  Burci,  and  Qnlselli.  The  object  aiuiol  at 
uis  operation  is  the  production  of  coagulation  in  the  aneuriitiiuil  wic  by 

oompnsilion  of  the  blood  contained  in  it  by  means  of  the  (;nlv«nir  cur- 
rent. When  two  needles  connected  with  the  poles  of  a  galvanic  battery 
am  tntrodiicod  into  u  raasi  of  fluid  blood,  a  firm  Rolid  coagulum  is  rapidly 
fiirmed  muml  that  connected  with  the  positive  [Mile,  while  at  the  same  time 
a  large,  »<>n,  «\tonjfy  ch't  mixed  with  bubble*  of  g»s  is  seen  at  the  negative 
needle,  and  n  dark,  tar>likt>  fluid  al80  mak«)  its  apjiearauce.  If  the  needle 
used  lie  made  of  steel  or  any  other  rejtdily  soluble  metal,  further  change* 
occur  ut  tht>  p<j8icive  j>ote  due  tothe  production  of  salts  of  iron  with  theacidi 
lilwrntt^l  from  the  bloid.  These  changes  are  spoken  of  as  secundary  elec* 
trolysin.  Th^  clot  formed  by  electrolysis  is.  therefore,  not  compapcd  simply 
of  the  tibrtu  of  tlio  blood,  but  cimtains  also  a  lar^  proportion  of  allHinHW 
coagulated  bv  the  chemical  action  uf  the  currcut,  and  must  be  looked  npoo 
as  a  foreign  IkmIv  around  which  we  liopo  onlinary  coagulation  will  occur. 

The  opcratiuu  of  galvauo-puucture  is  best  performed  am  follows.  Tare 
steel  neiKlles,  well  iusutate<l  with  vulcanite  or  gum-elastic,  are  inserted  into 
the  sac  uf  the  aiieuri-tih  aud  connected  with  the  op|Hieite  polea  nf  the  bntterr. 
The  neiMlIca  should  Ih>  alxmt  one  inch  apart,  paretlel  to  each  other,  and  so 
Inserted  that  n'>  jiart  of  the  iininsalitcd  [Kirtion  of  the  ueeillr  shall  touch 


TRKATMKNT    BY    OALVAKO-PnNOTtr BB. 


The  bett  h«tl#ry  for  ilie  piirfHwe  U  one  of  the  urdiiiury  medical 
with  nuBll  L«cliuicb<i  c«Uit.  of  which  from  tcu  to  Lweiily  may  be 
■nd  for  ■  lia)«  var7iiig  from  twenty  aiiuutes  to  half  hii  hour,  <>r  more — 
aeeordios  V*  the  efi^cl  produced.  It'  the  tumor  be  suflineiitly  nmr  the  eur- 
Im*  Io  b«  clearly  oiiierved,  a«  has  Uvea  tlic  case  ia  tt;rcral  of  the  aneiirisnis 
m  iHudi  U»  tnaunvut  liu  ljii*a  innpIuyL-d.  it  wilt  he  sbl-u  to  hecotnf  mnra 
laaWBBd  InBtUid  tba  expausilc  usiturL-  of  the  ptilHiition  will  b«cr>me  dimin- 
Mbad  aa  IIm  Dperalioti  pmgrK»«.  S<)ineiitmt<  l)ul)bleR  of  ga5  escafte  by  the 
aida  vt  ika  Degalirr  nt'eiUp,  and  a  littb;  thick   Urnwii  fluid  oozes  up.     Occs- 


lU 


to  aot 


It  tht  tomor  lim  IjfOD  ftxind  to  hwhII  uiid  ItecnniQ  rmonant  an  jiercus* 
When  a  diMtnct  rHi>L-t  hait  licen  prodiice<l  the  needles  may  he  with- 
I,  and  the  small  ptiitctures  cloeeil  with  Mm  iun\  c>>1lndion.  Tho  negative 
nill  be  found  uimhered,  while  the  positivn  will  be  corroded  directly 
rtfioo  to  tht!  umount  of  el»:trolytic  nclion  that  has  taken  place.  In 
prerfnt  thi«  rorrosion  of  the  positire  neexlle,  it  has  bc«n  suf^gested 
Jonn  DuDcnn  that  platimim  may  be  used  instead  of  i)teel.  Thcrp-  is 
ic*.  huwirver,  to  prove  thai  the  salts  of  iron  produced  give  rJK  to 
It  particQlitr  dnnger;  in  fat-t.  It  is  pmbahl^  th«y  aid  cuii^denibly  iu  the 
fif  th«^  firm  cii]t|;uhmi  Hurruundiuf;  the  aevdlr.  The  battvry  need 
I  opcntinn  is  of  obfiderable  iiiiportanci;.  It  has  beeu  pointed  out  by 
'll,  that  a  current  of  high  tension  and  somewhat  low  initrnBity  i»  le«8 
ftcnoae  lb«  production  of  undue  beat  (iuring  the  oiwration,  aud  cuo- 
1t  lea  prone  to  lead  to  inflammntiou  and  suppuratiou  of  the  eac.  A 
.therefore,  oompoteti  of  a  large  number  of  email  elements  is  superior 
<if  s  few  lar^  elements.  Some  operators,  and  especially  Basliau, 
hav*  ailTucaled  the  iotroduction  of  the  positive  pole  only,  the  negative  being 
alUciiMl  t^i  a  sponge  or  metal  plate  laid  on  the  skin  near  the  ancurltm. 
The  only  i«bjei;liou  to  this  mode  of  treatment  is  the  exceeirely  small  effect 
prodand.  The  eledrolrtic  action  which  takes  place  is  directly  in  propor- 
INC  to  tli«  iDtcnwty  of  the  purrent ;  and  by  the  introductiou  of  a  considera- 
Ua  mam  of  tbe  tiamies  of  the  patient  in  the  circuit,  the  resistance  is  so  greatly 
1  that  electrulysia  ia  reduced  to  a  scarcely  appreciable  amount,  tbe 
DcedU  appearing  almoet  unchaD^>d  aAcr  the  opcraiinu.  Othcni, 
■(BiBfliaTC  Introduced  the  ucntivti  needle  onlv,  but  as  thccoagulum  formed 
aft  thn  negatiT*  pole  is  soft  and  frothy,  but  little  good  can  be  cxpccicd  from 
tikit  owde  of  operating.  Dr.  Julius  Allhauti.  who  baa  etipcrinteudcd  the 
ayecathM  m  fire  caam.  in  strongly  of  opinion  that  "the  most  effeotire  appli- 
mAm  of  the  ciirrrnl  is  that  where  both  polpa  are  insert*^  into  the  »ac." 
CWidb  '•prratnl  In  thi«  way,  and  Dr».  Duiiciin  niid  Fnisfr.  to  whom  we  are 
iadalN;rd  for  ni.iny  imjMirtant  ohtiervationa  on  ga I vano- puncture  and  for  the 
ion  of  ri-liahir  insulated  needle*,  iupjtort  the  ."iamc  view.  The  opera- 
ar>c<otiipjiiti«>'l  by  but  little  |>ain,  and  it  ie  only  occaAionally  that  chloro- 
The  effect  of  n  single  operation  ia  »eldoai  nufHctent  to  cause 
improvement  iu  the  condition  of  the  ptUient.  and  it  require* 
-  '  -  r>-peAtrd  several  times. 

ii*d  ai  the  result  of  gal vano- puncture  is  somewhat  soft  and 
ana  unltts  supported  by  a  luodcraiely  firm  aao  aooo  flatiem  out  or 
.  and  tba  etmdition  of  thv  aneurism  baoomea  mndi  tbe  tame  as  it 
'  iha  oprauioo.  Little  more  than  tbe  most  teiiip'jrury  rclit^f  t-au 
far  ikk  Maon  be  expeH'-d  in  many  tmaea  ;  and  whenever  tlie  am-urisui  liaa 
hanBtdUHnir!    '  u  con  only  be   productive  of  niiechtef  by  haa- 

kaiar  Iha  taSa-  ngea  on-urriug  round  the  sac.     It  niisltt  Iw  Hup- 

pMM  dhal  ao  aoft  a  clot  would   readily  break  up,  an<l   that  the  danger  of 
lisBi  wtHiU  hr  great  in  conKqucnoc;  but  expcrieuoe  has  shown  that  it 


ANKVHISM. 


IB  nut,  no  sue))  nrridpiil  liavhi^  liiip|H<ni-(l  in  any  nf  the  raoofdad 
ocmsioiiiil 
tiiciit  m\Q«  the  priiici] 


illv 


irrnl.  hut  its 


Iml 


puralton  ot  the  sno  has  ocmsioiiullv  orcui 

much  \ct»  frroiiciit  HiDce  the  priiicipit^  of  the  opemti'm  hnve  Iwen  moro  fiillf 

Dodentoo^.     ['ho  torniatii^n  of  thrtighs  round  ine  netdlt- puncture*,  and  coo- 

sequent  hemnrrhngc,  han  not  been  iioiiced  except  when  the  ueedtcn  hav*  boM 

Imperfectly  insulnlwl.     In  fiiol.it  may  be  luiiil    that  in  ainicxit  every  caar. 

er«n  uheii  the  npcratiou  has  fniled  to  give  rdief.  it  hnn  at  any  ratA  dooa  Bo 

barm. 

Tho  sifltUiicfl  of  the  operation  have  not  been  f\illy  compiled,  but  thm  g«B' 
era)  re3<iilt»  of  lh«  jxibth^lied  cnwi  have  not  b««it  iiufttvonible  wbeo  we  coo- 
dider  tbu  lio|wl«s«  Dittiiri.'  of  the  caovti  iu  which  it  has  hi^ii  jMrfMrrnixl.  Of 
13  cn&e*  of  un«iiri«m  of  the  aorta  Irx-alcd  br  Cini«Ili'»  muthiHl,  five  urn 
cure*!,  and  no  i'%'il  (MnB^'quencvn  followed  iu  noy  ciuv.  Of  th«  eaiup  uuiuber 
whJcli  hnve  bcuti  oirenit««l  on  iu  thiti  t-ouutry  during  tbc  la«t  few  yean,  noHr 
bavti  bcuii  curi^,  out  at  least  eix  experienced  more  or  Ikb  rvlivf ;  and  in 
alinuet  all,  it  may  l>e  said,  the  operation  aimed  only  at  relief,  the  iliaease 
being  l(Hi  ndvannnl  Ui  warrant  any  hope  of  ctir«.  Alioul  sixty  other  cbmk 
of  aneurism  iif  vannus  arterii.^  have  been  collectetl  by  Ciaiselli  bm  havi^ 
been  njterated  on  Itrfore  1808;  but  iu  these  the  melhiMla  used  were  ao ' 
perfect,  that  they  cnnnut  be  fairly  coasidered  ns  bearing  upon  the  qt 
at  the  prcH^nt  time. 

When  we  compare  galv-nno-puncture  with  ligature  or  Dompraanon  in  tha 
trentment  of  exiennil  BneuriAni.  it  w,  1  think,  imponible  to  heaitata  fur  a 
moment  in  giving  a  deciik-d  prefcrenoc  to  the  latter  modes  of  treattmat,  aa 
the  results  that  hav*e  hitliertu  been  obtained  are  not  iuch  as  would  justiff  a 

f  rodent  .Surgeon  in  tHibniiltin^  his  patid-oc  to  nu  operation  of  ihia  kind,  when 
e  poaiesaea  such  eerutu  and  comparatively  safe  modu  of  treatment  aa  dd^ 
Stum  at  ootnpmsion.  In  inu-rnal  aoouriaiuB,  or  in  thoae  eases  in  which 
e  disease  is  so  siiuat^fd  at  the  mot  uf  the  neck,  that  the  artery  can  neitlMr 
be  ligatured  with  etaft-ty  nor  cumprt-aned,  galvauo-puncture  is  certainly  jiud- 
fiable,  especinlty  when  conjoim-d  with  projjtir  mtdical  irt'flcniont,  ft»  we  have 
ample  pnM>f  (but  nilh  the  kuoirkilge  uud  mean*  now  at  our  dbpo«al  we  can 
perform  the  ojieration  with  scarcely  any  danger  to  the  patient,  and  la  favor- 
able caifes  with  some  hope  of  relief.  Much  will  depend  upon  the  selectioD  of 
the  case.  CHoiselli  has  piinted  out  that  the  conditions  favorabte  to  jiucceat 
are,  that  the  aneurism  i>Iiall  be  sacculated  nnd  o[>euing  into  the  ressel  bv  a 
narrow  mouth,  ofvluw  growth  and  of  medium  size,  and,  when  thoracic,  »ita* 
at«<l  eutirely  within  the  thorax,  aud  that  it  shall  not  ia  aajr  aeritHis  way 
have  interfcrcMl  with  the  general  health  nf  the  patient.  Tbne  conditions 
aeldom  occur ;  and  when  tficy  are  nh^>ut,  the  moat  that  caa  be  hopad  fiir  ia 
tempurary  arrest  of  the  ptogrcK'  of  the  disease  and  some  relief  tu  the  patient^ 
aoAarings. 

IirjBtmoiT  vrnr  PRRmijrtHirp.  or  Irok. — ^The  Injection  of  anrarismal 
aacB  vith  a  soiuiiim  of  the  perchloride  of  iron  haa  aim  been  practiwd.  with 
the  view  of  congulaling  Uieir  contents  :  such  treatment,  however,  ia  attended 
with  great  risk  of  embtdium,  and  is  in  every  way  vaitly  inferior  to  the  ligaUm 
or  comprfssinn  of  the  artery  leading  to  or  beyond  the  aac,  and  ahoald  never 
be  employed  if  theiu"  ran  he  practise<l. 

Aneurium  of  the  gluteal  arterr  has  been  soccesaftilly  treated  by  injection 
of  the  perchloride  of  iron  in  at  least  one  case.  In  eases,  however,  in  which, 
either  from  the  HttoAtion  of  the  diseaiM'.  its  cnrnpliontion  with  oihfy  ri- 

sive  diseaxe  nf  thi"   nrti'rial  syntem,  or   its  multiple  ehnmcter,  1  .;id 

eomprf*i>on  art'  not  upplirable,  an  t'luleavor  might  be  nmde  to  priictirr  the 
eluttiug  of  the  hliMxi  in  the  tumor  by  distal  oompression  of  the  artery,  brf 


TREATMENT    BY    ACUPUNCTURE.  171 

attempting  to  coagulate  its  cunteots  by  injection  of  the  perchloride ;  and  I 
cannot  bat  think  that  a  satisfactory  result  might  thus  be  obtained. 

Hypodermic  Injection  of  Ebgotin. — Langenbeck  advocated  the  hypo- 
dermic use  of  a  watery  extract  of  ergot  in  cases  of  aneuriBm,  under  the  im- 
previon  that  it  might  act  on  the  muscular  fibres  scattered  over  the  sac  of  the 
aneurism  in  the  same  way  as  it  acts  on  the  muscular  fibres  of  the  uterus,  and 
by  causing  cootraction  might  gradually  diminish  the  size  of  the  aneurism,  if 
not  cure  it.  He  seems  to  have  tried  it  in  two  cases  only.  One  was  an 
aneurism  in  the  supraclavicular  region  (exact  nature  not  mentioned),  which 
had  been  previously  treated  with  moxas,  and  almost  cured.  The  symptoms 
having  returned,  hypodermic  injections  of  ergot  were  tried.  The  quantity 
ioiected  varied  from  about  i  gram  to  3  grains  of  Bonjean's  watery  extract  of 
ergot,  dilnted  with  three  times  as  much  spirit  and  glycerine.  The  injections 
were  repeated  every  three  or  four  days.  Decided  improvement  is  said  to 
hare  occurred,  but  pulsation  never  quite  ceased.  The  improvement  com- 
menced after  the  second  injection.  Ko  unpleasant  symptoms  occurred  ailer 
Um  injections.  In  the  second  case  a  man,  aged  42,  had  a  sacculated  aneu- 
rian  of  the  radial  artery  of  the  size  of  a  hazelnut.  An  injection  of  two 
nniiis  and  a  half  of  the  watery  extract  cured  it  in  one  day,  as  the  next  day 
It  coold  not  be  felt.  The  injection  gave  rise  to  some  inflammation  of  the 
mrrounding  cellular  tissue  which  disappeared  in  a  week. 

Tbifl  accident  I  have  seen  happen  in  one  case  in  which  I  tried  it,  but  no 
good  resulted  from  the  treatment,  which  cannot,  indeed,  on  pathological 
grounds,  be  considered  to  be  of  a  hopeful  character. 

IjiTEODrCTios  OF  FOREIGN  BoDiES. — The  intn)duction  of  foreign  bodies 
otf'  various  kinds  into  the  sac  has  been  attempted  in  a  considerable  number  of 
GHca  with  the  view  of  producing  an  artificial  coagulum  in  the  aneurism. 
Thus  coils  of  horsehair,  catgut,  or  iron  wire  have  been  thrust  into  and  left  in 
the  aac,  through  a  puncture  made  in  it.  The  results  of  these  operations  have 
nol  been  such  as  to  justify  a  repetition  of  the  treatment. 

AcTPrscTfRE  with  very  fine  needles  has,  however,  been  performed  with 
some  benefit  in  a  few  cases,  and  if  carefully  carried  out,  can  hardly  be  pro- 
ductive of  any  injury.  It  was  first  suggested  by  Velpeau,and  practised  with- 
out success  bv  Dunville  and  Agnew.  ^Marshall  has  in  more  than  one  case 
obtained  in  this  way  some  cousolidation  in  aortic  aneurisms,  and  MacEwen 
succeeded  in  curing  a  j)opliteal  aneurism  by  the  introduction  of  a  fine  needle 
while  the  femoral  artery  was  compressed.  Heath  attempted  the  same  trcat- 
meni  in  a  case  of  subclavian  aneurism  in  University  College  Hospital  after 
be  had  unsuccessfullyamputated  at  the  shoulder-joint.  Six  fine  needles  were 
intn>duced  into  the  sac  in  such  a  way  as  to  cross  each  other,  and  were  left  in 
for  fuur  days,  at  the  end  of  which  time  the  tumor  was  much  firmer.  The 
patieut  dietl  about  twelve  days  afler  from  causes  uneoimected  with  the  treat- 
ment, and  a  considerable  amount  of  f^rm  clot  was  found  in  the  sac.  This 
treatment  seems  worthy  of  further  trial  in  otherwise  hopeless  cases  as  a  sub- 
stitute for  galvaoo-pUDcture.  The  smallest  sowing  needles  with  heads  made 
of  sealing-wax  may  be  useil,  as  iu  Heath's  case ;  or  better  still,  the  fine  pins 
known  a?  entumological  pins,  which  i-hould  be  gilded.  They  may  be  Ictl  in 
for  from  fuur  to  five  days,  and  it  is  perhaps  ^nfer  to  <'over  them  with  some 
umple  antiseptic  dressing  to  diminish  the  risk  of  ulcenitiuu.  After  they  are 
mnxved  the  punctures  must  be  covered  with  culKxlion. 


172  ANEURISM. 


ARTERIOVENOUS^    ANKURISH. 

Preternatural  communication  betweea  arteries  and  veins,  though  uBuallf 
the  result  of  wounds,  occasionally  happens  from  disease;  ulceration  taking 
place  between  the  vessels,  and  thus  causing  an  aperture  Lo  lead  from  one  iDto 
the  other.  When  such  communications  are  of  a  traumatic  origin,  they  may, 
as  has  already  been  stated,  constitute  either  an  Aneuritmal  Varix  or  a  Vari- 
cose Aneurism.  As  the  result  of  disease,  aneuriamal  varix  only  can  occur, 
varicose  aneurism  never  happening  except  as  a  consequence  of  wound.  Then 
spontaneous  communications  have  been  met  with  between  the  aorta  and  the 
vena  cava,  and  between  the  iliac,  temoral,  carotid,  and  subclavian  arteriei 
and  their  accompanying  veins,  in  nature,  symptoms,  course,  and  treatment, 
they  so  closely  resemble  traumatic  aQeurisma)  varix,  described  at  p.  450, 
vol.  i.,  that  their  consideration  need  not  detain  us  here. 


SPECIAL  ANEURISMS. 


CHAPTER    XLIV. 

ANEURISMS  OF  THE  THOKAX,  HEAD  AND  NECK,  AND  UPPER 

EXTREMITY. 

ANEURISM  OF  THE  THORACIC  AORTA. 

t?YMPTOM;*. — The  symptoma  of  Intrathoracic  Aortic  Aneurism  are  of  two 
kiode :  autcuHatory  and  ratUmaL 

The  Anieiiltetory  Bigni  vary  greatly  in  dietioctness,  and  may  even  be 
wanting.  In  some  cases,  more  especially  in  fusiform  aneurisms,  they  are 
slniost  from  the  first  of  a  very  marked  and  obvious  character;  in  others, 
especially  in  sacculated  aneurisms,  they  may  be  absent  throughout,  the  uneu- 
nni  terminating  fatally  without  its  existence  having  been  determined  by 
Uie  stethoscope.  They  consist  in  murmurs  of  various  kinds  and  degrees  of 
mtensitr — bellows,  rasping,  or  whizzing;  in  the  second  sound  of  the  heart 
bring  audible  over  a  greater  space  than  normal.  At  the  same  time  there 
nwy  be  dulness  on  percussion.  These  various  signs  may  often  be  heard 
more  distinctly  upon  or  to  the  left  side  of  the  spine,  than  at  the  anterior  part 
<^  the  chest;  when  occurring  anteriorly,  they  are  chiefly  met  with  on  the 
rifiht  side. 

The  value  of  the  auscultatory  signs  in  the  diagnosis  of  aneurism  within  the 
che-t  is  not  perhaps  so  great  as  in  many  other  thoracic  diseases,  in  the  early 
tiA^v^  of  the  affection,  and  in  those  cases  in  which  the  nneuriem  continues 
small  and  sacculated  throughout,  or  is  so  deeply  seated  as  not  to  approach 
the  (>arietes  of  the  chest.  This  need  not  be  a  matter  of  surprise,  when  we 
r«fl(rct  huw  deeply  the  ascending  portion  of  the  aorta  and  the  arch  are  situ- 
aterj :  h-iw  they  are  covered  in  front  by  the  lungs  and  loose  areolar  tissue, 
tlirnu;:h  which  sound  is  with  difficulty  transmitted  ;  aud  how  they  are  cov- 
«r«*l  in  l>ehiDd  by  the  apine  and  its  muscles.  When,  in  addition  to  this,  it 
■  V^ime  in  mind  that  aneurisms  of  the  arch  often  prove  fatal  by  bursting 
in^■  runliguous  cavities  and  canals  before  they  have  attained  a  size  greater 
than  that  uf  a  walnut  or  a  pigeon's  egg,  and  thus  are  incapable  of  furnishing 
a  murmur  of  any  very  marked  kind,  it  can  be  easily  understood  that  the 
value  of  auscultation  is  but  small  in  many  cases  of  thoracic  aneurism. 

The  Rational  SigHB  of  intrathoracic  aortic  aneurism  are  of  three  kinds : 
Prwvure-effecis  ;  Pulsation  ;  and  Tumor. 

Pressnre-eflfecU  may  be  exercised  on  any  of  the  contiguous  structures; 
and  a  glance  at  the  anatomical  relations  of  the  thoracic  aorta,  more  particu- 
larly the  arch,  will  enable  the  Surgeon  to  judge  of  their  complexity  and 
inportanco.  They  will  necessarily  vary  according  to  the  size  of  the  aneu- 
ritm  and  the  portion  of  the  aorta  affected  by  it ;  more  according  to  (he  latter 
than  t<>  the  former  condition.  When  the  aneuri.-'ni  arises  from  the  root  of  the 
oerta,  Bn<i  more  especially  when  it  is  intrapericardinl,  it  i."  usually  of  small 


174 


HPXOIAI.    ANKUBISM8. 


size,  oad  iu  pressurc'cffecto  will  be  liuJo  obvioue.  Wbeo  tbe  aDearins  ktim* 
f'roR)  tlie  tmniniitioH  of  the  nreh,  ur  thf  ilesc.mting  aorta,  it  may  often  stlaio 
a  cuiuiderable  develupDivnt  witliuui  causing  anv  vi>ry  <ibvitiu»  preaaofv-eflMMi. 
AaeurisDii  ibaC  are  nituatetl  ui'Mm  the  wnairitg  uj  Ou  itrrh  nepcwrily  ^t» 
rise  to  very  severe  effects,  by  itx;  ct>ui|im«i><ii  tlit-y  uium  cxcrr-isp  upoo  mom 
one  or  ottier  of  the  vtry  iTii|M)rtant  atruriun-A  tlml  are  induiUtl  withio  tlw 
anrtir  urrli,  Wtipn  tlii>  aiUerktr  jxirf  nf  the  noria  bt  afieoled,  tbu  aseurlMn 
tnay  HLtaiii  a  vi>ry  ctio^iJuritblf  bulk,  even  coining  furwari]  »u  as  to  prq^Mt 
aod  pulsate  between  the  iritprcoatal  Ppaces,  without  any  vury  aoticcablu  pn»- 


t.  _sr»iJ 


!;■ 


>«' 


r-s--. 


Fig.  4fiX.— Broaioa  of  tniarv*n»bral  Fig.  4IVI. — AcmHini  nf  Dii«ara4lliig  Aort*,  krattag 

Subftmeoa  bj  a  •mall  AKontiim  of  an^l  IravciilBg  Vatt«fan*. 

[IfttceiMlitig  Aurl*  |iT«MJiig  b»ck> 
atanlB. 

■ure-*fll;ct»  Iwing  inHticed.  But  when  the  potfrrinr  will  <if  Uk  arUry  U  the 
seat  of  the  disease,  then  Bcvere  Byrnptome  aw  early  rvl  "p  by  tlic  cnmpmMinn 
aad  emsion  of  the  »truoturc»  lying  D>Dtit;uoti0  to  lh«  artery  anil  nlung  the 
•pine  (Fig.  463).  When  the  upper  pari  of  the  wirtie  rrrrh  is  the  sent  of  an«o* 
min.  a  peculiar  train  of  cerebral  aymptonift,  tiucb  ae  vertig<»,  iiw-nsibilitr,  (W 
defective  vi«oD,  may  be  ioduced  by  ita  interference  with  the  circulatioa 
thraugh  the  carotids. 

The  preefiure-offeots  that  need  chiefly  engage  our  attention,  are:  I,  Fain, 
2.  Oy9pna>ii;  :{,  Dyaphagia;  and,  -1,  OCilema. 

I.  Fain  is  ueuallv  ono  of  the  earliest  syniptonu  of  intrnthnracic  aneurifm, 
and  tif  freqiieiuly  o^  ^'rcat  value  in  a  diagnostic  point  of  view,  ns  it  Is  often 
moat  marked  when  the  other  syniptoras  are  the  lenst  developed.  It  is  gen- 
erally inori'  M-'vere  in  Baceuliiied  than  in  I'u^ifurm  aneuriBim.  and  when  the 
jjHMtitrinr  rather  than  the  antcrinr  o^inecl  of  the  vewel  i»  the  cent  of  dii'o— c. 
The  pain  \»  of  twn  dtstim-t  kindft.  Tne  finit  kind  to  IinciDatlng.  intermitiniti 
and  iiounU>rlc  in  ita  charaelcr,  cridentlr  dependent  upon  prneure  on  tbe 
BpinnI  or  Ryinpalhvtic  nerves.  Thin  pain  is  Mated  chiefly  on  the  left  ride, 
and  iibontA  up  the  ilide  of  the  head  and  face,  nlonff  the  upper  arm  to  tbe  dbov, 
nKiU}!  the  tntenvnto-hutneral  ner%'t?,thn)Ugh  the  ent^t,  orWtweeti  theseapaUa. 
Tlir  M-(^ttld  Tirm  uf  [uiin  ncrurs  usually  al  a  latf-r  nlAge  of  tbe  disease,  it  ooa- 
ciauoim,  mid  of  »  horiii);,  Imt,  or  biirniug  chararler.  It  seems  to  depend 
upon  the  pcrluratiou  uf  tb«  ti«»ue»,  more  expvtriiilly  the  honet,  bv  the  anea* 
nsntal  tumor,  and  occurs  chiefly  on  the  right  xide  of  the  cheat  (rig.  464). 


PRESSURE-EFFECTS    OP    THORACIC    ANEURISM. 


175 


2.  DyipouM  is  of  very  frequent  occurrence  in  intrathoracic  aneuriain  ;  in 
all  probability  it  is  more  uniformly  met  with  than  any  other  single  aymp' 
torn.  It  may  arise  fnitn  five  distinct  conditions,  and  its  characters  vary 
with  its  cause. 

s.  From  dire^  preamre  on  the  trachea.  In  these  cases  the  dyspnoea  is  at- 
tcodied  by  much  wheezing  cough,  and  often  by  whistling  sounds  in  the  cheat 
and  tubular  respiration,  and  by  slow  expansion  of  that  cavity.  There  is 
Qsuallv  expectoration  of  thick  tenacious  mucus. 

J.  Prom  dirtet  presture  on  a  bronehtu  (Fig.  465).  In  these  cases  there  are 
wheeling,  cough,  and  some  degree  of  expectoration,  with,  perhaps,  dimioished 
respiratory  murmur  in  the  side 
aflected,  and  puerile  respiration  in 
the  opposite  lung,  as  has  been 
poioted  out  by  Stoxes. 

:.  From  prtwurt  upon  the  lung. 
In  theee  cases  the  respiration  is 
companuively  little  interfered  with, 
the  spODgy  tissue  of  the  lung  ac- 
oMDmodatiogJtaelf  and  yielding  to 
the  pressure  of  the  tumor.  Atler 
a  time,  the  pulmonic  tissue  will 
become  incorporated  with  the  wall 
of  the  sac ;  and  then  more  serious 
difficulty  in  breathing,  with  btemop- 
trais,  will  supervene. 

f.  Dyspnt^a  is  very  commonly 
induced  by  irritation,  eompreaaion, 
«r  ttretehing  of  the  left  pneumo- 
ytutrie  and  recurrent  laryngeal 
merrtK  by  the  pressure  of  the 
tumor.  In  these  cases  the  muscles 
that  are  supplied  by  the  left  re- 
current laryngeal  nerve  may  be 
paralyzed,  8»  as  to  occasion  attacks 
of  iDlense  difficulty  of  breathing. 
In  many  cased  spasm  occurs  from 
irritation  of  the  nerve  before  it  is 
preej>e<]  on  sufficiently  to  cause 
paralyi-is. 

It  is  the  erico-arytenoideus  posticus  muscle  that  is  chiefly  affected  by  the 
roniprefeioD  of  the  recurrent  laryngeal.  As  its  action  is  to  open  the  glottis, 
it»  paralysi.«  cause's  an  imjiediment  to  the  entrance  of  the  air  by  the  collapse 
of  ihe  left  side  of  the  rima  [^luttidis — henco  the  dyspuo'-a  and  struggle  for 
breathing  under  exertion.  The  Vi>ice  becomes  hoarse,  croupy,  or  on)aking; 
the  cough  has  a  loud  croupy  or  metallic  sound,  and  it  attended  by  the  ex- 
pectoration of  thin  frothy  mucus.  The  laryngciil  stridor  oflen  does  not 
occur  in  ordinary  respiration,  but  is  pnidueed  under  exertion,  or  on  making 
the  patient  inspire  fully  and  deeply.  The  hiryngeal  symptoms  are  some- 
time* so  much  more  prominent  than  any  of  the  other  ^igns  of  intrutliurucic 
aneurism,  and  so  closely  resemble  chronic  or  even  acute  hiryngiti-^,  with 
inpending  a.aphyxia,  that  there  are  not  a  few  cases  on  rcconi  in  which  Sur- 
geons have  performed  traclieotomv,  on  the  supposilion  that  they  had  to  do 
with  cases  *if  pure  and  uncomplicated  liiryufjea!  disease;  and,  in  nther 
iafUmx*,  this  operation  has  been  performed  with  a  view  of  pridonging  life. 


Fig.  4B5.  —  Aneurism  nf  Areh  of  A'jrta,  of  the 
Hiie  of  An  almonil,  rprinftiDg  from  bctow  left 
Subclnvian  Artorv.  nnil  burgtiDg  into  left 
BroDchu!. 


176 


SPZ01A.L    ANEUBIbXS. 


wreo  wheo  the  depeodeDoo  of  the  latrnK^al  spurn  oo  aaeurUni  of  tlic  aoru 
baa  been  nicogniMd. 

Dr.  Oeorgc  Joliosuo  has  made  sqidu  iDifioriutii  ub«ervaU*otts  oo  the 
the  laryii{;flsoi)|i«  iu  thu  diatf uosia  of  ibt-  uiium-  uC  ilyspoifa  io  aortic  i 
He  Bfl^a  iliut,  ID  ciusvs  whvru  tlie  cauto  ia  prvasurc  on  the  recurreui  larysj^ 
Qervi>,  tbt'  larynx  Ik  aeuu  to  l>u  healiby.and  the  BpMta  may  be  aeeti  to  oooor. 
If  tli»  pri'^urt.'  tu:  suniciciiL  lu  ttbolieh  ibt:  fuaclion  of  th«  dbttc,  uailat«ra] 
[winilysii*  will  occur,  wbirh  i»ii  be  easily  auoerlaiufil  by  laryDgU8O0|iic  ^xani- 
Datioii.  TliB  voice  in  such  caeCK  ii:  neak  and  liunky ;  wbpruan,  ia  cskb  ia 
which  the  [treasure  i^  oq  the  trachea,  itfl  character  is  unchaoged.  When  a 
thoracic  aneurism  nreoMs  the  trachea  a^inst  the  apitie,  the  Lracheal  stridor 
and  tJie  voice-stiund  are  heard  with  remarkable  diatiiictm-ss  on  appIyiDg  th* 
atetboBcipe  over  the  upper  dorsal  vertcbne — the  »ound  being  ouoducted 
through  the  bonea. 

I.  Dyapnopa  may  be  depepdent  nn  compression  of  tlie puimonary  vein  by  the 
aueuriBiual  tumor.  In  cases  of  this  kind  there  wuiild  be  cwwiderable  Uvidity 
of  surface,  anti  signs  of  pulmonary  coDgcstion. 

The  dy!tpii<i<'tt  of  intrathoracic  nncuri^tii  will  uOvn  be  eiilficiently  intenae 
to  occa»iou  dfuth.  It  may  be  mistaken  for  onlniary  itsthma  ;  bitt  the  dij 
nosiif  can  usually  be  etfected  by  ob»erviug  that  iu  aoeurisni  the  pnroxj 
of  dyspncea  oflea  come  on  in  tht^  day  &»  well  as  at  ni^ht,  and  are  gn 
inctvHsed  by  change  of  po«itiou,  as  by  pluciug  the  patient  either  upright  or 
recumbent,  th«  tumor  thus  shifliue  it*  jwinl  of  prenure.  It  is,  as  Bellioff- 
blim  has  pointe^l  uut,  not  iolluenceu  by  atniuspheric  cbungcs,  mid  is  genorsUy 
aaaociatcd  with  laryngeal  etridor  or  ajiasm.  When  such  symptoms  aa  these 
are  Maociated  vith  pain  and  dysphagia,  they  poJat  very  strongly,  even  id 
Uic  absence  of  all  auscultatory  rigus,  to  the  prennoe  of  on  aneunuoal 
tumor. 

Aneurisms  situated  within  the  concavity  or  springiDg  from  the  ,  . 
porta  of  the  aortic  arch  are  those  which,  either  directly  by  their  pr 
on  the  air-tubcfi  or  the  pulmonary  veins,  or   indirecilv  by  tbe  influent 
they  excrciae  on  tbe  recurrent  laryu|c:eal  nerve,  are  chiefly  lUBociattd  uith 
dyapofca. 

3.  Bysphaffia  ih  a  symptom  of  sufficiently  fVequent  oocurreoce  in  aiieD< 
risms  of  tne  thoracic  aorta.  Eaton  has  dciermined  ita  existence  in  nine  out 
of  twelve  cases.  It  seldom  occurs,  however,  in  the  earlier  sta^ea  of  ihc 
diseaae,  or  when  tbe  aneurism  h  small,  and  hence  is  of  iimch  leM  diaj;- 
nostic  value  than  dyspuuA.  When,  however,  it  is  aaaociatcd  with  that 
symptom,  the  combination  becomes  important;  as  the  coexistence  of  tbe 
two  onditiooa  clearly  points  to  the  compreMiion  of  the  <ecK>phagus  and  Ui« 
atr-tubeit  by  a  tumor,  which  other  diagnostic  iiignH  may  prove  to  be  aittni- 
rianiat. 

It  ia  of  importance  to  bear  in  mind  that  In  some  aneuriitras,  npeciallr  of 
tbe  iJeaeenrliug  thoracic  aorta,  dysplia>;iii  may  be  one  of  tbe  most  nutrluHl 
aigna.  In  «ucb  caaes  as  these,  stncturt;  of  the  weophagus  baa  erroneoualy 
been  suppoaetl  to  exist,  and  tbe  patient  has  even  be«a  treated  by  the  iutn>- 
dnction  of  bougies  uo  ibis  ^upposiiiuo — an  error  of  praclicL-  that  haa  termi- 
nated fatally  frum  porforaiiou  of  the  aneurisoiBl  sac,  where  it  projected 
against  the  a«'jpli»guii,  by  tbe  point  of  the  iustrument.  

Tbe  difficulty  in  deglutition,  in  cases  of  ooBpreaaioo  of  the  cewphaguij 
aortic  aneurism,  is  almust  iuvuriubly  referred  to  tha  et^Mennl  notch.    T  _ 
dysphagia  is  commonly  awocialed  with  [miu,  or  with  tne  Mnaution  of  a  cord 
drawn  tightly  around  the  body. 

4.  (Edema,  with  muru  or  less  livldiiy  of  the  upper  extremitfet  and  head 
Mid  neck,  occaaiuoally  but  rarely  ocriire.    It  is  ge-nenttly  moat  marked  on  ibc 


aUKOIOAL   TKKATMKNT    OT    ANSCItlSM    OF    ARCB. 


■ad  sriscB  fmtn  th«  cimprcwion  of  the  superior  cava  or  the  innomi- 
M  bj  uwumrTu  itprtnging  from  the  fore  or  upp^r  part  of  the  *rcfa. 
uk)  Tnioor,  ohwrvablp  externally,  ar^  alwayg  ab^ont  in  th« 
rMrlrMaMof  intratborftctc  aortic  anetiristn,  and  v^rr  frequently  cr>ntinoe 
1^  tnrcognoBt  the  proercDa  of  the  affection  ;  indeed,  in  anenriems  npringing 
~  llic  int^aperifftn^lflI  aorta  or  the  concavity  of  the  arch,  death  usually 
I  pUor,  cither  hy  niptiire  into  one  of  the  wroua  eavilie*  or  the  air-tube, 
■r  by  tb«  exhaustion  indaccd  by  dyspiKm,  long  before  the  aneuri».ii>  has 
■I  nil  111  a  MiAdfm  flit«  to  be  reco^izahle  externally.  Tlierti  ar«,  however, 
ihm  portion*  of  the  tburacic  aorta  nhich,  when  afTeclfd  by  aii«uriisin,  vield 
atental  evidenoe  by  the  vxb!leiie«  of  pulMitiuu  or  tumor  of  ihv  true  uaUire 
of  tW  dfaaiw,  These  are — 1,  the  aut«rior  a«pect  of  the  ascendiou  aorln;  % 
ifca  MEmmit  of  tbe  arch ;  and,  3,  the  p<wterior  aspect  of  the  deeceudiug  aorta. 

1.  WheJi  tlie  aneuritfiD  is  nlualed  on  the  anlvricr  atptct  of  the  itKcnding 
avHb  and  tvmmn*crm(nt  o/  the  arch,  puleutioD  may  be  detevttHl  by  presure 
been  MB  the  tDterc<«Ul  ifpacve  on  thu  right  side  of  the  eternuni,  ami  a  thrill, 
tm  voU  u  d)stiui>t  impulee,  may  often  1h>  felt  over  that  side  of  the  chest, 
biAtaaiiy  external  tumor  becnmee  visible;  thus  eimulatiiig  the  beat  of  tfae 
iMSft,  ia  aiiditiuu  aad  opjKieite  to  the  seat  of  the  true  canliac  impulse.  Afl 
lbs  atMuriam  increases  an  external  lumor  appeant,  the  wall  of  the  cbeet 
baeooiw  absorbed  aod  perforated  cppoeite  the  point  of  greatei^t  impuUe. 

2.  WCeo  an  anenfinn  spriogs  from  (At;  nimmii  of  tiif.  arch,  a  pulsatinff 
iMBer  a]^wan  al  the  rwA  of  the  neck,  behind  or  even  above  the  margin  of 
ibe  etcranni,  mn^l  commouly  toward?  the  right  side,  aod  occnaionnlly  rises 

Ugh  oot  of  the  thomx.  and  ta  so  distinctly  felt  in  the  neck,  as  to  run  tbc 
of  bring  cdofounijed  wilb  aneurism  of  the  bmchio-cephalic  or  carotid 
Tj  (Vig.  470,  n.  160).     This  error,  Khtefa  has  fi^uently  been  committed, 
■pd  vbj«b  has  Ira  to  operations  on  the  arteries  at  the  root  of  the  neck,  may 
IJy  be  avoided,  except  in  the  case  of  the  bmehio-cepbnlic,  by  the  impo» 
of  tracing  vith  tiie  finger  the  lover  boundary  of  the  tumor,  and  th« 
«aof  difCiDciduIneM  oD  percitseion.aDd  poBsibly  of  impulse  or  of  au»* 
ritalory  eridvnce  of  aoeorism,  below  the  level  of  the  upper^ margin  of  tha 
inai  or  clavicle. 

Wbm  aoeuriem  springs  from  the  potttrior  wait  in  the  detemding  aoTia,m 

sting  (umor  tuay  gradually  develop  to  one  side  of  the  spiue  or  under  the 

iMla.  cosmoDly  on  ihe  leftside;  and  it  may  attain  an  excessive  size,  fully 

imixat  as  the  bead  ( Fig.  A^),  before  the  patient  is  destroyed  by  the  rupture 

lb«  tumor  exierually. 

Txzjtmr^tT — lo  tbe  great  majority  of  aneurisms  of  the  thoracic  aorta 

■  i-e  is  impoceible,  and  our  sole  reliance  must  be  placed 

.  nst.  it  he  admi  nut  ration  of  iodide  of  potasstam  (see  p.  140). 

Svgical  IieatBcnt  of  Anetuum  of  the  Aortic  Arcb. — Tlie  ioen  of  treat* 

saeoriim  ef  ibe  noriie  arch  bv  ligature  of  one  or  two  of  tbe  main  arteriea 

(b«r  ruot  of  the  seek,  Drigiuate'd  in  tbe  results  of  an  operation  perforated 

Cbrvtopfa^r  Ileatb  in  18(^  lor  the  cure  of  a  suppoeei)  innominate  aneurism 

tbe  »in)uliBOe<>u»  ligature  of  the  right  carotid  and  ^ohclavian  arteries. 

patient,  a  Wf^man  of  intemperate  habits,  survived  the  operation  tor  four 

rear*.  sp[<«'ariog  for  a  lime  to  have  been  benefited  by  it.     Cn  her  death 

luand  ibal    the  nneurtsm  irae  not  one  ef  tbe   innominate   but   of 

I  aarindipgaorta,  and  that  it  had  bees  practically  cured  by  or  atUr  the 

■*""      Dr.  (Vrltle  about  the  same  Ume  waa  engaged  in  a  ecries  of 

oWervntirn*  on  I  he  itpontaneoDS  coDtolldation  of  anenrisms  of  tbe 

at' '  :ind  that  in  »onie  of  these  cases  the  left  carotid  artery  had 

»tid  be  interred  frf>m  this  pathological  fact  that  ligature  of 

ri  Blight  be  of  use  in  tlie  treatment  of  certain  forms  of  aneurism  of 

t  II  —  I'J 


178  BPKCIAL    ANBURI81IS. 

th«  urcli.  This  eu^^gestion  watt  acted  od  br  C  Heath,  who,  ia  I'ST'i.  tied  tbt 
Icll  i-Arotid  artery  in  a  patieDt  of  Dr.  Cockle's  aflected  with  aDcurism  of  tin 
woending  and  traiitfvcrce  portions  of  tlie  arch.  The  patieot  was  bciM)fit«d  by 
the  operation.  Harwell  has  operated  in  two  cases,  in  one  with  Bdvantiig& 
In  the  other,  lu  which  the  left  aubclavian  was  also  tied,  the  patient  died, 
apparently  uninfluenced  for  eood  or  ill  by  the  operation.  Ucath  s  Bcoond  caM 
of  ligature  of  the  left  carotid  provoil  fatal  by  syncope.  In  all,  the  operation 
appears  to  have  been  done  13  timeaCA^hhurst) — in  six  ouce  with  mareorles 
mnefit.  In  at  least  four  of  these  eaaes  the  artery  was  ligatured  on  the  nip- 
position  that  the  anouriflm  ytts  situated  at  the  root  of  the  carotid,  when,  u 
reality,  it  uccupietl  the  aro.li.  IlArwell  iitates  that,  in  thoae  aneurisnu  which 
■lirin^  from  the  aorta  beyond  the  left  curotid,  tiir&ture  of  this  veMi;!  will  do 
mure  harm  than  good,  and  that  th<>  operation  nhmild  t>o  confined  to  thtwc  in 
which  the  tumor  appeura  on  the  lefl  Mide,  hut  not  far  from  the  median  lion. 
anil  Tige^  into  the  epiiitemal  notch  or  under  tlie  lelt  tiU^rtio-niaftloid. 

The  Simultaneous  Ligature  of  ^e  Right  Carotid  and  S.ight  Subolariaa 
Arteries  lur  nuvunsm  of  the  aortic  arch  iiait,  acc^rdiug  to  BurwL-ll,  been  dou* 
in  throe  cimb  only  for  aneurisin  diagnoBed  as  aortic  before  IJm  operBtton.  Id 
Bomo  utlier  caMs.  aa  the  ona  referred  to  ubovc,  diagnoeod  errooeousiT  a> 
innomiDate,  hut  pruriug  in  reality  to  be  aortic  ouvurisin,  it  has  bIm  Mto 
done.  In  the  Uiree  cases  of  reooenizod  nortic  aneurism  the  operations  wm* 
done  by  Harwell,  Lediurd,  and  Wyclh.  lu  all,  the  "ox-aorta  ligatura**  waa 
ttsed,  and  the  paticnu  lived  15  months,  di  months,  and  1  year  respectively 
afler  the  o])«rHlion  (Barwt^ll). 

The  ligature  of  one  or  more  of  the  main  arteries  at  the  n>ot  of  the  nedl 
for  the  cure  of  aneurii^m  uf  the  aorlic  arrh  involves  a  new  principle  in  the 
treatment  of  that  diseaAe;  ont^  that  differs  in  all  reeneols  from  that  in  which 
tbe  cure  of  nn  onltnary  external  aneurism  is  ei^tea.  By  whatever  way  the 
Surgeon  nets,  whether  hy  the  Hunterian  or  the  distal  ligature,  by  oompra- 
aion  with  iostrnmrnt  or  linger,  he  seeks  one  common  result,  riz.,  the  arraitor 
retardation  of  the  circnlntion  through  the  sac  so  aa  to  facilitate  the  depotiit  of 
laminHtwl  fibrin  or  firm  clot.  He  usually  acts  directly  uiMm  th»t  artery  that 
is  the  «eal  of  thi-  di^a^te,  and  in  all  oases  of  the  Hnntennn  o|M.>nt(ion,  or  of 
arterial  couprcssiiin,  the  supply  of  blood  sent  into  the  hsc  ix  mmt  niateriallv 
diminished,  if  not  altogetWr  arrested.  But  In  the  treatment  of  anrtlc 
aneurisuis  by  ligature  of  the  left  carotid  only,  or  by  that  of  tbe  right 
carotid  at  its  root,  and  of  the  right  Bubclavian  in  the  third  [uirt  of  id 
courK,  he  not  only  doca  not  diminish  or  retard  tbe  flow  of  bltod  throacb 
tbe  aorta  or  leoseu  the  qusntity  »ent  into  the  aneurismal  sac,  but  as  tlie 
Tolume  of  blood  ejected  from  the  letl  ventricle  at  eaoh  systole  continues  un- 
changed, a  larger  blood-slreum  muat  actually  be  tfarowo  into  the  aorta  b»- 
youd  the  point  at  which  tbe  deligate<l  vessel  is  given  off,  equal  in  amount 
to  what  would  nornially  have  passed  into  the  artery  that  has  been  tied.  Dy 
thus  innmasing  tbe  volume  of  btood  in  that  portion  of  the  arch  of  the  aorta 
beyond  tbe  giving  off  of  the  ligatured  arterj'.  an  increased  pressure  will  be 
tbrowu  upon  the  whole  interior  of  the  vessel  and  of  any  aneurismal  sac  that 
•prings  from  it.  Thus,  the  very  reverse  of  what  happcna  in  the  Uunteriaa 
or  ordinary  distal  operation,  takes  place  when  one  or  more  of  tbe  primarr 
branches  of  the  aortic  arch  is  tied.  And  if  a  cure  of  an  aneurism  in  this 
situation  be  thus  effected,  it  must  be  on  a  new  principle,  different  from  auj 
that  hna  yt^t  guided  the  Surgeon  in  the  treatraoot  of  this  disease. 

That  some  benefit  appears  to  have  followed  these  operations  in  a  few  of 
the  casM  is  undoubted  ;  but  how  much  of  tins  may  be  fidrly  attriboted  to 
tbe  direct  inSuenoe  of  the  ODoratiou  appears  to  ms  to  be  very  UDoertaiD.  For 
it  cannot  be  doubted  that  the  oonflneQient  to  bed  af^r  tlie  operation,  aod 


eUBOICAL    TRSATHENT    OF    ANEUHI8M    OF    AKCH.        179 

the  more  careful  and  regulated  life  that  would  be  led  by  those  who  had  been 
subjected  to  so  serioua  a  procedure,  must  exercise  a  very  directly  beueficial 
iaflueDce  upon  aoy  ioteraal  aoeurism ;  aud  it  may  fairly  be  a  question 
vbetberan  aneurismal  patient,  Bubjected  to  ao  operation  that  would  require 
eoD6DeineDt  to  bed  or  at  least  absolute  quietude  for  several  weeks  and  sub- 
•eqaeotly  necessitate  a  quiet  and  carefully  regulated  life,  would  not  derive 
aa  mach  benefit  as  have  the  patients  in  whose  necks  large  arteries  have  been 
(ied  for  the  care  of  aortic  or  even  of  most  innominate  aneurisms. 

The  oeceaaity  for  hesitation  in  the  adoption  of  these  operations  for  the 
cure  of  aortic  aneurism  appears  to  me  to  be  strengthened  by  the  acknowl- 
edged difficulty  in  effecting  a  correct  diagnosis,  in  many  cases,  of  the  exact 
seat  of  the  aneurism,  whether  it  be  innominate  or  aortic,  or  both,  or,  if  aortic, 
froBi  what  part  of  the  arch  it  springs ;  and  also  in  determining  with  abso- 
lute certainty  whether  a  given  intrathoracic  tumor  be  an  aneurism  or  not 

The  immediate  danger  of  these  operations,  whether  done  for  aortic  or  in- 
Domloate  aneurism,  is  also  very  considerable.  A  very  large  proportion  of 
cbe  patients  so  operated  on  died  within  a  fortnight,  and  in  some  cases  death 
resulted  immediately  or  within  a  few  hours  consequent  on  the  disturbance 
of  ihe  circulation  through  the  brain  by  the  ligature  of  one  of  the  greater 
arteries  springing  from  the  arch. 

Another  &ct  of  much  importance  that  cannot  be  ignored  in  considering 
tb«  advisability  of  subjecting  a  patient  with  supposed  aortic  aneurism  to  the 
operation  of  ligature  of  the  carotid  and  subclavian  arteries  bthe  undoubted 
very  slow  progress  and  prolonged  duration  of  many  of  these  aneurisms,  and 
tbc  possibility  of  a  spontaneous  cure  in  some.  Patients  with  aortic  aneu- 
risms frequently  live  for  several  years  after  the  disease  has  been  recognized. 
Under  proper  constitutional  treatment  the  severity  of  the  symptoms  may  be 
greatly  mitigated,  and  in  all  probability  the  chances  of  cure  would  be  about 
equal  under  the  two  modes  of  treatment — the  strictly  surgical  and  the  medi- 
cal— whilst  that  of  speedy  or  of  sudden  death  would  be  more  likely  to  occur 
to  those  subjected  to  the  operation. 

Some  Surgeons  have  tried  to  obtain  consolidation  of  the  tumor  by  coagu- 
lating its  contents  by  thrusting  coils  of  iron-wire  or  catgut  into  its  interior, 
but  it  need  scarcely  be  said  that  in  no  case  has  any  permanent  success  at- 
tended such  procedures. 

The  rapid  solidification  of  a  large  dortic  aneurism  is  not  unattended  by 
danger;  so  lung  as  the  contents  are  fluid  the  patient  goes  on  fairly  well,  but 
if  they  rapidly  solidify  the  pressure  of  the  tuniur  leads  to  great  distress  and 
rapidly  hastens  the  patient's  death. 

The  mode  of  treatment  which  has  been  more  frequently  adopted  in  aortic 
aneurism  than  any  other  is  galvano-pnncture ;  and  in  well-selected  cases 
this  may  be  productive  of  considerable  good,  or  even  occasionally  lead  to  a 
cumplete  cure.  In  27  cases  of  aortic  aneurism  thus  treated,  which  have 
been  collected  bv  John  Duncan,  5  were  cured,  10  relieved,  9  unrelieved,  and 
^  died.  Experience  has  shown  that  with  the  latest  improvements  in  the 
Mperatiou — well-insulated  needles  and  a  suitable  battery^there  is  scarcely 
any  danger  to  life,  aud  that,  even  where  it  does  no  good,  it  does  no  harm. 
It  ba^  been  applied  in  all  stages  of  the  disease,  from  the  time  when  the  tumor 
becomes  eutficiently  superficial  to  allow  the  safe  introduction  of  the  needles, 
to  the  time  when  it  has  perforated  the  chest-wall,  and  is  on  the  point  of 
bursting.  In  one  of  John  Duncan's  cases,  the  lite  of  the  patient  wiis  un- 
d'Aibiedly  prolonged  for  nearly  three  months  after  the  time  »t  which,  if  letl 
to  it«elf,  the  aneurism  would  have  burst  p.\ternftlly.  The  ca.-*es  best  suited 
for  galvaoo-puDCture,  and  in  which  even  a  cure  may  be  oeeasionully  hoped 


x&o 


SPKCIAL    ANKt'BlSHS. 


for,  are  thueu  io  wbich  the  tumur  u  of  slow  gruwth,  bas  not  ^vt  perfonilcd 
tlic  di(«t-wull,  mil)  in  which  it  rati  lie  iliagiiospd  iik  nac'cutHU^  and  romna- 
tiiicalirig  with  ilie  aorta  hy  a  rDinparativel)-  small  upi'iiinp.  It  »  intpmUBi 
kIbo  Ihnt  the  giaticntV  health  ehiiukl  not  be  too  much  broken  hj  saffering  or 
viflceral  dii«aM>-.  When  the  lunmr  projectn  through  the  parietn  af  Um 
thorax,  forming  a  sccon<isry  sac  outaide,  the  pnwpect  of  run;  is  iniiBiUii- 
InaJljr  vmall ;  but  even  then,  progreni  may  be  delayed,  ami  much  rvlipf  givo) 
to  th«  patient.  If  the  tumor  have  become  ditTuBed,  as  may  occur  when  it 
poiuis  in  the  back,  gal vano-punc lure  can  only  do  tiarm  by  increasing  the 
tendeacy  to  JDflnmmation  and  suppuration  alre&dj  ezuting.  For  lb«  del^ 
of  the  opcratioD,  see  page  168. 

There  is  ijdc  point  in  the  treatment  of  ume  forms  of  aortic  aneuriAU.  thai 
folia  within  the  province  of  the  8urgeon,  and  oo  wbich  hi«  opioiuu  may  be 
j^ht.  I  mean  the  advi^obility  of  opening  the  windpipe,  lo  rdi»VL>  the 
iticDi  from  iho  didtrcM  uctUBioucd  by  tin-  laryngeal  spa^m  that  Lviuinoniy 
attends  many  of  thcae  caacA.  The  deciaiuu  of  this  qumiiia  i*  alwaya  an 
anxious  one ;  for  it  must  be  born«  in  mind  that,  lu)  tb«  disease  that  itccaaJODf 
tbe  nMsme  iif  the  lar^'ox  is  neceaearily  and  inevitably  fatal,  the  i>|Mrralion 
eao  be  ex]iected  to  give  only  temporary  relief,  and  at  mod  but  a  brid*  pru- 
lungaliou  of  life. 

lu  determining  this  question,  the  Surgeon  must  bear  in  mind  that  sinple 
laryngeal  spasm  la  rarely,  if  ever,  the  cause  of  death  in  aortic  aneurisa  ; 
that,  allhough  the  patient  may  suQer  greatly  froiu  this  complication,  he  dot* 
[not  die  of  it :  but  that  the  ultimate  cause  of  death  is  ueuallv  intrathurmciu 
IfkreMure,  rupture  of  the  sac  internally  or  exleroolly,  or  exhnu^tiou.  The 
j^peratJon,  therefore,  would  be  justifiable  iu  those  cases  oulv  in  vrbich  it  ooold 
M  determined  that  the  spasmodic  dyspuma  was  purely  iHryngcftl,  and  was 
not  dependent  on  comprei«ion  of  the  air>MueBgca  withiu  the  chest  by  the 
aneuriHmal  tumor,  but  simply  on  the  irrilatioD  pntducixl  by  the  ittiplicatioa 
of  till'  left  recurrent  laryuin^iil  iivrve.  Such  cilm:«  are  very  rare  patbdlugiraJly, 
and  ueceeearily  moi^t  ditticult  of  accuruu-  iliagno(>is.  As  the  &ui^-4iu  will 
usnally  get  the  credit  of  having  kilU-d  the  patient  if  he  be  induced  to  perform 
the  o]>erntion,  and  the  relief  be  not  immediate  and  great,  1  would  advise  him 
not  to  operate  unless  the  diaguoeis  be  most  clear,  or  in  circumslancfS  of 
imminent  ileath  from  uncomplicated  laryngeal  Rpaum,  with  the  view  of  alKkrd- 
iog  immediate,  even  if  it  be  temporary,  relief  If  any  operution  be  dace.  It 
should  certainly  be  laryngotomy,  and  not  trnvbeolomy. 


ASKUBtBH  or  TRB    INXOHIKATK  ARTCRY. 

Aneurisms  of  ibis  artery  are  very  frequently  accompanied  by  dilatation  or 
actual  nnrurisni  of  the  aorta.  Inuomioute  aneurUii>s  may  he  eiUier  of  the 
tubular  ur  the  sacculuteil  kind,  and  usually  give  rise  to  »  train  of  senosv 
id  dnDgeruus  sytuptonis,  Irom  their  pressure  upon  important  [nirts  in  their 
nghboroood.  luoeed,  a  glance  at  the  relations  of  tliis  arterj'  will  show  the 
laportmnt  effects  that  must  be  tinxluced  by  the  pressure  of  a  tumor  spring* 
iBg  fVom  it.  Before  it  Iim  tlie  led  innominate  vein,  U>  the  outer  side  are  the 
lower  cv^rviml  tmrdiav  branch  of  the  pneumogatitric  the  right  inDoaueate 
rein,  the  ngbt  paeumogastric  and  the  pleura;  behind  it  and  to  its  inner  ude 
is  the  limchea.  An  aneuriatnal  tutuor  of  the  innominate  artery  may  eixtend 
backwards  so  as  to  come  into  relation  with  the  vet^hagus,  aod  upwards  so  ae 
to  pres  on  the  Hgbt  recurrent  larynginl. 

SmFTOKs, — ^Ine  geoeral  symptoms  of  an  aneurism  of  this  ftrterr  an 
exiilenoe  of  a  pulsacing  tumor  of  a  globular  shape  bebind  the  right 


or  THE  tKKOMINATX  — SYMPTOMS. 


181 


dftvicutftr  KrtimUti>iD.  atleoilexl  with  pain,  and  perlmps  ledema  of  tlie  right 
mIkoCUm  fiue  and  arm.  \Tiih  nomo  difficutty  in  respiration,  Inryngijal  cougb, 
■ad  djrapbafts.  Ttie  tumor  ij  usually  soft  and  oompredsible,  Siting  up  more 
nr  Ihi  <»m^lelv  Lbe  hollow  above  iKe  sternum,  and  cveu  rising  fie  fiigh  io 
thm  Boek  aa  tha  luwer  margia  of  the  cricoid  cartilage;  it  poshes  forwards, 
Am  thm  aUenad,  and  afterwards  the  olavicutnr  purtiou  of  tho  Bteruo-nicutoid 
■aaala,  and  haa  occasionallT  beeu  accn  to  extend  into  the  posterior  inferior 
iif  the  neck ;  and,  indeed,  is  generally  mo«t  ilistinully  dcfiucd  to- 
Ha  braahial  anpect.  In  anme  cases  no  Uiinor  rbefl  into  the  neck,  but 
tbaMBrnnm,  clavirle,  and  cmtal  i-»rtilng«  uf  tbe  firat  rib,  uir  found  to  be 
tbly  [lu^bnl  formint.'^  I>^y<md  cheir  natural  Icvul.  In  the  space 
thpri^ht  Ktcnirr-rlnviciilnr  articulation,  and  about  the  upjior  piirt  of 
■Boroam,  tbrre  vrill  l>e  dnliim  on  percussion,  and  marked  pttluntion  is 
Ml  in  tbe  first  inlercoatal  npace.  In  very  many  in^tannes  then'  is  no 
bat  menty  a  strong  impulse  with  the  heart'H  sounds,  as  distinct  ae  in 
I  omtiac  region,  or  creo  more  so ;  but  in  other  cases  there  may  be  every 

of  broil. 
Prtasttre-effiwts. — The  mo«t  importaot  symptoms  are  occasioned  perhaps 
r  Iba  preaMrD-oflecta  of  the  tumor  upon  the  neighboring  parts  afiectiog  tne 
llatt  tbe  Tenoua  drcnlation.  the  nerTes,  respiration,  and  oeglutttion. 
Tbe  Pvlae  19  uMially  iutlueoc*^!,  h«)ng  mtich  smaller  and  feebler  io  the 
t»dtai  aii^rr  uf  tli<^  sBected  thxn  of  the  sound  side,  and  in  some  instaacce 
c<impW<ly  arrested  ;  owio>;.  doubilees,  to  pressure  ou  or  occlusion  of 
lanbdaviKo.  The  pnUatiou  in  the  right  carotid  and  its  braaohea  \a  also 
inottly  macb  leas  powerful  than  in  the  opposite  veosel.  Tbese  signs  corn- 
ier orenr  before  any  external  tumor  is  neeu  or  can  be  felt,  and  hence  oon- 
ttitUbt  aa  imp->ruiot  element  in  the  early  diagnosis  of  the  disease. 

At&krfOMiit  of  tite  Soperficial  Yeiiia  uf  tbe  neck  and  right  upper  ex- 
tremily  is  of  frequent  occurrence,  the  external  jugulnr  being  the  vemel  that 
m  MoaUy  BfaC  evideotly  dilated  ;  at  a  more  advanced  period  the  superficial 
laeoos  veins  of  the  upper  part  of  the  right  side  of  the  chest  often 
turtonuB  and  form  a  dense  plexus  in  this  Mtuatton.  while  manvanas- 
with  the  r^phalio  and  thoracic  veins  abnvft,  and  the  superficial  epi* 
below^  As  the  pressure  incrcaaes,  (nlemB  commences  in  the  right 
:  aad  band,  and  may  speedily  extend  to  tbe  whole  of  the  head,  fiice, 
ana,  wbidi  bemme  hard  and  hrawnv  in  ciin^aenoe  of  wrous  infiltra- 
!■  ooetnauuire  I  have  bc«o  the  lefV  arm  hcconiewddenly  nDdetnatous, 
riM  lift  faiBoraioate  vein  being  preaaed  upon.  In  these  cams  tbe  eyes  become 
Marfaic  and  pmaioent.  and  the  lipa,  nose,  and  featum  livid  and  torgid  with 
blood,  as  w«U  as  odematoos,  ao  aa  to  alt«r  greatly  the  expreasion  of  the 

VlalB  of  a  dull  aching  character  in  experienced   in   tbe  situation  of  tha 
Uuftor,  froo)  ihr  oomprnwlon  of  the  neighboring  structure*.      But  in   the 
atacea  of  tbe  difteaae  tbe  patient  oflen  experience*  sharp  shooting  pains. 
■pparMiuy  of  a  rbeiimatic  or  neuralgic  character,  in  the  arm  and  the  side 
m  iW  bead  and  fiiee.  arising  from  prcasure  upon,  and  irritation  of.  nerves 
'  A*  MffTical  and  brachial  pie xu9r>>.     Tnking  the  ooune  of  tbe  ascending 
'  daOMkdniff  filamenta  of  tho  cvrvicnl  nlexun.  the  pain  shoots  up  the  side 
''iW  band  and  neck,  and  over  tbe  shoulder  and  upper  partof  ihechnt;  or. 
pnanra  upon  the  brachial  plexus,  it  radiates  down  tbe  hand  and  arni, 
■Boally  «mdalW  atrare  about  the  elbow  and  finger*.    The  muscular 
of  tbe  ripit  arai  ako  commonly  b«ooniea  impaired.     Persistent  dilaia- 
of  lbs  nsaala,  with  swcatioo'  of  one  nde  of  the  face,  occasionally  occurs 
pnaaurr  em  tba  synpathetie. 


183 


SPKCIJLL    ANKURISUS. 


) 


Vt(.  4M.— ABMlritn  <X  lb*  Innonitiiat* 
Arwrr  oMBprflwInc  fta4  itrttahlDit  tb« 
Awartani  LftrjngMl  ^arT•,  and  pit»btiic 
ih«  TrwbM  i«  Uie    Un  Sid*.      (Buk 

VUw.) 


Oysposa  i»  or  vt.>ry  c'4>iiiiii<m  occurrence,  noii  of  vpnr  v&ryiD^  dcvraaaf 
iuujuity,  fruni  fllighc  <lifficuUy  iu  breathing  up  to  faul  a^ByzM.     It  may 

proc^d  eitber  fntm  corapnaiioD  of  thie 
recurrent  iicrve.  or  f^ftn  prmura  on 
the  trnchoA.  When  tt  dfr|»«'ndii  on  iW 
former  coudiEtnn,  the  voice  ia  hoftn*. 
husky,  or  whup(>ring;  and  thera  k  a 
dr)',  cmupr,  oud  paroxjmnal  eomcli, 
iMually  ftccofnpanied  by  expeecotmnn 
ot'litn  Trttthy  niuouft.  fa  thMo  lanw, 
:ili.  I  ili'ath,  (lit  right  r«curf«itt  ocrra 
will  \w  fouixl  In  he  8tretc)»etl  out  and 
^reHlly  ftiingnt^  \*y  the  prcMure  of 
the  tumor  (Fijr. -l(Wj).  OoinprMainai 
the  trachea,  which  l>ecume«  tial 
and  curTe<I  over  V\  the  left  eidc  bj 
the  prolrusiou  of  the  tumur,  ia  a  com- 
mon  cause  of  tlsypnogi.  and  is  nnt 
unfreqncntly  aaeuciatMl  with  prwura 
iin  the  reeurreut  nerve. 

The    luryngcal    iiynpn'i'a    in   tlwac 

Rasee  iw  auulitgiiun  tn  that  which  oocnr* 

in  ayrlic  aneurisms  i  p.  I7-'>  i ;  the  odIt 

ditTerencc  liein^.  that  in  one  case  it  » 

due  to  presiure  opoti  and  paralTsi*  of 

the  muscles  supplied  by  the  riplit;  in 

the  other,  of  those  to  which  the  l«ft 

rccnrrcDt  nerve  is  distributed.     It  ta  the  paralysis  of  the  enco-arytencndaas 

■ticus  musel«  that  is  so  espocinlly  distreseing  nnd  daoKTous;  for  by  h» 

ral^is  ih«  oorresponding  side  of  the  glottis  is  clowd.    More  mrrly  by  far, 

the  right  bronchua  u  oompreMed  by  the  extennon  of  tbe  tumor  downaantt. 

Dysphapa  \»  of  sufticiently  frequent  occurrence,  and  vAri««  from  slight 

uneMdinvNi  in  deglutition  to  an  impoeeibility  of  swallowing  anylbiuu  except 

fluids.     I  have  never  Men  it  occur  without  having  been  preceded  oy  dysp- 

[lltea;  and,  in  everv  instance  that  has  fallen  un<ler  my  ubeervation,  it  baa 

I  BStociated  wjih  ]arj-tt};eHl  <lyripna-a.    The  voinciiitjuce  of  these  two  aymp- 

_9nu  if  readily  explained  by  the  anatomy  of  the  parts;  the  recurrent  nerve. 

lying  between  tbe  sac  and  owphagus.  must  sufler  compression  before  the 

Flnticous  canal  be  inlerlered  with. 

PitOtiNOi^iH. — The  prognnsis  of  brachiocephalic  aneorisni  is  in  the  higbeat 
degree  iinfuvorahlo,  though  tbe  disease  fre(|ueutly  does  not  run  a  rapid  coune. 
If  it  extend  upwards  and  outwards,  tbe  tumor  may  nciuire  a  very  large  itia 
before  any  very  important  urgan  or  part  is  implicated  ;  but  if  it  pnsa  bactk- 
Ja  and  inwards,  it  may  prove  fatal  at  an  early  jteriiK).  I  know  of  but 
1  CB«e  of  spontaneous  cure  (rt')>orted  by  J.  O^le  j,  and  but  few  instances  In 
which  the  rupture  rif  the  sac  has  taken  place.  Tbe  must  frajuoit  csose  of 
death  is  BHphyxia.  from  apaflmodic  closure  or  paralysis  of  the  larynx  Induced 
by  prcMUre  on  ihc  recurrent  nerve;  or  from  preaurc  on  the  trachea. 

DiAiiMMttH. — The  diagnosis  of  iriDominotc  aneurism  is  uaoally  euffleiently 
l«uty,  if  niK^ntlnn  he  paid  to  the  dymptoras  that  have  just  been  d«tait<^t.  Hut 
U  times  the  ditliculty  i:i  ho  grrnt  na  to  halUc  the  most  sngacious  Phy»iriatu 
and  most  cxperirm^d  Surtrcnns ;  ihnl  whirh  has  during  life  hern  considered 
*  be  an  anirurisni  of  the  innominate  nrti^ry,  hnving,  atler  death,  prowl  tO' 
one  of  the  vummit  of  ihc  H»r(ic  arch  rising  up  into  the  rotil  of  the  nrdc 
behind  th«  right  »temo-matito(d,  or  overlapping  tbe  brachioK-ephnlic  trunk. 


TRKATMCNT    Or  INNOHIirATS    ANRb'Riail. 


Tbe  twk  of  overcoruitig  this  difficulty  iti  diaguo«U  muet,  he  kfl  to  t)ie  laot 
of  tbe  Surgeon.  But  it  is  impoa^ible  tu  uvercetimalc  lU  inipurtaiice,  when 
the  quntioD  of  li^aturiog  the  arteries  at  tlic  n>ot  uf  the  neck  for  a  BUppused 
tDDotDlnalc  aoeuriiiia  it  contciuptatutj;  for,  in  ut  tciift  three  c^sve  in  which 
thia  operation  bae  been  done,  the  an;h  of  thu  aorta  hint  l>een  funiul  tn  be  the 
HAt  of  di»eR8c*.  tlio  iunoiuiimle  in  two  of  the  eufm  being  unaflected  by  aneu- 
ram.  I  am  aojnaiuttd  nbo  with  a  faiirlh  vase,  in  which  thn  (ipemtion  was 
eomateQced,  bnt  waa  abandoned,  an  the  oiiliclavian  con  Id  not  he  renchpd  ;  the 
^HUient  dyiof^  a  fi-w  iIuvm  afterwardu,  the  iinciiriHni  wag  fonnd  to  he  aortic, 
lieiu)^  up  iulo  thii  root  of  ihe  neck,  the  innomtnatf  lifting  sound. 

Treatmest, — Thi^re  are  several  InHtant-PH  on  recunl  in  which  a  properly 
^Oonducit'd  ivMirBe  of  riin.'>litnlii)nnl  treatment  has  cured  the  patient;  thus  a 
'vase  of  Luke's  waH  permanently  cnreil  hv  flmall  and  repeated  bleedings,  con- 
joinLtl  «ith  the  adniinistnition  of  digitnlis.     In  connection  with  such  treat- 
ment, diutal  preoHure  might  be  employed,  as  in  a  ca^e  that  derived  benefit 
from  this  plan  in  ^^ynie't^  hands. 

In  aneoriam  uf  tiie  iunondnate,  the  v««wl  is  so  short,  and  the  sac  so  situ- 
ated,  that  it  b  impossible  to  attempt  (o  apply  a  ligature  on  the  cardiac  aide 
of  the  tumor.  What  resource,  then,  docs  eui^ry  offer  in  tlie*e  cane*  beyond 
tbe  employment  of  coustitulional  and  dietetic  means  T  It  may  be  answered 
to  this,  that,  if  these  measures  fail  in  arnwtiug  thv  diseaw,  our  choice  must 
lie  between  two  alternatives;  leaving  tbe  patient  to  his  fate,  or  having  re- 
ConrBe  to  tbe  application  of  the  ligature  on  the  distal  nide  of  the  tumor.  On 
Jookiog  at  tbe  innominate  artery  with  reference  to  the  distal  operation,  we 
are  struck  by  two  peculiarities  in  the  vcuel,  which  must  necessarily  rnoclify 
to  a  coosiderabie  extent  not  only  the  s«at  of  the  operation,  but  the  principle 
i>u  which  it  is  c(inducte<l.  The  first  pecuHnrltv  to  which  I  allude  is  the 
shortness  of  the  trunk,  which  makes  if  impog^ible  to  apply  the  lic;ulure  to 
the  vet«el  itself,  but  renders  it  oeceaaarv  to  dcligate  one  or  both  of  its  tcnni- 
nal  branches.  The  olhei*  peculiarity  is,  that  in  no  circumstances  can  these 
Tcsels  be  so  ligatured  as  to  arrest  the  whole  of  tbe  blood  sent  into  the  artery ; 
lor,  altliougli  the  circuliiiioD  through  the  carotid  may  be  eotii-elv  stopped, 
yet  it  is  impossible,  from  the  seat  and  extent  of  the  disease,  to  tie  the  sub- 
clavian  at  any  point  except  Iteyond  the  sealeni ;  hence  that  blnod  which  ts 
deetlned  for  the  supply  of  the  branches  of  thJa  vessel — the  vertebral,  the 
tfayr«iid  axis,  the  iuUTnal  mainmiiry,  and  the  Rrst  intercostal — must  continue 
to  be  pro|)elled  inui  and  thnuigh  the  ^ac.  Throe  distinct  mii<lii!catioiis  of 
llie  distal  "peraiion  have  been  propKised  and  rc^^orted  to  for  the  cure  of  aneu- 
ntnm  in  thiHailnnlinn:  1,  Ligature  nf  the  Subrliivian  alone;  2,  Ligature  of  tbe 
Oarotid  alone;  and,  ^,  Ligature  of  Both  Vessels  with  an  interval  of  greater 
or  leas  extent. 

1.  Ligature  of  the  Subclavian  only  (Kip.  467)  haa  been  practised  by  Du- 
puyiren,  Wardrop,  Ijangior,  and  Ilroca.  Dupuytren's  and  I^ngicr's  cases 
were  soon  fatal,  and  Broca'A  experienced  no  relief,  and  died  in  six  months. 
Id  Wardmp's  caiie  the  tumor  diminished  and  the  patient  purvivcd  for  two 
years.  This  partial  succeM  may  fairly  he  attributed  in  a  great  measure 
to  the  accident  of  the  carotid  having  been  occluded  by  the  disease.  The 
results  of  this  pmctice  have  certainly  not  been  suffiricntly  favorable  to 
jostify  tlie  Surgeon  in  repeating  an  atlempt  of  this  kind,  opposed  as  it  is  to 
Ibe  known  priucipl««  on  which  the  dislal  operation  efipcts  a  cure.'  For, 
soppoeing.  as  we  may  safely  do,  with  Wardrop,  that  only  one-third  of  tiie 

'  TbP  Tnhles  of  0|)efationB  for  InnominaW  ADcuriem  given  in  fomiBr  cdiilon^  have 
not  beeD  rvjitixlucnl,  lu  ll>c  nutuWr  liui  m>  Kt^utly  iiii'n.-used  'jf  l«U-  }'<-»n  m  m  msks  it 
linpoMltile  lo  rvcord  nil  without  uecup^ing  too  much  tpiic«. 


JlL 


1S4 


SPECIAL    ANKURISUS. 


,  blood  that  ia  Beut  iatu  the  iDDotniDiite  Bads  its  wav  thivugh  tlie  cxtn- 
'tcaloniLl  portion  of  tlie  nubclaviiin,  the  rerimin<Ier  being  tla-ttiiiHii  for  iu 
brttuch«4  mid  Uio  carotid  in  eciual  proportions,  what  &ot  eao  be  ftdduoad  or 
j}riociple  laid  dowD  from  which  we  cao  expect  to  obUlD  the  cure  »f  an 
raoeurifim  in  otoe«  proximity  to  the  hoart,  by  cutting  off  for  a  short  tliiw  oolf 
•0  Bmall  a  proportion  m  one-third  of  the  supply  of  blood  sent  into  it!*  Aa 
■oon  as  the  oolliktoral  Vfaacls  have  dilated,  tnc  flow  of  blood  through  tbt 
artery  will  bo  the  Aamc  aa  before  the  operation,  as  the  supply  of  blood  to 


.s-l 


2' 


.^^/ 


\ 


r^ 


Vig.  467.— Biiiohio-wpliallit 
AKaniitin;  Llgilnrsaf  lln 
SabetkrUn  ooljr. 


Fig.  Ill-il.— Br»ehiu-i<*phalia 
AoMBiUn:  Llgatar*  ii(  tin 
CWtttid  on  I/. 


Pig.  leU.— l;r>c]hliM<a|ibaaa 
Anoarttni;  I.lgalmvnf  Iti* 
S<ib0k*iMi  N»4  C<nitt4. 


the  upper  limb  Id  maintained  by  means  of  the  amutumoBea  of  the  bnuirhea 
of  the  first  and  aecond  part  uf  the  sabclavian  with  Uioae  of  the  azilfary 
artery. 

2.  Xigratnre  of  the  Carotid  only  ( Pig.  468)  for  innominate  aneurism  waa 
first  p4Tfoni)ed  by  KrariH.  in  182^4.  The  tumor  diminished  for  a  few  dan 
afler  operation,  but  ni  the  end  of  seven  days  ioflammatioo  of  the  sac  set  ta« 
fi)llowed  by  obliteration  of  the  arteries  of  toe  right  arm  nod  the  branohM  of 
the  carotid.  At  the  end  of  a  year  tumor  still  exiated,  with  oon^unt  pulution. 
Next  year  the  anc  suppurated,  and  discharged  much  pua.  iSinoe  that  tima 
the  operation  hai  been  repented  by  Mott,  Aston  Key,  Ferguaeon.  Huichin- 

laoa,  Pirogoff,  and  tniUT  othen,  nmoanling  in  all,  according  lo  llolniea,  to 
iunet«en  casei.  In  onlr  one  oue,  that  openuod  on  by  Erans.  does  tha 
l^iseaK!  appear  to  haro  Wo  matM-ially  beoofit«d ;  and  in  that  inatADoe  tbt 
[nod  effects  can  tcnroety  be  attributed  to  the  operation,  bat  most  rather  ba 
looked  upon  aa  the  result  of  suppuration  of  the  sac  and  e>>u«equent  oblitera- 
tion of  the  arteries  of  the  arm  and  bead  of  the  aflect^t)  aide.  Key's  patient 
died  in  oonwqueooe  of  the  left  carotid  becuming  occluded  and  the  brain 
being  depriviHl  uf  ita  profier  supply  of  blood;  and  in  several  olber  oaaea 
death  is  refi-'rrvd  t>j  hviiiipleiria  an<l  other  cerebral  diaeasea. 

3.  Thu  Carotid  and  Subclavian  Arteries  (Fig.  4439)  were  tied  simultane- 
oufly  for  Ibe  relief  <}f  iiinnuiinale  aneuriitm  for  the  first  tinif  bv  Rnwi,  in 
\SA'i,  but  there  is  some  doubt  as  Ui  the  partuf  the  artery  to  whicli  ihe  liga- 

Iture  was  applied.    -Since  that  time  the  o[M!nition  has  been  perforoied  ny 


TREATMENT    OF    INNOHINATK    AKBURISH. 


185 


DurhAm,  Hulinm,  MoCarlhy,  Weir,  Liaiie,  FVIlijck,  Stiiiiaon,  Littl«,  Lnngley 
Browue,  Harwell,  Berjj;inHiii),  iiiitl  ullien.  According  to  Holrne!;.  the  toUll 
aumher  of  caxea  up  t»  1S82  iimounted  to  iwcnly,  tij  which  Bergmunn'e  caee 
must  be  mMed.  In  seven  vtmets  murked  improveinvnl  foljovred  the  riperntion. 
^timson's  patient  survived  the  operuliim  tweuty-oae  montha.  Four  in'>nth3 
«ft«r  the  aperatifiD  he  was  Huddealy  attackixl  by  left  homiplegia  and  itpliasiit, 
after  whicfi  the  tuomr  diminished  in  sice  rapidly.  He  partiuIlT  recovered 
m  the  p«ralysls.  After  death  the  third  part  nt'  the  subclavian  and  the 
id  were  aficertaioed  to  be  obliternted ;  the  eac  of  the  nDeuru'>m  was 
■lioat  tbe»ize  of  a  hea's  egg,  and  commijuic^atcd  with  the  eubclavinii.  nil  the 
braacfaes  of  which,  except  the  ioternai  nianiniary  (which  could  Del  be  found), 
were  patent.  Little's  ca&e  lived  three  and  h  half  years,  dyin^;  at  tuet  of 
pleunsT.  The  aneurism  was  prnctically  cured,  but  u  channel  exited  through 
It  to  the  tnbelavinn.  Of  Barwell's  four  cases,  one  died  from  the  aniesthetic, 
and  three  were  auccc^ful.  One  died  three  months  aAer  the  operation  of 
broDchilie,  and  the  second  died  two  vears  after  at^o  of  bi-onchitie,  and  id 
both  of  theec  the  disease  wns  practicallv  cured.  The  third  remains  well  up 
to  the  present  time.  In  Browne's  nnd  Bcrgraann's  cases  the  improvement 
eoDtiDued  up  to  the  last  report.  Of  the  fatal  cases,  four  died  from  rupture 
of  the  sac,  one  from  hemorrhage  from  the  ligatured  arteries,  one  from  shock, 
<one  from  hemorrhage  from  the  sac,  one  from  cxhatitation.oTte  from  uaphyxta, 
e  frum  the  anawthctic,  two  from  the  unrelieved  progress  nf  the  ani-unsm, 
and  in  two  the  caDM  of  death  was  doubtful.  The  operation  wan  attem|iled 
in  another  caoe  b]^  Cheveni,  hut  the  subclavian  vein  waa  wounded,  and  the 
patient  died  in  two  liouRi. 

The  carotid  and  subclavian  have  alan  been  tie-d  conoecucivelj  at  intervals 
varving  from  two  years  to  one  month,  in  six  coAeia,  bj  Fefirn,  Wiekham, 
Malgaigoe,  Mott,  Bickersteth,  aud  Admue  aud  Treves.  lu  nl)  cmw  the 
carotid  was  tied  BnL  lu  Feuru's  i;aee  two  years  elapsed  between  tli«  opero- 
lionij,  and  the  patient  died  four  tiiuuths  after  the  eubcLuviau  was  ti«d,  of 
pleurisy.  The  aneuriam  wa«  found  to  be  C'>u8<didated,  with  the  exception  of 
a  channel  leading  to  the  subclavian.  In  Wiokhum's  case  relief  fullowed  the 
ligature  of  the  carotid,  but  syuptoms  soon  returued,  und  the  subclaviau  waa 
tied  about  six  weeks  afterwards,  but  without  eflect,  thu  patient  dying  iu  two 
and  a  half  months  from  rupture  of  the  sac.  In  Mott's  case  a  practical  cure 
reralted,  the  patient  dying  <jf  phtliiijiH  tbree  yeam  alter  the  secoud  operation. 
Is  Adams  and  Trevea's  case  the  aueiiriem  wa«  coaeolldated,  but  death  took 
place  108  days  after  the  second  operation  from  rupture  of  the  sac  of  an 
aortic  aneurisoi.  In  the  remaining  ca»ee  no  bencnt  was  derived  from  the 
flpefatioo. 

A  r^jnmi  of  the  oases  of  aneurism  of  the  innomioate,  in  which  the  opera- 
CioD  of  ligaturing  one  or  both  arteries  beyond  the  sac  has  been  performed, 
having  thus  been  given,  the  question  arii<es  whether  tliesu  operatione),  or  any 
of  them,  should  retain  a  place  in  surgery.  This  question  niny  be  examined 
from  two  points  of  view:  1.  A^  to  the  principle  on  which  these  operations 
are  performed  ;  and,  2.  As  to  their  results  in  practice.  For  the  auocess  of 
the  distal  operation,  it  is  requisite  that  there  be  no  branch  given  off,  either 
from  the  Hic  or  between  it  and  the  ligature;  or  that  the  current  of  blood 
tbpMigh  the  sac  be  at  least  so  far  dimiiU!<hed  as  to  admit  of  the  deposition  of 
laminated  fibrin  iu  sufficient  quantity  to  fill  it  up,  by  o  process  similar  to 
that  which  hBp{>ens  in  a  case  of  ititeurLtm  treated  by  the  Hunterian  method. 
In  order  that  thi^  may  be  accomplished,  it  is  certainly  neceasary  that  the 
^^breater  f>orti'in  of  the  blood  paAsing  through  the  sac  be  arrested ;  for.  if  the 
^^^arrent  that  i^  still  kept  up  be  too  free,  the  tumor  will  continue  to  incrPA«c, 
W      ta  vn  have  seen  happen  in  ctaen  of  inguinal  aneurism  in  which  the  femoral 


^ 


from  the  brftchii>cenbalic,  as  tb«  subcIaviMi]  beyoud  the  MCftl^iii,  be  tiot),  and 
btit  a  third  of  the  olood  circuiAtiiig  ibruu^h  Ihu  msiii  iirtt-ry  hv  iirru»l««1, 
»r«  we  jusliGud  in  hopia^  that  the  uirtiulutiuu  tbruugh  the  sac  will  be  80 
intliienced  by  tho  dtveratou  of  this  stunll  ^uHutity,  IbuL  liiu  rvniaiuing  inu- 
Cbird«  of  tht>  bluod,  which  wiJl  elili  piuus  thruuuh  fur  ihu  supply  ut'  Lh« 
canitiil  uud  ihu  Liraucht»  oi'  tht;  subolaviua,  will  gradually  depueit  tbueu 
fibriuuus  latuiosu  by  which  uhltterucioa  of  the  lumor  is  tu  be  ofTected  ? 
Should  we  nut  ruther  eipect  that  the  larger  current  will  be  too  twwerful  to 
allow  the  rormatioQ  of  these  layers,  aud  will  continue  W  distend  the  sac  in 
aucb  u  way  aa  to  prevent  ita  coatractiou?  Surely,  if  the  comparalively 
auiall  nud  feeble  streams  of  blood  that  pass  through  the  epigHstric  aud  otrcuni- 
Qex  ilii,  are  sufficient  to  interfere  with  the  cure  of  an  inguinal  aneuritiui  al\er 
the  distal  ligature  o(  the  feiuoral.  theetroug  current  that  sweeps  through  the 
carotid  and  the  lar^'c  braDches  epriiigiog  from  the  «ubclnTiao,  with  the  full 
force  derived  from  chise  proximity  to  the  heart,  will  nvoet  probably  be  suffi- 
cieoC  to  prevent  all  lamiDation  10  au  aneurism  of  the  innomiunte.  That  the 
arrest  of  tlie  circulation  through  one  of  these  ve^els  only  is  not  sufUcierit  to 
iuSuencc  materially  tho  growth  of  the  aneurism,  is  evident  likewise  from 
what  is  not  unfroqucntly  observed  after  death  in  ensc^  of  thU  kind — one  or 
other  of  tho  vcoscla  being  fu^ind  compressed  and  oblitc-rated  by  the  pressure 
of  ihc  aac,  or  pluggefl  by  fibrin,  and  yet  no  alteration  in  the  tumor  resulting. 
Theae  cmtt,  which  arc  tolerably  numt^nms,  would  of  themselves  have  been 
sufficient  to  prove  that  aomeching  more  than  tbiji  amount  of  obstruction  is 
required,  in  order  to  effect  proper  stratification  of  fibrin  in  the  sac;  and  if 
w«  turn  to  the  result  of  the  twenty-three  ciisex  in  which  either  the  carotid  or 
the  8u))vlaviaD  has  been  ligatured,  we  shall  tiiid  that  in  one  cuHe  only,  that 
ojiernted  on  by  Kvans,  of  Belper,  has  a  cure  been  e fleeted ;  and  in  this 
iDStauce  how  was  it  accomplished?  Acconling  to  (be  principle  on  which  ic 
WAS  attempted  to  be  establiiibed?  Certainly  nut;  but,  ae  will  be  seen  by 
attenlinu  to  the  details  of  the  cnae,  Mid  as  has  already  been  pointed  out  with 
much  acuteoo^s  by  Oulhrie,  by  tb«  accideotiil  eetling  up  of  ioHammatiou, 
which  extended  to  the  »ac,  and  thus  obliterated  it. 

In  the  c««e  (that  of  Mrs.  DeumMrlt)iu  which  Wardrop  tied  thesuliclaviao 
for  the  cure  of  nneurisui  of  the  brachio-cephalic,  there  is  eouie  reason  to 
doubt  whether  the  iuTi.«t  of  the  pmgreiss  of  the  tumor  w»a  owing  to  ihe  liga- 
ture of  the  subiOuvian  artery,  or  whether  it  was  nut  much  iulluenced  by  uie 
ob«lruction  which  exiittcd  iu  the  caruUd  for  uin?  days  utU-r  tho  Q)icralioa, 
during  which  time  so  abundant  u  de|Hit;it  uf  laminated  librin  might  have 
occurred  an  to  arm;t  the  progrtiis  of  tbu  dtaeaMj  for  Home  leuglh  of  time.  In 
ihia  cuire,  aliro,  Guthrie  t^uppoeis  it  probable  tliat  the  intlamnmtiou  of  the 
tumor  niiiiht  have  IhI  to  it^  obliteration. 

From  a  careful  considenilinu  of  all  the  circumstances  of  the  cases  in  whirh 
ligature  of  one  ve(«el  only,  either  subclavian  or  carotid,  bat)  been  employed 
fur  brachio-ceplmlic  aneurism,  we  arc,  I  think,  fully  jn^titieil  iu  vuncluding 
that  in  sixteen  of  the  ca^es  the  fatal  rei^nlt  vas  Hccelenited,  occurring  as  a 
oonsequence  of  the  ligature  of  the  vessel;  in  three  the  progrees  of  the  uisGue 
WH8  not  materially  interfered  with ;  in  two  it  was  arreatetl,  tiie  patients  living 
for  iweniy  months  and  two  years  respectively;  jn  one  the  result  wa3  uncer- 
tain, and  in  one  case  only  the  disease  was  cured.  The  improvement  in  two  of 
the  case»  was  the  result  of  accidental  cireumstnDCCs,  which  were  unexpected, 
and  unconnected  in  any  way  with  the  principles  on  which  the  operation  was 
undertaken.     These  results  would  n<it,  in  my  opinion,  justify  eny  Burgeon  iu 


INNOMINATE— RESULTS    OF    TBBATllliNT. 


187 


•gain  miikios  bh  attempt  to  cure  an  innominnte  aaeurism  by  tbc  iif^ature  of 
eitb«r  the  BUOclavJRD  or  the  camiid  arttrv  aloue,  tlic  patieot  liaviuji;  been 
dirTWtIv  killed  by  ttie  operatiou  id  two-tltirilfl  of  llie  ciiBe«.  Of  tlic  rumniaiDg 
tliinl,  iQ  uo«>balf  the  patieuu  reojvered  from  the  operalioo,  but  lUc  <iisc-uw 
nn  it*  coune  as  if  ouauch  procedure  had  been  adopted;  aud  iu  tbo  rctuaia* 
ing  aleader  perceuuige  of  cases  the  improvcnictit  tliut  took  place  tu  two,  and 
Uw  cure  ID  the  ooe  Holiinry  iusiAQce,  were  due  to  accidcatal  drcutnitlaucee 
unconnecieil  with  th&  operatiuQ,  and  which  ooD^ueolly  might  have  devel- 
oped equally  if  none  bad  been  performed. 

We  have  yet  to  cnoHtdcr  the  opcmlion  io  whieh  both  arteries  are  ligatured. 
ThU  double  operaiioti  may  cithur  he  performed  with  an  itUen'ai  between  the 
opptitntion  of  the  ttoa  (igalurei,  suflicicnt  for  the  i-stablishmcut  of  collateral 
ctrrulauon  ;  or  the  two  vceuels  may  be  licatured  Hioiullauuouxly.  The  former 
plaa  baa  beeo  ado]ite<l  in  »ix  cases ;  the  latter  in  twenty-one;  not  a  sufficient 
luimher  for  any  eufe  deduction.    Of  the  eiz  cases  in  which  au  interval  inter* 

med  b(>iwei->n  the  iwo  o|ieration9  the  tumor  s^^ems  to  have  been  ]>mctica]]y 

red  in  three,  in  two  cnnea  do  relief  was  obtained,  nnd  one  died  directly  from 
the  operalioD.  In  the  twenty-one  cflKe*  in  which  the  vesAela  were  ligatured 
simultaneouHly,  dfiith  took  place  directly  from  the  operation  in  four;  the 
iliaease  waa  nnrelieved,  and  terminated  talAlly  in  eiRht;  in  two  the  cause  of 
death  isaoroewhat  uncertain,  and  in  ^ven  K'^at  benefit  oi-  a  praclicnl  cure 
ll«d.  It  is  intercf'tin);  to  note  that  the  later  cn^es  have  been  the  most  sue* 
iful,  and  it  w  reasonable  to  hope  that  this  i«  due  to  modem  improvements 
iSb  the  methods  uf  tying  arteries  and  dre«»ing  wounds.  The  case-i,  however, 
are  not  yet  euflicieutly  uum«rous  or  fre«  from  modifying  circnniittAncea 
tu  enable  as  tu  draw  any  certain  inferetice  from  them  :  we  muat,  therefore, 
rrvert  to  (be  prinriplu  <iii  which  thia  o[>eration  should  \m  uiiJer[ak''n.  This 
will  ditfcr  materially,  ucconlinp  to  whether  the  two  ortcritx  are  ligatured 
■multaneously.   or  with  a  sufiicicDt   interval    for  the   reeiitahliHiiment  of 

llateral  circulalioo. 

If  an  interval  of  two  yearti,  as  in  the  lir^t  oaae,  or  even  ot  two  and  a  half 
Lho,  as  in  the  second  instance,  be  alloweil  to  elapse  between  the  llgiiture 
of  tiiD  carotid  and  that  of  the  subclavian,  the  opemtion  reduces  itself  essen- 
tially to  that  of  the  ligature  of  a  ^iu^le  artery,  which,  an  has  already  been 
fehowo,  is  iusufficicDt  to  induce  those  changes  in  the  sac  that  are  neceti&ary  for 
the  accomplish  men  t  nf  a  cure.  If  [he  pulient  survive  the  effect  of  the  liga- 
ture of  the  carotid  for  a  few  weeks,  sulbeieDt  time  will  have  been  afforded  for 
the  proximal  end  uf  the  subclavian,  the  vertebral  artery,  and  the  thyroid  axis 
to  lake  upon  tbemaelvcoa  great  increase  of  development — the  collatemi  cir- 
caUtion  bcinj;  rarried  on  by  them  and  not  hy  the  \ei\  carotid  ;  so  that,  by  the 
time  that  the  subclavian  comes  to  he  li(;atureil  hevond  ibc  soaleni,  the  sac  will 
rtill  continue  to  be  traversed  hy  a  current  of  blood  for  the  supply  of  the 
branches  of  the  wihclavuin,  dilated  beyond  their  nnrnml  size,  in  consequence 
of  the  iftjik  nf  Kupplyin^  the  ripht  side  of  the  neck,  face,  head,  and  brain 
heiof;  priacipally  thrown  upon  thpm.  This  current  through  the  proximal 
end  (if  the  subclavian,  increased  a^i  it  will  have  been  hy  the  whole  of  that 
blond  which  is  destiiiC'l  lo  supply  the  place  of  that  which  should  pnw  by  the 
tarotid,  will  pince  the  sac  in  nearly  the  same  condition  as  it  wiis  before  the 
Ujpiiure;  nnd  will  consetpiently,  for  the  reawn  that  has  already  been  givoHt 
b«  too  powerful  for  a  cure  to  lake  place  in  the  course  nf  it*  atream. 

It  now  remains  only  for  ue  to  consider  the  »itnuttanrouM  ligature  of  both 
Tcswl« — an  operation'  that  has  been  performed  for  innominate  nneurism 
twenty-one  timeo.  Iu  rensouiii}.'  ujkiu  the  simuItanetHts  ligature  of  the  twr> 
vaiteU.  we  must  consider  two  points;  1,  !n  what  coiuiitiou  do  we  place  the 
2,  Is  the  danger  of  the  patient  much  increased  t 


188 


SPXCIAt.    ANEURISMS. 


fta  for  u  the  MO  is  ooncemed,  it  is  impoanhlc  to  plue  it  in  a  hector  oaodt 
tion  for  th«  d«poiit  of  Uminited  fibrin;  two-tbira«  of  the  blood  flitwiag 

tlirouffl)  it  b«ing  iirn?«t«d,  iind  that  only  tnivemn);  il  which  ii  •!'  ^'^ 

tb«  »U|>{ily  of  the  Ijnincbo^  of  the  siibclavina.     It  is  hy  uu  mttat.-^  •»- 

ble  thill  even  this  strfum  miiy  yet  bi?  too  large  and  furcihli"  to  nliow  thv  |tro- 
ocm  iif  nccliision  in  tnk«  pliic«,  v«l  it  is  intpoteible  sLill  further  In  <)imini>b 
it ;  ami  if  tb(>  unuurium  be  uicculati'd,  ani]  project  fmm  one  niiJe  of  th«  in- 
nominate arlery,  pHrticularly  to  it^  inteninl  or  mesiial  aspect,  it  il  by  do 
means  imponible  that  it  may  be  sufficiently  removed  from  the  atroftm  to 
allow  ooosolidatioi]  of  its  cootenbi. 

Dooa  it  add  to  the  danger  of  the  patient  to  ligature  these  two  roHels  sim- 
□Itaneously  rather  than  separately  7  I  think  noL  If  the  risk  of  a  douUa 
operation  is  to  be  incurred,  1  caanot  think  that  it  would  be  poaitiTely  ia- 
oreased  by  the  two  being  performed  at  oni-e.  instead  of  at  separate  intervals  j 
the  whole  of  tbe  ves^elii  that  serve  to  maincaio  the  oollat^ral  circulatioa  id 
the  head  and  upper  cxtri-niity  being  lcl\  without  iotorferenoc.  And  tlw  in- 
sult that  has  followed  the  limited  number  of  these  operations  corroboralci 
the  justice  of  tbis  opinion,  for  we  find  that  the  paiicDts  reooTered  from  tba 
opcralions  in  fiileeo  ool  of  the  twenty-one  cases. 

The  result  of  these  fifteen  caaes,  so  far  as  the  a&earinn  itaelf  waa  wa* 
corned,  vm  not  altoeetber  iinoatiufkctory  when  tbe  othervise  hoprieat  natars 
of  the  disease  is  taken  into  consideration.  In  acvcn  the  pauent  derived 
fpreat  and  unmistakable  benefit,  and  in  the  remaining  eight  there  is  no  rea* 
son  to  believe  that  the  operation  hastened  the  progress  of  the  cose  towartb 
death.  .^  far,  then,  as  actual  results  go,  it  it  evident  that  the  ehane«a  are 
decidedly  against  the  patient's  deriving  any  benefit  from  tbe  operation,  and 
at  the  same  time  it  must  not  be  forgotten  that  aneuri-ima  of  the  innominate 
artery  have  been  cured  by  palliative  and  oonfltitutional  treiiimenl.  It  does 
not  seem  ju)iti6able,  therefore,  to  reaort  to  the  dixlat  ligature  till  thnse  meaaa 
have  bad  a  fuir  trial.  If,  however,  rest,  diet,  and  ineilical  treatnient  fail  to 
arr«^t  the  progrew  of  the  disease,  tbe  amount  of  sucoess  obtained  from  oper- 
ative iuierlereuce  has  been  quite  sufficient  to  enoourge  a  repetition  of  it  ia 
weU-celected  com*. 


I 


ANBOSIBH  OP  THE  CABOTID  AUTUKY. 

Aneorismal  Tarix  of  the  Carotid  Artery  and  of  the  Jngnlor  Taiii,] 
the  rt-iiuU  i^f  punctures  and  stabs  in  the  nrck.  has  b>ecn  iiii^t  »itb  in  a  st 
cient  number  of  instances  to  establish  the  Higns  and  treatment  of  such  a 
condition ;  and  au  instance  is  retate<l  by  Mackniurtlo,  in  which  a  communi- 
cation WHS  e«tablii^hed  bvlween  tl>e«>e  ve»«eU  a«  the  result  of  disease;  but  I 
am  not  aci|uainteii  with  any  case  of  Varicate  Afieuri«m  uf  lbi«e  vcfksels  having 
been  recorded.  The  Sigyu  of  aueurismal  vorix  in  this  situation  prtwnt  uo- 
ihiug  (leculiar  ;  and  the  Trmtmcnt  must  be  entirely  of  a  hygienic-  cbanu'trr, 
no  o|>enilive  interference  being  likely  to  be  alteude*^!  by  any  but  a  fatal 
rteult-  It  is  the  more  d««irable  not  to  interfere  in  these  coses,  a»  the  disaiM 
does  not  ap)icar  to  thorten  life. 

Spontaoeoas  Anearism  of  the  Carotid  is  oot  of  very  unlrequrot  oooiu^ 
n-ucc:  ill  i'rmp's  Uiblu  ut'  0^1  uiifunHms,  25  were  of  tbe  carotid;  aad  It 
ranks  in  unler  ui  frequency  between  those  of  the  abdominal  aorta  aad  of 
the  subclavian.  It  occurs  more  frequently  in  the  female  than  any  other  as- 
ternal aneurism  :  thus,  of  tho  'Zo  cases  alluded  to,  12  were  in  women,  owing 
probably  to  it  soldom  being  the  rwutt  of  violence,  but  geuiiraihr  ariiiiag 
mm  diaeaae  of  tbe  coaOi  of  the  venwi.  In  Hnlmes'a  table  of  S87  anea- 
rlsms,  11  were  of  the  common  canitid,  10  being  spontaneous,  and  1  trnu- 


riA 


mi    COMMON    CA] 


189 


Bfttic.  Three  of  the  former  were  in  women.  This  aneurism  in  alMmnuk- 
kble  OS  occurrinfi;  at  efirlicr  sta^i^  than  nii^sl  others  ;  thus,  TIodf>90il  ItaiMta 
it  in  a  girl  of  ten ;  Sykes,  of  Philadelphia,  iti  one  of  eij»hteen ;  C.  Tltrath, 
in  A  woman  aged  twenty-three  (external  carotid),  who  was  suffering  from 
eiteiiBive  dtACAM  of  the  cardiac  valves.  The  right  carotid  is  much  mure 
commonly  atiect«d  than  th«  litft,  and  the  upper  purLiuo  of  tfa«  ve«»el  than 
the  lower;  indeed,  th«  bit'urculion  i«  iJie  most  couinjon  wat  of  aiieuriHiial 
dilatatiou.  The  root  of  the  right  carotid  not  iincumnionly  is  dilated  ;  but  I 
have  never  seen  or  hwird  of  a  caeu  iu  which  the  left  carutid,  before  emerg- 
iti|!  friim  thf  vh««t,  lin»  l>ecu  atlected. 

SvMVToMg, — A  carolid  aneurism  io  the  early  stage  presents  ileelf  as  a 
uiiall.  ovoid,  t>iiiuutb  tumor,  with  distinct  puleatiou  and  bruit,  and  n  well-cir- 
cumscribed outline  It  is  communly  soil  uiul  ciuuprviwible,  dimiutHliin^  lu 
•is»t>a  prtwur«,  aud  expanding  again  with  the  ii*ual  aueurisuial  dilal^itiun. 
As  it  iDcreaaev  io  size,  it  becunieB  more  solid,  uucaaiuue  sbootiug  paii>s  iu  the 
ikMd  ami  UL'ck.  and,  by  its  pressure  ou  the  pbnrynx,  ccsopbagus,  aud  larynx, 
{noduoca  diUJL-ulty  in  deglutition  and  rcRpiraciciu  ;  Kuuctimeit  lIi6  Hilivary 
glantis  are  much  irritated.  Ailer  a  time,  the  cerebral  circulation  bbcouiea 
inlerfered  with,  giving  rise  to  giddineos,  Impaired  vision  of  the  curres)K>uil- 
ing  eye,  nt^ses  in  the  ear,  aod  a  tendency  to  xtupor.  These  fiympt«)iD&  may 
be  oving  to  compreaaion  of  the  jugular,  to  diHiculcy  iu  the  tranFmiiviou  of 
the  bluod  thrvugh  the  tumor,  or  to  irrilation  of  the  cervical  ganglia  of  tlie 
pathetic.     The  ^ixe  that  the^  ancurisme  may  attain   varies  greatly; 

-illy  tbey  are  coufined  to  the  epnce  under  the  angle  of  the  jaw,  but  not 
,_  .fimuently  they  occupy  the  greater  pnrt  of  the  side  of  the  neck.  If  they 
he  allowed  to  iocreoiie  without  inlerferenoe, 
death  may  happen,  either  by  rupture  cxtero- 
allj,  or  into  ttte  pharyn^c  or  <i«i>phagUH;  by 
Mphyxia,  from  prcasure  on  llie  larynx  or  reeiir- 
RDt  nerve ;  or  by  fttarvatiou  from  compreseion 
of  the  ceeopbagus. 

ADCUrianis  of  the  carotid  are  uttually  of  oloir 
growth,  and  may  aometimeti  exiflt  for  a  consider- 
able number  of  years  without  giving  ri»e  to 
any  special  inoonveuience  ;  thiti  iii  more  particu* 
tarty  the  cane  when  they  are  seated  at  the 
bifurcation  of  the  arterj-.  I  have,  however. 
teen  a  ipontaneoun  aneuritmi  in  this  eitualiim 
attain  tbesiieof  a)>mall  orange  iu  a  few  weeks. 
When  at  the  root  of  the  ucek,  tlicy  are  more 
likely  to  be  attended  by  iujurioutt  pritu^ure- 
etlecis  at  an  early  pericKl. 

DlAUKOsit;. — The  diaguoeis  of  ciirutiii  aueu- 
risoi  is  without  doubt  laoni  dilUculL  than  that 
of  auy  other  form  of  external  aueurieui ;  the 
best  proof  that  this  is  so,  may  be  found  in  the 
ibet  tuatfOf  the  cases  in  which  Liie  carotid  artery 
bM  been  ligatured  fiw  suppoeed  ancuriHtn  of 

it  or  its  bmncbee,  in  several  iat^tanrce  no  t^uch  disease  existed — solid  cysts, 
or  otliCJ  tumors  of  the  neck  having  been  mifliakcii  for  iineurism.and  this  by 
Sorgeons  of  great  ami  acknowledged  repute. 

The  diagnoeis  of  aneurij-m  of  the  lower  part  of  the  carotid  from  timilar 
dueoM  of  iriher  arteries  at  the  nxit  of  the  neck,  as  of  the  Buhclaviaii,  verte- 
bral, and  brach to-cephalic,  aod  the  arch  of  the  aorta,  is  surrounded  by  diffi- 
oukiea,  which  can  be  cleared  up  only  by  a  careful  istethoscopic  examioatioD 


Fife-  ITO.-'Anouritinof  tU«8uiD- 
■nil  <if  111*  Aruh  of  Ik*  A»rtii, 
■iinnlKticif  0*iiiUd  ADeurUin. 


190 


aPBOIAli    ANKUUISHS. 


of  the  pan.  In  some  ftueurl^uiA  of  thu  arch  of  the  aorta,  the  aae  riMi  up 
iaio  till-  m-rk,  so  as  closely  to  aiitmlatc  a  raruUd  aneuruin,  as  Id  the  anpccwe 
cut  (.Fig.  470);  and  this  greatly  ioereases  the  (HBiniltTof  tb<>  dingnocJa.  la 
mich  ca«M,  Halmes  suggests  that  the  effect  pnnlurcd  by  carnfuTly  applied 
difttal  pnwitiro  may  aid  in  the  diagnoBiB.  If,  aflfir  a  i'evr  Iiouni,  whrn  tn«  cnl- 
laiernl  circtilation  nhouM  he  commencing  Co  onlarg^,  the  aac  shows  no  pigas 
of  diminished  tetiMon,  the  case  in  very  prohnhty  one  of  aorlin  aneurism.  Tbt 
principal  atfections  of  the  neck,  however,  with  which  aneurt«ni  of  tb«  carotid 
may  be  confounded,  are  varix  of  the  internal  jugular  vein,  fiolarged  lyiDptuitic 
glands,  ah«c«m,  tuniore,  cvstt  in  (he  neck,  and  pulsating  bniocnoc^lc. 

A  diUiUd  oTtrry  doubted  u;wn  iU/tif  may  oUisefy  rc*«ml>l«  an  aneurism  wbcft 
situaltxl  at  the  runt  of  tliv  n^k.  tMich  a  ca»e  i«  r««urd««l  hy  C<>ulsuo,  It 
occurred  in  woinau  of  ISti.  Nu  treatment  whs  adopted,  and  aflt-r  di-mth  tl>s 
supposed  aucuriiini  vras  found  to  be  a  reduplieatiuD  of  tb«  commoa  carotid 
flurruundt-d  by  iutliiratcd  c«ltulnr  linsuv.  _ 

From  ran>  the  diagnueis  niny  rcndily  bv  made  by  attenliou  to  lh«  fulU^^A 
ing  circu mdlunctw  ;  that  in  varix  Lhc  tumor  is  always  eoll,  does  not  puIH^^H 
expanMTcly,  and  diinini^hts  in  size  during  a  deep  URpiraLina,  and  ua 
prcffiing  tht'  vein  on  iu  distal  »ide. 

Glawuiar  tumor*  of  Uie  neei:  are  ollnn  very  difficult  to  distinguish  fi 
aneariun,  more  particularly  when  the  ariery  paHHes  through  and  ia  embracad 
by  the  tumor,  so  that  the  whole  mns^  di-tlinctly  riovh  at  each  puli^utiim.  In 
these  coMti  also  there  may  be  an  apparent  diminution  in  the  hixc  of  the  tumor 
on  compreasion,  by  the  artery  within  iL  being  emptied,  or  by  the  growth  ra- 
ceding  luto  some  of  the  interspaces  of  the  neck.  But  in  the  great  majivity 
of  insUnoes,  attention  to  the  globular,  oval,  and  nodulated  fed  of  glandular 
swellings,  and  the  nossibilitr  of  raising  them  up  and  pushing  them  awar 
tfom  the  vessel — which  may  Iwst  be  done  by  feeling  the  cnri>tid  with  the  hkh 
of  tbo  fingers  of  one  hand,  and  then  pressing  upon  the  tumor  with  tha 
—will  claar  up  the  true  nalurc  of  the  case. 

From  ab*K$te4  of  the  ntek  the  diagnosis  must  be  made  on  general  princi 
The  coexistence  of  ill-defiued  har^luess  and  (;ulargen>ent  of  the  gtatids,  _ 
inflaraod  state  of  the  skin,  the  ready  detection  of  fluctuntion,  and  Lhv  nbseoet 
of  expansile  pulmtiou  iu  the  tumor,  will  show  thai  it  is  not  Hm'urismal,  how- 
ever nimiUr  ita  other  ch»ractera  may  be.  It  is  ofimportaDceto  obaerw  alts 
that  an  aneurisoi  that  tiucluatea  is  always  forcibly  distended  with  stnM 
pulsation,  and  can  be  materially  diminished  by  pressure,  neither  of  wbicii 
circumiitances  can  pouibly  occur  in  abscess,  liut  if  abscess  may  be  mis- 
takea  for  aneurism,  the  conveive  also  holds  good ;  and  au  aoeniwn  may, 
unless  ciLre  l>e  taken,  be  mistaken  for  abscess — a  far  more  fatal  error.  Am 
there  is  one  variety  of  false  aneurism,  that  to  which  T^iston  has  invited  speOal 
atleutioD,  against  which  the  Surgeon  muiit  be  carefully  on  his  guard,  oo 
account  of  the  many  points  of  resemblance  between  it  and  aneurism ;  I  mean 
tha  case  iu  which  an  artery  has  given  way  into  the  mc  of  an  absce*.  In  ihit 
ciMi  fluctuation  and  pulsati^m  will  exisi,  ultbough  not  perhaps  of  a  dii>tesd- 
ing  kind.  An  important  diaguoslio  mark  will  be,  however,  that  Uie  nuUioa 
of  an  nneuri^m  is  di^tiueily  ileHnul  and  limited,  whilu  that  of  an  aheeeM 
never  is.  Aneurism  of  the  intamal  carotid  has  been  found  hy  8yma  to 
nmulatc  very  cIomIt  (Ateeu  of  the  tontiU. 

J\tflUfn  of  various  kinds — (!a^t';illomatou^  fatty,  and  fibrous — m»occar  lo 
the  neck,  and  rtiuse  Hume  little  cmbarrassmmt  in  the  dtsgnnais  Iron  anen- 
rlsm;  thus  Li»frBnc.O'Rcillv,  and  Kerr, ofAberdMD,  hav«  rvcorded  csMifai 
which  the  artery*  has  been  tignturcd  in  such  case*  bv  mistakfi  for  aneoTiBm. 
Tile  diagoosla  of  such  tumors  as  these  muiit  be  efiecte^l  on  ordinary  pHndplca. 
1  have  in  several  instauce*  met  with  a  small,  bard,  distinctly  circumscnbed 


eHKM 

Meoet  V 


LIOATURK    OF    TUB   COMMON    UAROTID. 


191 


tnnior  lying  ilir*cily  upun  the  carolici  artery,  and  apparently  ooDaected  with 
it,  and  rt^ct^ivin^  pulmitiun  from  it,  imually  prottuced  by  a  fit  of  cougtiing  or 
Iftugbiag.  TbU  tumor,  with  the  true  nature  of  vih\ea  I  nm  unacquaiatcd, 
nouiins  stationary,  and  doe«  imi  require  any  operative  iuterfereuce. 

The  thyroid  Uxly  is  not  uufrequentl;  the  seat  of  eDlurgenienls,  that  hnvo 
b«ea  mLitakea  Jbr  aneurism.  These  cotwtst  chiefly  in  a  circuit] acribiid  enlarge- 
ment of  one  lobe  of  the  gland,  which  extendi  laterally  over  the  conioinD 
carotid,  and  receives  pulHition  from  it.  This  kind  of  broDchoccle  luay  he 
dtagoofted  from  aiieiirieni  hy  the  communicated  pulsation  in  it  ceosini'  when 
it  IB  raised  from  the  artery.  The  most  puzzling  cascg,  however,  and  tnoBc  in 
which  mistaken  mar  most  ea^ilr  he  mndc,  are  instances  of  pul»'ding  bnncho- 
^eie,  in  which  these  tumors  have  an  at-tive  anrl  indepcnrlent  pulsaiiuii  or  thrill. 
Id  these  iostance*,  however,  there  are  three  ]poinu  that  will  almu^t  invurr- 
ably  enable  the  Surgeon  to  eflc-ct  the  diaguosia.  Thus  the  tumor,  aUhrnigh 
principally  cuntincd  to  one  lateral  lobe,  ulwayi*  aifi-'cte  the  i^^thinua  more  or 
MB.  Then  again,  in  brou(':ho4-t;lt>,  tfiat  portion  of  the  tiniior  ie  luo^t  tirinly 
flxad  which  stretches  towards  the  rawiiftl  line;  whilst  rn  cnrotid  nncuri*mihe 
fimest  altachmtnt  is  undftr  the  uterno-majitoid  muscle.  The  third  point  of 
dlflference  is  that,  on  dt^iring  the  pati("nt  to  make  an  effort  at  deglutition,  the 
eatargcd  thyroid  body  movps  with  the  larytix  and  trachea.  Ckfstt  iV.  the  thy- 
-raid  body  are  of  more  common  occurrence  than  pulsating  bronchoc(^te«,  and 
«OBWCime«  equally  Hiriicult  of  diagnrv9iii.  Dupuytren  ha.4  pointed  out  that, 
when  these  cy3t«  are  tapped,  the  pulsation  often  ber^omeo  stronger,  and  the 
duid,  which  on  first  flowing  is  serous,  may  at  ln<)t  herame  pure  arterial  blood, 
•u  that  the  Surgeon  may  snsppot  that  he  has  punctured  an  aneurinm. 

TREATtarsT. —  Digitid  Compression  ha*  of  late  ypars  b(vn  siirreiwfally 
«lDpb>yed  for  the  treatment  iit' carotid  «ne«ri«m.  A  cai^  of  aneurism  of  the 
401110100  carolid  arterv,  cured  by  iulcrnilLlvnt  digital  cumprerwiuu,  has  been 
recorded  by  Routce,  ot  Lausanne.  The  imtieut  wu8  n  male,  aged  68.  Com- 
prcBsioo  was  nunJe  by  placing  the  Ihuruu  against  tbb  anterior  «<lge  of  th« 
sterDo-maatoid  and  the  next  three  tingere  under  the  ponterior  edge  ut'  the 
muscle;  the  artery  was  thus  seized  and  i,-oiupn»Bed.  This  avoided  any  preo* 
core  on  the  pneumogastric  nerve,  which  waa  supposed  to  he  the  cause  of  the 
paio  usually  produced  by  attempts  to  compress  the  carotid.  The  compres- 
noo  was  applied  for  seventeen  days  during  seven  or  eight  hours  each  day; 
sjid  at  the  end  of  the  time  the  man  was  cured.  In  addition  to  this,  Uolmes 
haa  Qollecte<l  four  successful  cases  by  Sheppard,  Kerr,  Humphry,  and  Gay, 
and  two  uosuccecvftil  by  De  Castro  and  Delore.  The  pressure  should,  if 
pogeible.beapptiedabovcthe  transverse  proccm  of  the  eixth  cervical  vertebra, 
80  as  to  avoid  oomprea^ng  the  vertebral  artery  at  the  same  time. 

Li^tnre. — Since  the  time  when  Sir  A.  Cooper  first  ligutured  the  carotid, 
in  1805,  the  mettns  on  which  tbei^urgcitn  alnK»taIwaye  relie.^  for  the  cure  of 
&neurii?m  of  this  vessel  ia  dcligation  of  the  arl^ry  at  a  dislnnce  from  the  sac. 

When  the  aneuriitm  is  w  situated  that  a  sufficient  extent  of  he4ilthy  vessel 
•ntB  betwt^n  the  etcrnum  and  the  ba>>oof  the  tumor  to  admit  of  the  applica- 
of  a  ligature,  the  Hunterinn  operation  may  be  prnctieed.  If,  however, 
root  or  lower  portion  of  the  artery  be  so  involved  that  there  is  no  room 
Uo  apply  the  ligature  between  the  heart  and  tbeaeatof  the  diseaw,  the  distal 
'aperatinn  may  he  performed. 

Ligature  oif  the  Carotid. — The  patient  must  be  placed  upon  his  hack  with 

B  shoulders  supporte^l  by  a  pillow,  and  the  head  allowed  to  fall  bnckwardi 

as  to  put  the  aterno-mnstoid  slightly  on  the  stretch.     In  the  later  stages 

the  operation,  the  head  musi  be  bnmght  a  little  more  forwards  to  allow 

lite  muaele  to  be  drawn  outnardH.     If  brought  too  much  forwards  the  artery 

ima*  relaxed,  and  the  difficulty  in  paining  the  needle  is  increased.     When 


lfl:i 


SPBCIAL    ANSURISM8. 


thfi  8urgeoD  can  choose  the  scat  at  which  to  ligature  the  artery,  he  oiiiallT 
BolecU  uie  part  ot'  thv  vemel  which  biKct£  the  angle  formed  hy  tbr  aulrriur 
edge  of  the  slerno-mBHtoiil  with  ihe  omo-hroid  niueele  at  the  level  of  the 
cricoid  canilage.  The  course  of  the  nrtcry  is  markod  hy  a  liue  tlmirD  fintn 
Cho  ftAmo-clnvieular  nrticulatioD  to  a  point  midway  betwe«D  the  mmgUiii 
proocH  and  the  angle  of  the  jaw.  The  practical  gnidlog  line  during  the 
opcraliou  18  the  anterior  border  of  the  itcmo- mastoid,  which  forms  the  fim 
rallying  point.  The  artery  U  reached  by  making  an  iocieion  about  ifam 
Lnchee  in  length  in  this  line,  the  middle  of  the  wound  being  opponte  the 
cricoid  cartilage.  After  dividing  the  akin,  aupcrBcial  fascia,  and  platyitoa, 
with  the  branches  of  the  superficial  cervical  nerve,  and  the  deep  ecrirical 
fascia,  the  fibres  of  the  stcmo-matttoid  come  into  view  ;  the  inner  border  l» 
easily  found,  and  the  muscle  turned  outwards.  The  second  rallying  point  it 
the  upper  border  of  the  anterior  belty  of  the  omo-hyoid.  To  bring  this  into 
view,  tne  layer  of  cervical  fnacia  forming;  the  posterior  part  of  the  sheath  of 
the  alerDo>mHhtoid  ntuet  be  di>«8ectcd  through,  taking  care  not  to  wound  the 
desccndeQi!  uoni  nerve,  which  usually  lies  imucdiatvly  beneath  iL  Wben  tlM 
muscle  ie  found,  its  upper  bonier  iapuatieddoMUHardji  with  the  baodlaof  t^ 
scalpel,  and  held  out  of  the  wav  with  a  blunt  hook,  and  the  abesth  of  th» 
veaeela  then  corais  intuTicw.  The  Surgeon  now  prwseihia  finger 
towards  the  bodice  and  iransverec  proc«aaes  of  the  cervical  vertebne.  and 
artery  will  h«  felt  rolling  under  the  finger  over  llii.-  Ikjuc.  and  iu  exact 
lion  i£  thus  easily  aj>cvrtaiiivd.  The  vtisscl  is  eucliHHnl  in  u  shrath  of  cer 
liiscia  ouaiuiun  Iu  it,  tlie  intoroal  jugular  vmu,  and  the  puuumogaalrii;  nem. 
This  fiheuth  is  dividtil  into  three  com[>artnienla  by  dbilinct  libruua  aepla,  and 
it  is  imporlant  to  ojivn  the  mwt  intcninl  of  those,  in  which  the  artery  liea,  if 
poaHibte  without  dii'turbing  ihc  others.  To  do  thie,  the  common  sheath  muA 
be  openm]  well  t^)  the  tracheal  side,  aa  the  oonipnnment  for  the  vein  is  mud) 
larger  than  that  for  the  artery,  and  occupies  the  greater  part  of  the  anterior 
aspect  of  the  shejith  which  is  expoeed  in  the  operation.  AlUr  opening  the 
common  aheath,  the  special  sheath  of  areolar  ttasue  surrounding  the  arleiy 
mu&t  be  cjireliilly  divided  until  the  white  external  coat  ootnes  into  riev. 
The  needle  is  ttien  passed  from  without  inwards  (Fig.  471),  U-iwetn  the 
special  sheath  and  the  external  coat,  through  lb«  looae  areolar  ti»»ue  naturally 
iound  in  this  situation.  If  the  veeacl  be  properly  cleaucd.  it  is  iilm<«t  im- 
possible  to  wound  the  vein  or  pick  up  the  nerve*  If,  however,  the  wroog 
oonipurlnient  of  the  common  sfavnth  be  opened,  or  (he  special  sheath  not 
properly  divided,  either  of  thv^  accidents  may  h«ppen.  Almoet  all  the 
accidenis  which  may  liapt>en  in  ligature  of  the  carotid  arise  from  one  of  two 
causes,  either  drifting  too  Jar  outwards  in  the  deeper  part  of  the  inciaioo,  or 
not  cleaning  the  veeael  sufficiently  before  paaiing  the  needle.  In  caia  of 
aneurism  the  dilhculty  is  ofleu  increased  by  the  proximity  of  the  sac.  nad 
■ometimL-B  bv  iuOuuimutory  thickuuing  of  the  sheath.  In  femalea  tbe  tdgt 
of  the  tliyruid  body  may  overlap  the  artery,  and  precent  a  somewhat  pui  '" 
appearance  when  exposed.  Iu  performing  the  operationsnlKtatiuieiju»  vi 
are  occasionally  wounded,  which  may  bleed  ratlier  freely ;  if  so.  they  sbonl 
be  ligatured.  If  theoulerconiparlmentof  theeheath  is  accidentally  u[>ened, 
the  jugiilar  vein  swellei  up  so  as  to  obacure  the  artery,  but  all  difficultr  firota 
this  source  will  cease  if  it  he  drawn  oride  by  a  rclnicirir,  or  repressed  ny  the 
■Mistant'e  finger.  When  this  happens,  it  must  not  be  Auvolten  that  the 
proper  compartment  of  the  common  sheath,  and  tbe  special  ahcflth  of  th« 
urter^ ,  have  both  to  ho  opened  before  luuung  the  needle.  Tbe  MMuno 
gaatnc  nerve  should  never  be  seen,  as  it  lie*  deeply  behind  the  TcaMia. 

After  the  operation  the  patient  should  be  propped  up  in  bed  with  the  bead 
forwards,  in  order  to  prevent  any  strain  upon  the  artery.     Beat  eao  be  Kill 


XIOATUBK   OP   THK    COUUON    CABOTin. 


198 


perftctly  obtained  by  applying  a  Iciither  uplint  nioHl{ie(l  bHore  tbu 
itian  Ui  reach  fruni  the  loins  lo  xhc-.  back  of  the  li<?a<i,  and  lo  ovt^rJap  ihe 
■BnulHcrs.  It  ran  be  put  od  iminediatcty  after  the  operation,  and  worn  for 
the  ttrst  two  weeks. 

Ligature  of  the  Carotid  below  the  Omo-ht/oid  becomee  Deceeeary  if  the  aneu- 
ram  have  attAined  a  very  considerable  size,  extending  low  in  the  neck,  aiiJ 
Dot  leaving  p«rhaps  more  than  one  inch  of  clear  apace  above  the  claviBle, 
Thf  oj>er«lioii  i»  Wi^t  performed  by  dividing  the  Bternal  head  nf  the  sieruo- 
mastuid  cloM  to  it«  origin.     A  V-flhaped  iucision  must  be  made,  one  limb  of 


.^l 


Vlf.  471. — [ndfloo  for  Litttare  wf  tbe  Carotid  Artetj. 


rig.  4;2.— Di&grkm  Af  tht  Right 
CotniBsn  CAnlld  ArUry  «t  Iba 
ivatof  Ligaturt.p.t.  platjima; 
«.•).  itsmo-usMuU,  (Irnwa  to 
<iDa*lil«i  D.I.viiKi-b7ciiJ,<lnwii 
dnvmrarili  aod  Inward*;  (.A, 
wlornn-  byoid ;  n.  tb«  trim  J ; 
f .  laiamal  JogvlAr  fdn  ;  d.n.u. 
dMc«n<l«iii  noni  oarTa.  Tba 
pDAumuEiutHi!  Ua«t  >e«D,  a*  it 
ll*(  bablad  tlia  vaxaU, 


which  correapondfl  to  the  lower  two  inchee  of  tbe  inner  border  of  the  stemo- 
mastoid,  and  the  other  to  the  inner  two  inches  of  the  clavicle.  The  inclsiona 
ire  deepened  till  the  muscle  comes  into  view,  the  inner  head  is  then  divided 
and  turned  up  in  the  V'hnped  flap.  The  second  rallying  point  is  (he  edge 
of  the  sterno-hyoid.  White  searching  for  this,  care  must  be  taken  not  to 
wound  the  anterior  jugular  vein,  which  cromffa  th«  niuvcle  transversely  on 
iU  way  to  join  the  external  jugnlnr.  When  the  edge  of  the  muscle  is  found, 
H  amy  be  drawn  on  one  avlv  uith  a  'jwtula,  or,  if  necessary,  notched.  The 
•temo>thyroid  acarcely  rvquires  division.  The  eheath  of  the  vessels  now 
cocDea  inlu  view,  and  must  be  cuutiously  opene<l,  the  Burgeiin  keeping  care- 
fiilly  lo  tbe  tracheal  side,  sn  as  to  avoid  the  vein.  There  is  uaually  a  wide 
interval  between  the  artery  and  the  vein  and  nerve  on  the  right  side;  oq 
the  left  side  more  care  is  required,  as  the  vein  moat  commonly  overlaps  the 
artery. 

Alter  ligature  of  the  common  carotid,  it  is  interesting  to  observe  that  the 
collateral  supply  is  not  afforded  by  any  of  tbe  branches  of  the  corresponding 
meel  of  the  opposite  side,  but  by  tbe  subclaviuQ  artt^ry  of  the  same  side. 
Id  a  case  relale<l  by  i'<^rter,  in  w)iich  tbe  right  carotid  had  been  tied,  the 
nbdavian  and  vertebral  arteries  on  the  same  side  vere  enlarged  to  at  least 

TOI-  IL— IS 


194 


SPBGIAL    ANEURIflKa. 


double  th«ir  iiniural  iliBUietere,  and  the  chief  mmmiiiiicAliiMu  oulAide  the 
skoll  tiMik  placv  lictwet-a  the  superior  uixl  iuterinr  thynvid  nrlrriw,  whiefa 
vere  cnlArgod  ;  KhiUt  insidi;  the  craniuni  the  verl^hral  t»uk  ihf  \t\nct  of  titt 
intrrnnl  cnroiir).  I m lup^hutcly  alter  ihc  nptralJon  the  bhxNl  infty  bo  to 
{rtely  coDVevcct  to  the  dutiil  tiide  of  the  vf«Ael,  by  the  tr(«  rtininiiiuirAtioa 
•ubsUliDg  between  the  artcrJoi  of  op|M«iiit«  side«,  both  within  and  wiih<iut  tiir 
er*oiuro,  that  a  cfmlinuanre  or  a  f[>eedy  rc-tiirn  of  piiI»alion  in  Lbc  mi  iBof 
coDimoD  occurrence.  Thifl  conditiou,  however,  usually  diMi|>|>eAn  afUr  a 
tiino  by  the  grftdual  conimtidatioD  of  the  tumor,  »nd  iodet-d  iiiav  genmlly 
be  ItMiked  upon  a»  &  favorable  gijfii ;  l>ein^  very  avMoiu  luswicialcu  nitb  Unm 
uervbral  leyiuyUnns  that,  a«  will  immediately  b«  explniued,  comnxmly  pmrc 
fatal  nRer  luis  "{lernliiia.  Occaniitnaliy  llie  pulmlii'ii  cnutiuurs,  una  Un 
tumur  gradually  itK-rea«e«  in  siu  in  ipit**  uf  ihv  ueolueion  uf  the  main  tniok. 

iSiippur<Uion  uf  thr  mc  is  nut  of  very  uncuiuiiii>u  iK-currunw  after  the  Ib 
turv  >jt  thv  caruUil  lor  aneuriniu — ^omelimvs  even  otter  ho  ctia»idembl«1 
interval  as  fight  inuiilli*.  a»  happened  in  u  caM.>  related  by  Pout.  In 
majority  of  tlieee  iu«lnuces,  the  paLit'Ul  eventually  dotv  well ;  hut  death  msj 
reeult  by  the  tumur  prcesing  upuu  tbo  pharynx  and  larynx,  or  by  the  (Kvur- 
reoff-  of  sernmlary  hemorrhage,  which  may  lake  plaoe  t-ilber  from  the  part 
to  which  thit  ligaturu  hae  bevu  appiit-d.ur  from  the  ^uppuraliilf  isc  In  lh« 
fir^t  ini<iani.-e,  it  nBually  •jiH!ur»  about  the  period  of  the  aepuKtiua  of  tbe 
tifrnlure;  in  the  seoouu,  it  may  happeji  at  a  ron«i<lerBh]v  later  period,  even 
after  many  weeks.  In  a  cusu  under  the  ejtre  of  11.  Murris,  euppuralion  look 
place  round  the  twc  Gftetrn  weekii  after  the  lif^nture  wag  applied  to  the  main 
trunk.  Pu»  vns  let  out  hy  an  incision,  after  which  the  tumor  rapidly  in- 
creased, with  return  of  pnltfalion.  The  ?ae  was  then  laid  open.  Tne  anea- 
nam  whm  found  to  have  iipntng  from  the  external  carotid,  and  the  recurrettl 
•trcam  of  blood  was  deriveil  entirely  fr<im  the  brancbes  of  that  vflMel.  Tht 
trunk  aboTO  the  snc,  the  facial,  and  the  superior  thyroid  were  ligatured,  and 
the  patient  made  a  good  recovery.  As  the  suppuration  il  often  due  in  all 
probability  to  the  proximitjr  of  the  wound  and  the  ligature  to  the  (irn-uriam. 
It  bae  been  sugx<:-rted  that,  in  such  cases,  it  might  be  B«fer  tu  antici)>jite  itbjr 
laving  «f>t;n  the  mc  after  ibe  application  of  the  ligature  on  the  proximal 
eifle,  and  Iyiu^  the  vessel  again  on  the  distAl  eide.  thus  perfurniing  a  com- 
bination uf  AueTn  and  the  old  o[»«nitJi^4i,  It  would  appear,  however,  •■  if 
this  were  only  subslltuiing,  with  certainty,  one  evil  for  another  that  umj 
vcrv  powibly  be  uroided.  Besides  iheee,  which  may  he  loukeil  upon  as  the 
ordinary  accidenU  followin;;  the  uppiicHtiuu  ofa  ligature  fur  aneurism,  d«U- 
jintion  of  the  carotid  artery  ooc»«iuually  gives  riae  to  serious  and  ensi  fiuol 
dismrlmnce  of  the  iir^-ulHtion  within  the  erauium. 

SffecU  on  the  Brain  of  Ligmtnre  of  one  or  both  C&rotida.— Many  expui- 
meuts  have  been  made  hy  Mey^T,  Joberl,  atnl  ittbcrv,  upon  the  Inwer  anioioK 
with  the  view  uf  determining  the  effect  pnKluticdoo  the  bruin  by  the  li){aiara 
of  the  cnrotiil  arierim.  But  the  deiluctiou5  from  tlteaD  arc  of  no  value  what- 
ever when  Bp|ilied  to  the  human  Mjhjeet.  tor  the  sim)^  rcme-iu  (wbicfa 
aptiears  U>  have  bien  atnuigely  uverlcHikvd',  UiaL  in  many  of  the  low 
animals  on  which  the  ohaervattotut  were  made,  as  the  dog  and  rabbit,  (at 
UMtance,  tlie  comniou  cumtid  art4>rieH  are  of  secondary  i(up>irtanoe  *o  tuits 
the  cerehnil  circulntinn  is  t'oncerned,  iK'ing  di-^tincd  principallv  for  the 
supply  uf  the  exiernal  parts  of  the  head — I  he  hraiii  rleHving  il»  rhief  KUppty 
fr»m  the  verlchrals ;  whiliit  in  other  animals,  as  the  horse,  the  bruin  dvrivca 
m>arly  the  whole  of  its  lihwid  (n>m  the  rarntids,  and  hut  a  very  small  i|uaB- 
tity  from  the  vertebrals.  Hence,  in  one  case  the  carotids  may  be  ligatured 
witboDl  danger,  whilst  in  the  other  their  deligation  i»  ioeviiably  fnul.    The 


LIGATURE    OF    BOTH    CAROTIDS — RESULTS. 


196 


statistics  of  ligature  of  tbe  carotid  in  the  human  subject  have  been  collected 
by  Noma,  Ehrmann,  and  others;  and  more  recently  by  Pilz,  of  Breslau, 
(Ar^iv  fur  KUnische  Chirurgie,  1868),  who  has  collected  600  cases  of  the 
operation,  including  27  in  which  the  artery  was  tied  on  both  sides.  The 
causes  which  led  to  the  operation  were,  hemorrhage,  in  228  cases ;  aneurism, 
in  87 ;  erectile  and  other  tumors,  142 ;  extirpation  of  tumors,  71 ;  cerebral 
sffectinns  (epilepsy,  etc.)*  34;  and  in  38  instances  the  distal  operation  was 
performed  for  aneurisms  of  the  aorta  and  innominate  artery.  In  the  228 
cases  of  ligature  for  hemorrhage,  the  presence  of  cerebral  symptoms  is  noted 
in  69  out  of  167 — no  information  being  given  in  regard  to  61 ;  and,  in  these 
69  casee,  death  took  place  in  40.  Excluding,  however,  these  from  calcula- 
tiou,  inasmuch  as  the  brain  disorder  may  have  been  in  many  due  to  the 
hemorrhage  rather  than  to  the  operation,  we  derive  from  Filz'a  statistics  the 
following  table  showing  the  proportionate  frequency  of  tbe  occurrence  of 
cerebral  disease  and  of  deaths  from  this  cause. 

TABLE  OF  LIGATURE  OF  CAROTID  FOLLOWED  BY 
CEREBRAL  DISEASE. 


CATSK  OPOPBBATION. 

NUMBBB 
OP 

CARES. 

CAIEH  IN 

WBICB 

CEREBRAL 

APPCCTIOK 

RKSrBD. 

DEATHS 

FROH 

CRREBRAL 

DISEASE. 

DKATOS 
FROH  ALL 

Ckl'ttKH. 

NO  RECORD 
HKOARniHfi 
CEREBRAL 
SVHPTOHa. 

Aneurism     .... 
£r«ctile  and  other  Tumors  . 
Extirpation  nf  Tumors 
Cerebral  Affections. 
Diaul  OperKtion  . 

87 
142 
71 
34 
38 

32 
32 
13 

8 
U 

16 
20 

8 

... 
7 

31 

49 

•i5 

1 

25 

5 

8 
8 
3 
0 

872 

HC 

51 

131 

19 

By  this  it  will  be  seen  that  the  most  common  cause  of  death  after  ligature 
of  the  carotid  is  cerebral  disease  induced  by  the  operation  (as  was,  I  believe, 
firet  pointed  out  by  Clievers)  ;  and  this  result  appears  to  have  been  rela- 
tively more  frequent  after  the  distal  than  after  the  Hunterian  operation  If 
tu  these  cases  we  add  14  in  which  the  brachio-cephalic  artery  was  ligatured, 
we  get  a  total  of  386  cases,  of  which  96  were  attended  by  cerebral  symp- 
toms ;  or,  as  nearly  as  possible,  2-5  per  cent. 

We  should  necessarily  expect  that,  in  those  cases  in  which  both  vessels 
had  been  ligatured,  there  would  be  a  greater  tendency  to  cerebral  disturb- 
ance than  in  those  in  which  only  one  had  been  deligated.  It  would  how- 
ever appear,  as  is  shown  by  the  following  table,  that  of  twenty-seven  in- 
stances in  which  the  double  operation  has  been  performed,  death  is  recorded 
to  have  happened  but  in  two  cases  from  this  cause ;  while  in  another,  in 
which  convulsions  took  place,  a  fatal  result  did  not  occur,  and  three  other 
eases  were  attended  by  mere  temporary  disturbance  of  vision.  In  the  only 
case  (that  of  Mott,  No.  16)  in  which  both  camtids  were  ligatured  simulta- 
neously, with  an  interval  of  only  a  few  minutes  between  the  operations,  coma 
and  death  resulted. 


SPECIAL                                              ^^^^^^^^H 

^^^^^                   CASES  OF  LIOATURB  OF  BOTH  CAKOTIIIS,                            1 

^^H^                            IH-KatTOM. 

•OK.            iMSKiM.           '             iiATasnrLMATiiKK.              1          MUtitn.              I 

^^1                t    Dttl'trTTHBll 

•>. 

An«tiruni  b^      Kt](bt  ranaidllkd  brll>t|r»f-    Delinum.hMU-     ■ 

^^^L^^ 

fttiMtomnai*  of  1    Ir»ninl819;  l«n  by  R»tM-rt  .    |>let:M  uf   Ul      | 

^^^^L            Robert. 

tcftlp. 

for  vxtcoaioo  of  dtMAW,  la     •ldtt,At>dd«tk.     ■ 

1!<..57.                                                                               ■ 

IntorvBl  of  A  tnoath.                    B»m»>frf.       1 

^^^^^     3.  lIxcaiLl. 

Tun  goal  tumor 

of  b<>th  orbiu. 

I 

^H            s.  Uluamk. 

30  1  £rMii)«  tunur 

Un  IM   tint,   18S3;   Hgttt    Dmib  uo  tUid    ■ 

of  orbit. 

une  f««r  «(torw«rds. 

il«v  by  h«nar> 

rhii^ 

^1           A  Hdvet. 

» 

An«iiri«iD  by 

MiHtomuiM  of 

Lanmrolid,  S^>l    20;  right 
varoUd,  Uct.  3,  18:^7. 

RMu«er«d. 

^H           6.  lIAtLn. 

*i 

SrectllA  luRtor. 

8Mtt.  18, 18S1,  Abd  Jkn.  38, 
1882. 

BccotatmL 

^H           0.  Pkinoit. 

M 

EpiWn«>  ;       1  RJcIti  ck,rotid,  tied  Aii|t.  28; 
IIeini|<  r;;iii.         tv-n  (-nroiid,  >'i<v.  14, 1881. 

BMMnvd. 

^^M           T.  Pekbtox. 

S4 

P»rti»l  piirBlv-    RiRbt  (•■rotlij,  S«rt  7;  Uft, 
•it   And    hcmil-      Ud.  10,  1831. 

Baotvond. 

^H           8.  PmEaroH. 

■  II 

Bpll^^.        Tied  At  iularrtl  of  month. 

Racovand. 

^H           B.  Kont. 

C8 

AneurliDi  b;    i  Left  Mfottd,  May  '2*,  IKS4; 

BActirierttl:«0»- 

»nti»iijmo*'w  of  '    right  ou  Aug.  4,  miuq  jeur 

vuhtoa*    Ataf 

•caIi). 

eAf-h>t|«rAd^H 

^B          10.  r.  11.  Ham. 

18 

Epfltpa;. 

Bicbt   <!»rolid,    Ang.    1838; 

K«cu«*t«^^^| 

^^M                              ILTOtl. 

left,  JklKrcb,  1H3V. 

^^* 

^^M          11.  Vklfead. 

20 

Anflorinn  hj 
AiiAMamoib  of 

Riicht  canitid  firii,  Aufiusl, 

18^1))      left,     itb<iiil     Ihnw 
niuntht  Art«r«tHrd». 

]iccov«r«d. 

^^^^    12.  PiBiraonr, 

20 

Heatoirbt^ 

Left  cftrAiid,  Jar.  Ifl,  1M8{ 

BeadArlw    aad 

from   AneuHtm 

riRbt,  jAfi.  B,  184A 

ininiitln^  Aflar 

bj  aDAilooiosli ' 

«Ark        opirrE- 

of  MAlp. 

UtiBirecoiAty. 

^V         18.  Sllik. 

21 

SeoondAi-y 
lieiDorrh«gefo1< 
lowing  gun»hot 

wtiuitd  of 

tonpu«. 

Rrcctila  Uitoor 

InlATVAl  of  four  And  a  half 

Curad. 

^H          14.  J  .U.  Wae- 

28 

Tied  left,  Ootobcr  S ;   rigbt. 

Ound. 

^^m 

of  f»c«. 

Nov.  7,  1846. 

^^L^     16.  ROBKET. 

••» 

Anearlitn  hy 

L«n  on  J>ia*  6,  18481  rlgbt 

BMdwbR  ta»* 

tiuutitmoil*  of 

oo  PAb.  23,  1847. 

(KtrArj-dlUurk 

fonbaad. 

EiiC«"f  vtitoci 

^m        10,  Mm. 

•t* 

C»rdooniA  of 

IntervAl  of  Ilftean  miaulaa. 

recotny. 
CutUAandd«B|b 

rarulid. 

Entlepij'.          Intf>rvalor  halfA  vear. 
«  FiinKiii  of        RiKi>l  fl'*t^(  ^fl<  llirw  wmIu 
tiAial  HMi»."        I«l«r. 

ill  34  biwn. 

^H          17.  Morr. 

«•• 

It»-c-iTer«l 

^^^r          18.  BLArKMAy. 

1ft 

Tnnlinniry  b«i 

oi  vtti'itiofMk 

T-M                     ii. 

^^^^     19.  HUWBT. 

19 

EraoUl* 

l^ti  8nt ;  rigbt,  ona  tDonth 

tumor*. 

after. 

t.                           ..f 
VI'i.Pii        irvwlf* 

^H             20.   RXTKOLIM 

AnwHim  bjr 

Kl|;bt  cATotid  tied  W  B«t. 
nold*  in  1844;  Utt  bj  Vaa 

BacovMy. 

^^H 

EAAitotncaiB. 

^H               Vax  BuHEjr. 

Buna  in  t8d0. 

^H          XL  pAHKjm. 

46 

OkrcinoRiA  of 
nnirum. 

iDtervAl  of  thlrtf-two  dAjr*. 

UMtk. 

LIOATUBK   OF    BOTH    CAROTIDS — RE3UL1S. 


197 


CASES  OF  LIGATURE  OF  BOTH  CA'ROTIDS— Continued. 


fiWooD. 


a  G.C.E  W«- 

BKR. 

K  Cakxocbax. 


ft.  BiLLSOTB. 


ST.  BUENOEK. 


DATIR  OF  MOATUHB. 


&J  I  Encephkluid  of 
antrum. 


RiKhtctiriitid,  July  18;  left, ,  Afiersecondop' 


34 


Dec.  26, 1856. 


20         Epilepsy. 

Lar^e  morbid   I 

growth  of  face , 

(elephantiasii).  i 

Ounibot       I 

wound. 

27      Ulceration  of   , 

carotid  from    | 

syphilitic  caries 

of  petrous  bone;  [ 

Hemorrhage.    ' 


Left  carotid,  Dec.  2;  right, 

Dec.  19,  1857. 
Right    carotid     tied,     Nov. 

1866;    left,  June,  1859. 

Rieht,  May  12,  1868;    left, 

May  18. 
Right  carotid,  Dec.  13;  left, 

Dec.  20,  1864. 


Aneurism  by 
anastomosis 
and  wound. 


Left  tied  for  the  aneurism  ; 
five  years  afterwards  the 
right,  for  a  suicidal  wound. 


eratioo  the  tu- 
mor diminish- 
ed :  then  diar- 
rh(ea,  rigors, 
delirium,  ex- 
haustion, and 
death  on  six- 
tieth day. 
Recovered. 

Cured. 


Death  in  thirty- 
eight  hours. 

Return  of  hem- 
orrhageonBix- 
teenth  day; 
death  from  ez- 
hauEtjon  :  no 
cerebral  iym|>- 
toms. 

Disorganiza- 
tion of  right 
eye:  recovery. 


AAer  &  careful  examinatioD  of  this  subject,  I  think  we  are  warranted  in 
oomiDg  to  the  following  conclusions.  1.  Ligature  of  one  carotid  artery  is 
followed  br  cerebral  disturbance  in  more  than  one-fourth  of  the  cases,  above 
ooe-half  which  are  fatal,  2.  When  the  two  carotids  are  ligatured  tnUh  an 
mUrval  of  •ome  days  or  weeks,  the  operation  is  not  more  frequently  followed 
br  cerebral  disturbance  than  when  only  one  ie  tied.  3.  Pathological  inves- 
tigation has  shown  that,  if  the  vessels  be  gradually  and  successively  oblit- 
erated, the  patient  may  live,  although  one  carotid  and  one  of  the  vertebral 
aneries  have  been  occluded  by  disease  and  the  other  carotid  ligatured,  as  in 
a  caae  related  by  Rossi.  4.  As  in  a  case  recorded  by  Davy,  an  individual 
nay  even  live  for  a  considerable  time,  though  both  carotids  and  both  verte- 
braU  be  occluded — the  cerebral  circulation  being  mainteined  through  the 
Boedium  of  the  anastomoses  of  the  inferior  and  superior  thyroids  and  the 
deep  cervical  with  the  occipital  artery.  5.  The  reason  why  more  or  less  ex- 
iCDMVe  ohiitructiim  by  disease  of  the  arteries  leading  to  the  brain  may,  as 
appear*  from  pathological  records,  be  unattended  by  cerebral  disturbaoce, 
while  this  so  frequently  follows  ligature,  lies  (as  has  been  pointed  out  by 
Pllzi,  that  in  the  former  case  the  obstruction  is  gradual,  so  that  the  coltat- 
cfftl  circulation  has  time  to  be  established,  while  in  the  latter  the  interrup- 
Aoa  is  sudden. 

The  cause  of  these  cerebral  ajpnptoma  is  certainly  the  disturbance  of  the 
cerebral  circulation,  induced  by  the  ligature  of  the  carotid.  When  a  cun- 
oderabte  portion  of  the  supply  of  bloo<l  to  the  brain  is  suddenly  cut  otT,  two 
HU  tff  symptoms  may  ensue — one  immediatr,  the  other  remote.  The  imme- 
diate symptoms  are  those  that  generally  result  from  ftuictional  tlistiirbauceof 
tbc  brain,  consequent  upon  too  small  a  supply  of  arterial  blood.  They  con- 
■■t  of  Bvocope,  trembling,  twitehes,  giddiness,  and  impairment  of  sight. 


198 


SPECIAL    AKK0U1BU3. 


Aflor  thi^i  condition  hna  Itrpii  iiinintaintMl  for  a  few  days,  the  nulritinn  ilf  ft* 
urffnn  becomes  nialerially  averted.  Ami  sufUuing  of  ihi.-  ci-rebral  Auhtiaon 
ULKiH  place  ;  givioK  rbe  lo  a  new  and  more  serinUH  set  uf  sympUifns  iodict* 
five  nf  thia  pathulo^^ieul  condition,  such  oa  niuvuU\i>UB,  bemiplt^ia,  ud 
death.  In  oUior  oases  congestion  may  come  on,  Mther  by  the  inicrfrrMflP 
witl)  the  return  of  bluud  ihmugb  the  jugular  vein,  or  as  a  c4iaaec)U^-iiii-  uf  that 
Tenous  turgidity  which  we  commonly  oUacrve  after  tliu  tifruture  uf  a  nun 
arterial  trunk ;  or  pcrhaiM  coma  may  be  induced  by  apoplcctie  elTuMoD  iMm 
ft  itnt^ened  portion  of  the  orgnn. 

Effects  on  the  Lnn^. — Benidea  the  brain,  the  lnng»  are  not  uncommunly 
Kcundarily  aHt-cted  after  ligature  of  the  oirotitl.  To  |hi*  roinlilii^a  •pedal 
attention  liaa  bwn  <)irccle<l  hy  Johert  and  Miller.  The  ItiiigM  ap|iear  tu 
become  greatly  cunge>te<l,  ami  thin  condition  hsH  a  tendency  to  rtin  intii  a 
BuUiiciite  form  of  iiiHammnlion.  The  cause  of  thii)coii^e»tioM  of  tlie  liint^  b 
extreniely  inUresling.  It  tannot  be  owing  to  the  simple  ofwruction  nf  lh« 
pawage  of  tJie  hlood  through  lhi3  airotid  enusing  a  di»>tUTh«itc«  in  th« 
twJaQce  of  the  circulation,  and  thus  a  tendency  to  iulernul  cougeelinn ;  Ivr. 
if  this  were  the  cauite.  we  ought  tu  niei-t  uiih  it  generally  after  ligtiturv 
of  the  arleries  of  the  tirst  cloM.  Nor  c-nu  it  be  owing  to  any  injury  BUc-taio<nl 
by  the  eighth  nerve  during  tfa«  dcligation  of  ilie  artery ;  as  in  many  uf  lbs 
instauceu  iu  which  it  is  stated  to  have  occ^urred.  there  was  no  cvideoce  uf 
that  nerve  having  bevu  cxpoiMxl  or  daiuagcd,  and  uvery  reason,  frnm  ll» 
known  ekill  of  the  o|>crulon),  tu  believe  the  contrary.  1  am  rather  incDonl 
tu  look  upon  the  unuDiiully  frequent  occurrence  of  pulmonic  (Hiugwtion  aftrr 
ligature  of  the  rarf>tiil,  a»  a  setxindary  condition  cnnBe<)uent  U|htn  a  JeraniEe- 
ment  in  the  fiinctiitmi  of  the  br»in  and  meilulla  oblongaia,  primarily  iniiuced 
by  the  diittufhed  ctiate  of  the  circulation  through  that  ofgau:  for  we  know 
that  any  cause  which  deprewce  the  activity  of  the  nervous  rentrea  tmds  to 
diminiHh  propctrtionaiely  the  freedom  of  the  reapinitory  moveneDte,  and  ihoi^ 
by  interfering  with  the  due  {>erfornianre  of  the  act  of  respiration.  dieposMto 
congestion  of  the  lungs,  aaseen  in  injuries  of  the  bend,  in  apoplexy,  and  is 
the  uperaiioQ  of  the  sedative  ptisnns.  It  would  app4^r  from  the  df<>taiU  of 
Some  of  the  nn-orde^l  caMs,  as  well  as  from  Joltert's  experiment,  that  blttod* 
letting  ii*  of  consiiK-rable  Mrvice  in  the  reotioval  of  this  condition,  and  should 
euuMf>}U«utly  nut  be  omitted. 

Ligftttire'of  the  Carotid  on  the  IMstal  Bide  of  the  8ae. — Anmrism  of  ibe 
carotid  artery,  occurring  low  in  the  neck,  does  not  admit  th«  upplicatiim  of  a 
ligature  ou  the  csniinc  side  of  th«  tumor.  What,  theu,  i»  to  !>«•  done  in  sucli 
a  caw  as  this?  Should  it  be  leA  to  tbe  remote  chance  of  a  spootane^ms  cure, 
or  should  it  be  subjected  to  surgical  inlcrfvrcoce?  ■SjionLaneous  cure  in 
carotid  aueuriem  has  never  yet,  I  believe,  been  met  with.  The  Suriwio, 
tberefon;,  niui^t  endeavor  Ui  treat  the  disciase  by  ligature.  Two  plans  of 
tnatmeDt  are  oricn  to  bim — to  tie  either  the  innominate  artery,  or  the 
aarolid  on  the  distal  side  of  the  tumor.  The  lirvt  alternative  may  fairly  be 
Ht  aside;  for  not  only  are  the  easm  in  which  it  is  puKible  to  tind  room 
bet  won  the  sternum  and  the  sac  extremely  rare,  but,  even  were  pucb  an 
ioBlanoa  to  present  imtf.  few  Surgeons  wouM.  I  Lhink.  Iw  ju.'4titi»l  in  under- 
taking an  opemtion  which  hna  only  once  euooeedetl.  even  (p.  IVi)  in  lb<> 
most  skilful  nands :  we  are  consequentlv  reduced  to  the  allcmntivc  of  lin- 
lurlog  the  artery  on  the  distal  side  of  ttie  sao.  But  although  this  apevrnMU 
is  tbe  onlv  alternative  that  presents  itself,  yet  its  appHcaUon  in  practice  is 
att4.'ude«l  t»y  serious  difficulties  and  perplexities;  for  the  8ur^r«y>n  must  he 
able  to  satisfy  himself  that  it  is  actually  an  aneuritim  of  the  root  of  the 
earotld  with  which  he  ha^  to  do,  and  that  It  ii  not  the  trunk  of  tbe  innomi- 
nate or  the  arch  of  the  aorta  that  is  affected.    The  difficulty  in  doing  this  is 


DISTAL   LIGATtTRK   OP   CAROTID. 


199 


&r  grater  thaD  would  at  first  appear;  for,  od  examining  the  details  of  eight 
oMn  ID  which  the  distal  operatiou  has  beea  performed  fur  supposed  carotid 
aaeiirism,  three  must  be  excluded;  as,  after  death,  the  tumor  was  fouud  to 
frum  the  aortic  arch.  Iq  the  annexed  table  will  be  found  the  result  of 
ues,  ia  which  the  carotid  artery  has  been  tied  fur  aneurism  of  its  root 
OB  the  disul  aide  of  the  sac.  I  have  excluded  an  eighth  case,  as  there 
is  reasoD  to  believe  that  io  it  the  artery  was  not  ligatured,  but  a  portion  of 
Uie  abeath  accidentallv  tied  instead — an  accident,  by  the  way,  which  S^dillot 
has  witnevetl,  which  Korris  states  also  to  have  occurred  at  the  New  York 
HtiSpttal.  aod  which  I  have  known  happen  to  a  most  excellent  Surgeon 
ia  the  caae  of  ligature  of  the  femoral  artery. 

AXEITRISMS  OP  ROOT  OF  CAROTID   TREATED  BY  LIGATURE 
ON   DIriTAL  SIDE. 


OTEVATOK. 

SWX 

*«E 

REiH-LT, 

CAIISEOFDKATH. 

1.  Wabdkuf. 

r. 

63 

Recovered, 

19-M. 

1  Lambkkt. 

f. 

49 

Successful 

Uemotrbai^e 

1827. 

to  far  a.s 
,   Mneuriana 

w&s 
concerned. 

from  uppt^r 

portiiin  of 

■rtery. 

t  Bush. 

r. 

3G 

Recuse  red. 

1 

1827.           1 

! 

; 

4.3Io!rr- 

m. 

30 

Died. 

1     Sac  suppu- 

ooMaar. 

rated. 

1928. 

a  COLTEM  DE 

f. 

•  C3 

!  Kecovered. 

NoTop. 

1*4«» 

«.  Wood,  J.  R. 

Recovered. 

ISL4n. 

7.  Dkmhc 

m. 

38 

Died. 

Suppiirttlion 

of  S8C : 
heitiorrliage. 

«   La!ce. 

m. 

:;6 

Died. 

Inflammiitiim 

I«a2 

QSlii  d»y. 

of  lungs. 

RKMARKH. 


Tumor   diminished    until    fifth 
;    day:    tben  inflamed,  suppura- 
ted, and   burst.     The  patient 
recovered,  and  was  alive  three 
,    vears  after  operation. 
I  l^umor  diminished  after  opera- 
'    tion,  and  became  consolidated  ; 
»ac  filled  with  firm  coagulum, 
and  lowerpartof  artery  closed; 
ulceration     into     artery,    just 
above    part    ligatured ;     vessel 
dilated  where  ligatured. 
Suffocation  was  imminent  before 
operation  ;    tumor   rapidly   di- 
minished after  ligature.    Alive 
three  weeks  afterwards. 
Aneurism   of   arch   also.     Left 
carotid  tied. 

Tumor  and  pulsation  dimin- 
ished. Alive  and  well  three 
years  afterward«. 

Armurism  cured. 

Aneurism  of  arch  :  double  aneu- 
rism of  carotid. 

Tumor  Hlled  with  layers  of 
coagulum.  Ulcerated  opening 
communicating;  with  a|)ex  ')f 
left  lung.     Left  carotid  tied. 


On  analyzing  the  cases  in  which  the  trunk  of  the  common  carotid  has  been 
i^tured  on  the  distal  side  of  an  aneurism  of  the  root  of  that  vessel,  there 
are  several  points  of  interest  that  arrest  our  attention.  Thus  we  find  that 
ia  every  case  the  tumor,  immediately  on  the  ligature  being  tightened,  under- 
west  a  ooDsiderable  diminution  in  its  bulk,  with  corrugation  of  the  integu* 
■ests  covering  it,  and  considerable  subsidence  in  the  force  of  its  pulsations. 
Ia  ooe  ease — that  of  Bush — respiration,  which  before  the  operation  had  been 
aOeoded  with  great  difficulty,  became  easy  ;  and  in  two  others  iuSammaticm 
of  the  sac  took  place;  being  in  one  (that  of  Wardrop)  unattended  by  bud 
aaoseqaeoces,  and  in  the  other  (Demme's  case)  followed  by  death.  It  is  not 
Mfe  to  deduce  any  general  conclusion  from  so  small  a  numher  of  cases  ;  yet 


200 


8PB0IAL    AKECBISMS. 


the  result  of  Uieee  is  so  uoifonn,  thai  I  have  do  heeiiatioQ  in  sUtiDg  tl  u  mj 

'opinion,  that,  whether  we  reganl  ilip  prinrijile  iiii  nhicb  thi*  u|icniU(«i  la 
founded,  the  amount  ofBUCoeaa  which  li:i9  hiliivrlu  aUfiiileU  it.  the  neos- 
aarily  fuUil  reuitt  of  these  CHwa  if  Icil  l^i  ihvmw'lv<«.  t>r  the  nhoinice  of  aor 

|.othor  means  thai  bold  mil  a  reneoiitihlc  hnjie  of  bi-iittil,  th«  Surgiwa  is  joau- 

*fied  io  resorting  In  the  ligiiture  ut'  the  trunk  of  the  LNiromou  canilitl  oa  the 
dietal  side  of  the  sac,  in  vastA  of  oneuHwo  limibMl  to  iho  nxil  of  that  viwel. 
The  IrunL  of  the  External  Qeratid  is  so  short  tliat  it  eeldom  becomes  the 
seat  nf  anetirism  without  iuTolviiic  at  the  »inie  time  the  eod  of  the  cotumon 
artery  at  Its  bifurcation.  It  may,  however,  liecomc  aocummal.  Tbo  tumor, 
prcaeutluK  the  usual  signs  of  uncurism,  will  be  foand  situated  under  tbe 
ADglc  of  Uie  jaw  and  ab«>ve  the  level  of  the  cricoid  cartilage.    From  the  im- 

'__  ircant  nature  and  close  proximity  of  tho  parts  surrounding  it,  the  pmMure> 
effects  ore  serious  and  early.  By  pressure  on  the  hypi>gliiual  nerve  tbs 
muscles  of  the  corresponding  Aide  of  the  tongue  may  be  pamlvze^l,  so  that 

I  when  protruded  the  tongue  is  turned  towards  the  atfectod  aitfe.     Aphonia 

■  aod  dysphagia  have  been  met  with  a?  early  symptoms. 

The  treatmeot  consiets  io  ligature  of  the  commoo  enrotid  above  the  omo- 
hyoid.    AHcr  this  operation  it  may  happeu  that  puUntion  cootiBUca  faintly, 

ror  speedily  returue  to  the  &ac.  owitig  to  the  freedom  of  enlarged  aDastoOMMi. 

ilt  has.  therefore,  beeu  proposed  by  Morris  to  ligature  as  well  the  prilttuy 

[bnuiclies  of  the  exterool  carotid — a  project  certainly  diffioult  tn  execution 

ruid  probably  of  doubtful  utility. 


AKECaUM  OP  TU£  LXTlOtXAl.  tXkXOTW. 

The  Internal  Carotid  Artery  may  be  the  subject  of  aneurism  before  or 
after  it  haa  passed  through  the  carotid  canal  and  entered  the  cavity  of  tbs 
skull.  The  symptomn  of  these  two  classes  of  cases  differ  neoe^nrily  in  almost 
erery  respect,  as  likewise  do  the  termination  and  the  susocptibiliiy  of  the 

,ease  lo  ?iirfrii'Bl  intcrfi-r'^ncc. 

Extracranial  Aneurism,— When  nn  aneuriim  a^U  the  trunk  of  the  in- 

^lemal  cnrotii!  U-fore  it»  enlranct;  into  the  skull,  the  symptoms  prwiented  by 
thi«  diwKwdonot  mnterlally  dilfer  from  those  of  aneurism  at  Ibe  bifurcation, 
or  of  the  upper  part  of  the  commou  carotid,  except  in  onv  important  respect, 
which  WHS,  I  believe,  first  pointed  out  by  Porter,  ot  iJublio — vis.,  the  t«s* 
dency  of  the  tumor  to  extend  iuwards  towards  the  pharynx,  aud  to  protrude 
into  ibal  cavity.     The  leawm  of  this  is  obvious ;    when  we  cuiuuder  the 

iBnatoraical  relations  of  the  internal  carotid  artery,  we  at  once  see  that  its 
pharyngeal  aspect  is  that  which,  if  one  may  so  term  it,  is  the  most  superficial, 
aod  that  between  it  aud  the  surface  the  smallest  amount  of  soft  parls  inter- 
venes— nothing  lying  between  the  vessel  and  the  rauoous  membraoe  except 
the  thin  piiper-like  constrictor,  some  lax  areolar  tissue,  and  tbe  snperiar 
laryngeal  uerre  ;  whilst  externally  there  are  inlerpo^  l>t>iween  it  and 

liDteKOmeDt  tbe  layers  of  the  cervical  fn^ciu,  the  margin  nf  the  ^tcrno-niaat 

'the  oigastrio  t<tylo-hyoid  and  ^lylo-jfharyngeus,  and  the  styloid  prooem, 
ibove  the  digiiiftric  the  |)onttid  ^land. 

When,  thert-foro,  dilatation  ot*  the  vesjiel  tnke&  place,  it  necrssarily  has  a 
tendency  to  puah  forwards  that  f»art  ol'tts  covering  where  it  meets  wriih  leaA 

riflHStaBce ;  and,  this  being  to  the  pharyngeal  ride,  more  or  less  promineaea 

'will  oonsequently  be  found  in  this  cavity.  In  a  rase  that  occurred  toftyraa, 
this  was  especially  well  marked,  the  aneurism  uf  the  intrmal  ramtid  nimn- 
lating  doeoty  an  ahscesa  nf  the  tonsil.  In  two  cases  related  by  Porter  ia 
tbeaevcDtecnth  volume  nf  the  Dublin  Jaumnl  o/  Mtdiral  Srienet-,  thb  waa 
one  of  tbe  most  marked  features:  the  "appearances  of  tlie  tumor  (as  seta 


IADSES   OF    IKTRACBANIAL   ANBUBISM. 


201 


bv  ihe  mouth)  were  most  alarming;  tlic  pulsation  could  be  di^inctly  Men, 
*Kiid  the  blocrtJ  alrnti6t  felt  iiudor  the  mucous  inctulimuc;  it  ticcmcd  ready  to 
give  way  and  burst  into  the  uioulh  every  nionient." 

Tkeatme.vt. — The  ireatmeot  of  lhei«L*  ciitM«  ihtn  not  differ  from  that  of 
Boeuramfl  connected  with  tlie  carotid  nrtcricn,  and  iu^tod  at  the  upper  part 
of  th«  neck  ;  but  we  arc  not  in  poweuioo  of  a  Auffjcieot  ouoiber  of  iacta  to 
eaable  uk  to  determine  with  any  degree  of  precision  wliat  the  reftult  of  fur- 
gical  interfereDoc  in  them  U  likely  to  be.  If  we  could  give  an  opinion  from 
the  limited  number  of  cnaed  at  pn-5eut  before  the  prufewiion,  we  should  firal 
•  ^poaed  not  to  entertain  a  very  favorable  opinion  of  ibe  re«uk  of  tb« 
[anteriaa  operatiui),  as  applied  to  aneurism  of  the  internal  ramtid  outside 
'Uie  skull.  This  is  doubtless  owing  to  the  situation  of  th«  aneurUm  againat 
the  mucous  membrane  of  the  mouth,  being  i^ut-h  that  the  Hurrouiidiug  tisMies 
do  Dot  exercise  a  sutUoient  amount  of  preiwut'e  a>;ainHt  the  sac  after  the 
ligatiireof  the  vessel  to  allow  the  efficient  <le|>nsilionof  lameilated  coaguluin, 
and  consequent  occlusion  of  the  ariery  leading  into  it.  which,  in  Rccordanoe 
with  the  principles  that  have  been  laid  down  m  speaking  of  the  liuuleruit 
openitioo,  are  oeceHury  to  succen. 


ISTBACKASIAL  ASEUUIBll. 

ADeurisms  within  the  ekull  may  arise  from  any  nf  the  arteries  that  arc 

tSiel  with  in  this  Fitualioo,  though  some  EU'e  much  mure  liable  than  others  to 

fUbe  vc-currcncnof  ihisdiscBse.     Of  62  caeea  noted  by  Kir  W.  Uull.  thebatfilar 

mrtery  was  the  «rat  of  disease  in  20  cases,  no <1  the  middle  cerebral  in  15. 

Id  S  of  the  remaining  cased,  the  intcronl  carotid  wbs  allected  as  it  lay  by  the 

11a  Turcica;  and  in  0  others  the  anterior  cerebral  artery  was  the  seat  of 
neurum.  The  vcrttbral  arteries  and  their  branches  were  alTeeted  in  28 
CMea,  and  the  carotids  and  their  brnuchM  in  34. 

OAt'SES. — The  cauiw-s  of  intracranial  ancuriftra  arc  verr  obacure.  It  micbt 
be  mppiiud  that  the  compflralivclv  timall  diameter  of  the  arteries  wittiin 
tbe  skull  would  reader  them  little  liable  to  the  occurrence  of  spontaneous 
aaeunsm,  were  it  not  that  the  anatomical  characters  and  phyaiologicai  rela- 
tions of  these  vcs^la  predispose  considerably  to  the  occurreuce  of  tbio  affeo 
tioo  ;  there  being  no  other  net  of  arteries  in  the  body  of  the  game  size  as 
those  within  the  skull  in  which  spuutaneouA  aneuriitto  ko  frequently  occurs. 
Tbifl  can  be  accounted  for  only  by  the  thinner  nf  their  coats  ami  want  of 
an  external  Rbroua  sheath  rendering  them  uii:ihle  to  aupport  the  increaited 
IcDsioD,  to  which  they  are  occasionally  subjected  in  coasequcnce  of  the  alter- 
atioD  io  pressure  of  the  cerebral  circuialiaa  at  diDbrent  periods,  the  result 
of  aoiue  variation  in  the  relative  i^uautiticfi  of  the  dilfert'Ul  tluid»  witbiu  the 
•kull.  or  of  dcU-'rminatiou  of  bhiod  to  the  brain.  This  would  be  the  case 
iDore  particularly  if  their  uatunil  cla«licity  had  already  been  impaired  by 
the  occurrence  i>f  dt^^'cneration  of  tbair  coats.  As  Ihesc  clmagcs  are  the 
aatural  «!ODeequence!t  of  advauco  in  afrs.  «o  shall  find  the  tendency  to  the 
oceurreoce  of  ihie  diiteuse  increases  with  advancing  yeans.  Thus,  accurding 
10  Sir  WUIiau  Gull,  of  58  casea  iu  which  the  patient's  age  ie  given,  only  12 
ama  occurred  in  persons  undor  twenty -live,  live  of  the  patients  being  under 
twenty ;  of  tho  reiDaiuing  40  cases,  13  occurred  in  persons  under  forty  ;  of 
tlio  remaining  83,  2^  wern  met  with  between  iiirty  and  «ixty,  and  4  in  per- 
soDfl  above  sixty.  Of  (he  58  cases.  •i<'>  nen>  malcH,  and  2:1  fetiinlea.  Church 
bultevea  that,  in  the  young,  intracranial  annurism  Ik  duo  tu  enibi)liam. 

The  immediate  exciting  cause  of  thu  disease  is  mo»t  coromnnly  involved 
ta  ubectirity ;  somelimes  it  may  be  traced  to  a  blow  on  the  head,  to  a  fall  or 
1,  or  to  excess  in  drinking;  but  more  frequently  the  symptoms 


202 


SPECIAL    AKBURI3M3. 


^M^ 


>> 


/* 


K 


.( 


l^ 


?. 


mAnifeBt  thcmwlra  ntddeoly,  without  being  in  any  way  attributable  to  n^ 
extornnl  influsnces,  sod  occtir  in  vi>^>raus  kdcI  RppHrenily  bealtlir  p«n<ifit. 
Fatuoukiv. — Intracraninl  anturismu  are  ulm>«t  alwity^  furinff<t  by  the 
utiifiirm  ili!nU(ion  of  the  whole  of  the  calibre  of  the  artery — the  mcriilBtni 
TRrit-ty  beinK  rHrely  met  with.  Id  the  museum  of  Uoiveraly  (V>tte^  ib«» 
are,  however,  two  speeintetis  of  sacculated  UDCiiriBnie  of  the  cercbml  ortrriM. 
The  coal*  of  the  arterin  in  this  situation  beiug  very  Ibin,  and  unprovided 
with  any  exleraal  fibrous  sheath  that  would  eupport  the  iiupetiix  nf  tbi 
blood,  rupture  of  the  ve!>Ael  would  oncur  rsibrr  than  partial  dilalntinn.  if 
one  portion  only  of  the  eirouinferenee  wcr^dUcased.  Occasinnallr,  ihedili- 
tatjou  ut  fuBiform,  exicn4lin<;  over  itomc  length  of  the  artery:  tfiis  furm  b 
probttblv  CTinfinetl  to  tho  baftiliir  artery  (Fig.  473). 
The  iiiteaea  would  apfHsar  to  be  of  hIow  growth,  and  ihe  sac  sometinieA  b^ 

conius  Ailed  with  laminated  onagula  » 
completely  an  to  ocrludr  the  orifice  of  the 
an^ry  fr)ni  which  it  flprtnjff. 

Thf  .«{»■  that  nnfiiriAn)  in  thla  nituftt 
attainii  bffor''  death  mullii  i*  soinf 
considerable;  thuB.  in  a  «i»e  of  aoeui 
of  the  basilar  artery,  that  oocurre<l  unat 
years  ajjto  at  Uiiirer»ity  G>llege  Ilii*nital, 
the  tumor  wa»i  nearly  bh  large  as  a  walnoi : 
in  aiiotht-r  carte,  in  the  Mine  hovpital,  H 
»o»)cwliat  exceeded  t)ii»  eixe.  K.  W. 
Smith,  in  tb«  Ihibiin  Jmimat  of  Mr^imt 
•Sctenor,  vol.  xxv.,  meutioDtt  a  case  of  mul- 
tilueular  nneurijfin  of  the  left  pnelerior 
cerebml  iirlvry  us  large  aa  a  Broall  apple; 
and  Sem-»,  one  as  larj^  a»  n  brni's  pgg. 
On  the  other  hand,  they  occa»iooaily  pmve 
fatal  by  rupture  whilst  atill  of  very  «wUI 
sire — not  larger  than  a  pea  or  a  nut. 

It  is  iteldom  that  more  than  one  nf  the 
arteries  of  the  brain  aufTer  ancoriamal  di- 
latation. In  the  Mueeiim  of  the  College  of  Hurgeons.  however,  are  prr- 
pAj-otJonii  (\o8.  16H7  and  I&S8)  of  aoeurismal  dilatation  of  both  iatrmal 
carotid  arieriMi,  reumbling  "two  bulbs  about  five-eijihths  of  an  inch  in 
diameter,  filling  up  the  hollow  on  cmcb  side  the  sella  Tiireica.  nhirb  wnv 
evidently  dilatations  of  the  cAn>tiil  arierics;  and  from  their  bein^ filled  witb 
laniinie  of  coagulated  blood,  there  eimid  be  little  doubt  of  their  being  anni* 
risDu  uf  these  arteriea.  The  one  on  the  \tfi  side  wus  the  largcM:  l^ai  no 
the  right  aide  communicated  with  the  cavity  of  ibe  artery,  which  waa  doc 
the  eaae  with  the  other." 

A  case  occtirrol  in  University  College  Hospital  many  yean  agn.  under 
the  eare  of  A.  T.  Thotusuiu,  in  whirh  a  somewhat  similar  condition  existed. 
A  mat),  forty-uine  years  of  age.  had  fallen  on  his  head  some  months  before 
admission  into  the  hospital.  Since  tlieu  be  had  b<%u  KBrmloUB.  silly,  and 
very  irritable — becoming  readily  inloJiicale^I.  He  sudilenly  became  ooma- 
I'lse,  witb  voniitiutr  and  laborious  breathing  ;  he  could  cl<»e  both  ey«a.  hut 
the  ri^ht  pupil  was  dilated  ;  the  left  side  was  paralyr^il.  He  was  treated 
fiir  apoplexy,  and  beennie  slightly  better,  but  die<l  lo  ten  ibis's  from  the  flrat 
atlacK.  Ou  exiimioation,  an  iiucurism  a  little  larger  than  a  hazelnut  was 
found  on  the  trunk  "f  ihe  right  carotid,  where  it  gave  off  the  middle 
bral  artery,  and  luiother  »niafl  one  on  tlic  omree  of  that  artery.  There 
a  globular  aoenrism  on  the  corre«|ioDding  artery  of  the  opposite  side : 


n«- 


Vit. — Pufiferu  Anciirliui  o(  Bk^- 
■Har  AHafJ  Ikli  ■>[»■. 


STMFTOHS    OF    INTRACRANIAL    ANBDRISH.  203 

banlar  uterj  wu  thickened,  white,  and  opaque,  as  were  also  the  other 
larger  uteries  or  the  brato  ;  there  was  sofieoing  of  both  anterior  cerebral 
lobn,  cflpecially  the  right  ooe. 

The  arteries  of  the  braio  are  very  commonly  healthy  in  these  cases.  Out 
of  Umw  instances  of  iDtracraolal  aneurism  that  have  fallen  under  ray  obser- 
TatioD,  the  other  vessels  of  the  brain  have  been  healthy  in  three  cases,  and 
atbemmatiius  in  but  one.  In  one  case  I  have  seen  aneurism  within  the  skuU 
avnciated  with  aoeurism  elsewhere — in  the  thoracic  aorta. 

pREvURE-RfFECTS. — The  pressure  exercised  by  an  aneurismal  sac  situ- 
ated within  the  ekull  is  always  chiefly  directed  against  the  yielding  cerebral 
■nbetance,  which  ie  oAen  extensively  disorganized.  The  bones  of  the  skull, 
however  close  their  proximity  to  the  sac  may  be,  frequently  escape,  and  sel- 
dom Bufier  much.  This  peculiarity  in  the  eAects  of  aneurism  in  this  situa- 
tioD  may  be  partly  owing  to  the  very  dense  itnd  compact  character  of  the 
inner  layer  of  the  skull,  but  is  doubtless  principally  due  to  the  very  soft 
and  yielding  nature  of  the  contents  of  the  cavity.  Absorption  of  the  sub- 
jaoeot  bone,  however,  sometimes  takes  place  to  a  limited  extent;  thus  in 
one  case  (Moore's)  the  body  of  the  sphenoid  bone  was  indented  and  partially 
^wnrbed. 

The  parts  c^tmpreaaed  in  each  case  will  vary  according  to  the  situation  of 
the  tumor.  But  the  structures  that  principally  suffer  are  necessarily  those 
seated  at  the  base  of  the  brain,  and  forming  the  floor  of  the  lateral  ven- 
triclca.  In  Moore's  case,  one  of  the  optic  nerves  was  flattened  by  the  pres- 
•are  of  the  substance  of  the  anterior  lobe;  the  laraina  perforata,  the  roots 
ot  the  olfactory  tract,  the  anterior  part  of  the  corpus  striatum,  and  a  con- 
■derable  quantity  of  the  neighboring  white  matter  of  the  anterior  lobe,  were 
remored.  In  a  case  recorded  by  Lager,  the  portio  dura  of  the  right  side  was 
paralyzed  from  this  cause.  In  R.  W.  Smith's  case,  the  floor  of  the  third 
Tcntricle.  the  tuber  ctQereum,  and  the  origins  of  the  optic  and  olfactory 
■erves,  suffered;  the  optic  nerve  of  the  opp:)dite  side  was  flattened  and 
aoftened. 

Beaidea  the  changes  that  take  place  in  the  cerebral  substance  as  the  result 
of  preoMire,  important  lesions  may  be  met  with  ns  the  effect  of  the  interrup- 
tion which  the  presence  of  the  aneurism  ofTcrs  to  the  circulation  in  and 
BntritioD  of  the  cerebral  hemispheres.  Thus,  in  the  case  of  aneurism  of  both 
tDtcraal  carotids  that  has  already  been  referred  to  as  occurring  at  University 
dllege  Hospital,  there  was  white  sofleuing  of  both  the  anterior  cerebral 
lobei :  and  this  lesion  was  most  marked  on  the  side  that  corresponded  to  the 
largest  aneurism,  and  where  con^quently,  it  may  be  supposed,  the  greatest 
amount  of  obstruction  to  the  circulation  existed. 

SviCPTOMs. — The  symptoms  of  aneurism  within  the  skull  are  e.itremely 
equivocal ;  and,  indeed,  aneurism  of  large  size  may  exist  at  the  base  of  the 
brain  without  occasioning  any  symptoms  whatever.  An  interesting  Instance 
of  this  occurred  at  University  0)llege  Hospital  in  1848.  A  nmu,  thirty- 
seven  vears  of  age,  died  of  pulmonary  apoplexy  and  chronic  pncutiionia  of 
the  left  lung,  consequent  upon  the  pressure  of  an  aneurism  of  the  cimimence- 
meot  of  the  descending  aorta  on  the  }Miluniiiary  vt'iiH  of  that  .-iiii'.  On 
examining  the  head  afler  death,  an  aneuri-im  of  the  basilar  artery  n?<  large  as 
a  basetnut  was  met  with,  of  which  no  suspicion  had  been  entertained  during 
ble.  there  having  been  no  head  symptoms  whatever;  the  sac  <:f  the  aneurism 
wu  very  thin,  and  there  was  much  atheromatous  degeneration  in  the  verte- 
bral arteries. 

The  only  symptoms  that  are  of  constant  occurrence,  when  this  disease  gtH-s 
4a  lo  a  fatal  termination,  are  those  of  hemipleiria  and  apoplexy.  These  may 
oDOie  on  suddenly  without  any  previous  warning;  or  they  may  be  preceded 


204 


dfECIAL    ANKUHISM3. 


br  B  train  of  ptinnomeaa  indicative  of  the  extstenoe  of  ohroDie  diaeue  witlua 
tfie  oninial  cavity. 

The  nxvit  coiitCAiit  of  (ht^>  iilicnnmeiiA  is  pain ;  viUich  alTMU,  bow««*r. 
great  VAriely,  butli  in  nxWrU  aixl  clinnict«r.  ft  may  l>e  tliffuaei],  or  ta»y 
occupy  a  tixetl  point;  it  m«y  )»e  criritiouima  or  inl'-nnilllii;;  ;  it  may  he  ia- 
crcasfti  liy  iiiDVAmenU  or  ncCk>mpiini«il  l>y  peuullnr  smisaiiiuis,  a»  af  piilaatioo 
or  iif  opening  and  tiliiittitijL;  ihc  tup  of  tb«  craoiiim. 

Tlie  tight  niid  )R-aring  urv  urieo  impaired,  DimneM  of  sigbl,  <1ilalatioa  of 
oue  or  lioth  punils,  ptiutopliobia.  diplopia,  and  lusa  of  vieiun  bavv  been  mHioad 
in  e«veml  of  the  cwm»  recurded.  (Juwere  Btatt^o  that  iatrucraniol  uieurtsnM 
evoD  (jf  luore  size  are  pot.  ae  a  rule,  accompaoied  by  uuy  awociatod  ocular 
cfaaug«fl.  Nor  do  tbey  odtiu  cause  coasecutive  thaog«e,  uiileas  (beir  pnsitioo 
is  sucli  a»  to  preoe  upoo  the  npdc  oervcs;  tliere  is  then  losi  of  vision  vith 
atrophy  of  the  aerve  recognizable  by  the  ophtbalnioscope.     If  the  aDoariMi 

Crew  on  tli^  caveraoUH  aiaua,  there  may  be  some  fulnew  of  ibe  retinal  vno*, 
ut  tbia  is  u&ually  only  temporary,  the  pressure  beinf^  relieve<l  by  ib«  free 
oomniunicaliou  between  tlii'  uphthalmic  and  tnrial  veins.     Opiic  neiiriiU  is 
ire  OK  the  muU  of  intracraDla!  nneuriBius.     Ptosis  has  been  met  with  fiooi 


^preSBUre  od  the  third  nerve  by  aneuriein  of  the  poeterior  comtiiuDicat 
artery.  BuzKiag  DtMsea  in  the  €nn>,  and  dt^afucsi,  are  not  uncommoo  i^ 
toitis ;  doifocRB,  more  perticularly,  appears  to  be  ■  phenomenon  of  freqi 
occurrence. 

The  patient  rareW  looea  the  power  of  arLtculnlion  and  of  d^latition;  iin- 
pairnient  of  these  functions,  howci'er,  has  been  inet  with. 

Ther«  may  be  paralysis  of  the  «de  of  the  face,  shalcina  palsy,  or  oompleU 
hemipl^ia;  or  fits  of  an  epileptic  nature  may  occur.  The  ntental  oontUtim 
may  underf^  chanuM  indicative  of  chronic  disease  nf  the  brain.  There  m&f 
be  depression  of  spiritK,  IbttlpMUc-ss,  or,  aa  was  nolicetl  in  the  case  abttve  r^ 
laled,  the  lempor  may  become  irritable,  and  the  patient  be  garruluui  or  silly. 
Insanity  has  oeen  noticed  in  one  case.  As  is  always  the  case  In  eercbrw 
atfections,  the  gastric  function*  are  often  impaired. 

In  8<irae  casea  the  presence  of  aneurism  has  been  detected  by  a  loud  rough 
or  "wbixzint;"  uoisc  heard  on  the  application  of  a  stethuacope  over  no«  aim 
of  the  bt-u*l,  and,  pcrhups,  audible  to  the  paiienl.    This  sign,  however,  exu^B 
in  but  few  cases ;  but  when  it  docs  occur,  it  is  unquestionably'  the  iixiet  paibii^^H 
noraooic  of  all.    I  am  not  aware  that  it  has  been  nioi  with  in  nay  form  4^ 
cerebral  dbeasc  except  intracranial  aneurism. 

Thus  it  will  be  aevn  by  a  reference  to  ibis  llfll  of  symptoms  that,  with  tbe 

-exceiKJon  of  Uio  whisziuf;  noise,  no  special  signs  are  atfoniml  hy  anrurisma 

within  the  bIcmII.  which  will  enable  us  to  distinguish  betwueo  the  symptrtma 

oocuinued  by  their  presence  and  tboee  of  other  tumors  of  the  brain,  and  of 

organic  cerebral  diaeaw. 

Very  frequently  no  premooitory  ayroptoms  manifest  thomselvea;  the  patieu 
being  suddenly  seized  when  apparently  in  good  health,  with  apojilexy,  wbieh 
terminate}  rapidly  in  death. 

CUtmia  OP  Dbatu. — The  &tal  termination  may  occur  from  one  of  font 
caoaea. 

1.  The  tumor  may  <<xerciiw  such  pretmrf  ufton  the  vJwtt  MrArat  nwus  •• 
lo  occasion  denih.  Thin  mode  of  leniHOatioii  is  rare.  1  am  acquainted  with 
one  caMi  of  this  de«crintii^n,  which  t»  re|>ijrt«d  by  UuMhenherger.  The  symf^ 
Innis  were  very  renmrKnble.  CiMtststing  of  complete  hi?miptegia  nf  the  led  flid«, 
wilh  involuntary  unl^n'-piiflterlor  vibration  of  the  bend  and  body,  and  paral* 
rsis  agilans  of  ibo  right  leg.  Th«  patient  slept  heavily,  with  loud  snoring; 
n«  ate  voraciously,  but  oo^naionally  hatl  considerable  difficulty  In  degluttttoD 
aodurticulutiun;  hisinlelleot  was  clear,  but  very  alow.    After  death,  an  aoeo* 


IVTBACRANIAL — CAUSBa  OP  DEATU  rROH, 

Af  tlM  bwiliir  Brterr  u  Inive  ns  a  picoon'o  tg^.  coQtaioiDff  an  irregular, 
my  hard,  dry  el»t  of  blood  wus  rouna  pressing  on  tiie  pou?  varolii.  The 
wme  bad  givvQ  nay  at  'luc  p»int,  i;xini\-a«ali(iD  ukinu  jilaitf  inla  Lhesiilwtaoco 
of  tbe  piitu,  wbifli  was  eotlcnpil,  and  ul'  a  bluifib  color. 

2.  Td«  moM  frequcul  mote  m  wbicb  dvatb  takes  place  iu  these  casee  is  by 
lh»  amdil$m  rmplurv  of  the  tac  and  extravaaatiiin  of  bli»>d  into  the  cavity  of 
dwmnMtbnoid  and  toe  mahcB  of  the  \»a  mai«r  at  Lh«  base  of  the  brain,  or 
iBla  tbe  hu«fml  rentrioles — elllier  rrom  thu  aiieiirisin  projecting  inl4)  them 
iBd  iWregiviog  war,  ur  rupturing  iuui  the»>  cnt-ilip»  bv  breaking  down  the 
iBMrraaiiv  oer^rd'aubstance  iilff.  474, 475).    When  this  mode  of  termi- 


V- 


r 


rX 


\ 


V\g.  O*. — AMarlaai  of  Iba  L«n  iDtnnd 

lri«l«.     Vi««  *r  AkMruu  (roM  &b«««, 
pn^MliBf  UU  VMIrtcle. 


Fi)[.  1*5— Vi*«  at  lb«  ujBo  AB*iiriin 
(root  b«lo«,  «(iilt*4iieil  la  «iibei*De« 
»f  IlMniiphor*. 


aatW'  --~— "•  thpfy  are  occasionally  no  wflrning  or  premonitory  symplnms 
of  ir  'UnKer;  tbe  pnlient,  when  apparently  in  gootl  ht^alih,  n«^tng 

alrad^  'i<>nn  or  an  attack  of  n|toplexy,  nhich  is  sp«>dilr  fatal.  More  fire- 
•DeDtiy  a  KrW  of  thn^o  »ymiili>iii9  that  bavc  already  Dcen  mentioned  as 
■ttadlMC  muiy  ovm  of  tblD  diM«M>,  precede  the  fatal  event  for  a  longer  or 
■iMtter  tIBM.  Wh<>tt  rupture  itf  tbe  sac  and  ejctravasalion  of  bbiod  tnke 
IImb.  <le«lb  ie  in^vitablv;  at  lea^t,  T  am  not  ae«{uaint«(t  wilh  any  case  in 
•Meh  ibc  BppeArancv  found  nftor  ii<:-nl.b  couvertetl  m**  to  th>>  belief  that  tbe 
pBtkal  had  even  t<rropurarUy  nrcovertrt]  from  thi^  ci>tidiii<>n. 

Dmtb  ftvm  ninturv  of  the  tnc  «p|)earR  to  be  nio»t  frt-i)ti«nt  in  yotingvr 
•riyecta.  In  tbe  later  peric^Nj  uf  life,  an«uri«m  ix  cuniiuotity  tL^t»oci»tiH)  with 
•thwoMtuiu  diaeiuc  uf  the  vesseU  gvn«rnlly,  which  may  cau»e  dealb  by 
tohmaAng  and  effufinu  of  bitiod.  According  to  Gidt,  of 'iUcn«^e«  occurriug  la 
piianna  undvr  ibirty-fivu  yeare  of  ag«,  lli  (or  fit)  per  cent.)  were  fatal  from 
rvplure  of  the  Mr ;  while  in  ^7  OUM  over  thirty-five,  dealii  occurred  from 
ikm  eaoar  in  only  14,  or  38  per  cent. 

3.  Demlfa  may  rmilt  from  another  cauM  than  tbo  prreaure  of  the  aneu- 
riiBal  aae  or  ita  rupture  ami  ibn  extravaeution  of  ila  contenln,  vi&.,  from 
m0m)ii^  af  Om  mh^atiM  o/the  bntin  to  a  greater  or  lvf»  extent,  in  coneequencu 
■  tW  iKiiiln]n)''n  oflbreii  ti>  the  paaeage  uf  the  blood  through  the  nueiirisinHl 
vohfL  fn  the  <-ii«*  nf  aneurism  of  botb  ean)tid»,  alrcwiy  mculioiivtl  as 
WnV  r-,ivt-rriiiv  Cotlegc  liiwpital,  tlm  was  the  case:  bcAb 

aatorr  wrn-  nM-cieil  wlih  whiu-  soUening, and  this  oondiiioa 

.  «pacnlly  ohprrvable  oD  tbat  side  on  which  the  aneurism  was  larger. 


SPECIAL    AMKUttlSHS. 

4.  LiHtly,  doeth  msy  be  produced  by  the  mere  irntofion  f)caidoa«<d  br 
tb«  pmaure  of  one  or  more  Aiieurismitl  tuniurs  within  tho  r.maiuro.  OftliB 
ao  interesting  pxiiniplo  18  ufltirded  )iv  l)ie  history  of  a,  ciwr  of  anenrnm  of 
both  inlerual  oumtiila,  contniDod  in  Hio  Mii»ciiiii  of  tho  College  of  Surgwm, 
ftod  related  bj  Hir  <i.  BUdc  in  the  7*raHMriioii8  of  tM«  Soeietjf  for  tJte  In^mm- 
meni  of  Medical  and  (htrurpical  Knotciedge,  vol.  ii.  p.  192.  In  this  caap  ihr 
patient,  a  lady  aged  tii),  had  suffered  for  four  years  from  attacks  of  giddi- 
uesB,  beodoohe,  and  irap«rfc€l  vUinn ;  about  eixtocn  moaths  before  her  dealb 
she  beoflmo  ineaoo,  recovered,  and  then  relapsed  twioe  into  the  oariie  mate. 
After  havin|{  regained  her  Booses  fur  some  months,  iho  became  aSeoied  with 
giddint^at,  r^nciu  of  the  «ytd,  and  violent  maniacal  delirium,  which,  eoa* 
tinning  fur  sumo  wv«>kB,  caiued  her  death. 

Ailer  duath  the  fullowing  appearance*  were  found :  "  Upon  exaroininK  Uw 
body,  there  wan  no  appcarauc^  iu  the  br»>n  itwlf  that  ouuld  in  any  way 
acouuiit  for  the  tymptonu.  There  was,  ttidet-d,  a  greater  quaDtiiy  of  fluid 
thau  conniion  io  the  ventrirtes,  atxl  the  Hurfuc-c  of  it  waa  moitter  than  it  fa 
usually  found  iu  a  M>und  i>tate  ;  hut  in  all  other  cases  wbicb  have  occurred 
to  me  of  otvanio  affections  of  the  brain  proving  fatal,  except  Ihove  wbicb  are 
sudden,  sucli  as  apoplexy,  there  lis9  been  a  preternatural  quantity  of  fluid 
in  its  vvulrictcs.  There  were  also  spicula  of  bone  in  the  menibmue  furniiug 
the  falx.  The  inner  substance  of  the  crura  cerebri  was  of  »  brown  color, 
aud  more  tcudcr  than  natural.  The  optic  nerves  were  smaller  ibnu  ualnral. 
He  if  they  bad  been  wasted.    The  septum  lucidum  was  more  than  usually 

"  But  tlie  morbid  appearance  in  this  <'flso,  which  was  so  singular,  and  lo 
which  the  symptoms  of  complaint  seemed  chit-fly  referable,  was  two  bulba, 
about  Hve-ei^htlis  of  ud  inch  in  dianietiT,  lilling  up  tho  hollow  on  each  side 
of  the  sella  Turcica,  which  were  evidcmly  dihitaliuue  of  the  carotid  nrterin, 
and,  fniiii  their  hcinj^  tilled  with  Inminie  orcua^fuliiled  hl«HHl,  there  could  be 
no  douht  of  their  lH>itig  uneuriHrns  of  thi^^;  nrierii-ii.  The  dissoctiou  was 
madc!  by  Mr.  Hunter,  a«i»t<il  by  Mr.  Home,  in  tlie  priawncc  of  Dr.  .Tenner 
and  nivHolf,  and  all  concurred  in  the  o|iiinon  that  thr«c  tumors  were  aoru- 
risnut.  The  one  on  the  left  nidr^  wait  the  Inrjirpst.  That  on  tho  right  nde 
coromnnicated  with  the  cavity  of  tbe  artery,  which  was  not  the  case  with  the 
other." 

TRE.iTMKST.— In  th*  irentmMii  of  intracranial  flneuriara  iber«  la  oaually 
little  to  be  done,  th«  nature  of  the  eatw-  not  beinj:  sufficiently  obvious  in  tbe 
majority  of  instances  to  justify  active  meanures.  Should,  however,  the  lood. 
rough  whir.  I>e  dutincUy  audible  over  one  side  of  the  head,  more  especially 
about  the  bane  of  the  skull,  or  by  application  of  the  »telht>sc<>|>e  l«)  the 
BMstoid  |iroce«8,  and  i^hoiihl  KvniptoriM  of  cervbral  tx>iinpret«iitu  beKia  to 
Quiniftwt  thetti»(dves,  ligalurv  <>t  the  cnnitid  artery  on  the  »l1e4-teil  Hide  may 
with  projiriely  I)**  practiiwHi.  Thia  Iihh  lieer>  done  succvwfully  in  a  mutt 
inlerestiii)^  and  iuDtnivtive  c-atu-  of  iulrNcrnninl  aneurism  by  Cop,  of  Bristol: 
and  uiwoci'twtully  iu  one  at  Univemily  C'ollvgi!  ]I<w|itlal,  by  Barkuley  Hill, 
in  which  death  took  placo  from  hemorrhage  from  the  seat  of  ligatore. 


IXTRAOltniTAL  AHBUKISH. 

"  Inirnftrbilnl  Aneuriniim"  were  for  a  loiifj  time.  con»identl  hy  Rurgeotw  in 
b^  of  the  nntiire  of  trectibr  tumnn: ;  but  the  ermr  of  lhi»  npinioii  viiw  pointed 
out  by  Bu>k,  and  fiitb»e>|uent]y  hy  Xuiuietcy,  who  (inclusively  eliowed  Uiat 
except  in  lhi»e  very  rare  ca>w*  in  which  a  pulsating  tumor  of  the  i>rbil  i* 
congvoiial.  or  has  ap[>eitre4l  slmrily  after  hirtb,  or  is  assiKriatcd  with  ntcvoid 
tissue  developed  in  thu  eyelids,  it  iuust  Iw  luolted  upoo  as  beiug  due  io  the 


INTRAORBITAL — STUPTOUS   OF. 


207 


rity  of  c»»e*  to  the  preneace  of  no  eneuriam  or  nueumiual  vnrix  at 
.h«  orbit.  These  views  have  becu  fully  cuiiUriuvl  by  liivingtoo 
in  hi?  exhaufriive  paper  fuUDded  on  l-i  recorded  caaeg  of  [iLil»ntiu^  liiinur  uf 
the  orbit  collecteu  from  various  sources,  nad  iucluiliu^  ouc  \vvy  iiiCcnrHliiig 
cMe  of  bis  uwu.  The  vessel  iiffecled  appetirv  to  be  lu  sotue  iiiBUiitree  the 
ophthalniic  artery  iiaelf ;  ia  other  iiigtauces  it  wmild  &p|)ear  that  tliti  tiiitior 
ii  devoloiiod  wilJiiii  tlie  crauium,  sprin^iDg  from  iho  camlid  artery,  the 
ophihatimc  bdaa  but  aecuDdarily  atfeclod.  Di^leiis.  of  Parin,  hnt;  rwordeil 
three  cases  verinod  by  pn«i-monem  examination,  Ju  which  the  Fymptoni? 
arwo  from  an  nrterio<vcuouB  aneurism  afltiuiiag  the  cnrctid  artfry  in  tbe 
cavernous  ^ioua. 

Cacsek. — The  causes  of  JDtraorbilal  aneuriatu  arc  iii  twinn  vMAe»  very  oh- 
ftdJtv :  ID  otbois,  it  cvidiiriUy  luid  diruclly  has  uri}:iiint4Ml  fnini  ii  blow  upon 
the  beat}.  lu  the  firxt  cbiKi  oi'  case*,  where  the  dleeaise  htm  hei-u  nf  ttponla- 
oeoue  origin,  the  putieui  bus  Huddeoly  f(;lt  u  crack  or  luiap  in  the  nrbil,  lilie 
the  "crack  of  a  whip,"  or  tbe  "nnap  of  a  gun,"  and  llie  dit^fUH-  hati  then 
developed  gradually.  In  the  traumatic  cum-",  the  blow  upon  the  head  han 
omally  bren  aeverc,  attended  in  .4tinie  instance!!  with  oymplom!)  of  frncture  of 
the  anterior  part  of  the  ba.ie  of  the  skull.  In  several  cases  it  has  arisen  from 
peoetxating  wounds  of  the  orbit,  a.«  from  fttickg  or  small  »bot. 

Of  tbe  T3  cases  collected  by  Uivington,  32  were  idiopathic  and  41  trau- 
matic. Of  tbe  idiopathic  ca^e^  two  were  con^nltal,  probably  ^nnine 
ftpeciroeaa  of  cireoid  aneurism;  the  mean  n^  of  the  rest  wa«  43,  the  oMe«t 
JtteiDg  ()!>.  The  mean  ajge  of  the  traumalic  case^  wa^  between  SO  aud  31,  the 
<  extremes  being  11  ana  72.  Tbe  sjionteneou^  case*  were  most  coirmion)y 
ill  women:  thus,  of  30  caaes  io  which  ttie  »ex  ii  reconled,  21  were  females. 
Tbf  traumatic  form  ii  must  coumiou  iu  men,  the  number  being  31  nialea  to 
10  females.  Amongst  thu  iiliopathic  auKs,  lo  occurred  uu  the  right  side,  13 
C'U  tbe  left,  and  2  on  both  sidot;  of  40  traumatic  cuees,  10  were  oo  the  right, 
27  OD  the  letl,  and  3  ou  itiub. 

Symitomj*. — Tbe  first  seusutiou  experienced  is,  in  uponlaueoua  caues,  that 
of  a  loud  imapor  crack  iu  the  orbit  or  head.  This  U  lollowcd  by  cougestiou 
of  the  coujuDclivu,  difficutty  in  opening  thu  eyeli<hi,  a  feeling  of  tcQ!<tiin,  and 
.in  gome  instaDcee  severe  pain  in  aud  aruiiud  the  orbit.  Loud  whizzing, 
jvrildering  uolses  are  experienced  in  the  bead,  and  are  mueb  increased  oq 
iping  or  lying  down.  In  traumatic  cases,  a  persiflteace  of  congestioo  of 
conjunctiva  with  redness  and  some  a?demH  ot  tbe  eyelids,  and  tlie  occur- 
reoce  of  noises  in  the  bend,  are  imuiilly  the  first  iudJcatinns  of  the  mischief 
that  boa  uceiirrc-d.  In  all  cjises,  after  a  lime,  the  eyeball  becomes  unduly 
pfuntiucnt,  and  pulsation  of  a  thrilling  vibratory  character  can  be  felt  in  tbe 
itrbit:  uD  the  application  uf  the  ear,  n  loud  whizzing  bruit  is  discernible, 
licJi  extpods  uidcly  over  the  side  of  tbe  head.  Tbe  eyeball  itself  eventu- 
lly  falls  into  a  state  of  chronic  c<iti|i^-3tion;  ebeit)L>sis  occurs,  the  cornea 
iface  opalcsccut,  the  aqueous  humor  turbid,  and  si)^bt  is  impaired  or  lost. 
bfuit  and  pulsation  arc  diminished  or  cense  on  compressing  the  carotid 
ortfiry  of  the  side  afTccted. 

pRonNosiH. — I  thinlt  it  is  still  doubtful  what  wouM  bHp|>en  in  a  large 
number  of  these  cases,  if  the  disease  were  left  to  itself  without  ojieration.  It 
mifthl  be  supposed  that  it  would  prnbably  have  a  fatal  terminatloti ;  that 
rupture  would  take  place  either  into  the  cranial  cavity  or  cxternallv,  and 
that  auddeo  death  would  occur.  That  this  has  oceasirinally  tsken  pfnco  is 
]>ruv«d  by  rec*»rded  cases,  but  it  ts  by  no  means  a  necessary  consequence  of 
the  disease.  I  was  coiuiittcd  at  the  end  of  1865  by  a  genlleninn  about 
44  y<^r«  of  age,  who,  in  couHcquence  of  a  fall  on  the  head  a  few  months  pre- 
viously, had  been  attacked  with  symptoms  of  aneurism  of  the  left  orbit  in  the 


SOS 


SPECIAL    ANBtJBISHS. 


mnft  tnnrkod  manner.  The  bruit  and  the  pul)>ntiou  were  very  load  aad  dit- 
tiuct.  The  eyebflll  wiis  greiitlv  protni<i«(l.  the  coiijuaotiva  aad  eyeUdfl  ven 
oongeeted  nud  bwoIIcd.  Greavce,  of  iliiriuD,  with  whom  1  mw  the  euL 
'  Hgned  with  mo  in  urging  HgEture  of  thr  caralii)  anory  ba  the  odIt  meuii  «f 
cure.  Td  this  the  ntitieDt  would  not  ct>u^nt,and  preferred  taluog  bboboDM!. 
Bj  attcntioD  to  habita  of  life,  Bbfltinciia;  frum  Bcimulaata,  and  ordiiuuy  BwA* 
cal  treauncDty  the  tumor  subsided,  the  eye  retreated  within  the  orbit,  uid  the 
armptoma  diminiithed  grcAtly;  so  that,  at  the  axd  af  {ounetn  muntba  fVea 
ike  lime  when  I  first  saw  bim,  I  uudcrstaod  that  they  had  tu  a  very  gratf 
exteut  diaapp«flr«d. 

But  there  b  reason  U>  believe  that  all  the  cigiM  uf  iDimorbrLal  aoeuriia 
may  entirely  disappear,  the  diaeaie  undergoing  a  t[)ootuneiius  cure.  Oulbud 
relat«^  the  coK^xil'a  man  41  ye&raof  age:,  who.  in  oi>nMttjutfUi-«  of  a  (all  tin  the 
back  of  hJH  head  by  which  he  wad  rendered  iii»«nHtble,  vtns  i^nulitully  r-v'md 
with  ttymptotiiH  of  aneurinm  of  the  lutl  orbit ;  brtiit,  jiuUation,  <li|ilii)ii&,  uA 
protrusion  of  the  eyeball,  toi^ether  with  con|{«stiuii  of  tli^  evelidH,  l)«>inu 
marked.  After  the  diwaM  oad  cootinued  fur  a  coosiderable  k-ti^lh  uf  tt 
the  patieut  vas  put  upon  a  course  of  purgattvex,  with  a  eulomer  and  bell*' 
donniL  pill  daitv.  and  cold  lotions  to  the  furuhead.  Under  tbts  treatraeut  tin 
Bymptumis  grmiuallv  subsided,  and  io  three  yean  and  a  half  from  the  cam- 
nMDoemeut  uf  the  (futcase  had  entirely  disappeared.  Cullanl  liuliovoe  thai  in 
this  case  there  was  a  dilalutioii  uf  the  ophthalmic  artery  and  ite  braucba, 
arising  fnmi  and  maintained  by  u  morbid  stale  of  the  uphthHlmlc  gaagliua, 
whii^b  furnish^  vawHuotnr  fitument^  to  the  art«rie«  of  the  eye.  Tfaia^aa- 
glion  he  helievee  h)  hBve  b«en  injurrd  hy  eonirc-fmtp,  and  to  have  rcmaiaeil  io 
an  abnormal  state,  which  pru4lu(«d  dilatation  of  the  wall  of  the  ophthaltnie 
art«ry  and  itx  branches,  increwe  of  the  piilsntions  and  the  other  aymptoBn 
which  have  lieen  dencribed  above  It  ix  H%-idenl  from  thCK  casea  that  a  grave 
prognueis  should  ni>t  lie  hiuttily  given,  aa  it  is  only  by  watching  the  caoe  thai 
a  correct  ooncluriion  can  l>e  arrived  at  If  the  protrusion  of  the  eyeball  ooft- 
tiiiuei^  to  increase,  and  the  globe  itself  begins  to  PofTer,  and  vision  is  lost,  the 
pn^noais  become*  grave  and  the  case  taone  requiring  surgical  trfatmfnt.  1/ 
there  is  no  increiue  of  the  symptoms  after  imiiii-  months'  observation,  the 
patient  may  be  led  to  nature  unlms  the  annoyance  of  the  disease  is  so  great 
that  an  attempt  l<>  give  relief  beoomee  neccswiry, 

Patboixwv. — ^The  esKnlial  features  of  stM^lIrd  intraorbital  aneurism  or 

Sulsatitig  tumur  of  the  orbit,  may  arise  from  more  than  one  )mthidiigical  con- 
itioo.  Hiviugtoii  has  ollvcted  1^  fatal  cases  in  which  thv  iliseiuKH]  parts 
were  examined  hIWp  dttith.  In  one  only  (^Outhrie)  was  an  anennam  (ouIkI 
in  the  urbit.  lu  this  cnHc  tliu  disease  was  double,  and  there  was  a  circoat- 
scribed  aneurism  on  each  ophthalmic  artery.  In  three  cases  no  arterial  dis- 
ease was  found:  in  one  of  these  (U:Itlingeu)  there  wba  ubliteratinn  "f  some  of 
the  veins  nf  the  orbit  frum  old  iuQammau>ry  mischief,  in  the  other  two  (Bow* 
.man  and  Anbrey^  there  was  ohetruction  to  the  passage  of  blood  from  tbe 
orbit  through  thrombosis  of  the  inimcnmial  »iQU»es.  Id  one  (NuDuoley) 
there  was  a  circumscribed  aneurism  of  the  onhlhntmic  artery  before  it 
entered  the  orbit;  in  three  (Baron,  Gendrin.  ana  Nunneleyj  ruptare  of  aa 
UMtlrismal  internal  carotid  into  the  cavernous  unus  was  f<iuod;  to  «■• 
(Wecker)  aimplo  dilatation  of  the  parotid  in  tho  eaveruoud  sinuA  was  tlw 
cause  of  tho  discdw.  and  in  the  remaining  three,  recorded  by  iVIens,  aa 
aneuriemal  varlz  of  tho  carotid  artery  and  cavernous  sinus  was  fouad. 
Thews  three  were  all  the  result  of  injury,  one  arising  from  a  direct  woaod 
from  the  p<tinl  of  an  umbrella  thrust  into  the  opposite  orbit,  and  the  ollnr 
two  frtim  severe  blows  on  the  bead,  probably  aceorapanied  by  fracturei.  No 
CSS6  of  aneurijju  by  anastomosis  of  the  orbit  has  bsoD  demonstraled  by  past- 


TREATMENT  OP   tNTK JLOR»lTAi.    ANBURI9V. 

luortcui  i-xaiTiiiiatiui],  but  there  is  BtrouK  rcawiii  to  Iwlieve  that  two  cabm 
which  have  hvvu  ructirilcd  uf  oui))cvnilal  nri^in  were  of  ihia  nntun?.  The 
earlier  uUwrvurs  etup^KiKeil  all  case»  u>  iw  tlue  lo  aneurwm  hy  anti«lomoste. 
Th«  Ikllnc^  lit'  ihifl  upinton  wus  fifvt  piiiiURtI  oiic  by  fiuak,  who  r«ibrred 
the  eTuiptiittitf  Ui  a  rupture  of  the  nplithulniic  artery  and  the  developnieDt  of 
a  inrcutuBcriliwi  tr«iimatic  anciirUm  of  that  vessel ;  this  also  hna  not.b«Mi 
di'iDuuHLratul  hy  post-mortem  observation.  Niioneley  doubted  the  correci- 
tiew  uf  thia  vifw,  and  referred  the  syinptomR,  iu  some  cases,  to  a  peculiflr 
vmcular  Cfniilitiiin  of  the  partii.  de|M:-iident  more  upon  an  affection  of  the 
reini*  than  the  arceriee,  and  somewhnt  analogous  to  what  Uitcea  place  in  the 
exophtliiilmofl  nf  br4^>Dcho<!e]e.  He  pointed  out  also  that  in  other  ciiso:i  an 
iineiiridm  exic't.';,  hut  that  it  is  not  in  the  orbit,  but  behind  it  in  theenveimoua 
rinoH.  In  thette  latter  eases  he  showed  thiit  the  pn^imluence  of  the  eyeball  is 
due  to  distention  of  the  veins  of  the  orbit  from  obstruction  to  the  return  of 
blood,  and  the  pulsation  ia  commimieated  to  these  distended  veins  by  iho 
Boeurism  in  ihc  cavemoii^  tinns.  This  view  is  fully  confirmed  by  the  pusl- 
murlem  records  quoted  above.  In  cbo»e  c-a«;s  in  which  nothing  lieyoud 
ob«tructiiMi  to  the  returu  of  blood  through  the  cavernous  sinus  and  conse- 
qu<;4it  ililatAtion  uf  (he  orbital  veiue  has  been  Ibund,  the  cause  of  the  pulxa- 
tioo  is  not  Ml  evident.  Iti  other  cases,  it  is  perha{i8  possible  that  sutne 
derajigemeut  of  the  vsso-motor  inBuent^e  uf  the  sympathetic  may  really 
Dccuiuu  ibo  syniptfiniB  of  increased  vascular  activity  that  are  et>  chnrac- 
terislic  of  the  divvaae. 

The  Mc»udary  phennniena  that  are  observed  in  the«e  cases,  such  as  con- 
gestion of  the  eyeli'ls,  of  the  palpebral  and  ocular  eoiijuoctivfe,  amounting 
even  Iu  ehemosis  in  aiaoy  cases,  and  the  muddinesA  of  tlie  a<)ueous  humor 
and  leoB.  are  doubtless  due  to  an  interference  with  the  return  of  blood  from 
tbne  fiarts  Ihrougli  the  ophthaliuic  rein,  to  the  coiuteijueut  conf^lion  of  the 
BouUler  vessels,  and  to  etTuaion  of  scrum  into  thii  8ubconJtiD<-tival  areolar 
tUBue.  Tbc  protrusion  ni'  the  eyeball  ia  due  to  the  vascular  tumor,  what- 
ever its  preeJiHL-  nature  may  be,  and  the  dirrangement  in  viyiun  to  an  altera- 
Unn  in  tuc  axis  of  the  eye  conseuuent  on  this  oxtrusinn.  It  te  remarkable 
that  the  Imtit  in  ifaeee  cns4«  Khouul  bo  ko  loud,  not  nnlv  to  the  [latieut's  own 
•mses,  but  to  the  car  of  the  Kurj^on ;  and  thi^  ran  be  aecoutited  for  onlv 
by  the  proximity  of  the  cranial  bones,  which  may  act  as  conductora  of  sound. 

DiA«JS<i»»iK. — The  DiafpioaU  of  pnlnitin):  tumor  is  Hiiflicieiitly  easy,  but  it 
ie  just  an  difficult  to  detennine  accurau-ly  the  cuitiDe  of  the  disease.  It  is 
probable  that  nearly  all  the  traumatic  casea  nn^  due  to  aneurismak  varix  of 
the  carotid  artery  and  oflvcmons  sinua.  The  sLidden  onset  of  the  dinea-te, 
with  ft  crack  or  snap  in  idiopnihic  casei),  would  lead  to  a  presumption  that  a 
Mnall  aneurism  of  the  carotid  had  f^ven  way  into  the  sinna.  O^n^enital 
ca«K>a  are  probably  aneurisms  by  ai)Hj>tomiwii<i,  Beyond  thii*,  accurate  diag- 
Dosia  of  the  palhologitaxl  conditiun  iit  hardly  possible.  The  di.'»ease  most 
likely  to  be  mistaken  for  an  intraorbilnl  aneurism  is  a  pulsating  sarcoma  of 
the  booeii  of  the  orbit.  In  this,  however,  the  pulsation  is  less  expansile  and 
the  peculiar,  harsh  bruit  is  wanting. 

Trkatmknt. — The  results  of  the  esses  that  have  been  referred  to  above, 
ihv  tmrertainty  in  which  we  otleu  are  as  to  the  real  pathology  of  this 
disease,  and  the  certainly  that  in  umiv  iustanees  at  least  there  is  no  true 
ascurbmal  tumor,  wvuld  justify  the  -Surgeon  iu  having  recourse  to  medical 
treatment,  aided  by  digital  compressiHU  of  the  carotid,  and,  perhaps,  the 
■ppltcation  uf  Ice  to  the  forehead,  before  proceeding  to  operate.  TlnU  these 
naaws  are  occasionally  eucces«fiiL  there  can  he  no  doubt.  Giuppi,  of  I'ndua, 
baa  recorded  a  oiee  in  which  au  intraorbital  aueurieui  of  great  severity  was 
cared  )iy  intermittent  digital  compresvion.     The  compre^iun  WA8  kept  up 

TOL.  11. — 14 


3 


SPBCIAt.   ANEDRiaUS. 

for  periods  of  a  oiuiiite  or  two  wiLb  fre<)uent  iDtervals ;  preaurv  coiitinmd 
for  more  than  one  minute  chu»^  fainting.  It  was  cured  io  four  liajrt. 
VuDzetli  and  r^arraiuuszii  hnve  published  another  caae,  in  which  inlomtl' 
lent  digital  cuBkprcasion  waa  kept  up  for  five  minutes  at  a  time.  The  out 
VBS  complet«lv  cured  at  tlie  end  of  compreaeioD  during  KVen  huun  and 
twenty  minutes,  spread  over  eighteen  dajB. 

Ri\'iugtoM  lias  L'ullccted  16  cases,  including  thoac  juitt  nwutioued,  in  which 
digital  eompmeion  has  been  iidopU*d.  Of  tbcse,  5  were  idiopaibic  and  11 
traunintic.  Two  idiopathic  and  one  tmumalic  were  cored,  in  the  rut  no 
benefit  resulted  from  the  treatmeoL  In«trumcota)  compreMion  baa  beta 
tried  in  four  l-sm-s  without  result.  Galvanopunoture  has  been  triod  twice, 
once  it  failed  and  once  it  wan  fatal.  Coagulating  iojectionf  have  been  und 
four  times.  In  all  the  disease  woj  traumatic.  The  Bubetance  tiaed  was 
perchloride  of  iron  in  three  caseo,  two  of  which  wen^  eornl  and  one  derivid 
no  hcnetit.  In  the  fourth  case  a  sohilinn  of  lactate  of  iron  waa  injected  ai^ 
the  patient  was  cured.  In  sptte  of  this  succeaB  the  injection  of  coagula^^^f 
fluids  into  a  dilated  vein  in  which  it  is  impoesible  tcmporarilT  to  arreat  flP 
flow  of  blood,  can  hardir  be  regarded  as  a  safe  proceeding.  When  medioal 
treatment  and  compression  have  failed  in  producing  a  decided  impreanoa, 
the  only  course  lell  for  the  successful  trealmeot  of  the  disease  is  ibe  ap[4ie^ 
tiou  of  a  ligature  to  the  common  caiotid  of  the  side  atfected.  This  oparatioo 
baa  been  highly  successful.  Bivingion  has  collected  44  caaes  in  which  it 
has  been  performed,  18  idiopathic  and  26  traumuLic.  Of  the  idiopathic 
cases  3  diet!  and  15  recovered;  of  these  15,  12  were  cured,  in  8  vision  aai 
restored,  in  3  it  was  nut  regained,  and  in  1  the  cllect  in  this  respect  Is  otA 
mentioned.  The  remaining  8  cases  wi^re  bvueJUed  bv  the  operatioti.  Of 
the  2tj  tmuraaiiit  ea^ee,  .'1  died  and  23  recovered.  Of  the  'l\i,  14  were  nired, 
1  by  ouhtKeiiuunt  injection.  Vision  wna  not  nrgained  In  4.  In  5  the  opera- 
tion failed,  2  of  tliei4('  were  subsequently  cured  by  ligature  of  the  opposite 
artery.     Four  were  tianiully  curcvi  and  one  relnfwed  after  appan>nl  cure. 

In  a  vi'ry  iuteresling  caw  which  1  saw  in  V'elpeau's  wanls  in  1839,  both 
orbits  we^e  aAcctml  ;  and.a-t  pressure  on  the  right  carotid  arresliMi  the  putaa* 
tion  and  bruit  in  both,  ihnl  artery  was  tied.  But  ihnogh  the  di^eiwc  ws* 
cured  in  the  left  orbit  by  lhi.1  operation,  and  temporarily  arre»tMl  in  the 
right,  it  reappoared  in  the  latter  siltintion,  and  was  eventually  cured  here  by 
the  ligature  of  the  lef^  carotid. 


ANEL'KISU  OP  TUG  BUBCIAVIAR  AHTEBV 

AneuristDs  of  the  i?ubclaviau  occur  in  order  of  fretiuency  between  those  of 
the  carotid  and  of  the  bracbii>-cephalic  arteries.  They  are  must  frequeatl? 
met  with  on  the  right  side,  in  the  proportion  of  about  three  to  one  ;  and  thM 
w>mld  (ip|K'ar  to  be  lu  a  great  measure  dependent  on  tlieir  being  uccasloaed 
by  direct  violence,  or  by  repeated  or  prolonged  exertion  of  the  arm ;  Iboa 
tbey  caramouly  occur  from  falls,  blows  upon  theshoulder,  or  exceanve  fatigoc 
of  this  extremity.  From  the  fact  of  the  aneariflms  arising  from  esteroal  Tio> 
lenoe,  we  should  eipect  to  meet  with  them  most  frequentlv  in  malea,  aad 
this  we  do  in  a  remarkable  manner.  Of  120  cases  collected  by  Poland,  oaly 
11  occurred  to  fetunles,  and  in  4  of  these  instancca  the  disease  resulted  froa 
injury;  in  2  eaacs,  both  arteries  were  aAct«d.  The  disease  may-  be  seated 
in  any  pari  nftlie  vi.-8»el  on  the  right  side,  though  most  commooly  it  is  not 
dilated  until  afler  It  has  pn^sc^l  beyond  the  anterior  si-alenos.  On  the  left 
side  aneurism  never  occurs  bdnrc  the  arterv  has  emerged  from  the  thomx  ; 
and  then,  as  on  the  right,  it  most  commuuly  happens  io  the  third  [lart  uf  the 
course  of  the  veaeeL     Subclavian  aueuriam  may  occur  at  any  ago  abi>T<  31. 


•rVOLATIAN — SYMPTOStS  —  DIAGNOSIS — TREATMENT.     211 


!■  arm  eotumoa  in  raiildle  life  ;  and,  according  to  Poland,  U  three  timet 
-    'r     iieot  to  England  than  in  any  other  cxjuntrjr. 

■US. — Ad  aneumm  ol^  the  ^ubcUvinn  arlvry  ia  characteriMd  br  a 

ii-aiin^  oooipraMible  tunuir  of  an  elongittM  or  ovoid  ahape.  nituated  at  the 

•«■  i>(  the  poK«rior  ioferior  triangle  of  the  neck,  immwiiately  abuve  the 
«lsiriel«.  If  U  be  sinall,  it  wilt  duuippear  bebiml  this  bone  on  tbe  shoulder 
Wac  niMd:  aait  iocrt>a>>e«  in  fixe,  it  fills  u|i  the  whole  uf  the  space  between 
tb«  cMViele  and  th«  tra|>eziii».  otlun  nttaioing  a  very  considerable  bulk.  In 
CBMtn«e«et  of  the  prtwure  which  it  exercivea  on  the  brachial  plexiu  of 
■uvu  tberi!  »  pain,  oAen  attended  by  oumbu^w,  and  ext«<nding  down  tbe 
•na  and  fiugere,  OBuallr  with  Bome  weaknesis  of  those  parls.  In  some  in- 
■liaca  there  m  a  apKAOiodic  afiecLiun  of  the  diaphragm,  owing  to  irritation 
of  tike  pbrraie  nerve.  Thet^xtt^rnal  jugular  vein  is  commonly  distended  and 
rmritsmt ;  (Bdema  of  the  linad  and  arm  may  be  present.  The  tumur  does  not 
iaere—B  rapidly  in  size,  oiving  to  ila  being  tightly  compressed  by  the  aurround- 
iiw  parts ;  and,  as  the  disease  never  extends  inwards,  it  does  not  interfere 
wah  ibe  trachea  or  asophugus.  In  mme  cases  it  hna  been  known  to  extend 
donnmrda  and  backwards,  so  as  to  implicate  tbe  pleura  and  the  summit  of 
tWlitfl^ 

DlAOSOBls. — The  diagnosis  of  subclavian  nneuri^ni  U  usually  easy,  and 
proMia  no  point  of  a  jptcial  chuniclcr.  Mayo,  however,  mentions  a  ca*c 
B  which  aa  exoatoeis  of  the  Grst  rib  pushed  forward  the  anbclavton  artery  in 
■aeh  a  wn*  as  la  cause  it  to  simulate  an  aneurism,  and  eventually  to  arrest 
tk*  pabation  io  it. 

RncCLta. — As  a  subclavian  aneuriam  incrvflsea  in  size,  it   may  become 
£Amc«1,  and  bant  either  oxiemally  or  into  the  pleural  sac.     A  spontaneous 
IT*  baa  iDoro  fre^juently  occurred  in  this  than  in  any  other  external  nneu- 

TKBATMnrr. — The  treatment  of  subclavian  aneurism  is  in  tbe  highest 
qoaatiafactory.  Gumutr^mon  on  tht  enirdtac  «ide  can  be  employed  only 
IIm  artery  is  so  irregularly  distributed  that  it  rises  sufficiently  high  in 
ht  admit  of  praaure  being  applied  between  tbe  scnleuus  and  ibesac. 
8*eA  a  oowbinaiiuu  uf  irregular  anatomies]  distributioua  with  aneurism 
■at  of  BMHasilj  be  excessively  rare  :  but  in  one  case  in  which  it  iXM^urred, 
JMasd  luooneded  in  effecting  a  cure  by  digital  euiuprcssion.  kept  up  for 
MMiV-au  houn.  Tbe  tumor  tbeu  was  smaller  and  harder,  but  still  pulHuted. 
Tba  BatMol  leA  the  llospiul.  and.  nt  tbe  cud  of  a  mouth,  tbe  tumor  was 
lb«M  to  have  baoome  aolid.  and  to  have  ceaaed  to  pulsate.  The  uumbcr  of 
aaas  in  which  eonprenion  is  pcxisible,  may  perhaps  he  increased  by  |ierforin- 
ia^  tbe  opBtmtiua  under  prolooged  animtheMa. 

Ointt  I^tmurt  on  the  rac  has  lucceedcd.  It  has  been  tried  In  three  cases, 
aftdia  aJlsucetvifuny.  Warren,  of  R(>etj)n.roiult)  the  pressure  by  mtmns  of  a 
aaimb l ;  and  <'omi-r,  of  I'oplar,  by  means  of  n  leatlu>ni  cup  moulded  to  the 
•■■InBg.  The  allfrmpls  at  id)Uiining  couHilidalioti  of  the  tumor  by  eotulitu- 
ISmtmi  SMViw  or  by  ffo/watw-pwuiure,  have  hilhcrio  failed,  except  in  wmic  very 
ran*  [a«laB<v«L  A  ease  is  report^l  hy  Vontman  of  the  cure  of  !>iib<-iuvinn 
V-ilaalva'n  plan  in  eighteen  months.  Oaloano-puneture  has  been 
-  )iui  only  on o«*  with  success — in  a  chbo  under  the  cJtre  of 
!-•«  hftvo  bfni  sucreMfully  treflte*!  by  I*i»ngpnbeck,  i>f 
■■  Dilloit,  oC  Bern,  hy  the  tuhntlanrottJi  injniion  of  trffoUn 
its  over  the  tumor.  MaHipulntian,  as  recommendeit  by 
'.  11  irtrd  tiv«  timm  iTIolmc^ ' ;  r-ncc  in  the  bands  of  Little 
fMeeneAiIly.  ooce  by  Kcreuason  with  partial  success,  and  in  the  three  remain- 
i^  caaaa  wilbuul  any  advantage.    Tbv  tr^-atmeiit  undoubtedly  deserves  a 


SPKCJAL    ANKITRISMS. 

further  trial  in  Uiese  oasn,  wheo  ve  consider  the  extreme  danger  nf  tlM 
dbraso  and  lUt.  great  want  of  succcsn  that  atteudi  other  meant  of  cttr«. 

Ligaturt  of  tM  bnichio-cephoHc,  and  of  the  juMbvmui  •(•eVf.  iaterBal  to, 
hehind,  and  nevciml  the  Kuteuus  HDticun,  has  b«eo  pimotiaed  n>r  the  von  of 
this  form  ol'  aiieurMm;  it  hu  likewiM  beeo  propOMd  to  apply  the  diital 
0|H!niti<jn  to  the  treatment  of  this  dtsesoe.  and  to  atupatat?  at  the  tboul4kh 
joint. 

WhtfD  an  anetirisni  i»  vituuted  oo  the  right  eubclaviiiD  artery  on  tkt 
tracheal  vide  nf  the  siaileQue.  there  is  nu  war  in  wbioh  llic  flow  of  blood 
thruugh  it  can  be  arrested,  except  by  the  ligature  of  the  bruehio-ecplMlic 
unery.  Wlirn  it  i^  situated  bevond  tbo  HcaIoaui,or  even  bcliiod  it,  ligaturr 
of  the  vewel  basheeo  practised  m  ibe  fifM  pwrt  of  its  courta  befor*  it  raufati 
tbU  muticle.  Fur  mbc)a¥iaD  aiieiiriazD  on  the  leA  side,  ia  thcM  rituaUoaa, 
no  operation  coDducted  on  the  Uiinlerian  priuciple  would  b«  practicable. 

Let  m  DOW  proceed  to  examiue  the  rcsuiU  that  have  atieoded  ihew  opera- 
lire  propedurt'fl. 

Liffatnre  of  the  Braohio-oepholic — Tho  brochlo-cephallc  artery,  at  tnar 
be  Kcn  by  the  aecompoDying  ubie,  hod  boen  ligatured  MxtfK^n  timu,  and  lo 

OASEA  OP  MOATFRE  OF  BRACHIO-CEPHALIC  ARTEHY.' 


w 

lATITRK 

» 

Afmm»nm.       ■■». 

"**■       Of  PHSAII. 

aa«rLT. 

1.  MoTT.              m. 

67 

SiibcUrlsn 

IHed  on  'ifllh 

Ti«d  an  ini-h  t>rhiw  tiirnn-atliW. 

■ 

■no  u  rum. 

do-y. 

Liga(im>  Mpatalf<il  Id  fiHiiiwn 
imyt-      QcDitirrbaga  oa  Sfah 
day,  ttopptd  b;  praMure:  r*- 

1 

eurrrd  on  91th. 

S.  UOATX. 

— 

■  »■ 

Subclavitn 

Died  on  CTlh 

Llgiluni  H'paralod  in  fourtMB 

■  rifriiriitn. 

dny. 

day*.      Died  or  hei»iirrh«|;R. 

S.  IIalu 

«n 

•  ■■ 

SuIk-IkvUr 

Died  >'»  5ih 

Artery  waa  dii»a*«(l  and  r««a 
way.      lll^«diii<   arreaiHl  bj 

ntteufiitiu. 

d>,v. 

plug:  dralh  h^xnnthvf  cawN. 
Ckh  refermd  tt>  as  itrrurriBf  ta 

4.  Durrt- 

__ 

m  >> 

•■•         an 

I>i«d. 

TMKR. 

lbopraclip«iir  Du[Mi)ru«a. 

6.  XaoMAV. 

m. 

... 

SitbcUvian 
Bneumtn. 

Died. 

Dicdof  pflrintrditlifltty  bvai» 
an«r  oiiifrnlion. 
HtnwrrliaE:^  i-aiiip  on  cm  Iki 

0.  BUKD. 

tn. 

81 

SubcUvian 

Died  oil  IBtk 

V 

iin«iir)tni. 

A»y.                17th  and  iKlhdajt.     Upilurv 
a|i|iUo()   tu   upfwr  porttan  nf 
■rl«r>-. 

t.  LtXAOD. 

•  •• 

*«* 

Sii)wlHvI«n 

Dim)  un  2ht    I^»tBr*MpK»tedo(il7uiu^. 
dav.              H«[norrha(;p  on  Itfih. 

■ineiirisiii. 

B.  UCTIV. 

n. 

se 

llROuirrliaKfl 

Diud  m  12       Puiicliirtd  wouml  in  aiilU,  be 
boun.        1    which    ■iilMUvian    ««  iMi 

fefler  li);ftture 

ufMibclavlui. 

Iben  bracliii>c«|ihBlie~~ti«tL 

*  Tbw  arv  all  tb«  casw  of  I1f;«tur»  of  lb«  braebicHcephalk  arttry  th»  dvUlt*  «r 
which  I  hav4>  bw>n  ab)*  lo  nolleL-t.     Tfaia  artery  b  al*)i  >aid  Iv  bave  bMn  vtvm  UgmUmi 
hy  Vin-gi-tr,  and  twuo  by  KiiBahitt — all  thre»  paw  I  fatal :  but,  m  I  can  Hud  nn  datalk 
lba>*op«niliun*,  1  h«Vr-    .    ■  ■     >  ■'  r—  in  Um  abtivn  Uilil*-.     (lurK,  in  hi*  It*pnft  A 
trftty  ("Arehi>  fur    K  ^i«,"  vvl.    iil  ,  l^Ctij,  uni*.  In  ipatklof  at 

ii|Mr'*MC»nd  raM»:   "'J  Ij;    '-^  cai*  of  ligatiirf  i>f  lh«  lnn>i|Rtiiaie  «rMy  : 

lid  •varj'  Dfiv  t'i  ibrni  ba>  |ir«v«<J  laial."  In  Ibv  Ind*t  ralalogncor  lb*  Lib^vry  at 
iSurcpon-nrnTar*  Offir^,  'Watbinrtcti,  »  ■  r«rn-VDce  !••  a  pa|*«r  by  D.  L.  RfiMf, 
on  *■  A  ra«a  of  tucc-Mifiil  lij;ail>in  of  ide  innomlaatAartorj,"  AmarUmn  Mttttfml  tCmta, 
N«w  Torlc,  1^4.  I  ruunut  And  a  rvfutvimv  ii>  iln>  ck>*>  vliMwhoro,  and  baT«  oof  ' 
abl*  tu  luok  u|>  tb«  iirlglnat  f*ptr  bafora  tbau  thttu  wtal  u>  pr 


LIOATURE    OF    THE    IKNOUINATE    ARTERY.  213 

t.  A<E.<  OF  LIGATURE  OF  BRACHIO-CEPHALIC  ARTERY— Cfanimwed. 


.lATcaa 

or  PIRBASK. 


',•    A«SDT. 
111.  OHtpRlt. 

Sail  Fran- 
ti-o«j.  • 

II.  C.«P««. 
IK>.. 


I:!.  <;oRi. 

Bath.) 


.■.2 


;     >KTTH. 

.  N*w  Or- 

'■<«ni. . 


:i-2 


Subclavian 
aneurism. 
Subclavian 
and  carotid 
aneurigm. 

Subclavian 
and  carotid 
aneurism. 


Subclavian 

Hnd  axillary 

aneurism. 


Sutictavian 
aneurism. 


Died  on  8tli 

day. 
Died  on  9th 

duv. 


Died  on  -Hih 
dav. 


Died  on  ITili 
day. 


Recoverv. 


14.   BlCEKK- 

Ul 

41 » 

Subclavian 

Died  on  tith 

*TCTB. 

LiTerjKsil.l 

HDeunsm. 

day. 

Itublii).  1 
I'.  \V  Tn.i»|. 

ni. 

1!' 

Subclavian 
iinGurism. 
Subclavian 

1 

Di-alh  no\l 

dnv. 
Died  <i"ri  4ii 

Djbiin.' 

aneurism. 

dxv. 

Inllammation  of  lung,  pleura, 
and  aneurismal  sac. 

Uppcrondcifsterniim  and  inner 
end  of  clavicle  remnvcd.  Dya- 
pnnptt  and  retention  of  urine: 
|iiig  in  the  right  kidney. 

Hones  removed  a«  in  previouB 
oatte.  Patient  was  apparently 
doing  well,  when  secondary 
hemorrhage  appeared.  Imme- 
diate cause  of  death,  hemor- 
rhage, in  coni>equence  of  re- 
moval of  bandages  by  patient. 

Artery  cut  through  by  ligature. 
Cardiac  extremity  not  con- 
tracted, but  partially  plugged 
with  dark  congulum.  Inflam- 
mation of  subclavian  vein 
I  left).  Pus  in  anterior  medias- 
tinum. Aneurism  coiitmctad 
iind  filled  with  eoaguliim. 

Ligature  applied  to  brachio- 
[-ephalic  a  quarter  of  an  inch 
below  bifurcation,  and  at  same 
time  to  carotid  one  inch  above 
origin.  Hemorrhage  on  l&tb, 
'■)3<1,  and  olst  days,  arrested  by 
pouring  thot  into  the  wound. 
Ligature  of  right  vertebral  on 
.')4thday.  Tumor  returned  ten 
yean  afterwards  and  proved 
fatal. 

Direct  comprcisinn  tried  on  the 
nrlery  fortwodays.  Thenliga- 
iiired  above  and  below  the  spot 
where  comprfs^inn  had  been 
H|>p1ied.  Death  frum  hemor- 
1  liage. 

(iirutid  also  tied.     Apoplectic 

^y1rlpl^)nlS. 

Sirnndiiry  hemorrhage  80th 
and  ^il'lh  davs. 


N  B  — The  artrry  was  out  down  upon,  but  not  actually  ligatured,  by  Porter,  Post, 
AttL-D  Key,  and  Hoffmann. 

rrerr  imtance  but  one  with  a  fatal  result.  la  four  other  instances  the  opera- 
tion bAibeen  comtueQced,  but  abandoned  owing  to  unforeseen  difficulties,  and 
till*  br  some  of  the  most  skilful  operators  that  their  respective  countries  can 
hmtt'nf. 

Althou^ch,  ID  reasoning  on  the  propriety  of  performing  an  operation,  it  is 
BOt  io  general  worth  while  to  take  into  consideration  the  difficulties  that  a 
snrgfm  may  encounter,  provided  the  operation  be  at  last  applicable ;  yet, 
wlieii  we  coosider  the  fact  of  the  ligature  of  the  brachio-cephalic  having  been 
axt«ffipted.  ami  in  consequence  of  unforeseen  and  insiirmnuntablc  difficulties 
left  ODCoDcluded  in  so  large  a  proportion  as  one-fifth  of  the  cases,  and  these 
in  tb«  hands  of  Burgeons  who  were  as  well  able  as  any  to  accomplish  what- 


S14 


SriCIAL    AXKtrSISHB. 


evrr 


til 


•  pomr  of  •pwmliTC  mrgerr  to  do, 


.r  wM  hcrftBU  npoo 


uubt  bnei  ibe  oawtjon  iUelf.  befcra  pracnedJng  Ia  ijk« 


tht  ibaea] 


aUaa* 


ui  mberl 
kf  be  fiMittd 


vhieli 
Divrvlv  in  ttir  puuliuB  ud  ABmunicAl  relatirmi  of  the  TtsaeJ, 
ihr  oi<n<lilii>ti  in  vKtr):  tkc  utcTT  and  tlit^  adjacent  ■Croctara 
aflvr  tlir  i-vta^l  '•  --^oim^.     Tlius.  in  ^•^npr'«  raje,  thtt  aDearam.  ulilcli 
a  Inip}  (tiiis  I'  ''>'  wbiilv  of  ih«  tnfrririr  {VMterinr  tiian^Ir  u(  (be  DCck, 

being  nearly  ;»)>  •i>mm.'«  broad;  a^  no  pulmticn  wa*  trai<cable  in  tb^  Tcsaek 
beyood  ibf  Kueuriau,  it  wa>  tuirlc**  t»  attempt  ligslurv  no  tbv  tli»ul  nde. 
Oti  expoaUi|[  ihv  bracfakvcMWic.  Uiat  vn»«l  was  Touod  ia  b»  dncafcd,  aoi 
it  ima  act  tlH>u|;fat  dtMrabW  to  ftm  ihv  ti),'atur«  round  ii-  la  cooMifttraet 
of  the  cx]x«urr  uf  ibr  artcrr.  bowercr.  tbc  pulsation  ui  tb«  tiUKir  paduall/ 
(Umiuirlml,  and  at  laM  cwied  coUrvIr.  its  bulk  also  beovmiog  Icsa. 

In  K«v'b  i'nse.  in  whicb  it  'K*a  impnicLicablo  to  paw  tbe  n^liin;.  tt  was 
found  allcr  dcialb  thai  lb«  bracluocvphalio  vaa  disrased.  banc  dilated  ud* 
mediat«lv  after  i(»  ori^D  iotn  an  oblong  tuttior.  which  '>crupi«rth«  wlMlcirf 
the  arterr.     It  ts  rrmarkablr  that  in  ibis  caw,  as  io  rurirrV  inflamaMlka 

I  Menu  to  bavt.'  taken  plaM  in  thv  arta7  in  cooaeqiience  of  ibe  oeoMMiy 

I  handling  io  nhirb  it  waa  Mibjertcd.  and  that  the  pulaatiuu  to  Um  «Ht  vam^ 

[■Murnilv  dtniinL*>b«4t. 

Tbe  i{iifii>ulttrft  of  the  c^MtmiiOD  are  in  themiwlvfs  of  aeriotw  aagniiad*; 
arising  fnim  tbe  depth  of  tbe  mael,  ftmn  its  proximity  to  tbe  centn  of  tbi 
tniTulation,  and  (ntm  the  netfi^hortiood  of  large  veiriB.  which  may  bvconM 
turgid,  ntid  a  wound  nf  whiob  n>»t  onlv  obsmree  the  line  of  ind^on  witli 
TeuouB  blkHK),  bnt  inditcvs  a  risk  of  tbe'e&traooe  nf  nir  into  the  rirralatioB. 
The  trunk  of  the  artery  lies  bebind  tbe  acejDo>«Uvicu!ar  articulatioo  and  tbe 
upper  part  of  the  »tenium,  and  biftimtea  at  the  level  of  the  u;  I'-r 

oi  tbc  clavicle.     In  fmnt  of  it  ard  tbe  ateroo-hyoid  and  Mcmo-lli .  m- 

dea,  and  it  JBaoMed  near  in  tipper  part  by  the  rigbr  inferior  lh>roi.l  vam, 
and  Inwer  down  by  the  let)  iDnnniinale.  To  the  right  side  is  the  rijd;bt  innomi- 
ttate  vein.  The  pneumogastric  nerve  i^  bebiod  and  to  tbe  outer  aide,  not 
being  in  clow  relation  with  tbe  artery.  Behind  tbe  vessel  are,  at  fint  the 
tracbea,  theu  tbe  pleura,  the  trachea  being  dow  internal  to  the  arlerv.  Tbe 
artery  may  be  reachei]  in  the  deRd  body  by  an  iocbion  starting  Irom  the 
■terno-clavicu Is r  artinilntion,  and  carried  upwards  for  nboiil  threw  incbe* 
between  the  twu  beadn  of  tbe  vtemo-mastoid,  but  this  would  not  be  jiistifisble 
in  tbe  living  subject,  as  it  does  not  give  Mifficient  space.  The  eorlT  <lt«ps  of 
tbe  operaliun  shutild  In!  the  same  as  in  ligatatvof  tbe  lower  part  (.if  the  camtid 
(aee  Ligature  uf  the  Can*tid,  n.  193).  Tbe  stemo-faycHd  and  8tem»-tbyrc<id 
moBcIca  must  be  frvely  divi(lv«i,  and  the  c&rolid  expoenl  as  low  down  aa  pos- 
sible. This  vissel  K?rv<«  ns  th«  guide  to  llie  iunominnte,  tbe  linger  b^ng 
paased  along  it  till  the  bifiircntion  of  tbe  main  trunk  can  be  lelt.  The 
needle  is  then  guidnl  by  the  linger,  and  pannl  round  the  artery  Irom  tbe 
outer  nde.  Jl  in  iniilrnt  that  tne  ve«el  cannot  be  dearly  exposed  in  this 
node  of  operating,  and  the  nc>edle  u  tba«fbre  pMnd  aomcwluit  in  the 
dark.  To  ovdrcome  (lii*  tlilliciilty.  Cooper  removed  the  inner  end  (^  the 
davide  and  port  of  the  sternum  in  both  bid  ouea,  and  shonld  tbe  openujoa 
be  repeated  it  t*  probublt-  that  ibis  would  bo  the  aafnt  plan  of  expoBuig  lM» 
p| ;  at  any  rate  the  operator  should  be  prepared  to  adopt  it  at  an  exien- 

imm  of  the  jirooeeding  (irat  described  if  neccwu-y.  Even  when  the  difficnl* 
ties  iif  exposing  the  artery  have  been  surmonnted.  and  it  has  been  expoaed, 
its  Cfialii  may  be  found  m  ilisrasrd,  or  it«,  calibre  so  increased,  that  it  may  be 
undiwirablc  ur  im]>uiwible  to  paea  a  ligature  round  it.  Tbe  failure  in  deth 
*i>i2  tbe  arlerr  would,  however,  aa  wo  shall  immerllatcly  tee.  appear  to  be 
iMitraus  in  its  consequences  than  succeaa  in  tbe  attempt;  for  of  1^ 


LIGATURE    OF   THE    INNOMINATE    ART£RV.  21$ 

Atm  CHOI  that  have  jtut  been  referred  to,  in  which  tbis  attempt  v.tui  niadu 
■■d  did  Dot  Micoved,  ooe  was  cared  of  the  (Iim'sh.-,  tin-  artury  lining  ublilfy 
rBMd  by  tbrombosU,  cousequeoi  upoQ  iotiftiunmtiuu  of  its  coiiti).  »vl  uji  by 
lb*  naaipvUtlan  during  tbc  op«ralit>ri ;  ond  iu  auoiher,  Key's  [mtient,  ao 
aHanpi  loaeC  up  thi»  finici-a>  a|>{rears  to  have  b«eu  maik',  tbe  tumor  Ijvvom* 
iag  wwid  and  ocwing  w  pulsate :  nbi'reaa.  in  every  cn»e  but  one  in  which 
tW  vcBsl  was  ligatuml,  a  fatal  nxiilt  aiwetlily  eiiiiiie<l. 

TW  rbqIis  oi'  tbe  ligature  of  Uie  vnsel  arc  tb^ii  in  the  highest  d^ree 

di— mgiag ;  far  uf  the  oixteeo  cases  iu  ib<}  table  in  which  it  has  beea  done, 

salf  <aie  hM  rvoovered.    The  only  sucoesaAil  cnse,  that  in  whicb  Hmrth,  of 

Stm  Orleans,  was  the  operator,  is  one  of  tbe  most  remarkable  on  record,  but 

■  raUlty  aflbrds  no  evidpuce  as  to  the  possibility  of  safely  ligaturing  the 

hnwlii*>«ephaUc  trunk.     For  in  thifl  case  the  caMiid  was  also  tied  so  as  to 

*)p  tbe  regiugitont  flaw  of  blood  :  yet,  not  withstanding  tht^  prei'aution,  on 

■he  foortrenth  day  seTere  hemorrhai^  to  syncope  occurred.     This  henior- 

ftiajr  recurred  at  iniervala  for  a  period  of  thirty-seven  days,  and  xraa  tern- 

fotAiilT  arrested  by  lilltog  the  womid  with  shot,  till,  on  the  filty-lirvt  day 

•ft«T  th«  operation,  a  "  lerrifie  "  bemorrhn^ie  took  place,  stopped  by  syui-ope. 

A»  th*  bl««<lin];  came  from  the  distal  »iite  and  from  the  etibctuvian  artery, 

thft  wrtebral  was  tied,  with  [wrlect  Hiccess — no  bleeding  recurring.     Tliis 

bet  ■»  of  lite  utnireCsnr^gical  value;  it  shows  thnt  the  secoudary  hemorrhage, 

«Wck  may  be  ltM>k«d  opoti  almost  as  the  necessary  sequence  of  the  ligature 

•f  ibf   ionominal*?  ar1<.Tr,  may  Ite  arrested  antl  the  patient's  1if«  saved  by 

tW  ligature  of  tbe  priuciual  arterial  branch  that  oominuuicates  with  nud 

iknl  carries   reguniitant  blood  into  the  distal  end  of  the  artery  which  was 

•rigiaalir  ItgatureJ.     This  fact  is  entirely  new  iu  operutife  surgery;  and 

Am  ■tabusfaacnt  of  it,  as  well  as  the  skill'  and  courage  that  were  displayed 

m  dwooenttiTe  procedures  required  in,  and  tbe  general  manageraent  «t'thie 

MM,  tVMGt  the  highest  credit  on  .Smyth.     I  am  indebted  to  him  for  tbe 

Itutfaar  Ustarr  of  Uits  unioue  case.     After  ten  years  of  gt»od  health,  in  wbich 

tha  falirat  wu  able  to  follow  bis  employment  as  a  ship's  steward,  the  puba- 

lioa  rabtmed  and  tbe  tumor  reached  a  nize  larger  than  before.     Thinking  it 

■Mu   be  fed  br  the  Internal   inammar^'.  i^myth  ligatured  that  ressel,  but 

vjnuHit  any  reHit.     About  six  months  aJFler  an  absraffi  formed  over  tbe  sac. 

•■d  the  aneurism  became  diffused  into  it,  and  as  a  la^t  elTiirt  to  snvc  the 

HdoH's  life,  Smyth  performed  the  heroic  opemtion  of  laying  open  the  sac 

TbahesKmfaage  was  profuse,  and  the  openings  of  the  vessel  into  the  sso 

e— M  BOC  be  sseil.aa  that  the  operator  had  to  cmntent  hini««lf  with  plugging 

Am  vMiad.     Th*  patient  died  a  few  days  aAer.     Thn  post'raortem  examina- 

tiaa  ahdved  thu  ine  eireniation  bad  beien  carried  on  cbicBy  by  means  of  t)ie 

iiiaaliMiiTS  between  the  aonit^  intereostals  and  tbe  branches  of  the  axillary 

aftcry.     In  three  tnore  eaaca  the  operation  of  ligature  of  the  innominate  is 

•ud  to  have  been  cried  with  apeediiy  filial  results ;  and  in  four  oases,  after 

baiMf  aoaunenced,  it  was  abauJooed.    Death  occurred  fp^m  secondary  bemor* 

rfeay*  in  Mffai  cases;  fWim  intlamination  of  the  lungs  or  pleura  \n  one; 

fnm  pericarditi*  in  one;  from  di9en»eil  kidney  in  one;  from  phlebitis  and 

«app»Btion  in  one  ;  from  "  apoplectic  syuiptunis"  iu  one  ;  and  iu  three  from 

mmmm  thai  are  ool  raenlioned. 

la  ooe  case,  that  of  Hall,  the  arterr  was  transfixed  by  the  aneurism-needle; 
laaajfrfcag*  occurred  ut  the  time,  wliicU  was  arrested  bv  plugging,  and  did 
aol.  raear,  the  patient  dying  from  other  causes.  In  tlirec  cases,  tlt»«e  of 
Uatk,  BSaad.  and  Kizars,  tbe  hemorrbnge  cane  on  shortly  after  the  lepara- 
IMl  9I  the  Hgnturr  ;  hut  iu  Grtfe's  it  did  not  occur  for  fifty-one  davB  aller 
thil^  iJm  cicatrix  in  the  artery  having  then  probably  given  way  under  the 
of  noie  imprudent  movement  on  the  part  of  ibo  patient.     In 


i 


SI6 


SPECIAL    AKECRISMB. 


Cooper'*  aeoQud  caw,  the  patient  appeared  to  be  Koiog  an  well  for 

weeks,   when  seoondarjr   bemorrbage  appeared.      Learaiug   that   uuIUm 

ifurtber  could  be  dune.  I  lie  pmicut  [ore  oil' the  bandafiea  wbeji  alone,  an 

^blcd  CO  death.    lu  Bickcn^tiub't!  ouse.  tin-  urtt-ry  had  beeu  injured  by  tha 

prt.-viouB  coiiiprt-frjiittu  applml  by  lui-uus  of  a  leadeti  wire.    The  li^tur«  wat 

applied  ou  «ach  Hidt  uf  Uiv  bruisvd  epot ;  but  secciiuliiry  hetmjrrhagv  pr^Tod 

fatal  oil  the  (■ix.tb  'lay.     With  euch  mBults  as  th<!He,  thure  can  1m  but  ooa 

opiuiou  as  to  Uiu  extreme  danger  of  auvU  aii  oiwration.     Atr  its  perforoiaace 

liiia  hitburtt)  iu  evury  itii-taiict;,  (!x<%iiL  in  HniytbV,  4>ntuiled  dt.>nth,  and  |;eoar- 

ally  a  ajienly  death,  it  should  without  doubt  be  undertakoji  with  tnuirh  httJh 

talion ;  anil  it  could  only  be  wt  a  last  reaouroe  that  a  SurKeon  would  hava 

reconree  to  such  a  procedure,  in  the  face  of  the  conaequeooea  thm  hare 

hitherto  luvanably  t'ollnwml  the  application  of  a  ligature  to  thp  hraohio- 

cephnltP  artery  for  Hubciaviao  aneurisTO,    Thommn's  case  ia  the  oulr  oni 

in  which  a  ligature  not  intcniled  to  cut  through  the  coaia  of  the  artery  hai 

rbeeo  applied,     In   hia  case  the  nmtcrial  uaed  wu  the  ox-aorta  lif^tnre  rfr 

'cooinitruded  by  Biirwell.     Althou^di  the  patient  died  iVom  socondarr  hfimtr^ 

rhage  i»u  the  forty-second  diiy,  ihe  rveult  waa  lo  eome  denree  fii<' 

for  the  blood  had  e8ca|>ed  from  au  ulcerated  opening  at  the  bifun  :  ri<l 

not  from  the  aeat  uf  ligature.     The  opening  seems  to  bav«  been  the  result 

of  ulceration  fr<»m  a  amull  carily  lefk  aHer  partial  healing  of  tlie  <ro4iod, 

jAod  it  seems  probable  that  the  blood  was  supplied  by  a  recurrcDt  etreaai 

through  the  verlehral. 

Ligature  of  the  SabclaTiUL— Polaad  collected  tweDty-<«e  catee  io  wbicfa 

thia  arlery  has  been  tied  iu  the  third  part  uf  lis  course  fur  aubclaviao  or 

[lubdavio^xiltary  aneuriam.     Of  thnie  iiiue  recovered.     The  sac  waa  puite- 

[lured  in  two  cn-tes — by  J.,i9toa  and  Travers.     The  majority  of  the  duatht 

'Were  frt>m  hemorrhage.     Warren  relatee  n  remarkable  caae  occurring  lu  a 

lady  aged  thirty,  wbo  was  afHicted  by  an  aneurism  just  above  the  cla%'icle. 

The  patient  was  exceanvely  dcfurnted  from  club-foot  and  curvature  of  the 

Bpiue,  ao  that  the  lint  two  hbs  nwe  above  the  clavicle,  poaaog  obliquelv 

acroH  the  neck  and  carrying  the  artery  upwanls  and  bacKwnnu,  so  thai  it 

tlay  pnnillcl  tu,  and  about  nn  inch  from,  tlie  external  borter  of  the  irapa* 

xiuB.     This  peculiarity  of  position  enabled  Warren  tn  tiv  the  artery  on  the 

cardiac  side  of  the  tumor,  and  the  caae  hud  u  succcaaful  iiwue.     For  aiinu- 

risnia  situated  on  the  right  subclavian  artery,  behind  or  beyond  the  acalenua, 

that  veasel  has  been  Ligatured  on  tfte  Traehtal  aide  of  these  miHclea :  on  the 

left  side  this  operation  ia  acarccly  practicable,  on  account  of  the  dopth  at 

which  the  Artery  is  situated.    It  has,  however,  been  performed  in  one  caao 

by  Dr.  J.  U.  Itodgera,  of  New  York  ;  and  it  was  attempted  onM  by  Sir 

lAalley  I'onjter,  who  failed  to  secure  the  vessel,  and  i»  aaid  to  h«v«  wotHKbd 

the  thi>rfti.-i(;  duct.     In  another  caae  McOill  exposed  the  arter}*,  and  tempiv 

rarily  *-i)mpr*'w#d  it  with  a  |uiirof  forcenu     The  pleunt  wa*  wounded  in  lh« 

|0(>eration,  and  tite  piitient  die*l  on  the  xixth  day  of  plenriny,     When  we  ron- 

rider  the  anatoniicnl  reltilious  of  that  (H>rtion  of  the  right  subulaviHii  which 

llerveoes  between  the  braohi'>.cephalic  arterv  and  the  trncheal  etlgetif  tba 

Jeotia  amicus  luusclc,  we  nro  at  once  Htruck  with  the  great  difGculliea  of 

thia  underlakiog ;  and  whcu  wo  rcdect  on  the  poaition  iu  which  the  ligatnr* 

'will  be  placed  between  the  onward  current  of  olood  in  the  bracbio-e^>halie 

ou  the  one  aide,  and  the  regurgitant  streaiu  conveyed  by  the  vertebral,  lb* 

thyroid  axis,  the  internal  mammary  and  superior  iotercoetal,  into  the  aab- 

~  iviaii,  immediately  beyond  the  iieat  of  dvligatioD  oa  the  other  side.  w«  earn 

rcnly,  iu  uecordauce  with  thuaa  principlea  uu  which  the  lunualion  uf  ■ 

ilum  within  a  ligatured  vesael  l&kee  plane,  auti<-ipali>  Hny  hut  the  moat 

itroua  rceults. 


LIOATUKE    OF    FIBST    FART    OF    SUBCLATTAN.  217 

In  reference  to  the  mere  difficulties  of  the  operation,  Fergusaon  justly 
diaracteriies  it  m  the  most  serious  in  Surgery;  the  proximity  of  the  common 
<sroti(i  anenr  on  ooe  side,  the  internal  jugular  vein  on  the  other,  the  vena 
innomioata  below,  the  vagus  and  numerous  small  venous  trunks  in  front, 
tbr  recarrent  laryngeal  nerve  and  pleura  behind,  constitute  relations  of 
Hifficient  importance  to  justify  Fergussoo's  opinion.  But  supposing  these 
difficulties  overcome,  and  the  ligature  applied,  this  must  be  situated,  as  hag 
just  been  stated,  in  such  a  position,  with  a  strong  current  of  blood  flowing 
npon  laicb  side  of  it,  as  to  render  the  formation  of  itn  internal  coagulum  im- 
pcwnble,  and  thus  up  to  the  present  time  secondary  hemorrhage  has  invariably 
uccurred  when  the  ligature  separated.  Whether  the  application  of  an  ab- 
sorbable ligature  without  division  of  the  coats  of  the  artery  will  be  more 
•occcKful  remains  to  be  seen.  Besides  the  danger  of  secondary  hemorrhage 
from  these  causes,  there  would  be  the  additional  risk  of  the  coats  of  the 
arttry  being  diseased,  as  we  commonly  iind  them  to  be  in  a  more  or  less 
BorlHd  stale  in  the  immediate  vicinity  of  aneurisms;  and,  thus  being 
tendered  insusceptible  of  healthy  repair,  ulceration  and  sloughing  would 
take  place  along  the  track  of  the  ligature,  causing  the  probability  of  a  re- 
currence of  hemorrhage.  Thus,  in  Colles's  case  it  was  seen,  on  exposing  the 
subclavian  artery,  that  the  aneurism  had  extended  in  such  a  way  towards 
the  carotid,  that  it  was  doubtful  whether  any  part  of  the  affected  vessel 
continued  sound.  On  exposing  fully,  it  was  found  that  only  a  space  of  the 
vessel  three  tines  in  length  remained  free  between  the  sac  and  the  bifurca- 
ti>-«i  of  the  brachio-cephalic,  and  it  was  in  this  narrow  space  that  the  ligature 
was  applied. 

The  subclavian  has  been  ligatured  on  the  tracheal  side  of  the  scaleuus  in 
fourteen  cases,  all  of  which  proved  fatal :  twelve  from  hemorrhage,  one  from 
inflammation  of  the  pericardiumand  pleura,  aud  one  from  pysemia. 

The  cases  are  as  follows : 


vrasBa!*, 

HRX. 

AOB. 

F'ATK  or  PB«TH. 

1'4L'!1R  lir   lIKtTI). 

CrtLLtv 

■II. 

3.1 

4th  dHV. 

Ileniorrhsge. 

M..]-:. 

f. 

•21 

18ih  ddv. 

Ilomorrhape. 

IltVIiC.N. 

i". 

•>7 

]2ihdav. 

Hemorrbage. 

•  '  Rkilly. 

m. 

:itP 

14th  day. 

Hemorrhage. 

P&aTKin>>E. 

in. 

HS 

4th  tliiV. 

PiTicarditis  and  pliMirisy, 

I.:-T  >  ' 

II). 

i:{ih(la,v. 

Hi'itiorrha^. 

L:»T-'Sf  ' 

III. 

.P. 

:it:thdnV. 

Ili'iiiiirrhnyp. 

•(.TJLLllR.* 

in. 

101  h  daV. 

Hemorrhage. 

a^-tiOZK-. 

ni. 

4^ 

14th  da'v. 

Hemorrhage. 

ArTKBT.' 

... 

Illhdav. 

Hcinurrhage. 

Ar»  KKT.- 

... 

2-J.id«y. 

ili-morrhagc. 

AlTtT 

III. 

;V4 

>'ilh  duy. 

V\!vm\». 

lt*rsR. 

ni. 

•_'l 

24  hiitirs. 

Ht'uiorrhagp. 

H'HART  * 

f. 

... 

HUhdny. 

Hcmorrliage  from  the  carotEd. 

Thus  it  will  be  wen  that,  while  the  operation  is  had  iu  priofipli',  it  is  most 
aofortunate  in  practice.  This  appalling  Ttible  needs  no  coiiuiH-iit.  It  is,  to 
DT  niiml,  couclu^ive  as  to  the  merits  of  the  operation,  the  putivnt  having,  in 
•■very  ia,-*e  but  two,  been  carried  ofi'by  secondary  hemorrhage  from  the  distal 
tide  ijf  the  ligature,  in  conwqucnre  of  the  L-l<»st;  proximity  of  numerous  col- 

'  Ir.  ihi*  ca*"  the  '.arotid  wni>  aho  tii'd.  but  Iho  h<-ii>>>Trliai;t.-  caino  from  thi.'  ^uh- 
rlaiian     Fi(.  477  . 
*  Fic   47'".,                    '  Carotid  b1<«i  tifd.  *  Itofirn-d  t"  hy  .1.  H.  Tower. 

'    R*f*rreO  Iu  hv  J.  II.  I'-iwer.  *  (  iir>>liil  h]^i>  tied. 


218 


SPECIAL    ANEUBISM8. 


lateral  branoliei  (Fig.  47G);  and  iu  tlic  t«ocxoeptioo&l  cues 
ftllhougb  performed  skillutty.  prov(;<i  f&ial  jd  one  intUinM  from  pvrik-nnliiw 
nnd  pleuri^v,  and  in  th«  other  frntii  pyivmin,  betbre  (be  periix]  Kt  «hidi 
Kcondsry  hemorrhage  might  have  heea  expected.  Listoo,  in  cioe  cii*e,  ii|[»* 
ttircd  the  root  of  the  conimoD  C3rv>tid,  at  well  as  that  of  the  vobcUviu, 
doping  io  thi«  vay  tu  diminish  the  rivk  of  seoomJary  hctnorrhitge.  by  nrrot' 
Li)i;  the  curreol  of  bUwd  which,  by  sweeping  iotn  the  camtid  putt  thr  mutrtb 
ntthu  tubcluviao,  would  aecestnrily  waab  away  any  congulum  thiit  mi^ht 
be  formed  io  ihia  artery.  But  hi»  expectationa  were  not  realise<j  :  heoior' 
rhage  bmk  place  ta  usnal,  aad  from  that  portion  of  the  artery  which  lay  do 
the  dialal  side  nf  tha  lignture,  the  blood  having  been  carried  into  Lbii>  end  uf 
tbe  veawl  in  a  ralrofcmde  course,  through  the  connection  exiitiog  betivna 
ebo  vcMels  arlaiog  IVom  it  at  this  point,  and  thtwo  on  tbe  opposite  aide  of  tfaa 
haad  and  nertt,  ax  tllustrAte*!  bv  the  anncxeil  cut  (Fig-  47 1),  taken  from  ibt 
prapnmtioii  of  (he  eiutt;  iu  tbe  \Tnivcreity  C-<ilte^c  Museum.  Indeed,  ibtf  ■ 
tJto  prt'At  diinp'r  u>  be  upprehendetl  (ine'r  lij^Lur<>  of  tbe  aubclarbuj  uriery 
nn  I  he  li-Mi'ht^nl  side  of  tne  scalenus,  dej>cndiDg  as  it  doca  on  the  aoatumieat 


(W\- 


TIf.  4rA.--|jgM«r»«rth«SiilMUTtulnth*nnt 

Put  nf  lU  CVMfM,  bj>  LIltOK. 


Pi(.  177.— LifMMr«brtb«S«l 
CuoUil  (or  SiWlAtUa  Ai 
LiMoB. 


rtlatiotta  und  contivctiotiti  of  the  veswl.  which  un  .-ikill  uu  the  |)art  of  tb* 
Aperatur  cnii  in  nny  wny  ieweu.  aud  which,  in  my  opiniuD.  oogbt  certataly 
to  vaufK  the  t>]M?ntliua  of  litiaturo  of  the  BuhclaTmn  in  the  firat  part  nf  iti 
counw  Iti  1k'  bKuiBbt'd  from  stirgical  practice,  unless  further  expiirieDoe  ebova 
that  alMorbnble  liKnluri-s  cuu  be  applied  wtth  certainty  in  such  a  way  a«  to 
ucclmlo  the  artery  wilhtiut  diviiiun  uf  ila  ooala. 

Thu  niclliod  of  operatini;  that  hat)  been  meet  commonly  adopted  k  tbt 
•aow  aa  that  alrca<ly  drat-ribed  for  lijfature  of  the  root  of  Iho  carotid.  Wbea 
the  vneelfl  are  ex|MiM>d,  the  juffulnr  vein  i^  drawn  ouiwardi  with  a  copper 
fl[>ttluln,  nnd  the  Buhciaviaa  is  tnus  brought  into  view.  The  needle  {«  poaaad 
from  bvlon  upwards. 

When  mi  uiiruriFm  la  situated  <m  the  aubclavian  arterr,  in  tbe  |Kialerior 
inferior  triangU'  of  tbi*  neck,  it  is  neccmarily  impn««ible  to  ligmcun*  that 
xtmel  beyond  tbe  HcaleuuB.  ax  there  would  not  be  sufflcient  room  fr.r  the  rt- 
poture  of  tbe  artery,  which,  even  if  laid  bare,  would  in  all  nrohability  be 
found  in  t^Hi  diwased  a  condition  to  bear  tbe  application  of  a  lijrature. 

Thna  it  will  Iw  seen  that,  in  every  ««e,  except  t^mytbV,  in  whicfa  •■ 
"iam  of  the  Rubtlavian  artery  liaa  been  >ubjecte<t  Uj  operation,  wbathir 


90BCLATIAN— OTBEB    MODES   Ul 


TM8XT. 


219 


|Blm«  of  ihv  brachio  c«phRlio  or  of  the  aubclaviaii  lUelf  inttmul  tn  the 
ri.  xh*  rntilt  bsf>  b«vii  r  fats)  one.  As  ibis  unfortuonte  tenniuiitioD  is 
Ta  fK)  wmr  lo  b«  KUrjbut«d  U*  w»Dt  of  vkill  on  the  part  uf  the  operator 
s^^^Te  lw«ii.  nttboul  exception,  men  greatly  ttntiuijuiaheU  for  the  pof*e»>< 
^^^B  this  rvrr  quality — but  li  He|M-n(lenl  solely  on  certain  Hnatomical 
yBHvttie*  in  the  Brninjirnieut  of  these  vasaeh,  liy  which  their  succenfiil 
Tinutre  Ua»  bwn  rvacterei)  rM  but  iniponible,  a  repetition  of  lliese  attempts. 
■ttieb  niRT  faaiiien  the  patient 'a  death,  can  at  present  ecnrcely  be  considered 
JMiiSBble.  What,  then,  an-  ve  to  do?  Are  we  to  leave  patienia  laboring 
•Deari«n  of  the  aubctavian  artrry  to  inevitable  dc«(h,  without  luakinj; 
I  cflbrt  tn  Mve  them?  Or  di.«i!  Surgery  oRer  other  modes  of  treatnieoi 
tfauae  just  mentioned,  by  which  we  may  hope  to  arrive  at  mure  suc- 
eavAil  nsoli*? 

Wkhout  mentinnine  direct  pressure,  manipulntion,  or  galvnno-punclure, 
■Ucfa  m  certaialv  deserving  of  furtbt-r  triak  in  i-oinbination  with  ap- 
fnpriaCa  eoaMhalKinal  trcauneut,  three  modes  of  ircftiuieot  present  ihem- 

OMBpnaaion  of  the  ArUrr  where  it  panea  over  the  First  Rib,  and 
tly  no  the  Distal  Side  of  the  Tumor. 
tg»tare  of  it  on  the  Distal  Side,  alK>vp  nr  hrlow  the  Clavicle. 
Amputiiiino  at  llie  Shfttt!d<^r■j(li^t.  and  Distal  I,i(:aturc  of  the  Artery. 
Campretsion  of  the  Artery  on  the  Distal  Side  of  the  Sao  could 'be 
ooly  wbf-re  it  crossea  the  6rst  rib,  and  conM^iuenlly  would  b*^  appli- 
Mtty  to  anruriniw  of  the  first  part  of  thin  ve**<'i.     Thin  plan  has  never 
trivd :  partly.  [>erba)w,  on  acmimt  of  the  dithculty  in  Applying  pressure 
i*  thta  Mtuation.  aD<l  partly,  probnblv,  oo  accnnnl  of  the  want  of  huccp«> 
tkal  baa  aUanded  procedures  of  this  kind  when  applied  to  Teasels  in  other 
■taarioca. 

Tb«  ilificully  in  applying  the  compreaaion  might,  I  think,  be  overcome 
bf  fW  OM  of  an  instrument  of  which  a  representation  is  given  by  B<>urg«ry. 
1m  aftcinicy  uf  the  i.i>mpret«ion  would  he  materially  incr^«e«l  by  the 
■■|iliiji limit  of  direct  pressure  on  the  tumor,  or  of  galvano-puucture  or 
acapBDolurv  &t  the  same  lime,  and  in  this  way  a  coagulum  might  be  formed 
m  U«  Mc  AJlbuugh  tiHi  much  ought  not  tu  be  expected  from  tins  m<.>de  of 
tgmXmtMy  7«t.  I  think,  it  might  with  propriety  be  tried  in  casca  uf  the  kiud 
that  have  been  menljuocd. 
:^  Distal  tigature  of  the  Sabclavian  Artery  in  the  Third  Fart  of  ita 
beru  euggetted,  and  niav,  j><.-rhu)JM.  hold  nut  sonic  pnutpeot  uf 
in  Man  of  aneurism  situated  iM'hind  nr  inlemal  tn  the  M-alfiut.^.  In 
ihI  uc  springing  from  ihf  arterv  in  this  niluatton,  lht>  prineipul 
il  of  blood  vould.  in  all  prohnhiiity,  i)c  thai  which  i»  dcfitrneil  for  the 
mtpfij  at  the  tipppr  extremity.  Bnme  of  the  brancbeo  arising  from  the 
■iHvj  b«lDre  h  haa  pastied  beyond  the  flcidenns  nniioUR  would,  dunbtleR),  be. 
■an  or  Icai  mmpreaHd,  and  thuH  obliterated,  by  the  itimor ;  or  they  might 
k  obKrvelad  br  an  exten^inn  nf  the  laminated  Jihrin  over  their  orihcea.  If, 
IhMUfiiii.  the  mpply  to  the  upper  extremity  could  be  cut  nfl*.  there  might  be 
ililT  tifthim-  changes  taking  place  within  the  sac  which  are  necessary 
lotditeraiinD  of  it*  cavity.  TfiP  principal  obMacles  to  this  desimble 
luuld  n<!cnwnrily  be  the  transverse  cervica).  and  suprncapttilar 
which,  ticinK  the  two  voseeU  lliat  arc  more  particulnrly  destined  to 
the  rircuUliou  io  the  uppi^r  extremity  alter  the  ligHtur«  of  the 
iviaa.  would  nrc'.'««anly,  if  not  otcliidetl,  undergo  dilatation,  nnd  thus 
iiaitianii  to  draw  ton  large  a  current  of  bl(ja>d  through  the  sac  for  strntiBca- 
of  it>  eoat«Dl»  to  lalie  place:  and,  if  they  were  occlufied. there  nuutd  ba 
of  gangrene  of  tbe  arm  from  insufficient  vascular  supply. 


BiiptijtreQ  lifiraiur^d  the  axittnrr  artery  linger  the  pectoral  mnsclM  fur  a 
cue  of  dtibclitviAn  aueiimni,  two  arterial  branches  being  <l!vi<le()  in  th« 
incixiftns  thniiigh  the  fat  and  arcjlnr  tissue;  aiid  thu  patiout  dJeil  on  Che 
ninth  Jwy.  This  operation  could  nut  l>c  cxpwtcd  to  succeed;  for  between 
the  licnturu  and  the  sac  are  ihe  larj^e  and  nunieroua  slur,  acromial,  and 
thoraciu  brnnchi<«s  uf  (hu  uxillury  nrlory.  which  wouM  cuatiauu  lo  be  r«d  by 
a  ctirretit  soul  through  the  tutuur,  uml  llius  i>rt!clu<le  the  poaaibility  of  it« 
cuntuuls  being  sufficiently  stationary  f»r  ultimate  contraction  and  uure  to 
result.  Luugier  pertornied  the  diiilal  operation  in  a  supposed  ease  dl'  sul>> 
cUviau  aueuriain,  which  auerwanU  turneit  out  In  be  oat;  ot*  the  bracbio- 
ceplinlic  artery.  Iti  addition  to  Dupuytreu's  ease,  the  operation  haa  been 
done  by  P6tre<juia,  Schul>,  and  Canton,  lu  all  instances  without  benefit. 

3.  The  above-mentioned  diftirultiea  are  met  by  a  plan  <•(  procedure  origi- 
nally auffgcteUid,  1  believe,  by  1-Vri;u9s<>n.  It  in  Amputation  of  the  Arm  at 
ttie  ^houder-joittt,  Iblluwed'by  Distal  LigatnTe  of  the  Artery — a  dei<perate 
UDdcrUikin^,  truly,  but  for  a  desperate  disease,  it  rou^t  be  reineaibered,  ami 
one  that  under  oniinary  surjrical  treatnieut  it*  almost  incurablo. 

The  aritry  mi^ht  he  liyatiired  before  the  ampiitatiou.  "  II  is  known," 
Bays  Fcra:us.*au,  "that  tiniput-iitinn  at  the  shoulder-joint  ie  gt>nerally  a  very 
8UP0i«af(ir  operation  ;  90  far  as  this  wound  is  concerned,  then,  there  mi^ht 
be  little  to  apprehend,  but  the  effect  on  the  tiiinur  is  not  so  eneily  foretold. 
Ligature-  of  the  axillary  arl^ry  on  the  tiice  of  the  atuinp  rai;jht  here  be  reek- 
oned  like  Brasdor's  operation ;  yet  there  is  a  vast  ditlerenee.  lor  in  the  latter 
caae  the  same  amount  of  blood  which  previously  passed  towards  the  upper 
extremity  would  still  find  iia  way  di>wn,  and  probably  part  of  it  would  run 
through  the  aac;  whereas,  were  the  member  removed,  m  the  aaroc  quantity 
would  DO  longer  be  r©t|uircd  in  this  direction,  the  tumor  might  powibly  be 
much  more  under  ch<*  control  of  prcMurf^.  The  vnlue  of  such  a  mgumtictn 
remains  yet  to  be  tested,  however,  and  it  would  he  futile  to  reason  11  pun  it  at 
present.  It  might  be  ajudicioiitt  venture  firm  to  tie  the  axillary  under  the 
clavicle:  and  then,  if  it  were  found  that  the  aneurism  »till  increased,  ampu- 
tation might  be  performed,  either  immediately  before  or  after  the  aeparation 
of  the  ligature." 

Were  a  ca«e  of  aneuriara  of  the  tubclavian  artery  internal  to  the  scalenus 
to  [ireseut  itaeif  to  me,  the  plan  that  I  should  adopt  would  be,  first,  the 
emph'vmeut  of  pre«8ur«  on  the  veK*iel  at  (he  di»Uil  »ide  of  the  tumor,  if  prac- 
ticable ;  should  this  not  succeed,  I  wouhl,  if  the  distiiae  were  aituat^rd  behind 
or  iutvrnal  to  the  scalenus,  ligature  the  artery  in  the  third  part  of  its  cuunie; 
and.  did  that  nut  succeed  iu  checking  the  increase  of  the  aneurism.  I  would 
perform  ampulation  at  the  shouldcr-joiut,  m  rcconimetidud  by  Ferg'usson. 
Should  the  aneurieui  occupy  the  artery  al\cr  it  has  pa»ii^d  the  ttcnlenus,  direct 

freasuR!  on  the  sac  holds  out  the  bc8t  prospeia  of  succi:tu>.  Shouhl  that  fail, 
would  not  allcmpt  the  ligature  of  the  artery  below  the  criavicle  ;  aii  it  in  an 
operation  the  nsiilt  of  whii^h  is  moat  un satis furtury,  and  would  not  prevent 
a  large  current  through  the  sac  fur  the  supply  of  the  eolhtleral  circultition  of 
the  arm;  hut  1  would  at  unce  have  recourse  to  anipiitatlon  at  the  shoulder, 
and  then  ligature  the  vessel  as  near  as  posjtible  to  the  (iac.  It  is  true  that, 
even  in  thin  rasie.  the  ligature  would  be  below  the  hranchea  that  are  given  off 
under  th«.<  perUiraE  mubck>a ;  but,  at  the  arm  would  be  removeil,  they  could 
nut  undergo  any  dilatation  fur  the  supply  of  the  collateral  circulation  of  the 
upper  extremity. 

The  firat  case  tn  which  thia  nperatiun  was  performed,  vra.11  hv  Spene^  in 
1864.  The  patient  lived  for  four  years;  and.  although  the  aneurism  was 
not  curetl,  ihe  rMoll  affiirded  gnod  promieo  of  surce^w  for  the  future.  For 
the  6rst  ten  days  after  the  operation,  the  pulsation  waa  scarcely  to  be  felt; 


I 


I 


AXS0BISH    OF    THE    AZILLAKT    ARTERY.  221 

and  when  the  patieot  left  the  hoepital  the  tumor  had  diminished  to  one-third 
of  its  fi>rnier  size.  The  artery  was  tied  in  two  places — where  it  waa  cut,  and 
mibo  Just  berond  the  tumor.  Before  the  patient's  death — which  probably 
nrcmc  from  ioteniBl  aneurism — tlie  aneurism  had  increased  somewhat  towards 
tbe  chest. 

Since  this  Holden  and  Heath  have  performed  the  operation,  but  without 
•occeae.  In  both  cases,  however,  the  aneurism  was  traumatic  in  its  origin, 
aad  had  attained  a  large  size  before  amputation  was  practised.  Hence  the 
chances  uf  consolidation  and  cure  were  mBtenuUy  lessened. 

Ligature  of  tbe  Vertebral  Artery. — This  bold  and  difficult  operation  was 
fir«t  performed  on  the  living  body  by  Smyth,  of  New  Orleans,  who  had  re- 
coune  to  it  to  check  regurgitant  hemorrhage  after  ligature  of  the  innominate 
for  subclavian  aneurism  (p.  215).  I  will  give  the  details  of  the  operation 
in  the  words  of  Smyth  :  "The  head  of  the  patient  being  thrown  back  and 
tligfatly  turned  to  the  left,  an  incision  two  inches  in  length  was  made  along 
tbe  poateriur  border  of  the  sterno-niastotd  muscle,  cummencing  at  the  point 
where  the  external  jugular  vein  crosses  this  muscle  and  terminating  a  little 
above  the  clavicle;  the  edge  of  tbe  muscle  being  exposed  and  drawn  to  the 
inner  aide,  the  prominent  anterior  tubercle  of  tbe  transverse  process  of  the  sixth 
oerrical  vertebra  was  readily  felt  and  taken  ibr  a  guide.  Immediately  before 
tbia  and  in  a  vertical  line  with  it  lies  the  artery.  A  layer  of  fascia  was  now 
diTided ;  some  louse  cellular  tissue  with  lymphatics  and  tbe  ascending  cer- 
▼icml  artery  were  pulled  to  the  inner  side ;  ana  a  separation  was  made  between 
tbe  scalenus  anticus  and  longus  colli  muscles  just  below  their  insertion  into 
tbe  tubercle,  when  the  artery  and  vein  became  visible  ;  the  latter  was  drawn 
to  tbe  outer  side  (this  is  important),  and  the  needle  passed  around  the  former 
from  without  inwards." 

In  18^1,  W.  Alexander,  of  Liverpool,  suggested  ligature  of  the  vertebral 
■B  a  means  of  curing  or  relieving  epilepsy.  He  performed  the  operation  in 
Kveral  cases  at  first  with  apparent  bienefit,  but  subsequent  observation  showed 
tbat  the  improvement  was  merely  temporary.  The  operation  was  repeated 
in  two  cases  by  Watson  Clieyne.  The  method  of  0|>erating  was  that  above 
dewribed,  and  the  results  so  far  as  the  operation  was  concerned  were  satisfac- 
turv  in  the  great  majority  of  the  cases. 

ASEVEISM  OF  THE  AXILLAllY  AltTERY. 

Thi?  artery,  though  less  commonly  the  seat  uf  aneurism  than  other  large 
T^^«r«;ls,  iiuch  a«  those  of  the  ham,  the  groin,  and  tlie  neck,  yet  Ik  sufficiently 
fre<)uently  diseased.  This  is  due  chiefly  to  its  situation,  its  proximity  to  the 
Moulder-Joint  causing  it  to  be  subjected  to  the  very  varied,  extensive,  and 
oftrn  forcible  movements,  uf  which  that  articulation  is  the  scat.  Amongst 
the  m^att  frequent  causes  of  axillary  aneuri-sm,  may  be  mentioned  falls  upon 
the  shoulder  or  upon  the  outstretched  bandit,  and  in  many  ca^-es  tlie  eflbrts 
matle  at  reducing  old-standing  dislooationii,  inslitnces  of  which  are  recorded 
bv  Felletan,  Flaulwrt,  Warren,  and  (iibsun,  the  liea<l  of  tlie  bone  in  these 
CUM  having  probably  contracted  adhesions  to  the  artery,  in  consequence  of 
which  the  vessel  was  torn  during  the  efiort«  at  reduction.  Axillary,  like 
subclavian  aneurism,  occurs  more  commonly  on  the  right  than  on  the  left 
nde,  anil  i»  met  with  in  especial  frequency  amount  men;  of  37  c»^e!>,  onlv 
•t  'locurred  in  women.  I  am  acquainted  with  one  case  only  in  which  both 
axillarv  arteries  became aneurismal;  it  occurred  to  Furiicr,  of  Brighton.  In 
this  remarkable  case  both  axillary  arteries  became  afrt'cte<l,  an  interval  of 
about  fifteen  months  intervening  between  the  formiition  of  the  two  aneurisinal 
lamon;  and  the  subclavian  was  ligatured  on  both  aidoa  successfully. 


222 


SPSOIAL    ANIUBISMS. 


Symitomh. — III  axttlnry  anetiriBm  there  are  three  aeta  of  afmitDni^i 
tion  to  wliich  Kill  uhiiaIIt  enable  the  Surjreoii  to  rvco|n)>u  Wt  Atummi 
ar«,  the  exislenre  of  a  tiimnr  in  llie  axilla,  the  puju  that  It  oocauattti,  aod 
t))«  afTecUori^  to  vrhtoh  it  gives  nae  in  tliv  limb. 

Th«  precise  situation  at  wliich  an  an«unaai  of  the  axillary  artery  pn9«ot« 
exttTually.  will  depend  upon  whether  it  epriag*  froDi  that  portiou  oflbe 
that  Iic8  above,  beneAth,  nr  below  the  l««»er  fwctoral  muscle.  If  fr»ni  abn 
it  will  appear  M  a  tumor  seated  immediately  below  tJie  clavttle  and  occiipri  _ 
the  triHUguiar  space  between  the  upper  margiu  of  the  ieaacr  pectoral  and  thai 
buae;  if  it  be  lower  dowu,  it  will  raise  the  aoterior  fold  of  tbe  axilla.  Itvin^ 
prevented  from  exteudint;  much  out  of  this  space  by  the  deiue  fascia  diai 
airetcbee  acnMn  from  oue  eidi*  to  the  other.  The  tumor,  which  is  ai  ijntt  »(>ft 
and  comproBsible,  linn  a  whizzing  bruit,  and  iUs  pulj^alioDP,  which  an-  cx|iai)' 
gilu,  may  1»>  arrested  hy  pressure  upou  the  subtTtaviaii  artery.  wfa«re  it  paaa* 
over  the  fin>t  rib.  It  usually  iooreases  with  greut  rapidity,  owing  to  the  lUtk 
reuMAuce  opposed  by  tbe  looM  areolar  liaue  in  this  utuaUoa.  aod  BOtt 
commonly  extends  downwards  and  forwarda,  causing  the  hollow  of  tbe  axilla 
to  disappear.  In  some  rare  iiietaiioes,  however,  the  J,un)or  has  bean  koowo 
to  take  a  direction  upwards  under  the  lesser  pectoral,  and  into  lb«  areolar 
intenral  above  thai  muscle,  or  even  undcmeatn  the  clavicle  into  tbe  acmmial 
angle  between  it  and  the  trapezius.  It  is  fortunately  rare  for  an  aneurtsto 
to  take  auch  a  course,  as  it  would  present  serious  diificully  in  tbe  eonipra»' 
itton  or  lifraturc  of  the  subclavian  ;  and  there  is  more  than  one  instance  oo 
record,  in  which  the  sac  has  been  punctured  in  the  attempt  to  pasa  tbe  n«MU» 
n>uiid  this  ve«iel.  Whtn  the  aneurism  is  soaie<)  high  up,  it  not  unfraquesfly 
happeus  that  the  clavicle  is  pushed  upwiirds  by  the  pressure  of  tiio  tumor 
btfueath  it — »  cum  plication  of  considerable  monunt  in  reference  tn  th«  optn- 
tioQ,  the  diQiculties  of  which  are  greatly  increased  by  iL  The  pnttun  of 
the  tuTiKjr  upon  iieighborin};  parts  may  give  rise  to  »eriout  cooaequcttcvi; 
thus  it  may  pruduce  a  carious  state  uf  the  first  and  second  rib*,  and  ifc* 
compression  of  the  brachial  plexus  of  nervea  will  occasion  pain  and  numtt- 
neai  in  tbe  upper  extremity.  Tbe  o^fcfiotwof  the  limb  ocoasioued  bv  the 
aneurium  are  diminution  or  extinction  of  tbe  radial  puUe,  trdema.  coliIneM. 
and  loM  of  muscular  power.  In  soiue  cnsoa  the  brachial  artery  bevond  tbe 
tumor  would  appear  to  be  obstructed,  no  pulsation  being  perceptible  in  it 
Compreniou  of  the  axillary  vein  may  occasion  (edema  of  tbe  band  and  am. 
with  (Kime  diminution  in  the  tompirraiurc  <i(  the  limb;  and  tbwe  lympbioifk 
if  tlic  tumor  attatu  a  very  large  eize,  may  amount  even  to  indioatWOB  of 
impending  gaugn^uc. 

DiAONOrttH. — The  diugnnaU  of  uxillury  aneurism  is  usually  readilv  made; 
there  Itcing  but  two  diaeases  with  which  it  can  well  be  confiMiuued,  vix.. 
chronic  enlargement  and  Mippuniiiori  in  thi?  glaudsof  tbe  axilla,  and  pulsM- 
iog  tumor  of  th^  houeA  in  thin  region.  From  glantluiaror  other  aiaeamet,  tbe 
diagn-jAis  ih  generally  ca^y;  hut  I  have  Be»D  aome  oasv  iit  which,  pnbatlon 
being  eommiuiicated  to  their  eontentH  by  tbe  subjaoiint  artury,  it  was  sodw- 
whiit  difficult  to  distinguish  the  nature  of  the  tumors.  Here,  hawerer,  tbe 
hidlory  of  the  case  and  tt8  speedy  progress  to  pointing  will  indioalv  ita  true 
nature.  From  nu^uUitry  tumor,  or  osteo-aneurwm  of  OtK  hrad  of  Ou  Aiunimu. 
the  diagnosis  is  not  alwaY«>  so  easy ;  and  there  are  at  least  two  in"*--' 
record  in  which  the  subdavinu  artery  has  been  ligatured  tor  \\'»r. 
kind  OD  the  t>up|N>Aition  of  it»  lieiiig  an  aneurism.  In  thr»e  instam-t-* 
huwevi-r,  generally  lK-<<n  olt^-rved  that  the  tumor  first  made  its  apf 
uu  the  fi>r<'part  nl'  the  KlmuMer,  and  not  in  the  usual  sitwaLiun  of  aXfl 
aneurism;  that  it  was  from  the  tint  tirm,  smooth,  (.'lastic,  but  urarty  ioc 
prcaeible;  and   that,  although  it  presented  distioot  pulsation,  there  was  no 


k. 


beUuWMKMind,  but  radier  a  tliritlJog  bruit  perceptittle  in  it.  Tho  tnosl 
It  dwgnusLic  mark,  j>erlmpf^,  i^  tlib  J«cL  of  these  tumors  forming  a 
Bcv  ID  tiitu8tiuii0  io  wbieli  anpurtsms  of  the  axillary  urt^'r}*  would 
Ant  liiuw  thdiuMlvrs,  as  at  Uie  upper,  outer,  or  anterior  part  of  the 
dwlJw.  In  mort!  sdranwd  stages,  when  the  substance  of  the  hone  hns 
mdarpRM  abaurptiDO,  and  its  shell  has  become  thin  and  expanded  by  the 
MrtWfJ  ptMBurf  of  the  tumor,  there  le  often  a  dry  crac-kling  or  rufitling 
aoand  pensered  on  pressure,  which  ie  never  met  with  iii  ca^es  of  anourium. 

TUATMXirT. — 1  am  not  acquainted  with  any  instance  in  which  an  aneu- 
CHa  of  the  axillary  artery,  nul  arising  from  wound  or  injury,  ban  uuder- 
MBS  cpontancous  cure,  ur  been  oonsulidatcd  by  constitutional  trentmenU 
OiMprsMioD  or  ligature  of  the  subclavian  in  the  third  part  of  its  course  is 
ika  oqIt  meuis  of  cure. 

Alillaiy  aneurisms  arc  favorably  situated  fur  the  employment  of  digital 
mmptemon.  Vtj  this  means  the  oubclarian  can  easily  be  comraanded  as  it 
{■Maaa  over  the  first  rib.  And  the  success  of  this  treatment  is  likely  to  be 
Bvai  ;  6rst,  bf«aute,  the  mc  being  usuiilly  lar;^,  a  considerable  cjuantiiy  of 
Iw  eootaiDed  btood  is  well  out  of  the  current  of  the  circulation,  readily 
■uoKOod  may  thus  easily  coagulate;  and,  secondly,  because  the  cur 
.  of  blood  lhr<nigfa  the  sac  u  proportionately  small,  and  thus,  if  coagula- 
'  begin,  may  easily  be  completely  arrested.  Digital  eompr(.>ssiou. 
,  in  my  opinion,  should  always  be  had  recourse  to  in  the  tin^l  in- 
By  this  means,  aided  by  rest  and  constitutional  treatment,  the  prog- 
n^  of  the  tumor  may  be  stayed,  and  possibly  a  consolidaiiun  of  iu  con- 
tma  Bad  cure  bo  eflbcted.  This  occurred  at  University  College  Hospital  in 
ft  prtisnl  ■evfntjT'ODO  yean  of  age.  in  whom  an  axillary  aneurism  as  large 
^  »  dMddodt  *od  of  an  actively  progressing  character  was  cured  by  inter- 
■ttl^t  diktat  DKMun  ooottnued  at  intervals  for  between  two  and  three 
'  .dorti^  wnidi  dae  compretsioa  was  kept  up  in  all  about  twenty-three 
.  tba  eonaolUatioo  oorameocing  on  the  third  dny  of  treatment  after 
bdBrs  of  preasure  had  been  tried.  Holmes  nientiom  eight  cases  in  which 
^mib]  (nnprneiou  has  been  cried.  Three  of  these,  under  the  care  of  Cini- 
aJs  mad  DuLoJl.  and  another  Surgeon  wfaoee  name  is  not  mentioned,  were  of 
uaamati£  ursia.  and  of  these  two  were  cured.  The  remaining  five  were 
idiapatfaic-  Three  of  thew,  under  Cooper  Forater,  Peataon,  and  Riuoli, 
were  aired.  Two,  undrr  Turet  and  Vanz«tti,  failed.  In  Cooper  Forster's 
OMe  th«  oomprnMun  wa^  nppli<>d  twice  under  chloroform ;  on  one  occanon 
$1^  ihrtm  oBii  a  quartpr  lu^txr*  and  on  the  other  for  eight  hours.  In  Peatson's 
case  iW  prr^wMr**  uus  upplit^l  at  intervalji  for  a  period  of  nearly  lliree  mootfas. 
la  lit  JLX!  the  treatment  lasted  i-ven  longt^r,  the  cure  not  being  com- 

plttr  iy  *>x  months.     let  this  casti  the  arlt-ry  was  so  dilated  and  dis- 

SMad  tbst  ligature  was  impo«sible.  !□  Dutoit's  case  the  comprcnion  was 
^plini  for  six  houn  a  day  for  six  dayn.  Lund  has  also  recorded  a  case 
«>f«l  by  digital  ciinipressitm  in  two  pen«)ds.  the  6nt  of  ten  and  the  second 
4^  aarm  osd  half  boiirv, 

I«  aoocbcr  CM«  under  the  rare  of  S.  Jones,  compreesion  was  combined 
wiilt  tfas  application  of  ICsmarcb's  lnoudage  to  the  arm,  but  without  success. 
CoCBpfwaaao  by  instrumeula  on  tho  CMdiac  side  cnu  seldom  be  maiU*  a\y 
ytoobla  lo  aaeuiisnu  in  this  situation;  inasmuch  as  the  pressure  that  is 
MvaglK  to  baar  upon  the  subclavian  must  m*<.'i:MSunly  at  the  earoe  time  in- 
Caeaor  Um  greater  port  or  the  brachial  plexus  of  nerves  to  such  an  extent 
as  to  be  usradnrahU'  by  the  patient.  Vet  it  is  nut  impracticable,  and  neaiiB 
■Mk  bedevt-  rotime  this  tltffimilty. 

LifMure  ei'  i  .  y  b.  however.  Mill  the  Surgeon's  ofakf  resource  in  the 

oftbcM  tmm*.     The  part  of  the  vessel  uDivcrsAlly  selects]  for  the 


SS4 


SPXOIAI.   ABTKUKlSlfS. 


application  of  the  Lignlurc  is,  in  aocordnnce  with  the  Huntariftn  dft<>triliw.lllii 
«rtiicii  lies  on  the  fint  rib  beyuii«l  the  BC«)eDU«  aQticw  maclfl;  thh  pwt|R» 
KQling  tli«  udt'antagM  of  btjiag  aufficienlly  r«iiiuv«^l  front  the  ii«iil  uf  diMaw 
lo  iuBure  the  prulnthilitr  of  the  co«(i^  of  the  arlvry  bvin^  iti  a  vouad  9ta[«,  of 
being  by  far  the  mo«t  accessible,  and,  wh(;u  ijeligalvd,  oi'  allowing  the  colUl- 
eral  cjrculaliun  by  which  thv  Tilality  of  the  arm  is  to  be  maiutaiD»l  u>  nuntta 
uoiiijured.  Notwithstanding  these  oliviouB  advantage  preacnled  by  the  lica- 
ture  of  the  iiibclaTian  over  that  of  the  aiillarv  artery,  in  other  wnniislijf 
perlorioing  Hunter's  instead  of  Aael's  operation  for  ibe  cure  of  »(>>mtaDeuia 
axillary  aneurieni,  there  would  appear  to  be  a  leDdciicy  in  tfae  mindeorMm 
Surgeons  to  advocate  the  latter  instead  of  the  former  ot  these  openUiotii;  ud 
lu  subatiuile  for  one  thaL  oSere  the  udvantaces  that  have  Jun  be«n  mrntioaeii, 
a  procedure  that  i«  not  only  tuiu:h  more  dinicull  in  its  performance,  and  thai 
inierfiTes  with  the  collateral  cireulutii^n,  but  that  U  practised  upaa  a  riJaeawd 
part  of  the  veeevl,  in  dangcmu^  pri>xin>iiy  to  the  »c. 

Ltgature  of  the  Subclavian  in  the  Third  Fart  of  its  Conrie. — In  order  lo 
apply  a  ligature  to  that  tHirtion  of  the  «ubciuviun  artery  which  iDterveMt 
between  the  outer  edge  nf  the  scalenus  onticux  and  the  lower  border  of  the 
fif«t  rib,  the  patiejit  should  be  placed  in  the  recumbent  poAition,  the  am 
deprened  as  much  a«  nosaible,  and  the  bead  turned  somewhat  to  the  opponlr 
aide.  The  tltaation  <if  the  external  jugular  vein  should  then  be  atc^rtatiMd, 
if  poisible,  before  commencing  the  inciaioD.  It  may  lie  nt  any  point  belwwo 
the  posterior  border  of  the  Memomastoid  and  the  erige  of  the  trapMiua;  tncil 
commonly  it  is  close  to  the  former  muacle.  Ooeaaiooally  it  la  wanting.  Tlw 
opemtiou  h  coiumeiived  by  drawiu^  the  integument*  of  tlie  lower  mrt  oriW 
uin;k  dowowurda  over  the  cUvicU-  uud  lunkiiig  au  incision  about  lour  ioobta 
in  Iviigtb  upon  tlu*  bone,  dividing  the  i^kin,  auperficisl  fascia,  platyema. 
the  aupra-clavicular  bruuches  ol  thu  i.'ervical  plexus.  Wbeu  the  teoi 
takeu  utf  the  |Kirc,  this  incis'un  will  be  found  to  traverw  tfaa  bttae 
posterior  triangle  of  the  neck.  The  chief  object  of  drawing  tbs  akin 
wards  in  this  way  is  to  avoid  any  risk  of  wounding  the  external  jugular  t*u, 
for  as  thb  veanel  perforates  the  deep  cervical  fiLiria  about  one  finger's  bmndtk 
above  the  clavicle,  it  cannot  l>e  tlrawri  duwDwitnls  with  the  integnmenta.  la 
some  rare  cases  the  cephalic  vein  croseett  the;  davicle  and  joins  ibe  exlenal 
Jugular.  It  would  then  nece^siirily  be  divided  in  the  ftrst  inciaioD.  The  next 
step  in  the  operation  ia  to  tiod  the  external  jugular  vein.  In  order  lo  do  Ihii 
the  deep  cervical  fascia  miigt  be  carefully  diaeected  through  close  to  the 
olavioie;  immediately  beneath  the  fascia  a  rjuantitT  of  loose  areolar  tiawek 
aipOMd,  in  which  the  lower  end  of  the  extomal  jugular  will  conuBonlf  ha 
found,  As  soon  aa  the  daep  cervical  fascia  is  dividwl  great  caution  mtut  be 
used,  the  anxilsr  time  being  picked  up  in  small  pieces  with  the  forcc|«aiid 
Lacratched  through  with  the  pome  of  the  scalpel  or  torn  with  a  blunt  pmbeer 
rneel  director.  When  the  exiornal  jugular  vein  conk*  inu>  view  it  must  be 
treated  according  to  iu  jxiMtion ;  if  at  cither  end  of  the  woand,  it  mar 
be  drawn  a^ide  with  a  blunt  hook;  if  in  the  middle,  a  doable  ligature  wu»t  b«> 
paaaed  and  the  vein  lied  in  two  places  and  divided  between  them.  Occasion' 
ally  the  transvetae  cervical  and  supra-scapular  veins  form  a  plexus  witb  tbt 
external  jugiilar  imtuediately  above  the  clavicle,  and  the  difficulty  of  exposing 
tti«  artery  is  then  greatly  inrreaaed.  The  transverse  cervical  artery  \\m 
normally  above  the  wound,  and  the  supra-scapular  is  cuucealcd  behind  tbc 
clavicle,  hut  in  exceptional  cases  they  may  be  found  in  tfanspaocs  expoaedia 
tlw  operutioti.  They  niunt  tlien  be  urawu  out  of  the  way  witJb  blunt  boota, 
Dr  combinetl  culling  and  scratching  through  the  areolar  lieaun,  t'  '  ttsi 

edge  of  the  sualenus  antiuus  ia  reni'lied ;  tliitt  ta  the  "dirvcUag    <  nn 

which  tlio  fiugvr  ia  run  until  the  tubercle  of  the  Srat  rib  ia  felt.    Hits  i*  the 


- inobea 


LIOATUBS   OF   THIRD   PART   OP   SUBCLAVIAN. 


226 


^ide  to  the  artery,  which  will  be  found  immediately  above  and  a  little  behind 
n,  covered,  however,  and  bound  down  by  a  dense  faacia.  Immediately  above 
the  arterr,  and  in  cloee  contact  with  it,  is  the  lowest  cord  of  the  brachial 
plezos,  that  formed  by  the  last  cervical  and  first  dorsal  nerves ;  beneath  the 
arterj  is  the  first  rib,  upon  which  it  can  be  felt  rolling  under  the  finger  when 
firm  prcasure  is  made.  At  the  same  time  pulBation  will  be  felt,  but  this  must 
Dot  be  taken  as  a  proof  that  the  structure  beneath  the  finger  ie  the  vessel,  for 
tfw  lowest  cord  of  the  brachial  plexus  lies  so  close  to  the  subclavian  artery 
that  it  receives  a  communicated  pulsation  from  it.  On  firm  pressure  the 
Dore  ctill  retaiiu  its  round  form,  while  the  artery  flattens  out,  and  its  surface 


Fig.  4TP. — Ltgatare  ot  the  SubcIftTiBH  in  tb«  Third  Part  of  it«  ConriB. 

hecnmes  slightly  concave.    The  thick  fascia  covering  the  artery  having  been . 
cartfullj  opened  with  the  edge  of  the  knife,  the  needle  is  pne^ed  from  the' 
nerrr.  as  low  down  as  possible,  so  as  to  avoid  any  risk  of  injuring  the  pleura 
by  Flipping  over  the  upper  border  of  the  first  rib.     The  subclavian  vein  is  so 
fiu-  below  the  clavicle  that  there  is  no  possibility  of  wounding  it.     In  a  con- 
fkierable  pniportion  of  cases  the  posterior  scapular  artery  will  be  found 
fpringing   from  the   artery  in  this  part  of  itp   course.      In    296   arteries. 
ezamiDe<l  by  Quain,  it  arose  from  the  third  part  as  n.«eparftte  branch  in  101, 
r«  as  nearly  as  possible  one  in  three  cases.    If  this  conilitiim  is  met  with,  the 
ligature  must  be  applied  as  far  as  possible  to  the  proximal  ^ide  of  the  branch. 
If  Dc«efleitT  obliges  the  ligature  to  be  apjilied  oliitfc  to  the  brnnoh,  it  is  porhitps 
■aftr  til  tie  this  also,  as  the  anastomosis  of  the  vessels  in  this  region  i^  i<u 
abondant  that  the  risk  of  gangrene  from  the  obliteration  of  a  single  brunch 
would  be  very  small. 

VOL.  It. — I't 


226 


SPBOtATi    ANEDBISIiS. 


The  opcratiuD  just  i)e»cribeil  is  that  oommntily  aduplcd.  In  ortlvr  lli*l  rt 
should  be  ensily  cnrried  out,  it  is  in  the  fimt  place  necMtnrv  that  Uw 
Bliuulder  should  be  depressed  as  far  hs  pnssible,  bo  aa  lo  bring  l}i»  clavidc 
down.  This  is  a  niatlor  of  much  importance ;  for,  if  the  claviulu  bv  thriM 
unwnnlii  by  the  pressure  of  a  lar^  nneurisiu,  or  if  tl  lie  hi^h  in  cinieqoeDee 
of  emphysema  of  thp  lunes,  the  i^urgcun  will  have  to  find  the  artery  at  ihe 
bottom  of  a  deep  wound,  mstead  of  on  n  eomnaratively  placu;  ^urAiFe.  It 
iherefore.  the  clavicle  cnunot  be  thoroughly  deprc«cd,  more  room  moat  h» 
providivl  to  the  miperBcial  partx  of  the  wound.  Thia  h  done  by  makhiKft 
vertifal  incininn  upvranls,  cither  along  the  border  of  the  rtemo-maaloiaor 
fVom  the  middle  of  the  wound  for  about  two  inches.  Ai  theart«ry  u  in  time 
ca«ea  apnruarheil  mther  from  ahiive  than  trom  the  front,  the  9tni<-Lumi  mvl 
with  differ  Aomewliat  from  th<we  already  deicribed.  The  ponterlor  MU  of 
the  nmo-hyr>id  i*  alvrnyg  expnoed,  and  forms  »n  important  rallyinf,'  [tuiiit  in 
,the  operation,  aod  the  tmosvene  cerricnl  artery  and  rein  will  inoKt  cobh 


rif.  470.— iJiacraui  of  fti|tht  6ab<il«Ti» 
Aitarj  In  Thir4  fart  of  In  Cmin*, 
iwMMd  bf  irRiuDvrmlli  vollt  »n*rja*i 
V«tB.  n,  SubaUriaa  ttrtatj.  t.  Iti* 
terakl  JugulM  rvaaiitng  ItmniTmali* 
aolll  T«ln«.  n.  BnuibUI  pt«(U>  of 
MTTM.     M.  Omo-kfaid  mntelk. 


Tig.  4«0,— Iii«gT»ia  of  lb*  RaUlloni  af  lk«  Tblf4 
pari  of  ilifl  Sntiotadu  Arlarj':  f,  u»fmimi 
».  i.  aina>b;otil  i  s- a.  ■a«l«nai  anUoaaj  *,  ■. 
i(Bn)<i>mMlatil ;  *.  ■lUrud  JugnlM  ••tk;  k. 
brarlilal  |>lezu*;  «.  »tUrj. 


moaly  come  Into  view.  The  danger  of  including  tbe  lowest  cord  in  the 
brachial  plexus  is  greater  the  more  the  artery  is  approached  froai  obor*. 
Tbe  vertical  iiicUiou  Bhrmid  always  be  made  in  fat  ■ubjocta. 

In  some  cases  the  clavicle  mar  lie  so  high  that  tbe  artwy  cannot  b«  «x> 
poied  oven  with  the  help  of  the  vertical  iucision.  A  com  occurred  to  Sir 
A.  Cuuper.  iu  which  the  attempt  to  liirature  the  flubclavian  ortery  for  a 
large  aocurisra  of  the  axilla  vioa  foroed  l\}  be  abandoned,  in  conse({iiena*  of 
the  elaviclu  bulng  thrust  up  to  too  great  a  height  to  enable  bim  to  reach  ibe 
Tttsel.  The  extent  of  the  ditHi^uTty  oecasioned  by  this  olovatiun  of  tlu 
elaTiole  mnat  necessarily  depend  in  a  great  meooure  upon  the  baijtbt  ol 
which  the  subclavian  artery  happentt  in  any  particular  eaae  to  be  lituoied 
in  the  ueok.  It  is  not  uncommi>n  t>)  6ad  it  uulsaliug  so  high  iu  tbe  Beak, 
that  no  amount  of  eleration  of  the  clavicle  ny  a  subjacent  axillary  aneu- 
rism conid  raise  that  hnno  iibovo  the  level  of  tbe  vaaffif.  In  the  majority  uf 
oases,  however  (in  seventeen  out  of  twenty-five,  as  shown  by  Qusin  in  his 
work  on  the  Aricriet).  it  IS  either  below  the  level  of  tbe  hnne,  or  but  slightly 
roioad  above  it ;  so  that,  if  the  clavicle  were  thrust  upwardii  and  forward^ 
tbe  veosel  would  be  buried  in  a  deep  pit  behind  iC  Dupuytrcn  was  of 
opinion  that  thv  artery  c»ur4ed  hi>;h  in  persons  who  were  tbin,  with  slender, 
hmsi  oeck-i;  whcnMW,  in  thick,  Bii>jrt-neck(«l  peranm,  with  mu^rutar  sho«I- 
dern,  it  whji  deeply  svated.  I  havu  nfii-n  vcrim^l  fb^  truth  of  ibis  obeerr** 
lion,  both  iu  dtssuclion  and  in  cxamiaiug  tbe  pulwtiuns  of  the  vass«l  duciac^ 
lift. 


ACCIDENTS    DURING    LIGATURE    OF. THIRD    PART.        227 

In  order  to  obviate  the  difBculty  that  has  occasionally  been  experienced  in 
rcacbiag  the  arterr  when  thus  buried  behind  an  elevated  clavicle,  it  has 
be«n  propoeed  by  Hargrave  to  saw  through  the  bone.  The  most  serious 
ttbjection  than  can  be  raised  against  this  practice,  is  the  fact  of  the  clavicle 
bemg  sometimes  a  part  of  the  wall  of  the  aneurlsni ;  but,  supposing  the 
Surgeon  could  satisfy  himself  that  this  was  not  the  case,  I  cannot  see  any 
objectioD  to  thy  procedure,  provided  any  very  great  and  insurmountable 
difficultv  presented  itself  Id  passing  the  tignture  round  the  vessel  without  it. 

Aeeidenti  during  Ligature  of  the  Third  Fart  of  the  Sabclavian.—  Wound 
t^  the  ElxtenuU  Jugular  Vein  is  a  must  serious  accident,  as  entrance  of  air  is 
very  likely  to  take  place,  and  may  cause  immediate  death.  This  accident 
is  avoided  by  careful  dissection,  and  if  the  vein  is  so  situated  as  to  be  exposed 
to  the  risk  of  injury,  it  must  be  divided  between  a  couple  of  ligatures. 

Profuse  renouf  kemorrkage  from  wound  of  some  of  the  numerous  veins  in 
ibe  neighborhood  has  more  than  once  prevented  the.  completion  of  the 
operation.  Should  this  accident  happen,  the  wound  must  be  plugged  and 
the  operation  attempted  again  at  some  later  period. 

Wtmnd  of  the  Sae  is  a  somewhat  rare  accident.  In  some  cases,  as  has 
already  been  stated,  the  sac  passes  upwards  below  the  clavicle  into  the 
inferior  posterior  triangle  of  the  neck ;  when  this  is  the  case,  the  Surgeon 
incurs  the  risk  of  puncturing  it  from  its  close  proximity  to  the  artery,  as  it 
lie*  on  the  first  rib.  This  accident  happened  to  Cusack  while  ligaturing  the 
nbclavian  in  the  third  part  of  its  course,  for  a  diffused  aneurism  of  the 
Axillarr  artery.  An  alarming  gush  of  blood  took  place,  which  was  arrested 
by  plugging  the  wound  ;  but  the  hemorrhage  recurred  on  the  tenth  day,  and 
the  patient  died.  In  a  case  related  by  Travers,  in  which  the  sac  was  punc- 
tared  by  the  needle,  which  was  being  passed  round  the  artery,  the  Blood, 
which  was  arterial,  did  not  flow  per  saltum,  but  in  a  continuous  stream. 
*•  The  hemorrhage,"  Travers  says,  "  was  more  terrific  and  uncontrollable 
than  I  have  ever  witnessed,"  and  was  not  commanded  by  drawing  the  liga- 
tare  tight.  It  was  so  great  that  it  was  doubtful  whether  the  patient  would 
leave  the  theatre  alive,  and  was  arrested  only  by  plugging  the  wound  with 
aponge-tents.  The  patient  died  of  inflammation  of  the  pleura.  On  exami- 
nation, the  aneurismal  sac  was  found  to  have  a  pouch-like  enlargement 
upvards,  ovt-rlying  the  artery,  where  it  had  bi.ien  punctured. 

InrlasioH  of  the  lowest  cord  of  the  brachial  plexus  in  the  noose  of  the  ligature 
ifl  a  more  common  accident;  indeed,  the  mistake  has  more  than  once  been 
committed  of  tying  these  nervous  trunks  instead  of  the  vessel.  Thus,  Liston, 
in  the  first  successful  case  of  ligature  of  the  subclavian  in  this  country, 
pa.««ed  the  thread  round  the  lower  nervous  cord  ;  but  immediately  perceiving 
hi-  «-rri>r,  turned  it  to  account  by  drawing  aside  the  included  nerve,  and  thus 
more  readily  exporting  the  artery.  Dupuytren,  in  a  case  of  ancuri.im  of 
K>me  years'  duration,  succcedt'ci,  after  an  operation  that  lasti'd  one  hour  and 
forty-eight  miniitef),  and  which  he  desorll)es  as  the  most  tedious  and  diflicult 
be  rver  attempted,  in  passing  u  ligature  round  the  vessel,  iis  he  believed. 
Af^r  the  death  of  the  patient,  which  occurred  fn>m  hemorrhage  on  the 
Btolb  day,  thf  artery  was  found  to  have  been  pcrfurated  by  the  needle,  and 
ooe-half  the  veswl  and  the  lower  cord  of  the  brachial  plexus  included  in  the 
aonee.  In  a  case  related  by  Porter,  it  is  statfd  that  tlie  artery  comniuni- 
cmlcd  i>uch  distinct  pulsation  to  the  inferior  ucrvnus  trunk,  that  there  was 
■o  mean>  of  ase«Tlaining  whether  it  was  the  ves.-ol  or  tint,  except  by  passing 
the  nectlle  under  it. 

PunH are  of  the  pleura  in  passinj^  the  needle  i:*  not  usually  recognized  as 
•■«e  of  the  dangers  of  ligature  of  the  third  part  of  the  artery.  It  may, 
however,  take  place,  especially  if  the  nee<lle  is  pa^ed  close  tu  the  scalenus 


SFECIAL   ANKURISVS. 


uiticus  and  from  above,  u  oiuat  often  bo  the  case  when  the  clavicle  ii  much 
raised. 

Id  conoectioD  with  the  ligature  of  the  »ul>claviAn  in  thia  8ituati<iii  it  la 
impoasibie  to  oaas  over  in  sileuoe  the  Inct-,  that  in  lonie  itutancn  th«  >rt»rv 
tnkea  a  remarkably  high  course  in  the  neck,  aQ<l  that  to  some  nf  thnv  in- 
flluoces  iii»tmd  of  pawing  over  (tie  Bnl  dorral  rib,  it  hat  been  «ippor(«d  i<o 
a  bupefDumerary  cervical  rib,  the  annloinicul  reliitioni  being  thui  aenoutly 
diaturbed.  Ana  flgaiii,  if  this  8U|H:ruumerHry  cervical  rib  be  UDUMudly  short, 
the  vessel  may  be  found  to  lie  between  it  and  the  hral  doraal.  Anotovr  ftb- 
normality  of  great  rarity  \s  the  paaugQ  of  the  Bubclaviau  vein  behind  iht 
scalenus  nniicue  with  the  artery.  This  would  add  greatly  lu  the  difficulty  uf 
the  op(.-ralion. 

Ligature  behind  the  Scalenus  Antioas. — If  the  eac  eucroadi  apoo  the 
nc«k.  rising  above  the  clavicle,  or  the  artery  he  not  sound  in  the  third  part 
of  its  LMurse,  it  may  bo  necessary  to  ligature  it  behind  ilie  scalenus  juiticns, 
dividing  the  outer  half  or  twu-thirds  of  the  muscle.  This  ODeration  should 
I  not  he  considered  as  distinct  from  ligature  of  the  vessel  in  toe  third  part  itt 
llts  course,  hnt  rather  as  an  extension  of  that  proceeding,  if  it  be  found,  for 
the  reAsonn  just  mentioned,  unadvinuble  to  tie  the  artery  on  the  fir^t  rfb;  in 
this  way  it  haa  been  practised  hy  Diipuytrcn  and  I^iatim.  In  its  fintt  steps, 
far  an  the  exposure  of  the  scalcnun  amicus,  it  i»  the  fuimi-  as  that  for  the 

tligation  of  the  veasel  in  the  third  part  of  its  course.  Whi^n  this  muscle 
haa  oeen  exposed,  a  director  rau.it  be  pushed  under  it,  upon  which  it  is  to  be 
divided  to  the  extent  of  half  or  twiwthirds  its  breadth,  nlien  it  retracts. 

iposinu  the  vesael.     During  thi:i  pari  of  the  of>eralii>n.  «ume  dimger  may  be 

icurreu  by  the  phrenic  uerve.and  the  tmnsvenMtle«  colli  and  humeri  arteriaa; 
but  if  ordinary  care  he  taken,  this  will  uot  be  very  greaU  The  phreuic  nirrve 
lies  altogether  to  the  tracheal  aide  of  th«  incision,  if  that  be  not  carried 
beyond  one-half  the  breadth  of  the  muscle;  and  should  it  apj>«ar  to  be  in 
lh«  way,  it  may  readily  be  pushed  inwards  towards  th«  mesial  line,  iNnng 
only  loowly  invested  by  areolar  tinue.  I  have,  however,  seen  uq«  instanoa 
in  which  the  right  subclavian  artery  was  ligatured  fur  a  spuutaueoua  eylis- 
driform  aneurism  of  the  axilla,  anil  the  patient  died,  on  the  eighth  day*  of 
pneumonia;  <•□  examination  alWr  death,  the  edge  of  the  scalenua  waa  found 
cut,  ami  the  phrenic  nerve  divideit.  Had  the  injury  to  the  nerve  in  this 
[Saae  anything  to  do  with  I  lie  pneumoniti?  I  do  out  think  it  improbable;  aa 
''division  of  one  phrenic  nerve,  by  pandywng  to  a  certain  eilfiit  tlie  dia- 
phragm, and  so  Tar  interfering  witli  the  rtspiratury  movemeutB.  must  neoea- 
earily  have  a  tendency  to  induce  congestion  of  the  lung,  which  would  readily 
tnio  on  til  inflammation  of  ihal  ot^n.  I  have  Hkeuiw!  hean)  of  noe  caae  in 
which  incessant  hiccough  followed  this  operation,  and  aAer  death  the  [rftreftie 
nerve  was  found  reddened  and  inflamed,  having  prohuhly  in  some  way  been 
hiterfereil  with  during  the  exposure  of  the  vesael.  The  iraiuversales  ooIU 
and  humeri  arteries  may  be  avoided  by  keeping  the  incision  in  tlu^  musetc 
between  and  {mrallcl  lo  these  v^-sscls. 

Another  imj^oriant  point  in  roferenoe  to  the  ligature  of  the  vnael  in  tUs 
part  of  its  course  is,  that  in  tive  cases  out  of  six  on  the  right  aide  and  in 
one>hatf  on  the  lell,  the  superior  intercostal  arises  from  the  subclavian 
srj-  between  the  scaleni.  When  this  is  the  case,  there  w-Hild  probablv 
but  a  slender  chance  of  the  occlusion  of  the  artery  by  ligature  in  th» 
irilaation. 

Ono  principal  danger  in  ligaturing  tbo  subclavian  artenr  at  aay  point 

Eftbove  tne  tint  rib,  certainly  ariMi  from  intcafaratce  with  the  Ascia  which 

lia  between  it  and  the  scaleni  aiitaclcs,  aniftrattng  it  irom  tb«  pleura,  and 

which  ia  eontinuoua  with  the  areolar  tisaoe  of  the  anlarior  meduistinum,  bving. 


BSS0LT8   OF   LIGATURE    OF   SUBCLAVIAN.  229 

uit]e«d,  the  deep  portion  of  the  ascendiDg  layer  of  what  Sir  A.  Cooper  has 
described  as  the  "thoracic  fascia,"  and  which  helps  to  form  the  superior 
boaodary  of  the  chest,  being  continuous  in  the  neck  with  the  deep  cervical 
fiwcia.  After  the  deeper  layers  of  the  cervical  fascia  have  been  opened,  this 
fine  areolar  tissue  presents  itself;  and,  if  septic  inflammation  be  excited  in 
it.  the  morbid  process  will  readily  extend  by  continuity  of  tissue  into  the 
thorax  by  the  anterior  mediastinum,  invading  ultimately  the  pleura  and  peri- 
cardium. Hence,  whenever  it  is  practicable,  the  Surgeon  should  keep  the 
piint  of  the  needle  close  to  that  part  of  the  artery  which  lies  upon  the  first 
rib.  as  there  is  less  risk  here  of  opening  into  the  deep  areolar  tissue  of  the 
Deck. 

Keanlto  of  lagatnre  of  the  Sabolavian, — The  general  results  of  ligature 
of  the  subclavian  in  the  third  part  of  its  course  for  spontaneous  aneurism  in 
the  axillary  are  by  no  means  satisfactory.  Thus  of  48  cases  of  aneurism  of 
the  axillary  artery,  not  dependent  upon  any  external  wound,  tu  which  the 
artery  was  ligatured  above  the  clavicle,  I  found  23  cures  against  25  deaths. 
This  result  was  so  unfavorable,  and  so  ditlerent,  indeed,  from  what  I  antici- 
pated.  that  I  was  led  to  analyze  carefully  the  causes  of  death.  I  found  them 
as  follows : 

Infiftmmation  within  the  cheit,  etc.,       ....  10  cases. 

Suppuration  of  the  mc, 6  " 

Suppurative  phlebitis, 1  " 

Hemoirhage, 3  " 

GsDgrene  of  the  Iwnd  and  arm I  " 

Ctenf^ne  of  both  arms  and  le^, ]  " 

yol  (toted, 3  " 

25     <■ 

Thus  it  will  be  seen  that  the  two  most  frequent  causes  of  a  fatal  result 
following  the  operation  for  axillary  aneurism,  are  not  those  that  are  usually 
■net  with  after  the  ligature  of  the  larger  vessels.  It  would  therefore  appear 
to  be  owing  to  some  special  condition,  dependent  either  upon  the  application 
of  a  ligature  to  the  subclavian  artery  in  the  third  part  of  its  course,  or  upon 
the  situation  and  nature  of  the  disease  for  which  that  operation  is  had  recourse 
Vi :  and  the  important  point  to  be  determined  is,  whether  these  conditions 
art:  the  accidental  or  the  necessary  consequeuces  of  the  applicatioD  of  a  liga- 
ture in  this  situation  for  the  cure  of  aneurism  in  th(t  axilla. 

JnjiamtneUion  of  the  Contents  of  the  J^oraj-  proved  fatal  in  10  out  of  25  cases, 
•■r  1  in  2.5,  and  is  the  most  frequent  cause  of  death,  though  not,  I  believe,  the 
m'«t  frequent  untoward  complication  of  this  operulion.  It  might  at  first 
he  supposed  that,  iu  this  rt'^pect,  the  operations  on  the  subclavian  artery 
ruemuled  other  of  the  greater  operatiims,  after  which  pytcmlc  pneumonia  is 
»'jC>mmon  a  sequela;  but,  on  closer  examination.  It  will  be  found  that  this  is 
o-ft  the  caite.  Inflammatiim,  when  attacking  the  thorax  or  it-s  contents  after 
ligature  of  this  artery  for  axillary  aneurism,  is  not  cuTifiueil  to  thu  Innjrs,  but 
Tfri-  cummonly  affects  the  pifiira  and  prricanlium  iw  wc-ll  as,  or  even  in 
j>r>:-fen::nce  to,  these  urgans.  It  wi>ultt,  thertf'ore,  apptar  probable  that  it 
ar<v«  from  cau.«e3  that  are  e:*sontially  conncctoil  tither  with  this  operation  or 
wiih  the  aneurism  itself.     These  arc  rftorable  to  three  heads. 

1.  Septic  inflammation  of  the  deep  areolar  ti&Jue  at  the  root  of  tlie  neck 
loav  extend  to  the  anterior  mediastinum,  the  pleura,  and  perioardiuiii.  This 
wouM  appear  to  have  been  the  cau«'  of  death  in  a  patient  in  whom  Kuy  tied 
tht:  i-ubclavian,  and  hofi  been  especially  adverted  to  by  that  cxeelleiit  Surgeon 
in  his  relation  of  the  case. 


230 


SrVCIAL   ANEUBISHB. 


3.  Tbc  sac  may.  by  ite  precEure  iowordfl,  eocroacli  opoo  uid  (nve  liie  to 
ioflaiumatioii  uf  that  ))<)rlii)[i  gf  the  pleuru  wliicti  oorn>i>i>uDdB  U>  Ue  [Heitj'iur 
aspect.  Tbie  occurrct]  in  »  case  io  v.-))icb  Mnyci,  of  Winchfvtcr.  (.i)H'rste<d, 
and  is  more  liable  tu  liap{M;u  il'  BUppiirHtinn  have  litkcii  iila<v  in  tlif  nr; 
when  this  occim,  ailbcgion  may  tnke  plnr o  between  it  and  llie  pleuru.  nr  eveji 
the  tiwue  of  the  adjuceui  luti^  ;  and  the  coiitentfl  of  the  Buppurulin;*  !:tm'>r 
TDDV  be  discharged  idIo  the  pleural  cavity  or  air-tubes,  ant)  au  c'< 
01'  thi^  curioua  mode  of  lerminatioii  there  arc  nt  least  two  eases  <^  i; 

one  by  Hullen,  in  which  the  patient  recovered  ;  the  other  by  Grnes,  iti  which 
the  patient  died  from  the  escape  of  the  contcntA  of  the  sac  into  the  cavity  of 
"le  pleura. 
3.  Division  of  the  phrenic  nerve  would  neceatarilj,  by  tnteHVHog:  wltb 
lie  reepirniory  moveracuts,  induce  a  teDdcncy  to  cungmtioD  and  inHnnitna- 
of  tbc  lungs ;  and,  although  such  an  ttccident  must  ho  a  very  rare  ooe 
in  eases  of  ligature  of  the  i>uhclavian  for  axillary  nneurisni,  yet  it  undoubt- 
edly baa  occurred,  as  I  have  myttelf  witnessed  in  one  case. 
I  Suppuration  of  the  Sac  is  the  most  common,  though  not  the  ino«t  faUl, 
accio^ol  after  ligature  of  the  Bubctavion  for  spoDtaDenus  axillary  nneurina. 
it  waa  the  immediate  cause  of  deatli  in  six  cases,  and  occurred  in  two  of  tfao 
iti«Dts  that  died  of  inflammatiDu  of  the  chest ;  it  took  place  in  six  casw 
that  recovered ;  io  all.  founeen  cases  out  of  forty-five,  or  nearly  oat  io 
thre« — a  much  higher  proportion  Chan  is  geuenilly  observed  in  catea  of  lig»- 
ture  for  aneurism. 

What  occaaioDS  tbis  greater  frequency  of  suppuration  of  tbc  »ae  in  axillanr 
.aueuriaias  than  in  those  in  other  eituationer  The  chief  cause  to  wbicb  it 
kppeare  to  bo  attributable  is  Ihc  great  laxity  of  the  areolar  membrane  in  the 
kxillfi,  vhich  allows  the  tumor  to  increase  so  rapidly  in  Bine  as  to  exrita 
inflammatory  action  in  ilie  surrounding  liraues,  ubieb  may  speedily  run  ioto 
ippuration.  in)  long  ax  the  cuntcutK  of  the  tumor  eontinue  fluid,  they  will 
lecraearily  excite  le»t  irnlalion  on  surrounding  structures;  but  wbeii  odm 
~  ey  have  become  rioltdifitd.  whether  by  the  gradual  depoell  of  latni 
flhrin  during  the  progre!>!i  of  the  disease,  or,  more  sudilenly,  in  c<inBM| 

thoM^  changes  that  take  place  in  the  contents  of  an  onenriamal  aae  after 
fie  lifTfttiire  ot  the  artery  leading  to  it,  the  indurnred  ninM,  acting  like  any 
other  forei;:ri  body,  sets  up  inflammation  in  the  areolar  tiMiie  that  ts  \u  im- 
mediate c^inlnrt  with  it,  and  thus  diiipoiies  it  to  run  into  Auppumlion.  The 
more  s|>eeHily  the  JKilidiAcstJon  takes  nlnce,  the  more  di»pn!4iti<io  will  there  be 
the  occurrence  of  ihis  stcidcnt;  tlie  neigbhuring  twirls  heiug  unable  In 
immodalc  themselves  to  the  sudden  extension  and  compre*»ii-n  they  are 
ipelled  to  undergo.  It  is  probable,  also,  that  the  prnxiniily  of  the  wrtund, 
and  perhaps  acluiil  injury  done  to  the  aucurisiunl  eac  during  tb«  ojicratiua, 
are,  in  many  cases,  the  iminediate  causes  of  tbc  inflanimntion  and  suppura- 
tion. The  etntiiftics  col]c<.-letl  by  Koch  ehuw  a  much  grviitrr  mortality  in 
c«H«  iu  which  the  aubclaviaii  artery  hua  been  tied  for  spoiilaneoiia 
leurisms  extending  above  the  tipper  border  of  Ihe  ftectoniiis  minor,  than  io 
lose  below  that  point.  Of  17  oif  the  former  I'i  were  fatal,  of  23  of  llie 
Uter  only  10  died. 
The  iieri(xl  nt  whirh  suppuration  of  the  sac  may  be  expect*^  to  oecar  in 
FcBiea  of  axillary  aueuri»in.  aOt-r  the  llf^tun.'  of  the  subdarian.  must  nem- 
sarity  iu  a  great  measure  he  depi'ndent  on  the  state  of  the  sac  at  the  time  of 
the  o|ieratiuii.  If  inflammation  have  been  already  set  np  amund  it.  it  may 
happen  a  few  days  after  the  arterr  hne  been  tied.  But  if  this  ntorhid  pro- 
Jen  have  iHil  already  oummeDcetf.  ihc  period  at  vhich  sunpuralion  may 
moat  pniliahly  he  ex'pecleil  is  between  the  flrsC  and  second  month.  The 
period  at  winch  suppuration  nnd  rupture  of  the  sac  take  place  doca  not 


RESULTS   OP    LIGATURE    OF    SUBCLAVIAN.  231 

influence  llie  probable  tenniD&tion  of  the  case  to  any  material  extent;  ae, 
in  tbe  cases  that  prove  fatal,  death  occurrfd  at  vanoue  periods  between  the 
serenth  day  and  the  second  month  ;  in  Aston  Key's  case,  on  the  ninth  day  ; 
io  Mayo'ff,  on  the  twelilh  ;  in  Belardini's  and  Grafe's,  at  the  end  of  the  firet 
month ;  in  Rigaud'a,  at  the  sixth  week ;  in  B.  Cooper's,  in  the  second 
month.  The  recoveries,  likewise,  took  place  at  all  periods  after  the  ligature 
of  the  Teasel,  between  a  few  days,  as  io  Porter's,  and  six  weeks,  as  in 
HaJk>n's  case. 

Ad  axillary  aneurism  that  has  suppurated  may  burst  either  externally,  or 
into  the  lungs  or  pleura,  or  both.  It  is  luoat  usual  for  it  to  burst  externally ; 
the  tumor  eulai^es,  with  much  pain  and  tension  ;  a  part  of  the  akin  covering 
it  becomes  inflamed ;  fluctuation  can  be  here  felt,  and,  if  an  incision  be  not 
made,  the  tumor  will  give  way,  discharging  most  usually  a  quantity  of 
dark-colored  pus,  mixed  up  with  more  or  less  broken-down  and  disintegrated 
eoi^uluni,  and,  perhaps,  sooner  or  later  followed  by  a  stream  of  arterial 
blood. 

Occasionally,  but  more  rarely,  the  sac,  extending  inwards,  perforates  the 
eaviiy  of  the  chest  and  becomes  adherent  to  the  pleura,  and  may  give  way 
into  its  cavity ;  or,  by  pressing  upon  the  lungs,  may  become  incorporated 
with  tbem.  Of  this  remarkable  tcrmiuation  two  instances  are  recorded,  in 
one  of  which  recovery  took  place. 

The  first  case  of  the  kind  is  one  in  which  Bullen  ligatured  the  subclavian 
utenr  for  axillary  aneurism.  Eighteen  days  after  the  operation  the  tumor 
bc^D  to  increase,  and  to  take  on  the  symptoms  that  are  indicative  of  suppu- 
latioa.  On  the  twenty-sixth  day  six  or  eight  ounces  of  bloody  pus  were 
expectorated  during  a  paroxysm  of  coughing,  and  the  tumor  suddenly  dim- 
ioiflhed  to  one-half  its  size;  it  was  now  punctured,  and  6ve  ouocea  of  the 
same  kind  of  matter  were  let  out  with  great  relief  When  the  patient 
ooQghed,  air  passed  into  and  distended  tlie  sac  through  an  aperture  between 
the  first  and  second  ribs,  near  their  sternal  extremities,  through  which  the 
oootenls  of  the  tumor  had  escaped  into  the  lung.  The  discharge  from  the 
external  aperture  greatly  decreased  ;  the  cough  lessened  ;  and,  finally,  three 
months  after  the  operation,  the  patient  was  quite  well, 

GriWB  tied  the  subclavian  artery  for  a.\illary  aneurism  on  the  I8th  of 
February.  After  the  performance  of  the  operation  the  coutenti?  of  the  tumor 
Buliditied,  and  its  volume  progrcdsivoly  diminit!hed.  On  the  loth  of  March, 
the  patient  autfered  fmm  fever,  and  slight  ten()ernc»4  on  the  apc\  of  the 
tumor  was  perceptible.  On  the  lltth  he  was  sudiicnly  »ei/.cd  with  intense 
pain  in  the  choit,  which  was  {>articulurly  severe  at  the  base  of  the  right  lung, 
aad  extended  up  towards  the  axilla.  Respiration  throughout  the  right  lung 
was  brunchiat,  and  there  was  dulness  on  percussion  over  the  lower  ribs ;  the 
aneurismal  tumor  had  suddenly  disappeared  at  the  time  of  the  attack.  On 
the  I>Sth,  the  patient  experienced  a  sen.-iation  as  if  n  fluid  were  passing  from 
the  pl«ural  cavity  into  that  of  the  anourisinal  tumor ;  and,  upon  auscultating, 
a  splashing  sound  was  heard  at  every  inspiration,  tlie  noise  resemhllnL'  that 
pr.'Juced  by  shaking  water  In  a  closed  vessel.  On  the  'iOtli.  he  died.  Upon 
dissection,  the  aneurism  was  found  to  comniunicttle  by  un  aperture,  one  iuch 
sad  tbree-<)uarter8  in  length  and  an  inch  and  a  lialf  in  width,  with  the  pleural 
aTity;  this  opening  was  situated  between  the  first  and  .second  ribs,  and  was 
obvioufllr  the  result  of  ulceration  and  ab.-iorption.  eiiused  by  the  pressure  of 
the  tumor.  Both  ribs  were  denu'ied  of  their  periosteum.  The  ri;;ht  sitie  of 
the  chest  containetl  nearly  three  quarts  of  bloody  serum,  intermixed  with 
laminated  clots  and  flakes  of  lymph  ;  the  former  i>f  wliieli  had  evidently  lieeu 
lodged  originally  in  the  aneurismal  sac. 

Besides  tbe^e  cases,  a  somewhat  similar  one  has  been  recorded  by  Xerct,  of 


2»S 


SPKOIAL    ANBURiaUS. 


Najicj.  A  pnticiit  wn«  ndmitiod  into  t)i«  hospital,  suflbring  from  luBnoBtjM. 
nnd  on  cxamiumlon  wm  t'outiil  !•>  have  an  ani<urisni  nf  Uie  Irft  •abeuvin 
art<^rT  ov  liirgt>  as  n  chi-Alniir.  He  ilkvt  (tluirtly  aftt^r  admUdoii;  Mkd,  «a 
exnmiuation,  the  anetirintn  wun  futitid  lu  ciinimuDirfliP  with  a  lai^  caviljr  in 
the  upper  part  of  thf  lung. 

The  cause  of  dcAth  in  Grnm's  aiM-  was  prohahly  the  fact  nf  ihn  ixr  iipea- 
ing  anil  diKcharning  iui  (^int^nta  intn  tlie  pleural  c&Ttlj.  ThU  dcic*  im^L 
app(*-ar  to  have  )>cciirre<l  in  Hutleu's,  in  which  a  cfimniunication  wn*  niab- 
tislied  directJy  with  the  lung,  the  conteota  of  the  ahsc^si  BndJDj;  exit  ibruuKk 
the  uir-tubed.  The  process  here  was  analogona  t<i  what  iK-cMslouatlv  otrcurB 
in  hepatic  iib«cew  wneu  tlii^  o|>eu8  through  the  luog)>.  miht^iuM  hnvmg  prv- 
viouxlv  tnktfii  pUce  betweeu  the  uppuveil  ourfaow  ot  the  plfuni. 

lu  f'unier  s  c»&e  uf  asUlnry  nueurisiu,  ImUi  urleriev  l>ecmtn«  afivct«(]  Uj  tbr 
diaeaM,  aud  both  euhcl&vinua  were  tied  in  th«  third  part  of  their  ixiurve  at 
en  iutcrvul  of  abuut  liilvi-u  uii>uth8.  Id  this  niont  ronmrkable  aud  ial«f«it- 
iDg  caae,the  reoult  of  which  reifleots  much  credit  uu  chv  skill  and  dcdaoo  of 
tbe  operoti)r.  tiie  pallenUa  stODemBSou  by  trade,  made  au  (ixtvlleul  recover; 
from  the  titfit  o)ieratiou.  After  the  i!e<Nind  <)|reratiou  he  progrcaeed  tMA 
favorably  for  twelve  weeks,  by  which  lime  the  tuuior  had  diminianed  lo  nodi 
a«  to  be  mit  more  than  e  thin)  of  its  original  sise.  Without  ubriDui  reesoo 
febrile  disturbance  wt  in.  the  tumor  enlarged  again,  and  showed  agaa  of 
BUppurating.  Funier  now  loade  a  free  incision  into  it  Lhn>ugh  the  pectoral 
muscle,  and  let  out  18  or  20  ounces  of  very  ofTt>n8tve  pua  una  brokm-^town 
congiilum.    The  iintient  spee^^lily  recovered,  the  tumor  dJHippeariog  entirely. 

The  principnl  danger,  nnd  the  mofit  frequent  cause  of  death  atUr  tbe  wip- 
pnradoa  of  the  sac,  is  the  supervention  nf  profuae  Arterial  hemorrhage.  IVh 
may  occur  cither  from  the  distnl  extremity  of  the  artery  opening  into  the 
■AC,  or  from  one  of  the  large  branches  which  serve  m  support  the  cidlateral 
circulation  nvund  the  shoulder,  such  as  the  sul>»upu1nr  or  poaterior  circam- 
flftx,  coming  off  either  immediati^ly  above  or  behm  the  «bc,  or  from  the  wc 
itaolf  When  hemorrlingc  docs  not  take  place  oiler  stippunilion  of  the  ac, 
it  must  be  from  the  fortunate  circumxtanoe  of  tbe  occlusion  of  the  main 
trunk,  where  it  opens  into  the  tumor.  It  can  scarcely  be  from  the  occlwioa 
of  the  principal  collateral  branchca;  as  there  would,  in  this  event,  b«  a  dif 
fioulty  in  the  preservation  of  tbe  vilalily  of  the  limb.  It  ia  ea«j  U}  under 
fltand  that,  if  tbe  aac  sprang  from  the  axillary,  at  a  tittle  diatance  above  the 
orifices  of  the  subscapulnr  and  circumflex  nrt«riea,  nil  that  portion  of  iht 
main  trunk  which  intervenes  between  tbe  tumor  nod  tfaeee  vevcU  might  bf 
occluded,  nnd  thus  hemorrhage  be  prevented  on  suppuration  taking  place; 
wbikt  the  collatenit  circulation  would  take  place  uninterrupfe^ltv  thmngfa 
these  vQBBela.  If  this  portion  of  the  artery  have  not  been  occluded  by  inflaai* 
matioQ,  the  safety  of  the  patient  must  depend  upon  the  not-ident  of  a 
lum  or  piece  of  laminated  fibrin  being  liied  or  eotauglL<d  iu  the  mouth  of  i 
[,aao.  'I  hill  inn^  prevent  for  a  time  the  escape  of  arterial  blood,  which,  on 
endi  a  plug  being  lo<:jeeQeil.  may  break  forth  with  impetuositr,  and  either  oC 
onoe,  or  by  iw  recurrence  al  interval*,  carry  off  thfi  fMitient. 

Another  danger  may  be  superadded  iu  thcfie  oucs  on  the  nip|>uratU«  of 
the  aac  and  the  aupi'irventiou  of  hemorrhage — namely,  the  occ4irreBefr  of  la- 
flainmallon  of  the  pleura,  lung,  and  |>ericardium,  from  extenaion  towmrdaof 
the  morbid  prooeaa  g«)lng  on  in  the  sac-. 

Siifoadary  hanftrrhao*  d^iea  not  frrqucntlT  occur  in  aUiRa  of  ligatare  of  ihe 
Aubclaviati  artery  in  the  third  part  of  it*  course,  except  na  a  ciiUMcqueDo*  of 
siippuraliim  of  the  aac  I  mvself  have  teen  but  two  case*  In  which  il«Ath 
occurred  from  hemorrhage  taking  place  from  this  artery  at  the  part  liga- 
turoil.    One  of  these  happened  to  Liston,  and  the  preparation  b  pmerrod 


AXILLAKT — INFLAMED    SAC — TREATMENT.  233 

» 

in  tbe  Museum  of  the  College  of  Surgeons  CNo.  IGSo*).  In  this  case  it  may 
be  seen  that  the  artery  was  diseased  at  the  point  ligatured,  and  that  the 
bleeding  occurred,  ai  usual,  from  the  distal  side  of  the  ligature.  Barwell, 
taking  Koch's  table  of  79  cases,  and  adding  to  it  11  collected  by  himself, 
&a*ii  that  of  32  deaths  occurring  in  the  90  cases,  10  were  from  hemorrhage 
frora  the  site  of  ligature. 

Gangrene  of  the  Hand  and  Arm  is  but  seldom  met  with  as  a  sequela  of  the 
operation  we  are  considering.  This  is  doubtless  owing  to  the  fre^om  of  tbe 
anastomasiDg  circulatioD  between  the  branches  of  the  transversalis  colli  and 
ffuprascapular,  and  those  of  the  subscapular,  circumflex,  and  acromio-thoracic 
arteries,  as  well  as  between  the  superior  and  long  thoracic  and  the  branches 
of  tbe  interooetals  and  internal  mammary,  by  which  the  vitality  of  the  limb 
ie  readily  maintained.  The  principal  risk  from  gangrene  would  doubtless 
arise  from  the  subscapular  artery  being  in  any  way  occluded  or  implicated 
in  the  disease,  as  it  is  on  the  anastomoses  of  this  vessel  that  the  limb  is  mainly 
dependent  for  its  supply  of  blood.  But,  at  all  events,  this  danger  is  small, 
the  only  case  in  which  it  appears  to  have  given  rise  to  a  fatal  termination 
being  one  in  which  Cotlis  tied  the  artery;  gangrene  of  the  limb  came'  on 
after  much  constitutional  disturbance,  with  rapid,  weak  pulse,  thirsts,  sweats, 
nstleBsnefls,  and  delirium.  In  Blizard's  case,  there  were  sloughing  of  the 
me,  and  pericarditis,  the  gangrene  being  confined  to  two  fingers;  and  in 
Brodie's  case,  it  occurred  in  both  the  lower  as  well  as  in  the  upper  extremi- 
tiee.and  must,  therefore,  have  proceeded  from  some  constitutional  cause  alto- 
gether independent  of  the  mere  arrest  of  circulation  through  the  subclavian. 

Failure  of  the  operation  to  cure  the  disease  if  the  above  accidents  are 
STuided  is  a  very  rare  occurrence.  A  case  of  this  kind  occurred  to  Berkeley 
Hill  in  University  College  Hospital.  The  subclavian  was  successfully  tied 
for  a  large  axillary  aneurism;  there  was  some  tnflamniatiun  about  the  sac  after 
the  operation,  which  gradually  subsided.  Some  months  afterwards  the  tumor 
b^an  steadily  to  increase  in  size  without  pulsation,  and  finally  tbe  sac  was 
laid  open  and  the  vessel  tied  from  within,  and  the  patient  made  a  good  re- 
oorerr. 

On  reviewing  the  causes  of  death,  it  may  be  reasonably  hoped  that  the 
avtrage  of  success  will  be  materiuliy  increased  by  the  use  of  ligatures  which 
di^  not  di%'ide  the  ct>Hls,  and  by  the  prevention  of  septic  and  spreading  in- 
flammation in  tbe  wound  by  the  employment  of  antiseptic  dressings. 

Treatment  of  Inflamed  Axillary  Anenrism  threatening  Suppuration. — 
The  ca*e  of  an  axillary  aneurism  bocoiniiig  intlnmed,  iin<i  threatt'iiing  to 
Hippurate  before  the  Surgeon  has  had  an  opportunity  of  ligaturing  the  sub- 
clavian artery,  is  one  that  is  full  of  important  practical  consideratinns,  and 
that  admits  of  little  delay  ;  for  if  the  sac  rupture,  or  be  opened,  fatal  liemor- 
rhase  if  the  inevitable  result.  It  would  obviously  be  impossible,  in  a  case 
of  ^jKintaneous  aneurism,  with  any  fair  chance  of  success  to  lav  open  the 
tumi-r.  turn  out  the  congula.  and  ligature  the  vessel  above  auii  IkOow  the 
m-'Uih  -ff  the  sac ;  the  coats  of  the  artery,  being  mtt  only  diseased,  but  still 
farther  g'iftene<l  by  iuHummHtioii  and  supervening  suppuration,  would  not 
t»e  in  a  cunditinn  tu  hold  a  ligature.  There  jire  two  other  courses  open — 
viz..  liirature  of  the  subclavian,  or  amputation  »t  tlif  shouldcr-joini ;  and  in 
tbe  wicciion  of  uue  or  other  of  these,  tlie  Surgeon  must  be  guided  by  the 
pr>>irre?9  the  disease  has  made,  t lie  coiHlitinn  of  the  lind)  ns  in  cirL-nlatiou 
and  t»-mperature.  and  the  solidity  or  fiiiidiiy  of  the  coiilenis  of  the  tuinor. 

If  the  tumor  be  of  moderate  size  and  t'in'uniscrJbed,  and  tin-  arm  of  a 
g*""*!  temfierature  and  not  very  o-deniatous,  fii/olurt'  nj  the  arienj  may  hold 
out  a  n'««'inable  chant.*  of  success.  It  is  true  tlnit  this  is  but  a  ehaiice:  for 
the  blourl  will,  immediately  after  the  noose  is  tied,  be  carried  by  the  supra- 


284 


UPBClAL    ANSUaiSUS. 


scapular  an<l  posterior  scapular  arteries  into  tbe  tubecapaliir  and  cinnimllKK, 
and  by  lli«iu  into  tbe  axillury  at  uo  ^ri*at  dislnow  from  tbu  iiioutb  of  ibc 
eac ;  or  it  may  cuter  directly  iutu  tlio  ujoulIi  of  ibo  latUT,  if  tbe  tubacua- 
lar  or  circuiuUux  sbuutd  c-lianu^  bi  tako  their  nrigin  fnini  ibo  ditated  puruOB 
of  tbe  vcsiM^t.  llcuoe,  tbo  uuly  sul't-'guard  agaiii^l  iIh>  »u|<i-rvri)t.i<ia  uf  MOior' 
rbagi-  aa  Btmti  an  llic  eac  has  bum  tir  Ik-cii  ii[h!di>iI,  or  biit  dim-liurged  Its  ena- 
teuls,  will  be  tbe  iioctuaioo  bj*  thrumbneu)  of  ihac  jKirtinu  vi'  tbe  artfry  whidi 
interveiHS  betweeu  Ihwsa  two  collateral  brHiicla-a  hihI  its  luuulti,  ur  Lue  acvi- 
dvntal  tttitaugleiuuiit  iu  the  latlvr  uf  n  ruu^  uf  laminated  Hbrio.  Yetr  in 
che  rirctimstaiiou)  as  to  tbe  eiiudittoD  nf  tuiour  aod  Uiub  ibal  liave  joat  bini 
meiiiioDpd,  it  would  be  bul  right  for  the  Burgeon  to  give  the  ]iatient  a  chuioe 
of  preserving  hi»  arm. 

Shonld,  however,  hemorrhage  ocfur  nn  or  af\«r  tbe  discharge  of  tbe  cob- 
teata  of  the  auc,  the  Bubclavian  having  previously  beeo  ligatured,  «bai 
sliould  be  done  f  If  the  bleeding  be  modemie,  an  attempt  eliould  ht;  made 
to  arrest  it  by  plugging  the  wound,  nod  by  tbe  applinttion  of  a  oMspnw 
and  bandage.  W  it  recur,  or  Im?  »•  profu»«  aa  to  threaten  tha  life  of  tlt« 
patient,  what  courM  should  tb<^  ^sir^t-im  llieu  pursue?  Twu  lino  of  prw- 
oedure  are  op«u  to  him ;  t.-ither  lo  cut  lliroiiKh  tbv  pect^Tal  muscles  ao  at  w 
lay  the  sac  open  fully,  aud  nttcinpt  to  include  the  uleediug  oriHoe  bvlwwD 
two  lignturea:  or  t^i  nit)putnt«  at  tbt^i  sbuulder-joluU 

If  a  Burgeon  were  tu  uixiertuke  the  tirst  of  them)  altcrnatlTes  id  ■  oan  of 
spoataDeous  aneurism,  of  which  nione  we  are  now  epeaking,  h«  woold,  ib  all 
probability,  find  the  part  iu  sucb  a  condition  lus  would  prevent  tbe  pOM' 
Dility  of  bis  completing  tbe  opemtion  he  hud  commenced.  AfUir  Uyiag 
open  a  large  sloughing  cavity,  extending  under  tbe  pectoral  muaolca  pv- 
haps  as  high  aa  the  clavicle,  and  clearing  out  the  broken-down  oongula  oob- 
tjuoed  in  it,  in  what  atate  would  he  find  tbe  artery?  Certainly,  ibfl  probft* 
bility  would  be  aironglv  against  Its  beiag  in  aucJi  a  condiiioo'  aa  to  near  a 
ligature,  even  if  it  c'.)uld  be  included  in  one.  Its  ooata,  in  tha  imfni^tatr 
vicioily  of  the  eac,  oiuld  not,  in  accordance  with  what  wft  know  to  be  ai- 
noet  universally  the  ca8e  in  spi^iiuaueoua  anenrisms  of  large  aiie  oroldstAod- 
iog,  be  cKpoctc<l  to  bo  in  anything  like  a  flound  tirui  Biate.  and  would  aloMial 
certainly  give  way  uuder  prcesurc  of  the  qoom  ;  or  tbo  veasel  might  haw 
undergone  fusifurm  dilatation,  »a  U  common  in  this  situation.  befur«  gi 
riso  to  the  circumscribed  false  aneurism,  in  which  caao  it  would  be  im_ 
ble  lo  aurround  it  by  a  ligature;  or.  again,  tbe  subacaputar  or  eircumflci 
orterioa  mi^^bt  arise  directly  fmrn,  and  pour  tbeir  recurrent  blood  iuui,  tbe 
sac  or  the  dilated  artery,  and,  as  they  would  lie  in  the  mid»t  <>f  inflaiDcd 
And  itougbiog  tiuuea,  uo  attempt  at  including  them  in  >  Hjfature  could  he 
succcMfullj  o^e.  In  Buch  cireumi»liinc«d  as  th<«e,  the  daup^r  of  thn  patieul 
would  be  considerably  iucroasud  by  the  irritatinu  and  iuQtimmfltiiia  tbat 
would  be  occasioned  by  luying  ttjpbU  and  warrhhig  fur  the  bU'ttlitig  vrwal 
is  tbe  SBC  of  an  iuHumeil,  »u|i{mrutiug,  and  slougliiiig  MueurtHiu,  und  much 
valuable  time  would  be  Um  iu  wliuL  must  be  n  frultleit!  o|MTtiti'>ii ;  nl  ihi; 
clow  of  uliit-'h  il  noiild,  in  nil  prulmbility,  become  ueceatarr  to  liave  rvcuono 
tu  dinnruculntiorr  at  tbt;  ibouMer-juitit,  aud  thus  U)  remove  the  wb"!i*  dtfoat 
at  once.     1  itlunild.  therefure.  be  disposed  to  have  roooune  to  </■  'ow 

at  the  fhouUrr-Joinl  M  once,  i a  ull  caeva  of  profuw  recurrent  In  ..:ij«. 

foltuwin^  Bluugbiog  of  the  sac  of  uu  axillary  aueuriHm.  which  could  outlm 
nrrvsicd  by  dirwl  prcaaure  ou  the  bleeding  utiticv,  ul'tcr  tbe  subclavian  baa 
bci'ii  tied. 

There  in  nnotbor  form  of  axlllaiT  aneurlam  that  requim  immediate  am- 
putation at  the  fthuuldiff-juint,  whether  iho  subcluviau  artery  have  previoualjr 


LIOATURB    OF    THE    AXILLARY    ARTKRY. 


235 


bceo  HgBtDred  or  not;  it  is  the  caee  of  diffuse  aQeurism  of  the  armpit,  with 
tbresleoed  ur  actual  gangrene  of  the  limb. 

Ligature  of  the  Axillary  Artery. — Should  ligature  of  the  axillary  artery 
ml  MDj  time  be  required,  the  vessel  may  be  secured  in  one  of  two  situations, 
in  the  fpece  that  intervenes  between  the  lower  margin  of  the  clavicle  above 
the  pectoralts  mioor,  or  in  the  axilla  as  it  lies  on  the  tendno  of  the  latit-si- 
muf  dnrei. 

To  expnee  the  arterr  above  the  pectoralis  minor,  the  shoulder  must  be 
puehed  upwards  and  aflowed  to  fall  backwards  as  far  as  possible.  An  incis- 
100  b  then  made,  slightly  curved  with  its  concavity  upwards,  commencing 
immediately  above  and  internal  to  the  tip  of  the  curacoid  process,  and  ter- 
minaiiog  immediately  below  the  clavicle,  and  about  one  inch  from  thesterno- 
davicular  articulation.  The  skin  and  fat  are  divided  in  the  first  incision, 
and  the  pectoralis  major  exposed.  The  fibres  of  the  muscle  are  separated  in 
the  ioDer  end  of  the  wound,  and  the  finger  introduced  into  the  space  be- 
neath ^iding  a  probe-pointed  bistoury,  with  which  the  remainder  of  the 
motde  is  rapidly  divided  throughout  the  whole  length  of  the  wound.  In 
doing  this,  several  lai^  branches  of  the  acromio- thoracic  artery  are  divided 
and  must  be  tied  at  once.  The  next  rallying  point  is  the  upper  border  of 
the  pectoralis  minor.  This  must  be  found  by  tearing  through  some  loose 
arwlar  tissue  with  the  forceps  and  a  steel  director,  so  as  not  to  wound  the 
branches  of  the  acromio-thoracic  artery  and  vein.  The  cephalic  vein  lies  at 
tbe  oater  aogie  of  the  wound,  and  is  usually  not  seen.  \Vhen  the  pectoralis 
minor  ia  found,  it  must  be  drawn  downwards  with  a  copper  spatula.  In  so 
dcnng,  tbe  coslo-coracoid  membrane  beneath  which  the  artery  lies  is  brought 
fnlly  into  view.  This  membrane  is  seldom  sufficiently  distinct  to  be  recog- 
nized aa  a  definite  structure,  and  it  can  readily  be  torn  through  with  a  pair 
of  furcepa  and  the  steel  director.     It  is  perforated  by  the  acromio-thoracic 


Tig.  i-\.  —  bikgram  of  Ligaturacif  the  Fimt  I'art 
«!  tbr  Right  AtilUrj  Arrerv.  ji.m.a.  Pcrtrirm- 
-.»  aajur.  the  fibrri  )r]ianite(l  in  the  mner  half 
v!  ifac  «''UDi  adJ  (liridcil  in  Ibe  outer:  p.m.i. 
Part.ralit  ainnr:  o.r.  .ieruniio-thurncic  urtery 
•ad  T*in;  o.r.  AiilJarf  reio ;  a.  Axillae}' 
wtM-j  ;   II.  ItracbisI  |ileiui. 


FiK.  4S2. — Itiugrnm  nf  T.igiiture  of 
the  Axillary  Artery  in  iti  lower 
third.  r,'>.  Coruco-bmchialid  :  in.ii. 
Median  Derve;  ii.ii.  I'lnar  nerve: 
I. CM.  Internal  cutuneoii?  nerve : 
r.  Vein  :  'i.  Artery. 


artery  and  vein,  and  the  external  anterior  thoracic  nrrve.  These  will  be 
Ktn  mi  thf  areolar  tissue  is  torn  through,  and  vrnMri  be  drawn  inwar(I.<  with 
abluDi  hiK»k.  In  the  living  body  the  vein  next  cnnui'  into  view,  and  must 
be  drawn  inwards,  when  the  artery  will  be  seen  Ii>  its  nutcr  siiU',  The  in-odle 
miut  t«e  pHsseat  from  the  vi-in  ami  us  nvar  tlie  ctuvii'li'  i\^  po.ssil)le,  well  iibuvc 
the  r.riirin  of  the  acromio-tlioracii'.  If  it  is  |>(i,sjiil)lc  In  lie  oiilv  in  cluife 
pp.xiniiiy  to  thiit  branch,  it  would  be  safer  tn  apply  u  li^iiturc  to  it  aUo.  In 
ptaciL-iug  the  o|»eration  on  (he  dead  body,  the  vein  oftiii  is  not  seen,  iind  it 


238 


SPXCIAL   A>*GVBI9M9. 


b  customary  to  6n(!  the  nrterr  hy  followin;;;  r.hc  flfniiiiio-thorsric  lo  ita  origia. 
There  is  liuU  rUk  of  including;  a  conl  of  tlie  brachiftl  pli^xits,  lu  the  Dcrm 
lie  well  lo  the  coracnid  v'ulv,  iwpHrnted  by  a  Blij;hl  interval  (n>ni  tba  mritrj. 
It  U  frequently  found  io  the  dead  body  that  the  ligature  hu  bvea  appIiM 
above  the  lower  border  of  the  first  rib,  the  end  of  the  aubolariui  Mng 
aotuallr  the  reevel  tied.  This  operatioa  ia  a  very  ditficult  oDe,  OD  aoeovat 
of  the  (lepth  of  the  wound  as  well  n«  from  the  embarruameot  occanooBd  I7 
the  Dumeroua  venous  and  arterial  bniiiche§  which  raniifyaeroai  th«  fpaea  b 
which  the  veascl  lies,  and  li^ture  of  the  third  part  of  the  sabctavimu  m  ta 
be  preferred  to  it  whenever  it  ia  practicable. 

If  it  is  neccBsary  to  tie  the  axdiary,  aa  in  the  case  of  a  puucuired  woand, 
the  oporatioD  rcaimoieDded  by  Quthrio  ig  probably  safer  and  simplpr  tkaa 
that  just  described.  It  cotuiata  in  making  au  ini-iaiuo  from  the  centre  uflbt 
claviclti  directly  dowDwurd^,  in  the  course  of  the  veasda,  to  the  luidille  of  tba 
anii^rior  fold  of  the  axilla.  lu  this  way  the  akin,  euporticiul  fascia,  and 
grenter  pectoral  muscle,  must  be  aueceseivoly  divided.  The  leawr  perioral 
will  then  be  expoa«l ;  and  the  artery  may  lie  lifi^ntiired  above  ur  bemw  thit. 
without  further  division  of  miiacular  BubstaDce,  or  if  it  be  thought  dc*irabl« 
todeligate  it  under  this,  the  niuacle  must  be  cAUlioualy  cut  thrt)Uj7h.  \^*Iicd 
this  is  done,  a  very  di<itin^t  and  firm  fascia  will  came  into  view  ;  this  miut  be 
picked  ap  and  cnrefnily  opened,  when  the  artery  and  vein  will  be  teen  tyiof 
parallel  to  one  another,  thi;  artery  being  t^o  the  outer  Aide.  The  vein  bavtae 
neen  drawn  inwards,  the  aneurism- needle  niiiat  be-  carried  belwern  it  and 
the  artery-  The  second  part  of  the  artery  has  the  thre«  coril*  of  the  brachial 
plexus  in  close  contact  with  it,  tlie  inner  lying  between  it  and  the  veto.  Ai 
the  lotrer  border  of  the  pectoralis  minor  the  inner  bend  of  the  median  croMti 
tb«  artery.  Care  must  oe  taken  not  to  ioclude  thea«  nerve«  in  the  Mgattm. 
The  gnai  advantage  of  this  operation  is,  that  tlie  wound  is  o|>ea  and  fr«e, 
and  tliat,  conaequeutly,  the  artery  cau  be  more  readily  reached  in  any  part 
of  its  course.  The  disadvantage  is  the  great  divtsiou  of  muscular  Bulntaace 
that  it  entails.  This,  however,  need  not  leave  tiuy  permuneot  weakoeMof 
the  limb,  aa  by  proper  positiuu  ready  and  direct'  union  may  be  effMied 
between  the  imrts- 

Tbe  axillary  artery  may  also  be  lifraturod  at  any  point  below  the  lover 
border  of  tbe  pectoralis  minor,  by  maKing  an  inctaion  pnratli-t  to  its  coune 
in  the  axilla.  The  )^iding  tine  for  the  v«w;l  in  tUia  situation  u  obtained 
by  dividing  the  8|>ace  between  the  anltirior  ami  [losterior  folib  of  Uic  axilla 
into  three  eoual  part?,  when  the  artery  will  be  found  lo  lie  at  the  juoriidO 
uf  the  nntenor  with  the  middle  tliinl.  The  arm  being  held  at  an  obtuse 
angle  with  the  tnink.so  as  to  utako  tbe  akia  tetue,  an  incision  b 
ooramenciug  at  the  thoracic  liorder  of  the  axilla  and  extending  for  a 
nf  abont  three  inchf^  parallel  ti»  the  e(iurM>  of  tbcnrtery.  The  iocuioD 
be  made  so  oa  to  divide  the  tikin  only.  The  fascia,  being  expoaedf  nid: 
earel'ully  o[>ened,  when  (lie  Hxilliiry  rein  will  come  into  view,  and 

drawn  to  one  side  with  a  blunt  hook.     The  artery  will  now  Iwseen  su  

by  the  nerves  of  tbe  bmchini  plexua.  In  front  of  it  or  to  ita  inner  side  ff 
the  internal  cutaneous.  To  its  inner  side  Ih  twei-n  it  and  tbe  vi-in  is  ll»e 
ulnar;  the  ntrve  of  Wrtidwri^  ij-  still  further  internal,  Hsinillr  bfvnnd  the 
vein.  To  tbe  outer  side  is  the  median,  »nd  for  a  abort  dietanw  nln'Te  llw 
external  cutaneous  lien  nn  the  same  aide  of  the  vesael  before  entering  tbe 
oomco-brachialis.  Ijehind  ia  the  muaculo-tipiral,  and  aa  far  at  the  upper 
border  of  tbe  teres  major,  tbe  circumflex.  The  nerve*  are  easily  held  aside, 
and  the  li^iurc  is  paaK<l  round  the  artery  from  therein.  If  tbe  ligature 
be  applied  near  tbe  termination  nf  the  axillary'  artery,  as  it  lies  over  the 
ttiudomi  of  the  Intiasimua  dorsi  and  teres  major,  it  will  not  be  in  iBBinadiata 


AWXffBIftX    OP   THE    ARM,  rOBBABlC,  AND    BAXD.        237 


llT  lo  aor  \aryt'  lirancli.  Ahitvi;  this  point,  it  mostt  he  npplled  cloM 
ik«  »ulnu'ii|>iilur  or  the  circumtlex  arLeries,  *hw\i  would  perbap* 
■NBdwhal  uM  to  thv  tlnoger  of  seoondary  hemorrhage.  Iti  a  fat  axilla 
ibKfv  ts  Mthie  rUk  of  miwitne  the  artery  hy  <lri(liiig  too  much  towards  the 
pMter:  r  of  the  axilla.     To  nvoid  thia,  aud  also  to  get  rid  of  the  in* 

9^-—-  i'-l  l»y  ihe  sitimtiort  ot'  the  veiu  coveriog  the  artery,  Mal- 

(i.  •   itiat  the  iiicixiou  sbuuld   be  lunde  a  little  oear>>r  the 

amiit..-.  .n.^,,. ,  ...  Utc  Bxillu,  and  the  edge  of  the  coracobravliialia  nought 
m  lb*  first  rslt yioi;  [i<-<int.  Wbeu  thin  la  TouDd.  it  ia  drawn  slijibtly  forwards, 
•fcaa  Uw  uwdiao  ucrvv  will  be  seen  ia  contact  wilh  it.  If  liiis  be  dmwii  on 
warn  aide.  Xhm  arterr  at  onoe  oomee  into  view.  By  thio  method  ihe  artery  cao 
bs  lied  without  the  vein  Uriug  oeeu,  aud  it  ifi  iupusAible  to  mti«  the 
hy  gcttiD^  t^K>  far  to  the  iuner  side.  Ligature  of  the  axillary  i»  very 
njdjr  r«i|nirvd  for  aueurism.  It  haa  be«u  duue  aa  a  distal  op^ratiou  fur  Bub> 
dttTtaa  aoeuriam,  but  wiibuut  aucccM. 

AXBrmau  or  the  abu,  forearm,  ako  band. 


SpaaUaeoBR  atieurisni  rarely  occurs  bclrtv  the  axilla,  yet  it  may  occa- 
ifaHMlly  be  neC  with  at  any  port  of  the  appcr  extremity.  Thue  Palletta, 
Flaiam,  Pdletao,  and  othora,  relate  cues  ol  spoutaneoua  aneurtara  at  the 
hMd  of  Um  arm ;  and  L^iaton  itates  that  he  once  tied  the  brachial  artery  in 
■a  old  sbip-earpeaier,  who,  whilst  at  woric,  felt  a»  if  something  bad  snapped 
im  hb  arm.  Pilcher  hat  recorded  a  rase  of  aneurism  under  tlie  ball  of  the 
ligbi  Utovb,  vbicfa  vai  produced  by  repeated  though  slight  blowM  with  the 
kandle  of  a  bamner  mea  by  the  patient  (a  working  goldsmith )  in  ha  tradti ; 
tbe  mdial  and  ulnar  aricric*  were  tied  immediately  above  the  wrist,  and  the 
Ammt  vae  tbua  cured.  Aneuriani  has  alxi  been  met  with  in  this  aituatioa 
after  aCtempled  rcductioo  of  a  dialocation  of  the  thumb.  In  the  Museum  of 
tbe  Cvllcge  of  iSurgeoiis  there  it  a  preparation  of  a  radial  artery  with  a  small 
■MeriHB.  about  tb«  tliird  of  au  inch  in  diameter,  formed  by  the  dilatation 
«f  all  cbe  ooale  of  a  narrow  purtioo  of  one-half  the  circuDilereocc  of  the 
vi^bI.  a  liUk  above  the  origin  of  the  BUperficialie  volie.  .Spouiancuua  aneu- 
rMo  ia  the  Sanum  u  of  extremely  rare  ooourrenoe.  Todd  and  Arnolt  (at 
Catwniljr  ColLefC  Hoeuital)  have  both  Ncceasfully  tied  the  brachial  for 
Doua  aaenriau  ot  the  liirearm — in  il£  upper  third.  DeMorgau  reconla 
of  Sfwataneoua  aotiurisui  uf  (ho  uluar,  and  Spautoo  one  of  the  rulial 
In  OMM  of  the  cases  iu  which  tbe  brachial  artery  and  ita  primary 
hmrw  been  the  seat  of  sp«)ntaoeoue  aneurism,  diaeaeo  of  ine  heart 
■hI  mi  ibe  arterkl  lyBteni  in  nther  part£  hue  coexisted. 

While  ■pontaiieMa  aneurisms  are  ran.-  in  these  ttituatione,  the  traumatic 
feoH  of  tbe  dbeaee  an,  aa  has  already  iH^-n  stated  (vol.  i.  pp.  458,  4R.J),  of 
■an  ftii—>t  neoarrenoe,  and  may  rei]uire  ligature  of  the  hnirhial.  or  of 
oiWr  nf  the  BrtHiM  of  the  forearm. 

TiU-aTMEMT. — Id  ca«C9  of  aneurism  Ik-Iow  the  axilla,  direct  pressure  may 
W  cri«:d  with  atlvanlag^,  provide^i  the  tumor  be  of  small  sitx  and  unattended 
b»  ioflaminatioo  of  the  euperjat-eot  inleguments.  Compreasiou  of  the  trunk 
ti  the  arltry  above  the  tumor  i*  rarely  applicable,  on  account  of  the  pain 
tiMi  ii  ioduced  by  the  pre*Hum  upon  the  neigblxiring  nerrea,  which  cannot 
hi  ■slated  frt'io  ihe  artery.  Bi^idea  thi».  the  brachial  artery  is  fo  mobile, 
(^  tbe  fcunenw  so  small  and  n^und  a  bone,  that  the  verael  cannot  be 
g^Mij  aamunmBA  afaiusi  it  lur  any  length  of  time,  but  will  roll  away 

Eaader  uw  Drewur*;,  even  if  the  patit-nt  could  War  the  |iain  of  it.     The 
eadoB  ef  .LaBarch's  bandag«  under  ehtorofoim  iiiigbt  Iw  tried  iu  suit* 


2Sd 


8P8CIA.L    ANHDBISVS. 


Ligature  of  the  Brachial  Artery.— The  bracliinl  arter7  may  b«  lifnrtured 
in  thv  mS'Mlr  cj  ihf  arm.  which  is  considered  the  soiit  ufelecttou  of  thifluperv 
tion,  by  making  an  incision,  almul  three  inchos  long,  parallel  Lo  ami  upon 
the  iooer  cdgf  of  ihc  bic^pe  (^Pig.  483),  which  i;^  the  "  directing  Hue,"  »ai 
the  first  rallying  point;  the  fa^oia,  which  ia  expose*!,  must  be  upenrd  ea»- 
Aitlj  to  u  corrcdpundiog  exteot,  aad  the  edge  uf  the  bicepe  drawn  autwania 


Fig.  Its.— Um  of  Indrim  for  LiKstuni  of  Iha  Br««fcUl  in  tb*  aiMdta  at  ik*  wm, 

when  the  me-dian  nerre  will  rommonlr  he  ecen  crnaring  the  arlrrr;  IMk 
must  be  drawn  downward*  with  a  blunt  hook,  when  the  artery,  arconiMiilad 
by  its  two  vein*,  will  he  exposed;  these  vcttscU  must  then  be  «>pnriiLeil  UftM 
■>ne  another,  and  the  li|<atur«  panaed  and  tied  in  the  umial  war  In  P^''^^4|H 
ing  thiA  operation,  the  principal  point  to  nttend  to  it  to  cut  down  ii]>i>n  cla 
inner  edf^e  of  the  hicepo,  whlrh  will  t>e  the  sure  t^ide  Co  the  artery  i  Fi^ 
4M).  If  the  Surgeon  keep  too  low,  he  may  fnll  upon  th»  ulnar  otrn  aad 
the  basilic  vein,  whioli  niiuht  i*OMitily  be  miHiakeii  for  ihfr  brachial  arterv: 
by  takinj;  care  to  expose  the  fiom  of  the  bicepe  in  hie  early  inctaioo,  Ite  wlU 
avoid  iliM  error. 

The  fascin  over  the  raeiJiau  nerve  must  be  opened  tboroiiffhly,  oihennta 
the  artery  may  be  drawn  un  ouc  side  with  it  The  needle  moat  be  pamtd 
from  the  ucrve. 

lu  the  ttppiT  jtarf  of  the  arm  the  operation  for  ligature  of  the  brachial  b 
practically  ideutical  with  that  for  ilic  terminal  part  of  tha  axillary,  the 

inner  edge  of  the  curaco-brachialn  bring 

„  ^  taken  as  tbe  dtroctiug  line  anij  ifae  fint 

i-  -   _  rallying  poinL 

^-  -^^  A I  the  hrnd  of  the  Mow  the  brachial 

^^^fc  xrlcry  may  lie   reached   by  ninkine  an 

^^t  incirtion  about  twoinrhee  in  lrni:thdnwn- 

^^^^'^  Munl;'    and    outwards,    pnmlU-l    to   and 

inmieiliiitely  above   the    metlisn    basilic 

vein,  when  that  vessel  can  be  Mcn:  whm 

it  cannot,  the  inriaioD  mast  b«>  al  an 

anple  of  45"  with  tbe  line  of  tbe  limb. 

cnnifflencin);  alxiut  one  inch  exiemiil  to 

and  half  an  inch  al>o«e  the  tip  of  the 

inner  condyle  of  the  humerus,  and  ler> 

roinnting  al  tbe  outer  side  of  the  leodoa 

of  the  bieepa.      It  muH  not  be  earrietl  further  outwards  or  )be  median 

oephatie  vein  will  1h>  div'i<lr-i(.     If  \\\f  median  lutpilic  vein  is  seen,  it  must  be 

drawn  downward*  to  avoid  wiiiindiiig  cIm<  iilnnr  veins  which  entrr  it  below. 

As  t("in  a»  the  integurnenliil  structures  are  divided,  with  tbe  braiichea  of  tbe 

inlemal  cuUneous  ncrro,  the  strong  proceBs  from  tbe  tendon  of  the  bleepa  to 


J  I,      ■■■ " 

Pt(.  4S4.— DI»cruB  «r  lb*  p*rtt  ci>Been>«<l 
la  Llptar*  of  Ifat  Bn*h)«l  II  ibt  mid 
■II*  of  lb*  aria,       ■■  a,    MediaS  ntits 
drawn  lawftrUfi  A.  Ukav^ii  «.*.¥•&« 
dabIui  (  «.  hnokUl  *n«t]r. 


LIOATUBE    OF    RADIAL    AND    ULNAR    ARTERIES.  !289 

cbe  fiucia  of  the  forearm,  the  bicipital  fascia,  comes  into  view.  Tiiis  must 
be  carefully  divitled ;  the  artery  will  be  found  beneath,  having  the  biceps 
leoduD  to  iu  outer  side,  the  median  nerve  to  its  inuer  eide,  and  a  vena  comites 
on  each  side.  The  needle  must  be  passed  from  the  nerve.  It  sometimes 
bappena  that  the  operator  misses  the  artery  and  cornea  down  upon  the  bruch- 
taltt  amicus  which  lies  beneath  it  This  muscle  ia  readily  recognized  by  its 
nr&ce  being  composed  at  this  part  of  alternate  strips  of  tendon  and  muscular 
fibre?.  If  circumstances  require  the  operation  to  be  performed  a  little 
bii^ber  up.  the  edge  of  the  biceps  must  be  taken  as  the  guide,  as  in  the 
middlo  I't'  the  arm. 

Ligature  of  the  Radial  and  Ulnar  Arteries. — These  arteries  may  be  liga- 
turv^l  at  any  part  of  their  course,  but  the  operation  i:^  never  performed  above 
thr  middle  thinl  of,  the  arm  except  in  cases  of  direct  wound. 

The  Ulnar  Artery  above  the  wrist  may  be  readily  ligatured  by  making 
an  incision  (Fig.  486)  about  two  inches  iu  length  along  the  outer  side  of  the 
tendon  of  the  nezor  carpi  uluaris,  which  is  the  directing  line  to  the  vessel. 
Tbe  incision  should  terminate  about  half  an  inch  above  the  pisiform  bone. 
If  the  eilgt:  of  the  tendon  cannot  be  clearly  felt,  the  incision  must  be  made 
in  tbe  line  of  the  artery.  This  is  liiund  by  draw- 
ing a  straight  line  from  the  tip  of  the  inner  con- 
dyle of  the  humerus  to  the  radial  edge  of  the  pisi- 
iltrm  bune.  The  6r»t  rallying- point  is  the  edge  of 
tbe  tendon  of  the  Aexor  ulnaris.  As  soon  as  this 
is  dearlv  exposed  it  must  be  drawn  inwards  with 
a  bluot  liook,  tbe  wrist  being  slightly  flexed  to  re- 
kx  tbe  mD«cie.     A  distinct  tascia,  usually  marked  ""-       ^  fCcM.1. 

by  trmosverse  fibres  tben  comes  into  view;  this  y.^  <8S.  — Diagrnm  of  ibe 
must  be  carefully  opened  and  the  artery  will  be  xrimr  ArtBrj  at  the  Wri»t. 
feand  beneath,  accompanied  by  a  vein  on  each  side  jir.t»h.  Flexor  Rnbiimta  di- 
and  tbe  ulnar  nerve  to  the  ulnar  side  (Fig.  485).  gitorum:  fi.c.Hi.  Fieior 
Tbe  needle  must  be  passed  from  the  inner  side.  orpi  uimris:  rx.  Vdnc 
Tbe  artery  lies  between  the  tendons  of  the  flexor  <■.  Arury. 
carpi  ulnaris  and  of  the  flexor  digitorum  subliniis 

and  up<>D  those  of  tbe  flexor  profundus.  The  mistake  most  likely  to  be  made 
is  carrying  the  incision  too  far  inwanls  so  as  to  miss  the  tendon  ;  the  error  is 
Roignized  by  finding  fleshy  fibres  directed  downwards  and  inwards;  the 
tendon  is  to  the  radial  side  of  these. 

Li^tnre  of  the  Ulnar  Artery  in  the  Middle  of  the  Arm  is  a  more  trouble- 
fome  operation,  as  tbe  artery  lief>  deeply  on  the  flexor  pnifniidus  covered  by 
tbe  BUiterficial  muscles  of  the  Ibrearrii.  Ii  can,  however,  be  reat-hed  without 
difficultv  by  separating  the  flexor  carpi  ulnaris  from  the  contiguous  border 
of  the  nexor  digitonim  i>ublimi3. 

To  find  the  iutervul  between  these  two  muscles,  n  line  iiiuet  be  drawn  from 
the  tip  of  the  inner  condyle  of  the  bumcriit<  to  the  radial  edge  of  the  pisiform 
booe.  This  line  corres|>onds  to  the  outer  edge  of  the  flexor  carpi  uUiaria  and 
also,  in  its  lower  two-thinls.  to  tbe  course  uf  the  artery.  Tlic  upiKT  part  of 
tbe  artery  fiajises  beneath  the  superficial  muscles  of  the  foruarui  from  the 
middle  "f  tbe  hcilli>w  in  front  of  the  fureariii  to  the  junclion  of  the  upper  and 
middle  thirds  of  the  Hue  jur*t  mentioned.  The  operation  ie  thus  performed  : 
ibe  guiding  line  having  been  found,  an  incision  two  inches  in  length  is  iiiudc 
ia  it  f  Fig.  4bfi)  through  tbe  skin  and  fat.  A  white  line  comes  into  view 
fiinueil  bv  a  tew  tendinous  fibres  in  the  edge  of  the  flexor  ulntiris.  If  more 
than  ■'•ne  white  line  is  seen, a  piece  of  ligature  thread  may  be  placed  with  one 
cifi  on  tbe  inner  condyle,  and  the  other  on  the  radial  edge  of  the  ]>i:^ilnrm 
brjoe:  the  line  corrcapouding  to  this  U  the  one  sought  for.     Tbe  point  of  the 


SPECIAL    ANKDBISMB. 

luhlly  along  the  niilial  side  of  the  line,  Mftet  whtclite 

I  flexor  iilnarli  can  Uc  eosilr  Mjiarmud  villi  the  liuiiUtrf 

Tb*  ^ecli'in  of  the  tnlcrspuoc  is  tawarda  tlu-  ulna.     On  aiflr 

the  artery  may  a|ij)«Hr  at  onoe  with  a  rem  dd  each  nil 

:«a  Ute  fl<xnr  [ir»ruiuluri.    More  commonly  t)>e  ulnar  utrvi  it  Ant 

thii  comes  iiitu  view,  the  d>>xor  eublimii  mukt  be  nu««il  aid 

aiU.war<t»,  whco  the  &rt«ry  will  bt:  founil  comiDf;  out  fmni  b«iomtliii 

•»>»■  the  iit>rve  lower  down.    The  needle  must  be  |»aMed  fmni  thv  i&wr 


/Urd. 


Flf.  iM.^I,tiiw  of  Ia»|*t<ia  for  Uplur*  vf  tb*  Br*«bi«l  Artw?  bI  ibe  Vrnd  of  tb«  vlWv,  m4 

tb«  lUdlal  ktid  Vlami  ArtniM  Id  iba  fi-teanu  »iid  ■!  tba  wrUU 

V.  "^''^  comrann  error  Id  this  operation  coDBtstB  in  mtking  tiw  inc^Hon  too 
uucb  to  the  radial  side  and  openiug  the  ioterral  between  the  flexor  iiihlimu 
auil  the  palmaris  longus  by  mtBtake.  The  error  is  at  oao»  recognised  by 
Tir*"'  ''^**^  ""  '"'''"P"*  !*•***  tou-orda  the  radiiia  instead  of  the  oloa. 
The  Kadial  Artery  than  the  WriBt  may  be  ligatored  by  makio^  an 
mciBioD  about  one  and  a  half  to  two  inches  in  Icngtn,  a  quarter  of  an  inch 
out8id«  the  i«ndon  of  the  flexor  carpi  nidiali*— the  "directing  line;"  wben 
after  the  division  of  the  ^uperScial  and  deep  flMcis,  th* 
artery  accompanied  by  iUt  two  veins  will  be  expoeed 
(Fig.  487),  and  may  be  tied  in  the  uaual  vay.  Tbe 
artery  liea  bcttweeu  toe  tandooa  of  the  flexor  carpi  radi< 
alis  and  supinator  loogus,  and  in  separated. by  •ootc'  6U 
from  the  pronator  quadrntiifi. 

The  £adial  Artery  in  the  middle  of  the  Forearm  cao 
cwily  be  ligatured  by  an  incision  (Ftg.  486)  made  in  a 
lino  drawn  fruni  the  middle  of  the  hallow  in  fruot  of  t' 
elbow  tu  the  root  uf  the  styloid  prooem.  At  this  [tart 
is  overlapped  by  the  belly  of  the  supinator  longua. 
Ilee  on  the  insertion  of  the  prooator  leree.  The  iuci 
should  be  about  two  inches  in  length;  after  the  fiwcta 
divided  the  supinator  cumea  into  view,  its  internal  edM 
must  be  found  auil  the  muscle  tumetl  outwards,  A  dw- 
tind  bscia  is  found  beneath  it,  on  npeuing  which  the  art^^rj  mill  be  s«a 
with  a  vein  on  each  aide.  The  radini  nerve  ta  about  half  an  inch  to  ilie 
outer  side,  ami  iu  iiHuatly  not  seen. 

Lif^tnre  of  the  Uadiid  Artery  at  the  Wrist  hiu  »<)mt'tlm«  l>eea  done  ttr 
aneurbni  uf  the  palm,  but  in  ninn-  cuininunly  rci^uirod  for  wound.  Tba 
artery  at  this  luirt  of  itj  course  lies  deftly  on  the  extemal  laEeral  ligunent 
of  the  wrivL-Juiiit.  It  winds  round  the  lower  end  of  the  radius,  pasaiitc 
beneath  the  extensor  om'm  metacarpi  and  extensor  prim!  interno<lii  pnllkas, 
and  tfa«n  under  the  extctisor  sccundi  intemodiu  The  operaUon  is  |torfitrmed 
by  making  an  incision  from  (he  base  of  the  metacarpal  bone  of  the  thumb 


lk«    Rwlial    krimj. 
n4l»U*:  T.r.  V«la*i 


OP    THE    ABDOHINAL    AORTA — SYKPTOKS.  241 

btlke  pofterior  part  of  the  root  of  the  styloid  procesB  of  the  radiua  in  such 
■  nj  u  to  be  midwaj  between  the  teodoiis  of  the  extensors  of  the  firet  and 
NCBDd  phalmnm  of  the  thumb.  In  the  superficial  fat  will  be  found  the 
niial  vein  (which  must  not  be  mistaken  for  the  artery)  and  some  branches 
tftlie  radial  nerve.  A  fascia  extending  between  the  twu  tendons  is  then 
tonai  and  carefully  opened,  when  the  artery  will  be  seen  crossing  the  wound 
oUiquety  rather  towards  its  lower  end.  This  operation  should  never  be  per- 
kmei  in  preference  to  that  in  front  of  the  wrist,  as  it  is  more  difficult,  and 
ii  apt  to  leave  some  Btiffness  in  the  tendons  of  the  extensors  of  the  thumb.  ' 


CHAPTER    XLV. 

AXEUBISMS  OF  THE  ABDOMEN  AND  LOWER  EXTREMITIES. 
AITEUBIBM    OF  THE  ABDOHINAL  AORTA  AND  ITS  BRANCHES. 

As,  until  recently,  any  surgical  treatment  of  these  aneurisms  was  consid- 
ered impoenble,  they  were  left  entirely  in  the  bands  of  the  physician;  but 
■Dcc  the  introduction  of  compression  of  the  aorta  under  prolonged  anGosthe- 
■ia,  br  Murray,  of  Newcastle,  they  have  become  fairly  entitled  to  a  place  in 
a  woA  on  Surgery. 

Aanriam  may  affect  the  abdominal  aorta  at  any  part  of  ite  course,  but 
dw  moat  common  situation  is  near  the  origin  of  the  cceliac  axis ;  and  here 
tlM  diBease  is  often  not  confined  to  the  main  trunk,  but  one  or  more  of  the 
bcmncfaea  are  aleo  affected.  The  situation  next  in  order  of  frequency  is  at  or 
■tar  tlie  bifiircation.  Aneurisms  may  form  in  connection  also  with  any  of 
the  main  branches  of  the  abdominal  aorta,  most  frequently  on  the  superior 
■eMnteric,  splenic,  and  inferior  mesenteric.  The  aneurism  may  be  saccu- 
lated or  tubular.  When  growing  from  the  main  trunk,  it  is  usually  of  the 
fonDcr  variety. 

Stxptoms. — The  chief  sign  of  the  disease  is  the  existence  of  a  pulsating 
tQmor,  situated  in  or  near  the  middle  line,  somewhere  between  the  costal 
nargin  and  the  region  of  the  umbilicus.  The  pulsation  of  the  tumor  is  of 
the  expansile  kind  characteristic  of  aneurism,  and  there  is  frequently  a  dis- 
tiDCC  bruit.  Walshe  mentions  a  single  systolic  murmur,  a  dull  muftied  sys- 
tolie  sound  convertible  into  a  murmur  by  a  little  pressure,  a  sharp,  abrupt, 
ibort  systolic  murmur  on  the  letl  side  of  the  lumbar  spine,  a  systolic  mur- 
■or  audible  below  the  sac,  but  not  over  it,  and  occasionally  a  dull  8ecr)nd 
nand.  as  having  been  heard  in  various  cases  uf  abdominal  aneurism.  The 
exact  shape  and  size  of  the  tumor  and  the  nature  of  its  pulsation  can  in 
■any  cases  be  ascertained  only  by  fully  relaxing  the  abdominal  muscles  by 
the  use  of  chloroform.  The  sensation  of  pulsation  in  the  epigastrium  may 
be  Terr  perceptible  to  the  patient,  or  may  be  entirely  aWut.  Gmstant 
■duog' lumbar  pain  is  a  very  frequent  symptom.  The  pressure-signs  are  nut 
nwisllr  very  marked  till  late  in  the  disease.  Pressure  on  the  vena  cava  to 
iDch  an  extent  as  to  cause  cpdema  of  the  lower  extremities  is  almost  uu- 
ksown.  The  sac  may  press  on  the  lumbar  plexus,  and  give  rise  to  signs  of 
irritation  in  the  course  of  its  branches.  The  most  marked  of  these  are  pains 
m  the  groin  and  testicles  from  irritation  of  the  genito-crurul,  and  occasion- 

TOL.  II.— 16 


S4S 


9PE0IAL   ANRUmSMS. 


ally  shooting  pains  down  the  thigh,  in  the  course  of  the  nntfrior  oruTsl  or 
''^xteinftl  cuttineous  n^rve.  When  the  bodies  of  (he  verii?i>nf  an  •ttnifd, 
coiistHut  liimhHr  piii)  will  hv  tVecpiontly  prc^iil,  of  the  Minie  biirnii)]^,  boring 
character  ut  that  li'lt  in  thoracic  iiupurtsm  UDtltrr  Minitar  t*ircuiUF>lai)r<».  In 
■ome  CM»i»  Ihc  [ir<.iuinv  iimy  nilvcl  the  gruat  intestine,  cauainj2  cunMil^rmbl* 
difficulty  in  dereciilioii.  (>ci.-ii»ionn.lly  the  tumor  niav  atUiu  Ut  nn  eii«rmiHi0 
$\k  before  (teach,  half  filiing  ihe  cavit^r  nf  the  abilumen.  The  fatal  icrroiaa' 
tion  may  be  due  t^  uniilual  exhauBtien  from  pain  ami  interference  with  tlia 
fuuciiona  pf  tlie  abiioniinaJ  vivcera,  to  sudilen  rupture  of  the  sac  into  tlw 
peritoneum  or  Hibperitoueal  tinue,  orintosnuic  partof  the  alimeotarj  oaoal, 
or,  nii>re  rarvly,  into  the  pleural  cavity  through  the  diaphnigro. 

The  DiAUNUctiK  rests  coiefly  on  the  situation  of  the  tumor,  its  dtstinci  a- 
ipunile  pulaation,  the  existence  of  an  ancuristnal  bruit,  and  the  prcHUie- 
ugns.  Verv  marked  epiffostric  puhalion  is  not  nn  unfreqneni  symptan  ia 
amernic  piitients  eutfcriu);  from  ntonic  dyspepsia,  and  in  tbcee  caata  ytfj 
slight  prc»»ure  on  the  artery  from  a  stethoECopo  will  give  rise  to  a  iftttirt^ 
bruit.  L'nder  these  circiimstanci^.  it  is  aometimea  not  easy  lo  ipoak  paB> 
tively  n?  to  the  coiidiliim  of  the  artery,  hut  iu  the  majority  of  ouw  a  ou*- 
fut  examination  under  the  influence  of  chloroform  will  readily  dotal 
the  nature  of  the  diM-nsc.  A  dieptaeed  or  enlarged  heart  also  givn 
distinct  epigastric  pulsation,  but  this  can  hardly  be  mistaken  for  anec 
A  atUid  maat  offetxs  accumulau'd  in  the  transverse  colon  may  roceive  *  vflny' 
distinct  iropulae  from  the  aorta,  but  the  duuehy  feel  of  the  maaa,  ils  mfm^ 
ficial  nature,  and  the  history  of  the  caac,  will  usually  readily  detarauM 
its  nature.  A  prtyminent  lumbar  mnritbra  also  puabing  the  aorta  forwaid 
may  simulate  a  dilatation  of  the  artery.  Cantctout  tumbar  gtcmdM  aorround- 
ing  the  artery  may  give  rtfrc  to  cooftiderahic  difficulty  iu  diagnoaia;  and  bat* 
again  a  carel^il  exaroiualiun  under  cbUin>form  is  the  most  likely  uuana  of 
arriving  at  a  correct  conclusion.  Caneeroti*  tuinm-t  growing  from  the  ftpwai 
niav  give  rise  to  almost  insuperable  ditGculliei*  iu  the  diagnosis.  Front  fiuaasa 
of  the.  var'ni\i»  abdotuittal  viarern,  tlie  disgnusis  must  be  made  on  general  prino- 

Sles.  The  amount  of  fal  in  the  abdominal  walls  uecesBarily  baa  n  great  Ift- 
oeooe  on  the  diificultv  or  ease  uf  coming  to  a  definite  conctusion. 
TRfiATMKyr. — In  all  cases  of  aneurism  of  the  abdominal  aorta,  oonstiiu- 
tioual  Irentmeut  should  be  given  a  fair  trial  before  aoj'  more  wvcfe  meMiana 
are  adopted.  Tufnell  has  recorded  two  casea  in  which  a  cure  waa  eflhotoj 
by  diet  and  rest — in  one  case  in  21  dayii,  and  in  the  utber  37.  If  this  treat- 
ment fail,  the  only  resource  left  ia  oompreuion  of  the  abdominal  aorte. 
The.  piiiu  of  this  application  is  usually  very  iK-vere,  so  tlial,  in  ortli-^r  Ut  r^ 
lieve  it,  patients  should  l>e  kept  under  the  iutluvncv  uf  chlorufunn  for  many 
hours.  The  cnrdii  of  iutroduciug  this  mode  of  treatment  ia  nndiiubinllj 
due  to  Murmy,  of  Nt-wcostto-on-Tyue.  The  o|K>raii(iu  has  now  been  par 
formed  for  aortic  onpuriem  in  nine  cases.  In  fix,  undur  Murray,  OurbaM 
and  Mdxou,  Durham,  firee.nhow  and  Mulke.  Pollock,  and  8ir  .lamrv  Pagci, 
tile  [inKsure  \vu»  apfilied  on  the  proximal  side  uf  the  sac:  Of  ihcer,  tlima 
— Murray's,  Durham  and  MoxonV.  and  Oreenhow  and  Hulkc's— wen*  sue- 
ccasfut;  one,  Pollock's,  faikd;  and  two,  Durham's  seeondcftae,  and  Sir  JaoMB 
Paget'fl,  were  fatal.  In  throe  the  pressure  was  applied  OD  the  distal  aid*  of 
the  sac;  one,  under  Hrvani,  lerniiiiated  fatally,  and  the  other  two,  aodar 
Maraluill  and  Uarwell,  tJiiled.  In  every  case  the  pressure  had  bc<en  appli«d 
by  the  iuHtrument  known  in  this  country  as  Lister's  aortic  tourniquet.  That 
this  iu«trum<--ut  may  in  some  cases  be  fafely  apjiUed  to  the  alxlominal  aorta 
frotn  the  highest  point  at  which  the  artery  can  he  reached  to  ils  bifnrcaiiun, 
is  clearly  proved  )>y  results  of  the  caaw  above  mentioned.  In  Durham  and 
iiuxon's  case,  it  is  stated  that  "  by  poeitioniug  the  hotly  of  the  |iati«nt,  jusC 


or    THK    ABDOJUINAt,    AO  BTA'— TBB  ATM  BSfT. 


itafMca  TM  aflbnieil  for  tbv  iulrudurliun  of  Ihe  ^1  of  the  t4)urni- 
i^^H  brtweea  Uie  eanil&gtw  or  tii<;  rilis  ami  ilie  aneurism."  In  (_in>euh<>w 
uhI  BqILc'v  cue.  il  «a0  ii|>plie<l  luiilway  l>«(ween  (Ih*  xiphuid  cartilage  and 
nmbilirus.  iDinivdialely  above  the  tuniur.  That  three  uut  of  the  eight 
bavr  teraitnaled  faullyebowa.  however,  that  the  o|*eratioD  is  by  no 
deroiil  uf  danger.  Id  Polloek's  uasuwus^ful  vu^u  the  patient  suffered 
fhuB  hjemaltiria,  and  in  (treenhow's  caae  albumen  appeared  in  the  urine 
■ftar  Um  last  t>peraii<>n,  thii^  sliowiog  terious  interferenoe  with  the  circulation 
Ib  tba  kidnejr.  In  Marsliall's  caae  the  imtient  sulTireil  from  ret4.'tition  of 
mtittm  ftr  m>mc  days  nfl«-'r  one  oftoration,  probablr  from  some  iujury  to  the 
lljrpo|t«*tHr  pl«xu«.  Tn  Brraot's  caae  tiie  paa'tnartem  examination  showod 
biniai-  '  '<>-  meMntvry  and  iutctilinc  aiid  pentonlttg,  and  "the  tiaauea 
II  ^ipreawd  aorta  were  loaded  with  effusetl  blood."     In  Paget'! 

ai  had  formed  in  the  raefentcry,  peritouitis  had  been  gvt  up,  and 

itaric  artery  was  fimiid  lo  be  comprwed  and  floltcned.  and  embolic 

data  wtr*  found  in  itii  hraiichc*.     Id  Durham's  fatal  cam  there  wero  sigtu 
«f  braaiing  about  the  paocrest,  ami  the  aneurism  wua  found   lo  affect  tlie 
■HMrtMH  artery.     Tb*  time  duriag  which  the  presaure  ha^  been  maintained 
im  tmntd  cotuiderably.     Murray's  case  waa  cured  by  one  application  la^tin^ 
iva  bcmra;  Durham  and  Moxoa'a  in   10}  bouni;  Gre«nhow  aod   Hulke's, 
b«l2tfvaappliealioni  lasting  05  minute?,  4  hours,  aod  3  hours.     In  ManhaH'fl 
MM  iliatti  PTMaure  was  applied  without  serious  cnuseqiiencee,  ou  oue  occa- 
■ao  ior  lij  hours,  and  on  another  for  19  hoars.     Vomiting  has  been  found 
to  ba  a  trtmlileaome  cumplieaiion  in  several  vasea.     Of  the  sueceasful   auBS, 
IfntrnTN  is  the  ooly  one  io  which   ihe  pulsation  of  the  tumor  ceased  per- 
■^ntuir  imtnediiUelr  after  the  operation.     In  (ireenhow  and  Uulke'e  case 
ItimA  ool  tin&lly  disappear  till  ^me  days  after  the  last  npnlieation  of  the 
111 liii|iii il ;  and  in  Durham  and  Moxou'm,  akhou-;h  it  ceaftod  at  the  time,  it 
Mnmed   io  a  few  hours,  and  paraisteil   for  a  mouth  before  it   tiually  dis' 
■wiMn«1      Frun   iJie  above  caaM,  it  will   be  geeD  ihat  there  ia  abundant 
fndaaee  of  the  aafuty  of  the  proxitnai  operation,  aud  sufficient  probability 
-'  •nnceaa  to  ju.*ti|y  di  in  adopting  it  m  every  favorable  caaa.     Further 
oce  i«  r«>-{uiroa  before  abanduning  dUtat  preaiare  aa  absolutely  u»c)cu. 
tu  iSryaat's  filial  caae  the  uc  was  found  to  he  filled  with  firm  clot,  which 
VMS  cooaldered  to  have  been  sutBcient,  had  the  patient  lived,  to  have  cured 
tfea  anauriia.     In  Mar*h&ira  oaae  the  tumor  was  thought  to  be  slightly  more 
wRd  sAar  the  aperatioos,  but  no  permanent  cfToct  was  prodaoed.     The  dislal 
ofMfatioa.  bowerer,  does  not  aeem  a  very  hopeful  one.     The   nuniher  and 
mm  of  tba  brmodica  coming  ofl  from  the  aorta  at  it*  upper  part,  and  the 
fiafMMwy  with  which  the  «iKalic  axis  and  ila  large  branchcjiare  implicJiteti, 
B*  WT  aafhTorable  circumstancee   lor  distal  preMure.     The  anutomoeis  of 
Ibc  eolnilanil  veaseis  is,  moreover,  so  small  coniparwl  !■>  the  immense  ititer- 
witb  the  direct  circulation,  that  the  only  elfn:-t  of  fliutal   pre«8i)re 
be  fitr  maoy  hour*  greatly  to  increase  the  teneiou  in  the  vesseld  above. 
la  pcribmiiaK  the  opemtiou  of  oompression  of  the  aorta  uuder  proloiigod 
few  points  re4}uirF  npet-iitl  attention.     The  patient  should  be  fed 
tbe  day  before  the  operation.    Ou  the  day  of  the  operatiuu  he  should 
fluid  Dourtshmeat  only,  and  (he  bowels  should  be  well  emptied  by 
of  a   oo|i)oaa   enema.      The    touruiijuct  must   be  upplicd  with  the 
inunediatelv  above  the  tumor,  and  Mith  no  more  force  than  a 
itdy  iiiiwillji      H  much  force  be  rci|uirad  before  the  pulsation  in  the 
arterial  is  arreited.  it  is  probable  that  the  pad  of  the  tourni'juet  ta 
M*  in  tbe  right  ptaoe,  and  various  attempts   inUAt  be  made  till   the  b\kH  is 
fca^  wbare  the  aaalkai  amount  of  preasure  will  ctmtrol   the  circulalion. 
b  will  bv  Ibuftd  cunvenicot  to  insert  a  S'lfV  hollow  sponge  under  the  pad  of 


«4 


BPBOIAt.    ANIVSISBIB. 


1^  hMiRiKiart.  M  it  then  accotniu<xlatee  iteclf  tuore  mdil^  (o  tlie  faiti 
but II II  it  *"^  '^^  spinu.  I>urtng  ibc  ufwraliou  the  patienl  mutt  be  watebe4 
vtffT  Mrvfullv.  «nil  llie  iiiuriii(|Uet  elackriu-d  at  uDce  if  anv  aTmploiMflif 
ftilifw  >ni«'nr<'n<^  Obelinaie  vmiiiiiDg  may  render  thu  cuntiouaocv  of  tW 
t  -'n  inipouible.  It  is  difHciilt  to  say  whetbur  ibU  in  iliielo  prea>ofe«a 
l§fff»i»»tiMnic  or  to  ibe  influvoce  uf  tJie  chlurofurui.  During  ine  applic*- 
llm  ^  cbf  loarniqiiet,  it  h  aJvUable  to  bave  the  lower  liiulw  niiaed  ra  tW 
kl  aad  vamhIv  vnii)p«4l  in  oiUoa-woul,  ait  marked  coldocn  and  atiiom 
have  usually  been  noticed  arivr  the  conipreiebin  hsi  lasted  a  abort 
if  DfcMMry,  nutritive  eaetnata  and  brandy  may  be  admlniitTrd 
m^  lb«  aiMMthMia. 

INUL'INAL   ANCCRISM. 

Am  QiM  <'<*  Ing^uial  Aneurism  mar  arise  from  the  external  iliac,  or  fron 
|Wc(Mttnii)»  fcmurul  artvry  ;  lumt  truqueutly  it  spriae«  from  the  bitter,  and, 
'  laktM  K  dirvrlion  upwards,  )>UGbt.-8  ihc  ywrhimvuia  Lefon;  it,  and  thus  en- 
imnwCw  aonwwhnt  upou  tho  cuvily  of  the  alidonit^n.  The  an^urieni  a  cum- 
ImmW  of  the  circumscribed  tatse  variuly,  though  oonietiniM  tubular.  It 
ntrwtv,  if  ever,  l>ecome8  dltTiuwd,  for  the  reason  lonr  ago  pointed  out  by 
.  - '  ,  that  the  Ipmoral  artery,  above  the  edge  of  tne  mrturius  murde.  m 
hy  m  dense  a  shuath.  anil  Is  so  cloaely  bound  down  tu  the  wleb- 
CurMi^  lusoiii,  that,  when  dilated  into  an  aneurism,  it  does  not  reatUly  gtre 

SWiTt'tuii. — When  first  noticed. the  aneuriiim  isnfimAll.siifl,  comprmibla 
Univ>r,  wilb  jiuluitinn  and  bruit,  and  i»  generally  nltcnded  by  little  naia  or 
tuwasinnw-  It  rapidly  fnlnrg<>»,  however,  and  mnr  attain  a  conaiaerable 
<  MMt^itudf  ;  beiup  often  nimipuhat  lubiilaled  upon  the  surfare,  owtnz  to  the 
tuie<iual  i-iinstriction  exercised  on  it  by  the  fntteiie  under  which  it  ItcH.  At 
llic  'luuc  lime,  it  usually  becontea  more  solid  ■  and  the  puls&liun  in  H 
>>«  considerably,  iir  even  coaeeti  entirely.  A«  it  increases  in  aiae,  it 
....!.,  !.:;<;•«  the  iapbena  and  iVmoral  veins,  thus  giving  ri«j  lo  oedema  of  the 
limb:  and,  by  stretching  the  genito-cninl  and  some  of  the  bniochn  of  th* 
aalvrior  crural  nerve,  il  occasions  con^dernble  pain  in  the  tht^  and  leg. 

UlAOi(O0id.— The  diagnoeis  of  in^tuinal  aneurism  is  not  always  so  easy  at 
Might  at  first  ap|)eftr.  It  has  movt  frequently  been  confounded  with  abseni 
In  ibe  groin,  with  carcinomatous  tumora  in  this  rituation,  and  with  mtao- 
uwurism.  Tbv  diagno«bi  from  abgcesa  must  be  made  on  general  priuriplta: 
bat  in  tome  instancets  it  aiipeare  to  be  replete  with  difGeiilty,  as  there  are  ool 
lb  tew  caaca  on  record  in  wliich  uneurismp  in  this  situation  have  been  mislaliCB 
lUld  punctured  t'T  Hb»cv»eB,  no  error  that  has  three  times  fallen  under  mj 
jMmofaaervatioTi,  and  ono  which  has  in  everv  instance  proved  fatal.  The 
[  dinRnub  of  an  inguinal  auviiriem,  wdiditied  fiy  the  deposition  of  lamioBled 
flhiin.  and  pulnatiag  but  imli-itinuliy.  from  a  putsatitiy  tartomn  in  the  grain, 
k  lurrounded  by  the  grratetit  dJIhcuWv,  and  cannot,  I  believe,  frith  thenicanf 
we  at  present  ptwesB,  be  accomplisbeil  with  absolute  eeruinty.  The  fkct  of 
the  two  diftcnsce  having  in  two  inslancee  been  confounded  by  two  of  the  mosl 
dbtluguii»heil  Hurgeons  of  the  dav,  Hlanley  and  Byrne,  is  sufficient  eTidcnee 
of  the  difficulty  attending  tlwir  (liAgnoeiii. 

Tbeathknt. — It  occasionally  happens  that  inguinal  anenrtanu,  even  of  a 

very  large  size,  undergo  epontoneoiis  cure,  or  become  conaolidaud  by  direol 

prtature  citnjnined  with  coni<titutiunal  treatment;  but  these  iuitaooes  are  of 

I  neh  rare  occnrrcnoo,  that  such  n  result  cannot  Iw  relied  ou  in  any  iwe  ease. 

tCnmnrefsion  of  the  aorta  nnder  prolooged  annsthesia  has  of  late  years  baafl 

[fbund  so  successful,  that  in  do  case  uould  a  trial  of  it  be  omitted  wbai 


ILIAC — LIOATDRE    OK    THB    EXTERNAL    ILIAC. 


245 


povible  (see  p.  242).  Sbould  it  fail,  it  becomes  necessary  to  tie  the  vesBel 
ieading  to  the  sac.  lo  the  majority  of  instances  the  tumor,  though  it  may 
kave  encroached  OD  the  abdomen,  will  not  have  reached  too  high  for  the 
external  iliac  to  be  ligatured  ;  should  it  have  done  so,  however,  the  Surgeon 
mar  bare  to  tie  the  common  iliac  artery ;  but  in  some  instances  even  this 
Bay  not  be  practicable,  and  his  choice  must  lie  between  the  slender  chance 
oOned  by  constitutional  treatment,  and  the  fearful  alternative  of  ligaturing 
the  aorta. 

Ligmtnn  of  the  External  lUao  Artery. — There  arc  two  modes  of  tying 
the  external  iliac  artery — the  one  originally  practised  by  Abemethy,  con- 
■iderably  modified  by  Liaton;  and  the  other  introduced  by  Sir  A.  Cooper. 

Ahemeihya  modified  method  (Fig.  48S)  on  the  light  side  consists  in  com- 
meDciag  an  incision  at  a  point  about  one  inch  above  and  the  same  distance 


Fi(-  4Sd. — Ligktnre  or  the  Eilernal  IliiiC  b;  Abern«tbj'd  OperatioD,  modiBed. 

internal  to  the  anterior  superior  spinous  process  of  the  ilium,  carrying  it  in  a 
corved  direction,  with  the  convexity  outwards,  to  a  point  about  three-quarters 
of  an  inch  abt>ve  and  half  an  inch  external  to  the  middle  of  Poupart's  liga- 
tneoL  When  the  operation  is  on  the  left  siile  the  incision  should  bo  com- 
menced below  and  carried  upwards  between  the  two  points  mentioned.  The 
wmint]  thus  made  is  altogether  external  to  the  inguinal  cnnat  and  to  the  line 
of  tbe  epigastric,  and  above  and  internal  to  the  main  trunk  of  the  circumflex 
iliac  artery.  It  is  about  four  inches  in  Ien;,'th,  and,  if  necessary,  in  fat  sub- 
jects may  be  extended  at  the  upper  end.  After  cutting  through  the  skin  and 
taperficial  fascia,  the  tendon  of  the  exteriiHl  oblique  i?  carefully  tlivided,  as 
tsuch  %M  possible  in  the  line  of  its  fibres.     The  internal  oblique  and  trana- 


246 


SPECIAL    AKEDRISHS. 


vermtis  are  Dfxt  diviiletl  with  great  caution,  when  the  traiUTcnalM  iMida  it 
nacl>e<l.  uud  n;nigiii»!ii  Ity  itui  <liill  whit<^  iippeurance.  Benrath  tbb  wbb* 
brauc  there  is  nflf  ri  a  littlu  fat,  <¥]i<!<-tal  ly  at  the  Jnn-er  part  of  the  irooml.  A 
Itroail  piirlinii  of  the  fttfria,  at  thu  lower  end  of  the  wiiiiiif).  is  now  canifalljr 
I'nueti  with  the  force|ii!i,  and  rut  through  with  the  hUde  of  thewmlpel  ludon 
the  Bat.  A  bnmd  hernia-director  k  tbeo  introduced,  and  paned  uttdemmh 
it,  when  it  ehuuhl  l>e  laid  open  to  the  full  extent  of  the  wound.  In  doioglUi 
care  tnust  be  inkeQ  not  to  wound  the  peritoneum.  This  n  most  likelr  !■ 
happen  in  consequence  of  a  fold  of  that  membmno  overlapping  the  end  of 
the  director,  so  innt  the  knite  woundit  it  when  run  along  (he  grvtove.  T> 
avoid  this  it  is  safer  not  to  push  the  knife  auito  to  the  end  of  ifae  dirrctor 
The  risk  of  wounding  the  peritoneum  may  oe  also  avoided  br  uarinff  tbi 
tnuMT«tsa)is  fa^toia  with  the  tingere  jostcad  of  usine  ih«  koiRk  Bout  ikt 
.ftKiatmnsvor^aJiaand  fit8ciailiao&  arc  firmly  attached  to  Poupart'alif^ameat. 
Lh>  that  there  'a  no  ri«k  of  stripping  up  the  latlL-r  foAcia  in  «ucb  a  way  m  lit 
dijptocc  the  vesaeJs.  If  a  hole  be  made  io  the  faacia  trauBremali*  larga 
enough  to  admit  the  tipa  uf  the  two  forefingers,  it  will  be  found  alwayt  U 
tear  with  the  greatwt  ease  lo  the  full  extent  of  the  vtimuil.  When  lliit  is 
•ceonipliflhed  the  whole  inner  side  of  the  wound  is  drawn  inwards  and 
■lightly  downwards,  the  peritoneum  being  gently  teperated  fruiii  its  Ioum 
areolar  eoDnections  in  the  iliac  fo»a  by  the  Surgeon's  lingen;  tl  must  be  kept 
out  of  the  way  by  an  aseistant.  who  holds  it  up  with  a  brood  bent  copper 
spatula.  The  arterv  will  Dow  be  felt  pulsating  at  the  brim  of  the  pvl vis,  and 
is  readily  brought  into  view  at  the  bottom  of  the  nound.  It  is  escloeed  tD  K 
very  loose  areolar  f<healli,  and  has  the  vein  lying  to  ite  toDer  aide  uid  tin 
genital  hmnch  of  the  ;;euit'>-crtiral  n|>ipn  it.  It  h  crossed  near  Poupart's 
,  flgament  by  the  circunitlex  iliiic  vein.  The  investing  areolar  tissue  must  bv 
'scratched  through,  mid  the  ncedti;  pfuscd  from  the  inner  side  iM-twera 
tba  vcsscU.  When  the  vessel  is  much  dimaaed,  it  is  utUiu  very  loriuouv,  and 
may  dip  down  iul^)  the  pelvis  so  aa  to  make  it  difficult  to  uxpuee  it  except 
close  to  its  lower  end.  Orcasionully  cnlurgctl  glnnde  round  itie  artery  ^19 
•ome  trouble  by  obscuring  it  and  rendering  it  (fifficult  to  clean. 

In  Sir  AtUty  O>oper'$  opcraiion  the  outer  two-thinlti  of  the  ingninnl  canal 
are  opened.  An  incision  is  made  about  three  inches  in  Irngtli.  Itrginning 
oloae  to  Poupart's  llgtiment,  aboiil  half  an  inch  outside  the  external  aWlomiiuu 
ring,  and  terminating  about  one  inch  intf^rnal  to  the  anterior  sup^'rior  opiooiM 
'nrooeaB  of  the  ilium.  The  line  of  incision  is  not  quite  parallel  to  Poupart'a 
lijjament,  but  rather  to  the  tibres  nf  the  tendon  of  the  external  oblique.  Is 
dividing  the  Auperlicial  fascia,  the  luperticial  epigastric  artery  is  cut  and  most 
be  lig»lure«l.  The  external  oblii|u«  having  lieen  exposed,  asaiall  liole  is 
through  the  tetidon  at  the  lower  end  of  the  wound,  and  a  direi^tor  inserted 
which  it  is  divided  to  the  full  extent  of  the  wound,  taking  «aretu  cut  exscll? 
parallel  to  the  lihree  to  ue  to  injure  the  tendon  as  little  as  potsible.  The  knife 
niav  now  lie  laid  aside,  themibsequeut  eteiis  of  thv  oix-nition  being  cnrrird  out 
with  a  steel  rlircclor  and  the  force{>8.  'Iho  divided  tendon  of  ihr  vxtrmal 
obliiiue  being  held  open  with  blunt  hooks,  the  cunl,  Burrotmdn)  by  tbt 
Oreniasler,  and  tlio  lower  edge  of  the  internal  oblique  come  into  view.  Soma 
looee  areolar  tisme  aud  a  few  fihref^  of  the  rrcmanter  muul  now  bi'  Fcratcbed 
through,  elupe  to  Pnupurl'ti  lignnient,  and  the  Rngrr  pnsBctl  bcni'ath  thea>rd, 
which  muKt  be  pushed  upwanh*.  The  iran^venutliii  farcin  in  thro  carrrullr 
torn  through  with  the  director  anil  forcepe,  nnd  the  artery  can  then  be  fait 
ivovered  by  a  little  &l  and  areolar  liseue.  Two  copper  spaiulu'  are  then 
{aaerled  through  the  opening  in  the  tranaverealis  fascia ;  the  internal  of 
'Ib  drawn  upwnrdit  and  inwards,  rabing  the  oord  and  drawing  the  epi^ 
artery  out  of  the  way;  the  external  pulls  the  lower  border  of  the  iniem: 


must 


HBTBOtiS   or    TVt.VO    KXTBftSAL    ILIAC.  247 

ohliqac  intl  of  the  trflosireiiKlifl  apwartlfl  and  nutwMnli).  Both  npatolip  ratM 
liw  p«ritooeDm.  Bv  i'l«sriji£a«ny  a  litllc  loofte  areolar  tiMue,  the  artery  can 
h«  mxpam  i  for  «De  itteb  ana  a  half  or  two  inrhes  withniil  diffictilty.  It  ha« 
iW  genital  braodi  of  the  j^nil'vcrunil  lyiii^  on  it,  am]  U  in  crossed  by  tlie 
dnmBflcx  Uia«  v±iu  a  liltle  above  Poupart's  lif^tnfnl ;  the  external  iliac  vein 
■  Id  it!  inner  aide;  thtae  nuMt  be  careftillr  avoided.  The  needle  roust  be 
pand  from  the  iani*r  aide  not  lew  than  one  inch  ahore  Poupnrt'fl  ti}|rument, 
•»H  In  mrtM  the  epij^tric  and  circumflex  iliac  arteries.  After  the  opera- 
das  ft  (Iraina^fivtube  may  be  inserted  nt  the  lower  auijle  of  the  wound,  and  a 
Miciit  auture  iiiftertt^l  in  the  divided  tendon  of  the  external  oblique. 

Cn  eiMupuriDi;  the  two  o(>eratioQ»,  it  wuuld  appear  that  the  principal  di»- 
adranUf^  of  AbemethyV  i*,  that  it  \»  apt  to  leave  a  temleucy  to  nernial 
pnitniuon,  in  n"n*^(ueocw  of  tlic  abdominal  n'ull  being  much  «v««kea«d  by 
tW  fr-  -  '>int  nrv  ii«!c«Bary  tbruui'li  tbti  muwular  planes;  the  great 

>dvmi>  Nt.' it  i»,  that  the  external  iliiu.Muuy  be  liKiitured  at  any  part 

«f  ito  iwurw.  and  that,  if  r«t)uieite.  the  iocisiua  may  be  extended  upwards, 
•ad  iW  ooramoD  truuk  secured.  In  8ir  A.  Coopers  operation,  the  lint-  uf 
iadiiaa  lies  directiv  acrom  the  oiurse  of  the  epiffai^trio  artery,  which,  aa  welt 
mtkm  eirmtnflex  ilii,  if  it  ariite  hi^h.  an<)  the  circumSex  vein,  which  erosaea 
ibe  iliac  arlery  at  this  ttotnl.  and  ii^  otWn  anniewhat  funoel-shapeil,  tuny  be  iu 
dufcf  of  being  Kounue«).  The  ttpermatio  oonl  is  Itkewtae  anmewbat  in  the 
waj  IB  this  operation.  Dupuytren  artunlly  woanded  the  epiga.stric  artery  iu 
mm  case;  aad  Houston  had  much  difficulty  from  the  circumflex  vein  in 
Mother  iostanoe.  This  operation  has  also  the  disadvantage,  that  the  incision 
■|Manb  ouinol  be  convenienll y  prolonpet^I  so  as  to  deligate  any  portinn  of  the 
1  except  that  which  lies  immediately  above  the  eriiral  nroh ;  hut  the  peri- 
ia  MM  diatitrlted  than  in  the  other  case,  and  there  is  less  tendency  to 
pratniiion  afterwards.  .-Va  a  t:;eneral  rule,  I  think  we  may  eonofude 
Am;  Id  caaa  of  spontaneous  aneurkm,  in  which  it  might,  fVom  the  size  of  the 
naar  or  tka  diwased  state  nf  the  vcaseU,  he  found  neeenary  to  applf 
Ae  Ugawre  to  a  higher  point  than  wiu  intended  before  the  opL-ratiiin  com- 
nsacM,  il  will  Iw  safer  td  have  recourse  (o  Abernelhy's  plan,  niO'liBed 
a*  abnre  dewribrd,  for  in  this  way  we  aball  be  able  to  liffslure  the  veswel  at 
aay  part  fjf  it*  c^iarK;  whilst  in  ca»e«  of  bemorrba^  after  nmputatioo,  or 
of  tnHinuiticfoitKinil  aneurism.in  which  the  artery  is  ngt  likely  tt}  be  diseased, 
raeeane  sboald  be  had  to  CVwper's  operation,  more  particularly  if  the 
|mImC  be  thin,  and  the  abdotncn  flat. 

la  ooiuMctioa  with  the  ligature  of  the  external  iliac  artery,  there  are  some 
pHMlieal  poiatB  that  deserve  mention.  Before  the  operntioQ.  the  colon 
AaaU  be  anptied  by  mean^  of  an  tnemn.  and  the  pubes  shaved.  The 
tadMOB  is  thtt  abdominal  wall  must  be  Budiriently  exLcnaivc. 

la  Abemethy's  method,  modillcd  ns  above  described,  there  ts  no  fear  of 
waBdiairtbe  digastric  unless  the  inciaion  be  carried  too  far  at  its  lower  end. 
Tbe  aitary  may  be  ruuf^hlysaid  to  run  in  n  line  dran'n  fmmn  point  at  which 
ibe  AsBoial  anerv  oruasca  the  brim  of  the  pelvis  to  the  untbilieus.  In 
aaithsr  oMCbod  of^otwratiug  should  the  inri^iion  implieatJi  the  external  ring, 
U«  It  jcivv  rise  to  a  tendency  Lo  hernial  proiriiatou.  ('are  should  ho  taken 
act  to  woaad  the  peritoneum;  for,  alth-»ugh  two  patients  in  whom  this  was 
4aae  by  P<hC  and  Tait  both  recovertNl,  yet  il  is  uf  course  a  daiij^erous 
■wiJin'l.  and  ah-iuld,  if  poMible,  be  avoid^.  The  peritoneum  must  not  be 
tiiffa  ttp  tnofff  than  (>  anMilutrlv  neceKtary,  lest  hemorrhaife  or  subsequent 
pariliMkitti  ucvur.  In  rntsio);  llie  (leriloiieum,  care  mu!>c  be  taken  not  to  di*- 
ajMaa  fh«-    <  '•'  li   lin;   1(hm'Iy  in   the   Mibjieritoneal    tiMUe.  and  can 

■SMmIt  ■  -|>nluln.  or  pti»h«<)  over  the  brim  of  the  pelvis.     The 

■yaietfiin  <>i  Utc  pvriuitivum  i»  much  facilitatvd  by  the  Surgeon  holding  the 


;:z=-^     i^'ic; 


.    .rr-.   an.   nm 


t.  '      .    .rsi:  a  .r 


:-.-.—  ::.r  ria- 

"_      --■        UiSf  » 
:.  :  --.;:■  II.     .1^ 

,.*:      ..-■    .pfn.-.i  a 

:    -     ..'  |i:      is*- 

i  ■  :;.;;.!-  ti  j. 
:.:.:.:  .|  .i.i.  .5:^ 
■■:.";i.    Ii-i.l'::l.   :iAT 


.■l;.-- 


SgSULTS   or    TYlSa    TBI    COUHON   ILIAO. 


249 


B**  •utwtirs  wtib  Banrell's  sunplpmentarf  cfl»s  give  •omenhat  dif- 

mulu.     ileninrrhai^e  occurred  in  '24  of  tbe   141   cases;  of  tbesc,  9 

and   IS  di«xL     Gangrent^  trna  tntnl  in  0,  peritonitis  in  2,  retro- 

•upfiuration   in  2,  and  various  ol.tier  caiues  In  tbe  remaiaiog  6, 

tiafC  a  Uital  of  31  dmthn  in  llie  141  cases. 

liicalurv  nf  the  pxiertml  iliac  for  aueurumal  varix  in  the  oroin  afifurds 
'^-ifC  oiotrasi  with  that  for  »pontAneoua  aoearism;  the  fuur  casea 
ill  (imvin^  filial,  two  'tyinjj  of  (rnnKTene  and  two  of  hemorrhage. 
cmM«Gurbrie  h«!!  rvcoinuii-tMlcd  tbat  tb«  tumor  aboulil  be  laid  upon, 
Uiv  art«t7  li);aLur»l  above  and  below  the 
turv  ID  iL  Duriu];;  the  operatioa  tb«  artery 
W  mdilr  comm&ndvd  above  the  seat  of 
by  the  np|ilicKtt(>D  of  the  abdomipal  tounii- 
,  «UMr  to  the  aorta  or  to  the  ooiumou  iliac  at 
tbria  of  the  ftp!  vie. 
iMuriacD  ODcaiMuiiKlly  lakes  place  m  tM  groin 
of  the  amne  ride;  here  the  ligature  uf  the 
■Ucfval  iliac  will  cure  both  diseaaee.  Of  four 
«Hi  in  which  thia  oomplicntioa  occurred,  the 
vfumiion  waa  f ucceasful  in  three,  one  patient  dying 
«f  yaagrese:  and  in  him  the  popliteal  aneuriam 
«ai  m  tlie  point  of  bursting  at  the  time  of  tbe 
ifUBliiiii.  In  two  of  the  three  cuBm  that  re- 
—WW J.  pulMlion  rftumed  in  the  inguinal  aneu- 
liiM^  Imi  dtnpMared  aAf  r  a  time. 

LifBtu*  of  ae  Common  Iliae. — This  artery  was 
icM  lied  br  Gihaon,  in  a  case  of  gunshot  injury, 
iIm  patiest  dying  of  iieritoniiis  and  secondary 
tWMinliaiia  oa  t^e  thmeeuth  dav.  The  groat 
Aaerinao  Sorgvon,  M»tl,  wns  the  lint  ifbo  tied  it 
ftr  aaeariaai,  tlie  palleol  TDskin;;  a  goMi  recovery. 
If  Um  aAeurlsm  in  the  gmin  extenJ  so  high  that 
thcra  i«  not  Bufhcient  enace  for  the  exposure  and 
fi^tsrt  of  th«  external  iliac  artery,  it  becomes 
avscflMnr  Ut  tte  the  ovninioo  truuk.  Tbia  may  b« 
4aa»  by  «xtmding  the  iocisioo  ibat  serves  for  the 
%atar*  of  tbv  cxteroal  ilinc  upwards  and  slightly 
immmrdo  Ivwards  tbe  ambilicas,  to  an  extent  cor> 
iBpnarfiog  to  tbe  degrw  ofofaeeity  of  the  patient. 
in  tkal  it  asnnwa  a  somewhat  semilunar  form.  If 
th*  op«fatioa  is  oommeaced  with  the  intentioo  of 
■pfljriafaligaturv  to  the  main  trunk,  it  is  of  great 
■■pvtaoee  in  dctemiiniug  the  Icnjjth  of  the  inci- 
iiBa.aad  calculating  tha  puint  at  which  thv  nrtt-ry 

«kU  bs  mat  with,  to  remtiuber  the  di^rrent  betmnijt  of  the  parti  in  thr  neigh- 
kmrhamd  ^  du  retitjg,  and  tbo  retalive  fretfucnni  with  irAi'cA  fA«  origin  and 
^mimMmtt  ofthe  arterj/  terrttpond  uftlh  certain  JixM  poitdi  tJiat  may  readily 
bcddaeud. 

TW  poiati  of  importonoe  are  tbe  rolalinns  of  the  TcmeU  to  the  lumbar 
micbvK.  to  iIm  ere«t  uf  the  ilium,  and  to  tbe  umbilicus.  The  ordinary  place 
•f  dinboo  of  tbe  abdominul  aorta  is  ou  the  body  of  tbe  fourth  lunilmr  ver< 
lebcm,  or  on  tbe  invrrti-hral  duik  below  it ;  according  lo  Quain,  tbi»  was  the 
SBK  ia  Chf  ■•  of  \.\\v  biultcA  be  exniiiiii^,  or  in  1>S6  out  of  Idt}.     lu 

lafa'd  lu  II  li  ttetween  lli«  eiiuntloti  of  the  bifurcaliun  of  thv  aorta 

•wl  %ho  cnat  ol  ti*e  ilium,  wo  find  it,  accvrding  to  lb«  »ame  aualomut,  to 


Flf.   4».— Oblllvniiaa    of 
Pvinonil  V«1h  bj  InfMlaal 

AMdlilM. 


250 


SPEOIAI.    AXRURISHS. 


have  nu)g«d  to  about  four-fifth*  of  the  cases  between  hnlf  nn  iorh  BbnTB  ml 
below  the  level  of  the  higheet  point  of  this  part  of  the  tvme.  With  nfanan 
to  the  umbilicus,  no  definite  rule  tnn  be  laid  down ;  but  it  mmv  ba  brawlir 
8lflle<l  tliat  the  hifuraition  of  the  aortA  la  a  liltio  to  ita  led.  A*  a  graenl 
mle,  tliat  i^iven  by  Itnrgrave  is  perhape  sufficicotljr  good  for  ordiMirT  po* 
poaea.  If  a  poini  be  taken  about  half  or  thrve-quartcn  of  aa  tnch  btlnv 
and  a  tittle  to  the  l«A  of  the  umbilieus.  nnd  a  line  be  drawn  nn  each  mtt 
froui  liiU  point  to  the  centre  of  Poupan'R  lignmcnt,  we  obuin  aboni  ibc 
direetioD  of  tht  common  aad  external  iliac  arteriM,  On  dividing  tbcH 
tines  into  ihrco  equal  parts,  the  uppor  ihifil  will  correspond  to  the  oMsmM 
trunk,  AQiJ  the  tower  tw<>-tbirdft  Ui  the  external  Iliac,  and  the  juoctioB  af 
the  upper  with  the  middle  third  to  the  bifurcation  of  the  eomnidB  Ulae 
artery. 

The  point  of  division  of  the  itommrin  iliac  artery  i»,  in  the  tnajurity  of 
caaes,  opptwito  the  lumbo-sacral  articulAtiinn  ;  and  if  it  be  not  in  thii  aitoa* 
tlon  the  iliviaioti  will  pmhnbly  be  Inwer  <lon-n.  The  leii|^  of  the  vomI 
varies  greallr:  aecuriiing  to  (^uain,  in  (ive-seventlit  of  the  onea  it  rangfJ 
betweeti  oae  aud  a  lialf  and  three  inches. 

Tlie  artery  lies  at  the  brim  of  the  pelvis.  The  vtaat  oo  tbe  two  aiilsa  iflfllr 
in  their  relation  to  tbe  arteries.  The  left  vein  lies  to  the  tuner  sidv  of  Ibf 
left  artery,  and  then  passes  beneath  the  ri^ht  commnu  iliac  artery  to  join  tW 
right  vein  in  formtnu  the  vena  cava  inferior.  Ou  tbe  right  eide  tb«  Tcia  i* 
St  first  beueuth  antf  tbcu  tu  the  outer  side.  Tbu  comiuun  iliac  titmn  '» 
eroned  by  the  ureter  nenr  its  lower  end. 

The  Incision  to  expose  the  commnn  iliac  extends  from  a  point  alwHiloot 
inch  BXteroAl  to  and  uiio  inch  alxive  tbe  middle  of  Fou)>Brt'«>  lipiment  ia  S 
curved  dinNPitton  to  another  point  about  two  inchos  above  and  the 

distance  internal  to  the  antcriur  Fn[K>rior  iliac  spine.     Tbe  cunre  m      

such  thnt  if  pmloDged  the  inrifion  woulii  reach  a  pointabout  midway  bclwesa 
the  xiphoid  cartilage  and  tbe  umltilirus.  Care  must  be  taken  that  the  b- 
cisinn  1m>  not  carried  ton  low  down  or  too  tar  forwarths;  nnthinj;  oa  ha 
gained  by  doing  »o,  and  therA  tu  br^AideA  the  addiiirinal  risk  of  the  rirramHa 
iliao  or  epif^lric  being  wounded,  ait  hapitened  to  Mott ;  and  »m  these  are  th« 
priDcipal  agents  in  the  ADSDtomiwing  rirvulalion,  their  injuiT  is  a  aerioos  ac- 
cidenL  The  muscles  are  cnrefully  divided,  ts  in  th«>  operation  for  the  exter- 
nal iliac,  and  the  transversalis  fascia  opened  in  the  same  way.  Tbe  perho- 
neuro  now  comes  bulging  into  tbe  wuiind,  pressed  forward  by  its  cotiimta. 
It  must  be  gently  stripped  from  the  iliac  f(««a  by  the  Rurge^m  carefully  ia- 
sinufltiog  his  hand  blenenlb  it,  care  being  taken  to  r«isv  it  directly  inwanls 
towards  the  brim  of  the  pekia,  Ht  which  puiot  the  external  iliac  will  be 
fimad,  which  serves  as  n  guide  to  the  pureat  trunk,  Thv  ureter  always 
oomes  up  with  the  {KTitouvum,  and  is  ubuuHv  nui  seen.  Tht<  peritoneum 
must  be  well  drawn  inwards  by  hniad  copper  spatuln.  The  ligaturv  mm! 
be  pMsed  niuud  tbe  artery  on  the  left  aide  from  within  outwanlft,  a  alight 
•Oratch  having  been  made  through  the  fsficia,  euverinc  the  venri  by  ni 
of  the  linger-uHil.  by  which  it  may  also  be  separated  Ironi  tbe  noc^tmp 
ing  vein.  Oa  the  right  side  great  onulion  roust  be  used,  on  accimnt  of 
poBitiiin  of  the  luft  vein  l>eneath  the  artery  and  tbe  right  to  its  outer  I 
Id  the  later  stages  of  the  operation,  the  patient  should  be  turned  cm 
sound  f>ide  in  order  to  prevent  the  Intestines  ftrom  falling  over  and 
tbe  peritimeum  intu  the  wound. 

Atnlta.— Writing  in  1d^2, 1  stated  that  when  we  look  at  the  depth  at 
which  thLt  artery  is  situated,  its  ^rcat  size,  and  proximity  to  the  eentrv  of 
the  circulation,  and  conudcr  the  foroe  with  which  tbe  blood  rushes  through 
it,  we  cannot  but  bo  struck  with  the  raooeis  wbiofa  baa  attended  its  tigatar«b 


RESULTS   OP  TYIKG    THE   COMMON    ILIAC.  '251 

Of  17  CUM  io  which  it  had  tlien  been  lied,  8  were  cored.  au<l  9  died  ;  in  11 
at  thm  cMw  ihd  ItgAUire  wu  appii«d  fur  M>eurii^iii,  nii'i  of  ihew.-  7  n-cu^ured. 
Tht  4  thai  (ikd  pembdd  rather  from  the  amguituile  nod  cxtvut  uf  ibe  dia- 
flSM  thdux  from  thr  ■•ITrcts  of  the  ujwmlion  ;  nml  it  is  n>rimrkable,  as  »bow- 
iB|E  tile  power  of  th«  auutomoses  id  uiainuiniDi;  the  vitality  of  parts,  that 
IB  DO  iiMUDcs  did  nngreae  eosue.  Sinco  tiiis  )K-riud  th«  ujieraiii)U  has  been 
perfDfiiMd  laanr  iTnics,  but  witJi  much  less  salinfactunr  reaullB.  Stt!|tUen 
sMtlb.  of  Kcw  V'>rk,  published  the  ^tatistira  uf  ihis  oiwratiuu  iu  \HWK  fi'n- 
log  ch«  detail*  of  '.i'l  cases;  of  tiuxe,  ho  says,  'iO  died  aud  uuty  7  recovered. 
I  thiok  tbc  Dumlwn  should  be  24  and  S;  and  in  one  case  (Bui)be'e\  tlie 
(wt  infant  i  died  two  maQths  after  the  o[>eratii>ti,  tho  lij^aluru  bavin}^ 
1  aud  the  Brtory  In-ing  occluiled  and  ihtin  ihti  di'lj^alion  having  euo 
Ciirlt,  nf  Berlin,  in  rF|>r<>duciii>r  Smith's  tables,  adds  2  cases,  both 
To  lime  most  be  added  a\m  a  faiitl  case  by  Dugna,  of  Charleston, 
\§vt  in  vbidi  the  operation  h&n.  within  th^^  Inst  f^w  yt-nr^.  Keen  [itrformed 
il  dua  cooBtrr ;  noee  by  Bic-ken>t4-th,  of  Liverp'Mil,  stiooewfully ;  once  by 
lUlprnve,  of  t>ublin.  whose  patient  died  on  the  ^erenty-third  day  aAer  the 
tftnikn,  of  fan(rrent«  of  tlie  foot  and  profuse  discharge  fmni  the  wound; 
IM  ooeo  hj  Alauuder,  the  patient,  a  man  forty  years  ot  age,  dyin^  on  the 
lixtb  day  mmi  jcanilTene  of  tb«  luw^r  extremity;  by  Morraot  Baker  in  a 
natk  Ql  17,  for  hcm-irrbage  froro  a  branch  of  the  internal  iliac,  coiie«|Oent 
«a  vloermtiuo  product-^l  by  sacru-iliac  disease— fatal  on  the  day  lulloninK  the 
apentioa.  During  the  Anterican  War  the  operation  was  p«rfuriiied  in  5 
caao^  all  mistircvwfiil.  These  casai  increase  th«  total  number  tu  4-1,  uf 
wUcb  9  rvcuvrrc<l  and  ^o  died  ;  initof  thecnsen  the  peritoneum  was  wmiiided, 
sad  of  ibose  H  proTol  fatal.  Of  19  cnse»  in  which  this  vessel  was  lte<l  for 
b— orrlMmP.  14  proved  fatal ;  the  majorily  of  the  recoveries  took  place  alter 
flpHStii-n  for  annirism — which  c^mstituteti  about  half  of  the  cases. 

Tlw  Old  OpentioD  has  been  performed  in  more  than  one  cose  of  iliac  aneu- 
amm,  wbcn  from  tpccinl  circumstances  it  was  not  poBsible  to  tie  the  artery 
thm  Mc.  In  Hrroe's  well-known  case  the  sac  woe  laid  open  and  three 
-[iplied.  which  norc  believed  lo  include  the  exteniat.  internal,  end 
10  arteries.  The  patient  practically  recovered,  but  died  of 
aotte  mooths  after,  before  leaving  the  hospital.  The  poet-mortcm 
showed  that  the  ligatures  had  been  placed  on  the  external  iliao 
«fy.  Sir  Astler  Cooper  attempted  the  same  operation  in  the  coae  in  which 
ha  salvKiomtlr  lied  the  aorta.  Heath  laid  open  the  sac  of  an  iliac  aneu- 
nm  vhich  ha^  been  opened  hy  mistake  for  an  absceai  before  beiDg  admitted 
jl&a  UnivereilT  CoDefe  Iltepital.  Tbe  external  iliac  was  lied  from  within 
Aa  time  but  the  patient  dit-d  {mm  aecourlary  hemorrhage.  The  ulil  opera- 
«■■  tmn  tmiw  be  perdrttied  when  il  is  possible  to  compress  tbe  aorta  above 
iW  mc  ;  and  coiuec|uefilly,  ua  IIoImM  [>olntji  out.  tin  attempt  should  he  made 
to  etfr^t  a  cur*  by  eomjir'^-iMri  licloreso  dnn(:cnitu'  an  operaliuu  la  attempted. 
ftftWHt  hy  CompresHion  hm  been  >urct'.<<«tiilly  applleil  to  uneurism  of 
llw  iliac  aMi--rie«.  Tbe  comprevwioii  inu^t  W  iipj>)t(d  to  the  aorta  by  means 
itf  I^sMrr's  ti  LtfiiiiKii  t.  IU  ill  llie  tnrHliiieiiL  of  aiieitfinm  uf  the  alHlnminal 
■acta  (p.  '2  rnhle  number  of  cases  have  now  been  cur^jd  by  these 

■aaris  1-  -  — i  _..  jidy  been  n'fernwl  to  when  treatini;  Kenemlly  -tf  the 
wkject  of  fiupfcaMon  of  the  arteries  for  tbe  cure  of  aueurieiu.  Murray  itt- 
■Maoai  the  importaoor  of  cttuiplete  arrest  of  the  circulation  in  these  cases,  so 
Dot  Uic  sli^-btnr;  iMirrrol  of  blood  should  pas  tliruu^h  the  sue.  One  of 
9Mfa  waa  cured  in  ihrre-ciuartcrs  of  an  hour.  Uuo  of  Heath's  (of  New- 
U)  eosHoUdatrd  in  tntnty  niiuutee.  I^awsou  in  one  case  applied  two 
to  tl)«  ubiluminal  aorta,  the  other  to  the  femoral  uelow  the 
■bdoainai  tourniquet  liad  Iu  be  removed  at  tbe  end  of  tvieuty 


252 


SPECIAL    ANBORISlia. 


minute*,  owioe  to  collapse  and  vomiting;  tbe  rerooral  one  wiu  TnaioteiMd 
in  iKJsilion.  When  the  nlxlomiDal  ojnipreaBor  wan  removed  th«  pulaation 
hiin  already  dimiiiisbed,  nod  at  the  end  of  four  houre  they  ombhI  ;  tb» 
patient  innktng  a  good  recovery.  Hulmea  has  oullect^d  10  caan  of  iliac  or 
ilio-lcinomi  aneuriua,  treated  (iy  this  method  ;  of  thcw,  7  were  niml.  and 
in  8  the  treatment  bilcd.  Tbew  3  afkcrwards  underwent  ligature  of  tht 
artery  leading  to  the  sac — in  una  cue  the  abdominal  ooru — and  all  died. 
Theee  statisiica  clenrly  show  that  oo  operotiTC  troatmeDt  is  juBtifiabIo,cxotft 
after  the  fuilurc  of  corapreaaion. 

Ligature  of  the  Aorta.— It  is  impoaible  not  lo  eontetnplate  with  admi»> 
tion  the  man  wbi«»e  miud  n-aii  the  bnt  to  c^ACciv^,  and  whoH  band  «*■  tba 
first  to  carry  out,  the  detenniiiaiion  U>  apply  a  ligaiuDi  to  the  abdomiail 
aorta  ;  and  who,  gnided  by  patholoKicul  ohtiervaliua  and  physiological  «xpcii> 
meot,  vcnture^l  to  Arre«t  at  once  the  circiilalioit  tbrougn  the  maio  ebaiuMl 
of  supply  to  the  lower  half  nf  tlie  bixly,  trusting  to  the  collateral  cireala* 
tioD  fur  the  mnintenauce  of  th«  vitality  of  the  paru  thus  duddooly  deprived 
of  IiIimkI.  Sir  A.  Cooper  vu  the  fir&t  to  place  a  ligature  on  the  ourta,  ii 
1617.  Since  that  period  the  operation  has  been  fix  limeajperforiHd  fbr 
aneurism;  viz..  by  Jaoics,  of  Exeter;  by  Murray,  at  tbe  Cnpe  uf  Qood 
Hope;  by  Monteiro,  at  Ilio  Janeiro;  by  South,  of  Louduo;  by  McGiJtra,af 
Kicnmoad,  U.  S. ;  by  Htokex.  of  Dublin  ;  and  once,  in  ciniuiualaouei  wbkk 
will  be  preecolly  dcsLTilNHl.  by  t-VTuy.  of  Vicuna. 

TABLK  OF  CAKES  OF  LlOATUltK  OF  AKDOMINAL  AORTA 
FOK  A.NKURWMS. 


«(nta(o>. 

flax. 

ASB. 

l>ATB. 

RArCM 
IIP  AKBCatllM. 

ni^a«rroUL 

uavuk 

1.  Sm  A.  CooFXK. 

n.  1  US 

1817 

DIITumkI  tuguinal. 

XnciMoD 

UircKii'li 

MritaaButn. 

IhtBth  fa  M 
boun. 

'i     JaUC8. 

■a.     44 

18» 

£xt«rua]  iliac 

I><Mtb    In  • 

iur>!  dni: 

(few  b«on. 

pertlitiMuiu. 

Of>»D*d 

8.  Mi-asAT. 

IB. 

•  H 

18S4 

iDgolaaL 

AorU  Ued 

OcMb  ia  11 

Iwhind 

hoMf*- 

peritonvum. 

4,  MoMTStao. 

B. 

■  *• 

IMS 

Diffuwd   ingutnal. 

Ai»rU  Had 
twhibd 

pert  ion  oum. 

Deatb  an  Ittk 
day 

fi.  tioum. 

■b 

28 

leu 

OoDtmoB  iliaa 

Aurta  U«d 

bebiud 
perlufucum, 

I>Mtb    til   W 

fl,    McOttlBB. 

■1. 

80 

1066 

Lower      i^arl     of 
aurik.    Biitbcam- 
Bi'tn    lllav*,    and 
l«ft«KteriiK]lltac, 

Auru  tied 

bebind 
(wrttoneuiD. 

llnlh   la  U 

b»un- 

T.  W.  StuRn. 

IL 

60 

IMB 

lltw. 

AorU  tied 
brbitul 

|Mritt)R«tm. 

[>«Ub  in  » 
buurt. 

Id  Sir  A.  Cooper's  coae.  the  inguinal  aueurism  had  bunt,  and  tbe  aurta 
was  tied  about  turee-^uortera  iif  an  inch  above  iu  bifureuliun,  by  making  aa 
incision  three  iucbca  m  length  Ibruugb  the  abdumeu,  a  liulc  to  the  led  uT 
the  umbilicus,  the  fingere  taking  paased  betwcua  tbe  convuIuiiooB  of  the  in- 
toaUoea,  and  tbe  jieriinneum  covering  the  artery  being  ■oratebed  thr)Upb- 
The  paiient  aurrived  forty  houn.     Jamea  ligatured  the  aorta  maeh  in  tha 


LIOATVJIC   OF    ^BDOMiyAL    AOBTA. 


SfiS 


V  V  :^r  A.  Oxipf-r  did,  in  a  case  in  which  he  had  previously  em> 
tnr  ill«ial  o|w-rnti<*ii  fur  an  ii>t;iiiua]  aii4furi»m;  but  wtlhout  succras, 
psUrnt  >{>ct'<iilr  •lyiiif;.  Murray  ligutuni-d  tlj«  vesae)  by  inakiog  aa  io- 
iio  tli«  Itrft  ii'lo,  til  front  of  the  projccliug  <^tid  of  the  tenth  rib,  ouil 
ryiDie  it  downwards  for  six  inchm  tu  the  anterior  superior  epine  of  the 
Ttie  |«rta  were  then  carelully  divided  to  the  peritoneum,  which  was 
tdl  fn>ni  the  iliac  fijwa  and  the  pums  muscle,  when,  with  great  diffi- 
ItT.  and  by  Bcratching  with  ibe  end  of  an  elevator  aod  the  fiaKer-uails, 
nMMi  wad  made  for  the  p«Bsag«  of  the  ligature  round  the  artery,  xliich  was 
tioi  three  or  Jiiur  lints  above  ita  bifurcation.  The  ))&tieDt  dieil  in  twcuty- 
thnm  haur&  The  must  iutereatiag  cuae  on  record  u^  that  by  Montelro,  wlio 
tied  Um  uirtA  Ibr  a  large  fatae  aneurism  on  the  lower  and  right  side  of  the 
■MiMen;  bere  the  iocisioa  wau  uiade  much  us  iu  Murray's  case,  aD<l  iho 
axtarj  DgKtnred  with  great  ditficully.  The  patient  lived  lit)  the  tenth  day, 
b*  died  of  secondary  beniitrrbage.  In  !:*4>uLh'e  case,  the  aorta  was  tied 
~  tlw  peritoDCum  by  an  incision  on  the  left  side  of  the  abdomen.  Tbo 
died  in  forty-three  bouTB.  Mc<-iuire'a  patient  had  in  ancuriemal 
of  the  «ie  of  a  gooac's  ege  iu  the  lefl  iliac  region.  Dintal  preaure 
tlu  umbilicus  was  aiieniptcd,  but  could  not  be  done.  Tito  operator's 
fiMMtiaa  wan  at  firvt  tu  tie  tne  lefi  common  ilinc  artery ;  but,  finding  the 
dilMw  more  KKtentuve  than  he  expected,  he  enlarged  the  incision  and  tied 
Am  aorta.  The  mc  buret  during  the  ninnipulalion  ncceseurj  to  reach  the 
a«n&,  and  about  a  pint  nt'  blood  was  lust.  The  patient  died  in  eleven  hours. 
8tolu*  cwnprwicd  the  aorta  with  a  silTcr  wire  passed  round  it  in  the  way  of 
frlioUMl*.  He  made  a  crescentic  iociition  five  and  a  half  inches  b  length 
h  UM  Uft  Md**  of  tbr  abdomen,  extending  from  an  inch  beluw  the  t^^nlh  rib 
■o  iba  '  ''  Pnupart's  ligament.     The  abtlouinal  mu»cles  and   ttiacia 

InMv-    -  '  f^  then  incised,  and  the  |)eritoQcutD  expiKic-d  and  drawn  out 

of  lb*  iltav  liiwa.  It  was  accidentally,  but  only  slightly  wounded.  The 
ffttisttt  being  turned  on  his  right  sitle,  the  arferiea  aod  aneurism  were  ex- 
paavd,  and  tb«  wire  pawed  by  means  of  an  aneuruim-needle  round  the  aorta 
MBBadiataty  above  its  bifurcation.  The  patient  died  in  twelve  houre. 
FMm^  Um  meat  interesting  point  in  this  remarkable  case  is  the  fact  of  the 
flMtluB  rctaraing  iu  the  left  (sound)  femoral  artery  nine  hours  after  the 
nmmtiao ;  sbowiug  how  rapidly  tbo  collateral  circulation  cod  he  reestablished. 
Cmmj*»  auc  soarcely  belong*  to  the  present  category,  but  mav  be  mentioned 
b*i«.  Tbe  patient  was  a  French  soldier,  ibe  Dp|>er  part  of  wliose  thigh  had 
bam  ihalf CI r  I  by  a  ball  during  the  Franco-German  war.  Secondary  la-nior- 
rita^oocBrring,  Oserny  tied  the  common  femora),  and  also  the  superficial 
faBorml  below  the  origin  of  the  profunda.  This  arr£«ted  the  htuKirrhiigc 
Ibr  »  ttme ;  but  iu  #ix  days  it  recurred.  Cxcrny  then  Lied  the  cummuii  iliac  ; 
bo.  as  lbs  bttmonbage  coutinac<i.  he  ihou^-lit  thnt  he  had  tied  the  external 
iImt.  and  prooacded  to  apply  anuUier  iigat tire  — which  he  placml  by  mistake 
^  |b»  aurla.  Tit*!  pataut  survived  tWL-niy-Ki\  hour*.  In  this  ca»e  tixi, 
fi»tT-two  houni  after  the  ii|H>rutii)n,  the  injured  limb  wa£  C4)ld  and  as  if 
di»i,  while  tbo  oppm^te  liuih  was  warm,  and  retained  aeusatiun  and  mutton. 
Jr,  '^,'i..  ..i^m't,,n  there  are  not  only  alt  the  dangers  attendant  upon  the 
t'  the  drat  magnitude,  but  also  the  risk  of  producing 
'■,>.'ihi;r  the  abdomen  he  cut  through,  or  the  vestwl  ^nght 
.  up  th*i  fieritoneum  from  tbe  iliac  fiiasa ;  and  it  appears  to 
lit  tfullrnng  from  ao  large  an  inguinal  aneurism  a»  to  jtiotify 
siirta,  would  have  a  Iketter  chance  of  recovery,  or  mlhcr  of 
'  life,  by  the  adiiption  of  proper  cnnatitutionul  treaimcntt 
-'■ssurc  upon  the  tumor  and  tbe  distal  ligature  or  c^toiprixiiua 
LiMcr'a  aortic  cumpr[-«»or  might  be  applied  in  such  cases,  ao 


jai 
tare  «f  the 


tPKClAL    ANSURISUS. 


■^•^  i^Jtjtm*  i^  fl<*<*  ^  blond.  ShoiiM  the  opcrntion  be  tgain  atiMafttd, 
JLpf.  fi  ^tl»  J>Hibt  tluu  tb«  itici»i<ti]  nilupuii  hy  8ir  A.  Cuop«r  would  betk 
|MM,  M  tW  ouear  Af  peritouitis  ii  much  leas  uDd«r  the  [tKMUt  modacf 

X^tV^U!^  "F  W  lyiERN'AI.  Il.I.VC  AND  IIS  BttAycBlK— Ajl«OriMB  D^ 
„jft  iymmk  ^'liW  Intrmtl  IHat  Artery  U  extremely  rare.  The  only  eiue  okb 
«|ilrb  t  ui  ftnjountvd  is  uue  r«l«led  by  8(iii(lifort.  Th«  three  tinD<-j|Ml 
hiMwbO  fl^  t^  artery — the  GtuUat,  lh«  Sciatic,  and  th«  ftu/ic— bH«-«  ftH 
iMMiii««tiT  tlM«gb  rarely,  be«u  Ibuud  adwted  by  this  dUteue.  Of  iboe 
hlflMb*  tW  ghlKAl  bw  bvi'u  iiKwt  fre<[ui;ully  found  uaeurixDial,  the  pcatie 
gau,  sad  the  pndK-  lenat  frt^tiueiitly  :  iudt*fd,  I  um  sff^uRinted  with  ooly  «m 
f^mmof  «f  attfuri*!!!  uf  ll)ia  veewt.  It  in  the  prepamlinu  1701  In  the 
jIjjj^bi  fif  thr  Onllf^  (ifSur^oDg;  and  it  exhibits  on  RUcurigm  uf  ibe 
Ma«k  f^*  iW  fwdic  iiriirly  uti  iikjIi  iit  iliiim<-'tcr,  full  \ti  lamiiialod  ctul. 

«r  the  Qlut«Rl  and  Sciatic  Arteriea  may  be  either  tmuoMiie 

li*  Hanovfr.  ha»^  publinlipil  with  commenla.  in  the  AreMiw  fBr 

fit,  the  i-Kc-onb  of  thirly-liTe  caws  of  gluteal    Korl    acUtie 

.:ioh  must  be  addtvl  a  (Ttsc  nf  gluteaJ  Biieurism  dMcribed  bv 

__i«rf  Naplw,  iind  one  by  Bickeratelh,  oT  IjiverptMl.     In  tvr«ntT>«#TN 

^^^jtaiwwT*  the  aiiciiriem  wne  distinctly  gluteal ;  and  in  six  distinctly  KtAtie. 
f|llMm«  t^f  ihf  filutenl  nneiirisms,  and  tiTo  of  tbu  Bciattc,  were  of  irumatic 
^Mk;  (Uirtrfn  gluteal  and  four  eciattc  aDcurisnu  were  ApontAoeoua.  Th* 
29^1  iMfvrbm  bni  been  generally  found  8itu.-tted  ui  the  iipp«r  part  of  tb* 
MM  n'Mllc  nololi;  but  may  eil^itd  over  a  \aTgf:  portion  of  tb«  butlvdu. 
J^4litiriittruriiiin  lies  more  deeply;  and  a  portion  u(  the  «ac  may  b»  witbia 
^  ^lYi»,  Tbp  Hiice  of  these  itiieuri«ms  varitM  fmm  a  xlight  ■welling  lo  t 
ittm^  ^  latTP?  »*  A  child's  hcfld.  In  almoat  all  (he  record«d  oaMt  there  hat 
^MM  tin'O);  puliuitioo,  i«ocbroi)ous  wilh  the  heart's  bent;  and  whirring  aod 
^111  g  niiiriiMirn  are  beard  uu  audcullalinn.  Thei\- i#  atmnat  always  pain 
tlk  ifcv  tumor  il«elf  and  in  the  citurse  uf  the  nciatic  nerve,  which  may  be  fbl> 
^uil  Itr  pamlvBis  of  the  pHrtg  supplied  by  it. 

I'fcv  altWtiout  wilb  whicn  thene  ADeurisras  are  moat  likely  lo  be  eunfouodad 
UV  AbwHwea,  aoll  sarcomRta,  cyvta,  nod  sciatic  hernia.  The  diagnoai*  '» 
«MiM(linM  didScult;  tbui  Guthrie  ligalured  the  common  iliac  artery  for  a 
hfttfv  puluting  tumor  in  the  gluteal  re^oo.  which  prescaled  all  the  obar 
MM*  of  aueuriam.  but  which  prored,  on  the  death  of  the  patient  ei|^ 
Httuiiha  aniT  the  operation,  to  be  a  sarcoma. 

lUulenl  uneurtsma  have  on  aevenil  oceasiona  been  opened  by  mistake  for 
atwtNMara.  Aecurdin^  to  IIdIiih-^,  this  nceident  bait  inwt  frt^quently  happeoni 
tflivu  ibf  BiienriBm  hae  been  more  or  leas  diffVi»ed,  and  in  nucb  cacea  b* 
•lW)tt«tH  [hill  the  aj>piraEor  ^lioiild  be  u^  to  render  the  diagnoaia  certain. 

Ill  ilir  Trratmerit,  viiriiiua  lueibodH  have  been  uniployed.  TheaaehoMlttm 
ktid  9pin  and  the  |;luteal  artery  lit-d  in  Ave  itimns,  nit  of  which  recorcrrd.  la 
aottlhar  iiutaniv.  aller  luyiug  open  the  sar,  the  anenrintn  {}*tntenl)  waa  foond 
to  KXtrml  intn  the  jietvis;  and  the  internul  iliur  artery  waa  litsl,  with  a  fatal 
rMiilt.  Ligatare  of  fht  internal  iliac  artery  haa  been  perfurinrd  iu  elercD 
(«aM,  *ix  of  nhich  recovered.  Tke ooutmon  iliac arirry  \\ttA  \yt»n  tied  in  tbiw 
tiaara.  (ill  "f  which  proved  fatal.  Irjr^ction  of  the  prrehfitride  of  irun  baa  been 
tM'd  in  n'ix  cmv* ;  four  recovereil,  (»ie  died,  and  in  one  the  mult  is  unt  knowa. 
i.iffttt\tre  of  thti  neiatie  urfirry  without  npeoint;  the  aac  baa  been  pcrfonaed  ta 
Iwti  riun»,  iiiH-  of  wliirli  recoreri'd.  8p<pnlAiicouA  rreovery  is  rvporled  to  ham 
tHii'iirn*>l  it)  oiii-  rjiM'. 

Itf  atnra  of  the  Internal  Ilite. — This  veaaet  was  ligatured  for  tbe  Bnl 
lltuv  W  1^1'-     Tim  u|wnition  n-an  performed  by  Stevens,  of  tit-  Cmlx.  on  a 


tMOBAL    AND   POPLITKAL   AKBCKISMS. 


255 


wlw  oaflernl  fnim  an  aneariam  of  the  n%UA,  8Upi>oaed  to  be  <>t'  the 
wtcrTi  but  found  after  de^tb  ttir««  yeura  subMi)tjenlly  to  luke  iu 
uw  •ctaiic.  Stephens  iu  thiri  c»»v  lumlv  an  iuristcm  five  inchM 
lb«)«ft«cleof  tbeaodom«o,cAn.Tully<ji«e««t<;<l  Ibruugh  the  fwrietes, 
'  iIm  penloueum  fruin  tbe  iliac  fossa,  turued  it  on  one  side,  tugetht-r 
urMvr,  aad  paiw«d  a  ligature  round  the  artery  without  much  diifi- 
SiiUM  thai  tinK'  the  upi-niliuD  baa  be«n  done  twenty  limes;  iu  six 
auccew,  by  Antdt,  White.  Mult  (who  accidentally  wounded  the 
i),  .Syme,  M<>rtou.  and  Galloui;  in  fuurteeo  casai  unsucceMfully, 
..of  York  (whose  patient  died,  on  the  niueteentb  day,  of  eec- 
beuiorriiage),  by  Uiiceluw,  Turracchi,  CiautiDue,  I'urtB.  Laudi,  Kini- 
ftnOlIer,  Tbofnas.  J.  K.  liudgers,  and  Uigginsuo  ;  and  three  times  by 
ia  tfa«  AioericaD  Civil  War. 

tbal  has  hitlierlo  attended  tbif  upemlinu  b  certainly  remark- 
w«  take  intti  conslderatiuu  i  ht  <ie|>th  ul  which  the  artery  is  situated 
Mte;  it  matt,  1  think,  be  accuuntvd  for  by  the  fact  that,  allhuugh 
Uie  patieat  fudb  the  ordinary  ri^ik^  alteudant  on  the  ligature 
larger  |>elvlG  arleiriea  from  the  (?X[>osure  and  hnndling  of  the  peri- 
I,  Tct  ha  is  sared  the  danger  reaulling  from  the  gupcrreiition  of  gan- 
Lue  anH^t«>mt]8i8  t>etween  ila  braucbe^  and  that  of  the  neighboring 
k^og  tu  free,  and  the  course  traversed  by  the  blood  so  shorit  that  no 

arise  in  the  mainlenaoce  of  the  ouUatcral  circulation. 
ite|a  of  the  o{»eration  Dcccwary  for  the  exposure  of  the  inLcmal  iliac 
j«  prceiselr  analogoui  to  tboae  n>qutMte  ior  the  ligature  of  the  com- 
Kuk.  Wboi  the  veasel  ia  reacbcil,  it  must  be  n^memherod  that  both 
Hrtkal  and  internal  iliac  veins  are  in  close  relation  to  it ;  the  one  being 
awr  side,  the  other  behind  iL  As  these  veaaels  are  l>Tve,  and  their 
lin,  it  is  neoeMary  that  they  should  be  separated  by  the  finger-nail,  or 
i  end  of  the  aneurism-needle,  befure  the  ligature  is  pamed  round  the 
oare  must  be  taken  sImi  unl  lo  put  the  veMsel  too  murb  on  the  stretch 
rin|[  ibe  ligature,  le»l  ihe  ilio-lumbar  artery  be  ruptured.  There  is 
ik  M  tncluding  the  ureter  which  crone*  the  artery  ioternalty,  as  it 
■dhw  firmly  w  the  pcrituueum  and  b  pushed  on  one  side  with  iU 
laaglk  of  the  artery  varies  luuch.  usually  ranging  between  one  and 
Mi,  and  ai  when  it  is  ahort  it  has  a  tendency  to  be  placed  deeply  in 
it  wald.  1  think.  b«  more  prudent,  and  ocoasiou  leas  chance  of 
ry  iMUorrbage,  for  the  Surgeon  to  ligature  the  common  trunk. 

rEMORAl.  AXP  POPLITEAL  AXEUE1BX8. 

BT«,  in  the  preceding  section,  considered  aneurbma  affecting  the 
kicfa  are  hy  no  moans  unfre<)upnt.  Aneurisms  of  the  thigb  are 
but  thoep  in  the  bam  arc  very  commonly  encountered.  Thus, 
1  HHB  of  aneurism  recorded  in  the  British  medical  journals  of  the 
Htaiy,  Crisp  has  found  that  137  atlected  the  popliteal,  and  only  ti6 
Mai  artery.  Of  thc»e  6tj,  40  were  situated  either  in  the  groin  or 
ait  fif  the  tfaii;b,  and  H  only  were  truly  femoral  or  f«moro-|K)  pi  ileal. 
of  this  diJTvrence  in  the  t'rwitiency  uf  the  oceurronoe  of  aneurism 
-•  -T-t.  uf  the  veaeel.  may  be  acoiuntcd  for  by  atteutiuo  to  it«ana* 
t4.  In  lijuking  at  the  main  artery  of  the  tower  extremity,  in 
!r<  m  i'ouparl's  ligament  to  where  it  lermimiles  in  the  anterior  and 
ttbuls,  we  sM  thai  it  may  be  divide*!  iu  relalion  U>  the  mu>M:iilar 
aiUTuuud  it.  into  ihrve  prii)t:i|>al  |>ortiun9 :  I.  That  which  is 
rtao  Poupart's  ligament  and  the  luuer  margin  of  the  earturtu«, 
■Hsy  be  eunndered  inffttituU:  %  That  which  intervenes  beiwem 


SM 


SPKCIAI.    ANB0K1»M8. 


thin  point  and  the  aperture  iu  tbc  n<J<lucl<ir  tendon,  ood  which  mty  bt . 

ttt'lcrrtl  femoral;  ana,  li.  That  fliviHiun  of  Lhc  vctvel  which  corrapoBdi  h> 

bam,  aiid  which  mny  Ire  Cinisiilcri'il  popliUai.     Of  ihpw  three  dlTulfiBi,Ch« 

firet  itud  lut  are  eompnnuivttly  su|>erliriHl,  ntiil,  t>i<)ng  unsupported  by  mtud*, 

rviulilT  expand  :    while  the  central  portion  i)f  tho   anerf  ia  uliM^lr  tar- 

n>und«d  <iD  ull  sideft  by  muscular  maaan,  and  it  vory  unlikely  Lo  b«  Jil 

iotu  ail  ani'urUmal  tumor.     We  Rnd,  a.\m,  that  tho  ingoinal  portlim  uf 

T««t>i  it  dfwoly  and  firmly  iavested  hy  a  detiire  aud  nvMUot  (Sbro-a 

[•heaUt.  and  is  wpU  supported  by  the  faecia  lata ;  whlLit  iu   th»  puplt 

{ffiace  the  artery  is  surr-Miuded  merely  bjr  the  orilioary  aronlar  shealn,  i 

^  receivTS  oo  aiHincurotic  support.    This  diflerenrc  in  the  cunuectioos  t>f  tbeN 

[two  parte  of  tlie  Tcsel  maT,  to  a  <Trtatn«xicnt,c][plaiQ  the  erfiat«r  fr*qa«(iy 

■of  atieurwn  in  the  bam  tKan  in  the  upper  part  of  the  ibigk. 

AxKVKt^M  OP  THE  Dscr  Kesiokal  Aktcht  i«  of  extr«>Rit*ly  rare  ooev' 
rcoee;  iudvvd,  I  am  actjnainted  with  fire  caMi  only.    Oni^  of  ihem  ocotned 

ia  •  vcaD|  man  under  mv  rare  iu  Uuireriiiy  Out- 
lege  Uoipttal.  iu  1870.  There  was  a  larn  uxmr 
at  U«  «pMr  |NUt  of  Ibe  thigh,  over  which  lay  tbt 
Mperficial  Monl  artery.  pulMting  frvely.  The 
MMM  vae  cuivd  by  L'oiupreseiun  of  ihf  omBioa 
fcnonl  artery,  hydrate  of  chloral  bcin;;  irirea 
relieT*  jiaifl.  AiHrtbcr  eaae  u  recorded  by  llry 
aa  karrag  aewiiied  io  the  practim  of  'o>cIi 
Gay's  HoqiitaL  Tbe  aneurum  was  situated 
the  erigMi  m  ike  deep  ibaoral  artery :  the  ex 
tSae  aaa  tied,  bat  thepatient  di'e^l  nine 
dhr  ika  «pintiw.  Ff^.  490  is  ukra  fmm 
fatieBwlN  dMaf  potamonia  shortly  aAer  id- 
■AiiM  iMi  Vabanity  Collie  Ifospital. 
csiaiBaiiM  aAar  daub,  a  large  tumur  of 
ihMi.  aWcfc  hai  aol  beea  vary  oloaely  exant 
dafW  Bi^  ptavid  lo  be  a  dreattMcribed  t 

appanatly  arinag  fmm  rupture  of  a 
if'  artery,  moet   probably   the    r-^n*. 
■  »f  amtiliaai  (TJoiv.  Coll.  MiiM'Utn.  i 

are  moitled  by  P.  Manhall  mri  ^ 
WiM^     la  tke  oaw  which  aaa  under  itir  oare 


:•* 


na«MH 


IB  Ifae  Uewtat.  tbc  diecaae  waa  rvcu^iied 
Ut&mm^  <V^  vbicb  an  duuactcnetio 
astaadad  from  three 

to  tbe  middia  of 

y  sepantisg  the  addnetor 

aoeoriuQal  tigaa  were 

a  pecaiiarir  load  and  harsh 

'  fcmgral  artery  could  be 

of  tbe  tnmor,  but  dear  «( 

ia  Ibepefdiltat  aad  iu  divimnw 

■■al  mgm  bwhuI  ob  omipremug 

am  leaiofiag  tk»  pr—ure. 

of  tbe  deep  Moral  artery  eao 

of  the  MMU.    Tbe  diaga<aie 

suglaal  lad  uf  tbe  practhioaar. 


kw  iAUaw  iki* 


<w  OwalUd  w  ai>  M-ortm  U  IW  proAiaiU,  bM 
MBrtba  tbuwj  It  (u  b«  fiat  of  ■  partiaatiac  aiury. 


In  tha  DrmtmaU  of  these  ■ueurUme.  the  Surgeon  han  the  choice  of  lhre« 
OMtliada,  TIB.,  conprMMuii  in  tiic  t'l^iiu,  auti  lignturc  of  ihe  externa)  iliac,  or 
of  ill*  omniuD  frtnoral.  ll  ihe  cuiumuu  remoral  ever  should  he  lignlured 
farmsMirinn,  ikit  hnpcun  tu  me  to  be  the  ctue  bmt  suited  for  iL  But  the 
abwioa  bclwwn  the  ligature  of  this  artery  or  of  the  external  iliac  must  in  a 
pvmx  meavnrv  depend  u{M>ti  the  Surgeon 'd  judgment  as  to  the  r«lativ»  expe- 
aivocT  of  titber  n[>erRti<>n.  and  on  the  height  to  which  the  aneurii>iu  extendi 
vp  thm  grrrin.  But  nritlier  artery  ihniild  be  ligatured  until  roniprfiuiiiin  hao 
MHl  fairly  inerl  md  biu  faile^l.  This  may  be  done  digitally  or  by  Curle'd 
iaitnii'  '  r«  the  artery  paMea  over  the  brim  of  the  pelvis.     It  is 

MpaciM. .  ■  lo  lucceed  in  aDeurisni  of  the  prutunda,  owing  to  the  short- 

BMBof  tW  trunk  and  Ihe  way  in. which  it  breaks  up  into  many  auualomnejug 
bcMKliM.  Hence  there  in  not  a  free  current  of  bliKKJ  passing  from  one  large 
TCM»I  of  etttri'  U>  antilhrr  of  exit,  but.nH  it  in  broken  up  and  ba^  to  filter  out 
tfcfwyb  a  nunib«f  of  uiiuur  vee^eb,  ita  coagulnliim  may  readily  be  hruuffht 
•tnaU  In  the  case  treated  by  tiio,  cunipre««i'>u  effected  a  cure  in  twenty- 
fcar  boon,  though  the  aueuriKia  was  very  large  aud  active. 

AjmnuBUfi  of  toe  ^i'perficial  Fk.moual  a>'D  I'ovliteal  A  irrKitiBO. — 
Tb^«  occur  oommonly  ub»ut  the  midille  {ktiihI  of  life,  and  are  alniodt  inva- 
liabljr  met  with  in  maleti.  being  at  letust  twenty  limes  njore  fre(]ueot  in  them 
iktta  iu  wiHoes.  Both  aidcB  are  affected  with  equal  frequency,  and  ocea- 
■naallr  at  ibo  mno  time.  According  Ui  Cri^p,  milont  would  npixear  to  be 
morm  liable  U*  this  variety  of  the  dii^a^e  than  any  mber  cbu^.  Tlie&e  ancu- 
tmam  art  moat  frequeotiy  tuicrulatpd  ;  in  the  ham  they  are  always  so,  but  in 
lfe*lfa%fa  tbey  are  somotimes  luluil.ir. 

t^mflom*. — The  symptoms  of  Femoral  Aneurism  prewot  nothing  neeuHar ; 
ibvtOBior  osoally  enlarging  with  considerable  rapidity,  with  all  the  char- 
■EtarittM  nsna  of  the  diaeaw,  and  OMuroing  a  pretty  regular  ovoid  fahape. 
fbplitMd  ABeQriim  usually  commences  with  stiffnesa  and  a  good  deal  of 

r'  1  about  the  bam  and  knee,  which  I  have  more  than  once  eeco  mistaken 
riMUHMtifm ;  in  fad,  ••>  commonly  docs  this  happen,  that  the  Surgeon  . 
dbooid  Dcver  fail  to  p«ua  his  band  behind  and  examioe  the  ham  in  every 
erne  of  peraitteot  "  rheumatic  "  pain  iu  the  kue«.  There  is  also  a  difficulty 
iigfat«xiiDg  the  limb,  which  is  generally  kept  veiuiflexed.  The  tumor 
iwually  with  great  rapidity,  aud  Iihs  a  great  tendency  Lo  beenme 
Aftwed  ;  lbe»e  conditions  will,  however,  materially  dcpetid  on  the  side  of 
Ifte  aitery  from  which  it  eprings.  When  it  ariees  from  the  snlerior  aspect, 
DcxC  tbe  buuc,  it  iucrraari  slowly,  beiuji  compressed  by  the  firm  atructurcs 
bdbre  it.  In  thii'  ease,  bovever.  there  is  the  great  danger  that,  by  ii«  prea- 
Mff«  spun  the  bones  and  knee,  it  may  give  rise  to  caries  aud  destruclimi  uf 
Ifc*  jnini.  When  it  aprlogi  from  the  poatenor  part  of  the  artery,  where  il 
J,  it  increaara  rapidly,  aud  may  speedily  become  ditfiiee.  The 
uf  an  aoeuriam  in  thu^  situation  jiiuy  take  place  in  two  dirt-ctioDS. 
fMBuru-ptipliteal,  it  mav  give  way  into  the  general  aret>lar  li«jue  of 
.?.  .1,.,  i,|(nm1  dtfllntng  Utv\{  a*  hi^h,  perha[»,  as  Scarpa's  triangle. 
lined  lo  ihe  nam,  it  may  give  way  either  under  the  inlegn- 
the  superficial  wructures  uf  the  limb,  or  else  under  the  deep 
facJa  uftitc  Irg.  wbi-rcit  will  compreffl  the  posterior  tibial  nerve  and  artery. 
l»  all  Mam,  the  diflusion  of  popliteal  aneurism  ia  likely  to  be  followed  by 

'~'       'iHgncMis  of  popliteal  aneurism  has  to  be  made  from 

.  Ii'ir*al  fnlargements,  aoij  fn.m  dolid  tumors.     In  dis- 

"  nb»ee4*,  no  srrtriuH  ditfieulty  can  Well  be  experi- 

■  .1  tlinl,  when  an  aiit'uritim  ha»  suppurated,  coii«i<ler- 

tlilficuliy  ansrs  lu  determiuing  its  true  nature— whether  it  be  merely  aa 
u.— 17 


■ 


METHODS   OF   T'' 


tBNAL   IMAO. 


247 


oliliqtie  an'l  of  ihe  traoBvcnialis  iipwnn^ii  ami  ouUxAnU.  iluth  spatulie  ruBO 
ihc  peruoncum.  fty  cI<>ftHiiK  awav  «  lillle  ioo(<*  ureolm-  tissue,  the  nrterv  cua 
be  expowd  tor  une  inoh  and  a  half  or  two  iiichcw  without  difficiiltj-.  Tt  liu 
thff  genital  branch  of  the  genito-crunil  lying  on  it,  Km!  it  is  crossed  by  tlie 
orcnmfl«x  iliac  vein*  little  above  Poupart's  ligament;  theexteroat  iliac  vein 
b  to  it»  innerside;  th««e  nitist  be  curet'nily  avoided.  The  needle  niuet  be 
puie4l  firom  the  inner  side  not  lens  thiiu  one  incb  above  Poupart'a  ligament. 
•0  u  to  avoid  the  epi^uatric  and  circuiutlex  iliac  arteries.  After  the  opera- 
tion A  draiDA^tube  luuy  he  inserted  ut  the  lower  angle  r^i'the  wnund,  nud  u 
etteatautur«  iueerted  in  the  divided  tendon  of  the  external  oblique. 

On  compariae  the  two  oiwrattone,  it  would  appear  thut  the  principal  dis< 
aiivnntage  of  Abernelhy'a  ie,  that  it  ih  apt  to  leave  u  tendency  to  nernial 
pnitruniun,  in  cuusequeuce  of  the  alidoRiintil  wall  being  much  weakened  by 
Cl»e  free  iocleiuuB  that  are  uece««Hry  through  the  muscular  planes;  the  great 
advaDt«g«  alteudiuc  it  is,  that  the  external  iliac  may  he  ligatured  at  uuy  part 
of  it«  course,  and  that,  if  requisite,  the  incision  may  be  extended  upwards, 
and  the  ronimon  trunk  secured.  In  Sir  A.  Cooper's  operation,  the  line  of 
iDcbinn  lies  directly  acrora  the  course  of  the  epigastric  artery,  which,  as  well 
■■  the  cinrumdex  ifil,  if  it  nri^e  high,  nnd  the  circumflex  vein,  which  crosses 
the  iliac  artery  at  this  iKiint,  and  in  ofU>n  somewhat  funnel -shaped,  may  be  iu 
ifauiger  of  being  wounaed.  The  spermatic  oord  \s  likewise  somewhat  io  the 
WSJ  in  this  opemtioD.  Diipuytreo  actually  wounded  the  epigastric  artery  in 
m»  owe;  and  Houston  had  much  difficulty  from  the  circumflex  vein  in 
•aother  instAOoe.  This  operation  has  also  the  disadvantage,  that  the  iucieion 
apwarde  cannot  be  convenic-ntiv  prolongofl  so  as  to  dctigate  any  portion  of  the 
veanl  except  that  which  lies  imnicdtntely  nhovc  the  crural  arch ;  but  the  pert- 
toneom  is  fcas  disturbe*!  than  in  the  other  case,  and  thoro  ia  leas  tendency  to 
hernial  protruiion  atlerward^.  Ah  a  general  ride,  I  think  we  may  conclude 
that,  in  casod  of  spontaneouA  anenrism,  in  which  it  might,  from  the  ^ire  of  the 
tumor  or  the  dt-teasetl  fttate  of  the  vefwels,  be  found  neca»nry  to  apply 
the  ligature  to  a  higher  point  llian  wiwi  intendetl  before  the  operaliim  com- 
menced, it  will  be  Mifer  to  have  recourse  to  Abernethy's  plan,  niotiified 
ae  above  described,  for  in  this  way  we  shall  be  able  lo  ligature  the  vessel  at 
any  part  of  it»  course;  whilst  in  c«8e«  "f  hemorrhage  after  amputation,  or 
of  traumatic  femoral  aneurism,  in  which  the  artery  b  not  likely  to  be  diiieawd, 
recnut>e  eliould  be  luid  to  Coii|>er's  operation,  more  particularly  if  the 
patient  be  thin,  and  the  abdomen  tlat. 

Ill  connection  with  the  ligature  uf  the  external  iliac  artery,  there  arewjrae 
practical  points  that  de«erve  mention.  Uelbre  the  operation,  the  colon 
ibould  be  emptied  by  nicaun  of  nn  enemu.  nud  the  pubea  shaved.  The 
incision  in  the  abdominal  wall  munt  hts  t>ut!icieutly  extensive. 

In  Aberucthy's  method,  mndilimi  ii»  ubovu  described,  there  is  no  feur  of 
tronnding  the  epigaalric  unlefv  tht?  inrit^ion  bt>  carried  too  far  at  its  lower  uud. 
Thv  arttry  may  lie  ninghly  said  tn  run  in  a  line  drawn  from  a  point  at  which 
the  femoral  artery  cro^^es  the  brim  of  the  jielvia  to  the  umbilicu».  In 
neither  method  of  n[>erating  shouUI  the  iniMsiou  iin|)lii'aie  the  external  ring, 
Ittt  it  give  rise  lo  a  tendency  to  hernial  prntrufiion.  Care  should  be  taken 
not  tu  wound  the  [leritoneum;  for,  although  two  palienis  in  whom  thie  was 
done  by  l'<«>t  and  Tait  iKith  reaoveret),  yet  it  is  of  course  a  dangerous 
accident,  and  should,  if  pik^ihle,  he  avoidefl.  ThF«  [teritnneum  inur^t  not  be 
lorn  up  more  than  Is  ahwohitely  necessary,  lest  hemorrhasre  or  Hulisequent 
perilonilifl  owiur.  In  raising  the  peritoneum,  care  must  he  taken  not  u*  dis- 
place the  artery  which  lies  !fiiK«ely  in  the  suhiwritoneal  tissue,  and  can 
M  eaiily  ratseii  in  the  spntnla.  or  pushed  over  the  brim  of  the  pelvis.  The 
.Kpvadon  of  the  peritoneum  'a  much  fncilitabcd  by  the  Surgeon  holding  the 


LiaATUBE    or    THE    SUPERFICIAL    FEMORAL. 


2d9 


remored  or  taraed  on  one  Bide.  The  fascia  lata  is  then  divided,  and  the 
cnirml  abeath  exposed.  This  muBt  be  carefully  opened  over  the  artery,  and 
tbe  needle  passed  from  the  inner  side.  The  femoral  vein  lies  to  the  inner 
nde,  And  the  anterior  crural  nerve  a  short  distance  away  on  the  outer  side. 
The  origiD  of  the  branches  is  very  uncertain ;  tbe  Surgeon  must  select  that 
fmn  of  the  vessel  for  ligature  which  is  most  distant  from  any  branch. 

The  stfttistics  of  this  operation  are  so  unfavorable,  especially  when  per- 
formed for  aneurisms,  and  secondary  hemorrhage  has  been  so  frequent  and 
fUal  an  occurrence,  in  several  cases  requiring  ligature  of  the  external  iliac 
tar  its  arrest,  that  I  do  not  think  it  is  advisable  to  have  recourse  to  this  ope- 
ration in  preference  to  ligature  of  the  external  iliac ;  and  it  may  be  laid  down 
aa  a  mle  in  aurgery,  that  in  all  those  cases  of  aneurism  that  are  situated  above 
the  middle  of  the  thigh,  in  which  compression  has  failed  aud  sufficient  space 
doea  not  intervene  between  the  origin  of  the  deep  femoral  and  the  upper  part 
of  the  aac  for  the  application  of  a  ligature  to  the  superficial  femoral,  the 
extemml  iliac  should  be  tied. 

Lifatare  <rf  the  Superficial  FemoraL— The  auperfictal  femoral  artery,  in 
tia  ooune  from  tbe  origin  of  the  deep  femoral  to  the  aperture  in  the  tendon 


Pif.  401.— Ligature  or  the  ?ii|ierficiiil  Femoral  Artery. 

ot  the  adductor,  is  divided  by  the  cros,sing  of  the  sartorius  muscle  into  two 
portions  of  unequal  length,  which  have  different  relations  to  neighboriug 
■tnicturee.  The  upper  division  of  the  artery,  which  liea  above  the  anterior 
■argiD  of  the  muscle,  is  of  most  interest  to  the  Surgeou,  as  it  is  in  this  part 
of  its  course  that  it  is  iuvariably  ligatured  in  cases  of  aneurism.  It  is  true 
that  John  Hunter,  in  the  operation  which  he  iiitnidured  for  popliteal  aneu- 
riam,  exposed  aud  tied  the  vessel  in  the  middle  third  of  the  thigh;  but  his 
example  has  not  been  follower!  by  modern  Surgeons,  on  account  of  the  far 
greater  difficulty  in  reaching  the  vessel  here  than  in  the  first  part  of  its 
The  superficial  femoral,  where  it  lies  in  Scarpa's  triangle,  being 


SPKClAI.    AKEUR1SM6. 

eownd  ■writ  I7  lb*  oDBimoQ  int«gumcDt,  the  nuperficUl  fiueU  uh)  tbc 
hecia  laUu  ■*▼  ^  reaeb«d  by  as  sitopie  au  operation  tw  aor  that  the  i^urgvoo 
bae  to  pfrfcwm"  fcr  ibc  ligature  of  ibe  larger  ve«el».  Tlie  Him;  Ui  tbe  arifrr 
ii  ukf«  M  ^)it«»:  The  leg  is  flexed  and  ihe  thif;!)  rolaled  outwanU.  Tbc 
OuiBiuw  warfci  ■  point  exactly  Diidway  betweeo  llie  aoterior  aapcrtnr  tpifl* 
of  w  iK«M  *Bd  Uw  Byn)]»liyi»is  pubis.  From  tliis  lie  draws  a  liaa  Ut  tbe  ■(■( 
■fOniMMI  P***  *>f  ^)c  iuuer  coudyte  of  Ibc  feiiiur.  Tbe  poiot  aclcdcd  for 
nim  tW  aiMfT  BBSl  bu  alKJut  tive  inches  below  Poupan's  JinuDcat.  la  Um 
jjLiurt  «iU  IMO  be  at  A  »alc  distance  iroin  tbc  profanda,  tb«  loval 
tOJ.jj'ilJ  |«^t  ^'^  orifciti  r>f  that  veeecl  bi-ing:  four  iarhra  belov  th«  li|pBBtnL 
n*  iMeUna  ^y*S'  "l^l )  i^  °iade  in  tbc  Hue  abnve  iDdicnted,  and  i^iaold  bi 
|hw«  tkn*  b*  >ix  iuchpH  in  leoglli,  acconliu^'  in  tbc  ani<iunt  of  nv 
Al,     li   ttttst  be  so  arranged    that  iho  point  Keltt^livl  fur  the   ..  ..i< 

•fib*  liKaturotfhall  tie  iu  ttie  middle  of  its  li-ngth.  Theekio  anil  Miuerti 
Ihfwin  baviDjc  bfWQ  divided,  the  faM:ia  laiu  ta  ex[Hieed  and  opened  to  uie  aBOH 
«xu»l  «*  ihpinmion  in  the  iniegumeDte;  ihc  rausculnr  tihrt-snCiheaartoniM 
^v  CfHBV  uitv  %-tew.  W  the  incision  have  been  Diade  loo  far  inwards,  it  b 
Msib)*  ibal  tho  ft(h)uctor  InnffUi)  tuay  be  exiNvod  innteAd  of  the  aartoiiiii: 
t^  MT\tr  is  n*ndily  r^-cojiniized  by  ohM-rving  the  direction  of  the  fibr«*.  tbtas 
«^  kb*  adductor  bein^;  downwards  and  oulwardp,  and  tbfise  of  tbe  sartdfius 
«UtwD«iar<is  and  inwards.  The  edges  of  the  wound  in  the  fa»cia  being  beU 
aiian  with  blunt  hooks,  the  sartorius  is  seited  in  the  fon-ops  and  drawn  nal» 
wards,  the  fihrf-s  of  tbc  areolar  tissue  »iirn>undiu{;  it 
being  touched  with  tbe  edg«  of  the  ecal|«el,  if  nee**- 
Miry,  until  its  inner  edge  comva  into  view.  If  lb* 
ofieralion  b«  performed  a  little  higher  than  usual,  or 
if  tb«  sartorius  b«  feebly  developed,  its  inner  edge 
may  cniD«  into  ticw  as  soon  as  the  fodcta  lau  is 
divided.  The  edge  having  been,  found,  tbe  muscle 
must  be  turned  outwards,  uud  held  on  one  »ide  with 
a  copiMir  spatula.  A  litUe  looee  areolar  ttasue  most 
then  be  clc&red  away  from  beneath  it  with  the  handle 
of  thesoUpel.  and  the  shenth  of  the  vcesela  cmmi 
riearly  into  view.  The  sheath  must  be  caatloosly 
u|>cne<l,  a  email  hole  being  made  in  it  aa  in  tbe 
dia^nim  (Fip.  41)'J).  It  niun  be  remembered  tbat 
atler  the  fascial  ttheath  common  to  the  artery  and 
vein  hnn  been  opened,  there  is  »till  the  proper  abeatb 
of  (he  artery  to  be  divided  before  the  ligature  caa  be 
safely  passed.  The  vein  lies  beneath  the  anerr,  and 
consequently  the  needle  may  bepniaed  fnjui  ihtTinntf 
or  outer  side  indifferently;  it  should  be 
ttOATiaed,  and  then  he  threaded  and  withdrawn.  Uiiually,  do  D«rve 
during  Llieo|>(:rAlion,  but  the  internal  sanhcnousocca.'aiuually  comes  tuli^  vie*, 
and  niujit  be  ovoided.  After  the  operation  a  drainage- tuliu  hLouM  In-*  inserted 
iu  such  u  way  ihnt  iu  end  shall  lie  beneath  the  sartorius,  and  tbe  woutd 
b  elueed  with  aiilureft.  The  wound  is  (hen  semiflexed,  somewhat  ratnNl.  and 
laid  on  ils  outer  side  and  wrapped  in  soft  flannel  ur  cotton-wool.  Thrsrven 
pall]  which  is  ubuhIIv  coinplaiued  uf  about  the  luiee  aAcr  tigbtcaiug  tb«  tiga* 
turo  may  Ih'  relieved  by  it  Aill  d<>»e  of  opium. 

Iu  this  ojwratiun  tlitre  are  several  points  of  considerable  importaoct  tbat 

renuim  special  attention.     1.  The  incision  should  be  made  airecUr  iu  tbe 

liue  of  the  artery,  care  U-Jug  taken  not  to  incline  it  inwanu  in  tbt 

t  ,,  .>  ^)f  Ibcfiartoriuf.     2.  In  cuLUiig  down  upon  the  uru'rr,  the  sapbcooua 

ould  be  avoided,  by  taking  care  nut  to  make  tbc  ludikm  loo  Ibr 


Ltin  FMSsnl  ArUrj  *t 
ApM  at  &Mrp«'i  Tri- 
•lifl*.  ».  »»rWrlu»;  /. 
hCBora  I  (bf ktk ;  n.  mttrnty. 


K  It  h%a,  however,  Jiappened  that  the  ligamre  hns  been  plat 
mm-qn&rten  of  as  inch  at'  tbv  ori^ii  of  Iho  deeji  femoral,  without 
Briaus  aHuequencM  rvwiUin^.  fi.  The  greatest  <»re  inii<it  be  taken 
MKinil  tliu  femoml  vpin,  which  lio«  iH-hiiiil  iho  Hrtnry  in  the  sitiintinn 
lb  a  liirature  t!«  iiMially  np[)ii(Nl.  If  the  vubwl  is  tied  n  little  higher 
naJ.  tbc!  vein  wilt  Im>  towanU  the  inner  filile,  and  then  the  needle 
!  paflBcd  fn)ni  within  oiitwunlH.  Wounding  the  vein  is  best  avoided 
oag^hlf  cleaning  the  artery ;  the  while  external  coat  must  he  thor* 
cxpaaed,  and  while  the  needle  ig  being  nitMed  the  sheath  ihould  b« 
riHighIr  on  the  si  retch,  the  Surgeon  holding  the  edge  of  the  opening 
Mi  fn*m  wbit-h  he  b  parsing  the  needle,  while  the  lusistAnl  cjilcht^ 
■fctf  side-  in  a  pair  of  furcegu  and  draws  gently  upon  it.  In  pawing 
mU,  its  end  i^hould  be  kept  very  clo^e  to  the  artery,  and  made  to 
Hind  it.  The  veiu  is  generally  t>erfjruted  by  dipping  the  ui^odle  too 
nod  Iwiog  th«  contact  Iwtween  it  iind  ihw  artery.  When  the  needle 
^t  up  oa  the  outer  side  of  the  nrlvry,  it  anmll  purtioo  of  the  sbeatb 
iisMi  pusb^  up  br  it ;  this  must  hv  torn  by  piucbiug  it  with  th4 
,  Vben  the  needle  may  be  carried  round  the  vcsbuI. 
Mi. — Ugatur?  of  the  femoral  artery  for  popliteal  aneurism  b  an 
9a  that  ha«  b«en  au  frequently  perfurmed,  that  .Surgeons  seldom  think 
rding  caaea  of  tbis  descriptiou,  uuleaa  tbey  present  com  plications  or 
t  i^f  unusual  iuterwt  ur  wverity  ;  hence,  but  little  importance  can  be 
d  to  any  ^laliAticwl  deductions  from  r«!p«rte«i  caees  m  to  the  riitality 

oprmtinn,  although  they  may  perve  a;?  n  rough  estimate  of  the  pro- 

BiBinlaioed  between  the  <litlenrnt  Hccidoniii,  such  as  hemorrhage, 
IM,  etc.  that  follow  it.     That  ligature  ol'  the  femoral  artery  19  nt- 

wbfa  more  succeed  than  that  of  any  of  the  other  large  trunks  can 
>f  ao  doabL  This  10  not  only  in  accordance  with  the  gcucral  expi> 
afSnmtms,  bat  is  conBrmed  by  the  stali^lii'^  of  published  caseid,  even 
i  ■■Ictfig  alloTT&nee  for  the  pnibnbility  nf  more  of  the  uunueccMful 
leeWiAil  having  been  rcoirded.  Tliuii  of  1 10  instanMis,  collected  by 
0  «bicb  tbe  femoral  artery  bad  been  ligatured  for  popliteal  aneurism, 
ralve  are  reported  to  have  died;  amongst  tbe«e,  four  deaths  were 

hj  MCondxry  hemorrhage,  three  by  gangrene,  and  the  others  by 
ifai,  Utaniu,  cbe*t-diM'«ac,  etc.  Higher  rate*  nf  mortality  are,  however, 
^  wUhtr  anibor* ;  thun,  Norrta  stat^  that  nearly  one  in  four  die  after 
Htmiioa;  Ilutrhinson  findii  that  of  thirty-three  caaea  operated  on 


2d4 


IP£C[AL    ANEUBISMS. 


ai  to  mixlfTate  the  flow  of  blotwl.  .Should  the  oponitioD  be  agftln  Ulcoplcri, 
tli«rtf  i>t  lillle  diiubl  iIihI  tli«  inciHJuu  adopteil  by  Bir  A.  Coop«r  would  be  tbt 
MftKl,  as  tbe  oaug«r  of  iwritoojlin  u  much  leaa  iiader  the  preMwt  ntodeiaf 
trentiiient. 

AM^VRt-M  Of  THK  IvrERKAL  Il,!AC  AND  ITd  BkANCIII-:9. — All<*Uriaill  nf 
the  Trunk  of  the  Jntermd  Sdac  Ariery  it  extremely  rare.  The  onlif  cue  '"ith 
which  1  ati)  apnuaiut«ti  is  one  reUlud  by  8aiii)ifurt.  The  three  iiriodptJ 
branches  of  this  artery — the  Qiuteal.  the  Sciatip,  and  the  /Wic— barr  all 
occasiooatly,  though  rarely,  been  fiiund  afTected  by  this  disease.  Of  thos 
branch&t  tlic  gluteal  has  beea  tnost  frequeutly  found  BDeurtamal,  thr  srjBlJe 
next,  iind  the  ]>utlii!  leaeL  frt^quently;  iodeed,  1  am  arqiiainicd  wiiJi  only  eot 
inetuDoe  of  aiiciimri)  uf  this  vessel.  It  is  the  [ire[)aratinu  ITOI  in  tb* 
MLii>outn  of  the  (.Ville^  uf  Surgetms ;  and  it  exhibits  an  amMiriffOi  of  tbt 
trunk  of  ihv  [xidit^  luitrly  an  iuch  in  dinmoler,  full  uf  laniiuauid  clol. 

Aneitrismi  of  the  Gluteal  and  Sciatic  Arteriei  may  be  rith«r  umui 
or  »[i<iiitani»>u»t. 

Fi^L-hcr,  of  Hanover,  has  published  with  comtneots.  In  the  Ar^kit 
ktinUeiu  Chintrgie,  the  records  of  thirly-Hrc  cnMA  of  gluteal  and  aciaiie 
aneurism,  to  which  must  be  added  a  cnsc  of  gluteal  aneurUm  deacribod  by 
GalloEzi,  of  Naples,  and  one  by  BickerMeth,  of  riverp«H>l.  Id  tweaty-Mm 
of  tbe  caaeo  the  aneurism  was  di.ilinctlT  gluteal ;  and  in  six  dlstincclr  adatlr. 
Thirteen  of'  the  glutrnl  aneurisms,  and  two  of  the  sciatic,  were  of  tnituatir 
origin;  fourteen  gluteal  and  futir  sciatic  aneurisms  were  !tpoataiie>t>tM.  Tbt 
gluteal  aneurism  has  been  generally  found  ailualed  at  the  t)pp*r  pari  of  lb* 
great  M-ialic  notch;  but  may  extend  over  a  large  portion  of  the  bullockj. 
'Nriatic  aneurism  lie«  more  deeply;  and  a  p"rti'>u  of  tbe  •■*»:  may  l>e  within 
the  pelvis.  Tbe  slxe  uf  thege  itneiiri)>n)s  varies  from  a  flight  swelling  to  ■ 
tutuiiras  large  as  a  child's  head.  In  almost  all  tbe  recorder]  casea  then  hai 
been  i<lnnig  pulsation,  im>vhronous  with  the  heart's  l>eRt:  and  whirring  and 
buzzing  murmurs  are  bean!  on  auscultation.  Tlienj  is  alittiwt  always  pna 
in  the  luni»r  ilM-lf  and  in  the  course  of  thtt  sciatic  n«rve,  which  may  be  f<A- 
loweil  by  paralysis  of  the  parts  supplied  by  IL 

The  nflectious  with  which  these  auc-urisma  are  moet  likely  to  be  iimroundtd 
are  abacessea.  sotl  aurctimatu,  cysts,  and  sciatic  heruia.  The  diagnnts  b 
soiuetimee  ditKcult;  thus  Outhria  ligatured  tbe  cumniuu  iliac  artery  for  ■ 
Urge  pulsating  tumor  in  the  gluteal  region,  which  presented  all  the  char- 
ncton  of  aoeurism,  but  which  proved,  on  the  death  uf  the  |>atient  eight 
m«mt.h»  after  the  operation,  to  be  a  sarcoma. 

(jlutcfll  nneuriani!4  have  on  aevenil  occasiona  lieen  opened  by  mistake  for 
abooeaBca.  According  to  Holmes,  this  uccideot  haH  mnet  frequently  happanai 
when  the  aneurism  has  t>een  more  or  leas  dilFuxed,  and  in  such  caaea  ba 
auirgCMts  that  the  nspiretor  should  be  used  to  render  the  diagnoms  oertaii 

In  the  IWatment,  various  methods  have  been  employed.  The$Mluui 
(aid  opof  and  the  (gluteal  ari<?rr  tie<l  in  live  fitscn.  nil  of  which  roeovuned. 
another  instance,  after  laying  upcn  the  sac,  the  aneurism  (gluteal)  wi 
to  extend  into  the  pclns;  and  the  internal  iliac  artery  was  tied,  with  a  fatal 
reeull.  LigaUtrt  oj  the  iutcrtxnl  iline  artery  has  been  [wrlwrmcd  in  elerea 
cases,  six  of  u  liich  recovered.  Th<  rommon  Uinr:  arUn  hits  been  tied  in  thcte 
caaes,  all  of  which  pn>ved  fatal.  Jr^e^liou  of  the  ftrrAloridr  of  iron  has 
used  in  six  caaes  ;  four  recovenyl,  one  died,  and  io  one  the  result  is  not  I(d< 
lAyaturt  of  the  $eiatic  artery  williout  opening  the  sac  has  been  p^Tformed 
two  cases,  one  of  which  rec<uvered.  Hpoutaneous  revorery  is  rvfMtrteiJ  to-  bare 
occurrixl  in  'ine  mm-. 

Liguture  of  tbe  latemal  Iliac. — This  veasel  was  ligatured  for  the  fim 
time  in  1812.    ThK  operatioo  was  [wrfomied  by  Stevens,  of  Bi.  Cfolx,  ua  a 


I 


fORAL  anB  pAplitkal  axBukIsms.  266 

negrcH  who  dutff^rod  from  an  uneurism  nf  the  daios,  8Ufi|ti)«o(l  lo  be  »!'  tli« 
gluteal  artcrv,  but  found  after  death  three  yeani  )iiihi4ei|ii«t)i.ly  tu  Uke  in 
origin  from  the  iciatic  Stcphena  in  thiii  oai«e  ttinde  an  incision  tiv«  iiicb«s 
long  4in  the  led  wdoof  the  abdomen,  carefully  dij«»ect«d  through  the  paricte*, 
Bepantled  the  peritoneum  from  the  iliac  fu6»a,  turned  it  on  one  side,  lugethtT 
with  the  ureter,  and  paMed  a  ligature  round  Llie  nrtery  without  much  diili- 
culty.  Since  that  time  the  uperation  has  been  done  twenty  timw;  iu  eix 
cacea  with  eucceu,  by  AriicU.  M'hite,  Mutt  (who  aci:id«ntally  wbuiided  the 

feritoueum),  Hyme,  Morton,  and  Galiozzi ;  in  tburteeu  oiujcm  uueueuccHifully, 
y  Atkinson,  of  York  (wbo(<>e  patient  died,  ou  the  nitieteeulh  day,  of  eec- 
ondary  hemorrhage),  by  JJiKelo«,l\irr8ct;hi,  CiuuUoue,  Porta,  Laudi,  Kim- 
faaJl,  Allmiiller,  Thomiui,  J.  K.  Itudgen,  and  HiggiuBuu  ;  and  thrue  timce  by 
f?urKeon>*  in  tJie  American  Civil  War. 

The  aucc-ivna  llinl  haa  liilherlo  atti-tided  ihia  uporaliou  IB  certaiuly  rejuark- 
able,  when  we  Uike  iiilLi  coueideraliou  the  depth  nl  wbich  the  artery  is  siluutud 
«ad  itagrCMaiM;  it  must,  I  thiEik.be  uccouuted  fur  by  the  tiict  lliut,  aitliuu);h 
in  tbeae  cugb  the  patient  ruat>  the  ordinary  riske  altendanL  un  the  liguture 
of  the  larger  (lelvic  artoriM  from  the  expieure  and  handling  of  tho  |ieri- 
l4Uieuin,  yet  he  u  a^tved  tho  danger  resiilling  fnim  the  BU|H]rventi<>n  of  gau- 
grmae;  tbti  anatitomoeia  between  it(>  branohisi  and  that  of  the  neighboring 
Tnacia  being  eu  free,  and  the  course  triiver&ed  by  the  blood  bo  short,  that  ou 
difficulty  can  ariiie  in  ttie  maintenance  of  the  tiuliateml  circulation. 

The  atepa  of  the  oiwration  nect'eeary  for  the  exposure  of  the  internal  iliac 
artery  are  precisely  imalogoua  to  thoeie  requiBite  for  the  ligature  of  tJie  c-oni- 
iDDii  trunk.  When  ibe  vessel  is  reached,  it  ninat  he  rememberer]  ihnc  both 
the  external  and  interoul  iliac  veins  ure  id  cluee  relallou  to  it;  the  one  being 
to  its  outer  oide,  the  other  behind  it.  As  these  vessels  are  Large,  and  their 
CMls  thin,  it  is  nece^ary  that  they  should  be  separated  by  the  finger-nail,  or 
the  blunt  end  of  the  aneiirismneedle,  before  the  ligature  is  po^ed  round  the 
artery ;  oare  must  he  taken  aUo  not  lo  put  the  ve«»el  too  muL-b  <ni  the  stretch 
in  applying  the  ligature,  Ictft  the  ilio-lumbar  artery  be  ruptured.  There  is 
tittle  risk  of  jncludiag  tho  ureter  which  croaaea  the  artery  internally,  aa  it 
slwmva  adheres  firmly  to  the  peritoneum  and  i»  pushed  on  one  aide  with  it. 
Ai  the  length  of  the  artery  viiries  much,  u^ualty  ranging  between  one  and 
two  incbea,  and  oa  when  it  id  nhort  it  U&tt  a  tendency  to  he  placed  deeply  in 
the  pelvis,  it  would,  I  think,  be  more  prudent,  and  occasion  lesa  chance  of 
■ecoodary  hejuorrhage,  for  the  'Surgeon  to  ligature  the  common  trunk. 

FEUOttAL  ANB  POPLITEAL  ANRUBISMS. 

We  have.  In  the  preceding  fteetiuu,  oonsidered  ancurisnia  aHeeliug  the 
groiD.  which  arc  by  nu  nieau^  uufrcijuent.  Aneurismu  of  the  thigh  uro 
Bmcb  rarer;  but  those  iu  the  hum  arc  very  commonly  eucountcreil.  Thus, 
oat  of  551  caote  of  aneurism  recorded  in  the  Hritish  medical  journals  uf  the 
praeot  century,  Oitip  has  found  that  I'H  aHt;cled  the  popliteal,  and  ouly  06 
the  femoral  artery.  Of  these  iiii,  4'>  were  situated  either  in  the  groin  or 
opper  jiart  of  the  ihigh,  and  2)  only  were  truly  femoral  or  femuro-pupl ileal. 
Ine  reaaun  of  ihw  dilference  in  the  freciuency  of  the  occurrence  i>f  aneurititn 
difierent  parts  uf  the  vessel,  may  be  uccoiitiled  for  liy  utteiitton  to  its  ana- 
itcftl  relationa.  In  looking  at  the  main  arti^ry  of  the  lower  extremity,  in 
.  course  from  Poupart's  ligament  to  where  it  terminates  tn  llie  anterior  uiid 
paateriur  libiala.  we  Bee  that  it  may  be  divided  in  relation  to  ihe  muscular 
mames  that  tiurround  it,  into  three  itrincipal  portion.'i :  1.  That  whirb  h 
dtuated  between  Poupart's  ligament  and  the  inner  margin  of  the  sartorlus, 
and  which  may  be  euDaidered  inguinal;  2.  Thnt  whieh  intervenea  between 


2S5 


SPECIAL    AKBURI3U8. 


this  point  and  iha  aperture  !□  tbc  adductor  tendoo,  nod  which  miiy  be  coo- 
$\dsnd  femoral ;  aua,  3.  Thnt  divi»ii>ii  of  Lhe  ves»«1  wlitcli  c<trrre|w>ad«  tollK 
bam,  aod  which  may  be  KoaaUivreii  jwjfliteai.  Of  IhvM  lhr<w  <livUii<at,  tbe 
first  and  liut  are  comparatively  suiKTliuiul,  and.  twiug  unsupfxirted  tiy  muscle, 
raulily  expand  ;  while  the  central  purtiuu  of  tht>  artery  is  eluvcly  Mr- 
ruundod  oo  all  tides  by  muscular  mafisHi,  aad  ig  vury  unlikt'ly  U>  b«  dilaM 
into  UQ  aoeuri^nuil  tumor.  We  Had.  alm>,  that  the  inguinal  portion  of  tli« 
veBMl  18  cloecly  and  Brnily  iaveated  by  a  dense  aud  resistant  fibroareular 
ahcAtb,  and  is  wpll  supported  by  the  faitcia  laUi;  nrhiUt  in  lh»  popliteal 
space  iha  artery  is  surroniided  merely  bv  the  ordinary  areolar  sbeatlt,  aad 
receives  no  aponeurotic  dupporu  1\m  ditferenee  in  the  coDoectiuoa  of  Omt 
two  purls  of  Uie  vi!>ael  niav,  toa  certain  exleni,  explain  lhe  greater  frequeae^ 
of  ane'iimm  in  thci  ham  titan  in  the  upper  part  of  Xha  thigh. 

Anrl'kihm  of  the  DEi:f  Fi:moual  Artehv  ia  of  »;xiremcly  rar«  oeesr 
reooe ;  iuilt^l,  I  am  acquainted  v,  ith  five  eaaee  only.     Ouo  of  thesfl  oceumd 

in  K  v.tuiiu;  man  under  my  care  in  Univcrsiiy  Cbl- 
tcgc  Hit»pitul,  in  1870.    There  was  a  lar^  tunw 
at  the  upper  part  of  the  thl]fh,overwhicD  layjlM 
superficial  femoml  artery,  putsatiog  freeljr. 
diseaae  was  cured  by  cnmprcMlan  of  ib<>  ca: 
ferooral  arterr,  hydrate  nf  chloral  heine  pn 
relieve  pain.    Another  case  in  recorded  hy  Brrant 
aa  having  occurred  in  the  practice  of  Coca  at 
Guy's  Hospital.    The  aneurism  was  situalfd  at 
the  origin  of  the  dt^ep  femoral  artery :  ll)«  extMVtl 
iliac  was  tied,  but  the  patient  dit^]  nine  weclt* 
afler  the  operation.      Fij;.  AW  i«  (ak«-a    Cmm  a 
patient  who  died  of  ptieumonia  ithorlly  alter  ad- 
minion  into  Uiiiv<Titity   College  Hu«pil«l.     On 
I  >^H         '/*11^^H      exnmtnation  after  dealii.  a  large  tumor  of  the 
y \-^V         bJ  i^^V      thigh,  which  had  nt^  heeo  very  cloet^ly  rxamilMd 
\  -^    .^uJ^^r       during  life,  proved  to  be  a  cireuuiscribed  Um 
aucuriam  apparently  aribiiig  from  rupcurt  of  a 
perliirating'   artery,  nxiet   pmbably   the    oooae- 
uuencv  of  cuibulieni  (Univ.  Coll.  Museum,  VUAl 
Two  cuMX  are  recorded  by  F.  M&raball  and  J. 
Wal»t)ii.     lu  the  eaiw  which  was  under  mv  art 
in  the  liospitul,  the  dii»ea»e  was  refxigntxe«l  dv  the 
fullnwiiig  uigna,  which  are  charaetertatic  of  it: 
I,    A    large  tumor  extended   from  three  tarfafa 
])elow  Foupart'n  ligament  to  the  middle  of  iha 
thigh,  raiiiing  and  slightly  Hepnrnting  the  add 
BiiHclca  and  the  rectus  femnritg.    2.  All  the  ordinary  ant-urismal  aigna 
pment  in  this  tumor — the  most  marked  being  a  peculiarly  lond  and  ' 
bruit,  and  a  dry,  forcible  thrill.    3.  The  superficial  femoral  artery  eon 
felt  running  over  the  anterior  and  inner  aspect  of  the  tumor,  bat  rlntr  of, 
and  distinct  Imm,  it.     4.     The  pulnalion  in  the  popliteal  and  ita  diviainM 
WM  Strung  aud  perfect     5.  All  tlt*r  aneurismal  signs  ceawxt  on  o^mfrrflMlaf 
the  common  femoral  artery,  and  returned  on  removing  the  prasure. 

The  only  disease  with  which  an  aneuhun  of  the  deep  fenKffal  artery  cU 
readily  be  confounded  is  pul»atiDg  sarcoma  of  the  femur.  The  dia^ous 
from  ibis  muet  be  left  to  the  surgical  tact  of  the  practitioner. 

I  la  former  aditlona  tkii  c-mo  was  dascrllxd  ss  an  aofforlim  of  lb*  nmAind*,  b«l 
oarefbl  mteamtoNtioa  at  th«  pivjiMmUtm  sliowi  It  lo  tw  tmn  at  •  pvifunliQi'  vterj. 


^ 


f\f.  tva.~Vmlf  AacuriMB  of 

■  I'srlorktltig  MtMJ- 
U  CottMsn  Vmsral. 

4,  AsMiliui.  a«t  opaQ. 


or  ffUPXBrioiAL  pkmoral  and  poplitkal  ahtbries.    261 


la  Um  TVmtment  of  tbeae  aneiiriaiiu,  Ute  Surgeon  huit  the  choire  r>f  ilirre 
B*tbcid«r  via^  eonipr¥»i(iii  id  the  gntiu,  «ii(l  ligHturc  of  the  external  iliac,  or 
of  l^earamii  femoral.  Il  the  comniua  femoral  ever  should  be  lignturvd 
fcr  aacnrtMB,  this  fti>pmra  to  mv  to  be  the  case  best  sujled  for  it.  But  tlie 
Ankett  btlircen  the  li|niture  of  thiti  artiTv  or  of  the  external  iliac  mutit  iu  a 
znmt  meatart  depoDi)  upon  the  ^urgooii  s  judgment  ns  to  ihc  relative  exjw- 
dtrtH-y  of  rithcr  npt^rutititi,  nud  uu  ihe  hfit;iit  to  which  the  nneiirif>ni  extends 
vp  lk«  emin.  But  neither  artery  should  be  Itgulurcd  until  ci'tmpre«!-ion  hiiB 
mmt  birljr  irird  and  has  failed.  Thin  uuy  be  done  digitally  or  by  Carte's 
TMriiiiii  m.  «li«T«  the  artery  [uusea  over  the  brim  of  the  pelvi«.  It  is 
a|vci»llv  likely  to  luccred  in  aneurism  of  the  pmlunda,  owiDg  to  the  ^horl- 
••■I  nf  liie  tniuk  aad  th«  way  in  which  it  breakx  up  into  rnnny  auasloiiiiising 
bfmodkM.  Heoce  there  is  not  a  free  current  of  bliMxl  paiuin];;  iroiu  uiie  lurge 
wmmi  of  rstry  to  another  of  exit,  but,  ns  it  is  brolcen  up  and  has  lo  litter  out 
tlinwfh  a  D(imb«r  uf  tninor  veaaels,  il9  conKulntioii  may  readily  be  brought 
AbottL  lo  Itie  c*M  treale<l  by  me.  compresiion  eHei:ted  a  cure  ia  Lweoty- 
finr  kMin.  iboggb  the  aoeuristD  was  very  large  aod  active. 

Ajivjmaaa  or  the  Sutcrficiai.  Fkmokai.  ahd  Poplitkal  AnTx^iUBs.— 
Tkes*  iKTur  cDutnunlT  about  the  middle  period  of  life,  and  are  alniusi  iava- 
mbly  DKt  with  io  aialee,  being  at  least  twenty  titucii  more  frcqueut  in  them 
tkaii  in  »DD»t].  Both  sides  are  aflvctcd  with  equal  frequency,  aud  occa- 
■■■bIIt  at  ifaa  saioa  tiine.  Aecurdiu{;  tu  Crisp,  sailore  uinuld  iippvur  to  be 
mo€m  uaUc  li>  thb  variety  of  Lbe  diseuM.-  tlian  any  i>ther  ela»i.  I  bene  aneu- 
riMM  arc  mmt  fivquenlly  sacculnteil ;  in  the  hum  Ihi-y  an;  alwajis  en.  but  in 
tba  tkif  fa  tlkej  arc  eomeiimes  tubtitar. 

Jyipiaaw. — Tbe  sTraptiitns  III'  Femoral  Anearisin  |)rrsrnt  nothing  peculiar; 
tiM  tasMtr  Bsoally  enlarging  with  cnnsiderublu  nipidily,  with  all  the  char- 
■eUriiUc  aq^ns  of  the  disen.^e,  and  uisumiiig  il  pretty  regular  ovoid  shape. 
Va^litaal  Aneariani  u.<!uallr  nmimencefl  with  atttfnesn  and  a  got^d  deal  of 
pain  ab««ut  the  ham  and  kuee.  which  I  have  more  ihau  once  seen  mistakcQ 
M  rbramatiam  ;  io  fact,  so  commonly  does  this  happen,  that  the  Surgeon  . 
'  r-til  to  pn.<9  his  haD<l  Ix^hind  and  examine  the  ham  in  every 
I  "  rht  iiMiatic  ''  pain  in  the  koee.  There  is  also  a  difficulty 
the  limb,  whic^i  i«  geut-ralty  kept  semiflexed.  The  tumor 
with  great  rapidity,  and  has  a  great  tendency  lo  become 
cnditioos  will,  however,  materially  depend  on  the  8i<le  of 
Uw  artsry  frnn)  which  it  springs-  When  it  arii^es  from  th«  aoterior  aspect, 
Otsit  ike  b-  '  rvasee  elowiy,  being  c<.>Dipr(-«-ed  hy  the  firm  ntructurea 

before  it.     I  .>ye,  however,  there  ia  the  great  duugur  that,  by  its  pres- 

mum  opoo  th«  buui-9  and  koee,  it  may  give  riMi  l»  curies  and  destruction  of 
tW  jouM.  When  it  springs  from  the  poeteriur  |iart  of  the  artery,  where  it 
ipPMStd,  it  iucreiiwa  rapidly,  and  may  speedily  become  diHii^e.  The 
of  an  aacuritmi  in  tbu<  siiuation  may  take  place  in  two  directiona. 
fecnorvpoplittral.  it  niav  give  wuy  into  the  general  arailar  tiraue  of 

^1^  the  lilouil  dillbeing  Keelt  w*  high,  perhaps,  as  Scartia's  triangla. 

WWa  It  ia  con&ned  to  (he  ham,  it  niiiy  give  way  either  under  the  integu- 

ita,  and  Into  the  superBriul  slrttcturrs  of  the  limb,  or  else  under  the  deep 

•<f  the  Ifg,  wherr  il  will  compress  the  posterior  tibial  nerve  and  artenr. 

I  tamtK  th«  diflUsioD  of  popliteal  oocurism  ia  likely  u>  be  followed  hy 

~'       liagoneis  itf  popliteal  aneurism  has  U>  be  made  from 

<  Knntil  niliirgeiiicntji.  ami  from  solid  tumors.     In  dis- 

r-  a/mtrMt.  no  serious  ililfifully  can  well  be  expen- 

. I  llmt,  wIh-ii  Rh  aneurism  liQA  stippuraled,  consider- 

I  ^iAcmlty  arur»  m  ilclermining  its  true  nature — whether  it  bo  merely  an 

»i.i     II  — IT 


258 


>EOIAL    AKEI 


•bsoeM  or  ool.  Oo  such  tajh^  no  ilies4>,  the  otAte  of  the  drculBtka  !■ 
the  lower  part  of  tfa«  limb  will  throw  much  littht.  Bnrtot  htman,  oftca  of 
lorgv  elite  ami  miiltilocular,  nre  out  uafre^ucDtly  lucl  with  id  the  huii ;  hut 
I  hiivv  uevcr  fnuod  auy  grc-al  difficullv  in  dotci'niiniu}^  their  true  nntiirv,  thrir 
'alaslicity  uud  nmnducsi,  together  wiili  their  mobilily  aod  waui  nl'  imlMlJon, 
bein^  Ku6ii>k>i)U}'  iudicativo  of  thvtr  character.  The  mewl  aeriiiue  diaguuctic 
(liHiciilty  way  urise  from  eoufoupding  eulidJOed  ntieurisma  uf  the  ham  with 
aolid  ttimort.  uf  a  aarcomatiius  cbaractt-r,  Apriu|;iDjf  from  the  lihia  and  fcniur; 
and  I  have  known  one  race  of  aneiiriHin  in  Uiib  mmliljrtn,  in  uhirh  amjiuia- 
lion  was  p^-rfiirnied  on  the  ;4nppiwili(in  of  iiK  hiiin^  a  mtVul  itimor  i  Fig.  447). 

Tro^mrnt. — The  trealmrtnt  of  femnrnl  and  ]>>)|tlil(«l  aiK'uriBtn  may  be  ooa- 
daeted  either  by  conipre«flion  or  by  li^ntiirr!  of  the  reaarl  leading  U>  the  ne. 
Aa  a  gent^ral  nilf,  for  the  rea»mA  alrpjidy  msi^mI,  cumpreeeion  should  ba 
eninloye>d  in  prntf-renc^.'  to  Mature;  but  caaes  do  arise  in  which,  from  the 
failure  of  (v>nipri-ftsion.  or  for  other  reasons,  it  beoucDM  necraaary  lo  ligatate 
the  Ifeinoral  iirlery. 

The  Trentmmt  by  Campremon  in  pectiliarlv  applicable  lo  theae  anruritnt, 
and,  indeed,  it  ia  to  \\\t!m  that  it  hae  chiefly  been  emploved.  I  i\vrA,  there- 
fore, eay  nuthinjj;  iti>eciat  about  it  liere,  but  would  refer  ifie  reader  to  Chajiur 
XLIII.,  page  1<V>,  for  a  dtwi-riptioo  of  the  subject, 

Flexitm  of  the  knee,  which  may  be  consideml  a  modidcalion  of  compr«»- 
sioD,  is  applicable  to  thetw  cases  altio,  either  alone  or  in  cotnhinatinn  with 
comprewion  of  the  main  trunk.  It  is  peculiarly  applicuble  in  tboae  cam  in 
which  the  aneuriiiiii  is  uituatc  entirely  in  the  ham  (fee  p")^  1^6), 

Li^tnie  of  the  Common  FemoraJ. — In  li>nking  at  the  femoral  artery,  it 
might  at  first  be  nupp^iecd  tliiit  the  common  trunk,  situated  euperhcially 
betwe«n  Tuupart's  ligament  and  the  on^'n  of  the  profunda,  would  be  tM 
most  convenient  situation  for  the  application  of  the  li^ture  ;  but  experi«DC^ 
ha«  shown  that  dellgation  of  the  vessel  here  is  bv  no  means  a  ^acccsaAjl 
ration,  cspecialtr  when  undertaken  for  aneunsm.  This  arifiea  from 
shortneas  of  the  trunk  rendc-rine  it  necesBary  to  tie  the  nrterv  in  close  prox- 
imity to  the  collateral  bmnch  that  will  oonstitnte  the  moat  direct  and  imme- 
diate agent  in  the  anastumtiaing  supply — riz.,  the  deep  fcmomi,  so  that  tbt 
InternnT  eoagulum  would  not  r»idily  form.  In  addition  to  this,  a  number  of 
email  inguinal  brancbos,  the  superficial  epigastric  and  circumflex  iliL,  tha 
superior  and  inferior  external  pudic,  and  verr  commonly  one  of  the  eircom- 
flex  nnerica  of  the  thigh,  more  especially  the  internal,  ansa  ftom  the  common 
trunk  in  itd  short  course;  and  iheaevcMcls,  though  small  in  siao,  cooalituiea 
source  of  great  enibarniMinient  to  the  Surgeon  during  the  operation;  fiir,  if 
wounded  near  their  origin,  tliey  bleet^l  rnoKt  furiouiily,  and  are  a  eau»«  of  con- 
siderable danger  aAernards,  by  inlt^rfering  with  the  proper  plugging  of  the 
vessel.  The  ligature  of  the  coiunmn  femoral  has,  howerer,  deveral  advocates, 
more  particularly  in  Ireland,  where  tliR  oiieratioa  has  of  late  yean  l>cvn  ilooe 
nine  timeH,  for  wound  and  aneuri^fo,  witu  six  recoveries  and  \.\\tw  dcoths. 
The  succewful  cases  were  m  follows:  I'orler,  sen.,  three;  G.  U.  iVrtrr,  one; 
8myty,  one ;  Macnamaru,  one.  In  the  American  war,  however,  the  o[ieratiDO 
is  reported  to  have  boeu  pcrfurmcil  in  eighteen  cases  with  only  four  reoor- 
cries;  and  fiarwell  states  that  out  of  thirty-one  msee  in  which  the  artery  was 
tied  for  aneurism,  hemorrhage  occurred  in  eighteen,  and  of  tbcoe  tiralvt 
died. 

The  venwl  may  he  reached  by  a  vertical  or  a  transverse  incision :  of  th«» 
the  former  is  preferable.  The  incision  coniniencen  at  Foupnrl's  li^^iraent,  at 
a  point  midway  between  the  BymphyBtaiinbis  and  anterior  sufwrinr  iliac sptoe, 
and  is  carried  downwanln  in  the  line  oi  the  artery  for  about  two  iuchea ;  the 
aUn,   fat,  and  aupcrficinl    fascia  are  divided,  and   the  lymphatic  glaa^ 


LIOATDKX    or   TUX    SrfKRFICI AL    FEMORAL. 


■■■Ofva  or  luraea  oo  one 
wual  ifaaub  expuicd.    Tbi 
tW  DMdta  {MMBed  thim  the 
mIb,  and  tbr  anterior  crural 


or  turned  oo  one  side.  The  fiuv'tn  lata  »  thi'o  divided,  aad  the 
This  tuiut  be  uarerully  ofieniKl  over  the  nrtery,  aod 
iaaer  side.  The  femoral  vein  life  to  the  inner 
iml  nerve  n  ahori  diiilanoe  away  on  the  outer  side. 
Tbftcrtgia  of  thf  brari<-hi>M  is  very  uncertain;  the Sui^eon  niuM  i«lcct  that 
pan  of  ifae  v«vel  for  ligsliire  which  is  moBt  distant  from  nny  branch. 

Thft  •taltRtloi  of  thiit  nperation  are  m  unfavorable,  egpocially  wh&n  pet' 
fanaft  fur  incoriBOU,  and  secoodary  hemorrhage  Una  been  m  frequent  and 
Au»l  BD  nccurrence,  in  several  eases  requiring  ligature  of  the  externnl  iliac 
fcr  ia  amat,  that  I  do  not  think  it  ia  ndrisable  to  have  rreriurKC  lo  this  upc- 
ralioa  id  pniierence  Uf  li;d;aiure  if  the  external  iline  :  and  it  tnay  be  laid  down 
■as  inloiDHrKetT,  that  in  all  thoae  eiucsof  nncuri.^n)  ihnt  aresituntcd  above 
tfaa  auddl*  of  the  thigh,  in  which  compr^Hion  hn«  failed  and  sufficient  apace 
doaa  aot  ioierrcne  between  the  origin  u(  the  deep  femoral  and  the  upper  part 
of  tb»  aae  for  the  application  of  a  ligature  to  the  superficial  femoral,  the 
bf  lie*]. 


lal  iliac  thould 

Ucmtor*  of  the  Bttperflcial  Femoral — The  superficial  femoral  artery,  in 
tta  eoune  fn>iu  the  origin  of  Ihe  deep  femoral  to  the  aperture  in  the  tendou 


Fit-  tti'—UgUun  af  ttta  S^ptrtcUl  fauoral  Artary. 

■etor,  to  divided  by  the  croasing  nf  the  aartorius  muscle  into  twu 
of  nn«<]uai  len^li.  which  havp  difTprenl  rehiliunii  to  oci^liboriug 
Thv  upper  divifiim  of  the  nriery,  which  lies  above  the  anterior 
mmrjpa  of  the  muscle,  ia  of  moeit  int^rent  tn  the  Hurgeon,  an  it  ia  in  this  jmrt 
«f  Itt  niurae  tluit  it  ia  invariably  lifnttured  in  cases  of  aiifuriani.  It  in  true 
Am  Jrvho  Ht)Qt4-r.  in  the  operation  which  he  inlroducrd  for  (KiplitcAl  aneu- 
rim.  «xpnM<d  and  tied  the  veesel  in  the  middle  thiril  of  the  thigh;  but  hifl 
•xanple  has  Dnt  t>eeTi  followed  by  modem  Burgeona.  on  account,  of  the  fnr 
pmMir  diA^-altj  in  reaching  the  vcaael  here  than  in  the  fint  part  nf  ita 
QMUML     The  MfK^rficifl]   ft^monil,  where  it  lies  in  Scarpa's  triangle,  being 


260 


:CRISHS. 


covered  m«r»ly  by  the  ooiunutn  iDt^utnent,  tbe  euperficiA]  fanciii  aad 
faacitt  laUk.  amy  be  reached  by  eu  siiuple  bd  operatioD  u  suy  timt  the  Sui  _ 
bus  U»  p«rloriii  fur  tbe  ligature  of  the  larger  vrwels.  The  lut«  to  tbp  aii^ry 
is  tiikfu  Bn  lollowe:  The  leg  is  flexed  aud  the  ihifih  rotated  iiutwaitls.  Thi 
8urei-uu  marks  a  iwiot  exacdy  midway  bctwecD  tbe  aDterior  Nporlor  spiot 
of  tne  ilium  and  tlie  synipbytie  pubis.  Frutu  tbie  bedravrea  line  to  tbe  mail 
promiuc-ui  part  o(  the  iuuer  coudyle  of  the  femur.  Tbv  jHiiot  elected  for 
tying  the  arterv  must  b«  about  tivo  inches  b«Iuw  foupart's  It^auieut,  aa  the 
ligature  will  thru  b«  at  a  iMife  distance  from  the  pruitiinla,  the  luvm 
rptonlrd  ptiint  uf  ori>;in  uf  ihatvewel  beinif  four  inrlifs  hehiw  tlii^  ligament 
The  InriMnn  kPig.  4^1)  is  made  in  the  line  above  iinlit-iilrd,  and  ahixiM  be 
from  (bree  to  eix  iocbes  in  length,  accoriling  lo  the  amnunt  uf  ful  its 

faU     It  mtiBt  be  en  arranged   tliut  Lb»  ixtint  eele<-(frl  (or  the    ;<  <uo 

of  the  ligature  Ehnll  Ik>  in  ibe  niiddle  of  iia  If^ngtb.  The  dkiu  nml  Miprrlirtal 
fa»(.-ia  Imviiig  liefii  dividpil,  the  fuitria  lata  iB  e!(|Hie«d  and  ii|H-iieit  to  thoniBe 
extent  as  tlie  inciHion  iti  tbe  integuments;  ihf  niUKciilar  (ibresof  ibe  sutriorius 
Dow  come  into  view.  If  ilie  iDei»i<>n  have  been  made  loo  far  itiwarda,  it  b 
iMMJble  that  tbe  adductor  tongiK  may  be  exnoaed  itwtcfld  of  lb«nru>HM; 
tbe  error  ig  readily  recogntEe<)1iy  olworving  tne  direction  of  tl>e  fibres,  ibm^ 
of  the  adiliiclor  being  downwards  and  outwards,  and  those  uf  tbe  parloriui 
dowuwanl<<  and  inwnrds.  The  edges  of  the  wound  in  the  fascia  being  held 
a[Mirt  with  blunt  hooks,  tbe  snrturtus  is  seized  in  tbe  forceps  and  dra«D  out* 
vmrtU,  the  librea  of  tbe  urmdar  liasue  Burroan<ling  it 
being  touched  with  tbe  edge  of  tbe  scalpel,  if  neces- 
sary, until  its  inner  edge  comes  into  view.  If  the 
operation  be  performed  a  little  higher  than  usual,  ur 
if  the  sartorius  be  feebly  deveIoi>ed,  its  inner  edge 
may  come  into  view  ne  soon  as  tbe  fascia  lau  ' 
diviiled.  The  edge  having  been,  found,  tfae  m 
must  be  turned  outwards,  and  held  on  one  aid* 
a  copiwr  spatula.  A  little  looae  areolar  tUBUO  mtnt 
then  be  cleared  away  from  benenlb  it  with  the  handle 
of  the  scnlpel,  and  the  shenth  of  iho  veaela  cones 
clearly  into  view.  The  sheath  must  be  eaatiooaly 
opened,  a  small  hole  being  made  in  it  as  in  IM 
diagram  (Fig.  402i.  It  must  be  remembered  tint 
al\er  the  fascial  shenth  common  (o  the  arterr  and 
vein  has  been  ofieoed.  there  is  still  the  pruper  ahealli 
of  the  artery  to  be  divided  before  the  ligature  can  be 
lafely  passed.  The  vein  lies  lienealh  the  artery,  sod 
OMUequently  tbe  needle  may  be  passed  fmm  the  inucr 
or  outer  sidt  indifTercntly ;  it  should  be  pasted 
unnrmcd,  and  then  be  threaded  and  withdrawn.  Usuallv,  no  nerve  it  seea 
during  the  operation,  hut  the  iniirnal  inphenous  occattioually  coitie*  into  view, 
ud  must  be  avoided.  AAer  the  o))eratl(>n  a  druinage-tulw  should  W  iuscrted 
in  such  a  way  Lliai  its  end  shall  lie  beueatb  the  sartorius,  and  tlic  vroood 
it  c)'jee<l  «iith  sutures.  The  wound  is  then  semiflexed,  somewhat  raised,  and 
laid  on  its  outer  side  and  wrapped  in  soil  flauuel  or  cottonwool.  The  6v\vn 
pain  which  is  ii^unllT  vomplauicd  of  about  the  knccailer  tigblening  the  liga- 
ture niBV  i>e  relieved  by  a  full  doee  of  opium. 

In  this  ojK-Rition  there  are  icvcraJ  )K>iiits  of  considerable  importanre  that 
retjuire  spn-iul  ntlention.  1.  The  im-i^ion  Rhoutd  Iw  made  dirccllv  in  the 
guiding  line  ol  the  artery,  euro  bring  ttikcn  nut  to  incline  it  inwarifs  in  tbe 
direction  of  the  «sirti>rius.  2.  In  (-niiing  itown  iijMtn  tbe  artery,  the  aaphenoui 
Tein  ahould  be  avoided,  by  taking  care  not  to  make  tbe  incisiou  loo  far 


7t(.  -m.— IHftrua  or  tb* 
t>«ft  Faneral  Arltrr  at 
Ap9x  of  lJ«Br|M'*  Tri- 
Mtgtt.  ).  tMlvriafi  /, 
fMaotkl  tliMibj  •-  ulary. 


Abt  parallHl  wnou^  brunch  Lhnt  may  he  itiel  witli  niui't  Ik-  drawn 
ctdc  3.  AfU'r  ihe  slieaih  liii.-^  b€«ii  opened,  il  will  somelimrd  W  I'oimd 
tliat  a  mtlicr  lar^f  muscular  branch  is  given  ufT  fn»m  the  artrrv  at  about  the 
part  «h«rrv  il  wa«  intended  to  ligature  it;  it' so,  thi»  inii^t  b^ carefully  nvoidcKl. 
•*  vrll  aa  anr  amall  veins  that  croiw  the  main  trunk  in  thi«  situation.  4. 
TW  H^ture  «bniild  not  he  nppliffi  \t»s  than  four  inches  belovr  Puiipari'K 
UgUDVDt,  au  that  siifficirnt  fitacv  amy  intcn:cnt>  biMweeu  the  origin  ot  th« 
data  ftHBaral,  nhi<!h  is  uauallv  t'rom  one  to  two  inchn  hclov  the  orurnt  arch, 
aaa  tiw  poini  dfhgatcd,  to  n^mit  of  the  forinalion  of  a  proper  coa^ulum  in 
•L  It  haa,  however,  happened  that  the  ligature  ha*  been  placed 
thrw-qonrteni  <tf  an  ineh  of  the  origin  ot'  the  deep  femoral,  without 
IT  tnjuriou*  <  utit  rr-Miitiinf;.     ii.  The  };reategt  care  muxt  he  taken 

at  to  wiMMid  I'  il  v^in,  which  lie»  behind  the  artery  io  the  situation 

rbirh  a  tiKature  in  ukumIIv  Hppli>>d.  It'  the  ve«wl  ig  timl  a  little  hit;her 
uaual,  lilt  vein  will  t>e  towanls  the  inner  »ide,  and  then  th«  net;dle 
BiuMt  hti  p«Med  from  within  outwarda.  Wnunding  the  vein  is  l>e8t  avoided 
bv  tburoagfaly  cleantuic  the  arterv :  the  white  eKtern&I  coat  must  be  thor- 
ax 


jmi 


ily  axpoara,  and  while  the  needle  ia  heioe  imased  the  ehoath  should  be 
ilioraugfaty  on  the  atrvtob,  the  Sureeou  hofdiDg  the  edge  of  the  upeoing 
OB  iba  fide  from  which  hu  is  paaiog  the  needle,  wliilu  the  oMtstani  iiitehes 
tl»  opposite  aide  in  a  pnir  of  forceps  and  draws  gently  upon  tl.  In  pa«aing 
A»  aaadta.  ita  end  should  be  kept  very  cl<«e  to  ihc  artery,  and  uimlo  tu 
fliiflle  round  iu  The  vt'ia  im  generally  pcrfuruled  by  dipping  the  iio»lle  ton 
daaply  and  l.jaing  the  cnnlart  hetween  it  and  the  artery.  When  the  neeflle 
ii  DTOaght  op  oo  the  outer  side  of  the  artery,  a  Kninll  portion  of  the  i^healh 
■MBatinfli  poshed  an  by  it;  thin  muft  be  t^irn  by  pinching  il  with  the 
when  the  needle  may  lie  carried  round  the  resHcl. 
tM. — Lwature  of  the  fenmral  arlery  for  popliteal  aneiirutn  is  an 
aMtatifltt  that  aw  been  so  frequently  performed,  thatKurgeon.'t  fieldom  think 
«r  rceonling  oaam  of  this  description,  unleiK  they  present  cnmplicatinn.<^  or 
WMeba  of  anuaaal  intereK  or  severity ;  hence,  hut  little  impnrlAnce  can  he 
"  '  ;)  to  any  sUlisttea]  deducliont  from  reported  cn»os  as  to  the  fnlality 
'iperation.  although  they  nt&y  serve  as  a  rough  estimate  of  (he  pro* 
BMiintaiued  between  the  diderrnt  accidents,  ftuch  aa  hemorrhage, 
etc.,  that  follow  it.  That  ligature  of  the  femoral  arl«ry  >»  at* 
with  more  euccws  than  that  of  any  of  the  other  large  trunks  can 
gidniC  of  B4  dmibt.  This  \i  wA  only  in  accordauce  with  ths  general  expe- 
if  confirmed  by  the  stati»tica  of  published  casea.  even 
M-p  for  the  prubahilily  of  more  of  the  unsaccessful 
:  rco-mied.  Thus  of  HO  instanoes.  Collected  by 
.  -irtery  had  bevu  ligatured  for  poplileal  aneurism, 
maif  twelve  are  rep^rttxl  lo  hare  died :  amongst  theae.  four  deaths  were 
rawnl  bjr  aecoodary  hemorrhage,  three  hy  gangrene,  and  the  others  by 
pblabttist  tetanus,  ehoit -disease,  etc.  Higher  ratev  of  mortality  are.  however, 
^Mher  authunt ;  thus,  Morris  states  thut  nearly  one  tu  four  the  afler 
ttuo:  Hulrhin)!»ii  finds  that  of  thirty-three  casea  operated  on  in 
Iftrn  were  fatal,  five  deaths  resulting  from  gangrene.  Holmes'a  atal- 
,  which  an*  nxlrt-mely  valuable  as  being  collected  directly  from  hospitala 
'Irnm  publt^Ktt  rannn.  nhnTr  very  favorable  re^ult^.  Of  eighty-seven 
in  which  the  operatioa  was  peribrmed  for  f>!monil  or  popliteal  aueu- 
^IhlrtMfl  died,  and  in  three  the  operation  fitilcd  to  cure  thcdiaease. 
nmtrred  twice,  nnd  suppuration  of  the  »ac  not  once.  Of  the 
Il  fntm  smallpox,  two  from  wound  of  the  vein  and  phlebitis, 
.  :«aiim,  twe  from  gangrene  and  amjtutation,  one  from  nisease  nf 
dw  tudovya.  and  iIm  rest  from  various  other  causes.    Berwell  hn?  collected 


than  voccoBrul 
Crisp,  tn  which  tht 


£62 


SPEOIAL    ANKDRISMS. 


aloi)  frvm  hospital  re[Htrt8  67  caseii  («ciirring  in  Uie  tea  years  1870  tn  1K7^ 
in<-lii!tivp.  Of  ihe*e  10  dieH.  Most  of  ihe  tlfAllji  occurred,  boiievrr.  in  ih» 
fint  hnlf  of  thU  p^rifwl.  in  which  ^2  cftws  were  openled  on,  uith  7  i)<-nlla 
aod  2  flmputfttions;  while  in  tht;  m^oiikI  half,  out  of  35  c*ww  tlirnr  wrrv  ll 
deaths  and  no  ainputnlion^.  Bnruell  has  hI»u  contnu-t*^!  thr  nwull*  with 
refereore  to  tlie  various  nmt«riaU  tweol  aa  ligatun-^.  He  litnU  that  lu  14 
cu««s  silk  vii«  used ;  of  ihi'ee  3  died,  1  of  mitirv  of  sa  uneiicitm  «(  tb«  titi* 
of  liKiiture,  1  of  «ccondnry  hemorrhage  aud  I  of  p;:i.'mia,  and  in  1  oim-  i1u> 
antrumiu  relapsed.  Id  27  caees  catgut  was  used,  of  thwe  G  died  and  3  ir- 
lapaed.  or  the  deaths.  1  aruw;  fnini  crukv  unconnected  with  the  upvniioiD. 
2  of  eecoadur^v  bemorrhuge,  and  2  after  relying  l<>r  rt-'lapee  or  aaeurUni  at 

,  Uie  site  of  ligature.     In  4  casoi  the  ox-aorta  Itgaturt;  was  umhI  succeMfulljr. 

>Tb«  cutgut  used  some  years  ago  was-  eoroewbat  uncertain  iu  tt«  i|ualil)',  aud 
in  one  of  the  cawa  iu  vihich  sei.'oDdary  hemorrhage  nccurred,  it  waa  B|ipli«d 
without  antiiteplic  precautions,  and  cotisequeiilly  diflereil  but  little  fnitu  the 
old  iiilk  ligature  in  its  pn>pertie».  It  remains  to  be  determiaed  >*hat  forni 
of  ligature  gives  the  beat  rceulls — whether  catgut  prepared  according  in  tlte 
later  melhod^  {vide  vol.  i.  n.  -1*24),  carbolized  silk,  or  the  ox-wtrta,  appiitil 
in  such  a  war  as  not  to  divide  ibe  inner  and  middle  ciiata.  There  is  lictk 
doubt  that  the  low  deaib-rate  of  the  later  ]ieriod  in  due  to  improvement  to 

I  (be  ligature  and  in  the  aAcr-troatnient  of  the  wound,  and  there  li  evenr 

[Teiiann  to  hope  that  it  will  at  least  be  maintained,  and  probably  be  Airtber 
rcdHce<i. 

Accidenta. — Wound  of  the  Femoral  Vein  ia  without  doubt  the  miMK  wrirrtu 
accident  that  can  happen  in  the  (ipertttioo  for  ligature  of  the  superficial 

'  femoral  arLer)',  and  \a  one  of  wbi<-b  there  i^  cit|>ecial  risk  when  reconrve  it 
had  to  this  oiicration  tor  aneuriam ;  as  in  this  diaeaM;  thi-  fine  iireoUr  tiarae 
wbirh  naturally  connect*  the  two  vemeU  often  becomen  thickeuMl  anii  indu- 

,  rale<l,  iu  couftc(|uence  of  chr<«ic  inflanimntion  exteuiling  upward*  from  the 
•ac  to  tlie  sheath  of  the  vcmcIs.  It  in  l>esl  avoide<l  by  pajving  the  newlle  in 
the  way  that  bag  be«n  iilreatly  recommended,  unnrmed  and  without  tb«  em* 
ploymeot  of  force.  This  accident  ia  aluioet  invariably  fatal,  there  beinK  bnt 
very  few  inBtauccs  un  recuiti  in  which  patients  have  survived  it;  death 
uiually  resulting  from  septic  phlebitis,  or  the  supcrveution  of  gaufme. 
The  true  cauiw  of  the  fatal  result  in  these  cases  waa  tirst  pointed  out  by 
Hadwen,  who  showed  that,  when  the  vein  is  wounded  by  iha  MMurisHh 

'needle,  it  is  tranelixed  at  two  points,  tietneen  which  the  thread  is  drawa 
acruee;  and  when  tliis  is  tied,  a  segment  of  the  vein  i^  necessarily  includtsd 
with  the  artery  in  the  jitxiee.  It  is  thiH  incUieiou  of  the  l^!ature  within  a 
portion  of  the  vein,  where  it  acu  like  a  H.-tiin.  and  kee|iH  up  constant  Irriia- 
tiim.  that  orniHionn  thnimlHuHis  and  (lulHieiiueni  iliHiutegraiirm  of  ibr  cImI  ia 
Ihe  inLt'rior  fil'  the  vnuel  ;  ami  it  ia  ci>ni4e<piently  ihiit  circumHinnei',  ami  m«l 
the  murt^  wound  of  the  vein,  that  detenninee  the  greut  fululiiy  of  this  arvi- 
deuu  Guided  by  ihi.'*  view,  the  treatment  beoumes  obvious.  It  cowsins  ia 
renuiTing  the  ligature  at  onre,  and  thus,  by  taking  away  llie  source  of  irri- 
tation, converting  the  wound  into  a  Bimple  puncture  of  the  vesMd,  wbidi 
readily  heats.  The  Surgeon  should,  therefore,  an  so*in  as  the  accident  is  per- 
ceived, withdraw  the  ligature,  and,  o|M?ning  the  »heath  about  half  nn  ini^ 
up,  reapply  it  to  the  artery  there.  The  itemorrbage  from  the  punctured 
vein  readily  ceaM«  on  the  application  of  ii  comprcM. 

The  occurr^-nce  of  Seconaary  Hemorrliage  after  the  licntnrc  of  the  super- 
ficial femoral  ifl  a  troul*l««uiue  accidetit,  and  one  in  which  tbr  Surgeon,  to 
uite  Fcrifumiin*')  expreftviuo,  "  will  movl  oMuredly  find  himself  in  an  eventful 
dilemma ;"  and  in  which  it  in  neceeeary  that  bis  line  uf  action  sbduld  have 
HO  well  considered  Iteforehand.  as  he  may  not  have  much  lime  to  span 


rHkction  wbcs  rack  an  vveut  takw  place.  In  cbmb  of  tliia  kiml  four  linee 
wf  inmtBWfil  pn*eat  ihtrtii^tflvt^.  viz. :  the  tm|>li>yiiicDl  ut' jiresBure:  ligaturo 
of  the  ttmti  M  m  higlivr  pi>iiii :  (ItfligHlion  of  the  Liltvdiiig  artery  iu  the 
wvtiad:  ur  ntnpubilioa  u(  the  limb. 

iSvmmii  may  U*  upjilit^l  by  pliK-ii)^  n  griKluHtHl  cumprera  of  lint  or  coot' 
unmtA  fffMiifrr  nvcr  the  blei!<Iiug  uriliei*,  ami  fixing  it  there  firmly  by  u 
BOfiBiior  tuuniiijtii^  Thi^  nioilt;  nf  irfHtmeni.  nlihouf^h  cxlrtiuely  unccr- 
IMB.  Dcnuioaally  AUiKfudit:  xhoulil  it  not  do  ao.  however,  niul  bleeding  rvoiir 
mmamd  tuoe.  it  ix  um-Ic-ih  to  continue  it,  ■»  expcricnct'  has  ihowu  tbat  tbv 
h«DocTiiafte  «i]l  ri'nttnuc  until  (ht?  )Mi(ic-nt  i«  worn  ouL 

hifHmrt  of  the  tftiixrHcial  tV-monil  ot  a  hij;hcr  point,  or,  if  the  artery  have 
Wan  tirfl  Kio  liijih  l>ir  thi!>,  doli>;uli<iii  uf  the  common  iVmoral  or  of  the  t-x* 
knsl  ifinr.  pn-».-tit»  it#elf  a»  A  probiiblc  means  r>f  arrv4>tinK  the  hemorrbnge. 
ftwb  lioMcver,  id  fraught  with  dunjjtT,  and  Tias,  I  belif^ve,  in- 

tl         iMil  hy  gangrene.     It  might  »l  first  1m*  iiU|>|HHed  that  the 


limb  Mwutd  not  l>f>  tilac*^!  in  a  worn  situation  aOer  the  ligature  nf  the  exter- 
aal  Uuc,  wfaetbcr  toe  euperticinl  femoral  bud  been  previously  tied  or  not; 


Iha  aMMtaaNaing  t^auoela  remaiuiDg  the  eniiie  in  either  caw.  Btil  in  reality 
it  it  nnt  fv;  for.  although  the  blood  might  find  its  way  through  the  epigas- 
tric, Lb«  circumflex  ilii.  the  gluteal,  aud  sciatic  arlcrie^,  into  the  deep  femo- 
rmt  sad  its  braucbe».  yi-c  fmm  this  poiut  the  didiculty  of  it^  tranenii^ioQ 
■bftnifll  Uw  limh  ntiuld  be  muierially  iucrea«ed.  If  tho  superficial  femoral 
baafKti.  it  Mrr^'ra  aj  a  dirt-ct  and  ea^y  clmunel  for  the  cunveyaoce.  to  ibo 
9tmth  of  i1m?  lf|c  and  tiMil,  of  the  blow!  bniught  by  Uii-  aiuutli'>iu<jae».  But 
vfaea  the  Bupi-rfiinal  femaiat  ie  tied,  thi«  hiiKxJ  must  find  lU  way  ibroueh 
k  Mcood  cliain  nf  tinHatomneiof;  t«<«i'I«, — ihuv^e  ititerveuiri;:  U'i\ui'u  ine 
bcmaelHM  of  tfar  d^t-p  rt-nionil  nnti  the  arlicular  aru-ricit  of  ihi<  kuee ;  and 
ban  tlw  rvul  difficulty  would  arise,  its  iiii[Hil»f-  not  lifiii|r  sufficient  tii  over- 
COHM  tbe  olelnirljon  to  itfl  (Ui»>agc  through  LbeM<  enmlt  chuntiels,  which 
■MptU  not  improbably  he  still  further  obstructed  hy  the  pressure  of  the 
aacuriuB.  Khnuld  the  aruutomofiing  circiihition  be  t^ufficiently  fn?e  tn  main- 
tain tbr  vitality  of  tltv  limb,  it  is  not  impmbnble  that  thr-  recurrent  blood 
w.^h!  <*capr  fntrii  tbr  dini.il  side  of  the  liniilure,  nnd  thus  keep  op  the 
h— iifrhatfe  rxnctly  n*  in  t'ascof  wound.  It  iip(M>fir»  inde^'d  that  the  femoral 
M IW J .  in  a  <-«M7  of  H't-i>iiii>iry  hemorrhage  ntiei  the  application  of  the  li^a- 
tMt%,  i*  in  Very  much  the  -ntiu'  ouiditioii  as  nn  artery  which  bu  been 
woawM.  and  in  Mhich  the  b!ix-<)in^,  hnvin;;  l>een  suppressed  fur  some  days, 
kaa  Ktaroed  »  '  ••••v  :  nnd  certninly  liie  iK-st  aiurne  for  the  Surgeon  to 

the  t iteu  that  he  would  follow  iu  the  event  of  secondury 

rfaaf^e  oocumujt  iruni  a  woundeil  veeeel.  vis..  Utcut  down  u/wn  ^/te  bltea' 
m^ pmrt  *»d  affpiy  a  iijfulurt  to  it.  Thai  »ui-h  an  ojienitiun  is  surrounded 
«idi  <lifficaUie«  raonut  be  doubt^-<l  :  yet  none  would  preseut  tiivnisvlves  that 
flW  bchI  akiU  might  not  overcome.  The  burgeon  would  certainly  have  to 
est  iDlu  a  (lort  iDtiltmieil  with  blood,  in  which  the  difiereut  ti»ues  c<iuld  not 
majil|r  )—  ■!'-tiiigui>bed,  and  the  vevwel  when  reached  would  be  found  to  be 
iaimi'-  llMied  :  yet.  by  frve  direction  above  and  below  the  wound, 

■  [nrtx>4i  >>'  It  iriig;bt  at  last  lie  exposed,  where  ltd  conls  Would  hold  a  li;<a(ure; 
ar  ahtMiM  thia  not  be  found,  the  wound  might  be  firmly  plugged  from  the 
Uoom  with  ciimproKd  swioge;  or  the  bleeding  n[kertiire  might  be  louche<] 
«ttli  KbcB£tualrauta*7'.  nhoald  thcK  means  fail,  it  would  be  safer  to  ampU' 
liA  tkt  tmii.  than  to  rndf^vor  to  arrest  the  hemorrhage  iu  any  other  nay. 
of  the  Limb  in  perhaps  the  most  frequent  source  of  danger  aUer 
'  I  iral  arti-rv  ti>r  poptiteitl  anenrisni.  It  setdiun  iHxitiri 
«j  of  con«id«rublv  maguiludc,  have  become  diffused,  or 


SPECIAL    ANKlTHiaUS. 


Otherwise  intt^rfere  serinusly  wiih  the  cinnilaLiim  ihroiijjli  tlie  limb.  I  have, 
however,  seen  it  follow  llm  n[jeralioii  when  the  |»»|ilileal  nneurism  was  uot 
larj^or  than  an  orange;  but,  in  this  euge.  there  was  nmch  (eilt^ma  ami  i^unffea- 
tion  1)1' lilt'  limb  beture  the  operalion ;  and,  on  examination  anemanls,!! 
wm  found  that  the  prtpLiteal  vein  had  been  nbtitcrnted  by  the  premureof  the 
tumor.  The  gangrene,  may,  in  some  casea,  be  prevenleil  by  the  treatment 
that  has  been  pointed  out  nt  p.  445,  vol.  i.  Wlion  it  has  fairly  ilectared 
itaelf,  there  is  necessarily  no  resource  left  but  amputation,  and  this  nperatioD 
is  sufficieotlj  successful ;  for  I  find  that  of  fourteen  oasi-s  in  which  it  was 
done,  there  were  ten  recoveries,  and  but  four  deaths. 

The  Eetorn  of  Pulsation  in  the  Sao  nftcr  ihtt  operation  for  popliteal 
aneorifini  ia  by  no  means  of  frequent  occurrence:  yet  it  has  been  met  with 
in  some  instances,  and  Secondary  Aneurism  also  has  been  fciuod  in  this  sit- 
uation. In  these  costs  the  palii-nt  slicHild  be  pm  upon  a  careful  dielecic 
plan,  the  lirah  be  kept  clevnlt-d  and  itt  rwt,  and  direct  pressure  applied  by 
means  of  a  roniprrfw  and  bandage.  In  tiiiit  way  cHrcH  have  been  cfftclcd  by 
Wisharl,  Turner,  Uriggw,  and  Listnn.  Iu  conjunction  with  such  treatment, 
or  in  the  event  of  its  iii/t  sufficing,  the  compree<iion  of  the  common  femoral 
arterv  as  Ic  poseea  over  the  pubic  bone  would  iu  all  probability  effect  a  cure. 
Should  it  not  do  ho.  and  the  tumor  continue  to  increaae,  threatening  to: 
suppurate,  or  to  occasion  gangrene,  amputation  would  bo  the  sole  resource. 

If  calgut  be  used,  return  of  pulsation  may  be  due  to  premature  softening 
of  the  lifjature.  This  is  recognized  by  the  presence  of  pulsation  at  the  point 
at  which  the  vessel  was  lied  as  well  as  iu  the  sac  This  is  hardly  likely  to 
take  place  if  welL-preparod  irut  be  used,  and  the  wound 
be  kept  perfectly  aseptic.  Should  it  happen  before  the 
wound  is  healed,  it  may  bo  opened  up  again  and  a 
seennd  llpituro  applied  above  the  Hitiiation  nf  tho  {IrsL 
If  llie  cualit  appear  to  have  been  damaged  by  llie  lirsC 
ligmur«,  the  vPA>4el  may  he  tied  nn  each  Bide  of  the 
injured  Kpoi.  In  mme  ('a-iea  iti  which  nbsiiirbable  hga- 
Ciireti  havf  been  used,  the  recurrent  pnl^Htion  has  ap- 
peared at  a  much  later  period  in  mnsefgiience  nf  a 
rcHloration  of  the  lumen  of  the  artery.  Should  rhts 
happen,  the  artery  may  be  safely  tie*!  in  Hunter's 
canal,  ait  was  successfully  dnne  by  C.  Hmth  under 
these  rircumBtnnces  in  University  College  Hospital. 

Ligature  of  the  Femoral  Artery  In  the  Middle  of  tha 
Thigh  (Honter's  Canal). — TIte  point  nt  which  Hunter 
tied  t.he  artery  In  bis  earlier  eases,  was  &ituttle<i  midway 
between  the  groin  and  the  knee.    At  this  point  the  artery 


1 


\g.  4V».— t)i>Kr<iiii  ..r 
LlgalUT«  or  llin  Laft. 
FaoiOTftl  Arler^  in 
HunUr'*  Citttitl.  «. 
nrto(ia«  dfann  io- 
wanti;/.  rMcikelof- 

f  bf  llMeiOal.  npVMi] 

fraalj  I  m,  Ihe  ftrlcrj, 
villi  k  •miiU  a|i«(iiiJt; 
km  Iu  (Watt)  for  the 
fMMC*ofUi«  needle; 
uk  k«f  •■pbanuui 


ticj  in  the  an^le  formed  by  the  vastus  inlernus  on  the  ^ 
outer  aide,  aiul  the  tendons  of  the  adductor  longut>  and  ^ 
ad<luctor  mugnutt  behiiuJ.     It  is  cuver^l  by  a  distinct 
ftiscia    )ia»Ming  between  tb^so  HtrLicture4.  fiiriniug  with 
them  the  i^pace  known  tu  Hunter'it  cnnal.     The  vein  at 
ibis  point  lies  to  the  outer  side  of  the  artery,  and   the  ^ 
long  saphenous  nerve  enters  the  canal  external  to  tha  fl 
vessels  and  crcisites  them  3U[)erlicial1y.     The  sartoriut  ™ 
muscle  covens  the  fascia  closing  in  the  canal.     To  tie 
the  artery  in  this  situation,  the  limb  is  placed  iu  the 
eame  position  as  for  the  operation  in  Scarpa's  triangle, 
and  the  came  guiding  line  must  be  taken  tu  find  ibe 
«f  the  artery,  but  the  intiaioti  must  not  be  made  in  tliis  line,  but  one 
«  hnadth  internal  to  and  parallel  Iu  it;  otherwise  the  edge  of  the 


i>  rmriij  rniPKH.     The  ioctsion  must  b«  from  tl)re«  to  four  incites  iu 

,  mm)  in  Diitlille  piiiiiL  Diust  forivspoR^l  tu  the  niiddlo  of  tlic  ihifih. 

TW  ^rtA  lata  )■  expowil,  aud  opfncd,  and  the  Karlorius  then  cunics  into 

Tiew.     It*  'Hiter  edge  b«in)>  ftund.  it  is  pu^hi-d  inwards,  and  held  on  one  side 

with  ■  copper  fpatula.     The  faacia  cl«f:in!;  the  cunal  is  then  seen,  and  inuet 

W  nnriM^l   f»r  aboat  an  inch  ood  a  half,  Ihus  ex]i(«ing  the  ehealh  of  the 

T«Mrw  I  Vif.  493 1,     ir  the  saphenous  nvrve  ie  wrn,  it  must  bo  dranu  to  one 

«■!•  wicli  a  blunt  hook.     The  vein  doet  not  as  a  rule  rome  in(u  %-ien,  for  as 

thm  Kiab  ia  Ijring  tM  \u  outer  aide  it  ie  beui-alh  the  tirliTv  anil  concfHliMl  by 

iL     The  •braih  nf  the  urlery  ia  then  onrefully  openeil  ami  ihp  needle  pajweil 

tnm  tk*  uutt-r  Hide,  the  same  precatitionj*  lieinf;  taken  an  in  the  higher  opera- 

tim  feo  avoid  woiindinjET  the  vein.     The  ligature  ?hinild,  if  pne«ihlp,  be  |)iaee<l 

•tmot  oOB  inch  aUive  ilie  origin  of  the  nnastoniotic  bmnch.     The  ermrs  thiit 

IttTC  to  bo  guanlcd  n^jHiti^t  in  this  opcmlion.  ere,  firet.  operating  too  low 

damn.     U  noft  be  reracmbtTod  that   Hunter's  canal  is  situated  midn-ay 

hrtwwn  tbe  groin  and  the  knee.     Secondly,  if  the  wound  be  made  li>o  far 

mtt — ia  tfa«  ^iding  line  of  the  artery  itutead  of  a  finger'^  breadth  internal 

M  it— 41m  outer  border  of  the  eartoriua  may  be  iniwied,  and  (be  vastus  in> 

paavd  hwtnd.     At  this  point  there  is  usually  an  interval  in  the 

ibrai  of  tbe  masole  that  may  be  mivtakeu  for  the  edge  of  the 

Tin  error  is,  a*  a  rule,  easily  recogniite*!  by  observing  tlie  direc- 

tisa  af  ibt  aiNcular  fibre*.  tho«e  of  the  vastus  inlemus  being  directed  dowa- 

wardi  anJ  oatvanla.  nhile  lho«e  of  the  FnrtoriuA  are  nearly  verliciil,  ^tniitlog 

a  UlUa  iovsrda.     It  ia  important  thai  tlie  faiicin  eloping'  the  canal  ehould  b« 

•pBaed  freely,  otberwiae  ibould  pus  fornn,  it  may  burrow  along  tbe  artery 

uiBitehmfn. 

The  Slieiaal  Iliac  Artary  nmy  require  to  be  tied  in  cases  of  p'>pliteal 
aacarim,  wben  the  euperlieial  and  common  femomle  are  so  disease*]  as  nut 
to  admit  of  ligature.  TbiBoccurredonce  to  me.  A  gentleman  who  had  lost  the 
Wk  taei  aail leg  fmm  HpaotaoeouH  gangrene,  bceaiue  two  years  aflerwnnls  the 
aihjur  of  a  large  jxipliteal  aueuri^nt  in  tlie  other  leg.  Aacompreuion  failed. 
^^^Ma  ttectdeil  li>  tie  the  supertieial  femoral.  On  cutting  down  on  the  ve«8eil 
^^^^KaU  were  found  u  dEacascfl,  the  artery  it^lf  being  oylindrically  dilated 
^HP^W^btly  ancurismal,  that  the  operation  wtu  abflodoned  ;  and,  na  the  com- 
^^pao  fciBotal  firit  dilatrd  and  almost  inromprPS!>ihlc  from  ealcifiention  of  ita 
^X*»ll.  it  wa«  deeide*!  to  tic  the  external  iliac.  This  I  did  with  the  nhlc  aesist- 
anca  *>(  Sir  W.  Frrgiuffon.  at  a  rather  hi2;h  point,  the  vessel  being  s<imewhat 
tHMr-'  '•■<[  lower  down.     Pulsation  recurred  in  the  tumor  a  few 

host*  riition,  the  collateral  rirriilation  being  very  free,  and  the 

pafict.  iidnrv  hfinorrhage  on  tlie  tifti^iKh  day. 

lV>i  >  \i,  AM.VRie>M. —  In  cn^esof  tbift  kind  the  artery  has  been 

aaeanoaally  h^nnurrd  with  advantage  on  both  sidea,  either  simutunenuair, 
ar.ntb  more  safety,  a-nwcu lively.     But  lhe«  caM«  appear  to  me  especially 


pled  for  the  emplovmeut  of  nreMure,  so  as  to  avoM  that  diHturlinnce  of 
IbaDalaacvof  tbe  circulation  which  i«  certain  to  ensue  when  one  ve««el  is 
Bpitand  ml  which  may  act  injuriously  upon  the  opposite  aneurism.  When 
tbe  popliteal  anf  urism  is  conjnined  with  n  similar  aiseasc  in  tbe  grnin,  liga- 
Ittf*  M  ibe  external  iliac  ia  tbe  proper  course  to  pursue,  and  will  eB^ecL  a 
cart  of  botb  aflectioaa. 

DcrrtMCO  Poplitral  Aicki'rihm. — When  a  rtreutfrMsn'iet'  popliteal  aneu- 
rta«  aaiidcBiy  beeooaa  difftuerl,  the  patient  is  teized  with  fuiutnc«?^  or  Mckness, 
ariUk  pats,  nnmhpua,  aiw  a  hut  trickling  wnsation  in  the  lindi.  ibe  tetn|iem- 
tun  nf  whU^  (alia  at  the  same  time  that  its  bulk  incn-aet-fl,  whilf^t  the  inleuu- 
B«i<  aaamea  a  white,  i>hlning,  mottled  ap|waranre.  with  more  or  |pt<«  ]>urpli3>h 
Jiwaiiiiaiiiiii      AfWr  a  lime  as  the  tension  increases  inflammation  is  set  up, 


SPKCIA1.     ANKUIIISHS. 


,  and  the  skin  beoomea  red,  hot,  and  oidomaions,  and  ihc  whnir  swelltni;  imj 
'memble  in  apiiearftnce  o  Urge  nhweaii.  DiHVmioii  tiHiially  ctccurt  dWa 
cimiiiijK-ribed  aneurism  ha.<t  pxisled  in  ihfl  liam  ffn- i«>me  weelw  »ir  inontiut 
aiiii  on  the  ix;ctirri'iice  til'  9<>m«  BUiiflen  cxcTtinn.  In  nome  ciufm.  h«w«tTtr, 
the  Jisi'iiAe  a|)i)fars  to  have  been  ilillust-il  IW»m  the  very  fiwi.the  i-mau  baTtO)* 
given  wny.  And  MXtravaj«atitiii  having  Uikcn  place  into  Lb«  aroolur  tiMD«  of 
the  limb,  vrithoul.  preriuiia  consul idatlun  of  the  parta  Around  th«  artery,  or 
arty  Htteriipt  iil  the  furmatiuii  of  a  sac.  In  thew  caaea  thi>  extrava*iati'iii  into 
the  limb  mar  «-ither  be  omjuiuett  wiLb  niiiob  a-dema;  or  it  may  W  CijntirMd 
to  lb«  areolar  lisauu  of  the  bam,  nnd  to  the  upper  and  back  iwrt  of  Iht  lef, 
or  may  extend  dowuwHr<l«  uihIlt  ihe  iiiut»cle8  of  the  i-alf.  Wnen  tbe  patimt 
cornea  under  Ihu  uIksltvuIIuii  of  the  Sur^^iu,  Ibc  liinior  ia  fouml  t»  be  wrltd, 
eluslic,  and  irregular,  nitboul  pulKutiun  or  bru'tt;  ihe  limb  ie<leni«t'KiH,  aM, 
and  congested.  The  diugnusia  of  lhit>  form  of  nneuristii  ia  iif\en  cKtn-inrlT 
diOieult,  and  there  ia  great  danger  of  conftiundiu};  it  with  simple  eatniTai»> 
lion  into  the  calf,  uith  abaoei»,  or,  pooNbly.  with  mnliguant  tumor  of  tltw  leg. 
Treatment — The  daneer  aUeoaiDp  on  popliienl  micuriiim  is  frrratJy  i»_ 
creji^ed  hy  it'i  becoinin^ifitriisefl.  In  these  eircunisiunceB  the  ligature  wl 
arlvry  iiaunlly  filfordg  but  ii  uleudcr  proepect  of  i<nece%  the  collatarml  t( 
being  BO  compreescd  and  cluike^l  by  the  prc^tire  of  the  etfu^ed  IiIikmI  a>  oiit 
to  admit  of  ttic  circuiutiun  being  CHrrie^l  on  through  them;  hene<<.  in  many 
of  tbeee  cases,  the  only  reeoum  left  to  the  8urgein  is  to  amputate  th« 
limb. 

Amputation  for  SlJfuBed  Popliteal  ABearism. — The  qucetion  of  Am/ 
tuM  in  ca»e«  of  dilfuMKl  popliteal  aneurism  U  not  very  en^ilr  aubmitled 
any  very  poutive  or  definite  rules,  except  where  the  impending  pMfpttm  ■ 
•0  evident  as  not  to  admit  itf  doubt.  There  are,  biiwover,  certain  general 
coaaidemtionA  that  may  guide  the  Surgeon  iu  deciding  on  this  impcnant 
point. 

1.  In  Hime  caitea,  the  *»c  has  cither  given  way  toa  very  limited  extent:  nr 
elae  ita  walls,  hnvintr  bueoine  tbiti  and  expanded,  are  yiehling  rapidly  under 
the  prcfliure  of  the  blno<t,  becoming  confused  with  tlw  siirrouudtng  pajifc^ 
Here  tveibouh)  ligatui-v  the  artery  without  delay;  for  although  it  inliuti 
doni  thai  a  limb  can  be  saved  wben  once  Ihe  l)li)od  has  become  infiltral 
into  ihe  general  areolar  tieeue.  yet  it  ia  [WHible  that  sucb  a  fortunate  <»eear> 
renee  may  bapi>eu. 

2.  In  other  inBtHUces  the  aneurism  has  not  from  the  6rat  bevn  very  di»- 
Itntitly  circumscribed.  It  has  folluwed  the  inQictioo  of  some  nuThauical 
injury,  and  in  tho  course  of  a  week  or  two  has  acquired  a  c<^n«iderabtc  aixe, 
vritboiit  definite  or  dinttnct  limitation,  iHiiug  solid  or  but  lillle  i-omprcwiblt, 
Hucb  n  cose  an  this  ran  si^arocly  be  considered,  atrictly  «]M>akiog,  a  diSbaad 
niK-urum;  but  vet,  if  by  cireiuMeriied  we  mean  that  toe  bloud  ia  nrntaii 
in  B  irvKt  with  i^elinerl  walls,  it  acarcely  oomplies  with  such  ade6ntti«ai, 
tluid  hlooil  in-'in-:  nilbrr  prevented  from  eacaping  widely  by  a  icinporarjr 
barrier  of  con;;iila  t-nlan);I<il  in  the  loeee  areolar  tissue  of  the  part,  and  the 
vesael  ln-ing  I'xlcndvely  rupttireil  nr  oompletely  torn  acrtMS.  Here  we  are 
certainly  jostrlii^l  in  baring  reeourse  to  compression  or  ligature,  with  a  good 
pn«peci  of  tuocesa. 

'X  \V'b«D  the  ham  is  occupied  by  a  large  rapidly  increasing  tumor,  exteod- 
ing  perbftfrt  aome  way  down  the  cnlf  and  up  the  lhi>;li,  and  oncroaohiog  oo 
the  kne«.  the  skin  covering  it  lieing  more  or  less  tliscolored,  there  being  oo 
pulaation  perceptible  in  the  tibial  arteries,  and  tbo  veins  of  tlie  limb  being 
full  and  even  «'>n)ewhat  conge»u-d,  the  f<Nit  nedematous  and  *everal  dc^creca 
cooler  than  the  opposite  limb,  (he  difficulty  of  coming  to  a  decision  ta  ooo- 
ndnable. 


AVrtlTATION    FOR    DirPUBED    J'OJ-LITEAL   ANKURltiH.      267 

a  cam  WB  Me,  I  tliiiik  that  ihc  i^xisieiire  or  ab^nce  of  di^loDBile 
-  ■  dn:aiitMiince  of  vrrr  f;n-iii  iiii)Hir(»ii<-<',  and  may  sftvL^  to  guide 
ill  .1.     If  iixerv  he  dUtiDi-i  impiilso  of  n  diAtciidiuc  chunictrr,  uhich 

cv:.  . '  •  '•trd  by  rurn [it^"?!!!!)!!  of  t)ie  fcmarAl  artpry,  with  «<>tnc  dimioutjou 
dI  tb«  wttP  iif  tbc  (uiiKir,  it  in  evident  iKaL  bloi.Ml  i»  hriii^  iranitmittcd  through 
1^  »..-  -.nO  iliBt  tlii»  ci'iitaiiis  Mune  iluid  hlortd.  In  these  rirrumsiaiicos  U 
»  I  ihr  nrlvrv  is  tiii-d,  ftutifide  to  ii  (.-oii^ifU-ralde  extent,  ihiLs  allnwiiig 

n  fur  ihi*  cutivoyuoct?  nf  ihp  rnllalern)  circulatinn,  and  it  would  be 

I         -  •  give  fhc  pBlitiil  the  cliaiice  of  prtscrviug  hi«  limb  by  ligaturing 

li,  however,  ibc  tumor  biive,  from  ihi;  very  fin>l  time  wlieii  it  attracted  ibe 
pklieol's  uutit-«,  bwii  more  ur  Itse  milid  iiiiij  iiiuimiiimwibltr;  iind,  tlioiipfa  tt 
aar  at  an  rariy  (i-riiMl  haw  pulsHl^tl,  ifliii^  pulfati^iti  huve  >>it(tih-i)ly  rea!<«d, 
tkc  ■■euriwu  Kl  the  same  liiiiu  huving  ui>iler^<»v  r9|>iil  nnd  KtvM  iiuTfime  of 
bulk  with  much  teii!'i'<ii  and  Jividity  vf  tbu  iut(;guiii(.'Ute,  a^itriiiu  and  cold- 
Si^  of  tlif  iiiitb,  niili  a  tfudeuvr.  p«rbR|».  lu  vveicatiuu  and  tilcvratiuu  of 
iWtkin  coveriiisf  l)te  tumitr,  tbcrv  la  m>  resourof.  lefl  buL  Hni|>utati<iu. 

It  mu»t.  h()HW<^r.  be  Itome  in  mind,  that  the  aiieuri»ni  may  ht^rumt*  dif- 
Autd,  aiwl  L'Xleunivt-Iv  m,  wtttiotil  any  vi^ry  great  oliau^  in  the  e1)h|>i>  and 
MM  hT  tba  limb.  It  w  only  when  the  sac  ruptures  in  i<nrh  a  |)(*itiou  that  tbc 
bJaad  Moape*  ioln  the-  funeral  iireclar  tiK8Ue  of  ibe  limb  <ir  under  the  skio, 
tbafi  iBScb  leuioii  a(  the  iDtegiinieDtA  and  increaw  in  the  bulk  of  tliii  part 
tako  p|»ce. 

-i.  Wbm  a  rupture  ncctirs  )q  a  part  nf  the  sac  that  is  more  deeply  aealeil, 
the  bl-  -  '  •  -1  ravanled  uoderncatb  the  deep  fascia  of  tbe  leg.  ahd  if^  Itouud 
4am  '  :iu<l  itiaorganisal iou  of  tbc  interior  of  the  limb  may  be  tbe 

ftMit  much,  if  any,  change  in  its  bulk  or  in  the  color  of  tbe  inlegu- 

amt*.  ■  KXcemixe,  dc-eptv  seated  pnin.     There  must  always  l>e  cm- 

MorabU  ti»k.,  in  stidi  a  case  m  thia,uf  confounding  the  arterial  disease  with 
•  •oNd  UiDor ;  and  tbe  diagou^  can  be  eOet^tc-d  outy  by  rcf^rcooe  to  the 
imrij  kifltcir^  of  thf;  tmie,  and  more  [karltcularly  to  tbe  existence  or  ahftenoe 
n^palwlinn  at  tht«  period.  Indeed,  the  existence  nr  absence  of  pulsation  in 
Ha  ■  of  tbe  utmost  importance  in  reference  to  tbe  question  of  treat* 
like  piilfolion  may  have  ceaoed  in  a  cnite  of  diffuwd  popliteal 
I,  in  o)nHi)aencv  of  the  blood  that  hax  lieen  extmvasnted  being  »o 
and  bound  down  by  tbe  fascia  antl  muscles  under  which  it  is  e(fii»«d, 
U  compnmtm  the  moutli  of  the  nrlery  lending  into  the  »ac  to  cuch  au 
cslral  *•  to  arrMt  the  paBrag«  of  bbxid  ihrrtu^h  il,  either  wholly  or  so  that 
itratcra  iu  a  feebU  ■treain  of  iosuflicient  force  to  eonmiunicate  an  impube 
fetb*  fluid  that  ban  bcvn  extravasateil  into  the  limb.  This  pressure  may, 
■»  ai  ih*  cwM>  iif  which  an  illuiitrattou  haa  been  ^'iven  •  Fig.  -l-)7).  be  confined 
M  lb*  d»Kfi  paru  of  tbe  limb,  and  not  ^'ive  ru^e  to  much,  if  any.  general 
liMiia  uT  It,  tbe  blood  being  nmfined  bt-low  the  dc-ep  fn^ein,  where  it  com- 
■Maataa  the  amaaliuu  of  a  hunl,  solid.  eloEtir  tumor  devoid  of  pulsation. 
ttlWTiT  ahoald  rouM^tiueutly  not  Ivo  too  exclu-ivcly  directed  to  the  state 
•f  Kvnera)  l»n£iun  of  the  ^urfaiv  of  a  limb,  iih  thid  is  by  no  meuus  uecewarilv 
aft  isdication  of  the  atate  of  the  partd  tvcncHth  ;  but  tbc  Surgeon  should  look 
rslbcr  iv  iKe  pm>vnov  or  ahMncir  of  pulsntton.  If  pulsation  still  exii»t.  tbe 
Umd  moltnui^  t»  find  it*  way  into  rhe  sac,  and  moM  probably  through  it, 
tba  lcfui(«  of  ihit  {Mirli>  not  having  yet  reached  its  maximum.  If  there  bo 
•a  poUftlioo,  he  may  Ih-  mitc  that  the  entrance  of  blood  into  the  diffused 
iMHiriMti  bat  ivaiN^I  in  c>>i)M'i]iii-nce  of  coninn^AMon  exercised  on  the  nioutb 
•f  Uw  art^rr  leftdisc  Ut  it.  by  the  ir-nt^  cnmlition  nf  the  »urrouuding  tissues 
MMlittgl  *in  tb«  HIM*  of  bioud  ediiwd  beneuth  them.  In  such  a  stale  of 
tbia,  (be  vitality  of  tbe  lower  part  of  tb«  limb  can  be  maintaiocd 


26S 


8PBCIAL    ANRUKIsya. 


only  b^  tbe  blond  thnt  may  find  its  wny  throii};h  tho  umtnrnosme  chann«h; 
aan  tliia  inny  be  BUtticient  for  the  purpose  H'  ili«  tcnaiun  of  the  finib  he  at 
frencnil,  tlie  extra  vasntioti  being  coiifiuod  below  the  deep  fasciiL  Ifsuryiti) 
uiterferoDec  be  delayed  in  sucb  a  ease  as  tliiit,  the  deep  faBcis  will  soon  pn 
way  by  over-diiiLention  aud  rupture,  aiid  the  bloud  uill  be  infi  lira  led  inU'  th* 
Maerat  areolar  Uaaue  of  the  litnb ;  aud  then,  by  comprtaiiug  lb««  cotlatermi 
brauehcs  that  have  hiiherui  laaiutaineil  a  feebl«  circulation  in  it,  will  infiU- 
libty  occaaion  Kangreue.  If,  ou  the  other  hand,  recourse  he  had  to  U(;aiure 
of  the  main  artery,  the  anastoimiein;  circulatitio,  which  may  have  ban 
barely  aufficient  to  koc-p  up  a  fec-ble  %-iLality  in  the  leg  and  foot  will  be  m 
much'  iiiierfvr*:-*!  with  that  ^OKreue  uf  the  litnb  inevitubly  eii»u«a.  The 
only  rewturce,  thcrerore,  that  i:t  left  in  these  vjuk*  i»  l<>  fliuputDtr  at  onee,  in 
ordt-r  that  the  patient  may  be  ttavetl  the  nhm-k  aud  the  ciiuslitulitiQal  dift- 
turbnnre  oocatiimed  by  the  netting  in  of  mDrtifica.Uon,  a*  well  lu  tb*  (*ift 
and  risk  of  a  previous  iinnecf«)>ary  nperation. 

o.  When  (;an|freii<f  threatens,  the  le^  and  foot  havinf;  Iwcoiup  cold,  the 
skin  being  either  pale,  lalluwy.  and  mottled,  or  discolored,  of  a  pnrjilnh  hue, 
with  {)erhap!i  vesjeatiuui  aud  mueh  a*dcQitt,  whether  the  ligature  haw  beta 
previously  a^>plied  to  the  femoral  artery  or  uot,  or  whatever  the  condititv 
of  the  aueuri^iu  tuay  be,  whether  circutuecribed  or  dilTu^ed,  the  pntirut  will 
staod  a  bolter  chance  of  ultimate  recovery  by  having  the  limb  mniovvd  at 
ooca  above  the  kaee.  The  part  at  which  arnputattuu  ehouM  be  p«rfortnfil 
ia  these  cases  is  a  point  deserving  consideration.  If  the  femoral  artrry  ba*> 
been  lignlureil,  the  thigh  Khouhl  be  amputated  on  a  level  with  the  ligature, 
(be  artery  l>eing  cut  jnst  above  this.  In  this  way  the  double  risk  which  iht 
patient  uinild  otherwise  run  of  secondary  hemorrhage  from  the  Aeat  nf  tbi 
ligature,  as  well  as  from  the  face  of  the  stump,  will  be  reduced  to  a  si 
obance  of  hemorrhage  from  the  stump.  If  the  amputation  be  the  pri: 
operatioo,  it  abould  l>e  done  at  the  lower  third  of  the  thi>:h.  provided 
extravasation  be  confin<^d  lo  lielow  the  knee ;  or  higher  up.  if  the  eP 
blfwid  have  extended  alvove  this  joint, 

AneurlxmM  of  the  Tihint  Artcriri  nre  extremelv  rare,  except  as  the 
of  Wound,  yet  they  are  occasiunatly  met  witK;  artd  in  the  muDMim 
8t.  Oeorge'a  TIoKpital  is  a  preparation  of  a  soiall  aneurism  of  the  pnMerior 
tibial.  I  have  se«u  only  one  case  during  life — that  of  a  man  nufTi-nng  from 
canliac  and  renal  disease,  admitte<l  into  University  DiHegf'  Hospital  aad«r 
my  care  for  an  aneurism  of  the  anterior  tibial  at  the  lower  part  of  the  upper 
Ihinl  iif  the  right  leg.  The  signs  were  well  marked — pulwilion  fonnble  and 
eooentric,  bruit  loud.  Gompressioi]  was  used  without  avail ;  and,  as  he  was 
auanarcous,  no  other  surgical  troatnient  could  be  adopli'^l.  Ue  left  tbt 
htiepital  uncured. 

The  popliteal  and  tibial  arteries  sometioiefl  require  ligature  for  injorr,  but 
very  rarely  for  disease.     TTie  opemtioas  may  be  oriefly  de»<'ril»e<l  here. 

£i(fatai«  of  the  Popliteal  Artery.— The  nojiliteal  artery  mav  be  tied  at 
any  part  of  its  course,  [n  th^  hwr  two-third*  it  can  be  reached  oaly  by  aa 
inciiiion  in  the  line  of  iho  vessel.  The  external  saphenmis  vein  will  be  fonnd 
in  the  subcutanoous  tii>@ue,  and  must  be  avoided.  Aller  dividing  the  fascia 
lata  tbe  internal  popliteal  nerve  must  Iw  found  and  dmwn  lo  the  outn  sidsL 
The  rein  iheii  conies  into  view  and  must  bo  drawn  out  of  the  way,  when  the 
artery  will  be  expoiRd  l^ing  deeply  on  the  posterior  ligament  of  the  kne»- 
joint.  This  operation  is  never  undertaken  except  for  a  wound,  and  coDie- 
quentlv  must  always  be  more  or  less  of  an  informal  charncler.  In  xti  vpptr 
aird  tbe  ve«*el  is  reached  most  easily  from  (he  inner  side.  The  guiding  liae 
for  the  incision  is  the  puaterior  border  of  the  tendou  of  the  addueiur  magnus. 
The  knee  is  flexed  ana  the  limb  placed  on  Its  uuter  side,  and  an  ioeision  is 


I 


LIOATCRX   or   THB    POSTKRIOR    TIBFAI.. 


269 


o 

P 


^m  ihnv  to  four  inches  in  length  pnrHllcl  to  the  tendon  of  the  ad> 
"  ■'ixnii*  »>i'l  imnivliati'tr  bvhiud  it.  lt«  iip|>er  «xtreinitv  sbuuld 
til  the  jitntTlion  (•('  the  lower  nml  middle  thirds  of  the  thigh.  The 
> I prrficiBi  tnKiu  iir«  divided,  nviiidiu]:  the  long  saphenous  nerve  if 
I  I  ibi;  ileep  lasciK  o(»ened.  The  edge  ol'  the  teudon  of  the  ndductur 
j^y*.  ixbicfa  fcrms  the  fint  rallying  jioint  in  the  o|x:-raliou,  is  then  w^ugbt 
fer,  NMse  bnDcbe*  of  the  naastuutotica  magna  are  divided  at  thiit  vtage  of 
llMOpfratiaa  tod  rrqutr«  ligature.  When  the  adductor  tendon  p»  found,  the 
artari«>  ui«l  gniriln  nnd  inner  haaiBtriiiK  tnuscles  are  pushed  backwarck 
mitk  the  finger  and  behl  with  ii  copper  spatula.  Cnre  niu&t  bv  taken  not  to 
pam  thm  fntula  between  the  b»ne  and  the  artery,  which  is  ^urrnunded  in  this 
■Inalinn  by  Kciiniidrrnble  amount  ufloose  fiit.  This  fat  Udn;;  torn  through, 
lh>  ■itviy  ii  expowd  without  much  difficulty.  The  vein  and  the  inlernnl 
pBfftlwil  ttnrvm  Iw  to  tbo  outer  side  and  are  not  eevn.  The  lignturo  should 
■M  be  applied  loo  near  the  superior  articular  bntnchce. 


?  4  « 


«M.— oucwB  ut  urt  p..i>iu«*i 

r.T^la. 


FIC.4V&.— I>UgTBinof  Rij(bt  Pnftarlvr 
TibUI  Aitvry,  W)iln<t  Un«r  Utl- 
laolitt. 

A.  P«rt«rlor  Tibial  Arttt;. 

T.  Y.  Van*  Comllei. 

II.  Pottvriof  Tibial  Nmt*. 


ligMfam  of  Um  Pottorior  Tibial  Artezy.— The  line  of  directiou  of  the 
pMlcriar  tibial  ard-ry  in  from  a  puiiu  nUtut  one  inch  beluw  the  knee, 
Uril  f  '  '   frum  ihu  two  eldes  of  the  limb,  to  a  point  one  finger's 

^•sdi..  i  ihr  inner  inulleidue.     The  vewel  may  be  tieil  at  any  purl  of 

itt  M«r««.  '  •  rarrlv  bii'ti  uiuUTtiikcn  lui  a  I'ormul  operaiiuu  except 

•hiMn  (he  I:  I  ihr  rnlf  or  liehiml  thi^  inner  uiuHcoIub. 

Is  l&e  mid<iU  o}  (hf  U^  the  jHWterior  tibial  artery  t^hould  be  tied  only  for  a 
WbAiiit.  «nd  in  «urh  rirciinvitunrrK,  as  a  rule,  nu  regular  opcrutinn  can  be  per- 
i  ■  I  inciniui  iff  aiidlcieut  length,  tjiking  the  wound  for  its  centre, 

*>  tbniugh  the  gu»lnicneniius  and  .loicus  parHllcl  to  ihcir  librea, 

«  ■^-  have  Ix-en  cut  through.  tJie  deep  fascia  will  be  expired. 

TJii»  UMI-:  '--■   ■•■  -'il,  wheJi  the  artery  will  be  found  accompanieil  hy  its 

viitw,  aod  rve  to  the  outer  »ide.    From  the  dcptb  »t  which  the 

vomI  m  •il'jji'  <i,  mil  IDC  free  inctiiioiis  thai  it  ia  aecm^ry  to  make  tbnaigb 
nrtr^^t'  part^.  it  i>  eKirHitu-ly  difficiiU  to  apply  the  lignturv  in  ti)i«  »ituiitiou. 
tim  Uler  atci*  "      '  ;  -a  may  be  much  fitcilitnied  by  QexJng  the  leg 

as  ibc  ibi^,  ai>  -  .1  -iv  fiMtt,  BO  aa  to  relax  the  mu^clea. 

Tbe  roptlar  ujKi-ait^*u  a*  jjurfunued  uu  t4ie  d«sd  body  ia  rarely  re<]uired  on 


BPKCIAt.    AKBUniSMS. 

the  living.  It  i«  tlius  carried  out.  The  limb  \b  Hexed  and  laid  oo  \lt  ouur 
eide.  Ad  iuciBioii  U  miulc  four  inclics  i»  leitgth  parallel  to  ih**  ixwlrrior 
border  of  the  libiii  nnd  uboul  uuc  inch  IM-Iiind  it.  The  tolcranl  MpWooai 
vein  roust  be  avuidcd  if  iui  eilunticin  cau  bu  UKix'rtaiued.  On  ilividing  ibr 
deep  fuscia  the  eiigc  of  the  gttstrocucniiuB,  if  it  has  not  fallen  Mwar  to  ib* 
outer  aide  in  this  p<wition  nf  the  log,  will  come  into  view  and  ifi  tn  br'ntubad 
to  one  Aide,  oxpo«iQg  the  surface  of  the  Aoleu«.  This  is  next  to  be  dtfidad, 
the  edge  of  the  knife  being  now  turned  towards  the  jHioteriur  »artkot«f  lb* 
tibia.  After  cutting  through  nbotit  half  an  inch  of  mttseulAr  tiimie  ft  UoA- 
nous  layer  w  ex[Ki8«l.  This  ijt  the  leiidon  of  the  dwp  nijtfnre  of  lb«  mWh, 
nnil  furtus  the  tirsi  itii)wjrt»nt  rallvini:;  point  in  the  o|»eratiim.  Tb«  teodao 
liBviuf;  been  ex|K«ed  in  the  v.  hole  leot;tb  of  the  wound,  It  ie  pirked  up  in  tbv 
middle  nilli  a  pair  of  furce|>«  and  carefully  opened.  The  o{ier»t<ir  muM  ito« 
luuk  tu  MW  if  nuiscular  Ulires  aritte  from  it«  under  suHnve.  An  a  nit, 
no  tibrw  ariw  fn>ni  tbv  internal  bulf  inch  of  lb«  deep  surtiLtY  of  ibr  ti-Jidoa, 
■od  if  tb«  incKiuD  through  it  l>e  made  at  tbi«  {>oint.  the  tfioioo  lietWMO 
the  dc«p  and  superficial  muiK>)«»  io  which  Uie  artery  lies  is  iajnudiaidy 
u|>enud.  If  the  incielnn  be  mure  external,  the  tibrts  arising  from  tbe  decf 
aurfaoe  of  tbe  teudou  niuat  be  dividi>d  before  the  pnipcr  sfMLce  is  opened.  As 
800D  as  this  is  reuchetl.  the  outer  part  uf  the  buIcus  and  the  gottrDoneaiu 
must  he  drawn  well  outwnniti  with  u  iMp|H!r  B|iatula,  nnil  the  artery  emneatBla 
view  with  a  vein  un  ench  fiide,  and  llie  nerve  miMt  conimunly  to  theoolcriidB- 
Tbe  TCBsels  are  oovennl  by  a  tliin  fascia,  and  lie  on  tbe  fascia  carvior  ibe 
deep  muscles.  Care  must  be  taken  tu  dividing  the  aoleue  not  to  womnd  tUi 
latter  fascia,  ai  sbontd  tbts  happen  tbe  nrterj*  ts  eiisily  lifted  with  tbe  nper 
ficial  inusclee.  The  needle  should  be  passed  from  the  side  on  wbiefa  ibe 
nerve  lies. 

The  potttrior  Ubfnl  artery  behind  Ou  maiUoht»  is  reached  bv  making  «  Mat* 
lunar  incision  about  two  inches  in  length,  curnng  round  the  poatutor  awl 
lower  part  of  the  malleolus,  nnd  one  finger's  breadth  behind  it.  Aiktr 
diridiDg  the  skin  and  &t,  the  internal  annular  lignment  codka  into  view.  If 
the  guiding  line  have  been  accurately  adhered  to,  the  artery  will  appear 
imm^iately  tbe  annular  ligament  is  divided.  It  has  a  tbick-walled  veio  on 
either  lide  of  it,  which  may  be  mistaken  fur  tbe  artery  in  a  bloodletv  limb, 
uuleai  it  be  carefully  exammed.  The  nerve  lies  behind  and  exiemaJ  lo  Ibe 
artery,  and  tbe  needle  must  be  pawK-d  from  behind.  The  most  oummoo  crrvi 
in  tying  this  artery  ari»ea  from  keeping  to  the  convex  instead  uf  to  Ibe 
c^mcave  side  of  the  wound  while  deepening  the  incision.  The  deep  parti  of 
tbe  incision  thus  gradually  approach  the  malleolus,  and  the  u^ndons  are 
reached  instead  of  the  artery.  The  lendtjn  nf  the  tibialis  posticus  is  that 
exposed,  as  it  is  most  sunerRcial.  The  artery  must  then  be  IcMikvd  fnr 
behind  thit*.  and  immediaieiy  beneath  the  annular  ligament.  If  tbe  diswcliiMi 
be  carried  on  past  the  sheath  uf  the  tibialis  posticus  till  the  flexor  l 
digittirum  comes  into  view,  it  will  paa  beneath  the  arterr,  which  b 

usaallv  held  nut  of  tbe  wny  in  the  posterior  blunt  book,  and  is  thus  a 

Tbe  tfexor  tringus  jwllicis  lies  so  far  behind  the  artery  that  it  ia  soarodj 
powihle  to  expOM.'  it. 

The  Anterior  Tibial  Artery  may  be  tied  in  Mveral  situations:  but,  like  the 
posterior  tibial,  it  should  not  be  lipilunil  in  the  upper  or  middle  |«Tlt 
of  the  teg,  except  for  injury.  Tbe  ditbcultii'9  of  the  operation  are  b-^ienM] 
as  tbf  anklo,  where  ihe  nrtery  liecnmcs  supcrticial,  is  approacheil.  Tbe  line 
of  direction  of  the  anterior  tibial  nrterr  iH  from  the  inner  side  of  the  bead  of 
the  llbuin  to  a  point  exjictly  midway  between  the  two  malttvili;  and  tbe 
(.-oume  of  tbe  dorval  artery  ol'  tbe  foot  is  from  this  point  to  tbe  clefl  bet 
tbe  first  two  tow. 


LIQATURE   or    DOltSAL    ARTKRT    OF    FOOT.  271 

In  iIm;  upprr  lliird  nf  the  leg  the  artery  l!es  de«|tly  betweeu  Ihe  tihialis 
aatioo*  ma*i  nWosfir  cnrannioU  dif^torutn,  Barrouoilcu  by  veins,  and  liuving 
i>»  Dcrrv  to  the  ooter  side.  If  it  ever  be  found  oeweeary  tu  lie  it  in  thift 
MttmtioD.  Ml  inciuoD  »b<)uld  be  made  in  the  ^uidio^'  liuc  of  ihe  urttry.  from 
fiMir  to  fir*  ibcIm*  in  length.  The  deep  ffiscia  niusi  be  ci|)vued,  aud.  il'  tieres- 
mtw,  ooCciMd  tmiuvenely.  la  the  upper  fourth  of  the  limb  the  tJbJHlis 
■■Ucu  mm»  from  the  fvcia.  which  adds  eoojewhat  to  the  difficully  of  find- 
ibtnterrai  between  the  muscles.  The  tlreL  inienniiKculur  K[m<x>  to  the 
"of  th*  tibia  ii  the  one  to  be  aouj^hc  I'nr.  Wlx-n  it  is  found,  the  nnkle 
b*  fined  to  relax  the  mueclee,  vi'hi<-li  an-  llicii  held  iipiirt  with  ctippcr 
iIkl  The  artery  may  then  be  fU-atit-tl  with  n  ilirector,  iind  (he  needle 
'  obliquely  beneatJi  it.  In  operating  hijfh  np  in  the  limb  it  is  puettiblc 
io  altp  into  Um  epaee  beiween  the  iKTimct  and  (he  extenfiur  digitorum.  This 
•nor  il  u  oatx  recognized  by  fiudin^  a  diHtinct  fibroun  iiitermuseular 
HfOm,  DO  saeli  einieiure  existing  betweiui  ttie  tibialis  anlictiB  and  the  flexor 
4Mloram. 

In  the  middle  and  lower  tbirda  nf  th«  let^  the  artery  will  be  found  between 
xim  tibtmlii  anlicu*  and  the  ext«n<H>r  propriiis  pollicis  ;  the  latter  mn»cl«  dues 
■at,  bowervr.  reach  the  wrface  above  the  middle  of  the  leg.  The  right 
«BM*  m  fbond  by  keeping  accurately  to  the  guiding  line  of  the  artery,  and, 
uar  tb«  6ucia  is  opened,  taking  the  outer  border  of  the  tibialis  nuticus  as 
^bc  nUe.  Tbe  edge  of  the  H^xor  longus  digiturum  is  recognized  by  its 
fooaatd  |«odoo,  reaehing  con!>idembly  above  the  middle  of  the  leg,  with 
flaky  fibra  joining  it  on  the  outi-r  aide. 

The  Artnia  Dortalii  Pedis  runo  frum  a  point  midway  between  the  two 
■allcali  tn  ibe  baev  of  the  space  between  the  two  linst  and  wcoud  metatiireal 
boBflit  and  may  be  felt  pul^tiuj;  in  thij!  line.  It  lie«  external  to  Ihe  tendon 
of  the  exteoMr  pruprius  pollicis,  and  is  er^wsed  near  its  lower  end  by  the 
intmrnl  belly  and  tendon  of  the  exlenMr  brevis  digitorum.  It  is  sometimes 
•hMDl,  and  not  unfrMjuentiy  lies  external  to  the  line  just  mentioned.  It  is 
f^tchwl  by  an  inciaioo  in  the  line  of  the  artery,  one  inch  and  a  half  in 
trngt**.  the  lower  end  of  which  oam^iionds  to  the  base  of  the  epace  between 
th*  tnt  two  metatarsal  buoes.  The  superficial  and  deep  faacin  being  divided, 
dM  utery  may  immediately  oonie  into  view.  If  it  does  not,  the  inner  belly 
•ad  teodm  of  the  extensor  brevis  must  be  sought  for,  and  iu  inner  border 
m—rd  till  the  long  extensor  i?  reached.  If  the  artery  is  not  seen  posstng 
hmub  the  t/>adon  of  the  short  extensor,  thnt  muscle  must  be  forcibly 
Mllad  oQtwanlj  aud  the  veesel  sought  for  beneath  it.  If  it  does  not  then 
flOB*  lato  view,  il  is  probably  absent.  The  teriniontion  of  Ihe  anterior  tibial 
acm  accompooin)  the  artery  when  it  is  in  its  normal  situation,  and  lies 
■bmJW  to  the  outf  r  side  of  it. 

the  Panmea]  Artery  has  been  tied  in  rare  cases  for  wound  in  the  middle 
.h.  i.».  It  is  found  by  making  an  incision  about  three  inches  in  length 
-terior  border  of  the  Bbula,  which  is  the  firet  "  rallying  iioint "  in 
<f|iaT>itoa.  A  thin  tendinous  later,  forming  part  of  the  ongrn  of  the 
aad  tometimiw  n  few  fleshy  6bres,  are  lound  attache<l  to  the  bone. 
Ob  dividing  ihcae,  the  flexor  tongus  pollicis  comes  into  view.  This  is  cut 
rarafiilly  away  from  the  p»^terior  surface  of  the  boue,  and  at  its  inner  edge 
a  lube  uf  ftscia  b  (bund,  in  which  the  artery  lies  between  the  flexor  p<^llicis 
aad  tibialis  posUeoa.  This  must  be  opened,  nud  the  veo«  comites  separated 
wtcb  a  dtrvdor,  aAer  which  the  DCNxlle  is  easily  passed. 


C 


DISEASES  OF  THE  ORGANS  OF  SUPPORT  AKD  MOTION. 


CHAPTER    XLVI. 

INFLAMMATION  OK  BUNE  AND  ]T8  KFyKCTS. 

UENKBAL  rATHOLOOY  OP  IXFLAUMATORY  AFnxTlOira   Of  BOVB. 

Before  procepdioj;  to  consirtcr  tht^  dineases  of  bone  lui  they  pNaenl  Oum- 
telres  to  the  pmcttotl  Surf^n,  it  will  be  most  convenient  Uj  <Je«cribe  tb* 
difteri-ril  [Mithiilogicftl  effeclA  of  inflamnintioQ  on  tb«  teparnte  vtrurlQfM  of 
whivb  bono  is  oump<)MHl,  viz.,  the  perioeteom,  the  medulU  nn<t  lb«  camoo* 
tiMue.  The  nece«*ity  for  ihiit  arises  from  the  fact  thnt  tDflainroAtorj 
Uona  are  rarely  limited  to  one  of  the«e  ttructurM.  Thus  iiiflamtnatioo 
meitciug  in  the  ]>flno«tenn),it'  it  last  for  any  length  of  lime,  nlwayi*  prtxlucv* 
more  or  lose  mnrkeil  changei^  in  the  cvmipact  lissu**  beneath,  aud  iht*  ouicel- 
loufl  tiwue  is  never  Hllocted  without  the  perioelvurti  twmtier  or  Inter  takiay 
part  ID  the  loorbiU  proeece.  I  pro[>o«e,  tberefure,  tu  dettcribv  bricflf  tbt 
various  efleotv  of  inttummaliou  as  thev  tDauifvitt  themaelvm  in  th«  fUdvrmii 
fitructures  of  which  a  bone  is  uouipo«ed,  uttAvbing'  as  far  as  puauble  a  <l«6ait* 
usme  to  each  by  which  it  can  bv  referred  to  in  tito  clinical  deacriptioa  gf  lb* 
diaeaaes  ai  they  ix-uur  in  practice. 

The  prooesB  of  intbimrtiaiiou  iu  bone  is  eeaenLiallv  the  same  sa  in  all  otfav 
tHBues — fiuch  nio<litt<:ationis  as  exinl  Itetiig  due  iwlely  to  the  ntrncturo  of 
ftfliwt«d  part.  In  the  chapter  on  Intlunimation  it  wua  pmntetl  out 
the  more  acute  or  deetniclive  prt>oes»eB  of  iiiKHmmalion  the  inllamed 
becomes  infiltrated  vith  new  cells,  before  which  the  ori{;inal  stracturat  i&- 
anpcar.  In  the  soft  twrts  of  a  bone,  the  niedulln  and  perinateum,  tbia  lakm 
place  exactly  as  in  otner  tbauea,  but  in  compact  bone  this  proccea  is  natricud 
and  delayed  bv  the  densitr  of  the  Btructure.  The  new  tuaue  nodeiVMB  tbe 
iante  changM  In  bone  as  elsewhere ;  ii  may  eoften  and  break  down  {nio  rtua, 
it  may  undergo  fatly  degeneration  and  o— eatJon.  or  it  may  nndcrgodeTelcip- 
ment,'  the  prxluct  being  as  a  rule  oeseoaa.  instead  of  fibrous  tiasue.  as  in  tbe 
ioft  paru.  The  chronic  productive  inflammatonr  prooHaea  which  in  tbe  soft 
{Mirta  lead  to  fibroid  induration  or  overgrowth  of  ttto  oosnective  tisaue,wbeB 
afl'.«tiiiR  a  hone  lead  to  the  fumiation  of  new  oomous  ttHUe,  but  lb*  preeai 
i«  e^iM^utially  the  same.     As  in  otht-r  paru,  the  infimiiniatioQ  may  cud  in  di 

uf  the  nffscted  tissue.     Acute  infective  iDtluniiiialinns  al»o  are  met  with,    

the  chrunio  proceasea  associated  vrilli  the  develoumeut  of  tubercle  ore  c»>fO- 
muu.  All  tnaie  inflammations  are  identical  iu  eliuructvr  with  those  already 
deacribed  on  aireetin^  the  soft  parts,  such  diOerencee  in  detail  an  eitit  bciog 
duo  anlcly  t<>  iho  physical  pv<:ulinritiM  uf  the  tiMue  implii-atcd. 

Iiii-LAMMATuRy  rKiJCK»(i^i4  m  Tuc  rhiuufiTtLM. — The  |>crit«teum  h 
com|><««d  of  two  layen,  the  more  superficial  uf  which  coa»i«(»  chiefly  of 
white  libniuK  tiuue;  the  deeper  uontaiusn  large  proportion  of  yellow  vlaatio 
tiwue.     Funning  part  uf  the  deep  layer  iu  immediate  contact  with  the  buae 


TAB1ETIE3    OF    PERIOSTITIS. 


AMrstam  which  eonuunn  numerous  relk.  In  fj^rowing  bone  Uipjo  hnvo 
the  onUoftry  ftppearuice  of  the.  celU  nlwHye  round  immediately  ))r(ic«<1inK 
the  fernialiuB  of  nt-w  bone,  thesocallvd  «i»tf<>bliuU;  Ibey  are  grauulir  and 
■iBnibU  ui|{ulAr  in  oiiLline.  In  uduU  buii«  tke««  «re  repr«a«n(ed  by 
iaitened  eelln,  but  ihey  rendJly  resume  the  form  of  (wteoblasU)  under  sli}{ht 
dr-u>n<»  ..f  ttimuloliim-  The  periodtcum  is  exlrwmely  vawuiar,  llie  ve*«elB 
'*'  tp  in  il  uikI  (rnlfring  tlie  Haveniaii  i-jtaald  of  the  bone  beucalb, 

»i.  ,  u^i...  mu»  oervtv  may  be  trac«l  in  its  Wruclure.  The  effect*  of  ihia 
uructan:  in  miKlifyiuK  the  procetts  uf  iuUauiraatiuu  itre  ubvious.  The  ex- 
IniHv  raMtiUnty  uf  lliu  taembniUL'  favuni  exuUstiun,  and  the  inflamiaatury 
pf«d«ru  accumulate  moel  abundantly  in  tbe  deeper  layers,  and  bvlnveeii 
thas  Nid  Uw  bvue.  beueaili  the  demer  Eibroua  layer.  They  pcaelrale  also 
■ImK  iWvaaelB  iuio  (he  Huven)iiu>  canaU.  Owing  t»  the  abuuduut  nerv»us 
mppif  mad  to  UiQ  teusiuu  cnuned  In-  the  unyielding  uature  of  the  superficial 
iB^vnttf  Um!  peristeum,  indaniiiiatory  exDiltitioii  i»  oiien  accuinpaniod  by 
my  wvvre  pain.  Hhould  the  iiitlmnniBLion  lerniinatc  in  suppuration  the 
VMbI*  P— iiig  Irani  the  }>eri<«tenni  lii  the  bone  are  destroyeit,  nml  death  id' 
a  pHltim  uf  uui  eompaet  lianie  may  reaalt  This  is,  however,  by  no  menna 
tktmoBmmrj  cuciae(]U«Dre,  cepecially  if  th«  pcrioeteum  be  ecparated  only  t*)  a 
■■all  exteot,  aa  the  bimid-suiiply  Ytam  the  medulla  ia  t>ufficieot  bo  maiDtaia 
tfc*  vitality  of  the  deuudeil  none.  Sloughing  of  ibu  periosteum  na  a  result 
«f  iaflammatinD  ta  a  Aimcnhat  rare  occurrence  owiog  to  ita  abundant  vascu- 
karilT.  Chaeatioo  of  the  ittflanimattiry  produet^  is  not  common  in  perif^litis, 
Wt  la  bOCftaiiNiallT  met  with.  I..aiiLly,  new  houc  is  formed  with  grt-'st  rc-udi- 
anali  inHaniniatory  prooMSca  to  the  periocleum,  Lhe  mode  in 

vUc>  d   Iketng  the  same  aa  in   physiological  growth,  tliouj^h 

— Hng  i-.  y.     The  liillowing  arc  the  uamea  giveii  to  the  variouit 

iaAHasat:  t^es  i>ccurriug   in    the  periosteum:    (t>  Simple    Acute 

Feainailtif  live  IVriiMtlitLt,  a.  .Simple  nud  I^K-ali/ed,  o.  Inlectivo 

aad  Dilfb?"  n- <>Jt(-u{))a6Cii,-  IVrin^iitln  ;  '  4)  Chronic  Suppurative 

ftflaaiiUa;  (6i  nvrbiliiio  lVrli>6iilift. 

*■>!•  Ae«t«  Pario4titu. — Ihia  is  moat  comnoaly  the  reeultof  injory. 
Tb«  awsbniDe  ii  redder  and  thicker  than  oatarnl.  It  separatee  easily, 
mad  aa  it  ii  atrippcd  off  hue  threada  ar«  eeeo  pa»iog  from  tt  into  (he  Iwoe ; 
Aam  art  tiw  vamcIs  which  are  looaened  by  the  exuoatiuu  into  the  IXaveniau 
OBala.  uid  ootwequeDtly  draw  out  more  readily.  On  tcvliou  tbe  swulles 
amathnam  preaeata  a  toiucwhat  gciatinous  appearance  due  to  the  iufiltratioo 
af  itt  ateuotara  with  the  iullammatMry  oxudatiun  ;  thi^  h  muni  niarkeJ  iu  ibo 
daBpv  Uyon  oext  the  bi>ne.  Mii'nmiHipic  examinatiou  shows  unly  the 
acwaary  a{>pcanuioeBi  of  iuUaiumatiun — diiatatiou  and  fulncaa  of  the  veeaeU 
aad  oaiaWtHii  amall  round  rclU  intiltratiug  the  fibrous  Lieaue,  eaiictnally  its 
'  lann.  Bimplo  aeuie  |HTi<MtiLi«  aiayend  in  rceululiun  witli  u  |>erfeoi 
to  tL«  normal  coudilion,  or  it  may  |>usb  on  to  suppuration,  but  more 
il/  it  baciim»cbMnir  uud  uKounicii  ihc  i)»4ici)plHi<tlu  form. 

irt  Pthoatitis,  (ui  Simple  Acute  Fehostitu,  rctiuliing  from 
■jarr  oemiiaBaUy  irruiiiialea  iu  suppuration.  The  pua  forma  between  the 
^mKrBn..  An.!  iIi,  ti>.i<>-  and  slowly  perfiiralwi  the  fiDn>ug  layer.  It  abowi 
b'  rend  beneath  tbe  perioaleuni  or  to  separate  it  widely 

t^••t.  .1  i.i^>   l>e  (olhiw<>il  by  dentli  of  tbe  expoAetl  portion  of  the 

«aai(i;.  hut.  a>  iM-fore  staled,  v>'\»  ie  by  no  means  neceMary. 

Hi<  itucciiTs  Inflammation  of  the  Perioiteom  is  a  mutb  more  serious 
■flndWdk.  It  nctUTr  rtiii  llr.  if  not  fxrlurivrly,  in  vnuni;  subjects.  Tl  termi- 
■alw  Tvry  '  i  ><»  and  \Uf  pui>  diffuM-«  itj^elf  widely,  stripping 

iha  parMa;.  .,  souieliitkes  ilirouuhouL  the  wbule  extent  of  the 

Whui  It  ibftdH*  the  epi|jhyM5>  ibe  inflammation  andeuppuratiun 
T»t_  11,— J  » 


274 


INFLAMMATION   07   BONB    AKD   ITS   EPFKCT8. 


extetiil  in  the  growing  ti»ue  between  them  am)  the  alinfl,  nnd  tbiM  to  d- 
trenie  vaaee  the  whole  (]iii|>liy^is  mny  lie  louee  la  th^:;  cnviiy  tif  a  raiitmbMCH 
enclosed  wiihin  lh«  iiudtrstriiyed  fibnius  layer  of  the  p«rii)sti-ura;  BaaBx, 
this  is  perforated,  and  the  pUB  difliises  itself  nniongst  the  surn^unding  twncL 
In  BpiLe  of  the  ncnteness  of  llie  process,  the  penosleum  very  rsrelv  nlouglH. 
and  if  exit  t>e  given  to  the  pus  the  inleasity  of  tlie  iaflammatitm  nu^idnvkl 
the  perioHlilis  Hasumes  the  oet^oplnstic  Ibrm,  new  bone  hein^  abuothutllr 
de[>n«it(-d  heuentli  it.  Intcclive  pertoglilis  almost  invarinblr  imda  tii  dfatA 
ofa  ponBideralile  portion  of  the  bono  whioh  has  been  laid  bare  bj-tbvwpara* 
tion  of  the  membrane,  bin  the  extent  that  perishu  docs  not  mm— rily  cor^ 
respond  to  that  Mpamtcd  from  il^  periuKlvitm. 

UBleoplastio  Perioititis. — This  i«  taacmially  a  chronic  prooM>.  It  oooun 
ta  R  t'<iuMHHit'U(i-  of  ihe  slighter  fririns  of  Irrilaliou,  or  as  n  tcquel  of  artjt# 
inftiiinrnatiiin.  Il  i»  very  fn-qucntly  mm  with  ulfto  a»  an  an'omfinninu-ut  of 
more  deeply  seated  inflammatory  miitehief,  m  of  the  medulla  <tr  ouii-elloiM 
ti«tie,  and  in  the  neighliorhood  of  diseased  joinlH.  In  ynung  Mihjecta  Et 
reaultfi  from  very  slight  nourcesof  irritatioo,  bving  tb«n  merely  an  cxagj^era- 
tion  of  the  normal  process  of  growth,  lo  osteoplnstic  pen<«titii  tb«  owm- 
brane  is  thickened  and  more  vascular  than  natural.  It  aeparata  with  mu* 
ea«e,  and  its  under  surface  often  feels  gritty  from  small  frngmenti  of  turn 
bone  that  have  come  away  with  it.  Deaeatii  it  and  adherent  to  the  aampMC 
tiseue  ia  the  new  bone  formed  as  the  result  of  iho  proccw.  Tbu  taMf  h* 
arranged  in  smooth  layers,  parallel  to  the  surface  of  the  bone,  in  nodulaivr 
lo  pointed  proee^ca.  When  the  nodulatod  or  spiculated  manea  reach  aajr 
cAnnderahlc  size  ihey  arc  frequently  lerme^l  oMeophyte*.  Tbfl  new  booe 
fhrmed  in  the  mrly  8tii^'(«  of  rv^tcoplaslic  pericjetitia  is  soft,  and  Hpongy.bciif 
traversed  bylargeranaltx-onuiiuing  vtesctssurroiinded  by  rttund  oelU.  TIhk 
«anal8  are  sot  at  right  uiiglit^  lo  tliu  iitirfa<»of  the  bone.  Aa  rvcuvery  takes 
plaeo  the  new  bnnc  hi  [mrtly  alMorbed,  the  irre^'ular  nodular  or  »piculated 
mawes  are  auinotbcil  down  and  the  n^mainiJer  gradually  tncreaaes  in  deoaltf, 
till  il  bfcomex  indistiuguiHhable  from  llio  conipaet  bone  beneath. 

MtrnMonpic  examination  uf  the  parts  involved  in  MtMiplaMie  pMiMtilit 
ahowii  that  the  swollen  membrane  is  inBltrnted  with  small  round  eelU.  pro- 
iiortional  in  niimbor  to  the  acutenoflit  of  the  proccm.  Ia  the  deeper  bire«* 
in  contact  with  the  newly  forming  hone,  the  cells  assume  the  choraclrrirtie 
angular  .«hnpo  and  granular  nppeuranc«of  aBteoblasts.  There  seems  to  bet 
direct  tmiiMlion  from  the  gniniiliLlion-c-ellii  infiltrating  the  inOamed  mem- 
brane to  the  osteoblasts.  The  new  bone  is  formed  Riib!ic<)uontly  in  the  sacne 
way  as  in  uormal  owiGcatiou.  Some  of  (h«  osteobln»tti  are  •upixMrd  to  be 
trails  To  niied  into  a  homogeneous  tnteri-eltulnr  suh^initce,  vrhirh  ixxi^imt*  in* 
dtHiuctly  librillHted  and  subsequently  calcifie<],  the  reumining  cells  fortniai; 
(he  boDe>corpu«cles.  The  developiuvnl  of  the  intlmnmatory  new  growth  ittto 
bone  conimencet!  at  the  points  m<Mt  distant  from  the  veeeels,  and  eradaallr 
vncroHchit)  on  them  till  they  come  to  lie  in  channoU  surrounded  by  bene 
(ilavertinn  catuils).  We  have  befure  sv«u  that  the  same  chaotroe  iK?car  is 
the  formation  of  callus  iu  the  rejiniruf  a  fracture  i  vol.  i.  p.  501),  but  in  these 
circumntanocs  cartilage  ucoasionally  ap|K>ar8  before  the  developmeDtof  bonr. 
This  is  never  met  wilb  in  oeieoplaatic  iieriiMtiLis  ariving  from  other  causes. 

Billroth  is  of  opinion  that  the  new  l>»iio  doveta|H!U  in  wteoplaatto  Rri- 
aetitia  w  not  always  forme<l  solely  from  the  (lerioeteum.  That  it  is  so  in  Umss 
cases  in  which  the  compaul  tissue  bent'ulh  is  dead  is,  of  vourse,  evident,  but 
in  other  cases  he  believes  that  granulation- 1  issue  sprouting  out  of  the  opcb- 
.ings  uf  the  Ilnvcniinn  canals  takes  part  to  the  process.  In  tbe  uuioa  </ 
fllU!tQn«  the  callus  id  |>nrtljr  formed  from  tbe  injured  soft  parts  superficial  10 
the  periosteum. 


OSTEITIS — BARBVYIKa. 


276 


OkrMM  SoppantJTe  Periostitis  is  uot  commoD.  but  oocasioDBlly  the  peri* 
it  fiMM  Be[iAraii-l  i't'iia  tho  bouo  by  a  Bmall  quaotity  of  curdy  pus 
ii  OMl  wilh  ia  clironie  i^cCHes  clwwh(>re.    It  is  usually  merely  a 

J  WNMwa,  boin^  dtipeDdont  on  some  ot'  ihi-'  d«eiriicLive  choagis  to  be 

t^tfiMiently  deacribed  as  comin<^ncing  id  tbo  boDC  beneath. 

IjruiUtio  Fniostitii  and  GummiUa  of  the  Periusteum  have  been  already 
doflTibed  {lU.  I  p.  1070). 

Any  tocaiued  ebn>nic  inflammatory  svciting  of  the  pniinateum,  whether 
dmple  or  typhUtlir,  and  whether  accompanied  by  the  formation  of  a  new 
bdae  t^  not,  i*  ciimuntDly  t«rm«[l  a  node. 

I»KIUM*IATf.l:Y  PlUX'Hsf«EJ»  AFPECTIMO  THE  COMPACT  TlMUE  OP  A  BON'E- 
— Tt'i  :  i-'.-utf  uf  boot:  U  composed  of  lamelbe  urranf^ed  for  the  inoAt 

p*r.  iv  around  lh«  IlHver^ian  i.:anali>.     Beneath  the  perio«teum 

tW  Ibvui  .1^'  U*v  Utvir  (.-oticenlric  nrran^eineiiL  and  lie  pnmllel  to  tlie  surface. 
Bvtwvvu  th«  lanielU-  li«  the  bone-corpuscle«  ta  the  liiciiiiie  and  from  tlie«e 
U>«  filM  caoalkult  pius  through  the  bijny  t)«4iie.  The  Ilavervma  canala  are 
■Tiowl  Dau  iba  Buriace,  and  gradually  iuorcuse  in  ei^e  tuvranht  the  deeper 
pwta,aodwt  tbo  compact  and  the  caucelloUH  ti^^uc  gmduully  murgo  iutoeach 
odMr  wicboat  any  sharp  line  uf  ilistiuctiou  bctn'ivu  them.  Each  Haversian 
awal.  vxoept  the  very  smalleet.  contiiine  a  fluiall  artery  and  vein,  a  flattened 
Inapbatio  veoael.  and  a  pale  iierve-tibre,  Hurruiinded  by  u  small  amount  of 
Wif  !■  eoanective  Itmue  coulaininf!  branched  cells.  There  is  no  reason  lo 
bdBew  tlHt  the  bnae-curpuscleB  take  any  active  part  in  the  inflammatory 
in  bane;  all  the  changes  observeil  proceei]  IWim  the  Haversian 
The  nature  of  ihe  tifsue  in  which  the  inflammation  is  taking  place 
Uy  oaBMfl  «aine  modifications  in  the  phen<tmena.  Kxudation  and 
nfiipwii^!  "iiacles  occur  as  in  other  6triii?tiir<«.  hut  the  amount  la 

Miewhu •■  tiie  unyielding  nature  of  the  ^urmunditif;  tissue.     The 

■w Itlm  of  ihe  aJeltcate  eonnective  tissue  in  the  Haversian  canaU  will  more- 
over tend  Ui  cnmprem  the  vesseU,  and  thus  in  aouie  inflammation  of  comjtaoc 
booe  ileath  tif  thr  atTi-eteil  rutrt  is  %-ery  prone  to  occur  from  arrest  of  the  tlow 
of  Unod  through  it.  Should  this  iiol  hapjieu,  we  see  the  same  changes  occur- 
ring a*  ID  otlu-r  tWHia;  tbe  new  celts  iacrwwe  in  number  and  the  original 
tkeav  dmppoirt  before  them.  lo  huae  this  pn>oeM  is  nece^warilr  slow  on 
MeooDt  of  the  density  of  the  structure,  but  ultimately  a  ixirtion  of  tbe  s<did 
boo*  nwy  be  as  completely  destroyed  before  the  advancing  cells  as  are  the 
mA  tmmm  in  the  forinalioo  of  an  absoees -cavity,  or  in  ulceration  of  tbe  skin. 
Wlbea  nrtcowry  talcei  plaoe  the  inSamraatory  products  develop  into  bone 
iaeCcMlof  into  fibratHtmue  as  in  the  soft  parts.  The  compact  ttsue  is  liable 
aim*  In  ckraaic  inflammatorr  aAectioDfl  of  the  same  type  as  chose  leading  lo 
■braid  ndnration  of  the  son  parta,  but  in  bone  the  product  of  the  process  is 
oeir  oaMoH  liHOe  which  deretops  in  the  Hnvcriiian  canals,  gradually  uar- 
i«*iay  lh<m,  Mid  randeriDg  tbe  texture  more  dense  than  natural. 

Tba  iaiuDmatory  prooesaos  ubwrved  in  compact  bwiM  we  the  following: 
i1.  Buviyiagorruvnotiveoetoitu:  (2)  Osteoplastic  or  oondeiHing  osteitis; 
and    ^)  SiH;raaiiL 

l«r»iyiiiff  or  BanfiuUve  Osteitis, — This  may  occur  aa  a  secondary  effect 

■  jilaiBmaithi  ooniiMucing  in  the  periosteum  or  in  the  medulla.     It  is 

rred  alio  H  the  result  of  injury,  as  in  a  piece  of  bono  denuded  of  its 

.amenm,  or  on  each  side  of  a  fracture.     In  many  easei  lis  original  cause 

•  **ry  obaenrtL 

A  portion  of  oompact  bone  undergt^ng  this  change  is  In  the  oarliest  itagea 
at—rreJ  to  be  tltghtly  redder  than  natural;  the  openings  of  the  Haversian 
casab  aAnr  a  time  become  lomewhat  lucrea*cd  in  «iz£,  nod  consequently  a 
taffcr  onmbar  an  risible  to  the  naked  eye.     As  the  proceas  advancea  the 


lAtlOy   or   BONK    AND    ITS   tfttCTB. 

•  rMpiMMU  tl)««xpeDi>Pof  tlic  aolid  boDCfinrr.  .  m, 

.iMlbftVllflici^ni  mie  thcv  ran  be  »e«n  to  i  It 

pmL  gruialali'iii-ttMui-  siirriiuinliDjt  the  v«wiel.  It'  ii  [»>r;iwa  ^ 
au»  itagv  bv  mfMtTfiUHl.  it  jirfw^iiln  n  poroup  ^{"iDgr  npipriruci, 
nomlltius  tiMkue.  If  the  prucem  lulvanve  etitl  hirllKr.u 
i^ihuhumi  uf  a  \nv*»  nf  ilvnd  l>ui)^,  the  neigh bqriDg  enlnr^rd  lisTer- 
^Irfcv,  tKe  solid  <M>e<wu8  tiwuv  d inn ppea ring  eolirelr,  and  a  hA 
_  , . .  ^.^^aiatioD-tt8«uc  611a  the  Bpac«  once  occupied  by  soliil  bone.  Tbt 
'ag^ficial  Iav«n  of  the  ^anulatiun-lissue  may  break  down  into  puf  nodtr 
'  1^  MHH»  (Muilicions  (bat  give  ri«e  to  suppurniioa  elpcwhprv,  ur.  Eooald  tbv 
r,  thu  Dew  tinue  develops  into  bone  by  the  HLae  procew  ai  fa 
'utUnT*""""  pwtartitiv,  the  new  oti&eaui  liHoe  beiD}>  tint  formed  to  eaaiHctiua 

Tb*  miwO'iug  wteitis  may  be  limited  to  a  email  portion  of  the  boo*  aa 
ika  Mparaliiio  of  a  eetjueetrum,  or  niny  be  diflbaed  over  a  wide  ami.     In 

rtotU<*i'  CUM*  it  is  more  ctiroDJc,  and,  aUhough  rendering  the  liuno  more  pomn 
tan  natural,  rarely  leads  to  its  complete  destruction  for  any  great  t^xient. 
Micni»(*<il>io  examination  of  u  piece  of  bone  affected  by  rarcfyinK  oMcitis 

[ahuw«  t'x*  tollowiog  appearniiees:  In  the  earliest  Mafce  the  vcmwU  arc  di»- 
tvndrd  with  blood  ntid  numerous  cells,  probably  migrntnl  leur(K-ylr»,  ar« 
ft'umi  in  (be  delicate  connective  tissue  coniuinc'd  in  the  Haversian  rauaL 
]u  n  more  advanced  stage  ibeac  cells  arc  greatly  increased  in  nuitiVr,  and 
\hv  wall  of  the  caunl  ia  seen  to  have  been  C4>niumed  away  before  tlitriii.  Tba 
dr»lru(.'lion  of  the  oaaeoua  tissue  takw  place  irregularly  in  excax-aieJ  ctw- 
crutic  hollows,  6rKt  dcacribed  by  Huwnhip,  and  con»cipientlr  itanied  "  Uv%^ 

\ali\p'$  fanime."  A  large  number  of  tlieae  will  l>e  fmmd  to  be  filled  by  ceUl 
Iff  iHinBitlernble  lize  conlaining  several  nuclei,  encb  cell  corre«p«iDdtDR  toa 
lacutiB.  Thei^e  many-uuclenled  celli)  are  found  wherever  bnne  is  ntog 
dratruyed,  whether  from  intlammatiun  or  a  physiulo|;ical  nr'iceM,  a*  llbc 
development  of  the  medullary  canal,  nud  they  nre  vupputeil  to  play  MBa 
|ni|vonuut  part  in  the  absorption  of  the  <i9»euus  ti*^ue.  Fur  thia  rcaaoo  tbey 
have  revi'ivcd  tlie  unoie  oi'  oHtmtatt*.  Tliey  lie  directly  in  cotilarl  with  IM 
Kine,  the  rest  of  the  imce  aurrouudiug  the  vcmbcU  living  filled  with  the  imli- 
narv  »mall  round  cells  of  grauuliiiiuu-litsut-.  Their  mode  uf  devuluptnoit 
nnd'suli^e^uent  fate  arc  uncertain.  The  oeeeous  liaatie  which  ia  yet  nnde- 
■troyol  prewnlA  ulteu  uo  cvideuc  change.     The  boDe^xrousclen'certatnlf 

fihow  no  HiguB  of  taking  snv  part  in  (bo  pmoesa.  Sbuuld  they  ihow  any 
change  it  ia  one  of  degeneration,  not  uf  pnilifcratlna.  They  may  be  unnatu- 
rally granular,  and  arc  KomeUmcM  rt-pn-M-nted  merely  by  an  r<il-glubule,  xra 

,  uaM  of  fat  granules.     They  can  in  moat  cases  be  »een  to  be  unaltered  until 

'.tlio  lacunie  in  which  they  lie  are  opened  fay  the  advancing  abiorplir>n  of  tk« 

<OMeous  tieaiie.  and  after  that  their  &te  b  unknown. 

When  (be  deatnioUve  proceos  haa  advancefl  ^r  enough  to  fnnn 

[l)<lera1ile  space  fille<l  with  granulation- cells  around  the  itrigina]  vrw«4  of  lb* 
Uaver»ian  runal,  new  capillary  loops  art;  found  )>eDetrniing  umongat  the 
new  t)«>ue,  Jui<t  ua  in  the  development  of  granulation-tiMut:  in  a  wound. 

Tbc  destruction  o]  Inine  by  the  pressure  of  a  tumor  or  an  aneuripm,  or  ill 
Infiltration  by  a  malignant  gmwtb,  it  earrietl  out  by  the  »me  pr<>c«v«  aa  that 
Juat  described,  hut  in  the  former  <^a»4-,  when  the  iiarenian  mnab  baw' 
le  aofbcivntly  enlarged,  the  sjM-ciat  elements  of  the  tumor  penetrmta 
_jlto  them,  diKplncing  lliugranulHtion'ti»ue.    The  compact  tissufl  may  io  like 

[oianDer  Iw  inrndol  by  the  8|>ecific  (iniuv  of  a  syphilitic  gumma. 

Various  temia  arc  iipnlifd  clinically  to  this  rarefying  oetciti*  undtr  ha 
different  modifications.  When  the  proceaa  is  widely  dilruied,  a  large  pait 
nf  Uio  shaft  uf  a  booe  being  rendered  marc  povoui  than  natural  withoat 


i^fslnirlion  of  ilie  bony  tJseiie,  it  in  sometiraea  termed  injlammfitorif 
When  nnlv  a  )oraltsn)  Ar««  is  ftfTecLed,  as  in  th«  eepAration  af 
firom  livhije  Uinf^,  Hiih  cnmpleUi  destrtiotion  ot'  t)te  csmous  tiMue,  aiid 
tnbaeqiiMit  foriftiktion  nf  pun  fnini  th^  grannlfttioiMi»!iie  repUcin^r  it.  It  is 
twrmed  timiptt  Hlertilion  o/6ane.  W'ht-a  it  <K-curs  a»  lh«  result  of  the  infiU 
tmiiMi  of  toe  ciini[>]irl  tii»«itt'  Iiy  n  i«i)h|»erii)«toal  giitiirna  fiillnw^d  l)y  »ufleiiing 
MhI  MppanttiuO  nf  lh«  new  ;;r<iwtli,  it  i«  cIcHcribftl  its  »j/pftUHir.  caries. 

OrtMpUitlo  Oftoltis  or  Oauo-ielerotli. — Ttiid  ia  h1wh>-8  hh  extremely 

dbniBf<y  (•■K4«*.     It  iniir  nocur  ns  n  vequeocc  ol'  diffuso  mrefactive  tntteitis, 

v  rmilt  uf  some  cvotml  mischief  occiirriag  in  llic  cuDcel- 

ollii,  nr  U9  a  c<)DH;<]ueucc  of  evpliilia.     (.>i}t«i7p1itBt)c  <»teitia 

■-ri):v>l  l>y  a  iteTeliipmeiit  of  uew  bone  ia  the  coaaec-tive  linue  eur- 

:  the  vi'swIb  m  the  Haverainii  caniils.     The  mode  of  furmation  of 

'•■:  ■     OS  tisnie  if  tbeHme  u  iu  oeteoplB^lic  iieri«6titii>.     As  the  result  of 

:i  -  >'«  the  boae  becnraes  grreatly  increased  in  densitv.  frequently  with 

1 '  > ''.'  obliteration  t>f  maoy  of  the  Haversian  canals.  This  may  cvrn  go 
id  Uj  ^ucii  an  extent  as  to  cut  otf  the  raacular  supply  from  a  portion  of  bone 
tad  thus  oaaae  its  deuth.  The  bone  may  assume  the  consistence  of  ivory. 
At  tba  aAme  titne  it  may  incronsc  in  thickne^^.  partly  from  a  eimultaneous 
tfapaaii  of  bone  by  the  perioitteiim,  au<1  partly  apparetiily  from  inicntiitial 
frowth  in  tbo  bone  itself.  The  new  boau,  though  denser  io  structure, 
*aanb)«»  heallbjr  osseous  tisue  when  examined  by  the  microscope. 

Tlw  two  proetBHB  just  described,  oftteuplRsiic  and  rarefactive  osteitis,  not 

«afr«90«ntlT  ko  od  U<l4  by  side,  giving  rise  lo  thi^  appearance  known  aa 

n  boBC.     Tbe  ooropaot  tl<Mue,  whon  thus  affected,  becomes  more 

lluui  natural,  and  the  arningement  of  itii  Htruoture  is  oflea  more  nr 

1^  «oaipl«l«ly  altered.     In  normal  compact  tiniie  saime  of  the  «uperticial 

tatAcIhe  ii«  parallel  tu  the  .turface,  but  in  tbe  f^reater  part  they  are  arrunge«l 

>  ariJiilid  the  Haveniao  canals  ;   not  iinfre<)tienllT,  however,  we  find 

<-  oatt-iti*  that  tbe  eomcMicC  structure  unilerKoes  a  peculiar  laminated 

II.  w)  that  a  section  of  ii  preaitetiLi  throughout  parallel  luyent  uuo* 

i-MiKii   with  the  meibilla.     The  lamellso  are  ttepamted  fffm  eaoh  other  by 

ptak  Tasvulsr  tisiuc.     Thi«  rhiiu^'  in  Deceasarily  accompanie<l  by  consider- 

'    -ifK  of  the  nUuctud  bone,  which  may  cxirnil  throughout  a 

<i^tb.     Microscopic  examination  shows,  in  such  a  cnse  aa 

Ltua,  ;ii2t  tin:  ['ink  timue  lM!twii>n  i1il>  Imuv  lainimc  is  roni|>(Kt.>il  chiefly  of 

fgnad  cvUk,  UIca  thoee  ttf  nnlinury  gninulalion-lifleuc.  but  on  one  tide  of  the 

tW  oelU  in  rontnot  with  the  orm^oux  layer  arv  asi^umini;  the  form  uf 

indicating  that  fornialioti  of  Ixuifl  is  taking  place  :  while,  no  tbe 

mbtr,  the  fur&ce  of  tbe  lamella  ia  irrcj^lar,  preseotiog  the  bolluwa  known 

as  Ha««hip*s  lacons.  an'l  in  these  are  the  large,  m&oy-nucleateil  cells,  or 

bleb  arp  ioilicntive  of  ilenlriiclicm  of  Ikidc.     Tliip  pnn-ea.  when 

rn'fiv  n.  a  jialh Illogical  chau^,  ia  usually  re^rded  aa  inflammatory, 


kvt  '  analogy  In-lween  It  antl  normnt  gn>wib  h  evident.     In  the 

- —  of  a  child  the  medullary  canal  is  hollowe<l  out  by  a  proceas 

1  just  described,  and  new  b^ine  it.  constantly  'leposited  on  tbe 

'    !~'t[  -r>'(im.     In  ohn*nic  (.«teilis  with  "expanstoo"  of  the 

:    Tire  is  in  tbe  dilTo^iou  of  the  procew  throughout  tbe 

irr^'giitarity.      If  the  source  of  irntatiun  to  which 

-  due  Ik*  remove«l.  the  di-»tnicti*-e  part  of  the  change 

iorrai^I  on  both  pi'le*  of  the  liimellie,  and  thus,  while 

rt-  nr  Ic»  completely  retaine*!,  the  structure  Wf.oniw 

tiKr  tbao.  normal  conipact  tinue. 

,  ;"^mnric«  presented  by  tbe  dtaeased  bone  are  euch 

m  U»  — W>  tbai  ibe  ppriwtimm  takes  but  little  part  in  the  procTW,  but 


278 


IKFLAHJIATION    OF   BONE   AND   ITS   KFFSOTS. 


• 


more  commonly  expaosion  nf  ihe  compnct  li^ue  is  associated  with  laminated 
deptsits  ul'  new  bone  from  the  periijet^um. 

Expansion  of  bone  by  a  Uinmr  is  n  cbnnge  of  ihe  eanie  i-hiirafter,  the 
destructive  proceetes  just  described  taking  plaoo  in  the  parte  pren.'ipd  on  by 
the  growth,  while  at  the  same  time  new  bone  is  dev€l(>[>e(l  )>eneHlh  the  pen- 
oBtcum.  Thos,  even  when  the  tumor  exceeds  the  nonnni  bone  in  size,  it  ts 
ofteu  found  still  to  be  sun-oundod  bv  fl  shell  of  osseous  tissue. 

Svpbilitic  Osteitis  lins  been  already  described  (vol.  i.  p.  1070). 

aeoroBis  of  the  Compact  TisBue  may  be  the  result  of  direct  injury,  as  a 
flcvere  blow.  A  portion  ol'  bone  may  perish  from  its  vascular  supply  beingj 
cm  nfl'  by  «eparatiou  of  tbJ  pcri.ifleuni  by  injury  or  by  the  formation  of  puaT 
b*nealh  ihc  membrane:  aud  in  liki'  ntnuner  suppuration  in  iht;  medullary 
canal  may  cnune  llie  death  of  neighbortnc  coin[}act  tissue.  When  the  com- 
pact tiM^ue  bccoines  invotved  in  aoute  intJAniniatioa  c-xt^mling  to  it,  eilhec-i 
iVoni  the  medulla  or  from  the  perintileum,  it  ia  very  apt  tn  necrose  from  pr 
Dure  upon  tb«  veKseU  iu  the  Ilareraian  canaU  by  tlie  iuftanitTiHtory  exudation 
within  ihem.  Chronic  osteoplastic  osteitis  may  also,  iu  some  cniws,  ?nd  in 
necrosis  from  gradunl  obliteralioQ  of  the  Havei'siflii  canals.  It  ia  quite  poa* 
sible  that  small  fragments  of  bone  may  die  and  be  subeei^ucntly  absorbed  ; 
but  that  this  may  take  place  it  is  necessary  that  tbc  dead  portion  niu»t  be  of 
small  size  and  free  from  irritating  properties.  If  it  have  perished  in  couso- 
quence  of  some  infcutive  inflammation,  or  have  been  impregnated  with  de- 
composiug  matter,  its  absorption  becomes  impoesiblu,  for  absorption  of  bou0 
ia  carried  out  solely  by  the  medium  of  the  living  cells  before  described,  aad 
tbeae  cannot  exist  in  a  healthy  state  in  the  presence  of  the  virus  uf  an  iu* 
fective  process  or  the  product*  of  putrefactiuo.  Larger  fragments  of  dead 
bouc  arc  always  separated  froiu  the  living  and  east  oil'.  This  is  accomplithed 
entirely  at  the  expense  nf  ths  living  Imrif.  The  prnccBS  by  which  it  is  air- 
ried  out  in  merely  one  of  rarefying  osfeitiH  carried  to  its  highej-t  atage 
and  ending  in  complete  destrui'iion  nf  the  osseous  tissue  where  the  living  ia 
in  contact  with  the  dead,  il.ri  pince  being  occupied  by  gTannliuion-ti«*ne.  The 
Inyere  of  this  tissue  touching  the  dead  bone  break  down  into  pus,  and  thiia 
complete  separation  is  accomplished.  The  further  details  of  the  pn>ceflV.J 
will  be  given  when  treating  of  necrosis  clinically. 

Infi^mmatohv  Piuhjesses  in  thk  Medulla  of  Lono  Bonb^. — The 
marrow  of  a  long  bone  is  composed  of  fat,  supported  by  a  delicate  conopo 
live  tissue  and  traversed  by  vessels.  It  contains  numerous  cells  reseniblinj^ 
white  corpuscles.  In  contact  with  the  solid  hone  the  connective  tissue  as- 
sumes an  imperfect  membranous  form  aud  ia  mcr^  abundantly  vn»culnr,  mid 
this  layer  has  received  the  name  of  the  niwlullary  membrane.  It  is  unne> 
cewary  to  enter  into  any  great  detail  iu  describing  the  iufl«nim8U>ry  pro- 
omea  that  occur  in  the  marrow  of  bone,  as  they  are  the  same  as  in  other 
so(i  strQCtures.  The  Ibrmii  of  iu6uMno»tiiin  occurring  in  the  medulla  are 
the  following:  (1)  Simplp  oateomyetiti*  ;  (a)  acute,  (6)  chronic.  (2)  INf- 
fuse  acute  osteomyelitis;  (a)  neptic,  (6.i  infective. 

Simple  Acute  Osteomyelitis  is  unually  of  traumatic  origin.  The  pbl 
Qoniena  obseivt:<l  are  the  wme  as  in  other  sofV  purls,  dilatation  of  theTeseels,' 
exudation  and  mignttiun  of  the  corpuscles,  and  gradual  disappearance  of 
the  normal  tissues  before  the  new  cells.  In  compound  fracture  and  amputa- 
tions it  ocmsioually  endn  in  suppuration,  a  small  collection  of  pus  sometimes 
forming  which  discharges  itwlf  ihrnugb  the  open  end  of  tne  nifdullary 
canal.  In  simple  fractures  suppuration  never  laKcs  place,  but  the  products 
nf  the  process  are  devclope<l  into  bone,  thus  funning  the  internal  callus 
{vide  Repair  of  Fracture,  vol.  i.  p.  .503). 

Ostaomyelitb  in  its  early  stages  is  recognized  by  the  dark  red  color  of  the 


OSTB0HTBLITI3   OF    LONG    BUNE8. 


279 


€ 


Lftter  on  tbo  tai  HtMppeare,  aod  eoA.  Ussuo,  haviDg  the  ordinary 
ik  color  of  gr«DulntiuoiiB«i«,  takes  its  ptnce.    XI'  liouo  f'urni^  it  appears 

in  CBMut  vUlt  (be  prccxisUDg  omcous  uatua. 

Uuaue  oMcomyelitis  occurs  tioly  as  a  port  of  more  general  ioflnmmatory 

mMudmmot  bone.     'n)us,inan<«te(»plastir  ogtritin,  wvorten  fiDil  the  metlul- 

htj  tmami  encrtMiehol  nn  by  tbc  nenly  lornieil  (ii>»euU(4  li*aiic,  UDliL  in  some 

K  it  ompletrly  filled  by  «[>unf>y  bone.     In  nccrnois  v(  ibe  compact 

■he  Bei|rblmKDf;  nimliilia  lieL-<>ifte»>  cbrouioUly  inflaRicsd,  and  liie  pro* 

of  Ltte  prucrM  urii)er};n  i^sifii-niiuD, 

Aevta  DimiM  OitMmyelitii  i«  uue  of  tiiv  tii<«l  »«rii>u»  aflectJoiM  of  bone. 

It  uccun  in  twu  r>>riiij>,  iruviinntic  and  idtupatbic.     The  traumiLlic  ia  iiAUitlly 

II,  Ktid  It  Ilir  dirrct  c<-HJ«,'t|Uvln"u  yl'  decmnposiliun  of  the  d)»- 

>iind  ii>ii)niuiiii.'»tin^  v.nU  l\w  niflulliiiy  chohI,  a»  in  a  cou- 

iir  nniinitittUiu.     Thv  [iriKiufls  tit"  putrrlacliun  (HlTuMf  tlitrni- 

H  tiwtuc  t.f  tbo  Diedulla  and  wX  up«cul«  ii)tliiiiiiiiiilii>ri,  wliich 

purntiuD.  uud  often  in   giiiii^retie  "f  thtj  marrow.     Tliere 

t  abiiiit  till*  prort-}^  lit-yniid  thu  fact  Lbat   the  produfU. 

I  by  tbo  burritundin^;  sniid  bone  on  hII  sideti  except  at  the  »t)c-u- 

iial,  tend  to  difTune  t Ii6ii)aelvi«  rapidly,  ut'teu  QXleudiug  to  the 

-:iv  at  the  furlbf-r  end. 

Atn. i>.»-  oe4i'<)raye]itif<  may  rpsnit  also  from  the  virus  of  the  various 

iafective  iafliininialiuod  winch  attack  wounds,  as  er^'sipclus,  liuepitnt  t!au- 
ir   ■■ :-    '^vdin^  admtBeion  to  the  mnlulliirv  carml.     The 
■  wvm  tbeae  specific  inflammations  and  that 
<>■  irritaitou  caused  by  the  pro<lucl3  of  ainiple 

Entit'l  tiiiually  he  made,  a.4  ii  mny  be  said  ihal 
(i  lalio  ti*tc«mycliii9  rarely,  if  ever.ariscs  when 

Aad-  .      nf  I  be  wound  nro  in  no  aseptic  condition. 

Hiopaihic  Infective  Osteomyelitis  is  rarely  mci  with,  in 
this  OMiatry  at  any  nitc,  but  is  deiicribed  as  nf  tWquent  no 
by  ni.>?i  rifrman  wriltn;  in  fact,  the  eajfcs  which 
£ogli»b  pntholiifpvt^  de»rril>e  BS  acute  iulective  or  sup- 
piumtiTt*  prriiwtitis,  or  ns  acute  oecrosis,  are  by  German 
vntvra  »p<ikcn  of  as  acute  octeomyelitis.  The  diseaK  is  duo 
to  a  virus,  the  uatupp  q(  which  is  uncertain,  but  which  is 
hatieved  Iv  bv  carried  hv  the  blood  to  the  afiwted  boDi>,  and 
Amw  to  excite  scute  tonanioiation  in  much  the  »anie  way  as 
thtviraa  of  ecarlet  (ever  cruks  inHamiuutiou  of  (be  throat. 
•rtlutfafaiympBiliflaiumnlionoftbeparmid  gland  or  tettticle. 
TW  ^in»  tnernsca  in  quantity  in  the  inflamed  area  and  by 
tfbny  itaelf  in  the  nei},'liboriu};  parts  causes  the  spread  of 
iW  iBluaawtion.  What  it  i»  thai  de[erinint«  the  jmrtieu- 
kr  bona  aJfectn)  when  the  inllanmmlion  e<immi-nL'e«  in  ilie 
■sdalla  is  uncrnnin,  but  nbeu  the  )M'rinr^U'tjni  h  primiirily 
•AeCad,  and  the  ine<lnlla  only  iuiplinited  by  ex  ten --ion 
ihnajth  thv  oumpact  ti«siie.  thv  origin  uf  the  pmrcM  can 
•Am  be  tnuwH  to  a  blow.  Infective  otiMimyelltis  haA  been 
anifieially  induced  hy  iujuritit^  a  bime  subcutanc^unly  and 
ihm  iaj«iinp  poirid  lltiida  ciulaininj;  niicni«copic  orKua* 
iiow  tati)  tbt'  bliMxI-Mrvam.  In  the  human  nuhject  the  pus 
b«>nr«  HlFecitd  in  thin  way  ba»  Ikccn  reprntcdly  iihown 
itain  D)icr<iOr}pini»ntf,  but  no  »|>ecial  furm  hiis  as  yet  been  found  to  be 
'  ly  BMrKSStnH  with  th<'  rlit4^iiu>. 

•Mootad  niih  ttcut<7  ditriim.*  noieomyolitis  of  any  farm  presents  the 
\f  sppeftrancta  on  soclion.     Tliv.  medulla  is  in  porta  redder  than 


Ff|.  iM.  — nir. 

lUl*  of  tlum*- 
raa.alluKici*- 
loB  of  Ibc  Bl- 
bDK-Jalal. 


280 


INFLAMMATIOy    OF    BONE    AND    ITS   EPPBCT3. 


DAtiinil,  and  acflU«rr«l  hemorrha<^''>A  are  commnnly  mol  wtlh.  la  other  pmt1» 
It  is  pnlpr  in  en\nr  and  in6llr»teil  with  putt,  whliih  hirt*  atid  thcrr  ti  colleetad 
in  alMcitw-cnviti(«  of  variuus  size.  At  eacli  oml  of  tlie  bono  thf  morhid  cfnh 
clicion  extends  into  the  cnnc«lloU8  tiMtiM,  tlio  inRrmw  in  th»  apncnt  prvw^t* 
ing  the  8ain«  &|ipearitiiceM.  If  thu  mlouniyt-litt*  U  of  the  Imiimalic  f^plic 
iurm.grar  jfiiiignfiioii«  piitchM  of  mamivr  arc  iiMiallr  preMrnt.  nn>l  thr  mwa 
bone  is  ul>nminsbly  oir<.-U)tivv  to  iimell.  Tlitt  cximpdct  IIMU0  ehuws  un  definite 
chants,  but  tbe  periosteum  is  nlwiirs  swollen  and  freqaeatl/  acpHratoi  frucn 
tfa«  bune  by  the  t'ormntion  of  pus  Iwaentli  it. 

Acute  diffuse  oateMmyelitts  always  causes  more  or  Ims  exIi-Dsive  opcraait 
of  tbe  campflct  tissue,  piirtly  depriving  it  of  its  vascuhir  supply  when  sup- 
puruti'>n  tuLes  plaoe,  and  partly  from  extensi'in  uf  the  ditVuse  intlamoiatioo 
iat<}  the  Hnveniian  ennuis.  Tbe  veinii  of  tbe  alfeclvd  iKine  become  inflanwd 
and  tilled  with  ooaguluni.  Tbe  thrombi  being  invaded  by  tbe  inlectin 
material,  oofleti  and  dieintegnite.  and  the  fragments  bearing  with  tbrm  tha 
iufective  materinl  are  carrieil  Into  the  circulation,  and  thus  embolic  pynmta 
is  a  very  commun  result  of  diffiiae  otnteomvelitia. 

iNruMMAToKY  AfTtxTioss  OK  TBE  Oanceixocw  Tibbue. — The  cancelli 
of  the  spongy  tif«uc  of  bone  are  composed  of  ciaeotu  ttaiue  differing  io  no 
rcepoct  Mive  that  of  ite  arruogement  from  the  compact  eubatnnoe.  The  spam 
arc  filled  with  n  marrow  in  moat  parta  identifal  with  that  of  the  niedallarr 
canal,  but  containing  Iraa  fat.  In  the  voricbm.  rih«,  and  diplo^  of  tbe  akall, 
the  marrow  ia  red,  and  conijilue  uomoroua  cells  like  white  corpuaolea  and  utbisn 
apparenlly  intermediate  between  white  and  red.  Then  ia  oa  naaun  to  beUere 
that  uiy  of  the  patbologicAl  cbaoaei  ofaaerrAd  in  cancelloaa  bone  begin  in  iba 
oMeoua  tiaauo,  the  starting  point  of  avery  proceaa,  as  Glt  a«  can  be  aBMrtaiD«id, 
being  the  medulla  filling  tnc  cancellous  spacea.  The  fallowing  ore  tbe  L-hief 
iutliimmAtory  proccases  met  with  in  the  cancfillous  tiMue:  1.  Acute  difluM 
inHiiramatiun  ;  2.  Itarefactive  oAtcitis,  la)  without  suppuration,  (6)  with  sop- 
puriitioii;  !i.  Osteoplastic  osteitis. 

AoQte  Diffuse  Inflammation  of  the  CanoellouB  Tiisne  a  ibe  mme  process 
occurnu^  iu  llif  medulla  of  tlie  cnncellous  li»i>ue  tii>  lius  already  been 
de»t7rilied  umler  the  unme  of  acute  dilFuse  oeteomyelitis  when  sttaokinjf  the 
marrnw  of  a  long  bone,  nud  arises  under  simiiiir  conditions,  either  as 
the  reiult  of  the  cuutact  of  putrid  discharges  in  an  open  wound,  impiicatuig 
tbe  spongy  tissue  of  a  bone,  or  as  nn  infective  procesa  commeocintc  witbovt 
direct  communication  with  tbe  external  uir.  In  many  caeca  it  b  merely  aa 
extentdoo  to  the  ends  of  the  bono  from  tbe  medullary  caual.  In  it  tbe  mm- 
oeDous  qmcea  bccoinfi  tilled  with  pus,  or  the  modiillary  tiasue  may  becoiBa 

SBgrfiDoufl.    It  always  Iciids  to  nenrosia  of  the  osaeous  tiasue  aarroDorflBg 
eapacas. 

Xtanfying  Oiteitii  is  very  cnmrooo  iti  spuugy  bonm,  and  forme  the 
patbolofn'rnl  ithiingu  in  al&rge  proi>oninn  of  the  casee  rlinicnily  apakeo 
cariea.     llan-fying  iwteitk  la  eanrellous  bcme  is  eonntially  thn  same  pi 

aa  in  the  r{>tni>act  tissue.     Inflammatory  ezudalkm  and  miicmtioo  of        

eorpusdes  taKe  place  In  the  mi'dtillary  tisMie.  and  the  ori^nal  otmcturts 
ditftppear  before  th<-  inflFimniatxry  m^w  (growth  (Fi^i.  497  i.  Tbe  eanoelll 
bei-vMitf'  gradunlly  thinned,  lM<in;r  absurlied  in  exarily  the  same  way  as 
the  lamella' of  the  compact  ti»wue.  A  spiculum  of  btme  renkove<l  from  the 
indnmed  area  shows  the  same  irregular  oxoA%'aii<>ns  of  HoM«hip'»  la«nmft<,  in 
mn«t  of  which  oatMclaats  may  beneen.  The  b<tiie-c<irpua(de«  have  frequently 
uodorKtiae  latty  degeneratiun  and  aometimee  the  c^'lli  in  the  lacunn*  are  rep- 
r«a«iiie<l  merely  hy  oil-);lobuteH.  This  is  due  to  interference  with  the  nutrt* 
tioD  of  the  oeseoiu  tissue  consetjuentun  tbe  ehangee  oecurriu)!  intbr  mnlulla 
of  the  runcellous  sfUKee.    Finally  the  bouy  tisauo  In  the  a^oted  arm  nay 


284 


INFLAMMATION    OP    BONE    AND    ITS   EFKKCTS. 


periocteal  absoeaa  may  be  rollowe<]  by  necfww  of  a  icnle  nf  bono,  bat  Man 
commonly  nfler  Ihe  pus  ia  evactiuteil  it  Iteals  witiioul  further  imublv. 

Su&amiU  and  Chronie  fi^iodUis  may  (tccnr  ae  a  ^pqu«nre  of  the  ncDte  Ibm 
just  doBoribeil ;  or  the  dtficflSB  may  from  the  beginning  assump  ihu  form  wImi 
It  is  due  to  syphitie,  rhpumHUHRi,  or  oooura  ia  n  scntfuluun  subjeou  Cbnade 
perioetilis  ie  aiwnysnocompniiied  sooner  or  later  by  ibc  Ibrmatinu  ofacwbcHM 
QOMOQpla«ti>:  Porinatilis,  stc  p.  274).  The  BympUinM  oaoBist  of  a  hard.eloa* 
gAt«i],  but  aomowhal  puffy  swelling  without  culaneouB  rliaooloratrnD — a  madt 
— not  distinctly  circumBcribcd,  and  attended  by  much  pain  In  the  put, 
Mpecially  at  nigbt.  with  t<-nd<^rncw  on  prM»urc 

TRE.\TMElfT. — In  the  irealment  of  llie  atta^/orm  of  the  afl'eetion,  Itw  ttu 
application  of  lc6chM,  wilh  hnt  fomentatiouii,  will  arrait  ttM^JiM-^ue,  andgiv* 
r(;li«f  to  the  [ifttient.  Should  pus  form,  it  must  bi;  lei  out  by  iuoiitioo  m  mm 
as  it  i*  r«ci>({nixeii,  ttrict  oatuepcic  precautiuD*  being  ohwn'cd  in  order  I* 
diiTiiiiish  the  rink  of  uccrudin. 

In  ihe  mure  ^tronie:  form,  the.  continued  a<1miniiitr&tl(iD  of  ibr  irMlidc  df 
potassium  will  take  down  the  swelling,  remove  the  ii-wlurual  |Hiin«,  aad 
materially  improve  the  local  condition  uf  the  part.  In  thuw  case*  of  peri> 
oetitifl  which  are  of  syphilitic  character,  iodide  of  potaniuni  may  br  loolwl 
upou  almoet  as  a  Dpecific.  Added  to  this,  repealed  bli»icrinK  will  he  of 
(MMfUlinI  service.  If  there  be  much  thickening,  the  purUi  eutfvr  frr>m  lbs 
teusiun  uf  the  structures  ;  here  ci^niidcrable  relief  will  be  afTurdiKl  by  tbe  fnm 
division  of  the  periosteum  down  to  the  bone,  either  through  the  skin,  or  «ib> 
cutanetnislv  bv  menus  of  a  ti^notumc  slid  under  it. 


CnUONlC  OSTCITIS  AXD  I'GKIOerriTlS. 

By  Chronic  OsUitis  and  Periostitis  in  mcAnt  an  afTfcrJnn  usoally  attack- ; 
ing  bmi;  biinc«,  len<rm;;  to  ouitiderable    enlnr^mi^tit.   uith    alteratioa  in' 
slnictnrc.     It.  i»  most  common  in  slrumous  sulijfclH,  and  seenia  to  arise  frott 
slight  tniumatic  cnu'^os  or  expoisure  to  cold.     A  Sicrlion  nf  ibe  aftcted  boM 
showfi  I  hut  the  |>pri<«t«um  is  thickened  find  new  l>oue  is  being  fiirmed  bc^ 
Death  it  (05t<?<ipln«tic  I'erioatilio,  p.  274).     The  comptict  tiwot:;  ha«  Itrcoms 
more  porous  than  natural,  and  from  the  simultaiicowi  destruction  of  tfav  old 
bone  and  formation  of  new,  it  oflen  shows  u  pi-euliar  laminated  vxpaoiivi 
of  its  structure,  so  that  a  section  nf  it  prvsenta  an  appenrnnce  of  oonc«atiio 
pantile]  layers  (Barefying  Osteitis  and  Expandicm  of  Bone,  p.  276).     Tb«_ 
cancellous  tiaiue  ntny  at  the  same  time  become  denser  than  natural,  and 
bone  may  form,  filling  the  me<lullary  canal   (Ostetiplnstic  Osteitis  of 
Cancellous  Tinuc,  p.  283;.     As  the  result  of  these  change  in  its  vi 
component  norts,  the  whole  bone  may  be  cmiverted  inio  n  uniform 
with  but  little  dirtiuction  between  the  cancellous  and  compact  tinue.    WImb' 
the  process  becomes  exircnicty  chriuic.  as  it  often  don,  the  ualooplaitie 
CMBH  may  be  more  pronounced,  ami  the  enlarged  boa«  iMeome  exli 
deme  andivory-like  in  i<truciurc.    t'hronic  ostoitii  and  periotdiii  may  < 
alunc,  but  it  ia  more  common  to  find  it  anoeiateil  with   necrusia  of  mmU^ 
portions  uf  the  cancellous  or  oentnil  layers  of  the  compact  tissue:,  or  mUk 
the  prtvenee  of  a  chronic  abweaa  in  the  eanoellooa  tiasoe.    The  dlseoae  our  I 
afPert  the  whole  length  of  a  bone  (Fig.  503),  or  may  be  Itmited  to  ma  cbo. 
When  it  occurs  in  young  eiibjecti  it  is  often  accompanied  by  early  uoioii  of 
the  epiphyAm,  trliirh  may  cause  shortening  from  want  of  growth.     In  oiher 
cnitea  in  which  tht  nii<ldle  part  of  the  bone  is  chiefly  aflet-ted,  i-longatioo  may 
take  plni-e.     I  havetieen.  a.i  the  result  of  chronie  OiteitU,  the  tibbi  from 
aad  a  balf  lo  two  iucliea  longer  than  its  fellow. 


OSTEITIS   DEP0BMAN8. 


285 


Svxmom. — The  symptoms  of  chraoic  oatehu  consist  of  enlargeroent  af 
lib*  ■ftalwl  boav.  with  decpir  Mated  pain  in  aod  givat  (endeniess  of  the 
)teb;  tbc  nin,  »»  in  pt-rji'slilis.  i«  jj^atly  increased  »l  night,  and,  wIieii  the 
Ahm«  m  eoroDtc.  i»  much  inllu«uc«<i  by  the  sl&te  uf  the  Menther.  There  a 
am  ilwkgvr  cooni!ct«4l  with  (his  cundllioii ;  but  it  t>R«D  becomes  distressing 
fnmt  tbe  Bvrerity  of  the  tensire  and  nocturnal  pain  accent  pan  ying  it.  lu 
BtramouM  aut^Mrtit  thvre  is  dauber  of  tbe  pn>c«ni  becoming  iutenailied  in 
fsxto  <if  Um  b(io«,  and  thua  leading  to  necrosif  or  cariw  with  chronic  sup- 
fonLion. 

TaCATMCXT. — In  chronic  opteitts  and  periostitis,  when  the  bone  has  be* 
erne  tJbi«keoctl  and  enlari^t-d,  but  little  can  be  <liine  in  the  way  of  cure. 
The  wdmiutitm lion  ofiifdiiU!  of  puta^aium  with  the  occasional  upplication  nf 
feBMBS  will,  tiiiwcver,  do  mucli  to  arre«t  the  ]>rogreM  of  the  dii«ea^c  und 
idicve  pain.  Should  tbeie  Bttftltt  fiiil  In  giving  relicl',  and  the  juiin  continue 
af  Ml  excewrelr  diatreiBinp  and  penutent  churac-ter,  I  bavo  for  many  yean 
pMt  pimciiaed  t^  fiillowing  opention  of  linear  o^eoiom^.  An  iucihimi  aliout 
tbrve  isi^hes  long  ia  made  directly  down  on  ihc  chronically  indamod  and 
iadarat«i  b<m(»,  being  carried  through  the  periosteum,  so  that  the  scalpel 
(Tate»  apoD  the  bone.  By  means  of  a  Ucy  «  saw  this  cut  is  extended  into 
iba  aahMancQ  of  the  bone  as  far  as  tho  mc^lullary  canal,  or  deeply  into  )t« 
MBotUiMM  tiaraet.  Bomo  bleuding  occurs,  but  it  can  always  bo  armied  by 
fMiliea  and  presnife.  The  wouud  is  then  cloaed.  Nothing  relieve*  the 
MMhre  pain  m  efiertuatly  Qjt  this  an<l  nothing  stops  so  decidedly  the  tendency 
It  sMacidary  miichief,  whether  in  the  form  of  cariei  or  of  abscess.  In  this 
vay  tmaiuo  b  taken  otT;  arni  tbe  pain,  which  appears  to  be  de|>endeut  on 
lb«  compreasion  uf  iutlnmrd  boue  by  its  own  condensed  stnictui-e,  ti^  at  once 
nftkravd.  "Linvar  Osteotomy"  is  an  upemtion  ei>f>eci)illy  appliinble  to 
•■MOe  n<)iiea  of  the  long  bonea,  or  to  cbmnic  ■*teiti^  of  the  articuinr  ends  of 
iW  tibia. asd  i^  --<  «ever<>  mode  of  trt-iitnit-nt  limii  In-phiiting  the  boue, 

wUill  baa  eccari  .      '.'en  adopte^l  in  nikIi  o»m>  ;  xvliiie  it  ise«]uully  effica- 

ffam.  Aflrr  a  time,  »ben  tbe  progrtwt  of  the  diHen-e  wwvt,  tbe  enlarged 
kmam  Aoca  not  give  riw  to  any  very  seriuua  inoouvenicucu.  ejtcept  Huch,  per- 
b^B,  ■•  amy  m  occasioned  by  its  bulk. 


OOTEITfS  DEFOBMAXS. 

In  I87G.  i^lr  Janm*  Paget  read  a  paper  before  the  Koyal  Medical  and  Cbi- 
nmcml  t^octety  of  London  on  live  nir^.'i  ofa  general  disease  of  the  boni«.  u> 
•1^^  be  (avc'ibe  name  of  osteitis  deformans.  Tbe  most  ourkcd  features 
afthe  diseaae  an  tbe  following:  It  l>cfnnA  after  middle  life,  and  rung  ao  ex- 
iWBclv  alow  oMine,  lasting  even  as  Ixng  as  tuentr  ycarei  without  nHL-L'ting 
At ceBctal  health  lo  any  npprtciahle  degree.  "Tbe  diflcase  affects  uioat 
ftl^lttCBtly  tbe  iuog  bonea  of  thi-  lower  extremities  and  the  skull,  and  ia 
«KalIy  pywrneliieBl.  The  bones  enlarge  and  soften,  and  those  bearing 
«cg«bt  yield  and  beoMne  unnaturally  curved.  Tbe  spine  may  sink  and  seem 
toiMrlaa  vilb  greatly  increased  dorsal  and  lumbar  curves;  tbe  pelvis  may 
hsaanv  wtde;  the  urt'ks  uf  the  (eniurn  may  become  nearly  horizontal,  but 
tbe  Bnabs,  t»<'McT>T  nuMliupen,  renmin  strting.  and  fit  to  supfxtrl  Uit^  trunk." 
Tbe  skell  may  beittme  eaornmusly  ihickened.  yet  tht»  never  gives  rise  to 
My  Mgna  of  prrarurv  on  the  bniiu.  The  diseitM-  is  accouipanied  by  objure 
WM  aapcciaJly  noclurnnl.  It  has  oo  connection  uilb  syphilis,  gout,  or 
In  three  out  of  the  five  casea  recordeil.  Rarcomata  uf  bune 
late  in  life.     The  bonr-D  examineil  after  death  show  cliange»  eri- 

^  of  an  intUminaiury  cbnrnL-ter.     The  ■•ikuU  \>  uniforudv  thickened, 

bM  ia  the  loog  botM*  tbe  eoiniwcL  tieeue  is  chieQy  affected.    Tbe  tliia  layer 


284 


INFLAMMATION    OF    BONK    AND    ITS    XrK£C1 


perin<>tf>iil  ahsmwB  may  Iw  follnwcd  by  nncrfwiH  of  a  srAle  nf  hnnr,  bat  OUHB 
cotniiiiiiily  afl^r  tlic  piiii  i.4  ovnciiau^tl  il  beaU  witbotiL  further  tr>>ubl«f. 

Sabitciitf  and  (Jinmir  Pfrio»litU  may  occur  fU  a  wijui-m-*!  nf  the  acmi"  focm 
juflt  ile«(.Tih<r<l :  or  tb<>  Wt.4enM>  may  t'roin  the  begiiioing  aKtuinv  this  forto  wbcB 
it  ii  due  to  »yi)bili»,  rheiifnati^nt,  or  occurs  in  a  scromluus  «ubj«ct.  Cbroaia 
petiustitiit  in  aiwayfi  aco  mi  pan  text  sooner  or  Inter  by  the  fortoatjoa  of  new  boM 
(Ost«opla«ltc  Pt.*ri<>«<titi«,  *«e  \k  274).  Tb«  »yiiiptome  coositft  of  a  hard.dos- 
gated,  out  somewhHt  putfy  4w<>lljn);  without  cutaneoug  discoloration — a  na^ 
— ooL  dietiaclly  oi re u inscribed,  aod  attended  by  much  pais  in  the  part, 
eapecially  at  night,  with  t*?udcrues8  on  prewiirc. 

Tiiii.\TMi;NT. — In  the  trfulincnt  of  thu  acute  form  of  lh«  a^etioD,  the  ftw 
applicaiiuu  of  lueches.  with  hot  foiuuntatiotiH,  will  arrent  tbn  diiMauw,  and  gjw 
relief  U>  the  patii'Ut.  Shuuld  yma  form,  il  tuuiit  bv  let  out  by  iucisiun  aa  aoaB 
as  it  is  recogoized.  strict  untiseptic  precautious  being  obaerTed  (n  ofil«r  la 
dimiitiah  the  risk  of  necrosis. 

In  the  more  chrome  form,  the  continued  administmtion  of  ihn  tmliije  af 
potn.'V'iiini  will  tAke  down  the  swelling,  remove  the  nofturoal  pains*  ■■d 
iiiHt'Crinlly  improve  the  local  conditioD  of  the  part.  In  thiiao  cases  Af  |WfW 
n^iitia  which  are  of  syphilitic  character,  iodide  of  potimiuni  may  be  lottkad 
upon  almost  sa  a  specific.  Added  to  this,  repealed  bli^terint^  will  be  ol 
eeaeiittal  service.  If  there  be  much  thickening,  the  p&rt«  suHtT  fmm  the 
tension  of  the  structiirm ;  here  eonfiderable  relief  will  be  aff  trdt-d  by  the  fne 
division  of  ihc  periosteum  down  to  the  bone,  inlher  through  the  akin,  or  sub- 
cuianeounly  by  mcjtna  of  n  tenotome  slid  under  it. 


HRROKIC  0STKITI8  4KD  PBKlOfiTrTIH. 

By  Chronic  Osteitis  and  PehostitU  is  meant  an  alfeclion  ueually  attack* 
ill);  lon^  boiKv,  b-iidiii;;  to  c<>i»fi<ierable  eulargerm'Mt.  with  altvnttioa  la 
slnictUTV.  It  i»  nxMl  iximmou  in  ttlruiDons  eubjecUi,  and  seenw  to  nrisi!  (rom 
slight  trauiuHlic  causes  or  exivjAun*  iv  cold.  A  section  of  ib«  ofleotcd  Iran 
ehows  that  the  |ieri(<«t«um  is  thickened  nud  new  Ixiue  is  being  fnrmail  ba- 
neath  it  (Osteoplastic  PerioetilLt,  p.  21i).  The  compact  lisiue  ha*  bMoma 
more  porouH  than  natural,  and  fmm  the  aimultamtous  deelnK*tton  af  tba  old 
bone  and  formation  of  new,  it  nflen  tthtwa  a  peculiar  laminated  expEHioo 
of  its  8tnicture,  so  that  a  pection  nf  it  preeenta  an  ap)>OHrance  of  mneestrie 
{larallel  layers  (^liarefj'ing  OMeitis  and  Rxpaosion  of  Bone,  p.  276).  Tba 
cancellous  iissue  ti)»y  nt  the  snuie  time  become  denser  than  natural,  and  ttew 
bunc  may  form,  HIlin;;  the  medullary  cjinnl  (Osteoplastic  Oileitis  of  tba, 
CkncetloUB  Tissue,  n.  '2S:V).  An  the  result  of  theae  changes  in  its  vi 
component  nartii,  the  whole  bone  may  be  cooverted  into  a  uniform_ 
with  but  little  diatinetion  between  the  cancellous  andoomnact  tiasua. 
the  process  becomes  citreniciy  chrpnie,  as  it  oiicn  Hoes,  toe  oMfU{>laatic 
cMsei  may  be  more  pronounce<l,  Bn>i  the  enlarged  bone  become  esti 
dense  aod'ivory-like  in  fitruciure.    Chronic  osteitis  and  periostitis  aiayi  ^ 

alone,  but  it  ia  more  common  m  find  it  AMociated  with  neen«ia  of  hhII 
portions  of  tbe  canoellous  ur  central  layers  of  the  n>mpa*>t  tiMae,  or  wiUi 
the  prtwenee  of  a  ehmuic  abeceas  in  tbv  canoellous  tissue.  The  diseawe  nav 
afl«<ct  tbe  whole  length  of  a  bune  (Fig.  50!.'),  or  may  b«  limited  to  one  mm. 
When  il  iKTura  in  young  stibjects  it  is  often  accoropanii-il  by  (Miriy  uu'kmi  of 
the  cpipbynr-i,  nhich  may  cause  shorlening  fWtm  want  of  |:rowth.  In  vlfaari 
rases  in  nhii'b  ihr  miildio  part  of  the  bone  is  oliieflr  alfM-ted,  i-longatioa  BIjJ 
take  plni*r.  1  buve  ae«n,  as  tbe  reatilt  of  chronic  oeteitls,  tbe  tibia  fma  i 
and  u  half  to  two  iucb«a  laogar  tban  its  fellow. 


OSTEITIS    DETOBVJLKS. 


285 


Stvptomb. — The  symptaniM  of  chronic  (hstt^itin  rr]t).«ii>t  of  ettlsr^ineDt  of 
tKe  «tfocl«d  boDr,  ttilli  ileoplj  M«te<l  pain  iu  nnd  ^{rcat  tf'ixic'i-ness  of  the 
Ihab;  th»  Min.  m  tn  iHTi'tslillo,  in  gteAtij  inrr«'iu>ed  ul  ti'inhl,  aiu\,  wlicii  the 
iitmam  ia  etamoK*.  b  mui'li  int1ufnc«)  hy  the  otiiie  of  tlie.  wcath«r.  There  U 
a«  dan|p*r  couiM-ctrd  with  tbii>  comlitioti ;  but  it  often  lK-come«  rligtreitftiog 
fmo  tb«  MTrritT  of  the  Icmive  ami  nocturnal  paia  accomp>allfiu^  it.  la 
•Ininioua  lubjecttt  lhr^!  i»  ilanuer  of  the  pnxwtis  becoming  tatfrusitieU  in 
fnru  of  tiw  buoe,  ukI  thus  lewiing  to  oecruftW  or  cartes  with  chronic  sup- 
porstMo. 

TjiCATiiEyT. — In  chrotiiu  ostetlit)  and  p«rio«titU,  whcti  thu  bune  hu  b«- 
BMw  thickMwU  anil  eularged,  but  little  cuu  bu  duut:  in  thi'  way  of  cure. 
IW  aduiuii^imiiuu  of  iodide  uf  putimiuru  with  the  ucca&iuiini  upplieation  tif 
UlMera  will,  ii'iMever,  do  touch  to  arrest  ihu  prugress  >A'  the  liinemie  and 
idieve  pain.  .ShvuM  ibtsse  means  fail  in  giving  relief,  iiud  the  paiu  cuuliuue 
it  an  exoefwvelv  iliftresBing  and  {wDiftteut  charaoK-r.  i  have  fur  many  yeani 
!■■(  frmaiimi  tius  following  uperatiuo  uf  linear  o^leotomy.  Au  iueinidu  n!i«ut 
thm*  indin  toaji;  is  tna<lo  directly  down  on  the  chruiiiuiUv  intlanied  and 
hAinUed  bone,  bting  carri^Hl  through  the  periosleuni,  so  tn»t  the  scalpel 

rv  upuD  ihc  bime.  By  invunii  (jf  a  Hey  s  eaw  this  cut  is  extended  into 
snbMum  of  the  bcme  as  far  as  the  medullary  canal,  or  deeply  into  it£ 
oamUous  ttwue.  8oaic  bleeding  occurs,  but  it  can  slwHTa  be  arrested  by 
yaritioQ  ukI  pnasure.  The  wound  is  (hen  closed.  Nothing  relieves  the 
iMBsivr  pun  soc0i>otually  s^thia  nnd  nothing  stopR  wj  decidedly  the  tendency 
I*  eseoodarT  mitofaief,  whether  in  the  furui  nf  enries  or  of  abscess.  In  this 
va,y  tcfwion  k  tnkeu  off;  and  the  pain,  which  appears  to  be  depeodoot  on 
tb*  ooai|>rcaiino  ni  intlaroed  bone  by  iu  own  condensed  structure,  i^  at  noce 
nlie««d.  "Linear  Osteotomy"  u  an  operation  especially  applicable  to 
mmoaa  nodss  of  the  tnug  b^mos,  or  to  cbmnic  ii^teitis  of  the  articular  ends  of 
Uw  tibcft,  and  is  a  far  lew  At-vort  mode  uf  treatment  than  trephining  liie  b^tne, 
wUdi  hm  occasiooalty  be«n  adopted  in  »ueh  caaes;  while  it  isctjually  cHica- 
9mm.  After  a  time,  when  the  pr«)gre«s  uf  the  disease  ceases,  the  enlarged 
kmm  doM  not  gire  rifc  to  any  very  serious  incouveoience,  except  such,  per* 
hsfsb  a»  nay  m  occaaiooed  By  iu  bulk. 


OSTEITIS  nKFORMAN^ 

!■  Ift'O,  tur  Janiee  Paget  read  a  paper  before  the  Boyal  Medical  and  Chi- 
fnpeal  Sioricty  uf  ]»ndun  on  fivu  cuM-a  uf  a  guueral  diM*aM:  uf  thu  bouts,  to 
«ft£h  be  gare  the  name  <if  osteitis  defotmans.  The  nxvl  markurl  fcatiires 
i^lhe  diisai  are  the  folluwing  :  It  ht^giiit-  uftcr  middle  life,  nnd  runt^  an  ex- 
tniMly  alow  ooanr,  lasting  even  ni^  long  a^  twenty  vfurs  without  atfrcling 
lfcs|fCDC«Kl  bcahh  to  any  appreciable  degnn^.  "The  di:>eaee  nfferlH  mo5t 
fti|«fnlly  the  long  hooe*  of  the  lower  extremilieti  and  the  inknll,  nod  ts 
asnlly  eyaMDetrioal.  The  bones  enlarge  nnd  snfUn,  and  those  bearing 
■lis hi  yield  and  become  unnnturnlly  curveil.  The  spine  muy  niiik  and  seem 
nAnrieD  with  greatly  increniK<d  dnrsJtl  nnd  lumbar  curvtv ;  the  pelvis  may 

heHMB-  -•■'-■  ''-' i-  ijf  the  fcmi>rtt  may  become  nearly  horijenntal,  but 

Ihm  Ii;i  iH|it'0,  remain  strong,  and  fit  to  suppairt  the  trunk." 

Ike  akiK  <  til',  enormously  ihic-kened,  yet  tbiK  never  gives  riw  to 

aar  stpw  e  on  the  brain.     The  dittetiH!  is  acconif>unicfl  by  olMcure 

fMSib  Boi  e^iM.tiniiy  oucturnal.     It  has  on  c<-»nneclion  with  syphilid,  Rnut,  or 
Iu  three  out  of  the  tivi-  ^mv*  rcconled,  sarconista  uf  bone 
late  in  life.     The  Uitien  examined  aftvr  drnth  t>how  changi-s  evi* 
inQanimatory  chiiracter.     Thu  nkull  i»  uniformlv  thiekrned, 
the  compact  tissue  is  chiefly  allcctvd.     Thu  thin  layer 


imtky  at  aa  ioQarn 
Im  ia  iW  loBg  boD( 


286 


INFLAMMATION    OF    BONE    AND    ITS    KPrSCTS. 


of  compact  U^ne  on  the  srticuliir  siirrnce  u  thickened  and  nacTOtahm  m\ 
the  canoi^llcmR  tiF^up.  Tlit;  tliickened  boiie  is  mh  nnd  sponnr.  Itt  MbNiadii 
U  very  vascular,  and  tin  j^iirface  is  grooved  wiih  lioes  for  tne  TeMsb  of  t)hi  I 
pcriosreum.     Neither  the  periosteum  nor  the  medulla  proseat  Bay  wafui»i\ 

Microscopic  examination  of  one  of  Bir  James  Paget's  cases  bjr  U,  T.  Bullia , 
confirmed  the  uplnioo  that  the  diseii^  is  inflammatory.     Ha  lajni:   "TW 
whole  microBcopic  architecture  of  the  bone  had  been  altered  ;  the  laraetun 
appeared  to  have  been  almost  cniirelT  removed  and  laid  down  ■freah  oaa{ 
different  plan  and  in  a  larger  mould.'      Thecnlargt^J  llavenJan  emaaUem-< 
tatued  a  tissue  closely  resembliug  that  fauud  iu  ordinary  rarefytDg  osleiliih 
but  more  fibrillar,  and  containing  fewer  oelU.    In  aoiue  uf  liie  canals  da 
process  of  doa(r(ictic>n  was  evidoutly  pragreadng.     Ilowship's  lacuna^  wisfc 
osteoclasts  (p.  276)  being  seen,  whilu  in  other  paru  new  bon<:-  Mail  bebfj 
furmed  ss  was  shown  by  I  tic  presence  of  ustoobhuu.     Beyond  thiit  there  is  Da| 
evidence  to  show  the  exact  nature  or  cause*  of  this  disease^     Nq  traatoMM 
fle«au  tti  he  of  any  use. 


CHRONIC  AKWraS  OF  BOSE. 

Chronic  abioessM  in  bone  un>  u«unlly  met  with  in  the  eanoellutn  Iohw, 
sod  occur  with  special  frequency  in  tliu  head  and  lower  end  uf  the  tflni. 
The  alieccBs  forms  as  the  result  uf  rarefying  t^eteitia  of  a  lovalited  |iortioD  of  J 
the  cancellous  tissue  (p.  275).    This  process  continues  till  the  boay  eaaaetBr 
are  completely  deKtroyed.     Subsequently  the  intlamtnatory  imHluets  ttnileifa  • 
fatly  degt^neralion  and   sotlen,  fomiinff  thick   uurilv   fluin   eontaioliq;  wt 
recognizable  pus-cells  and  targr  ()i)sniities  of  fatty  di-bris.     The  proeeai  amy 
eoDimue  gradually  to  extend,  and  may  thus  undermine  the  eonit^oin  car- 
tilaee,  and  evi-ntually  the  alfcieess  may  burst  into  the  oeighl)orin  Fig: 

500).     The  lendt'Ory  for  the  pus  to  liurrow  in  this  dirc<clinn  i^  ;.  i  hf 

the  vant  of  fornintinn  of  any  new  bone  U-nraih  the 
earlilnj£e,  while  it  readily  ImWhs  place  umk-r  thr  mtI* 
ottleum.     In  youll^  subjects,  before  the  union  ut  the 
epiphyses,  the  pun  commouly  finds  its  way  U<  the  >nr* 
faces  through  the  soil  tissue  between   the  epipbysi*' 
and    the  diaphysts.     Verv  fr«()u«ntly,  hnwevcr,  tbs! 
disease  becoit>p«  exceaiively  ohrpnia     The  abecva  '»i 
then  uf  amnll  size  and  deeply  seated  in  the  canctUaosj 
tissue.    The  intlsinmation  in  the  bono  iinniaduUaljrj 
surroundiu;:  the  cavity  in  these  case*  often  amui 
the  gsteoplastic  form. and  the  colIectioD  of  pusbaoan 
surrounded  by  a  wall  of  eaoeasively  dense  hard  boM^ 
and  in  this  state  it  may  remain  andtanged  fur  naay  < 
nwatha  or  even  years.     Tbe  irritation  eauaid  tqrw] 
preaeace  of  the  pas  usually  ^ives  rise  to  eiuiMua  in-'j 
nanirantory  changes  in  tlw  natghboring  oompaci  timm 
and  poriusteum.     Theae  amune  the  form  dearribed 
in  the  pruvious  page  aa  "ebronio  oBtcitis  anil  peti- 
ostitis,"  and   pruduoa  ooosidcrable  general  enlarjte- 
□lent  of  tbe  affected  end  of  the  bone.     Chronic  ab- 
tOMses  ban  been  occasionally,  but  more  rarely,  met  with  In  tbe  medullary 
oanal. 

Tbe  i^unntity  of  pus  contained  in  a  cbrtuiie  abscess  of  bone  is  luiially  veiT 
small,  aiuouutini;  to  one  or  two  draelitns,  but  Stanley  has  rrotrdcd  casd  la 
which  an  onnoe  or  mar*  was  fouoil. 


Vtf.  MS.— AbMMl  Is  Ika 
Bw4  •!  Ik*  Tibia. 


GNHONIO    ABSOKSS    OK    BOKE. 


287 


II  may  iMppeo  tbut  iJ«^D«nitioo  of  the  luSiininmtorf  producta  ur  uuppu- 
■mtistt  wmj  lake  place  before  the  nirefviug  pruKEs  has  advnuced  far  eiiotigli 
to  tmmm  euaplHe  dcatruciiuo  nf  the  omcelluub  liiSBue.  The  uixlesiroyrd 
fcaae  Umb  permihm,  beeomcs  sepaiubxl  fruoi  ttie  eurruuDding  part«,  and  liea 
loow  IB  Uw  tBTiiy  <^  the  ahsceMi 

Ib  ioibc  ome*  abteeM  of  bone  is  associated  with  chronic  <«tPitt8  of  a  run?id- 
«nblc  portifot  ur  the  whole  of  the  shaft,  the  bune  beniiuin}:  greatly  enlurgi?d, 
flUduved,  and  generally  iliseamxl  from  end  to  end.  Fig.  oii'I  is  a  repreetuta- 
ifaaa  of  a  BMtnii  uf  the  tibia  in  such  a  state  uf  combined  tnippuration  and 
ludaannalnnr  hy^K-nniphy,  removed  by  aiiipuiHli'iti  from  n  womtiii  who  had 
•ffl^twi  fbr  'J^i  yt.-jLTs  from  the  disease.  !□  siu-h  Ktines,  amputation  or  oxcii-ion 
W     '  mvaua  <<f  relief. 

mrf  r}f  Chronic  Ab»KM  of  Bone  are  often  somewhat  doubifVil.     It 
■ecoxa  mln  i^ively  in  ^erot'iilous  subjects,  and  there  can  be  iiu  doubt 

tWl  Um>  II  I      '    i-aute  in  a  Itkrge  proportion  of  cases  is  the  deposit  uf 

labcrcJc  in  the  mc<liillB  of  the  oancflloua  tiwue.  This  sets  up  ioHamniatiun 
■nvBil  it  and  finally  eotlens  in  thf  same  way  as  in  ulJier  parts.  In  aome 
ABsa  11m  disease  arises  apparently  from  injury. 

Tbe  SkmjMona  of  chronic  abscess  of  bone  are  usually  of  the  folloving  char- 
acMr:  The  Mtient,  after  the  receipt  of  an  injury,  perhnpe,  hits  uoticra  that 
aiOBS  apDt  ui«  aflected  bone  has  become  swollen  and  painful ;  the  skin  cover- 
imt  >t  fWTM  its  natural  color  in  the  majority  of  cases,  but  in  some  instancea 
baeaBM*  nd,  gland,  and  oedematous ;  llie  pain,  which  is  of  u  lanciualing 
aa4  mMng  cbatadar,  is  usually  remittent,  onen  ceasing  for  days,  weeks,  or 
aoBtha,  and  then  retDrning.  under  the  influence  of  very  trivinl  cawses,  witli 
Ik  origiBBl  aaTerity.  It  is  especially  troublesome  at  ni^ht,  and  is  aluaya 
•■MlBtMl  «ith  a  degree  of  tenderness  of  the  part ;  and  indeed,  in  the  inter- 
lals  at  ita  accfwion.  it  will  be  lound  od  careful  examination  that,  there  is 
ahnaja  uae  tender  s{iut  in  the  enlarged  and  indurated  bune.  The  lung  per- 
Oktfnre,  Gir  vi-ant  pcrham.  tif  these  aigna  will  usually  point  to  the  exiBteneo 
■mall  cin'UttUMTibcil  ah«cess  under  the  thickened  wall  of  the  bune.  It 
„.„Ti  b*  htittie  in  miud,  however,  that  the  »inic  local  evrnptonu  may  be 
iadttccd  by  four  (Yinditinns:  1.  By  a  chronic  alwcesa  wittiout  necrosis.  2. 
Bjr  U"  '  '  '  -in  nf  n  -imalt  piece  of  dead  bone  surrounded  by  pns  within  a 
^mm  i'vrvious  caxing.     3.  By  simple  chronic  osteitis  and  perioslilut 

III  supjiuration  or  necrosis  ;  and,  4.  By  the  growth  of  a  ry.itic 
r  within  the  bonr;.     For  all  pnictical  purposea  the  dingntwiti  «» 
wj'  uttl'    ■  11  ■•■,  fls  the  opcraiive  trcolmont  is  the  same,  whether  the 

STaspt''ni#  III  the  t-oiidnfrntnl  of  a  few  drojis  of  pus  or  frutn  the  iurlu- 

NOB  of  tiM^ruvctl  boMf,  and  the  dia^fiuwi*  of  the  presence  of  a  tumor  can  often 
ka  BBB4le  only  by  n  i^ituitiu-  oiN-rnUuii. 

T1ied*Ji(r<?r  i.'t  rbr'mir»l»"C*>»  nf  the  end  of  a  long  b<^ine  will  greatly  de|)end 
M  ita  pivximity  in  tlif  tirtiinilar  iRiirthce.  If  nt^r  this,  it  will  probablr  leJtd 
•apcrnmuion  of  ihv  *.-arlilii|!«,  ><■>  that  lh«  pus  «olerv  the  joint,  which  then 
bBMMB  acutely  infiamt^l  uud  ulten  il^troyt^l. 

If  tJke  chronic  abrocw  be  situated  iu  the  diaphvsis  near  the  junction  tifthe 
^pipbyMs  with  the  shaft,  this  event  is  not  su  likvly  lu  occur.  The  surrouud- 
■m  boBe  umpljr  beeomee  Ihickentnl ;  nud  though  the  health  may  sutler  fr«>m 
lib*  MiBsUBt  wearing  pain,  tlie  joint  is  not  iu  peril,  and  relief  may  readily  be 
hf  oparaiioa. 

HfmatmaU. — As  a  cirourascribcd  abaeeaa  in  bono  cannot  perforate  thv  dense 
aCnietar«  orerljrinf  it  by  any  proona  analogous  tu  the  |>oii)tiug  and 
^  :  of  an  abscess  inttie  boIV  parts,  It  beoooKa  DeoesBary  for  the  Surgeon 
"op  a  TCDi  for  the  pus.    Thia  may  be  dom  either  by  linear  oaieotomy 
■r  Irf  thv  trvphioe.     lo  aone  eases  simple  linear  osieatomj,  as  dearriheil  at 


SS8 


IVFLAUMATIOl 


BONK    aXI 


ETPKCTft. 


to 


t't' 


"^ 


^;?ll 


[P.  285,  may  be  proot'iKd  ;  but  ahonid  *hc  bone  be  much  thi< 
oaKOtu  ■tructuivi'  t:r«ully  iii<lura(«4l,  the  trephinv  t«  tb«>  b>  ■<- 
uae  for  opeuiiig  the  Hbiicew.     The  prujwr  nay  or  doiii^  itiip  ha*  tieca  puHitwl 
out  by  Quesoay  kihI   BnKlie.     It  cuiuistit  iu  Irepbiiiiu^  lli«  Uiov,  m  m  to 

make  au  Htwrture  fur  xhe  exit  of  tbf  pm. 
S<i  WHHi  Ah  k  vent  has  bu«a  given  t'>  Um 
puti.  whirh  ie  UKually  chevsy,  tbe  |«twtit 
will  ex|)«rk-nve  great  and  iwrniutcot  re- 
lief. In  |>erlurn)ing  ihia  openilioo,  tben 
arv  Bcverat  poliiti)  thai  dcterre  specttl 
uttciiiioi).  Tlic  limb  having  been  ma4t 
btufKiic^  by  E^ninrvbV  uu-lbtMl,  ibe  burnt 
mml  be  cx|mBiHl  by  a  T-  ^^  V-fthapnl  in* 
ciaiuu,  tnade  over  the  sf>ot  which  baa  ben 
fouud  tobo  iinifurmly  U'niii-ron  prg— ire; 
and  ititbiH  the  iK-phiuc-  Khoiilil  beupnlicd. 
The  trephine  fthoulil  hB%*c  a  adibII  and 
deep  cruwn  of  th«  eixe  and  iIuim  r*prc< 
«cnt«>d  in  Fig.  501 ;  and  it  is  v«l  alwaji 
to  t>«  provided  with  two  instrummt^  t4 
the  aanie  shape  and  eizf  that  will  rxaetlr 
fit  the  Mine  bole,  l<<9t  one  become  diMhleu 
by  tbe  density  and  hnrdncM  of  the 
cftMe,  an  1  have  fivn  linppen.  Wb*D 
trephine  ha»  peuelratvd  to  a  fU 
di^ptb.tlio  bdtlun  ol  Ikiiip  may  bo  rf>fnov«d 
by  m*«ni*of  «n  elevatur;  but  ■  Id 

be  taken  not  to  |>erfurBle  the  i*  ■  -  k- 

oeM  of  the   bone.     The  tim»tmi  cavity 
i  ,  will  very  ooiuiiionly  at  once  bt  opeii«d  ia 

I         fl  _-     .  tliiB  MHy.Hi^iiiatl  •lUHmityofpatCMapiag, 

Lf  J  u'bich  may,  if  ihv  limb  be  not  blooaloK, 

(X  JiP  )  be  raidily  overlooked,  as  it   ia   ouricd 

'  away  iu  etrcaka  «iib  the  blitod.  whkh 

lluws  freely  from  thu  t-ut  boue.  SiMMild 
no  ]JU8  escape,  perbaiw  a  purtioD  of  dead 
bono  may  be  expoBed;  if  bo.  it  iniut  b* 
rciuo%'ed  with  a  gimge.  But  If  Dcitber 
thifie  (.sinilttionn  be  found,  the  Sui  _ 
niuHt  not  be  flisap|)ointed,  but  pienM 
neighboring    (wteoiiA   tissue   in   dl  _ 

dtrevlionii  by  means  of  a  perfbratiir.  whea 
perhnpci  the  ahftceas  will  be  opemnl ;  should 
It  not  be  tui,  the  patient  will  siill  in  all 
probnbility  be  maierially  heneliteil  by 
remoral  of  the  circlts  of  bone,  and  the  mnseqnent  relief  to  the  com 
of  the  aaseonti  ti»ue. 

The  operation  should,  if  possible,  be  performed  with  antiwptio  pfwcMttinjM. 
The  cavity  should  be  thoroughly  cleaned  with  a  small  piec«  of  sponj^ 
In  eonie  anliaeptie  aolittion  (as  chloride  of  line,  gr.  xx  to  ^4.  in  order 
remove  any  fragmeuu  of  necnised  bone  or  i^uiwdust.    It  may  tlien  be  d 
with  an  flKcifnl  aniisepttc  dnesing.     Ani-nig  the  best  are  carbolic  mi 
aitd  slworlM^it  iodoforiii  or  Haltcylie  wool.    The  drr  wool  dresdingi*  may  be 
u»cliaoi;i.-il,  if  nil  gixrx  on  well,  fur  a  week  or  even  a  month  if  no  dijci 
•oaks  through.    If  deconijioeiUwi  can  be  prevented,  the  cavity  ollen 


K 


nc.  Ml.— Bom 
Tr«pbla«. 


/ 


flR.  MI3.  —  SMtion 
of  Tibia.  *tio«init 
Ciirunlo  O'tilti* 
kaJCIroniBMrltMHl 
Akir«»M  at  UBoy 

}a<tra'  ilanlUMi. 


trPUSX   BBPTIC    O&TXOMTKLITIft. 


289 


BM  with  m  hlood-dr^t  into  wbioh  th«  (,'r*niilAlirin-tl<uup  rapiilly  i>prout«  fr^ra 
Iba  isrrauodiog  i-mo  uutil  in  two  or  tlirv?  we«Ic9  it  may  he  tmapleicly 
•■■ed.  If  tlM  cavity  become*  61led  witli  Kptic  (li#chan,t«,  die  process 
•f  haaJiog  w  mueb  delared.  Subvequeutly  the  L'raiiiilBtiou-tiasue  develops 
bone  and  tb«  limb  reooven  iti  fbrroer  strengto  aud  utility. 


mprusE  SEPTIC  osTROMVELrrrg, 

Difbac  acDte  tndnmrDstion,  einliug  in  suppiiration  nf  the  me^lullary  tiuiie 
of  a  bene,  msy  arisu  aa  a  oinspqiienoo  nf  n|>Rii  iajurios,  Biich  as  compound 
ftaetantcH-  amputations,  or  occur  as  an  acute  diMaMarisiii^  without  evident 
CBBM.  I  shall  here  deal  only  with  the  t^>rniercondiUon.  the  laitt>rlj«in^' moat 
aoavcBknily  oootidcred  when  discuniug  lbs  diaeaae  oummooly  knowti  in  this 
taaauy  aa  "acuie  necroeis." 

Aeaie  1001111  osteomyc litis  was  f  irmeriy  a  common  contequcnce  of  injuries 
by  vlUefa  iJm  inetlullary  ranal  was  opened,  such  as  oom|»ound  fracturi^  or 
•MMtatlKM  ami  it  wag  ntiio  often  niPt  with  when  the  rtincollou»  tissue  only 
r  :.  a«  in  pxriaion  of  tliQ  knee.     Compound  tiiMurvl  fmctuPM  of 

Hr,  .  -,.^  .-■;,>«.  t^uch  aa  r>?«tull  from  gimiihtit  wounds,  are  0|>eci»lly  prnue  to  be 
■^  hy  il.    The  oHiditioii  Is  ewtentiHlly  connected  with  <lec'>m position  uf 
'A*  dtsrb«rgt«  nf  th«  wiiiind  thn>ugb  which  the  hnnv  hn«  l>e<>n  exposed,  and 
sgfXciaHy  with  lh«  pr««>enoeof  septic  matter  ]>oa[  up  in  c<jntaot  with  the 
ntaloDary  rannl  or  cancellous  tissue.      The  impn>Ted    treatment  of 
«a<l  th«  use  of  auttsepiio!  has  now  almost  abolished  the  disease 
n  aivil  though  it  still  retains  its  bold  iu  ruilitary  practice. 

la  Offrtehi  very  run:  cases  dittuw  ostCMmyt'Iilis  has  been  met  with  as  tlie 
iwalt  of  •ubcnlaautMis  injuries,  lu  the  majority  of  these  cases  it  formed 
IT  eSeet  of  general  blood- poisouiug  fntm  a  foul  wound  on  Mtme 
mrt  of  tbe  body.  That  this  is  the  mt»t  probable  explanati<m  of  iheee 
■  abuwn  by  the  fact  thai  irimple  f'mcturta  can  be  made  to  suppumte  in 
and  offtctmiyrlius  <ma  olteo  be  induced  in  the  Injuren  bone  b^ 
JnsnTtiaj  Hfitie  natter  into  tbe  blood-stream. 

The  M^ok){7  '^  ^*  nroons  is  not  diflieult  to  unduxtand.  Tf  septic 
■■■er  he  frnt  ap  in  the  ilcfii  parts  of  a  wound  in  contact  urtth  the  oiwned 
aaeellBua  tissue  or  the  ntedullnry  rannl,  the  im>dui*lB  of  decomp«Micti>n  will 
mmdBj  diflbw  tbemsclves  into  the  sofi  mooullary  tiisuc.  This  becmes 
aaudr  inflamAl.  and  pus  16  rapidly  f<irn>od,  or.  owing  to  the  ronlined  tipitce 
•a  wbMi  tbe  medullary  tinue  is  ooDtAined.  the  iuHnmmntnry  Dwelling  insy 
unwaC  the  ortulstJon  and  caDse  sangrene.  Wheih<>r  it  end«  in  jipiuj^ene  ur 
■ypaftim  the  ptitducls  of  tbe  iDtlammalioo  in  tlieir  turn  d«'«om|N)«e.  and 
IbM  lb«  ptnmsa  rapidly  spreads  throujEhuut  the  loirdiillHry  tis8ue.  8imple 
U  ibuA  Miffieirnt,  in  mi_«t  i-ast«,  lo  explain  the  plieuoinena  of 
mtrftrnvi'liti*,  withiiut  su)i[H«io^  that  any  vjwKilic  vim?  i«  pmetii.  It 
■  pf  •  r,  that  iu  many  casM  tbr  wnund  ■»  miliy  iufecled  with 

ton*   :,  aiislofriius  (o  that  of  diffu!*r  phlej^monnDa  ervaipelas  or 

spmadtoi!  .  for  diiruM;  OAl'&miyel itis  mav  attark  several  jiaUents  in 

•■•  wn-'  .'   r^iiie  time,  aod,  in  fact,  ts  pre'Ji^ifjited  to  by  all  tmiso  condi- 

t>ii«s  rtre  aJmidv  bcfu  ilescribed  as  intlucuinng  the  <H'«urrenee  of 

«ber  uiiiTTivr  prueewcs  in  witiinda.  The  pus  and  gungreuoiu  mclutla  are 
alvaya  fhaodto  eoutain  micp«<-»pic  orgaui^ms.  but  tliry  are  not  uniiiirm  in 
^■MMcr.  Tbo  prorrss  i»  ofleii  accompanied  by  <<HVtistvedecon]piwilioii  and 
blMlBiaiag  of  ifa#  gaBgrrnoiiM  tiwuas  from  the  j^riifniti'in  of  8ulphtm>ttt^ 
byiWyn.     Bciptio  oste-  ■■^oueuf  the  iixwt  (-i>niiu>>u  c«u»e8  nfemiiotic 

ffWmt^     Tbecoanerti'  I  n  tiii^w  condilionKlia«  licett  n]K<rialIy  jxiinted 

tmhffit  Jiaeph  Farrer,  who  has  bad  abundant  opportunities  of  studying 
Tut.  II  —19 


S90 


IMFLAHUATION*    OP    BONIi    AND    ITS   EPfBOTa. 


the  diveaae  in  India.  The  rr«f|iiency  uilli  which  pywmia  follow*  ihit  aAc- 
tioD  IB  due  to  the  fact  that  the  v<^itiB  uf  Ixfue,  lytug  as  tbej-  do  io  rinEid  cttuk. 
do  Dot  rcadilv  eolla[>^.  a  c>.tudiiuin  highly  javorable  to  the  extroaoo  ef 
thrombosis.  I'he  thruiubi  tlius  toriued  U;cumu  iaiprc{{na(«d  with  ibe  pro- 
duct tif  the  uuhftilihy  proeois,  dieiut^|,*ratf,  uud  are  wuhcd  ou  iuto  the 
hUKid-HLrfniu,  cau^iu);  ecoltveof  8t)|i[mniUiiu  wlicrovor  Ihvv  lodge.  Il  ii  Uik 
that  rnftkui  itcptic  oeteoiuytililiH  a  tumi  diuigeruus  diseue,  rrvi|ui;nlly  pniviog 
fnlnl.  Then;  is,  in  fact,  a  Inptv  |iaLh(dogical  seiiueuce  of  iietvotuycUtu,  umicd- 
]>hlel>ilii«,  and  pyivinia,  which  i»  of  a  iiiarkeit  nliaracter. 

Pal-emholiatii  has  been  o)i(<«rve(l  in  iiiarir  casen  of  acutn  onleoniTclitN,  ibe 
liquid  fat  from  the  hrokenHlftwn  marrow  being  forced  into  the  vneela  nr 
Ifcaphatics  by  the  prpfwure  of  the  iriHammamry  exudation.  If  the  emboli 
are  impregnaiecl  with  the  prodtictn  of  ii^<.Minpo«itioti,  they  may  gir«  run  to 
abtOMHS  in  distant  part^  where  they  lodge. 

If  the  patient  esicape  the  dangers  of  pyiemia,  the  disease  almnat  iorariablj 
leads  to  more  or  Icaa  extensive  necrosis  afleclinf;  chiefly  the  inner  layer  of  tM 
compact  tissue.  The  long  se^^uestra  so  fre<|ueiuly  reniuvrd  from  sUianps, 
especially  afU^r  nruputatiuo  of  the  thigh,  are  the  result  of  this  proocw  {wm 
vol.  i.  p.  9»:'. 

After  death,  the  Appearances  presented  by  the  inflaiued  iKine  will,  if  it 
have  been  the  neat  of  compound  fracture,  b«  uaually  nicel  marked  io  the 
upper  fra|imet)t:  if  it  have  been  the  seat  of  aniputation  or  excieion.  tbejr 
will  extend  through  the  whole  of  the  bone  that  ib  Wti.  They  are  *t>  fulluvL 
The  periiHtcum  and  outer  surface  of  the  boue  will  appear  Ui  be  »tightlT  in- 
jected. On  uiakiu);  a  luajfiludinal  sevtiou  of  the  bouc.  the  part  thai  u  ia- 
flarned  will  lie  found  to  preftetiL  the  fnlluwing  upiiearauues.  The  tuedullary 
canal  is  Blted  with  pus  or  a  rvddish  purifonu  fluid,  often  ulioiuinahly 
otTcusive  ;  the  medulla  is  awollen.^oft,  pulpv,  of  a  deep  red  or  redd  tub -brow  a 
color ;  the  compact  Ixtnp  has  a  pinkish  Unge,  and  the  cancelhMts  omoovt 
tttructiire  i»  often  of  a  bright  rosy  hue.  In  a  cose  of  twrnpound  fracture,  the 
cuntrasl  between  the  deep  coloration  of  the  in  limned  jKirtiuo  of  boae  and  the 
naturally  pallid  apjicanince  preeeDled  by  ih&t  which  is  not  diseased,  and 
mor^  particularly  the  deep  rc<l  hue  of  the  ine<)olla  in  ihc  one,  and  ihe  pals 
yellowish  waxy-lookine  fat  filling  the  medullary  canal  in  the  other,  ia  niist 
striking  and  remarkable.  Fnyrc-r  describes  the meilullarv canal,  iti  adTantwd 
stage«  of  the  disease,  as  lieiug  filled  with  u  mass  of  dead  *blackcned  mevlalla, 
dcbria  of  hnnc,  and  pus. 

BvurTONA. — In  acute  osteomvelitiB,  after  an  injury  to  or  an  operation  ta- 
volving  the  bone,  the  Hnib  ^wellfi,  with  drep-aeated  severe  achiDK  pun  and 
much  leiidcmew.  Absceases  form  often  uoironnwted  with  inv  oriuinal 
wound, and  profuM  suppuration  is  establisbrd.  The  Nii}ipuraiKiu  mav  anMtual 
to  many  ouncw  of  pus  io  the  day,  and  thi-  dindmrj-f  i«  olVn  darlt-titinnd 
nod  fetid.  The  wift  part*  retract  from  the  h.nie.  aixl  lliin  nbere  fX|>.»*d  in 
dry,  yellow,  and  dead,  being  denudinl  of  jKtriotileuni.  Septic  iotlammatiia 
and  Bujipuratioo  of  the  diploc  are  not  unoiRimon  in  heail  injurii«.  in  audi 
QSsaa  the  scalp  it  swollen,  ihe  pcrioiiteum  lo(«ened  from  the  bvoe,  and  tb* 
outer  table  dry  and  bare.  If  the  outer  (able  be  cut  away  aAer  daub,  lbs 
red  dlpliie  will  be  found  infiltrated  by  oiibluiTe  pus. 

The  emutilutional  gymfAumM  are  those  of  severe  septic  fever.  The  tanptn- 
tare  b  seldom  below  103"  V.  In  many  cases  tb«  symptoms  soon  baoooa 
ihnep  of  acute  pyxmia.  If  the  potieot  escupes  pyuu-mia  the  fever  aafariika. 
and  ftulwrniui-nt  symptoms  am  merely  those  dependent  upon  the  praseaesof 
the  oi'cnved  bone. 

Tut:ATMKNT  consists  in  supporting  (he  patient's  eonstitntiDaal  poweri  bj 
A  tonic  and  stimulating  regimen,  and  by  scnipnloaa  atieotioD  to  hyguttie 
rules. 


The  lot  Mote  faniH  of  the  diseue  call  Tor  no  troatmeDt  beyoud  attcutiou 
m  rUaaltooB  while  the  sequoetrn  nre  becomiu^  loww  cnouj^h  for  Tumoral. 

Id  the  more  acula  fomw  which  threaten  to  tormiQate  iii  pyicmin,  nuthing 
can  be  done  m  far  id  the  a0)M!ti>4t  bone  is  concerned,  except  iu  removal ;  but 
vbetbrr  t  hta  shoald  be  done  lo  the  continuity  uf  the  hone  or  at  a  higher  joint, 
tt  a  qar«tiuti  on  which  ditforent  opinions  are  entertained  among  nurdcal 
aathnritio.  Xf  an  opemtion  be  performed  upon  (he  continuity  of  a  Done 
with  dilTiiM*  suppuration  in  the  medullary  canal,  the  aeptic  inflam- 
will  moot  likely  recur  in  the  part  of  the  bone  which  in  leth  Ilenct, 
if  •rroodnry  mitputntion  of  nn  injured  limb  ebouU)  l»e  rcnder^il  nec«<Mry, 
tb«  U.n^  l^-ioa  i»(!i:i;ied  with  osle«>iiiyeliti»,  i(  i»  Mronjily  urgetl  by  some  Sur* 
■■■■a.  a»p»mMy  by  .1.  R'>ux,  tliat  the  opemtion  Hhould  be  performed  at  some 
jalM  abr>ir«  the  injured  ami  iliMa^ed  bone,  in  jireference  to  ainputatiuu 
tbniugb  ita  Oitnticiuity.  Roux,  who  hai)  extensive  ex)*erienc«  in  the  Itilliaii 
war  of  1869,  AUix-irrwiulty  disarticulated  the  thigh  at  the  hip-joiut,  iu  four 
•MM  of  oat«ottiyeliti»  couM-ijueut  on  guneliot  iujurie«  of  the  lower  end  of  the 
tBmar.  Of  22  ca«tt  in  wliiub  lie  performed  secondary  disariiculation  of 
•tbcr  ioiota  lur  osteomyelitia,  all  rvuivcred;  whereas  every  twldier  died, 
vfacvalimb  waa  eccuDdarily  amputated  lhruu};h  the  <x)ntinuily  of  the  injured 
bm  after  tite  battles  of  Magenia,  Mnntebellu,  Mariguuuo.  and  SolferinO' 
On  Uw  other  band,  Larrey  did  unL  consider  di&articuliition  ubttoluUily  tudia- 
panwliln.  area  ia  naM»  of  acme  o»tn>myeliiLs  ;  and  I<on(rmorc  liaii  met  witb 
owoi  ID  which  recovery  has  folloHcd  tho  simple  removal  of  porlionii  of  dead 
ham* — the  dbeafle  in  thfw  instunces  hiiving  ii^nnird  n  chronic  form.  Fayrer 
adrmtM  that,  where  asteomyelilia  is  suspected  to  he  pnwent  in  a  slump  after 
«mpatetion.  the  mi.'.lulla  should  be  examined  by  n  probe,  If  this  eoon  ini- 
puge  oa  bcAlthy  bleeding  medulln.  the  Surgeon  may  wait  for  the  efforts  of 
•amn  %o  throw  ofl*  the  diseased  bone ;  if.  od  the  other  hand,  the  probe  en- 
(XMBicr  only  dead  bone  tod  pus,  then  the  sooner  amputation  is  performed, 
the  better. 

■n»e  special  danger  in  (Wteomyclitia  consists  in  the  tendency  to  the  (tuper- 
T«sti<>n  "'  ■-'•'— •liiebitip  and  pya-mia ;  and,  in  dwidiujf  upon  the  amputa- 
ti-jo  or  -  >cioa  of  a  bone  thu«  aflV^cted,  it  is  of  tbe  first   in)|»orLaQc« 

a-K  t»  d>-i:>>  iiK'  •■{>eraliou  until  py.'oniic  eymptome  have  »et  in.  There  is  a 
prrv*>i  brinueii  the  dt;vel»pmeut  of  the  local  inflammutiou  and  the  constitu- 
.  emia,  which  it  U  moot  important  not  to  allow  u>  slip  by.  During 
"1  the  pali«^nt  U  atfected  by  vufjfical  fever,  but  there  are  no  ngore. 
il  'tQkx  the  chnrnclerielie  rii^'ortt  and  the  hikfh  temperature  and  profuse  sweats 
"f  prsmU  havf  «*>!  iu.  I  believe  tliut  operation  can  be  of  uo  une,  as  the 
■■Umt  will  !■  -rish  from  secundHry  deposits  or  general  hlo(Kl-[wii.wn- 

a^      Bol,  Ix  .     T»  have  occurred,  the  amputation  may  l>e  done  with  a 

Mod  pmaprct  uf  ffuccvaa.  Tht-  uusuccetuful  results  of  the  treatment  of  this 
rfiars  i>-i.'l>n.  U  all  the  mon-  im|>eratively  necessary  to  prevent  it  by  the 
add)  lit  antlwptic  drvM»ing  and  pro[>er  atteutiou  to  the  hyeiejiic 

aorr-.'. t...  -.  tlic  patieut.     But  la  milil&ry  practice  tbia  ia  not  uwaya 

pavlblr. 

It  kaa  bmn  stiggeatffd,  Instead  nf  amputating  at  once,  Ui  scoop  ont  the 

anluMtt  with  a  sharp  spoon  sod  to  introduce  iodotorm  into  the  caual.     Per- 

'laa  rNXOtJj  recorded  A  caaes  in  which  he  carriol  out  ibiH  treatment 

.  crmntoms  of  oatenmyeliUs  had  set  in  after  amputations,     [n  three 

'  ttie  neduUary  rnnal  rcnmining  was  scrajjod  out,  and   in   ibc 

•  Ti)flh  of  from   n  ti~>  ;>  inches  was  treated]  in  this  way;  all  rc- 

iia.     The  trcjiimcnt  eerliiinly  dcservea  a  trial  wbco 

'     .    r«uou  uuHdvitaldu. 


29S 


IXPLAVMATtOX   OF   SOKE    AND   ITS   SFPSOTS. 


ACCTE  NECKOaW, 

Acute  >'ecrQib  is  bd  aciile  iiifective  iuQamnmlinn  8)in«iPt  excliuivrlj  OM 
witli  iH'fore  ihe  prowtli  uf  tlii^  bkvlcLiiu  Ims  C'iiii|i1rtrlv  (-cnMHl.  Tin-  a^leo- 
lidli  i»  Laonn  l>v  iiinii,v  ullier  iiaiiii^,  uticlt  as  rcuu-  iliHmi-  ]ii-ni<blilifc.  iiiftv- 
Live  pt-ridPlitit).  iiit't-i'tivi*  |i<.>riitetili»  utid  tKlfoniyiltttK.  noutv  iiiii-clivf  <til«*- 
ni^cHiit),  HcuU-  i4Up|)urat)ve  ppipby^itb,  necroeial  fever  ami  bone-tvpliuo  :  but 
the  term  "ariile  necrosis"  h  perhaji^  the  beM  in  tbe  preeent  oialc  i-i  uor 
knowledge,  as  it  dnes  not  imply  any  tbeory  a«  to  the  exact  nature  uf  the 
diM'BBe  unci  tlie  etarting  point  uf  the  inflatninatioii. 

Symii-oms. — A  typicnJ  case  of  acule  necroaia  pricaentstbe  following- symp' 
toms.  Tbe  patit-nt  is  usimily  a  child  below  Uie  age  of  puberty,  and  maU 
commonly  a  male.  H«  is  often  strumous  and  u»un1ly  in  »omt*w!ial  fi-rUr 
health,  iioasibly  the  result  of  a.  rewiit  ntluck  of  eomc  ucute  tpccitic  dljraic. 
ait  s.cnrlct  fever  or  nieiialcs.  There  w  in  most  «i»«  a  hi»lor)"  of  »i>me  iiti|:b( 
Injury,  hut  thi^  is  by  no  meflos  cunsuiDt.  The  attack  begioe  wiib  ■  HtidJim 
invuni'in   like  th«t  of  a  sptdlic  fever.     There  iff  high  tenip<T;>-  ■» 

renchiiig  lOo"  F.  or  even  nighiT,  occasioiuilly  with  a  rigor.     H<;'  -^ 

of  appetite,  tbir»t,  »tid  sometimes  voniitiog  or  dinrrliu'U  are  pn-in.'nu  At 
first  the  local  aflVclion  may  eccape  observation,  and  auch  tn^el•  bpj  nut  un* 
fre»|nently  mictakeii  »t  the  ommiencenient  for  oue  of  the  iicute  spvciGc  db* 
eiiiwB.  Uy  tbe  fwcond  or  third  day,  however,  Ihc  local  Fymploma  bccomt 
raanifeet.  The  piirt<  covering  one  of  tbe  loDg  bonce,  most  commatily  the 
tibia,  lennir,  or  humerus,  are  found  to  be  swollen  and  acutcJv  tender.  At 
Gr&t  tbe  skin  is  pale,  but  it  soon  becomes  reddened.  }iv  the  ?burtb  or  fiflh 
day.  or  »4fn)etimea  not  till  the  euti  of  a  week,  distinct  nuctuftUoo  ia  rrcog- 
nixed,  often  extending  over  the  whole  of  the  Bhatl  of  the  atfected  bone.  At 
thia  time  on  moving  the  limb,  dietiDct.  though  someivbsl  wft  crcpitua  nni^ 
be  felt,  aud  it  will  then  bo  found  ihat  one,  or  aomctimca  both  the  e|)iph}lM 
may  be  ioiwened  fn)m  the  dinphynia.  An  a  rule  the  Joiuta  csrape,  but  aces' 
aioiinllr  one  or  1)oth  of  the  artieulation»  into  which  the  bone  enlerv  becoiM 
di^teDiH-tl  with  fluid.  If  at  this  eiage  an  inciniim  be  made  inlo  the  iwolles 
par iB  down  lo  the  boue.  a  large  quantity  of  put>  efca|>c»,  and  on  iuertinf 
thf  finger  tht-  grealer  |>art  of  the  fliuphy«is  may  be  fell  to  be  denudeii  uf  iu 
peri-wri-um.  All  thl^  time  the  febrile  diitturbauce  iicr««t«,and  by  the  cud  of 
a  week  may  osetume  tbe  ordinary  eharaeteni  of  pyteriiiu.  Symptoms  uf 
pneumoniu,  pleuritiy,  and  pericanlitis  may  HUpcrvene  and  dmih  lakcplBi-e 
before  the  ufisceM  htia  bet-n  opened.  The  di^A.«>  docs  nut,  hiiwever.  alwara 
ruu  thin  typical  counte.  The  following  are  the  chief  niudificatioua  itiel  willi. 
The  threateuert  suppurutJun  iu  some  very  mre  cttsrt  tluOa  not  IaIic  place 
Till-  tnt1aitimati<in  of  tbo  {lerioftleorn  gradniilly  hulN^iitrs  in  inleunity,  and  a*- 
lumf^  iJie  i«ttriip1ai4tic  form.  A  cane  uf  this  kind  oceurre^l  lately  in  Uot- 
Ve»»ity  Odlfgp   Iliutpital   in  a  you  I  li  agt-d  about   It*.     Xiiimppii:  -k 

pini.'e,  tlie  acute  hyniploms  rapidly  8iit>>ided,  and   the  femur  l)e<  i  l'4- 

ally  enlnrgol  to  more  than  ilouble  ilH  niitunil  i*i»e  ihroiigiioiit  the  whol* 
ehaH,  tmui  formaliuu  of  uew  hone  under  tbe  i>eri«steum.  Jn  iPtlTer  m«es, 
although  putt  Tonus  early,  tbe  extvnt  tu  wliicli  tlio  p'jriovieum  is  t  ra 

tlie  lr>jiie  a  more  limited,  being  eunliut-d  to  one  end  or  the  mii'  .^e 

than.  In  lh<ite  ca»cs  ttic  course  of  ilin  dieeaM  ia  usually  lea  iwute,  and  iba 
•liaerMi  may  beei>me  loealizetl  and  gradually  point  towards  tbe  eurfiKK. 
8e|>aration  of  tlie  epiphyses  is  hy  no  nieaua  a  constHiit  necurrenoe:  tbe 
yuungvr  llir  imtienl  the  more  likely  it  id  to  (»ceur.  Billroth  sutea  tluU.  » 
diwan  of  exactly  the  anme  chameter  may  occur  in  adulla,  but  tbU  Iibobw- 
what  doubtful. 


ACUTE   NCCB09IS — RE3ULT3— PROGXOSI3. 


y>Oialtgy. — Much  difference  nf  npininn  still  exists  as  to  tho  exact  iinturc 

..^  iF.;.  •l<ac«M>  arwf  tLs  point  nf  nrifpn.     H  >tiii«)',  nml  witli  him  miHt  Knglieh 

rvganl  il  tut  an  aciile  tliirnse  iiiHitminittiiin  cummeiicing  iu  the 

'■>.      DiMil  add  uth«n  hftvu  fH]lili;»h<^l  oaAMt  proving  that  nt  any  rate 

-t^s  in  thi»  way.     In   (.ivrmany  antl   France  il  ia  more  cumraonly 

■  ■  "lO'imyditis,  aui  is  bflievwj  toconimi.'ni.'c  in  the  me'liilla, 
T                                  :hnr  in  folal   i-a»f*  it  is  vrry  oominnn  to  find   th*?  nnoiliilin 

I  en  p  fill  rating,  but  (his  l-i  by  no  nn^anff  cmAtant,  and  in 
If  I'viilouttv  secfindary.     la  a  case  which  lately  occurred 
IB  Uftir^^r  :'Lil,  a  sect^rm  of  the  b'luc  ehowe«l  the  medulla  to 

WiaSaiU'-'     '  <  >^,  in  •contact  with  the  part  of  the  ompact  tissue 

vUell  VBsiUaudfd  "*'  iit>  (•erinsteum,  the  remainder  of  the  niarnm  beiog 
ftHbetij  hodtby.  The  inttammation  was  evidently  of  a  more  recent  dnte 
tkaa  that  of  the  pnrir>steuin.     Others  have  suppnsod  that  the  compact  tissue 

■  primaritT  afiectcd.  but  of  this  there  Is  no  evidence.  That  the  infliLtnma- 
MB  ii  iniecUTe  in  chanicter  is  shovn  by  it«  tendency  t<j  epread,  and  by  Iho 
fitHililM  f  vith  vhich  it  i»  foUoweil  by  pyioinin,  even  before  the  abece^s  has 
WiB  opaoed.  Micruor^nnisms  have  been  repcatwily  domonatrated  in  the 
pam  wmn  firat  evacuite>u,  but  no  specific  furra  liu  yet  been  proved  to  be  in- 
fmriablr  aaociated  with  the  diAeaw.    The  hypothesis  Miggested  ae  an  expla- 

of  the  afltoion  is.  that  it  U  due  to  a  ^peclHc  virus  entering  the  btood 
without,  and  finding  the  nidua  for  ita  development  in  the  vascular 

rriag  tfasoc  beneath  the  periosteum,  or  in  the  layer  of  cartilage  between 
■.Kaft  and  the  epiphyie*.  the  determinini;  caum  of  the  local  outbreak 
baioi:  '  ca&M.  illume  slii^ht  injury  with  exLrava«iitioo  of  blixHl.     The 

pcai,  n  -let  out,  ia  alw^iy-t  free  from  any  unpleasant  oilor.     Thu  rapid 

of  tbi'  suppuration  in  |>artly  due  to  the  inf<-(rt)ve  nature  of  the  pun 
ilv  u>  lh«  fad  that  it  is  pent-up  beneath  the  dense  librous  layer  of 
■•mtn. 

— .\»  the  name  "acute  necroaia"  implies,  the  diiienM  almost  inva- 
ilta  in  Diorv  or  lew  exLeu»ive  death  of  the  compact  tissue.  The 
rii^rut  Ml  the  uecri^is  br  no  meaoa  necessarily  oorrcsp3ud»  t«  the  area  from 
which  the  mriosteum  baa  ho«n  nuaeil  by  the  pus,  for.  nft^r  iWn  has  been 
wfmeaaMfd,  the  mnoibnas  amy  adhere  again  U)  a  eomtiderable  exu-ut,  and 
lh»  miectioD  l»ciw«eo  hsTBBMhi  and  those  of  the  bone  be  ra£«tubli»)u-d. 
la  s  ca^  lately  in  I'nirentty  Colle^  Fl'iepitnl,  ihu  tibia  wa«  felt  to  be  Imre 
frna  ao«  aod  of  the  kIiaII  to  the  other,  yet  afler  fruc  iucl»iiinD  were  made  no 
follo<nid,  except  over  an  area  of  about  one  square  inch  nenr  the 
MiiL  The  aflcr-hiMt»ry  of  the  dead  bone,  the  pmoeas  of  »)>]>aration  of 
dweef|iieMmn  ami  repair,  will  1n>  tirtly  di>f>rri)i4^l  with  necroeu  in  ^'neral. 

MafMltfiL — Before  the  l'>i-at  symplonifi  btvitne  evi>lent,  ea|>ecial1y  in  lat 
<hililrwn,  the  dtaeue  is  earily  miBt&ken  fur  lya^  of  the  acute  flpecifii^  fevers. 
^'  'iltfiy  i*  thi"  m  happpo.  that  in  caaea  of  sudden  aevere  febrile  disturbance 
nbtAiI  aatun>  in  rhildreo,  the  Ivuiea  eliould  always  be  examined.  Whnn 
tnc  ■wrlllo^  wu  in,  it  may  be  mistaken  for  phlegmonnns  eryfll))elafl  or  oel- 
blUipi,  iMit  theae  ronilitinna  are  rare  in  childhoiM).  When  ouh  i^  Nuiipectnl, 
■  fancco'''  '  f  tie  luade  with  n  ftnxtved  needle  or  an  a»piralnr,  by  which 

the  ilM4r'  luallf  be  cleired  up. 

ProfWMU  —  1 ;  ■  -in  of  aoulr  necrtidii*  in  alwav:"  irrave.  but,  a«  Bill- 

nitb  pptol*  nut.  tl  !y  not  mi  fatal  am  hrwpiinl  Htnli^ti'-ii  wmild   make 

il  aKHmr.     T^'  >\u»i-e,  in  whirh  tht-  exten!>i<>n  of  th*'  inllnmmnlion  la 

SBrted.  nr*  ••>  'I'-^l  iit  home,  and  rmm^  uodcr  h'Mjiital  trenlinont  only 

•S  >  lal*r  periW,  lor  the  rem'>vnl  nf  the  n-ntn^tni.  In  fact,  the  i^reat 
Mjerity  of  caeoi  of  ext'*nMvo  nvcroiis  of  the  long  bnaua  iu  young  auhjecU 
an  the  neoU  of  Ihia  diaenMi 


r 


S94  IKrLAMHATIU.V    OP    BONl!    AND    ITS    KrrKVTS. 

TrratmeDt. — Tfio  iiiiIy  ir^'airtieiit  ia  lu  cut  ilowu  upoD  the  bona  aad  )h 
Aut  (he  pus  from  br-neuth  thr^  periosteum  •(  iho  carlicAl  iKieeible  period.  t» 
the  lliigh  ibo  inotM4in  is  l)p<it  made  on  tbe  outer  Mde,  in  ihe  Ut;  in  front.  t>v«f 
Uie  tibia.  Tho  inrtftionit  niti)<t  bt>  free,  and.  if  neocfnary,  eu'Virrul  itiav  Ikt  nuul*. 
The  wounds  nuixt  be  well  drained  and  treated  anlijieptic-nllr.  If  the  di^ 
chnrfTfs  be  allowed  to  derompoAO,  the  dnn^r  of  the  jmlietil  will  bv  i^reatlr 
increane^l.  Tbe  result  of  the  treatment  ii  muallv  iruutediati-ly  tn  rrllrvu  ikc 
constitutional  ftymptnms  and  arrest  the  progre«»  of  tlie  dtM^nw,  but  iu  •  rvr- 
tain  proportion  of  caws  general  infettiou  may  have  lakco  place  bvlurv  ilir 
abiMfiiui  vrnig  recotinized,  Hnd  the  re«ull  is  then  ulHays  fnlal. 

If  lifter  the  iuciaidne  huv«  been  made  the  disebiirgc  rptuain*  very  proTiui 
and  threuteu)i>  (<j  exhauet  the  pulivot,  aiuputuliuti  may  (ii>tni-titD»'«  b«  n«oe»- 
«»ry.  If  the  ^imlt  of  the  bone  i»  si^paniU-d  at  vuch  vud  from  the  opi|ibna 
and  lies  l^>i.>i*e  in  the  cavity  uf  the  abcc«'»«.  it  btfconiee  a  <|iici>ti<>ii  whether  it 
ehuuld  l>e  reiuuved  at  once  or  left,  iu  the  hope  that  it  uiuy  partly  rrcuver  «r 
may  at  leu»t  wrve  ae  a  aupport  during  the  tortUHtiun  of  thv  nvw  buuc  from 
the  perioeteuni.  Numerous  CHt<eB  havf  Uh'u  recorded  liy  liolmen, .).  B«ll, 
Macnuriiara,  and  i>ther»,  iu  whtcb  early  removal  lias  lieeo  practiir^l  «hb 
excellent  revulu-.  New  bone  le  »lnwly  formed  from  ihe  [irriaf<t<>nm.  and  after 
a  few  months  the  limb  in  in  muBt  cases  alnnmt  as  strung  as  beforf  lUr-.  nper^ 
thm.  llic  removal  of  the  bone  can  usually  be  accomplii^hed  by  aimply 
expoeing  it  by  a  free  iiicl''ion.  laying  hold  of  it  with  the  lion  fnrrrpa  utd 
twisting  it  out.  In  some  catc;*  the  operation  is  facilitated  by  dividing  tbk 
shaft,  into  two  pieces  with  a  cbaiii-saw.  If  the  bone  on  examinaiinn  he 
found  to  he  firmly  attached,  it  should  be  left  olone.  It  'u  only  in  tl 
rxsscs  in  which  there  a  reason  to  believe  that  the  whole  diaphysia  iit  «-inuii( 
from  ibe  perittftujm  and  ilio  epiphyses  that  the  o{)crHtiiia  ia^ustifiabin. 

CARIIX. 

The  term  Caries  has  be<>n  u»ed  with  oon^liJerahlc  I.Hxity.  so  thai  it  canaot 
be  said  to  have  any  dctinite  pathological  meaning.  It  ia.  in  fact,  applied  to 
every  slowly  progrevivc  ulceration  of  bone  except  that  c<»ucerue<l  in  Um 
aeparatioD  of  a  sequeelruu  from  Lbe  surrounding  living  buue.  All  thost 
iprooejBU  belong  to  the  class  of  rarefyiog  iuHammatious  uf  bone,  that  b  In 
lay,  tho  bony  tissue  is  gradually  abaorbed  before  au  advanring  indammatory 
oew  growtli  proceeding  rroin  the  vascular  tissue,  either  io  the  mrdolla  m 
oaocoTlous  boue.  or  iu  the  Haversian  canals  uf  compact  buue.  Tlivsa  pr%h 
Cttam  have  already  bvcii  di«cribcd  (pp.  *275,  280). 

Tbe  modificatioU)'  of  carim  dejiend  u|Hin  tho  caunc  of  th»  dttseatu'.  the  part 
of  tbe  bone  airrcitd,  and  the  stage  of  thti  procem  in  which  suppuraliv^D,  ur 
degeneration  of  the  inflammiitory  pnidurtfl  taki-H  plac. 

The  Caaui  of  carie«  an^  very  various.  As  in  nil  other  inflammatory  prcK 
ccasra  we  have  to  cunsider.  (irtt,  the  o(m.4titulional  or  local  conditi>in  which 
prodisposes  tbe  tianie  to  inflnmmulion  ;  and,  seroniily,  the  source  of  irriuuina 
which  is  the  immntiule  rause  of  the  proccfn.  Cariea  occurs  most  frcqiienllj 
in  slnimotis  subjct.'U',  in  whom,  as  before  slate*)  (see  Scfufula,  vtd.  i.  p.  1014), 
infill mmntiiin  is  pr(iri«  to  be  set  up  by  slight  causes,  and  to  pcr*i»U  Tb( 
imnu-dinte  cnuM  of  the  diftcase  is.  in  many  rnses,  au  injury-  This  in  vrrr 
frequfntly  the  case  when  it  slarts  in  the  mfi  tisaue,  K'lwvwn  the  i-nipby«M 
.aiHi  diaphysif  of  a  growing  bone,  or  tn  tho  IxxHes  of  the  vertebnc.  ThB  per- 
nsteiiceunhepriM-t-ss  in  these  i-n«e9  isduechtefiy  to  want  of  rt«t.  the  iliseuM] 
bane  Irciiiu  ci'tiMjiiitty  ex|M»ed  In  Blii;bl  n>ecbanical  injurv  itbeiiever  the  farl 
in  moved  or  th>}  ni:itilit  uf  the  body  i^  thruwu  up4in  it.  Tliut  this  j>  the  true 
explanation  uf  many  caaes  is  shown  hy  tbe  readioen  with  which  cure  tmkm 


TAItlXTtKS   OF    CAK1S3. 


295 


whrn  thr  rfi#wir(i  pnrt  n  pni  nt  pcrfrct  ret.  This  ia  also  well  illua- 
tn  MMnv  niM-»tif  iIim-hm*  Dt'tht;  li)[>-j<>iiit,  witli  carift^  of  th«  scelAltuluiu. 
If  tlwlacwtkni  tiiki>  i>lii(-f,  tlir  cmHoub  citvtty,  being  n>lievvd  t'roui  (lie  fricliuu 
•f  liw  h— d  of  thtr  lii>iiv.  triri^u^Dlly  b«alii  rnpidlx-  It'  tlie  c»ii»e  of  tbe  coo- 
teoaww  of  tbe  inflMiuoMtioti  b«  Dot  remov&l,  suppuratiuD  frequeuUj  takes 
Hk«- 

Atinther  rcrv  outnmon  c«tiM<  of  cari«s  is  tli«  deposit  of  tubercle  in  the 
CK»celloa«  itMu*  of  buDes.  Tubercle  UDdergoen  the  sntne  cbaogev  in  b<iDe  an 
•kmbeic;  it  cawatM  early  mod  Mibsei^ueutly  eotWus.  excitiag;  iuflftnimtitiou 
ia  ibe  f»H»  aruaml  it.  The  uboervaliuini  of  all  ])atiioiogtetii  duritig  the  last 
frw  jresra  have  teodixl  to  prove  that  tbe  great  majority'  of  nil  cat>efi  of  i-arlea 
■Atluig  the  Abort  booes  of  the  taraufi  and  tbe  caoceJlous  tissue  of  the  heads 
flf  Ae  loDi;  bouet  are  det>endt-ut  oa  ttiv  preaeuce  tif  tubercle. 

Tbe  fiut  tbat  Billrulli  baa  fuuiid  cbeeiy  tubercular  depoeaita  m  iuttrual 
wgana  id  &4  per  neat,  uf  tb«  cases  of  caries  examined  by  liiiii  is  a  strong 
CMlftmatiiciii  uf  ibu  view,  lie  gives  tbe  nroportiniis  iu  wliioh  thr»e  were  met 
^1^  indiaeaiieorthediflbreiitbnnM  as  follows:  8houliler-i')int,T7.T[>ero«nl.; 
boacaof  the  ch«it,  l>.'>,.'i;  ankle,  &4;  knee,  6*2.6;  clbow,'62.3;  epinc,  5ti,8; 
&1.2;  peimiTiOJ;  bin,  47.5;  tibia,  68 ;  skull  and  face,  'SSM.  The 
were  most  onrnmoDly  aflisctcd.  It  ia  probable  that  io  maoy  of  these  the 
infection  vas  »eooi)dary  to  the  disease  of  the  booe,  though  it  is  quite 
paaiUe  that  io  some  the  reverse  may  bavc  been  the  case.  In  some  eases  it » 
pmmbie  that  an  injury  may  serve  as  the  sutniog  point  of  the  diaeiise,  tbe 
Mfhtnd*  beiag  depTHituI  as  a  secondary  complicaiion. 

Byphilitic  carir*  h%»  already  been  deacribed  '.M-e  Syplulin,  vol.  i.  p.  IHTI). 
It  advCti  moat  {ViuinKHily  lln-  tturfac^  of  booccaod  i»  then  the  result  of  a  mttt- 
aaioK  ivbpvriovtcal  gumma.  The  dlwaae  doe*  not  penetrate  deeply,  hut 
Iwtfa  ih*  furlace  rougti  and  p<mm8,  and  'w  accompani^l  by  a  good  deal  of 
iaiiuBfa«tloa  of  the  aoft  i>Hr(f-  anmnd  the  affected  booe.  It  occurs  tuoat 
ftmMOtlr  in  adult*  and  \»  viry  •.-hmuic. 

In  all  forui*  of  caries  iu  whii.-h  HUppumtion  takes  place  as  »oon  aj<  the 
fHulcinv  abaceai  is  u[)eued,  dvpuuipmiuon  of  the  discharges  tiutjue«,  uuleas 
pncaMtMMa  ba  lakeu  to  prevent  it,  and  the  irritation  caused  by  the  contact 
«f  lh*ae|Hie  mailer  with  tbedi£cu«o<J  mi rfn^^t  lends  to  perpetuate  the  chrimio 
lafcaitaatioo  and  cause  uxtouxiou  of  the  ilcHlructiou  of  the  bone. 

In  VDCudff  of  joint*  cnriui  muy  n.-t;utt  after  drKtrmrtion  of  the  rartJIagea 
■araly  (roa  the  ctiiubined  irrilaliim  uf  the  frit-tiim  ur  pr»«urv  of  the  aniiiilar 
BoHba^  agnitwt  each  other  and  the  (Mutacl  nf  i>pptic  matter. 

Cbriaa  nay,  thervfore,  be  divided,  arconling  to  its  raune,  into  simple,  tnbcr- 
ealnr  and  sypbiHlIo.     All  these  formH  are  pmlinpowd  to  by  a  Bcrofiiloiia 
tiunioo  and  ^;gr«VBt<>d  by  de<.Mm position  of  the  diftchai^rra  when  this 
Si  Is  not  alarmya  ptmible  to  distinguish  clinically  betweeit   tbe 
vnrictifflu 

(.^riea  b  (firided  aUo  into  miptrfieial^  eentr^,  or  nrticu/ar  according  r^  the 
n»rx  uf  the  Kinit  athioh  it  atfeela. 

trrms  are  applies!  to  cariea,  according  to  the  varioua  modiRca- 
"rt'ni*  may  under)*'!. 

inatory  new  ^Tiiwth  fornift  rapidly  in  the  cancellous  »pace« 
...omie  filled  with  vaoi'ular  ):mnulation<ti»ue  before  which 
[!  •Mi  «)i»te  anay  and  finally  <li»4i|)pe«r,  the  dJMaae  is  termed 

_'■  '  i^irtV*  j'vngvia.    Thin  form  it  ciitnnion  in  the  short  Ixinra 

I  -  'if  lung  bones.    If  ihe  morbid  process  reaches  the  ravity 

Llii   :ui>i:atitiir  in'B<uila(i-iiJ-ti«t[e  e|iniiils  into  ii,  and  npnitds  over 
I.  •iices  and  svnuvial  menibruni'.  Itudiui;  finally  to  complete  di'ttructioD 

•if  ib»  nrticttlatioo  (are  Dtaeaaes  »f  Joints).    Atler  reavbiog  a  certain  degra* 


296 


1NFT.au  MATJON    OF    BONE    ANP    ITS   XFFKCTS. 


of  (leveI(innieiU.fnUT(leg«nerBlinii  tseu  tti  in  the  new  tisBtie,  anrl  ihbiiOMMUjr 
followe^l  by  »>itU'niliK  anil  sluw  suppiiraiion.  FtiOKntin^  i-nru*  '»  tnrm  mm- 
niiiuly  MHiJciftlt*!  »itn  llif  [ipewnce  of  lubcrcle,  biu  it  in  u-ii  yol  -  '  -'M 
il  i»  always  %«,  or  tliat  v,\>en  Uil>erclefl.  with  tli«  ctiarat-Ii-mtit    .  ^c* 

limiKl  III  the  rtmt;Htiiif;  ti^ue,  th^y  Itavc  Ittien  the  primary  musr  <>1  iW  |«io> 
com.  When  the  Ixtiit^  in  extfii^ivfly  d«i«triij«4),  as  ia  frir4|iiviillT  fn-f-n  to  iW 
v«rlcl>nii,  wiLltoiil  tht'  foniiaLinn  of  itutt,  tlif  ditaeaM-  x»  tfrmi-d  rJry  rwrtfvor 
Citrift  eicoa.  In  dry  L*Mrii.-«  the  jjraniiiuli^iii-limut'  r»ay  i*^  partly  abrntrbvij  u)d 
partly  dvvKlofxjtl  into  iivw  hoiit.',  if  rvcoT«ry  Ukm  placi;  withmit  the  fvrmm- 
tit'D  of  pus  at  atiy  ^tagc  nl'  thu  tliseuetf.  Tliua,  id  niuny  cams  ol'  rvouvetr  6vm 
carim  of  the  cijnue  we  tiud  thu  whole  bixJy  of  h  vertebra  baa  [lUappvarra.  tbtat 
nbuve  and  below  il  buviup  cuuie  iu  cuotact  with  eat'ii  other  and  Kecome  firmly 
UDiled  by  new  Ikioq  (see  Caries  ul'  the  Spiue).  When  suppurattoo  takea  plan 
the  pmcese  \s  usually  siow.  the  result  being  the  tonuaiion  of  a  chronical 
wiib  thick,  cunly  pus,  wbieh  gradually  udvaDcn  t'lward^  the  aarfiwa. 
large  pp>|iurtioii  oi  all  cbrotiic  abeoeaKs  met  with  in  Nirgical  practice 
in  this  way.  Wht-ii  the  abaoeea  npeiw  on  the  durliicT,  cxptwiDg  the  diJ 
buQ«  to  the  air,  the  pruoeas  IB  toiDetimes  spoken  of  an  open  MtrwK. 

It  fre<|ueDlly  happena  that  cawatjoii  of  the  inflaniruatory  (ffodacta 
clirunic  suppuration  UikcB  place  bofore  Uie  CRncclIuue  bucM  luu  been 
plelelv  dc&troyed  in  tbo  rareiactive  proceaa.  Tb«  unabaorlNM)  ftiifa 
then  (teing  cut  off  from  their  nutrition  periah,  and  we  tbiu  ^ct  th«  coodttiuo 
known  aa  eariat  nterotica  or  neerolie  carus.  The  ^gncuu  of  dead  huo«  may 
be  of  rMnaiderabk-  «iir/^,  funning  large  sequct^m  frurrouuded  by  cariuua  biioe, 
or  may  1»e  «u  «nmll  as  merely  to  gtv6  a  gritty  feel  to  th«  degrMiKnUt-tl  uraiia- 
lal  iuti-liwui:-  in  which  ihey  ar6  lying.  CWrica  n«crotica  in  I'rcqueiitly  aMwcialcd 
with  tubercle. 

GeHerut  Ajif>ettranee»  of  Curiout  Bone. — On  L-xamtniDB  a  macerated 
Sl>ecinien  of  cariuUM  bone  il  will  l>o  fouud  to  be  lutirh  mure  pori'Ue  and  Traffic 
tlmn  uaturnl.  the  caui-**!!)  I>piiig  thinned  mid  the  8|>iid4  enlargrd.  Hvtv  and 
there  eavtlie*  will  1«!  seen  wh«-re  the  c'tti)i.-elli  have  beeu  cumplctcly  dvaUvyod 
and  the  spaces  have  coalctfced.  In  tlie»e  i-avilics  Imnv  piociv  of  Atmd 
may  bu  lyin^.  A  lrci!bs{H!uinicu  sbunfr  the  lulluwiug  aj'jirtiranr(«i 
fn'm  tlic  cireumltTcncc  to  the  centre  of  th«  carious  italch.  Tlw 
UHirbid  i-lmn^u  i»  increased  Tasvularity  of  the  mnlulfary  ttf«ue.  wbidi  is 
retlder  than  natural;  the  next  ebauge  obeer\*ed  is  that  tJi«  nurmal  fatty  or 
durk-ml  beiiiiiliiid  marn>w  ha«  bectfUie  n-plnoetl  by  pink  gplatinoua  grauola- 
liun-liabui',  uud  that  thu  uaucvlli  nru  iH-cotuiug  thinned,  Nearvr  the  centra 
Uie  bony  cauivlli  eulirttly  diMpp«it.r,  and  Uhi  new  tiastie  beeomea  opaqoe  and 
pale  yellow  iViim  fatty  di-gfiut-raliun.  In  the  cfnlre  it  may  f»Tm 
maan,  Mifteniiig  in  piirtd  Into  a  thick,  curdy,  purilomi  fluid.  Even  In 
In  which  itiure  ia  every  rvaeon  to  bolieve  the  prooeaa  ia  lulten-idar. 
in  which  ibe  roiun«cope  ahona  the  anatomical  appraraneea  of  tlit^  iul*erck 
follicles,  gray  eranulationa  are  seldom  to  be  rwiieniaejl.     If  Uifv  ure  a 

they  are  mort-  likely  lo  be  f.nind  near  the  circumference,  where  Ihty  have]  

Vft  been  eoiut-alud  by  the  further  iuHaniniatory  chnnf^i-a  aMuml  them. 
Cnriea  i)ecr>)tiu»  prc^tnu  the  ^anic  appearAnc-*-^,  with  the  addition  of  frair 
tneote  >d'  dead  bone,  tiiixnl  with  ltt<-  ii(-;:<-iifruling  inlltimnialorT  proclueta.  If* 
tboae  are  decomjxwiug,  they  will  1h*  btiuk  nr  gray  in  color;  if  nut,  liicy  arv 
whitC'  If  the  prtK-e«(  have  been  very  chrv)nic,»njBll  )>u1clic«of  opntjux  wKita 
bone  may  ho  found,  in  which  calcjfica^uuhaa  taken  plai'cinlfaoiiitlaniiaaiofy 
producla  filling  tl>e  cancelli. 

In  aimple  or  dry  curie*  the  ftame  Bppeianinr«<v  nrr  found,  Imt  tbcrv  ta  no 
fatly  ilcgcDrratiou.  The  gniiiuluti"U-tinue  uaiiitnina  it*  pink  gvlatinoM 
•ppearaiMB  tbrou^Mut. 


CAR  IBS — SYUPTOUS— TRBATMBNT. 


11  caH»  of  4mrici  the  neishboriug  peri(«t«um  is  swollen  and  tliick«n»l 
boiw  w  fiimied  iHUimln  it.     In  cctitnil  caHcs  ihe  compact  imuo  u 
umilT  Moorvlimt  rarefied. 

Sttuatimi  of  Carie*. — Billroth  and  ModhI,  of  Vi«nna.  have  exaniiudl  tlio 
^jUHkiiio  <>r  tb«  rdaiivc  t'r«)uency  of  curios  in  diSereut  bonee.     In  I'.KHi 
.  thr  DumbMa  w«re :   ikull,  IDI  ;    facial  boDcs, -14  ;  vertebral  coliitno, 
tiiiiin.  clavidr,  and  ribe,  1^4 :  boDCH  of  fihoulder-joinl,  2'<:  elbow- 
wrist  and  hand,  41;  polviisBO:    hip-ji'int,  lt*9;  knee-joint,  2^10  ; 
I  and  foot,  150  ;  ftcapula,  4  ;  humerus  lehnd),  13  ;  rndiue,  2  ;  ulna, 
•••III  (abaft), .^1;  tibia,.'K>:  Gbula,2.    A  clafieiHi'ntiun  in  rogtuusgives: 
andspiue.  1091;  upper  liuihs.  18.');  loH«r  lin)ba,720.    Ilcnco  it  nppeara 
tkat,  while  any  bone  may  be  afoittxl  with  cariea,  it  ia  moat  frequently  met 
with  in  the  abort  and  eancelluus  Imut^ 
tfTMrpoMs. — TIio  *yuj]iiiioi«  indiialive  of  the  occurrence  of  cariw  are  very 

3airocal.  and  art?  Qui  utitreijutfutly,  in  ibo  early  HAgm,  nii^takc-D  for  those 
flrdinaiT  abii-tito  nr  rbeuuiatism.  Tlii-y  conitisi  of  |>uiD  in  this  bone,  some- 
witli  a  guild  deal  uf  n-dutr^it  and  awclliug  in  the  tofl  tiaeuve  iMvuriuK  it; 
t  la^t  f>>rut»,  i>rten  of  vousiderahle  »iie;  and,  uu 
Irtting  out  the  pUf,  Uie  character  of  the  diiMsave  will  be 
rvcufrnis«'i.  a*  the  bare  and  rough  bone  may  lie  fell  with  a 
•hie.  which  links  into  depresHJons  u|>un  ita  surface,  whivli, 
i^h  nHigb,  yields  readily  to  the  preaaurc  of  the  iustru- 
L.  The  i«vity  iif  th«  abfocn  gradually  coutnicls, 
rini^  6*tuh)ua  up«-ning«,  which  dtschartfepua  in  varying 
u  The  diw^hargv  is  freiiurully  felid^  uhIok  meiuis  be 
ui  prtrrvnt  iu  d<tcnnip<»>itiiin.  Granules  of  bone,  tlie 
01  m  fr.»iii  nrcrniic  carit*,  are  ortfii  iutermixcd 

with  :  liiu  been  Hhnwn  to  rtniuiin  a  coiiHiilL-rablc 

•UBK  uC  {ihoophate  of  lime.  The  tistu  lotus  u|)oningH  are 
HBRsllj  mtrmuodod  or  cmHTetilcil  by  hiirh  ''pon^'v  ^rnnu* 
Wlfcwa,  and  the  neighlmriiig  i«kiu  i^  diti'kily  iiitlanti^. 

TImvo  ainaaea  or  B«tut;e  nn-  nlVn    lon^  and  tortuous. 
TWv  wind  alooK  and  around  iht^  nt(i>ii-tr«.  tho  pun  findinx 
">2  the  linM  of  It-AKt  rt-)tii>iarire  in  tho  iDl«r- 
<u<*a  of  arvolar  tixnue.  tlie  t^xteroAl  opening 
-i'ual«d  at  a  coiMidernblc  iliatnnc«^,  |>erhap« 
tniiii   |]i«  diiWHjivl   \H>ar:      In    lh<««  caivn  a 
<l>le  pnilie  ia  re<]iiiro«l  to  traveree  the  ^inooai- 
-!iiliiu*  track  m  aa  to  reach  llie  bone  at  iia 
re  SayreV  %'ertebmte«l  jirol>e  (Fig.  ■"•413) 
li,   Iwiiif;   Ufxible    uud   iicL'oiiimvHl»linf( 
i'  Ihe  euoat.     A  similar  instrument 
y  SleeJe,  of  Urislol. 
utiitii:  these  long  t.iuuf'es  cllicii'iKlv. 
[lulntion  of  puc,  frequi-utty  Be|aic  ui 
■    'Irprev  of  prpwure  in   tlic   deeper 
•f  which  the  supfMirntiou  tiiay  bo 
'  indofinil).'ly,  the  fMttient  tinnlly  [M'mhin^  fmui  PxhanrtioB. 
— .;^  ^i>uo  ^Kiisuoing,  ur  albuniiauid  drKunanuiuo  uf  internal 


O    WMV 


kan. 


VvftabnMil  PmW 


^Tit^] 


kmcTT. — The  irMtmeot  of  cariea  must  bd  conducted  in  refureuo*  to 
the  ronMilutional  osuw  tlint  occhaioos  it.  thu  removal  of  which  ie  the  first 
•ad  noai  ^HOtial  ekMnent  iu  effecling  n  cure.  If  it  arise  from  fvpbilix.  this 
■DM  ba  Uealrd :  if  from  Uruum,  the  j^i'inral  health  muet  he  improved.  By 
iha  niDoral  of  such  cautea,  ilie  diaeaae  will  oAen  ooase  apontancoaaly.  and 


INPLAMMATIOK   OP    DONE    ANP    ITS   SPPCCTS. 


eve*!)  unrlei^i  cure,  ronre  csperislly  in  voting  eiibjccts.  Hrnee,  it  Is  well  ou 
ti>  he  ill  U>i)  i^n-At  a  hurry  m  iot«rfc-re,  bv  <ipcraLi%'c  mrnns,  in  rmrit*  of  tb* 
sdiaU  IhiDca  iil'cliiii'Iri:'!!.  I  liiiv«  u(U'ii  fK*a  tftsrs,  vajirciallr  ufcsrw*  of  lb* 
boDM  of  tb«  lintids  tin'l  fL'«t,  in  wbicb  an  iijwrHtiun  fur  ttiu  rrmovnl  iif  tbv 
"diwrntod  bum;  wM  appar(!i)llr  iiiilisjion^ablif,  n-cuver  BpuDlanmuslr  no  rhilD^ 
of  ftir.  «ii(l  HltcnlioM  fj  the  gi'iienil  bvaltb  of  tbv  child ;  the  divintegntM 
pArLicIt^  uf  thu  <liwiis«d  Ix^ne  bring  elimiualod  pipt,'«ni«al. 

Id  ihu  earlier  stages  nf  curies,  i>b<.)ultj  there  be  liny  acut«  infl«in luakirT 
8yiupt»iiiP,  meHBiires  should  be  tttken,  by  mean*  of  appropriHto  JiNml  bh 
cuuslitutiunal  uatiphtogistlcs,  to  eubdue  Lbe  activity  nnd  limit  tbo  Fst«Diia« 
of  tho  disease;  and  when  this  has  fnlleD  into  a  chronic  Ftat«,  coDiititutii.<iiBl 
alteratives  should  be  employe*!.  Arnoa^t  the»>e,  eod-livcr  oil,  tb«  iodidva, 
and  change  of  air,  more  capecinlly  to  the  sea-^ide  whea  the  pitlieal  is  ▼waK. 
•bould  hold  iho  fii^t  place.  CouDter-irrilatioD  is  of  little  avail  in  thtim 
>OMes  in  arresting  the  progress  of  the  di^-ase.  Bv  nieaiu  of  hiisten,  iodtw, 
nod  inutt,  thiokeuing  of  the  periostcuni  and  of  the  soft  etructum  cftTorine 
the  dinased  patch  uf  bone  may  be  ioaseocd,  and  pain  subduwt :  but  the  ml 
progress  of  the  obmoiu  disease  cannot,  I  think,  be  iiitlui'oc«t]  by  aucb  mraa^ 
when  once  it  has  poned  the  earliest  stage  of  ioBaiuniuuiry  ci<ngrsUon. 

Wbeo  the  disenM  has  lasted  somo  time,  aud  nature  tct-ma  uuabJe  lo 
elimionte  the  curious  bone,  all  reparatirc  notion  having  ceased,  or  beluit 
infffi<^icut  fur  tbe  restoration  of  the  integrity  of  the  port,  an  operviioB 
bcciimes  necessary. 

When  the  operative  procedure  is  carried  out  in  the  diseased  |Mirt  it*r]f.  U 
is  iraptiMible  to  be  too  careful  in  delaying  it  until  the  acute  stugn  of  tJi» 
disease  Hah  pnwed,  and  the  inllnaintation  in  the  bone  and  Summndiaip 
tissues  has  be<.-ome  chronic.  Unless  this  lie  done,  the  operation  is  very  apt 
merely  lo  give  a  fre^h  ini|}etus  to  the  disease;  and  fhouM  ilevomnqeitioo  i<f 
the  discharges  take  place,  septic  osteotoyelitis  of  the  aflectad  booe  liaj 
ensue. 

OperationR. — The  Dj^eniliuns  prnctieed  upon  carious  bone«  aro  of  fbor 
kinds  :  commuting  eillicr  in  simple  Ucuiovul  of  Ibo  Dittfascd  Portion  of  Bon*. 
in  r,xvi!>i<in  <>f  the  Oirious  Articular  End,  in  Kescviiun  of  tlic  Whole  of  tiir 
Jtuuv  alHxte)!.  or  in  Amputation  of  the  Whole  Limb. 

Before  proceeding  to  the  JUtnunat  of  the  Carioun  Pori'utH  of  (A«  Bone  the 
limb  should  be  rendered  bloodlese  by  Lsoiarcb's  methud,  na  the  operatur  will 
then  l>e  able  lo  see  exactly  what  lie  is  doing,  instead  of  working  in  a  derp 
hole  lilted  with  blood.  The  bone  is  best  removed  in  most  uaers  by  oicsoato' 
the  gouge.  This  instrument  iaeapeoially  nneful  in  those  cases  ilt  which  abort. 
UiicK  btiues,  or  llie  articular  ends  of  the  long  bones,  are  Bir<K-teil.  wiiboM 
implicating  any  uf  the  neiglittoringj'tinis.  In  applying  the  gouge,  the  diseased 
portion  of  iHine  should  be  exiHieed  hv  a  crucial  incision,  and,  if  neeusux*' 
cavity  ii|H-ne<l  by  namnll  trepnine.  The  gouge,  fixed  in  aahort,TtMind[ 
b  then  Ircely  applied,  and  the  diwased  li»ues  are  F<.-o<>ped  and  cut  ouL 
order  to  do  tiiis  efficiently,  it  it  detiiruble  lo  be  furni»)im  with  inslrunientsof 
dilTt'n'ut  shapes  and  aiEes,  so  that  there  may  bo  no  ilifficully  in  holluwtnK  •w 
cutting  away  every  portion  of  bone  thnt  is  diseased.  In  many  t-a»e«  ViJk* 
roann's  sharp  pptvins  mav  be  advantageiHisly  onWtituted  t(>r  gouge*.  I  bavs 
found  the  'j'>tiffe-farcfp«  (Fig.  oil)  very  useful  in  clearing  away  angular  fragp- 
menta  ami  projectious  uf  bone.  In  some  cases  ManbaU'a  o^ntrilv  <  Fig.  304) 
will  be  found  a  very  serviceable  inatrument,  clearing  away  the  softeosd 
carious  bone  without  risk  to  iho  surrounding  healthy  structurss. 

In  removing  carious  bone  with  theso  ioBtrumcnti,  the  Surgeon  nay  be 
■ometimcs  at  a  lose  lo  know  when  ho  has  cut  away  enough.  lo  this  he  anj 
gmetmlly  be  guided  by  tho  difTerenee  in  texture  heCweeo  Ae  dlnaaed  aad 


0?ERAT1UN    FOR    CARIES. 


299 


f 


Iwllfcj  bao«  :  the  formf>r  rutting  ftoft  nnd  gritty,  rendily  Tiplding  before  the 
t,  whiUt  tin-  UtWr  U  Imnl  iin«l   resishirtt;  wt  lh»t,  wueo  all  llie 
»  wmovwl,  thr  wnlbof  tlu-  cjivitv  Ivll  Mill  fie  telt  U*  Iw  compact  an«l 
III  Koie  cn»c».  ihp  timlttiv  b<>iie  tuny  tixvi-  beeu  K>ft«u«d  by  intlaiu- 
;  BbouM  thvrv  bo  any  ttoubt  tm  to  th«  cuixlition  of  what  bas  b«vii 
oat,  it  may  b«  solved   by  putting  thv  dttrittte  into  wat«r,  when,  if 
.  tt   will  h«ocitn«  vilher  white  or   black,  wliervas  if  hvallliy,  but   Ja- 
tt  will  prewrve  its  r«d  tiDL     lu  operating  on  young  vtiildreii  eipe- 
aaUr,  it  is  well  not  to  liave  the  gouge  too  sharp,  leet  'th«  iu- 
! .  but  eCiwnriK  benltbT  though  M>n)ewliat  Buf\entf<i  buue, 
aw»r  tofellMr  with  tlial  aftvctLtl  by  carief.     Aflat  the 
:iua  tne  cavity  m\M  be  carvrutiv  cleaned  tn  remove  hqv 
^urlcnR  fragmenta  that  may  l>e  leA  behind.     This  fa 
b«i  tioae  by  loeaita  of  pieces  of  upoage  held  in  a  pair  of  poly- 
jpM  ibnaeftt.     TbefiKiugeashouM  be  moistened  niib  chloride 
4^  Bse  (j^.  zx  to  .^1  »(  Bfl  to  disinfect  the  wound  tboruu^liiy. 
All  oobfAltbr  cnuiiilatioD-liwuc  lining  tbc  Biuuaes  ahimtd  i>i; 
■XHpad  ■•ray  with  a  sharp  spoon.     A  few  graias  of  io<loform 
■ajT  b«  intftMluccd  iniu  the  cavity  and  a  draioai^-tnbe  in- 
^n»i.    ThabcHdrMUD^ift  iodoform  or aalicylic  wool,  applird 
■a  w  ta  form  m  covering  about  an  inch  and  a  half  to  iwu 
iiwihaa  tkickov«r  tht  wmiud,  and  extrndingat  lefutsix  iticbes 
em  fmeh  m>df>  of  iL     This  dreasing  may  be  chnugc<l  at  the  end 
ft  a  ir««k  for  tb«  purpose  of  removing  the  dra!nag«>tub«>. 
A  ainilar  drcMing  i*  tbrn  applied,  and  if  the  part  altected  i» 
a«r  a  ^nt.  n  pbuter-of-Paris  bandH^c  may  be  Hpplied  uver 
it  atx'  '  'f  a  mouth  or  tix  weeks,  uiilfw  »t>[iit?  diocbar^f 

•bwwv  '■  Iwueath  it,  or  the  patieDl  c'liiipliiitDi  uf  pain, 

•r«ifl«f«  fruni  febrile  disturbance.  A  cumtidtTTibli-  uutidM^r 
«f  smtm  have  bcvn  trvaletl  in  tliia  way  in  Luivcriiily  <'4tllfgv 
BfiUl  with  llitT  t>t«t  rr«iilt«.  Ih  a  oofind«rable  pro  port  iou 
1km  iroBod  haji  beru  found  completely  baaled  wheu  the  second 
ibMHOfc  vraa  removed.  If  the  cavity  be  of  very  lurgv  nice, 
■or*  frttfucnt  drrwMtigz  may  be  neretcury.  If  the  matcnala 
fm  tbia  ilrvaiing  are  not  at  hand,  the  wiiund  may  be  dreaaed 
mill  <arfault«t  ml,  glycerine  and  <-nrb<ilic  acid,  tereb«ue  and  oil, 
tr  mmj  athtr  ttBdeul  antiiwptir  iipplimtiiui, 

Sm^tKmd  nt  removing  the  atlecled  bone  bv  means  of  instriimeniB.  ['itlb»ck 
hm  ffawMiaiaJaJ  that  it  should  be  diasolved  by  the  anptication  of  a  strong 
of  aalpharic  acid.  The  treatment  is  carriea  oat  na  follows;  the 
ini£un  or  cavity  b«ing  exposed  as  before  deacribed.  a  solution  of 
pkrtanf  atrung  aulphuric  acid  and  water  is  applied  by  menna  of  a  gUas 
or  md,  and  this  may  be  repeated  daily  till  lh(-  whole  iiiirfHce  is  quite 
fnm  6um  diaea«e«]  bone,  tn  deep  i*avicieri  o  piece  of  lint  sontcetl  in  a  weiiker 
•ilMiaio  <f4M  part  of  tbc  acid  l<i  Hvn  or  lix  of  waters  may  be  stnifed  in  and 
M  iir  iwi>  >ir  three  dayi.  The  ibniifb  reaultinn  may  in  a  day  or  two  more  be 
i_i  .ir  -.rt,  !:,..>...-  nn,]  tfaeHpplicatiou  refK-ated  if  any  di»va»ed  bone  can 
uient  ia  *aid  lu  be  efficaciuu^  and  the  ftnin  accoin* 


■hair*  UrtM. 
Into. 


■ht  articular  eodi  of  ilie  bose«,  as  thoae  thai  enter 

'   litr  elbow-  or  ilioulder-jniut^,  it  may  be  >o  situuted  aa 

.ml  iu  the  Kay  juet  iudicnliNJ,  but  I"  re«|uire  Krrif !or>  of 

thi*  u|ivrntiou  we  shall  cnufiiler  iii  a  »u)>«Fipicnt 

luvolvi-a  a  b>ine  hi  e&t«ai>ivcly  that  neilber  ol  the 

memtittg  {Mifk*  cati  aueccnfuUy  be  put  into  operation,  il  becomia  neceaeory 


800 


l.VFLAMMATIOM    Of    BONK    AND   TTS    BrrEOTB. 


Xit  (lerform  eith<>r  the  Ptn-rtion  of  thp  whole  nf  tlip  hmie  [f  it  W  of  mmII 
eiztf,  c>r  AmuntaUifn  of  the  liiut>,  if  »f  tjreHtor  iiinf{uitu«li'  or  if  the  DvigfaWr- 
\n%  juinU)  be  extensively  tifiecUid.  ThuD,  for  iuftaoce.  rcBPclion  of  tte  n 
calcis  may  be  required  for  i'aric8  of  tlmt  boue;  while,  if  the  i«bul«  of  tW 
tanus  b«  uSected,  aiuputatioo  is  the  only  rMouree. 

Thn  Iraiitiitioi)  frnm  Carlee  to  NecroBii  ii^  pusy.  Curies  may  be  rrgaiJed 
a»  n  conditiun  cineely  iirmkgoua  to  iilccmtion  of  tho  soft  timu««:  wUlM 
necrosis  must  be  looket]  upon  as  identical  with  Franp'rac.  WhilM  narim, 
however,  chiefly  affects  the  oincclloiis  Btrucciire,  nfcrneia  in  raei  with  io  Ilia 
compart  tissue  of  bono,  and  occurs  far  more-  frequently  in  the  ffhafLs  tbaa  ta 
the  articular  ends  of  the  lone  bones.  It  is,  however,  an  ermr  tn  mi 
ttiat  the  cancellous  structure  u  exempt  frurn  nocroew ;  thni  in  the 
the  tibia,  or  in  the  u  calcis,  small  masses  of  uccroAcd  bone  arc  not  na 
qu«nLly  found  lyio);  iu  the  iDteriors  uf  carious  cr  suppuratit>'/  mvitie*. 
DiBisrent  buutfs  i)r«  utl^ctMl  by  n«cr«M«  with  varving  dc^^rrae  i>r  -y. 

Tbo  tibia  at  its  unteriur  part  is  mmt  frequently  (ii»c>«sed  ;  th«  t-  :T* 

luwer  third  i»  alio  very  commonly  afltwlwl.     Tlie  lower  ^ml  of  the  )> 
i»  not  ify  oAeii  nwrooed  ;  but  not  uuoinniunly  the  phalanj^  of  thu 
fntm  uhitlon.  the  skull  irom  syphilis,  tliv  lower  jaw  from  th«  emat 
evolvetl  iu  the  nmnufacluru  of  iihuephorua  iiiaU^hw,  aud  the  clari«l»i 
ulua  from  injury  or  cousLitulional  causea,  are  found  aflectMl  by  necroaia. 

CAUhta*. — The  fausi-s  of  necrosb  arc  very  %'arious.     We  naTo  }u»t  • 
that  it  is  I*rtdurfu>iied  tii  by  the  structure  of  [Mrtieular  parts  of  Utnci 
is  more  frequent  in  Sfuiiu  buues  tlinii  in  othent.     Amon^  the  LXfUstitut 
oonditiuus  which  predts|Hi)<e  to  it,  we  must  rank  in  the  first  lineturoTulai 
syphilis.     Acute  lebrik*  dismrlMinf*.  ruore  particularly  scarlet  iiiid  ty ' 
fevera,  are  u>iL  unfrf'iueiit  aiu«*  nf  necrueis  in  the  young.     t<carlrt 
citrieeially  iti  apt  to  bu  tnlluwcil  by  pains  in  the  le|,'  and  ah'iut  ihi-  ktMc;' 
which  at  tint  anpcar  to  be  of  a  rheumatic  character,  hut  wliioh  sprvxlily  m 
into  absceiB  nna  are  attended  by  nil  the  symptoms  of  th«  mnat  acute  team  af ' 
necrosis. 

MiMt  of  the  local  4>nnditiorK«  which  fpve  rise  to  necrosis  of  bone  haw  baa 
already  described,  and  require  merely  to  He  mentioned  here.  Befor«>  the  o^ 
of  puberty  almost  all  dlsps  of  cxteniiive  necrosis  of  the  shafts  of  Iouk  Uhms 
are  the  result  of  aeut«  diffuse  perio»titi»  or  acute  necrosis  (see  p.  2it2..  In 
the  eaneellous  tiuiie  neorons  is  sometimes  the  result  of  scut*  osteoDiTelitis, 
but  morecomniiinly  Ari»eH  from  a  more  dmrni.-  form  of  iiiflamn.:  ■  'lea 

tuben-ul»r,  Bcoompunieil  by  rnsi-ittiiiri  uf  the  iiiHammKt4iry  pnnln.  \,A 

the  va^eularKUiiply  of  the  nlfei-ted  nrva  is  cut  off.      Aculr  o»l-  i«- 

iuu  injuries  uf  tioiie  le  a  <iimniuiicnu»e,  Mfiecially  itJlernm|iii  '*•: 

or  litiuuld  tlie  same  ouKlilion  nrinv  withuut  injury  (p.  -~'->),  tli- 
taki-s  plnc«.     Chronic  periostitis  ami  osteitiK,  wlwrn  the  dtm-aw    i 
iifttenpl»aliu  form,  nmy  urtt<luiilly  lead    to  necruais  by  oblitcnitioii  vt  (bt 
Huverfinu  luinaU  (p.  'i7H>. 

K<imetimt»  the  death  uf  bone  resultii  fnun  the  extensiou  uf  inHam 

to  it  friui  the  ueipliborin^  ti»«uc»,  an  in  sitme  aiM«  ul'  whitluw,  or  l.-..^.  ; 

deetructinn  of  its  [HTtivleuni  by  ii  neighboring  alificmi. 

Hyphililic  necrwis  \\nm-»  in  thrw-  ways:  first,  from  superficial  ulcHBtioci 
cxtcadinfi;  till  it  reaches  the  bone  and  desl-rovs  iu  perinateum;  aeeondly,  by 
the  formation  of  subi»en'vteal  vunmatJi.  whicli  linallr  soften  and  thus  cut  *iS 
a  piece  »f  b'me  from  its  vaanniar  supply;  and.  thirdly,  by  fradnal  obliieia- 
lioD  of  the  UaTcnian  canals  in  chronic  syphititio  cateiUa. 


'^ARIKTfEe    or    NKCR03IS — BTUI'TOMB. 


hoo»lhi» 
teUAma 


par: 


IbrDw  tbe  iioniediate  caiue  of  the  death  of  the  boQ«  »  the 
of  Um  flow  of  blood  through  it. 
la  eamr  caaea  nerroais  Mvura  ia  old  |wi>|tle  without  any  cvitlent  catuo, 
knog  then  a{>pareatJy  rimply  I  he  n»iiilt  nf  old  ufn:  This  I  huvo  wcu  nccur 
la  iW  lower  CM*  of  lIiu  huni(>ru^  and  lihia,  ^ving  rise  lu  rapid  and  luuullj 
teal  diaoggantiaiioa  of  tlie  Of  jghbtirin^  joints,  or  to  death  from  oxhaitstinn 
•Aar  proAiae  aupparation.  ThU  Seniie  X'eartsis  tony  be  loukecl  tipon  as  ihc 
■a»Dter|Mrl  in  toe  buoe  of  senile  Blo«ighinfz^  or  gangrt-iie  in  the  soft  pnrtA. 

iiaea  fVequently  give  riw:'  to  neoroHs.     Thiia  ihi'  donudatton  of 

■' ■.' rtffof  poriosieniii,  iiiny  lend  to  iu  de«th;  but,  though  the- 

■  !u-ii  Inew  its  vitality,  ycl,  if  the  mcinbranc  be  replace, 

rvt-d.  and  cTcu  when  the  bone  ia  expuaed,  .idhmioofi  ni»j 

.  It  and  the  ticighlKiriDg  soft  parta,  or  granultttionn  may 

o«i  hr  ill  *iir*"are.  which  eventually  form  another  pen<)«t<'uni. 

I'lrnily  ivt-urs  »it  the  rMult  of  the  detachment  and  dvnudatifit  <>f 

111-  ill  mvos  nf  bad  compound  fnifture  ;  «o  iiUo  the  applicKtion 

•f  crn :aati.  aa  th(^  fumes  of  phospboruii,  may  occoaiOD  this  diiwase. 

atxl  hcncv  it  baa  bero  found  that,  in  lucifer-match  manafactoriee,  necrnis  of 
tb*  lowpr  jaw  i*  a  freqaent  vonsequcQce  of  the  arrJd  fumca  that  are  elimi- 
BBtarf,  ftainini;  accva  to  the  booe  through  carious  tcetb.and  being  applied  to 
iW  cspcanl  alraolL 

OuuucTKBfi. — Id  «  hatover  war  it  originntca,  aecrotis  may  &ffect  the  outer 

liaiBN  oaly  of  the  bone,  when  it  may  b«  called  ptrriphemi;  or  tbe  ioaernioal 

^«n  iJmi  BurmuDd  the  mednllary  canal  may  pertati.  and  then  it  may  be 

aawfcwf;  or  ifae  whole  thieko^w  of  a.  shall,  or  of  the  duhetaDCO  of  a 

haa«.  Ul^  lose  lu  vitality,  and  it  t8  iheu  g|Hikeii  of  aa  Mat.     Tho 

'  {KWtian  of  buop.  culled  tfie  Sequeatrom,  prcstnia  p^culiarrhnrartcru, 

bv  wbifdi  in  duuri  may  at  unco  be  ret!)(>trtii£<^>    It  is  of  a  dirty  vi-lIowiKh- 

nitm  ailor,  and  has  a  dull  npiujuc  Iimk.  and.  after  cJi|Mii}ure  to  the  air,  it 

IpwdaaUy  beaiBHB«if  a  dpL-p  hmwn  or  black  tint:  the  margins  arc.  rapgcd, 

aod  BBOfW  ar  Itm  ^icnlalinl,  and  th»  frc«  -turfaco  is  lotcrabty  innoolh,  but  its 

^ -••■'' — '  •vrtu*  in  rery  irregular,  rough,  and  uneven,  presenting  an  erndt-d 
atcn  BpiN-amncc.     Thi*  eroded  appearance  is  very  marked    in 
■  '  -'  fi>rni  iu  lh«  interior  of  the  terminal  end  of  the  femur  in  » 

111  irr  ampiilaiitia,  and  is  well  iiluHtrated  by  Fig.  28,  where  the 

1  <ti  [>«rt  L*  (■.-iaip09<^  of  the  uhnle  ihickneitf  of  the  hone,  whiUt  ilie 

i  ^h  ami  jipK-tiiatcd  portion!)  ctmsbl  of  the  central  Inreni  i*(  Ixinc 

'•  r  layer,  and  hem-e  iheir  erodeil  external  nirtWe. 
vwif  ill  lhc(.-arK->-lt<)iii«ti£«ue,  it  in  usually  of  u  blavki«b- 
I  or  ovoiil  iu  sliupc. 

''  i'ccn  the  mult  "f  nn  acute  ioflamniatory  proems, 

jHri ■-•litis,  ihc  b'-'iir  li«ue  of  which  it  is  com- 

,  !■     r.iHce  of  »  ciirre»|M>Hdiiig  piece  of  healthy  Imjuo 

1  BtU-r  death.     On  the  other  hand,  whcu  tht<  dcnlh  of  a  piece  of 

!•■•  baa  been  a  complication  arising  during  Bomc  chnmic  inflaoimatory 

■PBCMa.  the  aeqnestmni  beniBevidemvnf  the  previ(m«dii>ca0e  uirnn  it.     Thus, 

''  '*  rrauli  finm  oatruplaHtic  npieiLia,  it  is  denser  than  natural,  if  from  rar<^ 

'.•  oatritis.  as  is  Dutnntouly  the  fwte  in  necruniH  nf  the  cancellous  tinue, 

'-r  and  more  pomtw  than  the  normal  Btnieture.  and  uf\en  eaten  out 

lar  cariliea,  or  may  present  p«trhes  of  calciticalinn  in  tho  cancel- 

w*. — The  aymptoma  of  neerasiB  are  divisible  int»  threi^  ilietinct 

:iw  6nc  they  are  thoM  of  the  diw^i-e  in  cotii<v<|ueuGe  uf  whicb 

■f  purtinn  uf  hone  has  tJikeii  place.  Iieing  acute  In  acute  diHliae 

fwrumuum,vmtmtmyvlity,  chronic  in  chronic  periostitis  and  laleitis,  tuWrcular 


80^ 


INFLAMMATION    OP    BOSK    ANO    ITS   BrrKCTi. 


caric*,  or  in  sjpliilitic  va^v^.  periiNitiUP  or  i>til)perit«t<>al  KuinraaUi.  Id  iIm 
WM-MUil  poriocl  tLc  priinnry  diM-ntc  liuving  cetuied,  lliv  (iriKri-w  of  Mparftliiaii^ 
tli«  dead  boue  from  ihe  living  uikcg  plHtx>  with  ilio  i'urmatiou  of  a  Hippuratiif 
IsYtr  uf  graaulalioQ  tifiauc  nt  ttie  exjHUi^c  (if  the  loll«r,  and  feimuliaucfOMlj 
iivw  Uuiiv  u  foriuiHl  t'n>rii  tliu  jtcriustcum  lu  luainUm  tbe  riEidiiy  uf  Uie  fmn 
wliuti  tliv  ileiul  part  btMNJinta  iuoee.  la  the  third  p«ri<jd,  tbv  dead  buae  baviai 
been  expelled  or  retuoreil,  thu  final  pruovaset  of  rvpuir  lake  plaoe  b^  whica 
the  nntomlmn  tn  the  pri))>i>r  ti'nx  and  Bhupe  uf  Ihu  canul  a  cBbcted.  Tbt 
particular  character  of  the  8ymptoni<4  defM'iidd,  howeTer.  not  (uilr  do  tbe  iCagt 
and  cause,  but  also  in  a  great  measure  on  the  sput  and  the  cxtpjit  of  im 
Deeroflis.  As  already  stated,  the  sequMlnim  mar  l>e  pt-riphfral,  oeairal,  w 
total,  perhaps  invoWing  the  whole  thickness  of  tfie  ahmd. 

The  Bcut«  diieaaea  caoaing  necrosis  have  alreadT  been  euffidently  dcscribMl, 
but  a  few  words  arc  required  on  some  of  the  chronic  forms. 

When  the  necrcsis  is  owociated  with  curk-s,  us  in  carie*  Deerocica,  tht 
syiuptijius  are  tliOM  already  deacribed  as  occurring  inthut  dUcflM?.  pain  Uka 
that  of  rht!uuatii«m,  and  tenderuew  with  gradual  eQlar^'oriu'iil  of  chf  atfrcud 
bono.  At  a  later  pt-riod  chronic  suppiiratioD  takea  place,  and  the  abac«»at 
last  poinia  beneath  the  skin.  Wh«n  lliin  is  opened  a  prohc  will  |intM>  iiiUillie 
carioun  cavity  id  which  the  seiiue«truDt  is  lyiu^.     When  tbe  ^'  -i  » 

small  and  ceutral,  it  may  become  enclo^'d  with  a  unall  quantii.  .  .;.l-«^ 
pus  in  a  dense  wall  of  solid  bone.  The  iiyniptuais  ar«  then  tbu»e  oT  chrvoic 
■baceos. 

Extensive  necrosis  may  oeoasionally  lake  place  without  the  formation  of  a 
drop  of  puB.  Cases  of  this  kind  have  been  described  by  :?ir  Jamea  PagtC 
under  the  namt?  of  ijulei  tucnuia,  and  br  Morrant  Baker  aa  necTMW  wiMairf 
ruppuralion.  The  symptoms  are  those  uf  chronic  usteitia  and  pericMUi 
(p.  ^t^o).  and  the  diagnosis  can  be  made  only  when,  all  means  of  tnalani 
haviup  failed,  trL'phiniuc;  of  the  bone  is  undertaken  for  the  relief  of  tlw  pals. 
In  Uaher's  cm*:  the  enlargement  exactly  roi>embk>d  a  tumor,  and  aa  spMh 
taneous  fracture  final  ly  t«M}k  jduee.  there  seemed  no  doubt  as  to  the  uatureof 
the  disease.  The  real  condition  wiix  diitcovcrod  onlyafl<--r  amputatMin  at  tft« 
hip-j»int.  In  thrac  cases  the  ocernsie  is  due  tu  nrrcM  of  the  rirculatioo  br 
osteioplaMio  perioatitis  oblilcniting  the  Haversian  canals,  and  the  jmrt  nrfftii 
ii  alwavK  the  central  portion  of  the  compact  tissue  of  tbe  shaft. 

Another  course  taken  by  necrosis,  especially  when  it  foltoMra  fewca,  nmr 
be  host  illustrated  by  briefly  describing  three  typical  cases.  Tbe  first  was  a 
girl  aged  14,  who  complained  of  pemlslent  pain  in  the  butt«»ck  afW  ao  at- 
tack of  rheumatic  iev^r.  A  hard  brawny  swelling  pradunllv  formed  duriup 
the  folloMitii,;  year.  It  «»»  aspirated  but  nothing  naa  fouDc(,  and  fean  wetv 
entertained  that  it  mit;lit  be  a  narcoma.  8i>me  weeks  afler  a  fitw  dntp  uf 
pujt  escafied  front  the  puncture,  and  on  dilating  the  o)>t<niii_  irv 

truiii,  nlntut  the  sixe  of  a  thiiiuh-aail,  Was  found  dtfUclx^i  \  of 

the  pclvit).     Tht)  second  was  a  man  aged  about  •t5,  who  voii'i  .)'  a 

shmlv  growiog  tumor,  abiftjt  2{   iocbea  in  diftnieter  uniler  the   :  .  1''e, 

that  hnd  iippfarpd  sonir  inuulliM  aflt*r  tyiihnid  li-ver.  He  was  #eni  iai<)  L  oi* 
wrsity  (A'lk'gi!  Hospital  by  an  aeounipliiihvd  practitioner  an  a  case  of  ear- 
rbu0  of  I  he  male  brfa}>t,  and  came  under  tbe  cans  of  Marcuif  Beck.  Tbifl* 
wnf  one  tmatl  enlarged  gland  in  the  axi]la,  and  there  seemed  nodonbc  abovl 
the  dingniisie,  but  to  avoid  aoy  powibility  of  error  a  deep  inciMM  wu  mt/kt 
iutu  the  growth.  Mhieh  grated  under  the  knife,  and  felt  and  looked  likeaor^ 
rbtn.  It  was  ac-omlingly  remove<l,  wbi--n  a  small  cavity  half  ao  inch  u 
diameter  was  found  ix:neatb.  eoolaiiiiug  Rumi:  casratiDg  Kranulatiun>lIaDc: 
tb«  fingttr  piwed  from  this  thn>ugh  the  iiectoralis  major  to  a  email  m^iu»- 
(rum  on  tbe  fiflh  rib.  The  third  case  wu  a  girl,  iged  about  14.  who  was 
sent  into  the  hospital  for  n  tumor, supposed  to  be  an  eochoodroma,ju«t  below 


of  the  ilium.    Ou  culling  dowa  ou  ii  it  pruved  to  he  a  chronic 
with  axcee<liDKly  ihick  welLs.  conuinioK  a  aequcatrum  ubuut  the  Bite 
itf  a  split  pvs  wtiich  bitd  been  separated  from  itic  ilium.    She  bad  rocootly 
KcoTrreii  from  trnlmid  fever. 

8«p«rmtioD  of  tae  Dead  fiooe  and  Formation  of  Proviuonal  Hew  Bone. 
— The  sc|uiraii«[i  of  tht  deiid  booe,  or  iu  Kr/oUatton,  \a  cjirrJLHl  out  by  a 
ffBBm  pKc'uv\j  similar  to  the  ranlc  in  which  a  »Ioufi'h  to  soil  tiffuc*  ia 
ikrown  off.  tbtf  uair  dilfercacc  being  the  time  requircfl.  Rarefying  ostcitia 
m  ael  up  in  iht-  living  tidtiue  where  it  meclii  the  dead.  The  dciaiU  nf  tbia 
pracen  have  atr«wdy  b««a  dracribed  '  p.  '^70.  vol.  i.).  An  the  remh  of  il  a 
BSfTuw  aoOf  u(  thr  living  bttuf  is  dei>tn>yftl,  and  ita  place  occupied  by  soil 
Wflar  graDulaliun.tiMue.  Thb  procc«H  goei*  on  tixmt  rapidly  in  ihf*  nitwl 
fiBOilar  parl«  :  thit«  w«  •««  the  graDuIaliiiu-laytT  timt  campletely  formed 
MBT  the  .IU  nod  mcMlullary  catial,  and   Kraduitlly  advancing  fr>>in 

tkaao  poiri-  -  ..  daad  Ume  ia  c<>m)ilet«iy  M-|iantled  frum  the  living.  If 
■  hnac  ia  irbicti  a  •e(|u«atrum  in  |wrtly  iM-parnlMJ  be  macerated  so  aa  to  de> 
ilrvT  thv  granulation-iinue,  a  groove  abtiui  onetwenlieib  Lu  a  quarter  of  an 
iBcb  wtdr  will  bu  Hen.  On  ibe  living  side  of  ihia  the  bone  is  porous  and  its 
Bavanaan  oaoali  enlargetl  and  grailually  ctialvscJug.  Ou  the  dead  side  the 
Wasnteioa  its  normal  cumpacl  atrurtun>.  Thu  line  between  the  dead  and 
liriaK  ia  always  eztreuiL'ly  irregular.  The  gninulation-li«euc  in  contact  wiih 
the  oimd  booe  yields  a  muro  or  less  abuudaut  supply  of  pua,  whiuh,  aecord- 
mm  tD  B.  Cooper,  may  coniaiu  &»  much  as  2-  per  cent,  of  pliiwphatc  of  lime. 
WMB  Um  scpaniliao  b  complete  the  lii^aii  bune  lies  ctiis^^^Iy  surrouudtrd  by 
wbbIt  craautotino-ttieue,  and  bathed  in  a  certain  quantity  of  pu».  If  the 
Ibm*  bp  oerorapoaiag  and  the  discharge  fetid^  the  pu.i  will  be  inrrcaiteil  in 
t{aan-  <naaqiiettoe  of  the  irritation  of  the  gnuulation-l issue  by  the 

WbcB  naoe  the  dead  booc  has  been  detachc-d  by  ihe  formation  of  this  line 

Wparaikm,  Datura  take*  steps  for  its  ultimate  removal  from  the  body. 
I  is  aa  eTidrnc<>  that  it,  in  any  circumstances,  undergoes  abflorption  to 
fTKAl  f^Tlent;  altliougb.  «#  Paget  and  Billroth  remark,  that  uorlion 
■  hii-l>  r<-miiitir  in  c(>atact  with  pndifi'rating  i!niiiulatiou»  may  unaergti  a 
4»n^n  nciKKint  of  diminution.  That  this  may  be  tto  is  rendered  more  pro- 
bable by  the  Iscl  that  the  ivory  pegs  u»e<l  in  the  treatment  of  ununited 
ftmctnrr  havf  Ki^u  \-.uai\  to  be  partly  abwrbed  after  wimc  wwk».  The  ab- 
»>rp*i<>u  .if  th."  m-»T^in  •>{  the  living  b«n«;,  in  the  fiirniation  of  the  line  of 
ttrpm'  ■  '<|]iir]«  ilie  faot  that  the  sequestrum  will  always  Iw  fouud  to  be 

of  D>  \'.'t  size  than  the  cavity  iu  which  it  is  lodged.     Th«  ultimate 

exp^it-t-jit  "J  Ute  l<Htsen<.-<l  ef(]U<'!<triim  U  e(fv<<ted  by  the  growth  of  the  gruuu- 
lati<MW  Im<|i.<«  il  puaiiiiig  it  oil'  ilm  surfai^.*,  or  out  of  the  cavity  Iu  which  it 
lies.  When  the  n^'crvvtl  l>')iie  ia  periplieral,  it  will  be  readily  thrown  otf  in 
th*  way.  althDUch  it  may  for  a  time  be  tixt^d  and  eulunglvd  amougel  the 
(imoalationft.  When  the  Mqueslraoi  is  inrdffinaled  within  new  or  old  boue, 
ttm  prv^cas  of  climioaiiun  is  nurnnaiJljf  very  tJirdy,  and  may  be  difficult  or 
iMMBlble  without  nirfiral  aid. 

Tha  Umt  reqaircd  ff>r  the  sopanitinn  >if  dead  bone  rarin  greatly,  When 
it  ii  saparflriaJ  and  saaall  in  itizo,  n  few  weeka  may  ^ulHce ;  but  when  the 
jiagar  Sal  booos,  as  the  femur,  the  smpuin,  or  the  iliutu,  are  atTeoted,  the 
f«Mi^  nay  be  esteoilad  over  lu^vrrul  vvare,  and  mav  u-rminale  in  the  death 
of  ibe  patient  from  exhau«ti<>n  liof.irf^  \t  U  cnncludwl ;  the  cont^litutiim  being 
harasBcd  and  w<im  out  l>v  h>><-lic  imlurcd  by  priliiae  tiuppuratiun.  Or  the 
mar  f:ill  III'  -lii-  ntat*',  tho  timh  Ivrroniing  rigid, and  the  tiasuCB 

iajluratiii,  i> ti»  a|M'fturrs  leading  down   lo  ex|t«»ed  but  atr 

nAiil  bMw.  aotl  thus  tiainy  a  jourca  oi  ooDttnut  annoyance  and  sutfering  cn 
ih*  patiafiL 


ftlfi 


8TBUCTDRAL   OHANOKS   IN    BONG. 


CHAPTER  XLVII. 


RTRUCTDBAL  CHANOKS  IN  BONE  AXD  TUMORS  OP  BONK. 
UYPCKTHOPey  OF  UONK. 

True  Hypertrophy  of  Boae,  that  is  to  say,  incrcMe  io  siie  witboul  alterv 
tiou  iu  tbrm  or  olrucliin.-,  U  very  nire.  It  occur*  as  the  tvi*uh  of  «X06MiT* 
us«,  io  coiuiuuu  witb  tlii'  viibr^vmeDL  uf  the  musdtt  ixueiicil  Jolo  it. 

Tim  tcTin  laflftmmatory  Hypertrophy  is  ofiuu  a[iplietl  tu  tbu«e  ohnwie 
inflamiiiaLory  prijcvsHcii  wliicli  crnuKf.  iiilitrjivRienl  of  a  bouc,  difTueed  orer  a 
coDuderaliit!  [mrt  of  iu<  ktigtli.  Wlicii  ilw.  lliirktmed  booc  is  more  epoogy 
fchao  natural,  ihe  nliaii>;e  in  term«l  Sjion^y  Ifijprrtmjiht/:  wbeii  it  ia  otaw 
welerojtis,  or  hardening  of  bone.  H|>iingy  bypi'rtmjiby  ocoare  in  its 
marked  form  in  the  difleit«e  dee)critH>4l  by  Sir  Jniiir?  Paget  as  oateilia 
maDB.  Scleroeia  is  moet  cimimonly  met  vriib  a»  the  reauU  ofayphilia  orafW 
riKoverT  from  chronic  oeteiu^  and  perioettila  in  scrofulooH  ButljeotA.  It  may 
affect  several  booea  at  the  same  time;  and,  in  the  lon^  bones,  may  lead  \a 
filling  up  of  the  medullary  and  Haverslao  canals  with  booy  aabctuioei  vUh 
MHne  tluckenine  of  the  bone  generally.  This  condition  u  not  reeognlmble 
with  certaintT  durine  lifo- 

Increase  of  Lengu  of  Bonet. — Allusion  ha^  already  been  made  at  p.  3B5 
to  the  bypertrophy  of  bone  which  BDmetimea  fullows  chronic  oatatit.  llui 
uici«aa»djKrowth  of  bone,  at  a  result  of  morbid  condition*,  baa  been  imwti 
gated  by  Stanley  and  Paget  in  this  country,  and  bv  Lang«nbeck  and  otbem 
ou  the  continent.  It  has  b«vn  observed  iu  conit«ctiou  with  necruiup,  cbroafe 
osteitis,  and  chronic  abaceas;  and  also  with  chronic  hypersemia  of  tb^  aoft 
parts  of  a  limb.  Langenbeck,  from  his  observations,  ooncludea  that 
changes  which  give  rise  to  irritntion  nnd  hyperiemia  of  the 
lead,  as  long  as  the  growth  of  bone  continues,  to  an  increase  both  ioUwl 
ami  in  the  thickness  of  bones;  and  that  the  iucrease  of  growth  in  length 
ailects  etjpecially  the  diseased  bones,  but  may  also  occur  in  a  bealthT  boue  of 
the  same  Umb.  Sometimes,  aa  Paget  baa  [Hiiuted  out,  the  Ioiik  existcsoe  ot 
an  ulcer  of  the  integumenle  in  a  voung  person  may  produce  tbicbuntop  and 
elongation  of  the  bone.  When  the  femur  undergties  elongation  in  tbi«  way, 
the  incQuatity  in  Icugth  of  the  limb,  uuU-8s  the  op|»>siLe  limb  bv  Ic-ngibmed 
by  artincial  means,  may  lead  to  talipes  of  the  fmtl  td'  the  leDgtbeoit)  limb  or 
U>  lateral  curvature  of  the  s|>ine.  The  tibia  s'imtrtimes  beeomea  elungaird, 
while  the  Qbula  remains  of  iui  normal  li-ni^tb;  and  in  such  cases  the  r>>rmsr 
bone  becoraee  curved.  The  dingntvis  of  thtH  condition  from  the  eunrattinef 
rickeuconsists,  according  to  Paget,  in  the  mftrk(<d  elonffation;  in  the 
at  thickening  of  the  vmh  of  tbr-  bon<^,  Trliich  are  usttafly  even  non 
«i)ual  in  size  to  tho  nhntt  than  in  tho  natural  state,  on  a«MUttl  of  the  tKl 
Isg  of  the  latter;  and  especially  in  the  fiact  that  "the  rickety  tibia  is  com- 
pressed, u.<tualty  curved  inwahls,  its  shaft  a  tlatlcned  Istrrally,  and  its  niargtM 
are  oarrow  and  spinous:  while,  in  liie  elongated  tibia,  the  curve  is  usually 
directed  forwards,  the  margins  are  broad  and  round,  the  aurfacea  am  ooft- 
vex,  and  tlie  coupreMion  or  llattetiing,  if  tliere  be  any,  is  fnm  befbn  bsek' 
waidi." 


iia  oi  lUff  son 
a  that  morW^ 
osaeaw  ti^il 
1  iaUis1eo|V 


Atbopht  of  Bokk. — This  term  compriece  two  conditEons:  one  in  which 
Um  (mm  k  waited,  and  armthiT  tu  wbic-li  au  arrest  or  critwtb  on-un. 

Atr^ikj  Dcetin,  as  a  tuitnral  riwuli,  in  old  ug«;  tne  change  that  Xakw 
placB  m  IM  lower  jaw  bfin^  a  faniiliur  oxnni|ilo.  In  other  caspA  it  hnpiiens 
m  a  mBarqn«n<c  of  fracture ;  the  nutricut  (irterr  nf  the  bone  having  bpen 
tan  arroM,  and  one  of  the  fragments  consequently  receiving  insufficient  va»- 
colar  wapfAy.  Atrophy  of  bone  commonly  occurs  nlso  from  disuAc,  an  is  the 
caiw  ia  old  dUlocalionii.  In  atrophy,  the  hone  becomes  thinner,  lighter,  and 
mot*  porotu  than  usual ;  the  compart  structure  disappenring  until  a  mere 
ya{icr4ike lawr  may  he  leA,  the  cAncellous  spar-es  being  expnntied  nnd  tillrn] 
with  mft  yeflow  tat.  Atritphy  of  honea  is  common  in  general  paralysis  of 
tW  isauw.  It  b  often  e«p«iftlly  marked  in  the  ribe,  and  is  a  ccmimoa  cause 
«if  fractiirv*,  octnirriiiij  either  ^pontRiieoui*ly  or  during  the  restraint  nevea* 
•arilr  *-niploye<)  iJurin^  a  maniacal  outbreak. 

ATTMted  Growth  of  bones  is  an  od'auionnl  consenueuce  of  disease.     Its 

rtroce  id  ricket*  will  be  presently  referred  to.     It  may  be  a  rwult  also 

diaMMs  of  the  epiphysee  and  joint*,  of  atrophy,  or  of  the  re«eilion 

Uw  •pipbyiis  in  children,  and  may  follow  the  formation  of  utcatrices  after 
iKRia  in  the  neighborhood  uf  joints.  Th«  elfecl  of  paralysis  ou  Lhe  growth 
mi  beoa  varits^  It  is  common  to  eee  normnl  growtli  of  the  Imues  in  limbs 
■ftetni  with  infiintile  paralysis,  in  ivhich  the  uuwtes  are  wui^terl ;  while  in 
«Cbcr  eaan  il  baa  been  materially  im|)aired.  'Diia  probably  depemls  upon 
wbdbar  the  epiphyaeB  are  pru[>erty  developed  or  not. 


•arilr  *-ni| 

^B  Arreste 

^^krarrrOd 

^Hf  varinns 

^WUw  •pi] 


BICXSTS. 

RrcKETS  a  a  general  dtsesM,  the  roost  important  manifestation  of  which 
is  an  imperfect  devetopnient  of  the  new  tissue  of  growing  bonos.  It  occurs 
<ntj  in  early  cbildhooa,  most  frequently  appearing  during  the  first  or  second 
JvKt  of  life,  though  it  has  been  observett  as  late  as  tb«  ninth  year  and  ia  said 
ore—innatly  tu  b«  eon  genital. 

Obim. — Want  of  sufficient  food  and  of  fresh  air,  want  of  cleanliness  and 
It.  and  ail  the  unhealthy  surroundings  of  the  overcrowded  poor  uf  a  large 
r.  are  Uie  great  causes  of  rickets.  Il  is  mrely  met  with  amongst  tb« 
Ithy  clasKs,  and  in  the  country  it  is  scarcely  seen,  even  among  the  p4ior. 
Idcst  or  improper  food  is  undoubtedly  the  most  important  of  the  more 
atnea  of  riclcets.  There  is  but  one  proper  food  for  a  child  during 
ftm  nisa  noaths  of  iU  life,  and  that  is  the  milk  of  n  healthy  vroman. 
The  ill-fcd  mothers  amongst  the  wi>rkiui^- classes,  exliauste^l  a.^  they  of\en  are 
by  rvpvated  ehitdbcaring  aud  unuuiurully  proloni^l  lactation,  are  very 
A*4ueutlr  unable  tu  suftjUy  milk  of  a  sullit.'iently  nutritive  qualily,  and  thus, 
mwtn  wbai  Mioklnl,  the  rbild  ii)  but  half  fed.  Should  it  be  bn>u<;ht  up  by 
kaad,  ia  order  to  save  t-xprnse,  flour,  or  various  useU-m  patent  prL'Twrntions 
^stsreh  arc  largely  uhhi  in  niaco  of  cow's  milk.  This  parly  feeding  nitb 
sarch  before  the  child  is  capante  of  digesting  it,  is  probably  the  most  fruit- 
IbI  cause  of  rirketa.  Kven  if  there  be  no  error  in  feeding,  there  is  reason 
to  b»KifW  that  the  oAprlng  of  feeble  mochcrs  tend  to  beoonie  Hckely.  The 
kaallh  of  the  father  has  not  lieen  shown  tu  exert  any  inBuence.  Purri't  boa 
laCaly  m^ntaioed  tlml  »yphiliR  in  ihn  parrats  may  cause  rickets  in  the  child ; 
fcsi,aC*lBiSi  thia  there  is.  ns  Sir  William  Jenner  ha.*  pointed  out,  one  un- 
aaawvnhla  anruraenl :  in  afamily  of  riokfty  children,  m  a  rule,  the  younger 
maber*  :■  ■"  'ted,  *hil"'  in  inherited  jiyphilw  it  is  exflrtly  tho  re- 

WH.     1'  rofula  Imve  no  definil''  connection  with  rirkeis;  in 

fcrt,  ihey  an>  mUU.iu  iiu-t  with  in  the  mmf  nuhject.     A  defirienry  of  lime  in 
A»  watar  of  tba  district  hiis  beeo  also  stati^  to  be  a  cause  of  this  disease, 


806 


INFLAMUATION    OF    BONE    AKD    ITS    EFPSCTS. 


■tAtiMS,  it  may  spoDlatieouBtv  fracture — uiBcctflpnt  that  I  have  MeDhBpna 
both  ID  the  femur  And  the  tihin^-or  insy  becoiiM^  »lK>rton«<l  orbeiit,  lo  umr 
JDatanccs,  again,  wlu'ii  the  iierioslouni  !>»»  Iweii  lo«t  bj  tlout^tiiiii;,  n»«  bow 
doea  not  ronii  (Fie.  507);  but  m  tliei>e()u«6trum  wparatffl,  tb«  lirab  b«coaMi 
■bort«ned,  Irxse,  defomied,  and  U)te]<rM. 

TRE.iTHKNr. — In  tbc  tr«ntmeot  of  aeenonfl,  the  indicntians  to  be  smobk 
pliahed  are  nufficiently  siniple,  tbou^h  tb«  inod«  in  uliich  th«y  have  t« 
be  carried  out  ofWn  requirw  mucb  patience  sod  skill  on  the  part  of  tlw 
Burgeon.  In  those  caew  in  which  the  bone  is  perishitig  frutu  book  cbronk 
prngrcfiive  diBea«e,  aa  chronic  oolvitis  and  |H<riueti(i0  with  ublitvmtion  of  the 
Haveniau  catinls,  or  when  it  is  asociatvd  with  c-ariee,  tlie  fint  putnt  u 
to  remove,  if  pueeible,  any  ounatitulional  or  local  cnuditiun  which  tmds  to 
keep  up  the  dt»easti.  ThuB.  ti>r  inotance,  if  it  ap|M.-ar  to  hv  the  rault  of 
fecrofuin  or  eyphili!!,  thutx;  conditions  niunt  be  corrected.  Ho.  again.  If  it  arw 
in  the  bwei  jaw  from  the  fumea  of  phoipborus,  the  pnlient  muat  Dea»- 
sarity  )>e  removed  from  their  intluence.  If  it  be  threatened  in  eootqwepflc 
of  denudation  of  l>une.  the  beet  m<Mle  of  prevention  will  be  to  lajr  down 
flapB  of  integument  Biid  bo  to  cover  the  exposed  Mirfooe.  Abaenws  should 
b«  opened  a«  soon  as  recognized.  In  caiwe  of  acute  infective  perinnitia  th« 
extent  of  the  necrosis  is  very  materinlly  limited  by  free  and  early  incuino*. 
and  in  this  way  the  ROpnrntion  of  the  epiphysett  can  often  be  prevented,  tod 
the  danger  of  death  from  eshBUBtinu  or  pva^niia  avoided. 

Eemoval  of  the  Sequeatmin. — When  all  that  is  poaBible  has  been  dnoe  ta 
arr*«l  the  morbid  condition  to  which  the  necrona  u  due*  ti»o  Bepamtino  of 
th)>  tequestrum  should  be  left  as  much  as  possible  to  the  unaided  ttToru  of 
nnturc.     The  less  the  Surgeon  iucerferea  with  thia  part  of  the  prticcw  tbc 
better;  for.as  has  ju*tUv  been  ob*er\*ed  by  Wedemeyer,  the  boundarieaof  (be 
necrosis  are  known  to  TCaturc  oulv,  and  the  Surgeon  will  moMi  pmbably  eilber 
not  reach,  or  he  will  paualtogctfier)>cyond  them.     Here  murb  patience  will 
be  required  for  many  weeks  or  montbfi ;  and  the  utmost  the  Surgeim  can  do 
is  to  attend  to  the  state  of  the  patient's  ht>alth,  treatini;  him  carefully  upon 
general  principlee,  removing  iuflammatory  mischief  by  appropriate  Dic^^a^ 
opening  abecesee*  as  they  form  in  the  limb,  limiting  or  preventing  tlie^^^| 
composition  of  the  difcbaVges  by  antiseptic  applications,  and,  at  a  later  parM^ 
lupporliog  (he  patient's  streogth  by  good  diet,  tonica,  and  g«iianl  tnatouat, 
calculated  to  bear  him  up  against  tne  depressing  and  waating  influence  of 
continued  euppuratton,  and  of  the  irritation  induced  by  the  rljunair 

80  loon  as  a  Kquertrum  has  beea  detached  fr^jra  the  adjacent  or  undcrly* 
ing  bone  the  Surgeon  must  proceed  to  iia  removal.  In  moet  eases  it  is  snm* 
dently  easy,  when  the  necrosis  is  superficial,  to  ascertain  ibat  this  aeparataaa 
bas  taken  place,  as  the  tini  end  of  a  probe  may  be  pushed  under  the  edge  of 
the  detached  lamina.  When,  however,  the  seuuestrum  is  deeply  aenled,  it  ■ 
not  always  so  easy  to  be  »ure  thai  the  separation  bas  occuned;  thcHigh,  in 
the  majority  of  cajKs,  the  intri)du(-iion  of  a  prohc  through  one  of  the  (istakms 
openings  leading  to  the  neeni«od  bone,  and  firm  prcwure  exerciseil  upon  tUs, 
will  enable  the  Surgeon  to  detL-et  that  degree  of  mobility  which  h  chanurtcf- 
i«tle  of  looseness.  In  other  cases,  however,  the  .xoquestrum,  thoiiKb  con- 
plelely  free  from  all  oaaeoua  conneetiottt.  still  continues  to  he  fixed  by  the 
preMiire  of  the  surrounding  granulationn,  and  by  the  extension  of  itn  Apicula 
into  the  rorrcsnonding  cavities  nf  the  new  oamoiis  rnHe.  Thi<i  re|>eci«llv 
happens  when  toe  sequestrum  lit  central  and  invaginated,  and  the  rlocir  lt«*l- 
ing  to  it  are  so  small  that  but  n  limited  ptirlinn  of  it  i»  expruied.  Hrre  ■ 
more  careful  examination  wilt  bo  re<iuire<) ;  and  it»  lt>n«ene#»  mav  MtmrtiroM 
be  determine]  by  prcsaing  u|M>n  it  wtih  a  probe  in  u  kinrl  of  jerking  manoer, 
or  by  Introducing  two  probes  cbnmgh  different  cloacx,  at  some  disteoc*  fron 


iriCBOSIS — REUOVAL    OP    SEQDBSTllUM. 


807 


«■  aaoUwr,  and  ftlteruaielv  bearing  upon  the  cxpoeeH  bnoft  with  nne  or 
■Ckar  of  Uwio.  Thvn.  ujeiuu,  if  the  souikI  clicjtrd  by  striking  ihi;  pmi  of  the 
fnhm  ■gsiott  the  sequwtruiu  be  a  peuutiarlr  hollow  uric,  ihc  lU'iachmcnt  of 
the  bona  mav  bt>  eiupvctrfl.  The  diiratiou  of  the  tliitisiiKu,  ulwi,  will  probablv 
throw  mtof  (ight  optin  tb^  probable  inAU'  of  things  inaiiic  the  new  cue. 

Tb*  ■rftamtion  of  the  arfjucAtniiu  having  been  Mcertained,  the  Surgeon 
aotf  wlopl  meuureii  for  ItJi  extrjirtioD.  The  part  should  tirst  be  rendered 
hicodiro  hr  FUmarch'n  ftppitraluff  if  the  disease  is  situated  in  a  liinh.  If  the 
Blfnaia  bt  p^rtpkeml,  all  that  is  neeef»ary  i»  to  make  an  incision  down  it 
ttCQOKh  the  MR  parti,  either  by  directly  cutting  upon  it  or  by  Hlitting  up 


n<.  y*  Fif .  a«».  fic-  >io.  ng.  si  i. 


rif.  its. — Stnigbl  l3«w  for  mnorlnc  Xt«nM«4  HOB*. 


Pi(.  SIS— X*eroil»-riK««^ 


with  a  probe-poiuted  bistaiury,  and  then  to  remove  it  with  a  pair  of 
»,  or  to  tilt  it  ott  the  bed  of  );runulitti»n»  on  which  It  l-t  lyiug,  by  iatni- 
-K-  ..,.,i  ..f  a,a  elevator  bcntaiiU  it*  eflge. 
W  -ill  if  ci-iifro/,  the  sequrstrum  being  embedded  in  a  new 

cam  liy  old  Ume.  thv  opemlive  proce<]nrea  for  its  removal  are 

ti  a  '  tietl  rhamrler.     Thr  difhciiltiea  here  oousiRt  in  tmxite  caaea 

is  ti>c  <U:;>i:i  :ri>ni  the  aurfart-,  nnd  in  the  ob(<tat-k'  o(rore<l  to  ita  paaaage  by 
Ct»p<A  part»;  to  ocfaer».  in  tht>  length  and  niacniiude  of  the  eecjimtnini  in 
pnipiirtHiD  to  the  noall  altr  of  thi-  cloaciu,  and  in  the  rannntT  in  which  it  liee 
m  •  dinetioo  parallel  to  theac  opcniuga.     In  coittng  down  u[><m  the  bone,  the 


SOB 


IIirt.AHMATION    or    BOXE    XVD  ITS    KrrECTS. 


SamOD  must  be  guide^l  by  the  direction  and  the  coutve  of  the  fiflulout 
InicKS  that  lend  to  the  priocipul  nperturee  iu  the  Dow  ckk.  lb*  iaduifDl 
beios  plBc«il  ID  the  axis  of  the  limb,  nod  cnrvfullr  dirccUd  atrajr  from  larp 
bloodvcHBels  nud  nerves.  If  the  pnrt  htm  not  been  naderad  bloodloi,  ha«* 
ever,  tb«  hemorrhage  i«  eomewhit  abundfuit,  in  oooMqiMDOe  uf  the  iujected 
itat«  of  the  tissues  furnUbiag  e  copious  supply  of  blooa,  and  their  rigid  one- 
dition  prcvcQliog  retraction  of  the  vcsels;  tbis,  howover.  nwy  be  amMid 
by  a  touruiijuet,  or  by  the  pre«ure  of  an  ueietaDt's  fingerm.  aad  wUl  aouo 
gradually  ctaw  of  itself.  Tlio  bouc  having'  bocu  frocly  oxpiieedjl  wiUforae- 
timea  be  found  thai  the  cloncn^an:-  oft^ullicient  stzeto  allow  the  rauly  extne- 
lion  of  the  MKHK^trum.  Rue  iu  the  mnjoriiv  of  caaes,  this  cannot  be  dune 
at  onrc,  and  t(i<!  a|Mirlur(«  iiiuel  be  i-iilargeif,  ciihur  with  the  gouge  or  iba 
trephine,  ficcording  to  the  deusity  uf  the  ni-w  cu»e,  and  the  amouot  uf  roMB 
required.  Occasionally,  wbcu  two  doacje  arc  clone  Lo  one  annlhor,  the  inter* 
vening  brid^  of  bntu-  uuiy  very  conveniently  be  remove<l  by  menna  nf 
cutting  pliers,  of  (litfiTcnt  Kbuprr;  (as  in  Figit.  f>fl^,  5(H),  and  510),  or  bv  mrana 
of  a  Iley's  or  a  filrnight  narmw  aaw  having  a  movable  hack  to  stim-n  the 
blade  (Fig.  512).  and  space  thus  given  for  the  extraction  of  the  (ie«iiic.*iroiii. 
Very  conveuii'iit  pliers  for  thia  nurpo*e  are  thow  reprewnlfd  in  Via.  nil. 
They  »rc  maile  with  gnuge  ends,  and  hen«  may  he  ((-riried  gouya-Joretpa, 
I  have  found  ihcm  extremely  serviceable  in  many  operations  iipim  the  b»nea. 
Care,  bo^Mfver,  tihould  he  taken  not  to  remove  niurc  of  the  ntw  rsM-  than  la 
absolutely  uei.'ee^iiry,  lest  the  ultimate  soundne^m  uf  the  limb  lie  ctidanp^red. 
Jn  DeL-rottie  of  the  lower  end  of  the  femur  the  bone  eurMundiug  the  •e«|u< 
trum  19  often  m  p(.'culiarly  deuae  that  it  can  be  cut  away  ao  aa  to  oxpoae  I ' 
dead  hone  only  by  means  of  a  chiaol  nod  mallet,  UB«d  with  coosidem 
force.  Fur  the  extraction  of  the  sequeatrum,  the  nioet  convenient  instrument 
u  a  pair  uf  strong  n«croBi»-fureepe,  well  roughened  at  their  cxtremitv,  sad 
straight  or  bent  ae  the  caw  may  require  i  Kig.  513 1.  Occaainually  tiie 
8Gt]uestrum  is  so  shaped  and  placed  thai  it  cannot  be  seized  with  this  in»tro- 
mcnt;  in  these  circumatances  it  will  b<<  uM-fiil  tu  drive  a  Kn.-w-pnibo  iFig. 
114;  into  it,  by  wbiob  it  may  either  be  extracted,  or  so  fixed  aa  lu  admit  of 


Fie.  »H.-B«a«.roretp. 

aeisure  and  removal  by  the  forrep*.  In  somccaaM,  additional  and  cunwnieni 
purchiue  tunv  he  obtaiiuii,  by  nxing  a  iH^ne-ffirtrpx,  »uch  as  is  rcproarotrd 
m  Fig.  614,  Iirmly  iuto  the  deud  bone.  If  the  se()ucBtrum  l>e  Ut*i  \vft  M 
be  removed  entire  thnmgh  the  cloacK.  it  may  perhafw  beat  be  cxtrmcte<l  pitcf 
.Bunl,  having  Ikhtu  previously  divided  by  passing  tlie  poiuta  of  nmrrow  bat 
Mxoog  cutting-pliere  into  the  iuteriur  uf  the  bone. 

Aiur  the  removal  of  the  iie<LUviitruRi,  a  smooth  hollow  cavity  will  bo  Itft  ia 
the  new  case,  fnmi  the  bottom  and  m\<x  of  which  blood  uamUly  wella 
up  frtfly,  iiiEuing  abundantly  (htm  the  vascular  boD«,aDd  from  the  mnula- 
tiiins  lining  its  interior.  Bliuuhl  this  hemorrhage  be  at  all  truublesoma, 
elevntiun  of  (he  limb  and  prraaure  will  always  arrest  it  without  dilBcalty. 
In  the  aobaequent  treatment  the  chief  trouble  arisca  from  lb«  accumulatioa 


HKCIIOSIS — AMFDTATTOX — RISSCTION.  309 

irget  in  the  cavity  from  which  the  hone  has  been  removed,  where 

er  ftro  prooe  U>  became  excewively  fotil.  To  prertut  this  the  cavitv 
■buokl  be  witfhed  nut  wlUi  chluriJe  of  zinc  Botulioti  (y:r.  xx  to  .^j)  imruedt- 

<'1v  atttr  tb«  operation  and  «>m«  crystalline  iodoform  spriakleO  in  It.  It 
be  drcMvd  with  salicylic  or  iodoform  wool,     la  this  way  it  cto 

I. ;  V  tooa  he  br<Hight  into  a  coaditioa  to  require  drvniug  only  about 

ottcw  •  w«ek.  If  tbeM  dmeinffs  ar«  aot  at  hand,  carboiic  oil,  tt^rebene'and  oil, 
w  elycvrioc  and  carbolic  acid,  may  be  applied,  and  the  wouad  well  syringed 
wito  Ofody's  duid.  If  the  dequetftrum  have  been  u  long  one,  and  have 
iovplTed  toe  greait«r  part  of  the  ehaft  of  the  bone,  it  may  happen  that 
iW  new  caw  w  oot  auflicieut  streuKtb  io  maintuiD  the  limb  of  its  projicr 
IvgUi  and  ahajw.  and  that  it  will  liend  or  hreak  under  the  action  of  the 
fivoea  aod  weigtil  to  w  htch  it  is  euhjected.  In  order  to  prevent  this  accident, 
h  will  be  Decessarr  to  put  it  up  iQ  li^ht  splints,  or  in  a  atarchetl  baD<la<^i. 
Aiker  tbe  removal  of  the  dead  Done,  the  sinuses  will  speedily  clu^e,  and  tlie 
liaib  isveatually  re^n  its  normal  sixe  and  shape. 

A^ntaUoB. — If  tbe  necrosed  bone  be  so  situated  that  it  cannot  bo 
llMinmul,  MKupyillg  ton  great  an  extent  and  continuing  to  be  firmly  fixed; 
■ad  if  U  tbe  aaae  dme  the  patient'8  health  have  been  wnrn  down  by  conxtaot 
dKharge,  mad  symptoins  nl  hectic  com«  on;  or  if  the  limh  have  generally 
beco  mmtiy  disorgnnined  by  the  morbid  procceaes  going  on  in  it,  recourse 
■MHt  M  had  Co  amputation  us  a  la«t  resource.  It  u  especially  in  the  lower 
tkird  of  tlie  thigh-bone  that  the^  Hvere  forms  of  necra!ti.<!  occur,  necesBitaling 
■Mpatalioa  nf  tbe  limb.  Wheu  necrosii  affects  the  flat  podterior  surface  of 
thta  booe  above  the  condyles,  a  special  s>-)urce  of  danger  occurs  in  the  poasi- 
balityaf  tli«  wquMirum  causing  ulceration  or  wound  of  the  popliteal  artery. 
locaaeaii'   '  n<l,  surl-lenly  fatal  hemorrhage  might  occur.     Should  the 

Wmofrbii.  i.  ahuoilant,  not  he  fatal,  what  course  should  the  Surgeon 

■ikft  in  suirlt  (-JUM-S*  .Should  he  attempt  to  ligature  the  veMel,  or  tthould  be 
anpatatr  the  limb?  The  line  of  practice  muKt,  I  think,  be  determineil  bv 
ifce  condition  of  ihu  limb  ilnvlf  and  by  the  state  of  the  patieut's  health.  If 
Umb*  be  both  tolerably  good,  the  limb  not  too  much  disorganized,  and  Lbe 
piiwafg  of  the  system  not  too  much  reduced  bv  hectic,  an  attumpt  might  be 
by  slitting  up  the  sinuses,  to  expose  and  secure  the  popliteal  arterr  at 
it  of  injury  id  it.  and.  by  ligaturing  it.  to  save  Jife  and  limb.  "But 
tlui  attempt  &il,  as  I  have  knowa  happen,  or  should  it  uol  be  ihoitgbt 
pmdart  to  make  iu  owing  to  the  low  state  of  the  patient's  strength,  or 
Am  dinriiaiaed  condition  of  the  limb,  amputation  must  be  done  without 
May.  Xa  an  idiopathic  diaeaae,  necrosia  of  the  tibia  retpiiring  amputation 
ia  imraj  mat  with ;  bat  when  it  is  the  result  of  bad  compound  fractures,  or 
of  uCbar  atrioaa  Jujorice,  removal  of  the  limb  may  liecome  imperative.  In 
■oMl  neewiia  of  the  lower  end  of  the  thigh,  or  of  the  shaft  of  the  lihia  involv- 
fa||r  1^  coBtiguous  joluui,  and  attended  by  deep  and  extensive  alwcecM  of  the 
tunb,  aaipBUuioo  u  imjH-rative. 

Bananon  of  tbe  whole  of  the  necroM<l  bone  may  be  ailvantacrously  per- 
ia  aoch  eaaaa  as  th(»e  of  the  nu^tacarfial  and  metatanial  bones,  or  in 
,,f  iK^  f^irearra  or  leg.  where  sufficient  slahilily  of  limb  iaoectired  hy  the 
nttis  !jc  or  bones  ti  leave  an  uneful  member.    The  diseased  bone  may 

b*  tLu>  1.  .u'.vctl  in  necrosis  of  the  ungual  phalanx  occurring  from  whitlow. 


I 


wbvrv.,  t^  the  exriston  of  tbe  dead  bone,  the  end  of  the  finger  may  he 
Mspaivpil ;  alsri  In  necroois  of  Dome  of  tbe  metatarsal  and  tamnl  bone«,  or 
Waaa  of  the  fnmrtii.  the  inferior  maxiILi,  and   ihe  fibula.     Subperioflteal 


niM:(ico  in  casKMof  bcii[i>  nccnjsts  has  been  nlrea/ly  alluded  to, 
Tbe  rciaarka  that  1  have  hitherto  made  apply  chieOy  to  necroBU  of  the  long 


810 


INrLAHUATION    OF    BONK    ANU    ITS    KrFBCTS. 


bones  of  the  c^tiKtoUiett.    As  there  an>  a  few  spociul  cnnsidentlinns  ooluivctM 
with  iiMrnNiu  nt'  the  Hat  bouc«,  we  will  uow  t-oiinitrr  thcve  briefly. 

ITecrosis  of  the  Sternum,  Scapula,  or  Bonea  of  the  Pelru, '»  ao  «xm» 
tivi'ly  ic<)iiiUH  prn<T?^,  there  being  but  v<.'r)'  ittlle  tcndcm^y  i(*  the  furmaiiRft 
o>'  a  line  of  itcparalion  and  tn  the  dciachtucDt  nf  thf  sie<\iteiitrum,  which  m31 
Continue  bare,  rnugh,  and  adherent  for  many  yearn.  >>h(iiild  it  b«  m  tituatM^ 
that  it  can  be  removed,  it  must  be  excised,  cvon  though  not  delncbc^.  Wboi 
the  ilitim  and  pelvic  bones  are  atfocted  indc-prndcntly  lA'  th*'  hip-joioL,  it  !• 
•eldora  that  any  operative  measure  can  be  employed  with  advantage ;  htrt 
v«  niu«t  leave  the  patient  to  the  chance  of  the  bone  being  at  ivngib  m 
loowned  as  to  admit  of  extraction.  Id  tome  csM*,  however,  if  the  diaeaMbt 
limited  to  a  purtiuu  of  the  crest  of  the  ilium,  or  to  the  tuber  techii,  th«drad 
bone  may  be  rentuv«d  ;  although  in  theae  instances  it  not  UDcummualy  htp' 
pvoe  that  iji^a^e  of  a  siioilar  kind  exists  elsewhere  about  the  sacnim  or 
spine,  that  will  «;veiilu»!ly  dwtr^iy  the  patient.  In  a  cast?  in  which  I  remowd 
a  |>ortiou  ui  the  eristit  ilii  for  necnigis  that  was  ap{tureiitly  LVcfiDGd  to  that 
bone,  it  wuk  found,  on  the  {mlictit  dyin^  some  wockK  uftcrwanlsof  nrrBpeU*, 
that  the  lumbar  vertt:brie  were  also  diseased.  Of  late  years,  ooaaidrrablt 
portiono  of  llm  pelvic  have  been  isiicc-eralully  excised  fgr  necroeis.  ma  will  be 
mort'  fully  mcnlioni-d  when  I  (Mme  to  8|>eaL  of  Dxi-ision  of  the  hip-joiot.  Tfat 
tuiier  ittchii.  when  alfkrii^d,  may  rvadtly  be  extirpated. 

Hecrosis  of  the  Cranial  Boaea  in  <if  fre<]uent  occtim-nce  a.'<  the  malt  of 
Btrumu  or  fyphili^,  or  tlin  iwii  conditions  cuojoined.  When  met  with  is 
children,  it  i»  usually  Btrumoua.olteii  occurring  after  measlea  or  wwlM  ftmr; 
in  adulta  it  is  UBually  syphilitic,  though  by  no  meaiw  inTariably  to,  baiof 
anmetimee  the  result  of  blows  tn  people  of  otberwiae  healthy  coiutitatiaa& 
There  are  four  situations  in  which  necrnnis  of  the  cranial  bones  awy  ooc«r, 
viz.,  in  the  vault  of  the  skull,  the  frontal  bone,  the  temporal  bona,  or  in  tbi 
sphenoid  and  ethmoid  bones.  When  idiopathic  necroeis  a&cts  the  vault,  it 
is  usuallv  syphilitic;  when  it  occurs  in  the  other  situations,  especially  in  thi 
temporal  bone,  it  is  commonly  strumouti. 

Tnree  forms  of  ne<>roeifl  aHi-ct  the  cranial  bones.  In  one  case.  th«  otrter 
table  ia  alune  affccte«l ;  thi«  |wri«he)i.  separate*,  and  exfntiatea,  granulati«as 
spring  up  frutii  the  outvr  Burfact>  uf  ihv  inuvr  table,  and  a  pruceM  of  rrpair 
is  thus  «tabliahe<].  in  the  second  form  of  the  diaease.  the  wii'>l«  tbicluMM 
of  the  skull  necroses,  separates  from  the  dura  mater  and  ourruunding  healthy 
bune  in  the  usual  way,  and  may  be  detached  in  large,  irretfularly  ftfaapw] 
pieces,  sometimes  of  lar^  sixe,  occupying  several  Miuare  inches.  Id  tbs 
third  form,  tbe  necrosis  ts  hard,  dry,  rough,  and  pitleu  ur  worm-eaten,  (wu^ 
tratiog  through  the  diploe  to  tfae  iuoer  table,  aepBraliog  veiy  alowty,  and 
lasting  an  indefinite  period. 

JUndin. — In  Dccrosis  of  the  cranial  bones,  there  is  always  the  special 
danger  uf  extension  of  inflammation  to  the  membranes  of  tbe  brain,  and  tbs 
C0D»equeut  occiirrenco  of  effueion  within  the  skull,  leading  to  coovulsiiias, 
eoma,  and  death.  This  danger  is  greatest  when  the  petrous  portion  of  tb* 
irnipornt  iMme  ts  afll>cte<l,  as  tlie  dura  mater  la  continued  into  some  ot  ths 
canaU  by  which  it  is  perforatei).  Cerebral  complication  is  lew  likely  t»_ 
occur  when  the  frontal  bone  i*  the  scat  of  disease,  more  particularly 
lower  part  nf  this  bone,  where,  by  the  intervention  of  thefrnntal  sinuses,! 
anterior  wall  in  altngclh<>ir  carriL-d  away  fn^m  the  inner  table,  and  from  all 
dangemuM  proximity  to  th«  membranes  of  iho  brain. 

Tlift  tSigti*  of  iM-eroai*  of  tito  cranial  bones  are  very  obvicMM  When  tbe 
vault  or  forehead  is  nfTfCted,  there  Ja  tendeme**,  with  some  puffineas,  and 
gradual  elevation  of  the  scalp  into  an  absceia.  When  this  »  opeDcd,  tbt 
nvcruwd  bone  may  be  felt  or  seen  lying,  bare,  at  the  bottom  of  a  sinus  or 


^ 


rouB  pomoD 
of  diacaae.  Ifaere  will  have  been  earache,  followed  by  profuse  fciid  dUcliarge 
fnna  liw^  nr ;  it  is  iiAimllr  MKrundnrj*  to  chruiiic  intlHDinmtioii  uf  the  middle 
r«r  «itb  perforatiuo  of  the  tyDi]>»uura,  escape  of  the  oeeicuU  auditiw,  and 
d«aiiMa«-  When  the  spheuuid  ur  the  etlimujd  ts  a(luct«<i,  deep  paius  Id  the 
Watt.  pvxwteDt  oNleaia  of  the  eyelids,  and  tetid  discharge  t'roiu  the  oose, 
win  r(rr«al  tbe  nnture  and  seat  of  the  mischief. 

Tbo  JVeaimfnt  of  Decnoia  of  the  cmDisI  buiiee  iviti  vary  according  to  tbe 
Batar«  and  tbe  Kat  of  tbe  diMSie.  In  the  dry,  pitt^^  variety,  exposing  and 
KrapiDg  tbe  dbeafed  ocmous  Bur&ce,  Qr  the  iipplicatton  of  a  litroug  unlution 
af  Milpbaric  acid,  will  nftea  bring  ubout  a  healthy  action,  provided  tbe  dis- 
BU  BDl  peD«tniled  too  deeply.  >Sbuuld  there  be  rettson  to  think  that 
iMMV  tame  ba»  been  perlbrutul.  it  will  probably  be  mfer  to  leave  the 
.  Ml  the  reparmtive  processes  of  nature  inan  to  trenhine.  If,  however, 
Miteriur  wall  of  the  frontal  sinua  be  the  seat  of  tbe  disease,  or  if  tbe 
MptKhrbilal  ridge  be  ■fleeted,  tlie  dr}'  and  rough  bone  mav  be  safely  re- 
aofwl,  H  I  bavD  on  more  than  one  occasion  had  to  do,  by  tne  applicatloD 
«f  the  Cnphloo  in  the  liret  instance,  and  of  the  gouge  in  the  olner  case. 
When  «xniltating  Qecnwis  of  tbe  outer  tabic,  or  of  tbo  whole  thickness  of 
ike  bone,  affects  tbe  vault  of  the  skull,  the  looseocd  plate  may  reudily  be 
fiflad  offitB  granulating'  betl  by  mcaos  of  the  elevator  or  forccjis,  after  it  has 
baea  &tri^  exposed. 

Kecfeau  of  ifae  petrous  portion  of  the  temporal  bono  may  be  looked  upon 
aa  ao  taeonible  disease,  which  is  usually  fiital  from  septic  meningitis.  When 
tb«  ap&efkold  or  ethmoid  is  the  scat  of  necrosis,  little  can  usually  be  done  by 
aparatJT*  iiiuHerene« ;  though  in  the  Inltcr  case  uurtiuns  of  sequestrum  may 
•oaaciitaes  be  extracteil  thruugh  the  n>j(stril»,  and  in  one  extraordinary  c»as 
•a4ar  nv  can  in  University  Coll<^  Il<ai)ital,  I  removed  through  the  mouth 
ilka  wliuM  body  of  the  sphenoid  boue.  The  patient,  n  man  agctl  fnrty-tbree, 
kad  tuflSfreil  fnim  ttyphilis  tor  fifteen  yean,  and  from  disease  of  the  hones  of 
tita  DOM  aad  upp«r  jaw  for  three  years.  The  anterior  part  of  the  hard  palate 
«a»  deitioyedt  and  it  was  through  the  fissure  eo  li>rraed  that  I  removed  tbe 
hova.  Tb'o  fragment  included  tbe  sella  Turcica,  and  the  routs  of  the  ptery- 
■aU  pvocoaos.  but  the  cUnotd  proccfaes  could  not  be  recognized.  The  iMiLient 
■■4  soflend  from  no  oembnil  symptoms  except  occaaiooal  headache  and 
aiaaa  Uim  uf  mimoiy.    Uc  ujade  a  eood  recovery. 

Tbe  PaMla  b  rarelr  nevrtieed.     I  have,  however,  met  with  two  instaDoeB 
at  ftimwf  aacwais  of  this  boue.    One  case  oecu  rred  In  an  elderly  woman. 
I  iimmtm  ^anr  ou  wiibnut  any  evident  external  cause,  commeacing  in  tbe 
pare  of  the  patella  and  gradually  implicaling  llie  bone,  until   it  be- 
eribrated.  when  rapid  AuppumtJve  ditforganiuition  of  the  kue^-j>>int 
lilating  antpulati<)n.      The  other  rase  occurred  an.er  simple 
frarlsre  of  the  patella,  in  a  man.  and  is  described  at  p.  604,  vol.  i. 

Biba. — Wbeo  tbe  ribs  are  necroBed,  a^ccmes  and  sinuses  will  uften  funn 
to  a  eoMsdefmble  extent  on  the  ride  of  tbe  chest.  These  must  be  laid  open, 
aad  ibe  «Bfased  purtion  of  b«ine  scraped  away  by  tbe  gouge.  lo  doing  this, 
care  OMM  of  ooune  be  Uken  that  the  n>ljaceut  inlerooRal  space  be  nnt  punc- 
hnvd  by  aa  aufbrtDuat«  slip  of  th<^  inKtriiinent — ao  accident  that  is  best 
by  pr»ttrcling  the  gouge  well  with  the  finger. 


SIS 


BTRUCTVRAT.   CUAMQK8   IN    UONK. 


CHAPTER  XLVII. 


STBDCrrUBAL  CUANQBS  Iff  BONE  AND  TLTHURS  OP  BON'E. 
nYPKRTROPllY  OP  BONE. 

True  Hypertrophy  of  Bone,  that  ia  to  say,  increaae  la  ibe  «rith»at  alunfr 
tioQ  in  form  or  Alructure,  ui  very  mre.  It  ncciira  u  the  nwlt  of  rxoCMTt 
uae,  io  common  with  th«  eotar^ment  of  the  muiiclea  iniierted  inU>  it. 

The  t«ria  Inflanunatory  Hypertrophy  is  often  applied  to  tboM  chroaie 
inflammatory  jjrucc-g^es  wtiicli  vaune  eulargcmeot  of  a  boii«,  diffUvcd  otVK 
coDBiderable  part  of  iu  louglh.  Wliou  the  tliickeaed  bone  ii  mora  *foafj 
thao  Datural.  the  chau^^  i»  tvrmcd  Spongy  Uyperirophy;  wheo  it  it  oaonr. 
,  tdenau,  or  hanlvuiuL'  of  bune.  Spon^'V  hvj>erfropby  occur*  id  its  mot 
markwl  form  iuthc-  diKuaiHi  describL-d  by  i^ir  Jaiuea  Fuet  aa  oateitis  dt!fo^ 
num.  Sclcru8u(  h  moot  cuimuouly  iiicl  Willi  as  the  result  of  ayphilis  or  aftar 
raeovcty  fnim  chronic  celeitia  and  imriutitim  in  scrofulous  subjects.  It  may 
mOvot  several  boocs  at  the  same  ttm«;  and,  iu  ihe  lunfc  boufls,  may  lead  to 
filling  up  of  the  mecltillnry  and  Haversian  canals  with  bony  subslaiioe,  villi 
some  tliiokenine  of  the  bone  generally.  This  condition  u  not  reoognitabls 
trilh  certainty  during  life. 

Increase  oi  Length  of  Bones. — Allunion  hut  already  heea  made  at  p.  SSS 
to  the  hypertrophy  of  bone  which  sometinicjt  follows  chronic  osteidc.  TUm 
increased  growth  of  bone,  as  a  result  of  morbid  coodidoos,  has  been  ioi^^^H 
gated  by  tManley  and  Paget  in  this  country,  and  hv  T^ngeobeclc  and  ocliaa 
on  the  continent.  It  haii  bet^n  obeerred  in  connection  with  necroeia,  cbroDte 
oeteitiit,  and  chronic  ab»cw«;  and  also  with  chronic  byi)encmia  of  tin*  wll 
parts  of  a  limb.  Laugt^nbeck,  from  his  oL>aervation«,  concludes  that  morbid 
changes  which  give  rise  to  irriialton  and  hypenemia  of  the  oassous  tiaua 
lead,  as  long  as  the  growth  of  bone  conlinues.  to  an  increase  both  in  tbe  Uoglb 
and  in  tl)e  thickueM  of  bonea;  and  that  the  increase  of  growth  in  l«ogth 
afleots  especially  the  diseased  b^ues,  but  may  also  occur  in  a  healthy  bone  of 
th«  same  Hmb.  Sometitnea.  as  I'aget  has  pointed  out,  the  long  existence  of 
an  ulcer  of  the  integuments  in  a  voung  pvnou  may  produce  tliickeotng  and 
eluugaliou  of  the  bone.  When  tlie  feuiur  undergoes  eloo^tiun  in  this  way. 
the  ineouality  in  length  of  the  limb,  uulcas  the  op[M«it«  limb  be  leagtheoed 
by  urtihcial  means,  may  lead  to  talipes  of  lh«  foot  of  the  lengthened  Unb  or 
to  lateral  curvature  rtf  the  spine.  The  tibia  sometimes  beoomea  elongaled, 
while  the  fibula  remains  of  it«  normal  length;  and  in  such  cases  the  rarner 
hone  bectmies  curved.  The  diagnosiH  of  thtf  condition  from  thecurratnreef 
rickets  consi^l^,  accunliiig  to  Pngi?t,  in  the  marked  elongation :  in  llie  ab«eiiea 
of  thickening  of  the  cmU  of  the  bone,  which  are  lUUaTly  even  more  nearif 
ei^uul  in  i^izc  to  the  elutft  than  in  the  natural  state,  oo  account  of  ibe  thii  ~ 
ing  of  the  lalLer;  and  cHjic^inlly  in  the  fact  that  "the  rickcir  tibia  is 
pressed,  usually  curvc«t  inwardit,  its  shall  is  Battened  laterally,  and  its 
are  narrow  and  spinous;  while,  in  the  elongated  tibia,  the  curve  it  usually 
directed  fnrwardt,  the  mat^ins  are  broad  and  round,  the  sur&caa  are  coo- 
Tox,  and  the  cotnpreailon  or  Qattening,  if  there  be  any,  is  ftom  balbre  b*^- 
wards." 


BTCKBTS. 


313 


AraorST  or  Bo!<t:. — This  term  conipmefi  (wo  cnoditions:  uuu  in  which 
ibc  htmte  b  «a»(ed,  aud  fttiother  io  which  an  nrrest  of  eruwtb  occurs. 

Atrophj  ocnire,  us  a  nnliiral  reMilt,  in  olil  nge;  the  chnD^  that  taltM 
plaoc  IB  fitc  Iowkt  jaw  bptng  a  familiar  exninplc.  In  other  coMes  it  happens 
m%  cotMe<]umiT  of  fracluro;  the  DUtricrDt  artcrv  of  the  bone  hnving  been 
tun  aoon,  and  onr  of  the  fragments  coiwequeritfy  receiving  tntiufficient  vaa- 
ealar  eapply.  Atniphy  of  bone  commonir  occur*  al«o  from  Hiwuiw-,  aji  Ia  the 
OK  in  old  dillcMBtMlis.  In  atrophy,  the  hone  hccunm  thinner,  lighter,  and 
!iorooa  ihtB  OMal ;  the  cotupaot  atructure  rlisappearinj;  until  a  mef« 
like  laver  may  he  left,  the  wmceMoua  «pac«ii  being  expRiided  and  filled 
«A  ••ft  yellow  fat.  Atr-phy  of  hont'*  %a  common  in  gt^nernl  paralyftia  of 
iIk  maanc.  It  u  often  especially  marked  in  the  rihn,  nnd  j.^  a  onntmon  oatiM 
of  firftctana,  occarriitg  either  spoQtaReou*ly  or  during  the  rettraint  u«4ie»> 
Mrilr  tnpl'>vr.l  durins  a  maniacal  outbr^^ak. 

Afrated  tirowth  or  boom  it  no  ocoafttontil  conseouence  of  disease.  lu 
arocBrrcDcw  io  ricketx  will  be  nrM«Dlly  referred  to.  It  may  be  a  rei>iitt  ftl»o 
i/Tmrioos  itiai  aar n  of  the  epipnywa  and  joints,  of  atrophy,  or  of  the  reeectioQ 
■f  iIm  •pipbyna  in  children,  and  may  follow  the  formaiioo  of  cicatrices  after 
bvrat  in  tbe  aeigliborhood  of  joiois.  The  effect  of  paralysis  on  the  growth 
t£  boBC  TmriM.  It  IB  comiQOD  to  ace  normal  growta  of  the  bones  in  lituha 
witli  infilDtile  paralysit^.  in  which  the  mucelcs  are  wasted;  while  lu 
it  baa  be«D  mai4.'rially  iniiwired.  This  probably  dcpeudii  upon 
Ui«  tfiphyaea  are  properly  developed  or  noL 


BICXETS. 


ip__. 

^^HneKXn  ii  ■  nnenil  disease,  tbe  moflt  important  maailcaiation  of  Trbich 
PHiM  iBparftet  a«v<Jonn)eDt  of  the  new  tiasue  of  growing  bones.  It  occurs 
oalj  m  «arlT  cfaildbooa,  moat  frequently  appearing  during  the  first  or  second 
j<«r«f  life,  though  it  has  been  observed  as  laie  aa  the  ninth  year  and  is  said 
oceHiomUlT  (a  be  congential. 

Oi»M. — Want  of  tuthcif  Dt  food  and  of  fmh  air,  want  of  cleanlineas  and 
Hi^t.  and  all  the  unhealthy  eurn.>timlings  of  the  overcrowded  poor  of  a  large 
atr.  are  the  great  cauww  of  rickeUi.  It  is  rarely  met  with  amongst  the 
apoUthy  claaaea,  and  in  the  country  it  is  scarcely  seen,  even  anK>ug  the  {Mior. 
Illffiiiilil  Mr  tmprontT  ftxjd  is  undoubte<lly  tbe  most  impurtaul  of  the  more 

rial  cmnaea  of  rioketA.  There  is  hut  one  proper  f<jod  fur  a  child  during 
llrat  nine  months  nf  ita  life,  and  that  is  the  milk  of  a  healthy  woroao. 
TW  iU-f«d  mothen  amongst  the  workiug-claaveB.  exhausled  as  they  often  are 
tff  Rpeat«d  rfaildbearing  and  unnaturally  pr»longe<l  lurtntiuu,  are  very 
AvfOesUy  onahle  tomppiy  milk  of  a  sufBciently  nutritive  igualily,  and  thus, 
•TOi  what  rackled,  thi^  child  ii>  hut  half-fed.  Should  it  tw  hnmght  up  by 
hand.  Ib  order  to  wvk  rxpcnae,  Hour,  or  varioue  uaehfs  patent  prepHrntiomt 
«f  alarch  ar*  laryely  luml  in  place  of  cow's  milk.  This  early  fee<iiug  with 
Owh  before  the  child  is  capalile  of  digesting  it,  is  probably  the  iniwt  fruit- 
M  ^uae  of  rirkrts.  Even  if  there  ho  no  error  in  feeding,  there  is  reason 
to  helirr*  that  the  ot^pring  of  fcchte  mothers  tend  to  become  rickety.  The 
hiKlth  of  tbr  fathi-r  hiu  not  been  shown  to  exert  any  influence.  Parmt  has 
hiaiy  nsintained  that  cyphUis  in  ihc  parents  may  cause  rickets  in  the  child; 
hvt,agaIoflt  thia  there  is,  aa  Sir  William  .Tenner  has  pointed  out,  one  un- 
bis  argument :  io  a  familv  of  rickctv  children,  as  a  rule,  the  younger 
are  mnrt  afTecled,  white  in  inhcrileil  syphilis  It  ia  cxiu-tly  the  re- 
TobiavJr  and  •crofulii  have  no  definiti>  connccli(m  with  rickets;  In 
bet,  tbvy  arfi  aeldon)  met  with  in  the  tame  subject.  A  deticicucy  of  linn:  in 
ihm  wmiMt  of  the  diatrict  bai  been  abo  stated  to  be  a  cauae  of  this  diA«ae, 


S14 


STKUCTURAL    CHAXGES   IN    BOKE. 


but  this  is  eviHeDtly  not  the  cnm,  for  ricketii  ii  far  tnorecoDimda  in  IjoikIoo. 
which  is  so  pplied  with  water  (."onitiiniiig  a  oonuderable  aniouDt  of  liiuu,  tlui 
io  C<lii9)!ow,  where  the  wnter  coDtaioH  merely  a  tmc<?. 

Symptoms. — ^Theso  vaay  b«  divided  into  general  fymploDM  aod  tlmi 
referable  to  the  chiioecs  in  the  bonei>.  The  ^etterod  aymptoioM  uc  Uie  roUs** 
ing:  the  child  may  be  thin,  but  is  muro  olteu  apparently  well-uourialiad, 
Bumetimea  very  iaL  Itc  mucous  membranei  arc  pate,  but  the  cbevlu  ui 
olteu  redder  than  natural.  Oa  caroful  cxaiuination,  huwovcr.  with  a  \tm, 
this  will  bo  seen  Co  be  caused  by  n  netwurk  uf  dilalod  capillants  iu  ibti  tnu 
iltio.  A  mcMt  cbarncteriatic  sign  xi  jtroftut;  ewtating  of  the  forfbead  nbca 
the  child  18  aelocp,  the  rest  of  the  body  ufteu  being  at  the  same  lima  bui  rd^ 
dry,  thoiigb  the  thermometer  rardy  shows  atiy  marked  elevatiou  of  urn- 
peraluri*.  Thoro  is  otU-n  general  tciidenieiw  of  the  bo<ly,  so  that  any 
naiHlliog  is  painful ;  imrtly  in  ci)n»i-qticum  of  ihiH  and  (tartly  from  the  heal 
of  the  body,  the  child  kicks  oti'  iu  bed-<!lr)th{'ji  ut  iiigbt,  wi  tliat  it  i«  aomvliiiHi 
ImpotwiMe  U*  ket^p  it  covered,  iinloai  it  is  tujule  to  sleep  in  tlaunel  dravctt 
and  a  jersey.  The  dlgentinn  h  ndeo  gtxxl,  but  there  is  a  teiidcuoy  tfiaUaclu 
of  gastric  catarrh,  with  a  furred,  white  tongue,  and  jierhaps  vomiiing.  The 
moiionii  ar«  clay-colored  and  offensive.  Flalidenct^  if*  common,  nud  owiaf 
to  the  weakncM  of  the  musrles,  which  is  often  a  marked  elVect  of  ricktti^ 
the  child  usually  becomes  pot-bellied.  The  spleen  is  frequently  cnUrgwd, 
and,  iu  some  cases,  the  liver  also.  The  urine  presents,  as  a  rule,  oothibc 
chamcleristic.  It  may  contain  an  exceas  of  phosphate  of  lime,  but  tbU  i» 
sot  the  result  of  soHening  of  the  bones,  but  evidctic«  of  imperfect  aaatmi* 
laCiuo. 

The  cMoTtfftj  t^»erved  in  the  bonet  appear  early  in  the  disease.  Tbcf 
coosisl  of  eulargvmcnt  of  thv  articular  ends,  most  marked  at  the  poiets  nf 
juiicliuu  uf  t)ie  tibiitl  with  the  epiphyses ;  in  oousequeuc-ie  of  which  toe  joiats 
apfiear  U>  be  swollen.  Th«  enlargumeut  is  aleu  espt;cially  marked  at  lbs 
Juuctiun  of  the  ribs  with  their  cartilages,  which  form  prominent,  ruuadeil 
swellings,  (elt  and  sometimes  clearly  seen  through  the  skin,  giving  rise  to"^ 
apiM'aniuce  which  ha«  been  termed  the  "  rickety  nwary."  At  a  later 
owing  to  ihu  soAnees  of  their  &trnclun,>,  the  Iiodob  bend,  giving  rise  to 
characterii^tic  deformitips.  Hiiinphry  and  Langeuhet-k  have  called  aileiil 
t4>  the  want  of  growth  in  leugtb  ofWu  obeerved  in  rickets.  Humphry  uyt 
that  the  humerus  anil  femur  are  about  one-fburth  itborter  iu  rickety  subjeott 
than  in  healthy  indiviilualsof  the  aame  age.  The  mi»timptirtaaCdefoniutMB 
arising  iu  dilfereot  parts  are  the  following:  The  Iwul  early  appear*  ta/f^ 
the  Itireheai)  being  especially  protuberant,  and  the  face  amall.  The  rai- 
taoelles,  especiallv  the  anterior,  arc  very  slow  in  clonng;  the  booes  of  tke 
ikull  may  be  thickene<l,  furming  pn>minent  ridges  OD  each  aide  of  theiuturt% 
though  oocBsionally  in  the  occipital  they  arc  unduly  thio.  The  npine  la 
young  children  usually  presents  one  long  curve  backwards  from  the  lower 
cervical  region  to  the  coccyx,  with  a  ompenaatiDg  curve  forwards  in  the 
neck.  Iu  older  children  there  may  be  merely  cxageeratioo  of  the  normal 
oonrat.  Th«  oA«i<  presents  very  chnriUMeristic  derormitici;  the  stcrsom 
prt^aoti  aonewbat  forwards,  with  a  deep  deprvetfion  dd  each  side,  caoMd 
the  sinking-in  of  the  soft,  newly  formed  part  of  the  ribs  at  tbcir  ani 
extremities.  The  deformity  is  commonly  termed  "  pigeon-breaat." 
dcpmsion  is  le*  on  the  left  side,  a«  the  ribs  are  supported  by  tha  hmtU 
The  lower  ribs  are  pushed  outwards  by  tbe  abdominal  viaoera.  The  aagl* 
of  the  ribs  are  less  obtuse  than  natural.  The  ehmetn  show  merclv  an  in* 
crease  uf  tbe  ni>rmal  curves.  The  Aiunenu  is  unially  bent  outwanis  at  tiM 
{naeitiOD  of  the  <lelloid  ;  the  froaes  e/tMefonarm  are  bent  outwards  id  tha 
lower  third.    The  ptbris  is  aarn>wed  from  before  backwards,  more  espedally 


if  Um  defonnilf  commrnci's  befnre  Lbo  child  has  leanicd  to  walk.  Tbo 
fmmr  pnscBUi  %  singln  long  curve  furtvardn.  Thu  tibia  anAjjibula  aro  bfiil 
Ihrwanfa  uiJ  outwanis,  or  forwards  only  in  Iheir  lower  lliinU.  The  de- 
fimuiica  btre  inentitintHl  are  the  most  common,  l>ut  other  vuriettea  may  be 
Mc«  with,  Aa  tb«  child  becomes  older  it  frequently  becomes  kDock-knecd 
nt  Sn«-le(tged. 

UeoUuon  ia  umially  much  delayed.  This  ig  nn  important  nymptom,  and 
it  M,  iii«r«fikn,  neccocary  to  rcraember  tbr  dates  at  which  the  teeth  itbould 
Tliui  may  bo  easily  done  by  the  following  formula,  which  ii>  accurate 
(br  cliDtcal  purpiiaM.  Taking  the  teeth  in  nnfltomical  i^rder,  com- 
tDg  with  the  a-Jitrat  incisor,  they  appear  at  the  followiog  datee  in 
b».7,  y,  1(1.  12.24. 
Frftgrtai  and  Prognoiii. — Under  |>ru)>er  trt-altDent  rickfU  can  usually  be 
fOnd.  The  l>«>oee  then  rupitlly  bcccnue  eulid  and  firii),  and  remain  |>erma- 
Msfcly  fixed  in  their  aboormal  shape.  The  coucavititr«  of  the  curves  become 
{artly  fllled  up  tn  jnve  the  buue  th«  neceeaarv  stn-iij^th,  while  abiuirplinn 
tokai  place  laterally  to  preserve  lightnf5s.  This  ia  uAen  very  ninrked  in 
tfat  famar,  the  antero-pceteriur  diameter  of  which  may  be  double  tlie  Irans- 
vwaik.  Aftar  reeoTerr  from  rickets  there  ts  freuuenlty  early  union  of  th« 
m^/iffhywrn,  by  which  toe  whole  body  is  etuoted.  Muscular  developnieut  is, 
huiwww.  oma  good,  and  the  patient  may  eventually  become  eutlicicntly 
powcrftil. 

Bicfceta  infinitelv  rarely  causes  death  directly,  but  hy  impairing  the  power 
of  eooghinr  it  iadirectly  causee  the  (htal  result  in  a  considerable  pnipurtion 
flf  tmmm  of  MiMtchitiB  in  children. 

PUlMlagy. — fieyond  the  fact  Ihnt  the  red  corpuscles  have  been  found 
4i4fiwH  in  namlMV,  eiaminalion  of  the  blood  has  thrown  but  little  tiKht  on 
ifaa  Am%at  The  Datnre  of  the  enlHr^coments  of  the  liver  and  spleen  are 
■aaavhal  doubt/al  and  require  further  investigation. 

In  lh«  boiMS  the  MBCfitial  features  of  the  morbid  process  are,  first,  an 

r^L^if^pamiiaa  of  the  proeeasea  immediately  prtparntory  to  the  development 

jf>  booa;  aeeondiy.  an  imperfect  coDveraion  of  t^is  nreparatory  tissue 

(rue  bone;  and,  thirdly,  a  grtht  irregularity  of  the  wliofe  process.     In 

•■*  there  is  a  growth  of  soft  bi,>ne.  Cut  no  sottontng  of  healthy  bone. 

-Mcu  tflpeMUa  ttasuc  as  has  been  developed  before  the  disease  cumuieaced 

noalDs  sochanged,  unleM  absorbed  in  the  proce«  of  the  formation  of  the 

■wlBllaij  awal.     The  pathological  appearances  are  best  studied  on  a  longi- 

to^aaJ  aacCioD  of  a  Ions  bone.     In  normal  ossification  a  thin,  bluieh  line 

is  mma  WtwMO  the  uoaltereil  cartilage  aud  the  newly  formed  bone  ;  in  this 


lb*  pndtfrrBiidQ  of  the  cortila^'c  eorpujcles  it*  lukini^  place  preliminary  to 
tWHraaiioB  of  bone.  In  rickets  this  line  is  much  tliiuner  than  natural, 
waA  irngvlar  procvffca  project  from  it  into  the  cartilage  of  the  epiph^is. 
Tk*  |iiiHiHi  b  waotioe  in  the  rcgulariiy  ubitirvird  iu  normal  ossificution. 
TW  HoKlerailag canilage-cclU  arc  hca|H>d  im-KK'^rly  togciher.and  patcbes 
ia  wbicli  flalcitlaiiot)  of  tbe  matrix  id  taking  placo,  are  met  with,  scallered 
iarv  and  tberr.  Tbe  vascular  medullar;,-  spaces  also  which  normally  pene- 
tiaie  IB  an  even  line  into  the  proliferating  layer  of  cartilage  ahow  the  same 
vattl  - ''  > — *nnly  in  their  deTeloptneoU  Some  will  be  found  projecting  an 
rifbil:  iirfa  or  more  in  advance  of  the  nlhers  into  tlio  unaltered  carti- 

Ma.  1  !)••»'  h{>acea  are  lined,  as  in  normal  bone,  with  nsieoblasta,  and  bone 
iifbrmerl  frofu  them,  hut  tbe  oaseous  tiasue  thus  produced  is  soAer  than 
flalttral,  aod  cartilag«fc«lls  unaltered,  or  merely  calrified,  may  he  found  em- 
baJJail  in  it.  Beaeatfa  the  periosteum,  eap^viallv  at  the  line  of  junction  of 
d»*  «)'  -  '«ith  the  shaft  a  thirk  tnyer  of  reddiHb.  vascular,  spongy  bone 

■I  Ibot.'         .    rijaoopic  c-xamiuiitinn  Hliowatliat  the  r«teoblastic  layer  benaatb 


I 


ai6 


STBDCTURAL    CHANaSS    IN    BOKE. 


the  perioiiteum  it  grently  increaoed  in  thickonw  ;  th«  iwteobln>i  ■ 
roua,  but  the  o«t«ogeDk'  fibr«t)  between  tliem  are  imperJuctl.T  d<- 
lime  aalla  are  but  ecaotilr  dcpoaited;  the  remilting  Mrufitun  i* 
•ol\er  [Itnn  uatuntL 

XreatineDt. — lu  the  trcniment  of  rickets  our  fint  t/adrnvor  mmfc  btto 
reranvv  iliu^e  cooUitioDB  which  arc*  kiiuwo  to  cause  the  rtweiwr,  Tba  cidU 
iniiBt  be  01  much  is  ponible  in  the  opea  air  aud  should.  U*  posible,  be  hdI 
into  the  oouotry.  It  mu«t  be  put  to  sleep  in  a  bed  br  itaelf  to  invurc  6«h 
air  during  the  nigbL  If  it  kicks  tu  clotheD  oil',  U  oiuvt  be  made  tualMpii 
looM  flannel  drawers  and  a  jacket,  to  avoid  the  rbk  of  catching  cold.  A 
bath  should  bo  givon,  of  tepid  salt  water  in  wiutur  and  oold  io  aummeri  eveij 
morning  and  evoniog,  or  ut  least  nnve  dailr.  The  diet  should  be  carefullj 
rfgiilmcd.  Bi'furA  mven  iiiunthd  it  ehuuld  mnatst  of  nothing  but  milk :  tbc 
mother's  milk  is  llio  be«t  if  kKu  itu  in  n  malK  of  health  tu  suck]«  her  duU; 
if  not,  the  iH-at  cow'ni  milk  mtixl  be  givvii,  diluti<d  at  fint  with  oii»4]tianif 
of  iu  bulk  of  wiirni  irat(>r  and  Hweett>M<st  with  u  little  sugar.  Ltme-waUl 
mav  be  addtxl  if  the  child  vomiu  or  naaviA  undigested  milk  with  iu  Mooh. 
Af^er  the  child  has  naMed  the  aerentn  month  a  small  quantity  of  properif 
pre[)flre<I  starch  food  may  be  added  to  the  diet,  but  the  supply  of  milk  omH 
not  be  diminished  ;  at  tea^^t  two  pints  should  he  given  naily.  Undenkoa 
meat  pounded  into  a  pulp  in  a  mortar,  or  the  juice  of  raw  meat  majr  nhn  be 
given. 

The  only  remedies  that  are  of  any  senrice  in  rickets  are  troo  aad  «o^ 
liver  oil,  the  <i>rnier  beio^  the  mor«  inipirUtnt.  They  may  be  givca  togMbir 
— one  drachm  of  steel  wme  »nd  the  same  quantity  of  the  oiT  being  lakM 
lhr««  times  a  day  immeduitrly  o/terfood.  This  trealnienl  must  be  ountiaoei) 
fur  lUAuy  mouths.  An  ocvasiunnl  dose  of  rhubarb  and  soda,  or  compMBd 
li()uoricv  powder  may  be  necessary,  and  if  tbc  tongue  be  vory  furred  a  anril 
ijuanlity  of  grny  |H)wder  may  sometimes  be  added.  It  is  uf  much  irapor- 
lauce  iti  preveuling  dvtormity  iu  these  cases  not  tu  allow  the  child  tu  walk  or 
Bland  much,  but  lu  let  it  laku  cxtircise  in  donkuy-panniere  or  haod-cfaain, 
and  t4i  t>up|Htrt  thoae  UmUn  that  have  a  special  tendency  to  bend,  wilfa  pro- 
|>erly  conslrucleil  sleel  hU|>[Hirt£.  whii-li  will  Ite  found  of  much  itse.  proruM 
they  are  not  imi  heavy,  ami  do  not  interfere  uith  the  acUuu  uf  tbe  moselca 
Melhixlicnl  iriaion  nUo  t^hould  l>i>  eioployed  to  stimulate  the  muaclea. 

Combination  of  tickets  and  Sotury.— Attention  has  laulr  been  drawn 
by  T.  8miib,  Cheadle.  itud  T.  Barlow,  in  this  country,  and  MOller  aad  otben 
in  Germany,  to  u  dieeaae  occurring  in  young  children  which  is  charnrlcriMl 
by  the  following  syuiptnnis:  afler  a  few  days*  illneN, nniewhat  sudden  sw«tt> 
iog  take*  place,  evidently  in  conupclion  with  the  booes,  usually  in  the  h  ~~ 
eziremlties,  hut  snmetimea  also  in  the  upper  limbs.  Of  nil  Ixines  the  fei 
are  most  frequently  afibct^xl.  but  mo^l  commonly  the  swelling  is  not  li 
to  one  bone.  There  is  subcutaneous  a-dema,  varying  in  amnunL 
tendf-rnesB  forms  B  most  pruu>inent  symptom,  and  tho  siigbtMt  mori 
eviilcullv  causes  severe  pain.  Th«  limbs  consequently  lie  moticmlcas,  i 
dition  which  has  been  termed  "  pscudo-paralytts.  The  swelling  uf  the 
is  ubuhIIv  uiost  marked  near  the  ends  of  the  ahafU,  and  in  extreme 
the  epiphyses  are  found  to  be  separated.  Other  bones  often  beoooM 
sulteeqtieutly  t'l  the  tiret  appearance  of  the  disease.  There  ii  mwllr 
elevation  of  tem[>erBture,  but  it  seldom  exceeds  1U1.5°  F.  Kpongy  ifuma  an 
met  with  in  nhoat  half  the  coses  ;  puriiura,  biemnCuria,  and  subooiijuociira] 
bcnmrThag**,  have  also  beeo  noted.  Tue  child  soon  beooaiM  extremely  ao»- 
mio.  and,  if  Dot  properly  treated,  rapidly  emaciates  and  dies. 

The  total  cBsos,  when  exaraiucd  afler  death,  have  shown  that  the  pain  aad 
swelling  are  due  lo  a  copious  extravasation  of  blood  beneath  the  periostaum. 


08TK0HALA0IA— CArSE. 


817 


It  wi{)r>W  from  ihe  bone.  'ITie  diseaae  Km  Iwen  dcscrilnjd  by  Ger* 
n  on  "acute  riL-kei«."  hut  RhHow,  who  liiw  curet'ull}-  analvzcd  22 
MUn  Uutt  in  tbrc«  ihe  sijint  of  rick«tfe  were  verv  jironouoced,  iii  wvcq 
PiwWiitriy  well  marked,  id  nine  slijelit,  and  tn  ihrw  ub«olu(«ly  wnuling. 
B«  tfaMvfnn>  MQcludfiS  that  Ehu  8cur%-y  \»  the  vasentin)  part  of  the  diteace. 
BBfickcU  bciuK  m<ir«  ur  l«m  accidental,  and  at  ninel  fHvoring  the  occur* 
^Bl^  of  tbe  Mj lipvriofltcal  betnorrliag«B.  lu  every  case  the  dieefi8«  ceeiui  to 
^p>   '  iht>  efiect  of  imprx>p<.'r  feMliug,  cl>i«fly  an  insufficient  supply  of 

^pL  .'UtA.  and  want  uf  vi-gvlables  iu   ulder  cliildreu.     Barlow   iliQK- 

tStm  9ii^,^^s  the  naaiB  of  '*  infantile  scutTv"  for  the  disease.  The  treat- 
t  ii  iMuall;  Eucccasful  if  ibe  diacaee  be  recogniEed  Id  time.  Milk, 
Uvc-jaie*,  sod  frwb  vegetables,  with  plenty  of  fresh  air,  feoon  relieve  the 
irnptaaa*.' 

Hotxmts  otBitnt.    osteohalacia. 

A  moti  dotruclivc  and  daugvruua  disease  of  the  buuet,  characicriicefl  by 
■oAtfUOff  and  iimffilitr  uf  the  ussiMiufl  etruclure,  U  occafiionally  met  wjtli. 
Thk  aflmloD  has  been  studied  with  much  uttenlioa  by  (.'uriing,  Stilly,  ^lan- 
ky. Msrlntyn,  and  hiiunann;  and  it  'ib  principallr  from  thuir  laburs  that 
we  arc  acquaiiited  with  the  chief  facta  relating  to  iu 

Is  Om  dwcafle  the  huDes  are  bent.  f>r  their  shuibi  broken  in  various  parts 
lof  the  body.  OonnoDally,  though  verr  rarely,  only  unc  ip  fniclured  ;  but 
|iD  vUmt  eaais,  as  in  Tvrrolt'it,  tliere  may  lie  as  many  an  l.wpnty-two  fractures, 
iar,  ••  Id  Aroott'p,  i}iirly-rtDe.  These  frattures  are  unattended  by  any 
Bt  the  formation  uf  callus.  The  Ivxly  becomrs  singularly  and  di»> 
iogly  diatoried.  On  examioing  the  bones  after  death  the  periosteum  is 
■MS  la  be  usaally  redder  and  more  vascular  than  natural.  A  section  of  tbo 
baea  on  be  mdily  maite  with  a  knife,  the  oaseoas  tUBoe  feeling  soft  and 
BtttT  aa  it  is  cut.  The  meduttarr  canal  of  a  long  bone  ia  iucreased  in 
iMHMler,  the  spaceti  of  the  cancelfouB  tisme  are  enlarged  bjr  coalescence, 
■Aw  deatructioo  of  the  t>oiiy  tmbccutie,  and  the  compact  tissue  Is  more 
than  nalural,  from  widonJitgof  the  Hiivtrrsian  canaK  Howt;ver  ad- 
these  rbanna  mar  be,  there  is  always  a  thin  unaltered  layer  uf  cum- 
imiD«(Uately  wDsath  the  pertuetvum.  The  enlarged  caucelluus 
Uaveniao  canals  are  filled  wilb  an  uilr,  red,  grumous,  semilluid 
oe.  Ulcrosoiipic  examination  shuws,  according  to  Coruil  and  Ranvier, 
fat  cells  of  thv  medulla  have  disappeared  to  a  great  extent,  and 
ptaoe  h  occupied  by  »niall  round  cells,  spiudle  cells,  and  some  Hattened 
Hemurrfaa^fCB  into  the  medullary  substance  are  common.  In  the  later 
tbe  contents  uf  the  mtMiulIary  spaces  coutaiu  a  aubetance  resembling 
■plcnie  pulp  in  appearaoce.  and  the  cells  contain  numerous  pigmeiit> 
Ics  derivMJ  (torn  ttie  extravasatt.Hl  btm^.  lite  trabeculie  of  Iwrne 
a*  if  they  had  bven  acted  on  bv  acid.  The  lime-salts  have  disap- 
fptin  ())<'  Isyerv  of  bone  nearest  t)ie  venels,  leaving  the  Uasue  trans- 
it, abuwing  the  bone-corpu^ctes  jusrl  ss  in  bone  artificially 
iti  .  ■»  prooets  padually  advances,  and  is  followed  by  ulwiirptiou 
tt  the  liseaieifod  matrix,  while  the  corpuscles  either  perish  or  mingle  with 
Am  ealla  of  kb«  altared  medullary  substance 

Tba  isfiB  aeaile  mollities  is  sometimes  incorrectly  applied  u>  the  atrophy 
tf  aid  Afa.     Id  this,  hnwever.  the  enlarged  sjiacee  are  tilled  with  yellow  fat, 
I^mI  not  with  the  chanu-trristic  Uaiue  just  dMcribed. 
Ia  elMfliical  ooBpontiuQ,  the  diseased  bono  has  been  found  by  Lecaon  to  be 

For  tartht  Infonnaifaai  on  tbli  latcratloir  dlictte  Uie  reader  U  nrcnvd  to  ■  pap«r 
Harbiw,  in  the  M«dio(vCI)irurKi«st  Tran»«ctloui,  toL  Ixvi.  p.  IU*. 


STRDCTUBAL    CHAN0B8   IX    BOVB. 

compoeed  of  18.75  p«rU  of  animni  mntler.  29.17  of  pboe^pliate  and  eacboaaH 
of  lime,  tnrl  52,08  of  wator  iu  every  litimlred  parts. 

Cause. — ^Tlie  «iii8v  of  the  iwmpIniDi  is  obscure.  It  Kbb  bf«n  Mated  thM  ll 
ilBouietirnes  connected  with  a  rheumatic  teiidciiov  ;  bm,  In  prerr  cnae  reconU. 
the  ttlbctiou  has  been  precolcd  or  accninpanied  bv  severe  pntns,  rrflenblilg 
rhcumutisni.  Iu  Bome  inHtancca  the  nntieiiU  bave  been  affected  with  «}rpbnM. 
It  )iio«t  comnioitly,  thouj^h  not  invanubly,  occurs  to  females,  as  pointed  uat 
by  Kilian ;  and  in  a  mujority  of  cane*  it  appears  to  have  a  conDrcttoo  vith 
the  cbilribeariuj;  ttate.  Amon^  131  patteat*  whose  hiitohe*  hare  Uvo 
collected  by  Litzmnuii,  of  Kiel,  there  were  S&  females,  in  whf>ni  the  dtMMs 
either  apricared  during  prej^nancy  or  i>ra»  modified  in  it«  eounw  by  ihii  coe- 
ditioii.  Of  the  remftiQiii);^  46  pAtienu,  IU)  were  females,  and  11  tnalfak.  It 
voml  ^nerally  attaekjt  H'luttJi,  having  been  obsenreii  in  few  case*  uuder  tb* 
age  iif  'iO :  iind  ll  niav  oit-ur  even  At  very  advancd  age. 

The  Seat  of  the  DUease,  according  to  Litzmann,  varies  aooordlnx  ••  b 
occurs  wilhio  the  childbearinc  period  or  in>lo])endently  of  this,  lo  i^>  child- 
bearing  woraeo,  the  whole  BKcletoii  was  utlectci  ia  0  cases  ooly,  aad  all 
booes  except  thoeeof  the  head  in  two:  while  ia  46  other  cases,  alt  paru  uf  tW 
akoloton  were  diseased  iu  21,  aod  all  the  bones  except  those  of  tbe  bead  ia 
six.  Tlio  peroentage  of  the  occurrence  of  the  disease  in  vorioos  parts  a 
showu  in  the  following  table: 


P»lTi M  87 

Spinal  Column        , M  ST 

cnicu ft!  w 

Lownr  Limb 17  7* 

UppPT  Limb IS  62 

Had       .        .        .        • 8  SS 


I 


In  rbildbparinp  women  the  disease  appeani  en  have  a  remark! 
tion  for  l)i»  pelvitt ;  it  U  probable, howeTcr,  that  a  careful  exnm:..  ajl 

the  bones  has  not  been  made  in  all  ca^es. 

Shteofthf-  Urine. — In  all  ou»es  that  have  been  recorded,  the  urioe  bas 
Ikvd  fouurl  to  contain  laru;e  quantities  of  earthy  matter.  Solly  p>)iot«d  out 
that  thi»  is  phoephate  of  lime,  which  has  been  absorbed  from  the  boos,  sad 
thrown  out  l>y  the  kidneys  in  the  urine;  and  somelimes  the  eliminatiooof 
this  matter  is  so  abundant  that  it  tormfi,  a»  in  one  of  tlie  case*  which  be 
relates,  a  calculus  cloKgtog  up  the  inieriur  of  the  kidney.  In  Maclntyn's 
caw,  the  earthy  matters  of  the  bone  appear  (o  have  been,  in  tlie  fitvl  instasoe. 
absorbed,  and  carried  off  from  the  kidueys  by  the  urine ;  but  afienrards  aa 
animul  matter,  of  a  peculiar  and  apparently  previously  imdfacribed  char- 
aeter,  wa^  diechiirged  in  ubuudauce. 

Symptoms. — These  are,  iu  the  early  stages,  extremely  obscure  aod  ift- 
sidiou!^.  Tlie  patient  comnlains,  iu  the  fint  instance,  of  wandering  pains 
about  the  Untlw  and  trunK  which  a»ume  usually  a  rbeumatio  eharaettf, 
though  they  have  been  nljservtij  to  be  uf  a  much  mure  severe,  panialaal, 
and  intraciable  nature  than  those  that  occur  in  any  form  of  rluBaBBlim. 
The  patient  becomes  (Ichilitatei).  unfitlBd  for  exertion,  and 
Spontaneous  fracture  now  occurs  in  some  bones  under  the  influence  c 
most  trivial  causes  ;  others  hecottie  bent,  and  the  ImhIv  citiwe^iutuiUy 
misshapen  and  difitorlMl.  T|il-  deformity  of  the  ]H>lvb  is  a  frei)ueni 
difficult  lal>or,  often  oeceesitatiitg  Qesarean  section,  or  Porro's  opera 
The  acctahuln  are  approximated  by  the  weight  of  the  hiMlv  pmstng  on  the 
head  of  the  femora;  thus  the  oblique  diameters  are  ilimfnubed,  while  the 


TUK0B8 — BXOSTOSKS. 


819 


is  carrii^  fowanl,  tlie  horiz'iiital  rami  oilon  cotniii^  nvarlr  In  mntact, 
■tine  prcM>nU  hoiiic  uf  the  abuomial  cliunictcra  ubove  described,  and 
AflBth  omuly  en-utuallr  results  frani  ct'nt*ral  exhaustion. 

Btacwais. — Tht  diaguuM«  nt'  this  atf(.-ciinD  has  to  b«  made  in  (he  early 
■ttfw  ftDin  rheumtatiMm.  This  ts  not  alwaya  raav.  and,  iudefd,  ia  at  Hnt 
tmpo»ibig ;  but  atWr  a  tim«,  when  the  peculiar  pnoaphatic  cnttdiiion  of  llio 
vruM)  uid  tht- rrnfriliiv  nr  dutnrtionfl  of  the  osmoub  system  iDanite^t  rhfrn* 
«1tc*,  th«  tnic  nature  of  the  affection  heoomea  apfurent.  With  rirhrta  it 
1W»1*"^  pnariblr  be  confounded,  as  riokeu  in  a  disease  of  childhoijd,  and 
aOaoBuuaria  \»  pe<:ulinr  to  ndult  or  nitvanc-eH  life. 

IhmtaMtt. — '>Viih  reganl  lu  treat meDt.  hut  little  can  b«  done;  the  ad- 
BiaiMratioii  of  lonic«,  and  a  x^niTiil  »iipportin^  plan  of  lreatim>nt,  niav 
amat  f*>r  a  time  the  prngrem  of  thi»  terrible  aOectioii ;  but  m  hen  oncf  it  ts 
dadwl,  it  ufually  pr<>;:r<-;«)»ei4  from  bad  to  worse,  and  at  la^l  de^iniys  the 
|B(MBt.  Opintni  may  I*  empluyeil  to  aUay  the  pain,  and  in  >[ni-Itilyre'i( 
oiac  s<uD«  tftnfxrrury  advantage  seemed  to  result  frum  the  admiimlrntiou  of 
alom  ;  but  au  rviui:-<iy  has  appeared  to  exereieo  any  [H>nlinu(iu8  advantage  in 
thM  rvmplaiot.  Caaes  have  however  been  rvonrded  in  which,  aftur  very  ex- 
teanve  aafWiiing  of  the  buses,  complete  rtvovciry  has  takon  plaiw. 


niMORS  OF  BONn. 

ExcsTOHB. — By  ^xoBUwis  is  meant  the  gr«)WlJi  of  a  bony  tumor  from  some 
of  ibc  nf  mill  atnietaraa  of  the  body.  The  causes  that  immediately  give  rine 
lo tliia  diaaaw  an  uaoaily  extremely  obscure.  Thorecan  be  no  doubt  that  in 
■ocae  iniUseea  H  it  hereditary  :  but,  in  general,  it  occurs  without  nny  distinct 
or  Appreciable  exciting  cause.  It  ia  met  with  chiefly  in  the  young,  deveiop- 
inp  *tv.ul  tbeagie  of  puberty.  KxoatoaU  appear*  to  originate  in  two  wfty^; 
*•  -  r  primarily  formed  as  true  bone  developing  from  periosteum,  or 

U;^^  ,'..~  frtult  of  the  tiMtfiefltion  of  an  enehondroma. 

ExoMcta  are  of  two  kinds — the  one  bard  and  compact,  the  other  tofler 
•ad  Bson  ppoogy.  The  hard,  or  Ivory  £xottosU,  is  usually  single,  rarely 
•sUipte.  It  H  developed  from  Bbrous  tissue,  but  in  structure  diflera  both  io 
iMMtnuioe  and  compuaitioD  from  normal  bone.  It  ts  extremely  com[ncl 
■M  wfcitc,  baving  a  section  closely  resembling  (hat  of  ivory,  but  poMe^cing  a 
livt  boor  structure.  Haversian  canals,  lacunse,  and  lamella.  In  chemical 
soMpanllDD,  it  ia  found  to  differ  from  healthy  bone  in  containing  more  of  the 
firT|r''nT*  aod  lesa  of  the  carbonate  of  lime,  and  also  in  the  projHirtioD  of 
taaaaX  umlux  bnng  smaller.  This  kind  of  exootoais  grows  principally  fntm 
tfc«  111  tMiMf.  and  lower  jaw.  and.  as  it  is  generally  of  small  aizc,  seldiHn 
^vdttcn  murh  inconvenience,  unless  it  project  into  and  compress  im)H>rtiuit 
pvta  'nma.  (^wiuel  relaie^it  the  case  of  a  tumor  of  this  kind  gmwing  from 
tktt  pabir  bone,  aad  [wrfitrnting  the  bladder;  and  it  is  occasionally  found  to 
^■iirt  ioUi  the  orbit,  or  fr<im  the  inner  table  of  the  skull,  upon  the  brain. 
Wmd  rxfwUMts  u  lefi  to  itself,  it  oiuy  become  stationary  ader  a  time.  Id 
•oo*  fnataDroi  it  has  been  known  to  nccroee,  and  tu  slough  away,  as  it  were, 
Ambi  tbe  paru  in  which  it  baa  been  situated.  Of  tbia  termination  Hilton 
aad  Bttrer  rvlatc  instances. 

*IVs  ftpongy  or  Canoelloaa  £xoiU)ief  grow  mure  rabidly,  often  attain  a 
maxiJi  lahli  ■itr.  nml  >ire  vpr%- commiinly  muliiplc.  ^\  hen  multiple,  thev 
ar  ii-iil  in  their  omingemenl,  and  are  orcaainnnlly 

K.  iiiTations.     Exoaii^i-ttof  this  form  aro  di-veloped 

ftttat  •  'nr«  atmi>«t  invariably  at  the  line  of  jiiui'tion 

Ht  %a  '••  Mhnfl,  and  unually  tx-lWre  pulK-rty.      Wlirti  tliey 

Wfftmr  at  a  iatw  penud,  it  has  be«n  sugge^l^d  that  they  arise  from  a  |>ortioii 


320 


STKCCTUBAL   CHANQBS    IN    BONE. 


of  the  carlilnjje  of  ihe  epiphvBw  tlmt  hm  escaped  oasifioition.  Wlien  grow-' 
iiig  tlicy  are  oovered  witii  a  tliiii  layer  of  cartilage,  but  should  this  be*'«ine 
completely  ossified,  ^rowlli  ctaM-s  iitnl  the  tumiir  remains  stationary.  They 
are  then  composed  of  a  thiu  layer  ni'  ci^nipact  tissue  surrounding  ordinary 
caucellaii9  boiie;  opposite  the  biu-e  of  the  tutuor  the  uoriaai  compact  ttaaue 
ia  wautiog,  m  Uiat  the  caucellous  tiiseue  of  ibu  tumor  ib  coutiuuouM  witli  that 
of  the  booe  from  which  it  it  gruwiug.  The  vxuolotnM  uf  yuuog  8ubiect«  thus 
frettueutly  ceiue  to  iuui'ea«e  wh«u  geueral  growth  comes  lo  au  euu.  Those 
commeuciiig  afl«r  that  time  nhow  luure  coutiuuuug  growth,  ami  more  urgently 
require  surgical  ioterfervnvv.  Spungy  cxostoiicii  aru  usually  peiluucuTated  ; 
th«y  are  irr«gularly  lobulateii  ou  the  surfaov,  Bometimcs  ruwrnbling  the  head 
of  a  cuuliQowvr. 

Tht-ir  most  coraiuoo  aeatti  are  the  lower  end  of  the  femur,  the  upper  end 
of  tht*  tibia,  Hud  Ihi.-  tippvr  eud  uf  the  humeru*.  Theix  alructure  lius  been 
described  and  figured  with  Tuiuoni  (vol.  i.  p.  ^50). 

The  Htfmptoms  of  exosl-^i^  are  eiiuply  those  ]>rodueed  by  a  bard  and  slowly 
growing  tumor,  t^unueett^d  with  a  bunti  aud  puahirig  Ibrwardti  the  soil  parts 
covering  it.  In  iiiaiiv  ciutts  it  priidu(;<w  neriouu  iticimveiiieueu  by  it&  preeaure. 
either  upon  ueighhorine  organs  or  mui^tma  catial»;  [>r  it  may  uccaeion  ulcera- 
tion uf  the  Eikiu  lying  aliove  it.  In  aouic  cu^ch,  exostosis  of  a  long  hone  may 
be  connected  with  an  urroHt  of  ilevelopmeiU  of  the  boue  from  which  it 
springs.  Thus  I  have  seen  the  lower  third  uf  the  ulna  completely  arteited 
in  its  d«veh>pmeDt  by  the  formatiun  of  the  exostoeen  at  the  lower  part  of 
the  middle  tlurd,  the  boue  beitig  permauently  shortene^l  and  ilwarfcd  below 
this  point. 

Treatment. — If  an  exoetueiH  be  so  situated  as  to  occasion  incunvenience  or 
deformity,  it  will  be.  neces^iry  to  remove  it;  and^asii  is  a  local  dieeaae,  there 
i»  DO  fear  of  its  return,  provided  thia  be  fully  done.  If,  however,  the  whole 
of  it  be  not  taken  away,  it  may  grow  again ;  and  Stanley  aecordingly  recom- 
mends that  if  it  be  so  situated,  as  upon,  the  ^kuU,  tlmt  its  base  cannot  be 
extirpated,  potaaaa  fusa  or  nitric  acid  should  be  applied  to  the  part  tliat  is 
left,  ao  as  to  produce  exfoliation  of  it.  The  removal  of  tbe«  tumors  is  best 
effected  by  a  Hey's  or  a  chain  saw,  or  cutting  pliers,  or  a  chisel  and  mallet. 
In  some  situations,  as  when  close  upou  iointit,  or  springing  from  the  cervical 
vertebrs,  they  cannot  be  interfered  with ;  and  in  other  caacs,  as  occasionally 
happeuB  in  the  neighborhood  nf  the  orbit,  their  dcusity  nud  hardness  may  be 
lueh  that  the  saw  can  scarcely  work  its  way  through  them.  There  is  ooo 
variety  of  exostosis  which  deserves  a])ecial  flttentinn.  It  is  that  which  sprltigs 
from  the  upp«r  surface  of  the  ungual  phalanx  of  the  great  toe.  It  forms  a 
Bmall  rouud  mass,  usually  about  half  as  Inrgv  as  a  cherry,  projecting  under 
or  beyond  the  nail,  and  giving  rise  to  much  pain  and  tocotiveuieuce  in  walk- 
ing. Dupuytren,  wlio  lir»t  described  this  peculiar  variety  of  the  disease,  has 
pointed  out  the  treatment  proper  for  it,  which  cousists  in  exposing  it  by  a 
double  elliptical  incision,  ami  cutting  it  offwith  tbe  acapel.or  a  small  pair  of 
pliers,  without  amputating  the  toe. 

Encuonueomata  or  Caktilaoixous  Tumoks  ok  Bonk  are  oRen  met 
with.  Thwe  have  already  been  described  wheu  speakiug  of  enchondnjma 
and  its  pathology  (p.  947,  vol.  i.),  and  need  not,  consequently,  be  more  than 
alluded  to  here.  Tliey  usually  require  resectioQ  or  amputation  of  the  atfected 
bone,  according  to  the  attachments  and  size  of  the  growth. 

FumoMA  uh'  Bum:. — Fibromata  are  oot  common  in  bone;  when  they  do 
oooar  they  spring  from  the  periosteum.  The  situation  in  which  they  are 
most  frequently  met  with  is  the  baao  of  the  skull,  from  which  thoy  project 
downwards  into  the  ]diarynx  and  posterior  naree,  forming  the  disease  Known 


TOWORS^HTDATIDS — SAROOHATA. 


321 


as  fl(»rouB  pqlypUH  of  the  noie  ividf  Diseit&ee  of  the  Nose).    Tbey  are  also 
occaeitmnllv  iu«t  with  io  cooDection  with  the  jaws. 

Crorrc  IVmoks  ok  Bune  nre  extremely  rnre,  if  we  exclude  those  met 
with  in  the  jaw»,  which  time  in  oouuection  witli  the  teeth,  and  theee  io 
which  the  cyetff  are  merely  an  acciduutal  furniatitm  in  a  BuHd  tumor.  The 
cyetic  tumora  deecrihod  hy  the  older  writers  under  the  nnme  of  i^irta  Vim* 
tow  are  always  sarooiuatous  growihe  in  which  cysis  liave  developed. 

Nitaton  deseribes  simple  cy«l8  of  houci  coEitniiiiDg  a  clear  ur  reddish 
Kfoue  Huid.  and  lined  niih  ti  eniuoth  memhraut;  liuvin»  the  appcnrnoee  of 
a  •eroua  membruui-,  ua  being  (HTHsioitally  met  with  in  llic  long  bones.  He 
Matu  that  the  cy^Lit  uuiy  hu  unilofutur  or  oiuttilueiiliLr.  He  describee  but 
ona  cue  a«  tmvin^  (rome  under  hl»  Dlirtervaiioii.  The  tumor  orcu pied  the 
femur,  from  the  tn>chanler  to  one  inch  from  the  condyles,  uxpiindin^  tlio 
whole  shaft  to  a  gri'Hl  sixe.  It  vrnt^  v.iitn\mst'.tl  of  iin  agglomL-rnllua  of 
cyn«,  m(i>Uy  al>out  the  tiize  nf  a  wahint,  hiiiI  »e|mratii<l  f'runi  i-uir)i  oiher  by 
bony  septa.  The  c)'sts  were  tiI1e<l  with  n-ddiuh  ei-nini.  He  iftitte:!!  that 
two  similar  turooi^  have  lx*n  recorded,  one  hy  Ilreflchet  and  t>ne  hy  Travorfl. 

The  chief  symptom  is  a  slow  and  almost  pninleiiA  enlargement  of  the 
aSrctefl  bone,  forming  a  smooth,  round,  or  oval  growth.  The  skin  covering 
it  is  of  nornial  color.  When  a  cerlnin  sire  has  been  attained,  »o  that  the  dhell 
of  bone  iii  expnnded  into  a  very  tliiii  lamella,  and  before  it  is  perforated, 
presanre  on  the  tiinior  occnsious  a  peculiar  crnckling  or  rustling  noi»e.  like 
that  produced  by  pre«Mng  t'>gether  a  broken  egg -shell,  or  die  crackling  of 
tin-foil.  Under  this,  the  eTtsticily  or  even  wniifluctvialioii  of  the  tumor  may 
he  felt.  This  Utictnation  ia  particularly  innrkcfJ  iillop  a  time,  when  the 
o»eoua  envelope  has  become  still  more  expanded,  or  is  partially  or  wholly 
abnorbeil.  When  the  shell  of  bone  beconiea  very  thin,  apontaue^ius  fmctnre 
may  lake  place. 

OyBta  of  the  jaws  will  be  more  fully  deacribed  with  the  diseases  of  tho«e 
parte. 

Treatment. — When  the  tumor  is  very  large,  removal  of  the  affefted  bone 
may  be  necrawary,  but  if  it  be  of  moderate  alite,  so  as  not  tu  have  materially 
sllected  the  iatt-^*rity  of  the  hone,  it  may  suffice  to  remove  wue  side  of  the 
wall  of  the  cytt  by  the  trephine  or  by  excision,  and  then  the  cavity  may  be 
allowe<l  to  gniDulnte.  and  itt^  walla  to  contmct.  This  plan  i)ai»  proved  espe- 
i«ially  euccwKful  in  some  of  the  cystic  tomore  i>f  the  lower  jaw;  and  I  have 
i^tifled  it  Aith  success  in  a  ^iiiull  cyst  forming  in  the  outer  condyle  of 
the  humeruA. 

Hyiiatiikv — Cavities  are  occasionally,  but  very  rarely,  found  in  bones,  in 
which  largt*  numlxTs  of  hydnlldBarc  lodged;  according  to  Stanley,  both  the 
ei'hinococcuti  and  the  cji^licercua  cellulo(>R-  have  been  found  in  this  ti^ue,  hut 
Boct  frefjuenlly  the  furnifr.  In  tlu-i^e  cases  a  cy^t  forrne  in  the  boae,  which 
beconieis  ihiu  and  expanded,  re»L'mbllng  the  ordiuury  Quid  cystic  tumor,  hut 
which,  on  exatnrnaliDn,  is  found  to  concuio  the  parasite.  Trie  Treafment,  as 
Htanley  observes,  must  depend  on  the  «ilimiiou  and  extent  of  the  diaeaee;  if 
it  he  A  long  Iwinc  tlint  isatlectcd,  and  it  he  much  expanded,  recourse  must  be 
had  tu  amputation;  if  it  be  a  Hat  bone,  the  cyst- wall  must  be  scooped  out,  and 
the  CBvity  dressed  from  the  bottom  with  stimulating  applications,  so  that  it 
mar  fill  with  healthy  granulations. 

CABCOMATA  OF  fiONE — PiiIMaRT  MaUGSANT  TuMOES  OF  BoNB. — It  18 
SOW  generally  recognized  that  true  cftucer  never  originates  in  bone,  and 
that  the  tumors  formerly  clawed  a«  primary  cnccphaloid  or  scirrhous  cancer 
of  bone,  osteo-cancer,  i«teo-cephaloma,  etc.,  all  belong  to  the  class  of  sarco- 
mata. The  fiact  timl  lliere  haA  not  been  a  single  well-authentioaled  case 
of  primary  cancer  of  bone  recorded  ^nce  the  di»tiiictioa  belwecu  carcinoma 


TOt.   II 


-:ii 


323 


STRUCTOBAL   CHANGES    IN    BONS. 


and  earcoina  was  ck>arly  ciilnlilishcil.  b  strung  cvidL-nro  in  favor  uf  tit*  tW* 
that  all  true  f-aD<vr  ctitumeiioM  in  cunntrctiun  with  prccxiitUu);  riiitheliutt. 
It  w  tmly  in  siich  boDCfl  as  tlie  Miperittr  timxilla,  and  tlii»r  in  t-<>Qii<--<'lioB 
with  the  mucotu  membrane  lining  the  cavilics  of  the  fuiv,  tliul  tru<.-  i.-mnrtt 
is  commonlr  met  willi ;  and  here  the  itfueoiui  tiwue  iit  ioviilvnl  tta\y  Ity 
exteiiHion  of  ttie  growth,  ttie  primary  scot  of  the  disease  beioK  l^  uuwua 
oiembrnne. 

The  subject  of  narconui  of  bone  ha«  been  very  tborouehly  investifrat*^  by 
B.  Gross,  of  Pbiladclnhia,  and  by  II,  T.  Butliii,  of  Londun,  ruJ  much  ti|;ht 
bu  beau  tlinmn  by  tlieni  upiju  the  cliiiiual  and  pa lhul< luteal  fcnlurr*  uf  thta 
diaeaaa.  Fur  tlio  |)iir)K>»i;  of  cIiiMificaliou,  sarcomata  uf  Ikhic  kit  dividvd,  fiw 
into  oentrai,  BiJriu^iii^  fnitii  lliv  wiacidloua  ti«eu«  uf  the  ravtiullarr  cArial,  and 
periotteai,  suoperiotteal,  or  peripheral.  ari«iiit;  on  tbe  aurlWv  uf  tbe  compact 
Done;  BCcoudly,  thi>y  are  subdividixl  aocordiug  to  the  structure  of  tlw 
growth,  inU>  tpindU-ceiled,  round-e^deti,  mu^i  ^mdle-  and  tQund-ceUed,  imd 
_  mtfeioid.    Grvoa  makue  a  aeparate  dlvMoo 

fur  (Hitwid  or  oflsirylng  Barcuma.  and  an»- 
ratea  rarliliigiiinue  tumura  eiairely,  plaeng 
them  iu  aiiuLber  group,  l^iiio 
oHsifying  aaroumala  auu  choudr*»' 
according  to  tbe  form  of  the  oells  (*f 
round,  or  mlxeily  met  with  iu  the  gm 

M^^^f^  .  margin  of  the  tumor.    Thf  micni 

'  ~     /      _     8l-ruc:ture  of  these  varioui  fumuof  aarcoi 
•         y      jS      has  been  alrcadv  deseribfti  in  tbe  cbi 
on  Tumitrs  (vul.  i.  p.  dill).     GriiA  | 
the  fulloning  ns  the  relative  fn-i)urnc 

the  di^L-rt^ut  forma  of  Bsrcomn  aiunnL     

165  caats  afiocting  the  long  lM>Det  whirb 
formed  the  ba^is  of  bi«  [luper.  Crntrvl 
tnyt'loid  sarcoma,  70;  {icriocftoal  (wifriaic 
sarcoma,  43;  ceutral  «piudle-c«llcd  aar- 
comn,  IH;  pcrimteal  round-celled  auouBH, 
13;  ocDtml  rouDd-c>;lled  aarooiiim.  13; 
periuelvul  ipiDdlc-ccllvd  sarcoaia,  9.  Of 
all  foriDB  of  sarcoma,  out  of  149  caaes,  87  urcurred  in  lualei  and  ^  is 
feiQalcs;  and  of  147  io  which  tho  age  wo*  uoertaiaed,  110  oocurrad  Wfim 


CO 


SftrwMs  Tumor  of    8oai>ulm:     FIril 
RMurrvnu*. 


J 


s' 


FlR.  II  r^UlOTMPofrf^  OlwrMlan  I 


30.    Tbe  central  aplodle-celled  sarcoma  waa  tbe  oaly  form  that  Orma  fboad 
Bo  ooour  more  fluently  after  30  liian  befure.     Ill  almo»t  half  the  cas«t  iba 


TUMORS — CENTRAL    SABCOUATA. 


a2S 


duease  wu  attributed  to  injury.  The  various  long  booes  were  affected  in  the 
followinz  order:  femur,  67;  tibia,  46;  humerus,  25;  fibula,  13;  ulna,  7 ; 
radius,  6 ;  ulna  and  radius,  1.  The  fultowing  table,  showing  the  malignancy 
of  the  various  forms  of  sarcoma  affecting  the  long  bonea,  is  bo  important  that 
I  reproduce  it  entire. 


ramu  or  barcova. 


PSKIOSTSAL  : 

Spindle-c«1led 
KLiund-<!«lled 
Oisiffing     . 

CaXTKAL: 

Biiund-celled 

Smndle-celled 

Mveloid 


llCrBCTBD 

HBIOB- 

B0KI50 

BOCT 

PARTS. 


l!(PKCtaD 

LYHPHATIC 

a  LAN  US, 


RBCCRBED   [     I.trBcrBD 
LOCALLY  THE 

APTRK         '        SySTBM 
RKMOVAL.     SENBBALLr. 


per  cent. 

44 

60 
40 

66 

18 
12 


Per  cent.     Per  oetit.     Per  cent. 


0 
7.69 
«2.> 

8.33 
0 
0 


60 
60 
41 

25 

20 

8 


100 
66.66 
65.62 

33.38 
23.07 
22.72 


When  the  internal  organs  become  affected,  the  secondary  growths  will 
generally  be  found  in  the  lung,  and  sometimes  also  in  the  liver  and  other 
Tiscenu  The  secondary  tumors,  as  a  rule,  reproduce  the  special  features  of 
the  primary,  such  as  ossification,  calcification,  development  of  cartilage,  etc. 
(Fig.  517). 

In  C«Ltral  Sarcoma  of  Bone  the  tumor  springs  from  the  cancellous  tissue 
or  medullary  canal.  It  is  usually  situated  at  or  about  the  articular  ends, 
expanding  the  bone,  until  in  many  cases  a  thin  shell  only  is  lefl  surround- 
ing the  mass.     The  symptoms  may  at  first  closely  resemble  those  of  chronic 


Fif.  .'I^. — Myaluiil  Plate*  ur  tii&nt.cclli  from 
a  TuiBvr  of  the  Lower  End  of  the  Femur. 


Fig.  r>l'.i. — FuMform  anil  Oat-ibaped 
Cella  from  .Mjeluid  Tumor 


[Kri4>i-titi^  and  osteitis,  or  abscess  of  hone,  the  only  means  of  diagnosis  some- 
times being  the  application  of  a  trephitio.  In  iimitt  case^,  however,  th«^  pain 
b  noc  Sti  severe  sut  iu  chronic  itiflitmmiitory  uHt'otions.  It  lias  bt-on  pointed 
out  by  Ricbet,  and  I  have  oilen  had  occnsinn  to  verity  the  fact,  that,  though 
the  articular  end  of  the  bone  may  have  been  compietcly  destroyed  by  the 
tumMr.  the  cartilage  of  the  neighborin}:  j'liiit  never  bfciiincs  implicated.  Iu 
tbe»e  t-a.-'ea  the  clnsc  proximity  of  the  tiiiimr  to  the  joint  may  Ifail  to  the 
dtcvflse  bein^  niistalceD  for  white  ."welling  of  the  arlioiilatioi),  »!>  I  have  more 
thaa  ouc<^  )«eeD  hap|>en  iu  myeloid  sarcoma  of  the  lower  end  of  the  femur. 
Th*  cartilage,  however,  being  undeatroyed,  there  is  in  these  ca.-^c.-  usually  a 


32-1 


STRUCTL'RAI.   CHANGES    IN    BONE. 


ponsidprnWy  preal^r  degree  of  movernent  than  b  pnwihie  in  white  swelling. 
CentrHl  sarcomft,  so  !niij,'  m  the  diiwa»e  is  couIiihmI  witliiti  the  walls  of  l>one, 
rfevclops  hut  slowly  nnd  ahow.s  hut  little  tendeocy  to  iitftrct  the  i^ystem,  hnt 
wlifin  (Hire  it  ext^mis  heyoiirt  aiifl  iiiiplicutes  tho  8i>ft  part*,  the  tianwr  bo-i 
comes  greatly  iccrenjieil.  fipontaneotis  fracture  i^  not  uuciiitDon.  Central 
sarcomalB  are  of  four  kiufie:  inyel'jid  or  ciaut-tiellecJ,  spiudle-ctllecl,  round- 
celled,  and  mixed  epliodle-  aud  round-cclTed.    'Lhmv  are  further  modified 


Fig-  5J0.— CnWIed  Nudale  of  S«r>jom«  of  th«  f.ung,  «rfiiin<Iiir7  to  n  fimiliir  growlh  tn  >  Inog 
Bone  (ISK  ilUn.).  a.  IttcaMflod.  Tbo  (1*1.  Kraj  *ur(iM«  rcpicMnt*  tlie  CiiltitiC'l  8t/^oma. 
B.  Nat  docaldlI<4.  Sbowi  ibc  gli*t«iiing  bkn  of  Celolttd  8(nMDR  i^KMlng  bctvecD  the 
2t»oula.r  aellf,  •rbioh  ia  *omt  ]>nrU  aUokrc  aalolflrd. 

by  the  formatiDU  of  cyals,  nalciilvaliuD,  Dssification,  and  the  development  of 
cartilage.  Kighty-one  cases  collected  by  Butlin  fhowod  the  following  struc- 
ture: ruund-celled  22,  of  whicli  17  were  simple,  1  calciSed,  3  oaeity'ing.  aod 
1  fibroid  ;  spindle-celled  19,  of  which  15  were  simple,  2  developing  cartilage, 


W.- 


Pig,  S31.— SK(i>n*ton  «f  Low«r 
Bod  of  Foinur  by  »  VLftAt/A 
BarcoicB. 


(bewlnglhiDianDef  in  itblch  Cliebon«iiitivii]*d. 
It.  Tho  (l««|i  (urfiii:*  of  th«  HMtloa. 


and  2  midiied  ;  mixed-wile*!  22.  of  which  18  were  eiaiple,  3  ossifying,  and  I 
calcified;  and  myeloid  17,  of  which  14  were  »im|iU"  and  3  containeti  hnnjr 
spicula.  Acoorditie  to  Grwa,  if  the  long  btmeaoiily  be  considered,  myeluid 
tumors  form  a  much  larger  proportion  than  in  BuUin'a  table. 


surcuninU,  except  ibe  niyoloi<J,  lend  to  tliffuso  tbutumilveii 
tbo  uvdullary  uaual ;  the  luvflniil  tiiiiiar  oAt'ii  r«aiaios 
if  th»rp\y  liuiiunl  f>  llie  articular  end  uf  the  bone  in  which  it  com- 
■MtKwd.  Am  a  central  fjiruoma  grows.  iU«  ljon«  hocaiuo)  "  exiH)uilt»l "  by  it 
ttU  »  mmt  UkII,  uTtcn  dpiiciuil  ia  pujria,  is  left.  If  thu  tuinur  be  Tbry  »u(t 
ur  tuaiaiii  ejrila,  this  may  in  parte  give  the  eeiiuiLiuu  of  "  eggshell 
ersdOinK." 

la  peripkenij  ar  perioiUal  aoreoiaa,  there  is  no  expArtAina  of  bone.  Th« 
mmur  is  tron  the  Brst  clastic  aad  6x^,ooinaieuciag  usuiillv  at  une  side, but 
efkcB  at  a  later  |M-ri<>il  enilirn<.-ing  the  wholo  booe.  The  forms  of  san.'onia 
net  irith  ta  fiOesampIt^  o»IU>ctf(t  hy  Butlin  were  the  tolli>win)j;:  Round* 
eellad  30,  of  which  2'i  were  simple,  6  oMifyin;',  and  '3  developing  into 
CMtflagc;  s|^iulle-cvll<tl  22,  uf  which  13  were  simple,  3  r^^ifving,  and  6 
^twtJouiug  into  cartilai^,  which  iu  sume  ca»cs  were  subsequently  becoming 
mUbiI  or  oddSed  ;  mixed  round-  und  spindle-celled  28,  of  which  1 1  were 
WBpia,  S  oaufying,  o  calafyjug,  and  6  developing  cartilage.     When  the 


t  af  fittt  of  Fmor  mwn 
SfMkSMM  f  mrtar*. 


Pif.  »S4.— PcTlpb«r«l  S|»ladt»-Mll«d 
8«ivaHii  of  SImA  9f  P««ar,  nw- 


_   na^Bea  or  ralcifie*,  it  Aoe»  not  peDetnt«  deeply  into  the  coopaet 
i:  wbeu  these  rhflDfreii  do  not  tnke  place,  tbe  booe  oeountes  eroded  and 
i.rc  u  vtry  likely  to  on-ur.     The  pnin  flccinnipanying  a 
I-  is  uKiially  Im*  M>vern  than  llmt  of  a  reiitml  win-oma. 
coti>i lilt* nee  Bcc>'irdliiu  I'l  tie  nature  from  finii  nnil  t-liiotic 
In   X'niit*  ctt»*>   pulxatiou  iif  a   thrilllDi:  Itiiid.  with   or 
'     [HTCi'ptihlt',  (;*(wrially  in  iiii  nilv«nr«''t  ^Ui:*'  ^f 
I  I'urily  of  the  tumor  ib  greatly-  increaiwd.     Cysts 

I     an  DM  Mocoiaaion  iu  the  ndlcr  fums  of  sarcoma. 


BTRUCTI 


mANGES    IN    BONE. 


In.— Ontral  MrcoTna  of  boo^  in  iu  earlr  itagM  90  clowlf  rtaernhla 
j«  oiMlw  sHd  perio»titU  tlial  it  b  trequenti j  impuMlbl*  to  com«  to  a  «r> 
iwi  h^«uc!u*i<.>«i  MB  lu  th«  nature  of  the  caw  without  cutting  <1uwd  hd  thv  boot 
«iiU  applTiii^  the  trejiliioe.  la  the  later  stages  the  diaguiM>ii»  hecnni**  mnra 
mtfti  iWgrrAt  eiilnrgemeotof  the  booe.  the  nccurrroce  uf'e^-'bell  cnck* 
lbs"  *'°  pmaure,  and  D)or«  specially  pulsatiou  when  it  H  {inwuit,  luakiof 
Ik*  nature  of  the  case  clear. 

Pn>ni  ryttic  tumom  of  bone  the  diaKDOiLl  U  often  impaHtl>l«^  M  ihm  grtU 
uiajority  of  cyetA  of  bone"  (except  in  the  iawsj  arc  really  soft  nreomua  >Uk 
mt»  ilevelopf-d  ia  the  tumor.  It  is  only  by  cuultif*  intn  the  diaeaMd  put 
that  the  nature  of  the  discaae  can  bo  a^ccrtaiiiM).  From  dmam.9ftk»  nmfk 
herinyjnlnl,  the  illagnittis  \»  made  by  obserriti};  thai  the  joint  does  ik4  mm 
the  centrti ul'  the  sneliiog,  and  that  nioremeDt,alihi)ut{h  Iiniit2d, k  ooC palafitl, 


>^*  V/ 


# 


\ 


Fig.  iSX— llnpLltj   KrflwinK  Bmllfn)""'  Tii*  Vlg.  Mi.     Btultim  -t  r«|<<>|l^  frmml^  ■pfl^ 

Bu»r  of  Ute   llMii  vf  tba  tlvmarBi,  witb  aftit  T«Hir  ol   ll«<ul  of   Himnwt  "fV* 

SlMioUncoa*  FrMlaraor  lb*  SbalL  mJ  avil  fl*»d  of  llainvnii  dMtTujxIi  b** 

CBrlll«ce  or  lD<-T>*lkll<in  noaBWUd.  Tasttf 
AMird  Uy  Mhllfe  (•rtlcsl  Hdm— tba  P«rU^ 
tenni  ln«ldii  nkldli  onl/  ««r*  tb*  Ommv 

ami  a  uiiacciompauie<J  by  uniting  or  cmekliiig  in  the  arliculatiim.  i^oaM 
the  tumor  have  pcDvtrBtV'J  the  joint,  which  is  very  rare,  the  diffi«aUy  of 
diiiKii'«i«  bvoonirs  greatly  locnniiiMl. 

Perifdicrnl  Siirconia  is  tuuei  ft-pqiiently  mistakni  Air  a  dretv»pat«<l  dmmit 
ahitVMi,  but  the  nlwouoe  of  true  Duciuation,  the  pmence  of  a  routtdetl  ed« 
to  tlie  tumor,  atid  ite  fixed  attachnifnt  to  the  lione  will  usually  raable  tm 
Suri!<*on  Lo  rrco^'oizc  thi-  niiture  of  thi*  <l!fteate.  In  nil  donbtftil  f^M^  (he 
sweilint:  must  b«*  (ttincturtvl  wiih  nn  aapiralor.     Even  whfn  thi-  ■  if 

a  tumor  ift  evident,  it  ia  not  alwnvit  eaiiv  to  make  nim  that  it  i»  >•        '        ut 


TUMORS  — TEK  ATM  EST. 


827 


Kxaminaii'in  undfr  chloroform,  with  complete  reliixatioo  of  the 
V,  will  u»uallv,  liKViever,  overcontf  thin  dJUieiilt}'.  "Z^ 

Tbc  disgnoftii  frotn  uncurtwi  is  necfiwiniy  (inaUfudvti  by  auy  difficulty  *o 
ib  nc  i»  {•«rviiiii«  to  fluid  biootj,  uml  prescntB  the  characterB  tliHl  are 
ih  in  tliiti  (■•mditiuii.  Hut  if  Iht?  sac  hiivc  bet-ftiiie  cniiiu»|idal«I  by  the 
of  aIniltRe*!  Uriiikp,  aa<)  thui^  Imve  UMiuined  the  characters  of  a  sulid 
r.  it  tony  rradily  fDuu)^h  be  inistak^D  f<.>r  a  tumor  itpringing  frum  the 
ftruriur«.  flDi)  nnijiutaiion  has  occssiooally  been  pertbrmed  on  this 
•appnaiU»D  <iu  io  Fij;.  44 1 ).  I'lilsatiog  aarcoma  mnv  be  mintaken  for  aneu- 
run  ty  OMuilomon*.  In  such  chm«,  however,  ihi.-  hiiitory  of  the  pmgrew  of 
ibc  JtMua  will  do  more  to  ctuciilnic  its  true  onture  than  anythiiig  elae. 

Havinj?  aMeriainnl  iho  prceeoce  of  a  tnnior,  it  mnaius  in  dttermine  the 
umlmrt  oftMe  growth.  In  many  cams  this  cauiiot  he  done.  If  tbc  tumor  is 
■f  iIaw  ^>«ih,  very  firm,  of  ooostdorable  size,  lobnlatcd  an  the  surface,  very 
dearly  drfinrd. and  immoTsbly  Hxf<)  to  the  bone,  it  may  he  aeimplo  cacboD- 
dfoma.  If,  wilh  thf  f-nnie  Bym[iiiinip,  bowcver,  it  h  uf  mure  rapiti  gmwth,  It 
V  b«  a  Mrcoms  developing  into  cnrtilago.  The  dintinctinn  ts  very  inipor- 
if  it  csiu  bf  inad^,  for  n  iimptechondnima  it  an  innocent  tumor,  and  the 
in  removing  it  may  carry  hi*  knife  close  to  the  grnwih,  hut  a  ebon- 
sarotjma  '»  usually  very  malignant,  and  amputation  must  he  Hone 
hoxv  lU  Uuftirlunniely  thedislmclion  is  often  inipne^ible.  When  tbc 
ta  cVQtral  and  t>ittinte<l  at  an  articular  end  of  a  long  bone,  e»f>ecialiy 
upprr  end  of  the  libia,  tlie  lower  end  of  the  femur,  the  iip|)er  eml  of  the 
WTMf  tir  the  lower  end  of  the  ulna,  or  on  the  lower  jaw.  the  chances  are 
gmt  -  T  of  ite  l>eitig  a  myeloid  or  giiint-celled  i^nrcoma.     According 

10  Gr  .  Iv  70  per  cent,  of  the  cvutrul  tumur»  of  the  long  bonev  are  of 

tkii  Dftuirt- .  Myelnid  tumurB  are  often  Homewhat  gtobtitar  in  form,  and  cTEts 
an  Tcrr  mmmon  in  them.  Thev  commonly  occur  between  '2o  and  'i5,  and 
fTDV  iftiwly  without  BlTectiDg  tlie  constitution.  When  the  central  tumor 
"leta  tbr  shaft  of  a  booe  it  la  probably  one  of  the  mure  maligtiaut  earco- 
ita.  eithff  round-celled,  Epiudre-celled  or  mixed,  myeloid  being  very  rare 
■ttoatioD. 

ipberal  farmmaln  cannot  be  clearly  ftietinguiKhed  fnmi  each  other. 

nerer  commences  MiperGciatly,  and  may  therefore  be  excluded.     If 

phatic  gtaode  arc  adeclcd,  it  i?  most  pnibably  a  round-celled  sarcoma, 

ndle-rellrd  form  very  rarely  epreading  in  thin  war.     All  forms  of 

teml  BBrcoma  may  equally  implicate  the  Biirroundiug  soft  parts. 

lopliabiDg  between  the  benign  and  malignnnt  tumors,  Paget  rtirccta 
tn  the  tuIIoiA-ing  tHjint^.  I.  The  a;:'?  of  the  patient.  If  below 
y  or  pogt  middle  life  tJie  tumor  h  prnhahly  malignant,  unle^d  it  be  a 
.ojfui  ti.»t<*is.  *2-  The  age  of  the  tumor.  If  of  more  than  two  years* 
^lumlt'Mi,  it  >■  probably  ma  r»iili',:buiii.  'i.  If  a  tumor  of  booe  have  doubled 
ttasize  iu  lix  niNnilut,  Dot  bt-iu^  inftamed,  it  is  probably  maligoaat. 
Trtatinent— Tumor*  of  boor  aro  neceautrily  beyonil  the  reach  of  con»li- 
i  ..r  l,.iiil  rvsdlri^ulH.  Surgeiina  are  con>e4|i)eDlly  ubligeil  to  re»irt  to 
'^rrviice.  Tf  the  tumor  be^irnple,  it  mav  be  powible  to  remove 
,  _  ....  .  „~t»  hv  gouifiug  or  cutting  it  out.  but  if  it  be  one  of  the  malig- 
t  anrcimuita,  tne  onlv  safe  course  coasistf  in  removing  the  whole  bone 
which  it  vpringa.  If  from  the  l"caliw.Hl  nature  of  the  growth,  its  origin 
■taa  articular  end  of  a  bitiM*.  and  its  central  jioettion,  there  is  rcusou  to 
ballet  ''ii<l  or  giant  celled  llln^(^»ma,  it  may  be  suflieieni  to 

fcaso'  '   thine  only  frtim  wliieli   it  gniwii.     In   the  teg  this 

aaa^^  imtaiwu.  but  iu  the  lower  end  of  the  radius  it  is  H<niclimni 

rill'  -  iM>  tfaeaflecirti  part  of  the  bone  without  removing  the  limb. 

tnuorft  M'  the  lower  jaw  it  u  seldom  ne<vM>ary  to  remove  morn  than  half 


8TBDCTURAL   OHA^TOXS    IK    BONE. 


the  bone  ti  mmu  If  part  of  the  ban«  only  be  removed,  the  Mm  aoHum 
and  medullary  canal  mu»t  b«  carefully  examined,  and  if  U  doc*  do*  appear 
heultby  morp  luusl  bo  t-iil  awny. 

If  tliti  tumor  be  |>uri[ihera[,  or  ifit  be  a  central  i  arcoma  of  any  kind  otber 
tban  myeloid,  do  oieuns  avail  except  tbe  complete  rernoval  uf  tbe  diiuaauj 
boDe.  Tbeae  operations  are,  however,  not  very  prouiUing,  mt  there  arv  Urw 
forms  of  malignunl  tumor  in  which  Uie  dtseuc  relunw  tourc  r:--  t 

tetNiudftry  manner  than  in  that  of  tbe  bonee.     Tbe  rafndlty  ul    i '  it 

will,  bo«e%'er.  greatly  depend  upcm  the  form  of  tbt'  iliseaae.  oo  tbe  timr  yium 
ampviiUion  \i  perfurmeil,  and  on  the  part  where  it  ia  practised.  AmputailuD 
shfluld  al«ay^  if  piffisible,  be  performed  in  tbe  earliisi  stngo  nf  the  il< 
before  gesenU  infection  faae  set  in.  If  the  glands  he  enlarged  and  i-a.  ..v  i.. 
be  already  present,  little  can  be  expected  in  the  way  nf  tiltimati'  cure  ;  y«t 
I  have  known  cnaes  in  which,  even  in  these  unfaTorahle  cirfumsiancra,  ibe 
|.palient«  have  miule  a  good  recovery,  life  having  been  pn)liinge>il  Rir  muDtfaa. 

The  ftoli'utiou  of  the  line  at  which  umpuiatirm  ehouhl  he  perfnrmrd  ■■  af 
Kreai  iniiHirtance,  and  the  nvull  will  nmlerlally  depend  upon  tlie  judgnMil 
dinplayed  in  thin.  If  the  limb  be  remove^l  in  thf-  c^intinuity  of  the  ilJiiiaard 
bone,  there  must  necessarily  he  a  great  prohahilily  of  a  very  rapid  relani 
nf  the  t;r<^*wth  in  the  stump;  and  thi.*  prohahility  amountJi  |/i  u  i- 
theao  nincH  in  whieh,  the  di!>eflju<  bein^;  central,  ihi-  whol«<  of  tbt  < 
canal  and  (-ancel)oti:<  mniclure  are  in6ltraled  by  the  tumor.     In  ras^  «1 

rriphcral  <li»ea»i\  ihii*  return  in  the  same  bone  may  not  take  place ;  indcrd, 
have  M>eii  one  iilM'  of  thf  kind  in  ivhii-h  the  HiM^W  at1i-^-(<-<l  tbt-  lowtTrnd 
of  the  tiliia,  and  that  Ume  via.!  amj)utaled  in  ilo  ujiper  third  ;  in  this  cue, 
Icr  a  Ia|iMt  of  some  mouths,  fatal  recurrence  of  the  dieease  liwk  place  ia 
^tfae  |>vlvic  bones,  but  not  iu  tbe  Hump.  Aa,  however,  the  peripheral  ii  mon 
ire  than  the  central  form  of  the  uisease,  and  aa  there  are  no  meaiM  of 
aecertniniug  tbe  precise  kind  before  removal,  tbe  rule,  1  think,  abcnild  be 
detiuile  to  amputate  at  or  above  the  next  joiut — at  the  hip-j"int,  id  roalig- 
oaDt  disease  of  thu  femur:  in  the  thigh,  for  that  of  the  boaea  of  the  leg; 
and  at  the  shoulder,  when  the  upper  arm  i»  afTerttvl.  When  the  lower  part 
the  femur,  however,  is  involved. ninpulation  throu^^h  the  tmchantcTB  may 
llDKimca  be  ftulmtituuit  tor  disarlirulatinn  at  the  hip-joint,  the  tatter  opera- 
tion beiu);  Ao  formidable  and  ro  iHtal  that  tbe  t>urgeon  mar  think  it  a<t- 
^Tisable  not  to  subject  the  patient  to  so  serious  a  risk  ;  or  ampuiaii>>D  mtgbl 
be  performed  ihrou^rh  the  trochaotere,  and  tbe  head  of  the  bone  tbon  reseccetl. 
In  this  way  the  wverily  of  the  operation  and  the  extent  of  wound  woald  he 
lessened,  whiUt  the  whole  of  the  diwased  bone  would  be  removed.  In  caaei 
of  myeloid  tarooma  it  ia  not  usually  Decenary  to  remove  tbe  whole  boas,  as 
the  disease  almoat  invariably  begins  in  the  articular  enda,  and  very  rarely 
exteuda  far  into  the  medullary  canal. 

In  some  forma  of  malignant  bone  diaease,  however,  the  muscles  Inserted 
Into  the  afrtrcletl  booe  l>ccoitte  apeodily  oataminaUtl.and  this  i.'ODtAniinatioa 
may  spread  widelv  ibnxi^h  (he  substance  or  alujij>  tbu  abeaih  of  ouy  par> 
tivular  tnuBcte.  Hi-nL-t;  1  think  the  rule  iu  these  case«  should  be  tu  am|Milats 
Dot  only  above  the  diseased  bime,  but,  if  practicable,  above  the  uriuini  of 
the  uiuwlee  iu  the  n«t):h))orbi>iM|  uf  the  di^east- :  thus,  if  there  be  a  mnli^tiaat 
tuuiur  of  the  bou4«  of  the  fureanii,  am|>utnti<jn  i>bould  be  done  not  only 
aliovi-  ilie  elbow-joint,  but  above  ibe  humeral  altacbments  of  the  muscles  w 
the  lor^iirm. 

The  |in»priety  of  ezmToft  of  sonw  bones,  as  of  those  of  the  face,  in  thb 
disease,  must  deiwud  oo  whether  the  morbid  growUi  la  liinitt-d  to  the  slrue- 
tures  that  can  tw  excised.    This  operation  can  rarely  lie  advaotagvoualy 


PUL8ATIKO    TUMURS   OF   BONE.  829 

pfvctiied  ID  iDMltptBnt  lumoni.  then-  U-iug  in  guiienil  too  great  an  implica* 
Uoa  of  tlw  9oU  t^tnidurea  in  tliv  ut:iglilii>rh(iiMl  tn  justify  it. 

£vx>iiDAKV  Sauoimata  Of  BoNc. — All  iiiHliKitnnt  ^rconmtn.  whcrover 
■niag»  «b«a  ihtj  beoome  genf^miir^l,  may  r<iriii  Pccondttry  gronllie  id  the 
hMH&  Thm  in  n  nee  of  sari^mm  of  tiiv  brpust  under  my  care  aome  yenre 
■KO,  ilw  final  mull  wiu  due  to  a  5«ciiu(tary  tumor  forming  in  ilio  stemum. 
Xdbuwtic  nrcoma  not  unfreaiiently  gives  rise  to  iecondary  tumors  in  the 
aMalnllft  or  canoelloiu  tueiie  ol  lione. 

Tmiji:  Ca?»cb«  ob  Cakcinoma  ok  Husk  is  nlwaya  secoodnry.  ScirrhM, 
*tM»  it  beef'im«ft  geocralizrd,  not  unfrequenily  gives  rise  to  a«ix>u(lftry  luiuurs 
«t  buse.  Fivif  CAM4  of  ihia  kind  have  occurred  laleiy  in  UoiTcnity  Gille^e 
HuHEMlal.  which  arc  good  exanipl»  of  this^  Four  occurred  after  c-xcii)itin  of 
the  br«*M.  In  two,  the  KcondAr}-  tumor  formed  in  the  7crt«bn«,  in  on«,  iu 
tb«  rib*,  and  in  one,  in  the  lemur.  In  the  fifth  enee,  in  an  appunotlly 
b«^thf  tnta,  th«  upper  jaw  was  excised  by  Miircud  Bet-k  for  nhai  was  Aup- 
pui«d  iu  h*  a  [tfimarr  tumor  of  tbi^  nuter  part  of  the  upjri-r  maxilla  and  ihe 
nnlmr  b»ne.  After  death  a  primary  Bcirrliu»  cauLtfr  vt'  ibu  pancreas  was 
imtmd,  awl  tin-  tumor  of  the  javr  preaented  the  same  structure. 

Jtahhelioma  of  buue  rarely  i>ccurt  aa  a  secoudary  growth,  it  is  luually  Uie 
nmlt  of  direct  exleosiou  froui  the  primary  tumor. 

A  Tvry  rare  form  of  malignant  growth  b  ocvaaionally  met  with  in  Ihe 
thymitl  budy,  which  almiwt  exactly  resembles  the  normal  gland  iu  structure. 
Il  haa  a  peculiar  teutleucy  tu  give  rise  to  eecoudary  tumors  of  the  Mine 
tfncutrr  in  the  bonea.  Cafes  of  tliia  kind  have  been  recorded  by  Colmheim, 
Sbvria.  and  others.     Id  some  cases  they  have  pulsated  strongly. 

Atl  Mcnadarj  cancentus  tuinore  of  bone  are  oenlrul^  L-ommeuciug  cither  in 
ihr  nmloHa  or  cawcellouii  tiwue. 

PtxsATiso  TcnoBs  OP  BoNK— 09TEO-ASEUIUBM. — Palaotiog  tumors  of 
hnae,  or  osteo-aDeuriam^,  are  ii  mixed  group  of  growihe  powMcaing  in  cr>mmon 
obIt  ooh  ffsiure,  thai  they  puli-ate  t^truiigly,  eo  an  in  some  caaee  almoat  tu 
riMwlilr  a  true  anruriiim.  The  grtal  majority  of  tiiese  are  aoA  vtu>cular 
««vMiiia£a,  in  which,  as  Billroth  has  pointed  out.amall  auouridmal  dilitlatioDl 
sav  exbt  no  the  vf«M>l-t,  whteh  form  a  cinw  network  throughout  the  maaa. 
Qr,^  mi-xt-i-*  that  pulftatiou  wa^  prewnt  in  20  per  cent,  of  the  myeloid  lumon, 
1.  .it.  of  tiie  (Antral  HpiiuIIc-celleil  growths,  and  S'-i  per  cent,  of  the 

c»  .    iiml-rt-lleii  gareomalB.  of  which  he  had  conecled  the  recordi*.     In 

prr.hhrr-i!  MrroRiata  pulsation  wan  very  rare.  Ic  ia  evident  that  ptiliuitioa 
tMitnvt  tw  recognised  to  central  tumors  until  the  bony  wall  Ime  been  com* 
plMflly  dalmyed  at  one  aide,  and  it  is  |XN>»ihle  that  the  fretjuency  with  which 
oaCral  -  [rulsatc-  divLinctly  may  bu  due  to  the  ftict  that  tlie  vm-cnlar 

■■■  ..  umr  IB  Hurmuuded  on  nil  side*  but  one  by  iiiiyivldiug^  huttv. 

Eidudtug  all  thi-ae  vases,  Lwg  uther  kiuds  of  pitJBitlia;:  tumors  have  bocu 
Jtaeribvd  aa  iiccurring  in  bone.  Iu  oue  uf  these  wbiih  is  verj*  rare,  there  is 
drrwloped  in  tha  buD«  a  structure,  which  is  uonipt^eil  of  a  vawnltz  sreotile 
UVaUt  chwrly  rcBembliag  a  capillary  uicvua  iu  slrucLure,  composed  of  an 
■iaiXT  of  vtikK  interlacing  in  every  way,  so  as  to  form  a  sod  reddish 
'(Fig.  527,'.  In  theaeoond  form  a  htillow  cavity  i?  formed  in  a  Iwme, 
d  oat  of  the  caDoelloua  vtrurLum  and  (illed  with  hloo<l,  partly  liauid 
lairtlT  coagulated,  nod  having  arterial  branches  opeuiiig  intuit.  The 
•bell  of  bone  lurrounding  this  cavity  is  very  thin  and  expanded,  and  afiera 
UM  la  ucDallr  completely  ahsorlH'd  on  one  eide-.  This  constitutes  the  "trat 
m  of  bona."    Iu  mode  of  nrixln  ia  un 


origin  ia  uncertain.  Volkmnnn  suggceti 
ikat  tft  aone  cases  it  nay  be  a  soft  snrcuma.  the  original  tiaue  of  which  has 
hmn  cBtlrelT  loAeAed  and  brukca  down  by  hemorrhage  into  ita  lubstflnce. 
Socb  caasa  'are  extremel;  rare,  and  until  some  have  been  recorded  with 


STRirCTCBAL    CIIAKOES    IN    BOMK. 

Acciirati*  mirroscopic  exnniiiintiitn  of  (lie  c(»niiitnM  cliH  and  ihe  inrTouniJia( 
hoiK?  wc  muet  hwitatc  to  form  «ny  opinion  of  llu'ir  Iriio  nalur^. 

Situation. — Piitonlmg  futreoniAtn  niity  Ko  Itiuiirl  nnvwhi>ro,  but  «it  nx*! 
comiiiiiii  ill  thf  b(.ncA  of  ilio  «ktti!.  tlie  lower  end  of  the  tibia  an«l  up(H:r  •i»«J 
of  iho  fi-nuir.  Njevoid  jfrowthfl  are  mort  ciinwiion  oti  lh«*  »kiill.  Thi*  "troe 
aneiiriaiii  of  houe''  lias  l>c«n  Mttl  tn  occur  mo«>t  frcqut-titJy  in  (he  bt-aU  ••!  ibt 
tibia. 

Symptom*. — Wlion  liie  tumor  is  merely  k  tnglily  vASCulftr  tarocAia,  ||» 
vympl'initi  tlml  il  gives  rifu^  to  arv  I  be  v&mv  as  btive  nlreAily  bern  drarrihrd  M 
iudiL-utingn  c-vntnil  eMruoniti  ofboDe,  with  the  Htldttion  uf  piiUatioo  sml  Imut 
In  these  the  piilEntioii  ia  very  ilisliuct  bdiI  KujierHcial,  am)  ciimmDoly  ufs 
thrilling  eharni'ler;  it  may  be  di»liuctly  expaueile  in  chiiracli-r;  the  bruit  « 
usually  Boh  nnd  blowing,  but  not  ut)tre<]uent)v  hiinh,  Inuil,  nnd  nhmuiir' 
In  true  osleo-aneuriBni,  acconling  to  ^'Slaton.  tfte  bruit  ie  ollcn  BttfraL    U 


•  /. 


;^^^-: 


■V«v^--'^-~ 


t 


Fig.  &ST.— AiMartata  k/  Aaactovoiii  of  Om  «f  tk«  Pwlital  Bokm. 

palsatto);  lanxtniata  I  have  henrd  the  bruit  peculiarly  loud,  rough,  snd  hidw 
Dcial.  Ou  compreasing  the  luaio  artery  leading  to  the  part  of  tbe  Iiidd  in 
which  llie  tumor  is  aitualed,  alt  niovemeut  and  bruit  eonitnonly  ceafe  in  it, 
and  the  tumor  lessens  in  biic.  By  preaeing  upon  the  grt^nth  when  II  b  thai 
ditniniahvit,  if  it  be  a  "true  aneurism  of  bone. '  it  will  coiunionly  be  found  to 
hnve  a  liouy  margin,  with  a  central  depression.  In  some  csjea  the  tuizKir  ii 
fed  br  euvi-nil  arterial  hruiiclio»,  which  uiiiy  be  felt  distinctly  pulsating  undw 
the  KKin.  Thi-  bt  nmre  imrliculnrly  the  ca^*  in  wtt  luireiini&ta  occnrrio, 
the  bonoK  r.f  the  pelvis  and  the  Ki>uputa.  nnd  then  the  bruit  and  pU— 
canniil  he  tnnilc  to  ceane  in  It.  All  ihi-vc  -Igns  ure  cornmonly  aomr' 
■ntermillrnl,  the  pnlnation  upfMaring  {H-r)iapf>  in  the  earlier  stnprn 
disease,  and  diHflp|)en ri ng  an  it  advunctv;  or  the  ruvuree  tnny  ixTur,  ihr  pal- 
wrion  and  bruit  becoming  diatinct  bi>  the  diiteiiM  inoreAMB  in  aixe,  and  raerti 
with  mure  revistJince  in  ita  ontwnnt  growth. 

{Hagnoti*. — U  is  of  considcmble  imptirtance  to  diagnose  the  diffmnt  forais 
of  pulBaling  tnnior  of  bone  from  one  aniriher,  ba  noth  the  treatment  and 
prngntttiit  Hitfer  acconling  »»  tlie  dtseaM  i»  a  "true  aneurum  of  honr."  or  a 
pulMtting  fart-oma.  The  true  iMteo-aneuri^m  U  m  rare  that  itJt  extaieacsi  k 
oAeu  denih^l,  nnd  should  It  be  met  wilh  it  will  have  so  many  t\pxi>  in  ctiOi* 
muD  with  Die  pulaating  sarcoma,  thnt  it  will  be  nlmn«t  impoMtnle  Xo  trS^A 
tb«  diagrnmiM.  It  is  well  to  beHr  in  mind  thnt  the  nialignaat  anrcomata  ire 
aometiriies  multiple,  ooourriug,  with  nutsation  ami  brnit,  in  more  Riiiiat)i''m 
ihuu  one;  tbns  1  hove  seen  );row|lis  of  this  kind,  with  iheir  si^ue  w-ll 
otiu-ked,  tjiriuging  both  from  the  pvlvts  Knd  frum  tbe  ribs.    Tbo  iruo  oatco* 


PDLSATINa    SARCOMATA^TREATMENT.  881 

■oeurism  has  been  described  as  occurring  only  in  the  articular  enda  of  long 
hunes  :  wbereaa  the  malignant  disease,  though  conimoniy  occurring  in  theae 
■ituatioDt>,  is  also  frequently  found  in  other  parts  of  the  body.  Besides 
these,  there  are  two  conditions  which,  in  many  cases,  will  enable  tlie  8ur- 
fcvon  to  determine  that  the  pulsating  tumor  is  an  osseous  aneurism  :  viz.,  the 
aheence  of  all  bruit,  though  the  pulsation  be  distinct,  and  tlie  detection  by 
firm  pressure,  after  the  tumor  has  been  diminished  by  compressing  the  artery 
leading  m  it,  of  an  osseous  margin  around  its  depressed  centre. 

From  ordinary  aneurism  the  diagnosis  of  ptilsatmg  tumors  of  bone  is,  io 
many  case*,  attended  by  almost  insuperable  diHiculties.  So  great  are  these, 
that  there  are  many  cases  on  record  in  which  the  most  experienced  Surgeons 
kare  ligatured  arteries  for  tumors  that  were  supposed  to  be  aneurismal,  but 
which  have  turned  out  to  be  pulsating  sarcomata.  A  principal  point  to  be 
attended  to  in  effecting  the  diagnosis  is  the  situation  of  the  tumor,  which 
mar  occur  away  from  the  ordinary  sites  of  aneurism,  in  parts  of  the  body 
vher«  there  is  no  vessel  large  enough  to  give  rise  to  such  a  disease — as,  for 
iwtance.  about  the  head  of  the  fibula  or  the  outer  side  of  the  pelvis.  Then, 
aemio.  its  incorporation  with  the  subjacent  hone,  the  want  of  a  distinctly 
limited  and  circumscribed  outline,  and  the  existence  in  many  cases  of  plates 
of  bone  io  the  wall  of  the  tumor — giving  rise,  perhaps,  on  pressure,  to  the 
peculiar  rustling  or  crackling  sound  characteristic  of  central  bony  growths 
— will  enable  the  Sui^eon  to  come  to  a  conclu.^ion  as  to  the  true  nature  of 
the  tumor.  In  this  he  will  be  further  assisted  by  its  having  on  compression 
a  toft,  doughy,  or  spongy  feel,  or  appearing  as  a  depression  surrounded  by 
an  oeseous  niai^in.  In  many  cases  al8<k,  the  less  impulsive  character  of  the 
beat  of  the  tumor,  the  peculiar  shrill  and  tremulous  whiz  in  the  pulsation 
and  bruit,  will  throw  much  light  on  the  nature  of  the  disease.  But  it  can- 
D<>t  he  doubted  that,  when  tumors  of  this  kind  occur  in  some  of  the  ordinary 
situations  of  aneurism,  as  about  the  brim  of  the  pelvis,  and  in  the  popliteal 
ffpace,  the  diagnosis  is  surrounded  with  difficulties  which  no  amount  of  sur- 
gical skill  or  ^ct  may  be  able  to  overcome. 

From  orHinarjf  tumon  of  bone,  the  existence  of  pulsation  and  bruit  will 
alwavB  suffice  to  distinguish  the  growths  under  consideration. 

TriMtment. — Pulsating  sarcomata  of  bone  must  be  treated  exactly  in  the 
ame  way  as  thnee  that  do  not  pulsate. 

Ligature  of  the  main  artery  has  been  practisted  in  several  supposed  cases 
of  "true  aneurism  of  bone,"  but  in  the  majority  of  these  the  disease  turned 
oat  to  be  a  soft  sarcoma,  and  consequently  no  benefit  resulted.  The  growth 
of  the  tumor  was  not  even  retardc<l.  Roux,  however,  has  reconle»i  a  case 
in  which  he  cure<i  a  pulsating  swelling  in  tlie  lower  end  of  the  radius  by 
lifcacure  of  the  brachial  artery.  Jjalieiniuid  riired  a  so-called  Bnpnri*m  of 
hooe  hy  the  same  treatment.  In  a  patient  of  Oiipuytren's  no  return  of  the 
difea^w  tnok  place  for  six  years,  when  it  recurre<l,  and  amputation  became 
■cceasa  nr. 


Dl:iEAS£S   OP   JOINTS. 


CHAPTER    XLVIII. 

.  DISEASES  OP  JOINTS. 

TuK  Tiirioua  jmals  of  the  body  oiny  become  the  scat  of  lattaaiaistury 
Aflvetions  of  as  acute  or  chrouic  cbaracler ;  of  .Strumnaa  l>iw>mM>:  <:ir  vT 
various  other  morbid  cotidilioas,  such  tu  wore  nr  1<2m  pvrninm'Dl  rigiditr.  or 
AnkylosU.  the  foriuutioa  of  Foreign  Bodies  within  their  cariticv,  uihI  Nca* 
mlgift.  lu  oiutlriiig  these  variouk  articular  uHklioDti,  !(  must  be  boraa  a 
tuiiiil  (hnt  a  joint  ie  c«)iupuiied  of  a  uumbcr  of  ditloreut  liuuea;  of  synoTiat 
utembrnne,  cartilage,  bone,  li^niciil.  and  capsulu,  or  tuvesiiii};  fibrous  eipsa- 
siou.  Id  Bay  uuc  uf  these  siructuree  the  diaaue  may  primarily  bqoii 
though  eTcntutilly  the  morbid  procras  oftoD  BprvBile  to  other  iumbbb  liMdw 
that  H'hich  wiu  originally  iiivolvuil.  The  loerit  of  baviug  Iteen  tb«  fint  lo 
poiol  out  the  true  nti^iJc  of  etudving  iheao  aflectiuos  io  rcf«reoc»  to  tlia  dit 
fercut  structtires  io  which  thcv  nave  orifrinaled,  and  to  have  kI  uidt  that 
coaree  pathology  which,  uutler  lhi»  general  terms  of  **  arlhritii"  and  id 
"white  swelling,"  confounded  lO};cther  iheae  various  diseaaei,  is  ouuiaJf 
due  to  Sir  BeoJamiD  Brodic. 

SYNOVITIHL 

Inflammation  of  the  SynoTial  Membrane,  tlie  most  commua  perhap*  itf 
all  the  articulur  atfectioiis,  may  h«  acuU-,  subucute,  or  cbntnic 

CAViiK^a. — SyiiovitiK  results  usually  from  e)ii»>sur«  to  cold,  espvciaily  to 
rheuiiinlic  or  jfoulr  o>iit>littitioti?.  lu  these  cases  it  oimmoiily  hajvuetis  that 
more  juiats  than  ouc  arc-  iui|)Ucatv«l  lit  the  sauM  lime;  aud  the  aflectcd  ar- 
ticutatious  ar«  morv  frLHjucuUy  those  that  are  Diust  oxpoacd  by  haraglks 
Uilnoest  covering  of  soil  purts,  and  by  being  apecialW  sut^cctsd  lo 
liuiu  of  tetuperalure,  such  ae  the  kueis  nuu  ankles.  Syuovitis  with 
rate  efiusiou  is  sometimes  met  with  iu  lliu  sbcomlary  stage  of  syphilis 
same  time  as  the  cutaneous  eruptions.  Gonorrhtea  is  on  occa&iiiual  csuw  of 
inHammatiou  of  the  synovial  mcnibranu  and  acute  synovitis  may  oecsr  fa 
iiyainiia  and  other  forms  of  blond- piiBuniug.  Injuries  of  joiola.  as  blwi^ 
tiniiaetf.  wounds,  nr  sprains,  will  also  frequently  occasion  this  inHami 
but  uKea  ari^iti^  fntin  such  caudcui.  it  is  UMially  aasocialed  witli  in 
tioo  of  ihe  ttther  ti-sturca  of  the  arUculalion, 

pATiiiiJXKiV. — As  uncomplicated  acute  svoovitis  is  never  fata),  wc ,^ 

have  un  op|H>rlunity  of  studying  its  iialhofogy.  It  would,  however,  apnnir 
from  the  rxaminntion  of  joints  in  casea  of  synovitis  iVom  tujurv.  ni  vA\  as 
frf>m  the  t?x|i.'rimfnl9  of  Riohet.  llontiet.  and  irthet*.  who  have  it:  ■    -mi- 

matic  i^ynovitU  io   itniinals,  llint   t here  is  in   the  timt  inMtanWa'  ina* 

tory  oon^wstiou  of  the  »ynoTial  nietnbratie,  with  I'M  of  its  pecuitar  aalisiy 
polish.  The  Bynovis  is  then  incn-sneil  in  i|unnuiy.  and  t»«c>MU<rs  tbia  aM 
serous,  and  aOifratitne  interraixc<l  with  iotliimmalory  exutliition  whicb  is 
puured  out  with  it.  If  the  disvoMj  pni^rt-as  lavorably,  ih^r  produrta  are  nor* 
or  Itn  completely  absorbed.  Iu  more  raru  cum-h,  the  con);:t8lion  and  swrllitig 
of  ibo  synovial  nicmbrane  increase,  until  ut  last  it  lKO<itiK«  so  turitid  and  di^ 
temlcl  with  bloofl  ami  cHusoil  flnids,  that  a  kind  of  chemtwis  rvsults;  a  tkto 
purulent-looking  fluid  is  poured  DuC.Gomposed  of  granular  corpusdcc—panty 


'SrOTITTS — ACUTE  —  CHRONIC.  333 

.mrbIh)  iMicoeTtM.  sad  partly  (leMjaatnnled  nnd  <legenernt*r)  endothelial 
Wfb— BiHitiDg  tu  a  wmuh  iiqtiiil. 

Inall  onwa  of  scuti'  iiynoviti»  tbe  rrii);f«8ur  liit-  meinbrsne become  swoUvn. 
■od  lli«ir  vonels  iDJecl««l  with  bj<»>d.  m*  that  th«y  fortu  prominent  reil  elcvA- 
boo«,  ««pmBlIy  Bt  (h«  inart^iim  of  th«  cnrtilaj^.  Th«  iDfluinmaliou  in  such 
fr^aeolJy  exl«udri  to  th«  oth«r  slriicturui  furmjng  the  joint,  and  ilie 
thca  forms  one  variety  of  acute  arthrititt.  lu  other  caaes.  gmiiuta- 
■re  throvro  out  on  the  l(N>fwr  |iortiona  of  the  menibmne.  nud  becouitug 
iajectcd  with  hloodvcaeli',  constitute  friuged  and  villous  oiembrauous  expan- 
•oaa,  lying  upon  the  subjacent  curtilage. 

SrapToiu.  Acute  SynoTitis. — The  Kvmptoma  nf  vynorilis  consist  of  pain 
isd  beat  and  lii^tentton  of  the  joiul,  with  fluctuation.  It'  it  be  large  and 
■gjWMJ,  the  pain  ia  severe,  e!ij>erially  at  uighi,  bein^  greatly  tncrea^nl  hy 
■■vtag  or  pnanng  upon  the  articulation:  it  is  ui>unlly  ^harp,  but  when  the 
Amhm  ocean  in  rheumatic  or  gouty  coui^titutiouf,  il  is  of  a  gniiwing  i'har- 
■flnr.  In  purult^nt  eyuovitis  rnim  pynmia,  it  is  usually  very  su|>prlirial, 
ImimA  atnitiH  cutaneous.  On  laying  the  hand  on  the  joint,  tt  will  be  felt  to 
Ic  i*L  The  nrtUiny  of  the  affected  joint  is  considerable,  and  evidently  de- 
pEDtia  oo  accumulation  nf  fluid  within  tho  synovia)  snc,  the  extreme  outlii»e 
«^  which  is  rtnden-rl  apparent  hy  tin;  tension  to  which  it  is  subjected.  Thua 
t&  tbe  kniw  it  riae«  up  high  in  the  thigh  under  theraeti,  to  tho  extent  of  three 
or  fear  tnchn  above  the  upper  Itnrder  of  the  patella,the!iwel)iDg  being  higher 
am  At  loner  than  the  onter  side  of  the  limb,  whiUt  in  the  elbow  it  rise:;  in  the 
mm*  nunnar  under  the  tendon  of  the  tritvp!;.  There  i<i  but  little,  if  any, 
tfblii  '  :><liog  tinueii;  and  hence  tJie  outline  of  the  joint  ciui 

W^t  irhwfjofi  perceived  in  it.     The  limb  i»  u«ualiv  semi* 

tiBBWi,  fuc  HI  tlii»  {owilinn  there  is  the  greatest  general  relaxation  nf  the 
KfBa«MS.and  it  conaequentlv  givea  the  pntient  nio^l  eaee.  The  joint  c'anoot 
bt  Moved  without  ooilMd«ra\>lo  pain.  The  constitutional  tebHle  dislurb- 
aDM  t>  tolerably  severe.  «*pecially  if  tbe  affection  occur  in  a  rheumatic 
oooatituliou. 

Qmaic  STiiovitu. — The  di^eflfr,  at  first  acute,  may  terminate  in  a  sub- 
■Mte  or  chrootc  form ;  or,  subaouic  at  ila  com mcu cement,  it  may  fall  into  a 
Axvnc  condition.  Chronic  ayoovitia  is  characterized  by  all  the  sTiuptome 
<rf  Uw  Bcntc  variety  of  the  diaeaK,  but  in  n  less  severe  degree.  The  tiweliing 
iodiNaLkncMof  tbe  joint  ara  the  moat  conspicuous  local  couditiouc.  In  Hime 
•■■,  Lb«  awelling  from  accuraulated  seious  fluid  ia  so  cousiderable  afi  to  mn< 
ttiUtm  n  tra«  dropiy  of  the  joiul — Hydrarthroiii.  ThiH  acrumulation  of 
fcU.  partnkiag  in  various  degrees  of  the  {IiiiricIit'  of  tierum  and  synovia, 
ii  mowly  prvceded  or  a(-n>itip»nied  bv  bvidt-mi'  of  >>yu<>vial  inllnmmatirin; 
bM,tlMM^gB  tbiagenenUly  ha|<|>i-ntf.  it  u  nut  invariably  ihe  cai*e.  Kiehet,  in 
pwrimlar  baa  rvcordnl  iuHtani-e)>  from  which  it  would  appenr  that  inflam- 
■MfiaD  ia  not  a  Deceasary  or  invarialiU'  arrompainiment  of  the  affection,  the 
■yaarrlal  McoibrmDe  baiiig,  indeed,  itn^temnlurally  white,  and  looking  as  if  it 
■M  bum  wnheil  or  Kiddene^l ;  and  though  ihrw  canes  arc  rare,  those  that 
MBOwaly  pnaent  tbrmMelvee  |o  the  Surgeon  being  of  a  decidedly  inflnnima- 
«».-.  r-%.^rn^t.-r  v.  t  (bcir  Dccasional  occurrence  is  suAicienl  to  eeiablish  the 
'.  e,  as  well  usofnn  inflammatory  form  of  the  disease, 

-i>vv-  >'.  An  ahnomial  nuaniitv  of  lluid  in  Ihe  joint  is  always  indi- 
r-  timrtmatwm  and  imdulnfion  anr)  by  the  peculiar  *hape  acpiired  by 

t»«  jiari.  lliaa  in  the  knee,  which  is  the  mo^t  common  M^at  of  the  affection, 
Ihn  |Mtclla  will  float.  MS  it  were,  on  the  tliiid.  If  the  dialenliKO  l)«  not  loo 
aiM(    '         '  i:i^er  on  thi^  kncora))  nnd  pushing  it  sharply  Inwards 

nr  i'  '  to  'ink  llirtiu;:b  the  fluid  and  »lrike  un  the  bon4 

Xkid  A'gu  ia  of  grvat  im|)orlajioe.  as  it  euablea  ua  to  dietiuguUh 


884 


DISBJLSES   OF   JOINTS. 


bptween  simpk  eynovitia  with  cffueion  hikI  rtistenlion  nf  the  joint  by  soft 
grHUiilHtioii-tissue  iii  tlie  cnrly  stages  of  while  swelling.  In  onJer  Lo  elicit  it 
the  pBliciit  inti^t  lie  lying  down  witli  tlie  miisi'les  of  the  thigh  perfeclly 
relnxofl.  All  the  niiturnl  Lollnwis  obuut  thf  kiioo  are  obliterated;  the  diS' 
tended  poucbea  of  the  synovial  meinbrune  project  distiuetly  dd  each  side 
above  the  patella,  and  the  Imllow  ou  each  aiiic  of  the  li^meututn  patella;  i« 
oblitemied  bv  the  infropfltt-llar  fat  which  U  piwhcd  d'owDwtrds  by  the  pr»- 
Bure  of  the  i!iiid  in  the  joint.  In  the  elbuw  there  u  a  ftofl  and  ductuatiog 
swelling  on  each  side  of  the  nlecraniiD,  extonding  above  it  on  each  side  of 
the  tenduii  of  the  triceps,  which  fnrms  a  deiircusion  in  the  middle  liuc  ;  and 
in  the  ahouhler  there  i^  a  general  rniiudneiu  tind  distention  of  the  iirticula- 
tion.  It  \A  hhk]  that,  in  some  ct\»ofi,  tUv.  ilistcncion  of  the  joint  hns  l>t;«n  so 
sreat  that  the  iiynovial  membrane  liiu  been  rii|i[ur«d,  and  the  Itnid  poured 
J()rth  into  thfi  aiirrounrling  areolar  Li»)tae,  In  these  ciisea,  however,  it  is  proli- 
able  that  nnme  deAtniclive  change  in  the  synovial  luenibrnne  prereiled  its 
rupture.  In  mnrtt  chnmic  ca»e9  the  iigiitiic-ntD  nmv  become  relaxed,  and 
»pf>uliiueoug  disloeatiou  may  lake  plaee  (vol.  i.  p.  02a). 

Insomecasesof  chronic  By uovitii'diettDvtcrueX'/irijr  Hill  be  fell  io  the  interior 
of  thejoiot,  ou  Jayiug  the  hand  over  the  articulaitou  wbiUl  it  ia  freely  moved. 
This  appears  tu  uio  to  be  due  ui  the  cxt^ieuce  of  bands  of  fibrinous  exuda- 
tion in  the  iuti^riur  of  the  joini,  thruugh  which  the  tluid  is  pressed  by  the 
articular  movementa,  aud  thus  oc4'a»ioiig  the  sensation  which  is  met  with 
under  similar  circumslanet-s  in  eulurgcmeuts  of  tbo  bursw,  and  in  fluid 
effusions  in  the  slituilhh  of  tumlonK. 

TEHMlSATroSB. — The  teruiiujidou.  of  synovitis  will  depend  miiinlv  on  its 
cause.  WIr'U  simple  and  uncompliojited,  arlnng  as  the  reaull.  jH-rliap.  of 
rheumatic  influenwH,  It  will  in  mottl  caaes  lermliiHlc  in  eumplcie  resfdutiun. 
In  tilhcr  iuHtanre^,  however,  as  a  ri>tiaeqnence  of  indiimmiirory  exudation, 
warty  vegetations  or  eoncrptions  may  form  within  tiie  joint,  or  bandn  .ttreich- 
ing  Rcrnea  it.-*  inierior  or  incorporated  with  ita  capsule,  may  ow^auion  more  nr 
less  permanent  stittiiP!«,  .Septic  synovitis  following  a  wound  generally  goea 
OD  to  supparation  within  the  joint  with  erosion  or  disintegration  of  the  car- 
tilage, and  eventually  to  complete  disorganization  of  the  interior  of  the 
articulation.  The  same  hnppeus  in  the  puerperal  and  py:emic  inflamma- 
tions of  joints ;  in  which  ca&(^  the  morbid  proce^  commencing  in  the  aynovinl 
membrane  extends  to  the  cnrtilngM.  eventually  destroying  them. 

The  chronic  or  subacute  synovitis  and  hv'drarlhrosift  usually  terminate 
fnvornblv,  although  the  joint  is  generally  left  in  a  weak,  relnxetl  ci>ndition, 
fmrn  which  it  may  not  recover  for  many  months;  but  occasionally,  more 
pjirticuisrly  in  strumous  constitution!,  the  disease  runs  on  t<>  suppurative 
di'slruction  uf  the  ji>iQl,  This,  however,  is  rnre ;  yet  its  occurrence,  in 
siinw  in^tauues,  should  make  the  tSurgeon  careful  not  to  confound  the 
Hiictuatiuu  of  serous  accumulatiim  with  that  uf  a  purulent  toiletiion. 
In  the  latter  inslau^.-es,  the  symptonia  of  acute  inHammation  will  always  have 
preceded, 

Tre-vtmkst. — The  treatment  of  synovitis  depends  partly  <ui  the  severity 
of  the  symptoms,  and  partly  on  the  cause  of  the  diseaae.  If  a  joint  have 
been  injured  aubcutatieously,  and  aynovilU  be  apprehended,  or,  indeed,  have 
commenced,  no  treatment  will  be  found  more  efficacious  than  the  continue<l 
application  of  ice  in  India-rubber  bags  of  sufficient  fize  to  envelop  the  whole 
of  the  joint.  In  Ihia  way  the  inflammation  may  ollen  be  checked  ur  cooi- 
pletely  Hrrestcd,  the  joint  being,  of  course,  kept  at  the  eame  lime  perfectly 
at  rest  on  n  splint  or  in  a  slin?.  Should  the  disease  have  made  prugran, 
and  should  the  ice  fail  in  arresting  it,  then,  if  the  jutient  be  yuuug  iDd 
fltroiig,  the  free  and  repented  applictitiou  of  leeches  to  the  inflamed  artioulo- 


TBBATUBNT    OF   SYNOVITIS. 


S8& 


liou,  followed  by  furaentatioos  and  acconipauied  by  perfect  rest  of  the  part 
ou  aspliut,  or  uu  pilluws  properly  armoged,  will  be  llio  iiioel  UKefuI  Lrvat- 
nirut.  At  the  eaiiie  lime,  ealiQC  punnitives  wilti  iiuliuiuuy  niuet  be  given, 
aud  tJie  pulienl  kepi  on  a  low  iliet.  The  Ireatiuent  of  Kviiovilb  fulJoniug 
Often  wounils  )iiu!  been  fully  deKurilH-d  in  lIib  chapter  ou  wouikIh  iif  Joinu. 

If  tlie  ilisease  be  rhattwttie,  le<H>heK  nmy  he  upplied,  followed  hy  hot  fomen- 
tations, und  rest  of  tliH  |uirt  in  the  elevate<i  jin^icion ;   aC  the  tmnie  time 

liryliite  nf  >mclH  may  be  given  in  ten-grain  iIiwch  if  there  he  niurh  febrile 
limirlinnce,  and  Dover's  powder  Bhoiild  be  iiilminiHt4>rerl  if  there  be  mnch 
pain  at  oight.  In  enmn  iiiHinnreH  prv&t  benefit  will  rnitilt  fn>m  the  adniinia- 
tration  of  Dover's [lowiler  and  rnLimiel,  in  small  hut  frequent  dimei).  If  the 
patient  be  gouty,  o>li-hicnm  shmild  be  given.  When  thf-  disease  is  of 
tmhiiUie  origin,  the  application  of  blistera,  followed  by  calomel  and  opium, 
will  be  attended  with  marker!  Hiiccfw. 

When  [he  synovitis  \n  mbii'Cuie  or  eJironic,  the  same  principles  of  treatment 
mait  be  adopted,  modified  according  to  the  intensity  of  the  affection.  Id 
ifaese  forms  of  the  di»en»e,  rest  is  perha[)s  the  mo^t  impurtant  element  in  th« 
treatment,  evcrrthing  else  proving  nngnlory  unless  thit>  be  attended  to;  the 
limb  is  usually  "best  nxed  hy  tenther  splints,  bueklei)  oti  so  that  they  may  be 
removed  in  order  to  make  the  necessary  applications  to  it.  In  these  chscb, 
repeated  blisterings  over  the  whole  of  the  joint  constitute,  perhajis,  the  must 
UMful  tocvl  meauf'  thut  we  posees*.  lu  n  more  sdvnnc^Kl  stage,  couulvr- 
irrilAlion  by  means  of  stimulating  embnwations,  t<ig<;ther  with  dotiches, 
€ither  of  warm  mth* water  or  of  i>omo  i*f  the  sutphitmus  (Springs,  such  as  those 
of  .\ix  Mr  BarOgtrs,  will  prove  most  ui^eful ;  and  when  all  inHnnmiation  baa 
b««n  Hulidueii,  and  w«faknes»  of  the  joint.  m*?rel_v  is  lefl,  the  joint  i<hnuld  be 
propwrlv  sinip[»eii  with  uoapplaster,  sprt-ad  upon  leather.  Amongst  the 
intcruul  reniefJifs  likely  to  be  of  moet  service,  may  be  mentioned  the  iodide 
of  poUs.>iiiin],  either  alooe  or  in  some  bitter  infusion. 

In  hydrarthioui,  rest  and  reiieated  blistering  will  iieually  pmniot«  the 
renoval  of  the  fluid.  Id  addition  to  this,  the  employment  of  pressure,  either 
br  m^ans  of  strapping  or  Martin's  India-rubber  bandage,  ana  friction,  with 
ansorbeul  remedies,  as  the  loiliDe  or  mercurial  ointment  or  olcaie  of  mercury 
cunjoined  witli  the  internal  administration  of  iudide  of  potassium  or  with  a 
mild  aiercurial  course,  will  often  procure  the  absorpiion  of  the  lluid.  If  these 
means  fail,  the  aspirator  may  be  used  to  empty  the  joint  of  m  fluid,  tho 
puncture  being  cliiKd  with  collodion,  and  in  extreme  eases  we  have  a  very 
powerf^il  rorthod  of  cure  at  ciir  conimntid  in  the  injection  of  the  joint  wiin 
tincture  of  iodine.  This  plan,  a  sufficienilv  hold  one,  has  Ik'l-»  much  em* 
plttved  bv  Jobert,  Vclpeau,  and  lionnet.  The^M?  Surgeons  utcd  the  tincture 
diluted  with  two  or  three  parts  of  water.  A  -<mall  trocar  is  introduced  into 
the  joint,  a  moderate  viuaniily  nf  the  wnuid  fluid  i*  Ift  out,  but  not  all,  and 
then  a  corresponding  fjuantitv  of  the  iodine  solution  ia  thrown  in  ;  and  alter 
beine  left  for  a  few  minutes,  is  allowed  to  escape.  Inttammation  of  the  joint, 
wbicn  is  a  neceMsry  result  of  this  procedure,  comes  on.  This  is  treated  by 
ordinary  antiphlogiHtie  means,  and,  according  to  thcstatcincnts  of  the  French 
Surgeonn,  has  in  no  caw  been  followed  by  any  serious  consequences,  but  In 
ssTAral  instanees  a  complete  cure  without  ankylosis  has  resulted  ;  a  new 
aod  healthy  action  having  been  imprinteil  on  the  synovial  membrane.  This 
mode  of  treatment  does  not  appear  hitherto  to  have  met  with  much  eiipport 
in  lht«  counir\- ;  yet  it  certainly  deserves  a  trial,  though  recourse  nhould  not 
lii;hllv  1m*  had  to  it,  »«  it  is  evident  that  the  induced  inflammation  might 
'Xuved  the  expected  limits.  In  one  case  of  hyHrarthnwi!)  «pf  tho  knee,  in  an 
old  nian,  in  which  I  employed  it,  about  six  ounces  of  thin  synovia  were 
ilmwD  off,  and  a  drachm  of  strong  tincture  of  iodine  was  injected  into  the 


888 


DISEASES    L>K    JOINTS, 


joint.    Slight  biflaninuMion  nnlv  fimupil;  nnd  iJiP  <H»wiw.  which  ' 
TBiin' sWndine,  Tfai  coinpletdy  *-»ire<l.      The  fhiil  ("'ints  llint 


«u  of  tw 
Teiin"  swiidine.  wai  coinpletdy  *-»ire<l.  The  fliiil  ("liiits  Hint  ii[>|N*«r  l« 
mniiiro  atteiitiuo  Hre  thnt  iii>  inHatiiiimtioii  Iw  >;'>iiiK  un  »t  thu  lini".  ilH>rF 
beiue  o"  tcuiItirDesa  ur  pnin  in  riiovinfi;  iho  joitil,  tn«  «fru»i»n  Ik^itiK  quit* 
nuBlvv,  *"*!  "^  ^  ^^''J'"  <^hrooic  chnmcler;  uml,  above  «lt,  lh»l  no  air  faa 
llluwed  to  cnu-r  with  the  injected  t\u'v\.  If  utlier  nwtlicNU  oftr*-"'"- ■■<  '«il, 
the  ioiol  niHT  l>e  liraiued  bv  meunt>  of  an   fnr]i«-rubb«r  tube  ir  '  ik 

■11  aoitwnttc'nrecauttonfl-  11  may  l>e  retniaed  fur  ti>u  ilare  or  »  i  nim^lit. 
the  dressiug  iliniuehmit  being  strictly  aiitiseptic.  The  cartMlic  gnuu  dnm- 
iur  will  l>6  foQDfi  uie  eal'wt  iu  the«v  c»»w.  AJIlt  dru|My  of  tbe  jmni  hm 
l^n  rtinoved,  ibe  arficulatiau  is  uhuhIIv  k-(l  weak  for  aoioe  lengtb  of  tine, 
in  c()0 sequence  of  the  slrvlcliiiig  tc>Ti*tiicb  its  ligametitd  hare  been  pubjttted; 
htn  i^''<l  doiiclica  aad  an  utuatti:  bandage  will  c»iiiiUlut«  tb«  bett  uittdc  of 
trcBlioeti'- 


ACVTE   ARTBRIT18. 

Bv  .■tflt'd  Arffx^'f'"  i^  mcntit  an  acute  itiAainmntion  atfi'olini;  thr^  nya^i'rial 
membraufl  and  mpidly  txti-nding-  frotn  it  tr»  ibe  other  #iruriiin'»  that  ralrr 
into  ibe  foriaalion  of  a  joint.  Thr  »ii-*ea«;  may  uritv  primarily  in  the  ►yoo. 
yitl  oiembraiie.  ur  ttic  ntfcctiim  uf  the  synovial  membmiic  may  !»<■  vcojotiary 
to  diWBW  beginrii»}C  ■■>  t'hc  bones  or  in  the  soft  parts  anmnd  th<?  joint.  In 
the  Utter  case,  tbo  symploraii  chamcterinic  of  nciltc  arthritin  do  not  »ci  hi 
until  the  niinchief  has  extended  to  I  he  cavity  of  the  joint.  In  some  fiinns  of 
acute  arthritis  the  »yraptonut  clearly  indicate  that  tbe  iDQaniioalioD  of  tbe 
flVDOTi*!  menibmoe  i>re(re<ie«  thnt  of  tbe  ligamentA,  while  to  others  liM 
eicleDNoo  U  at>  rHpid  ihftt  all  the  stnicturea  of  tbv  joint  may  seem  lo  b« 
Bflerte<i  ftimultaneoiinly. 

Il  will  he  iii'JBt  c-oiivfui^nt  tu  di-»crll>c  first  thcBviuptotuc  and  patholggjoil 
(.liniigi-fl  wbicli  nre  characterii>tir  uf  acute  artliri'tid  from  ubatertr  cwiwft 
nuy  artiw,  and  aflerwardp  to  point  out  the  uiwlificutioaa  of  tlie  prooia 
dependent  u(kiu  iw  mode  of  origin. 

Bymptoou.— The  symptoius  of  acute  arthritic  that  are  tnoM  marked  an 
t^paln.  heat.  Gwelliu);,  and  [it'culiar  ixuiliun  of  the  jotol.     Tb<* paui  i»  oi^^ 
gavere.  tcnsis'e,  and  tlirubl)in|; ;  k^i  acute  is  it  sonietiniett.  Uiat  the  P^dl^^| 
flciwnui  with  af^inv  ;  be  cannot  bi^ir  iho  bed  to  be  touched,  tbe  room  lo«P 
«balten>  or  tlte  slit^liti-nt  ujo%-enieut  commtinicaled  to  tbe  limb. any  attempt  at 
Muminalion  of  the  joint  in  such   cases  bein?  attended  with  lorapponabte 
urunr.     There  are  nsually  Duettirnal  exacerontioiw,  and  the  vain  is  txm^ 
monlv  referred  with  especial  severity  to  one  particular  #pot  iu  tbe  juisl: 
thus  It  is  generally  fi'lt  at  the  inner  or  under  side  of  the  knet?-joint,  and  at 
llie  ooler  attpt'ct  of  the  hift.     Tlie  Itr^it  of  the  discaaed  joint  a  tsmtiiiuMbl*, 
and  if  olU-n  acooiiipHnit'd  with  more  or  Imb  saperAcial  redness.     Tbe  titttmf 
b  uniform,  involvin)^  the  whole  of  tbe  articulation,  and  not   pmjocliai;  at 
oertaiii  parts  of  it,  as  when  rhe  synovial  membrane  alone  is  aBectnl ;  )t  is 
ffcnemlly  nut  vt-rr  considerable,  and   has  a  sol\  and  doughy,  rather  tttan 
3uciuaiing  fed.     The  pwUion  of  lh«  aHectetl   limb  is  peculiar,  and  l' 
Kitilude  is  involuntarily  adoptvd  in  which  tbe  patient  will  have  the 
atnouut  of  eaae :  tbus,  if  the  knee  is  affecteil,  it  is  semiOexed,  nod    i 
is  nitaled  outwards,  if  the  hip,  tbe  joint  is  flexed  aod  the  limb  abducu^d  and 
fotated  outwards  with  the  knee  semifleied  ;  if  tbe  elbow,  it  is  bant.     Spomu 
or  ttnrtiagt  of  the  limb,  otWn  of  a  very  nharp  and  paintul  ckaracMr,  oums 
on  ai  times;  more  particulurly  at  night.     Amount  the  moat  dmitnmmt 
lymptoms  in  tbn  mure  advanL-cd  stages  nf  acute  aisoi^aaiialioa  of  ajnat 
atv  tbe  painful  stariingi  of  the  limb  fmenevor  the  |MtLieat  falls  Mlaep.    Tha 


A 


ADg  relax«<l  the  soUeuett  liKHiu«QU  allow  (he  joint  to  hec<iiue 
^  ifllplKetl :  »  rvfli-x  ruutntL-tiou  uf  tliu  uiuaclw  iiniiifiliately  uike» 
■od  toe  pktiuul  wnkit)  with  a  [luiurul  ti|)»siiitKlic  jerk  iif  tht;  lirab,  in- 
■■K  K  feeling  of  alarm,  that  ih  ufu^i  very  (liAlreseiug.     The  eotutiiutional 
rfhWKr«MM*  is  verv  severe,  auil  of  an  uclivuJr  I'tilirilu  lv|w. 

UaviDK  nacb«l  this  staee.  ia  Home  va»m  th»  eviiiptoiiii)  gmdiially  subside, 
■be  hoUlwetu,  tiie  pain  ive/ea  its  acute  character,  the  swelling  elowk  Ji- 
■rnrrHf ,  aod  reoovery  takes  place  after  many  weelcs  or  mouths,  the  joint 
left  pemuurotly  HtiHentHl  from  coritmotion  of  the  iuflnmeit  tigamcDla, 
JIDM  firmly  ADkylosed,  the  articular  eurfaoes  beiug  united  by  denM 
fibriMW  liMM  or  boue,  according  as  the  cartilages  have  been  partially  or  com- 
flaely  denroyod  during  the  acute  stage. 

Jlera  oommxnly  ta  the  di4ea:?e  progreaaM,  suppuration  takee  place  within 
tft*  joint,  which  becomes  hot  and  red,  with  a  good  deal  of  throbbing  pain, 
Ihe  akin  oocering  it  is  (cdematoiu,  and  at  In^t  tiuctuatii>n  is  perceivcawhere 
aaratiui  are  thinned.  In  some  ca«ea  the  euppuratiou  occurs  with  very 
'  mpulity,  and  luxotloD  of  the  head  of  the  bone  takes  place.  In  other 
tb*  arnovial  menibntnt;  and  ca^nule  of  tbv  jttint  give  way  without  any 
MM  cif  tiganeal*  or  displacviDeul  of  bones,  pua  becomi»  iaKUrate<I  into 
Um  areolar  ti»ut?  Hruuinl  the  juiot,  an  abacesf  furiii!*  exU>rual  to  the  articu> 
)«ii;.,n  1.1..]  ■'iU'ii9i%'(i  uurtilenl  culleelioud  l)t;cuiue  ditTuMMl  through  the  liaib. 
"  ^'oiiies  lixMened  by  the  dwtruutiou  of  its  ligaments.  Lbe  boDe« 
".  and  grate  against  one  another  where  the  loerusting  cartilage 
■■■  t"  ved,  thus  giving  risu  to  very  severe  sulTering.     The  cartilages 

■■y,  nowcvcr,  in  some  coses  be  very  extensively  doetroyed,  niid  yet  no  grat- 
ia^ lakr  place:  tbift  ia  owing  either  lo  tlie  destructive  action  being  limited 
la  tkm  olge  of  the  incru^ting  cartilage,  the  oppot<e<i  .<urfaL'<?«  beiu^  »)iiud,  or 
rlae  to  the  taterior  of  ihi.-  articulation  being  nllod  up  with  graniilutiuu-uWuc 
■Ac*  iIm  reiuuToJ  of  the  cariilages.  But  though  al»oe»«,  either  wiihiu  the 
^mml  or  external  to  it,  usually  forma  when  the  Ikiqcs  grate  and  tliu  uirtilage 
dfani^gmtes,  VL-t  it  iiccB^ionally  happcnt*  that  dir^  conditiona  exiat— the 
yplAiMe  indicative  of  eru^ion  of  cartilage,  nuch  as  [*aiuful  sturtings  of  the 
bab.  pBting,  and  preteruutuml  mobility  of  the  joint,  being  present— and 
vat  DA  ahscww  forms ;  all  the  symptoms  suh;ti<ling  under  proper  treatment, 
Um  joint  rvcovcring,  though  with  a  certain  degree  of  aokylnaia.  But 
■^ M'-'f^e  alao  may  t>ccur.  Suppuration  may  take  phicc  in  a  joint,  the 
iieoibnuin  and  tbe  capsule  mur  give  way,  extensive  indttration  of 
ulk  tiio  deep  areolar  planes  of  the  limb  may  occur,  and  yet  no  laxity 
ligaiDctit,  no  preternnlnm)  mobility  of  the  b'>l)e«,  no  grating  of  the 
•or&c*.  indicate  the  disorganisation  of  the  articulation  which  n  in 
Ttiis  condition  may  occur  in  any  joint ;  I  have  moet  fre«|Uf  iitly 
There  the  upfxr  and  usually  the  outer  i>art  ui'  the 
>tAy.  andthe  pui>  dilluiu^  ilMilf  deeply  beneath  th« 
-li,  »imiKim«8  even  between  the  periosteum  and 
tfo  boOK.  '    thigh  nwells  greiitly,  (lie  lirab  becomes  o-duma- 

bm^  Wid  a  drep  ami  i<lw<'ure  nifnMtiuo  of  flnctunlioo  may  uerhajw  hv  felt, 
■an  sMcciallT  towanis  tlie  ouit-r  and  lower  i>art  uf  tlie  limb  juDt  abuvu  lbe 
fcwii  Tbe  swelling  of  tbe  joint  has  perhapei  eubeidcd  ou  the  escape  of  the 
pH  fram  tbe  mvity,  giving  a  fislsu  idea  of  security,  wbicb  is  confirmed  by 
lbe  abaHwe  af  signs  indicative  ut  disorgaiiiiuitiDU,  such  oa  lateral  mobility 
ar  '  -  — 'ir.^.  But  ou  pn»iog  the  thigh  downward?,  the  joint  will  Ihi  found 
I  potcJla  will  float  again,  and  them  ia  on  evident  oommunicatioD 

bfcv^n  tiiie  interior  of  tbe  synovial  membrane  and  the  extensive  difluscd 
ia  tbe  tbigb.     Id  caaee  of  thiri  kind  (he  pus  will  firat  come  to  tht< 
about  two  or  three  inohea  above  and  to  the  outer  side  of  tbe  juinl; 
wxn~  u- — '-t: 


■ 


C 


888 


DISEASES   OP   JOINTS. 


ud,  on  a  free  indxlun  bclug  made  hero,  immvutte  quantities  may  be  letoaL 
In  these  nuwi  lluctuntiou  ia  ollcti  miiekeil  by  the  (rdptun  of  tbie  limb.  aa4 
by  th«  tbickncdB  of  the  nvcrtyinf;  miUH  of  ai^ilnr  tissue  and  i- '  -  ^nd 
will  reqiiiiv  ihe  closest  exnmiimtton  and  the  m<**l  praciiMsi  hnii  .  <;» 

teciioii.  At^er  Riippiiralion  hiu  takrn  place,  the  c»>i))ititurKiiinl  <hBiiir)> 
pArtakeii  of  the  irritative  type,  the  patient  •iitftfrinK  upvero  pain,  ami  bi 
wi>rn  <mt  by  want  of  rent.  Atier  the  ahflccM  »  opened,  unleiw  iiiM-fiii]  mraoi 
are  taken  hy  draiiiflfce  and  nnti»eptioi  to  prevent  the  a(-cuiiMilii(i<>n  uf  d^ 
cumpwing  di»ehnrgM  in  the  artionlarcaviiv,  septic  |»«i8i>iiing  or  pyamia  ■ 
very  likely  tu  liillow  ;  ur  hectic  leading  to  (fealh  from  exhaustion  and  irrita< 
tion  may  uccur,  unless  the  difteaMHl  part  l>v  removed.  lu  ntlir-r  ant]  Ira 
■ever«  cased  it  fulls  iitUi  a  «late  of  cbmnie  thickening,  [x-rhapa  with  (iatulnw 

lopeniu;^  leading  duwn  lu  the  digeasdl  structures  ;  and  in  s'lme  •>f  the  mun 

fiiv'irable  instatices  the  putient  iitav  recuver,  with  a  pernianentlr  rigid  j"iaL 

Tbe  mutdes  iu  the  ovighburbiHKl  of  au  inftnrneil  jnini  undergo  a  »[ircM  of 

acute  atrophy.     The  wasting  and  tbe  llaccidity  are  buCb  more  tbau  caa  ha 

accfinnletl  for  by  simple  ditiu»>. 

In  Bome  cases  tbe  miiF^cular  chuuges  are  more  than  atrnphic.  and  rdla 
paraiwis  of  the  pttuda  0/ a  limh,  ntn^equent  upnn  itillnmmaLitin  of  a  jmni,li 
occaaionally  met  with.  I  have  i^een  this  singular  aHrriitm  in  tbe  enanar 
inuscles  of  the  thigh  snil  in  the  rausclee  of  the  dc-apula.  in  raara  of  aeata 
artbrili».  lo  iheae  ca^es  the  nHeeteil  ninecle«  rapidly  waste.  The  traaliog  ■ 
not  due  to  disuse  alone,  for  it  affects  certain  gmupa  of  Diueclrs  only,  Mhen 
which  are  equally  inactive  not  being  atrophied.  Uut  not  onlv  do  oertaia 
groupflof  musclce  in  the  affected  limb  become  wasted,  ai  for  in>unc«  Iba 
extensnn  of  the  thigh  or  those  passing  from  the  sonpula  to  the  buoHwus; 
whilst  the  other  muscular  structures  of  the  limb  preserve  tbeir   nnnaal 

l«ooditions,  another  change  takes  place  in  them.  They  loae  their  eJectrie 
irritability,  and,  in  fact,  hecome  perfectly  paralyred.  In  tbelnwer  extTMititT 
tbe  leg  cannot  be  extoode<l,  in  the  upper  the  arm  cannot  he  nuMd.     TbM 

,  condition  is  extremelr  chronic.     It  will   last  for  many  mnntb*  afWr  ibe 

Joint-afl'ection,  from  wnicb  it  starts,  has  been  cured,  and  may  lead  to  p«na»> 

[Dent  atrophy  of  the  raralyxed  muacles.     The  treatment  couatsts  in  Miuai' 
tion    of    the  aflecled    musctee,   by    aea-duucbet,   elei.-trioi(y.    and    fricili 
conibineil  with  methodical  mnvementB  of  the  limb,    (jtrychiiine  may  ba  p^ 
with  a<)vHntage  when  the  lower  limbs  are  affected.     I  have  seen  thia 
arthritic  paralysit  chiefly  in  persons  suffering  from  spinal  cxbautttuo,  is 
neurotic  women,  and  in  men  addicted  to  sexual  excesses. 

DiagnoBis — ^6#oejw  mav  form  external  to,  but  in  immediate  contact  with 
the  cu|eulc  of  a}ntnt,  nn^  closely  simulate  dtw-ase  of  tlic  articulati«>n.  Ia 
tfatac  cases  the  atwence  of  serious  constiiuUoual  diMurhnnee,  the  irn-gularity 
of  the  swellinf!,  gremer  <m  one  side  llian  the  01  her,  it»  exlenHinn  ^tvrr  biiny 

Ipnlnls,  as  the  [lari'llnur  iileeranon,  thetiuperticial  (^haraetrr  rifthv  tturtuatiuo, 
the  nlwncf^  of  nil  riu;idiiy  about  the  j'linl  orof  that  prrli'rnntnrni  uiobiliiyhi 
a  horitnuial  direclion  which  aniftifi  from  sufionin^  of  the  U^nmniia.  and  i»f 
other  severe  loral  nrniplomtf,  imrh  as  pain,  nliining,  louseoess.  or  grating,  will 
enable  the  .'^ui^t'oo  |o  etfi'el  a  correct  dincnnnis. 

pATnoi>>nY,— It  in  vfry  rarely  that  the  opportimily  arisM  of  examining  a 
joint  atfrcii-d  with  acute  arthritis  befnn-  it  ha»  reached  tbe  Bta|{«  of  «ttpfwr» 
tion.  In  that  ilaee  all  ibeeomponcnt  parts  of  tbe  joint  wilt  be  found  (n 
prment  marked  changes,  varying  eoniewhat  with  the  cauM  and  tbe  degree nf 
acutenexs  of  the  inllnrnmaiorr  prooeM.  Tbe  folluwtog  may  ba  taken  as  tin 
appearance*  in  a  typical  case. 

The  tgnnvuil  mrmhrane  is  thickeneil  and  intensely  injected ;  If  iho  diwMt 
has  a<lvaiu'«'l  beyond  the  earliest  *ta>:e.  the  membmne  tit  no  luDgvr  rvongnia- 

llle  aa  such,  being  converted  into  a  In/er  of  grauulatt>jaHissae,  tbe  site  of  tht 


iCUTE    AKTURITIS — FATBOLOGT. 


hmg  mftrked  by  flealiy  va^utar  projections  of  llie  name  tit^iic.  The 
llatioas  are  mMdid  hoalthr;  trnxit  c^mmoiily  ihey  pra&eat  the  same 
■pp— rancg  u  lhi««  oil  tl>«  surlnw  uf  aD  iiiflanied  v\txr  ai'  the  leg,  bi-iug 
■MVerad  by  a  dirtjr  jrelKiwiBit  layfr  cuiiiposcd  of  degenerated  ]2rauiilulii»D-<.t;lu 
b«)<i  iKgvitier  by  injuk"''"^  jntliiiuinat'iry  exudatioo.  It'  thv  joint  haro  been 
opcooii.  and  ilmrmpiisiuon  of  the  diKhurg^  has  laken  place,  the  diseased 
•j^OMviai  mt^fnhniue  may  be  covered  by  op>i<{uc  lucmbranoiifl  (lalchoa  aliiioei 
wimbling  a  diphtheritic  ineoibraDe.  In  the  latvr  stages  of  arth^tti^  the 
fTUuiUaioiut  TOVeriii^  the  opposed  surf  acre  of  luiy  |Niiii;hes  ol  tht>  syiiiivial 
■■Bbranc  will  be  (iiuiid  lo  liuvc  coalesced,  the  cavity  of  the  juiDt  being  iii 
typ  way  to  a  great  estuot  t>bliivrated. 

Micruseopic  exsiniouttou  of  the  diM-ssefl  tnutiihranc  ahow»  only  the  ordi- 
fiary  upeaianccs  uf  iDflammati'iu.  Th<-  iiKloihclial  rclU  (.iiveriii^  ihc  mcni- 
bcaac  have  di>a|iprare*],  tht!  flhruits  layer  id  firia  itifillraftwl  with  new  cctlp, 
WfcffV  which  (hf  <irt;;iiial  tii«Mi<^  more  or  Uvt  coiuptL'tcly  <li!=apiM>iir8.  In  the 
layer  of  nuad  cells  thiu  fornied,  sew  Tcaaelt  ar«  developed,  and  xranulaiioa- 
liwaa  ia  thii«  pniducrd. 

Tbe  rontenl*of  thn«ynovial  cavity  are  in  the  very  earliest  stages  coinpuaed 
of  thin'  pus  wixinl  with  synnvin,  hut  a»  thp  membrane  very  soon  cea»es  to 
fittM  its  DtMrmal  tecretion,  the  tluid  a.4«iimes  the  charftctcr  of  ordinary  pus. 
Ia  casrt  in  which  the  diMSjvA  stopa  short  of  suppuration,  aa  ahuuaaut 
«aaca)able  fibrinous  exudation  iii  tukiil  to  have  been  ohe«>rved. 

Tkt  tipamenla  are  early  aflt-cted  by  extension  of  the  inflammation  to 
Uwoi  fr>tn  tbo  iyoovial  meQibraoe.  The  bundles  of  6bre«  ar^  at  tir«i  eepu- 
firum  each  other  by  a  ouagulable  iiiQammatory  exudaliun.  and  the 
ita  thus  become  swollen,  aud  pre»ent  »t  fir«t  a  uuxy  or  stfniigelatinous 
■Maanore.  A«  the  dtMase  [)rogre«e«K  the  fihr<j«  become  softeiifJ,  and  the 
l%»Bnn!w  yt''ld,all<>wii)g' theoe»eou8fiurrfice<4  to  bedieplawl  by  the  touiecoa- 
tnxtt  iiiuNclt-1*,  or  the  woigiit  of  llie  limb.    Thv  inlliimmHtion  extends 

fraai  '  ^    :iitrnl»  to  the  peritMlcum  of  the  articular  fiitU  of  the  bouet  entering 

iaht  tb*  joinL  The  perinetitiB  thus  set  ii|i  usually  assumes  the  •wteoplastic 
fcri  (p.  ^4'),  and  irregular  masseu  of  new  bime.  often  arranged  in  jngi^d 
Mitactite-likn  procenee,  are  fonne<l  in  the  uei^lilHirho<Kl  of  the  ariiculaiioo. 
TUa  ■  More  marked  in  the  leas  acute  forms  of  the  disease,  or  whea,aAer  the 
I  wt yae  frnm  Uie  joint,  the  prucnss  has  become  ehn>nic. 
m^  paris  in  eoiUael  vUh  Oie  ligamenU  are  <rdematous  in  the  early 
____  ._^  bat  aabi«]umtly  as  the  disease  advances,  they  mav  become  fuM>d  with 
ibe  cafaalc  of  \\w  joint,  eo  thiit  it  is  impofk^ibte  accuratefy  to  eepnraie  ihein. 
ilbaiii  not  unfreipieDlty  form  outside  the  joint,  baring  no  direct  commu- 
aicatkiti  with  its  caviiy. 

Tkt  nutiLigen  covering  the  articular  ends  of  the  bones  in  all  easM  present 
Mosc  iinponaot  chan^e't.  These  are  never  primnrv  :  in  every  ca^e  it  will  be 
fcaad  thai  the  morbid  pr(«cess  pmoeeds  either  tVitm  the  articular  surface,  or 
tnmi  ibe  b>tna  beoealb.  When  the  latter  is  the  case,  the  alfectioD  of  the 
4Bfftila|Ce  i*  anlaoedenC  to  the  acute  arthritis;  this  condiiiou  coniruenoing 
tb«  cartilac*  is  perforated,  and  the  jitint  iKcomes  iufected  by  the 
r^-  i.r  ilirt  diiieaw  which  has  commenced  in  the  bone. 

irtilaue  is  Bt]<.H,'ted  in  conw^ueuce  of  acuteeuppuralive  inflam- 
Htint,  the  Hrst  change  olxtervetJ  is  a  !•«<»  of  its  nntural  snioolh- 
'\\,  III)  bltii>h-white  lint  IwiMiiies  more  opa<pie,  and  ofteu 
K9  a  filthily  yelloHt^h  linge.  This  is  followed  by  low  of  eolwtsiiL'e  in 
th^B  |Hfti  at  which  the  i>p|>ini«i|  nrticular  •uifaoes  are  in  contact  in  the 
&Ud  pnaitioD  asiUtned  by  the  ia6aii>eU  joint.  Finally  the  cartilage  is 
«MndMclr  ctcstsnyed  at  tliese  parts,  and  tlie  caucrlluus  tusiie  of  the  head  of 
^a  Maa  M  expoaad.  Aa  aouo  as  iR-rfontlion  takes  jilaee,  the  suppuration 
bMWMO  tiM  eaniloge  and  the  boue,  the  pus  being  furiued  from  the 


840 


.SES   OF   J0IXT8. 


Tasculnr  mpdiillnry  tiuue  of  the  pnncelloiis  ipices.  The  carttlics  ihM 
b«c<>iiii^  loitwiit^*!,  iiikI  in  l>nthe<l  bv  pus  on  vac))  side,  tta  nnlrittoa  tmBKOil 
olf  il  |>ert»hu8,  beconiea  yvllow  in  culur,  anil  toui^b  ami  IviUhrrr  in  ci-iiiiiiiltDc« 
Microscopic  exHiniimliun  sbowd  that  the  prt'Ct-w  is  oue  ut'  Biou^httit;  tad 
disiutegmtion.  The  nmtrix  is  upatjue  Htid  ^ranulnr.  and  the  c«ll»  #b(iw  do 
■i(cti»  ol'  proliferftiiuQ,  but  ou  the  contrary  have  bruk«a  down  ioto  a  mam  of 
fat  graiinlev. 

At  tbe  marglnB  of  the  carttla||refl  in  thos?  pnrti  not  cxpoted  to  prewuK.  aad 
in  those  ntAee  of  acute  arlhritis  which  tfrmiiiiitc  without  tuppunUino,  Ae 
destniciion  of  [he  cartilages  takes  place  by  a  pn>cen  of  true  ulcrratioo.  The 
cnriilnges  are  ovt'rlappttl  ni  (heir  niargitiB  by  tbi;  trrnniitnttnu-ltniue  (nrmtd 
fniti)  the  i[iflAine<l  synovial  inenibrune.  On  renn^vin^  tbt»  llie  riiriaiT  oftbe 
cartiln^  will  be  »eoD  to  he  marked  by  irregular  holloas  lilleil  with  a  finular 
tissue,  and  in  a  later  etage  ihc  cartilaginous  tii^ue  wilt  he  ftiund  it>  harn  ' 
de*tMyeil  va  a  greater  or  lei's  extent.  In  other  pnritt  iif  tlie  eartila^  ti' 
chaDgea  may  be  oheierreil.  but  they  arc  always  tii<»t  tnnrked  in  the  noirkhor 
hood  of  the  vascular  fring(«  of  the  Byuovinl  mnuhranr.  !^o  much  u  Oim 
the  cnw  that  Anton  Key  wan  led  to  believe  thai  the  dMitnirtinn  tif  the  canl- 
lage  wua  directlv  cfleetoii  by  the  development  of  a  fimbriati-d  or  frittgad 
vaacular  networfc  or  liMue  fmtn  the  nvnovial  membraDe,  by  which  the  fira- 
oeM  of  absorption  was  carried  out.  The  truo  nature  of  the  ehaii^*r«  ocror* 
ring  In  ulreralion  of  cartilajie  was  firat  doocribed  hy  I  tomlsir,  and  hia  ob- 
tervntionA  Vfw.  confirmed  and  extended  Rub»e<)nently  by  R»d(cm  and 
Rainey.  who  pointed  out  the  I'net  that  canilai^,  lik«  otber  extraratealv 
tisauee,  may  undergo  chnh(;ei«  imlepenitenl  of  the  prohm^lioii  of  Ttsaek 
iuto  it.  If  a  i-enical  Bection  be  ro»d«  of  a  piece  of  arlioutsr  carfilapt-  in 
procesa  of  ulceration,  the  c-han^^  obMrved  will  vary  with  the  ;'  -  <3f 

the  process.     In  some  ca»«v  (he  appearancef  will  cIomIv  rr»enil>  nl- 

ready  de^eribed  as  lK>in<£  met  with  in  uleeration  of  boue.  The  nurfar^  uf 
the  cartiltiije  i^  eeeii  to  be  irrt-fulHrly  hiilli>»ed  out,  lb«  hollowrt  lieini;  liMfd 
with  Humli  round  eelU.  liuvin;:  the  ordinarv  xjipearunee  of  the  uh, 
leu(^>cyl<!»  obecrvcd  in  acute  iuilaniniulioua  elmwhere:  iinnicdiatelv  I^l^-:.. 
Cheao,  the  matrix  of  the  uualtcrc-it  t-artilagc  ia  cloudy,  and  the  inLrtilae«-c«Ui 
may  Iw  icranular,  but  then!  is  no  evidence  of  proliferation.  There  is,  in  fiuft. 
Dotliing  lo  pmve  that  the  new  cuIIh  are  derived  from  lh«  pn-cxiating  caUl 
of  the  cartilage,  and  that  the  proivKs  in  not  exaetly  arialuguua  to  thtdaitni^- 
tion  of  bone  by  csIIh  derived  front  tbu  vascular  me<luthiry  tJiMim,  pcvlaUjr 
by  migration  from  ita  vesseU. 

In  lei»  acute  prooefoea,  on  the  other  hand,  the  destnietion  of  the  eartilapr 
19  undoubtedly  due  to  changea  rommenring  in  it^i  own  rellH.     In  a  rrrtinl 
section  proceeiding  from  the  healthy  cartilage  to  the  diwawd  surfai-c,  tta  , 
following  appearances  are  observed.     In  from  ihe  til>h  to  the  twelfth  l^J^^I 
from  the  flurfac«  the  cells  are  seen  to  be  iimlergoing  proliferalion  :  ia  <^^^| 
oapaale  two  to  four  eellx  are  found ;  proceeding  towarcls  the  dianued  waifmtM, 
lh«nnmher  of  cells  in  each  space  increaAeti,  and  ihcr  gradually  Inaethfiefcar 
octeriMic  appeamDce  of  eartduge-celU  and  become  indtstingaishabl*  fron 
the  round  oelU  of  gninulatioo-tiMUc.     As  the  cells  multiply  the  •••"^-  "ta- 
taining  them  necMwirily  increawa  at  the  «x[>i'na<>  of  ihcBUrroun'  t, 

and  at  the  name  time  the  rnfwule  beooniea  more  and  more  imlindiM  t  i<t»i  at 
laat  itisap|iear»  altogether.  Th«  matrix  newr  tb«  ^iirfncc  beeome*  cloadv 
Rod  grauulnr,  and  at  la»t  completely  ditmppennt  beforv  the  ealarutDg  cell' 
apacM,  which  then  eoalcace,  and  thus  there  i»  formed  on  the  aurfaee  a  layer 
rimipn»e«t  entirely  of  Bmall  ntcnd  eellit  identinil  in  appenranci;  with  ^kem 
of  oniinary  gmnulatiuu-tiwoe.  The  homugeneoua  intercellular  rabatasce 
may  then  wiftun  and  the  cells  may  be  cnat  ufl  into  the  joint  as  pua-cdla;  «r 


ACrTK   IXFECTIVK   AJtTURlTIS. 


llif  i1t*<«;M'  tPitd  tiiwnnU  ri'tMriry  new  vesjels  may  ppnetnitc  the 
_  ol'  ti'll*,  f>Aic^eiliii>;  Iniiii  ihf  iu-nrei>t  vntwiilAr  tiMuu,  am]  thus  a  vaa* 

ntlar  KnnaUlInn-itiMdc  mny  bv  furmeil,  vihicb  will  Lak«  part  iu  tho  pru- 
w^«  i>f  rrfkair  tn  Ijc  »iili:t4^)iieo(ly  dwM-rilMxI. 

Ill  onler  Ut  (lUliiij;uUlt  lIivm  thr««  pr<)CM!«i.«  from  eacli  oth«r,  we  may  term 
tbr  Grm,  tii^^-natx  witli  ilMiiitL'gratioi),  tlm  mccoih),  iilccratioi)  wilhoat  prolilVni- 
liou.  and  the  iliini,  iilrt'ruti'iii  with  pruliterntioii. 

■  hen  «s|KiMxi  liy  ilratriiction  <»f  iho  c&rli)ag«8,  Iwcirae  ufl«c(ed 
'-ply  )>y  the  iotlniuiiiaUiry  prMress.  The  chaugea  that  occur 
O'  -.1.  I  ■  ■;[  i.ii.  as  tfapy  are  idtjuiical  with  those  already  describetl  to 
V'-  i.'.i.r.^i  Ir.iUiiiront'jry  Pr-jcetise*  in  B>»ne.  They  usually  BMume  the 
(..rr.;  ■  1  r.i -.  i.iri  r.  <•  ustfitis  M-i(h  euppunitiou,  ur  Bimple  cariL-e,  but  if  the 
{■r<Ki-»  ii."  virv  ii'ute,  the  ioHammatory  pp>duci5  iu  the  caucclloua  BpaccB 
■My  brMk  dovTD  iotu  pas  before  the  bony  tralreculn  have  be^n  completely 
ahmtieil,  and  thus  ponions  of  the  caucellous  boue  tuny  be  out  off  fruiu  their 
oqiritioa  and  ueri«h  foriiiiog  sequestra  i  earif^  necrotica).  In  other  cawft 
th«  taflnramatHUi  iu  the  caiicelluus  spnccs  may  spread  rapidly,  and  diffuse 
leuiUTrlitis  bp  set  up.  This  is  espcL-iallv  prone  to  happen  when  the  urigi- 
■d  Tnaainmation  in  the  joint  is  septic  or  infcroiive  in  character 

CUc»ffl  AND  Vauict-ies  op  Accte  Artiiuitis.— Acute  artbricb  nriscs 
frow  nnuiT  diflereot  CMMUtt,  and  tho  citurte  of  the  dlseaae  varies  soinowhet 
acDatdii^  to  its  m<Ml«  of  firittiu.  The  fullowiog  are  the  chief  foruts  of  the 
m^l  wi'.ii  ill  [•rHctli''-. 
Tnnmatic  Artliritii,  or  S«ptic  Arthritis. — This  arises  as  a  conw- 
qixnot  wf  a  ptrtit  iniiii.;:  wound  rA  a  Juiut,  wiih  aduiiseiun  of  iuipurv  air  and 
|>Uit  drf-iiif^miiKiit  of  the  diwhnr^^. 
lidly  tormiiinlf*  in  viippurntion,  and  in 
nunrs  Imdf  In  (Ti>mj>lele  dcKtrucliiiii  of 
iculaliiiu.  It  lia»  he«n  already  fully 
Iml   «rilh   Injiiriei! 


of  Joints  (vol.  i.  p.        v^J 
rilii. — Acute  inflflm-     \.    ^ 


Infective  Arthritii. 

■•f  i(i)f  or  lunn-  jninls  bt  a  fomiiion 
tSStct  uf  ra<ire  than  one  ^>iienil  infvc- 
iIt*  proonB.  It  is  met  with  in  pyu.'mii\  aris- 
faf  InHB  frmindp,  in  pucrpfral  fuvL-r,  si-ark't 
ftpif.wiwllpox,  «nil  H<iii)(.>tinit«  afler  typhuid 


)C.' 


lifM  ore  pr^iUalily  cIom'Iv  Hlliml   if 

(■mt  mndilhtiti'4,  tin'  p-nenil  tnfec- 

iiv  frtiiii  lilt'  pUivntal  nurface 

.  ver.fn<iii  tin'  ulct'mied  thr«at 

r.  from  ihe  pustules  of  ainall- 

>  lh<>  ulcere  in  the  intestines  in 

.  just  as,  in  ordinarr  pyiEmiu, 

I-.1-  from  Ihe  unhciiltfiy  wound. 

hriti*  lieifiiH  suddenly,  with  very 

rAWal  fmin.     It  <liirer8  from  many 

Kirnta  of  arutc  arthritu  in  Ihe   mptd 

•Aw  jiiint  whtrh  oceiipt   nt   the 

,(  ,if  thr  uttnrk.     It    thus  re- 

fi-  in  giving  riw 

-     'xviinics  the  out- 

I   i^'vl   aynnvial    merahrnnQ. 

<T  :t>i-  (■tmpC,  the  joint  will  be  found  to  have  undprsone 

tl  membrane  ia  tojeetod,  and  the  fringes  urullon, 


Ylg.  it*. — lBt«rl»r  ot   liaw  dlior> 

BUlloU. 


S42 


DISKASBS   OP   JOIXTS. 


RTifl  the  cavity  of  the  artiptilntinii  conlains  a  (jiiantitr  nf  thin  put  mixed 
with  symivia.  If  the  pnliPiU  jmrvivf,  liowpver,  tiiori-  Inmi  n  few  ifnr«  ntlrt 
the  joint  hns  betttnie  nfi<H-U'«l,  tlie  inflnmmntioit  PxtciuU  Uy  ihr  Hi:  '«■ 

8trucli)in  of  Ihe  <'8rtilniri«  orinmiein,-*-*.  and  ihe  cwbi!  then  run*  V  ■  -j 

courMf  of  uculf  nrtliriti^.     It  i»  cunietimt^  possilile  lo  arrast  th«  i  ■( 

the  inflainmutiou  bofijre  the  <]e3truclivc  chntig«9  wl  in.  by  «.>«it1.  -^^ 4. 

free  dratuagc.  aiitl  BDtiM^plic  tn-atmeut,  but  even  theu  cun>)i)erabl<*  t>ikk«a* 
JDg  anil  cuarractioii  of  llic  cit)Muie  UMially  results,  Icavin);  the  Joint  BM>rtt  or 
]eaa  tixuti.  If  the  joint  b«  vpeued  without  aufficivnt  dniiiiatpe  mid  withoBt 
Elitiai'ptic  trvatiuvul,  flecotiipusitiuu  oflhu  pus  in  the  cavity  takes  place,  aod 
ithe  ontitiury  rvsulia  of  svptic  artliritis  follun*.  The  exact  proccM  by  wbidb 
the  joint  hecoiufa  intw-'luii,  itnd  n-hul  it  ia  that  <lcU'rmiou  lh«   ;  'ir 

juiut  or  juinls  \«liic'li  ar«  aitafkud,  ia  not  certainly  knowu.    Ti^  u- 

tained  ill  ihf  urtirulaliop  iu  all  forms  of  iofecltvi!  artUnlt*  \»  very  trritaui^ 
uu<l  (roiiUiins  iui(.-nK>rgaui»rns  iu  largi;  numbers.  (See  aUo  PyKinta,  vbL  1. 
p.  9170 

III  0c!arlet  fevor  it  is  not  uucnmmnn  for  the  {Mttipnt  in  sufler  fWm  Mj^hi 
swelling  and  noin  in  tliejoinia  resembling  rheiimatit^m.  Thii^  ^tihgida  wiib- 
nut  8upiiuratioo,  aud  ia  probably  dliiliQct  from  tbe  pymuiic  atTcction  jutt 
dc«rrit»ed. 

Aciito  arthritis  may  necur  sb  b  complicalion  aim  of  gminrrbtni,  bvt  it  ii  ■ 
rare  nccurrcocc.  The  milder  forma  of  inflnnmialion  of  the  joints,  tDclixieil 
under  the  term  jT'iuorrhiL-nl  rheuinnLiam,  will  lt«  described  in  the  fbapt«r  on 
GtiQorrh(pa.  When  the  nH'ection  assuroca  a  destructive  form,  U  ia  probably 
duit  to  pYU--niie  IiitWtioii. 

Acute' Arthritis  from  Ezposnre  to  Cold.  Acute  Bbenmatie  Artliritis.— 
This  ia  n  lioiiituhat  rare  at)*et:tiv>n.  Alti-r  exposiiru  to  cnhl,  i:»[<rriMlly  fr 
slecpii)}^  in  the  dim-d  air  aAer  l>einfi  hnite^l  hy  violent  exertion,  thv  patii  __ 
is  seised  iuddenly  with  acute  febrile  symptoms,  s<^iiii?tiM)it)  prffO<1f^l  by  • 
ripor.  At  the  same  lime  xwcllint;.  with  intense  jtnin,  coiiim«n<-n»  iu  oat 
joint,  miMtt  rommonlr  the  kiiro.  The  Rviuptums  at  Sr>(  to  c)"«>ly  rrwublt 
an  allack  of  acute  rheumatism  that  these  eases  arc  commonly  lini  admitted 
in  hosftital  practice  into  the  medical  wards  and  subaequentlv  tranaftvrail  la 
the  surgical.  The  distinclioo  I'rom  acute  rheumatism  is  made  by  ubserriof 
the  fidloH'iog  p'linls  :  the  skin  is  hot  aud  dry,  tho  nrofuse  sweatiu;;  of  rbrH> 
malic  fever  being  absent;  the  afleclion  rvmaiu*  limited  to  the  siuulc  joist 
attacked,  and  the  symptoms  are  much  mor«  severe  than  iu  urdiuary  riicii- 
mnlisni.  The  ligaiuenia  are  early  implicated,  and  then  is  little  ivoognii 
effusion  into  the  jitiiit ;  thv  pain  la  most  agoniune.  uhI  ia  uf  the  cmi 
already  ih-gcrilnil  ae  occurrini,'  in  acute  arthritis.  Pus  may  form  'n 
joint  in  a  ft  w  ilay^  frtini  the  (Mminenroment  of  the  attack,  but,  undrr  pr\>|i 
■  Ireatnxmi,  thi>  hyniptoniM  ur^imlly  Nub.xjd*;  >;rAduaIly,  ami  the  pittimt  slotnr- 
Ireeovera,  after  wet*k»  or  months,  with  the  joint,  always  «tiH'ent-d,  and  Dsaalty 
Irmly  ankyloHcd.  sometimue  even  by  bone.     The  oxanl  cause  of  the  diMMt 

not  certain ;  from  its  auilden  inviuion,  and  ita  arisinif  fnira  cxpnnni  to 
cold,  it  haa  lM»n  UTincd  rheumutii',  but  the  evidence  nf  its  l>rinK  aduallf 
related  t«  acut«  rheumatism  is  not  clear.  Volkmann  de«crib«  it  under  tJit 
bamc  of  Acute  Croupous  Arthromeninnili!!,  und  Niates  that  it  iiirbarartchnd 
by  an  abtindnni  confrnlnble  exiulution  both  into  the  »ynovia]  oirity  aod  iIm 
•ofl  Btnictureo  fonninf;  the  joint.  From  the  facts  llint  if  suppuratioD  lake* 
[tiaoe  the  cnrtilnges  artt  rapidly  destroyed,  and  thai  In  (rfher  •  '      e 

lokyloais  occur*  Biibsequeut,  prouibly,  to  siieb  •levtruetion.  Bnxli.  n 

tVvevi^i  ihut    Binietnre   to  he  primarily   utriedd,  and  named  Uic  iluiasc 
^xiuiory  Acute  Uk^ratioo  of  Carttlafcc     Al  the  present  tinw  aloeimttoa  of 


TARlKTIBa    or    ACUTK    ARTHRITIS, 


Arlirvnl  u>  l)r  invarialilT  wcomlary  to  mUchief  oomiocnciiig  in 
»«tnictiirr«. 

Ante  Arthritix  leeoadary  to  Disease  of  the  Bones.— <'hroiilc  discawd  of 
Am  biioiw  Qi'Mt  cnmmnnly,  wlion  tUvv  rxU'nd  u>  a  nei)>hhiirinf;  articulation, 
IimH  b>  B  rttmiiic  iliiiraiw  of  the  joint,  auiimiing  th«  torin  of  white  i)w«lline  to 
W  pTTwrntlT  df«cribt>il.  Thn  only  exception  lo  thia  rule  is  the  tcrofuloog 
atMcrw  in  th^  lirad  of  s  long  UiM'.  Thi»  may  perfurale  the  onrtilajje,  allow- 
big  itK  T'lnii'atit  to  eoier  the  Joint,  ami  acute  arthritic,  curiin);  m|>i<liy  in 
•BMwratino,  niay  be  aet  up,  if  the  cavity  has  been  already  opned  exter- 
nallT  aiiil  cMiiiams  <lerimiiMi«i»|{  pu^,  Heptiv  Hrthritii^  uf  the  uiiwt  acute  form 
al«ayH  I'tllow-  tirrf'iratimi  of  Ihp  i-artiln^e.  The  perfumtioii  uf  the  cartilage 
i:i  ihr-t^  miH-*  I-  <i  hy  a  pHK-'Mut  orulcerHttun  iilenlieal  iu  uhnractvr  with 

l'>:it    nirvxily  .  i  US  occiirricij;  in  acute  arthritis  cvnidieuciii);  iu  the 

:    thr  only  diUt-rpiicv  living'  that  it  pruveeds  from  the  deep  inKtead  of  the 
;>;;  i-iilar  »irtact  of  the  cnrlilngD. 

Acul«  indaniiiintory  pmcwses  when  oxtendiug  from  the  bone  to  the  joint 
alwaya  srl  up  acute  urthritin.  Arate  irifeetivt)  periieiitis  or  oi)t<i>niypliti8  of 
tbe  ah&ft  (Arai«  NcvniFii',  ]\.  '2ii'i),  iiMinlly  sto|s  at  the  epiphyses,  nod,  con- 
w^umtly,  tvMiiDi  cniiM>H  dinease  of  the 

nrj^hLx'rinir  joints.      This  rule  ift,  how-  4 

wnr,  not  almilutr,  and  pxceptlotial  rum 
u*  Biit  «tttJi  in  which  the  articulalMSH 
beoMiif!  nfTrrtrd.  In  these  there  \a  nt 
CtM  abundant  efliision  into  the  cavity  of 
IfaeajrDnTJal  menihmne;  this  rapidly  be- 
ooiMn  puroirnt.  and  destruction  of  the 
cvtilaur*  and  saining  of  the  lignruenta 
qwrkJT  fi'Uow. 

Aentr  («teomTeI!li8  attacking  the  grovc- 
■f  bnne  in  the  epiphysis  and  uauallv 
liiMting  in  its  nccrosia,  or,  as  it  is 
^iphytxtia.  is  a  not  uoconi- 
acule  arthritic  in  yuunj^ 
•alljn^4.  j  i>*  rauveo  of  tliia  alTec'tioii  are 
•ni  always  cvidrnt ;  somt'tintes  it  \«  at- 
Iribi"  '  ■  i'lry.  On  examiuinji  H  joint 
■Ari  ilia    way.    tlit*    apjifHniucvs 

slrea*!,^     iiiTu.ril'i-<l     a*    chnrncteriiitic'    of 

va\^  arthritis  with  iiU-cration  of  the  rartili^es  are  met  with.     On  making  a 

i~  from  which  the  diiK-aae  Ftarte«l.  the  bone  eontnined 

ii<i  ftirmint;  a  »4K|iH-8triim  batheit  in  pus,  the  cavity  in 

wbieh  it  he>  cunioiitiiUTatiug  with  the  joint  by  an  ulcerated  track  thri>u>;h 

ih«-  f-ariilfiir.-.     In  nthrr  vti»v»  the  cpipiiyais  may  be  separated  from  the  shaft. 

r-iiis  is  pn>luildy  in  must  csaes  an  infective  inflammation  closely 

i,,  ..  .  .  >-  infit-tivi*  pf;ri>islilb  and  oBteomyelitis. 

Bjphilitic  epiphysitis  and  its  etfecta  un  the  joints  has  been  alrendy 
dMcrthn)  I'vol.  I.  p.  I'l.S]  t 

Arata  Aitbritis  from  Diseases  of  the  Soft  Farts  extaroal  to  the  Joint — 
Afaarvwn  artsinp  fmm  any  c»iim<  in  immediate  rfmtncl  with  a  joint  may 
bam  tnin  ita  cavity.  Whrn  ihio  happens,  acme  arthritic  with  di<etructinn 
of  lite  anirulttliori  inrariiihly  followa.  This  accident  may  occur  in  acnte 
inflaifimali'io  And  Mipnnrution  of  the  banst  in  the  nciKhborhoml  of  a  joiuL 
la  pliU|tnir>onu*  ery>i{>ela«  the  jnints  fln>  occiuinnally  ofMtned  where  the 
ita  ore  in  clusv  cuotact  witli  the  aubcutaneous  tiasOft. 


Fig.  SZD.— n.  Cmtim  ftt  HmJ  of  Tlbik. 
b.  VnUiwliua  of  CafllUc*. 


«44 


DISSASKS    OP    JOINTS. 


AcDtfl  Arthritis  of  Infaats. — Undrr  tliiit  nnme.  T.  Smith  has  dcecribed  a 

form  of  Hciite  artliriti?  iitK-niinfcted  wiili  nvphilis  vr  injury,  run  uiiwiuiintmly 
met  with  in  very  young  chiUiren.  ll  is  t^uililun  in  oneeu  ami  runs  a  rapid 
course,  ending  in  auppurntion.  It  t^  nuMt  i:uiunion  in  the  kric^,  hip,  and 
shoulder.  The  Urat  symptom  i»  reslricted  movement  with  pain,  rapidly  fol- 
lowed by  swelling,  and  the  formatiun  of  pus.  In  some  ctaes  two  or  ihree 
joints  are  afiecced.  If  the  abseeaa  is  opened  early,  recovery  may  take  place; 
ankylosis  rarely  results,  but  more  coromonly  a  weak  movable  joint  is  left. 
The  di8*o«e  i«  fatal  in  a  considerable  proiM>rtioD  of  cases.  In  the  21  oaaea 
recorded  by  T.  Smith,  the  ages  of  the  pntienia  were  a*  follows:  8  under  1 
month,  4  under  2,  7  between  2  and  G,  and  :1  over  6  moulha.  The  post-toor- 
tciii  examination  of  the  fatal  cas*-'^  showed  rapid  lose  of  subslaucc  in  the 
artioulareiHl  of  one  of  the  long  bones  entering  into  the  joint.  Acute  Arthritis 
of  Infanta  does  not  »ctm  to  be  a  separate  disease.  .Some  of  the  recorded  cases 
wei-e  probably  py«tmic,  arising  in  very  young  infants  from  infection  from  the 
iinibilirat  cord  ;  others  were  intilaticefl  of  acute  epiphysilia  occurring  in  youDg 
children. 

Senile  Acute  Arthritis. — There  is  occasicmally,  but  very  rarely,  met  with 
a  form  of  acute  arlbrius  occurring  independently  of  any  external  cause,  but 
apparently  due  to  nccroiiis  of  the  cartilages,  from  simple  lose  of  vitality  in 
ola  pereoiie  of  feeble  couatilution.  I  have  seem  it  in  ibe  joints  of  the  foot, 
the  ankle,  and  the  stemo-clavieular  arliculattoo.  It  reseoiblcs  in  this  respect 
thai  form  of  senile  noeruBis  of  bones  described  ai  p.  301.  In  the  senile 
arthritis  now  alluded  lu.  the  pain  ia  very  acute,  the  eulargeiuent  of  the  joints 
considerable,  ihi;  Habiting  of  muscle  rapid  and  great.  The  couatilution al 
dtsturbuucc  is  pruporLionately  severe.  The  joint  that  it  mael  frequently 
allectji  it)  the  knee.  I  have  seen  Jl  also  in  the  wri»t.  Thie  form  of  arthritis 
muBt  not  Ik  confounded  with  the  dry  rheumatic  arthritic  of  old  people.  It 
(Jitters  from  this  form  n(  the  disease  in  the  acuteneae  of  its  local  nymptom», 
and  the  severity  of  the  ronalilulional  disturbance.  It  is  often  mistnken  in 
the  first  instance  for  Kiuit ;  hnt  the  rapidity  of  the  process,  the  formation  of 
pus  within  and  around  the  joint,  (he  necn^ls  of  the  contiguous  bones,  and 
the  separation  of  the  tncrusling  cartilages,  all  indicate  the  different  nature  of 
this  aneetion ;  which,  so  far  as  the  joint  itself  is  concerned,  is  incurable,  and 
which  may  terminate  in  the  loss  of  (he  patient's  life. 

On  examining  the  joint  after  removal,  the  cartilages  will  be  found  to  be 
ulceratefl,  the  synovial  membrane  softened,  awolteu,  and  injected  ;  the  liga- 
ments softened,  and  the  articular  osseous  ends  congested. 

Rkfair. — Should  the  patient  recover  from  acute  arthritis  without  removal 
of  the  joint  by  amputation  or  excision,  the  processes  of  repair  will  vary  with 
the  extent  of  the  mischief  done  before  the  arrest  of  tbediseaee.  The  inflamed 
ligaments  seldom  reprover  iheir  normal  c-ondition.  The  inflanimntory  pro- 
ducts with  which  they  are  inhllrHted  are  partly  ab8orl)ed, and  partly  developed 
into  dense  fibrous  tissue.  This  process  ia  accompanied  frequenilv  by  some 
contraction,  so  that  when  it  is  completed  the  natural  mobility  of  i^ie  joint  is 
more  or  le»  interfered  with.  .Should  the  pocition  of  the  joint  during  the 
attack  hare  ted  to  relaxation  of  any  ligament,  as,  for  iuatauee,  of  the  ilio- 
femoral from  flexion  of  the  hip,  the  ligament  becomes  sborteDed  as  the  joint 
recovers,  so  that  the  position  assumed  during  the  acute  et^e  becomes  a 
fixed  one; 

In  the  BynoTial  membrane  the  inflamed  surfaceti,  which  have  lost  their 
endullielial  covering  and  become  eovered  with  gniuuiation-tiwue,  adhere  to 
each  other  wherever  they  arc  in  contuil,  ami  thus  the  eymivinl  iKiuchea 
become  obliterated.  If  the  cnrtilagea  have  been  l)ut  very  Bupi^rfioially  ulcer- 
ated, they  may  become  again  smooth  without  forming  adhesions  between  the 


TBKATlieNT   OF   AODTB   AHTHRITIS. 

■ppowd  MiHheee.  If,  however,  the  dcelniction  ha^  gone  on  to  the  extent 
flf  the  fnrmntioa  of  ^anuUitf^n-iiMue  on  the  atirl'nce  of  the  cartilH^<«,  ibe 
oMxatal  j-mniiUting  turfacpa  owilesw,  tho  new  tissue  becomes  dcvel<»iM.iJ  into 
aemuiciai  lihrou»  tlMUf,  and  th(^  joint  is  pcrraancQlly  atiflt'tiL'd.  Ihisron- 
AtfcoQ  ia  fWfloribed  aa  fibmiia  ankylnats.  If  the  cartilage  hati  been  cnmplctcljr 
rfHCRkfed,  th«  oppnaod  gran  illations  on  niirraom  of  tne  bonc^  coal»oe  and 
4*ff«lo|i  into  boiM^,  and  ihiia,  oweoii*  niikyl<M«iit  rcttultx.  In  no  circumntanocs 
doaa  eftrtilag«  frh«n  oooo  do«triiye>l  berome  rpj^-ncrAted. 

TsKamnxT. —  In  tin*  trwitrnf^iit  of  *!«//«•  ftrthrl tin,  perfect  rwt  of  thearticil- 
Iumm  it  of  tJie  Kmt  inonient.  Uul^»>»  lhi»  l>e  »ecu  red.  no  other  treatmfnl  can 
b*  of  any  at-ail.  Tli<-  limb  hIi'iuM  \tv  coiiiturtnbly  ^iipporte<l  on  pillnwB,  nr 
6TeH  br  weil-mtuli*  nin!  eiiftly  pAcliltnl  8|iliiiti^,  or  i*)un(j  in  a  cradle.  For  the 
hip,  kn»^,  nrtinklr/riinnintf'fi  hip  and  kiitw»plii)U  will  b«  iotind  most  ellimnt. 
Bot  not  unlr  i»  ml,  iiiiMHiotiug  to  abeidiite  iimiiobilily  of  [hejuint.  ini|>erH- 
CJTHy  rr<|uimt  a»  the  iint  luuana  of  curu,  but  th^rv  u  a  second  lii^lM  which 
m  alrarst  of  tM|ij|il  ini|>i»rtiince,  with  tfa«  vtuw  of  rviuoving  pain,  and  prtrreut- 
iar  d«structiv<>  dteorptniKntiim  of  the  articulation  and  consequent  nukylueia 
— ^1  mrma  r'nehx  extvnfion  nf  thtt  limb,  so  n»  u*  separate  the  ariieulnr  Kurtiiciv 
t: —  -  ■  -htly  from  one  another,  and  to  prevent  the  exc«8*ive  and  agonizinf^ 
[  :  motiliB  partly  fn>iTi  the  preeaurEs  of  one  intlamiMl  articular  tfurfiive 

aSBiOM  tn?  uiher,  bjr  the  lontc  contraction  of  the  muHclea  of  the  limb,  partly 
hvm  Um  apinM  that  shake  the  limb  and  hofly  from  time  to  time,  when  the 
yalMBi  &Il»  to  ile«p.  ThfW  jmins  are  irnt  relievetl  entirety  by  eimplu  reel 
""  '  prtman — more  espwinlly  that  pain  which  rpflnlts  fnun  the  apafimndiu 
«f  the  muscles  of  the  limb:  but  ihey  nre  nsunlly  at  nnce  removed  bv 
liaD,  by  means  of  a  weight  nttnched  to  the  lower  yvnrt  of  (he  limb.  This 
bpartioalairljr  theeue  in  iaflammations  -tf  ihc  hip- and  knee-joints*.  It  i^  in 
IMM  f  fwn  that  the  ireif^l-estending  apparatus,  oombin<Hl  with  perfect  re!<t, 
i»  aa  adTaoiageotu.  The  weight  flhonld  b«  proportioned  to  the  a^e  of  the 
p*i;.ini       In  UM>  will  often  at  once  relievo  pain,  and  enable  ihc  snriVrcr  to 

L!'«p.  Fomentations  and  the  n^ual  topical  soothin;;  treatment  may 
•.•'.•M'Uied  with  IhcM- means.  In  the  acute  stage  of  the  dieeaftt-,  small  d<.'<«e« 
of  cailutoel  and  opiuui  in  |>ill  may  be  u»efu],  anil  at  the  same  lime  the  [lalieDt 
■KM  be  conBned  to  liquid  food  without  stimulantn.  Leeches  applied  freely 
l>tk»j»«ol  frequently  relieve  the  pain  and  diniii)ii>h  the  acotcneu  of  the 
mntanra.  when  the  diseoK  it  not  due  to  »  septic  or  infective  proces*. 

Btoold  there  mesM  be  tucd^ful  in  arresting  the  progrefls  of  th«  dieeitso 

WEir*  Mppuration  lakea  place,  the  inllanamation  ofXen  continues  in  a  mb- 

■■rfr  fcrm,  and  ^ime  modincation  must  then  lie  mmle  in  the  treatnieut.     In 

tfdi  eo^ditioa  real,  aheoluie  and  immovable,  ii>  equally  imperative  be  in  the 

aoDto  ttM^tf  and  may  be  «iGcurod  in  the  »uinc  way.     At  the  came  time  the 

IhbK  mav  be  re{iraK-4lly  hlti>t4>re<l ;  hui  in  many  in«taucea  mnj<t  beneBt  will 

be  d^ptvi-i!  frun.  i>i.<  rtpplicsliun  of  the  actual  cauii-ry.     This  n^ient,  when 

|vn|k  much  more  ci'ruiiu  and  viicH-sfful  revulli^  ihau  any 

-•'-—  i.i-irritalion  wilh  which  I  am  acquainted.     The  imlient 

ilieliced,  a  rnuierizing  iron,  heated  to  o  binck-refl  heal, 

I  r»  nij.i.nv  iirawn  over  the  di»ea«eil  articulation  in  a  scries  of  pamllel 

turttwt  which  an  •^pial  number  of  crocnliars  nre  again  dmnu,  8t>  as  not 

'-'  the  whole  ihickneH  of  the  inie  nkin.     A  (rooti  deal  of  inflamniH- 

1*  «et  up.  fiijlowecl  l)v  ftlight  itiippuration.     SVhen  thi^  baa  »ub^idt'd, 

jliim  of  the   hot  Iron  nmv,  if  neccfyinrv,  be  rc[>cated  ;  in  lW\»  nay 

.-nnwin;;  palti   will   uxnallv   Iw    removed,  and   siippurution  of  the 

-'"d.     F'>r  c"iunt«T-irrilaiit»  to  be  of  any  u«c,  ihey  must 

1    I    .re    nippuration    hae    set    in;    It    i»   only    toriuriiig    the 

II  BODicwanly  to  have  ix-ooiirae  U*  theee  agents  when  once  pua  haa 


J 


DISEASBS    or    JOIITTS. 

formed  io  the  artinjtatioD.    In  order  thai  full  iMttcfii  ibould  be  desmd 

from  lliis  iilmi  <jrireatiiu'ii(,  it  miipt  be  penwveml  to  itudiljr  fur  ■  rnMJihf 
a1iU>  IfOj^U  iif  liai)\  and  tJinuIU  he  roujnJDf^  wiih  a  rooderatd^  aatipUa- 
ffistic  Rii'l  altf miivK  ircatnii-nt.  With  ihis  Tien',  the  pcrchloride  of  metvurj. 
ill  (l<«ee  ol'  frutii  'loe  Hiittentb  tu  onfrtmliUi  of  a  gntD,  mmj  Iw  advaa- 
Uig(->>upl_v  i;i^*!0  wiih  the  compounil  decocttlMl  of  aaraaparilla.  or,  if  ther*  he 
mut'h  di'Iiility,  wiih  the  compctund  tinvtun-  uf  bark  ;  good  food  wmI  Miiaa< 
latiU  ht-in^  conjointd  with  it.  in  [iro|Kirtion  to  the  iocreaee  of  the  drhilitf . 
Aa  the  inllftniniatioD  about  the  joioL  subsides,  a  tonic  plan  of  trfatmrni  oe 
onliiiarv  nu-'litml  ]iriiicipUa  ahould  bi'  subaiiluted  fur  that  which  had  pi^ 
vioosly  b<^-n  eoijiloved. 

During  the  subacute  rtago,  if  it  be  thought  ueceanry  to  appir  rountn^ 
irrilatioo,  alMolute  re«t  of  the  joints  of  tho  lower  tirab  may  m>  obtaiixd, 
without  conlttiln>(  the  patient  to  bed,  by  the  um  of  Thomitii's  hip  fir  kite* 
liijint.  (Si-e  I>iieA««ii  of  the  Ili]>  adiI  Kxcitioa  of  \hR  Knrv.)  It  it  b* 
tni>i._'  <<  <-<-wuiry  id  a|>ply  any  cnuoter-irritation,  the  ittdanK*!  joint  »■▼ 

be   .:  steadied  by  the  appUoktion  of  the  itarch- or  plaatcr'bai>da^. 

the  pdLit^iiL  Llicn  beiiij;  allowed  Ui  move  about  oo  crutchea  or  id  a  cbair.    la 
disease  of  the  iuiait  uf  the  foot,  the  palieot  may  walk  on  a  pin  woodco 
rating  ua  the  bcut  knee. 

With  ffspect  Uj  the  local  treatment  of  the  inflamed  joint  in  tikt 
atagea  uf  the  disease  when  it  has  aaumed  a  eknmie  form,  it  may  b«  Maiod 
generally  that  so  lunfc  lu  it  is  tender  on  prenure,  applied  perpeudicuLartr  ur 
laterally,  m  lung  as  there  is  any  I'Kieeuing  of  tlie  ligaracuU,  or  pain  iodaaHt 
by  Riiivenienr,  it  must  he  kept  ulienliitf-ly  at  rrst  to  splints  or  by  a  ctarHird 
or  plaBler  bandafce.  During  this  periiKl  j^reat  care  muM  be  taki«  to  krrp 
the  Jittul  iu  the  p'^iliitn  which  will  lie  mwt  useful  to  the  patient  in  aftrr-liw. 
Bhootd  it  bprome  xtilf;  the  straight  one  for  the  knee  and  hip,  and  th«  frmi- 
Qfxefl  for  the  elbow.  In  niauv  cases  it  mav  be  useful  tti  strap  the  >><iat 
firmly,  in  the  way  recommended  by  8cott.  This  plan  of  treatment  ccnsisa 
in  spreading  on  pieces  of  lint  the  strong  mercurial  ointment,  U>  erery  ouaea 
of  wlii(-b  ft  drtu'hm  of  camphor  bus  been  aildi.->l ;  »triiM  of  fnap-plMttr 
spn-a.l  upon  leather  arc  then  cut  of  a  projter  Irnglb  nint  brrs''  -ha 

joint  h  lirmtyand  accuralely  etnippt^d  up.  the  limb  having  |>r<  v  ■.  ..cb 

Modaged  aa  high  as  the  joint  that  is  strapped.  This  dm>»ing  msy  be  loft 
on  fur  a  week  or  two,  until  it  Irxjaens  or  gives  riM  to  irrilstion  ;  over  the 
whole  a  starched  bandage  may  hv  applied.  Iii  many  case*  1  have  found  it 
Atlrnntngeous  U*  strap  up  the  joint  wjtli  a  planter  CMmposed  of  equal  parts  of 
the  empJustrum  amrituuiad  cum  hydrargyro.  and  the  vmplastruui  up<>nis  or 
belladonuiG.  These  applicittious  not  only  fix  the  joint  and  pnMuote  thu  ab- 
sorpli'tu  of  the  intlaumiatury  products  nithin  and  nruuod  it.  but  Iit  aetiag 
lu  guiille  counter-irritanls,  remove  the  remains  uf  the  inllummaUon  iliat 
be  going  on  within  it.  If  rrouvcry  have  left  the  joint  sttitfened  without 
uclunlly  ankyl"»ed.  the  nnturni  movement  must  be  n-sturei]  by  warm 
iog,  fomcututi'iu,  friction,  and  paw>ive  motion.  Warm  water,  in  any  way 
appliuHJ.  is  purticulnrly  niid,  indeed,  singularly  tiM-tul  lu  a  way  difficult  »/ 
explanation  in  restoritig  the  mobility  of  AtitK;nMl  ji<tnlti.  PdAire  uovenieat 
mu»t  bf  undertaken  with  grent  caution,  nnd  not  until  every  trace  nf  artiv* 
inlluiiiniation  hu  pAMe<l  away.  U  is  Itcttcr  to  keep  the  limb  lixed  a  nootk 
or  more  lunger  than  ii>  ulisoluiuly  nccewnry  than  tn  begin  painvc  OKnremrat 
n  day  too  soon.  Tho  rhancri>  of  nnkvtosis  arc  only  increased  and  tbachrMiP 
inflanimntion  prolonged  by  abandoning  the  trraimtnt  by  iierfitct  rest  beliir* 
the  nrotier  time. 

Snould  the  treatment  fail  in  prevritl  suppuration,  the  prognosis  becomai 
tut  mure  uu&vurable,  especially  when  large  joints,  such  aa  lb«  kate  or  hip, 


baul^ 


TREATUENT    OP    ACUTE    AKTHBITIS.  847 

■re  ftHectet) ;  an  likewise,  wlien  the  articular  ends  of  the  long  honea  are 
dtiea«e<l,  it  i»  seldom  that  the  joint  can  recover  itself,  as  caries  or  necrosis 
ire  ciiniplicatiug  the  arthritis  and  keeping  it  up.  When  the  articulation  is 
Tcr^'  einuuu0,  as  iu  the  carpus,  or  when  a  nuiiil>erof  small  joints  communicate 
vitb  one  another,  if  nut  ilirectly  by  synovial  membrane,  at  all  events  ia- 
direi-tiy  through  the  medium  of  ligament  and  of  Rbrous  tissue,  as  in  the 
lar«u«.  a  cure  can  mrely  be  obtained.  As  soon  as  the  presence  of  pus  is 
reoifcnizetl,  steps  muH  betaken  to  let  it  out  cotiiploteiy,  and  to  drain  the 
cavity  thoroughly.  It  is  important  that  this  should  be  done  if  possible 
before  the  capsule  gives  way  and  the  pus  becomes  diffused  in  the  surround- 
iog  luirts. 

When  distinct  fluctuation  is  felt  and  the  cavity  of  the  articulation  is 
erideiiltT  lull  of  Huid,  if  there  be  any  doubt  as  to  its  nature,  tlie  joint 
■boulii  be  punctured  with  the  aspirator.  If  the  fluid  removed  is  thin,  serous 
pas  mixe^l  with  synovia,  the  fomentations  and  other  local  means  of  treat- 
ment may  be  continued,  ami  aspiration  repeated  if  the  joint  filL-^  again.  If 
thick  pu«  is  withdrawn,  an  opening  should  be  made  at  once  and  the  cavity 
drvioed.  If  the  skin  is  reddened  at  one  part,  under  wlucli  ftuctnation  is 
Terr  distinct,  the  presence  of  pus  is  certain,  andasinration  will  be  of  little  use. 

An  alHce9«  in  a  joint  should  be  freely  opened  by  one  or  two  lateral  inci- 
Aau,  extending  fairly  into  the  synovial  cavity,  so  as  to  afford  a  free  exit  for 
the  pus.  The  practice  of  making  free  incisions  into  a  suppurating  joint,  as 
ftdv'icaletl  by  Guv,  was  a  great  improvement  on  the  foriiicr  method  of  merely 
puncturing  it.  The  small  aperture  that  wns  formerly  mnde,  without  any 
antiseptic  precautitms,  admitted  air,  in  cnnsequciK'e  <d'  which  the  pus  become 
offifosive  and  irritating,  and,  being  unal)te  to  escape  freely  gave  rise  not  only 
to  much  liica)  mischief,  hut  to  severe  sefitic  fever.  By  laying  the  joint  open 
frMly.  even  when  no  special  antiseptic  treatment  was  adopted,  much  of  this 
was  preventetl ;  exit  was  given  freely  to  the  pus  through  one  or  two  incisions 
extending  the  whole  length  of  the  articulation  ;  the  se|)tic  poisoning  from 

Cnt-up  and  putrid  matter  whs  prevented,  and  in  n>nny  cases  healthy  graiiu- 
tioos  sprang  up  in  the  caviiy  and  recovery  look  place  with  an  ankylosed 
juint.  The  chances  of  this  successful  termination  resulting  are  very  greatly 
JDcrvasei)  hy  the  adopiiim  of  eoiiie  tfiicient  method  of  antiseiitic  dressing. 
The  irregular  cavity  of  a  joint  i^  difficult  to  drain  portectly  even  with  the 
frn?!  incisions,  and  conf<e(|uently  it  is  of  great  iiii|)ortfl[i<'e  that  such  fluid 
IS  remsiin:>  liehind  should  not  he  allowed  to  dccnmpit^e.  Tlie  Uf^e  of  the  cir- 
boiic  ^pray,  though  not  essential,  will  rriidtr  I  he  |ireveiition  of  <lecompi>!iltion 
Bi'ire  easy  and  more  certain.  By  llie  comtiiiied  use  of  luiiiseptic  drninage 
ud  rK'l  niii:.t  excellent  results  are  obtained,  and  excision  of  the  joint  or 
aniputaljon  of  the  limb  usually  ovnidcil,  Ii  iw  mure  especially  in  tlie  knee, 
1-ihiiw,  aud  hip,  that  this  pniclice  has  yielded  such  good  n-sulls.  In  iconic 
cas(f,  even  when  the  joint  has  been  perfectly  loi.sp  imd  prating:,  by  perse- 
Ttranc-e  in  pro[H:r  treatment  a  good  and  useful  Mmb  may  be  left.  Should 
d«e<>m|M«ition  take  place,  profuse  discharge  followed  by  herlii-  or  chronic 
•eptic  i-ii^oning  comes  on,  and  ]>yietiiia  is  not  unfn-<juently  developed  ;  if  the 
p«lK-itt  tscU|M.'  these  dan^rs  the  joint  may  become  us>-less  or  ciindiei'some,  ami 
iic  removal  by  amputation  or  e.\ci>ion  most  be  practised.  When  an  atli  nipt 
is  made  to  save  the  j<'int  after  suppuration  has  taken  place,  very  speciid 
ailt-ntiiin  will  he  retjiiired,  in  consecjuenee  of  llie  softi  iiiiip  of  the  li-raments, 
h>  prevent  dis[dacem(-nt  of  the  <is,'*eous  surllu'cs  either  laterally  or  ainero- 
pfwtrri'fiy  :  this  may  be  pnMluced  partly  hv  the  wei;:lil  of  the  limb  and 
partly  by  the  tnictiou  of  tlie  muscles.  .Viiy  iiegl.-ct  of  prnper  precautions  in 
tiie  Uii>re  luinute  details  of  tlie  application  and  adjustment  of  projier  ap|m- 


MA  DisBASSa  or  joints. 

Mtwa  Buy  bp  followH  W  n  very  cottKiderable  vnount  nf  defurmiLT.  ^  -.»1 
iIm  limb  nlrpndr  iinfiTtiinnlelr  have  aasiimed  n  fftuUv  p'JFilioii.  hi  <--um> 

r'lte^  u(  the  KurKei^ii  iiej^lecting  to  eupport  it  properly  ip  r|diDU  ■ 
fAfly  aciit«  BUige,  tbo  piitient  may  be  nniesfhetizeH,  ao<l  ihr  limbalmlj 
auil  jcently  placed  in  fiuch  a  poaitioD  m  will  bo  tnoet  conducive  lo  hiaificr 
canifurL 

With  regard  to  tbo  trcatnicnt  of  tlio  upocial  fomia  of  acme  nnhritiK  liult 
need  be  Mid.  Tlmt  of  aatte  septic  arOirUU  from  n  wound  hiu  alrcaidy  b«s 
dvii'ribcHl.  lo  PotemU  AfihrltU,  lurat  commonly  Iittli>  cna  be  done  nn'tof  u 
tht*  (iMMiitQtiotinr  condilion  of  tho  patient,  but  sbould  ibero  he  no  Ti*r«nJ 
oiiufilJL-AtJiios  a  t!Ufe  iiui  uufn-i^UL-uity  n^ulu  after  fr«e  anliM^ptic  inrifwSv 
dniiaa^-,  and  i-eM.  Ankylnsb  hIiikmL  invariably  rcailltaL  la  Aatie  Ai  Uu'Uit 
from  Cnltl,  porfert  Kdt,  li-vcliiv,  uiui  \w\  fonivniaciniu  muft  b«  tried.  l9bMll 
nuppitration  iiikf^  place,  fr««  iDciajoriA  may  bcauccoHfal  in  uving  the  yilA 
111  Acute  Arthrili-  *eeondar%f  lo  diieatr  of  Ote.  6ona,tiM  Tt*\l[ti 'if  lt*»tmeM*n 
Hot  ven-  sutistiiciory.     An  Htt<>mpt  timy  be  made  to  aavt  th  v  n-mov- 

iuff  sec|ue8lrii  and  treating  llie  cnri'^iis  surface  m»  deccnlx-'l    i  iap<er  uB 

Dweaam  uf  Bcuea,  but  it  nfteu  ftiilt>,  and  anipulatioD  or  ^xl-l-muu  beooMS 
neuvsaary.  In  Aevte  Arlhritis  vj InjuixU.  tbe  joiul  niu»t  be  laid  fn^ty  open  M 
S'Hiii  as  pue  tbrnifl,  and  by  ibis  aieane  tbe  lliub  ctm  usually  be  savei).  la 
&»t/f  .4.rfAnli«,  llie  ti'efltiucnt  iiiust  bv  conducted  uu  ordinary  principle*  if 
nsst,  f'lmeutnLionis,  upiulec,  and  Huppurta.  But  at  lust,  lit  order  tn  prrrrot 
destruction  of  lilu  by  paiu  Hud  exbaualiou,  tbe  ifueslioD  of  amputat4ua  rill 
arise ;  nnd.scriuua  as  this  may  be  in  uld  |iu>ple,  it  will  bu  the  uuly  altmMtii* 
tuid  chance  of  ci!cu|>o  fmra  a  pmuful  denUi. 


[fuapB 


CHBOMa  BTUlTMOUa  AltTORITlS,  OIL  TITUTE  lOITKLIJXll. 

Bv  White  Swelling  is  mcflnt  a  very  chronic  formof  nnhritia  nccurri.^ 
scroitiloiia  Biil>iecli<.     It  vths  do«oril>e4l  by  Hir  Benjamin  Rrodie  naderj 
name  t>f  palpy  degeneration  of  the  synovial   membrane.      By 
(?eriiiiin    HTiu-ra    it    in    Icrinvd    fuugotis    intltintiiiatinii    ol'    jitiats    ( 
(ri?lciikiMilziinduii|;},  and    more  rucentljr,  for  reHM>n»  wbiob   Mill   be  statoi 
hereufl^r,  it  has  t>eea  pmpiieed  to  call  it  tubercular  arthrltit. 

Symttoms. — This  diwAMo  in  many  cases  su[>ervenea  abiwlr  on  iMnwi  kU^I 
injury,  US  a  twiitl,  %iv  blow,  or  sliRin,  but  in  others  no  ddioile  ■ — '--■  -;n  t* 
■«aigne<l  for  its  apftearance,  and  tbe  exact  date  of  its  cmimrnc*-'  tea 

difficult  to  ascertain.  It  may  commence  with  a  subacute  sro'iriii*  is  t 
flmmouB  lubiect,  assuming  its  peculiar  character  at  a  later  period.  It  w 
specially  liable  to  happen  in  children  and  female*.  Tbe  JiieaM  bcfb* 
gradually  with  some  pain  nod  slitliiesj  in  the  Joint,  causing  a  flt^l  liMp  ii 
walking  if  n  joint  in  the  lower  limb  is  atfecteu.  The  |>aiD  i>  incrwwed  aftv 
any  extra  exertion,  and  may  then  be  severe  enough  to  oblige  the  i^tTcm  I* 
ratt  for  H  day  ur  two.  when  tbe  Byni|iton)»  ireneralty  subeide.     \'  -  .'be 

■xomineil  durini*  this  stage,  there  will  unually  lie  found  some  fti^'  I'.ixa 

of  Hiovement,  eumptete  exleneiou  ur  ticxion  rnusing  paio.  li  tfae  juiuijif 
suptrfioial.  as  the  Knee,  elb(»w,  or  nnkle,  it  will  be  seen  to  b*  swollen.  ~ 
natural  hollows  are  ton  clearly  marked  than  in  health,  or  even  ciinipl 
obltleraled.  The  swelltDK  at  this  Mace  takes  the  funu  of  ihe  distended 
ovial  cavity,  us  in  synovitis  with  eflbnou,  but  it  does  not  give  the  tama 
of  fluctuation,  being  seniiclusitR  and  l>utpy.  Sometimes,  however.  It 
mA  that  it  U  readily  uitsiiLkeo  for  lluiu,  even  by  tlii*  experieunil  baDiL  la 
the  kuet!  it  may  he  dtatiiiirultbod  by  ulMrrvlnfr  that,  tliiiU(;h  the  poiclla  ii 
raised,  it  ououot  he  piubtd  ibiwit  vrilh  a  dixtiitct  iMMcuMiun  on  tbo  fmur,  M 
to  syuovtlis  with  effusion.     As  tbe  disease  advance*  tbe  joint  beeosMa  more 


CBBUXIC    ARTRR1TI9 — srMPTOMS. 


S49 


I,  and  u  the  ligameot*  become  iDiplicaicd  ifae  ewplliog  luees  the  ou^ 
\€t  llittByDOTiBi  nicmbnuio  and  asennioe  ■  more  rouuded  t'uriu,  the  buny 
m  bting  effiu^d  by  n  uoifijroi,  dougliv.  setaiclnstic  or  pulpy  bw«I1- 
The  inWfpicDentd  ooverio];  ii  pre^rvo  their  white  culnr.  rh<.-re  is 
'■■■Uy  but  litilc  paiu  felt  when  the  limb  U  at  rest,  but  niuiiun  becomu  nirin> 
'  oMiK  punful,  till  it  U  ni>  hm^T  pu^ible  tu  use  th«  limb.  Tlio  pcMittoti 
ttntA  by  till!  Uinh  lU  ihU  liuto  i^  that  id  which  the  patient  baa  roost  ensc. 
TiL.  thai  of  aeruiflejEioQ,  and  with  this  there  \»  a  cousidereble  dej^rec  of 
tfiAkcw  &ad  ri}{idity.  lo  thin  tun^e  the  tnllumniation  curomonlr  cxti'uda  tu 
Lk»  pvrifwU-ufu  t.>tverin^  the  artii-ular  emU,  which  becnoie  slightly  en)ar^;ed 
^  dr[N«it  (il  i»-M'  Ixiiii!  Irdiu  ufciettphittlic  iwriofttitis.  The  dej^rou  l<i  which  the 
•rlirui:^  -   ^ro  vtilNrL,-w«l   \»  very  difficult  to  e«ttmate,  a»  thi-y  are  uiimlly 

0«a*»<.>  -M.-uivtl   by  the  .■ivretliii]' nf  tlie  mirniundiiit;  sutt  [larlj),  aitd   ta 

e<aB(-i]ii(:uiL-  u|  tlii>  wiuting  of  the  iihiik-Ii-s  I'nmi  diM-u-Hc,  ihe  Krliculniiou 
»f»y"-arT«  iii'irr  •"■•'l>-ti  l^nii  it  really  li*.  If  the  <liit«i»e  (fintiiiui-s  t'l  priiyri'*^ 
ti-  •  in  at  ni;;lil,  n  «ymptoi»  which  itt  ^«i)f  rally  ^(:-^lll'll.tl 

t  .^  '  iicttve  i:hau}fcs  arc  takiii;;  place  in  the  eartiln):r«. 

Allcr  til  aw  lymploins  liave  penistiHl  tut  a  varying  time  Ihe  ^fneliiiig  lMH-«iuttt 
■an  pfOQiioent  at  utii'  part.  t]uclu»lioii  be(»>iuet^  muiul't-st,  nud  thu  rkiii 
V  mlilcDwl.  I-*in»lly,  if  not  nirlicii>aUHl  by  sur>;icjil  inlerlvreticv.  ihv  nlwccca 
UuiU,  disvhargiii^  imhcaltliy  pus  luixiiL  with  curdy  tuA«e<».  Buforv  thix 
laks  place  it  may  rvacli  a  coD^itlvrnhlv  eixo  aud  burruw  for  sotao  iliittHiice 
r —  -i_.^-..  .,.)j^j,y„  fjip  ni^ygyg  ju^  ,,,,1,  ucciasMfily  wcupy  the  whole 
■irit,  fur,  aH  will  he  |>oiiilul  out  iu  desL>rilnii^  the  [mthoh)};y  of 
lAf  iitseast.  Do  cavity  may  exUt  by  iho  time  the  absceM  forma,  the  wholf* 
Hr6ralAr  Bpue  being  itlied  up  with  a  maas  uf  unhealthy  granutution-tieeiue, 
!■  MM  nut  only  of  whieh  the  suppuration  may  liave  taken  plaice.  Iu  other 
CMM  lAft  sbBom  may  form  ouiatde  the  joint,  iiu|>prfictal  to  the  li^'anK4ii& 
Aftcf  tltc  Ahaoea  has  hur^t,  ita  cavity  uiay  >;nidually  contract  and  lieid.  but 
entnmoaly  a  ainiiouri  track  ia  left  Ifailiiig  to  the  diseased  jojui.  In 
,  c»(M»eUlly  if  the  iibaoMa  but  inotmplfteJy  eraptifa  itself,  decum- 
ItiMtiny  of  the  dWhttr)^«  "vtit  (o,  the  xraniilation-tlMae  filling  the  cavity  of 
tbc  jcNOt  niay  rmpi-ily  break  ditwii,  and  the  diMAfte  then  aH8unu«  the  tbrm  of 
aata  avptir  arthrilis  (p.  4ttH,  vol.  i.l,  with  severe  pain  and  rapid  destruction 
4^ Moh  oartila^  a*  mnv  hare  rvmntued  ut)rle«traye<l  at  the  tirue  the  chronic 
•faRgoat  bunt.  Tb«  limb  hwvIIs  nnil  l>vcouie8  a-dematou^,  aiwl  other  abvcaasva 
tmm  mrfnund  the  joiaU  The  iigameotx  Ikk'huib  furtlier  softt-neil,  grating  can 
ha  Mt  in  tbr  jniDt,  and  the  articular  surface  became  dinplacvd. 
Tha  local  pheaomvna  of  white  swellinu  mar  thus  be  divided  into  three 
I :  Snt.  that  in  which  the  diaeuw  is  TimiUnl  chiefly  to  the  Byouvial  meni- 
'  and  the  awcUiDg  nasumes  thu  forui  of  the  synovial  ciLvily  ;  secondly, 
in  whioli  tb«  linmeotr.  mrtilagea,  and  articular  ends  of  thu  bone  hu- 
implMatad.  aau  th«  swoUing  b^iomce  oval  or  rouuded;  aud,  thirdly, 
ilw  atatte  of  supporatioo. 

Tbe  cvutiiutiiiiial  aytaptonu  vary  io  the  liiOercnt  iitafps  of  the  dtaeaie. 
TW  gvnarat  baalth  does  not  appuar  to  saifer  in  tbe  6ntt  stage  beyond  Mime 
ili^l  lebrile  diaturbanoo  during  exacerbnliona  fn>ni  uverexortiou  of  the 
JBttO.  In  tha  aMond  ataf^  alao,  the  general  health  \s  but  slightly  impaired, 
^.-, — (  .-,....,  .,.,,.»  „f  ^xtia»e,  and  at  the  later  iieriod  from  want  of  reel  if 
t>  aet  in.     Iu  the  thinl  stage  there  is  pntgnfuuve  loot  of 

mrm^  II  ntieo  the  BU[)puration  is  very  chronic  there  10  uaually  aume 

•U^i  '  Icvattou  tif  tcm|K.-raiure,  6«ldoiD,  huwnver,  exceeding  101*^  F, 

JJWr  till.  <ir»i,  \\w  (•oiiaiilutional  sympCotne  become  more  severe, 

bcotic  aui  iu,and  luU-rculur  diwase  <^  other  organs,  such  as 

Cb«  laagi^  luu-y  cairy  fS'  the  patienL 


DISEASKS    or    JOINTS. 


P\TitOLOnio\L  CiiANOEs. — Tlie  patliolngtcal  chfincea  that  neror  hi  vMu 
Burlliiij;  liavc  been  very  Bccuraic-ly  ilt-ficribMl  by  Billrttth.  In  lb«  caHiol 
Btii^r«  ttint  linve  Ih-i'Ii  nbflrrvi-tl,  lUt  ^rnutrial  iriapta  nre  ffWdllni  ftsd  iW 
itu-iiil)mi)c  gi'ueriilly  thicker  tlmti  iiniurnl,  Biiil  hyiiencniie.  Tber*  u  kcm^ 
ally  DO  iacrcfleo  of  flecn.-ii<iri,  but  tbu  evDuvia  U  uflr-n  *licht1y  turlMM.  1 
have  oncQ  bad  the  oprxiriunitv  uf  frxaniiuiDg  a  j<i'nl  iu  tb'u  fttag«  to  a  cm 
of  diM^BM  of  ibc  kiice.  in  wbtcfi,  at  ihu  miursL  uf  the  pbyaiciaua  in  altMr 
danco,  I  aniputatvt)  at  a  »'ery  early  pcriiid,  io  the  biipo  of  n-'-'-r---  *m 
Mvcre  opitcpey  frtim  which  the  child  n-an  suflpriuir.     Th«  ap:  '  X 

icrvcd  wore  exactly  thi«e  dpscribeil   by  Billroth,  niitl    werw    limiM  ■  "*' 

synoviHl  menibrniie,  the  other  «lructiir«-»  enteriii|z  iiitu  the  articulati  ;■  •  j, 
ap|>ar«iitly  hpaltby.  A9  the  disea^'e  advniicei),  tht-  «yu<ivial  lu 
CARIM  thicker,  anil  lunre  vusculnr,  il:^  uatural  «niii<>tb  furfnt.'v  i- 
aptm^y  granulations  8|>i-iiit;  up  U|miii  it.  Thi»  ch!!ti;:f  in  e«]<f(.-iu>:y  uiar' 
in  the  xyiuivinl  friii(;e5».  These  form  iMjft  ntvi^es  uf  (•niiiiilaii'in-iiMuv  whi 
fill  lip  the  aiij.'lei-  betweeD  the  urlicular  surfuce*  nud  ({riidu»lly  cr«:p  "I 
the  eurtilagee.  Where  two  gruiiiitaling  syiKi^iul  surfacnarv  iu  ci>utact,a» 
the  pouches  uf  the  kiiei>-joiiit.  they  couluicc,  and  thtie  ihc  eavity  of  tb«  J4i« 
Ijccumve  graduully  (jhlitcrnlrit.  It  it  in  ei)nee(|ucnce  uf  this  liiiiitutino  of 
dtaeosvtu  the  synovial  lueinhrane  in  tlie  early  stagea,  that  tbu  aw^nincDf  t^ 
joint. obBcrvpd  cliuii'ally,  lakes  ihefurniuf  thedistetidnl  articulii'-  -y'  ■'•  ^*'m 
simple  synuvitia  with  eHueiuu.     Aa  the  diaeaae  advani-eo.  the  ol  ««■ 

nialiun  extends  to  the  lif^Hnienls  iind  ca]«ulc.  which  bcmntes  irilinniK-M  *itk 
the  inflainniatory  prtHlucls,  and  swollen  and  lanlareotia  in  appearaorr;  aial 
later  un  the  an^dar  tissue  aurronnding  tlie  joint  is  siniilnrly  nAwled.  It  n 
owinj;  |o  this  thnt  the  swollen  joint  1<m>s  the  form  uf  the  tliatendfd  STDiiftal 
menibrHnt>  uhirh  rhftracierized  the  earlier  staees.  and  becomm  rtiuiMled  or 
oval.  tSiniiillaneously  will)  ilie  nfTcction  of  the  lieamonls.  ibi>  ^mwib  of  tW 
gmniilaiion-tiwne  within  the  joint  cnnliniioa  anul  the  ayn»viitl  nn'tuhraae 
may  mnic  to  be  ropresenled  by  a  soft  pulpy  mass  nf  graniilnti'Xt-ltMtM'  fnm 
half  an  inch  to  nearly  an  inch  in  tbicknew.  The  (^rrowth  ^rndunlly  aprtndl 
over  ibe  titrtilaee.  covering  it  )iko  a  veil.  If  an  nttvmpt  br  mndv  !<» 
tbia  it  will  tie  found  that  the  advancing  vi\g»  can  lie  raiM'd  with  the  baodli 
of  the  scalpel  for  about  one-eighth  of  nn  inch,  beyoud  which  it  will  b<  a4> 
berent  to  the  cartilnge.  The  advance  of  the  grnntdatiun-l issue  oTcr  tb* 
cartilage  it  compared  oy  Billroth  lo  ivy  creeping  over  a  wall,  and  bvcmajv( 
gradually  attached  by  ila  roota.  If  the  grannlalion-lissne  be  scrapnt  ■way. 
It  will  be'  peeo  that  the  cartilage  is  being  gradually  coDsuroed.  itH  plan  bfioc 
occupii'd  by  the  vnscniar  new  tissue.  Finally,  it  is  completely  pierforaM. 
and  the  bono  beneath  becomes  einiilarty  affected.  In  the  bono  the  pnttm 
■laumoB  the  f»rm  of  mrrfyin);  o^U'itis  with  exuberant  growth  of  i>raBUl«fa» 
tiann  (8U)H>r6ciat  fun^nlin;;  caries,  p.  29-'>J.  The  {rniiiiiiation-li»ue  apm^ 
inxfVom  the  bone  extends  beneath  the  cartilage,  lonspDin^  it  from  its  aitadi- 
menl :  and.  as  now  it  is  Attacked  on  both  sides,  its  destruciioD  prtM!««di  akOfi 
rapidly  than  before.  At  the  aarne  time,  the  destructive  procew  b»v  extrad 
to  a  varving  depth  into  ibo  eaneellous  tissue  of  the  arlieolar  cad  of  tkfl 
bune.  "the  perioitteum  luually  aharra  in  the  disoasc.  the  iuflammatioa  at- 
luniing  the  osieopliutic  form,  and  leading  to  the  deiKiait  of  irrv)^lar  »•■■ 
of  boue  on  the  articular  ends,  chiefly  in  the  immedialo  neighb-iriiood  at  ii» 
JoioL  At  this  stage  no  articular  cavity  remains;  the  joint  is  reprr*enled 
merely  by  the  articular  ends  of  the  boue  more  or  lead  extensively  denuded 
of  cnriilago,  emboddi-d  in  asofl  pulpy  mussnf  gninulatiitn  tinue.  aurruanded 
by  the  infiltrnif'd  and  »i>f\ened  lignineotft.  When  the  granulalicit'luMH 
rearhi-:*  the  thi(-ktir*4  of  fmni  a  tjUiirtrr  to  half  an  inch,  it*  Vn»<-ulnr  «iU)>filv 
bouvoiea  insuflicicnt  for  its  healthy  uutriliuu,  and  fatty  degejicraliuB  *eu  ia 


re«B9t«    ■ 

b«o.t)«fl 

b«a4-^ 


CUao.viC    ARTHRITIS — PATHOLOOtCAL   CBAK0C9.         851 

dctm  MtrU  looct  distant  tn>m  tho  bnso  of  supply.     It  is  from  the  nppear- 

•<r  thv  RMM  of  unltcaltliv  frauulitti<M)-tiM<tie  lliat  lite  disease  rec«iv«(l 

tt»   tmniQ  i«f  "  pulpy  di'g^mcwli.io  of"  the  eyuo^'inl  mem boinc."     Th«  wtft 

na'fx  ti—ti^  u  piok  lit  dl'T.  ni»rk««l  by  y^ilWwish  pstcliM  of  fatly  degeneni- 

^-i»D  ntv*»  from  old  hem'»rrh «;;:«*.     Th«  fatty  deg^'nerntioii  in  f<4- 

I'.T  Mr  tat«r  by  eoneuint*.  hihI  thus  n  cbruttic  ubscvoM  with  fl<»ccu- 

cuuteota  IB  firnt«tj.     TliU  fr«tjiivally  occurs  in  on«  or  more  local 

.(•ra.  xtiliout  iriiplicnting  the  w'hoIt>  ruaM  of  graniiiatioii-liMue,     Thus,  in 

knee,  it  fretjueutly  occura  lo  the  site  nf  the  syuovial  [xtuchos  above  the 

Tbe  diaesM  tliwi  not  alwnva  be^in  as  just  described  ia  the  synovial  mem- 
mi^  ia  many  oases,  it  in  imp>wible  tn  the  preseDt  state  nf  our  kaowledge 
Mi^y  ID  wluu  proportiun,  it  eommeDces  in  the  articular  end  of  one  of  toe 
fciBta.  ma  superocial  fuugatiog  caries,  iiiinieiliately  beneath  the  cartilaj^. 
Ia  ihcaa  caaei,  so  soan  as  the  cartilaf^  is  perfureted,  the  chan^^  just  de- 
tlfihid  Odouuran  in  the  syoovtul  mejnbrane  and  completely  conoonl  all 
oMaam  at  the  primary  bctne  disease.  Clinii-nlly  it  may  Ih-  said  to  be  im- 
pMHilile  to  dialiflguisfa  accarat«fly  one  form  of  the  disease  from  the  other. 

Oa  niemeopic  ejiaminaticn,  the  dtflcascl  structures  present  the  followiag 
apfcumncra.      The  lignmetits  show  ihc   ordinary  chau)^  observed  in  in* 
tttmtd  flhroua  tissue.     The  fibres  are  sepamtcd  from  each  other  by  infiam- 
i—lfifj  productt,  eomposed  chiefly  of  small  round  cells.     When  the  procoi 
iivMT  ebronir,  nenr  fibroirl  tissue  also  may  be  found.    The  cartilaf^  sbnw 
Cfcaagfls  siiniUr  to  those  already  deKribea  in  acute  arthritis.     Betbre  sup- 
mntino  Um  taken  place,  ulceration  both  without  and  with  evident  pmlifera- 
mm  nay  b«  present  (soft  p.  •140).     The  deatructivi^  change*  may  be  observed 
M  cttlMT  surlaee,  according  as  Ibe  disease  commences  in  the  synovial   mem- 
braaa  vrtbe  boor.     In  tho  later  stages,  after  perforation  of  the  cartila(p>, 
bsCk  aurfifcOM  may  tie  similarly  nlfect«d.     AAer  suppuration  lias  laken  place, 
ofcarttlni^v  with  diHJuK'Kratioa  (p.  3.39)  also  luny  W  mt-t  viit)i.     The 
prraMil  tbti  apiHtaninceH  already  ilescribed  as  Iteiiig  met  with  in  fun* 
^pttBg  aarioB  (p.  21^0).    The  chief  interest  attaches,  however,  to  the  micro* 
^H^imaal  KppMuaneca  of  the  pulpy  ^•ranutation-ttssue  which  boa  rcpluced  the 
^norikl  mambnuie  and  tills  the  cavity  of  tlio  joint.    The  structure  of  this 

m  baa  b*«n  made  the  lubjcvt  of  iuvestigauon  by  Koster,  Kduig.  Voik- 

,D,  mnd  Haeter,  among  othvrs  in  Ouriuauy,  and  t>y  Orofl  and  Greenfield 

tfaia  CDnotry,  and  all  are  substantially  in  agrt-ement  as  Utits  nature.     The 

bqlk  uf  ibr  tinne  is  mode  up  of  small  round  cellit,  uniti'd  by  a  Htruc- 

■  inlrrtvllular  subelance  and   abiimlantlv  nupplieil  with  vesHels;    in 

nordii,  of  ordinary  gmnuliiiiun-tiswue.      lettered    throuch   this  «re 

taberrle  nmlulcs,  ditft'ring  in  no  retipect  from  those  met  u-ith  in 

stToetnnBi  (vol.  i.  p.  l'H()\     In  othttr  parts  the  graniilaiion-ti.'wiie  has 

fiuty  deffrnemtinn  and  bt'<ti>me  redaoed  toasUrncturelr^i  f;mnular 

Croft  and  Grfrnfield  pointeil  out  that  most  «ommunly  the  diM^al»ed 

iimut  mar  bs  dividi^l  inm  thrm  layers,  which  merge  into  each  other:  first, 

Hk  layer  oearnal  tbr  source  of  vascular  t^upply  (the  bones  or  capsule  of  the 

jgsnl).  oorr""- —I  "^  onlinary  ^nttiiila(ion-ti»»u«! ;  secondly,  a  layer  oonlnin- 

aif  ftu»r-  ^   cells,  surniund(»1  by  "epithelioid-i^lls"  anil  lymphoid 

mno'^  ■'-  i  io  tho  way  orilinarily  obsvrTed  in  nodulits  of  tubt^rvle, 

■M   J  ..aH-ulsr  areait  in  ibe  eurn^iundinu  vascular  granulation* 

IbBM*-  ■  tito  layer  most  distant  fnmi  the  base  of  vascular  supply, 

W  vbi  iifration  is  taking  place,  and  all  definite  structure  is  l<M)t. 

TW  tuLicf  <  4  are  not  ab!i.i1ul(.>ly  limittvl  to  th**  middl*;  layer;  n  fvvt 

■ay  b*  f*^'  ■■:  first  layer  in  the  awidleu  li^mucits  Hn>l  the  luolulUry 

of  ibe  disBaawJ  eaQeelluus  tiasu«.     The  praeeuoe  uf  this  strucluro  is  so 


mm 


8&2 


i>ISBA3ES    OP    JOINTS. 


iniuUuit  llMt  it  may  ho  r*igarAwi  u  cbaractcniiUc:  of  true  whiur  ■woUiuf  nr 
■fcraiWHis  arthritis.  lo  72  caiscBeiamiaeil  by  Kotiig  ii  wim  litund  in  St  aaA 
ill  tlie  remaining  five  tlm  material  for  exntuinfttioti  wa«  iI>  il  '  '  w> 
ciiuclusiuii  mulil  be  arrived  at  ax  u>  itn  prcBt^ace.     (."mU  ai.  .  -nJ 

oilier  olwcrver*  ngn.f  m  to  the  runsLanftV  of  ihe  prflWDce  ol  lutn  rvli'.  Tb« 
uuiiibcr  of  t;iaui  (.-ells  varico  in  itil}(-n'nt  caach,  bill  they  Are  alwavit  {im>a(. 
8ince  the  iliM-ovorr  of  tb«  tiil>crcl<>  hadtlufl  by  Koch,  th«  prenaoe  of  thii 
organtsm  in  the  pulpy  ti»9u«  of  white  sn'elling  h»u  been  fr^UAatlv  tUoMi- 
BCratcH.  Further  proof  of  the  tubercular  nnliiro  of  the  iliAMM  Vai  b««a 
obtained  l}v  llueter  an«I  others  fruni  inoculalitm  ex)>eriii)«uii>  carriexi  outoa 
animald.  The  statistics  of  while  ttwellin^  ^low,  moreuver,  that  in  a  rtrr 
large  pr<.ijH)rtion  of  liktal  ctaen  death  takes  place  fmm  eenvral  luberouUaiL 
Albrecht  Un»  lately  published  some  fitotistic-d,  iu  wbivh  it  in  aht^nn  lliat,  OM 
of  llio  fatal  ra^ee,  in  IJ4  dusth  occurreal  fnxn  tilWrcuIusis. 

At  the  prtiteiit  liiiiv,  ihcretort',  it  may  be  said  that  ihu  evidvDve  u(  ibt 
tubercular  luiturw  of  wliitu  en'i*lliug  is  alriiu«t  coucluaiw  ;  but  it  has  ttnl  htxn 
dctvrniiucd  ix-rlalidy  wht-llier  llio  develupineat  of  tiilHTnlc  in  llip  firuuari 
vhnii^-c  ill  ibu diiiettM],  or  wliHlbiTa  chntiiin  itifUtiiimtlitiuuf  aiiimidt-  character 
precvilo)  the  appearance  of  itie  tubercle,  the  iiilluiiiniatory  pnHlufta  furmtag 
a  suitable  iiidut  liir  itJK  drv<-lopmcnt. 

Ti;i:.\TiiK>>'r.  — ]ri  tltt!  irHalrimiit  of  wliite  swclliuf;,  we  must  bear  in  ound 
tliat  wf!  have  lo  miLnage  u  truly  t^crofulim)'  influniinuiiou  and  its  ctrvcLt*.  Oar 
tiret  object  should  he  to  prevent,  if  ixissible,  the  iicH-urrcnce  iif  auppuralML 
In  the  early  nla^,  when  the  id]'>acti»ti  hah  DOine  on  iDeidiuusly,  wttoont  auj 
very  at-tive  symptoms,  we  munt  trust  to  general  anti-titrum»u»  treatmeaL;  la 
the  iiiHuence  of  goo<]  diet  and  5ea-air,  and  to  the  adcninistrntioa  of  Uiiui% 
coddiver  oil,  and  iiwtine. 

In  the  lotvii  treatment  there  are  three  ^nt  principles  to  be  auriei  ovt 
1.  itett^ii/ith  perjett  imm<AUiti/ of  the  joint,  \s  by  far  the  moat  iaiportut 
element  in  the  treatment,  withrttit  which  nil  the  ctfortji  of  the  SurK«oa  tt 
prevent  euppurfition  and  diflor^unizfitirtQ  of  the  joint  will  be  fuLiI#.  *i.  Otm- 
preiM'vn  by  nienna  of  bandai^os,  I'trappiuff,  or  splinlo,  uill  aid  in  the  sb«>qH 
tioo  of  the  inflamm»tj<ry  products  ^n  and  arouml  the  joint,     'i.  '  -ri- 

tatiott  by  lueaue  uf  blisters  or  the  actual  CHUlvty  may  be  emplo;.  :--«. 

to  be  of  real  service,  ebuuld  be  n»ed  itefore  suppuration  has  occi;  ">l  .  aI'.h 
this  they  are  of  no  dsv.  The  limb  should  be  put  iutoii  juiaition  '» iiivii  •  an 
only  <Misy  to  the  (Wtient,  but  which  will  leave  it  m«et  useful  abould  a  stilT 
joint  nisull.  Iftt  be  one  of  the  joints  uf  the  lower  extremity  that  is  adectad, 
especial  rjire  routit  be  taken  that  the  [>atieut  do«a  not  bear  hu  wei^'bt  upttu  iL 
If  it  is  the  hip  or  knee  that  ii<  diseased,  the  bent  npliuta  are  thiae  InvesiW 
by  H.  O.  Tiuimaf  of  Liverpool,  which  will  be  dcacribvl  tu  the  neai  ehapccr. 
If  the  ankle  is  aHeeied  the  patient  muy  be  allowed  to  move  aUiut,  kDcdi^ 
on  a  "  pin  le^,"  with  a  trough  to  ^uopurl  the  limb  bdow  the  knee.  la  tW 
upper  linih,  rest  is  Ih»l  secured  by  w«-ll-|>adde«l  leather  or   _ '  ha 

splints.     In  many  cas4.'8,  both  in  the  upper  uud  lower  limb,  a  pin  .->ri> 

bandage  over  dannel  or  a  ^larched  lauidaKe  well  lined  with  ■-""-■i-Tadiliiif 
will  iw  found  a  most  useful  appliauce.  This  kind  of  appiicatioa  wUl  m 
found  U)  i^ive  moat  efficient  support,  and  will  kee|>  the  whoU- of  the  limb 
jwrferily  ntotinntras,  so  that  the  patient  can  taku  open-air  cxt-rriar,  and  walk 
with  the  aid  of  orut>'hr»,  without  risk  of  injuring;;  iho  diseasietl  joinL  la  thtt 
respect  thestarchotl  bandage  presents  greaiadvuntagra  over  theNhc^  I 
■pilots  ofWn  used.  It  may  readily  be  cot  open  opposite  the  diaoased 
■o  as  to  fldioit  <>r  the  application  of  proper  drrasings  t4i  It.  T)u>  | 
during  whirb  it  b  nec««iary  to  mainuin  p^Tfect  rust  varioa  in  different  caaa, 
but  if  tb«  disaasa  has  advanced  bayund  tli«  earliest  «ta>[ea  many  tnonliw  ur 


RUBUMATOID    ABTaillTIS. 


853 


wrn  ■  Tm-  rrquirwl.     The  poriitil  of  re«t  must  not  be  nhnrKTiefl,  for 

l«*r  ijf  ctLu~:  inTW  of  I  lie  joint.     Itnperfwl  rpAt  from  dofpctive  Apf>aratu8, 

trr  pru]iiB){ine  ttir  iluwii^e,  is  a  niucli  more  froijurnt  cauK  of  permanent  im- 
puriurnt  (if  fuiirlton  in  Ui(^  Joint.  6n  long  lu  tlifr«  iaany  teDaemeas  or  pain 
ic  markt^I  •wrltiii);,  iv»t  must  Ix;  mainlAiiifd. 

tAiho^  «cul«  exAc^rUftlionn  nf  thr  ilisea«e,  leech«»  may  sonietiriMfl  be  use- 
Mi  ttkrvr  iuii»t,  liowevfr,  be  used  aa  M^iarinfriy  u  po#eible.     Should  severe 

-'-- --tin»  at  (ii|;))t  Iw  i>re«ent,  without  evidence  of  HippuratioD,  th«  actual 

I  plinl  M  ile9cribed  od  p.  345,  is  extreinely  beuefici&l. 

<  r  uit   iDf1:iii)iiisUoti  liiu,  in  tbis  vrav,  be«u  reuiuvvd,  and  nothing  but 

tiini:  and  slill'iK-i^  uf  Ibv  joint  an:  tvtl,  mcai^un's  may  be  adopted  for 

iililioui!,  and  rc-»toriu^  the  tlexibilitv  ul'lbe  arttculatiun  by 

'  »-ii|  »iiiuulatiiti(  and  couuler-irritunt  enibprcattonii.  and 

Jib  \i\  di>ucb«suf  sea-water.     The  awellJog  and  putfiiii>i« 

I  '.r  with  the  debility  dependent  on  relaxaljuu  of  the  liga- 

|H:rhiif«  hmA  reiuedi«tl  bv  the  use  of  Scott's  etrapping;  but  prea- 

I  uul  be  applied  so  long  «»  there  is  evitlence  of  active  inflamma- 

1  .  ou  in  the  artifultition,  which  it  would  cerlninly  incrcnec. 

--  ('•rtu,  it  must  lii^  freely  opened,  with  strict  nnti!>eptic  preeaulionB. 

~  iiulatiou-tJeaue  may  then  be  scraped  out  as  far  as  possible  with 

:  f---i,.     If  the  incision  be  free  enough,  it  is  seldom  aeceesary  to 

.-)  draiun^^lube.     The  iodoform  oraalicytic  wool  dreeing  will  be 

-1  useful  ia  manv  case^,  and  a  small  quantity  of  iodoform  may  with 

'    l)e  iniriMlufed  into  the  cavity  of  the  absccas.     The  dressing  will 

iipng  after  the  first  dav  or  two,  as  it  becomes  soaked  hy 

.  bill  after  this  it  may  frequently  be  left  untouched  fur 

:r  even  a  mouth,  uuU-j«s  some  diacoorae  soaks  through  it^ 

>ire  not  at  hand,  any  of  the  forms  of  antiseptic  drcMiDg 

.i«».-*ib«^l  ill  tlic  .  imptt-r  nn  Wounds  (vol.  i.),  may  be  employed.     Poultirca 

ibatild  tKtt  Im-  Mpiilirii,  ns  they  fnvur  dei^im  posit  ion  and  increase  the  6uppu- 

tttiBB.  and  th«   piiiii'iit'a  general  health   uil]  siiHt-r  Inim  the  (;xhauNt.iiig 

JachaiiUJ.  and  hectic  may  cume  on.     After  EUppurution  has  lakeo  place,  if 

Iks  jvist  can  be  preserved,  the  subsequent  utility  of  tbe  limb  will  depend 

■awljr  Dpiiu  the  pusttioQ  id  which  it  is  allowed  to  become  aokylosed.     In 

ly  oisw,  io  spite  uf  treatineot.  especially  in  the  children  of  the  poor,  the 

sJowly  prioresses,  leading  to  complete  deatructioo  of  tbejuint.    Under 

cirv«im«Uncc«,  «xcisioD  or  amputation  is  the  only  resouroe. 


tXaOKK  UlKtJMJlTtC  JtKTUKITlS.  RHm.'MATOlO  AUTURmS,  ARTUItITI8 

UKt'OKHAT'S. 

Br  %hnf  lerms  is  mi^nt  a  chnmic  duease  of  the  joints  of  a  pro^rcauve 
t^sncter — painful,  (li'<fihUng,  (leformiug,  and  incurable.  This  disease  has 
Wm  Attrmetci!  '  tion  of  pliy^icians,  ami  has  h<-0Q  described  as  "  rheu- 

cafic  irout,"  '  I'f  joints,"  mid  "deforming  arthritis."    But  little  was 

kaowo  of  iin  tiLir  iitiiitri^'  iinlil  its  [>H[lio|ugj  was  studied  by  Professor 
.'>Min*  and  H.  W.  Smith,  i^f  Jiohliii,  who  accurately  describetl  it  under 
as  MkOM  of  "chronit*  rhfumatic  arthritiB.''  More  recently.  Dr.  Garrod  hov 
sJfcd  murb  to  our  kno«l»lge  of  this  disease,  and  litis  propoeed  for  it  the 
■■ff*  arruratr  name  of  "  rheumatoid  arthritis."  When  it  gives  rise  to  much 
imuwiina  of  limb  and  ^leformily  of  joint,  as  oAen  happens  when  the  hands 
•■«  chronically  aHected  by  it,  the  name  of  "arthritis  derunoans"  is  given 

This  diisse  may  oomiiiQDcc  in  any  joint,  and  may  omtinae  limited  to  it, 
or  m»y  ■xImhI  from  noa  to  the  other  until  most  of  the  larger  articulations 

TOt.   It.— Si 


854 


DI8EA8K8  OF  J01 


art!  involvcfl.  It  commence*  usunlly  id  the  joinu  of  ibc  limtw,  uitf  Mf 
ouiitiuiie  U>  be  confiucKl  to  them,  or  it  rimy  primariiy  attack  the  Umpoi*- 
iimxillarv  urLicuiatiuna  or  lliose  t>f  tbe  H|iitiHl  column.  It  occurs  in  \»4h 
wexva  with  lulcrably  «<|uaj  j'rvqiienov-  Hut  aorat*  joiuta  appvar  U>  b«  nun 
liable  iu  ooe  Bvx  than  in  thi:>  otlivr.  Thu»  tbv  biji  io  the  male,  tbe  knaaio 
Uie  renml«,  U  mor«  commonly  the  seat  of  th«  malady. 

RheiimntoUl  AnhrJtia  h  eMentially  a  discaiie  of  middle  age ;  wb«n  once  it 
lete  in  it  will  continue  for  an  indelinite  |>enod,  far  iuU>  old  age. 

Itbeunuituid  Arthrititt  may  atfect  one  or  two  joints  ayrotiHtttiaUlv,  fli]» 
cially  when  it  ncciirv  in  porBoni^  othenA-itte  healthy  and  out  niddlv  life,  b 
18  Lbcu  ui)unlly  coDfined  to  the  larger  urticulatioiM,  la  other  amm  it  nay 
attiicli  a  nuiiiber  of  jrtint^,  iiioluding  tho  amaller  artioulntiooe,  such  ma  th«i 
of  the  fiugrrs.  This  t^>rm  i»  otlen  icnncd  polffitriimUr  rfiruautUtid  arlkr^ 
Ut  disiiuguish  it  from  the  more  limiu-d  or  mnrmr^An'lM  affi-'cUon.  It  oAn 
Irads  to  >>rL>al  dcftirmity,  and  may  cniiroly  cripple  tbt-  fMitieoL  It  b  nil 
with  Kimotim€8  ut  u  coninaratively  carlv  agr.  eepcrially  tu  amt-miir  firmain. 

(Jbronic  Khcumatoid  ArtbritK«»ctiiiallycun«Utfl  [q  an  orftanir  rhangve/ 
fltructure  in  all  tho  various  component  parts  of  the  BlToctMt  y<\at.  Th» 
stATting- point  of  tho  diseaae  appears  in  most  rases  to  be  the  i-anila(;e.  TIm 
firat  chnnj^  ohMTved  ts  a  loss  of  polish  and  smonthnMi.  gradually  incrMilil( 
till  Uie  surface  becomes  Ttkety  in  appcarane<^.  Microscopic  examinatioo 
ahoiTR  thai  thia  chanf^  is  due  to  the  gradual  convpniion  of  the  mnlrix  lata 
fihrous  tiwue,  the  fibrilln-  of  which  are  nrranj^  at  right  aiifflM  to  tb*  aoi^ 
face.  At  the  same  lime  multiplii-ation  of  the  cartilage-cells  lakMolMt^lB 
that  the  mpenlea  are  found  to  contain  nn  exceao  of  cells,  whirh;  ]i<»w«v*f, 
retain  llie  nppearanc*  of  mrtilage-cells.  Tbe  cartitape  an  ailorcl  i-  i;nida- 
ally  worn  away  by  the  frtcti'm  of  th«  dtwaaed  8nrfa<-^  a:.-  '-r. 

until  the  bone  uexpoiiei].     AVheti  this  take*  place  the  ex|N'~'  ii.« 

iuorcMed  io  density  hy  the  (onimtion  nf  new  oaoeuus  ttMuv  liiliti^'  ap  ihs 
caaoellous  B|>ace«.  The  new  tiwuc  may  Iw  true  bone  with  Ihcuoic,  but  ia 
mauy  caaes  it  is  excessively  denw  in  structure,  coouins  a  ureat  exro*  u( 
llmtHulta,  and  appears  to  be  formed  rather  hy  calcilioittou  thao  by  oasifia- 
tioii  of  the  mouullury  tissue  of  the  cancellous  spari-s.  The  buoy  aurfteM 
thus  ex|Miscd  art'  worn  away,  and  greatly  altered  in  shape  by  the  ftictiao  1/ 
movcineui ;  al  tho  aame  time  they  l)ecome  highly  pulb-hed.  like  traiy  <v 
pon'olaiii — uUurualcd  or  p>rcoiHne<>us  a»  it  is  termed.  In  epitu  of  tb«  dsMty 
of  tlie  structurt-s  thus  fnrmod,  it  is  constantly  lieing  vroni  awmy  by  ftioliaa 
B»  lon^r  lis  iiiotton  is  lefl  in  the  joint,  the  next  layer  of  canceJIoua  ttntKr  ibn 
undrr;^oii)g  the  same  change.  These  deetnictirc  pmorasfa  cumBwooe  and 
advanrt-  iiioHt  nipidly  in  ihe  ifntral  parta  of  the  cartiingit".  and  while  thry 
are.  in  pnigrcio  irrigiiliir  carttlaeinnus  outgrowths  spring  fDm  ihi- circuro- 
ferenri-,  forming  in  many  cases  nao»-like  projectiotks  from  the  muvins  of 
the  artirnhir  surfaren.  These  cartilaginous  oatgrowth.4  are  oaaJftMatafl 
•nrly  p«'no<t,  and  thufl  form  rounded  irregular  osleophytcn,  nrten  rcacfaitif  a 
xery  considemble  <<iie,  and  impeding  or  completely  aholishing  the  mnre- 
mcDtsof  the  joint.  The  ocitcophytes  of  rbpumntoid  arthritis  differ  nvcotially 
fh>m  tboee  formed  round  a  cttrious  joint.  Their  form  and  appearance  bat* 
been  very  aptly  compnreil  to  the  ^utttnnys  of  a  wax-candle,  white  the  iwttfr 
phytes  riiund  a  cariMUs  joint  have  the  jagged  form  of  nialarlitRS.  Tbe  fact 
that  the  former  an*  deitdnpcl  frnm  cartilage  and  the  latter  fnira  granuIatioD- 
tisBUC,  forms  nnother  diMioc-lion  between  them.  Oi-cHsiitunlly  tsolatcd 
Dodulea  of  (Mnifying  cartilii):^  of  a  flnttened  form  are  found  in  the  sobserooi 
tissue  lieoenth  the  syooviNi  mi^iiihmne.  In  the  early  Bla^eR  lh«  linmenil 
and  synovial  mcmbnuie  show  but  Itttle  chaugv  ;  but,  aa  the  disease  ■aToocab 
tbe  capsule  of  the  juinl  becomes  greatly  wiukeoed.    Tbe  syooTial 


KHBUHATOID   ARTHRfTIS — SYMPTOMS — TRKATMKST.     856 

bnin«  becomes  o{Kique,  ami  its  friiigcs  increiised  in  size.  In  sQiim  case*  tbU 
enUrgement  of  the  inugw  is  vprv  coniitleraljle.  the  siepiirate  papillw  reacbiog 
a  great  sise,  sometirues  eveo  hii)r  uu  inch  In  iencth.  When  this  couditioa 
ia  veiy  marked  the  term  VUiom  Sy»Qviat  Membrane  \a  applied  to  it.  In  the 
free  extremities  of  the  enlarged  papitlie  rounded  or  flatteued  uodules  of 
carUliige  may  be  formed.  Thct>e  sometimes  become  brokeo  from  tbeir 
[       attwAroentfi.  sod  form  ioow  bodies  Id  the  joint. 

^^m  Id  tho  earlier  stages  of  rheumatoid  arlhritit<  there  mny  be  a  slight  exocae 
^Hwf  syuoria  which  'i»  turbid,  but  clfii&iou  never  furius  a  marked  feature  of  the 
^^  duMUC,  •nd  hence  the  term  dry  is  often  applied  to  it. 

I  A  iectioD  of  the  hones  entering  into  tho  ailucted  joint  show  thai  the  can- 

'  oeUous  tisBUe  tienenth  the  etitiriiatcd  surfncu  U  more^pougy  than  natural, 
the  spaces  beiof,'  fillL-.!  with  vt-Uow  fat.  In  consequence  of  chi^  atrophy  of 
the  bone,  tho  shape  often  beconrtis  conajderably  nllered.  This  Im  most  ohar- 
acterielieally  W!fu  in  the  uL-ek  of  the  fenmr,  which  l>ecoinCB  ahorteneil  and 
set  uiim-  Ht  ng}il  aii>{li-r;  with  the  altufi  than  unLunil. 

Suppurutioi)  rarely  tx-curs  in  rheumatoid  arthritis.  I  have  seen  it  only 
when  the  duoane  v&b  dev(^Io|)e(l  at  an  earlier  period  of  lif(>  than  u»ual,  at  from 
thirty  to  forty,  or  when  an  injury  occurred  to  the  atRwtcd  joint. 

Symptoms.— The  affoct/^l  joint  beeonua  partially  ankyhwed  ;  is  swollen, 
tender,  deformed,  and  uiieleiu.  tl  i»  the  sent  of  constant  pain  with  orcaaional 
eocacerbationi),  olien  very  severe  and  prolonged.  The  geiipnd  h(ji!th  may 
eoQtiniic  fairly  good,  thntigh  life  is  rendered  mii»erable  and  barely  endurable 
by  pnin  and  decre|>itiide.  One  of  the  mo3t  marked  features  of  the  diw^ase  is 
tlie  crepitus  or  crarltlinj;  felt  on  moving;  the  joint.  In  the  early  HtngoA  ihis 
is  Soft,  but  as  the  r-jirtitrtfr<^  become  destroyed  and  the  bones  exprwed,  it 
l>ccomf«  gradunlly  hamher  till  it  nmy  almoiit  resemble  the  crepiliis  of  a 
brikeu  bone.  When  the  sjut'vial  rnvmbmne  i*  vjllou)-,  thei*  i»  cotisiderablw 
fulnes!)  of  the  joint  with  a  very  line,  soil  crt^pitatiuu  In  movement. 

The  CaQMS  ut*  rheumatoid  arthritis  nre  fijr  the  most  iKirt  very  obscure. 
liuu^-coDlinued  exjMWure  to  damp  cold,  as  prolou|^d  rvsuUuce  lu  a  dauip 
liuuse,  or  ou  a  wet  and  clayey  eoil,  undoubtedly  prudiejxiiiet)  to  tbe  disease. 
uid  )u  many  ca^e  appears  to  be  (he  direct  oecasiuuiug  cjiuee.  The  spmiu  of 
a  joiuL  will  in  many  coses  appear  to  be  the  local  determining  cause.  The 
cvetltiol  cau»o  of  the  disease  is  unknown.  It  is  not  Kcrolula,  it  is  Dot  gout, 
it  is  not  true  rheuniHtiiiEu;  as  Oarrod  truly  oliservva,  it  is  much  easier  to 
prove  what  rheumatoid  arthritic  io  not,  than  tu  give  the  slightest  elue  Uj  what 
It  is.  It  is  treaerttlly  suppused  to  be  de}iendei]t  upon  some  form  of  mal- 
nutrition of  the  ^vatcni,  and  to  be  pre<liBjio8ed  to  by  depresaing  influences, 
physical  or  moral.  That  deficient  or  perverted  innervation  nmy  In  some 
manner  lead  tu  rheumatoid  arthritis  is  not  improlinble,  the.  more  so  when  we 
frittj^tdor  that  a  rwmewliat  aoalognutf  condition  of  joint  ha'<  been  described  by 
^  Charcot  as  one  of  the  characteristic  phetiomena  of  locomotor  alnxy. 

TuF-ATME-vr. — Little  «il  he  done  to  cure,  but  much  to  relieve  litul  retard. 
KtM  and  the  continued  application  of  wnrni  or  gtimulaling  ninsters  will 
sdbrd  relief;  and,  in  many  iustances,  the  ndiiiiuidt ration  of  ttie  iodide  of 
pouaeiura  will  lr«»eo  the  uocturual  pain.  Smith  recommemlt*  an  electuary 
composed  of  guaiacum,  sulphur,  the  oitarlrale  and  cnrbonato  of  potash,  and 
^nger,  with  a  small  quantity  of  rhuhnrb;  and  1  have  certainly  seen  benefit 
mult  from  the  adminiMmtion  of  this  remedy  in  some  cases.  Ammonineum 
tnd  cod-Jiver  od  are  both  extremely  uiioful  in  some  cases.  When  the  diseiiao 
il  ooce  fairly  establuihed,  and  has  asitiinied  a  very  chronic  character,  it  will 
^Kbe  (bund  of  great  imporlaticc  Ki  give  tho  atfecled  joint  as  much  rest  oi  poa- 
^Btible,  without  contiaing  the  patient  to  the  conch  or  house.  Tfiis  is  best 
f       «ffect«d  by  his  wearing  a  proper  supporting  apparatus.    When  the  hip  or 


i 


S56 


Diseases  0»  JOISTS. 


kniv  iH  iIh'  spnt  of  the  tlbonM',  the  Hpjjaradia  hhouH  cotiisist  of  ■  iirtn  trubrr 
pelvic  bund  having  n  Hlei?)  rod  extending  down  the  outaide  of  the  Imh, 
nineed  angiilftrlj  oppo«iit«  the  hip,  knee,  and  antcl«,  tittA  fixod  ini'i  a  ^M-fcrt 
in  trie  lutleof  the  b<Mit,  and  properly  adjitDteil  by  mcaiiHof  ntnipffand  luoulcM 
lenlher  to  the  thigh  and  leg.  liy  the  ii»  of  thij»  appamtiu  ih#-  weight  tit  tb« 
limb  h  taken  off,  and  all  rotatory  movement  of  the  hip  \»  prcventwl.  tn-awl- 
fro  motion  l^eing  allowed.  Thomas's  hi]>- or  knee-splint  will  •nmc'tiaMi  Ik 
found  niH-fiil. 

Min«rHl  wftterd  and  hatha  are  oflen  beneficially  Qwd  in  the  trcalnwoliif 
rbiiuaialuid  arlliritis ;  ihii^e  of  Wjldbad  and  Frnnit-nhnd  in  Ui-rmaDT,  tif 
Aixd«8-BaiuE  lii  Snvuv,  Riiri.>;<?«  and  Ihe  other  I'yrtfnran  viitphiimup  watrn 
in  FmuL-tf,  Buxtuu  and  Ualh  in  this  country.  I'hiiLwnrni  douching  Bod 
bathing  may  give  gniit  n^lit-f  itt  undoubted.  But  Ihnl  ibry  can  care  ao 
organic  joiu't-dieease  of  ibti  nature  of  Hieumatuid  arthritis  is  ecAroely  witUa 
the  bounds  of  probnbilitv. 

Chrome  Bheamatoid  Arthritis  of  the  Hip. — 'Hiis  form  of  the  di 
mencee  uitli  jmiii  in  »nd  about  ihi:  joint,  iui'reuH.Nl  nt  night,  and 

in  <lamp  or  cold  wuatber,  prci^fnling  in  thia  rwpaBl 
thi)  ordiuary  characteni  of  u.  rheumatic  auction;  m 
the  disease  advanccw,  tlie  pain,  vhich  in  continaooi, 
w  much  increased  by  standing  or  walking,  and  the 
movementi;  of  the  joint  become  gradually  nHirv  aad 
mnrf  impiiirrd.  The  pnlient  experieocve  uiegreancat 
dilfirtilly  in  Itcnding  the  Ixvdy  forwarda  froat  lit* 
hips;  he  cnnsequeiitly  Is  unable  to  stoop,  or  lo  ait 
in  the  onlinnry  pociition,  being  obliged  to  ke«p  tba 
limb  stmit;Iitenpil  in  nearly  a  direct  line  wito  tb* 
trunk.  The  dilficnlty  in  wnlking,  in  standing  «f«ct, 
in  stooping,  and  in  silling  iccmuea.  Th«  iroobaalcr 
will  be  felt  to  be  thickened.  The  limb,  at  first  pe^ 
hnpa  elighily  lengthened,  eventually  beoonMa  afaoil' 
eued  to  the  extent  of  about  an  inch  or  more,  owiog  to 
changes  that  take  place  id  the  head  and  oeek  of  tlis 
bone.  The  pelvis  also  awuniea  au  (>bli<}U«  directno, 
and  hence  tiie  apmireut  shortening  iMwomea  coaaM- 
erably  greater.  The  knee  and  foot  may  either  bt 
inT«rle»r  or  everted,  and  the  he^I  is  ratacd.  Tbi 
afaape  uf  the  hip  aleo  alien  couBiilerably ;  it 
flaLtened  |)*ist«riurly,  the  gluteal  mu!!K>ln  ' 
that  the  {old  of  ibo  uatea  dimiui»he«  aad  auifcatol 
lower  lever,  but  the  troebanler  projects  morv  tim 
natural,  and  oo  examination  seems  larger  and  thicker 
than  natural  (Fig.  630).  On  rotating  the  limb,  tiw 
niovemcnta  uf  the  boue  are  extremely  limited.  aa4 
crackling,  grating,  or  oeaeous  crvpilnii»n  will  tiAfB 
be  fell  around  tlie  joint.  As  Smith  rcmarka.  lb* 
lambar  vertebne  acqaint  great  mobility.  The  tUgk 
on  the  aflbctcd  side  is  wasted,  but  the  cmf  retains  its  nalural  site  aad 
flrmni'M. 

Paihologitial  (^nngtt.^On  examination  oAor  death,  tha  changca  already 
dexcribed  as  chamcleri»tir  of  rheumatoid  arthritis  will  b(<  f^iund.  The  ruand 
ligament  ts  destroyed,  and  the  hcnd  of  tho  bone  is  remarkably  allemi  la 
shape,  bring  tlntieoad,  greatly  increased  in  nze,  or  placed  more  or  \*m  at  a 
right  angle  with  the  ihall,  tometime^  elongated,  and  always  very  irreyubr 
and  tuberous.    The  oeok  ta  more  or  leai  abMrfaed,  and  io  ■ome  caaM  appean 


V 


—^s 


i 


Vlf.  Ull.— I'brMtlf  Hbia- 
»Ho\4  ArlbriUi  111  IL(bt 
Ili|i-Joiiit. 


BffBCriCATOID   ABTUniTlS   OP    I.QWBR   JAW, 


I  BwiiyiDe  fraeturo.  Tbe  nci>txibu)uui  jfuuerally  beromes  enlarged, 
I  of  a  mora  or  \cm  circular  and  fliittone<I  tthnpe  ;  but  In  othor  ciu<«s 
anytcting  and  omrmwcd  at  its  rim,  pinbriicin};  ttf^hll.vlhe  head  of  the  lliigli- 
otmm  (Fi^.  nil}.  Bdth  it  utiil  the  upper  pnrt  of  the  tbiKli-boue  b«c'oiue 
lienHM,  aort  perftrntfd  with  numcrouii  flmall  tiiraminn.  Massaft  of  buu«  aro 
eanoMDlj  thrown  nat  nbnut  the  base  of  the  trochanter,  bitt  ninrc  imnlctiluriy 
■liMS  IM  iot4>rtroi-hnnioric  line  wiLhin  the  rApAtilo  of  th«  joiut,  aud  nut 
■afraqventlr  in  thi*  »ofl  tuwiie  aroiinrl  it.  In  many  CAWa  the  ap|Ntrvnt 
]Bara«M  in  ihf  *ijj&  uf  the  head  of  the  bone  w  dependeut  oa  tbe  tltipoeitiim  of 
llav  --  -  '  (t*4e<(UH  liai>ue  uixm  il,  ratlier  Ibnii  <iu  uuy  t^xpnusiou  of  the 
Bpfk>[  ••  end  of  th«  ttii^h-lmn^.     Tbeae  iiihkm^  of  bouc  tioustituti!  otie 


-..s 


fl#.MIv^»9lk«  of  Uip-joiBt  Affaotod  by  Dtj  Ohronle  R1i«aMiati<!  Artbrltb. 


iIm  tDoH.  IfDpnrtant  characlera  of  the  iliseaae.     The  mu»ct<w   And  soft 

)u  tbe  ririnity  of  thi>  juiut  are  n<H?e-'Mirily  wastoil  from  disuse, 

t^ioftums. — It  occaMotully  bappenn  that  an  individual  laboring  under  this 

~      '    I,  mt«tin;;  with  »  fall  or  ctntuftion  im  the  hip,  pre-vnt*  Tigris  nf/ntriure 

if  tvet  of  ihr  ihitjhhtmK.  such  ha  »hortenii));.  eversion,  with  some  crepila- 

pcrha|*,  &nd  iniibilily  to  move  the  Hmb.    Tbe  diagn<wi5i  may  in  general 

liv  itttt-nttiiii  to  tlie  bi*t«iry  of  the  case,  and  by  elicilioi;  the 

i:ii.imi  linve  exisled  to  some  dejfree  before  the  .•K-cident, 

tlb'   i-^in  iiiid  ifiiTii'iIiilily  miiv  h.ivr  b<^n  increiuied  bv  it, 

Rheumatoid  Arthritii  of  the  Lower  Jaw. — f'brunic  rheumatoid 
'has  al?"  bivu  dc*ctib«.-d  by  Siiiitb  ae  occjusiunnlly  atrtctiuy  ihe  U?m[K)ro- 
vrj  articulation  iu  individuals  of  rather  ailvHuci.-<l  life.     Thia  dioeaifti 
i3rnjlDrtri<.-aI.  and  ;;iveii  riau  to  an  unlarm'tueut  of  the  condyle  uf  tbe 
eau  be  fell  under  the  zygoma,  alteudeti  with  inueb  pain  in  upeU' 
Dtuutb,  a  MfLsatioii  of  craekin;;  or  gratiiij;  in  iho  juiut,  and  eonie 
nriii  ..r  Uie  lymphatic  }!lniida  by  the  side  of  the  oeeb.     The  pain  ia 
r  "iiwd  at  ni^bt.  and  inlluenvvd  by  the  slate  of  tbe  wealhtr    The 

U-.  ■».-■-  iii^'  -■■',  Lbti  BlTfcle)!  fciily  of  the  jaw  projectin^j  and  being 
poahad  towari-  -dte  mdt>:  but  wheti  both  joinLfl  are  atferled  the  cbiti 

tbe  <  -  .    bfin^  <lrawn   forwards.     Tins  di^uirtion  ih  ehietly 

ttilbadi  'if  the  iirticnlnr  eniincnee;  for.  when  thi^  lake&  phiee. 

inl  plirj v-iiii  mii*cle  draHti  the  jaw  forwanH  and  lo  the  oppoiile 
wb«-n  b'-tb  nnieulations  are  equally  afrwled.  tlie!*i*  miiwlet*  ilibplaoe 
l]t  '  -     thctjlenutd  cavity  Iwconies  enlarired,  the  Hbro-cariila^ 

ir-  condylii  it  «oniriinK-fl  (•ready  thiekenetl  and  fliitlemsl,  and 

ijm  niagb.  being  ikruid  of  curtilage.     In  auch  ctuea  there  ia  little  bo 


DISEASES   OF   JOINTS. 

be  dnne  hy  medicines;  but  the  irPHtmeiit  miiitt  he  mnrluciml  oa  UieHsu 
principtoc  ««  In  the  same  ntlociion  AtlAi-ltiri;j;  iIi**  lii|i. 

Chronic  Rheomatoid  Arthritia  of  the  ShonM«r. — When  it  at^cu  tW 
»hr>ulilvr,  c-lir<iiiio  rlieuiu»lui<)  »rlliriti8  giv««  riM.- to  n  ('•>iiBiiK*rti(il(<  riiUr|;*> 
aioul  of  llic  ht-atl  of  llio  hiinicriie,  wiiMtiiig  am)  Hgiiiity  nf  tjir*  •Ivllnid. m 
iiinhilily  to  move  Ihc  i^lbuw  iipwiinla,  i-xcrpt  liy  the  rnlntinli  nl'  th<>  M.i(ittlk 
nil  llio  Iruiik.  In  fuot,  lhc>  Kt-Hpulifhtinicriil  artiLiiliilinii  Iw-in^  fixrd,  tU 
tiKivvmvnL*  of  th(*  (■InniMt-r  ure  etfecte"!  (hroiiLrh  th«  iti^ljutn  of  Ihr  MHjail*, 
which  bt>ei>nifs  nioru  mobilv  that)  natural.  The  artictilatiiin  u  thv  fratof 
much  puiD,  Umcinatiiig  »t  times,  but  genL'rally  uiiawiDg  aud  iatermtttiilt, 
being  (Jepe'nileut  on  ihu  atate  nf  the  weather,  aiifl  greatlv  iDorraaed  in  oiU 
and  net  seufions.  The  wliule  of  the  arm  becomes  wasted,  and  wmkemai  h 
power.  Ill  two  ioslaai-ee  1  have  seen  lh»  discuse  in  yiQtig  nod  utiNnria 
robubit  DUil  healthy  men,  betwceti  Iwcuty  and  thii-ly  yvikn  of  nge,  c<imlagga 
without  any  apparent  cause.  In  both  cases  tJio  joioi  continued  pernmmBllj 
rigid,  though  the  pain  was  relieved  by  the  use  of  the  iodides  and  by  IocbI 
oouuter  i  r  riuiii  oo. 

illSKASKS  OP  JOINIB  OF  CBKKBKAL  UK  SI'INAL  01UUI3t. 

The  sooalled  arthriy}tnlhir»  itrcnrriii^  as  the  rcitllt  of  ttiacBno  >>f  lliv  cMitnl 
nervoti»  syj^tom  niny  h»'  iiivi<li-<I,  nccnrdinj^  to  Charci>t,  into  two  i-Iubm^ 

1.  Arthropathy  of  Paralyzed  Limbs. — Acute  or  suhnruto  i:  '  •'^^^ 
with  oiusidi-rnbic  aivcllin^  rn>in  eir(i»ti>n  into  the  joint.  nuA  '  ■■» 
wver«  pniu,  is  iM-cjisioimlty  oh^t.TVftl  in  the  »nieiilutionii  uf  linil  u-\\ 
from  acut«  or  »ubiicute  iiiOniiiinntiun  uf  th«  lipinal  cunl.  >i  -  ciu 
observed  it  in  paraplegia  trom  Potl'e  disease;  Viguo,  J'trtrt<y.  and  6ir 
^Villiain  Oull  BK  the  re*«Il  of  pamlygis  from  trnumnlic  lesion  of  the  oofd; 
Scott  AlieoD,  and  othen  have  alw  met  with  n  similar  aH'ection  of  the  j^iiuts  is 
liniba  paralyzed  from  circumscribed  cerebral  eolteuing,  or  iolraccphalic  lifn- 
orrfaaf^  It  cotuca  on  at  the  same  time  a»  the  contmclioQ  of  the  miurla 
oumoiences,  ut^ually  fitWn  davh  to  a  month  ntltv  the  paralysis  baa  set  to.  It 
haa  DU  tendency  to  end  iu  annjiuratiou. 

2.  Arthropathy  of  Ataxic  Patient*,  or  Charcot's  Disease. — This  eoDdhioo 
waa  flr»l  ilt-T'ciil>e<i  hy  Chtircol.  Il  otfors  in  pHlicut«  f-utlvrin^  rmm  IncomoUr 
ataxia,  Bctting  iu  without  appn't-tuble  i-auHc.  uaually  at  that  jieriod  of  lh« 
diwa».-  wlu'n  want  of  ciK)nliiiiilioii  in  the  mufculitr  inoveuwDIa  beoaoua 
appttrent.  It  coniiiipurcf  uiih  a  jfeneral  und  of\cn  i>ntiriu<iuii  swellinif  uf  the 
limb,  cinnmonly  wiihoui  |tain  tir  li.'ver.  Atler  n  few  davH  the  ^neral  tarll- 
ing  di'^ujijioiirri.  hut  rlic  joint  rfmaiiit*  dii<i<'ii(Ifd  with  lluiil.  Sonietiinr*  ihr 
bur^A'  in  the  noIchUirhiftKl  of  the  articithitiou  nn^  aluo  disteDiled.  The  fluid 
if  <lraHrn  nfT  is  found  to  he  transparent,  and  of  a  |iale  lemon  color.  At  the 
end  of  some  weeks  or  tuonttia  the  swelling  8nh»ul<«,  and  the  •■  ''K  t>.'>v  r..i,irB 
to  itit  normal  itute.  In  the  niorc  typical  cm*.-^,  buwerer,  crv<  'la 
movi-menl  a  frw  week*  after  the  coitimeiicement  tii  the  n(ta<.>,  ><  " 
become  relaxi^l  m  the  effusion   is  alt^orlwd.  the  «iweou«  aurtu 

Btt<*r('<l  in  form  by  wearing  awiiy,  und  cmsecotive  diHhx'alion^  jirv  dm 
UDCtinimoo.  Even  un<Jer  (hew.-  cinunifluncc*.  however,  somp  drgrre  '>f 
mobility  is  lell  in  the  limb.  The  ji>int  im^ist  comm'inly  affcrtr>l  i»  tb«  kne«, 
tbcD  C(>mc(>  thti  ohoutdcr,  then  the  elbow,  the  hip,  and  the  wrirt.  Xtn 
vatAofoyi^l  ■  ■  ••  found  after  death  are  similiir  to,  and  in  many 

idcotical  W)tl>.     '  Irijudy  detcribcd  an  l>ctng  met  with  in  cfaroaioi 

toid  arthritis  \\>.  o<'>4i.     The  chiet  difrerence*  are,  firrt,  that  Um 
BVav  nf  the  surfaces  is  very  exlenFive,  and  the  Ibrniatioo  of  the  i     .^ 
cartilagiDoiia  oatgrowtba  round  the  ariiculation  is  very  limited,  or  erm 


ANKYLOSIS — FIBROUS — OSSEOUS.  859 

tinly  traatiog;  and,  secondly,  that  true  dislocations  are  common,  whereas 
io  rheumatoul  arthritis  they  are  very  rare,  and  when  present  occur,  not 
(Kmu  relaxation  of  the  liganients,  hut  Irom  pressure  of  the  bony  outgrowths. 
The  diagnoiu  from  rheumatoid  arthritis  is  made  by  attention  to  the  follow- 
iog  points:  First,  itd sudden  and  unexpected  invasion ;  secondly,  the  abun- 
daot  effusion  in  the  eurly  stages;  thirdly,  the  frequent  occurrence  of  dislo- 
ealioo  ;  fourthly,  tlie  occuHuual  rctrogresdion  of  the  disease ;  and,  lastly,  the 
fiict  that  it  occurs  in  conjunction  with  the  other  symptoms  of  locomotor 
ftiazy.  fur  which  I  must  refer  the  reader  to  works  on  Medicine.  The  l^eat- 
wtad  must  be  conducted  on  ordinary  principles,  rest  being  the  most  impor- 
tant means  of  preventing  the  advance  of  the  destructive  processes  in  the 
■Jticular  surfaces. 

ANKYLOSIS    OR   STIFF   JOINT. 

Anl-yloaii  is  invariably  the  result  of  partial  or  total  destruction  of  a  joint 
by  iodaniniatioD,  and  is  one  of  the  motles  by  which  Nature  eflects  its  repair. 
ll  consists  in  the  more  or  less  complete  consolidation  of  the  parts  around  and 
within  the  articulation.  It  is  of  two  kinds:  the  Incomplete,  or  Fibrous; 
and  the  Complete,  or  Osseous. 

Id  the  Incomplete  or  Fibroiu  Ankylosis,  the  stiffness  of  the  joint  may  be 
dependent  on  four  distinct  pathological  conditions,  which  may  be  more  or 
Itm  associated:  1,  on  thickening  and  induration  of  its  fibrous  capsule;  2, 
on  the  formation  of  fibroid  bauds  as  the  result  of  infiammstion  within  the 
fMDi :  3,  in  consequence  of  the  cartilages  and  synovial  membrane  being  in 
part  or  wholly  removed,  and  their  place  being  supplied  by  a  fibroid  tissue, 
by  which  the  articular  ends  are  t)c<l  together ;  4,  on  shortening  of  the  liga- 
0ieDt0  on  the  side  of  flexion  of  the  joiut.  The  stiffness  of  the  joint  may  be 
materially  increased  by  the  shortened  and  contracted  state  of  the  muscles 
around  the  joiut.  But  this  is  secondary  to,  and  not  an  essential  part  of,  the 
ankyloeis.  Fibrous  ankylosis  commonly  results  from  rheumatic  or  scrofu- 
lous arthritis,  and  is  the  most  favorable  result  that  can  be  hoped  for  in  many 
of  theM  affections,  especially  in  the  scrofulous.  In  some  cases  it  arises  sim- 
ply frtirn  disuse;  the  ligaments  being  shortened,  nnd  the  limb  becoming 
stii9«rned  in  the  position  in  which  it  bus  been  ttw)  long  detaine<l. 


Complete  or  Oweoai  Ankylosis  i^  of  two  kinds.  In  one,  nit  the  s'ift  parts 
within  the  jitiril  are  ile^tmywl,  tnid  ihc  Mssi-otis  tiiHliiccs  have  oiialesn-d,  or 
are  Ium^  tugetbvr  by  <lirect  bmiy  iiuioii ;  ttiis  ):<  nio^t  cniiiiiKnily  s-een  in  the 
hip  (Fig.  o-'Jlij,  knee,  and  elbow.  In  the  uthcr  kind  the  bunos  are  united 
partly  by  fibrous  tissue,  and  partly  by  arclic-i  or  bridges  of  osseous  tissue. 


860 


DfSBASKS   OP   JOIMTB. 


thrown  out  extenmlly  tu  the  articulation,  and  strelobing  acroH  from  wi 
etfif  til  the  other,  it  hna  lHM>ti  Hii|>p<#eil  that  thest!  mttMoi  prneeed  frvm  thi 
<H«i<icntinn  of  thi>  tigR*iipiil».  or  even  the  niUBcleii;  hut  trom  thr  irriTul>nt]r 
of  their  appearance,  it  \s  vviitetic  that  they  are  nrw  rormntinna.  Tfi«  tnt 
orosKOUB  ankytneis  Hoes  not  often  occur  as  a  oonwqiicnee  of  Brri>ftil<'U*tr 
ticQlar  inflammation,  but  ts  usually  the  result  of  pya-mic  nr  traumatic  iuflaia- 
matioQ  in  [wraonsof  a  healthy  constitution.  It  not  unfnM)Uonily  fai|>pHit, 
in  ol(i-«tanfling  cases  of  diseased  joint,  that  more  or  Imb  ivimplete  ankyltn 
16  taking  place  at  one  part  of  the  articulation,  whilst  (.-arit-A,  or  B«on«B  «l 
the  b<:iue«.  is  going  on  at  others.  ]t  iii  usually  oasv  to  maki^  the  DiagnaA 
bolwet^n  fibrous  and  o«sr>oua  nnkyloeig;  tho  joint  being  movable,  ibuuiffa  ptt- 
faatM  only  to  a  very  slight  degree,  in  the  false,  whiUt  h  is  riitidly  and  iDinuiV' 
ably  fixftl  in  the  true  torm  of  the  disease.  Casea  not  unrreijucuitv  oeevr, 
bowevcr,  in  which  the  rigidity  of  Lbe  etruclurM,]nuM'ul«r  and  im  "it> 

side  the  joint,  ia  so  great  in  tlic  fibrous,  and  tb«  DKibility  of  (be  ;  :if 

booc9  and  iiiiiiti>  m  free  in  the  os^ous,  thai  it  l>eciiRiefl  very  difficuU  (■>  iU<id« 
to  what  degree  Lh«  joint  is  stitfened.  Ilerv  the  ilin^'iioBig  iiiiiy  t>e  made  br 
putting  the  juitient  under  auwlbetici :  when,  if  (he  ankylosis  Im>  fiUnrui. 
the  juiut  will  be  found  to  yield.  In  fibrous  arikyWia  any  allempt  to  tDi>n 
the  joint  forcibly  b  usually  accoiiipai)ie<l  by  niueh  paiu,  with  iovoluolary 
ooDtraction  of  the  oiUHiles  conuecteil  with  the  joint,  wbllvt  in  usMvoa  sak^ 
lusis  such  attempts,  unlen  Tery  forcible,  are  {winless. 
Tkkatment. — The  treatment  of  ankyliieis  is,  in  the  first  inslancr,  of  a 

firecautiouary  nnlure;  that  is  to  i>ay,  when  the  .Surge<Mi  finds  Ibnt  the  otab- 
ifibment  of  ankylosis  ts,  as  it  were,  the  natural  means  of  rur«  ndopii'^l  by 
Nature  ta  a  dueply  diseased  joint,  bis  effurta  should  t>e  din*cird  u>  taktrit 
cnre  ihul  the  joml  becnmca  fixed  in  such  n  nnviitoo  as  nil!  Itave  th«  nioii 
u»eUil  limb  to  the  polieul.  Thus,  if  it  be  ilic  hip  or  knee,  the  nnkylivol 
joint  (ibouid  be  in  the  straight  i>ot*iuon ;  if  it  bo  the  dhnW,  it  should  bt 
pla«H'xl  at  a  right  angle,  and  ihc  Imud  in  tho  midutate  between  pronaticia 
and  »u  pi  nation. 

When  once  ankylu«ia  has  orcurred,  the  treatment  to  be  adopted  will  ilt- 
pend  partly  on  the  degree  of  ntitlucM,  whether  it  be  fibfius  or  nsoPtnu;  lod 
partlv  on  the  object  to  be  attained,  whether  this  be  merely  the  reiitoralioa  nf 
mobility  in  a  part  ankytosed  in  a  good  poaition,  or  the  remedying  of  the  A^ 
Ibmiilv  oceajtiiiued  by  faulty  Bukylosis. 

1.  tu  attempting  to  restore  the  mobility  of  a  Joint  ankylnsed  In  a  ro«) 
pwltion,  aj)  of  n  Rtmii;lit  but  slit)  kne«,  the  8urgeon  may  u«nally  imcc««d  if 
the  ankylo«tis  l>e  only  fibrous  (when  aom«  degree  of  miivenient  will  alwavi 
tw  peroo|)lihle  in  the  parlj.  by  the  employment  of  panire  m«>ltiiii,  frict^^u^ 
■DO  doU{-b<-]t,  Rtore  p:ini<jularly  with  warm  salt  water  or  the  mineral  miI- 
phurous  springs.  In  the  more  obniinate  CR«e«<,  and  where  the  iiiimobilitf 
appears  tode|ieiid,in  some  degree,  at  least,  on  filirmiK  buinl^^lrvi.-ti-ngairraM 
the  joint,  an  Httempt  iiii;;tit  be  mnde  to  rupture  theie  siilicir' 

Bayre  has  eMtabliAJied  ttu  iiU|x>r(aiit  pxiiit  in   Ibe  di<(in^  l   ihi>i« 

cnaes  in  wbieh  it  is  o«c«M*ry  to  cut  a  omtrHcifd  tendon  or  tnsaii,  and  tboe 
in  whieh  it  will  rield  hvstjvtcbiug  willuiui  division.  It  m  this;  if.  Mbca 
the  part  is  stnttcfiud  to  the  utm<~)6t  point  and  lirm  premure  id  motle  on  it  with 
the  finger,  redox  actiun  be  iuduued,  tbeu  it  must  ba  ouL  If  no  rvdax  coo- 
traction  ensue,  then  etretehiug  is  sufficient. 

%  When  (ibruuH  ankylusis  has  taken  placo  in  a  faulty  pnsiiino— 4C  ftr 
instance,  the  knee  be  biMit,  or  the  elbun  stritight — the  first  tning  to  be  dsat 
is  to  pUoQ  Uie  limb  in  eueb  a  pneitiou  that  it  wilt  be  useful.  Tnis  mar 
readUy  be  dune  by  putting  the  [latient  under  the  infiaeoce  of  chl»r>.ifc 
and  tbea  forcibly  Hexing  or  extr-uding  the  limb  ■■  the  eum  nutjr  raqonT 


LOOSE    CARTILAGES    IN    JOINTS.  861 

vbeo  vith  loud  snaps  and  cracks  it  will  usually  come  into  proper  position. 
Shoold  anj  of  the  teodoDs  or  bands  of  fascia  near  the  joint  appear  to  be 
MTticnlarly  tense,  they  may  be  divided  subcutaneoualy.  P'ither  some  days 
man  the  extension  ia  attempted,  or  else,  if  it  have  been  carried  as  far  as 
the  rigid  Mate  of  the  tendons  will  permit,  tenotomy  may  then  be  practised, 
and,  ID  interval  of  a  few  days  having  been  allowed  to  elapse,  extension  may 
lie  completed.  The  muscular  contraction  will,  however,  in  many  cases,  yield 
(ojmdaal  extension  by  means  of  screw-splints  or  weights,  and  thus  render 
teDotomy  unnecessary.  The  inflammation  that  follows  this  forcible  extension 
orfleiifin  of  the  limb,  is  usually  but  very  trivial ;  an  evaporating  lotion  and 
rat  vill  speedily  subdue  it.  Indeed,  it  is  surprising  what  an  amount  of 
noltnce  may  be  inflicted  on  an  ankylosed  joint  without  any  bad  conse- 
qiMiceB  ensuing.  AAer  the  limb  has  been  restored  to  its  proper  position, 
pnve  inotioD  and  frictions  may  tend  to  increase  its  mobility. 

3.  When  osseous  ankylosis  has  taken  place,  and  the  petition  of  the  limb 
ilt good  one,  it  will  generally  be  wiser  for  the  Surgeon  not  to  interfere; 
actft  in  the  case  of  the  elbow-joint,  which,  in  these  circumstances,  may  be 
extiiM  with  advantage,  so  as  to  substitute  a  movable  for  an  immovable 
tninilation.  If  the  position  be  faulty,  the  osseous  union  may  be  sawn, 
drilled,  or  chiselled,  and  broken  through  subcutaneously ;  or  a  wedge- 
Aaped  piece  of  the  bones  may  be  taken  out,  and  the  position  of  the  limb 
tbu  rectified. 

4.  Amputation  may  be  required  in  cases  of  faulty  ankylosis  with  so  much 
ttropbj  of  the  limb  as  to  render  it  useless,  or  in  cases  in  which  there  is 
McTused  or  carious  bone  coexisting  with  ankylosis  and  rigid  atrophy  of  the 
■Btcla  (^  the  limb. 

,  LOOeE  CARTILAGES  IN  JOINTS. 

It  Mmetimes  happens  that  the  synovial  membrane  of  a  joint  assumes  a 
Watty  Condition,  as  the  result  of  clinmic  diseas'e  of  the  articulation,  espe- 
OM.]\j  in  rheumatoid  arthritis.  This  warty  stale  of  the  membrane  arises  from 
kypertmpby  of  the  fringes,  chiefly  in  the  neighborhood  of  the  margin  of  the 
(trtilipfcF.  These  may  become  peiluuculated,  and  pendent  into  its  interior, 
r^w  this  condition,  which  gives  rise  to  occiisional  uneasiness  and  putfiness 
wxtitlhe  joint,  with  a  crackling  or  creaking  sensation  when  it  is  moved,  but 
little  cao  be  done  beyond  the  a{)|)lication  of  dii^cutieut  plasters  and  the  use 
"rfelislic  hnndages. 

«WiH  Cartilages,  as  they  are  termeil,  may  be  of  three  kinds.  1.  The 
•^^IImI  mffou-ittd  bodic«.  These  are  usnalty  numerous,  sometimes  filly  or 
^^K  in  nundjer,  white  or  brownish  in  culor,  and  cli>sely  resemble  the  seeds 
M  >  nielun  in  ibrm.  They  are  conipused  most  commonly  of  dense  fibiuid 
"■ue, and  ar«!  Iwlieved  to  be  due,  in  niiuiy  cases  at  hiisl,  to  the  ])e(Uin<'U- 
'*'«1,  tarty,  or  villous  growths  just  desrrilied  u,"  iK'injr  fiirmed  from  hy|K.T- 
tfiiihj- fif  ihc  syniivial  fringes,  becoming  broken  loojic  I'roni  their  iitiachiiients 
•*?'«  mi.vemvnts  of  ihe  joint.  In  oilier  cases  it  is  pussiltle  they  may  be 
**fOuii  frnrn  alterwi  blood-clot  or  fibriiiuus  exudiiliiin  into  the  synovial 
etTitt.  They  are  much  less  common  iu  jninla  than  in  i-lieaths  of  lenduua  or 
■yn-'vial  harrV 

i  Fni/fiifntji  of  true  carfihge.  These  may  be  deveIi)[K'd  in  two  ways; 
■'*i,  Id.iu  the  Ibrmation  of  carliliige  in  the  hypcrtrnjiiiifd  trinL'ts  ofa  warty 
■yoviii  membrane.  In  the  uurmal  cmidjiiiin  a  rarliiagccell  is  |)nMiit  in 
■""Tof  (he  rec(Hidary  papiihe  of  the  tVirige?.  and  it  is  easy  to  undcistaiul 
"'■this  can  fi>rm  the  starting-pnint  of  a  cartilairitmus  grnwlh.  In  oilier 
***ni  Billroth  believes  that  they  arc  ossifying  cartila>^inoU3  growths  iornicd 


862 


DI5BASU3    Of    JOINTS. 


lu   ihe  fibriiiiB  layer  of  the  gj'iiDviul    iiifinhrune   in  rhfii;  ' 

(p.  :i54),  which  huve  subMquenily  become  \w»c  by  liie  Wt-u.  : 
AUpcrfli'ml  luircn  of  (he  inombrane.  ThU  nrnlc-  ui'  nrif^iu  u  Kiuiculiftl 
duiibltul.  ThvM!  cartilogM  are  usunlly  tluttcDuil,  with  u  hijiuliui-^  irrtfuUr 
biirilpr.  auil  fn^u«nl1y  (Mntnin  Iriic  biinc  in  their  cfiilrni  |>urt«;  MititrUna 
lliey  may  be  |iflrlly  calcitietl,  but  contain  no  trite  okutdua  tiwuc.  T)u-y  maj 
•tlnin  a  tixe  »(  more  than  one  inch  in  their  ^renu-M  ■liantrt^J'-  Tkry  an 
UMlully  single,  but  occasionally  four  or  five  may  \k  fotiml  iu  the  aaim- julaL 
There  h  fltrong  reason  tu  believe  that  tbeec  cnrtiliif^lnout  boOict  nwy  UKreue 
iu  siiv  HiUit  Iwcuniini;  Umxg  iu  ibo  joint. 

a.  Numerous  t:n»:»  have  Utu  rccvrtlvd  iu  which  the  luuiw  Iwdy  wan  «»• 
dvubtetlly  a  piece  of  uuo  of  the  articulHr  (.-urtilHuw  bnflcen  off  by  mr4:Iuuii*«l 
viotencv.  Tbesv  presvnt  tbv  ordinary  tipp^aninco  of  urtictitur  cmrtiiau«,aiid 
may  uauully  bu  r«cvgDize<l  by  ihvir  having  ono  Bmuolh  Hurrac'c.  while  llw 
op|H>silu  fii^lu  hue  duiuII  gritly  frugiueutH  of  bone  utUchod  to  it,  which  ban 
been  torn  from  tho  cmik-oIIous  tiasue  ImooiUl     They  an!  always  auisl** 

Luoei!  t-artilngva  of  all  kinds  are  moat  oomintinly  met  with  ta  Uie  kom, 
but  not  iih(.i)niiuouly  c>cour  iu  the  elbow  or  th^  juinl  of  the  luwer  jaw,  aad 
(iccasionallr  in  ihn  hhouhl«>r. 

8¥MPro]i8. — The  twveriiy  of  the  f«yn)pu>tD9  will  to  a  great  extent  depoid 
upon  the  mobility  of  the  Un»e  cartilage,  and  ila  cuuiie<|U«nt  prealer  nr  km 
liability  to  be  nipped  between  the  opposite  articular  nurfacea  in  the  BHrrc- 
lucuta  of  the  joint.  When  these  bodies  are  tnlerahly  tinnly  attaebed  to  tb« 
synovial  nienibnine,  they  may  merely  (wcnainn  weiikut-Mt  of  the  joint,  with 
occasioDfil  synovial  clfuBioii.  When  loose  they  usually  give  rise  lu  a  veif 
distiuct  train  of  symptoms.  The  moat  marked  of  these  Is  the  Tery  iwvan 
pnin  which  occurs  in  particular  movenicnl^  of  the  limb.    Thta  c<  '  ■■  -uil- 

(ieuly.nnd  id  ol\cD  so  intense  as  to  cause  tmntDCSS  or  siekneas.      I  .'.\j 

fiilUtircil  by  a  degree  of  synovial  inlluntmniiuu.  ami  by  rdaiatioo  ui  die 
ligaments.  These  attacks  of  pain  and  of  smldcn  irnubility  of  the  part  oubs 
on  at  varying  inlervals,  as  the  result  of  movem<-nls  of  it;  tht.-y  ntninwinly 
happen  in  the  knee  uhilfft  the  patient  i«  walking.  It  is  difficult  to  fay  lo 
what  this  severe  pain  i«<luc.  Kichet  thinks  it  mny  be  owing  to  tbofyiwiial 
monibrnnc  being  pinched  botwvon  tbo  foreign  body  and  ono  of  the  articvlar 
surfaces.  I  think  that  it  lb  most  probably  du«  to  th«  foreign  body  beiaa 
drawn  iu  between  the  opposite  sarfaoce  of  the  joint,  when  these  art  •niaratsa 
anteriorly  iu  the  aet  of  nvxion  of  the  knee,  and  then,  when  th«  liiBD  ■•  «x- 
Lended.  acting  as  a  wedge  between  these,  tending  to  keep  tliMn  aeiMumia  avd 
interfering'  with  the  cumpleto  straigbleuing  of  ttie  limb.  In  aniMM}ntM0af 
this  w<vl);[<-like  action  of  the  loose  carliXsge,  llie  Uganeots  am  viDlaKH 
slrftrbef),  and  the  Rickoning  pain  consequent  on  thio  act  js  uqwriaoMl,  m* 
luwcd,  IIS  hnpiH-nii  in  u  viuleiil  <«prain,  by  rapid  vyu'^vial  dnniosi.  Thi 
Ben»ihitily  of  Lno  lignmfiilit  of  a  joint  j»  of  tlmt  {lecuiiar  nature  lliai  it  i* 
mlltfd  into  anion  only  when  an  utu-mpt  is  iiind<;  to  Htrttch  them,  and  ihM 
forcibly  lo  rminti'ract  or  <leiftn>y  iht^ir  natural  use.  Ligaments  roar  be 
without  nnv  suHering,  but  ibey  mnnut  bi>  eiretuliMt,  vither  by  acni* 
dismse,  witliuut  the  most  severe  |utin.  In  some  cases  the  loose  cartilage' 
be  ti'lt  ondvr  the  capsule,  by  carrying  tb«  finger  over  the  joiul,  slippiaE 
hack  W'ht-n  pree»ure  is  exerciitod  uiK>ri  it.  and  often  powwssing  great  momlitv, 
gliding  from  one  side  of  the  joint  to  tho  oth*^,  so  as  to  be  extrcmtly  dilTtcull 
to  fix. 

IMAnxoais. — ^The  only  condition  likely  to  bs  confouudfal  with  a  lonsc  body 
IK  the  >Ii  '  I  :•  III  i»f  ijnti  of  lIic  inli'mrlirnlnr  fihr't-oarliiagr*  of  lb«  koefc 
The  dit.i  :iu  uaualiy  W  niadi-  liy  I'bmTviug  that  imnittiliately  aftrr  the 

sudden  attack  of  pain  the  kueo  can  be  completely  extcatM  wbva  il  is  das 


to  the  presence  of  a  Iohap  hoily,  as  this  rarfly  if  t^vrr  WrotneH  jatniriRil 
l>etwpen  the  arliculnr  ^iirtiic^:  while  a  ilii^plucei)  fibro-curtilii^^  m^ually 
rcmains  out  of  po^ittoa  until  replaced  by  munipulation  or  tuoveiiient  of  the 
jnint,  BOil  unul  this  is  effected  cotnplele  exteiii^ion  is  ini])«»»il)le. 

TitiiATMKNT. — The  pBlliativc  treaimeot  consliita  tn  Biipporting  the  joint 
with  im  elastic  hundngc  or  koeti-cnp,  so  ns  to  limit  ita  movemeDta,  nnd  thus 
prevent  the  liiihility  lo  reciirn-nce  of  the  nttnrks  of  pain ;  and  in  this  way 
the  tixatioD  ant)  ultimate  absorption  of  the  carlilaf^e  iniiy  sometimre  be  ob- 
tained. This  I  have  several  times  sood  to  occur  iu  pntionts  who  either 
Klbaod  to  be  oi>crated  on,  or  iu  whom  an  operation  nas  not  thought  ndria- 
ablc  Adjt  intloinnialion  that  ba*  been  excited  requires  to  be  subdued  by 
propemntiphlogiatic  treatment.  In  all  operations  Ibr  the  removal  of  loose 
canUages  autitiiptic  precauttuns  of  the  must  rigoruus  chamcter  should  be 
■doMcd.  By  th«ir  aid  joints  may  be  opeued  and  explored,  and  foreign 
bodica  Axlractod  with  a  ti-ocdom  aud  safety  otherwtM  unattainable. 

If  th«  cartilage  occa«iun  great  aud  frcqutriit  ifufferiog,  «o  as  to  interfere 
lenously  with  the  utility  of  the  limb,  aod  if  it  appear  to  be  of  large  »ize, 
tnd  to  be  loose  and  single,  menns  may  be  taken  fur  its  extractiou.  Uut  it 
oiu-tl  )>e  bortie  iu  mind  that,  whiUt  the  loose  cartilage  is  at  motit  aa  iuc<m- 
venience,  though  perba{i8  a  serious  odc.  auy  uperatiou  for  its  removal  by 
which  the  Joint  is  ui^eue*!,  becomes  a  source  of  danger  to  the  limb  and  even  lo 
Ufe.  It  is  far  legs  dangerous,  in  fact,  to  leave  ihe  loreigo  body  than  to 
perform  the  upcratioQ  ucccsenry  for  its  cxtructiou.  Ileuce  an  operation 
thiiujd  Qot  be  lightly  propomsd  or  uudcrtnkeu,  without  Maruiug  the  patient 
of  tbe  iwariblc  cwogequciicvs  that  might  follow.  >'o  operulion  should  be 
ttaderLBKCD  eo  long  as  the  joiut  i»  itt  on  irritated  eLute,  as  the  result  of  a 
reveot  attack  of  puiu  mid  intkmiuatiou ;  tliii>  must  be  firat  subdued,  and 
tbcD  the  operation  may  be  proceeded  with ;  nor  should  it  be  done  if  the 
patieni*!!  health  be  broken. 

The  extraction  of  the  foreign  l>ody  has  been  performed  in  two  ways;  by 
direct  inctuion  into  the  joint,  and  by  subcutaneous  section.  The  operation 
by  direct  inciuion  used  to  he  eft'ected  by  directing  the  patient  in  the  tirst 
in-itance  to  make  those  movements  by  which  he  usually  gets  the  cariilage 
fixe<)  in  the  joint.  80  soon  as  the  Surgeon  I'ch  it  (as  this  operation  is  com- 
monly re»|uirp<l  in  the  knee),  he  pu.shed  it  to  one  side  of  tli^  patt-lla,  where 
he  Hxed  it  firmly  with  his  forefinger  and  thumb  ;  ho  then  drew  the  skin  cover- 
ing it  Id  one  i<ide.  aoas  lo  make  it  tense,  and  cut  directly  ilowu  upon  the  carti- 
l&g>'  hy  a  sufficiently  tree  incision  to  allow  its  eecajK-.  The  wound,  which, 
when  the  jkin  was  relaxed,  wii»  si>mewliat  valvular,  was  then  closed  by  a 
•trip  of  planter  and  iIib  limb  kept  at  re»t  for  a  few  days  until  the  iiiciniim 
wa*  hi'-alnl.  lSever«  inllanniiBtion  uf  the  joint  less  frequeutly  followed  thia 
ciMirve  Ofteration  tliiin  might  have  l>een  expected,  the  synovial  menibniuB 
having  probahlr  undergone  some  miKlili cations  that  reudcred  it  littie  liable 
Ut  tbia  proct>s«.  It  has,  however,  happened,  that  acute  synovitis  runuiug  on 
lb  suppiimliuD  has  set  io,  causing  the  patient's  death,  requiring  aoiputation, 
or  leading  Ui  ankylosis.  In  the  present  day  the  operation  ie  uiuuh  more 
ufely  perfiirmed  by  the  adoption  of  the  antit^ptic-  method.  The  inciHiou  is 
made  uirei;lly  on  tbe  loose  bu<ly,  without  any  valvular  arrungcuiciit,  and 
il^iif  the  o|ienitinn  n  drainage-tube  is  inserted  into  the  wound  for  a  few  days 
umil  tbe  pyniivial  effusion  excited  by  tbe  disturbance  id'  tli(^  joint  liaH  pMi'^ed 
uff.  The  carbcdic  spray  will  be  found  to  give  an  inereaw-d  safety  in  \H--r- 
furming  this  operation.  Sbouhl  it  out  be  UftLtl,  the  w<kund  may  l>e  irrigutinl, 
and  gnat  care  be  taken  to  prevent  the  entrance  nf  air  into  the  articular 
aivilT, 
It  bai  been  propueed  by  Chasaaignac,  in  order  tit  obviate  the  dangcre  uf 


L 


864 


U1SIEASB3   OP   JOINTS. 


direct  anil  open  wnon«]  into  the  joint,  to  rcmorc  tlie  Ioom  CBrtiUKv  ' 
ouUnooDs  section :  this  Ik*  ac-iMttnplUht-fi  in  a  war  that  I  hftvc  k«ii  [■- 
by  Lislon,  and  buve  oftfn  done  niy«c!f,  viz.,  hy  paitain^  a  u-uitUituv  (>btt>|MlT 
under  tlie  skiti,  afUr  Rxin}^  the  f[>rr-if;n  bnily  in  tin-  way  tltnt  litu  »\tTtAj 
been  deKrib«<1,  divii)iu>i^  tite  synnvial  menibrsuv  freely,  and  thrti  r*\wrnu£ 
the  cartilage  Into  the  RrtNtlar  tiiMue  oiibiide  tlii^  joint,  wlirre  it  is  limillT  fixM 
by  plaster  nml  Itanda^,  and  lefl  tn  he  eventimlly  »l)«iirlH*d.  Govmnil  n^ 
oommcndi  the  same  (uihciilaneiiiM  irn^d^  of  removal  nf  tb**  fon>!en  \f<''.  -.-  ' — 
the  inside  of  the  jnint;  hnt,  instead  of  leaving  it  to  be  sbtorbed.  • 
it  St  the  end  of  eiyht  i!h)-»,  by  «  frwb  iuciwvu,  from  tii«  mreolar  ti."  i 
which  it  ha*  b««u  lytn^;. 

A  ni'Wt  iiiwrid  iiiodifictttiou  of  ibis  method  has  I»wm  pnittiecd  by  Njuare, 
of  PlytiiiHitli :  it  von>iiitt«  in  lixiut;  tlie  tofitw  ciirtiiuif*'.  <liviilinii  the  oa{Wib 
RiibfdtuiieiMinty  over  it,  iind  then  prveaiug  tb«  forfi^u  body  into  the  opeaiey 
tbii!<  nuide,  retniniug;  it  there  by  n  voinpme  Hud  plasters.  lu  operatinf  hj 
this  nifthud  on  Iho  knee,  the  cartilage  should  be  fixed  bvluw  and  U\  the 
inner  siile  of  the  juatella.  boLweeii  it  and  the  bead  »f  th<;  tibia;  •  luag 
narrou  tenntume  in  then  tntriMliioNJ  obliquely  umter  the  Hkia  front  a  dutasn 
of  about  two  iiioliet)  beluw  the  Inrae  mrtilatre:  the  catwuit^  tf  the  jtiiot  ii 
freely  divide4l,'{ind  a  space  made  io  the  stibcntanenus  areolar  tiiuue  by  a 
alight  nweep  uf  the  blade,  and  the  Itwjw  mrlilnge  ia  then  preswd  into  ilw 
cavity  ihuH  made  tn  receive  it. and  «lid  alonf;  the  areolar  Unoe  f<<r  ali-wt  t«o 
inchea.  It  ig  flxeil  m  fitu  wilh  a  Hrm  pad  and  adhesive  planter ;  the  fni4  lad 
leg  are  hnndaged  up  to  the  edf^  of  the  eanilage,  and  the  limli  ii^  plared  •» 
a  «|dint.     If  no  inflammatory  ivtnptunu  ensue,  the  cartilage  ia  i-i  '>-m 

a  week  nfter  the  operation  ;  or  it  may  be  left  to  he  ab^orbcrl.     T  :  p- 

ttoo  of  theite  snlwninnooua  ni«thodd,  there  will  be  but  very  liltb-  Aa u^rr  iti 
indoHng  uudtjc  inHnmniation  in  the  joint,  the  enlraoceofnir  being  petr 
vented,  which,  and  not  the  mere  ^Ttion  of  the  cajrtnle  and  syiiovtal  mm- 
brane,  conalilutes  the  chief  rink.  Shouhl  there  be  mure  than  on*  iwar 
cflrliln};e,  the  opernlion  must  be  re[>cateil,  but  not  iinlil  anv  inflamraattnO 
induce"!  by  the  former  one  hiia  been  cultdned.  In  Ibis  way  I  hava  anoo^^ 
fully  removed  iu  succvssion  live  loose  oartilagei  from  one  kne«« 


ymntAixitA  of  lonrra. 

i^in  of  a  Beverectiaraoter  is  often  experienced  iu  or  around  a  joint,  dneely 

rimubitinf;,  but  not  de|M-mleut  u|hhi,  Inflummatton  or  othiT  structural  dbean 
lliis  piiin,  which  is  purely  n('unii;:ir,  may  have  ita  origin  either  in  wime  lool 
irritation  nf  u  nerve  leading  to  the  wneiiive  pert,  or  in  <  nal 

onlcr  of  n  hysterical  characier.     It  i»  thin  claju  of  eases,  oi  .it 

women  who  are  either  the  eulijects  of  hysteria,  or  are  of  a  hir;liU' 
temperament,  that  ^hoitltl  e«peciatly  be  con'^idered  as  Hearal^a  ftf  tha  Ji 
to  which  the  allcntinn  of  the  profeKioa  has  been  directed  principally  by  thi 
labom  of  Sir  B.  Bnxlie. 

fivMrTOMA. — It  ifl  generally  found  that  tlie  hip,  knee,  ankle,  or  shoulder  is 
tbe  joint  nirfcled — Ihe  hip  nod  the  kne«  more  ed|>ecially.  The  oeurahr*  ■* 
usually  localized  in  a  particiijar  joint  by  some  slight  injury  that  the  fmrt  ha* 
tustatuei).  But  it  is  important  to  observe  that  in  theM  rasiw  the  pato  "Ura 
doe-s  not  dev«lii)p  for  s'lme  days,  or  even  weeks,  atler  the  injnry  that  is  lb« 
aU«t(ed  cause  of  it.  .Severe  pain  in  the  joint  ia  complained  of;  and  the  Mnb 
a  nodeped  ci>m{Ninuively  useless,  orieu  with  a  ginnl  ileal  of  dipliTlinn  •» 
ooiltraclion.  On  examiiiution,  it  will  \rc  f<nind  that  the  pain,  which  U  citiD' 
monly  very  wvcre,  'a  BU|>crlU'ial  and  eutuiieoun,  not  existioii  iu  ihe  iotcrior 
of  the  articulatkai,  uur  increased  by  priHura  of  the  articular  surGuxa  agaioil 


XSCKALaiJL    or    joints — CAUSES — TREATMENT. 


IMC  ■DiitWr;  Bttd  thai  it  is  not  itrictJy  coofiD«d  to  tho  joint,  but  rxllates  for 
mmm  dlKancrarouiKl  it.  Tbi»imiii  imidva  ititfrmiiu'tit  iti  iiscliaracter.  and 
b  ftM|tiBBtI]r  anocfaiPil  willi  iifiinil};iii  clN?wlit!rt-,  ob  in  ihv  Bpiiic;  ami  not 
uifrc^uratlv  with  ulcriiie  irritation  or  diaeaae.  TJi(>  pnlienc  soinclini^  ac- 
.tn'itT-t  tli.^  irick  of  [irocluclttf;  lotid  tinappinj^  nf  some  muscle  or  teodon  which 
[  tlv  audible  all  nver  the  room  whenever  Ahe  walka  or  nioTcit.     At 

L   ».'  :  icne,  it  will  b«i  ohs^rved  that  all  the  sijuni  that  oushtto  arroiii[>Aiiy 

k^  -  uack.  of  inriammmtion  in  a  joint,  such  as  would  be  attended  br  ft 

I  torrrajv'i.iiiaj;  Bcoouut  of  paio,  are  ahnent;  there  iKing  no  painful  xtiirtiiigv 
I  of  t^  limb  at  oighl,  oo  neat,  nsiness,  or  swelling  of  it,  nor  coniatiliitiuual 
I  fKnt  «od  trriiatinn;  and  ihn  Htifferinj;  being  increased  by  cftu»>os,  sncb  iis 
I  ibMKal  nn-l  ^nioiionnl  diBtiirbauce,  thai  do  oot  iolluesce  organic  dievftse. 
..tri'iiis  rirciiineliiiicev  will  u^uiilly  enable  ihc  Burgvon  to 
iif  thi*  iiLlnck  williiiut  much  diflicultr ;  the  only  cases  in 
tir  will  rvally  t;xi)vnenc-e  any,  bein),'  tlnwe  iu  wbicli  the  tissutA  ari'iind 
int  baw  b«r«u  thickene^l,  imluruted,  and  alu>red  in  their  chamcleni  by 
^^•i^plicatiuiiof  couoter-irrttaots;  or  by  some  slight  articuhu- disease  having 
«l«n«i«  time  vKtsted,  but  having  been  cmred. 

CiL^iai. — The  neuralgia  is  often  referable  to  the  irritation  of  some  par* 
tirulur  nenrr,  either  at  its  origin  or  in  ilii  ccinree.  This  is  particularly  the 
Qw  with  neuml^'inof  the  hip  and  knee,  which  will  be  found  lobe  dependent 
on  irrilatioo  of  the  obturator  nerve,  owing  to  intrapelvic  disease.  In  one 
an  of  Moondftrr  abdominal  cnncer  under  my  care,  the  patient  wna  Hitcd 
wUk  kIm  noBt  intCDK  pain  in  the  right  hip  and  knee,  »o  bb  to  lead  to  the 
■li|*eiiia  thtti  theae  joints  were  dimaaed.  On  examination  oAer  death,  it  was 
Cnm  that  th«  pain  nsultod  from  the  implication  of  the  obturator  nerve  in  a 
warn  of  intrapelvic  cancer,  the  joiou  ih^uaelvcd  being  perfectly  sound. 

TuUTMETT. — The  treatment  niuAt  be  eonrtitutionaT,  directed' cupccially  to 

wftnahliih  a  healthy  condiiinn  of  the  uterine  orgaui.    If  there  be  amenor- 

riMKaad  uuenia,  aloflica  and  the  prepHnitioni  of  iron  must  be  given;  if 

VHrin  AT  aterine  irritation  or  congentton  ei:t«t,  this  muAt  be  removed  by 

|Mpr  local  raeana,  and  the  general  health  Htl4>ndeil  to.     Nervine  aatispae- 

■ans  and  toaic*.  »urh  as  valerian  and  bark,  or  aMcafo'tida  and  quinine  ill 

Ul  ddM».  Aboald  he  fnniU  adoiiuiiittred.     The  most  efficient  treatment  that 

<M  W  4lir«f.-tnl  tu  the  aflectcd  joint  is  the  application  of  euld  douchts  and 

■^Wpkrymeot  of  the  continuous  electric  current,  which  will  cure  ciises  in 

*^  all  other  means  havi.*  failed;  the  application  of  atropine  and  aconite 

■■*  Wof  service  to  allay  the  pain  when  uepeciallv  seven*.     If  contraction 

J*b«r  dmlortion  of  ihe  limb  exist,  tho  itaticnt  *fiou!d  be  put  under  an)i»- 

™fia,aad  extencion  or  rcctjtii-ulion  of  tlie  fauliy  }n«iii<jn  (hen  made,  rare 

■BliiBkeo  to  keep  the  limb  on  tjilinis  in  a  jirojier  niwiiidD  f'lr  ttonie  time 

tl»  openiitm.     Indeed,  in  neun)lio  or  hynfrti-nl  jninl  aH'ectinns,  it  is 

of  much  use  to  do  somethfog  positive  or  nbjertive  in  the  way  of  treat- 

■■!• »  as  to  give  ibe  patloot  an  excuse  to  get  well.     It  is  thna  tlmt  free 

■*B9iituiiai  or  slight  "  wrenching  "  of  the  joint  under  an.-estbetira  is  often 

*>*>MMaL     In  iilher  raites  the  gtvSl  effects  I'ullowing  this  treatment  may  be 

^fuMl  bTthe  siretchiog  and  restoration  of  the  normal  position  of  mnactea 

^ekbad  nrro  allowifl  to  become  contracted  and  displaced  by  long  con* 

•■Mfaiiy  or  fiiully  position  of  the  joint. 


I 


866 


EXCISION    or   J0IKT5. 


CHAPTEn   XLTX. 


KXCIStOK  OF  JOINTS. 

HuTURV. — The  operation  of  rcetvtion  aT  the  articular  ends  of  boaoi  data 
fn>nj  iho  very  oarliasl  periodfl  of  Surgery  of  wliich  we  have  any  nwrd. 
HtpiKMrnLeAl,!!)  bisC'liapUTou  lojurir*  oCloiiiU!)  np«jikiof  rtvacliiin  of  bona 
at  iJio  joiQU,  wlir'tlxT  of  tho  fuot,  ibe  lina<l,  the  li*^,  ihtt  auklt^,  the  forrt 
the  wrUu  08  hv'mfs  tor  the  ni-Mt  part  iiniittviidtHl  by  iUiip.*r,  vxivpl  from 
eu(te  or  iMUBecutivu  ft-vi-r.  <'t.'lf>uH,  in  KfM'ukiu);  of  n)ui]Hiuiii|  dtfiliHiitN 
uyn,  if  tile  bare  bone  pmioct  it  will  ulwavH  be  nit  4»b«tjK;le  U)  mlu<  ciuo ;  tl 
which  protruiles  should,  Ini-rcforc,  l>c  cut  off.  Paulu*  .i'.g'iaela.  my*  tbat,  tf 
n  Iviiie  pro}<!cU,  un  iifior  n  Irfliisvcnc  frnrrtin'c,  we  must  rut  it  otf.  ThiMk  h 
will  clearly  l>c  sct'U  tliut  it  ivti-i  ihc  practice  nf  the  aiicioiiU)  in  coiufxiund  di*' 
joraijous,  and  in  compound  fradurcit,  to  resect  the  pn>tru<lin|;  bfiiirs.  But 
that  (heprartlccof  reaction  in  t*aM«  of  disease  also  WN«  not  hitkuown  («>  thna, 
\»  evident  from  a  pnMUK«  oti  ti*tul«>  in  Uie  worka  of  Vniilu»  .Ki^tirla.  who 
directs  that,  if  the  ftsUilA  icrmiitatc  with  a  bone,  nn<l  if  tlmt  tw  li"t  diMued, 
it  should  tmly  b«  8f*rn|>od ;  but  if  it  l>«  carioiw,  Uiv  wli>d«  diswiwil  portioa 
ahuuld  be  vut  out  wiih  chi»eU;  and,  if  neursDary,  it  ii'ay  havQ  a  bol«  boml 
in  it  witha  ttviihiue;  and  a  little  further  <>&  hwenys.  "  the  vxtn-mity  of  a  \njm 
ui«r  a  joint,  ifiliMfuscd,  is  lo  hv  smw  n  uff;  and  oli«n,  if  the  whole  of  a  boM^ 
such  as  thv  uinu,  nuliuH,  tihiit.  ur  the  Ukv,  bt*  divunevd,  it  is  to  b«  taken  out 
entire."  Nuthing  can  probably  be  uiori;  ex|iiicit  than  this  etaleuivDl,  in 
which  the  practioe  'v>  alluded  to  ua  uf  I'reijueut  occurrvuce.  But  hi*  OJakei 
exeeptii'tiB  ill  the  i-un'  uf  the  bonee  of  thv  ^pitiu  and  |>elvis,  and  tlie  head  of 
the  femur,  which,  he  says,  should  nut  be  oj>eral«d  on  for  fear  of  the  Detgfabor- 
iuff  arteries. 

Th<>  praelice  nf  rwection  ihus  known  lu  and  oilopti.'d  by  the  am-ivnts,  and 
uieutioned  by  the  Arabian  writers  of  the  middle  affw.  fell  rMtnpU'tvly  iutu 
difutif ,  and  tieenia  entirely  lo  have  been  ftirjzotti'U  until  th<<  nit>Mlt>  <ir  the  lost 
Century,  when  i>ex.-ai>ional  nuticvs  of  its  adooUuu  aji|>eHr  in  Sur^^ical  etwayii.  Il 
WC18  Einit  employed  in  cases  of  compound  Irarlurcs  und  diifl<K'iition»  of  joints. 
In  military  practiif,  iht  Surj^fHtn,  lo  two  or  ihreie  in^tanMs,  pickt^l  out  and 
cut  away  frogmenta  of  thv  bnu<M  fonitin}*  the  wrist-,  elbow-,  ril)uuld<'r-,  bqi] 
ankl^joiDts  when  )tliAtter«Hl  by  gunshot.  This  early  revival  of  i  '* 
ioTolTed  no  principle  of  lrenlm<-nt :  inijwrff-cl  o|K;rati-.n3  beioj;  had 
toon  the  field  of  battle  wmply  ns  u  iiuUler  of  ci>nrL-nienci.-  in  |Kirttculnrt 
The  Sorjje^ms  who  |>erf-)rmed  them  did  ii^it  rocogniw  any  new  mlo  of  practice 
as  heinit  involve<l  in  thei-o  flmnco  nroeetlures. 

The  fint  resection  pnietiwd  for  injury  in  which  iho  orticular  ends  in  «o^ 
fxiiinii  (littocnti<m  were  fairly,  delih<Tntv1y,  and  succaafully  rrmored,  aDpean 
to  hare  occurred  to  Coojwr,  of  Kungny,  l>cfur«  or  at  latest  about  tb«  middlv  of 
the  last  ceolury.  The  precise  datuol  this  case  is  iinkoQWo;  but  Li<>wh  writ* 
ioft  in  IIW,  Hiys  that  it  occurred  "  many  years  ago;"  that  the  coda  of  buth 
Uhin  and  fibula  were  sawo  off  in  a  cvmpouud  luxation  of  tJie  ankle  ;  that  lbs 
limb  was  prveervod,  and  was  ao  useful  that  the  patient  was  able  to  walk  and 
gain  his  liTclihood. 

In  or  about  the  year  1758,  Wainman,  of  Shripton,  aawed  off  the  lower  aod 


tSTOBY   OF   EXCISION    OF  JOIN^ 


867 


flflha  hoBMrUBiii  &  cam  of  compound  dialoRatioDofthecHtDw-joint  with  rtcr- 
feet  aDeeeM.  the  patient  rernTcriuf^  with  uti  arm  amnnvahli^  *'a!tif  imthing  Imd 
t*rr  heta  untas;"  and  liU  cxumpli!  wasnhorliy  nflerwnnln  followed  by  Tyne, 
af  Glooeetlcr.  whu  iu  a  •imilar  chso  n-mnvcd  tno  and  a  half  inclirs  nf  tbo 
lirttcr  rnd  u(  •the*  humcruit.  From  this  period,  the  operation  of  exri$inn  of 
iK.  ir«:>  'ilnr  eodit  <if  l>4>n<>s  in  ca«<»  of  rompnund  dii>locationfi  nn<)  fractures 
i  I  ■  lii*(mtrH>  an  r»tAblL4lied  prnplire,  and    wa*  rxlennively   adopted 

ty  *  . ..  ;  ai  Fmncr,  who,  in  1794,  pxhiliilcd  tn.Sahalipr  nine Mldi^rsin  whom 

hm\  ffoccesafulty  excised  the  head  of  ihe  humpnit  for  giiDfibot  injury  :  by 

Igucr.  ii>  Uirrinstiy,  bv  Hvy,  of  Leeds,  aud  by  ouiDeroiw  othvr  Burgcotu  ia 
ttooeaolrr  and  abroad. 

Tfac  Bret  caw  in  which  a  methodictit  att«in]il  iit  r«»ect><>n  for  dirfaw.'  uf  tbo 
•rtM-tilnr  md  ofa  boDc  was  made  wcurit'd  to  Whit*;.  oI'Muuchwter.  iu  1768, 
•  "'iuov<!d  a  lar^'L'  portion  of  the  u|titf.>r  part  of  the  huuioru».  thoujrh 

ii  '  I'ul  whether  ho  aclually  v.tctsf.'d  ihi-  lit'jid  of  ihe  btiue.     However 

tlua  umf  tM,  be  bad  pruvioualy  MtistiL-d  Linii«lf  by  ex)>erinieDt«  on  the  dead 
hodf  OM  Ihia  aperaltou  was  practicable.  Although  tht;  head  uf  (he  humerus 
tBBj  nut  bave  be«o  renuivtHl  by  White  in  thin  caKo,  it  certainly  waa  Lhn<e 
ftmn  later  by  J.  Rent,  of  Newcantte.  who  in  1771  excined  hr  a  forniHl  and 
preuTanged  opeXBtina  the  cnrioiiti  hf«d  of  the  humerus  wilIi  complete  succcm. 
tiiaesamnle  wb»  followed  in  1778  by  Orred,  of  Chester,  who  also  operated 
■MoeMftillr  in  a  similar  case.  About  the  same  time,  1770.  Justamond.  Sur- 
ms  Id  the  We8tmini<ter  Ho^pilal,  removed,  in  a  case  uf  dtaea«e  of  Uie  elbow- 
J0MI>  the  olrt-nioiio  nnd  two  ihehe«!  of  the  ulna. 

In  176%  Filkiu,  of  y<irlhwich,  removed  the  articular  ends  of  the  femur  nnd 
liMa,  t'V*'thi>r  with  the  patella,  in  h  man  nffeotal  with  diaMMe  of  ihe  knee- 
Joiat,  '  from  a  fall  from  a  hor»e.     Filkin  was  led  to  this  operation,  in 

eon**'  hnTinc  experimentiilly  prnctised  it  on  ihe  Hc«d  subject,  ««  a 

■  ;i  rif  the  limb,  to  whioh  the  pntieut  refuMvl  to  aiibmit. 

'I  I  ii>i(llv,  hud  A  useful  limb  on  which  he  was  uble  to  walk 

Umg  diMUKoa,  and  wai  certainly  alive  uearty  thirty  year«  aAer  the  o]»crati->u. 
Tlui  jtmarkablv  caae  aeem*  to  have  attructeil  little,  if  anv,  attention,  and 
ilfclWil  vw  Dot  pabltehed  until  I'HO.  after  Park,  of  LiverptHjl,  brought  before 
Ftvtmmm  hu  Kcund  >ucce»ful  case  of  exctoion  of  the  knee-joint,  which 
in  1780.  That  Surgeon  bo'l  performed  his  fin<t  operation  of  tbia 
K  MOctHfully,  IU  r«g«rd«d  utility  of  limb,  in  17^1,  apparently 
It  nnr  knowledge  of  the  opemttoo  that  bad  been  done  by  Filkiu  nearly 

__ily  yean  prwionaly. 

Tbaflxnmple  Uiuaaet  by  the  Eoglieh  Surgeons  wu speedily  followed  by  the 
Jloranw  io  rntut-e,  who,  betweeu  the  years  1786  nnd  1789,  w?nl  various 
■saoin  Ut  thv  Freueh  Academy  on  this  »ubjocL  The  operation,  however, 
ns  rioJcnilv  opptaeil  by  the  great  body  of  Surgeons,  and,  with  the  exception 
of  ibnoeen^Muu  ramoTnl  of  the  head  of  the  humcrui),  fell  into  almost  com- 
plete Mglcot  both  ill  (his  country  and  abroad  for  a  period  of  nearly  forty 
naun,  miing  which  time  the  riH.'onls  of  l^rgery  do  not  contain  as  many 
tmtm*  to  which  the  articular  ends  of  bonce  were  excised  for  dlseiiae.  It 
o-^Mr.,in.l  ;»  tl,;.  lM!.,Mii.l  state  until  1831,  when  it  received  a  new  and  vijtor* 
applicfltinn  to  dtseaaea  of  the  elbow  wasconc^rnal, 
\  t.-.u  .■;  .\vme»  nuay  on  that  subject,  and  fay  the  practice  of 

]  tn  ituh»c<|uently  at  L'nivereily  Collefie  Hi»ipiiaL 

IO  int.)  iiir*e  oprratioDft  Were  again  pnmiiuentiv  brought  before  the  Pro- 

l^aiun  bv  lb*  twrtitrmance  of  exciiion  of  the  beau  of  the  femur  by  Ferij^s- 

'  .  ■  '  ;-ron  of  the  knee-joint  had  occasionally  l)een  ]trncli»ed 

\lor,  Deninii',  llt-yfelder,  and  otbera,  it  wim  not  nutil 

rvvtval  in  lAOU  hy  tiie  same  acoumpliahed  Surg(<on,  that  it  came  to  be 


£G8 


EXCISION   OP  JOINTS. 


extcDsively  pntctiied.    Since  that  period,  the  operation  of  exdsIoD  Iih  Im 
apnlieil  10  nlmuist  every  joint  witliin  rearh  of  itio  liargeiiu'ii  koiff. 

Before  pruccfnliiig  to  discuia  the  diffeffUt  n-»efli<-ti))  iti  ileiail,  w«  aait 
endeavor  to  \ay  doivii  wimo  general  ruWs  i'or  itivir  perloriuiuire  Jo  ihuOTCkM 
ID  vhicli  hIoiic  ihey  are  Rdiiii^ible. 

Indications  coh  Extisn>s. — The  exciwon  nf  au  artiouUtion  n»j  W 
practised  for  the  fuliowiii^  rciuioni^ : 

1.  A«  a  suWtitute  fur  amputation  in  cases  in  which  the  joinl  u  loMlai* 
twely  dtMOMd,  that  the  paiiuut  will  be  worn  out  by  tJie  diricbnr^  or  puk, 
unless  it  be  removed.  Here  a  useful  limb  may  be  secured  by  uut  Mcrifte* 
of  tlie  diseased  part. 

2.  In  some  cases  of  articular  disease  in  which  amputation  ufouU  imp!  h*jm- 
tifiaUe,  ^xciaioD  may  bo  done  iu  order  to  hasten  the  cure,  and  thus  to  aai* 
years  of  diiHeriog  to  the  patient 

'A.  Exciiiion  may  ho  duoe  in  cases  in  which  atnputatuin  u  not  pnutitMli 
as  in  some  cased  of  diseawi  of  the  hipjoint  or  of  the  temporo^maxillary  a^ 
liculation. 

4.  As  a  substitute  for  other  and  less  eflicieDt  treatment,  in  order  to  rvhrf 
thetUiiUyof  a  limbor  Joint ;  as  ia  osseous  ankylosis  of  the  elbow,  or  in  fiuiltj 
aokyloeif)  of  the  knee. 

5.  Kxcieion  mav  be  required  in  bad  compound  dittoeatioiu  and  fimtbtrm 
into  joints,  oepeciall  y  in  yunehot  injuries ;  more  parLicularly  in  those  of  lbs 
bead  of  the  humerus,  and  of  the  buuos  entering  into  the  elbow-joint 

As  a  general  rule,  excisions  are  required  only  in  ibuse  casta  in  which  the 
articular  ends  of  the  boues  arc  dta^jaseil  either  primarily  or  aoooodariJy.  If 
only  the  soil  structures  of  a  joint  bo  involved,  it  usually  happens  that,  wiib- 
out  the  Deceagity  of  resection  or  operation  uf  any  kind,  a  useful  limb  will 
result — in  the  upper  extremity,  with  tair  mobibty  of  the  arLi>>ulatiua;  ia 
iho  lower,  with  njuro  or  leas  compleu-  aiikyliieia,  sufficient  for  a  fair  ttaat*  wf 
eu[)jH)rL  But  when  the  consul  11  ciun  ia  very  atrumous,  or  the  bones  art 
primarily  or  trxtenttlvely  affected,  we  can  searoely  expect  thai  the  tiiab  will 
recover  to  surh  an  extent  as  to  become  useAtt. 

In  determining  the  necessity  of  cxri^ii^n  the  circumstanoea  of  the  patient 
must  lie  taken  into  consideration.  Amon^  the  upper  clasaos,  who  can  toytff 
all  the  advantages  of  good  fi>Ml,  change  of  air,  and  careful  nuntiug,  it » 
rarely  oecesAary  to  exct-xe  a  joint,  and  the  oporatiun  should  never  be  uniler- 
tnken  tilt  nrolonged  efforts  have  been  made  to  obtain  a  cure  by  utlirr  iur«n4. 
In  hiwpital  practice,  on  the  other  hand,  we  have  to  ileal  with  palientii  wbor 
circumstances  make  it  ftlmo»t  impossible  for  them  to  receive  the  pn>Itiii|^ 
ntleiition  essential  to  the  recovery  uf  •  chronically  diM:^iu<>d  jniui,  aqd  ja 
tlieiu  the  excision  may  uAen  with  advantage  be  perforiueil  even  at  nn  early 
jteriod. 

C0NPITIO.X8  OP  ScccBW. — Fur  resection  to  socoMd,  the  following  oodi&' 
tious  appear  to  roe  to  be  netX'Wary. 

1.  2hti  ditentr  thould  not  be  too  uifimvf.  so  that  its  removal  would  entail 
auch  ai)  (tmount  of  nmlilation  of  the  limb,  as  to  retider  it  lew  nwfol  ti>  tJia 
palieut  than  uii  artiticinl  (iiumlK'r  uould  be.  This  is  W)>i'cii)Ily  irupurtiiut  la 
lbs  lower  extremity.  If  thi?  buure  he  tu  uxbenaively  iitli'cleil  as  10  requite 
U  be  ootuidenibly  shortetit'd  by  i«v«rat  iocbflS-~a  limb  would  be  lefl,  wbirk, 
inatwl  of  serving  aa  a  proper  liusis  of  uupport  to  tlit>  |iaiivnt,  would  be  only 
a  uaeleea  incumbrance,  lu  the  upiwr  extremity,  length  and  strength  are  uf 
lens  (xiusoquencti  than  in  the  lower  ;  the  preaervatiou  of  the  baud  i-  the  cHieT 
Uiing  to  aim  at,  and,  if  this  be  etfected,  the  bonus  may  be  eaoroachnd  lU  la 
a  p«ater  i^xtfut  than  ik  pro|>er  in  the  hiuer  limb, 

2.  The  diacase  for  which  resection  is  practised  abould  ba  aBrnttd  to  ttwi 


OOHDITIOKS   OP   SDOGESB. 

ehmnif  before  »ny  openitiou  is  uudcrtskcu  ;  for  tbig  ihere  are  Iwti  reaflona. 
Finit,  iu  the  neule  stage  of  cliMirgtiuizutiifU  of  a  ynul,  it  is  aut  always  possi- 
ble to  My.  bowcvcr  uuproinifiiuj;  the  ci»v  may  ap|>oar,  wlictliiT  unkjlcBis 
may  oot  result,  eo  that  aa  uacf'ul  a  licnb  would  be  Ivti  un  mulil  be  nlituined 
br  iTscctiou.  And,  ev^tnidly,  if  ilio  ui'wl  be  excised  wbiist  acute  and  Hciive 
disease  in  going  on,  liiftammatioa  and  (litlU»c  eu|ipuratinD  of  tbe  medullary 
canal  are  Habit!  Ui  eet  in— a  condition  very  apt  to  be  followed  hj  pyninia. 
In  the  only  fauil  inatunree  of  reeeclinn  nf  tbe  elbow-joint  that  I  have  irit- 
nesMd,  death  n^ulct^d  from  tbiit  caune;  tho  operation  baring  been  performed 
vhilst  tbe  articular  atfVrliim  was  acute. 

'i.  The  mjt  parts  ahoat  the  joint  mvtl  be  in  a  Mij^ienHy  lumlthy  etaie.  There 
are  two  morbid  oonditions  connentiNl  with  tbe  oott  piirt--^  that  may  interfere 
with  the  succew  of  reiHection.  Kirat,  tbpy  may  Ih>  »i>  tKinnf^d  and  permeated 
by  ftiiitisetji,  and  su  adherent  to  the  honnt,  that  an  in.xufiicient  covering  would 
W  left.  Or,  secoDfliy.  the  long-continued  exifltence  of  atnimoiii*  disease  In 
joiBlB  and  hones  may  give  rise  to  great  infiltration  nf  the  tissues  around  the 
trtioalalion  with  chri>nic  inflammatory  products  <iften  in  a  state  of  fatty 
de^eoeration  or  containing  tubercular  cenin^  either  oaflenting  or  ttofleniug. 
Tbe  tiftHiM  in  this  atate  are  incapable  of  healthy  repair.  Cbmuic  ab»ce89<«8 
form,  leaving  stnnees  when  they  discharge  their  cantente,  and  tbe  iutegu- 
taetib*  beeunie  blue  and  doughy  ;  and  tbeaofL  part«  around  tben>at  of  opera- 
tion fall  iolo  a  state  of  atnimoiis  disoi^niulion,  that  prevents  alike  the 
Wmatiou  of  a  ImIm  joint,  o«»oou8  nnkylueit,  or  Iho  healing  of  the  wound, 
tod  thus  leadt)  inevitably  to  the  ultimate  amputation  of  the  limb.  Even 
tliough  this  exudation-matter  du  not  exist  in  large  ruiautity,  if  thu  joint  be 
peculiarly  loo«e,  owing  to  soflentng  and  diMirganization  of  ligamentous  and 
lendinouH  structures,  excision  ii  not  very  likely  to  Mucceed,  especially  in  the 
ukle  or  knee. 

4.  The  tinte  of  the  patient's  rminlitvtion  niuflt  oeceesarily  influence  tbe  Sur- 
geon materially  in  bis  determination  whelher  to  reeect  or  Co  amputate.  If 
the  coualitution  be  tolembly  ^ound,  or  even  If  the  general  health  nave  given 
way  as  the  simple  consefjueuce  of  pain,  irritation,  and  continue-d  discharge, 
leaectioD  will  nave  a  fair  prne^pcct  of  success.  In  fact,  when  the  patient  IB 
hectic  in  consequence  of  continued  suppuration,  the  removal  of  the  joint  or 
bone  that  maintains  it  may  be  advantageously  practised.  But  if  the  patient 
ii  suffering  from  septic  fever  in  consequence  of  the  absorption  of  toe  dig- 
cbargea  from  ill-drainiM]  cavities  opening  on  tbe  surface  by  narrow  ginuses, 
the  operation  is  likely  to  nccnsion  oateomyelitiB  and  pyecmia,  and  is  not  a 
tafe  moDsure  nnlil  the  ronstitutionni  disturbance  has  been  relieved  by  making 
fr^  incisions,  and  providing  good  drainage.  These  incisions  should  be  so 
placed  as  not  to  interfere  with  subsetiucnt  excision.  Again,  if  the  constitu- 
tion appear  to  be  very  much  broken  down,  the  patient  being  ana'mic,  wasted 
Of  Mcneetic,  especially  if  there  be  an  evening  elevation  of  temperature  with 
no  suppuration  in  the  joint  to  aecount  for  it,  excision  of  tlic  larger  joints,  as 
the  knee  and  hip,  is  not  desirable,  as  it  ia  very  probable  that  the  patient  iti 
luBering  from  general  lubcreulosis.  If  the  patient  b«  vcrv  hishly  strumous 
•r  decidedly  phthisical,  there  will  be  little  prospect  of  bis  being  able  to 
bear  up  through  the  long  convalescence  that  often  follows  resection.  The 
earlier  stages  of  pulmonary  phthisis,  if  unaceomnauied  by  distinct  elevation 
of  temperature,  neeil  not  he  a  bar  to  the  operalmn.  In  sneh  ca.<ies  I  have 
Mverat  times  had  occasion  to  olwerve  that  inb  general  health  improved  rap- 
idly after  removal  of  the  local  diiieaiM-.  Extensive  albuminoid  degeneration 
ttftbe  liver  and  other  viscera  ix  always  a  nerioua  obstacle  to  excision,  although 
Uiipulati'iti  may  sometimes  l>e  saiely  prnctiawl. 

5.  The  rtirane*  oj  lift  are  unfavorable  to  resections.     Id  very  early  child- 

vot..  II. — 21 


870 


SXCI8J0N    UP   JOIHTH. 


boedttbaMon^rnlinna  are  •eldom  Decenary:  tlie  aatural  prooeiMa  unull/ 
mfflt^Dg,  with  very  liule  MuiUnoe,  to  elimiuate  dJMMiNl  buaa.  and  the  d» 
orgaoiz^  joiute  aJmittiDg  reidily  eoougb  of  ankylous.  If  tbe  Jii—bt 
tou  6evvn>  for  tbU,  it  will  usually  W  found  to  be  naBodstcd  with  w  iUimum 
a  con^litutiuD  lu  to  iotcrlcre  with  healthy  reparative  acliou  uf  auy  kind. 
iVaulhcr  serious  objecUoD  to  these  operalioos  iu  youug  children  u  that, 
should  the  epiphyses  be  removed,  Uie  d«volopiueut  of  Uis  Ituib  will  be  ht  ■ 
Kreal  extcut  arrvetod.  At  advanced  periods  of  Itfv  dtntructive  ininl-di—si 
IS  DDl  verv  oommou,  atid  when  it  docs  hapjieii,  it  is  ^ucrallr  tn  ouoitiln- 
tions  not  ntt^  to  stand  up  nguiniit  the  prolnnf^  draiu  oiinaeriiibat  oa  thmt 
opcratifins.  It  is  at  the  <«rly  udult  apt,  whitii  the  diwaacB  most  freqncatJy 
occur  that  reader  reAcctinns  neomaary,  that  thesf;  opomtiona  ar»  bast  bocasb 

HKi\tii{  AtTicu  Kxoiaios.— The  mode  nf  repair  after  raacctioo  dlAit 
nt-cnrtling  to  the  circumstiinceB  of  the  oiJcration. 

When.  OS  vRry  comtnnnly  hap|>eus  in  casos  of  nocrosis,  tbe  perioatBaB, 
thickened,  inlilirnteil,  itnd  lonsened,  can  readily  be  detached,  or,  Jodsa^is 
iilready  sojiamtf^I,  williout  injury  to  it«elf,  from  this  dead  booe,  r«prodaeOKl 
Iff  new  osjNKiiis  tissue  t^i  a  very  considerable  extent  may  be  expecled.  My 
own  observntioQs  on  the  Hbula.  tibia,  and  utiin,  and  those  uf  Oilier  and 
Maifonneuv*,  pryve  the  importnncr  of  the.  peri.i8t«um  ti»  an  nrana  "f  rvp«ir 
after  the  extrnctiou  of  a  dead  ahnft  of  lioue  fmu  within  it.  I(«i>air  in  thii 
wav  i»,  I  believe,  cbiti6y  to  be  looked  fur  in  the  slnifts  of  (be  Umi;  b'ttkcs; 
altnough  some  surgeons,  oa  Annnndale,  of  Ediubiii^b,  have  doscriticil  the  m 
calcis  as  having  bMn  reproduced  afl«r  subperiosteal  «xci«ion.  Tbe  renatk- 
abte  oeteoMoeiio  properties  poaKeited  by  tbe  pcriosteuni  have  been  fully  add 
oODcluaively  established  by  the  experiiueuts  and  observations  of  Oilier.  lie 
has  shown  that  a  booe  is  oincb  mor«  rapidly  and  pcrl'iictly  reproduoed  mA« 
removal,  if  the  perioateam  be  left,  than  if  it  be  removed,  and  be  stala  ihil 
the  osleonDotic  pr^rties  of  this  menibnuie  are  greater  in  the  luug  than  in 
the  afaurt  DODOS.  Ha  in  of  opinion  also  that  raseotions  performed  by  tlw  sub- 
periosteal method  leave  better  resulta.  so  far  aa  the  aoape  and  formalioa  of 
the  uew  joint  are  ooneemed,  than  if  tbb  metnbnuie  be  sacriBoed.  Tbae 
obsemttiom,  indeed,  ooncluaively  ertabliah  the  ini|)ortaaoe  of  making  in  all 
onaes  every  aflbrt  to  preserve  the  pen'osleuni  during  tbe  reseciioa. 

When  a  short  boue,  as  the  os  calcis,  has  been  eulireiy  reaoved,  wtUi  !b 
peristeum  attached,  it  is  never  of  course  regenerated,  but  its  plaos  is  oocu* 
pied  by  a  thick,  5rui,  fibrous  cicatrix. 

In  sonic  cases  in  which  a  considerable  portJoQ  of  the  d[a|AjnriB  of  ■  iaaf 
bone  is  taken  awny,  repair  may  be  imnerfeotlv  Bccttuiplished  owing  to  aloaKb> 
lug  of  thfc  pc-riosteum.  In  a  caw  ot  this  kind  in  which  iwo-thinla  of  UK 
shaft  of  the  humerus  was  lost,  Mnccwen  suooeedcd  in  obloining  er>tnplaU 
restoration  by  irunsplanlatiou  of  small  fragmenls  of  booe  obiaint-d  from  the 
wedgfr-shaped  pieces  cut  out  of  ditlereot  patients  for  tbe  cure  of  ncksty 
curves  in  the  tibta.  The  fragments  measured  oboiii  two-fifths  of  «n  iorh  ia 
length  and  thicknvss.  and  the  operation  was  performed  with  aottsf^plic  of»- 
cautions.  This  iugcnious  mudo  of  treatment  certainly  dewrvM  a  farnMr 
trial. 

When  B  joint  has  been  excised,  <nlher  osseous  or  itipimenloua  aakyi 
mav  take  place  or  a  false  joint  may  be  forininl,  and  the  surgooa 
csaeavor  to  secure  the  form  of  union  most  suitable  to  the  oas«k  Thus,  wl 
the  knee  has  been  excised,  as  a  sound  and  firm  limb  is  ilteimhlv. 
ankylosis  should,  tf  poaublv,  be  brought  about ;  whilst  in  the  upper extnadtf 
mobility  is  of  more  importance  than  strength,  and  W9  cooaaqaeotlr  aia^ 
obtaining  firm  fibrous  ankrlosis,  allowing  ofeome  mohilitv  attne  wnatnad  a 
iUae  joint  at  tbe  elbow.    Xn  fibrous  ankyloais,  the  opposed  boaj  mutton  an 


OENKBAL    BL'L£d    IN    KXCISION — INSTRUMENTS. 


871 


united  to  each  other  by  dense  (ibroua  tissue.  In  a  false  joint  the  enils  of  the 
bones  become  rounded  and  covered  by  a  layer  uf  ^bruid  tissue  almost  resem- 
bling cartilage  in  deosity  and  smoothness,  and  are  united  by  a  capsule  of 
fibrous  tisNie  resembling  normal  ligaments  in  structure.  The  inner  surface 
of  this  capsule  is  smooth  and  imperfectly  covered  by  flattened  cells,  and 
thus  eomewhat  resembles  a  synovial  membrane,  but  the  cavity  is  moisteued 
with  serous  fluid  auch  as  is  fouud  in  false  bursie  and  not  true  synovia.  The 
muscles  that  are  naturally  connected  with  the  articular  ends  that  have  been 
removed  form  new  attachments  to  the  bones  either  directly  or  by  means  of 
the  fibrous  capsule  of  the  false  joint. 

The  question  as  to  the  arrest  of  the  development  of  the  bone,  and  conse- 
quenttr  of  the  whole  limb  on  which  an  operation  of  excision  has  been  per- 
Ktrued.  is  one  of  great  practical  moment.  It  is  well  known  to  physiologists 
that  the  longitudinal  growth  of  a  bone  is  carried  on  chiefly  through  the 
medium  of  the  layer  of  cartilage  by  which  the  epiphysis  is  attached  to  the 
shaA,  and  which  does  not  become  ossified  until  the  bone  has  attained  its  full 
length.  It  has  further  been  pointed  out  by  Humphry,  that  the  two  epiphrses 
uf  the  long  bones  of  the  limos  do  not  take  an  equal  share  in  this  develop- 
ment, thai,  which  unites  last  taking  the  greater  part  Thus  the  upper 
epiphysis  in  the  humerus  and  tibia,  the  lower  epiphysis  in  the  radius  and 
femur,  are  tbe  more  important  in  this  respect.  If,  therefore,  in  an  excision 
prmtrtiMd  on  a  growing  child,  the  whole  of  the  epiphysis  be  removed,  the 
subsequent  growth  of  the  bone  wilt  be  arrested  proportionately  to  the  share 
tbat  the  epiphysis  which  is  removed  takes  in  the  development  of  the  bone. 
And  if  that  epiphysis  on  which  the  length  of  the  bone  is  chiefly  dependent, 
be  removed, — as,  for  instance,  tbe  upper  epiphysis  of  the  tibia  and  humerus, 
or  tbe  tower  epiphysis  of  the  thigh-bone — the  development  of  the  limb  will 
be  very  otusiderably  interfered  with. 

Id  the  adult,  after  ossitication  is  completed,  the  epiphysis  loses  its  impor- 
tance as  an  organ  of  growth ;  and  may  be  removed,  if  necessary,  without 
interfering  with  the  subsequent  length  of  the  limb,  except  to  the  extent  of 
its  removal. 

Iss^TRL'MESTS. — The  instruments  required  for  resection  are  of  a  somewhat 
rarie^I  character  :  Btrong  i>calpels  and  bistouries,  straight  and  sharp-pointed. 
In  addition  to  these,  I  have  found  a  strong-backed,  probe-pointed  bistoury, 


Filf.  5:!:;.— liuUljtrV  Suw, 

with  a  limited  cutting  e<ige.  of  great  utility  in  clfiirinj:  tbo  bones.  Pcriot;teal 
elcTAtor?  of  various  forms  arc  ncceAsiiry  if  the  npfration  is  to  hv  perfurmcd 
ffubperi<>3te:illy.  The  plier.-t  ithouid  ho  of  variinis  sizes  ami  shapes  (Figs. 
^I*)  to  511),  and  gouges  will  be  found  useful  for  scooping  out  snspiiious 
patches  on  the  cut  oiueuu4  surfaces.  For  ordinary  purposes,  a  small,  broad 
amputating  saw  will  be  fouud  the  most  convenient  instrument  for  dividing 


872 


BXCtSlOK    or  JOTXTS. 


the  honm :  but  In  some  cues  a  oarrow  kevbole  mw.  or  that  imrodocvd  hj 
Butcher  (Fig.  •033),  wilt  aoswor  bpM.  Tbc  Iim-uhiuliI  iusii-timcnt  u  f«p»* 
eiall^  ttteful  when  it  ii  inun^ltsl  to  cut  tht>  btiae  nblitjuely.  ur  whfu  uw 
mue  u  limited ;  for,  as  the  bindo  i§  Durruw  and  iia  anglr  iiut  be  irtwncrd  at 
niciuaiv.  KDj  require<l  directiun  can  bf.'  cuiiiniuniealtcl  to  the  cut.  I  alauil 
inmriably  uw  it  in  preference  to  all  ntbu^  iu  rcAM-tiuui*.  But  widm)  f^l^ 
MODB  prdbr,  «special!y  in  r«aecl)bn  of  tlic  knr^-jniuL,  n  Hbori  and  vrry 
Dmad-blade>d  saw,  the  blade  being  of  breadth  grcaler  than  tbr  whole  ibirfc- 
nc«  nf  tbc  bone  In  be  divided.  Tbc  rbain-«aw  Is,  porba^  ni>t  nacd  m 
frequently  an  it  initfltt  be. 

OPKRATKiN. — Tbe  Step*  of  tbe  operation  must,  of  oourw,  tbit  wil^  (Iw 
diflTert-iiL  rciM'i'tioni;  but  tbere  are  Mine  general  rulea  iliat  uaj  be  laid  don 
a*  Bpjiticable  tn  alt  ca»e». 

1.  The  inctfliiins  through  the  auft  parfs  shouht  lie  HutfR-ieutly  free  Ivexpuae 
tbomughlT  the  boue«  to  w  removed.    Jiy  niukriig  tbein,  ae  far  a*  practicable, 

tiurallel  to  teoduDs,  bloudveteeU,  and  nerve*,  part*  o(  iin[)ortaDC«  niay  readilj' 
le  HVitided. 

2.  Ai  little  of  llio  bune  m  poseiblo  should  he  rrinovvd.  The  gnvge  voay 
be  applieil  to  any  carinus  caritim  or  patches  that  appear  uptm  ibe  aar&M  m 
the  freshly  out  bnne ;  and,  in  this  way,  Khorteuiog  tif  the  bone  by  thm  MV 
iQuy  be  materially  avoide*!. 

3.  Ill  young  ehihireu  tlie  epiphyMS  tihoutd,  if  puecible,  not  be  entiirlr  re- 
niuveil.as  it  ia  on  the  groHlh  of  this  iKirtion  uf  Itone,  nr  rather  on  that  nf  the 
epiphyseal  cHrtilBgimHM  layer  adjoining  the  ^all.  that  incrraie  in  length  at 
the  iHiue  it)  niainly  de}>ei]dent. 

4.  In  adult.i  in  whom  the  bone  has  attained  its  full  length,  tbe  Milpliyiil 
iDsy  be  mure  freely  rfmoved,  if  neceeeaiy.  But  the  shaft  fhoalif  ooi  he 
encroached  up4>n  if  it  can  be  poaeibly  av«ded,  and  tepecial  care  kbnuld  he 
taken  not  lo  open  the  meiiullary  oanal. 

Ik  Tbe  pcritifleum  should  lie  earefuliv  preacrvcd,  being  stripped  olT  the 
boDe  where  it  'n  ihirkt-i)e<l  and  liKmened,  and  manipulated  very  gently,  «» 
that  its  vitality  nmy  l>e  impaired  ar  little  as  pooMble. 

6.  It  i»  of  }:re)tl  im[Mirtanoe  not  to  conlVmnd  bone  wiftened  by  inftaistn*- 
tinn,  but  otherwiine  healthy,  nr  roughened  by  tlie  growth  of  n«tepphytcst  willi 
that  -vrhich  is  carioti*  or  ueenwed. 

7.  Skin,  hovrever  redundant^  shnuld  eelduffl  if  ever  be  cut  awv^. 
RapH,  at  finit  luo  large,  aoun  Hbriitk  down  tu  a  projier  size,  and,  if  trimi 
are  very  apt  tu  become  loo  «oanty. 

8.  In  cases  nf  ordinary  white  swelling,  the  pulpy  granulntinn-tiaravoccapy* 
ing  the  eite  of  the  eyuovial  membrunu  ebould  hv  rvraoved  as  tboroaghly  a> 
piwsible,  partly  by  ecrapiog  with  a  sharp  »])oun  aud  partly  by  ftwcepa  Mai 
Eciaeora. 

9.  After  the  operation,  if  the  skin  were  prerinuslv  anbn>keo.  tb*  mvaJ 
may  bo  treated  by  any  nf  the  anitrcpcic  methnds  already  described  io  Uw 
chapter  on  Wounds,  the  edgee  lieing  I'rought  together  a«  accuratel^f  mm  pa*- 
■ibiv,  and  proper  ptfirittinn  innile  fVir  drninnge  by  thp  iit»erttoQ  f^f  tubes.  If 
sinusfs  rxifit,  and  the  ilischar^rs  are  not  aseptic  at  the  linie  of  ibe  operation, 
an  altenipt  shnuM  be  made  thoroughly  to  disinfect  the  wound.  For  this 
purpose,  the  einuH«  should  bo  sumped  with  a  »harp  spoon  and  afLeraants 
■yrtoimd  through  with  asolution  of  chloride  of  zinc  (gr.  xx  to  jQ).or  lioeture 
of  iodine  (.^ij  to  Oij  i.  The  whole  wound  should  al«o  bo  wnsbed  with  ibe 
aanie  solution,  and  afterwards  treated  by  some  antiseptic  method.  Tboroofh 
drainage  and  antiseptic  treatment  have  of  late  rears  greatly  diraiDt»bed  tb^ 
death-rate  of  cxeisiuija  in  general,  and  especially  of  tbe  knee.  AA«f  thv 
dressing  is  applied,  the  limb  must  he  placed  on  a  pillow  or  a  «vll-|>«dd<«l 


•  IOI9IOK   or   THE    SHOULiiKH. 


873 


aeoonUnK  to  thp  joini  npenii«il  on.      As  healing  progrcnaon,  great 

idoa  ma«  ^  paM  to  poaitton. 

|0.  Tb«  CDUudtutiona]  afler-treatmenC  olioiiM  be  nnurishinji;  or  tttimulating. 

i  there  may  be  a  Kf*^*  drain  un  ihe  »T8teni,  should  profuse  suppuration  not 

uw)  a  nnilon^i^'d  nintitienKiut  u>  bed,  tlic  strength  iniiAt  be  kept  up  under 

b>5  ^mI  di«L     TtifM*  ri|;M>raiion8  are  altvays  {•crioii!);  in  many  caseti  fully 

loch  •()  as  the  amjHit«t.ii»n  of  a  corrfapundinjif  pan.  or  even  more  so, 

to  the  tar^  wound  that  h  often  inflicted  in  the  mr>re  eit«uflive  divl- 

of  the  bones,  to  the  ui*ue«»ity  of  making  tlie  incii^iona  in  the  midfit  of 

or  injuivd  slructurea,  and  U>  the  mor«  prulooged  chnractar  of  the 

•tnatnenu 

SbtHild  can«»  or  necn^eis  rt^luru  after  the  opernljou,  »teoniinry  reteciion 
hr  riv^utreJ.  Ttiis  1  have  dune  sucvesefuUy  ut  ihu  bip,  fliioulder,  and 
In  this  elbow,  iu  one  cu«e,  I  {terforiued  a  thinl  r^ectiuii  with 
ijjew;  the  tw(i  previous  upuratiou^,  which  had  been  [>crfonue<l  by 
aUi«r  aod  diflereoL  SurgeouB,  having  fitiied.  The  suoc-eBS  of  these  secondary 
nKetioa«  will  oeceaearily  be  greatly  dependent  on  the  poaHibility  of  eatab- 
;  an  improved  state  of  the  patient'a  constitution. 


KXCIBI09!*  ITf  THE  t'Pi'EH   L'XTHiaitTT. 


|ne  whole  of  the  appor  extremity  is  subservient  to  the  hand.  It  is  to 
Rttdcr  thb  more  widely  useful  us  an  organ  of  prehension  and  of  touch  that 
lit*  ahoulder.  the  elbow,  and  the  wrist-joiota  are  endowed  with  varied  and 
asMftilrc  morements.  But  the  moveraentA  of  each  one  of  thfisc  joints  M 
iMMl|pMal  thoM  of  the  others,  that  iiny  one  articulation  may  be  removed, 
^HHb  tJ)L'  limb  be  left  with  a  sufficient  range  and  varietT  uf  movemcQts  to 
mHvlh?  hand  tuteful  fi*r  all  the  nnlinary  purpovea  of  tile.  The  limb  may 
\m  ■borteoeai,  and  it  may  be  weakened ;  and  yet,  if  aufBcient  length  and 
lb  lie  left  t<>  enable  the  indiviilual  tu  use  hia  band,  an  immcnae  gain 
malL  The  limb  without  the  hand  would  be  a  comparatively  useless 
The  hand  left  in  its  iutegrity  is  useful  in  a  great  variety  of 
vmjv^  howtrrr  mutilated  the  other  parts  of  the  upper  extremity  may  be. 
providoil  ih«  r^urguon  can  save  the  hand,  ue  need  not  hesitate  to 


other  p'jrtious  of  the  limb;  and  the  shoulder,  elbow,  or  wrist  maj 
b*  rcmoTad,  an<j  the  patient  left  in  (he  poowion  of  a  moat  uKful  and  era* 
cfanl  aamber;  ehiirieaed,  it  is  true,  and  to  a  certain  extent  curtailed  in  lU 
aomamtmiMt  but  poMcailng  all  the  delicato  aud  iotricato  motions  of  the  hand 
ifiitl  fmr^edXHi  and  flroedom. 

"~      ildi;b-jihkt, — Kxriaifin  of  the  abonlder-ioinl  may  b«  re«|uirijd  for 
littiin*  '  I.  l)lM>a.4P',  and  i,  Compuuod  ami  ('-Muminutotl  Fructura  of 
Arlirulati'io. 

Sxeiiion  for  SUeaM. — For  dtsea«e«  excision  !b  not  so  commonly  re- 
■fl  in  this  aa  tn  many  ulhor  articulalinm ;  primary  diwase  of  the  soft 
stnictured  of  this  joint  not  b:<in^  vory  frequcnL,  and,  when  it 
ii«ually  termiuatin^;  in  dbraun  nnkyhisia,  without  buppuratinn. 
(rartiun  and  nrrroA^t]  bones  are  lacl  with  about  the  nhontdcr,  it  will 
ft^aeaUv  b<  fnun  I  thti  th<«  c<>r.i?>id  or  acri>mi»n  pronc^'t'ipf,  or  the  vrapular 
H(iiin.  are  at  fault  rath>T  thaJi  the  OMeous  stractures  of  the  joint  ilselt  In 
•ooM  cAM»  a  *in-ill  ■»|.i.~ttnini  lying  in  a  oariiMU  ravity  in  the  htnui  of  the 
kaaMvvt  may  b  i  by  slitting  up  MnuMS,  without  the  neoeMity  of  ex* 

ciiin|  Ibf  b«*d   -.  ■  .nn. 

Wmo  4Xoilioo  ia  rr»|unv<l  Ciir  d1<teaM>  nf  the  ^hi'ulthT-jujiil,  it  is  u»ially 
far  oariae  floramwiclDg  in  the  h>rad  »f  the  liunterus.  ■.■^pi^cially  in  cbildr^o 
MNJ  5<Mnf  adalta     In  those  ciui»  tt  will  be  usually  found  that  tlie  glenoid 


d 


874 


RXC1SI0N   or   JOISTS. 


csvit}' ii^  nflVctrd  H^rotxlnrily,  an<l  to  on  ]imili«<l  an  extent  tlint  it  nwlilr 
recitVfn«  wlicn  ihp  irritation  caiiwii  by  the  frinioii  of  the  heait  of  llic  hamerw 
againut  h  is  renmvod.  Allhough  in  oarconiBta  of  the  upper  enH  of  tW 
humerun  cxclnion  hnn  been  nractlite*!,  thifi  nppralioQ  la  not  iiniAllr  Atlrikaklt 
in  iiidi  rawf.  HickcriM'tli  lia»  ftuore«ifiil!r  rfmovwl  liie  bend  of  ihf  hurnetiH 
for  ©xoatmifl.  In  casen  of  intrarB]wiilnr  fnicturo  tliroiiyb  ili**  ne<'k  oflhe 
lium«nu,  wilb  detachment  of  tlie  Keml  of  the  bone,  (liwirvanir-ation  of  thr 
Joint  baa  re«tilt*Ml.  This  baa  been  laid  o|w-n,  and  lite  Ioom  bc'iu)  nf  tiie 
removed  In  two  rnatflDow  by  Brnioard,  uf  t'bic8gi>;  ibe  patient*  recott 

with  ttr>i-fnl  Itiiilix. 

Operation.— Partial  Exciaion  «{  ihe  bend  uf  the  humerus  In  snme  caM* 
of  ciiritw  hHi>  been  practiced  by  eliltiiig  up  Etitiievts  and  the  n:  n  of  tbc 

gutigc  or  sharp  sj«jf>ii  to  the  diwuseil  uwi-iiiis  eiirfuo«.     Of  'v,  na  in 

casta  reported  by  Fergunuii  mid  i?^<lijlut,  these  ujierHlidns  have  tw7t-n  attmded 
by  Dueceraful  n.«ull».  But  nt*t  uufrequeully  they  fuil  in  eflecting  a  curv,  Un 
dieenee  extending,  and  the  sinusvs  not  healing,  sa  that  evenliiolly  exoiMoo  of 
the  whide  of  the  dineaaed  head  of  the  bone  has  lieen  reiiuire<l. 

Complete  Excision  of  the  head  of  the  humerus  is  the  operatiMi  uanallT 
rptpiiped.  ll  may  be  pnictii«ed  iniieveral  dilfereni  ways — the  linevuf  iodfiiio 
tbniugh  the  stifl  parts  being  viiried  according*  lo  tJie  ronditions  of  the  caK. 
They  arc  most  commonly  mailc  on  the  front  or  ouut  side  of  the  joint  ihrwi^ 
the  ileltoid  muscle,  but  in  rxceptionnl  caM>8  the  hend  uf  the  bon«  ntar  be  n- 
movei]  from  l>cbind.  Kscbii>ii  may  be  performed  by  the  ningle  longitadinal 
or  its  modificiitions  the  ^  or  T-ahapcd  iocUion.or  hy  n  U-i*hapcd  incieioaor 
flap-operution. 

The  opc-mtion  by  the  witifffe  fongitvdinal  ineuum  may  bo  prrfitmed  W 
followi.  The  patient  Ivtnf;  on  his  hack,  with  his  ^hoalder  alightlj  projeeCiBK 
over  the  edge  of  the  Uble,  the  Surgeon  ent«r«  ibe  kuifo  to  toe  oatMe  amA 
above  the  ooracoid  proccM,  about  hntf  an  inch  betow  the  clavicle,  and  rarrifli 
it  dircrtly  downwards  for  from  tbr^w  to  four  inches,  nopping  iinmetliatet? 
above  tbc  insertion  of  the  pectornlis  major.  Tlie  fini  inoision  should  divlw 
tbe  skin  and  tilt,  and  nasa  throuijh  the  anterior  librus  of  the  deltoid,  tu  that 
whfn  tlie  Wound  is  held  open  Lbe  eapeule  of  the  shoulder-joint  come*  into 
view.  Thi«  iucioion  ia  imniediatelv  external  to  the  cephalic  vein,  whiob 
aboul'l  not  be  wounded,  and  divides  no  important  artery  or  D*:rve.  Tb« 
wound  lM.'inf!  now  held  open  with  blunt  buoke  or  copfx-r  Kpatulw  (Ktg,  634). 
the  bicipital  (crcuve  should  bu  felt  f>ir  betwe^i'n  ihegrentntid  iiiiall  tubfmuliM 
of  Uie  humeruj^.  A  longitudinal  iiicioion  h  then  nmde  firmly  on  tr>  tbc  IxHte 
along  the  inner  side  of  the  groove,  dividing  the  periosteum  covering  tbe  bead 
of  tbe  bone,  and  the  4-ai>!'nle  ha  far  n?  tbe  margin  of  the  gleniiid  cnvily.  If 
the  long  teuiiou  of  tbe  uieeps  be  stilt  undestroyed  by  the  discBae.  it  must  be 
turoed  out  of  the  groove  and  held  to  tbe  outer  »ide  in  n  bluut  honk.  Tbe 
aniitant  then  rotates  the  arm  fon-ibly  outHards,  m  as  to  bring  the  sniall 
tulH>n«ity  well  into  the  wound,  nud  tbe  ^rgeon  separati's  the  tendon  of  tbe 
subseapularts  aud  tbe  perioeleum  from  the  hone  with  a  periwieal  elevsior. 
In  muftt  ratv»  of  disease  of  the  joint  this  can  be  done  nilbo«it  great  liifllmUf , 
aa  ibr  adhesion  of  the  tendon  to  the  bono  is  Imiaenrd  by  tbe  inflnmniatinB. 
Sbonld  the  nd)ie«)on  of  the  u^ndon  be  lr»o  firm  to  allow  of  itJ>  l»eing  stripped 
olT  with  the  elevnCor  the  knife  must  be  used,  but  rnre  sbonld  be  lakro  to 
sbavr  the  cnrMulc  ftfin  such  a  way  la,  if  pnmible,  ii>  leave  it  :>till  e<noD^«te«) 
with  the  pi'nciirteuin  covering  the  upper  part  of  the  liumeru*.     Tl"  "•« 

being  mtslcii  inwards,  and  the  limnnllon-ed  to  fnll  over  the  edge  k, 

the  liirr*'  miiArli-a  irisrrtrd   into  ihp  great  tubfr.,iiily  are  separat*  ■  he 

bou«  in  tbfMmr  way  iu>lb«'»ulik(-apu]arit.     I'urln^lhta  [>art  of  it  <  <     id 

tbe  bice|is  tendon  muat  be  drawn  to  the  inner  side  with  a  blunt  book.     T)m 


EXCISION    OF    THE    SHOULDER. 


375 


■siMBiit  tlien  forces  the  head  of  the  bone  up  into  the  wouod  whilst  the 
Surgeon  separates  the  posterior  part  of  the  capsule  with  au  elevator,  leaving 
it  attached,  if  poeeible,  to  the  perioateum  below.  He  now  takes  the  limb  in 
kb  own  bauds,  and  having  the  soft  parts  well  retracted  he  pushes  the  head 
of  the  bone  out  of  the  wound  so  as  to  allow  the  easy  application  of  the  saw 
bv  which  it  is  removed.  Should  the  (mrts  around  the  bead  of  the  bone  be 
tnickeoed,  and  unyielding,  more  space  maybe  gaiiietl  by  making  a  short  cross- 
cot  at  the  upper  end  of  the  longitudinal  incision,  and  thus  converting  it  into 
a  modiScation  of  the  "[  or  T.  By  this  method  of  operating,  the  posterior  cir- 
entnflex  artery  and  the  circumflex  nerve  are  not  divided,  and  but  few  vessels 
will  be  found  to  require  ligature.  The  fibres  of  the  deltoid  are  little  Inter- 
tavd  with,  and  if  the  incision  be  not  carried  too  low,  the  insertion  of  the 
pectoralis  major  will  be  at  most  only  partially  cut  through.  It  is  recom- 
nended  by  some  Surgeons  to  make  a  small  opening  behind  through  which  a 
draiDage-tube  can  be  passed,  emerging  a  little  below  the  acromion.  In  doing 
this  care  must  be  taken  to  keep  well  above  the  posterior  circumflex  artery. 
By  this  means  drainage  is  certainly  facilitated,  and  the  healing  of  the  anterior 
vound  is  hastened. 

Should  the  extent  of  the  disease  or  injury  prove  to  be  so  great  as  to  require 
amputation  of  the  limb,  this  may  readily  be  done,  as  has  been  suggested  by 
Spence.  of  Edinburgh,  by  carrying  the  knife  round  the  inner  side  of  the  limb, 
and  su  detaching  the  member,  with  due  attention  to  those  ]X)ints  in  connec- 


Vtg.   U4. —  Ei«isii>n  at   Shuulilvrgoint. 
Lon(itadiDal  IneirloD. 


¥\g.  ya.—  filMtny  aftoraiii)>utiiTion  atShoul- 
der-juint  bj  Sjienoe'i"  .Melhod. 


lioo  with  the  axillary  artery  that  iiave  been  dopcribed  at  p.  4o6,  vol.  i.     The 
result,  as  seen  by  the  annexed  drawing  (Fi^,  o^'O,  is  very  salipfactory. 

The  *//i/)/i«i/ o;j«*a((on  of  excision  may  l»e  |»erformed  in  the  following  way. 
A  curved  incision  is  made,  commencing  at  the  pof  lerior  part  of  the  acromion, 
reaching  downwards  to  the  insertion  of  the  deltoid,  and  terminating  at  the 
outer  «de  of  the  coracoid  process,  liy  a  few  touches  of  the  scalpel,  a  large 
flap  compared  of  the  deltoid  muscle  niny  thus  be  raised,  and  the  diseased 
articulatiun  fully  exposed.  As  in  the  o|>eration  just  dcTrihed,  an  attempt 
■houM  l>c  made  to  save  the  capsule  and  iiuiintain  iti«  connection  with  the 
peri'«teum.  For  this  purpose  a  longitudinal  incision  i^hould  be  made  through 
the  caj«ule,  and  it  should  be  stripped  off  wltli  the  K'udons  and  periosteum  by 
meani  of  the  periosteal  elevator,  aided  by  the  knife  when  ncct-ssary.  The 
haul  being  pushed  out  may  then  be  removed  with  a  narrow  saw.    The  shaft 


KXCISION    or    JOINTS. 

of  the  humerus  ahuuld  be  eucroachcd  upon  sti  little  as  poasible,  ao  that  the 
arm  may  not  be  Bhorlcned  more  Ihao  U  necessary. 

After  the  removal  of  the  head  of  the  bone,  the  glenoid  cavitjr  must  ba 
exRminMl,  If  this  be  merely  superficially  carious  it  may  be  let  alouc,  but 
should  it  be  more  deeply  discaaed,  with  cavieica  hollowed  out  in  it,  perhaps 
containiDg  sequeatra,  the  dueued  part  must  be  removed  by  means  of  gou^(y 
forcepi*  and  the  fo>us^<  i^Are  bein];;  taken  that  all  diseased  bone  is  thoroughly 
scooped  away.  After  the  opcnition,  the  Hap  muKt  be  laid  down  and  retained 
in  p'K-ition  by  sutarea,  and  »  drainafre-tnbe  inserted  behind. 

When  the  sinimei^  open  entirely  behind,  it  is  jio^sible  to  excise  the  joint  by 
an  incit«ion  made  tliniiif;h  the  jKisterior  fibres  of  the  deltoid,  c<imniencinK 
immediately  below  the  root  of  the  acromion,  and  carried  downwanls  lor 
an  inch  and  a  half  or  two  inches,  but  not  so  low  as  to  endanger  the  circun)> 
flex  nerve  and  artery.  The  space  thug  obtained  is  limited,  and  does  not 
allow  a  metltodical  eiibperitjeteal  excision  beine|)erfurmed  us  above  described, 
but  in  nioet  caee«  the  capsule  is  softened  by  the  disenae,  and  the  adhesions  of 
the  tcuduua  so  fur  loo«cucd  that  Ihcri*  i«  no  dilHiniUy  in  forcing  tlic  head  of 


Fig.  ajO.— BxaUioo  of  Sboutdar-Jvlnt.     ElltpliMl  Io«l*ios. 


the  bone  out  of  the  wound.  Thi.*  operation  was  performed  with  Ihe  heat 
resnlta  a  few  yeara  ago  by  Christopher  Heath  in  Univer^ty  ColIej<e  Hospital. 

After  exctaton  of  the  joint,  the  arm  must  he  well  supported  in  a  nlin^,  the 
elbow  especially  being  raised.  A  pad  should  be  placed  in  the  axilla  to  pre- 
vent the  tendency  of  the  peclorali*  major,  teres  major,  and  laliwtimnft  dorsi  to 
draw  the  arm  inwards.  The  union,  winch  ia  by  graiinlalion.  i.'  usnnlly  slow, 
and  mu!-t  be  conducted  on  ordinary  principle*", 

J?f»iiV/. — The  shotilder-joint  in  its  normal  condition  pfwse.'wg  fivcdistincl 
movements:  1.  Rotation;  2.  Abduction  and  Elevation;  .'1.  dXdduclioti;  4  and 
6.  MovomeuUi  in  the  aiiltTo-puaterior  direction.  These  niovemeuts  vary 
greatly  iu  imiwrtauci-  in  the  course  of  the  ordinary  Hffairs  of  Hie.  The  most 
useful  are  th<»e  of  ul>ductiou.  and  the  two  iu  the  aiilero- posterior  direction. 
Theae  ar«  requisite  iuull  ordinary  trades  iind  for  the  (.'uidauceuf  the  hand  in 
most  of  the  common  occupations  of  life.     The  movvmeuts  of  elevation  are 


POIt  COMfOUXD 


rMUlNUTGU  rRACTURG. 


requtml,  exc«p(  by  those  who  fullow  cHmbing  octupatioDa,  ai  sailors, 
Weklajw,  rtc.  Now  th«  laodc  of  pertomiiatf  the  upenitiiin,  rs  wvll  as 
CW  efenitioa  iiMlf,  will  mntvrially  lafluauce  tb««e  diSereat  nioT«iu«i)M, 
if  ibc  rldt'iid  Ira  rtiL  cutuplvtvlj  acroe«  hy  bd  elliptical  inrittioii,  th« 
trr  Mf  •Ulurti-jQ  of  Lbu  arm  aoil  of  il»  utuvtuiou,  will  be  periiiaoently  toat. 
>6brc«  be  inorrlv  split  by  a  luugitudiiiiil  iuci^ioo  (Fig.  a34j,  Iber  luay  be 
il  or  ivgaiocd  ia  giral  {>arl,  Tbc  muvemcDte  of  rotaLioii,  «tc.,  wbich 
drjvcndFDt  (in  the  arlinue  ul  the  OiUH:K«  that  are  inserted  ioio  the  tuber- 
uf  tlic  huDHTUs.  are  ui>ually  {leriiiiiiiPiilly  lo«i;  for  io  all  caAcsi  uf  caries 
'th«  bead  Drthfhiiiiienin  miiiirin^  (•xfininD,  the  Surgeon  will  llnd  it  Dece»- 
aarr  lo  aav  thnm^h  the  l»<iie  below  ilte  tuberttsiitiee — in  il«  surgical,  and  not 
la  iii  auitonucal  aevk.  Hence  the  conoectiou  of  the  eupraspioatus,  infra- 
•liiBttos,  aod  l«rea  minor,  and  the  Bubecapularis  to  the  buue  will  all  tie 
■epMlteil.  Should  the  Surgeon  aucoeed,  hoMcver,  in  maiolaioing  tbc  cod- 
— etiaa  of  ihe  capsule  of  the  joiut  and  the  tr-mbwa  with  tht  ptriottcuai  by 
ajopcing  the  Bub|)t-rifsteal  method  of  operating  nbove  descril»e<l,  the  divided 
Uniiaea  mar  funn  nt^w  nttachincnU  lo  tlie  bimieru»,  and  the  muAcW  retain 
tbcir  fiinrti'ois  in  a  iiirnter  or  K-w  degree.  Thuse  muscles  which  addiit^t  and 
wUch  pre  the  aiiti'ro-puetertor  inovein«nt»,  vix.,  the  coraoo^braehialia,  the 
b&eepa,  the  |«^i-t»rAlb!  major,  latiasiinua  dursi,  and  teres  major,  will  all  be  pre- 
mred  in  thfir  iiilcgrilr;  and  lienw  it  ia  that  the  arm,  after  thi«  excision,  U 
lp»bl»  of  guiding  ttiu  hand  in  8«  great  a  variety  of  uuetVil  undr-rhanded  move- 
tla.  In  thr  ca«p  of  a  man  whoee  ahoiilder-juint  I  removed  many  yean  ago, 
saw  the  patient  about  Bileen  years  alter  tbe  oftralion  linrl  been  per- 
d,  and  then  found  that  the  upper  end  of  the  humerua  had  been  drawn 
«p  uodarnoath  aad  between  the  acromiun  and  coracoid  procvSMs,  where  a  false 
j«ai  had  formed.  The  arm  was  extremely  useful,  and  all  the  parts  l>el<iw 
tW  vlbow  wen;  well  developed.  The  upper  arm  was  sburteoed  by  two  and  a 
half  inebts. 

Excisioa  gf  the  shoulder-joint  is  on  the  whole  a  very  sueceaaAil  operation, 
ia  ngkids  life  as  well  as  limb,  llodges  has  cotle«ted  00  casee  of  excision  of 
9k»  mmd  of  the  humcTua  fur  di^eoae ;  of  these,  H  died  and  42  recovered  from 
<fc»  iwcfmiion.  Of  these  8  deaths,  3  only  occurred  before  the  thinl  moolh, 
■ad  3  we  fmm  pbthins.  In  2  only  of 'the  cases  did  the  deaths  ap|iear  to 
t*T«bHa  directly  ocouuooed  by  the  operation.  In  but  17  of  these  60  CWOB 
warn  iW  jplenoid  cavity  interfered  with  ;  but  it  is  a  remarkable  circumstance 
Ihu  n  BO  fewer  than'  7  uut  uf  the  8  fatal  cases  this  cavity  was  diseaseil,  and 
n^urvd  dther  gouging',  excising,  or  eauteriution.  Thus  it  would  upi>ear 
tluu  the  ehaoee  of  a  fstjil  termination  is  greatly  increased  by  the  implication 
t/  the  jleoiiid  cavity. 

2.  Sxeisios  for  Componnd  sad  Commiuiited  Fractnre. — When  excision  of 
ifcBflboakler.juiDt  is  r<-<)uirtd  for  ci)i[i|Kiuiid  and  cumniioutcd  fracture  from 
injury,  tbo  u|M-rali<)U  in  uf  u  leas  ttirmal  t'iianu-ter.     The  bulletholea 
he  laid  fiwlr  ojM-t)  iu  a  tungiluiliuul  diri'i-lion,  or  the  delluid  even  cat 
B  at  !i*  »ii[i«ri<ir  attach  men  t,  all  ]<><««  sjiliuters  removed,  and  the  ragged 
<-uii»  uf  bone  cut  otf  wiih  plii-n-  or  narrow  saw;  especial  care 
maoipulatiug  towards  the  inner  and  under  aides  of  Ihe  joint, 
of  the  plexus  of  mrves  and  large  tcsnIs.     Without  going 
i-]i«r  csfrs  'if  Percy,  Larrcy,  and  other  military  Surjiv^'UB  of 
»  of  thr  lostceuiury.  who  frctpiPUlly  practised  this  of»*^ralion 

''--,  the  tmtrv  recent  i-xpi-ricniv  of  the  ware  in  Kurojie 
■Avd  its  grrat  nlJIilv,  and  that  it  oiiglit  tiiVHriubly  to 
jiUAtiun  nt  i1k>  shouliirr-jitint  in  all  caiH'«  iu  whuh  tbe 
..iid  nenrr*  are  intact.     H<Nlgea  stales  that  in  DO  recorded 
froot  ail  awuroM  there  were  2<'j  deaths,  or  a  mortiUity  of  '2G  {ler  wnu 


S78 


BXOISlOil    OF 


But  in  tho  Crimean  war  the  tfeah  vtilb  moch  more  tulUfactorr.  Tbiu  Bn* 
<]«it8  relKti.-«  14  oiiJw  ix-curriti^'  in  the  Crioieii,  wtiK  mily  1  tlealb;  au<l  UiIn 
Britiiili  nruy,  of  14  ca^ra.  1'^  roctivi-rtxl ;  whilst  uf  60  am|>iiiiilt<>iii  aX  tlw 
abouider-joint  ]*J  wvrt-  litlal.  In  the  Aiuericftu  «tar,  tli«  tnortntilv  lo  A76 
cases  of  exeiaiun  »i'  the  Bhouhler-joint  was  at  the  rnl*  of  3!i.5  pr r  wnt.  Pri- 
iimry  exctsioua  w«re  ninn!  aucoctwful  tliun  KOHndary;  the  perwDta^  ^ 
nortaltlv  in  th«  forniur  (2o2  in  uumberj  being  23.3,  anil  iu  tb«  mfcauiuj 
(393  in  iiumberf  3«.(i. 

lilxciitiOM  OP  thkScaimjul,  partial  or  complete,  maybereiiuiret]  formria, 
necrosis,  or  luinor  of  that  bone-.  Caries  and  oecrosU  da  not  very  ooauDonif 
aflucl  thu  ttuipiila  primarily.  When  tlie  bone  bnconiM  the  ceat  of  Hum  <» 
CKMa,  it  will  ^■ncntlly  be  fiKind  lliat  the  acromJun  and  the  tipin<*  an*  tb«  parti 
affectetl.  Iu  eucli  Ra^c-s  tliL-  prugrtm  of  d»C4MB  is  inunlly  very  kIow,  awt  it 
will  genenilf  ba  found  ibnt  thf  carintiri  Imtie  may  he  ellWstuulfT  gtniead  mA, 
or  the  saqueatram  exiract^il,  by  U%'in};  open  siuuHs,  au'l  iliu»  Bxprnng  ti» 
dJaawod  oasMNU  surface  by  irri'gnfar  bikI  infonnu)  njiemtioa*.  Tb«  vbob 
bone  hae,  however,  become  atfeoteil  bv  ncerf«i«,  dry  (-iiri««,  and  dii 
Inflammauon  to  an  incurable  extent,  fa  two  instnnrc^  the  whole  hooe 
been  excised  for  disease  of  this  kind  folloTring  ampulntino  at  the 
joint  for  caricft  of  the  hnmerua.  The  operators  were  Rigaud,  of 
and  Ferguwon.     Bvth  caaea  dk)  well. 

The  prenervntion  of  the  arm  nflar  retnoral  of  tho  acflputa  i«  a  matiar  af 
very  cj^nsiilerfthli*  tmpuriflni-fr.  Tti^-  Siirfr«on  who  fir«  ventiirod  on  iha  beU 
opemtiunxfBQinoT&l  of  the  Whole  ScapaU  wasCumminK.  in  1808,  GatUll 
Bey,  ill  1830,  firat  amputitlr-l  t)i<-  Hrm  ntxl  then  proveetlrd  tn  extirpate 

nhonkler-blnJe.     In  }hVJ  Li;*tiiii  reirn>ve«l  ibi*  whole  of  the  up|»er  iwo-ihl 

of  the  et-n|iiila  from  a  lad  nitliout  tnicritlcin^  ibe  arnt.  In  l^'iS  Ijukf  tr- 
moved  nearly  the  whok*  of  th«  B(-iii»uln  Iroui  n  ^rt  of  foiirtM'n  fi>r  maliijtiaM 
disease,  eMHiiijj;  ncnms  the  bone  through  iu  iiwlc  and  tb»  root  «>!'  the  acm- 
mtoii,  and  Ihii"!  leaving^  [he  clenoid  cavity  and  the  acronitoti  nn>ccw.  Hay- 
tnaii,  Jaiiftoii,  WiJtzer,  and  Textnr  have  all  jHTformeil  Ktoiiiar  o^K-imiiuti*. 
removing  the  greater  |Hirt  of  the  bonu.  but  lenviu;i  the  glenoid  ravily  and 
nioro  or  leai  of  the  parts  alnivr  the  Dptiie.  In  1H37  Mimey  (U.  ti.)  cxciied 
the  whole  of  tlie  seaiHila  and  tiie  clavicle  for  an  cnormoun  uBtcu-earoMiia ;  ibt 
patient,  a  man,  waa,  according^  to  Gram,  in  excellent  health  fitUcn  youa  aAw 
this  operation.  In  IMO  Grow  rem(iTe<l  the  whole  of  the  Eeapnla,  with 
exception  of  the  glenoid  cavity,  by  sawing  through  the  nerk  ol  the  ' 
on  oplpo-anrcoma  weighing  seven  pounds,  indeed,  the  American 
have  distingniehed  Ihemselvcfl  highly  in  this  department  of  eurgrrr. 
in  1838,  McClellnn  removed  the  nhote  of  the  acapnia  with  thi*  clavicle 
■ofl  sarromn.  but  the  patient  died.  In  two  caflen  Gilbert  (U.  .S.) 
the  snipnla,  half  of  the  clnvicle,  and  the  upper  extn>mtly,  one  patient  Ir 
a  week,  ibe-  other  three  monthi,  after  the  operation.  In  184A  Muaaer 
fully  operated  by  the  removal  of  the  scapula,  the  outer  half  of  the'ola' 
and  the  upper  extremity.  In  tho  ea»o  of  Gron,  the  only  nortion  of' 
icnpnift  left  attached  to  the  upper  eiiremity  wa«  the  glenoid  cavity.  la 
16od  Svnic  went  a  Mep  further  in  thu  direction,  ani).  by  diiuirticiilflliag  iW 
bone  instead  of  Rawing  through  ita  neck,  removed  the  acapnia  aith  all  tt« 
p^H«Mle(l  enliru  fntm  a  woman  vvvetity  yt-ars  of  age,  also  K-a^ini;  the  ana 
iintoucbe<].  .Sncv  thai  perJixl  complete  removal  of  the  •ntfiula.  leaving  ibe 
arm  unliiuehi'd,  ha^  bwu  done  oeva^ral  limea  by  8yme,  Jonm,  of  Jeney,  Cock, 
Fergiimon,  Pidliiek.  Ilt-Hth,  and  utht-rv.  The  arm  mi  left  bevomea  iia*flll« 
CApable  of  ptrf'Tming  all  iht  undt-rluiud  movements  and  of  lifl'  '  -  <Vr- 

nble  wvi^lit« ;  uud  it  may  now  be  lortkeil  upm  as  an  »t«blislte'l  .  'ur- 

gery  that  it  ithould  never  b«  removetl  unleea  it  be  the  aeat  alsu  uf  due— i. 


iry  that  Brlditioii  to  the  excbino  of  tbe  scapula.     Fergosgnn 
iwing  through  the  root  of  the  ncroiuion  U>  dUariiculmiug  thnt 
li  to  give  grontpr  rouniJacas  to  tho  elioulder  nod  to  pitncrvc  the 
attarbmfnl  of  Xhc  tmficzjua. 

ParlLBl  ExciiioQ  of  the  Soapala  bun  usunily  \»vn  practised  for  tumoni  of 
that  hiiDt-.  Tbe  cxKot  of  buiio  roquirinf^  cxi-t^ion  will  noccsnrily  vary 
gnrntlr  ■'^cnrrliDg  lu  ihp  Kize  and  cliiinicler  of  the  tumor,  and  (he  jovt-ritv  of 
liw  DpumtloD  will  mainly  depcuJ  iipou  whether  It  is  the  ujipcr  or  thct  lower 
pAfftinil  of  the  booe  that  i«  the  M^t  a(  diaea^e.  Wlit-n  tbe  tumor  is  situated 
DMnrdi  the  lower  an([lo  of  th«  booc,  it  mar  be  pxpotMl  br  &  crucial  or 
T-vlMpMl  iDdaiim.  sod  the  bo«lr  of  the  honv  anwii  throajth  tnuuverielj' 
bdcrft  iLi  fieok  aoil  ipiuo.  In  such  <-tut(«  the  beinurrhaKe  neeti  not  be  very 
grrttt,  aa  the  main  Iruolc  uf  thn  snbAcapular  art«r_r,tir  eveti  the  dorsal  nrlL-ry 
of  lite  aeapula,  ii  uul  uec«»arily  diridnl.  If  the  tumor  eririii^  from  an<l  lie 
eoaaeHevl  with  lh(.>  M|iiQ(>  and  acromion,  ouly  projecting  forwurd*  over  tha 
Aoalikr  and  Iraving  the  r«9l  of  the  bone  aouod,  and  tbe  joint  uoaffecled,  it 
Mar  Im*  ffvely  <-x|HHetl,  the  spine  of  tlietcjipula  Bawit  or  cut  acru^  with  pliers. 
■M  tl>»  maw  ttirned  otT  from  iho  pt>iut  of  (he  shoulder,  ivithout  iujury  to  the 
artiv-iilatiou  or  ihr  imjiltonlioQ  of  vesscU  of  any  iMi)M>rtunce. 

Wi"-o  tlif  umiMr  "ccupiw  tbt  upper  half  of  the  «:flpulu.  the  caM  l»  much 
mnrt  >!<',  Hiid  [liu  line  uf  practice  t'>  bt'  nd<>pu-d  must  dc)>cnd  upon  Ihe 

pafv  .,    Ir  tliL'diKeaseinvolvi,- the  body  of  thob-iuf,  ciicrouchiogupou 

lb»attpf«-  or  iDfra'»!>iti<Hi»  f*>s»a.  extciidini;  forwardis  into  ihenxilla  hv\o\v  the 
awA  of  ifae  scapula,  and  ihuB  cominc'  into  r<iliiiion  with  the  suhecapular 
anrry.  it  would  Ih-  wiiirr  to  remove  ine  whole  l»nne,  than  to  atlftiipt  the 
TCWcuoB  of  the  upjK-r  half,  leaving  only  the  lower  angle,  which  would 
ba  awles  lo  tbe  [mlirnl. 

WK-n  tU^  hfnly  of  the  dcapiiU  ts  involved  io  a  morbid  growth,  extending 
:  •  r  jiart  or  whole  of  the  auhsioapiilar  or  infranpinouB  region,  and 
ri  '  <  nrds  under  the  latleeinuiB  dorsi  muscle  into  the  axillii.  the  caae 

b-   '  'ly  more  w>riouB,  a«  not  only  niufrt  the  wh{t|e  of  the  n-apula  be 

mnoioi,  Mil  ihefluharapular  artery  mum  be  divided,  and  ihenxillary  plerua 
af  acrVM  and  veMeta  brought  into  the  tield  of  operation.  In  tht-ae  caac«,  alim, 
tl  -  to  tbt>  prfaenration  or  removal  of  the  arm  hai»  to  be  conwd- 

■  *■?  tb.>  joint  i>  aoMnd,aiid  the  upper  part  of  the  limb  free  from 
■:  -i  ^-  -irveH;  and,  as  these  eondiliuii*)  ti^ually  exist  where 

;.-•  _      1        IO  the  »cnpiil:i,  thn  contemporaneous  or  antecedent 

in:  I  ';;:i(i    HI  <>1    itif  :inn  IK  wldoui  rv«piin:il. 

Operation. — Kxfi.ii.n  uf  tbv  «-apuIft  may  be  performed  by  exposing  the 
b.  r..  IT'-'  y  bt  V  eliin«*ni,  X-ehaped,  or  crucial  iticiHions.  Tbe  method  most 
•i.i-.i.r...}  iiaa  been  by  the  T-*I>ape<i  inciaiuu.  A  long  incision 
rom  tbe  acromial  end  uf  the  ctuviele  tlowuwards  alotigtbe 
■  iti'i.r .  t"  .  ,>  [  i  itiv  acapula  to  the  lower  angle;  frum  the  middle  or  upjier 
thirl  "f  thi«  a  seciind  inculun  in  curried  at  right  nngica  reaching  to  the  pn»> 
faerior  bonltr  of  (he  bone,  near  the  root  of  the  ppine.  The  Saps  thus  fonoed 
*f»  dismrfl  up  ami  turtK**!  back,  the  trapezius  l)einj;  miBeil  in  the  upper  flap 
(f  it  ia  o'jt  implieaicd  in  llie  tumor.  The  acromioclavicular  articulalii>n.  the 
(Kttrr  nui  (.f  tbe  cljivirle,  or  tin."  be«e of  the  acromion,  is  then  cut  through  ac- 
eonling  t*t  tberxienl  of  tht"  ilLj^nse.  By  feeling  for  the  notch  in  the  upper 
hnrder  of  the  acapnia  thp  silunlion  of  the  BUpm^cHpiiiar  artery  cnn  he  a^crr- 
ttMsed,  tmi  unless  il  ie  overlapped  by  the  tumor  it  muv  he  at  onoe  lied  and 
AfUcd.  Tbe  pnlten'or  scapular  may  be  now  nought  for  by  carefully  divid- 
img  tha  lenUor  bokuU  Kopulo!  henenth  w  hich  the  main  trunk  will  be  t'lund, 
maA  may  he  »cure<(l.  Ad  oaaletaut  can  then  force  hii  6oger  forwards  to  the 
«ppar  and  ouur  angle  of  the  wound,  and  eonprm  the  aubclnvian  artery 


i 


KXUI9IOK    OK    JOINTS. 


Bgalost  tbe  fir^t  nb.  Ttic  uiuaclcKatUiclied  lu  the  poBtarinr  border  mny  thca 
be  <)ivi<JtHJ.  till;  £L'rrulU8  luu^'uti!)  lii-in^  cut  as  uluM  as  posfclblo  U>  iu  iu&iTtiou. 
UR<1  tliL-  Uuuil  jiai»ji>il  to  tliu  VL-uirai  H»j)fct  oj  thu  botic,  which  ia  (bus  ilruwu 
ibruibly  biu-kivanis  uiid  oulwardg.  Tlw  musclija  atLai.:lu'il  to  the  curuc'uid 
pruccKK  way  then  bu  iliviikd  »t  ihu  pnK'uib  KaHii  thnmgh  at  its  n)ot.  The 
wliolo  bone  can  nuw  hu  drawn  Btill  further  outwiirdH,  nnd  the  joint  opened 
I'miii  thi'  iiinur  sitie  by  dividing  the  suborApiilaris  pitve  to  iti4  insertion.  Tbe 
diaaniculauuii  is  then  c^jnipieted,  nnd  the  remaining  muscles  divided, 
the  kiiid*  being  kepi  as  close  as  pcfwible  to  the  heme  ao  as  to  avoid  wnuodiag 
th.'  main  trunk  fd'the  8ul)9capular.  The  pnaterior  circiimdev  is  in  danger  of 
being  cut  as  the  long  head  ol'  the  triceps  is  divided  unless  the  edge  <>1"  the 
kfiilV'  he  turned  away  fn^m  it.  The  teres  major  should  be  cut  uear  its  attach- 
ment tn  the  scapula. 

In  thiii  operation  the  hemorrhage  is  neceasarily  copious,  and  may  he  dau- 
geri)ii3,  bill  by  cirnipres^ion  of  the  subclavian  artery  aft^r  the  early  stages  of 
the  operation,  and  the  inmiediale  application  of  8ir  Spencer  Wells's  forceps 
i.a  dorx-n  of  which  nt  Il-umI  xhotild  1]«  :il  haiiil)  to  every  btc«dii)j;  puint,  it  can 
lUually  be  ke]iL  wtsll  undvr  ooritrr*l.  in  cue  of  IIr'  earliest  cases  of  removal 
of  a  portion  of  the  scapula,  in  which  Lietou  took  away  the  upp«r  part  of  the 
bone  fur  a  vascular  sarcoma,  the  bleeding  was  frightfuJ,  and  was  arrested 
only  by  the  most  energetic  means. 

Aller  the  operation  the  flaps  must  be  laid  down  and  retained  in  position  by 
sutiirvs,  free  drainage  being  provided  by  means  of  tubes. 

Result — In  lum  ^'on  Adeimann  published  the  results  of  6]  cases  of  total 
retiiuval  v{  tbe  scapula  which  he  had  collecte^l  from  medical  literature.  Of 
tliiwf,  46  recovered,  14  died,  and  in  1  the  result  wa«  not  ascertained.  These 
cni^ex  include  th<ise  in  which  the  arm  was  removed  at  the  t<Hnie  time  as  the 
scapula,  and  several  in  winch  the  ampnlation  or  excision  of  the  head  of  the 
hunierug  had  been  performed  ai  itomc  previous  time.  la  17  cases  in  which 
the  subsetjueut  utilitv  of  the  arm  wo^  mentioned,  it  was  very  good  in  12,  in 
1  unlv  was  il  recorded  as  being  very  slight.  In  fact,  the  danger  is  much 
less  tban  might  at  lirat  be  supposed  from  au  operatiou  of  such  mai;nitude. 

Clavicle. — ^The  clavicle  may  require  to  be  portially  or  whollv  excised. 
In  caries  or  Qecroeis  of  this  boue,  portions  of  it  may  be  gouged  away  or 
extracted  without  much  difficulty,  the  bone  being  rarefy  affeciea  through  il« 
whole  tbickncsa,  and  its  posterior  part  uot  requiring  rumoval;  but  when,  in 
coDsequCQce  of  the  growth  of  tumors,  the  removal  of  tho  whole  or  greater 
part  of  the  bono  is  neceaiury,  llio  operation  is  one  of  the  mo»t  Imzariioiis  lu 
surgery,  as  a  glance  at  the  anatomy  of  the  parts  lying  beneath  the  bone,  and 
encroflched  upon  by  the  morbid  growth,  will  indicate.  In  I82d  Mott 
excised  the  clavicle  for  an  ■■<«tleii-sarMKna"  which  measured  four  inches  in 
diameter.  This  o|>eration  vras,  one  of  great  difficulty;  it  occupied  fimr  hours 
in  ilA  performance,  and  forty  ligatnre.4  were  required  to  restrain  the  heranr- 
rhage.  Tbe  subclavian  vein,  thnraric  duet,  and  phrenic  nerve  were  exfmsed, 
but  the  patient  made  a  goiid  recovery,  and  was  alive  many  years  afterwards. 
Similar  o{>eration?,  but  not  perhaps  of  oulte  so  formidable  character,  have 
been  performed  by  Warren,  Travers,  t'urlis,  of  Chicago,  Coopej",  of  San 
Francisco,  and  other  Surgeons.  It  is  obvi«>usly  impcwsihie  to  lay  down  defi- 
nite rules  for  the  performuni-e  of  an  o[>rrfltion  in  which  the  circumstances 
must  vary  so  greatly  in  each  case  as  iu  thi^,  and  for  ihe  safe  conduct  of  which 
the  Surgeon  must  be  indebte<l  mainly  tj  bis  Nnatoniii.'jt1  knowledge.  It  may 
be  slate^l  generally  that  the  bune  rei]uin-e  to  be  ex|K»sed  by  a  free  incision 
along  its  uliule  length:  il  ia  then  <«uwu  across  or  disarticulated  at  itsacr<.)mtsl 
arliculMtioii,  and  cJirefully  di»«ei'te*i  out  iu  ii  direction  from  without  inwards, 
Ibe  sternal  end  being  forcibly  twisted  out,  and  in  ligamentous  ouuuecliuns 


EXCISION   OF    KUBOW-JyI.Vl 


881 


.■■doiiiK  rarr-  Mag  inken  lo  iLvot<l  the  important  vesBela  siid 

nnio  !!'  ;>art  -if  tiie  j^Kwlfrinr  iriancleof  the  neck,  anil  lo  prevent, 

W  bptuiT  Ix  iVirv  (liviifjiiii.  tlif  «^iilry  of  nir  int>>  niiy  vein  wliicli  it  tany  be 
••WBWT  Id  <]ivii|«.  Tbe  sternal  ♦•ii'l  only  cf  the  clwvide  ha«  W*n  cxciwd 
W  Ihii'j,  ».f  BijugaT,  in  a  cawf  in  w  hich  'lisloc&tiou  buckwntda  hml  tt-euUed 
Gkhb  deformity  of  the  tfaue,  nnd  (be  liixn(«d  end,  grttdtiully  prrsaioj^  upon 
tlM  ■Mopbftcii!',  thrvHteiiefJ  the  life  lif  the  ptitient.  The  bone  wiu  cut 
Uin«|b  hi  rot^uH  ol'  n  Hoy's  MW  Hb»ut  itu  inch  truni  its  sternal  eud,  and,  the 
•UnnKijTicular  ligameuU  haviii^;  been  divided,  th«  portion  of  hom*  wa» 
faniWr  dented,  and  at  lavt  extracted. 


■A' 


lOiXT. — In  tracing  the  history  of  the  introduction  of  excwion  of 
joint  into  surjjical  prxclice.  *»€  find,  (w  i*  the  case  in  Mtveral  other 
p«ni,  tiral  il  na-  lir*t  jwrtiitlly  niid  iliLti  «)<»lly  duDP  fur  injury,  and  pro* 
"  hy  one  Siiri;i-nn  bihI  tventunlly  praeliev*!  by  another  for  diBi.>KM>, 

to  IT.'iS  i.r  1769.  Waioinan,  in  a  esse  of  curni«ouiid  iJiBli.>cali^jn  of  the 
iwed  off  the  hiwer  end  of  the  huuieruit  just  above  Ihe  fuMui,  leaving 
|«tieot  «ith  a  floxible  and  awful  arm.  Tyue,  <>f  CftouL-e«t«r,  did  Ht* 
removing  l«io  and  a  btitf  ineheti  of  the  loner  end  of  cho  humerus,  in'a 
uf  ci>iii[>ound  dialocaliuD.  JueUinioud,  of  the  Weslojinster  HosFiilnl, 
«>•  the  flm  to  uperatv  in  a  caw  of  diiwoMi:  this  be  did  in  1775,  rctuuving 
lb«  olccfWKW  Mid  tliu  ini:livi)  of  tliu  ulna.     Park  prupuwd,  but  did  not  hare 


28'Z 


XXCI510K    or   JOINTS. 


ao  opportaniiT  of  practntng,  the  oomplrte  extirpnttuD  of  ibcjnbit.  Tkii 
WM  none  fur  the  first  time  by  Stnreau,  eenior,  In  171)-l,  and  apiio  Itjr  .Mi^nt^, 
junior,  in  Ii*.i7.  LiUlv  wm*  done  Irom  ihit  time  until  llic.  i>{MTBti<4t  «« 
rcvivt-<i  by  the  Siir({«(»o«orL**<l«;  in  ISlft  b>-Slon*fiel"),  in  1SI!>  by  Oj-K'Wy 
and  Ilvy.  It  th«'n  mode  rapid  procr^M  in  profeffii'>nnl  r»timatt>>D,  and  «a> 
spftcitlly  )>trK«'Iy  practia«<l  by  Synie  Bud  Liston,  luid  th**  Siirffi-«>ii»  i.f  tlw 
Bdinbiir  iiary.     Tlic  excision  of  lb*  flUiw-jni!  i  ir«  frt- 

quwully  [  :  diaii  that  of  any  othiT  mC  ((•'■  !irti.-nb':  i- koei, 

■od  tbv  rwuli  i>na  upi>D  lh«  whole  bcvu  •  i>. 

Tbia  o|Hrttli«iii  may  bv  re<^uirod,  1.  {■■.  )  ■    ■    ■    ■■■f  the  Juiut;  2, 

for  OnMMUB  Anlcyl(j«i«;  aud,  K.  for  C<>iu]Mxiud  i'VaciurvD  and  Di:'bK.-ati<>i)& 

1.  Strumoiu  ArUiritia,  or  while  rwdiing  i  p.  'iAi*).  u  tlit*  diwasc  fur  nbkfe 
excttioQ  of  tbt!  elbdw-joiut  ~u  moet  cutuinouly  required  in  young  aubjecit.  Il 
may  commeuoe  either  ia  the  synuvial  luvmbratie  or  in  tbv  boauu  Li  thm 
(liaeflBe,  the  limb  becomes  uselen,  the  juiut  is  extremely  painful  on  movt- 
ment,  and  the  surrouadiog  mfi  parta  are  awulleii,  sp>iupy,  and  perforated  by 
•iBoaea  fnim  the  opcniogs  uf  which  fuugaling  jfrHiitilaiioii-tuBuc  tuoally 
pnjwla.  lo  nidcr  Bobjecle  the  mischief  will  usually  Ih^  found  Ui  be  t»ai^ 
priQeipally  in  the  liones,  and  the  eweltinf;  of  the  mirmundinc  parts  ia  oftca 
not  great.  There  mnT  be  merely  oue  or  two  sinUH^  leading  down  to  cmi 
or  necrosed  bone  in  the  condyles  or  the  olecninoii.  the  joint  hang 
neotlr  flexed  and  the  arm  useless.  On  opening  tbt-  joint  loos«  pi 
dead  Dom  may  be  fnund  lying  Ja  the  hollow  of  die  olecranon,  or  in  ooi 
the  condyttit  of  the  humerus,  the  re«t  of  the  articular  surfaoes  bcln; 
witb  more  or  1«m  rouiplcic  destroetion  of  the  ariicular  cartOaees. 
commonly,  the  radiu.i  ia  the  last  bone  that  is  aflicicd,  the  ulna  aod  the 
articular  cod  of  the  humerus  being  (;eDenUly  first  diaeued.  In  soom  csmi 
exctwioD  i*  reouirod  on  account  of  acute  deatnietive  arthritis  toofCidarT  to 
suppuration  laKing  placo  oulaidc  the  joint  and  extcndinj^  into  iL  Tbo  eltuw 
fonns  an  cxci^ptiou  to  l)ie  rule  that  exctaion  of  a  joint  a  not  tn  bo  uodertalitie 
whilv  there  is  a  hojm  of  obtaininj;  a  curebyankyliMis-  Provided  tbv  patient 
is  oihcnriM  liedtby,  the  op>eratioa  may  be  perlonuud  as  soon  as  it  it  eviJoat 
thai  the  muvemoou  ufth«  joint  will  beltwtsbouJd  reoovery  lake  pUoe  inukr 
simple  treatmeoL  

3.  If  ostemu  tmijfhtit  b*ve  occurrcl.  whether  in  the  straight  or  in  the  ~ 
poailion,  excistoa  may  advaotugeouBly  be  pructisod,  provided  the  palii 
in  c'v^l  li*'aith.  TbJ(i<f)>vrAti>iu  was  first  performed  in  1827,  br  Bbm  Bi 
of  I'hibidelpliiA.  Wh<:n  ibe  elbow  is  anayl'jscd  In  the  straiKht  pialltoa, 
arm  in  ouiLu  uwL-ldai;  and  aur  uperutioo  by  which  Uexiou  ofthelinib  can  be 
obtaiucU,  even  without  mobility  uf  thejuiut.  will  add  most  malemlly  to  th« 
fntimt'a  eomfnrt,  miUeriu^'  the  hand  uvailabte  fur  must  purpoaea  of  life.  In 
enea  of  anffuhr  oahcous  :iukylu0[s  of  the  elbow,  a  wedged-ahapod  piiMX  of 
boav  abould  be  removed,  iw  that  a  uwf\il  and  movable  articulation  may  bi 
•ubatitutCHi  for  ouo  that  is  ricid  and  fixed. 

S.  In  raws  of  compound  Fneture  or  di»ioaUi<m  of  the  elbow-Joini,  mora<ir 
\tm  cnnipletG  mtection  of  tiu;  ppiirtuHn^,  and  puatihW  tpllmered  fragBMnt% 
mar  be  i«quired  (pp.  &t>B  imd  VyiH,  vol.  i.). 

Operation-— KxiMion  of  the  elbow-joint  miyl»*  [vrfornii  '  "  H,  iW 

X-»tinp4'<i, '>r  l)i<r  ^iii^lc  lon^iLlidiimt  inotsinu,  or  bv  two  li-n  I   tna^ 

ions.     I'^ich  iiirtlio'l  has  ilfl  Hilrocittvs.     Ttio  |-|-sriii[N*d  ■>[  .-ni 

in  inakit)};  no  inriMion  {MLrallcl  lo,  and  A  little  tn  th<-  mdiiil  -  ic  a| 

Derve,  atiotbcr  nlon^  tbr*  uiit«r  sidt-  of  tb»  j"iut,  and  iiiiitiue  ^he  two  by  a 
CTOis  cut,  diswcting  up  nnd  d€>wn  ihit  tw.>  »<]uarr-  (laps,  and  clearinK  the 
bone*  laterally.  It  was  soon  found  by  Burj^ons  that  by  thb  laetbod  a  -nty 
mneoawtry  amoUDt  of  tncistou  was  p'ractt)>cd ;  and  accordingly  the  rertical 


th«  ouiar  tide  was  diipeoiwd  wiili.  nnd  the  h*-Ahaped  operation 

,  This  eoaatMd  Id  mokinv  the  icingiitiilinal  mciaion  parallel  lo,  and 

m  Hule  Ui  the  rmHtd  nde  of  iht  ulnar  nerre.  and  ihc  rrnwKrut  over  tlie  uie- 

iii  tli<>  I'till^  iiit!  of  the  jninU     Si))we<]Uont  experieiirc  has  shown  itiaC 

iv  b(!  »lill  furtliLT  aimplified,  and  the  operatirm  re<hiced  to  a 

..-  .iiial  imuiion  carried  over  the  centre  of  ihe  joint  in  thn  middle 

ilmve  diiwnwnrda..     In  comparing  thcflc  dilfcrrnt  methntU  of  opt-rat- 

i..n.-  ..;^.Q  t|,g  prvlcrence  to  the  single  longitndinftt  incision,  iis 

;i  in  nil  opdiuarj  cases  for  the  complete  and  ea«y  removal 

ar-.i.-iitauiTK     IJnth  the   H"  and  T-slwped  iiicUlouA  involve,  more- 

wvr,  a  i?ouiplft«  trauitvi^rse  divi^on  of  the  tendon  of  Uie  tricep«,  in  conw* 

MBBOr  of  which  the  p'lwer  of  at-tive  extt^nMoii  of  the  limb  may  be  luett  nUer 

nmvarr  from  lh«  operation.     Should  the  soft  elnK::ore8  tonarda  tlie  outer 

ndv  of  (hr  juint  nut  yield  iiiitUciently,  a  i-roee-cnt  can  at  ouee  b«  made,  iio  ns 

t»  lilTrnt-  thrrm,  nntl  i;ive  the  fjoryeou  more  room,  by  turning  up  llie  two 

tnBD.'  '  that  will  ihiiin  lie  formed. 

Th'  i".^'  arc  the  auccwssivc  Bie|»  of  the  uperatiou  by  the  T-t-hapwl 

■■d  Mngln  l'in|'itt]<linftt  iui-isium.  Should  the  former  be  aduplud.  i-itlior  in 
BoaM^oma  uf  Ui?  situation  of  the  eiuua*:^  or  of  prcvioiia  inuiaioiie  for  the 
raDef  uf  abMOMBB.  the  arm  being  hold  ucruee  Uio  che»t,  the  peruunilicidar 
Bit  aboiild  be  made  parallel  tu,  and  a  lino  or  two  tu  the  outer  aide  uf,  the 
Blnar  awe;  bdog  commenced  at  least  two  indbm  above  the  point  of  the 
alatrmnoo,  and  carried  down  U>  about  three  inches  below  iL  The  iran^verM 
mdriiia  mav  th^n  tie  made  directly  acroas  the  end  uf  the  olecranoti.  U)  the 
talcr  -'  '  (lie  joint,  and  extended  as  fiu-  aa  the  extremity  of  the  outer 
«a«d>  ~>38;.    The  two  irianpitar  flans  thus  made  irmst  hediHsecte^l  up, 

tbe  W&Ue  tit:;!ig  curned  cIom  to  the  bonnt  <  Pig.  it^B  i.  The  enlisequeDt  5te[ia 
Mgmlbemkme  iu  the  operation  hy  the  Hiujfle  loii)i,'itudiaal  incitu'on. 
^^^^■iKa  aiMration  hy  the  siityti  longUudiwil  inemon  the  arm  13  held  in  the 
^^^^BvB  JoK  doMribm,  and  the  inrrtision  ia  commenced  from  two  Ut  three 
^^plAei  beirtW  the  tip  of  thf"  oten-nnm  and  carried  dire<:tly  over  the  miildle 
^mt  thml  pmnMs.  ti^rmioatinK  a  kiiniliir  dustanoe  al>i>v*>  it.  If  the  part«  are 
Bvdi  nrollfn,  thv  longlh  of  the  iomion  muni  \w  incrcitsed  m  aa  ^)  allow  of 
th«»»d'-  l.-!",'  hrld  Wfll  aiMtrt.     The  incision  must  lie  uarried  firmly  down 


loCh 
tadit: 

Um  ioDi;iiii  I 
ttad  abavf  1 


at  c;<^mpI«U'ty  to  divide  the  tendon  of  the  triceps  in  a  longi* 
m.  The  arm  t»  then  aliglitly  extended,  and  )>ofl  part8  cleared 
»dn  of  tht' joint.  To  do  thui  (he  tliiimh  mu«t  be  ptuhe<l  into 
il  -lit  in  the  tricopii.  and  the  tt>ii<liin  thus  put  od  the  «trelch 
i;  from  its  attnchmenL  If  the  {leriosteum  is  swollen  nod 
by  inllatnmalioa,  lhi»  m»y  li*"  wholly  or  iu  part  done  with  it  iwriis- 
ml  dvnUor.  and  tbn  cmnvcli'm  hftweeu  the  ti.-uduu  and  the  p^riosUrura  he 
proBtTod;  mon  commonly.  how<<vi*r,  tlio  kuifv  has  to  be  used.  AlWr  the 
irioMS  is  ssDarated,  the  n^muiniiig^  tmft  purt«  must  be  car^^fully  turned  off 
thm  uiBer  nd«  till  thi.'  internal  exutvle  coioee  int^i  view.  Id  doing  this  the 
•d^  of  Uh  knife  should  nU-ity*  Ik*  kupt  against  the  bones,  or,  if  pouiblu, 
iIm  perKBtaal  alovstnr  ihould  bo  ns-d,  »  >  limt  the  ulniir  nerve  may  be  turned 
if  the  inil'er  condyle  wilhiul  injury.  If  the  incision  be  properly  made 
I  tlt«  knife  kepi  in  contact  with  the  bone,  the  nerve  ought  not  to  be  ex- 
durioff  the  opemtinn,  more  particularly  as  il  is  usually  embedded  in 
mca  tiwufls  surrounding  it.  NVhvn  the  inner  side  ■>f  the  juint  has 
•aAdentlr  olouicd  llie  40II  parts  must  be  turned  back  in  the  same  way 
ibc  outer  liae.     In  doing  this  it  is  very  important  to  save  uninjured  the 

^  teodloous  expansi<in  that  paaaes  from  the  trioepB  over  the  surface  of 

|lb«  aacMiaDu*,  lo  be  attached  to  too  posterior  border  of  the  ulna.    If  this 
b«  prwrvad,  the  aoaneotioa  between  the  triceps  and  alna  is  nuioloiaodt 


su 


Excisioie  or  joints. 


j,and  tlie  putieat  will  re^'ain  the  pow4>r  of  active  extencKm  t.f  ■'         -  i  whta 
tmnrvrr  has  taken  place.     Whco  the  posterior  fnrt  ot  t)i>  .  .^  tins 

hcBD  lanl  Imre,  the  tip  uf  the  olccrnnoa  ihoulii  be  reruofe<l  by  ciiluutt-|iUa. 
BO  a«  to  ^'ivv.  friv  *Cixm  to  the  articuUtioD.  The  limb  ti  thcu  tlezcd  fonflrijr 
til)  the  forearm  tuueliL-s  ihvarm.  the  humerui  beiDt^  hehl  vcrtirally  at  rigbt 
angles  to  the  table ;  tlic  forearna  ia  at  the  same  time  |mUud  liiwaixlp  tim 
table.  The  lateral  ligauieiitt  being  then  divided  bv  a  touch  uf  tbc  koiiir. 
the  articular  surJafe  of  the  humerus  projects  from  the  wouud,  aod  can  be 
mnoved  by  a  narruK  aw  cutting  from  the  anterior  Hirfaev.  W  the  M«n 
inner  condyle  i'orm  Uh*  sharp  n  point,  a  sitiall  piece  may  1m>  tvmnvtwi  trttb  the 
bono  foreera.  The  bonvs  of  ihu  forvariii  arc  tlien  toraed  out  of  the  woaad 
by  the  aaaiBtant  and  clenued  with  the  elevator  or  Ituife  till  thti  cmrtilag^ 


rig,  Ulv-KaabtMiT 

Imtiti/om.   B^iMMi 


covered  aurfaeea  are  sufficiently  exposed  to  be  renrnvcd  h^  the  saw,  Tb« 
brHcliiul  artery  is  so  ootupletely  protectee]  by  the  brachiahs  aniini*  that  U. 
cuuld  not  easily  be  woundei],  but  if  there  it  much  pulpy  swetliog  of  the 
syurivlal  menilinine  it  will  aonietitnes  be  found  ui>efhl  to  prrea  a  copper 
epatula  iKtwi-en  the  boiitx  to  facilitate  the  exposure  uf  their  ends  for  aawinc. 
The  ulnar  nerve  in  iu  danger  while  the  inner  Hide  of  \hu  uIha  » tieing  rleaaed 
for  the  saw,  and  eomctiniea  during  the  mwing  of  ihc  \miw,  nail  it  muM  thefe- 
tan  be  runnled  or  drawn  on  one  side  by  a  bent  coptwr  Bp:itula  or  a  blonl 
book.  Should  any  sinuses  exist,  especially  Limflrds  the  inn^r  side  of  the 
arm,  they  had  better  he  left,  untouched.  I  havn  more  than  nnrv  kuimn  the 
ulnar  nervr  rui  acrnss  by  the  .Surgeon  in  laying  open  what  apj^arfd  to  be 
vrry  KurM>rflrial  dnusi's  iu  this  situation. 

In  this  ofierution  it  ia  nf  great  fHiDAOijufncr,  an  far  as  the  nner-tititity  of 
tbo  arm  is  i-nnci'mcd,  not  to  remove  more  of  the  bt-inn  lenKthMim  than  is 
alwolulrly  norcMmry.  The  ^haA  of  the  humerus,  for  inntann',  shimid  nerer 
be  encrf>nchr>d  upon ;  it  will  l>r  quite  eutlieient  lo  limit  the  rtri»i<>n  to  tbe 
ariirular  surfiic^-.  .Should  any  rarions  portions  of  bone  extrnd  hrvond  this, 
I  think  it  in  Itctter  to  acoop  them  out  with  the  gouge  than  t<>  mnoTF  them  i« 
any  other  way.    The  exciuon  of  the  ulna  and  raJtua  tlmuld  not  b«  carried 


tJCCIRION    or    KLBOW    UV    LATKRAL    iNi 


rs. 


885 


I  todrvidi'  the  inwrlioM  of  the  brachinlis  anticut  and  bicepa.  After 
Um  nrticiilKiion,  a  jiractical  questioo  of  considerable  importance 
Ma;  vii..  to  what  extent  llie  resection  of  the  artifulnr  enda  shonl<l 
W  cftirwd.  If  tbpy  be  all  diseated,  there  can  uf  course  be  uu  duubt  as  to  the 
pM)mi<r  of  rvmoviug  the  ends  uf  the  throe  bouet.  So,  also,  if  the  humerus 
BM  uloa  be  diAnuetf,  the  bead  of  ibc  radius  should  be  cut  oB'  on  a  level 
•itb  tbe  aeeUoo  of  tbe  ulna.  But  the  iniportaDt  point  U,  whether,  in  the 
•vcotof  only  one  b^oe  being  implicated,  by  disease  or  injury,  tho  SurgeuD 
AfiaH  iiaiit  bimself  to  the cxeiaiou  of  this  aloue,  or  should  remove  tbe  other 
cva..  CWmerly,  in  accordance  wilb  llie  priuctptd  of  conservative  sutyery, 
thai  ftisMwil  or  iuiured  pej^  alonts  should  be  tmcrifict-d,  I  have  atlvocaled 
itrnvhtf^  the  beallby  articular  enda,  ami  only  removing  that  which  vaa 
diseatrd;  but  tocmsiDg  expiTifnce  hait  convinced  me  that  the  practice  is 
trmofous;  and  ihrnt,  if  tfaf  joint  be  imty  partially  exciMNt,  anliylosis,  or 
fttoniof  tbe  disase  in  the  bnnr»,  in  very  apt  to  i!nt=ue.  I  wonlrl  tfaerefiiro 
■dvias  that,  in  alt  cases,  the  whole  of  the  arlioulatiou  be  removed,  as  well  na 
!■  IhoM  eaMS  in  which  (Operation  in  reffuired  in  consequence  of  commt- 
MfJ  ukI  compound  fracture  of  only  one  of  the  bones ;  as,  for  inatanoe, 
■  b«i  ibe  lower  epiptiTsi^t  of  the  humems.  or  the  upper  end  of  the  ulna 
only,  ia  tbe  scAl  of  such  injury.  In  excision  of  the  elbow  for  &ulty  osseous 
■akjliw&s.  a  piece  of  the  united  bouM  about  an  inch  in  length  should  be 
mwa  oat :  tho  cuts  sh»ul>l  he  made  at  right  angles  to  the  shalis  of  the  bones, 
amd  Um  pieee  reniov4:d  uiuftt  include  equal  portions  of  humerus  and  of  ulna. 
Tlw  optratioD  by  two  Utteral  ineieioiu  tias  latelv  been  recontmendeil  by 
Hosier  ai)4  otben.  Tbe  advautautrs  claimed  for  ttiis  metbo<l  of  onerntiuf; 
W*  Ibat  it  saTM  to  some  extent  tne  injury  tu  the  lric6p«  iitvolveu  in  tho 
•Ibar  BslhodM.  that  it  proridei  better  Uraiuu^a',  and  thut  the  i»car«  are  left  at 
ib^  latanil  ae{KM:l«  of  the  new  joint  iutttead  of  behind.  Tlie  inner  iucisioa 
M  be  ibe  sborter.  ajid  be  made  Unit,  the  uinitr  nt^rvu  beiuj;  turutd  out 
'•  groove  and  the  internal  latvnil  ligiimeut  of  tiiv  joint  •iivided.  The 
oaier  iDfriai<^o  should  be  of  couniderable  leu^,  aud  should  pass  ulos«  to  the 
mJial  bonier  of  tbe  olecrunnn.  Hueter  recommends  that  the  exlernal 
klarml  l^amuit  should  lie  divided  and  the  head  of  tlic  radius  rcmoveil  lir«t. 
YW  Iwwar  cod  of  tbe  humpnm  can  i.bea  be  dislocated  and  fonml  out  at  tbe 
«Kl>nuU  wooad,  or  sulfiriently  exposed  to  be  safely  sawn  with  a  narrow- 
"  '  '  mm;  after  which  tlie  olecrunon  and  the  uppej'cnd  of  the  ulna  can  be 
~  witb  tbe  elcTBtor.  prolrudct  from  the  wound,  and  removed. 
1  mtbuda  of  opemtiDg,  it  \»  E:enemlly  recommended  to  save  as  much 
pBfkMnmi  ■•  posnbTe.  Oilier  slates  that  the  results  obtained  by 
*  raeclion  are  far  better  than  those  by  the  older  melhndfl.  In 
'  it  will  be  found  that,  in  excision  for  disease,  whether  the  knife  or 
elevator  be  used,  if  tho  rule  of  keeping  the  instrument  close 
booe  be  fullowed,  the  greater  pari  of  the  periosteal  ooverini;  uf  the 
baaa  will  be  aived,  as  its  adhesion  ini  alwuys  loo^-'ucd  by  the  inHammntion. 
Xb  priouuy  exciaiona  for  injury,  on  tho  other  hand,  the  greatest  care  must  be 
tftkp»  to  aafe  the  periofteam,  otherwise  a  flail-lilcc  joint  is  very  apt  to  mult. 
Ib  Bftoy  casn  of  exdsioD  of  the  elbow  no  vessels  require  li^ure,  though 
tbww  may  be  free  ^teoeral  (xtzing.  I  have  never  seen  iroubleaomu  bleedinsp. 
Aibr  Ibe  operation  Ibe  wound  may  be  closed  with  Mllures  and  treated  accord- 
IM  to  tbe  rule*  alreaily  laid  down  (p.  866). 

Uacb  'tf  the  suixwH  in  tlie  rvault  of  tbe  exciuon  of  this,  as  of  other  jninls, 
will  depeod  opoo  the  care  and  alleutioo  bcMJiwed  un  the  altor'treatincul  of 
tbaewe.  Tbe  i»bject  of  the  ireatinent  is  to  obtain  a  strong  false-juint  |xje- 
■■faw  all  tbe  natural  movcnien(£  of  tlic  ctbuw.  lu  order  to  do  this,  a  some- 
vbM  otllemit  caoiw  of  tKatiocDl  must  be  adoptetl  in  ditferenl  cases.     In 


SXCISION    OF    JOINTS. 

■It  ULvMOBft  for  (luesM.  vre  have  to  guard  against  ankjloei* ;  uotliie  amhilitjr 
iavarv  tbi^sikI  I  haro  never  seen  it.  Iii  priiuary  exctsjou*  fur  injuir,  a 
4lHUflw  joiBt  ii  ant  uii(*uinnii)ii,  C8|ivoiiiUy  it'  niuclt  buuu  hatf  bean  mmami 
MKtibft  pcfioiCaani  not  pri^KTvod.  I  liavr  luvl  willi  it  in  ooa  vaac — ikalal 
a  jM«ac  vomao,  the  lower  ciiilDf  vrliijuf!  humeruB  waa cnoiphitely  diaotyinilrf 
bv  Bftk&«  and  the  ellxtw-juiiic  op«iicil.  In  thia  oaae  Uie  lower «t>i[AjrnB  of  tW 
hinMfW  wag  MtcMed,  together  with  the  iirticular  eodiof  tlietilnaam  nwlfaM, 
A  (mmI  ncDVvrjr  loi)k  place ;  but,  altliough  everv  care  was  takra  to  aopfnrt 
iMHsb  am  RplintA,  a  very  muvuhle  joint  waa  ten.  In  ezddaaa  for  diMH^ 
«r  i>r  ike  aeoondary  reanlLs  of  wounds,  we  mar  in  most  cases  ditpenaa  with 
aaMnif  After  the  operation,  the  limb  mar  be  laid  upon  a  pillow  nearlj  ■ 
IM  «xleBd«d  poeitton.  H<ime  of  the  Kriinburgh  8urgeotu  have  reoonncodad 
Ikftt  the  limb  should  he  placed  in  the  fully  extended  powtion  iHlh  m  twy  _ 
jmth  w«^t  extension  applied  lo  the  wrist  to  prevent  the  boiM*  flH^ 
«oaiui(  in  actual  contact  with  each  oilier.  This  iraaunent  haa  been  trioflpH 
I7ld*«rntv  College,  and  found  10  be  very  comfortable  to  the  patient.  M 
ikaaod  0^  a  weeK  or  ten  i\nye  pawtive  movement  roust  be  cooicneiioed.  la 
doing  this,  care  mu^t  be  tAkL-ti  nut  t»  grind  the  bony  surlacv*  ugaiovt  eadi 
vilwr;  gentle  exleosion  mtiH  )*e  nmintained  while  the  angle  ot'  tbe  limb  it 
altered.  At  first  it  ia  ftutKcii^nl  merely  to  alter  the  position  of  the  Itaib, 
louing  it  lie  in  the  flexed  ))ceition  uue  day  and  the  extended  the  next.  At 
tbr  wound  beala  more  extenaive  morenienta  may  be  carried  out  daily.  Pr^ 
nation  and  lupination  miiat  not  be  neglected,  and  iu  carrying  out  tboe 
movrmeuts  the  uluu  must  hi;  held  steady  with  one  hand  while  the  nulJui  if 
n»t«tod  on  it  by  the  uther  hand.  The  puin  ucoompanying  pamve  taoviawrt 
ta  much  Iim  if  it  be  commenced  early  tniiu  if  it  be  delayed  tUI  fibnutuifaa 
bu  taken  plave  between  the  bunes.  SplintB  ore  required  only  if  thors  ll 
he  any  tendency  to  difiplacemviiL  immediately  after  nperattuu,  if  mora 
the  uBUul  amount  uf  butte  hai  been  remove*],  nr  if  there  shuuhl  beany 
dtoicy  to  excenive  looKnen  of  the  new  joint  atWr  (he  third  week.  Tkt 
pntieot  can  usuhIIv  leave  bis  bed  at  the  end  of  the  second  waek,  and  tfaa  ana 
nuBt  then  be  carried  in  u  sling. 

In  prinuiry  excisions  for  injury,  n  properly  conatrncted  aplint  ta  frequently 
rtquireil  for  some  weekii,  as  the  tendency  is  usually  toward*  a  flail-like, 
fibrous  union  rather  than  to  nnkylosis.  A  splint  jointed  opjMjiiite  the  elbow 
will  be  found  useful  in  many  cnsc!t  so  ns  to  allow  of  vartatlon  of  poaitioo 
when  necUBary.  Pronntion  and  inipiualion  must  not  be  neglficted.  and 
must  lie  made  when  the  splint  is  removed,  as  no  apparatus  has  yet 
Inrentnl  which  will  allow  of  these  movements  being  carried  out  Id  • 
way  whiUt  it  Is  applied. 

By  the  mIhivc  mode  of  treatment  a  useful  false  joint  can  almost  alwajrs  ba 
obtained.     In  two  cases  which  I  have  had  the  npp>irtunity  of  diatecting,  oos 

sixteen  ni'HUlis  noil  the  i>tl)*-r  two 
years  and  a  half  alWr  (he  opera- 
tion, it  was  found  that  ibc  rndf  ot 
the  Iwinrs  were  rounded  and  firmly 
held  together  by  a  cnpeulc  of  dense 
ligamratotM  tissue.  In  tJiii  way  a 
moat  exoellent  and  uaeTul  limb  vtU 
mull,  having  the  four  mofioinnni 
of  flexion.  extenaioD^proauuioataod 
supinuliun  nearly  perfect,  with  bnl 


FIf.  ftil.— Arm  attar  BicMva  of  Klbw. 


the 


little  deformity. 


as 


.ybai 


aoeompnuying  out  (Fi^  641),  which  was  ulcon  nearly  two  jnam 
operation  fnim  a  |iaticnt  ol  mine.    A  ooaobman,  whoee  elbow-joint  I  exc 


able  la  drive,  tu  lift  ■  pail  of  water,  and  to  do  all  tlie  dutlei!  of  liui  ero- 
plonDenl,  n«irlT  ss  null  as  if  the  arm  had  retained  \u  uormiil  cnnditinn. 

nbuald  tfafK^ie  aoy  danger  of  Biikylosis,  the  pntJeot  tnitv  be  p\it  under 
cUomforui  nod  forcible  6fxion  and  exte-tuinn  be  employed';  aA«r  which, 
paMTv  oiijtioo  must  be  kept  up  daily.  If  thi«  fail,  care  must  be  tak^n  that 
tkm  aakThHs  takes  plnoe  iu  a  flcxod  position. 

fiboulil  rT4'ii rrpnc<>  of  diseaw  take  place,  reoectjon  may  be  aj^ain  renorted 
4d  with  McoMK.  In  line  ra«e,  inilee^l,  whir-h  had  been  unsoocessfully  operated 
■•  (wiee  by  other  !Sur(;<v>n«,  I  excised  the  boD€«  about  the  elbow  for  the 
tUnl  dBM  with  complete  8Ut'c(-»s,  rt>nH>vin^  a  roDsid^rahle  portion,  u«nrly 
tllPHi  incfaM,  of  tb«  necnM<d  fihnll  oT  tli«  liunierux,  and  the  t-arioiia  uiipvr 
^Mki  of  Um  radiut)  aod  iilua.  Id  this  case,  which  waii  that  of  a  boy  about 
ttmnBKa  VHars  of  afcv,  complete  recovery  look  pkc«.  He  had  a  riio«t  useful 
AMtti  n^inin^  ibr  tmir  m»v<?itieiiM  of  lh«^  joinl.  pruiiatioii,  siipiualiou, 
tmxiaa,  and  extension,  tiud  iIhk  nutwitli«laudiii)f  his  Ueiii);  of  a  most  etru- 
tD-iuri  babil.  Hix  munthe  aftvr  tho  excieiou  h«  ntu  oblif{«d  to  huvu  one 
thi;;b  anpuuied  fur  diaessc  of  tlie  bone,  and  he  cvButually  died  at  the  end 
of  two  and  a  half  yean,  of  canes  uf  the  epiue. 

SanUla. — Kxciaiuo  of  the  elbow-joint, fo  far  as  life  is  cuncerned,  isa  very 
MMBHifiil  oparatidu.  The  result,  when  it  in  prartimsl  tor  coRi|>oiind  fracture 
«r  dialaaulon,  has  been  alreiuly  stated  at  pp.  it&7. 4)4S,  %-cd.  t.  When  prae- 
lind  IbrdtMm  U  u  equally  salisfactory  ;  and  indeed  death  can  occtir  only 
fiioaanB*  onforeeeen  and  Hccideotal  complication,  such  m  may.  and  does 
OW— iiliiilli  follow  any  npemtion.  1  have  \mt  onlv  one  patient  out  of  Tc-ry 
wmmf  in  whom  I  have  excised  the  el  bow -joint.  Tiie  principal  danger  aAcr 
lUioperaliou  ari^ca  from  dil)ii»e  Buppumtiun  of  the  medullary  canal  of  the 
iMaatWt.  I  have  acm  thii  hapfK'n  in  two  fatal  cases  in  the  practice  of 
oAmil  prBrata  developing  in  bi>ih  inManec«;  and  in  a  third,  in  which  the 
patMAl  1^  hill  life,  it  It  probable  that  death,  which  was  attributed  to  fuieu- 
iIa,  oecorred  from  the  #amc  cause. 

CuxA  OR  Kadica- — One  or  other  of  the  bone*  of  the  forearm  luu  occa- 
ij  bwn  cxcived  with  advantaf^,  leaving;  a  aufficienllr  iiwful  limb  with 


f\g,Ht.—Aiutiwa  ntitt  R><liu>  hM  1>o«n  tcmsrtd. 


Pir.  W9.— Tb«  UmIIui  kli«t  JtttMBVKi- 


„..!., _  ;„  .1...  !,nnd.    OnniochaD.of  New  York,  and  Jonea,  of  Jeney,  have 

I  the  whole  ulna.  Iu  a  caw  recorded  by  Weist  (*U.  8.), 
Kii>  K'  iilna  W8A  removed  on  account  of  ^ut»faot-wuuDd,  Care 
Ut  prrM-rvi^  as  much  aa  iMjattihle  of  Lhu  periiwteum  ;  and  reproduc- 
boiw,  fitrniiojt  «  very  useful  lliub,  had  taken  place  nl  liic  end  uf 
•  year.  Bulta,  of  Vir)i;iuia.  haa  rQiiiijvtnl  the  whole  radius.  In  a  numau  who 
VH  onder  my  core  about  twenty  yean  ago,  I  alao  resected  BuccenftUly  the 


3»8 


BXCISIOK    OP    JOIl 


wbolfi  radius,  with  the  exception  of  iu  trticular  baid.  which  «m  mmad 
(Fig.  &-13) ;  Anii  H  usfttil  arm,  uf  wliicli  tli«  auuexed  figur«  is  a  Bvod  kmk 
■eatntiua,  mas  l«(l  I  Fig.  &42).  A/t«r  a  time  (he  liattd  fraiiuall;  iodiatt 
towards  t)i«  radial  side  of  the  arui  :  hut,  although  the  iirticuUtiuD  bet««M 
it  Bad  the  furvarto  ia  but  a  tlmiiier  one  Lhruugb  the  medium  of  the  nlaa,  • 
Tcr)'  useful  member  will  be  left.  These  operaliituv  do  unl  rMiutni  asf 
•pecifio  riilefl  for  their  perfortnaiice  ;  the  boue  n  expoved  by  a  laog  indHon  to 
tiie  direction  of,  and  made  by  slitting  up,  tb«  sinuses  ibat  burrow  amiippi 
the  muscles,  and  is  then  carefully  dii«ected  out  from  tbe  pMla  vmattftt 
which  it  Mi's ;  es[>eciBl  cure  being  lak«u  to  prcvcrve  the  periaalcom  and  »Mf 
new  bony  dcposiu  that  may  aln-ady  have  been  formcil.  lo  one  case  m 
whinh  the  vIltDw-juint  was  involveil,  and  the  nuJius  disowed,  instead  »f  am* 
piitaiitig  tlie  limb  I  obiatut-d  an  excellent  result  by  excttifm  uT  the  anic»l» 
tlon  as  well  as  uf  ilio  afrL-et«d  booe.  The  jmiirnt,  a  hullder  about 
years  of  af^,  was  ahli>,  fnur  years  alter  tbe  otieratinn,  tn  use  hia  bai 
on])'  in  nil  llic  ordiimry  purpoees  nf  life,  but  also  in  hii«  trndr. 

The  Olecranon  has  been  nircea»futly  removed  in  sc.me  instAt)«f«:  for  db' 
«a«e  by  Birkett,  of  Guy's  Mospital ;  and  no  account  of  nou-uniuo  aAer  (no- 
tnre  by  'Xewman,  of  Stamford.     In  each  case  a  useful  arm  was  retaiiMd. 

Wrist. — Exmion  of  the  wrist  f^^rmerly  found  kM  favor  with  Sargnos 
tbao  the  removnl  of  other  joints.  The  objections  ra)se<d  to  it  were,  fir«,  ibai 
Id  caries  of  the  carpus  the  duease  very  ojlen  extends  rapidly,  with  great  ooa- 
•titutional  disliirhftnc(>,  t^'  alt  the  emAll  hones  that  enter  into  its 
Md  coniMHnieiitly  partial  oper:ttt<>ns  rarely  succeed  in  i-uriuK  ih*  di___ 
aod.BeconoIr,  that  owing  lu  the  su|>erficial  character  <>f  tht'  urti'.-ulatioo,  i 
its  oloae  couuvctiuu  with  the  lluxor  aud  vxteusor  t■.■o<l<>ul^  mvthudical  ofwra- 
tions  by  the  older  metltod^  wurt*  aluKjst  invariaLiiy  followed  by  a  stiff  and 
useless  band.  Tbe  «x[H;riui)L'e  <jt'  the  liut  twenty  yettrs  has,  bowevrr,  abtmo 
that  L'ljmpk'lti  eXcision  of  Ihu  carpus  with  tbe  lower  ends  of  th«  boDt*  wTtbt 
I'urvarm.  uud  tbe  baeve  of  the  nictururpal  boues  may  in  proper  cases  ba  uiKlvt^ 
taken  with  a  good  prosjiect  of  preserving  u  useful  hand.  1  had  a  rase  in 
lKr)8,  in  the  person  of  a  middle-aged  man  iu  whom  the  whole  carpua  ami  a 
portion  of  the  bases  of  the  metacarpal  bones  were  removed,  and  who  mw- 
ered  with  a  very  useful  hand,  with  some  power  of  flexing  and  oxtnuliog  ifat 
wrist,  and  with  very  considerable  mobility  of  the  lingen.  To  Hir  Jarpti 
Lister,  and  to  West,  of  Uirmingbam.  however,  is  due  tbe  merit  of  ucoTing 
the  praclicHbtlity  of  the  operation.  The  mode  of  operating  planDetl  by  ifas 
former  of  the^-  .Surgeons  will  be  dcwribed  here.  But  t^forr  giving  tkl 
details  of  ibis  operation,  it  may  bo  well  to  nKniion  the  priuciptrs  on  wfaieb 
it  is  founded.  On  looking  nt  the  mnvemcnts  of  the  wrisl-j'>int,  it  will  h«. 
seen  that  they  are  aomcwnat  limited  in  extent,  so  that  it  tolerably  fira 
flbraui  aokylosis  can  be  obtained  between  the  tower  coda  of  the  radiiu  and 
nlna  and  the  upper  ends  of  tho  ineta«arpal  bona.  Che  normal  amonnt  uf 
moTCOieDt  ia  maintained.  Should  these  movements  be  kol.  or  sbonid  lim 
onion  b«  so  loose  aa  to  necessitate  the  appticati'in  of  &  rigid  apparatus  to  mp* 
port  the  wrist,  th«  hand  may  still  be  perfectly  useful,  the  lost  inovrmeoi  ai 
tbe  wtist  IwtDg  supplemented  by  those  of  6exion  and  extension  at  tb«  elbow. 
But  the  hand  cannot  he  useful  if  tbe  flexion  and  extension  of  tbe  flopem  be 
seriously  interfered  with.  The  enenliiil  principle  of  Lister's  operatioD  is  to 
save  uninjured  all  tbe  tendons  concerned  in  tue  movements  i<f  tlie  Utomb 
and  tlngen.  If  we  look  at  tbe  tendons  that  surround  the  wrist,  we  sludl 
Sod  them  divisihlc  into  five  {{r'>uii8:  1.  Tbosc  siieciul  to  tbe  thumb;  2,  Tbs 
Bxt«DBors  uf  llir  lingers r  3.  The  llexorB  of  lb«  nngers;  4  and  A.  Tbe  «;: 
aors  and  the  flcxora  of  the  wrisc  Now  tbe  incisions  are  so  pfauiaed 
save  absolutely  the  whole  of  tbe  first  tbrea  grou]v,  and  to  divtda  only 


ftXCtBlON    or    WRIST — LtSTKIt's    OPBRATIOl 


389 


bttdiiat  of  lfa«  wriit  proper,  noi)  IfaTse  nre  cut  bo  clow  to  tlii-ir  ioBertions  that, 
m  a  rule,  tfaev  Amu  uew  aitacbmeaU)  and  resume  tbdr  fuuctii^is  la  recurery 
tmfcu  pUcf. 

lister's  OpeimtioiL — From  tbe  mult  of  two  cas»  of  severe  injury  to  tbe 
wnM-ioinl,  «bieb  ircnvereil  with  UHcful  tiaiiiU.  Lifter  wns  kxl  U)  lh«  uonda- 
Mk  lltM.  with  prutier  after-tn>atment.  Lhu  leuduoa  abijut  tbe  wmt  migbt  be 
PHT  fVoely  haodleil  wiUiuut  pvrnHtticot  siiflben  resulting.  At  tlie  same  lime, 
b*  Loped  by  remuving  tbe  whole  uf  the  cartilaginuuB  surfaces  tu  be  nliie  to 
pBTTCBt  rvrurrencc  nl  ibe  disease — which  is  the  common  ending  of  cases  uf 
pftftwl  ezrbion  of  the  wrist-joint  for  (*nries  of  the  rarpun.  At  tlto  time  wbeo 
at  poblisbvd  his  pajtrm,  lie  had  performed  the  o|>eni(iun  of  esci^i»n  of  the 
wriM  AfWn  titiini.  The  method  of  uperaling  was  eMCOtially  the  same  io 
all:  r»rious Binall  dvlaiU  bt>iugaltere<l  as  experience  suggesteu.  The  opera- 
tjott,  ■•  be  tinw  iM-rform?  it,  i*  done  u  fallows:  Before  commencing,  Eamarch's 
hinitay  and  i<>unit>pici  ahouM  be  applied,  iis  without  them  the  oozing  of 
Mood  mi«rfrrrs  considerably  with  the  operation.  Auy  adhcsiuua  of  the  ten- 
lioai  Umd  exntiag  must  be  forcibly  broken  down  by  moving  tbe  joints.    An 


ric.  BA4.— IHa«r»»  ^I   V,  rul.     A.  V*ep  Fi^.  ftO.— A.   IUJi>]  ArUr;.     Tt.  TnJna  of 

WmkmMt  Arvk.     B.  Tr>|HnUM.    0.  At'  Rtlwar  8«c<iBJi   iDlarooJlt   rullleU.      C. 

5«rf*M   uf    UlMk   OTM-   «ki«h  BxiMiMir  ItidUU.     I).   EilMMorCaninuBU 

mmtm.    <Luur.t  PiglMfiun.     K.   E«l»*i>r  Mi«tu>l   Pij|iii. 

y.  KiMKMr  Ptlmi  Inieraihlii  fulliid*.  a. 
BKt«n*or  Oulj  HMuftqit  fV>!1lcli.  Jl,  Bi- 
|sa*ofCMr|ii  ttHiolit  LoQfior.  I-  KilsDtor 
C^rjii  RaUUlia  Brvflor.     K.  BiUnkv* C^rpi 

(U*i«r.» 

M  BOW  made  "  from  about  tbe  middle  of  the  donal  aspect  of  the 
nthiB,  oD  a  level  with  tbe  styloid  pr\>ceBa,  downwards  and  uuiwnrds  towards 
tto  inacr  side  of  the  metacariM>-pbalaDgea)  ariiculaiioQ  uf  thu  thumb;  but, 
M  Racbing  ibe  line  of  tbe  radial  iHinlemf  the  melitcarpal  boueot'thc  index 
logtT,  it  te  carried  downwards  louk'ttudinally  for  half  the  len|;tb  of  that 
baM."  T^b  UmMoo  abould  coinmeuce  in  ihi;  an/le  firmed  by  tlie  ttMi'lims 
af  th»  ooanaoa  extensor  of  tbe  fini^<rs  and  the  extensor  st^rundi  intemwiii 
pallia*,  and  the  upper  part  shnuld  nin   parallel  to  tbe  latter  tendon,  bat 


890 


KXCisiON  or  joi^Tn. 


witbouc  injuring'  it.  The  tcmlon  of  the  cxt^nso  crarj^  radialis  brarior  vill 
be  rut.  but  tliut  of  tb«  lougior  will  «ecii|K<  fV>r  the  |irpM>ot,  aod  ibn  »o%\* 
furmeil  bv  the  two  |i«rl»  of  the  inoi»ii>D  shouhl  he  cloa«  to  lliv  ino«r  uiJ*  W 
ita  insertion.  If  the  firal  part  of  the  incidioD  Im*  carried  t(.>o  far,  tbvrc  M 
djiDger  of  vritundinj^  th«  railial  artery.  Th«  noA  parts  arc  th^n  to  be  md*- 
ntcl  oar«futIy  (row  the  bonw  on  tlra  radial  side  of  the  int^ioD,  lb«  teaa«H 
of  the  extenwir  carpi  radtalis  loDpor  being  now  cut  hb  cI<«<!  tn  il«  iuMrtioo 
BS  poesible.  The  tenduo  of  the  extensor  Kcuodi  interootiii  pnlliri»  asd  the 
radial  artery  are  (o  be  pushed  nulwants  out  of  the  way.  Tlie  tra|iextiiia 
Diu)<t  then  be  aeparated  from  the  re«t  nf  the  earpue  by  cutting  in  tbt  looKito* 
dinal  luirt  of  the  Incision  with  the  bone- for oejiti.  The  soft  paru  tax  the  Dlur 
side  ut  (Ik-  radial  incision  tire  now  Lo  be  dteacctcd  up  aa  far  as  eaa  be ' 
Tcuicnlly  dune,  the  remainder  bein^  railed  from  the  ulnar  iDeWon. 
tbia  is  being  done,  the  u?Ddon«  must  b«  relaxed  by  extending  thr  joiat. 

trapezium  le  not  to  be  removiHl  yet,  as  anv  auemnl  lo  diseect  it  iHit  b 

rotnoviiig  the  rest  of  the  rur|iu)i  would  enilangiT  tnc  rndiil  artery  and  lb* 
tc-ndon  of  the  flcxnr  carpi  radialifl.  The  ulnar  iocUion  is  nriw  Ut  b«  nadi. 
Tt  muBl  be  a  free  iDotRit>n,  commencing  at  least  two  inches  abfive  the  end  af 
tbe  ulna  und  imraedintcly  to  the  palmar  aspect  nf  the  Uior,  and  carried 
directly  downwards  between  the  fiexor  carpi  ulnarU  and  the  ulna,  and  than 
tiraight  on  as  far  aa  tbe  middle  of  the  palmar  aaprct  of  th«  fifth  ni«UC«rpal 
bone.  The  lendonn  and  mtH  parts  on  the  domum  of  tbe  carpus  are  now  lo 
be  completely  raised.  In  doing  tbi«  the  tendons  oitiat  bo  relaxM.  and  ibey 
are  to  be  railed  u  little  M  iweeible  from  the  radius  or  iiieia--ar{>u».  Tbs 
vxteiii-ipr  carjii  utnari^  i»  to  l>e  cut  «»  near  its  tn»ertii>n  att  (Kwible,  and  iba 
dorsal  und  iulernal  latvrHl  li^iniufiils  itmr  now  be  divided.  'J'hvii  lh«  #oft 
parts  are  to  be  miavd  from  llio  pHlmnr  sepecl.  Tlir  kuife  must  \*v  carried 
cloee  lo  the  ulna,  wt  as  not  to  wuiiud  the  artery  and  ner%'e.  Tlir  [linfMna 
boue  is  (o  be  ee|qim[irit  and  Wfi  alluchc-tl  to  tbf  Ifiidnn  i.f  tht-  llrxor  carpi 
ulnaris,  which  is  n<>t  lu  Im;  cul.  The  iK'xur  lendnns  are  to  lie  rBie«d  fnim  Ibf 
metBCiir|tiil  Ixiues,  but  in  doing  this  the  hook  of  the  unciform  boav  mtMt  ba 
clipped  ulf  with  (he  bonc-f<irre|ut,  and  rare  muHt  bv  taken  nut  tu  cut  baluw 
Un  Dasn  of  the  mi'tarar)Mil  btmi-K,  for  feiir  of  wounding  the  d««p  palnar 
arcfa.  Tbe  tendons  muxt  he  relaxed  during  this  [lart  of  tJte  iipcnoitia  bf 
flexing  the  writit.  The  bone-furceps  may  now  lie  intnMluceil.  first  bftvm 
the  rari>U5  and  radiue,  and  th^n  between  the  rarpuF  and  mriacarpus ;  by 
this  meaufi  I  he  whole  of  ihe  carpal  bones  (except  thn  tra{>rzium  and  ibr 
piriform  Iranc}  are  iie|mrBl<Hl  from  their  conoecttoDS.  and  may  U-  extiarfsd 
in  one  maiu  with  a  Inrce  pair  of  aciiuestrum-forceps,  any  baadi*  which  RUin 
tliom  being  touched  with  a  knife. 

Tbe  ends  of  the  radiuA  and  ulna  may  now  be  eniily  nrotnided  from  tbs 
olnar  wound.  If  on  examination  they  be  found  only  khirbily  diseased,  tbs 
ulna  may  be  sawn  obliquely  so  as  to  remove  onlv  its  articular  surface  sod  te< 
leave  almost  the  whole  of  the  styloid  prooen.  A.  thin  slice  mar  be  taken  olT 
lh«  end  of  the  radius,  sii  as  just  i/t  remove  only  the  cartilaginous  sorfaM: 
and  iiit  articular  stirliice  for  (he  ulna  mny  be  remored  by  cutting  lungiiudi- 
nally  with  the  bone-forcepa  or  a  chisel.  By  leaving  the  ulna  as  hiag  as 
possible,  and  by  Miving  Ihe  styloid  proccM,  the  tendency  to  divptaueownt  •/ 
the  hand  lit  the  ulnar  side  i-t  somewhat  cuunteracted.  Ifthe  bones  Im>  extes- 
stvely  diseaaetl,  the  gouge  and  bone-|iliere  must  be  used  freely.  The  next 
step  is  to  ex|Kwe  ihi*  Imw-s  of  Ihe  metacarpal  boti«s,  and  lo  treat  tliem  in  the 
lami!  way  as  th«  mdius  aiid  ulna,  M%'iiig  as  much  bune  a«  ptaaible,  b«C 
removing  all  carlilaginouii  vurfitci-)>  with  a  uurrow-blaitcd  saw.     Tbr  i 

and  third  arvt  nxwl  rsi^ily  protruded  from  the  radial,  and  the  fnurth        

fiflh  fmot  the  ulnar  wtKiuil.    The  lrai)ezimn  may  ibca  be  dlewetcd  oot. 


KXOlSloy    OK   THE    VBIST — XKTKK-TKilATM  KNT 


391 


E'  brid  in  a  itroDg  pair  of  forcops.  Id  dmog  thifl,  care  must  be  tttkeo, 
l»tit  !■>  Mound  tilt  rmtial  »rlvty,  which  is  iti  isUmk  relutioD  with  its  outer 
,  •n<l.  KTomHy,  not  lo  out  th«  tendtm  of  tlie  flexor  carpi  radinlis, 
h  li^  in  jt«  ^r>iove.  When  the  tmpeziutu  is  removed,  the  imte  uf  the 
tfMrt]K^r[>al  Urne  of  the  thumb  iimy  be  pushed  up  and  cue  off  with  tiie  bnne* 
plirn  of  ji  unall  mw.  It  \»  better  to  remove  it,  fu>  it  may  suffer  frooi  recur- 
rvnr*  iif  thtt  diseaM-,  ntid  by  lis  removal  the  thumb  in  rt'duced  io  length  to 
lb*  tmme  exteut  xs  the  tinfrers.  Lastly,  the  pisiform  bone  may  be  exannoed, 
■ad  cklter  removed  ciiiirply,  or  iU  cartilaginous  surfaiv  cut  otf,  as  the  case 
w^BJwa.  During  the  ojieratiou,  the  only  tendoiia  uccoHarily  divided  uro 
ibe  cxtcxMura  of  the  wrist.  The  flexor  i?»rpi  radialt^  mar  escape,  from  it« 
■tlMhini'nt  bctog  situated  low  on  the  ham-a  of  the  seonna  and  third  nitiA- 
CBraal  bones,  and  Uie  flexor  ulnnris  is  MX  utucbcd  to  tho  |>i8itbrui  bone. 
AJl  ibe  exl«moia  of  the  thumb  i>hould  be  uninjured.  All  the-  icudoos  necoa- 
Kriiv  divided  vast  be  cut  a«  long  as  p«iwiblc,  so  that  thvy  may  form  neir 
aUaobiDCSta  io  tiMinoet  advaaiagcoua  poeitions;  aurl,  in  raising  the  flexor 
■ad  ntlMHor  tendons  tb«y  most  be  disturbed  an  little  ns  poaaihle. 

AjtfT  trmlmimL — The  radial  wound  may  be  closely  united  with  auturM. 
Tb*  ulnar  wound  may  be  clcecd  at  each  end,  hut  the  middle  of  the  wound  is 
tn  ha  kcM  open  by  mrans  of  an  India-rubber  drainnge-tube,  to  allow  free 
exit  of  diM-niirgt.  Tlio  hand  is  Ut  be  plm-ed  on  a  splint.  The  nifist  conve- 
■ient  is  a  simple  wooden  r plini,  "  with  un  ohtnee-anj^led  piece  of  thick  cork  " 
mutk  rw  it  to  a-i  to  nminluin  ihe  hand  in  a  state  of  semillexioii,  with  the 
«riM  •licfatly  extended  ( Kit',  o-tti;.    The  thumb  is  flupimrtel  by  a  bar  of 


y:>- 


Fl|.  MS.— Ljmm'*  .^tiltnl,  wlUi  Cwrk  Suppuit  for  llsntl. 

ork  stnrk  on  thi*  under  surface  so  a^  to  project  at  the  »ide  (Fi^.  M7),    The 
Iwn  ii-  I  U  in  Rfti-r-treittrnvnt  are  to  got  th*"  finger*  perfectly  movable 

asd  <!  '  tirm.     Fur  th«»c  pur)Ki«e«  pa^ive  nii>ti>>ti  must  be  cumnienred 

IS  emrly  aa  the  lecond  day  iu  the  Aug(-rs,  each  being  bent  and  extended  every 


Plf.  a*;,— IImxI  kftar  ExelilMi  sf  Vriit.  Ui<l  ea  S)>lti»U 


4iy  fnllv.  while  the  itri*l  it  k>*|it  tirnily  i^n  the  itplint  and  iiiii|iirt>ed  a«  littlo 
■  MHifikr  during  the  ireatiiitiit  of  lh»>  fiui;eR).  Spvtrial  care  n>u«l  be  tuk«n 
In  wui  th«  ■Mtacarix<-(>hiil»tiL.'i-nl  nrtictilBiiung,  whi>'h  are  very  apt  U>  rt>iiiain 
atUt  PnKMtioa  and  ^npionliou  luutil  not  be  t>H>  long  uegki:t*'d.  I*aM*tve 
■naiiin  moat  be  mninlniueil  as  hmg  h»  there  is  any  leinl(-ucv  to  the  r>>rmatii)n 
if  aill'"*'""-  m  (hr  shrnths  of  tlii-  lendonB.  As  (he  hitnd  befuines  atnmiiter, 
IW  f^>  '■  splitit  mpiwrting  the  fiiigvre  may  be  cut  oB.     The  jwlient 

■: — •  .<  I.    anme  support  M  long  as  he  feels  any  weakunn  in  the  wriaU 


99% 


EXCISIOTT  or   JOIVTS. 


Tbcro  ii  oft«n  some  t«nHonoy  to  flr^ippinf;  of  the  wrict  to  the  nlnmraMl^ 
which  is  1>«1  cwjotewct^d  hy  a  jiniporly  cnslnicted  (^utu-pcrciui  qiltal. 
The  thumb  i«  apt  to  be  ilruwn  in  towanlt  ihe  iu(J«x  hn)c«r;  this  miu>t  W 
pKveoled  by  a  thick  pad  of  Hot  kcpl  from  tbo  earliest  litne  between  Uh 
two. 

Tbe  cwential  pointt  are.  Hrat,  exact  attention  to  all  the  detaih  of  IIm 
ojteration,  ftuii,  next,  a  careful  aQ<l  palieutty  conducted  after  •treatment. 

Besolt*. — Since  List<<r  detwrribed  iiia  nielhod  of  o|>eraling.  oxnifioo  of  tW 
wmt  for  diwaM  bus  become  »  recognized  operation  of  Surgery,  and  has  been 
pracUsed  Mjccesefully  by  West  (live  casm.  Uitleapie,  and  manj  olfaer  SuT' 
geoDi.  Id  military  surgerv,  however,  according  to  the  atetutkn  of  Um 
Aaeriean  war,  tlte  mulLi  ol*  the  operation  have  been  far  from  eneoarafilf 
ta  regard  to  the  amount  of  mobiliLy  let)  to  the  hand. 

Hand. — In  ihe  removal  of  duensed  or  injured  portions  of  the  hand, 
as  a  geueral  rule,  of  tbe  greatest  importance  to  sacrifice  as  little  i 
of  tbe  ur.healtby  or  injured  structures.  In  all  operaliooa  oa  Uw 
indeed,  wc  loust  nave  twu  great  principles  in  view — the  preMrvatkn 
utility  of  the  member,  aiid  tbe  maintenance,  so  fiir  us  practicable,  of  ita 
symmetry.  Utility  is  neccAsarily  the  primary  ooosideimiioo ;  bal  if  a  pan 
be  not  useful,  it  may,  as  in  tbe  case  of  tbe  bead  of  tbe  mIddU  oMMcarpal 
bone  in  amputation  of  the  corresponding  fincer,  be  nrriAced  for  the  parfMa* 
of  preMtving  the  symmetry  of  the  maimed  limb.  The  hand  in  the  oreaa  af 
jHvntfruMH  and  of  tayek;  and  in  all  operations  applied  in  it  we  ■boaiil  an- 
deavor,  as  far  as  practicable,  tn  mfliotain  its  «ffici«-ncr  in  both  th«M  rwpticfc 
It  b  also  of  importjince  to  bear  in  miud  th»t  two  i^rent  clawei  of  actioiM  can 
be  carried  out  by  thti  hand— thute  that  re<juire  force,  and  thoa*  that  raqnlri 
delicacy  of  manipulation  rather  than  itrenfftb.  By  a  surgical  ocwraCioa  «« 
may  tometim«8  succeed  in  preaerving  one,  tnough  we  are  compelled  to  sftcri- 
fioa  tlM  other;  and  in  thiii  n^pecl,  our  procetlure  should  be  a  jipKid  d«al  io- 
flueDC«d  by  the  occu|>ati<iu  of  Ihe  patient.  Thus,  by  prirtial  exctaiuti,  we 
may  leave  a  linnd  that  would  enable  a  i-lerk  to  hold  hts  pen,  but  which  wooM 
be  almcet  uaelcae  to  a  laborer  or  blacksmith. 

In  looking  at  the  hand  from  a  surgical  uoini  uf  view,  we  may  cunridsr  k 
as  being  oompoeed  of  two  constituents — the  hand  pru|>er,  and  the  f%smh: 
the  tbuiob  being  an  Accessory  to  tbe  band,  and  un  oppoaeat  Io  the  mt  dT 
tbe  niemltcr,  without  which  it  is  eusceplible  of  a  cum  para  lively  limited 
utilitv.  Hence  the  thumb  is  of  equal  im|H>riance  to  the  rest  of  im  hand: 
and  ine  pruiervaiiou  of  iti^  three  bones  is  as  much  to  be  coosidefvd  aa  tfaat 
of  Ihe  remaining  fixteen  thnt  cnliT  into  the  confnrmulion  of  tbe  metaeBrpOi 
and  fingi'ni.  In  all  uisiii  of  injury  or  ili^eaw^  implicating  the  thomb, ' 
effort  ought  tn  Iw  inadt  for  it;i  preservation.  Kven  if  il  lie  left  stlffeoeri 
inraiMible  of  tt<>xion,  it  will  l>e  a  most  lu^fnl  opptmrnt  to  the  rest  o 
haml.  Hhonlil  it  lie  found  neccwnry  to  flborten  it,  care  muRt  be  taken 
juf  Utile  i-uriiiilment  as  poaBible  be  praciiHcd  :  a  portion  of  a  nlialanx.  nr  to 
mc'tnitnrpul  iHtne  even,  is  uf  essentin)  utility  in  giving  t>lrrngln  and  breodtk 
to  tbe  gnuip  of  the  hand.  In  eases  of  diwAM'.  a  very  nsefiil  m^^mber  may  hr 
left  by  the  removal  of  a  [>ortiua  or  tbe  whole  of  the  nn^nnl  pbnlnnv,  of  tb* 
metm^rpo-phnltingettl  arliciiiHtion  or  even  by  tbe  excision  of  tl>c  nwtat^rpa) 
bone,  the  jdialuugrs  I>ftng  left.  Tlieee  ^*anni)s  opi.-rH(ions  are  easy  of  fi«r< 
formnnri,-;  an  inrwion  tbroiigh  (he  dii'cafcd  and  (ii»<irganixed  soft  [>*rtB  mUI 
expiiec  the  necrxised  )>one  or  carious  joint,  which  must  be  removed  by  cutliof* 
plier*  or  a  narn>w  uiw. 

When  the  thumb  Iia»  been  f-jrced  back.nr  badly  lacerated  by  |Mi«iIer.Qaak 
or  gUQ-liarrvl  L'Splwiuus,  it  may  oRvn  tie  enved  by  being  rvpluccii  and  main- 
tained iu  (waition  on  a  splint,  with  sucue  form  of  aotiwptio  drasaing  nppUad 


■od.  should  Hiu|iutiiLion  be  required,  it  ruut<t  be  done  io  nccordance 
tbe  rule  jtut  itieiilioDtHl — of  saving  an  tiiucli  as  poeaible  of  the  injured 

!■  tlM  oonMmiiTe  surf^nr  of  the  Fagm  the  pmerration  of  flcxino  and 
txtanriao  in  the  p«rt  ltd  is  the  main  Lhine  to  be  aimed  nl ;  a  rigid  Bturup  is 
alvmn  in  the  way.  The  presorvatiou  of  tneM>  luovemontd  hccomi^  more  im- 
partanl  in  pntportion  014  toe  palm  i^  approached.  It  is  of  more  cooscqu^nre 
lJ»t  Um  proximal  phalanx,  which  carries  the  ri^t  with  it,  should  be  cupuble 
•f  baiag  bent  into  tbe  palm,  tlmo  that  the  diHtal  can  he-  t^excd  on  the  wcond. 
If  tW  pff^ximal  phalanx  ran  be  bent  dowu,  a  very  nmall  dcj^ree  of  move- 
in  the  diaui  one  will  be  sufficient  to  furnish  pliabiliiy  enoujzh  in  the 
to  make  it  a  uwfut  member  ;  but  if  the  proximal  one  be  utitfened,  no 
■nt  of  niiibility  in  the  diatal  phalanx  can  make  it  UKeful. 
!■  pmervin^'  rhi-oe  movemeot«,  it  is  neoef^ary  to  be  particularly  careful 
•f  tb*  aheaili*  *>f  the  tendons.  If  they  be  in  any  way  opened  or  injured,  It 
«iU  ^family  he  found  either  that  the  tendon  i^loughg,  or  that  it  become* 
■dbwcDt  to  ila  iheath  in  such  a  wajr  tbot  all  moventeat  is  lott,  or  at  least 
41  Ml  It  impaired. 

Tba  only  phalanx  that  can  be  excised  with  advantage  is  tbe  distal  one. 
1%  often  happens,  in  the  destructive  disor^auizatiou  which  results  from  whit* 
Inw.lluit  this  oeeniMw:  when,  instead  uf  aiupulating  tbe  end  of  the  linj^'cr,  it 
amy  ba  remaved  by  au  incisioo  on  its  patiuur  aspect.  Disease  of  tht;  plmiau- 
gw  artienlatioDS  uiually  K'ads  to  amputation  of  the  aflected  finger.  The 
rain  Sir  peHfarmiog  ibrao  variouit  n|ieralii}UH  hard  already  t>ccn  laid  down 
«  mk  IM  e<«Pf.,  vol.  i.,  m  which  I  inuHt  n-fL-r  the  readpr. 

KoaectifNi  of  lh<!  Xetacarpal  Boae.  cithtrr  of  the  thumb  or  index   Bnger, 

villuMit  the  removal  of  the  c«irn«[Mmding  digit,  h  orca-tinniilty  ri-ipiired, 

■on  particularly  in  raitea  of  injury  ;  it  may  readily  lie  done  by  miilcing  a 

IwgiUidinal  inriBinn  over  the  donial  asjiecl  of  the  bone  to  \te  removed,  rare- 

falfr  /iMachini;  it  fmni  surrounding  parts  hy  kcepinj:  the  edge  of  the  knife 

.igainst  the  hone,  aviiiding  the  tendunit,  nnd  then  either  disartictdating, 

-'  ••  pfrfi-rahlr)  cutting  acrtWB  the  neck  of  the  carpal  end  of  the  bone, 

->ut,  and  M'parating  it  from  any  distal  attachments  which  it  may 

AHer  the  n.-ini)va1  of  tbe  m<>tacAr{>nl  boue  of  the  index  finger  in 

'^ay.  but  little  dcfnnuity  results,  and  a  very  useful  hand  will  be  left, 

'  <rly  in  children,  on  whom  I  have  more  than  uDoe  had  occasion 

-  partial  resection  with  success.     If  the  periosteum  b«  saved, 

lie  to  sume  extent  reproduced,  hut  iu  orilcr  luobtuio  thi;^  result 

!'■»  k'^p  1h«  finger  drawn    forwards  by  au  elastic  extending 

liL>  first  phalanx  from  being  pulled  bock  oa  to  the 

:.itachi.'d  tu  it. 


COMIKRVATIVK  8VROBRT  OF  THE   I-OWKR   KXTRFJJITY. 

il  coaservaltve  nperallona  that  are  practised  on  the  lower  extremity,  it 
'nttal  ttii[>irtBt)ce  thai  n  goml  basis  of  suppon,  of  sutlicient  length 
----   bf  left  In  the  body.     ThcM-  operations  differ  thus  in  some  im- 
r»  from  thi*o  that  arc  practised  on  the  upper  extremity.     In 
r>r>.'rvnt)iin  n(  the  baud,  even  though  in  a  mutilaleil  ci)Ddi- 
.,:  :iT  which  the  Surgeon  aims;  ami,  providwl  this  be  attained, 
it  cm:  ;>aralivclv  little  bow  much  the  arm  may  bo  shortened  or  im* 

aairr.  t  ■  r.     In   llie  lower  extrennty,  however,  strrngtb,  Irngth,  and 

fofiji'  >l  to  the  {>ntieni'«  comfort  and  utility,  and  unless  these 

aa  b*-  -  inten-xts  are  bt-tter  served  by  tbe  removal  uf  the  limb. 

Mad   tbe   adajitatioo   of  sumo    artificial    contrivance,  ttion    by   leaving   a 


Id 
iiof  « 
Ottd  f^r 

frwta- 


8M 


rclSION    OF    JOINTS. 


Bhortrnert.  wasKsl.  nnd  crippleit  m«mber,  which  is  unequal  to  sapport  the 

Hif-joiVT.— Kxcbton  or  the  head  of  the  thigb-bcme  has  of  lota  ytam 
been  H  K<K>il  (leitl  |irnctiM!(l  in  mm?  ciucit  of  hip-joint  diMMe.  Thai  npwv 
tiitn  tnnv.  titm«v4>r.  nxwt  cooveoieDily  be  oonndared  in  AonnMitioii  with  that 
ftlTtM-linii  (Cha(il«T  Lfl.). 

KxKK. — KxciBtmi  ot'the  kno*-jninr;  wan  uritiimlly  perfttrmrd  at  th*  ck« 
of  the  IftHt  [-trnttirr  \>y  Pnrk.  Fiikiii,«i)cl  the  >Ii>n^ui»,  but  it  fell  intu  tltflfiiror 
until  it  «M  revived  in  I860  by  Fergtueon,  aince  which  Itmc  it  baa  h*to  axtcft- 


ft|-  M'. — Tbonaf'*  Rn**-(p1lBt. 


rig.  Ut>.-TI>9MM^«  KHv^pUM  AnM. 


8iv«ty  pnioilAcd.  Durini;  the  lut  few  yrarv,  >iu<x*  the  operation  has  bvca 
robblni  of  miiDV  of  iu  dHtigera  by  the  tinprovn)  mcthotU  of  treating  wovnJ*. 
It  bad  bi^n  purformod  more  frrqiicntly  ibnti  ever,  and  with  ftlea<)i)y  iniprav- 
loa  rr«1ilt«. 

Excision  of  the  knee  hi  tiodertukcn  in  the  great  majority  of  cawa  for  «hit« 
iw<?llii](;  of  the  joint,  hut  SurKci'Dt  difTcr  cuuxiderably  m  to  tbs  period  at 
which  ihp  opvmtioo  thoutd  bo  |M.'rJ<jrmed.  All  are  anvcd  that  I 
the  upper  lud  middle  chuwei,  and  io  country  praciice,  it  vnould  be  ein| 

only  as  a  Ia«t  rcaource.  ••  a  vubititute  for  HiDputaUun,  when  all  other  :      

have  iHik'd  to  cure  tbo  dtMaie.  Oo  iho  other  band,  many  -Surffeou*  haT* 
bceome  bo  dtaheartened  with  repeated  failure*  to  cure  wbila  iweliing  of  tbe 
kne«  io  the  children  of  the  poor  of  large  cities,  that  Lboy  bare  reaorted  to 


rfMA 


WUITE    SWKLLIKO    Of    KNEK — TBKATMENT. 


895 


MOMoa  at  s  T«rf  mrly  pen<xl.    It  is  not  wise,  however,  to  aOopt  a  uuifbrm 
Bodvof  trattuwDt  fur  all  OMca;  eacli  ehtiuhi  b«  juilgej  dd  ite  uwn  mt;rits. 

Tb*  IfWtowni  ijf  a  i-ase  uf  while  8welliDj;uf'lhe  kneeshouiil  Iw  cuiidticLeil 

■I  the  prinriplcs  already  laid  down  <  p.  STt'I) ;  but  a  brief  skeloh  of  the  points 

VsTitt^  spi-dal  reference  tu  tliia  jiiint  may  not  be  out  of  place  here.    Fn>m  Uie 

arlicM  stage,  perfect  rt«t  of  the  joint  is  eeeeotial ;   witliout  this  there  is  no 

hape  of  care.     Tbia  may  be  obtained  by  the  Application  of  aonie  rigid  appa- 

the  ptaBli'r^of- Paris  or  starched  bnndnf^.  renching  from  the  fold  of 

f  to  the  torn,  the  pelicnt  being  alloweil  to  move-  alinut  on  crutolitv, 

II  putting  the  foot  to  the  ground.     The   most  efficient  npiuLrntu^  is, 

the  simple  sod  ingenious  splint,  invented  by  H.  O.  Thomns,  of 

Uvarpoal  (Elga.  6-48,  549).    Besides  giving  the  mrist  perfect  rest,  this  hn«  the 

ptat  ajfanlue  of  learing  the  joint  expikaed  sl^  that  tlie  etfei^ls  of  the  treat- 

mmteam  be  ouerved,  and,  at  the  same  time,  it  enables  the  [wtient  to  move 

ahiMil,uiQ  Fig.  549.     The  flpiiarfltua  con«Bts  of  a  well-paddod  iron  ring, 

cwCRil  with  JL-athcr,  from  which  an  iri>n  rod  extends  downwards  on  each 

Me  «f  the  leg,  termitiatiog  iu  a  second  ring  at  the  lower  end.     Attached  to 

Me  «f  the  iron  rods  w  a  piece  of  tfofl  leather,  which,  when  the  splint  is 

mlWd,  mar  be  brought  up  behind  the  limb,  and  secured  to  the  other  rod  br 

m^  fb)de(I  over  it  and  fixed  with  strong  pios.    This  leather  is  not  esseatial, 

■■d  n  cBao5  ceiea  the  limb  cao  be  lietter  fixer!  without  it.     The  ftjot'piece 

'■^Ptwuled  in  Ki|^.  519,  M9.  is  required  only  when  the  splint  is  used  to  fix 

^  Kmb  ailer  excision  of  the  joint ;  in  other  c«8os  it  is  not  only  useless,  but 

i*J*iiwk     In  ordinary  cnscs  iu  which  the  limb  is  tolerably  i^lraight,  the 

9VMtus  is  thus  applied  :   The  ?plini  mui>t  be  of  such  a  leugtli  as  to  extend 

''^tluwD  to  four  incheg  beyond  the  fooL     Two  striits  of  strong  strapping 

*'^H*|MU«i  of  suffictent  Ivugth  to  reach  from  iminolintely  helovr  ihn  head 

"'lartiUa  [a  oae  inch  beyond  the  S'lle  of  the  foot;  to  one  end  of  each  of 

IW  a  stout  tA{ie  is  firmly  sewu.     The  atri|)«  arc  (hoo  applied  u>  the  liideKof 

tWli^  iIm  tapes  being  below.     To  give  ailditional  Hecuriiy,  srmie  nnrmwer 

tt^aam  be  wound  Kpiraily  round  the  leg,  care  being  taken  not  to  appiv 

Ibai  ciraUaHv,  or  with  tuflicient  tti;hMi«iq!  to  constrict  the  limb.     Over  all, 

•  laBDrl  haoffflgc  mav  he  nppliLNl  t'rom  the  ankle  to  the  upper  end  of  the 

Ada.     The  >tri)n  of  pfuster  thus  upplied,  if  of  proper  quality,  should  retain 

liwir  bold  wtthuutRhifUngfor  many  weeks.    The  limb  is  then  pascal  ihroitgh 

1^  uppt^r  ring  of  the  uplinl,  whirh  h  ptiihed  upwflrd.4  till  it  gets  a  lirm  bear* 

iajf  acainst  tiie  luhmMity  of  the  i.<)ohium.    The  flplint  t»  then  secured  lu  )x«ii- 

tifm  bv  tvtuir  ihi-  Ui\w!i  altnched  to  the  iitri|is  of  plaster  to  the  ring  nt  the 

K  i  til.     It  is  not  intended  in  so  doing  forcibly  t"  extend  the 

!  :  :  retain  the  upliiit  »t<-n<lily  in  (•'•oition.    If  the  patient  is  to 

«alL  iiot.  it  i*  iK-itrr  tolmvea  bur  fixed  ncrose  between  the  two  ver- 

tiaai  I  III  -tir  inch  nbove  their  lower  ends  to  wliich  the  tapes  c»n  W 

■wl*  fast,  '    I"  I     "•:  they  lire  quickly  w>>rn  through.     The  liuib  l>eiiik'  thos 

Im«J  !'.miiiiu(iir. :tHy,  lateral  and  anlcn>-i>o»lvri"r  movements  are  prevcntwl 

L  '  Mul  flrip  of  tilosler,  about  three  fevl  lung  and  three  to  five  inches 

a — ^ ,     ..•'  to  be  Npplieil  to  the  middle  of  tbe  Ihigb,  and  the  other  to  the  leg 

■pporite  tbe  calf.    Tht-Etrip  of  plaster  is  first  fixed  to  one  of  llie  lateral  ro^lc, 


af  th 

hlaiBlr^^' 


rer  or  under  the  Itmb.  and  liauk  to  (he  name  bar,  lite  remainder 
-in;;  wound  round,  including  iKith  linrs  and  the  limb.  The 
»  then  Hpplifnd  iu  the  same  way,  but  is  fixeil  lo  the  opposite 
A  broad  Htrip  of  Itandageor  plaster  ift  then  applied  behind  the 
kaaa  betwero  the  two  lateral  nKU.  s-o  Hf  to  HUpjfrt  the  ham.  Tbii^  h  not 
■anaiKrv  if  the  lenthcr  t''  fived  lo  the  splint,  as  in  Fig.  .'>4H.  T^atly,  a  flan- 
••1  hamlagf  ir  lied  from  the  tivex  to  ilii?  groin.     If  properly  put 

ap,  tbe  a|)|ian>.  .  requlrechanging  forsonte  neeka;  thelaiKsmay 


890 


J01XT3. 


injuring 


The  tendon  of  the  cxtcnso  crarpi  radialis  brevmr  will 
be  cut,  but  Ihiit  of  the  loTigii>r  will  r^cRpe  for  the  preitrnt,  ntid  the  angle 
formed  by  the  two  porta  of  the  inciftioii  should  be  close  to  the  inner  side  of 
it*  in»erlinn.  If  the  flrst  part,  nt'  the  inmion  he  rarried  tno  far,  there  is 
dau£:er  of  wounding  (he  ra<Iial  artery.  The  soft  parts  arc  then  to  be  sepK- 
raletl  carefully  from  the  bonts  on  the  r&diul  side  of  the  inci^itm,  the  teonon 
of  the  extensor  carpi  rndialis  louginr  bein|>  now  cut  as  closft  to  it«  insertion 
ae  p«)«8ib)e.  The  tendon  of  the  extensor  secundi  interni;dii  pnllicis  and  the 
rndiaL  arlery  art>  to  be  pu»hei.l  outwards  out  uf  the  way.  The  irajieziuTn 
muet  tlit^n  be  «ep»ra(e<l  fruTti  l\w  rest  ot'ttie  corpus  by  ciittin^r  in  the  ton);itu- 
dtnsi  part  of  tlie  incisiou  with  th«  bone-furcefw.  The  toil  parta  on  the  ulnar 
eidv  ut  the  radinl  iuciiiion  arv  now  lu  be  dieeectcd  up  kh  fhr  »«  cau  be  con* 
veuicutly  'lucte,  the  reniKiud«.'r  bvinj;  raitted  from  tlic  ulnar  iuciiiiou.  While 
this  is  iwiug  done,  the  tvudoni:  niual  be  relaxed  by  vxluuiliu);  thw  joint.  The 
trupeziutii  18  not  to  lie  rurnnved  yet,  aa  auv  attempt  to  diwccL  il  out  heluro 
reraioviug  the  rest  of  Ihc-  c-urpun  would  euilanfitT  the  radial  arterj'  and  the 
tendon  of  the  Bt.'xi>r  carpi  niiiialiti.  The  ulnur  inctaion  is  now  to  be  made. 
It  miiot  be  II  t'rve  iniriMtou,  cmiitnencin^  at  least  two  inches  above  the  end  of 
ihe  ulna  anil  immediately  to  the  palmar  a»|}ect  of  llif?  bone,  ami  carrkd 
directly  downwunln  liutweeti  the  flexor  curpi  ulnarit)  and  the  ulna,  and  then 
Straight  <m  an  tiir  as  the  middle  of  the  palmar  aspect  of  the  i\t\i\  meliicarpal 
bone.  The  tendimH  and  eoft  parts  on  the  dorsum  of  the  c»rpu8  are  now  to 
bo  completely  ruti^od.  In  dobi^  thin  the  tendons  iiiuftt  be  relaxed,  and  they 
are  to  be  raJRi'd  a»  Itllle  an  tiu'sible  from  the  rndiue  or  melncarpus*.  The 
extensor  carpi  ulnart.-*  \^  to  be  cut  as  near  itfi  insertion  ne  pdnsible,  and  the 
dorsal  and  internal  lateral  lipiments  may  now  be  ilivide<l.  Then  the  eoft 
parts  are  to  be  rai6e<l  from  the  pnlmar  aspect.  The  knife  must  l>e  carried 
close  to  the  ulna,  so  as  not  to  wound  the  aiicry  nnd  ncrvo.  The  plsitorm 
bone  is  to  be  separated  and  Ic-f).  nitaohed  to  the  tendon  of  the  flexor  cnrpi 
ulnarifl,  which  is  not  to  be  cut.  The  flexor  lendons  ore  to  be  raised  from  the 
metacarpal  bones,  but  in  doing  tbia  the  hi>ok  of  the  unciform  bone  must  be 
clipped  off  with  the  bonc-force|!«,  and  care  must  be  token  not  to  cut  below 
the  ha»*(t  of  tho  metacarpal  bones,  lor  fear  of  wounding  the  deep  palmar 
arch.  The  tendons  must  bo  relaxed  during  tbia  part  of  the  ojieralion  by 
flexing  the  wrist.  The  bone-forceps  may  now  be  introduced,  first  between 
the  carpus  and  mdlus,  and  then  oetwccn  the  carpofl  and  rac-tacar|H]» ;  by 
this  means  the  whole  of  the  carpal  bones  (except  th<^  trapezium  and  the 
piriform  bdoc)  are  separated  from  their  conneclions,  and  may  b(>  extracJed 
in  one  mass  with  a  large  pair  of  sequestrum-forceps,  any  bands  which  retain 
tb'cm  being  touched  with  a  knife. 

The  ends  of  the  radius  and  ulna  may  oow  be  easily  protruded  from  the 
ulnar  wound.  If  on  examination  they  be  found  only  tdighlly  diseased,  the 
utuii  may  be  sawn  obli(]uelv  so  as  to  remove  only  its  articular  surface  and  to 
leave  almost  the  whole  of  tlie  styloid  process.  A  thin  slice  may  be  taken  off 
ibc  end  of  the  fRdiui!,  so  as  ju!<t  to  remo^'c  only  the  cartilaginous  £urfat;e  ; 
uid  its  articular  siirface  for  the  ulna  may  be  removed  by  culling  loogitudi- 
nallv  with  the  bone-foreeps  or  a  chisel.  By  teaviug  the  ulna  as  long  sa 
p(ie«lblc.  and  by  saving  the  styloid  process,  the  Ccu<lcncy  to  displacement  uf 
the  hand  to  the  ulnar  side  is  somewhat  counteracted.  II  the  boDcs  be  exten- 
uivelv  diseased,  the  gouge  and  hone-pliers  must  bo  utt(t<l  freely.  The  next 
step  ts  to  expose  the  bases  of  the  melacarfial  hones,  and  to  treat  thcni  in  the 
aaniif  way  as  the  radiui^  und  ulna,  caving  as  much  tiouc  as  |Hieaible,  hul 
removing  all  cartilaginous  i^urfact-s  with  a  narrow-ldiulwl  saw.  The  second 
and  third  arc  most  easily  protruded  from  the  radial,  and  the  fourth  and 
fifth  from  the  ulnar  wouuil.    The  trapezium  tnay  then  be  dissected  out, 


BXGISION    OF   ENBE-JOINT.  397 

loaas  reaalting  from  old  disease  or  injury,  by  which  the  limb  has  been  rendered 

Opsr^OB. — Excision  of  the  knee-joint  may  be  performed  my  making  a 
hoisc>boe  incision  with  the  convexity  downwards,  commencing  at  the  side  of 
one  condyle  of  the  feraur,  and  passing  immediately  above  the  tubercle  of  the 
tibiA  to  a  corresponding  point  on  the  opposite  condyle  (Fig.  550).    By  Uiis 


FIf.  990,— Elliptical  iDcliion  In  Bxoiiioii  of  the  Knee-joint 

ilkeiiioB  the  ligamentum  patellse  ia  divided,  and  the  patella  turiieJ  up  in  the 
^iptical  flap;  the  crucial  ligaments,  if  not  already  disorganized,  are  then 
*">  be  cat  across,  any  remaining  lateral  attachments  divided,  and  the  bones 
dared  for  the  saw.     In  doing  this  the  limb  must  be  forcibly  flexed,  and  the 
hife  carefully  applie<l  to  tiie  posterior  part  of  the  liead  of  the  tibia;  for  this 
purpose  a  blunt-pointed  resection-knife  is  the  beat.     The  articular  surfaces 
most  DOW  be  sawn  off.     This  may  be  done  with  Butcher's  saw;  but  in  order 
to  insure  a  perfectly  smooth  sectiim  of  the  bnnes,  mauy  Surgeons  prefer  to 
use  a  common  saw,  somewhat  broader  than  that  ordinarily  employed  in  ampu- 
UlioDs.    The  lower  end  of  the  thigh-bone  sliould  first  be  removed.    The  saw- 
cot  may  safely  be  carried  from  before,  backward,*,  or  in  the  opposite  direc- 
tion, as  there  is  no  danger  of  injuring  the  popliteal  vessels.     It  must  be  made 
iccurately  at  right  angles  to  the  shaft  of  the  femur,  in  the  anteroposterior 
direction  ;  but,  in  the  transverse,  it  should  be  parallel  to  the  articular  surface, 
that  ta  to  say,  the  inner  side  must  he  left  slightly  the  longer,  as  the  internal 
eondyle  is  naturally  lunger  than  the  outer.     If  the  condyles  retain  their  nor- 
mal shape  it  is  not  difficult  to  judge  the  proper  angle  at  which  the  saw  should 
be  held  ;  but  if  tbey  are  extensively  and  irregularly  destroyed,  the  following 
guide  may  be  taken.     The  patient  lying  flat  on  his  back,  the  thigh  is  flexed 
to  a  right  angle,  and  adducte<l  till  the  inner  sitle  of  the  knee  corresponds  to 
the  middle  line  of  the  body;  the  saw  is  then  tube  held  parallel  to  the  surface 
of  the  table.     A  thin  slice  is  next  taken  off  the  tibia.     It  is  usually  recom- 
Deoded  to  cut  fnmi  behind  forwards  (Fig.  551)  to  avoid  wounding  the  pop- 
liteal vessels;  but  if  ordinary  care  be  taken,  there  is  no  risk  of  doing  this, 
Bod  it  is  more  convenient  to  saw  in  the  opposite  direction.     The  section  must 
be  accurately  at  right  angles  to  the  shall  of  the  tibia  in  both  directions. 
It  ham  been  recoiDmended  to  saw  the  tibia  concave  and  the  femur  convex, 


EXCISION    or   JOINTS. 

Q^g  a  BuichcrV  mw,  biii  it  is  diffictiU  to  do  Ifain  m*  llmt  tba  bonoi  ihall  fit 
iocurstely,  ntnl  llif>  mf^thnd  iire^enbi  no  advanuige  over  the  onltowv  var  of 
Operntine.  Cam  xuu»t  bo  takf^n  tt»t  to  remove  more  <it'  Ibe  Ikuw*  tms  b 
■motiitely  neci^-uiry,  fniM^ciallj  in  joiiti);  subjects,  Ir^t  iho  etiiphvMf  be  ana- 
p1et«ly  renmred,  an<)  the  f^rnvilh  of  ())<>  limb  inurffi^il  with.  It  i»  lutiallj 
«uffici«iit  t«  remove  from  one-third  to  three- fourths  of  an  inch  "•"  •'"■  »'*J«. 
aud  about  one  inch  or  an  inch  and  n  half  of  the  thi^h-hone  tV 
653}.  Ill  voung  (.-hildreu  the  ends  of  the  bone*  can  »onietim<4  he  i>i 
a  knife,  Hud  the  amouai  taken  away  acctiratcly  limited  U>  the  dt^^ 
It  Dot  uuTrequenlly  happvofi  that  carious  cavitiv*  are  fuuad  ext'.n 


\m^-.  "^T 


■1. 


Fit.  ill.— !.*«•(  B»>l  mt  S* 


Pic.  ui< 


IXfA  at  Tibia. 


fig.  MX.— l>pw  Kn4  •(  T>W> 


the  lerd  of  the  Miction  ihni  \\i\»  Wn  made;  when  ihio  io  thtr  en#i,  it  U  bottcf 
to  apply  the  i^itu^  t^  th^m  than  to  «aw  the  botM  below  thvir  IpvcI.  f^btwld 
the  o|>eratioD  b«  perrurmed  for  ilororruity  coDBeaucDl  u[M>n  badly  mdciord 
IVanturtt  or  di«I^Jti<>na  about  the  knee,  a«  baa  oeen  donn  Miccnafutly  Hi 
Humphry,  of  Camhridji^-,  it  may  be  oeoMMiry,  to  order  tu  briu^'  the  limb  mto 
gowl  pusitiun.  tu  remove  a  wedge-shaped  pi«c«  fn>m  uuu  of  the  b^iuca. 

If  tlie  patella  be  nuioli  dtaeawd,  it  luusl  be  rviuoved  :  if  it  be  ualy  Bltxbtiy 
cuious,  it  may  be  scraped  or  gouged  out;  aud,  if  healthy,  iu  acouriuum 
with  that  principle  uf  coiuervatJve  surgery  by  which  no  Houud  part  n  i*- 
movcd,  it  Mioiild  be  left,  becoming  consoiidnted  with  and  strejiL'  -  )ht 

juiuL     The  articular  surtacv  of  the  patella  un  the  ihiffh-bune,  Hi:  udl 

aome  way  up  it«  furepart.  may  advanta^msly  be  atict-d  off*,  ao  na  to  l«av* 
an  aneotUBurfafw,  iuatead  of  a  cariilaglnoue  use,  Inr  the  atudimttit  uf  tb* 
patella. 

I  have  always  found  the  operation,  as  it  has  jiuat  been  dcMsribed,  uaif  of 

(lerformanoti  uiitl  f;<»t>d  in  ite  reaults ;  but  varioua  modificatioiu  •raadMlld 
ly  dilPerKot  8ureeoiu.  Thii«,  ft<ime  make  one  straight  transrer*^  tnchina; 
othrrB  two  parallel  incisions,  one  on  each  Mdc  of  tbe  patella,  or  au  H-*>ba[vu 
incision,  iiml  thus  open  the  articulation  from  the  side.  Jooet^  nX  Jcnev, 
who  hod  great  experiencB  id  this  operation,  advised  that  the  skin  bs  fm> 
•ected  up  by  roeans  of  a  semilunar  incisiun.  and  then  that  the  UginnataM 


J 


IXOIBIOir  OF    KNEE-JOINT.  898 

td  by  bring  pushed  with  the  pnti^lla  and  the  quadri<*«p(i 
I  oiif  ftiJc,  tl)^  joiDt  llioii   iifMfii«il,  Mild    (h«    Unura   fhwq. 
CMbsft  mdvtw  ibal  lb«  |>iitelU  bo  nlwnyif  rvinovvd.     Vulkniann  reconiDieiidis 

■  atmigbt  incinuD,  pawing  t'roru  oue  cuudylv  uf  lb«  femur  U)  the  other 
trmaart^ntily  ncroM  ib#  taiddle  ol'  the  juilella,  which  is  then  sawn  through 
•o  aa  to  expow  lh«  joial.  Aftvr  Ibe  articular  endii  of  the  /«fniir  and  tibia 
bars  b««a  remored,  the  fra^menU  of  the  patella  are  tiuited  to  each  other  by 
mdarm  of  utfrut.  carbolimi  silk,  or  wire.  II'  its  articular  surl'ace  is  dta- 
fMed,  it  mu«t  be  sliced  ufl  ur  scraped,  The  reaultd  obtaitied  br  this  niPthtid 
AT*  vcrjr  guod;  th«  paldla  readily  utiites  br  bone,  and  either  romaitta 
aovmbla  or  beootDca  fixed  to  ibe  femur.     The  nttnchmeul  vf  the  quadriceps 

■  llmtfir  and  ligaiuentum  putellie  being  undisturbed,  the  tendency  to  dis- 
jttmaaA  aS  the  tihm  bnckwanU  alter  the  operation  'i»  cuunteraned,  and 
in  vslkinj;  the  arlioa  of  the  rectus  iu  brining  the  Hmb  forwards  is  pre- 
asmd. 

K.  Dftrr,  of  tbe  Weaunio^ter  Il'^epilal,  has  very  iDf;eninu?ly  and  bucccm- 
hiif  modl6Ml  tlie  opnmtJon  of  excision  of  the  knee-joint  br  unuinf;  the 
boMft  on  the  "Tenon  and  ^lorlice"  principle,  thus  eecurine  more  solid  bony 
Alil^laitai.  He  cuts  the  end  of  the  femur  into  a  wedge-«hapc,  cuaatitutinv 
tbe  icaoD,  and  cots  nut  a  mortice  in  thij^  upper  cud  of  the  tinia,  Jnt^  which 
tb«  wwlga  shaped  «od  of  the  femur  is  driven,  and  maintained  with  absolute 
fixitT  br  nwaos  of  a  wire  aniint  with  foot-piece.  This  is  disturbed  ab  little 
w  tmarinl-n  until  firm  union  u  established. 

After  tlie  tods  of  the  bones  hare  been  removed,  in  caneti  of  white  swelliDj;, 
tb«  palpy  Kranulatitin-tinuc  representing  the  synnvial  membrane  miiHt  be 
dwMd  away  mt  com[ilet«ly  aa  pueaihle,  partly  by  scraping;  with  ii  xbnrp 
sprMMi  and  fartly  by  tbe  um  of  iiciaaora  and  forceps.  Some  caution  h  uec«» 
muj  in  civaniug  the  poslfrior  part  of  the  joint  to  avoid  wounding  tbe 
Wlililll  <f<snU.  The  henlinj;  of  the  wound  U  much  facilitated  and  tbe 
■Mn^lMOl  fuppuratiou  din)ini«he<i  by  this  pruceediajf.  If  aiiiu^efi  existed 
fcafow  lb*  operktion,  they  may  be  scraped  and  cleaned  with  a  aoluliou  of 
cUurids  of  xiae. 

In  order  to  keep  the  bouee  in  position,  some  Surfteone  drill  thcni  obliquely 
at  the  aoLoriur  part  and  secure  them  by  a  couple  of  strong  sutures  of  catgut. 
larboJbed ailk.  ur  win.  Strong  catgut  aoewera  tfao  purpose  very  well,  and 
vill  not  aofien  for  about  two  weeks,  atler  which  time  it  is  no  longer  needed. 
If  the  wouud  is  not  aseptic,  wiro  sutures  are  the  best,  if  any  bo  used. 

ll  IB  very  imporlaut  liiat  all  hemorrhage  should  be  thoroughly  arrested 
lafim  tbe  vooim  is  cbseed.  In  some  cases  do  ligatures  will  be  refpiinvl,  hut 
■■nUly  two  or  three  of  the  articular  anerie«  funiii^h  nufKcii'nt  hemorrhage  to 
MqnifW  RMtainL     The  flap  when  laid  down  will  uftcu  anjM'ur  inciuiveniently 


Mar  ami  tbirk,  but  it  munt  not  be  curtailed,  an  it  will  eventually  contract 
aaa  fit  wdl.  An  a  rule^  ilrainage-tubee  are  not  ne<?(»»ary,  and  the  Hap, 
baviag  do  tradentT*  to  become  diaplatwd,  only  requires  a  fewitutur«s  to  hold 
it  to  piMition. 
The  rcanll  of  the  operation  will  depend  mainly  on  the  care  taken  in  the 
'  •trvatmetit,  and  id  the  ftucce«ful  preveiilinn  of  decomfKxiiijon  iu  the 
It  is  rawntial  for  success  that  (he  Hmh  should  be  kept  at  |)erfcct 
Ittrihefinrt  few  weeks;  any  apparatus,  lher<-fore,  which  requirea  complete 
ivaJ  for  drcsains  tbe  wiMjnd  );h<iuld  be  avoided.  A  narrow  fi|»lint  of 
DBcd  imn.ricleDoini;  fn>m  the  buttock  to  the  heel,  will  uiMialiy  answer  llio 
pttTPc—  sufficiently  well,  (t  muBt  Ix'  i>ndde«l  where  it  >»  in  contact  with  lliv 
IbjfB  aod  tbe  calf  lo  such  nu  «rxtcnt  ttiat  it  h  not  in  actunl  cunlact  with  tbe 
iAaa  ia  tbe  bam.  IimuitbeKxed  iu  p-jeiiion  by  a  Hnuncl-bandagQ  above 
«Bd  faakHi  tbe  knee,  over  which  a  firm  pU»tur-ol-i'aria   bandage  must  be 


EXCISIOy   07   JOIXTB. 


There  ia  often  some  tenriencjr  M  dropping  nf  the  wrat  l/»  the  ninnr  n^ 
wbicfa  U  best  oounleraclod  by  a  properly  citimtrurtcrl  gmt»-i»«T'  ^la  "rtlint 
The  thumb  is  upt  to  bo  ilrawn  in  ti)wnr<U  tht?  ind«ic  lin^vr;  r'  .  \tt 

prevented  by  a  thick  pad  uf  lint  kept  frum  the  earliest  time  I-  .' :.  iW 
two. 

The  etwntinl  points  are.  fint,  exact  attention  to  all  the  detaih  of  tk* 
operation,  and,  next,  a  careful  and  palieullv  cunduct«d  nfler-treatmeaL 

Beanlts. — .Since  Listvr  described  hii  niethtMl  of  operating,  oxriainn  nf  ibo 
wrist  for  disease  htm  become  a  reoogDiwd  operation  of  Buri^ry.  and  hat  bren 
praotbed  succewfully  by  W««t  (6re  cases',  OilleBpiv.  and  many  otiwr  4|Mh| 
nom.      In  military  surtrery,  huwever.  aecordiug  to  the  statutica  of  i^^| 
Anten'can  war,  the  r»ullii  of  tho  o[>erHtioii  have  been  tar  Oom  eocouragHf 
in  regard  to  the  amount  of  mobility  letl  lu  the  hand. 

Hand. — In  ibe  removal  of  diseased  nr  injured  portions  of  tlie  hand,  it  ii. 
OS  &  general  rule,  of  tlie  greatest  importance  to  eacrifice  as  little  as  poMble 
of  the  unbealtby  or  injiireil  structure*.  In  all  operations  on  the  bavd, 
indeed,  we  inttsl  nave  iwu  great  principles  in  view — the  preservatifin  of  the 
utility  of  tJie  member,  and  the  maintenance,  stt  fnr  as  practicable,  uf  iu 
symmctf)'.  Utility  is  neeesarily  the  primary  consideratiort ;  but  if  a  part 
be  not  useful,  it  may,  as  in  the  case  of  the  head  of  the  middle  metacarpal 
bone  in  amputaUou  of  the  corresponding  finscr.  be  «acrtficed  for  tbe  porpcae 
of  preeerving  the  symmetry  of  the  maimed  limb.  The  band  U  the  nrnii  of 
prdtention  and  of  touch;  and  in  all  operatirtns  applied  la  it  we  afaoald  «■• 
deavor,  as  far  as  practicable,  to  maintain  its  cfficitrnry  in  both  these  rcspecM. 
It  is  also  of  importuncc  to  bear  in  niinri  ihfit  two  xreat  classes  of  acUoos  (■■ 
be  carried  nut  liy  t)i(^  baud — tlnwe  ibat  re^juirc  force,  and  those  that  rwfwfm 
delicacy  of  msnipulalion  rather  than  «lrengtb.     By  a  surgical  ■"  '  we 

may  mnielinies  Hucce«d  in  preserving  one,  Inongh  we  are  cnmptl  i  ri> 

fieo  the  other  ;  and  in  this  rrnperl,  our  procedure  should  b«>  a  t; i  ■lii.iin- 

fluenced  by  the  occupation  of  the  patient.  Thus,  by  partial  ex.i.ni.,  we 
nukV  leave  a  hand  that  would  enable  a  clerk  to  bold  bis  pen,  but  wliicfa  wouM 
be  almoit  useless  to  a  laborer  or  blacksmith. 

Id  looking  at  the  hand  fi-om  a  surgical  point  of  view,  we  may  ooMidM  it 
as  being  composed  of  two  constituents — tnc  hand  proper,  and  tftio  Tfciai; 
tlie  tbuiub  being  au  accessory  to  tbo  baud,  aud  au  upjxiueut  to  the  rrst  of 
tbe  member,  without  which  it  is  susceptible  of  a  cum|>arati<relr  limited 
utility.    Hence  the  thuiub  is  of  equal  imporlaiice  to  the  rust  uf  the  baod: 
aud  the  preservation  of  its  tlircv  bancs  is  us  much  to  be  considered  as 
of  the  rbniaiuiug  sixteen  that  eiitt- r  into  tlic  conformation  uf  the  mctaca 
and  fingvra.     In  nil  cases  of  injury  or  diiicaee  implieutin^'  (he  tliurab,  e 
effort  ought  to  be  made  for  itii  pn-aervation.     Kven  if  it  Im  lefl  stiflcjicd 
incaiwhle  of  llfxion,  it  will  be  a  moA  um  fiil  opponent  to  the  rest  of  tbe 
hanil.     Hbimld  it  \w  found  neceeary  to  shorten  it,  rare  mn»t  b«  taken  that 
an  tittle  curtailment  us  possible  be  nrarli)<eil :  a  portion  of  a  phalanx,  nr  its 
mctucnrpiil  lio»i^  even,  in  of  i-swniinl  utility  in  giving  cirrngtii  and  brp«ltb 
to  the  gnup  of  the  hand.     In  n%»es  of  dinease,  a  very  u-ic ful  menibrr  maT  fa* 
lefl  by  tb«  removal  of  n  |Kirtion  or  the  whole  of  the  un){uul  phalanx,  of  tht 
metnojirpo-phnlangofll  articulaliou  or  even  by  the  exctaiim  of  tho  mf'tatArpal 
bone,  the  ]ihalnng<'»  being  left.     Thc«e  various  oiicrniiouii  an>  r«sy  of  per< 
formanoc;  an  inosixn  through  the  disrnsed  and  tliiu>rgnniE<^  soft  )>arts  will 
expire  tlic  nixTined  bone  ur  carious  joint,  which  must  be  removed  by  cultia^ 
pliers  or  a  iinrniw  saw. 

Wh*fti  ihr  tliuiidi  has  Iwrn  forcvyl  back,  or  badly  lac>  r  <  i-mder-AMfc 

ur  guu-trarrvl  pxphjoiona,  it  iitity  ufivu  be  Mivetl  by  bein.  d  aad  siaiB* 

Ijtined  In  pueitiuu  on  a  splint,  with  some  form  of  antiwptiu  drwaiag 


OWKB    BXTREMITY.      803 


t»U:  sod,  fbnolii  atii|>iiuiii»n  bt  roauired,  il  niugl  (le  douo  iu  iiccurilaaco 
with  Um  nilc  just  iiH-riti<jncil — of  aavtog  nt^  much  as  poeeitile  nf  tbu  tujured 

in  Um  OQOKmuiv?  aarj^err  of  the  f  u^n  the  preservatloa  of  flexinn  aod 
■tiwiw  in  the  part  left  is  the  nuiiii  ibiof;  tu  be  aimed  si :  a  rigiil  atump  is 
thmft  Id  the  war.  The  prcscrvBtiim  of  ibeee  movements  bectimes  ninn;  im- 
portant iu  pnypurtioii  an  llit-  [talni  is  npiimached.  It '»  of  more  consequence 
Ami  the  pniximal  jihalftrix.  uliii'h  carriea  the  rest  with  it,  Bhould  be  capuble 
of  bcitt|(  bent  iiili>  the  p»hn.  than  tliiit  the  distal  can  be  flexed  ou  the  Mcond, 
If  the  pmxiroal  iihalnnx  ran  Ik>  Ik-dI  down,  a  very  small  de^iree  of  move* 
mtaH  in  the  dUtal  one  will  be  oufficient  to  funiish  pliability  piirnigh  in  the 
fagtr  U>  make  it  a  useful  ineniber;  hiil  if  the  proximal  one  be  Htitfened,  no 
awaaoc  of  moluliiy  in  the  distal  phalunx  can  make  it  ui?«ful. 

In  prewrt ing  these  moveneots,  it  i^  Decenary  to  be  pnrticulArly  cnroful 
uf  the  sheaths  of  the  lendona.  If  they  be  in  any  wav  opctiod  or  iniure*!,  it 
will  iteverajly  be  fmiiO  either  that  the  tendon  sloughs,  or  llint  it  becomes 
•dbcrTDl  tu  ita  sheath  in  such  a  way  that  all  moremeot  is  lost,  or  at  lea»t 
prmtly  impaired. 

Tbs  imly  phalanx  that  can  be  excised  with  advantage  is  the  distal  one. 
Il  qfUn  happens,  io  the  devtructive  disorganization  which  results  from  whit- 
low, ibat  th»  Decrneci ;  when,  imtead  of  amputating  the  end  of  the  (ini;«r,  it 
OMj  be  removed  by  an  tDcisioo  on  its  palmar  aspect.  Disease  of  the  phalan- 
gmi  wtivalalioDi  niually  leads  to  Amputation  of  the  affected  tinker.  The 
hiIh  lor  rerfbrming  these  various  operuiion^  have  already  been  laid  down 
•I  pp.  Il4e<«9.t  vot.  i„  to  wliicli  1  must  refer  the  reader. 

BitiHino  of  the  Metacarpal  Booe,  either  of  the  thumb  or  index  finger. 
vithmi  the  removal  of  the  eorre»|>onriiup  digit,  is  [leca^ioDnlly  refmired, 
■arc  particularly  Id  cases  of  iujury  ;  it  mar  ro«dily  bo  done  by  innkin);  a 
lauritadiaal  inrbiitn  over  the  dur^al  aspect  of  the  bone  Io  be  removed,  care- 
fiil^  deCKThiuL'  it  fnmi  i<urriiuudiu^'  part^  by  keeping  Llio  edge  of  the  koife 
civ^agaitut  the  b<>ne,  avniding  the  teuduu^,  and  tlien  either  dtearliculatiog, 
•r  <  «Kac  t*  prcferublf)  f>utt)ag  across  the  neck  of  the  cArjial  end  of  the  bone, 
luming  it  nut,  and  scfuu-aling  il  from  any  distal  attachments  which  tt  may 
main.  After  the  removal  of  the  metacarpal  bone  of  the  inrlex  linger  in 
this  way,  but  tiltl<*  dt-rormity  results,  and  a  very  useful  hand  will  he  left, 
man  particuUrly  in  rhildn>u,  on  whom  I  have  more  than  onr«  had  oc<^asion 
Io  prmet'fr  ihia  partial  re^AcCion  with  success.  Tf  iKe  periostrum  b>!  saved, 
tbe  b'iClfl  mnv  U'  !»  Konif-  <>YterU  reproduced,  but  in  order  tft  ohtnio  thi!>  result 
it  is  B'X^'warj'  |i>  kni-p  On-  fiiij^r  drawii  forwards  by  hii  eliutic  extemliug 
apparatus,  v*  pmvrnt  the*  dm  phalanx  from  being  pulled  back  on  to  the 
•arpoa  by  the  ino*4-ti.'«  sttuched  to  it. 

COWSIEKVATIVi;  HtntflEIlY  OF  THE  I-OWER   KXTRKMITY. 

In  all  oiDfcrvative  operatiuns  that  are  practised  on  the  lower  extreniily,  it 
Is  of  eaential  imp>rtaiH'«!  that  a  giMKi  haaiB  of  support,  of  suflicieut  length 
and  atahility.  be  U'ft  to  ihe  b<»ly.  Thnf*'  operalionfl  differ  thus  In  srtnie  ini- 
partanc  mpt-cis  from  thiwf  that  are  iimeti?^!  on  the  up{>er  extremity.  In 
iW  latter,  the  pmtervaiioii  of  ili<?  hand,  even  though  in  a  mutilaleil  condt- 
tlMif  u  the  thini*  at  whirh  llie  S(irgi-<>n  aim?  ;  ntid,  provided  thin  be  attained, 
h  am'  norativelv  lilllc  how  much  the  arm  may  lie  8hortt'ne<l  or  ira- 

psir*  I  .  r.     In  the  Inwvr  extri-niitv,  however,  strfugth.  It'iigih,  and 

»  il  to  ihc  pnti<'nt>  c(>mfiirt  and  utility,  antl  uiitei«  theftc 

r-  ■  inU-rests  »rt\  bi-ttcr  s«.-rve>J  by  the  removal  of  the  limb. 

and   tiM>  adaptatHtn   of  some  artificial  coDlrivaoce,  than    by  leaving  a 


^ 


rtg.  a4».— Tbunui'i  Ka««-*pllBt. 

rivelr  prnctiacd.    Duriofj  ihe  lost  fev 
robbeit  of  iiinny  of  its  daiiaere  by  tbc  '•■ 
it  hn«  bec-o  iwrfurnicd  more  frt-qumlli 
in;;  r«-'5iillfl. 

Kxcision  nf  iho.  knee  is  uodcrtitkeii 
swelling  of  tbe  jnint,  but  Surgeour 
witicb    Uie  ii|>priitinii   abuuld    bo    •' 
tb(>  iijiper  mill  niMille  (;1uiu^>.  w 
only  as  II  Insl  rcwxirtx,  as  a  ^nl  ■ 
iJilive  tiiilwt  («-i  cure  llie  iliwjaai!. 
become  so  dwheurteiie<l  witb  n  i 
kuM  in  tbe  chitdreu  ol'  'i' 


.  Til     ill     I. II       ■        ■  U. 

k.  itendsitnis  c«u  be  iitiiised 

Ml  Mkptvd  to  th«  tn.4am«nt 
J  SrcuttBi  necoiaifT  Ui  Bavti 

«e  IB  MS«  of  lauUy  anky* 


4 


i 


.xoUoD  of  tbe  Knee-jofDt 

'led,  and  the  patella  turned  up  iu  the 

■,  if  not  already  disorganized,  are  then 

ml  attachincntB  divided,  and  the  bones 

the  limb  must  be  forciblr  flexed,  and  the 

.iTior  part  of  the  head  of  the  tibia;  for  this 

ji-koife  is  the  best.    The  articular  surfaces 

i:iy  be  done  with  Butcher's  saw;  but  in  order 

-i-ction  of  the  bones,  many  Surgeons  prefer  to 

.  broader  than  that  ordinarily  employed  in  ampu- 

:  tie  thieh-bune  should  first  be  removed.    The  saw- 

;  from  before,  backwards,  or  in  the  opposite  direc- 

■r  of  injuring  the  popliteal  vessels.     It  must  be  made 

ics  to  the  shaft  of  the  femur,  in  the  antero-posterior 

irnnsverse,  it  should  be  parallel  to  the  articular  surface, 

.:ier  aide  must  be  left  slightly  the  longer,  us  the  internal 

y  longer  than  the  outer.     If  the  condyles  retain  their  nor- 

i  tlifficult  to  judge  the  proper  angle  at  which  the  saw  should 


896 


KXOISION    OP   JOINTS. 


b«  tit;l)t«Ded  if  tlipjr  iK-cunie  looee,  mid  Uie  llaiitiel  bnndagv  reapplie*]  tUiljr. 
but  ttie  i»lra|i{>iiig  slimitil  iitit  Uo  Ltiucliuil.  lu  nuikitif;.  ■  pftUuu  ta  win 
on  tlie  ImkiI  <»('  llii!  ttound  eidu,  b*)  u»  to  t'4{unli»!  Uil-  leu];tb  of  the  >«ro  llufci 
(Fig.  MIJ  I.  A  briMil  etrap  iiiuy  tH<  cJirri<*<l  frmit  the  epliut  over  tha  ttopimtt 
sliuuliler,  UB  ill  Fig.  bA^i,  hut  iT  the  (>xt«'iisii>D  iipjHirBtuB  is  pmfierly  fiaM  Co  th» 
leg,  and  the  Ui[>rs  ti«<i  liiilticif^titly  li};hl]y,  thin  in  not  neccwmry.  A  TboOM^t 
flpTiitt  upplied  fiH  alnive  rleaoribeii  ia  perhnpe  the  mn^t  perTecit  sppAnUais  erv 
iiiTcuLeii  IW  fixing  the  knee,  il',  hun-ui'er,  ull  the  detailt  are  not  »li—d<ri 
to,  it  becomee  as  uaelpee  na  ao^  other  form  of  sptioL  Kren  if  tbv  llMb  b 
flexed  to  a  oonaiderable  angle,  the  Thomas's  splint  may  be  applietl  ai  abor* 
described,  slight  moditicationa  being  made  to  suit  the  altered  poaitloa  of  tb« 
limK  AAcr  a  few  weeks  in  bod  the  Umb  will  usually  booome  •tnugfai«  if  ■• 
onkylnds  exists. 

During  the  time  thnt  the  limb  is  on  the  splint  the  aeceeaory  mwntaf  I 
ment,  such  bb  oountcr-irritation  or  pressure  by  nn  elastic  bandagi^  MMfi 
cniplDycd,  should  tboy  be  cunitidenyi  nocoftury;  but  in  a  lar^  proporttoo 
elites  BintpK-  rvttt  Is  ull  that  h»  ret)uired.  If  the  joint  impnxrca  apd«r  ibi* 
treuliucnt,  it  must  Im  patitnlly  continued  for  many  montlis,  or  eren  a  year 
or  mure.  Should  the  juiiit  (.-uiitinue  to  enlarge,  and  ab«ce8»es  furm  in  spit* 
of  thu  treatment,  nr  Bhoulil  the  case  be  teen  lor  the  fir»L  lime  af^vrlbow  oun- 

Itlicatians  buvu  arisen,  u[>erative  interference  ie  rvquired.  It  is  uul  oeceMary, 
luvever,  to  have  inuEwdtate  recourse  to  excision  ur  amputation.  If  tbe  gen- 
eral health  of  the  patient  is  gou<l.aud  his  surrounding))  favorable,  an  attempt 
may  be  made  to  save  the  ends  of  the  boui;*  by  making  free  indsious  along 
tlie  lateral  itspeuls  nf  the  joint  as  far  buck  us  pumible,  so  as  to  dnun 
cavity  lliomu^hlv.  If  ihey  are  made  too  near  the  patella,  a  pouch  b 
behind  the  incision  on  each  ttide,  iu  which  tlie  discbarge*  may  ac<*umuU 
The  incisions  tthould  extend  from  the  level  of  the  upper  limit  of  the  poa^ 
of  aynuvial  ntemhmnc  above  the  patella  lo  the  head  of  the  tibia.  If  •• 
afaeoess  be  found  burrowing  beyond  this  )H)iut,  the  knife  must  be  carried  fur* 
ther,  so  as  to  lay  il  frucly  open.  The  iiicixioiis  having  been  mwlo,  the  palpy 
grauulaUon-lissue  titling  the  ca\*ity  of  the  joint  may  lie  freely  Mntped  away 
with  n  cbarp  spoon,  nna  if  a  carious  patch  be  felt  on  either  of  the  booos  ll» 
also  may  be  trented  in  the  same  way.  In  some  cases  sequestra  may  b«  found, 
and  removed.  Ity  this  mvide  of  treatment  gcmd  rtvnlts  have  been  obtaiosd 
by  H.O.  Thomas  and  Rushton  Parker,  of  Liverpool.  It  ia  specially  adapted 
to  children  under  fonruvn  or  fifteen  years  of  age,  and  the  yiHinger  tbe  chUd 
the  better  hope  there  it  of  huco^m.  In  adults  it  is  rarely  to  ne  reoommeiided ; 
Dor  it  it  prartimble  when  the  U^nes  are  extensively  destroyed.  The  o(wf»- 
tion  should  t>e  (xTturme^I  with  the  strictest  nntiiwptic  prvcautioos.  In  tb« 
after-tre«tuient  dminage-tubea  are  not  necesMiry  it  tht-  iiicisiims  are  iutficiealJf 
free.  Tbe  dressing  must  be  cliaii;.'e4l  at  the  end  of  thr  tin>i  twenty-f<>ur  bogn. 
as  it  will  be  soaked  by  theabondant  blitudy  and  serous  diacharge  nbirb  Huwa 
away  iriinit^liiitelr  after  the  o|Hrniti<)ii.  An  niiti><cptiv  cuttuU-MtHil  drrayio^ 
either  of  itidutiirni  or  salirylic  wool,  may  then  Ih-  npplied,  envehipint;  tbr  kotm 
wiilcly  lit)  <-Hch  eidf,  nml  siirntiiiidiiig  tJie  splint.  This  niny  t>e  trU  undi*- 
turlietl  till  lutiuc  diH:bargi'  nonka  out.  uulcas  severe  pain  or  elevation  of  ti3D< 
perature  indicate  that  all  is  nut  goinji  i>ti  well  Koiiig  struugly  recummiwls 
tbe  unplicnlion  uf  sonic  iodofnnn  to  tliu  inside  of  tbe  joint  at  tbe  uperatioa. 
Bboulit  the  treatment  fail  to  nrrwt  iho  disease,  the  indaioiM  ean  be  utilind 
in  a  subwviurnt  excisinn  or  nmpuution. 

When  the  forrpoing  methods  fiiil.or  in  cases  not  adapted  lo  the  traatliwal 
by  incision,  excision  of  the  joint  or  amputniiun  becomes  needHary  to  Hve 
the  life  of  the  pntioDC 
ExeisioD  of  the  knee-joint  may  be  practised  also  In  caara  of  (aolty  anky* 


ncum  pAtfllie  is  divi<i«I,  itnd  ihc  jintclla  turiifti  up  in  the 
'     -^■: .    .      I  .  .    crucial  ligaments,  i>'  duL  KiK'niIji-  tli&<ir^unii:^(),  are  iheo 

to  DQ  cut  ai-rMti,  iinr  rcnminiiig  lateral  atlucliniL-iiU  (livi<)«^l,  an<l  the  hniica 
dwnd  (or  tho  MW,  la  doing  this  IIib  limb  must  be  forcibly  flexeil.  nad  the 
k^fl  ouvfollr  spplicl  In  the  pOfteric>r  part  of  the  bend  of  thv  tibia :  for  this 
pvrpowa  blunt-pointed  r«sectioD-knif'p  i»  the  b««t.  Tbe  articular  (urfuoea 
■mmA  bow  be  lawn  off.  This  may  be  done  with  Butcher' b  mw  ;  but  io  order 
lo  iannv  a  perfcctlv  mooth  tection  of  the  bonw.  manr  Burgeons  profer  to 
■WftOtMBinuaaaw.K'mewbat  broader  than  that  ordinnrily  eraplored  in  aoipu- 
tatiaaa.  The  lower  cod  oF  the  thigh-bone  ehouid  lir»t  bo  removed,  Tiie  saw- 
CBi  wmy  MJely  be  oarriod  from  before,  bnckwards,  or  in  the  oppoeile  direc- 
tiod,  Af  ibece  is  do  duni^rof  injurini;  the  p).t|)l ileal  vessels.  It  mutt  be  mnde 
itmtely  ai  right  angles  ^)  tne  tilinft  of  the  femur,  in  the  aiiteru-|Hi6li.Tior 


dtrarttun;  but,  iu  liii'  trHnt<ven>e,  it  should  be  parallel  to  the  artit-ulur  F^urface, 
that  is  lo  aar,  the  inutT  vide  nmxt  be  U-ll  elighlly  the  hin^T,  n»  the  internal 
eaadrfoiiiiatamlly  longer  tbnn  the  outer.  If  the  oon<lyM^s  retain  iheir  nor- 
anlafaape  it  is  not  difficult  Uj  judge  ibe  i>rri|)ernugl(i  ut  which  the  saw  should 
tte  ImM  ;  but  if  thi^y  are  cxtcn!<ivi'ly  and  irn-'gularlr  det>tn)ycd.  the  fidlitwing 
m'lA^  tT.nv  I-  taktoi.  Tho  patient  lying  flat  on  his  hack,  the  thigh  w  flexfd 
.<-,  and  ndducud  till  t)tP  inner  aide  of  the  knee  corresponds  to 
'  >>u>.>  of  the  body ;  the  saw  in  then  to  he  held  parallel  to  the  surface 
'le.  A  thin  «lice  ui  next  taken  off  the  tibia.  It  is  nsnally  recom> 
eat  friini  behind  forwards  (FiK-  551)  to  avoid  wounding  the  poi>- 
-■U:  hm  if  urdinary  care  he  taken,  there  is  no  risk  of  dmng  this, 
•    :      ■  '  rittosaw  in  tbeop(KN>it<!  direcliftn.     The  seelinn  moat 

be  accura:  ue}m  to  the  shaft  of  the  tibia  in  hulh  direvUuo». 

U  haa  bees  f««w<uuK'ude<I  to  saw  the  tibia  coacave  and  the  femur  conv«z. 


S9S 


KXC18ION    OP   JOINTS. 


using  a  Butcher'd  itnw,  but  it  is  diffictilt  tn  do  thiiw  that  the  boiiM  iiball 
acourntcly,  and  the  method  iirPHcnts  no  advanlage  over  the  ordimiry  wmf  nf 
operatiug.  Cure  luuflt  bo  taken  not  to  remove  more  of  (Jie  bona  than  k 
auolutflry  neocwnry,  eopeeially  iu  youn^  subjects,  lest  the  epiphTHB  b*  oom- 
pictely  removed,  niid  the  growth  of  tlio  limb  interfered  with.  It  ia  BHiallr 
Biifficient  to  remove  from  one  third  to  three- fourths  of  hu  inch  of  the  tibia, 
and  about  one  inch  or  an  ineh  nud  a  half  of  the  ihigh-biinc  ( Kiga.  6o3  and 
653).  In  young  children  the  ends  of  tho  boneacaii  kometimubeslioed  ofl  with 
a  knife,  uud  the  amount  taken  away  accurtuoiy  limited  to  the  diaeawd  tfaanea. 
It  not  uufrequeutly  happens  that  cariouK  cavitit^  are  found  exl«odJng  bduM 


1^^:/1T 


^«r 


Pig.  ia.- 


■iMwm  la4  of  r*aar. 


Tig.  9»l.— AppllMtt«o  or  Bui<li«t'*tten  iv 
IImJ  of  'Hbla. 


the  level  af  the  section  that  has  been  made;  rtca  tb'u  is  ilic  ease,  it  ia  better 
to  apply  tho  goui^c  to  ihem  ihau  U)  .saw  the  booa  below  th^ir  level.  Should 
Um  operatiou  bo  [n'<rl'<trm(--d  for  di^formily  coiksequiuit  uptm  badly  Kduci^d 
fVaAlurea  or  dtAlncJilioui  about  thu  kneu,  as  has  been  dcme  aucoMafully  by 
Ttumpbrv,  of  Cambridge,  il  may  be  neceasary,  in  order  to  brint;  the  limb  intu 
good  puAititin,  U>  r«nu>ve  a  wedg«-ahaped  piece  from  one  of  the  huuM. 

If  tnv  putella  be  mueb  diwoMd,  it  mu»t  l>e  rcmuveii ;  if  it  bo  ouly  klijilitly 
carious,  it  may  b«  »orapM  or  gou^reil  out :  and,  if  healthy,  in  ii ■.-<.'•  irdaiwa 
witb  thut  nrineipli-*  of  oiiwervalive  8uruery  by  which  no  »<^uud  |>nrL  m  riK 
Diov^sd,  il  sbimlit  be  Ml,  l>vt-omiiig  coiiDolidnli^l  «illi  and  ulrraiithrQitig  ilia 
joint.  Tbi^  articular  Murfacr  of  tbr*  ]>«l<;'Ila  on  the  tlii^b-ltouf,  whirb  extvoda 
•ome  way  up  itH  forepart,  luiiy  jnlvniitiiLicttuBly  )w  "licfd  nir.  8<>  a«  to  Icaw 
an  OIKOU8  surface,  instead  of  a  cartilairinuue  uuv,  for  tlie  attaoknioat  of  tlia 
patella. 

I  haw  always  found  the  uporatiou,  oa  il  has  just  been  dcacribed,  mnj  of 
uvrformanw  and  good  iu  its  rcaulta;  but  various  iu»<llli<«tioos  araadoptad 
by  ilifTerout  Surgeons.  Thus,  aome  mako  oue  straight  iraiitrcrac  iacMaa ; 
utbers  two  iNiraircl  incisions,  on«  on  eot'h  niUe  of  lh«  patella,  ur  au  H-rhaped 
iodaiun,  nud  thus  upen  th«  articulaiioo  from  the  side.  Jonea,  ol  Jvnmf, 
who  bail  KTuat  oKperienoe  in  this  o{«ration,  advised  that  tbe  skin  be  dto- 
aairted  up  By  meaus  of  a  aomilunar  indrion,  and  then  that  the  liganeiUam 


XX0I8I0N    or    EyEK>JOINT. 


399 


prcKrvcd  br  l>eing  pushed  with  ttie  patella  and  the  quiidric«ps 
Icmloi)  to  o»v  8iilv,  t)ie  joitit  ih^ii  opeuod,  mid  tli«  buD«B  sawQ. 
Ocben  kdf  iw  that  the*  patella  b«  alwnvA  rcinov«d.  Volkninnu  r(>conitii«iids 
■  atrmigfat  inciviaii.  passing  frum  uii«  cou<l)-i«>  of  the  femur  tu  the  other 
trUMTenely  acrt^ci  the  muMIe  of  ihH  patella,  which  i»  tfa«a  sawn  through 
«u  ■•  to  expoae  the  joint.  Aller  the  arliculur  eutU  of  the  teinur  and  tibia 
hare  b«eu  reaiovvd,  the  fragtnenta  of  the  patella  are  uiiile<l  to  each  other  bv 
— tiir«i  iif  oatfpit.  carbolixed  silk,  or  wire.  If  its  articular  surface  it  dis- 
■■Md,  it  must  btt  sliced  oti  or  9crape4l,  The  results  oblaiiied  by  this  method 
■>«  xtry  pwd;  tlie  patella  readily  uDite«  by  bone,  and  either  remuinH 
mofmble  or  beenmea  fixitl  to  the  feiuur.  The  attachiueut  of  the  quadriceps 
•xMaior  and  Itgauieulum  patellu^  being  uudislurbed,  the  teudency  to  dis- 
plMMDeot  of  the  tibia  bu<'kwanls  after  the  o|jenitiuii  ja  oouDteracUKl.  and 
fai  walkkig  the  acuuu  of  the  rectus  in  briugiag  ibe  limb  forvrarda  »  pre- 

MVVfld. 

R.  Dmrr,  of  the  Weetminsler  lliie>pital.  hns  very  in^niously  and  eiicce^s- 
JiUijf  aHMUfied  the  npcmtiou  of  psci«i»n  of  the  knee-joint  br  uniiing  the 
oo  thc"TeDiiu  and  Mortice"  principle,  thua  securing  more  aid  id  l>ony 
jiatiM.     He  cuta  the  eud  of  the  teinur  into  a  wedge-«nBpe,  constituting 
tHHiB,  and  cuU  out  a  mortice  in  the  upper  end  of  the  tioia,  into  which 
wdgfrahapcd  end  of  the  femur  is  driven,  and  maintained  with  absolute 
1115  hj  Bseaoa  of  a  wire  splint  with  fbot-pieee.     This  is  disturbed  as  litde 
I  MMUile  onli)  firm  unioo  is  established. 

Aftar  the  ends  u(  the  bones  havi:  been  removed,  in  caaea  of  white  swelling, 
polpf  |;raDulaUon>tia«ue  representing  the  synovial  membrane  muiic  be 
away  m  completely  a^t  poeihli-,  pnrtly  by  scraping  with  a  sharp 
and  |iArtly  by  the  uae  of  actsannt  and  forceps.     Some  caution  is  necea- 
in  cleaning  the  poMerior  part  of  the  joint  to  avoid  wnunrling  the 
vaaaela.     The  healing  of  the  wound   ia  much  facilitated  and  the 
It  suppuration  diniinished  by  this  proceeding.     If  Binuset*  existed 
the  opemtloo,  they  may  be  acraped  and  cleaned  with  a  solution  of 
f  iUoride  of  xinc. 

Ib  urdar  to  keep  the  bonca  in  poaitioD.  some  Surgeons  drill  them  obliquely 
.Ml  Uw  aalariur  part  and  ■ccare  them  by  a  couple  of  strong  sutures  of  catgut, 
liaed  nlk,  or  wire.  Strong  catgut  answers  the  purpove  very  well,  and 
*iU  aot  aoAcn  for  about  two  weeks,  after  which  time  it  is  no  longer  needed. 
If  iha  wound  ii  nut  aKplic,  wire  sutures  are  the  best,  if  any  be  used. 

Ii  is  very  imporlaut  that  all  hemorrhage  should  be  thoroughly  arrested 
[iMlbrQ  the  wouiid  is  clumd.     In  some  caaes  no  ligatures  will  be  rei|uired.  bat 
Ujr  twu  or  three uftht  arti(?u]ar  arteries  furnish  sufficii'nl  hemorrhage  to 
lOin  ifMrainL     The  tlap  nhi'u  laid  down  wilt  often  appear  inconveniently 
and  thick,  hitt  it  mui^t  not  be  i-urtaited.  a*i  it  wilt  eventually  mntract 
Itt  wvll.      As  a  rule.  draiuagc-tnlK-^  are  nut  necea>ary,  and  the  Hap, 
khariog  no  tmdcney  tu  become  displaced,  only  requires  a  few  euturee  to  hntd 
i«  ID  pi«itirin. 

The  reaalt  of  the  operation  will  deiM'iid  mainly  on  the  care  taken  in  the 

nTt.  .-.ir-Atment,  and  in  the  i>ucceasful  prevention  of  decompnoitinn  in  the 

■  ■*.     It  i»  ca»ential  for  Auccesa  that  the  limb  should  Iw.  kept  at  jterfect 

I  ic  firwt  few  weeks ;  any  apparatu-t,  therefore,  which  requires  eotiiplete 

for  dreaiing  the  wmind  should  be  avoided.     A  narrow  splint  of 

^jiijaDnc«iiron,Mte»dtnKfnim  thebnltock  to  the  heel,  will  nsually  au^m^r  the 

par^M*  MfTtdaotlT  wall.     It  must  be  padded  where  it  is  in  eonuct  with  the 

'  lki](li  and  lh«  calf  to  audi  an  extent  lliat  it  is  not  in  actual  contact  with  lb« 

ill  tka  hacn.     It  must  be  liied  in  [xisition  by  a  flannel-bttndagv  above 

■od  balof*  the  knae,  over  which  a  firm  plaMerH>f>I*arts  baudage  must  be 


4O0 


k:icision  or  joints. 


applied.  Herou  Watson  rucuninieuds  a  soU  iroD  nxJ  or  bar,  applit^I  aat» 
riorlv,  reacliiijg  Truiu  ibv  gruiu  to  the  toes.  Tbu  \tu\iei  part  ia  *lraij;liL  far 
tliir  Oii^'li.  ill  lliu  Diiddii-  iH  ail  arch  [>u»iu)^'  uver  tlio  kuee ;  ihs  lowftr  part  ■ 
HLraigliL  Ibr  tlii!  leg,  aiid  b«iit  at  au  auglv  fiirwardii  op|Hiule  tbe  aakk  lo  fil 
thv  dur^uiii  iif  tlio  r<Kit.  At  tlte  limur  end  op)i(ieil«  ibe  aukle  it  m  book  br 
whidi  Ltie  Hint)  uin  hv  auspuiidud.  The  spliut  haviug  buuu  pruperiT  padifaa, 
ia  &xa\  in  iitnition  with  a  plaoter-of-I'arta  liaiidaf^.  Tfaomaa'a  sptiot  witli  a 
fuot-piei-e  >  r  ig.  (AH)  uliio  will  be  found  a  very  tiiBcieut  appnntiu,  and  may 
be  eecureil  alwvo  and  lielow  tbe  kn(;«  tvitii  u  plaeter-of-P^is  boudaga.  B^ 
aoy  of  these  metuiB  the  Ittnb  may  be  immovably  fixed,  white  the  kocc  ■ 
samcicntly  cxpoeed  to  allow  of  dreoBing.  Whatever  upparaius  ta  cbnan.  H 
must  he  applied  while  the  palieot  is  stjll  under  chloroform  ticfon*  Icmviag 
tbe  operaliDg  table.  As  soon  ns  tbe  wound  ia  heated,  the  limb  may  bs  la- 
eased  completely  in  a  plasier-of-Paris  or  starched  bandage  till  the  boom  an 
firmly  united  to  each  other. 

If  proper  attention  be  not  paid  to  tbe  position  of  the  limb,  bowing  oai- 
warda  \»  apt  to  take  place.  In  order  to  prevc-ul  displar«rment,  it  baa  betn 
propoeed  to  divide  tbe  haroatriag  teodoDB ;  tbif>,  however,  I  havp  nftver  ibvad 
Beoeaeary,  uur  doea  it  Mem  to  me  to  be  advisnble  u>  complicate  tlie  oparmtiM 
by  HUcb  an  addition  to  it. 

The  beet  drvwiog  for  an  exciaiou  of  the  knee  ifl  that  which  r«qiiin»  ehaa|^ 
ing  leaat  Ireqiiontly,  and  moat  etiiciently  prevent!  deconi|H«ttioD  of  lh«  dtf- 
obargea.  >\  hatevcr  dreaeiog  be  choaen,  it  abould  be  changed  at  tbe  end  of 
tbe  tint  24  houra  to  get  rid  of  tbe  early  diacbai^  Tbe  dry  aotiaepttc  woot- 
drewiugs,  which  can  uftuu  be  leA.  untouched  fur  2  or  3  weeu.  give  exaellcnt 
rvsullfl;  but  if  they  aru  u»e<l,  cure  must  be  taken  tu  apply  ewntgb  wool,  a 
tbicknefin  uf  at  leaat  three  iucheii  being  retjuired. 

Tbe  form  of  dreasing  ia,  however,  of  secondary  imi»ortaDoe  to  tiie  raatnle- 
nauce  of  |>crfect  reeu  If  tbb  l>c  atleuded  to,  caseous  aakrlQsia  will  eaaoe. 
and  a  go«Al  and  ubcful  straight  limb  nsult.  In  Iwu  caaes  1  bave  meoBBded 
iu  getting  ttgood  Ufflb  with  a  parliully  movable  joint;  both  tbeae  easeilPne 
in  children  ;  aod  I  am  dispoaed  lo  ibink  that  in  voiing  patteota  tbb  rcNlt 
may  ofica  be  aalu^actotily  attained.  Iu  adalte,  fiowever,  oeaeoua  ankyloaia 
tthould  always  be  aimeil  at. 

Selection  of  Cases  for  Excision. — It  is  geucrally  rMogniaed  that  exdakn 
of  tbe  kuce  abould  not  be  uudertuken  n&r  the  ago  of  30.  Gant  has  !•> 
corded  cases  succeeBfully  operated  ou  as  late  as  53,  but  tbeae  are  quitv  excep- 
tional. Excision  is  not  as  a  rule  to  be  recommended  in  rery  young  ehildnai, 
u  it  it  apt  to  lUTctit  the  growth  of  tiip  limb  to  such  au  extent  as  t>i  render 
it  uaeleas  iu  afVer-tifc.  Moreover,  incision  of  the  joint  and  scraping  arc  itsnally 
aucoewful  at  this  ugc.  About  14  ur  10  i»  cousidered  bv  most  burveoM  tM 
moat  favurable  age  for  tbe  operation.  It  should  not  W  underlalcen  wboi 
there  is  any  vittceral  diM-aoc,  ^jteciatly  if  there  is  tul)«rcutar  diavaae  of  tW 
lungs  or  albuminoid  det;enerfttit>ii  of  the  liver.  Extennve  diseaae  of  tbe 
boon  ia  uut'ttvuralile  to  llie  o|>eratii>ii.  It  need  tutnlly  l>e  said  that  the  opwa* 
tion  ahould  not  be  undertaken  when  tb^re  i*  hope  of  euro  by  iiimpler  ^ 

In  tbe  International  Coogroaa  of  INISI  Kucher,  of  Berne,  maintained 
white  awelUng  exoUnou  of  Uie  knee  insures  a  mure  rapid  cure  aod  a 
limb  Lban  any  oonserralire  meLbod  ol  irealmeoi.  but  lob  riew  b  not 
ally  aeoepted.    If  the  disease  b  reoognisad  eutlicieutly  early,  and 
properly  br  perfect  rest  of  the  joint,  axciaion  should  be  required 
exuepliKual  coses. 

Beaalti. — In  determining  tbe  propriety  of  parfbrming  the  operatinn.  tbsn 
are  two  iHiinte  to  bu  oousidered:  1.  Tbe  dugar  alUodiag  tt,  and  'i.  Hm 
utility  ol  the  limb  left  after  operation.  .  — 


I 


RSStlLTS    OP   BXCISION    OF    KNKX. 

1.  SuiiKiea  bBT«  been  very  abuDdnDtly  publUHeJ  with  regard  t»  th« 
openiti>:>n  of  tixcieion  of  the  kove,  with  the  object  partly  of  thowiag  the  ab- 
•olut'  ty  fttnl  jHirlly  ofcontraAtiagexcwion  with  ampulatioD.     At  the 

pff<ac;.-:  :Ltsw  rv^juire  cotDplete  ruvUiuu ;  tint,  becaujK  the  death-rate 

Lm  been  greatlr  reduced  br  the  improved  after- treatmeat,  and  Kcoadly, 
faeonaa  many  hui^eoDS  perform  the  operalion  id  hospital  practice,  uot 
■wnly  aa  a  aubvlUutc  for  amputAtion  in  casen  past  cure  by  any  other  meatu, 
bot  aa  a  roeaiw  of  rapid  cure  replactog  prolouged  conservative  treatmeol. 

The  f«IU>wiug  are  acuoogst  tbe  muaC  important  of  the  older  elatiMiial 
-TKUfda. 

I^niteea,  writiog  ia  ld69,  gives  the  etatistics  of  000  eaaes  io  vrhich  excieion 
of  lb*  fcoee  bad  been  perforoicd.  Of  431  ca^es  operate<l  on  for  diseast^,  300 
rttowaad  and  131  died — a  morulityof  SO  jier  cent.  The  result  ofexcisjoo 
far gvaahoi-bjury  hiaalrcady  been  alluded  te  at  p.  3&5,  vol.  i.,  asgenerally 

BMUiBfiKlOfT  • 

On  eMB|Mmng  Um  niortalitj  after  ampulation  of  ihc  tln't^h  with  that  fol- 
InmiBg  excjaioo  of  tbe  koee-joiDl,  some  stattdtics  ithow  no  very  ninteriui  dif- 
tknmese  iu  tbc  rate  of  mortalitr  after  the  two  operationa.  lu  IStiU,  8watn 
fiMttd  dial,  in  472  caau  of  excisioa  of  the  knce-joioc  collected  by  Price, 
MaoConnac,  and  himaelf,  there  were  116  deaths,  or  24.o  per  cent.';  while 
IB  S4  ampatatinns  nf  ibo  thigh  there  were  13  deaths,  or  24  per  cent.  Other 
raoent  statit^ics,  again,  show  dcridedly  in  fnvor  of  exel^on.  Willclt  has 
eolbded  tbe  caan  that  occurred  at  St.  Bartholomew's  Hoepital  during  a 
jpwied  of  six  Tears.  He  finds  that  of  S6  eaaes  of  excision  8  proved  &tal; 
wilkt  -aaes  of  amputation  of  the  thigh  for  dtMflM  no  fewer  Uian  37 

4M~  J  a  preponderance  in  fnvor  of  eKciaion  over  amputation  in  the 

ratio  ul  ;^1  against  44  per  cent,  of  deaths.  Bryant,  however,  aayv  that  Lbe 
aMrtatiiy  after  tlie  two  operations  varies  much  according  to  age.  Thtt*, 
manmff  patieoia  under  20  years  of  age,  in  69  amputations  of  the  thigh  for 
tfiHaMof  the  knee,  3  only  died,  while  i>f  97  case*  of  excision,  27  dleil;  in 
119  ampotatiuUH  t>etwe«u  the  litres  of  30  and  4*),  38  died,  while  of  74  exci»- 
kwa.  39  died.  He  hence  concluded  Ibat.  during  the  earlier  period  of  life, 
aaaJMOD  »  a  far  more  &tal  operation  than  amputation ;  whilst  at>  more  ad- 
faaoad  aigfa,  though  still  more  &tal,  the  balaauo  in  £ivor  of  amputation  ia 
kMBtrtkiBg. 

Tbe  fbllowin)!  may  be  given  as  oxaraplea  of  later  reaulla.  Holmes  states 
tbal  at  Gor'n  liuttiital.  where  iwme  of  the  Surgeons  are  strong  advocates  of 
•art/  vxcsBiou  perlurranl  with  antiseptic  prt^cnutiuns,  ii\}  joints  were  exciaed 
ia  a  period  of  o  yemn  witli  ouly  ti  drailiH.  Kuchcr.  also  an  advoeata  of 
earlTaiitiaqitM  excisiiin,  in  1881  rcuitnled  G4  autvi  with  U  denihe,  3  fnmi 
mfUm  polanohij*  In  the  early  days  of  the  anlirieptic!  treatmuiit,  1  from  ht-iuor- 
rfaaff,  1  :-  '  licucid  potaouing,  and  1  from  acute  tubcruulueis.    Meea- 

'mg,  io  Of.  .U3trati'  the  effbcta  of  the  nuHle  of  dri-)<«iag,  has  oolleeted 

02  easM  fran  tbe  hi«pilal  at  Kiel ;  2t  were  pt^rforniiHl  l>elure  the  lutroduc- 
liaa  of  tbc  antiseptic  treatment,  of  these,  7  dietl  dir(.>ctly  from  the  o[>c'nition; 
3S  wic  tstaled  by  anluteplic  meth(Kl»  involving  fre<]Ut!Ut  ehange  of  drew- 
iag,  and  of  tl»c«e  '2  died ;  the  remaining  4^  ca»ea  were  treated  by  the  lasting 
•Mlirpiir  dmwng,  and  of  these  only  I  died,  from  hn:rmophilia.  Of  the 
9S  cat**,  14  underwent  suhaequent  nmpuutino.  Sack,  of  Dorpat,  in  1880, 
poldiskrd  the  raotlu  of  144  cai^^t-  treftte^l  ftiitiAcplic-alty  by  various  Surgeons; 
of  ibow,  i&  or  17.3  )ier  cent.  die<l :  4  from  infective  prooeasea  in  the  wound, 
IS  ftoa  toberculoita  and  other  genera}  ditiea^es  existing  before  the  opera* 
1  firaoi  cbturfjfonn.  and  1  from  curbulic  acid  poisoning,  2  from  cnu.4es 
~  with  the  operation,  and  4  from  causes  not  stated.     Of  llie  1 19 

TOLtt.— M 


40S 


BXCISION    OF   JOINTS. 


wh(i  Riirvive*!,  1 1  uuitcnvftit  itulMcqiidii  aiupulatiou,  making  exacUj  75  per 
Mot.  'if  sii(vr«w!4,  an(i  2ii  per  rent,  of  fniluwii. 

2.  The  itecond  point  that  haA  to  be  detertiiined,  Is  u  to  tlie    tHHily  a/  du 
I/imb  oA^r  the  operntioii. 

On  this  jxiint,  the  result  of  recorded  cniw*  itt  in  favor  of  tbr  op*r«tiaa. 

Id  one  of  ParkV  ciues,  operated  on  in  1704,  that  Surgeon  itAtc*  ibat  llw 

putient  ( a  Hiilor),  seven  yean  after  the  operation, "  trail  able  to  |^>  ahitt  witli 

ooD«idemble  nf^lJty,  and  to  perforin  all  the  duties  of  n  Mnman.     In  fttuv  of 

tli«  lutt«r  i-ases  the  result  haa  been  equally  cood.     One  of  Jones'*  patieoto 

,(b  Ik>j-}  "could  run  and  walk    quickly  without  any  aid  uf  a  click,  oould 

land  on  tbe  liiub  uloue,  aud  piroueltinl  and   hopiMw)  two  or  ibrae  Tanla 

irilbout  putting  tb«  sound   liuib  to  the  ground.       In  Mveral  »f  tnr  uws 

au  exci'llout,  strong  and  «trai};ht  limb  has  been  left,  uspful  fur  all  unU- 

Ary  purpusca.    Iti  a  cat-e  whicii  I  extiuiiued  «even  renre  aiXvr  the  op^raliuo, 

le  limb  was  wvU  uouriahvd,  straight,  firmly  uukyiuaed,  and  but  vvrr  liult 

shortened.     The  palivut,  a  lad  of  twenty,  euukt  walk  right  or  tvn  inila^  tad 

even  Jurmi  and  stand  on  the  limb  wilhuuL  the  least  pain,  sigu  of  weokaoi^ 

or  ditHailty.    In  very  young  children  the  r(«ull  of  the  uperaiioD  ta  not  nlla- 

factory,  tlie  leg  continuing  shortened  and  wasted,  not  developing  with  iha 

rest  of  the  Unly.     'I*hi8  ia  apparently  due  to  aud  dependent  ujNin  iIm 

Tctnoval  of  the  epiphyaia  of  the  tibia,  UD  tbe  Jategrity  of  which  the  growtb 

of  that  bone  is  dejteudent. 

Afier  the  operation.  oflMous  ankvlo^  takea  place  with  a  firm  cioatrix ; 
the  limb  Is  8horlene<l  from  one  to  three  inches,  Aconnling  to  the  amount  of 
^JtKino  removed,  but  by  means  of  a  hieh-beded  shoe  ibis  inonovmiienoe  is 
itly  remedied.  It  baa  been  orged  flgulnst  exrision  uf  the  kost-jotnt, 
lat  oonva1e«cence  ia  tedious  and  prolonged ;  btil  thi^  argumrtil  can  with 
Justice  have  bnt  linle  weight.  If  a  useful  limb  can  be  preaervoH  lo  th» 
patient,  it  can  matter  but  littlr  if  a  few  additional  wei^ks  l)e  devolit)  to  tba 
procMlure  by  which  it  is  obtained;  and  indeed,  it  is  a  question  whrtber  in 
many  casea  the  patient  may  not  be  nble  to  walk  just  as  soon  after  tht  fici- 
■ioD  of  tbe  knee-joint  as  after  ampulntion  uf  the  thitfh  ;  fur,  m  hae  bwn  very 
properly  remurke*!,  though  the  amputation  wound  may  be  b«Aled  ia  Uuw 
or  four  weeks,  it  may  be  as  many  nioutb»  bi<fore  on  artittcial  limb  cut  b* 
worn. 

Do  the  whole,  from  tbe  evidence  before  us,  it  may  be  ooocladed  ibal  in 

ftroperly  fclccted  cams  excision  is  preferable  to  amputation,  as  iuv<^vJor 
OM  mutilation  and  'but  little  more  risk.    In  the  statictici  ooUcolvd  bj  tiaok 
above  quoted,  13  out  of  26  deaths  arose  from  visceral  diaeue  oxistii^  bcfen 
.the  of>eration.     If  these  citMS  bad  been  submitted  to  nmpulaiion.  probably 
nanv  of  them  woald  hnvo  recovered,  aud  ibe  dcathrato  uf  the  exciiioia 
rould  have  been  r^-duce-d  (o  under  10  per  cent.     The  opoiatiou  ihi>ald  not 
put  oH'  too  long,  till  the  paticut  is  exhausted  by  pain  and  diM:bar;ge,  and 
tinuce  round  tlie  joint  ftorloniteil  by  numeroiu  sinusce ;  but,  on  the  other 
I,  it  can  hardly  bo  cunsidored  juslifiuble  to  r«M>rt  lo  exctuuo  wllhoota 
J&ir  flliirt  to  cun*  the  disease  by  simple  ireatmenl.     Kvery  case  mun  bv  d^ 
|«ii1c4l  on  lu  own  merits,  and  the  results  obtained  wit!  be  in  prDportiiin  u>  tk* 
Judgmf-nl  shown  by  the  Surgeon  in  selecting  tbe  proper  eaiea.    In  a  dooUfal 
caiK  iht-re  is  anuther  oonslderation  which  cannot  be  altogether  di*card<<tl  in 
ensbllng  us  tu  form  a  judgment  as  to  tbe  preferable  operation.     And  it  is 
(hi«,  ilint,  in  couitef)uen(»  of  receat  Improvements  in  surgical  nu-cbanirs, 
nrfifii'inl  limlw  Att  now  coiMtrnetcd  of  so  durable  and  uwful  a  character,  as 
to  -iipplv  lo  n  grtnl  extent  the  loss  sustained  by  amputation,  and  ibis 
■particularly  if  the  lliab  have  be«D  removed  early  to  life,  nhvu  tbe 
caa  more  readily  adapt  himself  to  new  mctbods  of  pnnfrMMon, 


i^m 


COXBEBVATIVB  SUHOEBT   OF  FOOT. 


40i! 


TllE  Lbg. — The  Tibia  is  very  fr«|uently  the  seal  of  cflriu  in 
id  Inwer  epiphysea,  unit  uf  necrusis  iu  the  shaft,  re«]iiiriD)(  partial 
aptniti<>o  for  ibe  renmvat  of  the  tliseattetl  pgrtiuue'.  OccaiUiually  h  very 
flMMtdcnble  extent  of  (h«  sbafl,  indeed  the  whole  of  it,  may  be  removed  ia 
aitoUi  ftf  tteorcR*.  as  n  l90«?tie<l  sequestrum,  from  the  interior  of  the  perlos- 
tmrnn,  mon  or  lew  ooniolidated  and  streogtheoeil  by  the  depofit  of  new  bone. 
Boeb  opatmtioaa  prwent  Dothioff  sjiccial,  and  tbe  result  is  usually  very  latia- 
fiurt^ry.  (he  limb  ibit  U  left  beiac  atroog.  useful,  and  sound. 

Th«  Fibola  is  le««  frr<)uently  toe  wat  of  operation,  but  it,  like  the  tibia, 
BBT  require  pnrtini  reraovHl.  lo  one  axsn,  tliat  uf  a  chiUI  six  years  of  age, 
1  fueeaefuUy  removed  tbc  whole  of  the  necr<^«ed  fibuln.  This  operation  u 
readily  iknc  by  slitting'  up  the  sinvisea  in  &  dircctinu  »o  as  to  expuee  the 
in,  whicb  tnay  then  be  dmwn  out  witboui  difticulty  <'  Figs.  534  and 
E).    AAcr  ibe  oporaUoD  an  iuoereplintmuat  be  applied,  in  order  to  obviate 


y 


rif.  <j^i.— List)  Willi  Rwroalt  ot  Fibul*. 


V^.  ibi. — Limb  mttei  R«ai>r»l  of  FIbuU. 


Ibe  teodeocy  to  raras  wbicb  will  ensue.  In  the  case  fmm  wbieb  the  anucxod 
drmwiitgi  are  taken,  rcry  cotuiiderahio  reparative  action  waa  ml  up  iu  the 
pentMteom  and  mti  tiMu'et  ahmg  (he  line  nf  hone  that  had  iK.-eti  ntmuved, 
nvm  oMeoas  roatt^ra  apparently  beint;  dcpouicd:  and  the  t-hild.  when  exam- 
incd  tw»  veara  after  ibe  oix*rnUi>n,  bad  an  excellent,  well-nourinhed  and 
onAil  lim'b.  The  foot,  bo«-«v«r,  bad  a  tendency  to  be  drawn  inwards, 
apmrently  owiag  to  the  llcxure  bavii))^  overcome  the  anlaKoniam  of  the 
fnffftfftl  cxtensura.  This  deviation  inwards  was  counteracted  by  the  patient 
■mring  a  properly  fonnlnictcd  bwt,  with  wbloh  walking  was  perfectly  easy. 
Foot.— In  looking  at  the  division  of  tbo  fool  into  il^  three  Rreot  oompo- 
n  part»~4iMs,  metutareuf.  and  tardus — we  shall  perceive  that  firmneaa  of 
it  is  riven  by  the  foot  rwstinz  on  the  heel  behind,  and  on  the  ball  in  front 
i  br  the  projertion  of  tbe  bMad  liuo  of  the  metatarso- phalangeal  articu- 
more  particularly  that  of  the  ureat  toe ;  whilst  cla«ticitv  is  commu* 
itail  tn  the  tread  by'ilie  play  uf  tlie  toes  and  roetotantal  Intne*.  Tbe 
dhillrfiT  of  ihe  foot  may  be  lost  without  any  very  serious  inw»nvenience  lo 
1^  [      '  }>ut  (he  preservatiuo  of  aiability  and  firmness  of  gait  are  of 

■^R>:  Tuoce ;  and.  as  thews  are  secure*!  bv  the  bevi,  tbo  ball  of  the 

Um,  osmI  the  breadth  of  the  anterior  purl  of  the  fiM>t,  these  are  the  most 
.  partt  lo  preaerve  in  all  reeecUoua  uf  this  purl  uf  tbe  body. 


404 


Bxcrsxov  or  joints. 


In  nu  region   nf  thi?  botlr  have  ihe  good  edrc^  it(  mrxlem  c< 
wiriierv  been  mnre  dblinrtlv  fthntrn  Uun  in  the  Tumtu.     In  ih--  'I 

titiu'w''  of  ^'urKery,  if  a  peniiD  hnd  a  "  white  snplliiti;"  of  iht-  i>< 
fwi,  or  a  dUea^  Unu*,  he  was  at  oace  oandejuun)  U\  amfniu^  >' 

Hiuii.  No  distinction  was  drmra  betweeo  diaeose  »f  the  diUr-rrot  parta  <4 
tli«  fool,  nor  anj  atteoipt  made  to  save  the  aouod  by  tliv  aacrificv  uf  tba 
diH«BC<l  pKrt. 

Until  a  coirip«iraUr«ly  recent  period,  indeed,  "diwawd  famnia**  wa«  iW- 
icribed  us  a  whole.  Surjj^ue  did  aot  endeavor  to  ronke  out  the  exact  uttcnt 
and  uraouuL  of  ihv  di»etuic,  hdU  any  ca»e  deM-ribed  lu  "  disrAwd  tonuu  "  «aa 
I'>jkv<l  upuu  an  rt-quiriu^  nniputatioQ  of  the  leg.  Tbti  rule  of  practice  llica 
ubaerved  wna,  aiuuui^t  the  wealtlik-r  clii»ea— tho»e  who  could  afford  liiii 
expense  of  a  "  cork  leg" — to  nuiputJite  a  little  above  the  ankle;  but.KtnuDipK 
the  poorer  clowea,  to  rvuiuve  the  lug  about  a  couple  of  incbva  bcluw  the 
knee,  so  as  to  give  thu  putienl  a  stump  which,  when  tteot.  would  &l  into  the 
Socket  of  a  wooden  pin.  Thu»,  in  thi.>  latter  «u«  U9|iecially.  not  only  was 
the  leg — ittu^lf  tH'rfei.-tly  souiirl — HUTiHce<),  but  llie  pntieiit  waa  cxpnanl 
great  adiiilional  daujier :  for  if  tliere  be  one  point  mow  than  another  w" 
has  been  indJuputably  provetl  by  Burgical  Btatisliun,  it  b,  that  the  luurtal 
aAer  amputation  incr('aM8.citc(«Pupart^,inexaotpri)i>ortiun  aaweapp: 
the  trunk — evcrv  additional  inch  which  we  remove  augmenting!  the  dao 


to  the  patient.  Yhts  practice  continued  to  prevail  anul  <_'li((|mrt  dn-w  »•> 
dt8tinctiont>  bptween  the  trejitment  to  be  pursued,  according  as  the  di 
aflccte<l  the  anterior  or  the  p'Wterior  taraal  bnnnj  and  articulntion*. 
showed  that,  when  the  anterior  articulations  only  werf  atfecteil,  ain(Hitad< 
at  tho  junction  of  the  astmgaliu  and  caleaoeum  uitli  ihu  scaphoid 
ouboid — an  (iperatton  which  goes  by  tho  name  of  "Chopart't  ampuUttioQ" — ' 
ought  to  be  iierfomod  ;  thus  removing  the  whole  of  the  disease,  and  allnw* 
log  the  patient  to  recover  with  a  shortened  foot,  with  the  bwl  nreaerred — 
one  on  which  he  could  bear  the  weight  of  his  body,  and  whicn  would  be 
highly  useful  to  him. 

The  next  step  in  the  comwrvative  surgery  of  the  lower  extremilr,  in  cmm 
of  diaeaced  foot,  was  the  operation  intrmloced  by  Syme— that  of  d\«articala- 
lion  at  Ibe  ankle-joint.  This  was  certainly  a  great  advance  ;  for,  the  dap 
being  taken  from  the  heel,  the  patient  has  a  stump  on  which  be  can  bear 
firmly.  Tho  oporatiuD  is  also  a  very  safe  one.  According  to  O.  \V*hv,  17 
deaths  only  occurred  in  IDl  cases  of  this  operation.  1  have  performed  H 
manv  times  without  a  death ;  and  thia,  in  the  low«r  extmoity,  i«  octXMBily 
■Btisloctory. 

Sinre  the  introduction  of  anieslhetic  agoots,  Cjiuarvativc  StirgBty  hm 
taki'U  great  etnde»  :  aud  I  think  Conservatism  in  Surgrry  may  be  r^!ard*d 
11  Ihn  nnniTirr  rrsnit  nf  *i  iimirhrriii      For,  nllhough  u|K>nitionsoi  \ 

were  peribnnea  yean  ago  tiy  Park,  the  Moreaus,  and  othvn.  and  lli'  ; 

demonstratjMl.  vf-t  the  oiieratiuns  of  gouging,  scraping,  and  partial  nsoctiusi 
were  so  horribly  painful  to  the  palifnt.  and  occupied  so  much  time  in  llidr 
performuuce,  that  patients  dreaded  to  aabuiit  to,  aud  Surgeons  dediMd  lo 
undertake,  them.  Of  late  ymn  Surge<jiM  have  learned  to  discriutlnat*  d» 
case  of  one  part  of  the  tarkus  from  that  of  another,  and  to  apply  approprtaia 
tnvtment  to  each. 

looking  at  the  subject  from  adlagnoatiopoiDtof  view — and  the  treatinrflt 
is  mokt  intimately  connected  with  niinut«  and  aeourate  diagiwuta — wo  AhA 
that  the  pathology  of  dtimwea  of  the  tarsus  is  cloaely  eoaBeet«d  wUb  its 
healthy  anatomy.  C^>mpc>M>d  of  seven  bones.  It  pre*ent«  ibur  distinct  artica* 
latioDS.     By  the   term  "articuhitiun,"  applied  to  the  torsu*,  I  do  tMA 


DISEASE   OF   THE    TARSAL    BONES. 


406 


merelv  the  connectioD  of  contiguous  bones  with  each  other,  but  distinct 
amoTial  sacs  shut  off  from  communication  with  other  synovial  sacs  in  the 
iooU  Thete  are  well  represented  in  the  annexed  diagram  (Fig.  556).  The 
poeterior  ealcaneo-oMragaloid  is  the  first  of 
them;  next  comes  th«  (a)  anterior  caleaneo- 
aMmgatoid,  the  synovial  membrane  here 
BervJDg  also  for  the  oitragalo-gcaphoid ;  the 
ealeaneo-euboid  (6)  is  the  third  ;  and  the  ante- 
rior tartal  tynomal  membrajie  (c)  is  the  fourth 
and  largest  of  all,  and  the  must  important  in 
a  surgical  aspect.  It  extends  between  the 
scaphoid  and  the  three  cuneiform  and  the 
cuboid  bones,  between  the  cuneiform  bones 
themselves,  between  the  two  outer  cuneiforms 
and  the  bases  of  the  second  and  third  meta- 
tarsal bones,  and  also  between  the  external 
CDueiform  and  the  cuboid.  The  articulation 
between  the  cuboid  and  last  two  metatarsal 
bones  is  shown  at  d ;  and  e  is  that  between 
the  iotemal  cuneiform  and  the  first  meta- 
tarsal bones.  These  two  (d  and  e)  are  not, 
strictly  speaking,  tarsal  joints. 

In  the  vast  majority  of  cases,  so  far  as  my 
experience  goes,  it  is  the  osseous  structures, 
and  not  the  articulations,  which  are  pri- 
marily diseased.  The  bones,  being  cancellous, 
far  removed  from  the  centre  of  circulation, 
and  exposed  to  alternations  of  temperature, 
readily  become  the  seat  of  congestion  and 
cari«a,  but  rarely  of  necrosis;  and  in  strumous  subjects  not  unfrequently  fall 
into  a  tuberculous  condition.  Caries,  whether  simple  or  tuberculous,  once 
set  up  in  bones,  speedily  implicates  the  articulations  secondarily. 

Now  it  will  easily  be  understood,  on  casting  an  eye  on  the  arrangement  of 
the  tarsal  synovial  membranes,  that  the  extent  of  disease  will,  in  a  great 
measure,  depend  upon  its  original  seat.  Thus,  a  person  may  have  disease  in 
the  OS  calcis,  extending  even  to  the  cuboid,  witli  very  little  likelihood  of  its 
proceeding  further  for  a  length  of  time.  Such  disease  is  limited  to  the  outer 
part  of  the  fiwt,  does  not  involve  its  integrity,  and  rt-iidily  admits  of  removal 
by  operation.  But  let  him  have  disesise  springing  up  in  the  scaphoid,  or  in 
one  of  the  cuneiform  bones,  or  in  the  bases  of  the  second  or  third  metatarsal 
bone^.  and  the  morbid  process  will  rapidly  spread  througli  the  whole  of  the 
anterior  and  inner  part  of  the  tarsus,  mid,  in  all  probability,  no  operation 
of  resection  can  be  advanhifreously  cni|doYC{i.  Ilt^nce  the  seat  of  disease 
intlutrnces  materially  its  amount  and  extent,  and  the  kind  of  o[>eration  re- 
quin>d. 

When  the  fiM)t  is  affected  bystrunmui}  diseni^o  it  becomes  painful,  the 
Mti<'nt  being  unable  to  bear  upon  the  tut's  or  anterior  ball  of  the  foot, 
hwelling  '»f  a  uniform  character  takes  place,  with  tfiiderness  at  some  point 
opp<«iti->  the  bones  or  articulations  that  arc  rhiefiy  Invulvcd  ;  and  eventually 
aiiM.>eftK^  f'Tni,  leaving  sinuses  throu|rh  \vhi<'li  the  probe  passes  down  upon 
8oft<'n«i  and  carious  bone.  These  eviiiences  of  disease  are  usually  much 
marke<l  about  tlie  dorsum  and  sides,  ^herc  tlio  bones  are  mi>8t  .supcrticial, 
the  sole  l»eing  often  comparatively  fr^-e — an  important  point  in  reference  to 
opc-ration, 

Tbe  bones  that  are  most  frequently  the  result  of  primary  disease  are  the 


Fig.  55R. — DUgnm  of  Synoriftt 
MeinbraD«s  of  the  Foot. 


EXCIttIi 


calcoDeum,  tliu  Uitrflgnliis,  the  M«pboi<l,  Lite  ctil>i>i(l,  nt»l  tho  ricUiUum]  boat 
of  the  f^ri'al  uk-.  NN'^heo  (lie  dlflruc  it  liuiiteil  li>  otic  or  iitq  of  ibca*  bnoft, 
«xcit(i(>u  is  usually  practicable;  but  wbon  il  exlmido,  tbrough  the  infliMBee 
of  ibe  cdnnpcting  urlivulalioDt,  tu  other  bnnra  uf  the  tAniu  or  dmUUUmm. 
partial  ttiuputaliuo  will  jirubnbly  be  required. 

Prinuiry  disease  of  the  articulatiuus  of  the  fixit  is  a  lev  freqaent  oaiMa  <if 

opcrutiim  ihaD  caH«a  of  the  tnnul  titinra  leatliDg  accuudanly  to  aa  inplioi- 

tifltt  of  the  c(>otiguuu4  articuljilitim' :  and  tliu  parlioular  operation  nx|ttir«d 

|«ill,  in  a  great  [ueasur?.  ilf))<'iid   u(kiii  tlii>  extciit  of  iiiifilitatioo  of  tht 

tynovial   nicmbriint-a  nf  th<>    ftN)t.     When  tlic  i-alcniieo-aetragaluid  or  ibr 

'  ciilcitiie(>-rul>ui()  articuliili»nK  are  atone  alfcvted.  with  their  wnliguoa*  bmiei, 

lVM>^rtic>u  nf  the  bones  and  joiuiii  inip1icAle<l  will  i4\t-n  lit-  altenil<>d  by  rery 

i«»lidtnct»ry  rfsulls;  but  ulien  the  large  aDlerior  tnnitt]  uyitovial  mttubniDe 

tb  in  a  atate  of  chnmlo  dJM^se.  either  primnry  r,r  aeeoiidiiry  Ut  diarftsC'  nf  the 

'tcnphoiil,  the  c-iintlfurni,  or  nf  either  of  the  metatarsal  bime«  oiiiinectetl  pith 

it.  then  rcscclion  b  ftcarcely  iidmtiwble.  bd<I  Choporl's  nmputiuion  oflVra  iIk 

beat  mentis  of  ivlief.     Tn  tin  in  m  a  Lion  of  the  lnr|Et>  and  cunplii-alnl  snlt-Tiar 

[larsal  tynovial  membmne  c^nimonly  comiDeocra  in  ditiewN*  of  th«  Mrapboid. 

It  niny,  usually,  be  reci'ir"'*'^   rwdily  enough  in   it»  uarlicr  »taL--   '■'  ^^ 

pain  and  swelling  that  l«l(c  place  ucniae  th«  line  of  articulation  l<<  .« 

•caphoid  uad  cuneiform  bone»,  the  paiu  being  );rpat)r  incn-arc'l  U\  i-rmnat 

I4be  foot  down,  utid  extvudJnu  ai-nau)  the  whole  lirvadlh  of  the  foot.    Althoun 

lit  u  UBUnlly  iTiiMtt  (wvvri-  at  the  inner  »ide,  which  is  the  firtsl  Htfrctefl,  ret  toe 

I vcternal  secliou  of  thie  complicated  articulation,  that  betweeo  the  r-Xtcnul 

ineiform  and  the  cuboid,  becoming  involved,  cBuiea  luffertng  to  b«  «xpcri* 

d  on  the  outer  aide  of  the  foot  as  well.     In  the  mom  adVanoed  nOgm 

of  this  particular  disuave,  the  foot  aasotnes  a  remarkable  bulbous  or  clubbrd 

MppnrtQce;  tlm  syninietry  of  the  heel  and  the  outline  of  lb«  ankle  ore  on- 

>  impaired,  but    the  forejmrt  and   dorsum  of  the  foot  are  maUjr  awaU«, 

glaxed,  ami  somctimeii  pertbrate^i  by  ainusea  diBcbarginf;  thin  pua.     I  look 

upon  ihia  disease  of  the  anterior  Urtnl  eynovitil  membrane  as  a  dttfiack 

aneclifiD  of  the  foot,  requiring  to  be  dia^owd  from  ibe  other  urumnoB  m- 

dnmmoiiona,  and  in  its  advanced  atogea  demudiog  Chopnrt'e  amputation. 

Il  may  he  stated  generally  that  thcKsult  of  disease  of  the  tarsus  will  he 
di'peudent  mninly  upon  whether  it  is  acute  or  chronic,  prograsivc  or  sift- 
tionur\-,  difflised  or  limited.  When  it  is  oetiie,  ita  limit  cannot  be  defined. 
and  niVr  iho  removal  of  one  port  ion  the  disease  may  he  ligfhutl  up  afresh  in 
llir  fiiruciures.  oneoua  or  articular,  that  have  been  leA.  When  pfnyrasw'se, 
^tlierv  will  b«  found  to  be  a  g*ner»l  tendcni^v  to  disease  tu,  ur  diaurgmnitatJun 
of,  ihr  tarsal  stnicturM.  and  partial  uperaiiou  cau  Im?  productive  of  link 
pxMl.  AVhvii  it  i^  difftuffi,  extending  into  the  larj^i-  aulerior  lar^ttl  or  tartft- 
>|ii«'tnUir!uil  fli-tifulalioiiD,  partial  operation  cnu  nvnil  uirfhintc.  U  H  id  ifaiMi 
tntr*  in  mIiicIi  ihti-  dietiiac  i«  chronic,  timited,  and  tliitivuaty. or  nearly  »>i,tkal 
excik'ioo  auiJ  imtLinl  •i|ii'rution  can  bv  beneticiat. 

Excision  of  Tarsal  Bouei.— Any  one  of  the  urml  Itonra  may  hr  il.r  w«i 
of  primary  diseaite,  which  may  b«  limited  to  the  Imhiv  «riuiniUly  I. 

or  may  extend  lo  neighboring  articulations,  or  thntugh  the  wli  >. 

There  are,  however,  fuur  bones  which  may  be  looketl  u{Min  ac  th<  --^ 

at  centres  of  tarsal  disease — vit.,  the  0»  falcis,  tfw  Astrauaiw,  tbo 
■ufaoid.and  Cuboid;  oiul  as  regards  fretiueury.  they  arc  commuiirj  aSfedBd 
tno  "Tiler  civen. 

The  Os  Calcts,  frvm  its  ezpuB«<l  situation,  iBrgv  siu*.  and  sposgy  structMi^ 
is  more  fn-<|U>-ntly  tho  seat  of  curies  and  iirervis  than  any  of  the  oUmt 
banal  lM>nc8.     Very  mmuHmty  llic  ducoHt  is  limited  to  this  boo*;  in  oUmt 


M 


EXCISION  or  THE  08   CALCI8. 


407 


v^ 


-fe. 


Pig.  ^Ij7.— I)I»oueor<l«  Cnlnln  RDdCuhiild.  nnd 
of  Ualoaooo-isubuiJ  Joint;   Linaaul  Incidiun. 


insUocca  it  extendtt  into  the  cailcnnco-tiAtragfllind  or  calcaDeo-eulKiid  artica- 
iRtioDa. 

When  the  diwaae  is  situiited  in  the  poeUrior  ar  lateral  part  of  the  ban^,  the 
loighboriog  articulntions  are  iteUlom  involved,  and  then  the  removal  ut'  the 
Biurbid  alructiirea  by  gouKinS  ^i" 
luuftlly  nucceed  in  effectiiit;  a  cure. 
)  have  frequently  hiul  occai^ioii  ill 
thb  way  to  wxtop  out  great  portion?, 
jiiiuetiniOA  tlie  whole  n('  tlje  interior 
of  thecalciiiieuRi,  «itli  the  nKwt  ex- 
cellent results.  Kveu  when  tlie 
cuboid  i»  extensively  itiiplicnted  tut 
welt,  and  the  calcHoeo cuboid  iirticu* 
latiun  is  the  sent  uf  dieeiuw,  the  dt«- 
«rgaoiz«d  etructure«  miiy  ulteu  be 

moved  by  guu^ugaml  partial  r«- 
aectioD,  as  in  the  casu  of  which 
the  cut  (Fig.  557)  is  a  goud  repre- 
aeotatioD,   where,   by    means  uf  a 

,|,-»haped  iucioiou,  theee  bonps  were  expoeed.  and  their  carious  fMirtioos 
guugeu  ouL  iShould,  however,  the  caries  have  aiTected  the  tupcrior  or  anterior 
vortioHB  of  the  fron«,  then  the  inijilicalion  of  the  aetragaloid  or  culmid  iirlicu- 
utiou»  may  rvndpr  ihe  excisiim  of  the  whole  Imne  neceesary,  nfi  the  only 
nMBiia  of  preventing  extension  of  secondary  misrhief  to  the  tarsiie  gciieraliy. 
6o  unfi^-qiient,  however,  it*  disease  of  the  articulnr  aspeota  of  thi^  Uine.  that 
its  Complete  removal  le  ver\-  seldom  neeesanry.  Out  of  at  least  fifty  raHes  of 
caries  uf  the  oe  calcii>  thatliave  been  uuder  mv  aire,  I  have  had  occnsinn  to 

Iexcifle  the  whole  bone  only  once ;  and  Fcrgiiaaon  states  that  he  has  never  vet 
pbund  it  neceasnry  to  do  this  operation.  Indeed,  excision  of  the  oa  cnfcia 
ihould  not  he  lightly  undertaken.  The  large  aizo  of  the  hone,  its  impor- 
tance as  ft  bn^is  of  support  to  thi;  bo<ly,  and  an  the  point  of  attachment  of 
the  strong  musek-a  ot  the  ealf,  should  induee  the  Burgeon,  whenever  prao 
ncnble,  lo  avoid  its  complete  extirpation,  and  to  limit  himself  to  the  appli- 
Catiou  of  the  gouge,  or  sharp  sp.K>n,  even  though  he  may  have  to  scoop  oQt 
the  whole  of  tlit-  interior  of  the  bone,  leaving  little  more  thun  an  osseous 
shell.  This  will  fill  up  with  liense  fibroid  tissue,  which  will  pmbably  cvcotu- 
iilly  undergo  partial  oaaiticatinn,  and  leave  Uie  foot  as  useful  as  ever  for  all 
purpvisos  of  Mipport  and  progressinn, 

Operatjon. — Excision  of  the  os  ealcis  is  usually  performed  by  turning  a 
heel-llap  back,  and  then  carryinj;  lociaious  forward  into  the  e'de  of  the  foot, 
by  which  another  flap  is  turned  up,  and  the  calcnoco-cuboid  articulation 
flxpoeed  and  opened  ;  after  which  the  knife  is  carried  between  the  astragalus 
and  calcaDeum,  and  the  latter  bone  detached.  By  this  operation  the  sole  of 
the  foot  is  BOtoewfaat  exteusivelv  incised,  nnd  cicatrices  are  lell  over  the 
faeel. 

Id  order  to  avoid  this  inconvenieuce,  I  have  found  that  exarticulatioo  of 
the  OS  calcis  may  readily  he  performed  in  the  following  way.  The  patient 
lying  on  his  fnce,  a  horseshoe- incision  is  carried  from  alittle  in  front  of  tbe 
calcaneo- cuboid  articulation  round  the  heel,  ulong  the  sidea  of  the  foot,  to  a 
corresponding  point  on  the  opposite  side.  Ths  elliptic  dnp  thus  forme<l  is 
dissected  up.  the  knife  being  carried  close  to  tlio  bone,  nnd  tl>e  whole  under 
sarfacc  of  the  oa  euleis  thus  exposed.  A  perperndtcular  inclition.  about  two 
inches  in  length,  ie  then  ninde  behind  the  heol,  through  the  leudo  Achrllls.  in 
tbe  mid-line  nnd  into  the  horizontal  otic.  Tiie  leiulon  is  then  detached  from 
its  insertion  and  Uio  two  lateral  flaps  arc  dissected  up,  the  kuife  being  kept 


J 


XXCISI02?    OF    J0IKT8. 

[«lMe  to  the  bones,  frnm  which  ihe^  mii  paru  are  well  clcarrrl  'Pig.  5SS). 
The  bliiil«  ia  Lhou  carried  over  the  iipp^-r  anrl  pootorior  part  of  lh«  cm  isldi, 
the  srticdlAtion  ia  iipeoexJ,  the  int«n~«9e<>uA  liA^menU  iire  rlividcH,  aad  ibeii, 
br  a  few  touchu«  with  the  poiot,  the  iHtne  U  detachfii  f'n>in  iu  roonoeiioai 
with  the  culioid.  ThU  boD«,  U'>>;ethcr  with  thn  a»lrxgfi.\u».  mutt  then  h» 
examined  ;  aaH  if  any  disease  be  nmt  with,  the  gim^  nhr>ulii  be  applied. 
Should  unkyI>i«iH  have  taken  place  between  the  ii«  cnlria  and  ihe  a*tr«gali 
u  I  have  found  to  one  caM,  Ids  bones  may  readily  be  dlrided  hj  meaMi 


L 


I     .// 


rig.  9&S.— Bioiilaa  ol  ili*  (>■  CmM*. 


/' 


Fig.  a^o  -  dmmx  uf  lU  (» <:^«u. 

I.   Fmm  kafura  Op»raUa*;  1.  Vunt  altar  KhMm 


I 


Butche^r's  taw.  By  this  opcrntion  all  injury  to  the  sole  U  avoided ;  and  th* 
Open  Boele  of  the  wound  being  the  moel  dependent,  n  ready  outlet  ia  aflonled 
for  the  diBchnrees. 

The  drawing  (Fig.  5S9)j;ivcfl  an  execllent  ropreaentation  of  the  stale  of  Uk* 
foot  M  a  pirl  before  ami  aAer  the  excijiion  of  a  diMfcaed  ea  caleia — a  aome- 
what  Hnlfood  bin  moMt  usc-ful  foot  reaultin);. 

Snbperioiteal  EtcUlon. — Oilier  has  dwcribed  a  mode  of  retooring  Um  oa 
calcia,  in  such  a  wny  timt  ibe  perioetvuin  may  be  preaerved  au  a«  Ui  allnv 
the  rv)t«;n«niiiun  of  the  bune.  A  cur\-e<l  invtaino,  cuiunteacia^  on  the  oat* 
tide  uf  the  lendu  Achillis,  at  the  level  of  the  nnkle-joiut,  \»  i-arrinl  down  at 
.fiv  ai  the  external  tulwruaity  «f  the  <«  caleiv.  uiid  theiji'e  aloot;  ibe  aide  ef 
the  foot  OS  faroj  the  posterior  end  of  tlii^  lifUi  meUitanaU  l»ue.  Tlw  fla|i 
iieiuit  rntfvd.  the  fwrioaU'uiu  niid  leiidu  A<-hillia  are  ae|NU-ated  froBD  the  ' 
whicli  in  then  fUrthur  denuded  of  it«  pcriiwutum  as  Jai*  aa  can   be 


dUi 


EXCISION    OF    THS   ASTBAOALUS.  409 

^bc  VifninieDtnas  attachmeDtB  are  divided,  and  the  bone  is  remnved.    In  fact, 
W  cariw  of  the  m  csIcib,  it  may  often  be  found,  as  in  performinfj  Syme's 
UDputation,  that  the  thickened  periosteum  strips  off  the  softened  and  carious 
^Qe  Ai  readily  as  the  peel  off  an  orange;  hence  a  formal  process  of  dissec- 
tion is  scarcelT  needed. 
_  Ui^nry  and  Heetilts. — Excision  of  the  os  calcis  is  a  very  successful  opera- 
Ut\o.     It  seems  to  have  been  first  performed  by  Monteggia  in   1813;  the 
w»ult  appeared  promising,  when  the  patient  died  of  scrofulous  disease.     The 
oi*nttion  then  fell  into  abeyance  for  twenty-four  years,  when  Robert,  ia 
I^^T.  iu  a  case  of  necrosis  of  the  bone,  removed  the  diseased  portion,  leav- 
lOjithe  healthy  peripheral  layer.     The  same  Surgeon,  in  1844,  in  a  case  of 
t»riw.  removed  the  whole  bone  with  the  exception  of  its  upper  articular 
Wrftce  and  the  inner  side  of  the  body.     Greenhow,  of  Newcastle,  in  this 
wmnlTT,  and  Kigaud,  in  France,  appear  to  have  been  the  first  Surgeons  who 
Mc«»fb|ly  excised  the  whole  of  the  os  calcis.     Their  cases  both  occurred  in 
1*^^;  and  since  that  time  the  operation  has  been  performed  in  a  large  number 
ofcMegin  this  country  and  in  America,  and  establislicd  as  one  of  the  many 
important  developments  made  in  late  years  by  Conservative  Surgerj-.     In 
rrtnce,  it  seems  to  have  met  with  little  favor,  though  it  has  been  success- 
fuH.^  performed  there  in  several  instances,  by  Oilier,  Giraldcs,  and  some 
"•lier  ^rgeons.     Guerin  says  that  the  operation  should  not  be  attempted: 
•nd  girw  as  his  only  reason  for  describing  the  operative  procedure,  that 
English  Surgeons  have  not  feared  to  undertake  it. 

Pitlaillon,  of  Paris,  in  an  able  article  written  in  18G9,  with  the  object  of 

*iTocating  the  performance  of  the  operation,  has  collected  the  records  of  64 

"*«.    Of  these  he  sets  aside  9,  of  which  he  has  not  been  able  to  find  sufB- 

(WQlly  accurate  statements  as  to  the  result.     Of  the  remaining  55,  39  were 

Wccefsful — this  term  implying  that  the  patients  were  enabled  afterwards  to 

*>lk  without  artificial  apparatus  or  sup))ort.     Of  the  remaining  16,  in  6, 

crutches  or  other  apparatus  were  necessary;  in  7,. subsequent  amputation 

Tas  demanded  on  account  of  return  of  the  disease  or  inutility  of  the  foot ; 

and  there  were  3  deaths.     Resection  of  the  entire  bone — in  a  few  cases  with 

other  jMirtions  of  the  tarsus — appears  ti)  have  been  performed  in  39  of  the 

5".  rases ;  of  these,  30  were  iiltogether  successful ;  in  4,  artificial  support  was 

necestary  ;  2  required  suhpe^juout  amputation  ;  and  3  died.     The  operation, 

aecijrding  to  Polaillon,  Ikis  l>een  more  successful  in  children  than  in  adults. 

He  I'taies  that,  of  12  cases  under  10  years  old,  all  were  successful  ;  between 

the  aj;es  of  10  and  20,  there  were  14  Buccfsyful  case?,  and  3  failure." ;  between 

2"!  and  30.  7  succef^ses  and  9  failures ;  and  bt-tween  30  and  40,  6  successful 

rAsei  and  3  failures.     Kcpri'ductioii  ()f  the  bone  occurred  in   12  cases;  11 

l»ein;r  in  individiuils  under  20  years  of  age. 

The  Aitragalas  is  situated  in  a  po>>irlou  of  irroat  sur<rical  importance. 
Articulating  with  the  malleolar  arch  al>ove,  with  the  i-nlcaneum  below,  and 
with  the  scaphoid  in  fnnit — forming,  as  it  were,  thi'  keystone  of  the  foot — 
it  b  porfecily  evident  thai  any  disease  coiiiiiienciii;:  in  it  is  vtry  likely  to 
Rpread  l'>  and  involve  all  the  iimrc  impnrtant  slructurfSof  the  fWnt.  Seldom, 
indeeil.d'H-s  <Iis(-ase  uriginating  in  this  binu-  loriLr  rcinain  cuntined  to  it;  and, 
eo  far  as  my  experience  gnes,  giuij;injr  npi-ratioiis,  cvi'ii  if  pcrl'ormcd  at  nn 
early  n*'ri'H].  are  rarely  of  niucli  benefit,  the  nicirbid  process  <  ontinuinLr  to 
extend  notwithstanWing  their  eniployiiniit.  Indeed,  in  dtsi'asrd  iistniL'ulus, 
I  believe  that  excision  ouirht,  us  a  rule.  t'>  be  practised  in  preference  to 
poHiring.  ointrary  to  what  is  the  ca?o  in  tlie  caleancuin. 

l>is*;ajK;  primarily  originating  in  the  astragalus  inav  sjirrad  in  tliroe  direc- 
tiom»:  upwanis  into  the  ankle-joint,  downwards  to  the  calcancuni,  forwanla 


410 


EXCISION    OP   JOINTS. 


to  tliP  fcaplirti'l,  and  thvuin*  through  the  larv(^  anterior  BTnoTiml  mviabvu* 
to  liw  rati  of  thtf  lanal  httaett.     The  ireuliittuit  nill  vanr  a«»nltng  to  Ui 

direction  and  uienl  of  li*  4» 
«sae.  It  may  be  arrvngnl  uaiK 
four  beaJ^ 

1.  Wbcn  tb»  aMnmiim 
it  tiiArriMd,  Wt  find  wnat  ii 
iu  Ibi!  ilnLwio)!  {¥i^.  o60).  wUck 
reprcftcnls  the  foot  nf  a  boT  wbor 
a«lniKa)u»  I  excueil — •wdfiaf 
ju»L  in  front  of  tbe  BuUleolar 
Kj.  (.«— DiMM»  of  A«lr»(*lt".  arch.nitli  ltstiilcu«op#t)iBKilM4* 

iiiff  diiwii  to  tlic  (li^c-ttMMl  artratfr 
ItM;  ibe  Biiterior  nart  of  tbo  foot  nod  tbe  beel  ht'ni)(  tjuile  KXind.  If  Utt 
di»t^M«  be  limiU-d  ti*  tbt  outer  side  of  tb«  hone,  <>r  l»  itJi  bead,  it  ia  uoMtbU 
thnl,  by  freely  o[Miiiiug  tbe  eiuuses  and  iipitlyini;  tlie  ptu]{r,  tb«t  c»nm  |^| 
be  i-utirvly  reniovetl.  But  (bis  uperaliuit  i«  not  tut  gulUfaclocy  bers 
wberc  ID  ibe  foot,  as  it  ij  by  iio  iiiuauB  eujr  to  iivuid  opening  tbo  aslrm^tliH 
icapbuid  articulatiou ;  and  if  this  Im*  dune,  tIjseiUH!  will  almost  ineritaUy 
extend  tbruugb  the  tanai  articulations.  ExftBJini  uf  thv  astrasalw  aloot, 
thciURb  sometimea  rctjuirctl  for  diaeoae,  U  pcrhap§  mure  freqttvntly  called  fi^ 
in  tooee  casci  of  voupnund  dislocaiioo  in  vfbicb  ihe  bunv.  baving  bata 
ihrowQ  out  of  its  bed,  eventually  becoines  carious  or  necruMS. 

Tbe  opermtiou  of  excision  of  the  wbolu  of  tbe  astragalus  fur  iliecwM  wkJ 
be  doDP  an  follows.  A  curved  incisioa,  A-om  four  to  six  ttidMB  in  InglfcT 
aliould  1m>  mnde  iriinie<liately  behiud  the  outer  mallraliia,  and  cairiai]  lbr> 
wanl  oti  tbe  oui<->r  pare  of  tbe  dorsum  of  the  foot  to  npfnahe  tbo  lurtnA 
of  the  bone.  Tbe  divisiuDs  of  the  external  lateral  ligament  of  the  anw 
joint  are  ibcn  cut  across;  the  Uiiidoni!  of  the  pemnens  brevta  nnd  terttv^ 
and  the  i-xt«Dtior  brcvis  digiiorum  muarle,  dividinl.  Ibit  the  mmsa  fif  e«ta- 
•or  tondotut  in  front  of  tht-  foot,  with  (he  dntMlis  nediH  artery,  tnitA  ba 
untouched.  Tb<sc  should  be  drawn  forcibly  inwArnit.  'the  ptrrtDeoi ) 
tendon  may  l>e  drawn  bHckwards.  The  foot  is  th^^n  stmiiKly  twintc^l  ini 
tli«  futragaliu  cleared,  and  its  li^mcnu  divitk^l  from  the  nut^r  aide  in 
cession  aa  tber  present  tbcnuelves.  When  tl>«  op«^ratiou  is  door-  for  Hi 
of  the  bone,  tnese  structureA  will  uitually  he  moro  or  leas  aoftc^Ml  and 
ganitf d ;  when  for  iujiiry,  they  will  in  a  jirent  inNWurA  hav«  Im>«o  torn 
throii;:b.  IIcDce,  in  actual  operation,  tbe  sanic  lt^e.^*  cannot  be  followed  m> 
raettiixlically  8»  may  be  done  on  the  dead  subjrct.  The  bone  tuuKt  now  be 
acized  with  liuii-forc«p»  and  drawn  well  uiit<>rit»  Iwd  :  tli<*  knif*- 1>  'ti«il 

to  any  rmtrHinini'  slructurM,  but  bein^uscd  very  rnrvfully  Umn:  iritf 

tide  of  tht-  bont*,  lt>tit  the  plantar  artrrin  U-wuundc<l.    Uti>l'  tba 

•ofU-iieil  and  cariuiMkinf  usually  hr«ak»  down  niiif  liaa  l<i  b<  :  <  (^ 

nwal.  or  il«  neck  nmy  i*^  v»L  acrow,  aud  tlic  hi-nd  iwparatviy  rtiu«(Vv>l  fn«> 
ita  arltculnli'iii  with  tlie  scaphoid.  If  tbe  bonu  hnvv  been  dialnrated,  and 
ibi  l(}[anift)U>us  ouooevtiims  tliu^  turn  thnmgh,  or  if  tbcM  bav«  bven  diaar> 
ouiizrd  nnd  softened  by  diseueu.  il  may  ruadily  enough  Im  removad  aa 
joiit  described.  But  if  the  ihsciius  tinuu  itwiH'  be  rariuus  and  •ofteoeil.  and 
tbe  lipinivntoufi  ciinuitcltons  ttilenibly  flouml,  then  tbo  oporalinn  beeoiiKa  ex- 
tromoly  trouliluninif,  t«liou«,  and  pmlongcil — tbe  bonii  brenlting  down,  and 
having  ti)  bv  removed  pirL-univui  by  oieanfl  of  the  googp  and  pUera. 

Tbp  rf^U  'if  tliiH  oiwrntiiiu  is  very  jtati»tiivt'>ry  :  a  good  and  ninrmble  v- 
ticululii>n  may  be  lell  betwei'n  the  matlwli  and  calcanmun,  nnd  the  limb  ia 
but  littlo  shnrttmcvl.  Arrordin)(  ti)  Hancock,  of  100  eawa  in  whicb  tb« 
>  waa  removed,  76  recovered  with  good  and  oicfbl  limba ;  moondnry 


mm 


Eicisioir  or  the  anki-h. 


41X 


UBpatntioD  wag  p^rrormed  in  twn,  with  one  deitth ;  lo  olhera  died ;  ud  ia 
14  the  ivaulu  nre  not  knowo.  The  opomlion  was  perrormed  in  U4  caws  for 
eempouDd  dislocaUon,  with  SO  complete  rccovcriea;  in  20  of  simple  disiiwa- 
tioa.  with  H  complete  rccoverieB;  odJ  in  10  for  caries,  perfect  recovery 
MkiDC' place  In  6. 

1  Vt  hen  the  dtMue  hu  ejrttnded  from  the  attragaitit  in  the  mntffolar  nrrA, 
exeiswn  of  tht  anide-joint  will  be  required.  This  operfllioo  nmy  most  conve- 
nieotlj'  be  i>erforined  in  the  following  way.  A  Bemilunar  inciaion,  nhoiit 
foor  inchefl  in  lcnt;lh,  should  he  mad«  along  the  outer  and  iaferior  aspect  of 
the  jttini,  round  the  lower  hortler  of  the  external  malleolus  (Fia.  5G0  i,  nnd 
ihonld  be  carried  sufficiently  forwardii  Ut  give  »|»aoc  without  aividiug  the 
«atleo8or  tendons  or  the  dorsal  artery.  A  perpendicular  cut  should  then  he 
made  along  the  back  of  the  tihuln.  Th«  peroneal  tendons  need  out  be 
divided,  but  should  be  ilrawit  downwanin  and  backwarrln;  the  lower  end  of 
the  fibola  should  next  be  cut  acnj^  and  detuclied.  The  antragaluB,  which 
will  now  be  exposed,  ehould  iKeti  be  separated  from  its  cooDections,  which, 
if  tiwy  be  much  discaewl.  may  usually  be  readily  done.  li'  Dot  deeply  affected, 
it  will  be  more  Uriuly  held,  and  should  tlico  be  cut  across  with  plier»,  and 
each  fragment  lifted  out  of  it«  bed  with  gouge  or  pliers.  The  foot  may  next 
be  well  drawu  lo  the  iuui-r  side,  and  llie  lower  end  of  the  tibia  carefully 
itolated ;  the  koifc  being  used  with  great  caution,  uud  kept  close  to  the  bone, 
lest  llie  p«jeterior  tibial  artery  hn  injured,  or  the  toft  jmrta  may  be  stripped 
Jtoid  the  bone  with  a  perioeteal  elevator.  When  the  ligaiucutous  structures 
attached  to  the  bono  hare  been  separated,  the  inner  oiaTloolutt  is  cut  off  with 
bone-foroepe,  and  as  much  as  necessary  of  the  low4>r  end  of  (he  tibia  removed 
hf  a  gou^  or  chain-saw.  Should  there  \m  any  diccae^j  of  tlif  iirticiil»r  sur- 
neM  of  thecalcaneum  or  »c«phiiid.  tliit<  mw^l  be  piuged  away.  After  the 
opemiion  the  limb  must  be  placed  on  a  suitable  splint  CFig.  5til ,'. 


Pif.  G6I, — Liub  tttmt  Ktcialoa  «r  Iba  Ankt»J«lBt. 

3.  When  the  disease  has  exiended  from  ihe  aMra/jalHg  upteanig  inlo  the  mal- 
ieolor  arrh.  und  downwards  into  the  ealctmntm,  the  line  nf  pructioe  will  depend 
on  the  extent  of  the  implication  of  the  on  calcia.  If  the  greater  part  or  the 
wbole  of  this  be  involvetl,  no  resource  is  left  but  amputation — rceertion  not 
leaving  a  naeful  fout.  If,  however,  the  calcaneiuii  he  only  partiv  involved, 
it*  upper  fturfiice  only  iteing  affected,  n  great  deal  may  be  dune  by  con»erva- 
tive  flUrgerT-  The  trealment  in  such  ca^'s  constats,  genernllv,  in  removing 
the  astragalus  from  its  bed,  ami  gouging  away  any  (lisea^cd  Ixmc  which  may 
exiM  either  on  the  upper  surface  of  ihc-  caloaDcum  or  on  the  under  surface 


412 


KXOISIOy    OP   J0TXT3. 


of  tbe  malleolar  arch.  Very  lurgy  porLiuus  of  bone  may  bo  romoved  from 
this  situation.  I  tiavu  taken  sway  the  wbule  of  the  malleolar  arch  »nd 
astraKaliu,  ami  giiiifiW  out  tliL>  ufifxT  t^nrface  of  the  us  calde  wry  freely :  noil 
yet  tfic  patient  Itas  recovered  nitli  a  strung  and  movable  foot,  but  very  UlLk 
shurtvueil  ur  deformed. 

The  accompanying  cuts  (Fig.  J5fl2)  are  taken  from  a  ynung  man  on  whom 
I  performed  the  operation  jnat  described.    The  foot  in  perfectly  uwtbl  and 


"N 


Pi|[.  MI. — Exolilun  uf  AKrajfaluK.  1.  F.j<it  Ufuro  0|.ar-j(lon.  3.  Koot  ill  mo&Uit  ftfttrib* 
mnoval  of  iha  MiHanUr  Arob,  bodi  5l&ltoot[,  tko  AauagalDi,  aod  «  parthm  of  tba  Upp«r 
SorfM*  of  tha  CatoaDctiia. 


Strong,  and  tbe  falu  joint  at  the  ankle  movable.     There  are  cases  in  which 

we  find  (hat  Ehe  dlMase  baa  extended  bo  far  beyond  its  primary  Beat,  ihat 
ampuiaUon  rather  than  n»ection  i«  required.  But.  in  the  majority  of  io- 
stances,  removal  of  tbe  oittragalua  and  gouging  away  the  upper  esurfncu  of  the 
calcancum  will  suffice. 

The  rf/iiiU  of  exciaion  of  the  tibio-tarsal  articulation  is  generally  good. 
Spillman  says  that  of  73  coaes  50  were  Bucct^aaful.  Among  these,  tHc  outer 
mnlleolun  was  removed  in  22,  1  of  which  required  Bccvindary  amputation, 
and  4  ilied.  This  leaves  51  cases  of  removal  of  the  tibio-larsol  joint;  in  12 
of  theiK,  the  disease  was  of  traumatic  origin,  and  the  operation  wan  aucccaattil 
in  11;  in  37  it  was  consUtutionnl,  and  nf  thc«e  22  recovered,  7  died,  7 
rec|iiired  »econdAry  amputation,  and  in  1  the  di5ea«e  continued  two  yeai* 
after  the  operation. 

4.    If  the  dit^ea^  have  e-xlendai  from  the  nMrafjahu  lo  the  toaphotd^  Utdj 
tfaeuce  i»f<i //i«  anlrrior  mn^e  of  titrmt  joinU,  ihe  foot  will  have  oeoome  I 


BXCISION    OF    MORE   THAN    ONE   TABSAI.   BONE. 


418 


■v«1r  dkorcmDiKod,  that  partial  rceoctioD  will  be  of  tittle  or  do  service; 
Wl  tfil rUcolation  at  tbf  anklt^-joint  shoiiM  \k-  jirnctised. 

Kxenko  of  thr  Cuboid  Bone,  cithf  r  in  wbole  nr  in  pnrt,  nmv  be  required. 

^Wnnl  Bsobaoo  ie  hero  lionc  uich  the  guiigc.     When  the  wbole  of  tbe  bone 

bttkao  awar.  the  SAIi  mctotjir^al  bone  also,  with  tbe  little  too,  will  probably 

i«^|Un  TVOMtTol.     This  may  be  done  by  making  ibc  San,  as  depicted  in  Fig. 

K.rnl.  L,  (mly  commencing  the  incimon  about  an  inch  lurther  back,  oppoelte 

^  oUaaeo-ouboid  articulatioo,  and  openiDg  this  instead  ol*  the  oictittarBo- 


flbt 


*, 


Tha  teayhflid  Bone  a  very  commonly  the  seat  of  primary  diKaae ;  and,  as 

thn bad*  ia  ooaiiect«d  in  front  with  the  large:  tarsal  synovial  membrane,  aud 

laMnorlr  with  that  which  is  oommoo  to  the  caleaoeo-asLraffaloid  and  a^tra- 

^,fJagaf«ftid  articulAiixus,  the  greater  part  of  the  taraua  u  apt  to  become 

'isffolTed.     It  sijuida,  indeetl,  next  to  the  astragalus  iu  its  power  of 

a  great  rxk-nt  i>f  the  font  when  diseased.     The  extent  of  Ibis 

isfuch,  that  cxciiiun  of  tite  priniarily  diseased  bone  would  prolv 

rHMom  be  attendert  by  much  b«n«&t.  and  Cbopart's  ampatattoD  ur  dis* 

nbtida  at  the  aukle-joiut  becomes  neci'ssary.     !Next  to  disease  of  tbe 

Mifalni,  I  look  iip'>ri  strumous  iadamntatiun  aud  cariee  of  the  scaphoid  as 

BWdiMiuctive  to  tlie  integrity  uf  the  foot. 

^^wi  tbe  Ctmeilora  BonM  are  tbe  seat  of  cariei,  it  vill  generally  be 

^u4  Iliti  the  middle  cuoeifurm  is  tbe  bono  primarilr  affected.    Tbeuce  tbe 

tcxieads  to  the  lateral  ones,  or  to  the  bases  of  tbe  second  Hud  third 

booes  (Pig.  5(i3).     In  such  casbs  the  anterior  ursal  syuovial 

I  usually  becomes  extensively  implicated, 

,  ut>  Brujiutatiun  will  hv  roiiuired.     But 

ruoue  oustUoue  to  be  limited  to  ibc  middle 

and  the  coDtieuouii  DiciaLarsal  boma, 

lllitpatieot't  general  nealth  be  good,  removal 

aftctrd  nmentis  struecures  by  the  gouce, 

laitrar:  '■■  cariouji  cuneiform,  may  be 

MmiIiJ  by  ni  r«3ult^. 

InfaJiB  of  more  than  one  of  Che  Tarsal  Bones 

isMMiJoea  requinvl  in  rhronic  diKCAM',  and  may 

Wn  an  excellent  ami  useful   limb.     No  formal 

nits  fnr  the  oppraiion    can   be  laid    down;   the 

Mine  of  prooncilini;  muit  depend  on  the  nature 

rflJw  ease  and  ibr  judgment  of  tbe  Hiir^on.     In 

1  bfl  «bo  wait  many  yedm  since  under  my  care 

nth  v*rT  exten»>ive  and  chronic  disease  of  these 

1   retnovml    tht>  lower  three  inches  of  tbe 

aii<l  iT'Otted  away  cuufciilt-rrtbli-  {xiriioiiti  id' 

[end  of  thf  tdtia  and  *<{  rht<  Kf>lrH{jaIu»,  mli-n- 

I,  and  culxiid — remuviti^  ti  whole  band  ltd  of 

Imuc  :   yet   a    pcrfn-t   cure   rwndteil.  the 

'BatitDt  rrrnrrriiii;  wilh  a  ]>tniiig  luid  um-CuI   foot. 

'TW  o  ca]rii<  and  astragalus  liiive  been  both  eucecfi«fully  removed  by  T. 
Waklcy  b  li^.  and  by  Watsua,  of  E'linbur^h  ;  and  the  oa  calcis,  almost 
the  wbfde  a»traindua.  aud  a  part  of  the  (tcnjdioid,  by  Nicholls.  of  Cbelmstbrd. 
XulTaney,  in  n  caac  of  disease  of  tht?  tantitf  cnnaequent  on  compound  di^lo- 
Hlioo,  rcnovnl  the  imater  part  of  the  scaphnid,  half  tbe  ob  calcis,  all  the 
■Mra^u*.  and  the  biwrr  end  uf  the  tibia.  Kayrer  removed  ibe  articular 
■■da  of  the  tibia  and  fibula,  the  m  calcis,  astragalus,  and  scaphoid  tor 
fiHOMe,  ID  a  boy  9  years  old ;  and  l^hmonn,  of  Polzin,  in  a  case  of  eariea  ia 
a  iBMi  agvd  -40,  naaoved  by  subperiosteal  excision  tbe  entire  tm  calcis,  the 


Pig.  MS.— PJ>«ftM  of  CtlB^ 
(orm  Booh. 


414 


EXCISlOX    or   JOINTS. 


■stngalue,  and  thr  scnphoid  bono«,  the  foot  liaviDg  a  pe-r'  <  :' 
|iMmuict'  thro>;  ntontlia  after  ihe  o|t«ralion,aDd  the  patient  -' 
irell.  witliout  n  stick. 

lu  iufantD  tm<i  veiy  young  cbtldren,  (liveaseof  llie  tarsal  articolatioBiat 
ov«B  lionev  mar  nftcn  he  n.'coverc(i  fn>ro,  without  the  ueccvritr  nf  bavnif 
noourie  toopcmtiou,  by  ftU«nliun  to  the  child's  geuenil  heallb.aud  brgiriac 
the  port  rc^t. 

Tlie  SallMli  alone  seldom  re<)aire  reaeotion.  Should  dtfacrof  then  <!■ 
so,  ihu  opcialioD  mny  readily  enough  be  accomplished,  in  tlio  outer  maUfohi, 
by  divliliiig  the  bone  with  cutting  (iHen ;  but  in  the  inner  aialloaliii,  mm 
oare  is  required  in  nvoiding  the  flexor  tendons,  the  artcrr.  and  nerm,  waA 
the  bone  bad  better  be  cut  across  with  a  chain-iiaw.  The  jwriusteiim  ihwM 
be  saved  n^  much  na  possible.  The  reiuovnl  of  the  outer  mallooliu,  urnUlar 
of  the  tower  end  of  the  fibula,  18  npt  to  be  followed  by  ft  leaileBcy  lo  twiiK  rf 
the  fmtt  outwardri^ — in  fact,  lo  a  kind  of  valgus. 

The  Metatarsal  Booe>  with  their  Toes  ocawiriuallT  raqiiira  noninL 
ThiA  is  more  pnrtii-uiurly  tht>  ea«e  with  the  6rat  niid  the  nAh  ^  P-  13S,TdLL). 
The  middle  mctatarsnl  bones  ciionol  advaotageousiy  b«  taken  away,  teaviaf 
merely  the  firat  and  loat ;  but  the  two,  ihrw,  or  even  the  whole  four  of  ihs 
external  mctaittr«al  bones  may  be  resected  in  CArly  life,  and  a  uaeful  £0! 
left  A<>t<)u  Key  has  recorded  a  oue  in  which,  in  coowqueDce  of  injurr,  he 
ampuiated  the  lour  outer  mctaUir«al  bones, the  cuboid,  and  the  cxtenuJ  aad 
midrlle  cuneifurm,  leaving  merely  the  line  of  bones  supporting  the  great  tse. 
The  first  metatarsal  bone  waa  left,  supported  only  by  the  alendrr  articular 
surfnce  of  the  internal  cuneiform  ;  but  it  soon  got  firmer  atlai-iimcul«,  aiul  s 
very  gtx^Ki  f<H>t  nsuile*],  by  which  the  patient  retained  in  n  gtvat  mooMrn  hit 
elasticity  ■»("  tread. 

The  Phalanges  and  Artictilations  of  the  Toei  »eldom  require  rcwctMa; 
as  a  Ketivnil  nili-,  tlieir  aiDpiilaliiin  ig  preferabK-. 

Thi-  Great  Toe  not  unlmjiienrly  ri>t}iirre»  removal,  io  whole  or  in  pari; 
but,  as  it  enters  liin^iy  into  ihtt  tVirmation  of  the  srcb  of  tlie  fool,  ao  nOfB 
of  it  RJimild  t>e  takeu  away  than  is  absolutvlv  neccMary.  It  is  opt. 
of  iniportnnt'u  tliut  the  balj'of  the  great  toe,  if  poasibl*,  M  pmvvMt 
occasionally  this  may  be  c(tl>ct«d  by  excision  of  the  mettttawo^pball ^ 
articulation  rather  tbaa  by  the  amputatiou  of  the  member.  ^\  itb  rrgarf 
to  the  removal  nf  the  toe  and  itn  mctaUrsal  btine,  I  must  refer  lo  p>.lS3i 
vol.  L  Wbcoevrr  it  i»  practioflblc,  the  pmiimal  cud  of  the  bone  elHNikl  bs 
iaved,  in  order  that  thu  insertion  of  the  tcudou  of  the  {leronoua  loBgvs  aajr 
be  preeerved. 

AMPDTATIOX   t»   JOIXT'DlfllUSES. 

In  ihnae  ca«e£  in  which  excieiou  uf  the  dtM-iwi'd  joint  ia  not  advisable,  ia 
ooDSequencc  of  the  acute  character  of  the  articulitr  diM'a^v^  the  cxistMuw  not 
only  of  constdvrahit;  suppuraiioo  but  of  ^rcat  local  and  coiulitutiuoal  irrita- 
Cion,  or  the  peculiar  naturvof  the  joint  affvcte<l,  amputation  mar  be  ttte  aule 
rcaouroe  left  to  the  Surgeon.  Il  is  eBpeciollr  iu  nriicnlar  d'lscaw  of  the 
Angers  and  Iocs,  of  the  tonuit,  carpus,  ankle,  anil  knet'.,  that  tht*  opcratioti  is 
required  ;  and  thnu^'h  it  in  much  Icm  frequently  practised  now  than  fnrmfrly. 
yet  the  cases  of  deslnictive  disease  of  joii>l8  r<i{iilHnf;  amnutati<io  are 
atuoQgst  the  most  frf^quent  in  operative  surgery.  an>l  wilt  di)tibllr«s  conitaae 
td  be  so.  The  r^urgeon.  howovcr,  mutt  be  cart^ful,  vrbtl^  he  avoids  nialion- 
lay  to  make  it)otlV<-luid  attempts  to  Mve  the  limb  at  the  grral  hnaard  uf  the 
uuient'i  lilV,  nut  to  ampulatp  until  it  la  clear  timtall  other  m««nii  liave 
Milvd  ;  the  |iatJeuL  continuing  to  loM  gruund  so  that  a  liirlhi-r  perMvrraa«a 


AUrUTATIOK    IK    JOINT-DISKAaB. 


415 


il  locml  and  cODSiiluliuDsl  trentmcDi  would  prohablr  end  io  bU  death,  ox- 
OMO  WK  being  jmicik-able.  Sj  far  from  ampuintluu  being  bu  opprobrium 
li  utrgtry  in  soch  caaet  as  th€««.  I  look  upon  it  as  one  ot'  the  greateit 
IBUBMW  of  our  art,  that  bj  a  simple  and  «i»y  operation,  wltich  removes  tho 
^hM  umI  aaeleaa  limb,  tlic  life  of  the  patient  m&y  be  saved,  and  bis  health 
ifeeifiljr  rolored. 

In  unputAling  in  oues  of  chronic  joint-disease,  in  which  the  lirab  haa 
Wb  lh»  acu  of  protou^Kt  suppuration,  it  will  be  found,  just  at  in  mnuT  cums 
<4  wteonAmrf  aioiHitoiiun  after  iujurice,  that  the  condition  of  the  niasdt-s  of 
the  limb  ia  peculiar.  ItKiead  ot,  &»  in  ciuea  of  primary  ampiitntion,  being 
■lark  in  oalor  aud  retrai'ling  fonribly  and  une(|ually  when  ntt  acnw.  they 

■  ill  btt  found  to  he  pulr,  w>ft,  flabby,  and  retracting  but  titltr,  if  at  all; 
llMJAbliag  in  tht^  mpt^cl  the  oiUscIhI  iu  a  dead  Ixidy.  lu  ci>niu^|iience  of 
ihia  altemliiib  In  lli*-jr  «trut-lure  and  phytiiologicn]  projierties,  the  flaps  need 
UuC  be  init  M)  ttitii;  iu  ftmpiilation  fur  chrouic  nuppurative  joiiit-diseiue  tm  in 
QIP^  (tf  priutBf^  niiitiuuni  n. 

CinntB«UacM  influencing  Hort&Uty. — The  morlalitv  after  amputation 
Ibr  joints bcMMS  ii  capevially  indueuced  by  tliree  cuuditiooi! ;  vii.,  ibe  ti^at 
vf  Htm  Operatiuo,  Utu  Acute  ur  Chrvoic  Character  of  the  Disease,  and  tho 
€Mwtttut*oan.l  Coiiditioi)  of  the  PatieuL 

The  infiueoctj  ul'  thti  aeat  of  operation  has  already  been  discussed  at  p,  107, 

Tbe  dmrttion  «/  the  diatom  exercitcs  a  most  important  influence,  especially 
n  tbe  larger  jutnle — more  jNirticularly  the  knee.  As  a  general  ruk-,  it  may 
Im  ■tatcd  that,  the  mnru  uuL-urole  the  suppurative  dt«tructioa  of  a  joint,  tho 
taBaBceosful  ta  the  aniputittion  of  the  linih  likely  ti>  be;  pyaemia  being 
apKsaJIy  apt  to  itupcrveno.    {^Bee  p.  107,  vol  i.) 

In  T«ry  acut«  iMSBS,  the  Surgeon  ought  to  evacuate  the  pue  by  tiKans  oi 
Ave  iMaiduiMi.  and  endeavor  Ui  pontpom-  amputation  until  thP  active  Bup- 
pBfBiive  aUgv  has  jtaafled,  and  the  a0t>i'-ti<tn  haK  Hiih»ided  into  a  rhronio 
tarn.  Id  chmaie  raaes,  the  suooeaa  of  ampuiatii'n  ia  very  great.  It  cora- 
ily  bappens  that  a  patient  who  has  befn  racked  with  pain,  and  been 
ting  to  body  fur  wm-Iu  before  the  local  source  of  irritation  was  n>moved, 
•naudly  the  night  after  the  operation,  and  rapidly  gains  fleab  and 

«iwetb. 

In  i!-*-™-!"!fig  upon  the  adviaahility  of  resecting  a  diMaaed  yAnl  or  oi 
■■pci:  limb,  the  Surgeon  must  be  guided  not  only  by  the  amount 

f^  di«ra>r  in  the  articulation,  but  by  the  cnnntiMiomii  mndiliait  of  the 
fnticot.  lo  aiufiutatiiiu  the  chi«f  dangoni  are  Imtitediate — from  elmck  or 
■eOD'!  ^iiV-      !■>   •'XutMiou    the  ehock  la  unl  i*'  severe,  in  o>ii?^ 

«MBc'  '■>  Ivcing  lurlhtfr  Irom   (be  trunk,  and   Ihrmigh  i'limpara- 

uvdy  cuperticul  and  unimjKirtanI  parts;  no  large  bloixlvuMeU,  (ierv»s  or 
««ai  Mosclrv  are  dirideil,  and  there  if  nu  danger  of  wi^judary  hemorrhage. 
B«l  in  ea  dsngen  are  cliietly  r4-nii>l« ;  the  pnppumiive  pnfvew  ia 

«Ami  Idog  '  <  ').  ntnl  the  discharge  of  pus  ubundiint ;  the  patient  may 
OUBaai|itcstJy  pot  have  Bultirluol  constituti'nal  power  to  carr^-  hiiu  ihnnigh. 
£o  fiir  as  rrT*ip«la»  and  pyicmia  arc  concerned,  the  danger  in  probably  the 
■MM  in  both  opsrationa.     In  addition  to  tliis,  it  must  be  boruo  in  mind  that 

■  pnlieot  who  would  nut  aeree  to  part  with  a  limb,  will  ofleu  couMut  tu 
bar*  a  joint  ur  bona  exdaed. 

As  pIitbiHS  DoC  unfrrqueotly  coexists  with  the  advanced  fumis  nfstrumous 
jsinls,  the  aocMioa  of  amputation  under  thise  ctrcumslaurea  becomes  one  Ol 
vary  ouwioerabla  importance.  If  tho  phthisic  be  rapidly  progroaing,  and 
tbarm  bv  *  alrong  boreditarr  tendency  to  the  di»eai<e,  or  if'^it  hava  advance^l 
"  lauAcniog  of  ine  lung  antl  the  formation  of  cavities,  it  will  be  useless  to 


4ie 


lriS&A8£»    OP   THE  SPI»K. 


optimto.  If.  hMWdver,  tJi«  pbtliisis  be  but  ili^ht  and  incipKnt,  ami  Uw  ft» 
irnwi  nf  llii  ili»ea»e  be  apimreull.v  «lue  to  tbti  lucal  irnULiuij  uraod  dttcliaiit 
fmin  tliR  joliil,  Ki  tbo  couGuciucuL  to  bed  tbut  ibis  Doceaoiuim,  and  to  tm 
eeaeri)!  dt-privaiuiu  of  buolih  tbat  eiiaui«,aui|iuuinoii  oiaT  Dot  »ii1t  b<»Gilj 
Cut  advaiun^utfUHly  practitH^l;  uud  I  bavc  purfurmcd  it  lu  nuutj  iocfa  ON 
to  tbe  uiauiUvil  advauuigu  i>f'  tbe  patiuuU 


cnAPTEn  L. 

DISEASES  OF  THK  SPINE. 


8PIXA   HIPinA. 

It  occAsionally  bapiR'ntf  thnt,  from  oongeniiiil  malfitrmation  eomeaoeflt  ■> 
arroBl  of  dovelopnieiit,  tlie  fipinoUB  jiroccswa  of  i»iim<>  of  the  vertCDne  m 
dcRciccit,  aod  llii?ir  lainiiiie  either  ahacnt  or  Bcpnnili^l ;  the  mentnge*  of  tkt 
spinal  (^>r<l  are  ibua  unprotected],  nnH  pnijecl  tlirnii^h  the  mpcrtun*  ts  lb* 
boaes,  giving  ri^  to  a  iiimor  «t  the  part  where  ihe  iirren  of  ' 

Chft  MKoud  ftiructiirea  occurs. 

ClunArTERs. — The  tumor  !□  spina  biBdi  is  uiaally  oval,  its  hmg 
corruprtodiDg  with  that  of  tbe  spine.  It  varies  in  sixe,  fnmi  that  of  a 
walnut  to  an  orange;  bat  occasionallr  it  attains  an  immense  liulk,  c<jual  tn 
tbat  of  a  eliild's  head.  In  some  ease*  the  ttimor  is  lobuluted,  having  ao  im- 
perfect «epl  urn  ^iretcliinK  acn^as  it;  in  otb^r  inHtnnoN,  Lwn  or  more  dUliact 
tnmora  have  b?en  met  with  in  the  apioe.  The  "kin  ci>verinj:  il  is  umally  of 
Qormnl  color;  but  when  th«  tumor  is  of  coneidemble  site,  it  mar  hm  tbtH 
and  have  n  bloish  or  coniiested  appearance,  and  prewnt  a  certain  dwna  of 
traospareucr.  Iti  these  circumotaQoea,  aleenttion  from  distention  and  thui* 
mug  of  the  ikiD  may  eventually  take  place.  On  examintog  the  tvBor, 
which  m  bard,  though  elastic  when  tbe  child  is  held  upright,  it  will  b«  Toaai 
that  it  beoomea  aofl  when  the  child  u  laid  borisontaJl^.  It  aoinvtiBM*  W- 
ooiDM  teiue  darinr  expirntion,  and  eoAer  during  ioflpiratioii.  FlnctuatiDa 
la  Qsually  i)erceptiole.  and  Ijy  pressure  the  bulk  may  in  some  caat>  bai 
tinctly  lessened,  while  nL  the  same  time  increased  teniion  may  be 
at  Lbs  anterior  foataoollc,  thus  demonArating  the  conuectiuu  of  tb»  i 
tbaaubaraohDoid  space. 

ThQ  wall  of  tbe  aae  in  apinn  bifida  is  eomposed  of  the  whole  of  Um  na» 
branea  of  the  oord  Auted  together.  Thev  arc  covered  by  tbe  oldn  and  a 
varying  amount  of  &L  Sumelimea  the  dtin  ia  appnrenlly  waMtinn,  or  ii 
thlnnt.'<1  and  ftiaed  with  the  membranen  so  aa  to  be  no  longer  ncogntBibl& 

Bpinu  bifida  rauy  be  met  with  in  any  part  of  the  rcrlebral  colamn ;  It  li. 
howevrr,  nliniMl  luvarUbly  fouuil  in  tbe  lumbar  or  lumbo'^aeral  regwMi, 
tliii*  part  o{  the  k|)inBi  eauul  living  tbe  lost  to  close  In  ftetal  lift.  Thw  cas» 
tn  wliicb  it  ap|M^ni  higher  up  are  of  rare  o^tnirrenM  ;  inatoncea  of  the  kisd 
ar»-,  however,  ini-nlionrd  by  t'ruveilhier.  When  it  occurs  in  the  Mrrlcal  t* 
dorsal  n^gioii  tbe  spinal  rortl  is  most  fre<|iien[ly  adherent  to  lh< 
'  wmll  of  ibo  tumur.     In  the  lumbar  r^iou  tbi^  is  lea*  common,  tli 


malformation  takes  plaoc  nl  a  eomparativoly  early  period  of  ftetfll  life 
vheD  ihe  <!or()  reaches  to  the  fourth  lumbar  vertebra,  it  tnuot  impuasible  for 
it  to  lie  in  ilic  flac.  The  spinal  nerves  in  the  great  majority  of  c&sos  project 
in  long  l(>o|M  into  the  sac,  aHherirtj;  to  its  walla  for  aonic  diatatice  and  then 
retiimiog  to  the  intcrvortehral  foramina. 

Tbe  tumor  i*  difttemled  by  the  cerebn>>8pina1  fluid,  which  in  chnracteriEed 
by  it*  <Jcar,  limpid  ap|>earaiice,  by  itii  low  ^peritic  gravity  (lOO-i  to  lOOG 
King  the  average),  and  by  its  contaiuiii);  merely  a  trace  of  albumen,  a  cod- 
nderable  (|uantily  of  chlnrid^  of  ^otiiuni,  and  a  trace  of  i^ugar.  The  8ii|>ar 
can  usually  be  rccoirnizeil  only  after  cnret'ul  reparation  of  the  albumen  and 
conoenlratmn  of  the  Huid  by  eva)Hjrativn. 

Spina  bifida  is  not  unoonimunly  a^iM^ialed  with  other  deformities,  et^pe- 
dally  c)ub>t~oot,  talipes  calcaneus  beiu^  the  moat  common  form.  Oa]<<ei4 
■Ifto  have  been  reourderl  in  whiuli  the  child  was  at  the  Mime  time  hydro- 
oepbalic.  In  tliese  cases  the  central  canal  of  the  cord  has  been  found 
dilated. 

PBo<i>-osia. — The  prognueia  of  spina  bifida  will  dupcad  upon  the  siso  of 
ihe  tumor,  on  the  coudiiioo  of  the  skin  voveriug  it,  aud  on  its  situation.  If 
it  be  of  small  size,  with  healthy  integuiueutal  investment,  and  without  ten- 
itacy  CO  iurrease,  the  patient  may  live  to  adult  a^,  provided  care  be  takeu 
to  protect  tJie  tumor.  If  of  lurge  aizc,  it  is  generally  talal,  the  child  usually 
dying  at  an  early  age  of  couviilt^iona.  In  other  iuslancts  the  tumor  iu- 
ereaseii,  the  8kin  covering  it  hecomra  thin  and  rod,  uti^rates,  givw  nuy,  aud 
death  rei4uU»  fnmi  aepcic  meningitia.  It  may  be  staled,  aa  a  gvnt-rni  rule, 
that  spicm  bitinla  if  more  dangerous  the  higher  it 
is  nlac^'d  on  the  fpini;, 

Tkeat.mknt. —  In  lhB  treatment  of  spitia  bifida. 
the  line  of  practice  must  be  determined  by  the 
lizc  of  the  tumor  and  by  the  conditioo  of  the  skin 
covering  it. 

When  the  tumor  is  very  large,  and  the  skin 
covering  it  has  become  reddened,  showing  a  t«n- 
ijcncy  to  give  way,  tapping  and  compression  com- 
tutted  offer  the  bwt  cbaoce  of  safety.  The  case 
from  which  tbe  accompaDying  drawing  is  taken 
ma  cured  in  this  way.  It  w^s  that  of  a  young 
girl.  Ac  birth  the  tumor  was  small,  but  it  grad* 
nally  ineren.*ed  in  siw-,  until  at  the  ago  of  thirteen 
it  bad  attained  the  following  dlmeneions:  Circum- 
ference at  base,  2'>  inches;  length  over  greatest 
c>jnvexily,  19  inches;  breadth,  14i  ioehea.  The 
tumor  occupied  the  lumbo-aacral,  aud  stretched 
over  both  gluteal  regions.  It  was  tense  anil  trans- 
lucent;  the  skin  reddened,  very  ibiu,  aud  becora- 
iog  darkly  congested  at  the  more  prominent  |>art, 
evidently  in  imminentdanger  of  bursting.    Health 

ejtceileiit;  development  good.  I  tapped  tbe  tumor  and  drew  off  101  ounces 
of  cerebro-spinal  nuid.  When  emptied,  an  aperture  U  inch  long  aud  three- 
(|uarter«  oi  an  inch  brond,  could  be  felt  at  the  lower  lumbar  and  upper 
Moral  regions  to  the  left  of  the  meainl  line  Thi?  part^i  were  well  padcM 
with  cotion-wool  and  »ii|>poried  by  an  elusttc  bandage.  No  iU-effects  fol- 
lowed the  lapping,  Thiit  was  repeated  tilnc  times  in  eighteen  weeks,  085 
ounces  in  all  of  clear  cerebro-spiual  fluid  being  drawn  off;  the  largest 
tapping  Biuounied  to  120ouDce<t;  the  smalkst  to  9:{.  AfWr  each  tapping, 
melhodical  compression  was  employed.  The  ninth  tapping  -wa^  followed  by 
TOL.  II. — 27 


rig.  5iM.— L*rg«  Spina  BIMs, 
cunj  bj  (appipg  nnd  prftt- 
Mra. 


A 


*4  U^^MM.  W 

*<' 

I*  &(<,■•  a 
«M  b*  W  mill    111  ~  I  hav* 

la  Ow  ]PH«.  W««rw,  M«rt<M,  sf  OlMfvv.  Mg^Md  Ik*  MB  if  As  1 

Mf  ••  IB.  %,  kAde  «f  paCMMM  gr.  xxx,  ] 
htm  Wi4  n  ahijy—hw  of  oim  witkaa 
•uaodirf  «■/  prvriow  aod*  of  inBlacaL    TW  ad«Hni  of  tk>  |_  , 
■oluUoa  HiflB  te  ba  Uat  [ft  diftm  VMXremAj  dovlr,  Ksd.  ooan^Mdy, 
th»  paftlwi  b«  kept  »twht  sad  pwtimllj  erect,  ii  hs  Itula  taodoan- 1 
mtMd  tafoi  ike  epiaal  aaaL    Tke  qfaaaiitT  isiaeivd  akeald  kt  ftwa  kitf  i 
dmekai  la  a  dnuhB  aad  a  balll    It  it  oert  daae  kr  mmam  «f  a 
r^nKBt  fiiud  with  a  fioe  plariaaa  aeadla.     If  ike  mc  m  Mbm,  ikt  i 


OABIK8   OP   SPINE—ANOULAB    CUBTATUBB. 

BM^r  fint  be  Intrndaced  am)  a  »mali  quautity  if  tht'  fluid  druwu  off,  but  in 
■Mat  caMB  the  iodu-g-lycerine  A)lutioD  may  ho  directly  injiTted.  The  punc- 
Uin  Biuil  be  carefully  dooed  witb  lint  mid  colltidion.  81iould  the  eno  coo- 
taaQ«-  to  leak  at  the  puucture,  suppiirHlioii  and  meiiiugilui  are  very  HLely  to 
•ecitr.  Afwr  the  injectivo  a  9iiddc1  bandage  may  be  applied  over  aume 
«uUaa-wool  uuveriog  the  tumor,  and  the  child  must  be  kept  a^  far  lu  poesi- 
bU  in  the  re«umbcnt  ]H>aiti')ii.  A  complete  atatiiiiical  repurt  of  ihiii  trcut- 
tD*iit  ha*  not  ret  bc«u  collected.  At  the  time  Murtoo  published  hi^  paper 
in  laHf^,  he  knew  of  14  cases  in  which  the  treutmeot  had  beeu  tri«l;  of 
tbawt,  11  were  ftuccudsful.  Since  that  lime  uumoroui^  ijuccc«aful  casu  have 
bn—  ret^irded.  in  muay  of  wbJch  the  mc  yttts  m  thiD  that  without  the  operu- 
tiaa  li^  oHild  not  have  beeu  proluugcd  beyuod  a  few  weeks  or  moalha.  In 
B  eMMtd'rtble  Dumber  of  other  cujk«  ocithir  good  nor  harm  resulted  from 
tb*  tmtmvot,  and  iu  two  at  least  sudden  or  rapid  doulh  hma  oocurntd  after 
Um  injectiuti.  Still,  when  we  cuntider  the  hopclu«ut;ss  of  th«  diseasa  in 
■oat  easea  it'  left  t<>  ilKcIf,  the  amount  of  suceeau  obtained  has  been  such  as 
lo  JBBtify  tiui  tmtmcDt  ID  all  suitable  cases. 

AatiMplio  drainage  mad  removal  of  the  sac  have  been  tried,  but  the  reeulu 
bave  BQt  bMB  Rucb  as  to  eocourage  a  repetitioo  of  the  treatra«it. 

r-AUiKm  or  TDK  SFI>E — AXOl'U&H  CL'BVATl'Ki: — 1^717*8  DlhEABE. 

This  disease,  which  c<3nj{sb<,  in  ita  full  development,  of  destruction  of  the 
bMica  of  some  of  the  vertebrae,  with  disintegration  of  the  corresponding  in- 
t*rverlebnl  fibro-cartilaKes,  most  commonly  occurs  In  young  children,  svme- 
lisMS  even  during  the  nrtt  year  of  life.  It  iM,  however,  met  n-illi  at  Inter 
pwioda,  not  uncommonly  commencing  at  puberLj',  and  sometimes  much  lat«r 
tfiU.     I  have  seen  it  »et  in  tider  tilly. 

PBtholt^y. — .\n!^iilar  curvature  of  the  apine,  or  "  Pott's  ilitteoiie,"  ait  it  is 
cwaibonly  catlt^  au*r  PercJval  Pott,  the  celebrated  Surgeon  to  St-  IJartbolo- 
naVs  Hospital,  who  first  accurately  de-icribed  it  in  1779,  mity  origiuato  in 
two  diiloreut  structures  of  the  spinal  columu  ;  viz.,  1,  the  biMlies  ol  thu  ver- 
icfans;  *i,  tba  inlervertobral  fibro-cartilages.  The  relative  frequency  with 
whid  tb«  dlstasc  oommsacea  in  these  two  structures  ha^  been  the  subject  of 
oooiidefable  diCTervncc  of  opinion,  tome  Surgeons  maiulaiuiug  that  in  the 
EPCal  nsjority  of  cases  the  uitervertobrul  cartilage  is  iho  startiug  pujut  nf 
wc  destructive  inflsmmation,  uud  others  that  it  is  mruly  if  ever  primarily 

■;*■— '-l    "^^ "■■— ■>f  this  uncertainly  aeeuut  to  be  that  by  the  time  the  opp<»r- 

^nmining  thu  disanscd  structures  the  murbid  chunges  are 
*>?  aiirAii<-<i  [Kit  a  i«  impiiHeibte  to  say  where  thev  cummcuccd.  In  the  vast 
ma^atiiy.  if  Dot  in  all.  of  the  specimens  obiaineJ  at  an  etirly  stage  of  the 
AmuBi  troa  pftUcnis  dying  ui  icime  accidenULt  cumpticatiiiu,  there  in  no 
4Mbl  tbal  tbe  starting  point  of  the  murbid  dmnge  13  the  b>mc.  H'hile, 
rtnuifiiffl.  we  are  noi  in  a.  [•'LtitiMo  t'l  deny  that  the  disease  may  originate  in 
lb*  hitcrvertehrml  iliBke,  this  minle  of  origin  is,  to  Bay  the  least,  rare. 

Tbe  patbologioal  pnHVHM-d  t>rcurring  in  caries  of  the  verlebne  diBt'r  in  no 
aiBterial  r«apMt  fVxmi  tli-M^  aln^dy  described  (p.  2^j  aa  taking  place  in 
BaBoalloua  bone  elMwhen*.  When  tht^  dideaei''  oonimeoces  in  the  ix>De,  the 
v«Bvla  .).<'  the  iiir-.tii1lnn-  tiMue  Are  fir«t  rliJAteil  iu  the  affe«led  area  ^  )ndiim> 
■atcr  ;  tKe  tissue  next  bedmc*  iuSlirated  with  small  round 

BKlh  U.   <  ihe  uurmul  8tructur(«  disap|M?ur.     Thus  the  cancellous 

fpooM  bet'  I  with  nt)w  eielU,  aiiion;;4t  which  capillarv  toofM  may  pon^ 

trata  'grai • -iMiir)-     Thn  bony  traheculie  enclo«iing  the  Hpacea  are  Bret 

tbiBBr«i  and  ftn»lly  C'>ii)pt«telr  abaorliett  by  the  advancing  cell-growth;  thus 
a  nnnim  of  tbe  cancellous  ti»tie  ol'  thu  biKly  of  a  vertebne  may  be  de- 


4» 


DISEA8SS    or    THE    SPI5X. 


MroTwl,  itd  pinrp  beiDe  tMrrupied  by  grnDutntion-tUeu*.  The*c  cbangsfeia 
Ha  eiMDtis)  (iiirt  of  all  variciiiit  ut'  cam» ;  tlic  Cnte  of  lb«  grwoUdcitt-liwi*, 
howevvr.  difR'rs  in  'liferent  csms,  the  following  b«iDg  Cne  vh'wf  ti»idifi(» 
tiuns  of  tbe  subHqueot  processes: 

1.  Xbv  gr«nuliilioD-li»>Mie  replacing  the  rancellotu)  booe  n.i%y  l*c  ftlMorbtd 
Bppareutl}'  as  the  result  of  tfa«  preMure  exertvxl  upon  it  by  tlie  wt^jcbl  ufUM 
triiak.  Thud  a  steadily  pr<)gr««eivt;  dvetruction  uf  bone  ninr  iMki;  p\»tt 
without  there  being  any  extt^uatve  accumulation  of  grantiintion-tiMur,  sad 
without  the  furmatioD  of  pus.  Tbis  dry  cunV«.  as  it  ia  termed,  Is  rrry  ^M- 
moD  in  tbe  spiue,  bciug  the  process  that  takes  plac«  in  tbo«e  nunierrMw  c*m* 
of  angular  curvature  in  which  the  patieut  eiiciti>ea  without  tbv  fi>rniatioci  «r 
an  abscess.  Its  progresa  u  »)D)etinies  very  rapia,  Ivatliug  to  great  lieformtlr 
in  a  very  short  time. 

%  Instead  of  being  absorbed,  the  granulntiua-tiflHie  muy  utxlcrgo  &ltj 
degeneration,  and  a  slow  process  of  suppuration,  with  the  furinuii>iu  of  ninly 
pU8,  may  lake  place.  Tne  pus  gradually  accumulates,  forntiuu  a  duoaic 
absceas,  vhioh  slowly  forces  it£  way  to  the  surface,  fullciwiiig  the  Uneaof 
KsiMauce. 

3.  The  grauuIatioD-tiseue  rnay  caseaie  rarly,  before  the  bony 
are  completely  absorbed.      The  unahsorbcd   bone  llien   periahes, 
sequestra.     Thi«  necrotic  furies  ia  very  common  in  the  spine. 

4.  The  grauulatioQ-lissue  may  calofy.  This  ia  not  uncommon  in  ifae 
It  is  said  to  be  one  mode  of  cure,  especially  when  the  disease  b  tul 
and  the  area  affected  very  limited,  llic  small  calci6cd  nodule  lying  bar»- 
lealy  embedded  in  the  surrounding  bone.  Small  nccroaed  firagmeots  of  tma- 
cdloDS  bone  with  it»  spaces  filled  with  calcified  inflammatorr  products,  are 
•ometimes  met  with  in  the  discharge  from  abweasea  ccmnectca  with  angolar 
curvature  of  the  «pine. 

5.  Lastly,  if  all  sources  of  irritation  are  rejnoved,  the  rnrefying  osteitis 
may  cease  to  extend,  and  tbe  grfloulalion-liasue  become  develntxtl  into  bote, 
thus  effecting  a  cure  of  the  disease.  The  points  at  which  earn^  most  cob- 
munly  comniences,  are  first,  in  the  growing  tissue  between  the  autiUgiDoui 
duks  forming  the  upper  and  lower  ports  of  the  body  of  the  Ttrtcbnr: 
•Mondly,  beneath  tbe  penosteom  in  firont;  aad.  thirdly,  in  the  cvnbml  parts 
of  the  bone. 

The  destructive  process  extends  not  only  into  the  boor,  but  alao,  usuaUr 
At  an  early  |>eriod,  into  the  intervertebral  fibro-cartilngca.    As  the  diaiass 
oommenoes  most  commonlf  betwven  the  eoipbyieal  cartUa^  «nd  the 
the  thin  layer  of  cartilage  la  aooa  dcstroyeti  by  the  suae  foca—  m  m 
served  in  the  destruction  of  nrliculur  curtilage  in  chronic  iufiami 
ioiulB  ^p.  350).     The  granulatiuu-tiMtue  tlicu  pencirait^  into  tbe  inL__ . 
nral  disk,  which  is  destroyed,  after  which  the  morbid  proceei  cxteBda 
the  body  of  the  next  vertcbrn. 

The  causes  of  the  disease  when  it  oommeDocs  m  the  bona  are.  fiiel,  ti 
ID  an  unhealthy  fiuhject.  and,  secondly,  deposil  of  uberelei,    The 
the  mijst  common  starting- iKiin I  is  the  soA  growing  tissue  between  tbe 
and  the  epiphysial  layer  nf  cartilage,  and  that  it  is  usually  siluated  i 
niilcrior  imrl  which  would  he  moat  powerfully  compreiaed  during  fui 
Ilexi»n  of  the  spine,  is  strong  evidence  that  the  primary  cause  of  the  >li 
b  frequently  an  injury.     In  some  case*  there  is  a  clear  history  of  injury, 
an  a  mil,  but  oA  tbe  dUcfttw  is  mnitt  common  in  young  children  and  enaimi 
insidiouMy,  the  history  cannot,  ss  a  rule,  be  implicitly  relied  upno.     That 
the  disease  ii  in  a  very  large  proportion  of  cases  due  tn  tbe  dep<-  < 
is  now  almi«t  universally  recoifnixed.     The  evidencv  In  proof  • 
foHowing:   First,  tbe  disease  frequently  commence  in  many  iuilvj^ 


OA.ItIES   OF   SPINE — TUBKROULAR    NATUKB. 


cmtrvit,  (>ft«»  in  llie  botlif^  oi*  dilTercnl.  vf^rtebrre,  ami  in  MtiiatitniB,  sucli  aa 
ihu  fmnt  i}i  a  body  or  in  it»  centml  [mrM.  wh'cli  nn?  little  expiiw*!  t»  injury. 
Seooaflly,  in  paCietitn  ilyin^of  advantx-^l  vnncs,  atfecting  onr  part,  ot'tlie  upiuQ 
eeparate  oeotree  of  disease  in  an  earlier  stage  are  freciueutly  J'otind  in  iiltier 
vertebm.  The  granulation-tissue  removed  from  these  has  l>e«n  elinwn  to 
CDDtain  oon-vascular,  casentin^  nodules  presenting  the  characteristic  anat<imi- 
cal  atnicture  of  the  tubercle-nodule  or  -fillicle  (pol.  i.  p.  1010),  atirl  further 
tbe  presence  of  the  tuberclc-bacillus  ha»  hf^n  dcmongtrnted  in  many  oaiKH. 
Thirdly,  the  early  cascatioD  of  tbe  inHammntory  products  and  the  chronic 
•uppuration  correspond  with  the  course  followed  in  tubei'cular  inflainmatinns 
elsewhere.  And,  lastly,  a  considerable  proportion  of  patients  dying  of  cnriea 
of  the  spine  are  found  to  he  infected  willi  (^enoral  tuberculosis. 

In  whatever  way  the  disease  conim)^uceA,  the  moat  common  cause  of  its  per- 
Bltence  is  tbe  uiechnnical  irritation  of  the  diseased  surfaces  by  the  friction 
cf  movement,  aggravated  by  the  weight  of  the  parta  of  the  body  above  the 
aflected  vertebrfc.  In  other  cases  the  presence  of  sequestra,  which  cannot 
find  a  way  out,  way  keep  up  the  disease  indefiuitely.  It  B«etn9  probable  that 
cariee  originally  tuberculnr  may  become  simple  in  character  as  the  disease 
progresaes.  The  nriginnl  tubercular  centre  may  completely  caseftte  and 
eufteu,  excitiujr  in6aminatioa  in  the  tissue  around  it,  and  be  thus  eliniiuat«d, 
the  subsequent  progreae  of  the  disease  being  due  to  the  mechanical  cause* 
aboyo  mentioned.  In  other  cases  the  tubercular  prnces.-i  may  infect  the 
»urr<iuQding  parts  and  maintain  its  characteristics  to  the  end. 

I  kaijW  of  no  exact  descrifdi-ju  of  anv  primniy  pttiholor/ical  c/ianjM  takittff 
jtlaci  in  the  intervertebrai  di/h.  .\»  belore  BtateJ,  we  are  not  in  a  positicn  to 
d«oy  that  disease  may  originate  in  these  structures,  but  by  the  time  the  case 
cornea  to  be  eiamiucd  after  deitlh  the  librij-cartilii^  has  disappeared,  and  we 
find  ouly  lie  signs  of  rarefying  iwteitis  in  the  vertcbne  on  each  side.  Luscbka 
states  that  there  ii  n  synovial  ravity  in  each  disk,  and  that  tbe  lobes  of  th« 
pulp  correspond  to  tlie  villi  of  a  synovial  mnmbranu.  If  this  be  true,  it 
would  be  in  this  structure  that  any  primary  intlamrnatiun  nr  dopoait  of  tuber- 
cle would  take  place,  and  not  in  the  denite  fibrous  and  fibro-ciLrttlagiuous 
layers  fomiiug  the  outer  ?.oneA  of  the  disk. 

The  nature  of  the  pnthologicnl  changes  l>eing  borne  in  mind,  the  coarser 
morbid  ap|H>araiices  are  eafllly  nnderst^tod. 

Dry  cariee,  or  caries  without  ttuppurntion.  forms  the  simplRi^t  varii^ty  of  the 
diseaae.  It  aflecta  usuallv  a  limited  poition  of  the  spine,  often  two  vertebra 
only  with  the  intervening  intervertebral  disk.  The  deatruclion  of  the  bn<lie« 
of  the  vertebrse  in  the«e  cases  often  takes  place  somewhat  rapidly,  anrl  at  the 
*ame  time  tbe  osseous  tissue  is  imflened  bv  extension  of  the  rarefying  osteitis 
for  ik.nie  distance  from  the  centre  of  the  disease.  In  consequence  of  this,  the 
weight  of  the  body  above  the  d ii4«:-H»i:t]  vortebrie  causes  a  binding  forwards  of 
that  |>ortion  of  the  cjlumii.aniJ  a  corruspnndiug  projection  backwards  of  the 
spinous  procMM*.  A  vertical  iu*clioTi  mride  through  &  spine  thus  affected 
shows  the  anterior  common  ligameut  thickened  and  swollen.  The  bodies  of 
the  atlected  vMrtebrai  are  softened  and  partly  deslroyetl,  the  destruction  being 
almost  invariably  more  extensive  auteriorlv,  us  this  pnrt  is  eK|>09ed  to  the 
greater  pressure  when  the  spine  is  bent  forward*.  The  intervcrlehral  car- 
tilage between  the  two  verteorre  ha*  more  or  less  completely  disappeared  ;  if 
any  remains,  it  will  be  at  tbe  posterior  part.  Tbe  opposed  surfaces  of  the 
vertebrie  are  covered  by  granuLation-tisaue,  and  are  soniuttmus  mutually 
adapted  to  each  other  as  the  result  of  friction,  in  the  cancellous  upacos  of 
the  bono  on  each  side  the  normal  medulla  has  disappeartnl,  and  its  place  U 
taken  by  the  same  tissue.  The  perioiiteum  coverin-;  the  remniiiiug  portion 
of  the  vertebne  and  frci^ueatly  also  that  of  the  vertebra  above  and  below  is 


422 


UISEASKt)    OF    TUB    SPINE. 


afitK!t«U  ^}y  wteoplastic  inflammfttioa,  irregal&r  spicuUted  nodulci  of  new 
bone  beiu);  formvd  bvncnib  it.  The  spiii««,  tbe  trauBverae  and  the  articuUr 
prooeesesli«ini;iiDa(rectv4l,  there  is  aouiiFlocatioD.andoiiiisMjueoUy  tbcipioal 
cDunl  ie  but  little  it'  at  alt  uarrowcd.  Siiould  tbo  dlaeMB  eeaae  ftl  Ibu  aby; 
as  ii  fm]ueiitl.v  <i<H«,  ibe  ^roiiulation-ttasue  of  tbe  oppoaed  aar^aoes  roaleMca, 
aad  sulweciuently  becomes  <tevel»pe<l  iala  biiiip,  and  tbe  noglc  f'>rniM  br  the 
bending  oi  the  siiine  is  li]le<l  up  by  a  buttress  of  booe  fornied  bpomUi  the 
perioetfiim,  aod  tttits  the  spine,  attboujrb  re  taiuing  its  deformed  pasitino,  ma/ 
Itecome  as  struog  m  before  the  diseaae  (Fig.  S6G). 


ti. 


•^- 


N 


n 


'm 


Fig.  &M.— AngnUr  CurvAtiir* 
■f  ihs    Uaraal    Spina    from 


rtg.  MM.— CkriMur  UodiM  of  LvnUr 
Vartabrw;    do  ftllMBpt   ■!   A*kf- 

lOWK 


Id  other  caaoa  of  carie*  of  tbe  spin«  the  diiaaae  u  more  extensirv,  comt 
iaa  Crom  many  coalrce.  often  situated  in  diflVreat  vert«bne  nod  UDCoBMotcd 
with  eacb  other.  These  centres  arc  situated  moat  commoDly  in  the  iiotncdi- 
ale  Deigliborhood  of  an  intervertebral  disk,  but  are  not  uncommoD  on  the 
surface  uf  the  body  beneath  the  periueteuiu,  and  are  aomclimGa  deeply  ia  tti 
substance.  A  macerated  specimen  shows  the  bone  to  be  cMxn  out  tale 
irregolar  boHows,  around  wnich  th«  oancelloua  U«ue  n  morv  poroua 
natural.  In  a  5<eab  ipecimen  Uiesc  hollows  are  filled  vith  oaaoooa  mi 
tlon-liflBue.  When  the  diaeaae  coranwneee  near  an  intervertebral  disK,  ihlsl 
soon  dettruyed,  and  the  cantigumiB  surface  of  the  Dtxt  Tcrtcbni  beooniea  ita- 
plirated  fFig.  tAHi>.  Tbi>  frintioD  of  the  diseased  surlkoca  against  each  ociMr 
then  agKra%-aii-H  the  pnyreas,  ami  leads  bt  more  rapid  destraolkMi  at  tlic  [ 
wbare  Iney  an*  iu  t-uiitact.  It  is  this  form  befrinnin^'  in  inimeroua  einit««al 
b  moat  CTidently  tubemilnr,  and  most  frequently  tcniiiniitea  ia  aappai 

In  aiitiie  canes  infltf>ad  of  the  bone  lierng  more  spODfnr  than  natural 
the  excavalinmi,  it  muy  lie  »eon  in  the  macerated  specimen  ihac  the  oat 
has  assumed  an  mle'iplafitic  form,  the  cancdloua  tissue  being  denser  tliaa 
natnral,  and  iui  tr8heoiil»  thickened,  just  t»  n  snne  of  dense  Ixme  {a  <AfS 
found  an^'Und  a  chronic  abwme  in  the  cAncellotis  rnds  of  the  long  baaea. 

When  the  ^liieevie  tr-ad»  Ui  fuppiimtion,  the  pus  frrriuently  raiam  tb#  aal*> 
nor  common  ligament  from  the  vcrtcbrw  for  some  (lictance.     THla  tf  twm 


CARIES   OF   SPINE — PATHOLOGICAL  00DR3K. 


428 


^J»  hap[)en  when  the  reHiiIling  chronic  absccts  ha?  opened  extpmiilly 
>nie  s.;ptic'  fritm  the  adiiiissiiin  of  impure  sir.  Kapid  destruclinn  of 
the  iutervertebrnl  tihks-  with  which  the  pus  comes  in  conmct  then  freiiueiitly 
Ukee  place.  It  is  not  uiiciuiitiii>n  to  tintj  the  vertebne  for  Bomo  distance 
above  and  below  the  centre  of  (license  bare  in  front,  and  looking  mi  if  mac- 
eratfid,  while  the  cartilages  between  them  faave  more  or  leas  completely 
dnappeflfed. 

Tne  chronic  abscesaefl  forming  in  connection  with  caries  of  the  spine  are 
direct««]  CO  the  lateral  aspect  of  the  bodies  of  the  vertebra'  by  the  great  thick- 
<  of  tb«  anterior  common  ligament.  As  the  pua  accumulates  the  nlisceaa 
t«Mkea  tta  war,  as  in  the  case  of  chronic  abscesao  generally,  in  the  directioa 
of  least  re^'tancc,  usually  following  the  coiirac  of  a  veswl  or  burrowing 
beneath  th«  bscic  covering  muscles.  Thus  in  diwnae  of  the  dorsal  vertebrie, 
Um  abacess  follows  the  tuUTCostal  artery  and  passes  between  the  rihs  with  the 
poitertor  branch,  appearing  under  the  skin  of  the  back  as  a  "  dorsal  abscess." 
Jo  tbe  lumbar  region  the  aluceM  niiiy  in  the  same  way  follow  a  lumbar  artery 
■ad  form  a  "lumbar  abacea,"  or  enter  lh«  sheiith  of  the  peoas  muscle  and 
form  a  "paou  abtoen,"  pointing  h«low  I'uupart'tt  ligiim«nt. 

When  the  caries  ii  complicated  by  necnMia,  the  aetjueslra  are  frequently  ao 
entangled  in  the  excavated  cavity  in  the  body  of  the  vertebne,  covered  in  ia 
front  by  the  thickened  anterior  ligament,  that  it  i»  impossible  for  them 
to  make  their  way  to  the  surface,  and  thus  even  if  the  disease  censes  to 
extend,  suppuration  may  be  indefinitely  prolonged  till  it  causes  the  deatb  of 
the  paiieut. 

Toe  angular  projection  backwards  of  the  diseased  part  of  the  spine,  corre- 
■pondiog  in  extent  to  the  amouut  of  destructlou  of  the  vertebrie,  forow 


i<^ 


ng.MT^ 


-KaiivaJ  Csrri  of 
8pls«. 


Wf.  MS.— FlMlEifly 
CbftDipi  of  CaiTv  In 
Ani{utBrCurvatun). 


uf    8|itn«    Id    A<)v»noS4l 
Stage  of  Anfular  Curr»- 

tan. 


usually  the  iiiost  rnnrlceil  fenliire  of  the  disease  CFigS.  fi€7~<569).  The 
mechanism  of  this  is  easily  undeniloiKl  by  reference  to  the  pathulopy  of  the 
BHeotioD.     The  bodies  (oo«  or  more)  of  the  vertebne,  bein;*  Bol'tened  or 

Eartly  destroyed,  at  last  give  way  under  Lbe  weight  of  the  upper  purl  of  the 
t>dy:  the  upper  part  beudn  forwartls,  and  the  epini-s  project  posteriorly. 
At  the  same  time  that  the  upper  part  beuds  fortrnrdti,  iha  lower  part  of  the 
■pine  rarely  maintains  the  upright  position  as  it  did  in  Fig.  olio.    In  Uw 


424 


UlSEASES    OP    TlIK    SPINK. 


great  mnjoritT  uf  cae^  there  U  a  compeoMtlitit;  iarurvatioo  jn*t  Mow 
tlie  uxcurvatiVl  verlubra,  nud  lo  lliU  wnj  the  u{>{)Cr  part  of  uik  \a»Ij  i> 
r-urriuil  ervct.  Tho  aogle  of  cxuurvatioii  varJcv  acuoriliag  lo  tli*  number  ■( 
VLTb-linil  boilica  ilaitruyed,  nutl  tin.-  t-xlvut  of  llie  Itae  uf  lulMtaucc  Tka 
c:n>iiti>r  llw.  iMitiilKir  i>f  viTK-bra-  iifti-'i-u-d.  llio  more  obtinte  will  Iba  uiglaij 
Whrii  one  vertebra  only  or  rhlctlv  is  <li««B»e(],  ilireu  epiuiius  firvcoHBl 
projeet  to  form  tbe  angle,  that  of  tbc  tltKcaaifl  verlcuni  b^iug'  lbs  ■!■& 
If  two  nr  tbn^'  be  dueaw«l,  five  FpinunB  pruiHvwx  usunlly  nntrr  iJir  furav* 
tina  uf  the  anf^le  of  excurrntion,  anil  llirn  tbe  whole  of  ihttt  (lortion  iif  tkt 
column  will  be  diaplneed  backwards,  (giving  a  tbirkennl  ntid  briMu)rn«d  hi« 
14)  the  excurvBlion  in  the  Inteml  direction.  ]d  the  doriml  rof^iitn,  tf  m  atnck 
vertebra  is  diseased,  the  projection  is  u^Miilljr  very  marke<l  and  sharp  ■•  tlw> 
heodiiig  forward  of  the  veriebm  turns  the  long  oblique  ."pine  almost  dirritljr 
backwards,  forming  a  sharp  prominence.  lo  the  Inmbar  region,  wber*  tba 
spines  arcshortnnd  point  directir  bnckwarHs,  ihe  projection  bmore  roondidt- 

It  is  comparatively  seldom  that  the  spinal  cord  becomes  oompraased,  li ' 
or  diseiwed  dnnng  tbe  prygre»  of  Ihii  afrt-etioD.  It  may,  howc^T  ' 
presBed  on  by  (be  sudden  and  acut*-  develupnienl  vf  thi 
especially  in  caws  in  which  the  rarefying  oeleitis  is  widely  .1  r  .  : 
tlie  bodies  uf  the  afloijted  vertebm.  leading  In  mpid  and  exieiuive  modeamt 
More  or  less  complete  pamplegiu  may  then  enfue.  In  other  caam  tbeoan 
may  l>e  comprawd  by  thickening  of  tbe  meninges,  or  from  inflamnialdr^ 
exudation  into  the  caual.  in  some  oasM  in  Mbich  owing  lo  the  diicaM 
attacking  the  pwlerior  portji  of  the  bodies  ur  alfectiug  Ibem  trr«giiUrly 
in  each  a  way  tnat  the  posterior  exciirvatiun  of  the  auine  u  sligbt.  tlw  dui 
mater  may  be  implicated  and  diffuse  tipinnl  nicniogilu  result.  Tbla  b  rfjir- 
cioUjr  likely  to  happen  in  esses  coniplicateil  with  al^-L-^,  if  after  openiagi' 
diaenargea  are  allowed  to  dccom[xiee.  In  other  cases  the  conl  nuij  ' 
sufleneu  uppogite  the  seat  of  curvature. 

The  mtnl  €ommon  teat  of  uirieD  uf  the  spine  is  the  lower  domi  nr  the 
junction  of  the  dorsal  and  lumbar  regions.  It  if  not  uncommon  in  tba 
middle  dorsal,  and  may  occur  at  any  imrt.  R.  W.  Piirker  states  that  ta 
140  casc«.  the  disease  was  tu  the  eervicnl  region  in  d,  in  the  dnrsol  in  K2,  ia 
the  dor*o-lumbnr  in  21,  and  in  the  lutnbiiror  luinbo-«acr«]  in  37. 

SvMiTOJJs. — Angular  curvature,  or  l'ott*9  disease  of  ibc  spine,  commmilT 
begins,  especially  in  children,  in  a  very  insidious  manner.  It  occurs  lunialljr 
in  strumous  children,  and  is  generally  referred  to  a  fall  nrblow  on  the  back. 
The  symptom  that  most  ot>en  first  attracts  attention  it  tbe  childV  atttindt, 
which  is  alier«l  and  very  charaelcrifilic.  The  IhmIv  is  held  stitfly  straijtliC 
and  upright ;  it  i»  neither  l>enL  ni>r  turned  lo  onp  side  when  th»-  cbttd  m« 
but  the  S|>ii)e  is  moved  &»  a  whole  and  in  a  rigidly  fixed  manner. 
•houtderH  are  raised,  the  cliin  is  thrown  up.  snd  the  t(>e«  are  ali(tbtJy  ti 
in.     The  t'hild  walks  with  gn-at  eanliun.  and  very  attttly. 

One  of  tlie  eKrIiettt  Avuiptniiis  cotiiplaiiied  of  is  ofieu  an  ill-d«6l]«()  Ml 
licial  pain,  extenilin^  round  tbt^  trunk,  more  severe,  jierhapa,  00  one 
than  on  the  other,  and  oecHaiounlly  refrrred  to  (be  stomach.  ARrr  a  tJiM 
tbe  L'bild  becomes  unable  tu  stitud  upright  uasupporteil,  has  a  teudrt»-y  u 
lean  the  body  tbrwanls,  or  to  supfxin  it  by  reatiog  tbe  iunda  on  tbe  kneaa, 
or  by  ■eicing  hold  of  anything  that  will  serve  as  a  tempomry  nippiiri,  mdi 
•8  a  chair  or  table.  It  will  be  found  also  iJuiL  llie  child  experienoea  gmat 
ditBcultr  in  rnifling  itself  without  awitilauci!  from  the  faoriioniol  iato 
sittiiig  |KK>iti')n,  or  in  turning  siflewuys  in  bed  without  the  use  nf  its 
On  exauiinnlion,  one  or  two  of  iho  spines,  usually  nhoui  tbo  middle  of 
back,  will  be  found  to  be  n  Httlc  more  promintnt  than  tbe  rat;  and.  on 
prvMing  or  tapping  upon  them,  pain  will  b*  complained  uf.    Tba  obiU 


^ 


arHPTous  OP  oxribs  of  spink. 


425 


itnntcd  in  iti  jrrowth ;  and,  if  the  disease  be  not  arrct>l«d  br  proper 
t,  wilt  oootiaue  more  or  le»  hump-  or  roiind-lwoked  for  lite.  Id 
IbediMsw!  vill  run  oo  to  the  formntinn  n(a.haccs»,  as  'will  imroo- 
diuaijr  be  dueribed, strumous  manifestations  occurring  elsewbf^re,  and  death 
•VMMnallr  reanliing. 

!■  orfiult  ihe  dflUf^r  and  the  symptoms  vnrj  according  to  the  Mat  of  the 
■fceiiaa.  It  is  mf«t  liantp^rons,  oft*n  iiidftpd  rapidly  falAl,  when  the  ccrvinal 
mrtebne  are  implicntM:  for,  aj  the  bodies  of  these  are  shallow,  caries 
RsdllT  pctieirativ  to  the  spiual  cai»al.  and  the  cord  or  it«  roetubraDes  may 
ifca*  te  iaiplii-alt^l.  When  the  dotrual  or  lumbar  vertebrw  become  diseased, 
the  Atfcclioti  is  n^t  so  iniuiediately  oerious  to  the  Iti'c,  U9  It  may  b«  to  the 
fiicurv  of  the  fxitient.  In  adults  it  olleii  ooiomeuces  with  obscure  flying 
pain  in  the  luins  or  back,  appari>utly  uf  a  rheumatic  character,  «houtiug 
t  IxHjy  or  d'lwu  the  thighs.     On  examining  the  spine,  wliich  feela 

■  !)«  patient,  and  which,  as  in  the  child,  is  incapable  of  supjMirliDg 

hut)  ur  (if  eoabling  him  to  raise  or  turn  him»^lf  without  aBsislauce,  tender* 
oexR  on  pn-eiur«  or  on  tapplnjr  will  tie  exfierienoed  at  oDb  jxiiul.  and  he  will 
■iDoe  when  a  B]w>nge  wrung  out  of  hot  water  ie  applio<l  to  ihiH  [tart  of  the 
^toe;  although  there  may  be  no  appearance  of  excurvation,  the  tik'm  cover- 
tar  it  >*  bypersMtbelic.  After  a  time,  however,  the  spinous  procean  of  one 
or  mure  vcn«br:e  will  be  found  to  project  distinctly  lieyond  the  general  line 
of  the  column.  Thii>  part  becomes  the  #At  of  constant  aching  pnin,  increased 
by  aiiivejnt>nt  or  by  pressing  upon  the  bend  or  shoulders.  It  must,  however, 
br  rvmrmbi-ri-d  that  caries  of  the  bodiet  of  the  vertebrae  may  take  place  to 
a  eocutiderBhle  extent  with  little  or  no  nogular  curvature.  In  theae  cases 
fell  tbe  nrdinarv  symptonu  of  cariN  of  ihc  spine  will  )>e  found,  exeejit  tbe 
ncnrralion.  It  will  be  observed  that  tbe  spine  ban  \n»t 
b»  natural  fre*  mobility  and  flexibility,  moving  fixedly, 
itilBr.  and  as  awhule,  when  the  oatient  leans  forward* 
(tr  Mcways.  The  patient,  when  laid  flat  on  his  hack, 
cwkDOl  nii*e  himself  into  a  silting  position  without  the  aid 
of  hie  bands  or  elb-^ws.  and  be  cannot  turn  »harply  and 
■nddMily  over  upon  his  face,  but  stragglM  with  outstretched 
w  in  rain  attempta  to  do  so.  Occwkinally  the  incipient 
otrrstunf,  when  it  occun,  aasumcs  more  of  a  lateral  than 
of  no  kogular  dinvtion ;  and  in  one  fatal  case  I  have  seen 
tba  iptBO  actually  bent  hockw&rds,  so  aa  to  be  incurvated 
at  tbo  anu  of  the  disease.  In  some  oases,  the  true  angular 
•xcarvatioci  dependent  on  cnrin  of  Ibe  bodies  of  the  vor- 
yAnt  naj  be  aaocJated  with  the  ordinary  lateral  curve 
of  debility.  Tbe  lower  lirnhN  biwomc  weak,  and  the 
pttf*'  walks  wilb  a  peculiar  shuffling  toiiering  gait,  the 
tqp  befaqr  untspread,  and  the  feet  turned  out  Tlin  w<-ak- 
Bflsi  »f  the  linlM  b  flspecially  marked  in  going  upstairs, 
and  may  be  laitad  by  iltrccting  the  patient  to  Htand  uni:!U|>- 
Bortod  on  one  leg,  and  rai«e  the  other  ho  us  tu  pl»n>  the 
p,.^  „r..n  tbe  seal  of  a  chair,  which  lie  will  pruhably  be 
ri  lo.     Not  unfrequently  there  ii  more  or  less  of  a 

I,  r'*'~ii«>n   a«n)cmted  with    the    muscular  weakncn — a  spociea  of 

D-  r  (laralvftis  which  is  very  charactcrislic     Sensation  is  not 

ii  nver-ocutf  in  parts,  whilst  therA  is  an  ataxic  atnle  of  the 
low**  extremili**.  pn-Aetniiig  a  peculiar  and   characteristic 
iH-nomena.     The  deformity  of  the  spine  mav  slowlv  in- 
.    >i    mar   beoome  unable  to  etand  ;   and  iiaralyais  of  the 


n|.  Kd.— Ailltuila 
ofChil'llii  AugU' 
Iftr  CnrvBturs  la 


r>QiT 
muse 
train 


4S6 


DISEASES    OP    THE    SPINK. 


iiiiiiiii— ij^^ 

■faaofiMa  a^^^H 
MC«r.  bvt^^H 


tnuseles  of  the  lover  extremity  may  come  nn   together  with  a  lendeMf  U 
nlaxitiou  nf  the  ephincler  nni.  iiin]  relcnlion  of  tirine. 

Paraplegia  does  nut  uccur  m;  frvguentlr  ns  miglit  have  bren  •nMd*4 
whei:  ne  (.Ninsidfr  the  very  nculc  mdbIo  that  in  lormeil  bv  the  diMAMii  tpltt* 
ID  extl«ni«  cues  of  «xciir\-atii>u  But  the  aftitiul  eanal  ia  Dot  iii>i:»)a*l<i 
upoD,  m  there  U  uo  liisplacemeiit  <<t  the  lamiti.-i.-  aad  tninsTevM  procnHsi^ 
the  vertetini>  in  the  form  of  HialQCStion,  (he  ilernrmity  being  due  cimplT  Is 
beodiog  forwards  owiog  to  the  deatructtoa  uf  the  bndiei — heoco  the  oinl  ■ 
□ot  compreased  aa  to  a  dislocation.  When  paraplegia  dne«  occur,  it  if  dv 
mult  or  comprewion  of  the  coni  at  the  sent  ol*  dUeace  &om 

exudation  unna  the  tueoingce  or  in  the  canal.     Tfaeie  beoonie  i.  __ 

a  time,  and  tieoce  the  paraplegia  is  not  of  a  permaoeot  chaiacCar.  bvt' 
pan  off  after  Bome  months,  or  a  year  or  two  at  muet,  eren  tboogh  el 
irritnhititv  nnd  scneibility  may  for  n  time  hnvo  been  completoly  mt. 

Pleoritio  Attacks  of  a  l'K>alized  chaniL'tcr  depeodaoi  on  extendmi  of  tfat 
)ntlammnlii<n  uf  thi-  vertebral  subatancee  to  the  cootignons  pltana  Dot  in- 
cumniUDly  ouciir  when  the  eariea  affcc(«  the  dorsal  inoe. 

AblOOU  oonimoniy  make?  ha  appearance  b8  tho  diaeaw  pro^eHca;  aad  fal 
some  cases  it  occurs  bc-forc  anv  of  liie  other  si^B  exccpe  pain  and  ■lakwiM 
of  the  apioe,  and  oertaiuly  before  any  dcforoiily.  When  the  afaueH  fooK 
as  Btanlcy  bos  observed,  the  imlId  conaequcut  on  irritation  of  tbe  qiinal  cm 
and  nenrci)  is  usually  letwenra  for  a  time. 

It  must  Dot  be  aupiMfwd  thai  abaces  necessarily  follows  in  all  caML  b 
children,  esneorally,  wo  often  meet  with  great  oxcurvation  witboul  any  sap- 
puratiun.  In  adults  it  is  very  rare  to  see  angular  eurvnture  wiiboal  tw 
formation  of  an  ahac<«s.  The  exact  eaiues  that  determine  the  furmation  of 
pUA  are  not  certain  in  all  casoa.  In  many  it  is  undoubtedly  due  lo  the  irri- 
tation cauaed  by  the  friction  ol'  the  diseased  •urlaeen  ajtainst  each  other,  aad 
prop«r  treatment  adopted  early  will  do  much  to  jircreut  JL  Suj>puratioa  is 
also  more  likely  tu  occur  when  the  patient  15  poorly  fed  and  expaaed  to 
general  unhygifiiic  fiurroundin)^. 

Afl  cases  in  which  abacew  does  not  form  usually  recover,  we  have  bat  litlls 
defioiia  knowledge  as  lo  the  eiacL  nature  of  the  disease,  whether  it  in  tabe(> 
cular  or  not.  On  Uie  other  hand,  the  majority  of  cases  io  which  denlh 
place  are  fjund  to  be  aaeucialed  with  the  presence  of  tubercle  in  the 
bones.  It  tins  been  assumed,  therefore,  that  the  cases  of  angular  cui 
without  euiipurution  are  due  tu  simple  influiiimatiun,  probably  of  tnuimatie 
oiigin.  white  tboise  with  suppuration  are  tubercular,  but  the  cvideaoe  baut 
sufficient  til  justify  au  alwoluie  ttatcmctit  to  tliis  eflecu 

In  casra  which  rocuver  witbout  euppuraliuD,  the  diseased  bodiaa  bseo— 
fueeil  to^jrther  inUi  a  single  mass,  acro»  which  bridges  of  osemia  tlamaata 
sonirtimra  thmwn  out,  so  as  tu  sLreDgthen  the  othcrwiae  weakeaad 
Indeed,  tliis  nnltyliMis  and  fusion  of  the  bodies  of  the  diseased  Tertafara' 
be  looked  upon  as  tlu'  imturul  m<xlc  nf  cure  nf  an^tilar  ciirvulure  of  1 
spine;  the  only  way  in  which  it  can  take  place  a'hen  once  iltr  iIIk'i 
advanced  to  any  considernhle  currni. 

When  pus  form*  in  4:t)niHvtion  with  diseaaed  sptne,  iho  eituatiiia  aad 
cnurHA  of  the  absoeas  den*  nd  mainly  upon  the  pan  of  the  spine  afliieled: 
thos.  for  insiaDce,  when  the  cervical  vertebra  are  diseased,  the  ahaoesa  arill 
cone  forwards  hi-blnd  the  pharynx,  and  may  •H-rattiortally  extend  undvr  the 
aceroi>-ma«toid  muscle  to  the  side  of  the  ueek,  where  it  opens;  sutoeUnica, 
though  very  rarely,  it  psssea  into  the  chest,  and  in  other  caaca  ibiu  1^ 
axilla. 

When  the  disease  la  seated  in  the  upper  or  middle  dunial  »ptD«,  the  afaseess 
most  commonly  pasaoe  backward*  between  the  puetcrior  ends  of  the  rifaa. 


rORMATtON    OF    ABSCBSS   IS   CARIHS  OF  SPiyE. 


forming  a  doreat  abte^g.  Id  Bume  cases,  however,  in  which  the  middle  ilnrsa] 
rerlebne  are  duene^d,  ihe  nbsce!«  may  extend  downwards.  When  it  takes 
this  direclion  il  moet  commonly  posees  under  the  ligHmentiim  areiiatum 
internam.  and  ihvis  enters  the  fiheatii  of  the  peoaa  muscle  nud  takes  the 
conne  to  be  described  immediately.  In  rare  ea»o«)  it  mnv  puss  between  the 
pillare  of  the  diaphragm  with  the  aorta  and  follow  the  large  vessels  in  the 
subperitoneal  tir^ue  9upcrlicin1  to  the  fascia  of  the  psoas  and  tliacufl.  forming 
an  accumulation  tilling  the  iliao  fossa  and  pointing  above  Poupnrt's  liga- 
ment, or  it  may  extend  dovDwards  into  the  pelvts  and  csonpe  with  the  gluteal 
artery  through  the  great  sciatic  notch,  giving  rise  to  a  large  alwrcss  in  the 
gluteal  region.  It  is  remarkable  that  in  caries  of  the  dorsal  vertebrsc  the 
pus  doea  not  tend  to  encroach  on  the  chest  or  the  pleural  cavity.  When  tho 
lowcf  donial  or  upper  lumbar  vcrtcbnc  arcdiflcaseri,  the  pus  enters  the  sheath 
of  ihe  peoas  or  the  Dubfttaooe  of  the  muscle,  thus  noostituting  the  common 
affection  termed  Ptoan  ahf^cM.  A  |)»oas  absije/is  fnllowsi  lhe  oour»o  of  the 
niQMie  from  which  it  derives  its  name.  It  is  firmly  bound  down  in  front  by 
the  fascia  covering  that  muscle  and  the  iliacus,  which  is  usually  considerably 
tliickcned  and  is  never  perforated  by  tbe  pus.  The  psoas  muscle  is  usually 
extensively  destroyed.  The  pus  is  prevented  from  extending  downwards 
ioto  tbe  pelvis  by  the  attachment  of  the  ilio-psons  fascia  to  the  brim  ;  there 
la  nothing  to  limit  its  extension  outwards  over  the  whole  surface  of  the 
Uiacus.  though  the  altachnieni  of  the  fascia  to  the  crc*t  of  the  ilium  prevents 
its  pBSBlug  beyond  that  poiut.  Thus  we  lind  that  a  psotis  abscess  usually 
extends  outwards,  forming  a  large  fluctuating  swelling  fdliug  the  iliac  foesa. 
At  tlio  accumulation  iucreusos,  it  puwes  beueuth  Puu|mrt'8  ligament,  most 
ootDtnoQly  by  a  somewlinl  narrow  neck  situated  iu  the  line  of  the  anterior 
crural  nerve.  It  is  thus  at  this  part  situated  to  ilic  outer  siile  of  the  femoral 
Teasels.  Fluctuation  can  readily  be  felt  l>etween  the  swelling  on  the  thigh 
and  that  in  the  iliac  fosea.  There  is  very  distinct  impulse  romnuinicAted  to 
Uie  part  outAide  the  abdomen  on  coughing,  and  this,  combini-d  with  the 
oomewhat  sudden  appearance  of  the  aweliing  on  the  thigh,  may  nmke  it  iu 
aome  respecia  resemble  a  hernia.  After  reaching  the  thigh,  the  ahfleeffl  ex- 
tttlds  downwards  to  the  outer  side  of  thfi  vessels  for  a  short  dislanre  till  it 
meet*  the  profunda,  ami  following  that  vessel  it  passes  under  the  femoral 
artery,  which  ran  be  felt  9lret<rhiiif!;  ncrosw  it  in  front.  It  then  nintinnca  its 
ooUTW  under  the  adductor  lougiis.  and  forms  a  large  cavity  at  the  inner  side 
of  the  thigh,  having  the  gracilis  stretched  over  ir  inlernally,  the  adduftor 
magnns  behind  it,  and  the  adductor  lonpiis  in  front.  Processes  frerjuenlly 
extend  fnjm  tin:  main  cavity  alniig  the  brandies  of  tbe  profunda.  The  most 
common  of  lhe*e  ppdougalions  is  one  winding  round  (lie  neck  of  the  femur 
with  thf  bnincheit  of  the  iulerual  circiimllox,  and  ])aK<>ing  through  tbe 
interval  K'Lwemi  the  adductor  mai^iius  and  the  r|i]ndratii»  feraoris,  brcoming 
superficial  imme<lirtely  behind  the  trochanter  major,  Iwtweeu  it  and  the 
taoerosity  of  the  ischium.  Tbt*  alwcess  seldom  extends  l>eyond  the  upper 
part  of  tbe  thigh,  but  it  may  contititie  its  course  dowiiwardtt,  until  it  renclies 
the  popliteal  space,  and  may  even  piiiM  some  distance  downwurds  between 
tbe  deep  and  vuperflcial  musclett  of  the  calf  following  the  main  vestiels.  I 
have  seen  an  abscess,  which  to<ik  its  origin  in  disease  of  the  dorsal  verlebnc, 
opened  bv  the  aide  of  the  tendo  Achillis  (Kig,  S*'2.  vol,  i,).  A  psoas  abscess, 
when  fully  developed,  usually  coneists  vi'  four  parts — a  narrow  track  iu  the 
upper  pni*t  of  the  psoas  muscle,  a  wide  expan^iion  in  the  iliac  fossa,  a  second 
narrow  part  extendiog  under  Pniipart's  ligament  and  the  femoral  vci^atlB, 
and  a  large  cavity  on  the  inner  side  of  tbe  thigh.  The  rlifficiilty  of  projjerly 
draining  such  a  cavity  by  an  opening  in  the  thigh  only  is  evident.    In  auiiie 


428 


OlSXASES    or    TQK    SPINS. 


cues  ihe  alxioen  mny  follow  both  pmas  muscles,  and  pniject  ia  eaeli  pala 
at  Uie  flame  time. 

A.S  in  tlie  dorsttl  region,  the  nbiOMt  may  p«M  backvrarH*  in^u^iil  uf  dowt* 
ward^,  and  point  in  the  loin,  forruing  a  tumbar  iiA^tw.  Mt)re  nxtly  U 
may  burrow  umoDfrat  Ibe  \»ytn  of  the  abdomitinl  uiiifclei*  and  poiot  in  ffvut 
In  diMaMof  tbe  low^^r  lumbar  vertebra^  and  upper  pnrtof  ibe  Mtrrum  ih«{iai 
may  gel  beoeatb  the  fiucin  covcriafr  the  |)yrirormi»,  aod  then  MInwiiiK  tlM 
□crves,  mtty  point  in  tbe  bullock  b^ueitlh  tli?  t;lut«ua  maximus,  itr  it  mar 
extend  dowuwarda  to  the  i^chio-reclni  fman.  In  all  spiual  abeceoM*  MBall 
sequmtra  d<.-riv(;d  from  the  diseawd  verlehnc  are  uot  UDconini»aly  fouml  n 
tbe  pu».  lu  tbe  patient  Irorn  wbom  Fig.  ^~0  was  taken,  aeveral  fmjcmpab of 
buoe  thus  came  awny  I'rom  an  abftcem  that  vino  upeited  in  the  Pm<  'itn 

Ibigh.     Much  cur<ly  matter  is  usually  preaeat,  makiiii;  it  impi»M '  lay 

cum  fa>  empty  ihu  mc  by  ajipiratioo.  The  truv  source  ul  orif^iu  wi  ti»«w 
■beoeaseB  nay  itauulty  be  dultfrmiae^l  by  ao  examination  of  ibu  epiuf.  and 
feeling  an  impuUe  on  coogfaiug  ooromunicated  lu  ihuir  vxireme  poiotaj 
presentation.  In  peoae  abscees  there  is  some  6esion  of  tbe  thif(b.  with 
on  forced  extennon.  Cieneral  <Edema  of  the  limb  may  occaaiuoallr  arat 
fnim  a  peoRH  abecees  after  it  haa  reached  tbe  inner  side  of  tbe  tbigb.  Id  ran 
cues  after  opening,  if  septic  inBammation  follows,  the  absoGH  cavity  may 
ulcerate  into  the  hip-joint,  causing  acute  and  rapidly  destnietive  anliritia 

DlA()Nt>8M. — The  diagnnaia  of  parien  of  the  spine  is  made  at  tbe  fint  siiekt 
of  a  patient  affected  by  tbe  disease,  when  once  ibc  angular  deformity  ItM 
taken  place.  I(  is,  however,  difficult  bclbre  excurvaliun  oeours.  Iwing  tiuii- 
cated  at  tbis  period  only  by  tbe  existeoec  of  pittn  in  the  baek,  and  by  ^km 
symptoms  of  Hpinal  irriiatioo.  At  this  stage  it  mny  be  mistaken  for  s|iiMl 
or  interooatal  tieuraigia,  for  rktumatum.  or  jbr  ttane  in  the  kidnrf.  The ' 
sbtenoe,  bowerer,  of  a  cootiououB  Bxcd  puiu  in  tbe  bscit  should  alaray* 
to  a  rmipiiuon  as  to  tb«  true  nature  of  the  disease,  lest  the  grieCous  irrr 
commiltfril  of  Irc-atiiig  as  mer«  neuralgia  or  rbeumurum  what  may  tunii 
to  be  incumble  dtaeave  of  the  spint^'  itself.  Here  the  tenderoen  no  pnawilt, 
the  increased  sensibility  to  the  application  of  beat  *«ill  determine  the  Piatat 
the  alfuction.  Tbe  pain  elicited  by  rotation  or  br  no ter<^po<!t«riiir  mun— rt 
is  a  very  valuable  symptom.  In  luoat  cases  pain  on  beudiug  back  wank  b 
moat  complained  of.  The  patient  can  stoop  forwanls,  but  if  bent  backwarll 
sutfers  much.  So  also  pressure  on  the  bead  or  shoulders  greatly  iat 
the  pain  of  the  part  aflecied.  The  ebape  »i  the  baek,  with  lo«  uf  Um  : 
and  graceful  curves  of  tbe  epine  with  a  tendency,  though  it  be  nty 
projoiTtion  of  some  of  tbe  i>puiouB  priKie>!«os.  the  teeline  of  weakMW 
nacK.  the  difliotilly  in  rising  from  a  sitting  or  horixontal  p>jsiti<in.  in  tm 
or  In  KUiudiiig  on  one  leg  unaided,  the  biM  of  the  natural  flexibilitv  ufj 
apine,  and  (sp<H-inlly  the  <H-ru  rrenuc  of  these  syniploinij  in  early  chilifl 
ynutb,  at  a  p«-riiMl  when  tbe  other  dkeaaea  with  which  it  may  be  c<ui 
rarely  occur,  and  are  still  more  rarely  petBistent,  would  lead  one  to  MupBel ' 
the  existenw  of  caries  of  tbe  spine. 

The  diagnrwifl  between  ab«Kiae*  localiuMl  in  tbe  lUtualioDS  raentioiMd,  and 
tlio»e  ari«tng  fntm  dtseased  spinr,  is  not  always  easy  ;  aa  purulent  eoUc«lioaa 
of  rarioui  kindf>  may  fiirm  in  the  different  plauMi  of  areolar  tbxue  In  the 

neighborhood  uf  the  v.«rlebral  c<dumn,  without  any  dbeaae  exi- vt  it. 

Thua,  a  large  pMias  abscess  descending  in  the  sbcatb  of  tbe  mii'  i  r^ 

wnlirig  under  I'oupart'd  ligament,  may  norur  from  Mtuve  irritAi:"ii  •■!  iIm 

arc^dar  or  fuMrial  structures  without  disease  of  nny  of  the  vi>r(cbrv.     In  iIwm 

cases  of  sirnple  abscAM,  the  diagniw)*  fnmi  tb«  psoas  alisci'}-.- 

vertebral  disease  is  usually  easy,  as  there  will  be  an  absent 

lion  uf  tbe  spine,  or  even  of  lenderncM  along  it.    Aj)  peoos  ab«;««B 


>TAG50SIS    or    CAHIES    OP    9FtN£. 


429 


van  TMtebrmI  ouim  almuet  invarinhly  pmtciitj;  in  the  ^ruin,  anr)  a  Inr^ 
■■>(■■  IB  Um  gruio  niAf  arise  from  Tariou.4  other  conditions..  jiiHepriii|«ui)y 
ttwoA  VBlttbral  di^ose,  the  i^urjceon  irni.'it  atlcmt  mrefullv  to  ibe  iliHgti<»i8 
itf  iWw  VKrkrtM  cuiifli linns.  AbtceM  and  fiuHwtting  tv^ffUngt  fit  0\t  grvin 
mmj  uiM  fr«im  ihe  fu)lowin|z  cau.4eA :  I ,  fniin  large  chronic  collecUoii«  of  pus 
m  ibe  aubcubuuMtifi  or  inttrmuKular  planes  of  areolar  limiie;  2,  fntm  ili«- 
«Me  uf  tlic  arf-iilar  liiAiio  nroiind  (ht^  kidneys;  3,  from  pericu'cnl  alH»c«es  (uu 
the  right  «iije  unly);  4,  from  ilinrab»c«M,  whether  forniiug  merely  under  the 
iUae  imacui,  nr  dependent  ou  diseuw  of  ibe  pelvic  bone»;  5,  from  hip-joint 
fliMaar,  the  aWcam  bein^  pelvic :  0.  from  larg«  buboes  or  (rlaudular  abscesBee; 
7.  frutn  an  eoiprvtna  [ferluruliiig  the  pleura  and  finding  its  way  down  beliiud 
ill  '  rxftm;  a,  from  »*r>jus  or  hydntid  cvbIs;  and,  U,  femoral  hernia  with 

t'.  •  mc.     TlinK:  variuus  coUectiuus  way,  however,  with  a  little  caution 

Ik  r4;a.>iily  dtstingiiiehol  from  the  ordinary  forui  of  epiuul  abecees  thai  de- 
kwimIs  aloog  the  |«u)ts  intucle.  In  the  tiret  place,  in  all  these  cases  there  lA 
aa  ■bsenw  of  that  dorsal  pain  and  tendemuss,  with  niorv  or  less  exoarratiuo, 
•hic-b,  ibough  not  invariably  present, are nommonlynirt  with  in  |i8oa8 absoeM. 
TImb,  ■CBiQ,  if  Uie  cullectiun  be  pcrinephriiic,  there  will  have  l>een  preriuu^ 
tlisre  are  ooexistiojf  sytnptonia  of  renal  disease.     I  have,  however,  seen  an 

I  flependeiit  on  onrin  of  the  vertebrie  not  only  useuiue  the  perinephritic 

bnt  open  inb^  ibe  pelvis  of  the  kidney,  thus  simulating  chronic  pye- 
Ulilk  In  Utia  case  the  ibagnoBis  was  made  6y  a  careful  examiiiHtion  of  the 
pOK,  in  which  molecular  inaEee.'t  of  carious  bone  were  found.  The  chemical 
aad  micrcMeopic  exainination  of  the  pus  in  all  cases  of  doubt  should  never 
Ik  ovitud.  tr  there  be  caries,  it  will  present  nnmislakable  eridence  of  tba 
'  of  dkinle^mted  bone.     If  it  occur  in  the  areolar  tiasae  around  tlie 

,tbefns  will  be  peculiarly  oflinsivc,  will  present  itself  in  a  1e^  distinct 
■■■Mr,  and  will  probably  be  Msociticd  with  symptoms  of  intestinal  irritH- 
twa.  Moreover,  pc-rinc-phritic  or  pericii^eal  absccawss  being  superficial  to  the 
Qifte  tiuna,  do  not  extend  below  Poupart's  ligament  ox«ept  in  some  rare 
casH^  in  which  the  absccaa  is  acute,  and  forces  its  way  irrespective  of  the 
nttnebmcntt  of  the  fasciie.  Thus  I  have  seen  the  pus  in  a  {tericoecal  absoeas 
^BM  under  Poupart's  ligament,  and  present  as  a  large  sloughy  abscess  at  the 
apfCT  and  outer  part  of  the  thigh,  in  those  rare  cases  in  which  an  empgema 
mm  limad  ita  way  between  the  layer?  of  the  abdominal  muscles,  and  praaentad 
im  tW  gfvin.  the  examination  ol  the  cheat  will  point  out  the  nature  of  the 
lo  o£«Da«i  cmiMeied  mOt  Ote  diteate^  the  hip-Jvinl,  there  will  be 

.  looal  «vid«DOcaof  thesource  of  the  pus.  l^e  only  real  difficulty  consiets 
in  ifiMkenng  a  paoas  absceei  dependent  cm  disease  of  the  vertebral'  culuiuu, 
Mfacak  naobes  tbe  thigh,  from  iiiac  abstv»t,  whether  it  take  iU  origiu  in  the 
iaean  areolar  tivue  of  the  iliac  foesa,  ur  be  connected  with  disease  of  the  oor- 
aapondia^  bona ;  and  in  the  latter  casca  the  difUculiy  is  oAen  uotalitde 
iaaiaaBcd  in  aonaH(ueoce  of  the  ittac  abeoeBa  findiog  its  way  into  the  sheath 
at  the  paoaa  muscle.  If  the  iliac  abeoees  be  superficial  to  the  fasciii  ilinca,  it 
Tear  rmrdf  paHes  beneath  Poupart's  ligament,  owing  to  the  lirm  attachment 
ef  tneae  twu  itructurw  to  each  other.  In  very  rare  casra  such  absceeoea  find 
tbeir  waj  aloog  the  spermatic  cord  or  dnwn  the  femoral  sheath,  and  tbua 
leave  ibe  abdonwo,  but  these  could  not  be  confounde<1  with  peoas  abeoeves. 
W^-r-  •'•-  collection  of  p««  forms  beneath  the  fascia  iliaca,  there  is  nothing 
t>  it«  cxt^'bding  to  the  paoas,  or  paiuing  down  under  Pounart'fl  liga* 

CB«Tii,  aiiii  the  di^termination  of  itJi  origin,  whether  from  disea«e  ol  the  ilium, 
flr  »rrt»hn«%  ur  fr\im  a  ;tirain.  can  be  mode  only  by  the  pre«ence  or  abefnce 
a/  tbc  nrmptonu  of  diseaae  of  the  spine.  Wheitevf  r  the  ab«icef»  is  Wneath 
tba  fiwua,  there  are  iKiiue  signs  of  irritation  of  the  iliivpauas  muscle,  which 
are  naoally  wanting  when  the  pus  u  in  the  subperitoneal  tissue.     Thoao  signs 


4S0 


PISCASKS    OF    rUE    STINK. 


jin  nwBt  RiBrked  when  ihe  nhAcc«»  exUDib  along  the  whole  lenglb  of  thrt 
ptoas.  There.ifi  tlicn  iin  innhilitjr  io  Maud  upright,  lo  cxteod  th»  l»e.  aad 
pain  is  com|ilatni.-(l  of  in  wiilkiii)^.     I'tona  abeceoo  aUd.  in  nmuY  r-.-  nn 

ou  the  ihijjh  sudJenty,  the  |inlieot  lindiug,  qa  waflhin);  hiiiiM--ir  .  m- 

iDg,  that  h«  hajt  u  large  soft  tumor  in  the  gruiv  ;  whureat  iliac  dImw-^cmb* 
oQ  more  gradually,  and  {ireKents  in  a  mure  difl'uK«J  and  losa  ciruiimacnM 
manner. 

Iliac  and  pwiu  abecenes  require  to  be  dii^unised  alwi  from  certmia  fonn«f 
QncurUtii  of  the  abdomiital  aorta  or  (Viae  arteriet;  Khiofa,  Iiasrhij;  btcwDt  dif- 
ftiwd  by  rupture  ol' their  aacbave  furmed  large  notj-pulaaLiusrxtniTaMtkM 
in  the  flhenth  of  ibe  psoas  iu  the  iliac  foua.  In  aucii  cases  llif  prrvi'jys  h» 
tory,  the  nb^cDce  of  distinct  fiuctuatioD,  and  puasibly  sletbosoopic  -irrnrn 
tiuD,  together  with  ibe  rapid  incruase  of  the  tamur,  will  throw  lixhi  Ml  ik 
true  oaLure  of  the  case. 

In  other  ouo«.  ngaia,  when  the  abscas,  afler  deeply  burrowing,  has  pv* 
furated  the  litM'ia  lata,  iu  fe«l  closely  reseinblcs  that  of  certain  JoOg  immm*. 
Horo  the  poedibiliiy  of  diniinbbiog  the  siiA  of  the  swelling  do  pr^HUC, 
and  impuUe  on  (wughin^,  and  the  absanoe  of  a  solid  edge  to  lite  aveOta^ 
cnablo  the  Surgeon  t»  ti\iiai  iho  dii^osn. 

VtMU  femoral  hernia  tlie  w>A.  und  HuctuaLing  cbaraoter  of  the  nwclUDg,  in 
gradual  return  when  preaaure  b  taken  otf.  its  situation  external  to  or  bdoa 
the  femoral  veasels,  aod  all  abseooe  of  gui^liog,  constitule  ibe  chief  dhcia- 
guiahing  characters. 

Itorge  •erou*  eoU«etiond  and  hydatid  tuniord  are  occasiouaJty  auA  with  intht 
iliac  fiiMa  and  gRiio,  presenting  iu  their  progresa,  their  »iu,  and  their  ductus- 
tion.all  tliecharacteitof  clirouicabiiccas;  from  which,  however,  the  rHarvctcr 
of  the  fluid  let  out  on  puncturing  them  will  immediately  dtatiu^ub  thtns- 

pKO'iSiirii!!. — The  progowiti  is  neceasarily  unfavorable.    It  luu  tw<i  aspects 
1.  A9  tu  ihe  |>er»iitt«-nf<^  uf  iJeforniiiy ;  '2.  A*  to  the  Life  uf  the  I'mtieal. 

1.  Deformity. — The  angular  curvaturv  arising  fn^m  ciihea  of  the  bodJMff 
the  vertebra  is  necen-arily  an  incurable  delorinity.  The  dJiMSUied  qnM  it 
soldered  aud  held  together  by  fujiioii  <'i'  the  partly  destroyed  Tsrtobrml  boiliei; 
and  any  utlem])t  ut  ^traighleniug  or  unfolding  this  exc-urvattoo  wooU  ki 
auendetl  by  the  grea.te«L  ri^k,  Irum  danger  of  exciling  irriiatioo  of  tbospilaal 
meninges,  ur  opening  the  spinal  canal.  When  oxcurvatiou  has  ukca  ptaesi 
there  has  been  loee  of  subsuince;  and  this  cauuut  bo  repoircil.  Heooe  iks 
spine  musL  remain  shortened  io  fruut  and  bent  out  posteriorly,  giving  riatla 
Lne  ordinary  fitnits  uf  humpback. 

2.  Life.^^>  fiir  iu>  life  is  conoemed.  the  pmgnoais  will  depend  on  aewcfal 
coDditiooa.  The  Bnst  tit  whether  the  disease  is  aecompaoied  or  not  by  sappa- 
ratioD.  When  suppuration  weurs,  much  will  depend  00  the  extent  of  the 
varies:  if  several  vertebra)  be  a^cted.  su  that  the  cum  is  very  loog.  dbe 
disease  is  Deocasarily  highly  dangerous  from  the  extent  of  osaeotis  strveiafc 
implioaled.  It  was  lung  ago  remarked  by  Boyer,  that  the  most  fatal  rasn 
were  generally  those  in  which  ibo  .t[)iae  preaerfed  its  stndght  (MwtiM^ 
whereas,  whi-n  ii  was  much  curvrcl,  ileath  seldom  rasulted.  The  truth  of 
rvoMrk  I  have  had  frequeul  occasiuu  U*  Torify:  and  the  circuaistanoe 
appear  to  be  owing  to  the  fact  that,  when  the  ^pim^  continue*  straight  at  tht 
same  time  that  the  bodies  uf  the  vertebra  are  lubon'ulous  nod  carmis,  asky- 
Insis  eannot  orcur,  so  that  the  spinal  canal  in  u|>cti  and  the  cvrd  irrilatad; 
whereas,  when  they  have  fallen  together  nod  v<>ry  conoidurable  gibbwity  haa 
rwaltci),  ankylosis  more  readily  lAknt  plaoe,  and  thus  an  imperfect  cora  il 
eOected.  The  size  of  lh«  absceMMV.  and  the  nn»ounL  uf  discharso  firon  thiw. 
must  also  oeocwarily  seriously  inllnuuce  the  resull.  If  they  be  Tvy  busa, 
and  aoaliauotisly  disohargiog,  hectic  and  ounsequent  death  wilt  prohaUy 


TBCATMXNT    OF    CARIES    OF   SPINE.  431 

The  preaeoee  of  sequMtra  which  will  not  come  awaj,  and 
pcev«ttt  hcalioK,  rtad$  gnwAij  to  tno  gravity  of  th«  cae«. 

TltRATMliMT. — The  fir^t  and  gri-iil  principle  iu  the  treatmvat  of  angular 
c«irv»tur«  ofthe^nioe  u  to  take  <jU'tlie  weight  of  the  upjwr  partof  lb«  body 
from  tliv  dii««u«d  verhrbne,  and  at  tbe  same  time  to  lix  tbe  v«rtebral  coiumo 
■0  a*  \»  ynrvat  dti.turbnnc»  of  the  b«aling  proc««s,  thai  uf  nukyloais.  bjr 
wbicb  tbo  iiiiM:htvf  U  repaired,  aud  consolidation  ullinjately  eltect^d. 

TlKae  gr«»l  priociplev  uf  li(;ht«uiu((  the  weight  upon,  and  wcuriag  the  rast 
«C  tb*  diteawiil  portion  of  the  »piu«.  may  be  carried  out  bv  oue  of  tliree 
■■•ihiwii,  lia^  1.  the  maintviiuucu  of  the  homootai  posiliua ;  2,  use  of 
iDThaaioii  apparatus;  '.i,  the  emplovuieut  of  a  plaster-jacket  or  one  made  of 
otbar  material,  moulded  to  the  body.  Theae  various  methods  tnay  be  com* 
faiaad.  Thua  nHnt  the  applicBtiou  uf  the  ptaaterol-PartB  or  felt-jacket,  the 
hotiMltal  poMtiun  may  be  enjoined.  Tbey  cannot  be  empluyed  indiscrimj- 
■alflfy.  OiM  methud  will  be  more  suilalile  than  another  at  dilTerant  age6,  in 
tMjttM  stagtt  of  the  tjrtrnan,  or  according  as  it  adects  differmt  portiona  of 
ihasaluniB. 

la  iufiuiUt  the  utmost  that  can  be  done  IB  U)  enjoin  i^trictty  the  maintcuauce 
of  the  rvcumbeot  pieition  on  a  sofV  pillow  or  amali  couch.  In  children  and 
ymukf  adulu.  the  plastvr-of-ParU  jacket  will  be  found  to  b«  moet  service- 
•ble,  eombined  with  long-continued  rc8t  in  the  horizontal  poeicioD ;  whilst  in 
pwaoa  of  mnre  mature  age,  felt,  or  eo-called  poroplostic  jacketd,  or  some  of 
tiM  vBrfena  fonaa  of  mechanical  apiwrutus,  will  bo  of  must  use,  for  by  the 
aat  of  cboH  the  palicut  may  sit,  suud,  ur  walk  without  risk  of  aggravating 
tlk*  diseMi.  Auo,  the  weight  of  the  head,  shoulders,  and  oj-nu  Ea  great 
ta  adaltt.  and  reqairea  to  be  takea  ofl*  the  spine  by  properly  devised 
Bteehaaical  means. 

Aa  Co  the  penod  for  tbe  application  of  these  various  means  of  securing 
rsst,  all  that  need  be  aald  is,  that  one  or  more  should  be  employed  in  as  early 
a  sfea](e  of  tbe  diseaae  as  possible.  So  sooo  u<i  the  extDteuce  of  an  angular 
carvatune  i>  determined,  ao  time  must  be  lost  in  securing  roit  and  support  to 
ikatpiiM. 

Am  to  tile  seat  of  the  diseaao  and  the  corresponding  choice  of  means,  it  is 
dUfaalt  to  give  more  than  very  general  rules.  But  it  may  bo  said  that  when 
tha  aarvieaToir  upper  dorsal  sjuiue  is  alTt.'ctod,  meohaoical  apparatus  will  be 
fiMiad  to  be  must  elfeetive.  When  the  middle  or  lower  dorsal,  or  lumbar 
spia*  ia  the  seal  of  diseaae,  thou  the  plaster  or  felt-jacket,  according  to  the 
age  of  the  patioai,  will  be  found  to  be  otost  useful. 

When  tha  reeumbvnl  pueiiuun  is  bad  recourse  to,  it  is  necesaarJly,  if  it  can 
be  matataincd,  the  moat  effective,  and  should  in  no  t-ase  be  omtttcd  as  an 
vljoact  to  other  mBihuds  of  aeeuring  reet.  It  will  be  fuuud  that  the  prone  Is 
fWilhiabU  to  the  supint'  poeture,  uud  the  (Hitivnt  should,  if  old  enough  to 
■ultBttand  the  Imporlanoe  of  reel,  be  laid  upon  a  projierly  constructed  prune 
—eh.  The  prone  piwition  is  certainly  the  beet;  fur  not  ouly  is  the  project- 
lag  aagla  Ibrioad  by  the  e-xcurvatnd  spine  nut  injuriously  corupretaed,  aa  it 
wmM  tie  ia  the  snptne  or  lateral  poBitiun,  but  the  juiticnt  is  more  oomfortu- 
bb;  and  it  is  easier,  should  it  be  neccMary,  to  apply  i«ues  or  tbe  ac'tual 
eaatciy.  At  the  same  time,  the  back  not  being  the  lowest  part  of  the  body, 
tJbcre  is  a  le«  teodeocy  to  cougestion  of  the  Apiiial  rcius,  und  tu  consequent 
iftoeaae  of  tb«  intfammaiury  duflvning  ol'  the  bones.  Formerly  the  pattcot 
WW0  thm  kept  in  tbe  recumbeot  position  fur  many  months,  seldom  lem  than 
twelve  or  eiyhloen.  till  all  the  acute  symptooM  had  dt8np|)e«red.  Since  the 
iaIiadQetJou  uf  the  trvatmeat  by  the  plaster-jacket  to  be  immediauly 
4aei(bed,  this  b  un  hiujjer  aocessary.  If  the  syuiploou  are  very  acute,  the 
■oil  may  be  oaed  for  a  short  time,  but  m  souu  as  possible  the  plaster- 


J 


4SS 


DISBABKS   OF    THK   SPINE. 


jacket  flhoiiM  he  Rpplii^tl,  and  the  patient  a1l»n«Ml  to  mov«  nbout.  Wlien 
fligna  of  acute  disf^Ase  have  (iiauppeiircd,  and  the  licfiirmity  alnne  rcroaiiui,the 
apparnltis  slinwn  in  the  accompanying  figure  may  somelimes  be  worn  with 
advanU^^e  (Fi^.  .'371).  It  omibincs  cbrcu  printaplea  in  its  action — 1,  a  broad 
pelvic  band,  forming  a  firm  has'\a  nf  support  round  the  lower  part  of  the 
trunk  ;  'J,  lateral  u]>ri^bt  »teni»,  termiiialJng  in  crutche*,  by  wbivh  the  weight 
of  the  he*d  aud  etioulders  i»  taken  off  the  diseased  spine,  and  traiDtmitted 
directly  to  the  pelvic  bai*e ;  and,  '.i,  a  posterior  plate,  wbich  by  iiieuut  of  a 
ratchet  cuu  he  brought  to  bear  directly  upon  the  excurvat«d  part  ol'tbcspiue, 
end  support,  aud  in  some  degree  rectify  the  [K«itioD  of  this.  Taylor's  sup- 
port also  (Fig.  512)  is  an  apparatus  of  great  utility,  wore  specially  iu  the 
aUvHUced  fltagea  of  angular  curvature  of  tbespine,  where  aDkyloais  biu  taken 


Ui 


tig.  971.— Afiparatni  Tor  6vp|>orllDK 
til*  Trunk  Id  V«tl«bnl  Ckrie*. 


Fly.  173.— Tkjrlar*!  Splul 
Support. 


plaoe  between  the  diseaA^  vertebra.  It  baa  a  tendency,  in  conneqiience  ot 
ihf  upright  iron  dorsal  rods  being  jointed  backwardK,  to  uplift  the  head  and 
shoulders,  and  tbuii  often  improves  conntderably  the  attitude  of  tbe  pAtient. 
But  this  very  advantage  in  ibe  later  ntage*  becomex  a  murce  of  incon> 
venieuce  if  not  of  pmitive  danger  in  the  earlier  periods  of  the  disease,  as  it 
tends  to  separate  vertebne  in  proceae  of  consulidalion.  It  is  of  considerable 
importance  that  tbe  patient  should  not  be  allowed  to  dispense  with  proper 
support  too  soon,  otberwise  he  will  to  n  certainty  iiulTer  ii  speedy  rcla|)9C. 

Treatment  of  Diseased  Spine  by  Flaster-ot-Paris  Bandage. — Lewis  A. 
Sayn-,  or!New  York,  baa  very  iogeniou^ly  iippiit'd  ibepiaeUT-ul- Paris  bandage 
tn  tbe  treatment  of  caries  of  tbe  gpiue  with  angular  curvature.  Tbe  follow- 
ing  is  a  brief  summary  of  tbe  details  of  tbi?  method  of  irealmetit. 

The  fibin  being  removed,  a  thin,  closely  woven  vest  without  sleeves  is  put 
on  next  the  skin.  Tbe  child  then  standing  under  a  tripod  stund,  tu  tbe  apex 
of  which  is  atached  a  block-and-fall  arrangement  carrying  a  hiiriiioutal  iron 
bar,  a  padded  collar  is  buckled  rouud  ibo  bead  aud  catu,  while  padded 
itimjpe  are  paa^d  under  the  arms  :  straps  arc  then  pa^iseil  genaratery  from 
the  ftollar  and  arni-alirrups  to  tbe  iron  bar  above  ( Fig.  oTA).  By  shortenlnjf 
or  Icngtbeuiu^  these  strapt*.  the  relative  tension  upon  tbo  bead  and  arms  can 
be  adjusted  with  nicety.  The  indication  that  the  propcramount  of  cxlenmon 
has  wen  made  with  tbe  pulleys,  is  the  comfort  experienced  by  the  patient. 
He  must  on  no  account  be  raised  completely  from  the  ground.     When  thus 


TftEATHSNT  OF  CARIES  OP  SPINE — SATRE'S  JACKET.      433 

Hivpended,  the  spine  bcconioa  mucli  strBight«r;  the  eare  are  liAed  from  the 
sboulden,  aad  the  dii^cosed  surfaces  of  ibe  verlebne  are  prevented  fmm 
prmioK  upon  one  aoutlicr. 

A  thick  towel  foMcd  ebuuM  be  placed  under  the  vest,  over  tbe  forepart 
of  the  abdomen.     When  the  case  u  dry,  this  is  drawn  out,  and  thus  spaoo 


:^^ 


(^ 


Pi(.  573.— Application  ofBayrv't  Pla»t*r  Ja«1l«t. 


Pig.  574. — 8»jnj'ii  Jofkit 
Applied. 


ia  left  for  expaimion  uf  the  abdomen  dtiriug  meale.  Tliis  prccautioa  ia  a 
rery  ioiportaut  detJii).  Iib  omioHion  may  he  attended  by  very  iucouveuieut 
coneetjueucea. 

Plastcr-of-Puriii  bitndiigi<H  are  tbi^n  careriilly  applied  muiid  tbc  body  ftum 
the  pelvis  to  the  arum ;  nn<l  Htrifw  of  thin  pcrlorateii  tin  lire  ptucciloy  tho 
flidea  of  the  spint?,  and  u  ecrond  Inyrr  mI  plut^ter  hnndage^  pai«^M  n>uud  (iio 
whole  (Fig.  fi73 }.  The  slnipH  being  now  removf-d,  the  chih!  is  luid  upon  a 
Riatlrct^.  Ah  .-^Mvn  ha  the  ciide  is  dry,  the  fihdnminul  pafi  it)  withdrawn  ;  and 
the  patient,  when  erert,  is  found  tn  ne  from  one  to  one  Htid  a  half  inch  taller. 
In  caaea  of  caries  of  the  cer\'icHl  region,  a  headpiece  ia  Bdjii8te<l  to  the  body- 
GMMt  by  neflD?  of  which  the  spine  may  be  relieved  of  the  weight  of  the 
head.  After  two  or  three  moDtoa,  the  cnse  may  be  slit  down  the  front  and 
wot.  II.— 2fl 


484 


DISEASES    OP    THK    SflNU. 


iwteoed  with  eyelets.  After  niich  in-aimeot,  it  is  rnmmonty  MM  llMft 
rMpiralion  l>ec'*nies  euj  and  the  drculatinn  fretj,  whik  arnifitiMM  (llM  IB 
irntiiliim  of  nervo*  mihside.  Sayre  strongly  icisisiU  on  th*"  imp<^rUofe  rf 
practical  detnils,  »iich  m  the  dm  of  ton9e-texturp<l  haiiHHgr»  iui<l  »uitabti 
pluter,  a  closely  fitting  elagtic  thin,  and,  above  all,  securini;  m  perfect  mdwp- 
tation  of  the  case. 

The  eeeenlial  fkoints  to  be  attained  by  thU  treatment  are:  lit,  Mu()««mt« 
extension  of  tli«  liUeatied  Bj>iiie  by  miiipensiou ;  2d,  Fixation  of  the  apiae 
when  so  extended  iu  a  IJrrD  and  li^ibt  casing.  The  pluBler-baudajiv  moat  ool 
therefore  be  luoked  ujHin  na  a  mere  eubetitmo  for  the  ordinary  ap|ianaua.  It 
fulfils  one  indicatiou  vrhivh  the  more  mechuuioit  c<julrivanc«  canoot  acooa- 
niish — by  K-curin;;  uodvnite  czlviiDJon  of  the  diseased  apine  at  tbe  time  uf 
itji  application.  It  ia  luore  cttpei-iullv  Iu  case*  of  the  lower  duraal  and  luiD- 
bar  vertcbne  that  the  plasler-of-Pana  jacket  is  so  useful. 

When  the  cerviciil  and  uppyr  duraal  vertebrae  are  nflected,  a  special  q^ 
trivaoce  (Fig.  &76i  is  refjuired  t»  atendy  the  bead.     A  well-coaae 
jacket  will  last  aud  should  \w  worn  for  al  leant  six  or  eight  nantha 
change. 

Jackets  m&de  of  aollened  leather  or  felt  "  puroplastic,"  tu  they  an 
may  be  moulded  on  in  the  same  war — the  patient  being  suspended 
Stiyrc's  triangle.    Tbev  are  useful  alter  the  plaster-jacket  has  been  di  .  _ 
tinucd.ond  have  theHuvBlitagfi  of  being  removable  fur  purposeiuf  abliitioo. 

With   regard   to  the  value  of  counter  irritants,  bucd  as  blister*, 
moxK,  or  the  actual   cautery,  mvich   dilTereacc  of  opinion  exi«U 

Surgeons.  For  my  own  part,  I  hcUeretlien 
nf  little  use  in  any  eaa*.  to  do  much  harni  in 
by  irritating  and  weakening  the  patieol,  and  t< 
indirectly  oiBadvautageoua  in  all  by  {irvtMil 
the  application  of  tbo«e  mechanical  tnMw  «l 
are  nece^ary  for  the  rest  and  support  of  Urt 
cased  spine.  Should  active  couoier-irnlAtiooi 
be  emnloyed,  it  roust  be  used  in  tbe  earUeU 
of  the  disease.  Nothing  cau  be  morv  imaeii 
or  indicate  a  more  prufouod  igoorBUOC  of  palbo> 
lo^v  than  to  use  it  after  abscess  has  ooee  formsd. 
The  ordinary  cooslilutiuDal  treatment  that  ii 
adopted  iu  strumous  diseases  uiust  be  empluved  is 
these  cases.  Much  benefit  will  be  derived  fr«B 
the  use  of  cod-liver  oil,  iron,  the  ph<wphala^■ad 
above  all  gnod  air — countrv  or  tea.  As  in  lU 
other  eases  where  bone  It  dweaaed,  at  least  thiM 
years  must  tie  devoiei]  to  the  cure  of  a  caao  of  aa- 
gular  curvature.  But  that  cure  ooadsta  cDly  ia 
the  preaervHliou  of  life,  nut  the  removal  of  i^ 
furmlty,  which  la  the  inerluble  nwilt  of  osrioaB 
ankytoais 
The  formation  of  abscess  is  best  reatrained  by  tbe  eontinaoun  wnployttMOt 
of  rest  aud  support  Should  absceas  unfortunately  form,  thn  duigvr  be- 
comes greatly  iocreaAed.  The  question!*  as  to  when  and  h»w  ibe  ahsciM 
should  M  ofkened  will  now  huve  to  be  answered.  With  rMpect  to  the  Snl 
it  may  he  aaid  that  ibe  JNirgeon  need  be  in  an  hurry,  but  lot  iba  abswia 
come  well  forsrard  at  one  point,  w  tlmt  tho  pus  may  lie  beacath  iha  Cuaiik 
it  must  not  be  allowed  t/)  point. 

Tbe  danger  of  opening  these  larue  abscesses  is  two-fold.     1st.  b  iiilMMtl 
b  tbe  possiDility  of  putrefaction  of  the  pus  left  in  tbe  cavity,  aisd  the  aim- 


Flf.  ftrs.— AppsralM  forDU- 
«SM  of  Carrlml  or  lfp|>«r 
DVfMl  B|<lB«.  riMiM 
JukaL  wttb   '^Jurr-WMt." 


PI9KASI    or   TDK    CERVICAL    SPIXS.  4S5 

It  developmeat  of  «ptic  pnisoniDg  or  pyium'iA.  With  the  view  of 
Mug  ituM  Stirgtionfl  were  rurmprly  in  thcr  habit  of  inakiog  vavular  iocis- 
hum,  tUM  cArefVilly  ctoiaio);  tliom  wltli  hnruJip  pins,  9i.>  aa  to  praveot  th«  eutry 
rf  ait  itkta  tba  me  of  the  abic^^s.  Now,  hnwever.  such  precautioDs  are  uo 
kioyer  neoeaMry,  anti  by  opvaiu^  the  ab«ceu  with  strict  aDttgeplic  precau- 
timm  Aod  tba  eiupluym«ut  uf  dminage,  the  daog^r  of  septic  iofectioD  is 
gn^r  ImmdoH.  2fl.  The  toorv  remote  daoger  of  abjcoas  cooaiaU  'm  tbo 
risk  or  buctic  rrom  the  lang-cuotintied  discbarge,  kept  up  by  iacurable  bouo- 

lo  •tpeoiagtbewabsoeaaesaQtaoiaioo should  5rat  beniadt;  Just  large  eoi>ugh 
to  •'ItDit  the  Soger,  which  should  be  iiumeditLUily  piujed  iiitu  the  mvity.so 
(kat  it  nay  be  explored  for  oequealn  before  the  pus  esoapes,  while  lis  vrnWs 
■iwftill  tniM.  In  dunal  or  lumbarabwesaeathenager  may  possibly  be  made 
lo  roBoh  Um  diseased  spinet  and  if  a  Kequestrum  be  fell  U^tia  it  might  be  re- 
■^Tod.  A  psoas  abscess  should  be  openod  if  paadiblo  bofure  it  leaves  the 
abioiom,  by  ao  incui'>D  cl'»e  ab^ve  P^upArt'a  ligaiuant  external  to  the  line 
of  dw  Tcawla.  If  it  puiots  at  the  inner  eide  of  the  thigh,  aa  incuUon  may 
bt  OMdv  in  tlut  situBtion  as  woll,  but  this  alone  will  never  drain  the  whole 
aarily  Uioroughly,  owing  i-i  tb<  narrowaoM  of  tho  sac  of  the  atucess,  where 
ii  paaaas  beDeatb  the  femoral  reaselEi.  It  has  lately  been  ituggested  by  P. 
Trwea  that  m^re  direct  drainage  may  be  obtaioiMl,  the  dUeasied  vertrebrte 
•xaoiiaed,  and  pj»iblr  sequedira  rem»veil  by  milcin>r  n  vertical  incistou  in 
■heapaee  between  the  last  riband  the  ilium  immMialely  internal  t)  the  outer 
•1^  of  tlw  erector  spiotc;  thin  mu«ele  i^  exposed  and  drawu  towards  the 
uddlA  line,  the  quadratus  lumborum  may  theo  be  vut  throu)^  c1<mo  to  the 
traaiTWse  proceates,  the  pooas  mu«cle  incised,  and  the  vertebne  rvuchfd  by 
euutioaing  the  operation  along  the  deep  aspect  uf  that  structure.  Hi  re- 
c  jnli^d  thr«»  cues  in  which  he  had  performed  the  oporNtiuo  with  very  satis- 
V  result*,  in  one  uf  which  a  sei^uestrum  vrn*  found  loose  aud  removed. 
...  ^.-llHwIected  cases  it  certainly  deserves  a  further  trial.  After  a  lumbar 
»r  pKua*  absoess  baa  been  opened  for  some  time,  and  the  discharge  reduced 
in«  rsry  small  amount,  the  patient  may  be  allowed  to  rawe  about  with  a 
pfMpar  plaster  support,  through  which  au  opeming  may  be  made  oppiMit«  the 
nw  for  drsHiBg  the  wound;  or  a  poroplaslic  or  leather  s[ipp:>rt  may  be 
■ad*  vhioh  eao  b>  remjvcd  when  nec»uary.  Antiseptic  dresjiag  mudt  be 
■oaliwMtl  aa  toog  as  any  discharge  contiauet. 

DISBABE  OP  TUE  CBKV1CA.L  HPIIfC 

Wv  have  bitlifrtu  contidered  cariw  af  aSecting  thn  dorsal  and  lumbar 
•pioo.  B4t  lite  a.imp,ii3e4<e  may  be  developed,  though  much  less  fre-]ueutly. 
m  lh«  c^i*  '•□.     Tbo  reason  of  it^  gr^satur  rarity  here  arUus  from  the 

esopsnU-  ■  >  'r>  uf  caucetlous  structure  ia  the  uervicil  vertebrie,  aud 

htnoe  tha  lew  tMUtieocy  to  etnim::)U8  or  tuburculous  osteitis,  tbe  diseasa 
prt>b>ably  aomaiaiioiag  rather  iu  the  tigameatuus  than  in  the  omboiu  strnih 
tarva. 

Tba  aiictia  ara  the  usual  unos  of  pain,  rigidity,  and  swelling,  difiuaod  and 
Ul-clafiaea.  But  thare  is  in  the  oervical  region  no  tendency  to  angular 
«i^^,<>-t-ft;..ru.  This  is  owing  to  the  shallowneiis  of  the  bodies  of  the  vertebral 
c  mg  thai  ooalesoenoe  aAer  their  destruction  which  is  characterUdo 

wi  i.ti"  »aid  diaeoM  in  the  dorMl  and  lumho-doraal  regions.  But  the  patient 
itaBabta  lo  sapport  or  to  turn  his  head;  be  h^Idj  it  in  his  hoadi  when  in 
the  OpHs^l  fMsitirm,  and  rotator  iho  whole  bady  when  ho  attempla  to  lonk 
raaML  There  will  be  pain  on  any  attempt  at  m-ivomont,  whether  rotatory 
«e  MUafti'poslenor,  and  on  downward  pressure  on  the  vertex.     Although  no 


I 


436 


OISUASUS    OP    THE    8IMNK. 


.  MigalKr  cumtnrB  can,  for  the  reuaon  just  stale*!,  Uke  plnoe  in  thi«  nfin«, 
'the  ipiDOUB  proceeses  may  become  irregular,  one  or  twu  {irujf^ctiiig  ui*re  Uui 
the  (ttherfl. 

Diie&Be  of  Hu  Articulationa  between  the  Atlai  and  Axis,  asd  botvca 
the  Atlas  and  Occipital  Boue,  cooMituiev  one  of  the  idocc  eerioiu  fonn*  uS 
vertebral  earies.  In  tticBc  cases  tlifrc  are  pain  Nod  swelling,  with  crrat 
difficulty  or  ah^ilule  inabilitr  to  move  the  head.  Fatients  aSc^lcd  witf  tbii 
disease  present  a  remarkabfo  na  well  as  a  iliatrcHing  appearBDoe.  Tba 
■terno-niastoiil  tnuscles  arc  remarkably  tense  and  prominonL.  and  tlw  seek 
h«iug  perfectly  rigid,  they  are  unable  to  turn  the  head,  but  wb*D  tbey  wans 
to  look  round  have  to  twist  their  whole  body  ;  at  the  same  timt>,  lb^  wmk* 
nes«  in  the  ntxk  usually  compeU  thcni  to  support  the  bead  wit^  both  bands, 
putting  one  under  the  chin,  the  other  undi-r  iho  uct<ii>ui.  and  so  boMing  k. 
Tfa«  diseajie  may  nuddenly  terminate  fdtfllly  by  luxation  of  the  allaa  forvmnU, 
compreaaion  of  the  cord,  and  asphyxia ;  or  ruutv  slowly  by  hectic  or  gradual 
iaterference  with  the  r«>ti|iinitory  tuuc-tionn. 

Jktrvphtityiijieal  ab»ce*«  may  form  as  a  consequence  either  of  discasB  of  Um 
bodies  ol'  the  upper  cervical  vertebra;,  or  the  articulations  of  the  fint  iwo. 
It  couimences  with  induration  and  swelling  of  the  areolar  tinue  at  tlM  bad[ 
of  the  {iharyux.  Subsequeolly  the  swelling  becomes  soiler,  auil  Qut^tuatioa 
perceptible.  The  posterior  wall  of  the  pharynx  b  pushed  forwards  agminsl 
the  pcetcrior  narcs.  giving  a  iKiculiar  uuii^l  tone  Lo  the  iruirv,  and  if  the 
abecen  be  large  it  uiay  cause  uilHculty  iu  breathing  and  swallowing.  Tbr 
formation  of  rctro-pharyngeul  abecim  in  young  |ieople  should  aUays  Ind  lu 
an  cxaminatifiii  of  the  n-rvical  spinp.  The  hIhuvos  may  buret  intu  th*-  pharyr  ~ 
or  may  extend  outwanlx,  and  point  at  the  side  of  the  tieck.  coming  furw 
under  thesterno-mastnid. 

The  TVeatmnil  of  Duoiec  of  the.  Cervical  Spine  must  be  condncicd  on  ibit 
flame  principles  as  that  of  angular  curvaiurc,  by  ahftolute  rest  nod  atleatiao 
to  lilt  general  health.  The  actual  cautery  may  sometiroes  he  of  lue  hefim 
■Dppuration  has  taken  place.  When  there  i»  much  pain  il  rouat  he  applM 
on  »ch  nide  i>f  the  i;)>ine  nt  the  back  uf  the  neck.  Aa  great  and  iumnediat* 
danger  may  result  from  the  sudden  displacement  of  the  vertebnt  nnd  nio- 
sequent  compression  of  Iho  cervical  cord,  the  head  requires  t»  if  slradM^l  by 
proper  atiparnliis,  calvutnie^l  tn  nuppnrt  and  slvady  its  movementa.  H«yr«i 
jacket  Witt)  the  "jtiry-maft"  *  Fig.  i>id)  is  the  mwt  eflicient  ap|iBr«tus  Ibr 
diwase  l>e!ow  the  first  twfi  rertebrie.  In  disease  of  the  atlu«  and  axt*,  the 
head  must  l>c  fixed  absolutely  no  that  rn>  movement  i«  pnwiblr.  Thr  palKiil 
should  be  confined  In  beil  iu  the  rvcumbtnl  position,  with  a  heavy  ennd-lM(| 
on  each  side  uf  the  head,  (.tenlle  weight  exleoBion  by  meitns  '>f  a  nJltr 
holding;  on  ihu  chin  and  occiput  attached  to  n  cord  passing  ihmii^h  n  pnlWr 
at  ihu  head  of  the  bed  is  often  useful  for  relieving  pain.     Wh'-  .(• 

synipt'ims  subeide,  an  a]ip«mtus.  such  as  is  repre^nteil  in  Fig.  u 

may  be  appli<-<l. 

Ketro- pharyngeal  abecea  la  a  serioua  compttcatioa,  for  when  it  bunU  mla 
the  pharynx  it  eroptiee  ilscif  imperfectly,  and  decomposition  of  the  di^ 
chargn  ensues,  thus  perpetuating  the  disease.  To  avoid  this,  J.  Chime,  nf 
Edinburgh,  recnmmcuds  that  it  should  Iw  openctl  early,  wbra  pocvible,  by 
aa  incision  mode  behind  the  stcrno-mastoid.  The  carotid  resets  and 
pnmnogBsiric  nerve  roust  b«nuilied  forwards  withont  injuring  the  sbraih 
of  fiucia  in  which  ibcy  are  encloaed.  The  abaoe*  can  tJius  be  tr««ted  anii- 
•eptieally.     In  this  way  he  luccesafully  treated  a  large  abaccH  eoniainbf 


dgbi 


ODQCCB 


of  pUB. 


8ACR0-1LIAC    DISEASE.  437 

OTHER  DKEASES  OF  THE  SPINE. 

Gomaata  of  the  Spine.— Cases  of  ^rttal  destructioD  of  the  bodies  of  the 
veitebne  by  the  formattoa  of  B/philitic  gumnmta  conimeucioz  beneath  the 
periosteum  have  been  recorded.  The  disease  closely  resembles  ordiaury 
caries  of  the  spine  in  its  symptoms,  and  the  diaf^nosis  can  be  made  only  by 
the  history,  and  the  coexistence  of  other  syphilitic  aSections.  The  treatment 
is  mechanical  support  in  addition  to  the  ordinary  internal  remedies. 

Rheumatoid  ArUuitii  may  affect  the  apine.  The  intervertebral  disks 
atrophy,  and  bony  outgrowths  form  from  the  bodies,  which  may  bridge  over 
the  spaces  between  them.  The  natural  movements  are  thus  restricted. 
Berood  this,  it  causes  no  very  definite  symptoms,  and  it  requires  no  special 
treatmeDt. 

TuaOTS  of  the  Spine. — The  bodies  of  the  vertebrie  are  not  uncommonly 
the  seat  of  secondary  cancerous  growths.  Primary  sarcomata  also  are  occa- 
siooally  met  with.  The  symptoms  are  pain,  usually  very  severe,  localized 
at  one  spot  in  the  spine,  followed  after  a  time  by  some  excurvation.  The 
tumor  projects  sooDer  or  later,  if  the  patient  survives  sufficiently  long,  into 
the  spinal  canal  and  compresses  the  cord,  causing  paraplegia.  Except  in 
caacM  in  which  the  tumor  is  secondary,  the  diagnosis  from  dry  caries  is 
■caroely  pu«ible.  Early  supervention  of  paraplegia,  with  slight  excurva- 
tion, in  a  patient  past  middle  life,  would,  however,  suggest  the  presence  of  a 
tomor. 


CHAPTER     LI. 

DKSEASE  OF  THK  SACRO-ILIAC  JOINT. 

Disease  of  the  Saero-iliao  Articnlation  is  a  rare  affection.  With  but  few 
exceptions,  systematic  writers  on  Surgery  were,  until  recently,  altogether 
siient  upon  this  subject.  Boyer  and  Cheliua  mention  the  disease  ;  but  it  is 
only  by  Nilaton  that  any  detailed  description  of  it  has  been  given.  This 
may  be  partly  accounted  for  by  its  rarity,  and  partly,  perhaps,  by  its  having 
Dot  unfrequently  been  confounded  with  some  of  the  varieties  of  disease  of 
the  hip  or  spine. 

Sacro-iliac  disease  is  essentially  a  chronic  affection,  la!<ting  for  months  or 
years.  It  appears  to  be  strumous  in  its  origin,  partaking  of  the  uature  and 
character  of  ordinary  "  white  swellings."  I  liiive  uevcr  seen  it  in  young 
children,  and  in  all  the  cases  which  form  the  bnsis  of  these  observutious  it 
hu  occurred  in  young  adults  from  14  to  :5(1  yt-ars  old.  The  exciting  causes 
of  the  disease  are  obscure  :  I  have  not  beeu  able  to  trace  it  to  blow  or  injury 
in  any  of  the  rases  that  ha%'e  been  under  my  cure,  although  there  can  be 
very  little  doubt  that  such  causes  might  excite  it. 

l*ATllOLO«;y. — The  disease  may  conimcnc'c  primarily  oithtT  in  the  pelvic 
bones",  or  in  the  articular  structures  of  the  siioro-iliac  Junpiitm,  The  annexed 
drawings  ('■'g*-  -"'"S,  577),  taken  from  a  boy  who  died  of  tftanus  frum  the 
irritation  of  an  isfsue,  ^^ix  weeks  after  the  cummencoment  of  diseasp  in  the 
eacro-iliac  articulation,  show  erosion  of  the  cartilajres  in  patclies.  Tlie  next 
drawing  'Fig.  578),  taken  from  a  man  about  30  years  of  age,  who  died  of 


438 


DISKASS    OP   TDK    BACRO'ILIAO  JOINT. 


thi«  aflectioo  afler  uearly  two  yean  of  suffering,  shows  the  HiaraM 
moat  aiiv«ucfd  Mage.  The  bntips  are  hare  atxl  nmgh,  bui  in.t  iicc 
Uiey  are  cyniplvU'l}-  titprivwl  of  their  i-nrrualiiiK  ranilnpe.  Therp  in  iw 
erueiou  of  thcui,  uu  cuvity,  no  sign  of  tiilxTciitoiiB  iii6Itnilioii ;  un  cviikiKT, 
in  fHcl,  of  primary  <ii*e<)UB  dbesse.  The  lipamonloiie  girtietum  nf  lb*  arlicv- 
Ialit>n*are  uuly  [mrlially  dortroyod.  The  intfrojswiu*  li(,'«nn-iit  w»#r»prci«Ily 
in  a  »<utul  stale:  il  had  pn-Hervpd  to  a  great  fXltnt  its  (irmni-M,  n-  >  -  -  ^rwl 
t(p  be-  di%'ii)cd  with  ihe  eoalpel  in  nrdtr  to  fxp<«e  the  tnlrnnrnr  i  ind 

the  oiiiHiwd  iieeeims  »iirfac(«.     The  stnu'lurca  that  apjirar  cbiciiv  !o  Dirt 
euflVred  lire  ihe  rynorial  and  cartilaginoue  eleiiK-iii»  nf  th«*  joint.     'Tberc  air 


c^-^-~^p-j> 


6««ro  lliM  DUo«**  tu  \U  urly  •■■(a. 
rif.  97*. — SMrnot.  Tl|.  ITT.— iDam. 


Tig,  &*».—£•« viu»«  DliMM,  mtin  tdnmnt- 


oonnalty  but  imperfectly  develuprd  in  the  «acTo-i|i«c  •rtirulaticD,  b«ri  my, 
pnibahly  t>[i(iu|;li.  readily  uiidcrgn  diptirsauixiuj;  rhangnei'mtithat  anahipiua 
tu  (hncL' which  inke  plart- in  thvio-callru  "pulpy  drgtueratiun  of  tbeayoMial 
mttiibrane  "  in  mruiui^ua  juiuis. 

Si  JiiTOMt*. — The  pyniplHiiifl  charaoteriatic  of  this  afff  iliuD  arraoge  iWoi- 
Klvf»  it)  five  (liHtifiL-l  groujHi — viz..  I'aiii.  Swelling;,  I^aRienra*.  AllrrmtkB  b 
the  .Shajn'  of  thi*  Limb,  and  AUcess.     "nirae  we  diubi  ttudy  t*-|>aratr1y. 

I.  Pain.— Otif  of  the  earlieM  eyiiiplnnia  ua  BeDhaiii-ti  ol  pa-itfii!  «f!ikt>n» 
at  the  \tv,er  part  of  the  bai-k  stid  fiicruni,  itirrtat'cd  by  n  -bi; 

body  in  walking, stooping,  or  evca  iti  alanding,  giviuf;  tht-  *•  ■■  ■  t^r 

bcMly  were  falling  asunder.  Thr  pain  is  inrrvaBed  by  any  erion  ibat  nib 
the  n-xpiratory  uuii>cleA  into  action.  »ut-h  as  coughing,  ^tictzing,  or  laugbiog, 
and  is  greatly  «j,'grava(cd  by  straining  at  hImiI.  Ab  the  diwaM  adraDcr*, 
the  i-flin  bccooKt  more  ci>ntinnou»,  and  of  a  gnawing  or  rhrumat-'-  ■>■-■  — (*t. 
Its  inie»»iiy  varies  greatly  ;  in  ecDie  iiiMsniTs  it  is  thn>ughoui  ^  •  pi 

on  mov4-tn(-nt,  in  others  it  is  nitwt  inlrnfcly  agculzing,  the  patidn  -i<>i'«iBg 
with  agony,  and  unable  to  obtiiiii  rri)t  in  ntt^'  (xsitioi].  The  ]«in  in  ib« 
gluteal  rtgiin  niny  in  tonic  cs^tt)  be  due  to  irritation  of  the  lunibv-tacnl 
cord,  which  lire  in  close  contact  with  the  arlirulation.  It  is  aocompaakd 
by  a  |ieculiar  feeling  of  weakness,  of  falling  Btundrr,  or  of  want  of  sajipocl 
iu  the  Inner  parts  of  the  body.  This  puin  is  o>nfincd  I"  the  glufal  rrftiiv 
and  groiu.  and  d<>ea  not  extend  far  down  the  limb.  \Vh<D  ibe  palieoi  it 
lying  on  bia  back  or  aide,  the  limb  ou  the  aflcct«d  side  may  bt  al^  « 


9ACR0-TL1AC   DI9EASS  —  STHPTOUS. 


mdiluctei),  i»r  the  head  of  the  ihtgh-bone  may  Iw  pnseed  up  againet  the 
acctaliulum,  wilhmU  any  incrpaee  of  pain,  provided  the  pelvis  be  fixed  by 
the  preiTi-ureof  the  hands,  if  this  be  not  done,  considerahle,  even  intulerable 
pain  will  be  experienced  on  moving  the  limb.  So,  olso,  if  the  Hurgeon  sciM 
the  eidea  nf  tlie  pelvis  in  his  hands,  and  move  ihem  to  and  fro,  or  prcu  them 
together  tranaver«ely,  cr  wpmralc  tbeni  by  proMing  the  anterior  superior 
Spines  ft*undtr,  pain  will  be  elicited,  the  afltctcd  joint  being  then  influenced 
by  the  movement  communioated  to  it.  There  b  ttden  general  and  diStiaed 
tendeme8«  on  pr■^a«u^c  over  llic  gluleul  region  ;  but  thia  la  len  about  the  liin- 
joiut  than  in  coxalgia,  and  grailimlly  incrcust-^  as  the  finger  ia  pre»ed  hacic- 
warda  upon  the  ^eroiliae  articulutiun,  do  that  it  may  at  laiit  be  localized  in 
a  amalt  «|v>l. 

2.  Swelling. — A  puffy  intumeHeenee  is  perceptible  early  in  the  diaease, 
along  the  line  of  the  afTet^teti  articulation.  It  »K!tuitie!>  a  wmievrhat  elongated 
appearance  from  above  downwards,  and  does  not  extend  to  any  diHtance  out- 
warda  under  the  gbiteal  niuecles,  nor  does  it  invade  the  natural  hollow  behind 
the  troehanler.  As  th«  disease  advances,  and  suppuratiou  lakes  place,  the 
swelling  iucreaces  materially,  and  aeeuniea  diflereut  and  peculiar  cuaracten. 
Offing  to  the  formation  and  didUaiou  of  absccts. 

3.  Lameness  in  an  early  symptom.  The  patient  walks  insecurely  ;  has  u 
feeling  of  waul  <'f  proper  Kuppiirt  to  tho  body;  leans  f<jrward,  and  usee  a 
stick,  lie  puts  the  fiiot  on  tlic  ullcetcd  side  to  the  ground,  but  docs  not  tread 
QpoD  it  so  firtuty  as  upon  tlic  other.  He  cuuout  stand  on  the  foot  of  the 
auectcd  side,  or  twist  nimmrlf  suddenly  round.  As  the  diecaee  advances, 
tbe  powers  of  support  and  progrcssiou  diminish,  and  nt  Inst  the  paticut 
Iwoomee  uuable  to  assume  the  eicc-t  putiiiou,  tying  io  bed  usually  on  ihc 
aouud  sidi-. 

4.  Alteration  in  the  Shape  of  the  Hip  and  Length  of  the  Limb  is  an  early 
and  marked  8ympt<tm.  Fnmi  the  very  commeiic-eiiient  of  the  ditieaiie,  the 
limb  on  the  aflected  side  will  seetn  to  be  longer  than  the  sound  one  ;  ihti  tip 
of  the  inner  mallcolua  being  usuaIIt.  bs  the  patient  liee  ou  hia  hack,  half  an 
iDch  below  the  level  of  ihe  same  point  of  bone  on  tbe  opposite  side.  Rut  on 
dose  examination,  it  will  be  found  that  the  measuremetit  front  tbe  anterior 
posterior  spine  to  tbe  inner  nmlleolus  gives  the  same  result  on  both  sidee: 
nence  ibe  elongation  cannot  be  owing  to  any  change  that  has  taken  place  in 
the  liones,  or  in  the  three  large  joints  of  the  lower  extremity,  but  must  be 
dependent  on  some  disturbing  cause  situated  beyond  the  anterior  superior 
Bpiae  of  the  ilium.  On  more  close  investigation,  thia  point  of  bone  id  found 
to  be  at  a  lower  level,  and  at  the  eame  time  imire  promiuent,  than  its  fellow 
on  ihv  oppiwle  «ide ;  tht,-  diepliicemtMit  is  thus  produced,  uot  by  any  obliquity 
of  tbe  pelvis  coosetjucnl  on  a  twist  un  the  luriilnir  spine,  as  iti  hi|>-joint  dis- 
ease, but  by  the  tilting  forKnrds  and  rotaliiui  downwards  nf  the  whole  side  of 
tbe  pelvis;  for  the  displacement  which  takes  place  is  a  double  oue.  The 
vweliiog  of  tbe  atfected  articulation  not  only  pushes  forwards,  but  rotates 
downwards,  the  anterior  and  superiur  portion  of  the  ilium;  and  hence  the 
anterior  superior  spine  is  not  only  at  a  lower  level,  hut  is  also  more  promi- 
oent  on  the  diseased  than  un  the  sound  side.  The  limb  itself  usually  lies 
straight,  and  is  wasted  and  eufeebled. 

6.  Abseess  occurs  only  at  a  lute  period  of  tbe  disease.  Many  months,  a 
year  or  more,  may  elnpee  before  suppuratiun  is  fairlv  ealtihlisbed,  or,  at  all 
events,  before  tbe  formation  of  pus  is  so  abundant  and  so  circumscribed  that 
it  can  be  recognized  as  an  ahscc^.  I  have  observed  aliscess  iu  connection 
ffith  tbih  disease  in  Gvc  siiuatious — vis.,  over  the  arlicuhition,  in  the  gluteal 
and  in  the  lumbar  regions,  within  the  pelvis,  and  iu  ouuuectioQ  with  the 
rectum. 


440 


DISEASE    or    THE    SACBU-ILIAC    J< 


Thfl  6rst  indicatirin  of  abaiceu  i>'  m«t  with  over  the  dbesMd  ■rtiealaliaa. 
The  puffy  swelling  which  is  th«re  iwrceplible  io  the  earli«r  tum  of  Um 
mffeclii>D.  gradually  softens,  UDtil  at  la#t  lluctURti<>n  u  ettablMhed  io  iL  Fniai 
this  point  it  may  apread  outwards  iolo  the  gluteal  regioa,  nearly  aj  far  a*,  but 
nut  euvelopiug,  the  trocbaDt«r;  or  il  may  take  another  course  aod  Knrtcfa 
upwards,  forming  a  considerable  accumulatioa  in  the  Ibid,  upoa  aad  joit 
above  the  crcol  uf  the  ilium.  These  forms  of  socrottiac  abaoeM  are  orira* 
pelvic;  tbc  other  varicliet  arc  intrapelvie.  Tbcae  latter  are  of  thrni  kiadt. 
'  To  OQO  form  the  pus  poaecs  out  of  the  sciatic  notch,  nnd  under  the  ^rcat  glu- 
teal musclo;  in  the  next  it  f^ritaue  dowowanls  into  the  tschiu-ractal  fiMt, 
aod  preseiQU  by  the  side  of  the  recuim;  and  in  the  third  vnriety  wUek  I 
have  cibaerred,  the  abecesa  ojK-nii  into  the  gut,  ahumlant  puriform  diadiarfi 
lakes  place  p«r  anun, and,  Hatim  from  ihelHiwtil  pAMin)c  into  ihe  mipparatiog 
caviir,  a  lympanitic  abaoesa  reauliu. 

PkO';nohik.— Tiii:>  proj^noals  nf  this  disease  is  always  most  un&vorablc^  I 
am  not  prepared  to  eay  that  it  fo  of  neceaeitjr  fnml.  Imt  I  have  never  «ea  a 
pAtieni  rec(>ver  afler  the  full  developmoDt  of  the  di»oase,  and  aA«rmppai*- 
tif>n  had  set  in.  I  have,  however,  seeo  a  case  oared,  io  which,  from  tlM 
history  of  the  symptoms,  the  thickeniu]{  orer  the  sacro-iliae  «rtictilatioc>B,aiid 
the  perumneot  displaoement  of  the  side  of  the  pelvis,  then*  was  every  rtaann 
to  believe  that  this  diMsee  had  existed.  But  id  tliis  {Dstaece  do  abs«eas  bad 
formed. 

DiAONWis. — The  diagnoeix  of  Mkcro-itlac  dEseaM  is  important,  aod  ool 
always  easy.  There  are  five  distinct  aStMrtion^  with  which  it  may  btt  coft- 
founded — vis.,  ntiuralgia  of  the  bip,  sciatica,  spioal  disease,  diseme  of  tb* 
bip-joint,  and  dii)ea««  of  the  pelvic  buutat. 

1.  yenralyia  of  the  hip  in  young  fcmakti  may  readily  i-uouuh  be 
foundc<l  with  the  earlier  stnges  of  eaoro-iliao  disease.  But  the  widely  i 
and  suj>erticial  nature  of  the  pain  in  the  neuralgic  afTection,  the  ooexii 
nf  the  hysterical  temperament,  the  sex  of  the  patieDt,  and  the  abaenoe 
limitatina  of  morbid  notion  to  the  neighborhood  of  the  diseased  artirulntifm, 
render  the  true  nature  of  the  affection  Butficiently  clear.  The  ohliquiiy  of 
the  pelvis  which  oooasionally  occurs  in  neural^a  of  the  bip,  and  causoi 
appnrcDl  elongation  of  the  limb,  is  readily  removed  when  the  patient  live  oa 
toe  back  ;  whereas,  in  sacro-iliac  diaca^o,  poeltion  does  not  affect  the  displan" 
ment  of  the  limb  on  the  sAected  side. 

2.  Stnatieeu — In  this  affection,  the  age  of  the  patient,  usually  more  advaoead 
tlian  that  of  the  suhjecis  of  sDcro-ilioo  disease;  llio  seat  of^the  paia.  Mum 
the  articulation,  and  iu>  extout  down  the  back  nf  the  limb,  the  t—dif— 
being  io  the  line  of  the  great  sciatic  oerre,  and  not  over  the  artteaW 
lion,  with  thi-  absence  of  eloogatioD,  will  enable  the  Sorgean  to  efleei  ihe 
diagiioHis. 

3.  From  ipinal  di^eaat,  the  diagnoris  U  usually  sufficiently  easy ;  far, 
altlfkut;li  the  Mtuation  of  absoeas  resulting  from  carles  nf  the  vertebns  nay 
ill  mnuy  caMW  be  the  same  as  that  whicli  is  occupied  by  the  onllec-tiuDS  of 
pus  reeuliiiiif  from  sacroiliac  disease,  yet  in  caries  uf  the  spine,  in  the  fssl 
inajortiy  uf  ioBlaiices,  excurvation  of  the  vertebne  bas  become  ;'^•'■•'■^-"tly 
inark(>i]  by  the  time  that  the  absceas  has  assumed  so  great  a  ma^*  to 
occupy  the  inferior  lumbar  or  gluteal  regions.  In  those  rare  eascv  m  wnidi, 
»s  ill  au  instance  th&t  was  soue  time  ug'j  under  my  care,  carles  of  the  Ter> 
tebnr.  with  conncrutivo  abscess,  takes  place  without  any  aoguhir  eui 
it  will  be  found  that  (be  patteat  complains  of  tendemsss  on  the  Surveon  [ 
ctMsing  thr  Bi<inc  ojtpiMiti'  tlir>  seat  of  disease;  that  the  spinal  ooltlMa 
lost  its  Rexihilily,  moving  f>tiffly  and  as  n  whole;  that  thoro  b  aa  ahaeac 
that  elongation  of  the  limb  on  the  aflhcted  ride,  dependant  on  dl 


DlAOXOdlS    OP    SACBO-IUAC    D18KASS. 


441 


of  the  <riog  of  (be  pelvis,  which  \»  M  early  observable  in  sacro-iliac  diseaM; 
tmi,  ImUjt.  that  «x«niioat)oa  nf  the  sacro-iliae  svachoiidrosia  oeither  elicitu 
pafai  Bor  nrwk  fwclliog  or  aoy  of  the  other  aigos  of  disorgauizstiou  of  that 
■rticoktioo. 

4.  Ditent*  0/  iht  hip-joint  »  the  aifection  that  it  most  eaailjr  oonfouDded 
vkfaHMffo^itacdiacaae.  and  that  from  which  it  \»  of  nine  I  importaoce  Ui  make 
iW  diaplonB.  It  is  oepccially  from  that  VRriety  of  bip-di»eaTC  which  com* 
9*  10  the  oootnbuluiQ,  primurily  inrolvee  the  pelvic  bones,  and  only 
iahtr  iniplieatea  the  joiuL,  Ihac  it  is  difficult  to  disLingtiitih  sacroiliac 
!;  and  the  imporlaQoe  of  efibcting  this  diagnosis  is  grc»t  whco  wq 
that  ibcae  eaaw  of  bip-diaeMe  may  ue  Huccea^fully  subjected  to  opera- 
Im  iotrrfereoor,  wblUt  Micru-iliac  diaease  does  uot  admit  of  relief  or  removal 
far  Uwae  meaiu.  The  diagnoeia  betveen  oozalgia  in  all  its  forma  and  the 
dWaar  we  are  at  praent  coniildering  may  be  eflfbetcd  by  attention  to  the 
AlltMring  rircameuinopa. 

■.  Thr  seat  »f  pain  on  pressure  varim.  In  hi|Mliftcaec  the  |)nlient  aufPcrs 
CBMal  MrTfrvly  wh^n  pr^vnure  ia  exereiiied  deeply  behind  and  above  iho  tro- 
tfcaTilrr.  in  the  hollow  behind  that  oAseons  prominence,  or  when  the  cam- 
prBMiao  m  eierci«ed  apiinat  the  anterior  part  nf  the  h)|r-joint.  In  sitcro- 
uiac  diaeaae,  little  i>r  no  pain  is  experienced  on  preADure  in  these  situations  ; 
ba&  iWiliniiM  H  elicited  by  pressure  upon  the  Mcriim  and  ainn;;  the  line  of 
j— «ioo  batwCD  the  sacrum  and  ilium,  behind  am!  altogether  awuy  from 
th«  bip. 

i.  Tbe  ararcneDta  that  occnsiou  pain  ar«  different  in  the  two  diaeaaea. 
Is  bip-dbeaae,  abductiun  and  mtalion  oulnnrde,  or  presaurt^  of  the  head  of 
tiM  thigfa-bone  into  the  acvtabulum,  aggravate  the  euBeriiig«  of  tli«  pali«nt 
td  a  cnmlc  or  leas  degree,  oReu  to  an  unbcamblu  cjElcot.  In  «ucro-iliac 
the  thigh  may  be  uored  in  all  directions,  ab-  or  ndduclvd,  rotated, 
or  extended,  wbilat  the  patient  is  lying  on  the  back,  without  any  id* 
%yf  lotfiprinjr,  pronded  the  tide  of  the  pelvi*  be  fixed  by  the  Surgeun. 
Bboald  this  precaution  not  1k>  taken,  the  movement  impresaed  nn  the  thigh 
wfii  be  nnnmuottiated  to  the  dtaeaaed  arliculatioo,  and  will  nweanurily  occa- 
siasMffiiring. 

e,  Tbe  ugm  oonneeled  with  the  alteration  in  tbe  length  of  the  limb  diflbr 
in  the  two  iHanairr  In  hip-diseaae  there  may  be,  and  usually  ta  in  the 
adraaoad  ilagcB,  considerable  ahortening.    This  never  occurs  in  sacru-iliae 

ti.  'I  ■     itinn  of  the  level  and  of  the  pn^minence  of  the  two  anterior 

Mpari-  ,  V  in  mcro-iliac  diitenav,  may  be  cmt'iiundcd  with  that  ari.iing 
from  ib«  obltqiiily  of  the  pelvis  usually  occurring  in  tbe  early  stages  of  cox- 
al|m.  But  here  also  the  diagnosis  may  be  effected  by  obacrving  that  the 
(tt^lacamwit  of  tbe  bone  in  sacro-iliao  disease  is  pernianeut,  and  ia  not  in- 
floeocvd  h*  ■-—'•<  IT.  The  ol)ti<|uity  of  the  pelvis  in  bip-^lisease,  giving  rise 
tuBpparrK  xio  iif  the  limb,  is  dependent  on   a  twist  in  the  lumbar 

•fjiiw*.  wh>  '   reetilie<]   by  placing  the  patient  nu  hi^  back,  nnd  using 

A  Itul*  tou  :..    Till.-  alteration  in  the  level  of  the  two  ilia,  in  »acro- 

ifiae  diaen--  Mu-d  by  change  of  poaitiwi,  or  by  any  movement  that 

■ay  be  it:.  I  bo  epiuc. 

6.  Dim"  'C  b<mea  may  uf  couree  occur  independently  of  any 

■Aotint}  '  '.ac  articulation:  and  ubcn  to  occurring,  it  always 

■•  fnim  the  joint — the  cr«i  of  the  ilium,  the  tuber- 
:  the  ai-elabulum.  bein^  the  utual  seats  of  the  disease. 
••crura   in   ih*'  fir^l  of  Lhes«  two  ^ituati-JUA.  the  rcsultiDg  abscwa 
altains  a  Vfry  larve  i<!ze.  and  ia  alt<»gctbt'r  al»ive  or  below  the  ayo- 
dMnirnsu,  the  tvnllin*  of  which  can  be  fell  clear  and  uaohscured  by  awell- 


w£m  u 


442 


DISKAHB    ur    THK    HIP-JOIKT. 


ing  of  Bny  kinti.  'NVheii  tlie  abscoaMtiire ')|M>ri^l,  the  Mitu»w  tbikl  rtvult  vtlt 
lv»<l  tlirccUy  down  tu  tlii:  mu^li  and  cariuuo  bum%  exttuiiuRliua  iif  «bi«li  miU 
teav«  uo  doubt  as  to  the  iinturv  iit'  the  aasat.  In  lliewi  crmm,  alio,  do  chMM 
takes  place  iu  the  length  of  thu  limb,  or  iu  tJie  pnattUoi  uf  tlte  nd»  of  IM 
ilium. 

Wli«a  the  moetabulum  in  primarily  affected,  ibe  difficulty  r>r  lUiyprMi 
may  l>p  greater,  in  cnrutequence  uf  tbe  larf^oizeaud  iilWo  iutntMlvic  natan 
of  lh«  awoeeveei,  and  the  coexistence  uf  a  certain  amount  uf  dicpl 
or  plongstion  of  the  limb.  But  here  tbe  tnnie  cirrumbtaoco  that 
tbe  BtirKcou  to  effect  a  dlaenoeia  in  ordinarjr  coxalgia — vti.^  tha 
moveineot  influeticlnp  the  hip-joint  merelj',  and  the  incnaaed 
limb,  as  determined  on  measuring  from  the  anterior  fioperior 
prevent  his  fnlling  into  error  pa  to  the  true  nnture  of  this  dii 

Treatment.— With  respect  to  treatment  1  have  but  litltc  to  mjr,  and 
that  by  no  menns  xnt  is  factory.  The  treatment  niuat  be  conducted  na  ikt 
Mine  general  principles  that  guide  us  in  the  managemeDt  of  cmm  of 

dbeasee  of  the  epiuv.    The  );real  uhjecl  is  to  prereni  tba  fonnatloa^ 

abaCMB.  If  tlie  curt;  hv  forlunatt^ly  Hc-c4tmplisbe<J,tb«  patient  will  probably 
recover  with  a  limb  tbnt,  thoujih  weHkvnwl,  in  but  little  impaired  in  uliltty ; 
for,  tbe  nacro-iliac  junctioa  being  uuturatly  a  Bxeil  j(>int.  it  mntlerv  littte  if, 
in  the  adult,  it  become  aokylwed   by  disease.     Long-continued   rwt  in  iha 

firnne  poBition ;  fixing  the  pelvis,  hijr-joint,  and  thi|th  br  means  of  a  larf* 
eatber  cap  and  epiiot,  or  a  plasler-of-Paria  bandage,  which  ebuuld  embfavf 
tbe  whole  of  the  limb  from  above  the  crest  ol  the  iliuiu  to  tbe  aole  of  Ike 
foot;  oouuter-irrilation,  iu  the  earlier  stages,  before  suppuraUoQ  baa 
(after  that  had  occurreil  it  is  vone  than  iieelees) ;  thu  iMlmiut.«tnitiaa  of 
lifer  oil,  imo,  and  ituilnblc  t<inic«,  nro  tbe  means  to  be  emploj'ed. 
afaeoesg  forma,  this  nnut  be  u|]euvd  in  a  euitahle  and  conveuieat  spoi, 
antiseptic  procautiunit ;  and  tbe  powers  of  the  palient  must  be  kcf»t  op 
ordiuary  dii'tctic  mcauH  and  modirinal  touicw.  with  tbu  view  s>f  pn 
aukyhviK;  but,  unfortunately,  little  advantage  uiiually  fitllows  tbe  treat. 

beyond  the  mitigation  of  suffering  and  some  proloupilion  of  life.     V 

onoo  Kiippurnlion  bait  <iet  id,  our  hopcfl  of  a  cure  tire  mutcrlallr  lenened.  I 
am  not  prepared  to  slate  that  the  aAection  is  inevitably  fatal  when  It  kas 
reached  this  atage^  but  certninly  in  the  very  great  miij»rity  of  inatmnen  il 
in  ao;  the  profuiie  discharge  fmm  the  large  an«c«iM«i  cinnecteil  with  it  m- 
duoing  hectic,  and  exhnuMing  the  powers  of  life.  Ko  operative  intrrferaata 
ia  admissible. 


CIIAPTEK    LIl. 

DISEASE  OF  TUE  UIP-JOIST. 

Uir-DtBKABB  pmeots  so  many  points  of  peculiar  ami  serious  iin| 
that  it  ii  usually,  and  nut  improperly,  deacnbed  as  a  disltoct  aflectioo.  af 
from  other  iuintdisease*.  Like  afl  these  it  may  be  acute,  aubarute.  or 
chn^mic,  and  nuwt  conimonty  occura  in  strumous  subjects ;  iodwd,  I  think 
ita  punuectiou  with  ermfulu  u  generally  more  dttflincily  marknl  ibao  tbat 
of  moat  other  affections  uf  the  joints.     It  almwt  invariably  oecnra  bafum  iba 


oKNCKAt  rriio-ouE.VA  OP  aiP-DiaiEAse.  448 

of  pahertr.  Oat  r\f  -18  cnn»ccutive  cases  ofthii*  di^eas^.  of  Hbich  I  look 
.  I  fin!  thut  it)  Id  ouly  'lit!  it  i-ontmence  at  or  arter  tiltetrtk  yvnra  of  nav, 
$»i,  ■  '  'II  B  cues  ooly  it  hap|i«o«<l  nbove  tlie  *gv  of  t«r<>nt)r.    The 

^aWrx  ■  ii-.  i.f  caam  apitear  tw  give  a  very  wmilar  proportion;  thu» 

it  I  vsM;titi»liY  a  <liM-a£e  of  chililhuod  or  early  vouLh.     It 

»  iCed  tusli^hi  cAUMA.such  an  over-exerliuD  in  a^Dg  walk, 

•  _'.  a  fall,  or  silling  iii  tin*  wet. 

.  ..ii»-  or  ii.t.  OunL^sE. — All  the  iiifliiiiiniatorT  afTeclioni  attacking  the 
caxo-lcawrml  articulation  are  uauallv  confounded  under  the  term  "  Hip- 
Dbcue "  ur  0>xalgia."  Thi»  is  too  ;:cneral  an  exprewiinn;  aoA  we  ^liall 
iad  iscJutlviJ  uoiler  it  several  ilbtinct  i'urms  of  disease  that  ditfvr  from  one 
■■Miwr  ia  paUiology.  fiymplums.  reaull.  and  treatment.  On  loitkint;  at  the 
Jipjaint  ia  a  aurgiiMil  point  of  vien',  we  tind  it  to  be  ciimnoeed  of  three  di»- 
lacC  partJt,  \'iz.,  tiic  M>ft  i^tructiires,  the  aeeiabiilnin,  ami  the  head  of  ihe 
lilMt-bmie.  Any  one  of  theae  may  be  principally  fir  priiiiftrily  ufK-f^ted; 
aiM  we  mav  accordingly  divide  hip-joint  dittcawt  iutit  three  dieiinct  forms — 
Aftkritie,  Aeeuibnlar.  and  Femoral.  Tbia  division  is  not  purciv  paiho- 
lagical,  for  in  all  three  forma  when  the  lat^r  eiages  are  reachrcf,  all  the 
eMBpnacnt  parta  are  moru  or  lew  extensively  a^ied.  Thu  diBttnction  ia, 
bawanr,  of  pradical  importaucf,  especially  in  itA  bearing  on  the  qucatlon  of 
aearioa. 

GidtiutAL  PiiiafaucHA  or  Hir-DUUSR. — Before  procwHinf;  to  describe 
Mcb  •BMraU'  form  of  mxalsia  in  detail,  we  may  conaider  brivBy  the  cnndl- 
tfana  wbich  are  morti  or  less  commnn  to  each  variety  "f  the  affection — vii., 
r  ^     >tude.  Imperfect  mobility,  Suppuration,  6iuiuea,  DulocatioD,  and 

A 

1.  Fain. — 'I1m>  pnin  In  bip-juitit  diw-nao  vari^  ^really  arcordini;  to  the 
bich  the  al)«Ytiiiii  aHume».     in  the  more  chroiitu  forms  of  the  ilitK-nse 

it  ii  at  6nt  ■li^ht,  and,  perhafM.  r\.'ftTal)te  mthtr  (o  the  knee  ibun  to  iho 
bip:  Ibia  n  pariieularly  the  «use  in  the  femoml  variety,  and  may  b« 
caplainnl  by  the  irritation  of  tliu  articular  Iminc-li  of  the  obturator  nerve, 
imuaiutf  a  rvfrrred  paiti  to  be  felt  in  the  terminal  braocbea  hy  the  inner  etde 
lit  thm  aaecjittnu  Both  the  bi]>  and  knee  receive  articular  brancbes  alao 
frMB  Uw  anterior  crural  and  Eciaiic  uervea.  That  from  the  obturntiir, 
hmnvTf,  rntcrs  the  round  ligumenl.  and  is,  perhaps,  for  thtH  reason  tm- 
pHaBUal  early  io  eaace  Id  which  thu  disease  cororaeiioos  in  tbe  head  of  the 
■oar. 

In  th«  arikritie  fnmi  tbe  pain  is  always  very  acute,  even  intense,  seated  in 
tbe  joint  itw»lf.  and  Krenily  increaiied  by  any  movement,  however  aliKhi.  of 
Iha  limb.  In  the  acetabular  form  of  the  iliBeai«e  the  pain  Is  not  at  firrit 
nfitfred  to  the  joint,  hut  rather  to  tbe  iliac  foi«a  or  aide  of  the  pelvic;  it 

■knrarda  beoumea  aercre,  gnawlni;,  and  deeply  seated  in  the  articulation. 

Bfacvar  alijcht  the  pain  may  be,  it  ia  always  greatly  increased  by  moving 
the  liinb^  by  preaaine  the  nurfncea  of  the  artirulaiii:<n  tDfielher,  or  by  abduc- 
Utiu  nt  rotation.  Hence  the  patient  iisubIIt  kcepe  the  foot  raided,  and 
awfrty  Hip[Hirted  on  tb«  potnt  of  tbe  to«9,  tbe  knee  and  bip  being  fleicd 
aad  adilucled. 

2.  Tbr  Attitods  of  tbe  limb  ia  peculiar,  and  variea  io  iliffereDt  slsgn  of 
diavAM-.     In  the  early  alage  tbe  limb  is  ubuhIIv  »li;:hlly  flexed. abducted, 

id  ff^aied  ouiwardg,  nr,  in  other  wnrda.aaBUineti  the  pfwitiou  of  natural  n-st. 
ID  uf  this  (Kxiliun  ha»  liei-n  the  subject  of  much  ditcutaion.  It  baa 
bam  pntved  M[M-rimi-»lally  by  n«uoet  and  othem.  thai  tlie  limb  enu  Iw 
Mkd*  to  MBUtiie  this  attitude  by  l'<irrtbly  irijevtin^^  Huid,  to  an  tensely  Io  dia* 
fend  lb*  eaptule.  The  accomiiauyiug  figure  well  shriwa  this  fact.  It  ia 
fi«M  ft  phaHognfh  kindly  furnished  me  by  A.  K.  Barker,  of  a  prvparalioo 


« 


444 


UIAKASK    or    TUE    HN'-JOIMT. 


'rrn^^ 


made  hy  liinuelf.  Tlie  right  hi|VJoiQt  wiu  forcibly  dijtifaii«d  witli  A«U 
ioJ€cU*d  ihruugli  11  bote,  drilled  ioco  it  thruu(;h  ttm  ilio-pvctioeal  eaiocMiL 
That  the  linili  may,  thvrvtorc,  assume  Iho  pusiciuu  from  di«teaLitio  of  tht 
capoulo  by  ciruttiuu  rniiii  tlic<  ityiiovial  lueoibraue  ctuiDfJt  be  doubted  :  bvt  it 
lliu  grciit  nmjority  of  casea  tjf  )it|>-diiwa8C  there  is  uo  reason  to  btlwra  tbat 
luiy  Buuli  disiealion  takes  place.    That  the  poaitioD  im  oot  merely  mechaBJial 

is  showD  iQoroover  by  the  fact  thai  la  tha 
varly  stages  uf  tlit>  disotae  it  usually  dbap- 

ftean  under  clitomform.  Jt  may,  hcwcvtr, 
le  ansuiiied  that  iht  pusition  taken  by  tbe 
liml)  when  ull  the  ligaments  are  tcnsciy 
BtreU-h(wl  hv  injpctine  the  joint,  in  also  tkat 
in  which  ihere  would  bo  ihr  mn«t  peribd 
general  rolnxation  if  ihe  fliiiJ  were  iM  OBt; 
this  pwition  would,  thereforr,  ho  inTolns- 
tArity  iiMtimed  by  the  patirnl  when  ifc* 
OAraiile  19  inflaniivl.  It  has  afto  bcM 
pointed  out  by  Barker  that  in  full  exten- 
sion "  thu  leverage  of  the  femur  norini:  no 
the  Y-ligament,  and  the  tense  :>  n 

of  the  capeute  as  a  fulomni,"  vt:L  .  .  ib* 
head  of  the  femur  against  the  acetabulun, 
and  for  Ihiti  reswn  the  patieut  inruluntahly 
kcepa  the  thigh  ftlightly  tiexed. 

Hilton  attributed  the  frasitjon  of  tlw 
limb  lu  a  reflex  contraction  of  the  uusda 
fiurrounding  the  joint.  coosequeDt  apon 
nnatomical  ilifllrjbution  of  tb«  Dt 
being  a  rule  in  all  joints  that  they 
branchee  from  the  ^nie  nervts  that  ffopplj 
the  musclei  acting  direetly  npon  toes. 
According  to  tliU  vieiv  the  Hexino,  abdtlfr 
tion,  and  rotation  outwards  are  due  to  the 
HlroujE^r  niU8clf>9  pftivailing  over  the  wimker. 
It  hna  been  eiig^)>lod,  also,  that  the  p>«* 
tiun  mar  be  due  tn  the  direct  irritation  of  the  flexors  and  external  rotaton 
which  he  more  imnioliatcly  in  contact  with  the  capsule  than  the  exlMiMfi 
and  internal  rotators. 

When  the  limb  is  abducted,  if  the  patient  he  put  in  the  erect  position,  tb« 
pel  via  Is  tilted  in  such  a  way  that  tlie  itnterior  Bti|)erior  Illnc  spine  of  tlM 
diswied  aide  will  be  found  to  De  somewhat  lower  than  its  follow  ;  al  thasaaw 
Uni«  the  sound  limb  is  adducted  to  n  d^-gree  corn'Apondin^  to  i(i>  I'^i 

of  the  anVctf^l  Hide,  aud  thus  the  two   iiinhs  are  tirooeht   [>tr:r  i-h 

other.     The  ku^  i*  flexed,  party  on  account  of  the  t"  af 

the  pelvis  and  tht  liexioD  of  the  hii>-jomt,  and  jMirtly  !>•  .Iia 

toea  only  to  the  ground,  the  cIsAticity  of  the  foot  is  bruught  into  plav  ami 
the  pain  preventad  that  would  arise  from  the  jar  of  the  limb  if  the  patient 
trod  on  the  heel.  The  position  assumed  by  the  affected  Umb  givci  riae  tn  aa 
apparent  elongation.  OAea  in  these  casea  of  apparant  leagtaeaing  there  u 
actual  afa<«tening,  but  roeasureuieut  from  the  anterior  superior  spiooui  pro> 
oesa  to  the  inner  malleolus  on  each  aide  shows  tbelallaey  of  this  appearasea. 
Aa  the  diseane  advances,  the  poailinB  of  the  limb  uodergms  a  cnMplvU 
change ;  the  flexion  remains  and  ia  increased,  but  at  the  aame  tima  tb«  thigh 
hcconiiii  adduot«d  and  roiaiisl  inwards,  so  that  the  knee  ia  carriad  aguaal 
the  lower  part  of  the  sound  thigh.     The  eauw  of  this  pnition  baa  heaiii  iha 


»Tf .— Pa«IUM   Miu»f4   br  tb« 

Ilmli    on    Totelbl^    4UUii<llox    Ilia 
eaptvTc  of  ifa«  bip  Jotnl  wilk  (aid. 


dta 


STMrroMs  UK  Hip^ 


ISifAdK. 


446 


■abject  uf  u  much  fliOUrenoc  iii'  upiniou  tte  that  of  thn  earlier  duptticcmeni. 

In  auOM  caari  it  itt  uuiliiubtedlj  due  to  destruction  of  the  ^fnO  ut  tiiv  booe 

ABkt  {JBrtial  (If  (■■•itipleU-  dislncatimi.     tn  these  aise»  it  t»  acooniMoied  by  dis- 

liart  »h  irii  iiiii|i;  with  ilUplaocniRat  ul'  the  trochanter  nhove  N^IhIuu'r  line 

"Siach  mure  oimmonly,  however,  it  sets  in  luti^  befuru  thera 

rf  exiKiwire  dMtmcliftn  of  the   head  of  tlio  bout ,  aud   must 

U.  other  cniiset,     Ru*cit  hw  Bni;ge«(C'd  that  it  may  be  due  lu  the 

ipjHrr  and  {Kn-terior  wall  of  tlie  act-tahiiluni,  i»u  cuualanllj'  tnet 

tli«  earliest  destructive  proce«ftc«  tu  hipKliattise.    In  coose- 

•invtic*:  •<!  iiui<  iti«  bead  i»  di^plai'i^  upwards  and   buckwarda,  so  sligbtlv  at 

■ni  w  out   tu  ^i\K  riw   l<j  sigus  uf  dieliwatiuu,  but  cuuugh  wheo  the  ilii> 

ii^tuiicot  \t  uusi^ruuud  tu  cHU»v  adducttuu  uf  thtr  timb.     The  altered 

D  uf  the  limb  ba*  be^ii  iui.Tilx.-d  uIb^j  tu  tKitWuiii),'  and  yielding  uf  tbe 

part  uf  tbc  ciijwuU-,  the  puAteriur  aiid  uuler,  wlulu  tbe  inner  aud 

Mrt,  which  is  UMiub  Blrungur,  retuiua  ila  luughn«e;  lu  tlie  exieruul 

RilBlun  DcootDiag  itapiicatcd  early  in  ibe  dtDease,  aa  they  lie  aicM  cloeel/ 

!■  natact  with  the  cajwule,  and  tbuo  ceadag  to  oppoee  toe  adductors  aud 

isterual  rotatura;  and  lastly  tu  ihu  position  aasumeu  io  bed  by  tho  patient 

«faaa  tbe  diaeaied  hip  becomes  too  tender  to  bear  any  pmeure.    Probably 

•11  tkcM  oauMa  are  oiure  or  leas  cotuvrued  in  the  pruduciioa  uf  the  adductcd 

pBMliiai*  «mch  acting  in  a  diflereiit  degree  according  to  Iho  ctroumsianoe*  «f 

Wbca  atlduotion  eela  in,  the  {lOBition  of  the  pekifl  undergoes  a  change.  Id 
onier  lo  bring  the  limbs  |mratlel  and  iti  h  Dtraighl  line  with  the  biKly,  tbe 
narifni  ntut  duH  raise  tbe  pelvis  uo  tbe  aflected  side  and  abduct  tlic  »«und 
liaih,  UkiMtu'viiig  rise  tn  apparent  shortening  of  the  lirnb  ou  the  !<ide  of  th« 
4iania*.  Tlti«  luay  occur  without  any  real,  or  with  very  slijifhc,  ahorteniug, 
tLc  aiiHMint  iif  whicb  cait  be  iijccrtaioed  only  by  meQAurctiiciit. 

Tbi  tiieoiic>rihcpelvband  limb  are  accompanied  by  corresponding 

ckaog'  <   >    |Mi«iti<m  of  the  spine.    Owing  tu  the  tilting  of  the  pelviv, 

Ikcr*  1*  a  iatrnil  c-um:  prmiuced  in  the  lumbar  region,  the  concavity  of 
vkich  look*  toward*  the  eievnted  side  of  the  pelvis,  and  in  order  to  keep  tlw 
bodr  alniglit«  tben  is  a  oimpeiiMliog  curve  in  tbe  oppoaite  directioD 
Ingmr  up.  At  the  aanie  time  tbc  fixed  dexiou  uf  the  thigh  is  corapeurated 
far  by  aa  antaro-poitenor  curvature  of  tbe  lower  spine  with  the  concavity 
fanraxda.  or..aa  it  b  termed,  iordotit.  This  conceals  the  dexiuu  of  the  hip- 
j>.iint,  K>  that  the  two  limbs  may  lie  side  by  side  in  bed  apparently  straigbt, 
wfaan  in  reality  the  diaeaaed  hip  v  Hexed  to  a  oonaiderable  angle.  When 
tka  Unbi  art!  id  thla  poeitiun,  if  the  band  bo  pasnd  under  tlie  lumbar  spine, 
il  will  be  found  to  bo  arcbtHl  forwards,  not  touching  the  bed.  In  order  to 
liaiMi*  tbe  amount  of  ilexiou.  tbe  plan  recutumciuled  by  II.  O.  Thomas  is 
tic  bcai.  As  tbe  patient  lies  on  hi6  back,  tho  iound  limb  ahould  be  Hexed 
Id  Ibc  AiU  extent  at  the  hip  and  knee,  and  prewed  upon  lirraly  till  the 
laaihkr  apiae  btioomea  mraighl.  nod  tbe  band  can  no  longer  h«  paMed 
hala—ii  it  and  the  btnl;  tbe  tbigh  of  tbu  aHbcted  limb  will  then  he  raiaed 
hum  th«  bed,  and  thr  true  angle  of  Hexiou  hevumeig  ajipureut.  Tbe  degree 
«f  ^.i.iii.-tu.ti  or  ahducliiiii  ia  bcflt  recognized  by  putting  a  tape  acroM  troni 
f!  r  fuprrlor  fpioc  Ul  the  other,  when  the  angles  formetl  by  the  limba 

n  -  ~.rv  at  iiucA  clearly  iiei-n. 

im  in  lenj/lK  are  recognizo]  by  meaaurejncnt  from  the  anterior 
'■'•  the  inner  condyle  of  the  lemur  or  the  inner  malleolus,  the 
"-vd  a*  aeeurattdy  »*  [KMsthlc  in  the  umc  p<wition  uo  the  two 
i:  ^naUT  m  -  ri>i(t)irrd,  the  plan  d<>ftcril)ei(l  in  the  chapter  on 

Fnctorea  '.vol.  >.  p  v  be  adupie<i.     Tbeurctically   rca.1  teugthcuiug 

mmj  Moeur  in  cudsu4uuuv«  of  effuaion  into  the  joint,  but  practiuiijy  tho 


I 


446 


UISKASE   OF    TBK    HlP-JOlNT. 


aiuuuiit  SO  caueed  ia  too  emnll  to  be  n?coe:nized  by  niMwiwil.  Ttm 
Hh>iru-uing  mftif  ariae  from  dL-8trurtion  of  tlic  bead  of  the  boofl,  dklmUtaa, 
and  waut  of  growth.  lu  oifl  cases  it  is  welt  to  meaAUro  the  tibia  WfUfiMly, 
and  tu  compare  it  witii  the  Muod  limb.  In  thit  way  the  profioniaB  if 
shori^miug  duo  to  general  want  uf  grotrih  of  the  limb  may  Im  iJBiHi, 
rotif^hlv. 

3.  Limitation  of  movement  tu  a  cuustant  Rymptoin  in  all  fornu  of  klp- 
dbeaw.  The  degree  of  limiuilion  nf  flexinn  ii  Bsnertaionl  bv  griMiiiBf  Uii 
aide  of  the  pelvis  with  one  ham),  while  tho  thigh  ta  clowly  raWd  fr>jm  iW 
bed  with  the  other.  In  this  way  it  i»  easily  a«certaiD*^l  how  much  of  tW 
apparent  flexion  ix  dtte  to  ninveiiH'iit  of  the  peWut  atid  luiuhor  fljMiia,  aa^ 
bvw  much  to  true  luovement  in  th«  joinU  The  ile [jrw  of  ptmibla  exi 
is  r«co};uized  by  the  method  of  nscerliiining  the  an|;le  of  flexioa  reouni 
by  II.  O.  Thoiufts.  To  ai4c«rlAiu  the  limitatioo  of  nixluctioa  or  addoi 
a  l»[>e  may  be  pibised  acniiM  tlio  pelvis  from  one  anterior  sjiiiie  t"  iJm  vihar, 
and  nnotbt^r  tape  niny  hv-  held  at  right  auglea  to  tbi»  to  indicair  tbv  cwrMal 
|iueJlioii  of  the  limb  when  Htraight;  tho  limb  muy  then  bv  ^"ontly 
from  side  tu  side,  and  the  di>t;r«o  of  ruobitity  uulcd.  In  etunuting 
pooaiblo  amount  of  rotutiou,  the  hip  and  kue«  must  be  flexml,  and  tb« 
aylea  of  the  femur  grasived  unci  rutatoil  willi  ou«  band,  while  Lbe  pelvis  !* 
steadied  with  the  otht^r.  It  may  be  lokeu  u  a  safe  rule,  that  if  flvaiua. 
rotation  outwards,  and  HlHluclioD,  can  be  carried  to  such  a  drgn^e  as  ut  p\am 
the  limb  in  the  attitude  assumed  by  a  tailor  when  sitting  cross-legged,  iben 
is  no  disease  nf  the  bi|K  This  poeitiun  {Kitfl  the  n)und  ligamrat  firm]; 
the  stretch,  and  if  tlie  head  of  the  ferour  ia  diseased,  would  eaiue 

■  able  pain. 

4.  Bnppuration  in  not  a  neceasanr  consequence  of  inflaroroation  of  the 
joint,  ih()U>;h  in  Rinimous  subjects  )t  more  commonly  ncours  than  not. 
often  »ee  the  aHMritte  variety  run  its  course  without  the  fonnaiioa  of  pos, 
although  occasionally  suppuration  may  occur  early  with  severe  oatMCilutiood 
disturbance  and  ^roat  pnin.  In  tho  acetabular  nnd/emanil  varieCiea, 
usually  forms  sooner  or  later,  b«ii)K  the  (lire«l  cxmaequence  of  lh« 
of  difwased  bone.  When  the  disirase  commences  in  the  femur,  ouppitralMa, 
taking  ]>\ti<x  early  with  severv  const itulioont  disturbance,  is  usually  asso- 
ciated with  more  or  l«wi  extensive  nucrueiit  of  the  bead  of  the  bane.  In  tlM 
acvtubular  forra,  abscess  is  often  one  of  the  earliest  signs  of  ttriffin  laifirfcitf 
sometimes  prec««ling  the  other  signs  of  hip-disease. 

The  ab«ceM  iu  disease  nf  the  hip  usually  ap|H>ars  lirst  behind  tlte  joiot. tlkt 
DOS  haviog  escaped  from  the  capsule  by  perforating  the  |M»terior  part,  wUok 
u  the  thiuniist.  It  then,  iu  most  oases,  c<.)nie8  gradually  forwanls  b  *~ 
the  gluteus  minimus  and  me'lius.  Having  reached  the  anterior  boi  _ 
the  glutei,  it  passes  beneath  the  tensor  vaginie  femoris,  and  the  upper  part  i 
the  sartoriue,  forming  a  swelling  in  the  upper  part  of  the  thigh  belaw  iha. 
anterior  superior  iliac  spine.  I'  nna  thiv  point  it  often  burrom  domi — ^^ 
and  o[ieDB  behind  the  thick  band  of  fascia  iutu  whieh  the  temor 
Amoris  is  inserted,  in  the  lowvr  part  of  the  upper  ihinl  of  the  Ibigh. 
times  the  absooss  appean  in  fntot  of  the  joiut,  though  this  is  rare,  owii 
the  thickness  of  tbo  oapauto  in  this  situuiioa.  When  the  acetabalura  b  [ 
forated,  the  absccaa  fbrros  between  the  obturator  intemua  and  tiw  bone,  ike 
muscle  being  at  lut  extensively  dosiroyed.  The  pus  is  ootifined  beoeaib  ihe 
pelvie  fascia,  which  becomes  greatly  thickened,  and  sbats  off  the  ahsosM 
mim  the  gcueral  cavity  uf  the  (iclvis.  As  the  pus  increasei  la  <)uantJly,  'a 
burrows  upwards,  and  perforates  the  attaohment  of  the  pelvic  fascia  at  the 
brim  of  the  pelvis,  coming  to  tite  surface  above  or  under  Poapart's  Ugaoteat. 
It  very  rarely  escapes  by  the  small  sciatie  notch  along  the  ooums  of  tba  !■»•  i 


Oll'-JOIXT    DISEAfiK. 


447 


itor  iolrrDiu,  ant)  il  never  ri^r:hefl  the  great  6Ci:itic  notch, 
the  thickened  {wivic  fueeis.  When  ibere  ia  extcnsiire 
tif  tl)c  (telvicbiMjee,  the  nbscMS  may  find  il^  way  iulo  tbc  iruo  pelvis, 
tad  poipt  bcsiiJe  the  rectum;  but  this  ii  rare  la  hijMliseiiw.  Still  more 
imrtlT  Ibe  pm  may  vtcape  frum  thv  fruut  of  the  joioi  and  gut  into  the  peuas 
■UMM,  funning  a  peoas  abscess.  When  Ibis  uccunt.  it  i»  prubablf  due  to 
iIm  cxitfeDce  •»  a  c<iii)municuti<'Q  between  the  syauvial  membratie  of  the 
jafait  awi  theborsa  beuesth  thepaxne  in  I'runt  uf  ilieurticulatiuo. 

b.  Wbea  the  abaoaaBoe  have  burat  or  been  <ipi>nc<l.  Sinuses  art*  left  liehinrl, 
an  aueative  rxaminalion  ol'  thu  jioailiun  and  dirfclit>u  of  which  is  of  jeresc 
impnrtatice  in  rurniing  an  tihininn  as  to  the  seat  of  the  i)&^(h)U»  disease.  There 
are  thre*  aituatiiin»  in  whien  siniinw  are  met  with,  which  vary  according  to 
thvir  point  of  iirijnn  fmiu  the  alwce8S,and  the  piMilinn  of  the  discnaed  bnne. 
1.  Wkeo  the  aiuua  opene  iwo  or  three  inchm  bctlnw  and  u  little  in  front  of  the 
creat  trucbaater,  akwut  the  inaertiuo  of  the  tcnMir  vngiux  fem'iria  muscle, 
u«t  dtwase  t5  almost  invariably  Jemantl  or  nrikritir,  2.  When  the  stiiua 
ia  ia  thtf  glulral  region,  it  may  indicate  ffmonU  or  arthritic,  but  not  iiufrQ* 
uiwtly  W  depeuduii  on  ptJric  disease ;  tbe  acetabulum,  or  a  pi>rtion  of  tlM 
dnnam  ilii,  Imng  the  [>art  liivolvM.    3.  The  sinna  may  open  tn  the  iiubie 


vithcr  aK<iTe  or  t»elow  IViunarl'in  li^ment :  in  this  situation  it  i«  alm<j«t 
ly  dia^oetic  of  dtaeaae  ot  the  peiric  bones.  When  it  ap]i«ore  above 
tba  GgMKnt,  it  probably  leads  to  iatrapetvic  ahac««s:  on  the  other  hand, 
mhtm  It  opens  m^w  Puunart'e  ligament,  there  is  generally  diseaae  of  tbe 
maae  of  we  pabes  or  idcbium. 

b  is  iadeed  ooly  by  altentiuu  to  these  circumstances  that  the  Burgeon  is 
MftUsd  in  many  oases  to  f<jrm  an  approxiniste  opinion  oa  the  sent  and  ex- 
ist of  tbe  vaseous  disease;  fur  the  dtseasvd  buuv  it  often  so  covereil  in  by 
bsallby  nseouB  strocture,  as  when  the  inner  lupect  of  the  great  trochanter 
is  a&eted,  or  by  inflamed  and  indurated  tinuee,  that  the  probe  oaoDot  tottcfa 
it:  or  tbe  sinuB  tnsy  be  so  tortuous  that  a  straight  probe  cannot  folloir  its 
viadioeHL     Sayrc's  Vfirtebrated  probe  (Fig.  503)  is  very  useful  in  these  cases. 

Bdt  tber»  is  other  important  loforniation  obtainable  from  an  attentive  cod- 
tiiUrtUuD  of  thi'  situation  of  the  sinuses.  It  is  with  reference  to  the  proba- 
bit  oauirb  of  the  osdeoua  disease.  In  femoral  coxalgia,  this  is  almost  invari- 
ably cariee— enmetioice  simple^  in  other  casus  tuberculous,  and  acc4uionally 
onplieued  by  necrasis  of  the  head  of  the  bone  ;  hence  tho>se  sinuses  that 
l^ilft^*  tbe  exulenoe  of  primary  disease  of  the  upper  epiphysis  of  ihi?  thigh- 
Vase  pnive  this  to  be  of  u  carious  nature  :  whilst,  ou  the  otoer  hand.siDUses 
oeenrrtuK  >i  'l'^  pubic  region  and  by  Poupart's  ligament  ore  almost  invari* 
t^-jKUideni  on  iUp  nresenoo  of  necrosed  bone — necrosis  being  tbe  form 
.--3>«!  ihai  atTi-vu  the  aoeiabutum  and  polvie  bonc& 

6.  DiilooatioiL — lu  tbe  adTaoood  forms  of  hip-disr^asc,  dislocation  of  the  . 
bead  of  th<i  iliii;h-hi>ue  conamotily  oocun.  and  may  arise  from  three  causes. 
^  Tbe  joiut  umr  if-  dustmyed;  the  oapsalar  ligament  having  given  way  in 

Jueaoe  of  indamuiatory  soUoniug  and  ulceration,  and  the  head  uf  tbe 
inx  thrown  out  of  the  cavity  by  the  action  uf  tJio  surrounding  mu^ 
cla.  h.  Caries  and  partiiU  abwrptinn  of  the  head  of  the  thigh-bone  may 
have  taken  place.  s<i  tbat  it  uo  lonnvr  lilla  up  the  cotyloid  cavity:  aud  the 
l^fMMBK  KM  oAeo  tbe  upper  margin  of  the  acelubulum  being  at  the  same 
line  ikMriijnd.  it  slips  out  on  to  the  dorsum  ilii  (Fig.  560).  e.  A  fungous 
mam  ■my  q)nMi  gp  from  the  bottom  of  the  cavity,  and  tbus  tend  to  push 
the  booe  oat  of  it :  and,  after  it  has  beeo  so  extruded,  this  gruwib  will  oon- 
pletely  ftll  the  aeeuhulum. 

The  occurrence  of  dislocation  is,  in  the  great  majority  of  eaan,  preceded 
hy  the  foroMUiao  of  abeceH  in  and  around  the  joint;  but  in  some  instances 


448 


l)lSBi.SK   or    THE    Hir-JOIST. 


it  happens  in  conaeqiicnoe  uppartMilIj'  of  sofl«ning  of  the  ligmmcQU,  tiw  bad 
ofihtf  bona  being  thrown  out  DlLhencetabulum  without  thuBaperrcntioa^ 
(My  »iga  of  sdppurntinn.  In  iheso  cttsai  a  false  joint  may  be  furnxx)  qm 
the  dfinium  ilil,  whute  the  hone  lodgra.    When  it  it  lying  in  a  aupparattig 


Ftf.  aM.— Aaul«  DImm*  of  Blp-Jwal  Ib  hu  AJ«Ii.    IlMlniwUM  of  U«m1  u(  Vi 
SoflMlnf  or  LlfkMMBU,      PUIooUiMB  M  U  lti«  Ooniiu  IDL. 

ca^nty  it  will  always  he  fouml  to  be  in  a  carious  iitat«,  and  then  wi 
or  at  ra<M  an  imperfect  one,  ia  made  at  the  oonatnicdon  of  an  articali 
aniund  it. 

Dislocation  may  take  place  In  any  varietr  of  the  dlsMiap,  bat  It  ia  omM 
oommun  in  the  fenionil,  in  which  the  heftd  of  the  lhE^h-lM>ne  ipt  inon  nr  ka 
diistri>ye«l.  In  lb«i»e  caaes  it  w  unual  tu  find  the  upiwr  and  peat'-'  '  t^Hi 
of  thu  Ncvtnhulum  with  which  thv  dieeasvd  ht«d  haa  been  In  f  -•■O' 

BiTfly  de«tr»yeil,  a«  that  thu  cavity  is  enlar^l  in  this  directing.  In  tlut 
way  the  iinlerinr  and  tower  purt  uf  Lh«  cavity  i«  relirviil  rnni  the  fnc^jM 
of  the  ditwasud  head  i>f  the  fviuur,  aud  is  rre<)ia-iitly  fi'inid  ti>  hv  undc 
repair,  th»  utirfuco  which  has  been  dvuudvd  uf  mrtilugv  iwinjf  nnronMi 
h«aUby  granulatina-tiaaue.  In  ninceratr<l  epcctmens  of  lhi»  kind  tb«  Hi 
mrt  of  ui«  aoetabaluRi,  against  which  the  dtu-ase-d  bead  at  the  fnna^ 
liecn  lyine,  shows  the  porous,  apongr  apiicaranve  indiratirn  uf 
ueUMlia',  wuilo  the  lower  part,  which  has  been  relieved  by  dupUu  . 
the  Amur  upwards,  shows  evident  figm  of  repwir.  new  bone  nariBg 
fbrmed,  cloaini;  up  the  cnncidlous  apnoee,  and  often  rendering  tke  atzite 
more  dense  than  nacnral.  Theaa  appearaDoes  ahow  that  tbe  M)MabiitBK, 
when  affected  aeoondaril^.  will  readily  ntpair  in  many  eaaea  if  nlimd  tnm 
tbfl  irriution  of  the  friction  of  the  diaeated  hend  of  tbe  ftmnracutHl  iL 
Wbeo  ih«  aoetabnlnm  ii  primarily  affected,  or  axlHumly  dtatrqwd  wte- 


BTSIPTOUB   OF   ARTHRITIC   OOXALQIA. 


ondarilf,  Ihc  bead  ofllic  femur  id  in  euius  ausea  ilielucatcd  ou  tt)  Lhu  tlorBum 
ilii;  iu  utlier  iuelaui;ts  it  is  not  Liinkwti  out  nf  the  niLytoiil  cuvily,  buL  Lbia 
becomw  tt  last  jierlbnilfHl,  ami  itiuy  allow  tJte  head  of  iIib  Itone  lo  slij)  ioto 
ibe  pelvis. 

7.  ADkylosu  may  occur  either  with  nr  withtnil  previous  siii»|ni ration.  If 
ibe  joint  hnv«  mippuraied  and  the  hcail  of  the  bone  be  thrown  on  to  the 
dorfium  ilii,  a  faUc  joint  may  cventiinlly  form,  or  oeseoUH  iinkyloBLi  in  a  more 
or  IcHi  faulty  pcsilioD  take  plnce.  If  the  head  nf  the  bone  continue  in  the 
■relahuhim  without  mippurntion,  osseous  ankylosis  may  ensue  with  but  little 
Bhorleniiig  of  the  limb. 

Patiioixkjy  and  Symitoms  ok  the  VAKiotra  Forms  op  Hip-disease. — 
It  is  Dot  ofien  that  the  opportunity  presents  itself  of  examining  a  hipjoint 
in  the  earlier  stages  of  coxnigia  before  complete  disorgnnizatiun  of  tlie  joint 
has  taken  place.  It  ia  impossiblo,  therefore^  to  define  with  certainty  the 
exact  startiDg-noint  of  the  diseaM  in  every  case.  There  is  no  reason  to  doubt 
that  the  hjp-jomt  is  liable  to  all  the  various  forma  of  dratructivo  inflanimn- 
tjon  already  described  aa  occurring  in  other  joints.  Thus  we  muet  with 
Acute  Arthritis  (p.  3S(j),  ariEing  iu  somo  cawa  Hpparuntly  from  expuoure  to 
cold,  io  others  fn>m  acute  veteumyelitJB  and  nccrueia  of  tlie  epiphysis  uf  the 
head,  iu  others  from  extension  of  BU[)puralion  outside  the  joint  into  the 
cavity  of  the  articulation,  and  io  rare  cases  from  general  blood -poison  log.  as 
in  pyemia  or  puerperal  fever.  More  commonly  the  disease  runs  the  courae 
of  while  swelling  or  strumous  artliritis  (p.  346),  aod  io  the  hip  as  io  other 
joints  the  morbid  process  may  commence  ia  the  sVDovinl  membraue  or  id 
the  cuDcellous  tissue  of  tbe  bones.  When  arising  lu  bone,  the  head  of  the 
femur  is  so  constaullv  the  teai  uf  the  priinnry  disease,  that  tliis  variety  oiay 
be  termed  Femoral  Coxalgia.  It  must  be  remembered,  however,  that  cliui* 
cally  it  in  im|»nseibte  in  tlu<so  ca«c8  to  dclcrmiuc  th«  actual  sturting-point  of 
the  di^«a«(!  with  any  tiegree  uf  certainty.  Thus  R.  J.  Godlec  has  rejvtrted  a 
eaee  in  which  the  diseat>e  was  running  the  ordinary  chronic  course  of  while 
swelling  of  tbe  hip,  and  was  apparently  receiving  great  benefit  from  treat- 
ment when  the  child  died  from  tubercular  mcningitii^.  The  cxaininatinn  of 
the  hi|>  ahowed  two  small  luhercular  centres,  each  forming  a  cavity  about 
the  size  of  a  |»ea,  fillt'd  with  sofl  j;rnniilattiin'tiiv<<ue.  One  was  Fiitiiiitrd  in  the 
growing  bone  in  c^mlact  with  the  Y-«haped  curtilage  of  the  arctabnlum,  and 
the  other  in  the  same  tissue  between  the  epiphysis  of  the  head  and  the  neck 
of  the  femur.  The  synovial  membrane  was  injected,  and  ita  fringes  swollen 
and  becoming  converted  into  BranulRtionttMue. 

LttMly,  the  hi|>-juint  is  liable,  i-4]>ecinlly  in  adults,  to  a  form  of  disease 
which  may  be  termed  Pelvic  or  Atttabtdiir.  This  commences  as  inflfimmu- 
tioit,  teri]iinutiiig  in  iii-crusis  uf  the  rami  of  tbe.  pubes  or  i»t'hiiim,  the  disease 
subufqiiently  extending  to  the  ucetabiiluiu,  aud  thus  giving  ri»6  to  disease  of 
LIjl-  joint. 

Arthritic  Coialgia,  Acute  Arthritis  of  the  Hip.  Sijinplotng. — In  this  fonu 
of  the  dise&MJ  the  patient  is  seized  nith  Kigns  ot  acutu  inllarnmaliou  of  the 
joint,  coming  on  rather  rapidly,  and  with  great  cunstilutioiial  disturbance 
and  pyrexia.  The  pain  in  the  Joint  is  most  excrucintiug,  accompanied  by 
spasms  and  twilchings  of  the  limb,  and  market]  by  noutunial  exacerbations. 
Tbe  suffering  is  so  iuteiwe,  that  the  patient  cannot  Ijear  the  slightest  niove- 
meot  of  the  limb  ;  a  fit  uf  coughing,  tbe  weight  of  the  bed-clothes,  or  Iho 
shaking  nf  tbe  bed  by  a  pereuu  leaning  sgaiiiitt  it,  will  give  rise  to  tbe  most 
intense  agony  ;  and  in  the  intervals  of  his  suffering  the  patient  Is  in  constant 
fcur  of  a  return  of  the  pain,  to  which  he  looks  forward  with  touch  anxiety. 

Iu  tbc£c  cjises  the  limb  is  Aexed,  everted,  abducted,  perfectly  helpless,  and 
moUooIes:  the  nates  will  be  found  flattened,  aud  there  b  tisually  some  ful- 

TOI-  II.— 'JO 


460 


iisBASK  or 


^^Tol 


neu  about  the  Aiit«rior  part  of  the  joiut,  or  to  iu  oaternd^  in  Uw  IhUm 
beliiad  tlie  triKihttutor.  Tticrc  h  aleu,  theoretically,  true  «Jaagmtioa  cf  iL  is 
coaBe4ueiice  of  tho  uajt^ulu  lH>cuuiiii^  iliBtvud^il  with  fluid,  and  pu«litD);llM 
bead  of  the  bone  dowuwards,  but  itiis  twtduui,  if  ever,  uccure  tu  •ocli  aa 
extent  as  tu  bu  rocuguizablc  bf  QiBMsiininient.  On  mvasuriD^.  in  ordtr  b 
ascertain  the  true  length,  it  is  DeceaBary  tu  examine  the  two  licnlM  togttbrr. 
and  tu  place  the  uuuiid  in  exactly  the  eama  |HKiiLJon  sa  tbe  diara*ed  uae; 
unloB  ibia  be  done,  error  will  very  probahlv  creep  in,  for,  on  [iiiawifJM  ihi 
lover  extremity  from  the  anterior  superior  ilinc  Bpino  to  the  lower  bomrW 
the  pot«lla  or  the  iuner  aukle,  it  will  be  found  to  be  of  greater  length  wbei 
abducted  or  extended  than  when  ndducted  or  benL 

Id  »onip  caaes  the  dbtenttua  of  the  capaale  with  PTnovinl  fluid,  at  tbft 
result  of  the  inflaminntion  in  the  joint,  may  be  M  great  ha  to  Icftd  to  it* 
rupture,  and  to  the  sudden  di.'<lorBtion  of  the  head  of  the  bone  oo  to  Uw 
dorsum  ilii,  with  ^eat  futin  and  much  BliorteDiuc;  thia,  however,  i«  of  very 
rare  occurrence,  ine  dislocation  seldom  taking  place  until  nAer  aliMMMi  twa 
fbmKd  within  the  joint,  and  tbe  articulntiuu  has  been  thus  de»troy«d. 

Jt«tuit$. —  In  this,  the  arthritic  form  of  bip-diseiue.  variooi  t«rmiiiati(n 
may  take  place;  the  result  de[>ending  greatly  upou  the  cooatitutioa  of  IW 
DBtient,  the  nature  o(  the  diwase,  and  on  the  manner  in  which  the  "IftftfifB 
u  treated.  Iq  the  moet  favorable  circumstauoea.  as  the  inBammatioD  la  flub- 
dued.  the  dieeafle  falls  into  the  subacute  cnndition,  and  reoonrj  gradomUy 
but  very  elowly  takes  place,  with  a  limb  that  GODtiotta  stiff  and  putiaUj 
ankyloeed,  aa  well  as  waited  and  aumewbat  shortened  from  disnsa. 
times  complete  ankvloeis  occurs  without  the  previous  formation  iif 
In  lIio  majority  of  instnucc^,  however,  abscGBs  furm»,  nud  then  the 
may  cither  be  worn  out  by  the  continued  irriiatiun  of  the  di»eaae,  or  by  tbt 
priit\iBenc8a  of  the  diaebarge:  or  great  ehorteniug  taking  place,  either  by 
dtritlruciiun  ur  ^paration  ui'  the  hend  of  the  bone  or  it«  uialocation  out  at] 
acetabulum,  the  cavity  of  the  abs:cei<i!i  tuny  ultimately  contract,  the  saqi 
if  any  are  prcaent,  may  exfoliate,  the  carious  surfaceB  heal,  and  the  sinoHi 
close  after  ycam  of  Bulfenng.  In  the  meet  fovorable  cirenraMances,  when 
once  the  joint  ban  been  ncutelr  inflamed,  a  year  or  perhaps  two  will  elajae 
before  the  patient  can  Uftc  his  limb  with  any  degree  of  security.  The  aamy 
of  the  |tntient  de]>end.i  in  a  great  measure  on  prerenting  the  occnrreaeeoi 
suppuration.  In  a  certain  proportion  of  cases  in  which  the  disease  eon- 
racni-e«  with  the  acute  symptoms  above  described,  suppuration  rapidly  Ibllowi 
in  spite  of  any  treatmenl.  In  many  of  these  the  arthritis  is  depea<~ 
acote  oateomyelitis  and  uecrosiit  of  the  epiphym  of  the  head,  am)  nti  o] 
the  sbscew  Uiis  may  be  fouud  as  h  seiguestrum  io  the  c»-  he 

8uoh  cases  are  not  distiuguishuhle  at  tiret  from  those  in  »<  < 
is  purely  arthritic,  couimencing  iu  the  mt\  }>urU>.  If  the  [niteut  be 
strumuUB.  acute  arthritis  of  the  hip,  from  whnlevcr  c»u»e  iiriitin^.  can 
be  prevented  from  rencbiug  the  stage  of  suppuration,  but  if  tbe  |Niticiit  lie 
tolerably  healthy,  and  ihu  Jisease  be  not  due  to  acute  oetoomyelitis.  inpiMira- 
lion  may  be  avoided,  and  then  reoovery  may  take  place  with  a  useful  Im  ' 
somewhat  stifl*  and  crippled  limb,  liita  lurm  of  hip-disease  is  rare  in 
adult,  but  should  it  oa-ur  the jmtieut  iieldtjm  recovers,  heotie  and  ex> 
speedily  carrying  him  off.  The  Uvea  of  children  may,  however,  tie  i 
even  in  thesi!  cireumstauoea;  bat  they  will  be  left  permanently  lamed. 

PtiUulotjy. — The  pathology  of  acute  arthritic  coxiilgia  ta  the  same  as 
of  acute  arthritic  in  other  joints  (p.  339).     t^urgeoiiM  have  referrvd  im  oi 
to  all  the  con|KMMOl  parts  of  the  joint.     Aston  Key  believed  the  rarnMl 
meut  to  be  very  freqtMOtl;  the  starting- point  of  the  intlammatioD,  aad  ia 
MuM'um  of  University  College  we  have  a  beautiful  wax  SBoilel.  supposed  ta 


COXA  Lot  A  —  ABTHHITIC — riCMORAti. 


451 


QloMrmte  Um  uode  of  origin;  but  it  w  uot  pnesible  froiu  thU  to  say  wh«iher 
tk*  dunae  ooanieDoeti  iu  the  ligaraeoi  itself  or  io  the  syaovial  mcoibniDe 
eovvring  it.  Prubably  all  tbc  furou  of  acute  artbriiU  described  as  •>ccurriDg 
in  other  ^oiDla  may  oixrur  ulio  in  the  hip. 

Cbrouo  StnoDOiu  ArthhtU  of  the  Hip,  White  Swelling  of  the  Hip. 
^•■■ral  Coxalgia.  Symptottu. — TIiq  di^euw  usuallr  i-oiunicuccs  very  iueidi- 
•nly.  It  aivumeB  a  subacute  cliaracter,  aud  \s  rliielly  met  with  iu  younff 
vlitlam).  Tbn  first  Rymptum  that  iitiuuUy  iitlmcb^  attuutiitu  is.  that  the  child 
litnpi  mkI  walks  in  a  peculiar  Ahiittiin^,  hi>[>piii^  iimnoer;  he  dots  not  ataad 
irmlr  apoo  both  feet,  but  mta  on  the  toee  uf  the  atri!(-ii;d  limb,  tlie  knee  of 
vhieli  Is  bent.  The  limb  will  be  seen  tn  \m  everttxl,  Kmimwbat  abtlueteil, 
■Hgbtly  flexed  upon  Ihe  thigh,  with  thf^  knee  partly  b«>ut,  and  appanmtly 
Iwiger  than  the  other.  This  is.  however,  apparent,  and  not  real ;  for  on  lay- 
isj  the  child  on  its  back,  it  will  be  found  thatj-hepelris  h  placeil  oblii|uely; 
the  anterior  cupcrior  ^pine  on  the  nffecled  i^ide  being  at  a  lower  level  Uian 
that  no  tJie  Mund  one,  and  at  the  Mime  time  turned  aomewhat  forwards. 
iraaeal  of  the  limb  from  this  point  to  tbc  ankle  will  ^how  that  there 


V 


rtti 


s. 


^ 


Pig.  Wi.  —  Cwivaj 

iia>4<>rrhigii-b9: 

■fUr  <iel«)«a. 


\ 


rig.  141.— Ctir«Kie  DImu*  «r  Illp-JalBl.  Blausw  OB  ooMr  Mt  -rf  Tbigb. 

■a  altarttitiQ  in  Ita  length.  The  causes  of  this  peculiar  attitude  have  been 
■tnviT  dmcribeil  (p.  443).  At  the  earue  lime  that  these  symptoms  ace 
l,th«  child  usually  cuiuplaiufi  nf  [luin  in  the  bip,espBci&llyon  proning 
>tba  finmtof  thvjoiut.  nr  behind  the  tntchnnter;  thi«  is  increased  bystand- 
!>£,  walking,  or  any  nlU'mpi  to  lK>ar  upon  the  joint;  abdudinn  BiM,aM  rota- 
liaa  of  UMlimb  •lutwardn,  or  furc^ed  eicteOMon,  are  itarticulnrly  painful,  and 
tmj  eaacuvinn  of  it,  ae  by  Btriking  the  heel  or  kuee.  will  greatly  inereotte' 
Aa  ■Kflbrine.  At  this  stage  of  the  diaeaae,  for  the  reasons  already  given,  the 
pMlHil  will  oflen  rrfcr  to  the  knee  rather  than  the  hip  as  the  seat  of  pain, 
aftd  a  eanloa  8argDon  might  be  misled  and  trout  the  wron'^  juiot ;  the  more 
m>.  aa  ihere  is  not  nnfrnjacntly  a  good  deal  of  cutaueoui  soniiibility  about  the 
ittiMf  rids  of  the  kneo-jomt  (p.  443).    Limitation  of  movement  (p.  446)  fornw 


nrSEASB   OF   TUB   BIP-JOIXT. 


I  muiioi 


one  of  tliQ  parlipitt  fiymploniK  of  (he  dlHa»&  On  tiintrn^  Uie  t-hitti  utMW  lb 
face  it  will  W  i>luierv(-<l  ihftt  the  natra  are  somowliat  Hntteticd,  tlie  fitld  beuf 
In  A  great  measure  nbliieraled ;  ntiH,  il'  it  bo  a  fonialo,  the  labium  oa  ih« 
affcclcH  side  will  he  wen  tn  \*c  (tlaccd  at  a  lower  level  than  oalln-  -  ■:••  \  -.at. 

As  the  dii^eaM  aiJvancet,  nht^Cf^ef^s  ma;  form  at  any  \mrt  in  tl>.  <4 

the  jmnt.  They  nuiet  diiiinionly  IK-Clir  uu<ler  the  (;luiei  lutiiirh'w  nn.i  i>  nanr 
Ta|tlnH^  Iemori»;  biiL  sonielimi's  at  the  niiieriur  ]iArt,  under  ihr  |>cnin«« 
muscle.     Wheu  in  ihia  itilunliun,  tlioy  i icon*! lui ally  pive  riw  !<•  viry 

Bulfering  tluwn  the  iuuer  »idc  yf  the  ihigh  by  exertieiiij^  pn-Murv  upvo     

ublurntur  iii.Tve,  ubieh  may  sumL'tiiuw  ln;c(iine  tighlir  stretclx'*]  Mfrr  tht 
wall  ol'  the  Bubjaceiit  abacns,  lu  the  later  Klugve  nl  the  diw-iuc  the  notiabo- 
lum  is  uot  uulrequeiitly  perforuted.  uud  the  pus  theu  accumulatai  bctw— 
the  pelvic  {kscia  atid  the  bone,  deKtn>yiug  the  ubturatiT  ititvroaa  to  ■  gmtu 
or  Ie»  extent,  ami  finally  making  ita  way  upwards,  and  pnintiiig  at  Tuupan't 
ligamenL 

It  is  about  thJH  period  that  the  change  from  ibe  abducted  to  the  addueisJ 
pneitioD  (p.  44^)  takes  place,  followeil  by  true  ehortenlof;  uf  Uto  Umb  ^F^ 
6^0).  The  ehorteniDgof  the  limb  nriwe  in  chronic  caaea  p«rtljr  ftrMB  wul o^ 
f;n>V!th  con^qucni  upon  di«uee,  but  it  is  chiefly  due  in  iD'Kt  caaei  to ' ' 
tiun  of  the  head  of  the  bone,  ueuatly  accompanied  by  diilocatioa  Uj 
dorsum  of  the  ilium.  In  these  cases  the  rcmaiiis  of  the  dislocated  head 
b«  lett  through  the  thiu  and  weakened  muHcles  in  ita  new  situation. 

PailiafoQy. — It  is  very  rarely  that  the  opportunity  occurs  of  examininjj  ■ 
bip-juint  in  tlio  earlier  eta^^'ca  of  coxalgia.  By  tht-*  tinte  th«  patirnE  A\r*  or, 
wbcrc  exi'i»<i<)n  iii  perfurnic-d,  the  ligameula  ar«  awolleo  and  »■  -h* 

•yooviat  ineiubrflnf  u  repn-wnted  by  a  pulpy  mesa  of  tiranuluti<<i  M 

cartilages  baw  mure  or  leaa  completely  <iiimj>]>cared,  ao  j  thi-  dt- nudoi  ««»eooa 
anr&oea  both  of  the  acetabulum  und  temur  ure  in  a  tliLtc  of  funKniinj;  mriva, 
Il  MAma  probable  that  raseA  running  the  clinical  courae  juat  dcwcnbed,  nny 
commence  as  primary  lube-Tcular  iuflammntion  of  the  HViiovtml  inrnibraoc, 
or  B»  tubercular  caries  of  the  bones  aecoodarily  enleiidinK  t*'  the  fToarial 
membrane.  The  evidence  derivi.-d  fn)m  the  few  ca»es  nbicb  havr  livrn  ra- 
•mined  at  an  early  stage,  tcudii  Lo  prove  tbat  the  former  is  the  excrptioD  aad 
tbe  latter  the  rule,  and  moreover  that  the  b<jiie  in  nbicb  ibu  disease  earn- 
mcDcut  i»  atmuvt  invariably  Llie  femur.  The  gruwins  tteaue  betwtgo  da 
etMpbysb  of  the  bt:ud  aud  the  neck. or  beneath  the  articular  cartilage,* 
to  bea  comiii>>u  stunioglMiiut  fur  the  disease.  The  fullowini;  apppani 
found  in  a  child  about  vi^iht  yearv  uld,  nhi>  dii*<l  in  I'uivmitr  *'  '  » 

EEtal  of  imrumiinta,  and  nhose  Ixxly  una  rarefully  eicamincil  by  ^^  t. 

I  *  good  example  nf  tbe  early  cdmliliona  met  wiib  lu  tulM-rcolar  i'  r :  >i  :  •  <>f 
tbe  hip.     The  Bymntom^  of  bip^llbease  hail  f.\lBte<l  only  iibmit  (>i\  m..  a-.. 

Tbe  joiol,  whirh.  iDchidln^  the  arelabulum  and  cafvule.  nas  reawvid 
entire,  oonrained  a  crinMderahle  miantity  of  dirty  yelbiw  pus,  The  ligamrntnia 
terea  was  flattened  and  covered  nilb  spota  of  yelluar  lymph  ;  il  was  ntuA 
■oflened.  tenriug  with  tbe  grealeat  ease.  The  synovial  membraoe  waa  gai- 
erally  ureatiy  thickeneil.  ioteiirely  injected,  uf  color  varving  fnun  bright 
red  to  null  orange,  and  co%'ere<l  by  8{H>ta  of  yellow  lytnpfi.  The  oirlUag* 
lining  the  aet-tiibuluiii  np|irare<I  to  W  healthy,  except  ju»t  aniuiul  tbv  inaar- 
tioa  tif  till'  lignmentiim  teres,  where  it  was  aoftrr  and  i"   ;  uk-look- 

iug  than  normul  l'i>r  about  one  to  two  lines.     The  ran  i     _  :gig  tb* 

rixwd  of  tbv  frniur  ap|K-nred  at  first  eight  to  bo  entindy  uiiullectMl. 

On  making  a  verticnl  si-cti'/U  through  the  acetabulum,  and  thf  kt»d  and 
neck  of  tb«  femiir,  tbe  great  trochanter  was  foutid  QDoasiBod,  witb  Uw  ucs)^ 
tioo  af  a  point  in  ita  centro,  and  ita  ODnoecUon  to  tho  bomr  was  weak  mad 
auUj  torn  asunder.    The  epiphysis  of  tbe  bead  was  almost  oonfJeUlf  tm^ 


STUPTOMS   or    ACETAII0LAR   0OXA.LQIA. 


fieH ;  llie  Ime  i4'  junction  Ireing  etill,  hnwever,  mnrkefl  by  a  band  of  bluish 
and  very  hard  cmrtiUpe,  wlucli  extended  frr  about  three  lines  *jn  each  side 
acmes  the  bone.  In  the  ceotre  of  this,  extending  buth  into  the  epijthyaiB 
and  the  diaphrBie,  wni  au  eburnatetl  portion  of  lione,  yellon-,  hard,  dense, 
and  compart,  thfw  peculiarities  being  most  marked  in  the  portion  belong- 
io^  to  (he  dinphysis.  In  miwt  pails  this  innss  contrasted  strongly  in  color 
and  in  oinsiMcuce  wltll  the  reddenf^l  cancellous  lis^ne.  The  encrnsting  car- 
tilage, though  generally  nppeuring  healthy  cxtcrnallr,  could  now  ho  eccn  to 
be  a  got<d  deal  worm-enton  iiitiTimlly,  nnil  iiidi'od,  deatroyed  at  one  or  two 
poiota.  Where  the  nioaa  of  har<i  biine  (mhh?  near  the  aiirfflco.  the  rtflwrtion 
of  ihe  synovial  membrane  waa  desimyed.  Below  tliii',  in  the  ncnlt  and  the 
upper  part  of  ihe  abaft,  the  cancelhiurt  tis^uo  waii  very  lax,  the  walla  being 
verv  thin,  anil  the  nitrilull:t  tilling  them  fxtninrdiimrily  rrd.  The  niiHlnlla 
al  the  cDUJinenut'rni'nt  of  the  nu>diil!Hry  (-aiiiil,  abmit  otio  inrh  and  a  half 
below  the  trochanter,  waa  excpfKiinply  red  and  vaiicutar.  Oi-cnpyirig  many 
spots  of  the  caiicollons  ibMiie,  and  hImi  one  or  two  nf  the  r^dflened  medulla, 
were  many  little  maMes  of  the  f^r^  of  millel-sepd!!,  looking  like  transparent 
cartilage,  hard  and  reswling,  yielding  no  juice,  not  breaking  down  at  all 
easily  under  thft  finger,  torn  with  difficulty  bv  the  nee<lle,  and  when  torn 
showing  grfat  numbers  of  nuclei  and  fibres.  They  pervnded  the  wbtile  bone, 
and  were  fonnd  al»ii  in  the  acetfthulum,  but  in  smaller  nnmbers.  Some  of 
them  could  easily  he  enucleated  where  the  medulla  was  soft,  others  could  be 
■eparated  only  with  dilHculty  from  the  cancelloii«  bone. 

Fnmi  this  account  it  U  easy  to  perceive  that  the  disease  wa*  tulwrcular ; 
that  it  commonce<)  in  the  'Mseous  structures,  chielly  of  the  femur;  and  that 
it  seii^ndarily  impticnied  the  «o(\.  articular  stniclures. 

Acetabular  Coxalyia. — In  xhn  acetabular  forjii,  the  disease  originates  in 
the  pelvic  bones,  ani)  the  artirutation  and  head  nf  the  thigh-bone  are  only 
oecondarily  involved.    The  di.wa.ie  of  the  pelvic  bones  has  more  of  the  char- 
acter of  necrosits  than  of  caries;  but  the  two  morbid  conditions  are  in  many 
teases  coexistent,  the  acetabulum  being  carious,  whilst  the  rami  of  the  pubes 
|;ftiid  ischium  are  necrosed.     The  soft  articular  structures  apedily  become 
['disDrgauized ;  the  cartilage  encrusting  the  hcful  of  the  thigh-hone  is  de- 
stroye«l ;  the  femoral  head  it^lf  becomes  eroded;  but  the  disease  does  not 
extend  into  the  neck  or  trochanters.     This  form  of  hip-joint  disease  is  more 
common  in  adults  than  any  other  variety. 

The  Sif>n//li»n»  are  irsiially  obscure  in  the  early  stages,  but  become  very 
unequivocal  as  the  disease  advances.  There  is  pain  antutid  tlie  htp  rather 
than  in  the  j'litit  itself;  this,  however,  bocotnes  tender  on  pressure,  and  the 
.  patient  cannot  bear  on  the  linih,  but  no  alteration  takex  place  in  iui  length, 
allhoiieh  it  Itecomes  greatly  wanted.  Abscess  invariably  forms  porhajM  at 
first  within  the  pelvic  cavity;  but  it  soon  prewnts  externally.  Somotimca 
it  pas.**"  down  by  the  aide  of  the  rectum,  or  through  the  sciatic  notch  to  the 

f [luteal  region;  but  generally  it  points  near  the  pnbea,  under  Poupart's 
igament.  Hectic  comes  on ;  the  suflcringa  are  greatly  inereaned  ;  and 
death  from  exhaustion  speedily  ensues  tn  this,  whieh  is  by  far  the  most  fatal 
form  of  hip-disease.  In  eases  of  this  form,  dislooation,  though  it  is  met  with 
now  and  then,  rarely  takes  place.  Sometimes,  however,  the  destruction  of 
the  flcetahulnm  is  so  extensive  that  the  bend  of  the  thtgh-hone  penetrates  it, 
and  pasMfS  into  the  jwlvic  cavity.  Hishn-ati'm  is  moat  frerjuenl  when  the 
di»ea>e  has  destroyed  tlie  hea*!  of  the  bone;  so  thai,  the  head  being  no 
longer  present,  no  iniE>edimeot  i^  otTened  to  the  action  of  the  muscles  around 
the  jiiint.  and  the  bone  at  length  slips  from  its  position  in  the  cavity  of  the 
acetabulum. 


454 


DISEAHK    or    THE    U[P-JOI?IT. 


Pbogno8I8  of  Hip-joist  Duea^e. — ^Tlie  prognosis  in  catfs  of 
bip  luual  U;  rngunk-il  rniiii  Iwo  poiiile  of  view  —  I,  u  cooctriu  (Im  Utt^l 
llie  Pnlivnt ;  2,  at  to  the  L^lilUj  of  the  Limb  that  will  bu  left. 

1.  Life.^ — DiocasLMirihe  hi]i-J()int,  uiiil  urtliv  rouii^^uoiisiMwoui  nrac 
is  <)»ii^eruuH  to  life  in  pn>)K)rti<)ii  U>  LtieuhttiKlHiiin:  «utl  iliu  Uiuc  nDliuu&im 
of  Umeu)i|iuration;  anil  t\m  is  (lencnrlciil  jiiirlly  on  Uiv  {tatirmV  con-iila* 
iion,  but  cliirfly,  and  in  th<!  Bn-t  drgrce,  un  ihi-  u-xti-nt  auil  tuturo  of  tlw 
oeaeoue  iliwnse.  In  the  nrlhrilir  form  of  cuxal^ia,  Kuppumtion  i*  oAvu  pr^ 
vented  by  reet  and  appropriate  treatment;  ont)  when  this  is  the  cmir,  tfa* 
pniientwill  usuallv  recover.  If  sunpuration  tJikcs  place  in  CMn  of  ihii 
kind,  recfivcrr  nccA  not  be  despnirco  of;  but  cnnvalesecnoe  will  be  cnatljr 
protntcted.  In  sueh  enEefi  nuich  vrill  depend  on  the  patient's  oomtnalka. 
If  that  be  highly  srrofuloua  or  tubercular,  the  prognosis  bceomM  cocftupood' 
injflv  bad. 

When  the  bonea  that  enter  into  the  compoiition  of  the  hip  are  the  primary 
seat  of  disease,  the  ease  usamea  a  much  graver  anpect.  but  even  then,  uotler 
propter  tnratmenl,  tbi.'re  is  a  good  prfjpiwot  of  cure.  I  bt>ti«ve  tliat  much  «iU 
ilepeml  on  thv  aituatinn  and  exteut  of  the  <3ineo,  and  nn  the  i|ue«tioii  wbelhcf 
it  be  prinian'  and  tuberculous,  or  becondary  to  diaeane  ul  the  suft  j'uot> 
finictureif.  Iti  the  latter  caae  the  head  of  the  bone,  denuded  of  ila  cDcniatiog 
cartilage,  raAeued  and  carious  upon  the  surface,  may  be  thn-wu  <ta  to  the 
donoDi  ilii;  profuae  and  long-conlioued  suppuratiou  will  enaue,  yt-t,  under 
good  and  careful  nianaaeiuent,  and  without  opentlioQ,  I  have  iu  mum 
UHtaocea  aeen  recovery  lalte  place. 

Id  those  caeca  in  which  the  diecaae  ie  primarily  femomt,  and  fk|MBdiDt 
upon  tubercular  deposit  iu  the  head  of  the  thigh-boue,  the  pntgDoaia  b  Ml 
favorable,  for  although  iu  a  certain  pro|RirtioD  sponutneoud  cure  may  tak« 
plae<-,  under  proper  treatinent  even  without  operative  iolerfereuci:,  a  lam 
numlH-r  die  from  generul  tuberculosis  or  worn  out  by  hectic  induool  by  tai 
hinif-couiintiL'd  suppurution. 

The  condition  ot  ihv  ptlvie  boneji  ia  one  that  more  materially  than  anyaM 
other  circumBtance  infliicncra  the  prognoaiB  in  caaea  of  o'Xalgia.  Wbto  tba 
Aeetnhulum  alone  of  thcfv^  bones  {«  nAcctod,  the  proguons  will  turn  «pM 
whether  ihii  aeetAbntar  diseaan  be  primary  or  ftceondary.  K  it  hi"  priiaarjf, 
Ininipelvic  flbdceM  will  probably  form,  jmrnting  above  l*oupart*«  li|t*meiit; 
and  whether  the  head  of  the  thigh-bone  be  diRlocnleU  or  net,  I  believe  thai 
death  must  neretaarily  ennue.  unlewt  the  diiiensed  oaaeoua  slnicturiea  fa«  rs< 
aaed.  If  it  be  tftmdary  to  dii*eft»c  of  the  head  «if  the  ihiph-Kune,  the  rooiU- 
tkm  of  the  acetabulum  need  not  aeriouRly  ntTert  the  pri>gii'#ta.  Id  thcaa 
Oaae*  the  head  of  Die  Intne  becomea  dialocnteil,  and  \\m  very  riuplaoenwiit  It 
'  tba  first  step  Mwanl"  i\w  cure  of  the  dii««>AM*  in  the  nivUbuluni.  Tim  surliK* 
of  this  C-HviLy,  which  ii>  nHit;lieue<t,  «n<l  deprtv<Ht  of  it«  cncninlinE  cartilagt^ 
■iMH^Iily  hecunii^  cuvered  by  grniiulHtioiiK  ThrM  become  developed  lOtO 
fibrmtts  liwiie;  mid  in  the  coune  of  a  short  lim<*  the  whule  cavitr  IiwoM 
Sllv<l  up  by  K  di-oBV  fibroid  growth,  which  is  in  fitrt  the  medium  of  n|Mirof 
the  diHctLM>l  and  disused  iKvtabular  cavity. 

NVbcn  thi>  diaeaae  cxleu<Ia  to  the  iMoeoua  Dtruclures  anmnd  the  acetaUmlBiD, 
cuch  as  the  rami  of  the  if*chiiiiii  and  pube!<,  the  body  and  tbo  tuboraaily  of  tht 
istrhium.  and  the  upper  lip  of  the  acetabulum,  and  evoa  tlw  dfrnan  vi 
the  ilium,  it  uaunlly  partakes  more  of  the  nature  of  necrona  (luui  of  cuMk 
and  is  iKTfectly  incurable,  except  by  o])eration.  In  ntCDflve  pelvic  dwMR 
such  iiK  Lhi»,  natural  means  are  quilo  unable  to  eflecA  a  cure,  and  the  paiieal 
.inUBt  die  of  hectic  or  intercurrent  diseaw,  unleaa  racourH  be  had  fo  the 
•  cxdjioo  of  the  head  of  the  ihigh-bone  and  the  whole  of  Uie  nccroead  aod 
oariouB  MBooas  atructurea. 


ni  tbp  "Comtiiiuce  of  the  Clinical  Societv  nppoinled  to  inquire 

liie  vi  eidfljou  ftfi  a  me&os  of  treatiog  diBcaae  of  ihe  hi|>-joint  in 

iMAnnil,"  coDtaind  the  ruMt  acoaralc  information  we  poasttBOoacerniiig  tiio 
drnk-nueof  bip-tliseiue.  in  liie  statistica  furnished  l)v  Hovnrd  Mareii  of  tho 
iinMtad  by  nim  iu  th(>  AU-xaoilm  Minpiiul  for  Hi|)  Dincaso  io  Childhood, 
1867  Rnd  1879.  The  U)tal  number  of  ca*-«  amounted  to  401.  Theso 
Buf  be  ilividcil  first  into  277,  or  6d  per  eent.,  in  irhirh  suppuration  UioV  place, 
Attii  124.  ur  :U  per  rent.,  in  which  no  absceaa  formed,  ihc  folliiwinjf  table 
•hwn  lh«  reaulu.  Th(«e  closwcl  as  "verified  cures"  were  examined  by  the 
diiBtuittee.  The  value  of  the  a(ati.4tim  is  enhanced  by  the  fact  that  the 
pHl>ciit»  ml  tht--  Hip  Hi«pitB)  are  kept  under  treatment  or  watehed  m  out- 
pMWnt*  ms  for  a«  ponible  until  llit^  final  reHult  i.4  knonii.  Palienix  re<|uinn)( 
gynHion  are  »ent  eluewhere,  am)  c>.>iiBe<^ueut)y  are  ]>Uc<-d  in  a  separate  clasa. 


V«ria«l  rurc*  . 
Bag^^rfJ  cm««  . 
Id  fri^wvH  of  cure  aod  Elill  under  ubcervatiuo 

«,   App«r*iitly  rnjr«d  on  ilivcbar^ 
^  ApfMLnmiJi' e(>nval«ec«ni . 
«.  In  progreu  oa  ductiar)^  . 
ladatnltncvM  .... 
CWm  atlU  uader  trMtttieot 
.  Uttdtf  tnalrnvnl,  apparfnllj  iocurablft 
.  Dnttba                          .... 
Op«nticMu 


wiiu 

wrrrmct 

■tcrrrHATioii. 

Ht-rpfNATioa. 

02 

81 

83 

24 

7 

n 

ir. 

» 

11 

41 

0 

5 

% 

14 

& 

8 

n 

87 

la 

17 

0 

277 


U4 


figar«i  ^eld  a  (lefoeatagd  of  42.3  of  cum  or  conviilesccDb,  '2A.2  nf 
'plcte  eascf,  end  'Vi.->  of  Heaths.    Of  the  S7  caws  iu  n-hivb  death  took 


ffaeaaArr  luppumtton,  10  died  of  menitigitifl,  20  died  of  albuminuria  and 
dffvpajr.  3  of  albatninuria  and  phthisis,  5  of  phthisis,  9  of  exbauKtiou,  2  of 
crympalaa.  1  of  pywmin,  and  24  fr^m  unkaowu  caucea,  19  of  vbich  had  been 
twctnriccd  as  incurable.  In  the  \'\  non-suppurating  cases  which  terminated 
fiually.  death  took  place  from  the  folloa-ing  causes:  7  from  meniugitis.  1  from 
pktliMai.  1  frora  tubercular  pucunionia,  1  from  croup,  1  from  iutercurrcot 
4kmmm  (nature  unknown),  and  2  from  unknown  consee. 

En  ibe  iMiM  wilbauppumtionoiiilin^  iu  cun*  the  uvemjire  duration  of  tresl- 
maM  WH  abaat  4  years,  in  the  uouaupptiriiiiu;:  cases  it  was  about  H.  In  the 
fittftl  aanpumtinf*  rams  the  averai^i  duration  of  life  was  3)  year«. 

d.  Vtiuty  of  Uie  Limb. — When  once  the  bonce  or  ligaroenu  enteriiif!  into 
llw  hlp-juiat  have  be<itni«  iiil)urn<-Ml.  mon^  or  less  lamcuc)>(>  wilt  invarialtly 
naalt,  h(i«tfT«r  carefully  cuidudod  the  trcntnioru  may  \w.  Thi'  iimounl  of 
\mnmtatm  may  nuui^L  in  a  mere  stiffnt^riH  tiiioul  the  hip,  n  tlifliculty  in  alnlnr- 
tinn,  in  flexion  of  lh«>  tbiffb  on  the  pclvtA,  or  in  free  rotation:  or  it  may 
«sV>nd  lit  atmilulr  UM-lcMneM  of  lli«;  shortened,  withered,  and  deformed  limb, 
wtiict'  '  -II- '-  iFiKcrlrw  frim  the  pelvis,  Mispended,  ah  it  were,  by  the  ilio- 
(isBrr  tit,  and  flli^htly  flcxcil  and  adductc-d.    The  extent  of  lameneM 

will  drjunn  (111.  [!v  11(1  rri  the  form  iif  the  disease,  and  to  «ome  extent  upon  the 
tfcaUnent  adiiiir<<i.  '>iit  si>me  will  over  be  left.  Wheu  the  coxiil^ia  is 
aprti  Hie,  aoil  sufipurntiuii  h»*  i\ni  taken  place,  nnkylmih)  uf  »  more  or  Iras 
CDanlcte  fbrra  will  usually  cnstiv;  ami  if  the  thiiih  have  been  kept  in  the 
«lra^i  position,  a  suificieutly  useful  limb  will  be  IcfU  but  slightly  short- 


456 


OI8KA8E   OF    THE   aiP-JCIlNT. 


ened,  and  possesa'ag  free  com  pc  tun  ting  morcnient  in  Uie  lonabu  ipnt, 
enabliti);  tlie  patk-iit  t<i  ewiu;r  il  witli  iHcitit}'  h»  lie  walks.  If  mpfiiinUHa 
have  Uilcen  placp,  nod  the  head  of  ihc  Iwoe  have  beea  ahaofbcd  oriuwoaUd, 
the  linih,  even  tiiiJer  the  m<i6t  judicinus  treattneiit,  will  he  lell  onmidcnblt 
ehorteued,  weiikeiied,  irnsted,  and  iiiore  ur  iess  addurleil,  with  the  knee  r■^ 
ried  Hutiiewlml  furwnrds,  ns  well  as  luwanh,  and  the  paiiftit  walking  otua 
most  imperfectly  and  with  f^reat  ditHoiillv  on  Ilie  fHtiiit  of  him  uwflL 

Of  the  83  oases  of  oun;  fmni  tlie  Hip  H<iepital  veritied  by  the  mmflalttCiv 
69  an  dosoribcfl  nn  "good  cures,"  11ns  "nodenuelj  guod/'^and  3aa  "aam 
with  caosidcrable  lameness." 

DiAOSosiB. — In  making  the  diagnosis  of  coxnigia,  care  must  he  tak«a  noc 
to  confuund  it  in  it«  early  iitages  with  au  ordinary  attack  of  rfusttmatitm,  a 
miiitake  that  nnt  unfrequently  happens.  The  alteration  in  th«  ahape  oad 
position  of  the  limb,  the  oblitcnili<>n  of  the  fold  of  the  natc«,  and  the  liaifr- 
atioQ  of  the  pail)  to  oue  joint,  will  ufually  prevfint  the  Surgeon  from  fallii 
into  Ihit  error.  With  du£a»f  of  thf.  kne^,  care  must  bo  taken  Dot  to 
faipnljseaBe,  in  coDsequcnce  of  tile  pain  iu  l)ic  early  otagti  bdog  ooMl 
referred  to  the  former  joint ;  here  the  abeeoco  of  bdv  pQaitiT«ai|pi  or<__ 
about  the  knee,  and  tlie  existence  of  all  the  tieiis  oi  atMuae  la  tb*  hip 
have  already  been  noticed,  will  citable  the  Sur^uu  lo  dtagaaaa  the 
Beat  of  the  aflection.  Luterat  curvature  vj  (he  $pitie,  accontponitid  br 
ratgic  loutlc-nieat  in  the  hip,  oceaeiuiially  gives  rise  bo  apparent  thorteniii| 
the  limb  with  pain  and  rigidity;  but  in  these  cases  the  t-xUtroce  v( 
spinal  uifectiou,  ihu  eupurfieiul  nature  of  the  paio,  and  the  ahsence  of  in- 
crease nf  Kuffering  when  the  joint  ti  firmly  e<)ra|)reBsed,  or  uf  paiofnl  ataxt- 
inga  at  night,  will  indieute  the  true  nature  of  Uie  afliTiinn.  Ahtotm  quit 
occaainnally,  though  rarely,  form  in  the  vicinity  of  the  hip  withoat  that 
joint  being  diseawd.  Should  this  take  place  towards  the  anterior  aspect  uf 
the  articulation  under  the  pertineuit  muscle,  it  may,  by  its  preaaar*  npoa  tht 
obiurittor  nerve,  occafiinn  ]win  in  the  thigh  and  knee,  as  in  thoM  raaw  i» 
vhich  the  articulation  in  afleoted :  here,  however,  the  siiunc]  stale  of  tla 
joint  at  it»  posterior  and  outer  part,  the  absence  of  all  oblt'piiir  of  tbt 
pelvi*.  and  ot  the  otlier  liigns  «if  the  true  hip-diseasc,  v  ' 'e  tlie  dia(^ 

Dosi«  to  be  effected.     The  diagn<*iii  from  mrnr'Uine  <  ■  **  beea  ^ 

Bcrilwd  a)  p.  441.  In  tufauttt  injffimtruition  of  the  'jiatidi  in  the  yrvim  nay 
stniulatu  biivKliitea^e,  as  the  child  Ilexes  and  adducLn  tbv  limb,  and  acnoMS 
at  any  forcible  attempt  at  extenidon.  It  cat)  be  di»tinguiBhe«i  from  tip- 
disease  by  fevling  the  glands  if  the  child  be  not  too  fat,  and  by  otiserriaf 
tbat  tlie  thigh  can  be  completely  iLexed  and  freely  rotated  without  oatutag 
ngas  of  pain. 

Acute  hi()-diseaBe  may  be  mistaken  for  i^ityphlitu.  The  child  lies  wiUi 
the  thigh  Hexed  on  the  abdomen,  and  contpIainB  acutely  when  the  rtgbtgmia 
is  pn-Nied.  The  diagnoals  in  easily  etfected  by  antestbetii^ing  the  paiicsO, 
wbea  manipulations  of  the  parts  will  decide  the  precise  seat  uf  lb*  laflaai* 
BMtiun. 

It  may  be  taken  as  a  general  rule  lliot  if  the  thigh  can  he  Bexad 
right  angle  without  any  movement  of  the  pclvi».  iwTfepiible  to  tbe 
placed  nn  tbe  oiiterior  superior  spine  and  tlie  neigbtioring  part  of  the  i 
and  if  while  in  that  position  with  the  knee flexe^l, the  li;iiiiirran  be  odtlac 
•nd  rotated  outwards  till  the  heel  is  over  the  S'lund  thigh,  there  is  oo  disroas 
of  tbe  hip.  This  morcmcnt  is  so  readily  mode  in  young  children  tbot  it  is 
on  tatj  morle  uf  excluding  hip-disease,  though  of  cnurM  if  the  moveoMM  II 
impoasible,  it  dona  not  prove  iu  presence,  as  limitation  of  moTement  may  be 
da«  10  causes  otitsidc  tbe  joint. 


BIP-JOIKT    DISBASE— TRBA.TUBNT. 


467 


(T. — The  treBlmont  of  diwasc  of  ihe  hip  inuat  be  coodnctcd 
will)  rdmace  to  Uie  forto  of  the  diseaitc.  thf^  acuionrsa  uf  the  aitaok.  and 
thmmwaVf  of  the  local  nnd  r<m.4tilutii>nat  Aymptonu.  la  all  ciues,  tliis 
■ftciSoa  miut  be  luanai^  in  acoonlanrc^  irilh  those  goaeral  principles  that 
fnide  Da  in  llie  IfcaliuvMit  of  inHampd  ji)inL<i. 

It  b  of  especial  impurtance  tn  adopt  early  mcamircs.  If  we  wiih  to  pre- 
rettt  the  oecantnct  nf  ouppurAtion,  dUlocation,  or  ankylrisui,  the  chihi  roust, 
oa  il)«  vup«;nrentiai]  uf  the  <eariie«l  ^ynipUim*  of  impending  misrhli^f  about 
(he  JMinl.  he  put  under  proner  cotislituiional  treatment,  and  complete  reat  of 
lite  lituti  miwt  be  eecurw  by  a  projwr  splint.  By  early  att«nlion,  a  cure 
my  Iw  vflrctt-d  -  nhereM,  if  the  ca*e  bv  iiei^lected  in  il:*  first  8liig(»,  the 
Otinai*  tlie  Surm-.'n  «iii  dy  i«  t"  8ftve  the  lif*^  ul'  the  patient. 

Wlivn  tht  dU4nu>«  is  of  ihi*  acnte  Arthritic  kind,  thti  pnlient  must  of 
want  bo  kt- pt  in  bed,  and  absolutely  at  rest-  I^'u  treutment  will  be  of  th« 
i£^t<Est  Mvtiil,  ifnli-"?  we  adhere  rigidly  to  that  principle  which  ii*  [wra- 
■MDt  lit  of  nil  acutely  tullaiia-d  juints — tib«olute  rest.     Iii 

faflklii'  ,'juint.  there  are  three  inetliwla  of  securing  this;  1, 

hjr  ni««os  of  k  weight  attached  to  the  limb ;  %  by  the  long  epliut ;  aud,  3, 
by  ThooMs's  hip-eplin:. 

Tba  particular  luethud  employed  must  de[>eud  eotnewhat  u)H>a  the  acute- 
■t»  of  the  cymptonis  auit  the  p^aition  of  the  limb.  As  a  Thoniafi's  epltnt 
reqaim  (o  be  accurately  fitted  in  the  limb,  and  shuuld  be  specially  made  for 
the  pAlieutT  one  of  the  &n\.  two  meaiii*  has  ui^ually  to  he  adopted  nl  tirsL  Of 
the  two  meihwlfl,  that  by  the  weight-extensinn  is  ibe  beat,  as  it  completely 
rebera  the  [Minful  Aturt'iiigs,  aod  is  adapted  to  nil  rasen,  however  great  the 
degree  of  flexion  or  lHl>.-ral  dLiplacement  may  be.  In  applying  exIeiiHim  by 
BCHW  of  a  weight,  the  fidlowin^  plan  should  be  adopted.  The  patient  la 
plaornl  upon  a  ban]  mattress  The  angle  of  flexion  and  the  degree  of  a1»1uc- 
lioa  or  addtietion  is  then  a»eerrnined  by  the  methoda  already  de«rrilHHl  ip. 
4i6'),  as  the  exten^iion  must  at  Hrst  \>f^  n'lnde  as  nceurately  as  possible  in  the 
line  of  the  abnormal  p'^iliou  the  limb  ha«  asitiimed.  A  long  broad  strip  of 
■dbcWTp  plnsler  is  then  applied  of  xuHicieot  length  to  reach  from  a  few 
iacbcf  above  the  knee  on  each  fide  of  the  limb,  and  to  leave  n  loop  pmject* 
ing  beyrmd  the  tnde  of  the  f>>ot  for  about  one  fiMJt.  In  the  loop  is  placed  a 
nm»  of  woo«I  three  taches  ia  length  to  form  a  spreader,  and  thus  to  prevent 
fBJnrnMM  prrswre  on  the  malle'>li.  A  hole  may  Iw  drilled  thnwigb  the 
ipr—d«r  and  the  plaster  covering  it,  nod  through  this  the  coni  I>enring  the 
««%ht  ia  pMivd  and  secured  by  a  knot,  Narri.iwer  strips  nf  plaster  iiru  then 
■lUfftrt  diagooally  riund  the  limb  (o  fix  the  fir^t  piece  more  weurely  ;  great 
emrebeittx  taken  ibnt  no  atrip  pnasea  clreularty  round  the  timb  in  i^uch  a  way 
aato  coostrirl  it.  A  flannel  Daadage  is  then  applied  from  the  malleoli  t'l  the 
■uddla  of  the  thigh,  to  insure  the  adheaioii  ol  the  plaster.  A  long  splint  is 
tWa  applied  to  the  tound  limb;  without  ibis,  although  by  extensioa  the 
pala  nay  be  raBwred,  adduction  or  abduction  and  some  degree  ot  flexion 

looi  OB  prenoted,  as  the  patient  wilt  turn  on  one  »ide  and  avoid  the 

ptill  of  the  weight.    The  long  splint  being  fixed,  the  weight  is  applied 

ri.r-.  i-iMing  through  the  spreoder  and  over  a  pulley.    The  pulley 

'.  to  MiDe  apparatus  allowing  of  its  being  raised  or  lowered  oa 

tnar  require.    If  the  proper  apparatus,  such  as  is  used  id 

t  at  hand,  a  pulley  may  W*  reauily  made  from  a  cotton-reel 

■  'i  wire  paiutT^I  thr<»iigh  it,  by  which  it  can  be  slung  to  the  beck 

a  rhair  or  a  r1r'the*-hor»e.    The  weight  of  the  hf>dy  serves  as  the  counicr- 
«SlciH)«o.  and  if  to-rrMarr  the  fo'>t  of  the  bed  may  ue  raised  on  blocks  to 
prmot  the  policnl  i>lipjiing  down  in  (he  bed.     The  most  convenient  form  of 
b  a  tm  csa  filled  with  shot  or  water,  till  the  degree  of  extcoiion  ob- 


458 


DI8IA8K   OP    THK    BIP-JOINT. 


Uined  is  oomfortablo  to  the  pntieut  Tbc  pibIIct  nnd  weight  iir«  to  W 
Rc[)iuted  in  euoh  a  vaj*  that  the  oxteneion  phnll  act  on  Lho  limb  fjifvcilx  ia 
tho  lino  of  its  abDormal  pc«itioD.  To  do  this  ibv  disoucd  limb  mnM  b* 
rnlet-xl  till  tlio  lumbar  spine  ia  in  contact  witji  the  bed,  anil  tbv  d«gn*< 
abtluction  or  ntiilut^tion  must  correspoad  to  tbacnotcrl  before  ibo  apt 
wu  applied.  Duriug  the  atrut«  U&gib  any  forced  attempt  lo  drag  tn 
immediately  iiiui  iia  nnrmnl  |)ositiun  would  only  oegrnvatc  the  pain,  but  br 
makins  the  extension  as  above  (icKcrlbed,  it  will  be  found  that  the  Ubo 
Bpeedily  falln  into  iha  proper  po««Uioii.  At  th«  end  of  each  day  the  palley 
tuuat  lie  rcmljiiHtf^cl  so  »h  gradually  iri  brinj;  the  Unih  parallel  tn  itt  kUow. 
In  rec«al  csgunt  »  few  ilavft  will  often  auffiof  to  liriu)(  the  limb  lolu  iu  Domiil 
poaition,  ill  more  mU'aiii-ei]  ctv-tif  numr?  w^^kn  may  bv  rujuirt-d.  If  Am 
treatment  has  to  Ix*  coiitiuural  for  any  leuf^ih  of  tiine^  tho  apiaaratu* 
Motod  in  Fig.  5d3  way  be  empluyeJ.    In  it  the  pelvis  and  body  are  ~ 


n&^ 


^Jlia^.d^'*'  -k.Atltf 


Sig.  ftKU— Ap[«nU*  for  BiLeailoa  hy  W^sbl*  ta  Hlp-Jo)>t  t>l 

the  1)0(1  by  means  of  hroail  felt  strapH  and  buckles.  A  Iraiber  Bnkle-«tru 
U  then  placed  round  the  foot  and  lowar  rart  of  the  leg,  and  a  paddM  beu 
above  iiie  knee.  From  tho  fltdes  of  each  of  these,  iirapt  are  came<l  (•■  » 
point  »ix  or  eiphi  inobra  bevoml  tliP  foot,  where  they  are  attacheti  u>  n  trin*- 
v^nw  iron  to4,  four  inohe*  long.  From  thia  the  eoM  nuBpendinn  the  wrJcht 
putut'jf  over  a  pnltey-frame  fixed  to  the  end  of  the  bed.  The  wfiglit  nppii-l 
sh»uM  l)v  fmm  two  to  three  (tounits  iu  children  up  to  ux  year^i  of  ai[y :  Anir 
pounile  between  the  ages  of  «x  and  ten;  live  or  «iz  pound*  from  ten  tP 
thirty. 

If  the  long  epltnl  alone  be  uard,  il  uiuet  be  appHeil  aj»  fur  fractuml  tbi^. 
the  perineal  baud  Ix-ini;  iii«pviiM-d  with  if  it  causes  ]>ain.  A  sioglr  tMig 
Bpliot,  tbou(;h  nHxIemlely  vtUvient  in  tbtr  a<lnlt,  ui  of  tittle  xtsc  tn  chiJdrvn.  i* 
tliey  always  mntiairi:  hy  twistiug  thti  budy  lo  maintain  a  cuusidemblc  drcn* 
of  flexi'jn  with  adiluctiun  or  alKluctiou.  llamiltuu'B  'loublu  long  splint  (I*'^. 
237.  Tol  i.  p.  •'>Vt4  I  should  therefore  Iw  applied,  by  which  much  Itettcr  pontm 
is  obtained.  Wcif^bt  extension  can  be  applied  with  this  if  rrtpiirad.  Whn 
there  is  much  adduction  or  abiltiction,  the  part  of  ihe  »plioi  cuirrmpondinc  lo 
the  hip-joint  nu  the  diseased  side  rimy  be  »awn  through  and  6ued  with  a 
hince,  allowing  of  movement  in  the  required  direction,  the  lower  end  beinf 
otthcBamc  lime  loosened  from  the  croBe<-bar;  tho  lateral  dtaplaecmeui  cma 
then  be  currecti^d  hy  meaiui  of  ladia-rubber  bands  acting  on  toe  lower  end  of 
the  ipliiit  from  a  nail  or  pcv;  drivi-a  into  the  oroe§-h«r. 

Thomas's  splint  ( Fi^'s.  HM.  oHo)  ia  by  far  the  best  appwmtus  L-rer  invcDted 
fur  the  treatmeot  uf  all  forms  of  hip  diseoM.    It  may  Ite  applied  at  any 


Thomas's  splint  for  hip-disbasb. 


469 


aad  •hoold  be  worn  till  the  cure  is  complete.  It  will,  however,  often  be 
ftmiid  most  coDTcnieDt  when  there  is  considerable  a^ldtiction  or  abduction 
with  acute  pun  in  the  early  stages  of  the  disease,  to  correct  this  by  means  of 
^  weight  extension  used  as  above  described  before  applying  the  Thomas's 
a^int.  Thomas's  splint  is  the  only  apparatus  that  maintains  abaolute  rest  of 
the  joint,  while  at  the  same  time  the  patient  is  able  to  move  about  during  the 
wlxMe  or  greater  part  of  the  treatment.  The  splint  consists  of  a  flat  bar  of 
Mrfi  iron,  varying  from  three-quarters  of  an  Inc-h  to  an  inch  and  a  half  in 
width,  and  firom  three-sixteenths  to  three-eighths  of  an  inch  in  thicknesB, 
■eeording  to  the  age,  size,  and  weight  of  the  patient.  This  bar  must  be  long 
CDoagb  to  reach  from  the  lower  angle  of  the  scapula  to  the  middle  of  the  leg 
immediately  below  the  prominence  of  the  calf  The  upper  and  lower  parts 
most  be  straight  to  fit  the  back  and  the  leg,  and  between  these  it  must  be 
bent  into  a  curve  accurately  fitted  to  the  buttock  of  the  patient    To  this 


Fig.  JM — ThomM'i 
5f>liiit. 


Fig.  6!>S.— Tboniai'i  Splint  Apgilieil. 

vertical  bar,  three  curved  transverse  bars  of  soft  inm  about  i  inch  thick,  by 
1  to  t  inch,  are  fixed  as  in  Fig.  •^84.  The  up|)er  of  these  .should  be  of  uiifli- 
eient  length  to  embrace  the  chest  about  as  iiir  as  the  nipple  on  ciicli  fide. 
The  middle  bar  shoubi  be  immediately  below  the  curve  for  the  bultuck  in 
the  vertical  har.  If  it  be  placed  too  low,  the  splint  h  more  apt  to  twist  round 
and  allow  of  flexion.     The  whole  apparatus  is  padded  with  a  thin  layer  of 


460 


DIBKASK   or   TUB    RIP-JOINT. 


felt,  or  flsiioe),  covered  by  lonth^r.  Tlip  stMal  is  npplie^I  tn  such  a  war  tkti 
tbe  curved  part  of  the  verticil  bur  li>-s  mi<lway  belwivn  tipe  l(ik'r<i*itr  of  Om 
Iflclilum  Alia  lh<-  IrocliiiiiU-r  mnjor.  Tti«  currc^i  paru  Hrv  ttit-ti  brai  *»  ■•  to 
fit  the  cliesl,  llii^Ii,  nnil  Iv^  comlbrtAhly.  A  aLn>ii[:  yU~t:*-  of  biiotU;;^  it  [nMttti 
ihnMiL'li  tbe  rin^js  in  tlie  v.m\»  i»f  tbe  cbeal- pivcv,  mul  tUtI  tirmlr.  A  bntt) 
tf(>dv<biiii<liigK  ^rowan's  down,  viilini.or  fl»ii0fl,  u  tbvn  woiiml  nmod  t^  »«• 
tiral  l>ur,  so  ns  U.'  gft  s  govd  buld  of  it,  nnd  tbi-a  mrrinl  tmi  or  ihrr*  tiaxi 
round  ibe  budv.  A  aiirrower  baadage  ia  tbeii  applied  tu  tbe  ibiich  mwl  Wf. 
If  the  jNilient  U  to  walk  about,  bmces  of  stroDjj  caVicj  inu«t  be  fixe«J  Ui  \)m 
chnl-piece,  nnd  carried  over  the  eboulden,  otherwise  the  apliat  will  tin 
down.  If  there  is  much  Bexioa,  the  spHot  luny  b«  beut  forwani*  lmm&&- 
ately  below  the  buttock  curve  to  a  degree  a  little  leas  Ibaii  thnt  of  tb«  lis^ 
wbich  oiny  be  allowed  tu  lie  upon  il  with  the  knee  eligbtlv  beat.  Id  tUi 
pinitioQ  it  18  secured  by  a.  few  lurus  of  bnudfigc  rouud  the  ihigb  ■ud  lr]£.  la 
m  few  dnys.  if  the  patieut  be  kept  on  hi6  back,  ihe  weight  of  tbe  lini'>  v31 
hoveexieiidod  the  bip,  mo  that  ibe  whole  le^  is  uuiformty  iu  coatavt  with  ibi 
splint,  which  may  tlien  he  !>trai^'liii^ued  a  little;  and  tliiit  ie  repeated  nad 
the  flexion  in  corrected.  The  viu'ticnl  )>ar  must  never  be  bcAl  oppoHta  iht 
koML  If  tbci-c  is  much  ndductiou,  it  ia  often  conveuient  to  twtK  the  T0>- 
lical  bar,  mi  that  its  anterior  tupect  looks  very  slij^htly  outwards  fmio  helio 
the  buttnck.  TheM  alterations  in  tbe  shape  of  tbe  epUni  niuAt  be  canid 
out  by  the  Surgeon  himself  with  strong  in>n  wreuchts  made  for  the  purp«a 
A  little  experience  ts  required  tn  tbe  manipulatiou  of  these  HpIiuU,  hot  tKt 
oeceMuiry  skill  is  easily  ac((uired.  nnd  will  well  re|>ay  the  Sur);:eim  far  llif 
trouble  involved  in  m  doing.  Tbe  ttpliot  must  be  worn  euntiQunuftly  dtr 
and  night  till  all  aymptoius  Imve  ^ubtiided,  oflen  fur  one  or  two  years,  u 
walking;  with  crutcbe«,  Lbe  putient  is  raiwd  by  a  palleu  ou  the  fiuit  uf  tht 
sound  limb,  eo  that  the  uppusile  fool  di>F«  not  touch  the  (irouud  iFtfi;.  S^i- 
Should  suppurntiou  take  place,  Thoma^'^  eplint  U  Mill  tin  iir«nim 

apparatus,  «8  it  leuves  the  parts  uncovered  iu  which  iheahc..  ii.    Ou 

§rval  ndvaoUi}^  in  Thomas's  splint  is,  thtit  under  the  au|)eniit>  i 
ui^eon,  auy  ouiumoD  blacksmith  can  d<>  tht'  ironwork,  and  an  ^ 
padding,  anil  it  is  thus  ei|ually  available  (<jr  country  or  city  ptacuo*^ 


r 


*H» 


Hi.  Mt. — Smyn't  KiUailiBf  A|>cusliK  far  Ulj-JttUt  Dii 

A  vrrv  tnf^nou^  exiendin;^  apparatus  fir  hlp-jainl  disease,  at  any 
ita  deveiiipntfut,  fmni  lbi>  larlicel  to  that  of  abscess,  has  b«>en   invent 
Kayn*  l  see  Fi^.  !tH*\  i.     Hy  iticana  of  ihin  apparatus,  exiri)flt>in  is  made 
the  tlii;;h,  and  '.uimlcr  vxit'iision  from  the  mlvis,  the  apparatus  being  lei_ 
enerl  by  a  rack  utid  pin  ion  on  tbe  outtr  Iwr.     It  previ-uu  the  atcemiif^l* 
cou(ineuii-nt  to  In-d,  nnd  keif|M  the  limb  in  a  ttrai^bt  potition. 

AtVr  nil  m-ule  ■ympLoms  havt*  diiuip]>eared,  the  joint  ntav  sormIims  hs 
CADveniently  fixed  by  means  of  a  leather  »plint,  the  utan-ibM  nandaijr,  or  tbs 
plaster-of- Paris  liandiipe.  Of  lb<*v  I  prefer  the  »taroh.-ii  bandajp*  »«  b«ia(. 
more  eanily  applied.  Tbe  hip  part  roust  Ixi  s(rengthriir<l  with  a  piros  « 
pastebonrd  lined  with  cmlico,  luHicicntly  long  to  extend  ilown  the  wbol*  of 
tbe  back  of  the  thigh  to  below  tbe  koee,  lo  u  to  aapjiort  tliat  joint  wko,  ami 


SXCISIOII   or   THB    HEAI>  OF  THB  THIQV-BONE. 

Lhe  spicn  baoilnge  must  l>e  ajiplied  in  r«j>ealeil  tums.otliernUc  the  apparat.ua 
Hill  Dot  tix  ibe  juiot.  In  applyiug  (hi»  or  any  other  Apparatus,  it  u  olu<u 
aeccfsaiy,  especially  id  cliiKlreii,  to  admiuiBler  clili:>roforin,  lui  llie  pain  oct'a- 
tioned  by  the  oecessary  moreiuetits  may  be  too  severe  U>  be  boroc  witliuut  it. 

Wheo  the  disease  Ims  from  the  first  been  eubaeute.  as  is  ii^tially  tlie  case 
when  it  coiuineacea  iu  the  head  of  the  femur,  the  mme  treatiiiciit  iiiuNt  he 
pursued,  but  it  muj  uol  be  oeceesary  at  auy  time  to  cnntiiio  the  pnti<!ni  to 
Ut],  or  to  have  rcxort  to  weight  exiensioii. 

The  conetiiutional  treatment  must  be  conducted  on  Ehoee  principles  ajreudf 
laid  down  in  the  chapter  on  dUea&e«  of  joints  in  general. 


CXCUIO:(  OF  TDB  BEAD  OF  TBE  THIGH<BOXE  AND  OF  TOE  QIP-JOIKT. 

White,  of  Manchester,  in  17f>9,  was  the  first  to  propoee,  and  Anlhony 
While,  of  the  Westminister  Hospitttl,  in  1K2I.  was  Iho  first  t«  perform, 
exciHon  of  the  head  of  the  femtir.  Thiti  he  did  on  a  boy  eight  years  old, 
who  bad  had  diftcase  of  the  hip-joint  fur  three  or  four  years,  and  in  whom  the 
carious  bead  of  the  thigh-bone  rented  uii  the  dorsum  ilii.  Whit«  removed 
the  head  and  irochauter?  of  the  bone,  and  the  patient  recovered  from  the 
Dperatiom.  dying  of  pbthi»i«  five  years  nrtcrwarns.  The  prvparalJou  U  iu 
the  museum  of  the  College  «'f  Surgeons,  This  operatiyi:  was  repealed 
by  Uewfton,  of  Dublin,  in  ISi^i;  and  then  seen*?  to  have  been  forgotten 
in  Great  Brilain  until  it»  revival,  in  1>>45,  by  Fergu»»on.  But  in  the  mean- 
while it  had  not  entirely  esrapvd  the  attention  of  C'onliiietital  Surgeons, 
Oppenheim,  in  lJi29,  and  Seutiu,  in  1^32,  excisetl  the  head  of  the  femur  for 
gunshot  injury;  and,  in  18+'i,  Textor  pLiblijiheil  an  essay  on  the  eubject. 

CaMa  reqturing'  Operation. — Di»e«)<«a  of  and  about  the  hip-joint  may,  so 
far  aa  the  qui'stion  tjt'(i|>eratit)ii  is  concerned,  be  divided  into  (wogreucctaiiaes 
—those  in  which  no  suripurHliou  lakes  place,  however  acute  clie  inflammation 
may  have  been ;  and  thuMi  in  which  abscess  forms. 

To  the  fir«t  class  belong  these  cases  in  which  ihe  synovial  membrane  is 
primarily  attW^tod  with  8ubs(?t)uent  implication  of  the  eurLilagea  and  liga- 
ments. In  thia  form  of  coxulgia,  the  patient  commonly  recovers  with  a 
iffeneil  or  even  completely  niikyloeed,  though  useful  and  etruight  litnb, 
locattf>n  of  the  head  nf  the  bone  not  having  oeeurreil.    In  sucn  casea,  I 

lieve  that  excision  ia  never  nt-edcd ;  at  least,  I  liave  never  had  orcaeion 
to  do  it.  nor  have  I  ever  aecn  a  caee  that  seemed  to  me  to  juatify  such  a 
procetlure. 

The  second  class  of  cases— thoee  in  which  ahseesa  forms— are  by  far  the 
moei  ntnneroufi^  In  the  great  nmjority  of  these,  however,  the  head  of  the 
t<-nnir  M  the  part  primarily  affected,  and  in  these  recovery  will  lake  place 
evenluallv,  umlcr  properly  conducted  medico-surgical  treatment.  But  the 
recovery  in  nuch  casM  i«  always  so  far  incomplete  that  the  limb  is  left  much 
crippbtl,  and  of\en  of  but  litlfe  utility.  In  eases  of  this  kind,  after  years  of 
suflirring  and  confinement  to  bed,  and  after  a  hard  struggle  for  existence, 
we  find  the  unfortunate  patient  left  oventuslly  with  a  limb  that  is  shortened 
Ui  the  extent  "f  from  two  to  fonr  inches,  wasted  and  addiicU-d,  with  a  pro- 
jecting deformed  hip  seamed  with  cicatrices;  the  remains  of  the  head  of  the 
ibntur  l>eing  'lij'Iocaied  from  the  acelalmluni,  and  adherent  to  llie  dorsum 
ilit  by  firm  aukylwis.  The  limb  is  unable  to  support  the  body,  and  cannot 
be  exlende-t.  nor  can  the  sole  of  the  foot  be  firmly  planted  on  thu  ground  ; 
but  the  leg  rs  to  a  certuiu  extent  useful  in  pr^igreissioi),  the  patient  ueing  it 
as»  kind  of  paddle  to  push  himself  on  with,  as  he  limps  ou  the  point  of  th« 
toes.  Id  theae  cades  it  is  iutereeting  to  observe  how  nature  compensates  fur 
the  loa   of  all  abduction    and  rotatory  power  in  tbe  hip  by  giving   an 


462 


DISIASK    or    TUK    U1P*JQ1NT. 


extr«tD«l7  iiicreaMd  d^ree  of  mobility  tu  the  lunihur  .        '       :  to  Ihatthi 

imtieDl,  ID  wulkiug,  swings  the  pelvic  from  tbeee,  nu'l  : K'**'  *^*K>*> 

makes  up  Tor  tbe  Foes  of  ibc  natural  movcmenla  in  the  ilio-fiMwJ  •ft«>> 
lation. 

Bui  tliougli  recovery  laLos  place  eveunially  Lii  ihti  mmymtj  of  omb  rf 
cuxulgiu  Ihm  have  aovauucd  oveu  to  euppurmi'm.  yet  iu  nucat  — Md  noia 
few — iuHtaDRds  the  jHtLient's  cunsLUutiou  beooraw  unetgunl  to  tbm  cUmin  m- 
poBod  upon  ii,  am)  laiul  hecitc  eventually  8U[>erveneau  Tbis  is  tbm  dind 
oODSaqueoce  of  tbe  wasting  atnl  «xhau«Uug  influence  uf  the  loag-ooniuuii 
diacharge  of  pus  from  niu>«ps  of  carioun  or  necraeed  bone,  Uio  czicmirfar 
too  deeply  seated  to  be  eliniinntcd  by  natural  processes.  It  U  in  Mirh  caM 
as  these  that  conservatiTe  surgery  Hte|w  in,  anrt  endeavorB  to  mto  ikt 
patient's  life  bv  the  removal  of  the  mnrbid  can.-^  that  keepn  up  tbr  dii 
which  is  wasting  it  away.  The  object  here  a  simply  to  save  life 
removal  of  diseiued  bone.  For  the  same  reason — lhf>  presemtioa  m\ 
from  hectic — tbnt  the  .Siirgeoo  amputates  in  an  extreme  case  ofaapmii 
diMrgauiutlion  of  the  ktio«-joirit,  be  cxciaes  In  an  extreme  cASe  of  amo 
izatiuu  of  the  osseous  structurcfl  that  «nler  into  the  furmnlion  'if  th«l 
joint;  nmputstiuu  i«  here  too  formidabb"  a  proo««<liQg  to  Iw  iiuilcrtak«li.j 
yet  the  removal  of  tbu  diseased  bone,  Ib*^  irriLalion  and  suppuratton  frott 
which  are  rapidiv  dtntroyiug  the  imtient,  is  an  imperative  necessity. 

PemoraL  coxalgia  id  the  form  of  (be  disease  tliat  ta  most  benefitad  by 
operation.  Iu  sevtre  caiwe  of  this  variety,  the  upper  epiphysis  of  the  Ihigb- 
bone  will  be  fuuud  l^'ing  in  a  aiate  of  cari««  od  tlie  dorsum  ilii,  in  a  supffr 
rating  cavitv,  nilb  amuses  leading  down  to  it.  Tbu  pelvic  bonea  are  aooBd; 
the  ac«labu[um  te  fillud  by  ^brous  tinue,  though  pusibly  it  mar  Im  sli|^lly 
rougheneil  and  necrueed  at  one  lip.  The  soft  atrueturas  in  the  KlntcAl  icgjoi 
are  thinned  and  wasted  ;  the  Jimb  is  sbortenod  and  adducted.  Iu  snob  OMM 
aa  these,  the  patient  will  probably  perish  if  let\  to  the  unaided 
nature;  or  tf  be  recover,  after  years  uf  sufierlng.  it  will  be  with 
8borteiie<l,  deformed,  and  but  little  useful.  Hesecliiju,  being  limited  tu 
upper  end  of  the  thigh-bone,  or  at  mo»t  to  tbe  roughened  lip  of  the  aortafatt* 
lum  as  well,  is  an  easy  operation,  removes  the  cause  of  tbe  nastiug  dti 
and  bectic,  and  in  no  way  increases  tbe  already  existing  Bbon«ntng, 
limited  tu  that  jwrtiou  of  diseased  bone  wbicb  is  already  lying  uon  and 
behind  the  acetabulum,  and  which  is  affected  by  caries  uf  too  extoiHTC  i 
dccp-»oatcd  a  character  to  disintegrate  and  crumble  away  tn  tbe  diwl 
au  that  a  natural  cure  without  uporaiion  could  take  place. 

When  once  siipnnmtion  hmi  taken  place  within  the  capsule  of  tha|aiait 
the  sooner  the  pui  u  evncuateti  tbe  better.  Ko  good  can  pombly  coma  ftwi 
tbe  retention  of  ptu  in  the  joint.  It  leads  only  to  further  diaorgaalasiao  tt 
tbe  articular  structures,  to  fre«b  conHlituLtottttl  irritation,  and  at  It 
bumting  uf  tbe  capsule,  and  the  furmutiun  of  large  cxtra-nrlirular  at 
To  Annandale  we  are  indebtetl  fnr  havinj;;  put  this  prxoticr  to  tb« 
experience,  and  by  making  a  free  incision  into  the  poetcriur  part  nf  tb*^ 
in  ^injunction  with  antiseptics  and  good  drainage,  obtaining  tba  iMBt  Mti^ 
factory  results. 

It  is  only  in  very  acute  cases,  bowf<rur,  that  this  treatHKOt  can  bt  pfictJMd; 
more  oommonly  tiie  pus  forma  sKjwIy.  and  is  not  raoognind  liU  it  fncns  a 
oomidarBble  extra-articular  abecoaa.  tjuoh  abaoeaBM  abould  b«  opaoed  oariy 
and  &cely,  and,  if  poniblt),  with  antiseptic  prvoautions.  At  tM  Ciaaa  thi 
abaoaai  is  opened  the  cavity  must  be  tlioruugnlr  examined  with  the  fianrta 
aaardi  for  se<|uestni,  and  to  aaeerEaiu  if  imaaible  the  situatioa  uf  iha  dSeasa, 
the  uoaition  and  eize  of  the  opening  in  the  ca[iaule,  and  tbe  condttioa  of  the 
be«a  of  the  bone. 


SABLT    KXCISIOy 


Disease. 


468 


L 


If  dii1o«ilion  have  taken  place,  an<I  the  limb  cnn.tpqupntly  hnvc  l>pcome 
a  good  deal  shortened  or  dt^tiirmed,  In'iiig  perhtipn  nrlH(irt«d  iitid  inverted  so 
^Ar  as  to  be  twisted  over  the  other,  or  drawn  up  upon  the  abdomen,  much 
may  be  done  to  leswen  the  deformity  by  pnttitig  the  patient  under  chloro- 
ibrin,  bringing  down  the  limb,  and  fixing  it  by  a  proper  «>plint.  Ankylosis 
ia  ii  good  p<«itii>ii  may  thu«  be  BomeUnies  obti*,iu«d,  and  tlie  pnlicnl'e  coiidt* 
Uiaa  be  greatly  improved.  It  ia  n  question  whether  hu  attempt  at  reductioo 
tshould  be  made  in  thew  cnees  of  coD8eciiliv«  dislocjttion,  hb  It  ia  very  rar«iy 
ithai  it  wonM  prove  perrauueacly  8ucce«»ful,  the  acetabulum  being  eitliej* 
filled  up,  or  the  head  of  the  buue  eo  dia«a«e'l  and  lessened  iu  size,  tliut  it 
would  not  remain  iu  it»  cavity  when  put  back.  Occa^ioually,  however, 
reductino  may  be  »uc'cesBf"uIly  ttrocted.  In  n  woman  imder  my' care  at  the 
Hutpital,  with  spuutaueuus  disiucittiuu  uf  the  biporubuul  a  mouth's  duration, 
rtdttCtiOD  was  tdlecled  by  mouue  uf  the  pullvye,  and  Ibe  hend  of  the  huue 
npliu^  io  the  cotyloid  cavity,  where  it  rvmaiued  fur  some  weeks ;  beeuuiing, 
however,  displaced  aj,'uia  iu  cuu(ie<4ueucu  oi"  iUi  being  necessary  to  remove  a 
btmdage  that  wba  applied,  ui^  she  became  allected  with  inElammatiun  oi*  the 
lungs,  and  could  not  uetir  its  pret^^iire.  It'  nukyloeis  be  likely  to  occur,  the 
Surgeon  must  endeavor  tti  securt^  it  with  the  limb  in  n  titrui^ht  position ; 
MberwisB  great  inconvenience  tn  tiic  patient  may  rennil,  CHpeciully  it'  it  occur 
in  the  position  repreflenled  in  Fig.  582.  Atler  atttiH'Jnint  Inui  i'orrucil,  the 
mobility  of  the  lumbar  vertebne,  and  more  particularly  of  the  lumho-sacral 
articulation,  will  he  tbnnd  to  be  greatly  increased  ;  ao  ttiat  at  laHt  the  patieut 
will  walk  with  little  inconvenience,  rotating  the  pelvis  oti  them.  If  the 
ankyloeifi  lie  not  (^KSeous,  but  the  result  of  the  arthritic  form  of  the  disease, 
sod  especially  if  the  heud  of  the  bone  be  still  iu  the  acetabulum,  the  limb 
nuty  be  Ktraight«tied  by  f^ircible  exteneiion  and  rotation  uuder  chloroform, 
and  the  heel  thus  brought  to  the  ground. 

Excision  of  the<  head  of  the  femur  hsA  usually  been  done  in  advanced  cams 
of  the  disease ;  but  Annandale.  Crolt,  and  others,  adviae  that  recourac  b*  had 
to  it  in  the  earlier  atoge^.  In  those  cs^es  of  hip-diseaite  in  which  signs  of 
suppuration  are  present,  they  recommend  that  an  antiseptic  exploratory  in- 
cisioD  be  made  into  the  joint,  and  the  head  of  the  femur  examined ;  if 
ftpQDd  diseased,  it  should  be  removed  by  sawing  through  its  neck.  Should 
there  be  oaseouo  diiieaae  l>eyond  this  in  the  acetabulum  or  in  the  femur,  it 
ntut  be  cut  away.  Annandale  in  led  to  recommend  early  operation  of  the 
kind  mentioned  in  tboi^e  casm  of  bip-diM<ai?e  in  which  slgna  of  Kuppuration 
exist,  by  the  conxideration  that  the  bead  of  the  femur  is  usually  carioUH  iu 
tbeae  oases,  and  that  its  early  removal  is  likely  to  check  the  further  progress 
of  the  disease,  and  to  leave  the  patieut  with  a  useful  and  movable  limb. 

Early  excieion  is  required  aim  iu  those  cases  iu  which  the  head  of  the 
femur  is  necroeed.  Tbis  (V)uditinn  is  not  easy  to  recogai:&c  except  by  digital 
exftinioation  of  tbo  articiitatiou  from  the  wound  made  la  ojicuLng  the  abscess. 
It  may  be  suspectad  to  be  preeeul  when  the  symptoms  have  act  in  with  great 
acut«u08B,  and  have  rapidly  reache<l  the  »tuge  of  suppuraliuu,  this  form  uf 
hip-disease  being  not  unfruiiueutlydueto  acute  osteomyelitis  of  the  epiphysis 
of  the  bead  or  acute  epiphysitlB.  If  the  BOijiioscrum  is  loose,  it  may  be 
removed  in  some  cases  without  any  further  ]iortion  of  the  bono.  If  it  is 
still  attached,  the  neck  may  be  sawn  through,  and  the  head  alone  takeu 
away. 

When  dislocation  takes  place  early  before  the  head  has  been  extensively 
destroyed,  giving  rise  to  very  mnrkerl  flexion,  adduction  and  miatiini  in- 
wards, excision  of  the  bone  is  often  the  only  meang  by  which  the  limb  can 
be  brought  into  good  position,  and  in  such  cases  it  may  be  undertaken  at  an 
early  period. 


464 


DISBASB    OF    TUB    niP-JOIXT. 


Id  ttie  Acetabular  Pelvic  tiirniofoxnlgia,  th<»  ulLimnle  rtstutt  b,  f  UUim. 
iDtvitiibly  Taca),  it'  tlii?  tli.«euse  ti«  atloivcd  to  run  iti  uwu  cirunv  uuibittiJ 
by  ohi^riition.  I^nrge  pnrtiiii)»  rit'  tlie  })elvic  bimcs  in  aotl  afound  thr 
acclaiiulum— Hucli  a»  the  tuher  ami  runutii  of  the  unhium,  the  ramua  of  lh» 
pubra  anil  the  dorfliim  ilii—fhll  into  a  etato  o(  iiecnwis  ;  tbc  raviiy  In  him 
nerforaied  i  Fig.  ftft") ;  ao<l  the  head  i»f  the  thigh  bone,  still  ij'mm  b  k, 
becAtiics  (tcniidril  of  irn  cnrtila^iJnouB  investment,  roughvtiM  and  csnOM,  ■> 
i«  well  seen  in  tlie  annexed  drawiug  (Fij;.  i>fi8>,  taken  rrom  a  pMiencoi 


C? 


Bui. 


■  iivh  of  tbn  I'otTl« 


flf.  i. 


l>>Ck- 


miuo  who  died  of  tble  IVirm  of  the  dUeaM;  or  it  mar  be  dialocatvd  la  a 
cariuus  6t8te  «m  t«  the  ilor»uiu  ilii.  Lnrge  abicesscs.  iutrn-  aa  wbU  iu  c»tj»- 
pelvic,  form,  mid  the-  i»iticnt  dit-s  ncirn  out  by  bi^'lic  i  the  natural  vfTirU 
of  the  {tarts  being  entirely  uuavailins  t«>  scjiarate  and  to  eliminate  wok 
large  uecruecd  uiaaaeb.  deeply  lying,  aod  ouvcrixl  iu  by  the  upper  end  of  ^k^ 
tbijrh-biiue, 

Exciaion  is  imperatively  required  abo  Id  ihoeo  caeca  io  whicb  the  aoetabo' 
Uiiii  has  been  iierforateil  aecondnrily,  in  cuaseqoenoe  of  disease  c<>auiie&ciD| 
ill  the  head  ul  the  femur,  as  by  no  other  meaus  can  the  iatra|ielvtc  aba — * 
nhirh  re«ulls  be  elFicieiilly  draine<).  It  la  not  enough  then  m  remove 
head  of  the  femur  only  ;  the  bone  nmst  he  unwn  below  ihp  lri>rham«r,< 
wise  the  upinrend  of  ihe  bone  will  »lill  inltrfrrt-  wjcli  draiimj.T.       ^. 

Bemoval  of  Diseased  Acetabulum  and  Pelvic  Bones. — Until  a  eumi 
lively  r^tcnl  [K'ri*id.  .So rjit'ons  ffiir.ii  to  iiudcriake  the  retijoval  of 
carious  and  necruiied  purtions  of  the  [telvic  bitues,  and  acetabular  du 
the  hi[>-joinl  was  acciinliii;;ly  ullowed  to  run  its  fatal  course  unoli* 
IlancooK  nan  the  first  Siir^on  who  undt>rtuok  the  n'liiovul  of  Ur]n  norlinai 
uf  llieM-  boui'4',  Riid  Hiucu  then  the  operntiun  liitu  been  duiio  sei>*enu  tjmia  far 
Othera.  In  no  cnw,  hiia,  I  believe,  more  extensive  diseawi  been  nmorm 
with  a  Rowl  result  than  iu  a  girl  who  wiis  sent  lo  rne  many  y«ani  aco  bv  wf 
friend  Mr.  Tweed,  and  from  whom  I  reroove<l  llio  upper  eiul  uf  tne  uixa' 
bone,  the  ac*:tabulum,  the  rami  of  Ihe  pubca  and  uf  the  ischium,  a  portuia 
of  the  tuber  ischii,  luid  part  of  the  doraum  ilii.  This  patient,  whiii  ad* 
roitted  into  the  Hospital,  was  in  the  last  stage  of  diaiMse.  athaasiad  kj 


inai»> 


m 


EXCISION   OF   HIP — METHODS   OF   OPERATING. 


466 


eooBtant  discharge,  and  must  ioevitably  have  epeedily  sunk  had  no  effort 
been  made  to  remove  the  cause  of  the  proBtration.  At  the  operation  she 
was  BO  exhausted  that  it  was  necessary  to  leave  her  on  the  operating-table 
lor  some  hours  before  she  was  sufficientlv  restored  to  bear  moving  into  bed. 
NeTertheless,  by  the  free  use  of  stimulants  and  nourishing  foc^,  she  im- 
proTed  rapidly ;  and  when  she  recovered,  the  limb  presented  the  appearance 
m  the  drawing  (Fig.  589) ;  it  was  straight,  shortened  about  two  inches; 
sood  movement  existed  at  the  hip;  and  she  could  walk  with  much  ease. 
Coostitationally,  she  was  in  perfect  health,  and  has  continued  bo  up  to  the 
time  when  she  was  last  seen,  about  fourteen  years  after  the  operation.  In 
three  other  cases  I  have  successfully  removed  large  portions  of  the  acetabu- 
lum and  of  the  contiguous  portions  of  the  ilium  and  ischium.  la  cases 
■ach  as  these,  the  result,  if  they  are  left  to  themselves,  must  inevitably  be 
&tal.  There  is  no  danger  of  laying  open  the  pelvic  cavity  during  the 
removal  of  these  masses  of  pelvic  bonet  for,  as  Hancock  has  shown  during 
the  progress  of  the  disease  the  fascise,  muscles,  etc.,  lining  the  pelvis,  become 
so  thickened  that  they  form  a  barrier  which  effectually  protects  the  pelvic 
caTity. 

Kethods  of  Operating. — From  the  preceding  considerations,  it  will  be 
observed  that  there  are  two  distinct  operations  practised  on  the  hip-joint. 
The  first  is  simple  resection  of  a  portion  of  the  upper  end  of  the  femur,  and 


t'\g.  ii)0. — EiciBion  in  Femoral  Cuzklgik. 


Fi(.  M9. — lUtnlt  of  ExcUioD  for  E:it«Diiive  Ac«Ubultir 
C«xalgia,  three  jHri  after  OperHtiun. 

the  second,  the  removal  of  more  or  less  c)f  the  acetabulum,  and  of  the  con- 
tiguous pelvic  bones  as  well.  For  the  removal  of  the  upper  end  of  the 
femur  only,  the  following  plans  may  be  adopted.  The  operation  may,  in 
most  casesi  be  performed  bloodlessly  by  applying  the  India-rubber  tourniquet 
in  the  ssme  way  as  for  amputation  of  the  hip-joint  (vol.  i.,  Fig.  9).    The 

TOL.    II. — 30 


46a 


DISEASE    OF    THE    BIP-JOIKT. 


iidTanUgc*  gained  1>7  so  doing  arc  very  grtat,  as  it  enables  thr  Sur^MO  l» 
a»cvrtaia  the  condition  of  the  trochanter  and  up]M<r  eoii  of  i)i«  frnmr  vilfc 
great  accurucy-  The  patient  i»th<;i)  placed  on  theeuiind  aidi^  If  tli«  dJMMl 
be  femoral,  the  slutcnl  region  |)erfonit«d  with  einue«e.  and  the  *oft  paite 
thinned,  the  head  of  the  bone  lyinK  dislooated  on  the  dorsuni  ili),  it  MtfioH 
to  pan  a  director  down  one  of  the  chief  eJuuaes  leadinc  t>>  the  rari'Hia  bMi. 
and  to  elit  this  up.  li'.  however,  the  bone  be  more  thickly  coTeird,  aad  bi 
not  easily  reached  with  the  probe,  and  if  the  Hiouaes  o\>ea  od  the  tldgik  al 
some  considerable  distance  from  the  sent  of  diwaao,  then  a  T-abaped  ineinM 
abould  be  made  over  the  'ipuer  end  of  tbe  thigh-booe,  mi  aa  lo  expun  H 
(Fig.  590).  The  limb  eboulu  now  be  adductexl,  roialed  iuwarda.  aod  pothad 
upwards  by  an  asgiataot,  and  iho  iM>fl  etructurett  aepttraled  by  a  prube-poiMad 
knife  from  around  (he  upper  end  of  iho  bone,  so  that  the  whole  amoiit  tf 
iliseaw  may  come  int^i  view.  The  up|)cr  end  of  the  femur  u  then  oat  off 
Willi  a  saw,  iJie  ttofl  ]>arta  around  buiug  jirolfcted.  if  oeoceMiry.  by  nw  of 
reirarlore. 

There  in  one  practical  question  with  rfvard  tn  the  amount  of  tbe  upvs 
eml  "f  ihe  thigh-bone  to  he  removed,  whi<ii»  refjuin-s  i-t)nfli<Ierntiun  ;  aiul  tkn 
18,  Should  llie  Ix^iic  be  snivn  thruugh  bcUiw  tlir  throat  tn)rbaii[4>r,  or  ihrMwli 
tl>4^  neck  only,  leaving  tht*  trtKhantcr?  The  prarlinv  should,  I  think,  dlftr 
according  to  the  nature  of  the  diKOAe.  If  thin  be  feraoral,  it  is  be#t  t^)  talc* 
away  the  ffreai  trochanter,  as  the  caries  1ia<i  generally  rrnrhed  it*  rancrllnfw 
fltniclure.  or  it  may  beinlillrAh^d  with  tubercle.  But  if  the  dismx-  br  aorta- 
bular,  and  the  pelvic  Ujucabc  the  part^  most  exteii^irely  and  deeply  alfcrtcd, 
it  will  DufHoe  to  remove  the  heH<l  only,  leavitifr  the  tri>rbant«r,  which  tf>  aot 
afiected  in  these  caae»-  After  removing  the  head  yf  tlip  bone,  the  upper  tui 
should  be  examined,  and  niiy  carious  part»  gouged  out.  The  acetabulum 
must  then  be  examined,  and  any  rough  or  ueorowd  Ume  tying  at  il«  v^ 
should  be  guugCfl  away. 

In  caee»  in  which  the  situation  and  extent  of  Oie  einoses  leave  the  Sur- 
geon a  free  cImucc  for  tbe  faitualiou  uf  his  iuciriiou,  the  plan  rvvommewM 
by  Hayre  will  be  found  to  give  excellent  reeulu.  A  semilunar  incisiull,ii 
made  with  i(«  C4)nmvity  forwards,  cummrneiug  »bove  the  tn'chaatcr  lauv 
miilway  between  it  ami  ibe  cresl  of  ttif  ilium  ami  carrieil  dowtiwardtbahnl 
the  bone.  The  iimt  iucisinn  must  go  direetly  down  to  the  bone  ihroQ^fa  ifcs 
perioeleum.  Tbe  soil  parts  are  then  pulled  furwards,  and  the  periosuui 
diviileil  by  means  of  a  amall  but  strong  curved  bistoury  as  far  as  poaiUf 
round  the  bone  below  tlie  trochanter,  in  a  direction  at  right  angls  lo  Uw 
lower  part  of  tbe  tlmt  Incision.  Tbe  Surgeon  timu  ]mvIs  the  perioMeara  with 
the  niusclen  attarberl  to  the  trochanter  off  the  bonv  with  a  strong  pftiaslfl 
elevator.  The  joint  i»  then  tboMtighty  iineoed,  and  the  bead  of  the  boas 
inmed  nut  by  which  the  (teri'stcum  u  peeied  off  fmm  ih<'  inner  nde :  lasUvi 
the  bone  is  sawn  through  aliove  ihe  trochanter  minor.  Hy  Kuving  tbe  p«ri»- 
leom,  Sayre  stales  that  be  obtains  more  perfect  repair  wilb  Icm  ahortennc 
and  a  stronger  and  more  morable  joint 

In  some  rases  the  head  of  the  femur  may  be  very  t^unvenit-ntly  exflbal^ 
an  anterior  iiK-iaion,  as  recommended  by  K.  W.  Parker.  Tb«  inciaiaa  aha 
be  earrie<l  through  the  interval  U-lween  the  Ton»<>r  vnginoi  feworie  and  thf 
Harloriuv.  The  finger  Iwing  intnxluce*!  ioUi  the  wound  nsMS  dincttr 
baokwartlH  past  tbe  anterior  bonier  of  the  gluleus  mediua  and  gf  uteoa  nim* 
nus,  and  external  to  tfa«  head  of  tbe  rectus,  and  thua  reaabea  ih*  nesk  wT 
tbe  femur.  As  this  is  the  direction  taken  by  the  abaocai  in  a  larRe  pnpv 
tion  of  oaMa,  no  oulitog  is  re<)uire«l  atUr  the  Interval  between  the  aartorMi 
Aod  the  tensor  vaginie  na#  been  opened.  The  neck  »f  the  bune  may  thai  ht 
oawD  through  with  an  Adams'e  saw  (.Fig.  &tl8),  and  the  brad  rvoMml 


KXCI8I0N    OF    HIP — METHODS   OF   OFEBATING. 


467 


teqaestrum  forceps.  This  method  is  adapted  to  those  cases  only  in  which 
tlw  htmd  of  the  tKioe  is  alooe  diseased,  and  it  is  not  necessary  to  remove  the 
Irochmnter,  and  more  especially  to  those  in  which  an  abscess  is  pointing  in 
the  situation  of  the  incision.  Experieoce  has  shown  that  the  wound  drains 
hirlj  well  in  most  cases,  but  should  there  be  any  accumulation  of  dis- 
ehu^i;e8,  an  openinK  can  be  made  behind  and  a  drainage-tube  inserted,  the 
aoterior  wound  being  allowed  to  close.  No  muscles  or  other  important 
■tnictores  are  divided  in  the  operation.  It  should  never  be  attempted  when 
the  moetabulum  ia  perforated,  as  it  does  not  provide  efficient  drainage  for  an 
JBtrmpelvic  abscess,  and  it  is  not  advisable  when  the  head  is  considerably 
dbplaoed  backwards  on  the  dorsum  ilii. 

in  sawing  the  bone  in  excision  of  the  hip  the  ingenious  instrument  in- 
noted  by  Gowan.of  Guy's  Hi:Bpital,will  be  found  very  useful  in  some  cases 
{Tie.  591}. 

In  tbe  acetabular  form  of  the  disease^  where  large  portions  of  the  pelvic 
bones  require  removal,  the  early  stages  of  the  operation  require  to  be  con- 


Fig.  69i.—QoiTBn'B  Uiteutume. 

ducted  in  the  way  just  described;  the  incisions,  however,  being  made  more 
freely,  but  not  carried  so  far  forwards  as  to  endanger  thu  anterior  crural,  or 
to  far  back  as  to  wound  the  sciatic  nerve.  After  the  removal  of  the  head 
of  the  thigh-bone,  all  loose  necrosed  pieces  are  to  be  taken  out,  and  then,  by 
means  of  ordinary  cutting  or  gouge-force]>8,  the  acetabulum  and  other  carious 
oaseous  structures  are  cut  away  piecemeal.  Those  portions  of  bone  which 
have  necrosed  are  usually  lying  loose,  or  else  may  generally  be  readily  sepa- 
rmted  by  the  finger,  or  by  the  handle  of  a  scalpel,  from  the  subjacent  soft 
structures;  ami  the  muscles  and  fasciit;  lining  the  pelvic  bones,  being  thick- 
ened and  infiltrated  with  inflammatory  products,  otlectually  protect  the 
contained  parts  from  all  injury. 

Excision  of  the  hip  should  be  performed  with  nutiscptic  precautions  when 
p^Mdible.  If  foul  sinuses  exist,  these  may  be  temped  with  a  s^hurp  spoon, 
sod  cleaned  with  a  small  sponge  dipped  in  a  solution  of  cliloride  of  zinc, 
aod  held  in  a  pair  of  sinus  forceps.  Some  simple  nutiscptic  dfL'ssiug  may 
then  be  applied,  and  the  limb  fixed  with  a  luni^  splint. 

Ferg;uBdun  recommends  that  tlie  extciisiim  should  be  made  from  the  oppo- 
fite  thigh,  round  the  upper  part  of  which  a  socket  is  fixed,  to  which  the 
band  It  attached  (Fig.  592).  Much  advantage  will  l)e  derived  from  the  use 
of  the  bracketed  thigh-splint,  from  which  extension  may  be  made  by  means 


468 


or  TBI   HIP-JOINT. 


of  A  weight.     Wlien  tlie  wnand  baa  partlv  healed,  if  Cb«  ritiuitiaa  of  I 
iDcieioii  allowi  of  it,  n  Thomas's  bip^llDt  m&y  be  Applied  aad  lh« 
hUowed  to  move  about. 

BefUlU. — The  result  of  exdiion  of  tbe  hip-joiot  faaa  to  be  ooQ»d«red  fren 
two  poiols  of  vifrvr:  1.  As  to  the  Mortatitv  iaiaie<iiateljr  iTfetsbl4>  Co  tha 
nperntioD ;  aod,  2.  As  to  tbe  Utility  of  ibe  Limb  that  i»  left  after  tte  per- 
hrmaace. 

Morlalitif  ajtfr  the  Openiion.—Snyn,  of  Hev  York,  In  1660.  cc4lcc4cd  lU 
elatlHtini  nf  lOU  caees;  of  tb<«c,  rcM^nvtry  took  fdace  in  71,  36  died,  UkI  in 
2  the  TWu\l  h  not«4l  oa  beioe  unMii^KfAntiin'.  Leisrink,  of  Bamban.[ 
pubiieli(M!  in  thn  Arrhiv  fur  Kiini/vJie  Chintrgie  I'JSTOl  the  statiMics  «  ] 
cAsm.     Id  24  uf  tbeee,  or  13,(i  per  cent.,  death  occurred  tram  Istercui 


Fif.  avt.— AfpMKluf  t*  Im  nt*a  arttr  Sx«l4lm  eX  HIp-JaikL 

fflgeawA    inoatly  pytemia  1 11)  aod  lepdcemia  (S).     FourteeD  paduita.  or  % 

per  cent.,  died  withia  a  fortaight  from  cxhnuHiou  ;  14  otben  dieJ  bcl«t^ 
this  time  atid  tbe  end  of  tbe  nnt  mouth — m<.«L  Imm  exhauAtioo,  ana  tnm 
amyloid  diaeaae,  and  two  fnim  phthisis.  From  the  bcgiiiuiog  of  the  ttanBk 
moDth  to  the  end  of  tbe  yrar  after  the  operatiau  there  were  27  Wf  thtc  flff 
1&.3  per  cent. ;  while  9  dieil  in  the  course  of  two  or  more  yeaia,  of  f^titirii 
and  other  diseases.  Lei^rink  slatce  that  id  17G  oAae«  of  exoLiion  of  the  ^f, 
than  mrc  altogcihcr  98  deaths.  Of  ibis  apparently  high  mfirtalitr.  1m>*> 
ever,  ooly  about  one-half,  or  26  nor  c«nt  of  tbe  whrile  ensci,  ran  Ik-  n*rribed 
Id  the  opcraiioii  itAelf,  or  to  the  mlcrcurreooe  of  pyitjiiia  uiid  oihrr  JjwrtiM 
nhicb  are  liable  to  attend  operative  procedunes.  Ttie  other  half  of  tli» 
deaths  wer«  producixi  by  cxicD^ion  of  iho  disease,  by  diurrhn-o,  or  by  pbthisii 
or  other  di^^-osc  of  iotcmal  organs — probably  iu  maoy  instancr*  exiMioi;  U 
tbe  time  whi-n  tbe  operation  waa  perlurnxNl. 

The  mortiUity  following  the  operation  npj>enr«  to  have  brrti  -  ~rr 

in  Kusland  aud  AmericA  than  in  Franco  Hiid  O^rmnny.     In  ft 

publisliL'd   the  statiatics  of  45  caacA  nperalei)  mi  by  hiniw>lf;  -  -    '  ' 

feoovered,  lA  died,  uitd  8  were  still  under  treatment  «t  tbv  time  k>\  t'l-.  t'.j-'' 
Of  (be  40  per  ceul.  of  dentha,  \l\S  died  directly  from  tbo  o|M!r«lioD,  13.4 
from  some  lorm  of  tuber(,-ulur  <lt»ea>p,  R.(t  from  ullmiiiinoid  diacase.  and  1.4 
from  causes  uocouoected  with  tbe  joint  atl'ertion.  Of  203  cnsea  of  exdiMi 
ruUctTted  hy  the  committee  of  tbo  Clinical  Society,  29,  or  13.7  pcircraL,iiM 
directly  from  tbciipcratiyo. 

The  result  of  my  owu  experience  is,  that  the  mortality  dir«ctly 
to  tbe  o])cnitiou  itself  is  but  email.     Kxeisiou  of  the  head  of  the  ihlgh-l 
or  of  the  hip-juiut  slauds  in  a  dilTcrent  position  from  similar  o|>rniiinnt  nw^ 
tlml  oo  olbrr  joints.     Tlie  Surgeon  exciH-e  tlie  elbow,  abnuldcr.  or  ankle,  ia 
order  to  restore  a  useful  limb  t'l  tbe  palient.     Ext-ibion  of  these  joints  is  a 
subiiliiute  for  the  loes  o{  the  limb  Iir  amputation — mil,  as  in  tbo  case  nf  iIm 


Vp.  to  preraat  the  ulmnst  ineviUble  loss  of  the  life  of  ihc  patient  by  ooa< 
tiaoaam  of  hectic. 

'2.  In  MtimatioK  t1)e  viUity  of  the  limb  ieji  after  the  exeitiOH  oj  the  hip-jaint, 
w«  nust  eotupftre  it  with  the  kiud  of  luemWr  thut  would  be  left,  in  the  eveat 
of  Um)  patkot  Burviving  Hufficicntly  tou^  for  n  natural  care  tu  result.  U 
woald  be  tnamfcstlr  iihsard  to  cnm|wre  a  limb  which  hul  beoume  seriously 
cripplrH,  nithcrnl,  diMtued,  and  shortened,  before  bd/  upentioa  waa  uoder- 
tUMl.  with  oac  in  whlnh  do  tnorbid  process  bad  ever  taken  place.  So  atau 
wold  H  he  anjuiit  to  i>>mpar«  it  with  the  vtate  of  a  limb  leli  after  a  slight 
■Ctkck  of  coKa))(ia,  in  which  operation  could  nf-ver  have  hccume  Deeeatary, 
Mr  baT«  b«ea  o in l^ni plated.  But,  on  eompartnf;  the  rcitulta  of  caaea  of*^ 
rmieH  oo  with  tho»<'  of  c^'^ea  which  recover  nnooUQCoUdly,  after  cariea  and 
dcaUiictive  dijtiDtegration  of  llie  upi>er  rpipDysis  of  the  thigh-bone  have 
cibted  for  years,  we  shall  Bml  Uiat  (he  iMtlaitre  b  by  no  means  against  those 
hicb  excision  hn«  been  done.     Ae  I  do  not  consiider  the  operation  neces> 


ts 


mrr  iu  caM*  nf  oriArtfic  coxalgia,  I  do  not  compare  the  rcault  of  these  ciutes 
vitk  that  of  those  operated  on,  but  ooatine  myself  entirely  to  tbo«e  in  which 
than  has  been  deatnictive  bona-diiteeee.  Iu  those  Tare  oases  of  this  descrip- 
tioe,  when,  afier  yean  of  prolonged  tfuficriug.  recorery  is  at  last  accomplisfaed 
(nr  natural  muoxia,  the  Hmb  IcA  \a  more  or  less  completely  oukyloeed  nt  the 
Up,  vaeted,  shcinened  to  the  extent  of  two  to  four  inches,  partially  flejied 
apoo  the  pelvis,  adductcxl,  with  tlie  knee  puesibly  stitToDed.  semiflexed,  and 
aavaaoed ;  the  patient  is  jufit  able  to  put  the  Utes  lo  the  ground,  without  the 
pevBT  of  beartu}:  upon  or  rotating  the  limb,  hut,  wbeo  he  wtehee  to  turn, 
IwiMing  the  whole  pelvis  by  the  aid  of  the  greatly  increased  mobility  of  the 
luiilHrspiBe. 

Aflei  smuMaifiil  excision,  the  r<^nlt  \s  much  morA  mli«factory,  as  may  he 
•eaa  ia  Fig.  589.  The  prinripul  abnormal  ap[K>arunrB  iu  the  limb  it?  its 
ahorteaing,  to  the  extent  usually  of  from  two  tu  three  inches — to  the  extent, 
iM)e«d,  to  which  the  preexistiocr  disorganization  and  dUlocation  of  che  head 
tit  the  bone  had  previously  reduced  it.  It  is  well-nourished,  straight,  firm, 
■ad  admits  of  «My  and  rapid  progression.  The  nnkylo«iji  is  fibrous,  not 
t—eous.  The  pntient  \»  thus  enabled  to  flex  the  thigh  on  the  pelvis,  and  to 
wldttct  it:  but,  just  s«  in  cases  that  have  undergone  n  natural  cure,  the 
power  of  exteraal  rotation  and  of  slKluctiuii  is  lusl,  the  mobility  of  the  lumbar 
tpine  <oni  .'  for  the  I'vm  of  these  movements. 

JDlsEA-  Gkkvf  THtMUANTKie  (ii.-ca«ioua)ly  occurs  with  abscess  in 

tha  opper  ttud  •^•uivr  part  of  tlie  t!)iL'h.  at  fir«t  siglit  closely  reaemhliug  hip- 
Smmme :  but  a  little  careful  exiiminiitiun  with  tiie  probe  and  by  manipulutiuu 
uf  the  limb,  will  soud  cinviuce  the  ^urgeuu  timt  the  joJut  is  free  from  disease, 
aod  that  the  murhid  prucees  is  limited  to  the  trocliauter,  aud  possibly  the 
nRA  of  the  neck  of  the  thigh-bone.  Disease  of  the  trochanter  te  more  cum- 
BUW  in  children,  but  is  occasionally  met  with  in  adults.  The  must  common 
palbological  ntDdilioo  met  with  is  necrosis  either  central  or  fu|>erficial.  Iu 
<ldIdrMi  this  nay  be  the  result  of  injury  or  of  acuU:  idiopathic  osteomyelitis 
of  the  epipliysis  of  the  trochoniLT.  Tubercular  caries  sonielimes  occun  also 
InlkiseptphyKsJust  aain  that  of  the  head  of  the  hone.  Iu  these  cases  the  limb 
slMHlId  OB  made  bloodies,  and  the  trochanter  freely  exposed  by  a  cunrod 
incWos  (Fig.  ^9^1 ;.  Sc(|uestra  may  then  be  rcroorcil.  ur  flic  dtseascd  osseous 
itrartans  gonged  away.  In  such  opcratiijus  I  have  not  only  suceeaafully 
reaovsd  the  gn-ntrr  part  of  the  trochanter,  hut  have  scooped  out  oven  a 
pfjnioa  of  ihf  int/-rior  of  the  carious  neck  of  the  thigh-bone  at  its  trochan- 
t«>nr  Mi\\  :  ihc  inevitable  disorganiEittion  of  the  bip-joiot 

«hu!b  Wo  J  .  ■  -    ,  .      •(  the  disease*)  booe  bad  l>t*en  allowo*!  to  remain 

is  filgae  proximity  tu  the  articulation.    Id  thb  operation  the  Sargeon  oeces- 


4T0 


DISSASB    OP    THE    HIP-JOIXT. 


■uilj  comes  into  very  cluee  proximity  wttb  the  <iifi6ule  ol'  the  )uiiit;  nd 
unleee  grent  cure  bi-  taken  Una  may  he  upeiifil,  ntid  ihiiR  ihr  vry  mitdimS 
induced  which  the  operalion  Ih  unuprtuket)  to  preveaU     I^h 
be  found  m  be  »o  extpii><ivt!  that  it  l>econirfi  Dccraary  tne\<  i  jc 

con  be  easily  done  wilhont  ext^tiiling  the  incisioo. 

AmI'LTATION  in  C'APB*  op  DI8EABE  OF  THE  UlP-JOIXT. — The  qi 

aniputatioD  in  caers  nf  dtsmra  of  the  bip-joiot  h  one  that  xnutl  often 
presented  itself  to  the  Sur^etia  when  he  ba^  contemplated   the  abc 
wflBterl,  and  deformed  member  that  is  frequentlr  lelt  tidvr  tb«  mart  vt 


X 


/ 


A 


\' 


Fig.  &03, — In«i»1«R  •x|)«*lBg  lb*  (SfMl  TrovhMtUr  for  lli«  rvmovat  of  Jlimil  ba*» 
Ktwirrfa'a  bandsf*  applied  to  rander  tb*  opinlkxi  UmJIm*. 

vanretl  fnrme  of  the  diaease,  and  which  cnn  never  bu  rcDdrrrd  nwrul  aai 
'basie  of  ^oppKft  to  the  body  by  any  mechanical  etiDtrivaucv,  bowrver  akil- 
fblljr  designed,  but  must  always  remain  not  only  11  tuclesi,  but  a  cumbfow 
Appendagt;. 

It  appears  to  me  that  In  the  more  advanced  chronic  c«ir»  of  bip-joint  dt»- 
«aji<-,  tiiifl  oftcration  is  justiflabic,  and,  indeed,  i»  to  be  advocated  in  certain 
circum«tniii-rit.    Thew  aro  aa  fnllowa: 

1.  In  caM^  where  the  diaeAM  IB  confined  tnthe  head  of  th«  frmnr.or  wben, 

if  any  portion  of  the  pelvic  hnntu  be  attaekMl,  ii  be  to  so  limited  an  «xt«iit 

a«  til  be  readily  removable  by  tlifl  fcouge.  excision  would  ntrcvwirily  b«  tbe 

tiiual  pmclico.    But  if  the  paticul'a  health  be  too  low  to  bear  thtt,  or  if  tW 

.  lUnb  be  to  thortcned,  atrophied,  and  deformed  bj  long  dime  ■•  to  be  incA- 

rnbla  of  furuishiuK'  proper  support  to  the  patient,  tlwo  ampotatios  at  tbt 

oip-joint  W'lultl.  J  think,  b«  a  proper  pnic«aiire.     I  do  not  thiolc  that  tbt 

merv  dettruciiiin  of  the  cartiiaginoue  lioinfc  of  the  acetabulum  aboiild  mili- 

tali*  a^.'aiuat  the  perfornmDce  ot  the  opentioo :  fur  me  conilanlJy  am  fai  Up- 

[Juiot  disease  when  tlie  hfad  of  the  bone  bae  been  dblooaled.  or  after  aiapa- 

JtatioD  nt  the  hipjoiut  fur  scrideut  or  ordinary  diteoar,  that  tb»  act-tabu  lorn 

I  fllli  up  with  o  (Irnw  libniid  mnK  after  l^e  dntraciion  f>r  removal  nf  iu  nir- 


ANKYLOSIS   OF    THE   HIP-JOINT..  471 

ilage.  But,  if  the  pelvic  bones  be  so  far  diseased  that  the  oecrosed  or 
EMioQS  part  does  not  admit  of  removal,  then  necesiiarily  amputation  would 
■ot  be  justifiable. 

2.  When  the  disease  involves  the  shaft;  of  the  femur,  which  may  be 
necroaed,  or  atrophied  to  such  au  extent  as  not  to  leave  a  sound  limb  after 
the  removal  of  the  upper  epiphysis,  amputation  would  be  proper. 

3.  Amputation  would  be  justifiable  auer  excision  has  been  tried  and  has 
hiled  ID  securing  a  useful  result  to  the  patient,  the  limb  being  left  short, 
weak,  loose,  and  (edematous. 

4.  Id  a  few  cases  amputation  has  been  successfullr  performed  when,  after 
excision,  the  discharge  from  the  sinuees  had  continued,  and  albuminoid  degen- 
eration of  the  viscera  had  set  in.  Cases  have  been  recorded  by  Marshall 
and  Barweil,  in  which,  afler  the  operation,  the  size  of  the  enlarged  viscera 
sensiblv  diminished,  and  the  general  health  greatly  improved. 

5.  Lxcision  of  the  hip  is  occasionally  followed  by  osteomyelitis  of  the 
femur,  and  acute  necrosis  of  the  shafl.  Should  the  patient  survive  till  the 
process  becomes  chronic,  amputation  affords  the  only  chance  of  life.  The 
operation  was  successfully  performed  under  these  circumstances  a  few  years 
ago  in  University  College  Hospital. 

ASKVL06I8  OF  THE  UIP-JOINT. 

AnL-ytetii  of  the  Hip-jo\nt,  following  its  inflammation,  differs  in  its  degree 
of  completeness  and  in  the  position  of  the  limb.  Thus,  it  may  be  fibrous  or 
(SKoosi  or  the  limb  in  either  of  these  cases  may  be  straight, or  more  or  less 
kied  on  the  abdomen  or  adducted. 

The  most  impttrtant  point  in  all  these  cases  is  the  direction  of  the  limb. 
If  Ibt  be  straight,  but  little  treatment  is  required,  or  indeed  possible.  When 
tJKhetd  of  the  bone  is  completely  ankylosed  with  the  limb  in  this  direc- 
<•<».  the  offieous  structures  of  the  nead  of  the  iemur  and  of  the  acetabulum 
^'^'^  fiued  together,  absolutely  nothing  can  be  done  to  improve  the  patient's 
ttiodiijoa.  The  lumbar  spine  will  acquire  increased  mobility,  especially  in 
■  rotiuiry  direction,  and  the  patient  will  stand  and  walk  with  ease.  The 
™Kf  (JifBculty  arising  from  the  position  of  the  limb  will  occur  in  mounting 
MUn  and  in  sitting. 

If,  however,  the  ankylosis  be  not  complete,  but  fibrous,  even  though  the 
Mb  be  straight,  the  freedom  of  movement  may  be  much  increased,  and  any 
'mIit  direction  as  to  abduction  or  adduction  maybe  in  a  grent  measure 
WiBtdied,  by  douches,  friction,  pressure,  or  even  forcible  movement,  and 
McuioDallr  by  the  subcutaneous  section  of  tense  band.s  uf  fascia,  or  of  ten- 
oiaoua  ana  muscular  structures  about  the  anterior  superior  spine  of  the 
ib'QiD. 

If,  unfortunately,  the  limb  have  become  ankylosed  in  the  flexed  or  augu- 
W  position,  means  must  be  adopted  tu  straighten  it ;  and  this  must  be  done 
vbetber  the  ankylosis  be  fibrous  or  dcscous.  For  here  the  deformity  aud 
ioatilitT  of  the  limb  arc  always  cousidornbic  ;  and  increasingly  so,  the  more 
the  ankylosis  approaches  to  a  right  angle. 

Id  rectangular  ankylosis  of  tbe  hip,  the  foot  cannot  bo  put  to  the  ground 
■0  long  as  the  spine  ie  straight  (Fig.  094).  In  nrder  tliat  the  toe  should 
loach  tbe  ground,  it  becimies  neL-essary  that  the  iHidy  be  bent  forward  ;  and 
tbe  lumbar  spine  will  consequently  be  thrown  into  a  very  considerable  arch 
with  the  convexity  forwards  (Fig.  .')*)">). 

The  extent  of  the  angular  deformity  in  thii?  kind  of  ankylosis  can  always 
be  easily  mesjured  in  the  fi)llowing  way.  If  the  patient  be  laid  flat  upon 
bis  baclE,so  that  the  lumbar  spine  touches  the  mattress  on  which  he  is  lying. 


472 


DIBKASX    OF    THE    HIP-JOINT. 


the  knee  will  be  n\»eti  above  t.h«t  of  the  Muod  limb,  and  the  uiele  fonnad 
betnec^n  the  thipli  and  trunk  vrill  be  iit  uiicit  very  pcrccj^lible,  Bui  if  iht 
kaee  he  depret«<ed  mi  a«  U>  bf  brou^bl  t'>  thv  Mimi.'  Ivvtl  ii^  (itat  nf  tfa«  wuod 
iirnb.  llicii  (lie  nutcriMr  *u)!*Tiur  spin**  of  ihc  ilium  is  rutaU-d  furwonlt.  ud 
th«  lumbar  epiuu  arcUtHl  liirwarUs  tu  au  uxteuL  jiruponiunai«  to  tiie  aa^  si 
dfiformily. 

This  aanilar  ankjrioeis  of  tbe  hi[hjoiDt  requires  to  be  corrected,  and  tl» 
limb  to  be  uroufpht  into  a  straiglii  ptnutiou,  «>  thai,  eveo  if  it  be  theruatA, 
the  paticDt  may,  by  meaiiK  of  a  bitjli-hefWd  biwi,  rent  it  uiian  tbe  gnma4,, 
aud  u»«  it  as  a  lueaiiB  of  BUp|iurt  niid  uf  pruj^remtog.  This  nia/  oainlljr  ht] 
efieutcit  without  much  dillicuUj-,  when  tlie  auk^ lobia  b  filwiHW»  bj  flbidr 
axteusiuD  under  ohloMform.  the  limit  being  thua  oflni  broagfat  ■trafghti 


■  i*' 


PlesloB  ot  Linb  on  PoItU. 


MH)    Camlur*   of  Spla*   la 
l^Mit  an  n  ran  n A. 


once  withuut  anr  material  difBculty.  BuL  iu  other  eaves  ifab  otnoot  b«d«» 
b,v  nimpio  extL<n«oo,  rcsUlaiiiHi  Iiciug  riOered  br  tbe  mtliGlis  oD  tb*  aatcrior 
and  ujipi-r  part  <>f  the  thiuh.  In  such  eircumelanoo,  thaw  that  ufTrr  wfM 
reeialauff  must  bu  JiviJcu  subcutaucouely;  and  the»f  uill  uhusIIt  be  fuswi, 
m  bu  Uie  rectus,  tensor  vagina)  femortK,  fai^tioeuit,  and  gracilis.  Sfler  ibt 
limb  hue,  iu  thie  way,  been  struigh tuned,  niid  mainuintti  f«r  Bnmo  lisM  is 
tbi>  ptrniffbt  iM»itioD  by  maam  of  thu  lon|r  splint  ur  wiriifbl  apf«ralas  ar 
Thomnit'.-i  nplint.romns  maybe  aihipCfd  by  {taa^ivc  miiUitu  and  frii-tiuai  la 
restore  the  mitbility  of  thv  j'tint. 

Opwafcion  for  Oiteous  Asgttlu-  AnkylotiB.— When  oitooua  aakytuabi 
the  hip  ha»  wcurrerl  in   iht*  Heated   piraiiion.  tbe  cane  nri-wwirily 
much  more  BeriouE :  nnd  ttic  rectifii-niion  uf  the  position  nfiliL-  limb,  and 
rc»t«rntion  of  iu>  mobilitv,  can  be  clfix-te^l  only  by  siirpical  n|M!ratioii. 

The  onerution  by  whieh  these  nhji*cU  are  arnunpHuhwl  coosista  in  tbe  diri- 
^ou  of  the  Up|>er  Part  <if  tlie  Femur;  through  iu  ueek,  if  any  raanUHef 
that  atrurture  Atill  exist,  or,  nt  nil  ewnts,  nlMtve  tlie  tmcbaot/^r  minor. 

Thr  fini  opemti'iu  nf  llie  kind  wai  iK-rfornicd  by  Rhi«  BartAii.  io  IfQft. 
It  waj>  dont'  in  the  i-aw-  of  a  wiilor,  21  yciin  of  np-,  wbn.  in  •  n-v  <^ 

an  injury,  had  an  (•*«'oo»  ankylmii  uf  the  hip  in  n  m-nrly  rr,  .    ^mu- 

tioo.     Hnrlon,  aoconlinc  in  C>rn«3i,  made  ■  rnicml  ii)-  i^r  and  down  ut 

the  great  trochanter.    The  tutJtoleo  ««n>  dutaehed  m 1  mnAutmai  Ui*_ 


OPEBATI0H3    TOR    ANGDLAR    ANKYLOSIS    OF    HIP.       478 


fxne  sawn  through,  the  great  trochanter  and  part  of  the  neck  of  the  femur 

^«ng  divided  traDSversely.      Whether  a  simple  section  of  the  bone  wae 

Bade,  or,  id  conformity  with  Barton's  usual  practice  in  ankylosis,  a  v- 

AiMd  piece  of  bone  was  removed,  I  know  not ;  fur  oo  this  point  American 

ulnorities  differ.     But  the  limb  was  brought  into  a  straight  poBition,  and 

pot  up  in  a  fracture-apparatus  for  twenty  days.     At  the  end  of  this  time, 

Give  mutioD  was  commenced,  and  at  the  end  of  four  months  the  patient 
a  movable  iaise  joint,  so  that  he  could  rotate  the  limb,  abduct  it  for 
ttntT  inches,  aad  carry  it  backwards  and  forwards  to  a  atill  greater  e^itent. 
The  caM  was  therefore  eminently  successful.  The  operation  appears,  liow- 
ner.  to  have  attracted  but  little  notice,  and  to  have  been  hut  rarely  followed 
brtAhen.  It  is  true  that  Barton  himself  operated  a  second  time;  and  that 
Rodfrere,  of  New  York,  in  1830,  did  so  successfully  on  a  man  47  rears  old. 
The  example  of  these  American  Surgeons  was  followed  in  Europe,  \)yTextor 
in  \\M,  and  by  Maisonneuve,  in  1847,  on  a  girl  of  18,  successfully.  Rosa 
•r.^.  A.)  operated  in  1857,  on  a  woman  of  23.  In  the  two  latter  cases  no 
&1m joint  was  made;  but  the  bone,  afler  being  straightened,  united  again 
by  ctllns.  In  March,  1869,  I  performed  a  similar  operation  at  University 
College  Hospital,  on  a  girl  of  16,  who  had  rectangular  osseous  ankylosis  of 
the  ri|rht  hip-joint.  The  patient  made  a  alow  but  a  good  recovery  with  a 
(traight  and  useful  limb.  There  was  no  attempt  at  the  formation  of  a  false 
joint,  but  consolidation  took  place  at  the  line  of  section. 

The  operation,  having  a  double  object  in  view,  viz.,  the  rectification  of  the 

porition  nf  the  limb,  and  the  establishment  of  a  mobile  false  joint  near  to 

the  obliterated  ilio-femoral  articulation,  was  thus  shown  to  be  practicable  ; 

Tel  it  had  scarcely  taken  a  place  in  surgical  literature  or  j>rncticc,  until 

Sayre,  of  New  Y<)rk,  in  18G2,  by  perfitrming  it  in 

two  cases  successfully,  brought  it  promiacntly  before 

tbe  Prufejtaiun,  and  thus  led  to  its  establishment  as  a 

KWpDiied  oj>cration  for  the  remedying  of  these  dc- 

fonaitie*.    Sayre  is  undoubtedly  entitled  to  the  great 

merit  of  having  established  the  operation  on  a  dis- 

tmct  principle.     His  object  was  twofold  ;  first,  to  go 

"^  the  trochanter  minor  in   the  section  of  the 

bjne.  JO  as  to  retain  the  attachnieul  of  the  psoas 

uJiliacus  muscles  to  the  sliaft  for  the  pur|inge  of 

inioa  ;  and  secondly,  by  cutting  out  a  sfmicin-ular 

piece  of  b<jne,  with  it.-i  convexity  upwHrd?,  and  tlien 

rounding  nff  the  upper  end  of  the  linvcr  i'rajrnn'nt, 

EDOre  nearly  to  imitate  the  natural  chape  of  the 

j-riul.  fur  the  purposes  of  motion  and  to  provoiit 

»lippin;r  of  the  bones.     Fig.  olM}  i^bows  tlie  situation 

anil  shajte  of  Sayre's  section,  and  of  the  jiifcc  nf 

bone  that  he  removes.     The  section  i>f  the  bi>iie  is 

efectel  after  its  exposure,  by  means  <jf  the  cliiiin  faw  ;  the  transverse  .section 

bein;r  first  made,  the  convex  one  ni-xt  '  Fiir.  ■'''*"  i, 

W.  Adams  hos  devis*'d  a  niucli  more  i^imjile  operation,  having  in  view 
the  same  objects.  Jlis  plan  h  to  divide  iIr'  nock  nf  the  thi;:h-l)'ine  ^tibnifa- 
neouf/i/  about  ita  centre.  Thi.-*  idea  lie  put  in  practice  in  l'e(vnil>or,  IftJi', 
whvn  he  [terfornied  the  first  sHhciitaneous  sectii»n  of  the  neck  of  the  ftinur 
frir  the  relief  of  dcformily  resulting  fnun  an^'iilar  ankvlosis.  Tlii:^  cipora- 
tjon  is  done  as  follows.  A  tenotome,  haviiiL.'  been  intro.)ueed  a  little  above 
the  top  of  the  great  trochanter,  irf  carried  straight  down  to  the  neck  ut 
the  femur,  dividing  the  muscles  and  ojK'ning  the  capiiule  freely.  The  knife 
being  vitbdrawD,  a  saw  of  this  size  (,Fig.  -jOS),  s<-t  in   a  strong  handle,  is 


i"fJi.  ■'''.'''. — LincB  "f  Sei'tion 
in  !?uyre's  Opfnitiun  fi>r 
Ank,vl'iBia  of  llip-jotDt. 


474 


DIBSABK    or    THE    HIP-JOINT. 


panvd  dnwn  to  Um  bone,  irhich  U  cut  through  fruni  befi>r«  fatckwrnrdi  i  FS( 
d91)>.  The  seotioD  of  the  bone  uikea  »  few  txiiuuk'».  uud  ii  w  owch  ui  mi  gJT 
BIEug  as  of  fnwiag.  The  wouoil  is  then  diwod  br  m  nad,  and  the  UbI* 
bruu^ht  £trai(>hi.    Bcforti  this  could  be  done  in  Aiuduts  fint  cam,  il  m 


Pig.  &tl7.— AppltMtlMi  ot  Cfckln  8«w  In  S*jt*'*  OpamtMi. 

neoeasary  to  divide  the  long  hesd  of  the  rectus,  the  adductor  lonitti».sad 
the  tensor  vagioie  Armori^  muscles.  In  perronuing  tbia  nfx-nitixn.  u  AifaiM 
jurtly  observes,  it  is  of  great  importance  for  the  Hurgeuo  to  '■  'ioil  lh» 

altered  ilirectiou  of  the  «liall  of  the  femur,  which   ib   obu  .<-tc<l  ■• 

well  as  llcjccd  forwards,  su  that  the  divisioD  uf  the  neck  ua>  W  mad«  at 


\ 


n(.  Its.— 4i*«  nad  in  AiUa***  0|i«miim. 


r>f .  AW.— A|^ll«ttU*»  or  !!•«  I*  Xm* 
ftf  ThlKk-b«K«  III  AUl^MtOfttham 


right  nnt;h»  Co  thv  axis  of  the  bone  and  not  iib1i()uvlr,  or  to  a  dtrMtna 
more  orU-es  jmrullel  tn  the  ehnd.    Aflcr  the  o|M:ratioa  in  Adatna'a  firat  < 
au  rudfavor  wiu)  iiuide  by  paisive  nintiuu  lu  nrt  a  lalst  Juiui ;  but  tfaia  ti 
unHUCOiwfiil,  the  attempt  was  abandoned,  and  the  limb  allowed  to  salt] 


DISEASES    OF    BURSJ. 


476 


ift  the  Bttuight  poeitioD.    Since  thia  case,  the  operation  has  been  repeated 
■McmfullT  bj  Adams  and  by  many  other  Surgeons. 

Xaande'r  preferred  a  chisel  to  the  saw  in  practising  osteotomy  of  the  neck 
rf  the  femar,  and  bad  much  success  in  the  operation  so  performed. 

Oo  comparing  this  operation  with  those  which  had  preceded  it,  by  Barton, 
StiTc,  and  others,  there  can  be  no  doubt  of  its  superior  simplicity  and  safety ; 

nid  although  it  is  perhaps  less  likely  to  be  followed  by  mobility  of  limb 

tku  Then  a  piece  of  bone  is  cut  out  by  Sayre's  method,  yet  it  must  be  ad- 

mxuA  that  not  only  is  a  movable  false  joint  of  doubtful  utility,  but  it  seems 

to  have  been  very  difficult  of  establishment,  so 

fim  u  the  tendency  to  bony  ankylosis  afUr  these 

■MioDt. 
Cnn-  or  SeiMor-le^ed  Deformity  is  cccasion- 

alJT  net  with  as  the  result  of  ankylosis  of  the 

hifKJ^HDti.    Fig.  600,  which  Clement  Lucas  has 

alloired  me  to  take  from  one  of  his  cases,  illus- 

tntta  admirably  the  peculiar  positions  assumed 

l^tbe  lower  extremities  in  this  remarkable  de- 

miitj.    Its  mode  of  origin  is  somewhat  obscure. 

Hm  view  to  which  Lucas  inclines  is  probably  the 

eorrcetone,  viz.,  that  it  is  due  to  a  gradual,  prob- 

altlr  nnconsciously  developed  action  on  the  part 

ct  th«  patient,  with  the  object  of  placing  the 

HmU  in  the  most  favorable  positions  for  pro- 

KKKioD.    One  leg  is  usually  affected  first — after 

k  time  the  other  follows.    Progression  is  from  the 

knemiot  the  hips.     The  two  limbs  usually  be- 

mnie  equally  affected — but  in  a  case  that  I  saw 

»iih  Tyson,  of  Folkestone,  tbe  lefl  was  crossed 

•w  the  right,  the  latter  being  nearly  straight. 

^Ixwlil  it  ^  thought  desirable  to  attempt  to  cor- 
net ihii  deformity,  an  an:esthetic  should  be  given, 

ur]  if  the  ankylosis  is  not  perfect,  the  adhesions 

Bust  be  bniken  down  and  tiic  limba  straighteiied. 

wv  the  neck  of  the  femur  <m  either  side  niiist  be 

dii^l,  and  the  limbs  brought  into  ptjsition. 


Fig.  GOD.— Cross-legged  Dcfor- 
mil;.     Ldcm'i  cue. 

If  the  ankylosis  is  ossc- 
cut  across  with  saw  or 


CIIAPTKK     LIU. 

IHSK.\SK.S  OF  SYN'OVIAL  MKMBEt.VNES.  AND  OF  MUSCLES. 


DISKASIH   or   lU'ItP-K. 


^E  burex  which  naturally  exist,  either  under  the  skin,  beneath  the 
"°*cle»tnd  ligaments,  or  around  tendcms,  are  subject  to  varioiiii  disfases. 
T°<»e  MCB  are  Hometimes  developed  from  continued  friction  in  cituations 
"ere  they  are  not  naturally  met  with  ;  thus,  fur  iugtiince,  bur?!!'  have  been 
'""fiat  the  projecting  point  of  ii  hump-bac-k,  on  the  prumiiuiit  piirli*  of 
"Ob-fect,  or  at  the  extremity  of  a  stiuup.  These  abnorniul  burse  al.-'o  may 
^*t<»M  diseased. 


476      DISEASES  OP    SYNOVIAL  MK1IURANE8,  AND  OF  UUSCI.K3. 


Sitnatioiu  in  which  Bnrsae  exiit. — Dursse  &r*  either  dee[^Heaie<l  or  euU- 
cutaneous.  The  dwp  lnird:i>  iire  as  »  rule  more  perfectly  develM))w,l,  olonwly 
rttembling  true  nvnoviaL  tac-s,  and  in  m:iny  places  commuaicaliug  witli  the 
cavity  of  a  neigiiborin^  arliculntion.  The  subcutaneoue  butBte,  situated 
over  promineut  booy  poiat.'*,  appear  io  be  little  mare  tbnu  ealarged  areolar 
spaceti,  and  »r&  la  mo«l  places  acijuircd  after  birth  a»  the  result  uf  frivtioa. 
The  folluwing  arc  ataoug  the  mu^L  important  ttltuatioas  of  the  bursu.  On 
tlie  front  of  the  neck,  according  to  Verneuil,  there  are  three  bureee,  one  in 
front  of  the  pomum  Adami,  one  iu  the  thvn>hyoid  space,  extending  to  the 
under  eiirface  of  ilie  hyoirl  hone,  beneath  the  stemo-hyoid  muBcles,  and 
another  above  the  hvoid  bono  botwccQ  the  gouio-hyoid  and  genio-byoglossua 
muacie  of  Ihe  op|Kiaite  sida^  Bonoalh  thct  ilclcoid  and  the  acromion  prooen 
is  11  large  bunia,  often  conimunicaiiiig  with  ihi;  fihoulder-joint.  In  the 
ncighborhooit  of  the  elbow  an;  »  large  HubctilJitioiiua  bun>a  over  the  ole- 
cranon, and  a  timall  one  b^utworn  tho  hiccpx  tnudun  and  tliv  bone  tinme^liaLely 
above  the  in^rtiun  nf  the  muaulc.  In  the  neighborhood  of  the  hip  are  throe 
barsiD  about  tho  grfat  trochanlor,  a  large  one  betwt-cn  it  and  the  gluceas 
maximuit,  and  two  smaller  aarji  |}et\T-ei?n  the  smaller  glutei  and  the  bone. 
Another  hiima  of  considerable  sirx;  lies  over  the  tnhorosity  of  the  ischium. 
In  front  of  the  joint  in  a  bursa  beneath  the  p»nas  and  illacus  muscles,  fre- 
quently commuDioAting  with  the  cavity  of  the  articulation.  In  the  netgh- 
biirhood  of  the  knee  there  are  two  bnr»ie  in  front,  the  bursa  patellie  between 
the  deep  fascia  and  the  bone,  and  that  bi^neatb  the  Hgamejitum  patellfe, 
between  it  and  the  upper  part  of  the  tubercle  of  the  tibia.  Occasionally  the 
upper  part  of  the  synovial  pouch  of  the  knee,  is  «but  off  from  the  general 
cavity  of  the  joint,  and  forms  a  separate  bursa  beneath  the  extensors.  In 
the  bam  there  is  a  large  bnrwi  belweon  the  inner  condyle  of  the  femur  and 
the  gatitrucnenuus  which  frui(uently  citiimuulcutcs  with  the  joint,  a  nirailar 
smalh-T  bursa  uu  the  outer  side,  nn<.>ther  between  the  bicL>|M  tendon  and  the 
exlurual  lateral  ligament,  and  otht-rs  beneulb  the  seiui-raciubrauusus,  the 
popiiteuE,  imd  the  eurtorius,  gmcilis,  and  semiteudiuoyus — between  Iheoe 
mucetes  and  the  bnne.  At  the  het;)  tliere  is  a  large  bursti  between  the  tendo 
AchillLs  and  the  os  ralfia.  The  above  bunste  are  all  well-developed  and 
constantly  present,  and  ore  those  moat  liable  to  disease ;  but,  iu  addition  to 
these,  a  number  of  leas  perfectly  formed  auboutaneous  sacs  are  met  with  in 
■H  parts  of  the  body.  The  moet  important  of  these  are  in  the  following 
situations:  behind  the  anglo  of  the  lower  juw,  on  the  eymphysts  of  the  cbin ; 
on  the  acromion,  the  external  and  internal  condyles  of  the  humerub,  the 
styloid  proccBBee  of  the  ulim  and  radlut^;  on  the  dorsal  surface  of  tbe 
metacnrpo-phalnngeai  articnliaicn^  au<l  on  the  dorsal  aspect  of  the  phalan- 
geal articulations;  on  the  anterior  superior  spine  of  the  ilium;  on  each 
condyle  of  tho  thigh-bone,  the  tuberosity  of  the  tibia,  the  two  malleoli,  the 
dori^al  aspect  of  the  toes,  and  on  the  plantar  aspect  of  the  heads  of  the  first 
and  linh  nienitarsnl  bone#. 

Morbid  Alterations. — The  continued  irritation  of  bursiehy  the  pressure 
that  is  exercised  upon  them,  may  cnn^  them  to  Inflame,  to  enlarge,  to  be- 
come thickened,  or  to  undergo  various  other  changes  In  structure.  This 
enlargement  of  the  biir^c  in  particular  situations  is  oAen  connected  with 
special  omploymenl«,  by  which  continuous  and  severe  preftsurc  is  exercised 
upon  certain  part*  of  the  body  ;  thus  frequent  kneeling  will  occasion  enlargo- 
meat  of  the  bursa  patelln,  hence  called  "housemaid's  knee;"  mincra  are 
oocarionally  subject  to  an  enlargement  of  tbe  bursa  lying  over  the  olecranon, 
hence  calt<^  "miner's  elbow"  (Fig.  601);  and  wcavc-r*  to  the  sonie  condition 
in  that  over  the  tubcroiuty  of  the  ischium,  giving  rise  to  "  weaver's  bottom." 


XORBIS   GHAirO£S   IN    BUBS^.  477 

Th«  6Tfl  following  pathological  conditioDS  maj  occur  in  the  bursie  in  any 
p&n  of  the  bodv : 

1.  The  bursa  maT,  in  consequence  of  continued  pressure  or  irritation, 
become  Bimply  enlarged  and  filled  by  the  excesaive  secretion  of  a  clear, 
nur-colored  seroos  fluid. 

2.  Inflammation  may  take  place  in  the  bursa  with  or  without  previous 
alargement.  The  inflammation  bo  set  up  speedily  runs  on  Co  suppuration  ; 
tod,  when  the  tumor  is  opened,  fluid,  consisting  of  an  admixture  of  the 
Imnal  secretion  and  pug,  escapee.  The  bursa,  when  tts  contents  have  sup- 
puited,  may  either  give  way  externally,  pointing  like  an  ordinary  abscess, 


Fig.  001. — Gal»rK«d  BuMk  over  Olecranon — Miner's  Elbow. 

aoo  the  integuments  covering  it  sloughing ;  or,  the  pus  may  escape  subcuta- 
neouly  beneath  the  deep  fascia,  and  form  a  widely  spreading  abscess  around 
ibepvt. 

3>  The  enlarged  bursa  may  contain  a  dark  fluid,  usually  of  a  brownish 

M^,  with  a  la^e  number  of  small,  flattened,  elongated  bodies  of  about  the 

>»  of  grains  of  rice  or  of  melon-seeds,  floating  in  it.     These  bodies  are  of  a 

■broid  structure,  and  their  mode  of  origin  is  not  certain.     They  have  been 

iippOKd  to  be  formed  in  some  caees  by  a  fibrinous  exudation  into  the  cavity 

of  the  bursa,  their  i>eculiar  form  being  the  result  of  the  movement  of  the 

put.    In  other  cases  they  have  been  suppoi^ed  to  arise  from  villous  growths 

HBiilar  to  those  observed  in  the  synovial  meinbranes  of  joints.     That  they 

may  be  formeil  from  extravasated  blon<l  8li;i)  ^eenis  prubable  from  the  fact 

that  S.  ti.  f?hattock  has  discovered  crystnis  of  hajmatoidin  in  some  of  the 

Ntecimens  in  the  museum  of  University  College.     Tlie  fluid  is  sometimes 

A>und  to  C4>ntaiu  chotc^terine. 

4.  The  wall  of  the  burea  may  gradiiiilly  becoiiie  thickened  by  a  growth 
of  dense  fibroid  tissue,  until  the  tumor  bccimieiii  perfectly  stilid,  or  at  most 
a>ntains  but  a  small  cavity  with  a  little  serous  fluid  in  its  centre.  The  sec- 
tion of  a  bunia  thus  solidified  presents*  a  Iniiiinuted  or  fuliuted  iippearance. 

5.  Occasionally  in  gout,  bursie  may  bcciniie  the  sent  of  a  deposit  of  urate  of 
loda.     This  is  most  commonly  met  with  in  the  bursa  over  the  olecranon. 

The  symptoms  of  the  disea^ts  of  hursiL'  in  frent;ral  will  be  best  studied  by 
ootuidering  them  a^  they  occur  in  the  burnu  [lutelhe,  which,  from  its  expo^d 
lituation,  and  its  liability  to  injury,  render  it  more  prone  to  boccmc  diseased 
than  any  other  similar  structure  in  the  body.  I  shall,  therefore,  first 
dcacribe  the  symptoms  and  treatment  <>f  tliat  bursa,  and  subscitiiently  briefly 
allude  to  the  similar  morbid  conditions  in  some  of  those  situated  in  other 
p«ru. 


478      U18KASE8  OF   SYNOVIAL  1IEHSKASR8,  AVI>  Of  JttlSCLU. 

DtsEABCs  OF  TiTB  BvBBA  Patkll.c. — The  TarioQi  afloctioiu  to  wbiflh  lb 

buna  u  liiibl«,  may  be  diviilcd  into  iwu  cla*K«:  1.  luBamnulory  aSMCicai; 
and,  2.  lOiilarKL-iueiilft,  <j|'  a  6uUl  or  of  a  solid  cimnicter. 

1.  Inflammatory  Aifections. — TtiU  Uuna  Li  IVv^ueuily  Ibe  oeat  of  Simfit 
Injluwmiition.  Uii'tue  ]>re«i]rt:  in  kne«liii{^  ujxjq  u  bttnJ,  irregular.UMl  cm 
surface,  sucii  *»  tfk<ue,  b  likely  lo  excite  iudaiiiinaUun  ;  ii«ace  ita  frei]VCMj 
io  Uoui<«ii]uiila,  wh<>9e  occupatiuu  ubiigoa  llieiii  to  knuel  a  ifrtMt  d««l  oo  Aoun 
uod  GloiK*  steps  ;  and  licDt-c,  ulsu,  lliu  coioiuun  tille  t^t  "  avuMaiaid's  kam,'^ 
given  u>  tliia  and  to  many  (ftbur  ufTectiona  of  tlu»  bum.  But  Ifaia 
alchougli  fre<iuent  among  tiuuaomaids,  is  not  liiniled  to  tben;  for  it 
Id  females  folluwiog  oiber  tKH;u|>atii)US,  aud  iu  nicu  si^  well  oa  in 

In  aioiplo  influuiniatitiu,  bowever  Mtcaainned,  tht;  buna  baeocD«a  mW 
suddenly  ewullen,  tense,  red,  and  hot,  wiib  aome  fluctuation  deeply  uoia 
tbe  inlfgiimenla.  The  flwolling,  hmt,  fluctiiaiion.  and  redacaa  nr  a  doikj 
color,  alt  EJluatc'd  in  front  of  the  patPlla,  poiototit  the  nature  of  ibcaffwliv. 

The  'IVeahnenl  of  tbiti  inllamriiatiiiD  ib  aiiu|it(>  cmtugh.  Loecbea,  fuJIvnd 
by  eTaporatJUK  I'ltions,  anrl  keeping  the  patient  at  rest,  nrr  the  m— na  H  b 
•mployctd.  tinder  thie  trt^atmont,  the  dineaae  trill  frequently  uttierpt 
reeolutinn  in  the  cour«o  i>i'  n  few  daya.  It  mav,  however,  ga  atx  !»  •uMw- 
ration,  and,  in  rare  casea,  to  diseaae  of  the  patefla  itaelf.  or  aluugblng  or  tht 
bursa. 

Sujijiiiralion  of  the  fiumi  occurs  iu  perhap«  the  rnajoritT  nf  eaaea  of  acoli 
inflauiniBliiiii.  Thi«  is  n  iiiall4.>r  uf  great  rnriMqttPure  -.  b^cauaf  th»  ■rcuae> 
laticm  of  pue,  being  of  targe  t>ize,  and  tending  to  diS'itae  itiirir  nntuud  the 
kne»-joiut,  is  liable  to  Iw  mtelakeu  tor  al)«ceaa  in  that  articulation,  t^ne- 
timee  it  wilt  \mnt,  and  the  pu»  discharge  itself  extvrtuUly  tu  tbe  utuaJ 
manner;  but  very  generally  it  givve  way  Rtibeutaneoualy,  invariably  to  tha 
outer  aide  of  the  nut',  and  it«  voutcuta  spetKllly  dilliiae  th«tnwlvw  widely 
around  the  joint  beueulb  the  luKcia  lata. 

The  biatory  of  the  case  atlurds  the  means  urdiagnosw.  In  aupparatiaa  «( 
the  buna  pntulla-,  the  ab&ceas  conimeuoes  by  a  supertlcinl  nwvlliog  asd 
inflammation  in  front  of  the  knee,  which,  adier  a  time,  cxtcndj  UUmBt. 
enveloping  the  joint,  the  fluid  gr»viljiling  on  eai;b  aide,  but  more  eintdaSr 
oo  the  outer  one,  nearly  aa  far.  {wrhnp,  as  ihv  hamilxiogs.  There  will  haft 
been  none  of  the  signs  indicative  of  acute  arthritis  accompunyiog  tba  ftiva- 
tion  of  this  large  abecem;  nn  startinga  of  the  limb,  no  laxitv  arfatm  in 
mtnring  the  articulation,  uo  grating  of  the  urticulnr  ends;  and  liule,  if  aay. 
oonatJtuiiooal  dieturbancc  The  movements  of  flexion  and  exCenaioo  of 
joint  are  free  up  to  n  certain  point,  where  they  are  checked  by  tb« 
obatacto  of  the  purulent  accumulation.     But  the  moAt  importani 

ugQ  ii  the  relation  of  tbc  abaooas  to  the  patella.     In  a  supnaraiing 

Ebo  patella  ii  invisible,  being  corertd  by  tbe  fluctuating  swellin];:  in  eibtioa. 
whether  avnovial  or  purulent,  int^j  tbe  joint,  ibo  patella  ii  above,  fluaiinf 
upon  tbe  duid. 

Tbe  IVeatmeMt  of  this  condition  is  simple  enough.  A  (rtm  inciiioB  bmk 
be  made  to  let  out  the  pus,  and  ibu  sbnuld  be  done  if  poMible  before 
abaoCM  baa  extended  beyond  the  natural  limits  of  tbe  bursa.  Tb*  In  ' 
t'^  UBitnlly  mmle  in  the  middle  line,  but  hotlT  drainage  is  obtained,  and 
«L*nr  over  tbe  knee-cup  avoided  if  the  iHi:iitioii  Ih<  made  al  the  outer  aide.  Tu 
do  tliifl.  a  very  small  puncture  may  be  made  iu  front,  and  a  probe  iotrodMad, 
the  [xiiut  tif  which  may  be  made  to  project  at  tlie  outer  limit  of  the  caTky. 
Tbc  probe  may  tbcu  be  cut  down  upou,  and  a  drainage-tube  IntruduiW,  tM 
anterior  puncture  being  allowed  tu  eloae.  If  tbe  abeceaa  be  of  euuaidi 
stie,  an  incision  must  t»e  madu  on  each  side,  care,  of  cuuree,  being  taJun 
to  cut  su  deeply  tui  to  injure  tbe  cafwulc  of  the  joint.     If  antlaoplie 


OISBASKtf  or  TUK    BURSA    P ATELL^—KNbABOEMKNTS. 


art  takflD,  it  is  iiec«Hary  only  to  niuke  an  opening  of  euffioicnt  size  to 
adjoil  a  dimiiuige-tube,  butuixler  other  circiirastaDoes,  the  incision  raiiiit  he 
mock  won  fna.  Tbe  burrowing  beneath  the  inscin  lata  that  not  tinfre- 
^jMOthr  fhUows  sfaioeai  of  the  bursa  patellic,  ie  due  lirAt  to  not  opening  party 
•aooffa;  BMaRdly.  to  ioaudicient  draiiinge;  niiil,  thinlly,  to  iIefomiv»itioD 
of  lb*  «fi»eh>rgc8.  and  cannot  be  regarded  as  an  unavoidable  accident  of 
Slwcwe. 

Btoeii  of  the  FatalU.— Somclimw,  but  very  rarely,  BbAcew  of  the  bursa 
fldbt  will  giv«  riM  lo  disease  of  the  patella  itaelf.  Caries  of  ihia  boue 
■ewindtry  to  luppuratioo  of  the  burw,  ii,  eo  lar  05  my  exj>erieuce  goes, 
ttxaMdiBgly  rare.  I  have  k«d  one  case  of  the  kind — that  of  a  woflian  who 
wtta  ia  t)i«  UuApital,  under  my  fare,  several  yeara  agii.  When  adiuitled,  she 
bfttj  Mferrral  fistulous  u|ieuinga  uo  the  forepart  of  the  kuee-joiul.  through 
*~  '  [irobe  led  down  lo  a  rough  and  oartiiuii  iwlella.     On  iut|uiry  it 

«^  .hum)  tlial  she  had  bad  iotlanimfllion  of  ihe  burnt  )Nitella! — "bouse- 

aaiil**  kuee" — which  had  run  on  to  ftujipunitiou,  but  tbut  the  abececH  had 
pwr  been  frvelr  laid  ojieu.  The  present  condition  bad  resulted  from  that 
aappaiBtioD.  I'lie  joint  itself  wait  uiialleoted  ;  there  was  no  pain  in  it,  and 
ilk  nMTntKaU  were  perfectlr  (nv.  I  laid  open  the  sinuses,  and,  finding  the 
•alMipr  surijic«  of  the  patella  sofl  and  carious,  i-ciuove<i  with  the  gouge  tbe 
dMaanl  bone  to  which  they  led.  About  tvo  or  thn-e  woeka  after  this,  the 
jaiat  bceatoc  suddenly  vwollen,  evidently  filled  with  pus,  and  theeeatof  aeute 
ftin.  In  ci)DK^uent.-v  uf  the  severity  of  tliv  symptoms,  it  ))ec>nme  necessary 
to  rrmoTr  the  limb  nbuvc  the  knee.  After  am|>ut4itinn,  it  was  f(kund  that 
the  dimww  had  <'xtt-ndrd  through  the  ]uLtellar  (iirtilage,  perforating  it  bv  a 
naall  aperture,  and  no  given  riw^  lo  suppuratiun  within  the  joint 

fllMxgfclog  of  the  Bursa  Fatelhe  oceaaiotmliy  ncfun*  n»  the  reauli  of  iu 
inflainouti'in  and  hiippumiioii.  A  woman  wait  admitted  into  tbe  HiMpital, 
in  wboiu  (bu  bursa  had  iuBamed  and  Buppurated  ;  and  tioc  (*uly  the  bur&ie 
bot  abtt  tlie  intcftatnenta  covering  ic  ha<l  alnughed  nway,  leaving  in  fnml  of 
tba  kxiOb  a  cirt-uliir  nUer  ai*  large  as  the  palm  of  (he  hand,  having  a  flabby 
«iirr>rrnii>t  undermined,  purple  edges.  The  patella  was  not  expceed.  Under 
•  ■  :-.^tiiii.-iil,  tlie  nicer  slciwly  healed. 

- — LTgementa. — We  now  pnx^ed  lo  the  consideration  of  tbe  second 
'  <  n  ;r  of  diaease  of  the  burea  patelhv — that  in  which  there  are  no  evident 
rtfua  of  ioBammatioo,  but  in  wbich  there  ti*  enlargement  of  the  bursa,  owing 
1m  Uw  accomulnlinn  within  it  of  bursal  tluid,  of  this  fluid  mixed  witJi  solid 
hodiw,  or  of  s»lid  fibniid  depont*. 

&a^  Enhryrfntml.  or  Dropty  of  (Ae  liwm. — The  bursa  raa^  jtresent  a 
sMpIt  aalantaaeot,  dependent  on  the  accumutatinn  of  fluid  in  itA  interior. 
OniiBlMd  pruwiro  exareMtd  upon  the  burea.  as  iu  kneeling,  is  the  common 
CHlBe  nt  tlus  aAction ;  hence  it  t're<piently  occurs  amongst  houeeniaid.'i,  and 
i—lltulia  tbe  troe  "housemaid's  knee."  But  it  ii-  a\m  coramon  amongst 
atkar  pcopla,  whukc  vocation  neoeHitatea  long-ounlinued  kuecline.  One  oaae 
itf  lb*  afinciuo  in  I'niveniiiy  Oollcge  Hcepital  wae  in  a  cjirpot-biyer;  it  was 
la  all  iaienla  aikd  purposea  a  "houBcmaid's  knee."  A  mau,uge<l  thirty,  who, 
la  eoMaeooHwe  oi  haoitually  kneeling  ufMiu  the  left  knee  in  laying  duwo 
(mrpMa,  had  a  tumor  there  ua  large  aa  an  orange,  indolent,  f.n(t,  and  ducin- 
ai'— _-  •■'■■■'If  AD  enlarged  bursa,  was  admitted  int^i  the  no«pital.  It 
«  tneani  of  a  trocar,  clear  fluid  was  drawn  off,  and  a  setun  «hb 

|M«-T  ■!  \  the  r-anulu,  and  k'H  in  tor  5ix  or  seven  day».     ^ppuration 

bfok  {  liL'  the  ftrton,  the  tumor  collapiied  and  coiilractotl,   and   the 

p»Hrr'  n  :I   cure<l,  on  the  twolnh  day. 

The   .  :-  tumor**  i:4  very  simple.     If  the  eflbsion  haa  taken 

pltae  w*fBfeAbai  mpidty,  and  dUtioctly  io  conuection  with  some  injury,  the 


480    oi8i:a.sb8  of  syxovial  u&uiiZASzs,  x2to  or  xomlu. 

apjilictttioa  of  tiocture  of  iodine,  or  a  blister,  wUI  saccsod  in  indocsBy  ftfaan- 
tiuu  111'  tiit>  L-DiiUtiiii'il  UukI.  Wliru  tliv  iti»i>arw  b  inore  citruoic,  tbaa  aaallj 
tail.  Tlie  tluid  may  th<jii  U>  wiUnlrawu  liy  uieans  of  the  aapirslur  aod  pn*- 
BureupiilkHl  with  an  Iiiilia-rubbt-r  buiiilfi^v.  If  tliuiduea  not  Aucctwd.  m  wpk 
au<l  siicuuasnil  uxvUe  of  trcatniiuit  u<iiitii8U>  in  mmiing  tiiu  mc  wiUi  m  trudr. 
liod  jiaasing  a  setua  lliruugti  the  uuiuIh,  vhlivr  by  tueou^  uf  a  l*Ktg  »umi(k 
nMdio,  or  by  uaing  an  eyed  [trubo,  and  uuiliu^^  ilitwn  ii(i»d  tbe  fod  uf  H  «uk 
a  scapel.  The  ecton-Lhreadfr  should  be  lefl  iii  uuUI  ihuy  excite  free  tappm- 
tiun  and  theu  he  wiUidrawa.  Tho  only  rok  of  Una  icvulmcut  is,  Uut  mat 
piu  may  fona  than  caa  readily  draia  away  by  the  otierturen  ihruu^b  wUdk 
the  MCou  p«!iHca,  and  cuDW^jucDtly  a  scpLio  abtceaa  uf  tbe  btina  inay  nmh^ 
requiring  a  free  incision  for  iu  relief.  In  onlcr  to  avoid  ihia  ri*k  aotitoptic 
drainage  may  be  aubtttitutcd  for  the  leton.  A  unall  puncture  it  made,  ud 
au  Iiidia-rubbcr  drainage-tube  inaerted  with  all  antiMptic  pr«cautia«c  b 
many  ciuen  a  week  or  ten  days'  drainage  will  suffice  to  correct  tho  tcnimcj 
to  orersecrelion  without  any  infiamiuaUoa  or  (uppiiratiao  being  set  ap.  IW 
racolt  is,  however,  made  more  certain  by  exciting  a  slight  de^nM  of  lim^ 
iuEUmmattoQ  by  iojeotiag  the  carity  at  the  time  the  tub*  is  in—rtwl  wilb 
carbolic  acid  lotion  (1  in  SO),  or  K^lutioD  of  chloride  of  lino  {^20  gr.  la  $< 
or  liuclure  of  iodioe. 

Chronic  Enlargement  frith  KelOQ-seed  Bodies. — Tbe  next  uSttHim  to 
which  tbe  bursa  patellie  is  liable  is  cloeoly  allied  to  tba  kit,  mkI  appMii  Is 
be  au  advanced  d^ree  of  it.  It  consists  in  a  cbrooioonlargciiMCitor  ilia  baa*. 
Um  oottta  of  which  are  more  or  less  tbickeosd.  Tbe  couteata  <if  the  buH. 
6o  enlarged,  consist  of  a  dark  lluid,  in  which  float  a  number  of  aniooib  oni 
bodies  of  clio  size  and  shape  of  melun-eeeda.  I  have  seen  this  coadiiiaB  n 
both  the  male  and  the  female.  It  may  liedistinguislied  from  stmpUi  colarf^- 
mcnt  of  the  burem,  by  the  peculiar  rrarrkling  ecuaatiun  which  ia  cuauaaAh 
oated  tu  the  baud  wIil'ii  tht^  tumor  'u  luanipulaied.  This  ariim  from  tfas 
melon-eeed  borlies  floating  uIhiui  uinl  nibUtug  aguiiut  each  otber. 

Tbe  Trfifitmrni  of  tbid  at)i.-ctiun  cousiitte  in  tiiukin);  an  inciaton,  with  aali> 
septic  prevail lionn,  free  enough  to  allow  tbe  mel<iu-.«<'e>l   b<idit»  1*^  pus 
The  C-Bvity  may  then  be  syringed  out  two  or  ibrce  timra  with  <■ 

lotion,  U>  iiMure  the  removal  nf  all  the  solid  bodies ;  a  draioai;-  

inaerlcd  aud  relaineil  for  a  neck  or  ten  days,  tbe  wound  lietng  tnwlad  hf 
some  form  <>f  anti^pUc  dre«stng. 

Solid  Tumors  may  be  formed  iu  conoection  with  ibo  bur>a  paflW-  Br 
many  tbe^  an-  etipposi-d  to  be  tbe  rvsult  of  a  di^pwilioa  of  a.  Iibr>>id  malcrial, 
which  graduully  takes  the  pbice  of  the  fluid  of  att  urdtoary  "  hintaeuaid** 
knee,"  uud  which,  luBload  of  taking  tbe  form  of  melou-««cd  bodiea,  is  d» 
poeiled  iu  cooceutrio  nuuaee,  and  thus  accumulated  in  the  interior  of  tbe 
cyst.  This  has  uul  been  tbe  vtuv,  howt-ver.  iu  maiir  iualancee  that  I  bate 
seen.  Iu  these  cases  I  bvlivve  tbtre  in  a  truu  Sbroiti  growth  in  tbe  watt  ft 
the  bursa  from  tbe  very  tint ;  the  tumor  is  uever  fluid,  but  bard  and  wbi 
from  tbe  cumiueucemcut,  uud  iMUtinutu  slowly  to  aui^meut  in  site,  until  ll 
occasions  sufficient  iuoonveuit'nt.^  to  require  rumovai.  Iu  aotoe 
has  been  a  previoiu  bypbiiiiie  taint;  the  patient  complains  of  pain  l 
lumor  like  that  whicb  is  exfierieuced  in  n«MK-s.  and  it  is  by  no  omu 
poMlble  that  there  may  be  a  Bvphilitie  origin  for  theae  tumon.  Hu' 
that  may  be,  in  the  caM»  that  nave  fallen  under  my  ob«ervatiiHi,  tbe 
have  never  been  fluid,  nor  have  they  originated  in  pmsurv.  but 
have  been  primary  depositaof  fibroid  matter. 

IVtatnent. — There  \s  nothing  to  be  done  with  such  tumors  but  to  di 
them  out.    This  may  l>e  reipiired  in  one  or  in  both  knees.     With  the 
ordinary  care  the  jomt  runs  uo  riak  ;  but  much  iniuble  may  artse  from 


D1SBASBS    or   OTHBR    BUR9.«. 


log  up  ttiut  liiyer  of  deep  fiisciu  whicit,  afler  i^urnMimliug  the  knee,  is  flxed 
to  the  hfinlvrs  of  the  imlelltt.  ir-iicli  an  accident  is  Liable  to  be  followed  by 
infiltration  ami  deep  uliei;efiH  in  the  bain,  uiilew  careful  attenttnii  be  paid  to 
<Iniiriagf>  and  to  the  preveiiitoii  nrdectimmteitiou  in  the  dischargee.  In  order 
W  provide  more  effifient  drainage,  it  will  often  be  Ibiind  convenient  to  re- 
aM(Te  the  tiimnr  byaciirved  incision  at  theonter  border  of  the  tumor  iuatead 
of  in  the  middle  line.  This  plan  has  been  repeatedly  tried  in  University 
College  Huepiial  with  the  l>est  resulta, 

DieKAsn*  OF  OTiicK  Buiw.i;. — The  diseasea  of  the  Bursa  Patellse  being 
taken  as  the  type,  the  atfectioits  of  the  other  more  important  bursic  require 
to  he  but  briefly  ntlude<l  to. 

Enlargement  of  the  Pre-hyoidean  Borea  or  of  that  between  the  gcnio- 
hvuid  niu^cic-d  is  not  very  uiicomnion,  tbrraing  a  Inr^e,  thiu-walted  tluctuat> 
iog  tumor  in  the  front  of  the  neck  and  beneath  the  cbtu.  When  [he  bursa 
btlwecn  the  gcnio-hyoid  musclcB  is  the  seat  of  dUeaee,  the  cvat  may  puah 
Qp  into  the  fl.mr  of  iho  mouth  between  the  gcniohyogloesi.  When  the  pre- 
hyoidean  bursa  is  aSvcted  tbe  cyst  tends  to  extHud  downn'Ards  over  the 
larynx,  formiDu  uoe  of  the  varietiea  of  the  so'caUed  "  hydrocele  of  the  wrck." 

TmidfMTi/.— Theae  cysia  can  iisually  be  cured  by  tapping,  with  injection  of 
cbtortde  of  zinc  or  tincture  of  iodine,  followed  by  atitioepLic  drainage.  The 
■alls  are  too  thin  and  their  attachments  too  deep  to  make  it  advisable  to 
attempt  their  removal  hy  diswction. 

The  Bona  beneath  the  Deltoid  is  not  uncommnnly  enlarged.  The  sfTec- 
lion  assumes  ni'.>.<t  frec|Ufntlr  the  form  of  simple  chronic  enlargement  with 
i>r  withmit  the  presence  of  melon-seed  bodies.  It  forma  a  rounded  sweliing, 
causing  prtiminence  of  the  deltoid  with  distinct  fluctuation.  The  Trualawnt 
i-oDsista  in  as|>irHtion  and  blistering.  Should  this  fail,  or  should  the  aofi 
i-racktiug  on  movement  abow  the  preeencc  of  melon-seed  bodies,  an  iucisioa 
mav  be  carefully  made  at  the  most  convenient  spot,  and  the  sac  emptied 
au<i  drained  for  a  week  or  ten  days.  Thiit  operation  nmet  not  be  undertukca 
without  due  consideration,  and  muat  be  performed  with  the  strictest  anti- 
aeplie  precautions,  as  ihe  hunui  frequently  communicaue  with  the  articular 
cavity,  and  any  septic  proceea  oouurring  in  it  would  aim(«t  certainly  lend  to 
deatructimt  of  the  shoulder-joint. 

The  Btirta  over  the  Oleoranoa. — ^Iiiflammatinn  in  this  bursa  ending  tn 
suppuration  is  a  common  result  of  falls  on  the  elbow,  with  or  without  a 
wound.  It  causes  severe  pain  and  redncsit,  with  cudenm  cxteudltig  a  long 
way  above  and  below  the  jidnt.  The  pus  may  burrow  uotuc  distance  down 
the  forearm  unlena  early  nieasuroji  he  taken  to  prevent  it.  The  indamma- 
tiun  very  rarely  extends  to  the  elbow-joint,  but  superficial  nccroaia  of  the 
olecranon  sometimes  occurs.  Chronic  enlargement  with  some  thickening  of 
the  wnlls  forms  the  affection  known  asi  ••miner's  ell>ow."  Solid  tumors  of 
the  bursa  are  rare.  It  is  not  uncommon  to  find  the  bursa  the  scat  of  gouty 
depoflita.  The  Treatment  of  these  affections  is  conducted  on  exactly  the  same 
principle  nn  in  the  correspond i op  conditinns  at  the  knee. 

The  Barsn  abotit  the  Trochanter  Major  are  occasionally  the  seat  of 
chronic  inflammatory  enlargement  or  dropsy,  and  of  acute  inflammation 
terminating  in  auppuralion.  The  latter  condition  is  of  great  importance 
fn>tii  its  aimulftiing  nip-disease,  or  sometimes  causing  it  by  implication  of  the 
joint.  The  diagn<i»iii«  can  be  made  only  by  observing  that  the  characteristio 
deforniity  of  the  hip  is  nWent,  and  on  opening  the  abscess  the  linger  >iill  not 
b«  »hle  to  detect  either  di»-»«(.-d  boue  or  any  connection  with  the  joint.  The 
treMlmt'iil  ib  vunducle"!  on  nrdiniiry  [>riiicipiL-s, 

'L'lie  Bursa  over  the  Tuberosity  of  the  Isohium  is  sometimes  enlarged, 
forming  the  condition  termed  "  Wuuver'e  bottom."     The  enlargement  is  oileu 

TUU  11.— 31 


I 


482     nisEASKSOl 


iMBRAHKS,  AXO  OT  MUSCLU. 


solitt,  aD<J  may  cauee  great  dmcomf^jrt  in  lilting.     Uoder  tbcMdrmMMlUHM 
tl  may  l)p  sali-'lv  remuved  by  tlic  kiiifi-. 

Tliv  Sar»a  beneath  the'  Pkoai  is  rarely  enlarged,  but  caaw  luive  bm 
rctfitrdtd  ill  v\  liicli  ductuutiti);  luniun,  coutaioiuj;  eeruus  duid.  kavv  Imoi  ttit 
with  lu  tlie  ^ri>iii,  uud  liave  been  Buppiwvd  Ui  have  ariseo  in  tJiis  wftjr.  TImi 
tuniitni  an-  iW|iiy  wated,  and  cli«cly  rraemhle  paou  absceMn :  thev  btCMw 
tense  ubt-ti  llif  thtgli  is  exl^iidt^l  and  lax  during  flexioo.  Tbvir  true  Dttaiv 
can  b«  afirertaiiietl  unly  by  the  use  uf  the  aapiralor.  'They  miwl  be  trialrf 
im  ihe  priiiriplt^  alreaily  laid  down,  but  the  frequent  conimunicaUeo  of  lUi 
bursa  with  tbc  hip-Joint  iriimt  be  bnriie  in  minH. 

The  Barete  in  the  Ham,  e«|>ecially  that  beneath  (he  inner  head  of  iW 
gaslritcneniiiia,  not  iintrei|UHntly  Iwcome  enlarged.  Their  walla  btcot 
alightlv  ihickt-ned.  but  nii-iuii-lH<dies  or  Milid  enlargement  are  rare  Tbt 
diet<--Hdi-d  burtrn  forms  a  ftuctuating  Ewetllng,  whirh  becomet  tnim  dariag 
extension  of  the  Joint  and  ]ax  dunng  flexion.  There  ma?  be  aoaie  aligbt 
pulftatioD  eumniunicated  from  the  popliu-a)  artery,  and  toe  swrlltng  nay 
thus  rewmble  an  aneuriani,  but  the  ptilMtton  U  not  t:x{i«DHile,  and  tb«  tuaxv 
does  not  dimiuiBb  in  size  uii  uonipn-saiiig  the  femoral  artery.  Sometimw  by 
firm  prewuru  the  cyst  may  be  made  (itirtially  to  empty  itself  into  thi  knvr, 
the  Hgne  of  fluid  in  the  joint  then  becoming  apparent.  Tbve  eolarpd 
bunne  in  Ibe  ham  usually  cause  but  little  pain.  Tbe  skin  ooveriog  tbt 
■welling  is  normal  in  appearance.  Tbe  Trtatmenl  must  be  conducted  witb 
caution,  owing  to  tbe  close  proxiniily,  if  not  actual  commoDtcatioa.  of  tbe 
bursal  tumor  with  tbe  juiat.  Pattiting  with  tincture  of  iodine  and  bliatering 
with  elastic  prasure  may  lirftt  be  tried;  if  that  fails  aspiration  folluno 
by  prraiure  may  be  tried;  if  that  ib  not  suconBfuI.iDJectioD  with  iodine  may 
cure  ihe  disease.  When  everything  else  has  Jailed,  ontiMptia  drama)^  irili 
UBually  effect  a  cure,  la  one  case,  after  evvry  other  Dtmie  had  tailed. 
JohnKMi  i^iiiith  successrully  diseecte^l  the  cyst  out.  Icavlog  tbe  pedicle  wfaiofa 
pnrwid  andcr  the  gastrocnemius.  Tbe  operallnn  was  pmarmcd  uoder  tl* 
carltolic  spniy,  and  ibc  wound  treaud  antiH^ptieally. 

The  Bursa  beueath  the  Tendo  AchUUt  at  the  bod  in  sninetiiDea  dit*in*l- 
II  furiiMi  a  fluctuating  swelling  ou  ench  eide  of  the  teodun.aod  may  HDillali 
dtsvAMC  of  the  aitkle-joint.     liie  treatment  presents  untbiog  peculiar. 

Bunion.^  When  the  bursa  which  lie«  towarda  the  plantar  tur&ee  of  ike 
head  of  the  raelatansal  bone  of  the  Krenl  toe  becomes  enlarved,  or  ^la 
a  new  mc  is  formed  upon  tbe  inner  ana  poeterifir  aspect  of  this  none,  thedb- 
ease  termed  a  bvnioH  occurs.  In  this  flfrecti'in,  the  cnlorgemeiil  of  ihebwrn 
is  usually  Mcondary  to  an  alteration  iu  the  shni«f  and  p(«itJon  of  the  gnu 
toe,  wbitfh,  JD  consequence  of  the  pressure  of  [)arroM-|>oiiite(i  bt<AU.  has  ma 
thrown  uulHardfeiD  an  obliq4ie  direclion,  sitas  lu  liu  over  or  under  some  of  ite 
contiguous  digits  (I''ig~(i02.i;  in  thii  way  a  sharp  angle  is  furiued  at  ttiejl 
tion  between  tbe  timt  phalanx  aod  the  metatarsar  bone  of  iho  great 
This  angle,  being  constantly  presevd  upon  by  tbe  boot,  bn-nuie*  irritatid; 
aod,  for  il-1  prtitectioD,  the  buf»&  that  i*  llierc  naturally  situated  becu«a«» 
•nlargeil,  ur  an  ai'lveniitioui  one  forms.  From  time  to  time  the  bursa  uid  lh« 
projecting  angle  bveomv  irritnled  and  inflamed ;  and  the  morbid  pn^'eas  tbos 
Ht  up  may  run  ou  to  suppucatlou  of  a  very  troublesome  kind,  a  tUlu 
uoboaitby  pus  being  torm^.  Hliich  is  disi^'hargcd  tbntugh  an  oprtiiog 
baeonca  fieiulou*,  and  mny  ilegenerate  into  a  ntoet  troublesome  indolrot : 

TVnitmcnf- — lo  the  Ireattueut  uf  this  affection,  tbe  first  thing  to  b*  i 
tu  relieve  tlie  prcasure  on  tbe  part  by  wearing  properly  sbapad  boot% : 
with  ihr  iiiuereideofibesole  straight  from  tlie  toe  to  the  be«l.    Ifaoeii' 
iotiantiimtion  l»c  excited  lu  tbe  part,  it  must  be  nlhiyed  by  the  nw  of 
fitoi-bathe,  and  fometitatious;  tlio  cutaneous  irritation  that  ia  Icfk  na;  bcrtl 


OAKOLION. 


4S3 


iiitinx  the  mrfaoe  with  a  ■tmng  »ololii>n  of  Ditrnt«  of  silver. 
eciiuD  uf  tbo  toe  may  biM  he  reinodied  by  usiug  ibc  ingcuiiiii« 
eoairiratioe  I'Fig.  (<tili).  Lbu  oc-Liuu  uf  which  coosmU  to  tlr»»-iug  the  uvcrtcd 
tmd  of  Um  k>e  iowarilE  by  ibe  oiDst&uc  action  of  a  st«u<l«r  »tfi«l  spring. 
SmoU  iboK  meaos  fait,  tbv  iKieitiim  of  the  u>g  way  bo  reotedifid  bv  Uio 
lltviKoa  of  the  external  latt;ral  ligameucof  (iie  metatariMvphalangvat  artfcula- 
bo*,  or  uf  ibe  teuJou  uf  ihe  adductor  pollicis.  or  uf  the  innur  head  of  Uio 
flexor  bnrrii  p4illici«;  the  luc,  when  reatored  to  ita  iiueitioa,  being  for  a  time 
hcpC  Snd  upon  au  under-apliiiu 


rv«   MS.— DlMoflftd  FoM,  rran  Pr««- 
nM  and  tliikiaB. 


rr 


Fig.  003.— A|i|Mf«lii*  for  DcrOTmiljr  of  Pa«l 
in  Fig.  <«E. 


Aa  tbcve  methode  of  treatment  are,  however.  Kidom  successful,  it  hR.<;  been 
fgMlaJ  by  C  Hnar,  late  House  Sur^on  to  University  OAlege  Hoapitnl,  to 
p^ofta  amiwptir  'tfneotomy  of  the  niotatarul  bone  of  the  great  toe  through 
liw  Dock  of  the  hone.  This  op4>ratioD  has  been  most  successfully  performed 
hjr  A.  K.  Barker  in  one  raso.  nod  deserves  n  further  trinl.  Barker  removed 
saaall  wedge-ahaped  piece  from  the  inuer  side  of  the  metatarsal  bono,  and 
fraetariBp  toa  remainder,  brought  the  toe  at  onct*  into  gixid  position. 

Oocamonally  in  elderly  people  the  bunion  will  inflame  and  auppuratc,  and 
the  machief,  extending  to  the  metatar«o  phalangeal  articulation,  will  cause 
^^^MTipuaintion  of  the  joint.  Tbia  u  a  fttat«  of  things  not  devoid  of  anxiety, 
^^b  it  Dot  anfrequejitly  nippcns  that,  if  the  constitutional  powers  be  enfeebled 
^^  Bce,  a  low  fliougby  erysipelatouH  inflammation  may  be  set  up  in  the  foot, 
WWi^  rrantoally  may  terminate  fatnllr.  Should  the  joint  be  irretrievably 
diaorifanized.  and  the  palii>ut's  strengld  admit  it,  the  toe  should  be  remuTea 
kf  amputatii^n — after  wbit-h  the  cariuun  bead  of  the  metatarsal  bone  will 
■stially  heal  without  diiBculty. 

D1SXA8K8  OP  SBEATSV  OF  TEyiWXS. 

TW  synoTtal  sbeatli  of  a  tendon  it  lEablo  to  two  forms  of  disease ;  viz..  the 
dasvlupokent  of  a  small  sac  in  immediate  roooection  with  it,  forming  a  ryatic 
CMHtf ;  aod  acau  and  r-hnmic  indAmmatlon  or  tanoeyoovitia.  The  teu'doiil 
of  the  har»d  ar^  m-st  lialile  u>  Uitb  theae  aflectiotM. 

'  ■  I  ^   '  •'  larm  ganfdion  i«  applied  to  both  theae  conditioa»,  and 

'  -*i>.vi-  iMiAuicu.    Tb«  «iiftfM«  ganglion  is  a  »aall  cyst  of  o«w  lor* 


ataA 


484      DISEASES  or   SYNOVIAL  MBUBRANKS.  AND  OF  UUSCLRS. 


matiou  in  close  coDD«4::tioD  with  a  synovial  aheath  ;  the  compomtd  '%*  a  tliUt»> 
tiof)  of  the  sheath  Uw\f.  and  is  a  CfinsequeDce  of  chruiiic  teuosjTDovitta. 

Sinple  Otuglion  con»i!>ls  oi  a  cyst  varyiog  in  bik  from  a  i^irrrv-»toMU 
a  \tirnt  marble,  and  coutaiuing  eumetiiuc-s  a  clear  traiuparrBt  fluid  uf  a 
yelluwiflh  colur,  but  more  comnjonlr  a  pinkiah  or  yellowiah  gelaUooitt  nli- 
scaace.  It  occurs  as  a  saiooih,  ^luCular,  elastic,  uiid  itinie  tumor.  iMiaJijr 
titualod  ou  the  tmck  vt  the  wrist,  where  it  furitis  a  'Ijstincc  roupJ  pnJK- 
tioQ :  it  may  occur  also  oo  tbe  dorsuoi  of  tlic  louu  In  boih  siituiiifto*  it « 
ilistioctly  <>ouuccI{hI  with  the  shcatlia  of  the  extensor  ipnilnns.  Aa  ibe  gia- 
^liun  incmaes  inuKC,  it  often  givt*  riee  lu  paioful  iK-niu)(itinft  in  the  parte  bC' 
low  it,  by  preaaing  upon  the  tiei};hbonag  uarvcs ;  tliiis.  a  ganglion  al  Ui« 
back  of  the  wriat  ofteD  prnlucai  pain  and  weatcueea  io  ibe  band,  by  rja»- 
pmaing  some  of  the  bruuchoA  of  the  radial  or  ulnar  uerTf  Hbii-h  an 
atretche4l  n%'er  it. 

Ganglion  in  by  far  the  inuat  coturoon  of  all  the  tumors  that  oet-ar  oo  Um 
band.  In  all  cawa  of  uvul  or  muudt^d,  sinonth,  elastic  tiinixr  on  the  baad  ut 
fiujuien,  whether  painless  or  neuralgic,  the  first  poiol  to  dettrniiite  'a  vbatbtr 
it  be  jpinglion  or  not ;  but  (•anglion  should  always  b«  su»pe(.-lMl. 

A  email,  bard,  and  painful  ganglion,  varying  iu  ttiw  iVum  a  ptn't  htmd  U 
a  cherry-stone,  it  met  with  in  connection  with  the  (lexur  trmtoDs  of  th*  fin- 
gers, uauully  on  the  proximal  phalanx.  If  it  ioierffrrta  seriuusly  wilii  iba 
use  of  the  fingers,  it  may  be  diasect^d  out. 

The  mode  uf  origin  of  a  simple  ganglion  li  very  doubtful.  PagH  looks 
upon  it  aa  a  cystic  transform  atloD  of  Ui«  cell*  CDcIooett  in  tb«  fhogfbk* 
procwses  of  tb«  ayuuvial  membrane  lining  ihe  sheath  of  the  tcmloo.  Bill- 
roth  believes  tt  cummences  a»  a  pouch-like  iirutrusjim  Irum  the  ahrath,  tJia 
uvck  of  which  becomes  gradually  narroweil  til!  at  last  a  separate  rysl  is 
formed  lying  on  the  sb^^alli,  but  uot  commuuicnting  with  iU  TheniiaDonml 
•vidtttco  in  support  of  either  of  lli«s«  viewii. 

2\r*aimetti. — Wbeu  the  gnuKliuu  Is  soiall,  as  ou  the  hack  of  tba  wriat,  it 
may  commonly  be  got  rid  of  by  being  ruptured  by  forcible  pmaurt  witk 
ibe  thumb,  or  by  a  blow  with  the  back  of  a  book,  or  by  being  lightly  oran* 
praacd,  by  niear^a  of  a  coin  wrapped  up  in  a,  piece  of  lint,  and  nrm^  mimpfmi 
upon  the  swelling.  If  it  do  not  diaapiwar  tn  this  way,  the  boi  plui  m  t» 
punoiuro  it  subcutaneously  by  means  of  a  valvular  opening.  Ut  equceae  nut 
ila  euulontJi,  acnrify  the  interior  of  the  cvst,  and  employ  preeaurc  1/ lb* 
gangltuD  give  rise  to  much  pain  and  weakneaa,  and  cannot  be  made  la  A- 
appear  by  the  uao  uf  the  means  jitst  indicated,  it  ma^  uiually  be  vttj  am- 
veuiently  and  aafcly  obliterated  by  passing  a  aetoii  of  two  threada  luxwyh 
it,  drt-ssin)^  it  autlsoptically.  and  leaving  it  in  for  four  or  tive  daya.  unlit  auf- 
Geiuul  iufl&mmatiuii  hiu  been  induced  for  the  obtiieration  uf  ibti  cyst.  Sitoulil 
llie*»  meant  fail,  it  muy  bo  dissected  out.  if  it  lie  thought  adviaable  ti>  faat-a 
recouna  lo  this  suincwhat  seven  procedure,  which  i*  attended  with  aotne  riak 
uf  inllummation  extending  up  the  sheath  uf  the  teodoo.  I  bare,  ItowvTcr, 
ou  acvcrel  occasiona  performed  tbia  operation,  without  any  iroublnMa*  ooci> 
[j  •equeuce*  ensuing. 

IspuiMiiATfox  or  THE  Sbbathc  OF  TK*ti>oy6.  TsiroeTNormK— TUs 
is  oucaaioually  ujet  with  aa  the  leault  of  strains  and  twislBuf  the  baod.aboSt 
the  wrtsL,  of  the  extensor  temloiu,  nr  the  long  bead  of  the  Mcvpa.  Il  is 
very  ooniiuuii  iu  the  extenx>r  miiwles  of  the  thumb  from  featlwrisg  the  oar 
in  rowiug.  In  this  atfeetion  there  >»  swelliug  of  a  puffy  cbararter,  with  t«h 
deriiew  when  ihc  |iart  is  pressed  oo  or  ninwd ;  and  usually  a  peetilour  Im 
i>nii  '     '  oation  u  coiumunicnted  tu  1  he  Surgeon's  band  wlicn  he  esataiDas 

the  ■  i-^tru    The  urackliog  ia  ispeually  markeil  in  caaea  in  wbidi  the 


Kh° 


itiflammRtidn  and  efTusioa  Iiave  become  chrooic,  when  the  difleate  appear?  lo 
partake  of  the  nature  of  a  ilifTused  ganglion. 

Treatment. — The  trealineiit,  when  the  dwpiise  U  acute.  ooDsUte  IQ  the  ap- 
plicaLiun  uf  ^utlc  t)ri:««uro  hy  measH  of  a  bandatie,  with  rest  of  the  part; 
when  it  lias  «nsiime<!  a  ohrittiic  character,  iho  ai>pltcation  of  btisiere  and  ibe 
niernin'  uixl  iLrnriinniiicum  ploi^Ltir  will  be  fcmnd  mtisL  uiM.-rul. 

Compooad  Ganglion  i;;  a  chronic  L-fTuiition  iuici  the  shc-uth  of  a  tendon  with- 
out any  inauift'«L  •tij.Mii^  ni'  iiillintiiiiHtinn.  thoti;:h  it  \»  usually  re^irded  aa  a 
very  chn>riir  infliirniimLory  pr.K'i-iw  Hnah>;;()tiK  to  ithniuic  syoDvitiM  of  a  juim, 
''l  n  met  with  chicflv  in  thi^  |mlm  nf  the  hand,  ami  the  dorsu[ii,)mle,  or  inner 
lie  of  the  fiiDt.  U  may  idle n  atluiu  a  very  niudi'lemblc  size,  and  theu 
UfiUally  beconioii  irregular  in  uhnpt^,  owin^  to  ativuriil  tt-ndoiiM  hi'^ing  im- 
plicnteil  br  it.  Often,  in  Lhi(<  fitrm  of  ^n^linn,  the  rthf^alh  b  thii^kened  hh 
well  at)  dilated;  and  ihe  contained  lliiid  is  dear  and  yclltiui^Ji,  lh<>ii;^h 
u»ubI1]f  thinner  than  in  the  simple  ganglion.  Thf^  ahp»th  itHtilf  is  vaHciilar, 
and  lineil  hy  a  re<l,  fringed, and  velvety  niemhrani<:  thetlnid  may  limn  beilark 
bloody,  and  (vmiAin  maMes  of  bii H'-<K>lored  Bhrin  or  a  large  number  of 
_  ular  bodies,  like  those  met  within  certain  forms  of  enlarged  bursje.  The 
■pitearance  of  a  so-called  eompound  ganfrlion  at  the  wrist  may  in  somi^  cnaes 
be  the  first  lodic^tion  of  dlteaM  of  the  bones  of  the  carpus,  as  the  synovial 
sheath  eomeA  in  cli^«e  contaet  with  che  bones.  In  a  cflso  lately  in  Tlnirereity 
College  Hospital,  the  com  pound  gnnglion,  which  contained  melon-seed  IwHlies, 
was  apparently  cured  by  nittisi'plic  drainnge.  Some  montbA  afier  entries 
of  the  carpus  manifested  itsidf,  neci-X'-iiatinjj  excision  of  the  wrist-joinL 

TrfJitmmt. — A  KAngliiiQ  i^ihiated  in  the  palm  of  the  hand,  and  extending 
under  the  annular  ligBmont  snmc  little  distance  up  llie  flexor  tendons  of  the 
forearm,  ie  a  very  troublesome  diaeasc.  Synie  ih^cu  in  mended  that  the  sac 
ehould  b«  laid  open,  and  the  annular  ligament  divided.  This  iieumii  to  me 
an  unnecessarily  severe  pntcedure;  and  I  havu  in  several  instiLucus  curet] 
the  afTection  by  milder  means ;  iu  oiie,  by  iujeutinj;  a  small  <juHutily  uf  tiiie- 
ture  uf  iodine  into  the  cyst  through  a  puuctuns  in  the  palm,  and  iu  two  or 
three  other  cases  by  the  use  <d'  the  eeton.  The  seton  is  iimst  euKily  intro- 
duced by  squeezing  the  Duid  from  the  pulm  into  the  shceiiths  of  the  flexor 
lend<ms  above  the  wrtsl,  making  a  puncture  iutn  these,  and  then  putihiiig  uu 
eyed  probe  anuefi  with  two  or  three  threads  along  the  tendons  under  the 
■onutar  ligament  into  the  centre  of  the  palm,  where  it  is  to  be  drawn  out 
'  rough  a  small  incisioa  mB«le  down  upon  it.  The  seton  threads  may  be 
losked  in  rarbi>licacid  and  loti'm.and  the  operation  and  dressing  conducted 
on  antiM'ptic  principles  to  avoid  excessive  eunpuration,  or  an  India-rubber 
Hraina^  tube  may  be  substituted  for  the  silk  tbrea<j.  Compound  ganglia 
hi  other  situuLion^  muat  be  treated  on  similar  principles. 


DI8EAH[-»   UF    HUBULES. 

The  voltiiiuirr  muscles  are  not  often  the  seat  of  primary  disease  of  any 
kind.  Fatty  De^neratlon  of  muscle,  as  met  with  in  surgiml  prsctice,  is 
usually  the  result  of  want  of  use.  Tn  such  cascii,  the  muxculHr  fibres  Hr« 
llnerely  alrojdiied,  and  the  fat,  which  resembles  normal  adi|)iMe  tissue,  is  ac- 
etimulat«d  between  them.  Hucli  a  condition  is  recovered  t*ri>ni  if  the  cauw 
of  the  want  of  nee  be  removed.  True  fatty  dejjeuvrution,  in  whin-b  the  pro- 
toplasm of  tiic  muscular  fihrwi  HudL-rgoi-B  wuvvntioii  iut-)  fut-grunules,  is  not 
common  in  the  voluntary  itiu»cle»,  0(>ificatlou  of  UasclM,  that  is  to  my, 
gmdual  atrophy  of  the  muscoisr  (ihrva  with  the  development  of  the  bone 
fruni  the  conuective  tissue  hetweeu  tbem,  has  been  met  with  In  very  rare 
casM  in  the  muscles  of  the  back.     Inflamicatory  Affeotiou  are  usually 


A 


486     DISEASES  OP  BTNOTIAL  UBUBnANKS,  AMD  OF    MCSCLKI. 

Mcoodary.  th«  muscle  b«uig  implicated  bjr  «jcl«neiuti  rniiti  kurn/untlior  p«rti. 
I>itfuiK>  inltammatioii  »f  the  vdluntary  niuwiee  witb  duMinittalwd  auRMMi 
h&H  been  iihwirved  in  pjipmiH.  AtncvflBeB,  as  we  have  alraadr  Men  in  paoai 
abscess,  may  enter  the  ohenrbK  of  initRclra  and  cnuse  cuneitlvraole  d<«raieiM 
of  tiiBUe  "JUteumatie  injtammatinn  "  of  niuHcJrs  in  iiii-t  nilh  ■•  loaifaB^ 
int^rcttsial  rheiimatiani,  etc.,  but  of  tbe  exnrt  nnlure  of  ibe  pruc«ai  wc  knwv 
but  little. 

Syphilitic  Oiaease  of  Umcles  has  Iwen  alivady  ilpFcrib^tl  ^tuI.  i.  p.  1073). 
It  otciir?  an  ditfusf^  folenmis  of  the  muscle  or  giimmsla.  (.iiimmata  ban 
been  met  with  in  the  triceps,  vasluii  rxtemuA,  stemo-niintitid,  and  many 
other  mnacles,  but  especinlly  in  ihtnw  of  the  (onffoe.  They  crow  •!(<*!?. 
infiltrate  fiiirroun<ling  pnrts.  nnd  soften  if  not  relieved  by  trFalnifni.  Th«t 
are  not  iinfrequently  multiple.  Tbey  are  accompanied  hy  arhtnf*  pain,  and 
•tifibew  of  tbe  afiected  muscle.  They  derive  iheir  impunnnca  rhiefly  fmai 
their  rflBemblance  to  some  of  the  tumors  to  be  immcdintcly  rlmrribcd,  which 
boi  oocMiooally  led  to  their  beinjt  cut  out.  The  diagnosis  is  «8ccted  Bt  ibe 
hiBtory  of  syphitw,  the  slow  growth  and  bardnr?«  of  tho  tunti^r,  ita  miU*- 
queut  aoncniug,  and  the  i>atn  at  night.  They  dii>appear  or  ilimititab  rapidly 
undt^r  ii.HliOi'  of  putamium. 

Tnmori  of  Mnacle. — primary  tumors  of  muftcle  are  oof  comnatiD.  Th» 
gruwths  met  with  are  the  variuus  foroM  of  sarcoma,  sometlfnea  c^ntaininir 
much  libruus  tissue  (libru-sarcoDia),  uimetimee  mfl  <round-c»Ilt><l  or  »|imi)l^ 
celled  Mfcoma),  chotulromata,  myxoiiiata,  6hmmata,  nievoid  jtrowtb*,  aod 
hydntid  cysta.  Primary  carcinoma  uf  niu!H.-]e  never  (K-cura.  Teetso  col- 
lected witb  much  industry  the  parlioulani  ofd'i  cave*  of  tumors  of  musrln  •( 
oil  kiude :  about  one-thinl  of  these  were  sufl  urvomala.  It*  were  deecriiwl 
as  fibrous.  H  cystic.  &  hydatid,  and  5  nwvoid.  Halii^aul  sanMrnata  are  in>*1 
comiuoo,  according  to  my  experience,  iu  the  lower  limb.     Wbeu  lb«  apfwr 


FIb.  M4.— Flbni-Mr««tD»  vf  lb«  Sartofta*  Mnnl*. 


Bnbs  are  af^ded,  the  muoclee  that  have,  acconlttig  to  T«e»aii, 
frequently  attacked  are  the  (tectonilis  major,  deltoid,  and  btcrai.  Tbe 
miiscli-s  of  ibn  trunk  ami  neck  an*  seldom  duenaed,  with  the  exception  of  tba 
rectus  obdoniinis,  which  Bpp<'nn  to  be  very  liable  to  tnmors, 

Of  twelre  consecutive  case*  that  I  have  had  under  my  care  in  wbicb 
tumors  of  different  kindit  developed  primarily  in  muscular  tiiwie,  tbe  follo*- 
iug  arc  the  particulars.    The  first  case  was  ttiat  of  a  woaao  aboat  4^  yiatf 


am 


'HORa   or    UUSCLKS. 


tn  whom  ft  Eibro*cf»tic  tumor,  m  Urjce  m  a  cooonnut.  developed  in 
tii>D  Kith  tiio  teiuor  vagina-  femoris,  formiDg  a  large  maat,  wnich  I 
^MCdTil  out  milily  from  o\i^r  tlie  hip.  The  eecoDd  cme  wus  tlint  nf  a  lad 
•boot  m,  in  wbom  a  cv«tic  tuni<jr,  us  largo  aa  a  fooUil  heud,  thick  walltHl,  aod 
iffff'tl'ffg  et«&r  Buid,  dervlopett  in  tbti  aubsUiioe  of  llio  adductor  breria  of 
tlw  iblgti.  from  whiidi  it  was  diawcletl  uiit  vith  do  liitlo  dilHculljr,  aud  with 
«  turn!  reiulL  The  third  case  woa  that  of  a  man  from  whom  the  accoa>> 
putjiiij;  drawings  are  ukeu  (Figs.  6U4,  QOb,  606;,  ia  whom  a  fihro-enrooma 


-8Mk  Tliw  «(  TuiMr,  ibowinf 
BaffUrlv*  Miwcla. 


¥ig.  €04.— FroBt  View  of  Tumat,  Ul>l  opm 
.   wid  ibowts;$*rU>rtn>.  1. 


d*vdoMd  wilbio  the  sheath  of  and  id  the  subtlaace  of  the  ftartonua  muscle 
of  tiw  left  ibich.  in  cuDsvau«ncv  of  aetmiii.  AHer  growing  slowly  for  about 
fix  yvare,  it  had  attatuud  tliv  sue  of  a  child's  head,  wbeu  I  removed  it, 
lsgttfa«r  with  txyvn  or  vight  iiK^tivs  of  the  niusole  from  the  ioside  of  the 
afaamtb  of  which  it  had  origtuatvd,  aud  with  which  it  was  closely  iDcorpo- 
rmted.  Tbu  shciilti  of  the  femonil  vvmeU  which  waa  exposed  for  a  ooeid* 
eimblv  exteat,  was  uunSected  by  the  dis«'a«*.  KecurrvDce  took  place  ia  lets 
than  twelve  rooutha  io  the  cicatrix,  uod  wheu  the  secondary  tumor  had 
■tiainwl  the  sixe  of  an  oelrich's  egg,  it  was  removed,  the  piitient  moking  a 
cuod  recoTenr :  hut  the  disease  again  returned,  and  eventually  proved  fatal. 
Tba  fuarth  case  was  that  of  a  man  aged  about  forty,  in  the  sole  uf  wboM 
SmC  a  r)-9tic  tumor,  about  as  large  aa  a  guoee's  egg,  was  developed,  sprioging 
&YKD  the  dexor  brcvis  dtgitonmi.  Thi»  wai*  vnrel'ullv  di^eected  out;  but  id 
«.  finr  months  the  pniieut  returned,  with  a  "^olid,  elastic,  rapidlv  growing 
tOBor,  evidently  a  oialignaDt  sarcoma,  developed  iti  the  cicatrix  ■  V'ig.  t)07). 
The  foot  «as  amputated,  and  on  section  the  mass  proved  to  be  a  soft  sareonia, 
aftd  If  havB  dereloped  from  the  muwular  structure  just  ntinied  (Fig.  60^). 

Id  UiTM  caaea  the  tumors  were  hydatid.  Id  one  patient,  a  youog  woman, 
tba  imam  was  teaied  in  the  deltoid  ;  in  another,  a  medical  man.  about  50 
fMS  af  aM,  the  tumor  was  senie<j  at  the  outer  edge  of  the  latiuimua  dorri ; 
ai»d  Um  Uurd  waa  a  geotlemaii  about  60  years  old,  in  whose  biceps  the  dis- 
oomineAeed.  In  oach  of  than  cases,  oxcisioo  of  the  tumur  was  success- 
til  y  practised. 

In  the  eighth  case  tbe  tumor  was  an  enchondruma  ia  the  tibialis  aoticus. 

bare  sees  two  nlher  cases  of  enehondroma  in  muscles :  odc  situated  iu  the 
exierouH  of  the  thigh ;  the  other  iu  connection  with  tbc  pectoral 
nosele.  The  uitith  coje  was  a  sarcoma  of  the  rectus  femuns  in  a  mao  aged 
21.  wbiL-h  I  exciseil;  the  tenth,  a  malignant  growth  in  the  auteiJor  abdom- 
ioal  wall  id  uo  elderly  geutleniui) ;  the  eleventh,  a  soft  surcoiiin  of  the  muscles 
of  IJm  calf  in  a  mtdolft-aged  lady,  for  which  amputation  was  practised  :  and 
tkm  tvallUi,  a  sareona  oT tbe  forearm  in  a  lad. 


468      U1SBA8B8  OF  STKOVIAL  MEUDBANES,  ASD  OP  VCBCLBS. 

Tumots  developing  primarily  in  the  tatcrmuscular  areolar  plana  an  et 

very  cKifnmoD  occurrence;  bul  these  are  very  rliflercut  from,  and  muit  Ml 
be  confouniJed  willi,  tru«  tumors  of  muscle. 

The  T^Mlmeni  at'  these  varioitii  inuACular  tumon  tnuK  be  rooindiTwl  oa 
ordiiinrv  surgiciil  principle*.  When  <if  an  inmirent  chRfartrr,  ■»  rvitkor 
tiydmicf,  fihniUR,  erectile,  or  enchondroniatnuii,  iher  may  be  diiwclwl  oM 
ffxim  the  niuHcular  tuiue  amongst  wliich  they  He,  aod  no  fear  of  ncamaet 
uecd  be  entertained. 

WlieD  they  are  malij^nant,  amputation  of  the  limb,  if  tbe  tumor  b»  Ikror- 
ably  situated  for  such  ad  operation,  is  ^^nerally  the  ooly  reaourc* ;  partiil 


f\f.  M7,— Kallfaanl  Tnnor  In  Sola. 


ri(.  SOS — B*et)iMi  «r  PmI,  alivwlac  ilt 

of  Tamar. 


Meratioiu  are  nMinlly  worse  than  wtelnw,  as  they  are  fiillowed  tit  a 
reearrenofl.  Teevan  has  made  the  inf^nious  snggmiioij  of  apnlriitg  to 
malii^nftnl  tumors  of  muscle  the  wirae  rule  of  practice  ihnt  soidTca  of  is 
operAiii)DB  on  bones  similarly  afTcctrd;  vix.,  tn  remove  the  wnole  uf  ite 
of^D  that  is  the  M«t  of  diseuc,  exclsiDg  the  entire  muscle  fnmi  its  nri| '  ^ 
iia  insertioD,  and  thus  ellminaline  from  the  sytitem  the  whole  of  tht 
mass,  which  will  be  confined  wiinin  its  sheath — a  <itnirlure  that  for  a  I'lOf 
time  resists  the  outward  pressure  of  a  morbid  (growth.  The  sug}t«»tt(jn  tt 
foun<le<]  on  mrrect  pathological*  prineiplee>;  the  imlv  olnection  lu  it  is  its 
diffiriilty  of  application  io  ncluat  pmcUce — there  b«ing  few  musclcB  ao  *ilB> 
Bte<l  that  they  cmild  with  safety  bo  completely  «xtirpstM. 


LATERAL  CURVATUBB  O?  THE  SPIN] 


489 


CHAPTER  LIV. 


DEFORMITIES. 


LATERAL  CURVATURE  OF  THE  BPINE. 

This  affectioD,  on  account  of  the  frequency  of  ita  occurrence,  the  defur- 
m\tj  it  occaBiODS,  the  tediousnesa  and  uncertainty  of  its  cure,  has  received  a 
good  deal  of  attention  from  various  Surgeons;  and  much  has  been  written 
«n  it  by  tboee  who  have  specially  devoted  themselves  to  its  treatuieut;  yet 
the  whole  of  ita  pathology  and  management  lie  lu  a  very  narrow  cumpasa. 

Lateral  cnrratoTe  of  the  spine  most  commonly  comineDcea  at  an  early 
period  of  life,  usually  between  the  ages  of  twelve  and  eighteen — seldom  be- 
fore the  one,  and  not  very  commonly  after  the  other.  Girls  are  moat  fre- 
<]uently  the  subjects  of  this  deformity,  which  but  rarely  occurs  in  boys.  It 
appears  to  consist  simply  in  a  relaxation  of  the  muscles  and  ligaments  of 

the  spine ;  in  consequence  of  which  the  vertebral 
column,  being  no  longer  able  to  support  the 
weight  of  the  nead,  neck,  and  shoulders  becomes 
curved  to  one  side,  a  corresponding  deviation 
taking  place  in  the  opposite  direction  at  a  lower 
portion  of  the  spine,  in  order  to  preserve  the 
equilibrium  between  the  two  sides  of  the  body 
(Figs.  609,  610).  The  first  curve  usually  takes 
place  in  the  upper  or  middle  dorsal  region,  the 


Fig.  1109.— Lftteral  Curvature  and 
Rotation  of  Spiue- 


Fig.  610— Outlioe  of  Double 
Lateral  Curvature. 


Fig-  611. — Quadrnple 
Curre. 


convexity  tending  towards  the  right  side  ;  the  second  or  compensating  curve 
occurs  in  the  lumbar  region,  the  convexity  looking  towards  the  left.  In 
some  instanccB  there  is  a  quadruple  curve  (Fig.  611).  At  the  same  time 
that  these  lateral  curves  take  place,  there  is  a  tendency  to  rotation  of  the 
bones  of  the  spine  upon  one  another,  in  such  a  way  that  the  bodies  of  the 


490 


IIPOBMITIBV. 


vertebnu  forming  the  dorsKl  curve  are  twistenl  nliglitly  to  ibe  rijtbt,  «kU* 
tboM  wliiuh  CQtLT  iutu  ttie  tbriuaiiua  vf  the  lunil)«r  i^rvc  art-  turuH  ■tifhtlr 
lu  the  k'ft.  I  Fig.  009).  This  twiat  U  Huiu(>t(me§  sligltt;  but  id  other  insuiMii 
it  is  very  niarkuil.su  tbal  cborc  u  a  duubtc  (lisplauenieal — Ut«ntl  mnd  rvuunr. 
Oh  examiuing  tbc  boiies  ami  iutervHrU-'brul  fibrocartilAgra  after  ill  Mi. 
«ven  in  castw  uf  very  coasidcrable  disborliua,  □»  (lisoaw  will  appear  la  tboa; 
except,  iierhapa,  that  tlie  bodlea  of  Mime  may  have  been  eliehtfy  eDni|inaMl 
wbure  tbey  fiirtti  tbi<  prinuipat  ooacavity  uf  the  arch,  Tbc  lianMiila  afff 
tu  be  fllretrht^l,  r»laxnt,  ami  fluniuwliat  weakened ;  anil  (Ee  moaela  m 
usunlly  pale,  Oabhv,  and  appnr«ntly  wanting  to  power. 

Mhcuaxiam. — t^Mm  a  o<>ti5i<lt'raiiun  iiftbe  palboliigy  of  this  aflbctlon,ib 
mechiiniBin  beroraes  auffieiently  apparent.  The  srdnal  rolaniB,  being  com- 
poMxl  of  a  niiiiilter  of  separate  bones,  pnawflam  no  firmnesa  in  ilaelf,  or  power 
of  8elffU|ip(>rl.  btit  i.<t  miiintatniNl  in  the  erect  pnaitiiai  by  the  cIimq  oaMMf 
in  which  lis  itt^narate  elemeniA  are  knit  tof^lher  by  ligamenlnu*  and  nmM«kr 
strtictures,  nml  by  th<>  way  in  which,  when  thiis<  iHxind  l^-gflber  lu  a  wbnlch 
U  suppiirtcd  oti  each  eiJc  by  the  Btmng  niaM  of  the  ere<.-t<>r  KpinK  and  its  pn^ 
lurifpitiuuH.  The  proper  tension  of  tbeae  ligamculous  Hnnport*  and  muKnlar 
niaKKM  i»  uH|)«ciBlly  ni*ceflMiry  for  it  to  maintain  the  weight  nf  ih«>  bnd  aaA 
sbuulden.  which  is  tbniwn  on  the  cervical  aod  the  upper  [xjrtioti  c»f  tbvdanal 
spine.  If,  front  any  cause,  the  li^ments  beoomv  relaxwl,  and  the  otnMla 
lose  their  tone,  or  it  the  weight  uf  the  upper  part  uf  th<^  body  increaat  A> 
proportionately  t<>  the  iiugmentntion  in  the  strength  of  th«  Hgaoienti  lad 
muscles  that  BUp[>urt  the  spine,  the  vertebral 
column  will  necessarily  give  way  under  the 
preseure  to  which  it  is  subjected  in  a  direct  line 
trom  above  downwards,  and  will  consequently 
become  curved.  .Most  coramonir,  imieed  almost 
invariably,  this  takes  place  in  a  lateral  diree> 
tion,  the  fipine  vielHing  more  rendily  in  this 
than  in  any  other.  In  some  rare  cases,  hnw- 
ever,  the  lower  portion  of  the  cervic«i  or  the 
upper  dnrsfLl  region  will  project  backwnrda  in 
an  arched  manner.  oin^titulJng  the  disease 
termed  Kyphosis  (Pig.  6\'2);  and  in  other  cases, 
of  still  les  frequent  occurrence,  there  may  he 
incurvation  of  the  spine  in  the  dorso-laiiiliar 
rcej^na.  giving  rise  to  Lordosis  (Ki^.  tll.l). 

The  directions  in  which  [he^e  various  enrvca 
take  place  are  eiaggeratiooA  of  the  natural  in* 
cliustioD  of  the  spinal  column.  In  lateral  eurta- 
Hire,  the  chief  convexity  takes  place  t^twards 
tbe  right  -tide, causing  a  projection  of  that  «houl- 
dur,  uhii'h  in  mmt  right-handed  people  ttaoiae- 
what  more  promiueui  than  tbe  other  lu  typiiotU,  the  uxcurratitiii  tak« 
place  in  tbe  lower  cervical  and  upper  dorsal  regions,  whicb  are  ostoralty 
pp>minent;  and,  in  lordotit,  tbe  incurvation  U  most  marked  to  tiie  Iniabsr 
region,  in  which  there  is  naturally  a  curve  forwards. 

0&CSK8. — These  various  kinds  of  deformity,  as  has  already  been  rtatad. 
usually  cimnience  in  girls  about  the  ago  of  puberty;  at  a  time  •>(  life  whn 
(he  lunioity  of  the  mui<vular  system  not  uofreiiueutly  bcoumcs  leaKord  b; 
the  ooonrrenco  of  anvmia  aud  tbow  sMtcs  of  impaired  bealtb  tint  m  (n- 
c|ueDtly  stl«vcl  the  eeubltshini'nt  of  tJie  uterine  funoiiim;  and  bafim  tks 
(Meous  and  lii;amenu>ua  structures  of  ths  body  are  folly  developad.  Al 
this  puriiKl  of  life,  also,  it  fre^|uently  bappeoa  that  tbe  spiae  baooawi 


Fl^.  fill.— 


r.f.  «iv- 

t^JaUt. 


^^m 


Aj  rioogatcd  hr  a  rapid  increa-se  in  growth ;  or  that  it  becnmev  nver- 
_i>l  bv  ib^bftdv  (levelnplng.  and  (he  shoutdpre  and  bust  becfiming  unduly 
uhI  PtpuidM.      Indeed,  bo  frequent  ie  the  nccnrrence  of  a  certain 

gf  latml  curvature  of  the  Bpiiie  from  tWc  various  causes,  about  the 


■M  vf  fvhertjp  in  girls,  ihnt  tew  («cape  n  londenrj  to  deviation;  of  eo  elight 
•  Kind,  hiiw^rer,  im  nut  to  ndniic  of  recognition  bb  b  disease.  But  if  ibte 
wodcDcj  he  increased  by  injurioua  habita.  amongst  which  are  all  onesided 
in  which  the  body  is  twisted,  as  in  playing  certain  gnnici*.  mme 
il  instrameols,  or  iu  leaning  over  a  table  in  drawing  And  writing,  the 
■H|^  devtalit<n  luay  rapidly  inrr«aae  until  it  assume*  the  true  charactera  of 
iMBftJ  curvBiure.  OirU  who  grow  too  rapidly  are  e«pfcially  predisposed  to 
lateral  mrveturr.  Their  strength  diM«  not  keep  pace  with  their  growth, 
cl,  auklcK,  or  knees  often  give  way,  and  the  <!pine  inclines  lo  one  side. 
Itxral  curvature  is  common  aliu>  in  girU  of  a  lotally  diflVrent  make, 
women  of  a  short  aud  thick  build,  in  whom  the  bust  and  ]ihuulder« 
}B>«  Urgely  and  early  developed,  are  very  liable  to  lateral  curvature.  la 
too  gmtt  a  weight  is  thrown  on  the  spine  before  its  oesotig  and  tiga* 
— iltom  structures  arc  sufficiently  developed  aud  solidified  to  enable  it  to 
•apport  this  burden.  1  do  not  think  tinil  there  is  auy  evidence  to  i>linw  that 
thks  ii  either  a  strumous  or  u  rickety  allVctiuu:  iudeed.so  I'lir  as  my  ob«erva- 
tiom  fow.  1  should  certainly  eay  that  siruuioua  girls  ar«  lets  liable  to  (he 
dfan*  tbmn  thoee  of  a  nervous  tL-m|ierament:  and  it  occurs  at  an  age  at 
wfaieb  rirkela  w  practically  uuknown.  Amongst  the  more  common  preilis- 
poaiai;  ouwm  must  undoubtedly  lie  reckoned  the  sedentary  occupations  and 
aaffrratlng  bahilH  ronimnnly  enconragrd  in  girts  in  th<i  wealthier  ranki*  of 
nfc,  which,  by  preventing  due  miisculnr  development,  at  the  tuimn  time  that 
ibey  induce  a  general  lom  of  tone  in  the  system,  may  directly  n(-ca.<>ii)n  the 
Aataae.  In  growing  lads,  lateral  curvature  may  Ik  pro<luccd  by  a  habitually 
naincniMKl  faulty  position,  as  in  sitting  too  long  at  the  di^k.  or  in  fidiowing 
certain  occupations,  .^n  tnc<]uality  in  the  focal  length  of  the  vlniou  nf  the 
two  «Tf»  is  another  very  wimmoo  predisposing  cause  of  laternt  curvature, 
the  |«tient  habitually  twisting  the  b«>dy  forward  on  the  i^ide  id'  the  defective 
•re.  so  as  to  endeAvor  to  ac(^>mmrMlale  the  virion  of  it  to  that  of  the  stronger 
Ode.  That  th«-  real  muse  of  lata^ml  curvnturo  of  the  S|'iue  is  lo  h«  fdund  in 
&uUy  habit*  tif  life,  and  not  in  m-x.  'h  evidenced  by  the  rarity  nf  the  ntlectii'in 
girU  of  the  Ulxiring  class,  as  conipareil  with  its  frer^uency  amougst 
I  of  toe  wealthier  or<ler«  of  society. 

The  ceuM*  of  the  nnten»-|HMiterior  curvm  are  usually  to  he  found  iu  some 
frolty  faabiU  of  the  patient;  either  giving  rise  to  an  habitual  'toop.  and 
lbi»  laying  (he  foondation  for  kyplKiais,  or  thruwing  too  great  a  weight  on 
tb»  b'ine,  and  thus  giving  rise  to  lurdoaiB.  Myopia  and  other  impairments 
of  riiii'n  causing  the  perMW  so  affected  to  stoop,  io  order  to  bring  the  page 
B«mrrr  the  eye  in  reading.  Is  a  oommon  cause  of  round  shoulden,  and  in  mun 
axtresno  degn-ea  of  kypbusis. 

Srom  or  Latkral  CirnvATi'RE. — The  signs  of  this  afTectinn.  when  it  is 
vdl  marfceil,  ntv  distinctly  obvious.  The  serpentine  character  of  the  curve, 
ili  diNibie  nature,  tbe  convexity  on  one  side  usnally  looking  to  the  right 
thowlder,  and  tn  the  other  to  the  left  loin,  wilt  rentier  it«  natur*:'  evident. 
M<Mt  nNDtDfinly  it  commences  in  a  gniduni  manner,  the  Hret  condition  that 
■anwCa  Btlenhnn  being  the  prominence  of  the  right  ^cnpiiln.  which  \»  sup- 
pateA  In  be  "growing  out :  "  ur  the  ftcmoclavicnlar  arlicutation  on  the  »ame 
«de,or*oaie  of  the  cartilages  of  the  ribe,  have  been  observed  to  project. 
WbcMTVer  the  Surgeon  is  nonsuited  for  such  symptoms,  he  should  at  once  ex- 
•ouare  tlw  spine,  which  he  will  generallv  find  to  have  an  ineliaation  to  the 
rijfht  aide.    In  the  early  stagea  of  the  diaeaae,  when  the  devtatign  is  not  very 


492 


iSFOUMlTl 


rltstinctly  marked,  the  rciidieftt  mode  of  iletArTniniog  it  a  v*  ]rl  th«  p«licM 
stand  upright,  taking  cnre  thai  tli«  fevt  are  well  pUo«U  tog^ctlivr.  and  uiat  At 
attitude  is  not  furce^l  but  nnturtil;  llie  StirKeou  should  then  run  bia  fagir 
down  the  liack  from  one  spiDuus  pnicess  to  nu<iLher,  tuucbiog  radt  at  W 
passes  it  with  a.  pen  djppc<l  Jo  ink;  in  this  wajr,  when  lin  ha*  reached  lb» 
Inwtir  part,  he  will  have  mapped  out  the  murM  of  the  vertclirnl  cnluom,  aa4 
thus  mur  six>  at  a  glunce  the  nature  and  exicoL  of  its  displntTnitMJt.  At  lb* 
same  time,  lie  will  probably  observe  that  the  two  hijis  do  not  r\r  *'  rr«- 
spfjod,  the  left  being  wiiiiDwIiBt  thmwu  out.    Very  iMiuinfrnly  iJi-  -4 

dealnf  iicurHl^'n  t«uderae«s nbout  the  Miiue, ciio«tiLutiDg  thrnrdibary  irnt»- 
bio  or  liyHtvrical  itiiiae,  and  ui  tlii;^  early  stagu  llirri>  iiiny  br  anaftnia  aad 
syniptiinw  of  impaired  nutriliou. 

As  iliL'  disfaM«  advan<tn.  the  curvature  beoomeB  more  marked,  aed  ai  ilw 
samir  timt%  owing  to  ^l^^ion  of  the  nolumn.  a»umM  a  sllgblJy  aninilar  rhar- 
acbcr  wht-re  miwt  convex.  The  ribs  nii  the  right  aide  are  lbn>»n  <nn  tad 
hulifing,  and  carry  up  the  scapula  with  tht^ni.  whilal  ihnetr  nn  the  \e(l  are  soak 
and  depressed  tFig.  61-tj.     In  fact.  thf»  wh.>lr  of  the  side  of  the  d»«t  «mI 

body  pnrtakds  in  the  projeclioQ  of  the  tfittf 
on  that  side,  and  tbiu  adds  mtieh   tci  tW 
g<>neral    defonnity;    whilst  the  left  iU«  af 
the   chest  is  citm«pondin|;ty   b(«lt<>md 
Slink  in.     Wheu  the  (liiea»«  has  adirati 
tbii  atAK^.  ^neral  deliility.  omaciatioti, 
pallor  Mitiie  on ;    th*?  nutrition  of  iha  boilf 
neUiji  ini|iairerl.  jmrtiy  by  ll'  ---^itiiitv 

nliich  tlio  t)iorucic  nml  h^xJ  i  jiu>*a» 

siibiivCt^l,  nn-l  |iarlly.d>jut)U< --.  i-  .rritatiiiii 
ut'  tlie  tipiimi  ci>ril  iiidutitl  l>i  i..'  <  rratnrt. 
During  the  eiirly  |iart  of  ibr  diisaw*.  ihm 
spine  prtiMTves  its  Ih'xidilitr ;  and  whilst  l^ 
curve  is  still  rw^trit.and  the  pntimt  roung,  if 
the  weight  of  the  hold  aud  sbouUlfn  W  taJtea 
olf,  it  will  at  once  reiHirav  its  almi^ht  *i\n^ 
tioo.  Thud,  if  the  tiatii>nt  be  lifttH)  of  ^k 
ground  l>y  raining  hfT  u|>  with  thp  ^>^^H 
under  tlit!  axillni.  or  if  she  be  )ai<l  <t<i«ti  tP 
her  fare  on  a  flat  r»uoh,  the  back  will  lall 
iDin  a  straight  iMwittoii.  or  may  rvadlly  be 
made  to  do  ao  hy  slirbt  traction.  AfUr  tht 
diseaae  has  exutad  fiir  some  time,  itr  if  tfas 
patient  have  paneri  that  age  at  which  oaa- 
Bolidatiun  of  the  bones  and  ligamaiu  ii 
completed,  the  disli>rtinn  will  eoniiniM  pv- 
manontly,  in  whiitever  position  she  may  be  placed.  This  is  not  iroly  amimg 
tit  the  deformity  of  the  spine,  but  to  the  ribs,  and  lignmtntous  aotl  nuBcahr 
stnicuires  generally  of  itip  trunk,  having  bscomo  diflt>trt(<d,  sborlcoed,  aad 
fixci)  in  tlieir  abnormal  p<«iti4ii. 

TliBATMlivr.— The  tn'Mlineul  of  Isterat  curvature  of  the  spioe  shotild  W 
CDoduct^d  on  ratioual  principles;  and,  when  dJvevKKt  of  thn  my<sti>rr  with 
which  some  intvrtat«il  sjwcialists  havi*  surrounded  it.  it  becomva  a*  aimpk  sa 
that  of  any  otliur  chmuii.'  9ur}{ii.-at  aflection  nf  the  bones,  joint*,  or  asuscW 
There  an*  thrt.»<  prini.-ipl«i  of  In-atmeut  lliat  rei)uire  to  tie  «!«rried  uul  id  ihs 
manai^eraent  of  these  casea.  The  iinl  is  the  impnivement  of  the  jtnicral 
health — unlsas  this  be  effected,   notliiiig   can   be  done;   the  servod  is,  tv 


u 


J 


Fig.  SI>1.— Ii«i«r»l  CvvKtnr*  of 
Sfiitt*. 


TBBATMBST  OF  LATBBAt  CUBVATDBB. 


498 


rn^tticQ  (he  niusclea  of  llic  epiue;  and  (he  third,  to  take  away  as  much  aa 

'  )le  the  ireight  of  the  head,  neck,  and  upper  extreuiiliee. 

The  admininlnttion  of  sonio  of  the  nsildcr  prejiaiations  of  iron,  with  a 

course  of  aloSticfl  for  the  reguialiuu  of  the  uterine  fuuc-lioo.  is  of  grcai 

moDieot;  at  the  efime  linic,  a  iii>urL*l)inf;  diet  of  nDininl  fimd  should  be 

allowed,  and  the  pniifint  i'licnu reined  tu  take  exercise  iu  the  ci)m;ii  air.    By 

these  means  tta- nulrilinn  ol'lhf  Mi^lein  will  hi;  ini|>n)V(il,  and  the  tone  of  the 

musrk'a  restorpd.     The  niiiwpular  jmwfr  ir.Hv  be  more  directly  sirciigllicncd 

by  haviuj;  the  Iwrk  well  Kpoii/ed  with  Fiilt  itr  vine^r  in  colli  wuter  every 

tuoriiinf;,  and  meihodirally  nihlied  Iroin  lop  tn  li^itlom.     The  Iritlion  thuiild 

i>e  ap])lied  priuripally  In  the  ereelor  ispino!  niu>:rlFH  unil  ihcir  proldgijtalioiiD 

on  each  Hide  of  ihe  verlelirul  column.  Bnd  tiiHV  lit  done  either  wtlh  the  linked 

band,  or  with  some  ttli^htly  Alimnliitin^  end)nK-ntion.     At  ihr  i^inir  litiie,  if 

rlheapntient's  strength  will  permit  ir,  lint  not  olherwihe,  the  HKf  nf  tin'  hiiiid- 

ilwing  may  bu  alhiwed,  or  cnli^thenic  exercistn   practified,  niiil  Kuimniing 

learnt;  by  it  the  buckis  ntrHJphtened.and  ita  muscles  braced  more  etreeliially 

ih»D  in  any  other  exercise;  these  exercises,  however,  should  not  be  continued 

if  they  induce  aleelini^  of  futi);u«  or  exhaustion.     WhilHt  this  plan  is  being 

ei»evtred  in,  the  [uitient  slioukl  Iw  made  to  lie  recumbent  for  a  fc-w  linura 

lily,  silting  or  etaiidiug  as  little  as  possible.     By  tbe«e  means,  aMiduoufily 

continued  for  some  length  of  time,  the  muscles  of  the  back  inay  be  mtrengtli- 

ened,  and  increase  of  the  deformity  prevented;  and  in  this  way  ibe  sli);liter 

.ease*  of  lateral  curvftture,  tbo«e  in  tvliicb  there  is  a  tendciK-y  to  rather  than 

Ik  full  development  of  the  disease,  muy  be  cured.     Should  tbf-  focal  length  uf 

[the  two  eyes  vary  mnterinliy,  this  inuat  be  corrected  by  the  use  of  pniper 

fglaBwa.    All  faulty  biibit8n)u#t  becurrecle<.l — oue-liHuded  gamee  laid  aside — 

la  writing;  or  drawing  a  sloping  desk  sliould  be  used,  tu  whicli  the  child 

should  ait  eijuBreiy.    If  the  girl  rides,  olie  iihould  learn  to  ride  alterualely  uu 

the  oB*  and  near  sides. 

lu  alight  cases  of  lateral  curvature,  great  evil  may  be  occasioned  and  the 

deformity  increased  by  the  unueoewury  employment  of  cumbervoiue  ma- 

.  cbinery.    Tbe  heavy  apparatus  that  is  often  applietl  to  growing  girls  over- 

Sowers  am]  campreMca,  rather  than  supports  and  directs  the  imperfectly 
eveluped  and  atill  vielding  skeleton.  By  the  use  of  complicated  machiDes 
the  muscles  of  the  oack  become  weakened  and  atrophied  from  disuse;  the 
jielvis  is  compressed  and  cuniracted  ;  and  thot^e  very  evils  are  produced  by 
the  mecbaniciaa  which  it  i.^  tbe  object  of  the  Surge<jn  to  avert  or  correct. 

When  the  alTectiim  ia  I'urther  advanced,  though  the  spine  still  continue 
flexible,  if  there  be  decided  projecliiiU  of  the  ribe  on  one  side,  and  tbe 
^jlhoulder  and  hip  be  prominent,  with  apparent  ditfereuce  in  the  length  of  tbe 
limbs,  and  mucfi  init)airment  of  the  gentrul  heiilih,  more  decided  mctflurea 
of  treatment  must  be  had  recourse  to.  In  thc^c  eiittee,  as  in  those  just  de- 
scribed, the  constitutional  pmvcra  muat  be  curefully  attended  to  on  ordinary 
medical  principles;  iron,  and  good  living,  with  freHh  air,  being  the  basis  of 
tbe  treatment.  At  the  same  time  that  wc  cndcuvor  to  improve  the  strength 
of  the  system  in  this  way,  and  that  of  the  rnueclwstif  the  back,  especially  by 
cold  bathing  and  frictions,  it  Is  ntseotial  to  adopt  means  to  tnke  oH' the 
weight  of  the  bead  and  ahouUlers,  end  to  prevent  its  continuing  to  keep  up 
and  to  Increase  the  deformity.  This  may  be  done  in  iwo  ways:  by  keeping 
the  patient  in  the  recumbent  position,  or  by  allowing  her  to  go  about, 
wenting  proper  *upp->rts. 

Tbe  recumbent  position  in  the  treatment  of  lateral  curvature  of  the  spine, 
iboutfh  a  valuable  nitana  bs  nn  adjunct  tu  other  nieH^ureti,  has  been  greatly 
abutMrd,  by  being  emplo}e<l  a:*  an  excluaive  plan.  Thij  should  not  be, excejtt 
Hhen  tbe  patient  ia  unable  to  aland  or  walk  with  comfort,  as  h&ppena  in 


A 


494 


UErORMITIKS. 


ttxtreme  caws,  when  it  may  be  nefiessary  to  oooSna  ber  for  ■  tima  to  tUi 
pofthion,  until  the  proper  muscular  [Miwer  lias  beeo  rcetonMl  by  Um  ajMoiMi* 
use  of  oloctricity  or  other  meuos.  These  inatanoea,  bowevar*  »f«  wy  nn; 
too  much  00  to  cuuetitute  the  rule  in  the  treatment,  Whciwvar  t^  naa»> 
bent  pu«ition  \p  employed,  the  prono  aeeniii  to  me  far  prcfenibte  to  Uw  MfiM, 
fur  r«uou0  mentioned  when  speaking  of  angular  ourvatun  of  ibo  bmi 
(p.  431 );  and  the  bat  couch  for  the  purpose  is  «-rtaioly  Verral'*.  Jhk 
paticiDt  aUituld  be  kept  on  this  during  the  intorvalii  of  exercise,  not  heun 
alloweil  to  sit  even  at  meals  or  to  stand ;  she  will  very  soon  bccooM  mtem- 
toiiu>i)  to  a  poftiiton  that  at  first  appears  coastrained,  and  will,  prolMUf, 
«p«eili1y  be  able  to  slcop  in  il. 

The  Heobanioal  ContriTanoes  oouMructed  for  tho  purpose  of  Ukiag  iW 
weight  ortlii:  head,  uc«-k,  utid  upper  extrcmittH  off  front  tbe  iraak«Mdspiii^ 
ar«  o(  very  vtiriuud  titrnm,  and  have  had  much  iugenuiiy  expoideid  in  Uisir 
coni^tructiou.  They  all  have  ihrei:  principal  objeCU,  linwever  mu«ll  ibeit 
detailn  may  vary,  viz.:  1,  to  form  a  broad  oasis  of  sunport  round  tbe  pelrii 
by  nteanri  of  a  otrone  weil-fitliug  band ;  2,  to  carry  utf  the  wvipht  of  tbc  Jmm) 
and  n]>per  extremities  from  the  spiue  by  means  of  lateral  crutdif*,  whicb 
tniui>mit  il  to  thii(  band ;  und,  3,  tu  inHueoce  the  convexitiw  of  llw  aptaal 
curve  by  riicaus  of  movable  plates,  acted  upon  by  rack-and-piniuo  or  •erv« 
power.  The  best  of  ihv«e  mcvhunical  contrivances  fortupporiing  the  ungbt 
of  the  head  and  shoulders,  is  the  apparatus  represented  10  the  sccouipasyiaf 
wuodcul  (Fig.  6I0).     By  it  tbe  projcctioo  of  tbe  right  shouhlrr  may  b* 

gradually  brought  down,  thv  left  uDs 
raiecd,  and  the  weight  \>(  the  whol*  af 
th('  ut)]ior  part  of  tnv  body  sttppoilad. 
By  this  contrivance  alone,  pi 
and  carefully  adjusted  to  Uw 
tion  of  the  (k-lormity.  moK  paliMli 
may  bv  trratod  without  tha  mesari^ 
of  any  contioenieut  wliacevcr:  ttm 
spine  being  by  degrees  restored  M  it* 

firoper  direction  by  very  mdually 
ncreulng  the  preaiare  and  sapptft 
of  tbe  inotnimenl.  at  ibe  aaue  tioM 
that  tbe  geoeml  health  is  rareftlUy 
attended  tt^i,  and  the  patient  tias  tW 
beiiffit  nf  good  air.  At  Br»t  tbe  «l- 
strument  need  lie  worn  only  dorinf 
tbe  day,  but  alter  a  time  it  stHHtlAf 
kept  oa  at  night  a*  well.  la  li 
standing  and  severe  cases  of  Ul 
curvature  of  the  sniae,  wbesi  its  flexi* 
bilily  is  Inst,  aoil  llie  pntjccttoo  sf 
the  rilw  has  iMvume  pcmMnest.  • 
euro  ciiiiiidl  be  rxnrvtt-d.  Dor  can  it 
b«  broDght  about  bv  any  mcaoa;  but  the  patient  will  denve  grvst  coaUoct 
and  support  from  tbe  use  of  this  excellent  instrument,  and  thr  tDct«Ma  rf 


i\ 


Vl|.  •■&,— Sptnhl  itiipiMft  for  tmUnl 
C'arr»tur«. 


tiiQ  disease  may  thus  be  prevented.    Savre's  plastpr  jacket  baa  baan  __ 
for  lateral  curvature,  but  is  now  generally  condemned,  as  it  prsvaala  bow- 
ment  compteU'ly,  and  thus  increases  tbe  wcnkoess  of  the  mtMctln. 

Tbe  treatment  of  /Wcrior  JCtenrvation  of  the  spine,  witboataarias  or  oCber 
organic  diseaitt  of  the  vertehrul  column,  is  beat  condncted  by  Uw  we  of  tba 
iDAimmiot  tien*  %urt-d  (Fig.  (iHii,  which  is  coostnicCad  OMtatJnUy  « ifat 
aamo  principles  as  thai  tor  lateral  cunratore,  with  tbQ  axespliaa 


CAUSES   or   DirOBMITT   OF    NECK    AND   LIMBS.  495 

l»ck-plate  is  to  arranged  u  to  pre«  upon  the  projection,  and  thus  gradually 
to  brine  it  into  proper  poBitioo.  In  caaee  of  kyphosis  eepecially,  attention 
ibouldM  directed  to  the  aeose  of  vision,  and  myopia  or  other  impairments 
should  be  corrected  by  the  use  of  glasses,  the  stoop  being  olten  dependent 
on  oear-sight. 

In  Fb&lmoT  Jnatroaiion  the  apparatus  here  6gured  (Fig.  617 )  will  be  found 
the  most  useful  appliance.    In  fact,  all  these  varieties  of  spinal  curvature 


Fi(.  ftlB.—Spiaftl  Support  Tor  Poiterior  Fig.  61'.— ^piiml  Support  for  Poilciior 

EiCDrTKtion.  Ipcurvation. 

nar  be  remedied  by  the  use  of  instruments  constructed  and  acting  on  the 
Buic  simple  mechanical  principles. 

DEFOSHITIIiS  OF  THF.  NECK  AND  LIMBS. 

Various  deformities,  such  as  tmiint,  wry-neck,  d^nA  clubfoot,  are  due  to  a 
disturbance  of  the  normal  equilibrium  that  exists  l>etween  aotaironistic 
muscles  so  that,  by  the  paralysis  of  one  set,  or  by  the  spHsiiKKlic  action  of 
the  uther,  the  proper  balance  of  power  is  Imit.  and  the  limb  or  part  deviates 
from  the  position  that  is  natural  tu  it,  l>€ing  drawn  aside  by  tht*  more  )K)wer- 
ful  set  of  muscles.  These  deformitee  may  be  congenital,  or  they  may  be 
•cuuired. 

The  primary  mischief  is,  in  many  cases,  seated  in  (he  nervous  system  ;  in 
others,  but  more  rarely,  in  the  muscular.  The  ligamenis  and  bones  become 
nolv  secondarily  altered  in  shape,  l>eing  shortened  or  comprt^sed  on  the  side 
towards  which  the  limb  or  part  inclines  or  is  drawn.  Fiiscia?  aloo  liecome 
shortened  and  tense,  and  the  disused  muscles  ar«  apt  to  bci-dnie  soJt,  wasted, 
and  flabby.  The  contracted  muscle  after  a  time  beconK's  jwrmant'iitly  rigid 
and  shortened. 

VAVi'tif. — The  causes  of  these  deformities  arc  very  vnrinus  ;  but  tliey  may 
be  referred  t<>  the  following  heads. 

1.  Prolonged  Abnormal  Position  of  a  limb,  as  in  an  unrt'duccd  <lisl<ira- 
tion  Mr  an  ankylosod  limb,  may  It'ud  tn  ])crmiinrnt  di't'nrrnily.  It  iiiny  be 
tak>.-n  as  a  gent-ral  pathological  law  thiit  iigariienti^,  faM'i:c,  mid  to  a  li-.<s  ox- 
lent  niutfcliv,  if  kept  for  a  sufficit-iit  Un^th  uf  time  iu  it  (oiitinnoiisly  rcliixed 
state,  bfCiime  shortened  to  accomnxxlali.'  thenisclvi-!*  to  tlic  pc^itinii  in  nliicb 
they  have  lieen  placed,  and  thus  remlcr  tlit.'  di;'|>lii('cni('nt,  whii-h  iiri;;iii:illy 
caiued  the  relaxation  permanent.     The  most  marked  exuiii|)l<--  of  thiii  i^  etxu 


496 


UBPOBMITIBS. 


in  ouM  of  piou  abecesB,  io  which  the  patient  has  bera  conBfw*!  IS  ht^i 
montlu  before  death  with  the  knees  consUuitly  flexed.  Aflrr  a  tii 
ptete  extension  beoomee  impoesihlu,  riuI  liifoectioii  pmrei  th»t  th»  U  diivtt 
shortODiDg  of  those  lignmenu  that  are  re\tixe*i  in  flexion.  A  aimiUr  •!»»«»■ 
iDg  of  liguincDta  or  fasciic  may  occur  after  frarliirc^,  if  ihe  parts  be  kctx  fir 
too  lon^^  a  tiiao  in  one  posiiion.  mon;  pariiculurly  if  they  be  boaDa  aad 
malted  uigether  by  the  preaeure  of  tight  btuidagee.  There  is  no  daafar  bav^ 
CTvr  of  such  u  coudition  hciug  developed  in  the  time  ordinarily  raiuirrd  fit 
the  treiLimeDt  of  a  fracture.  8onie  forma  of  congenital  clubCiot  Iut*  bm 
supposed  to  bo  due  to  a  prolonged  abnormal  position  n{  the  linib  during  n- 
irauiwrioe  life,  but  the  e%'iden»>t  of  this  u  not  very  ialisfuclory, 

2.  Oontraotion  of  iniuBmatory  new  grovthi  or  of  tJimai  vhkb  b&n 
been  infiltrated  with  iafluaiDttory  exudatioiu,  is  a  fruitful  cauae  of  dvfoi 
iti«9.     \i  cxdm|)l^fl,  may  be  mentioned,  the  coDimcUoD  of  tite  dcatrii 
bums  in  any  part  of  the  bftdy,  acquire'l  taliuea  equinus  from  eooi 
follciwiug  ft  tiecp-iveattd  abacCM  in  Lhd  ailf,  and  oentracted  knee  or  hip 
m(lunimau.>a  of  the  iuiuL 

"i.  SArangement  of  the  proper  antagooiitic  action  of  certain  proapi  •( 
Knscles. — Tlii*  nmy  anan  Imm  a  variety  yf  chiiso. 

(a)  The  PMition  of  the  Limb  may  ^iv«  one  groop  of  nitMcles  au  a<lvaa- 
tAge  over  tlieiroppuneotB;  thus  in  itiKKse  of  the  knee,  the  Oexnl  (itaitMa 
gives  tlie  flexor  muiclea  an  advantage  orer  the  exteoaur*.  and  we  eoos^ 
queutly  Hud  that  the  head  of  the  tibia  Iwcoaies  after  a  time  iliaplaved  to  a 
greater  or  tesa  degree  backwards  into  the  ham,  merely  by  the  tonic  cunUBe> 
tioo  of  the  muscles  wiLhuut  any  weakuera  or  paralysis  of  their  DpiKtoenti. 

t  B)  Parali/tU  or  parttie  oj  one  gnup  of  mtue/ea,  the  eonlractlUty  of  their 
aniag'iuioie  c<.>nliuuiHg  uurnial,  id  q  commun  cause  of  di-forniity.  as  the  rela* 
tiv«  balance  of  action  la  dealroreil,  and  the  Htmngvr  muiH:les  a  ill  pull  tlw 
part  over  to  their  side.  The  causes  uf  ihts  ooodiuoQ  may  be  io  the  msi 
thccuiielveii,  iu  the  nerve  supplyia^  them,  or  in  the  central  poftloot  of 
nervous  system. 

The  muscle  itself  is  seldom  the  seat  of  the  primary  le^oo.  G.  V. 
haa  pointed  out  that  a  single  muscle  or  group  of  muttclcs  may  be  woaki 
and  their  contractility  in  response  to  electricity  impaired  bv  exenaira  ___ 
witbont  sufficient  iDtenrnU  of  rest.  This  is  often  accr>mp«ni«i  by  spasm  ofllM 
opfKinent  muscles,  sometimes  tonic,  iHit  more  often  clonic,  and  thus  deftHmfaj 
mar  result.     This  ia  not,  hovcver,  a  common  cause  of  actual  dnftfrmitr. 

The  conductivity  of  a  motor  nerve  is  frequently  abotUbed  by  wound,  in* 
Jury,  pressure  of  tumor,  exposure  to  cold,  or  neuritis  frum  other  cauaen.  k 
soud  t-xamplo  of  the  elfbcis  uf  teeioo  of  a  tnotfir  nerve  in  pruduotng  d^ 
Ibrmity  may  be  seen  in  the  peculiar  oon<liii«u  of  the  band  and  forsann, 
deaoribed  at  p.  565,  vol.  i.,  m  reimlttag  fr»m  ]>aralyiiis  of  the  musculo>«piral 
nerve  In  certain  fractures  uf  the  hiinifrus.  In  panilysia  of  ibe  facta)  oerra 
fn>m  cold  the  face  is  distorti'd  by  being  drawn  to  tbu  sound  side.  Intrmal 
sijtiiut  niav  result  from  paralysti  of  thtf  »ixlh  nerve  froni  preanirw  up^Mt  it  as 
It  enters  tlie  iirbit,  the  exterunl  rectus  Iiniiiij^'  its  }M>>>ter  iiud  tha  cya  bciflf 
dmwn  inwards  by  tbe  action  of  ita  nniaguuisi.  the  iuterual  rectus. 

Dtaeaie  of  tbe  central  nervous  svstem,  mure  especially  uf  tbe  apinal  oird, 
ts  ■  fVeqoest  cause  of  deformity,  which  is  very  common  iu  ioliiDcy  aitd  early 
cbiidhuud,  as  n  cuniequence  of  Infantile  PonLtyaia.'  This  ilisense  ■•  now 
kuuwu  to  be  due  to  iudammuiiim  nf  the  anterior  gray  curuua  of  tbe  amL 
Al  flni  there  u  extensive  inralyeis,  which  gradually  rliArs  up  as  ifac  aoste 
stage  poeMa  oiT,  uHen  leaving  merely  n  single  group  of  muscles  pemaneotlj 
paralyaed.  u,  fur  instance,  tlir  itbia'tis  anticus,  and  the  exteoaon  of  tbe  Inaa 
As  the  result  uf  this  the  i<Mi  becomes  extended  by  the  unoppoatd 


DEFORltITT    OF    XBCK    AND   LIMUS — TREATMENT.         497 

of  tbe  calf,  aod  one  form  of  acquired  citth-font  in  imnluced.  Little  haa 
made  the  important  ubaerTatioa  ttiat  many  ciii!Cfl  of  defnrniity  id  infuuts 
appear  to  be  due  to  mischief  inflicted  on  the  base  of  the  brain  during  pro- 
tracted and  instrumental  labon>. 

Aiiuther  e:[ample  of  deformity  from  disease  of  the  central  nervous  system 
u  theclub-fbot  and  occasionally  club-hand  also,  met  with  in  cases  of  cncepha- 
locele  or  spiua  bifida. 

c)  ifpatin  of  a  tmitde  or  group  of  mttscfei  also  may  give  rise  to  deformity, 
the  itpiMiuent  muscles  remaining  perfect  in  their  coiitnictility,  but  being 
orer-balanced  by  the  continued  contraction  of  their  anliigniiists. 

Spnsni  may  Iw  the  resnit  of  flirect  irritation  of  the  central  nervous  system. 
ThtA  Wiruld  appear  to  be  the  case  in  some  forms  of  sr]uirit.  It  may  also  be 
reflex,  resulting  from  some  |>eriphernt  irritation.  This  \vc  coninionly  see 
happen  in  cases  of  contraction  occurriii^tr  frorti  the  cutting  of  tettth,  the  irri- 
tation of  worms  in  the  intestinal  canal,  iu  the  si>-calle<l  hysterical  contrac- 
tions from  uterine  irritation,  etc.  From  all  these  various  ciiuscs,  contniction 
aa<i  coodcijuent  deformity  may  arise.  In  some  cases  deformity  will  cease 
afier  removal  of  the  caut>e  ;  but  in  other  instances,  in  which  it  has  been  of 
lun^  iluration.  the  deforinitr  nill  continue,  r)\ving  to  the  mu.xcles  having 
fiilleo  into  a  kind  ot  ri^id  atrophy,  being  shorti'ued  iind  wai5ted. 

4.  When  deformity  has  arisen  in  the  lower  extremity  as  a  consequence  of 
any  of  the  above  condition:*,  it  becomes  greatly  aggravittcd  hy  the  weight  of 
ikt  boJii  acting  on  the  deformed  limb.  This  we  see  ct^pccially  marked  in 
old  club-feet. 

Treatment. — The  General  Treatment  of  deformity  consists  in  removing  the 
cau«e  of  the  contraction  iu  those  ca^es  in  which  it  is  de|>endent  on  central 
(.•r  peripheral  disease  or  irritation  that  admits  of  remedy.  Thus,  if  s<iiiint- 
iog  arifle  fniui  pressure  upon  the  brain,  the  eye  will  asr'ume  its  lilniight  direc- 
tion when  the  congested  vessels  are  relieve<I,  or  the  ofliised  fluid  absorbed  ; 
or  if  a  contraction  of  the  hamstring  muscles  arlst-n  from  the  irritation  of 
worms  in  the  intestinal  canal,  a  purgative  du^o  may  cure  the  atfcctioii. 

Electricity  is  perhaps  the  most  valuable  agent  we  possess  for  the  treatment 
of  thijde  deformities  that  arise  from  paralysis  of  one  set  of  muscles  allowing 
those  that  retain  their  healtliy  contractility  to  draw  the  parts  over  to  their 
lide.  Thus,  for  instance,  if  the  muscles  supplied  by  the  external  popliteal 
nerve,  the  lihialii  anticus,  the  estmsurs  <tf  the  toes,  and  the  iKrniiei — are 
paralyzed,  »o  that  the  muscles  of  the  calf,  ttit-  tibialis  purlieus,  and  the  flexors 
of  the  i<ie:<  draw  the  fo«)t  into  the  [losition  of  Talipe.'-  I'.ijiiiniis  and  Varus,  the 
eleL-tri<.'iiy  must  be  applied  to  the  toruu-r  {irmip  of  mnsek's.  The  continuous 
current  nill  be  found  the  most  efhcient,  tara<itziitiii[i  being  of  but  little  use 
if  deeenerative  changes  have  eomtueiiced  in  the  paralyzed  muscles.  In  the 
case  just  dwcribed  the  sjumge  couueetcd  with  tlie  positive  jiole  should  l»e 
lied  ovt-r  the  extenihl  po|)Iiteal  nerve  behind  the  head  of  the  fibula,  and  tlie 
Dejfative  s|Min^e  applied  freely  over  the  paralyzt'd  uiuecles  till  tlie  skin  be- 
come* uliifhtly  reddened.' 

Fricti  II  pri)j)erly  applietl  forma  a  useful  adjniict  to  eleetriiitv,  and  great 
i^re  ntui>t  be  taken  to  keep  the  limb  warm  by  jtrojicr  eloiliiiiL:,  without  wlilch 
the  'ithtr  treatment  will  be  of  little  avail. 

iu  nany  cases,  the  cmlruetion  may  be  slowly  Imt  very  etlietmiUv  i)vcr- 
cme  liv  the  use  of  suitable  appnriiius,  linviiig  a  iMiistiiiit  ilastie  or  t<'U>ive 
action    k<lt   up   by   nuaos  of  bunds   of    vulciini/td    Imlia-rublHT  or   ;iiel 

•  F...-  ,].  'a:'.  ..f  the  tn-ntnicnl  "f  iiiirtilv7;i<l  iini-i'l--  tiy  •■l-'i-iiii  il\ .  I  [iiii-r   [■■i'.  ;■  iln- 

t*».j.-r  ;  ■  ■['■.■l:il   Wiprki   ■■»    ih'-    rllljfct,  i-jH'.'iiilly    -■   Kli  .  [r;-  JIV    )Ti     .\[.il;i-ir.i>    iitxl  Siir- 

S*r>'    ■  i".  fi    V.  I*'«ire,  nrid  tin-  -cli-cli-'ii  In-tii  iln^  Wmk-  --i    limli.'ion'    <'!'  IJniiNi-rn'i, 
publ>h»'J  hy  ihc  N«w  SyOeiihani  SiKit-ty  in  U'HJ. 

TOL.  II  —32 


4M 


DSrOKHITISS. 


Siring.    The  tlctiii)3  or  these  vsriouB  npplinocee.  thnogh  balaang  tb  iJk> 
e|>»rini(>nt  <}f  tW  inHlrtiinciU-muker,  eaiuiot  W'  1i.hi  mrvlulljr  RtiMMHd  hr  ih* 
Sum;eoa,  ivhi».  after  all,  in  urHcr  to  guide  udiI  conlrul  lUv'tr  Bctiob.  itiait  ha 
thoruuglily  i-oiivc-rwiut  wilb  ihe  m«<rhaiiical  priutij>l<--9  inv"Ivo<l  Ii>  tli-L-  r*- 
DtrucUnii.     Ill  m»iiy  uf  tlio  iili};ht«r  siid  lem  chnnic  casn.  (i 
iDAy  Ik)  ronicflitil  by  the  employmeDt  o(  tJi«M  tnjliler  ntviins,  • 
joined  ;  but  iu  lh(««  whioh  Hre  congeiiilal  or  more  pertaauviit. 
ef  the  Tendons  at  fault  U  the  oiilr  luode  uf  rfHloriug  the  iinturm   <^-ii'i  <i'<u 
or  (1)«  pnrt.    Ttie  orihopadic  department  of  aurgery  uwia.  in  a  t^rval  mcaMic. 
ita  vxletviic-e  lo  the  Jubors  of  JX'l[>«c)i  and  Stromeyer,  aiul  ita  jterfeetium  m 
tfaose  uf  LiLlIe,  Taiiiptin,  iind  Ai)hiii5. 

Tenotomy. — By  Ivuutomy,  iis  at  pruH-'iit  prai'ibed,  b  meatit  i1m*  Mbeatas*- 
otiK  divii-ioii  uf  a  cuiitraiilfd  Iftidon  by  itii'aiix  of  a  uarn>w-blat)r<l  luufr 
iFijTfl.  I'iH.  G\'J,  620)  ialrmluced  f>hlit|iu'ly  ihnmtrh  n  puuctun-  by  Ita  mde. 
In  liuiiiji;  tliift,  it  aliould  be  boroe  in  ntind  that  tb<*  nnrninl  analuinieal  nrf»- 
ttou»  of  twrts  are  often  a  gowl  deal  disturbed  in  ataea  of  (tdbncUy  ;  tat 
tbuo  tfni)t>nji  tnav  be  npproximntrd  Ui  nrtcrit^  and  Derrea,  rrum  wmkhtH 
the  luiillhy  conifilion  uf  the  limb,  they-are  widely  M-parnted. 

In  the  operati'in  of  tenotomy  tbi^  knife  tnar  be  uani  in  nnf  n€  twn  vm. 

In  the  mnjorily  of  ca^ee  the  tendon  maybe  most  cnnvunitittly  dtrHlrd  of 

intnKlucing  the  blade  iM-neuth  it  eidewavi).  and  then  turning  the  nlgw  aeu>K 

It,  and  ^ontlchiu^  through  it  bv  a  kind  of  fine  luiwiitg  mnTrmt-nt,  thu  basJU 

of  the  knife  being  used  aa  a  ft^ver,  to  pre«  the  eilge  ae»ln»t  the  imJmk, 

whiUt  it  I*  made  tense  by  an  nuilsiant.     The  aecond  way  u  to  paaa  tb*  !■»•■ 

tonic- aii|4'rficially  U>  the  teiirlon  hclH*e<ii  it  and  t)i<>  Akin,  and  tiw-D  Ia  tan 

the  edge  against  it  uhilel  it  w  niA<lc  light  by  an  Kiwivtanl.     In  (hi*  plaa  tW 

danger  of  woundini;  th<' akin  in  :i '  A  dn* 

or  two  only  of  blixwl  is  h<ft  iu  tli>  n  :  aoJ, 

H»  the  divided  tendxii  rotracto  witli  h  -  ^  *f, 

A  mp  wit)   be  lelt  Wriseen  the  lMi>  n  iiatf 

nn  ineh  t»  an  inch  in  widlb.  a•.-ccl^lini:  to  t^  jm- 

viouB   amount   of    tension    in   tlic  part.      If   tfM 

rouflclea   have  been  contracted   for  •MM  yemn,  it 

will  commonly  be  found  that  Lbo  faaciia  in  ibt 

uei^hborho4Hl  uf  the  tendon  have  betxHoe  riipd  ai 

unyielding,    forming  corde    or   bauda   M 

aen»a  from  the  Bide  of  the  ^ap.     If  tb«M 

tenw,  tbcy  may  be  divideil  iu  ihe  uiu«  way: 

in  many  inKUmtrt-s  it  will  he  touud  attt-r  tlie  lapep«f 

u  nhnri  Lime,  that  iJiey  will  yield  by  Btntrliiiiir,  aai 

ronM>4[iu'nlly  will  not  require  divuion.     Aftrrlfe 

neirtiim  has  iH-in  made,  the  amall  piiui-turv  abMU 

Ih'  cliw^'d  with  a  pad  of  lint  and  a  rtrip  uf  fiaaur, 

the  admi»ion  of  air  into  ihi<  wound   bdog  ou^ 

fully  gnanird  uguin^t.     The  whole  iuorr*  nf  tfct 

oprmiion  dependnon  this.    Hhimtd  ain-nirrapraA- 

tng  inHfimmation  and  Riippumtion  will    to  a  et^ 

lainly  Ih<  »et  up;  whiTra*.  if  this  bv  ■nuilad,  iW 

wound  will  h<-ftl  wiihoiii  uny  iotlomm-i'-  r  ^■■■^■ai 

that  rauaed  directly  by  ihv  injury.      1  -itiy 

of  air,  and  not  the  subeutane^iuft  woitn<l,  that  guren  ri»e  In  »j,n-n<ut)^  iniam- 

niatinn.     Anlinepticr  an-   «h"lly  uniU'<r«»nry   in  trnoU.my.     If  the  mbci- 

laneiiu*  -eetiiin  be  done  with  the  nuwt  ll^l^nlt^y  iiir-r,  n.i  dang*'r  of  aoppon- 

tiun  will  renult     After  tei|.>u»my  the  part  ehimld  then  lie  simply  b*iwtaH 

and  either  lefl  without  any  appuratun,  or  Bupj>ort«d  by  %  aplinl  id  the  na* 


I 


rr(*-  ItlA.  >10.   K«- 


TiBPOBMITIEa  OT  THB  PACE  AND  NKOE — WBT-WECK. 

Tx^itioii  that  it  occtipttid  liefore  tlie  tendon  wim  cut,  no  Htti^mpt  nt  extensioa 
hein^  niiule  for  llirre  itr  four  diiys.  Al  the  expiniliori  of  tliis  time  repnir 
will  have  oommeiiceii,  anil  then  proper  mechanical  contrivances  may  be 
sdjiisied  for  gradonllv  reoutring  the  normal  piieition  of  the  limb  nr  part.. 

.SByre^adiipts  a  diflerent  niPlhod.  He  inKkes  extension  immediately  after 
the  division  nf  tcndnti^.  and  fnaciie.  and  I  have  seen  excellent  results  follow 
fthi?  practice.  It  is  not,  however,  applicable  in  all  ceims,  as,  in  some  inataitcefl 
tof  talipes  of  old  standin<;,  the  contraccion  appears  tn  exiiit  in  the  Hgnnieota 
\na  well  as  in  the  more  superficial  slructnrfs.  In  such  cases  considerable  re* 
instance  will  be  offered,  and  lon^-cuniinned  cvtcnsion  he  required. 

The  mode  of  Eepair  fa  Dirided  Tendons  hfi3;;iven  rise  to  some  contro- 
verir,  there  Wing  txfo  theorloa  witli  regard  to  the  process.  According  to 
one,  the  grnoulaiion-tiMue  between  the  divided  and  rctraeted  ends  gradually 
DiiileTgiiet  a  process  of  contraction,  analogous  to  what  takes  place  in  tho 
cwatrix  of  a  bom.  so  as  to  cause  approximatiun  of  the  cut  ends  of  the  tendon 
■t  the  expense  of  the  muscle,  which  becomes  partially  tenj^thcncd,  until  at 
last  a  transverse  linear  cicatrix  merely  is  left  at  the  line  nl'  seclii>n.  Adams 
ha«,  however,  cnnclusively  shown  that  this  iheury  isern>DeoU!!,and  that  refiair 
i*  efivcled  by  lb«  formatiun  of  vascular  ffraauUtton-tissue  lietweeo  the  cut 
ends,  (.'hivfly  frum  lliu  shesth  and  »ofl  parLn  around;  that  thin  undergoes 
uradital  development  into  tibrouK  ti»HUe ;  and  that  the  teiiduii  is  actually 
lengthened  and  remains  (wrtnanently  »o,  by  the  formation  nf  this  new  mute- 
rial,  which  eventually  reserablea  the  norma!  structure  of  tendon  so  closely 
that  the  micro8co|w  fails  to  detect  any  appreciable  diRerence,  and  that  it 
cno  be  ilirttinguislied  only  by  it«  more  tranwliioent  appearanco  from  the  old 
tendon.     Id  tact,  the  pan  is  completely  filled  up. 

In  cases  of  congenital  nialfonnulion,  the  i|ueatioa  frequently  ariies  as  to 
vhelher  tenotomy  should  bejierformcd  in  early  icilancy,  or  delayed  to  a  more 
adraneed  age.  As  a  general  rule  1  think  that,  if  operation  will  certainly  be 
Decfsaary,  it  should  not  be  flelayed  ;  it  is  not  more  liiHicult  at  an  early  iH'rio<l 
of  life  than  at  any  other,  no  dunger  attends  it,  ami  when  |H)rriirniiMl  during 
tufancy,  there  is  a  far  Icds  chancu  of  ttic  deformity  \mu"  permanent,  than  if 
the  ofHTntitui  he  dulaycil  for  somt-- veiire.  But  it  rau«t  bo  remembcreil  that 
many  tstight  deformities  and  coiitrai-tioHH  in  infanta  nmy  bu  removed  without 
opvraiion,  by  attention  Vi  jirojier  nu-i.:liauiual  and  hygienic  mc^ns.  The 
Harseon  should  noi,  therefore,  be  too  ready  to  operate  in  slight  ctwc>t  at 
wnoer  ages. 


DEFVIRMITIES  APPECTISO  TIIR  FACP.  AND  KFCK, 

WnT-^ECK. — Wry-neck,  Torticollia  or  Caput  Obstipum,  arises  from 
apasm  uf  one  of  the  stern o-moitloid  muscles:  the  ln-nul  being  drawn  to  the 
aflccted  aide.  On  el'-«c  L-xaminattun  in  wrv-ncck.  it  will  he  found  that  there 
is  a  triple  displacement  of  llie  liead,  which  is  drawn  downwards,  rotated 
from  the  aJlVi-'ted  side,  and  inclined  laterally  towards  it.  The  features  lutie 
thvir  Kymnietry.  The  half  oi'  the  face,  and  even  of  the  bead,  uu  the  aSiicted 
eide,  tH.'c»uiea  loss  [tcrfectlv  developed ;  and  the  true  lints  of  the  eyebrows, 
eyes,  and  mouth  hiH:om«  dispta<xd  and  lowered. 

In  torticollis,  the  alfected  steruo-cleidihrnHjitoid  will  be  found  hard,  defined, 
Bntl  shortcnetl ;  sometimes  iHith  divisions  of  the  nnn-rlis  are  equally  ti'nsc, 
standing  onl  in  stron^r  relief,  do  as  to  look  almtwl  like  two  diiitinct  muscles. 
In  other  cases,  ona  divislcm,  ami  then  moKt  usually  the  Jiternal,  is  chiefly 
nAfCted.  After  a  time  the  cervical  vertebrie  particIpuEe  in  and  maintHiti  tho 
displacement,  lircoming  rotated  on  their  axi«i  and  i-iirveil.  Rventtmlly  the 
vhole  annual  column  shares  in  the  iliBjilacement,  and  lateral  curvature  sets  in. 


500 


DEFORMITIES. 


Tile  (1i?«'per  niuselcs  fJl>o  he^rorne  •brirtened,  am)  the  nntrrior  mikripn  *oi 
clavicular  atiacliDieDt  of  llie  trapezius  will  often  be  fiwod  Lvsm  and  ynut- 
Ddlurully  dffioixl, 

Caute*. — Wryneck  appears  to  be  ocoosiooallr  cvagonital ;  more  frvqnnrilf 
it  is  acijuired,  txiiuiug  ou  Id  i-hildbood  after  oicattlef  or  tcarlnUDa.  wualtr  m 
•  cuDiequencc  of  iananied  cervical  ginuds,  aod  ii  tlicD  duo  tu  tba  poauoa 
iiwtiociivcly  aaeuracd  bv  the  bend  in  order  tu  relax  luiucular  tcoMoB  on  tW 
inflamed  nideof  the  necK.     It  not  uofrequeuily  coiniuencei  whfc  m 

Mill  ucok  Ironi  raid.     In  oilier  case's,  a[;aiu,  it  ia  piiK>W  fpaani'-  :■»■ 

eion  of  tlio  niU8rU-  varying  at  diU'frent  tJiiicv,  duta]ipenriu)'  vrbeu  ihv  chkU  il 
anffiBtbcliu*J,  uiid  being  uvercomo  by  gentle  tmriiun.  lo  tbeae  cam*  tW 
epiiiul  accetsory  nerve  m  probably  ai  fault,  and  it  is  uwiug  lu  irritackw  ti  fc 
tbut  the  eteruo-innKtdicI  and  tra|M-*ziuK  uitiMrlea  take  on  a  ^potmndEc  adka. 
In  epatun  of  both  sienio-iiiastuid^  ibo  head  u  ibruwn  forwartU,  tbe  maacUs 
projeciinf^  in  great  relief.  In  ibetie  easoff,  ilic  diseue  will  ueuallT  l>e  fnini4 
to  nave  bad  a  rliininiutic  origin.  Deformity  in  llits  situation  may  oerur  aW 
from  diseased  ecrvical  vcrtebnr,  or  from  the  traction  at  the  eiratrtx  of  a  bom. 
The  condititins  bere,  however,  are  peculiar,  depending  upon  rauM-g  thai  an 
irreapertive  nf  the  iitftte  of  the  miiArles,  which  are  not  trn»c,  and  niav  ilia* 
readily  be  distingiii»he<l  Ironi  the  true  form  of  the  disease  pr>Hlu(T\l  (n  tht 
causen  above  mentioned. 

IreatmcHi. — Tbe  treatment  of  tortioollisarifiing  from  piTmam-nt  *hort^nig|| 
of  oneof  the  .iteriio-ninstnid^,  which  is  the  common  form  of  ;  ■ 
best  be  conducts!  by  ilivUliii>;  the  inlVridr  atlacbment  of  lb»  _ 

allowing  the  bead  co  reffnin  its  proper  position,     Tbedivi«i«>u  nf  the  mascll 
is  a  sonienliHt  deticAte  operation,  uu  accoonl  of  the  iniporlnni  vlrucluivt  that 
lie  immediately  bt-hind  iL     Ity  makiug  I  he  iucisiou,  howwer,  throofli  ilt 
from  behind  forward*,  close  to  the  sternum  um)  along  thv  clavicle,  there  ess, 
if  ordinary  care  be  employed,  be  little  risk  of  doing  any  damage,  as  tbnt 
bones  carry  the  lower  attachment  of  the  muscle  forwards,  and  sepanle  il    - 
frum  subjacent  jwrts.    The  teoaton  also,  into  which  it  is  ibmwa  by  its  spasa,  I 
dratva  it  away  from  thet^inttid  sbealh.     Insrvi-rnl  instances  io  which  I  have  ^ 
had  iH'HMaion  to  perform  this  ojterntion,  no  dillicully  whatever  has  been  rire- 
rienced  in  dividing  the  sternal  altacbmenl  of  the  muscle,  which  !■  OMnily 
very  tense  and  prominent,  by  niiikiii|^  a  jiuncture  un  the  (uDer  sUie  of  the 
tendon,  puehinij  a  narrow  dirvetor  behind  the  mitsele,  draiiiog  the  latter  br 
wnrdD.  and  then  [«»ing  nn  onlinnry  tfruutume  behind  the  lendoe,  with 
flat  nidc  tuwanlii  it,  Jum  in  front  uf  ifae  upper  niargio  of  the  steraam, 
cnllini;  forwards.  whiUl  l\\e  muscle  is  put  well  upon  the  stretrb.     In  divii 
the  clavicular  ineiTtton.  the  safest  plan,  1  think.  ciDabln  in  makings 
ture  with  a  scalpel  upon  and  down  to  the  clnvjcle  in  the  (Tllular  space 
lies  betucen  the  two  allachments  of  the  muscle,  ami  then  pushing  ■  lf«c. 
binat'piiinird,  narn>w-bladed  tenotome  beneath  the  insertion  of  ib«  muiciK. 
dividing  ihiit  in  a  <lirertion  forwards.     In  this  aituali-tu  also  the  director  nsT 
be  tisoil,  unlew)  the  parts  are  very  tentie.     Care  must  be  taken  of  the  estcnw 
jugular  vein  at  the  outer  edge  of  the  muscle.     Should  this  vrwcl  run  tttcoft- 
veniently  close  to  the  edge,  the  nnfer  plnn  is  to  begin  Iho  operation  from  ths 
outer  Hide,  making  the  tirvt  puncttirt*  here.    Afler  division  of  tbo  tciKUMi,thi 
deep  fascia  nf  the  neck  will  somirtimcs  \tc  found  ttp-lching  acreas  in  finaaD^ 
tense  Imnds ;  ihew,  hnwcvir.  hud  iK-lter  not  be  iiitcrltn^  with,  ai  thay  will 
yield  in  lime,  und  iitiich  ri»k  of  injuring  the  »ulK'lnviDn  and  caroUd  TWsb 
Would  at  lend  piiy  attempt  nt  their  diviiion.     Nurehi'iild  th«cdgeof  iW  kaUk 
ever  be  turned  iiiwanl«.     Carr  must  be  taken  to  divide  tbe  iDliaelc  eow 
pleirly,  but  not  to  carry  the  incision  tuo  freely  or  deeply.     (  barn  hnrd  «l 


erbr   J 

ith  bs  I 

n,  aad   I 
vidttcj 

m 


^t^m 


liKFORMITIES   OF   THE   ARK    AND    HAND. 


501 


more  than  ooe  case  in  which,  from  want  of  due  precaution,  abundant  henior 
rfaaf^  (>cc-urretl,  and  of  three  in  which  fatal  results  followed  the  operat'um. 

After  the  operation. the  position  uf  the  head  must  be  gradually  rectified  by 
ptuper  apparatus.  The  beat  inatrumeut  for  this  purpose  is  the  one  invented 
Dj  Bi^};,  and  here  figured  i.Fig.  021).  It  consists  of  a  pelvic  hand,  a  ver- 
tebral »teni.  and  arm-pieces,  the  ul>ject  of  which  is  to 
Kvure  a  firm  ba«is  of  support  to  the  neck-lever  (1), 
aD<]  the  raaxitlary  lever  (2).  The  neck-lever  pasites 
round  the  head,  and  takes  its  bearing  against  the 
tem[>>ral  bune  un  the  side  towards  which  the  head  is 
•Wfltvted.  The  maxillary  lever  acts  against  the 
luwer  jaw  on  the  oppuaite  sirie — that  which  is  turned 
up.  By  meana  uf  a  ratchet-joint,  the  neck-lever,  the 
action  of  which  is  verticnl,  turns  the  head  from  the 
fide  to  which  it  is  deflected,  whilst  the  maxillary 
lever.aoting  horizontally,  rotates  the  head  on  its  a-xi^. 
By  the  combined  action  of  ihese  two  forces  the  head 
is  re^t<im1  to  its  vertical  {Kwition,  and  the  chin  re- 
placetl  in  the  mesial  line.  In  this  way  the  curvature 
of  the  cervical  vertehne  may  gradually  be  corrected ; 
sbouM  it,  however,  have  exi8te<l  for  a  considerable 
time,  it  may  have  assumed  a  |>ermanent  character, 
and  a  twi«t  in  the  neck  wilt  eimtiniie  for  life.  If  the 
operation  l>e  not  delayed  until  too  late  in  life,  the 
features  will  gratlually  regain  their  ttymmetry. 

The  exposure  and  division  of  the  spinal  acccjt»ory 
nerve  has  Iteen  practised,  but  not,  I  believe,  with  any 
benefit.  When  wry-neck  is  secondary  to  dii>oasc  nf 
ihe  cervical  vertehne,  little  can  bo  d<inc'  boytmd 
maintaining  the  spinal  column  in  as  ttteady  and  fixed 
a  pi«iti<tn  as  possible,  by  means  of  mechanical  sup- 
port I  vide  Fig.  331,  vol.  i.). 

In  th<«e  rases  in  which  the  wrr-ncck  appi-ars  to 
be  dvp4rn<lent  rather  on  puralysiii  of  one  stcruD-mastuid,  than  on  spasm  of  the 
other,  elei'tricity,  and  the  application  of  stryvhaine  to  ii  blislerud  surface 
over  the  muscle,  will  be  found  most  useful. 


Fig. '121.— Iling-H  Apj.*. 
riitu«  fur  Wrj-nack, 


HKFOKMITIIS  OF  TlIK  .4I!M  ANl>  II.WM. 

CoBtraction  of  the  Arm  is  not  uf  very  CDmniiHi  occiirn'ncc,  t'xcept  as  the 
n--iili  of  burns.  I  have,  htiwevirr,  met  with  four  ili^tini-t  f  iriii:*  nfcuntrartion 
uf  the  furi-arm. 

I.  Then'  nmy  he  ankylosii<  of  the  <-lliow-joint,  the  fnrearm  being  Iwnt  iit  a 
n;:tit  aiiirle  with  the  arm,  thr  result  nf  <li<i!-nse  •)f  i>r  anuind  the  articiiliitiin. 
If  (hi-  ankylii^'i.''  be  fihroii-i,  and  tin-  niusclts  strnn;;  and  firm,  a  very  oi^cfiil 
linib  ni:ir  In-  n-.^turt-d  by  breaking:  dnwi)  ndJK'^ioi):!,  under  chlorDt'Drni,  by 
for'-ilih'  Hi-xinn  and  exiensiim.  nod  then  u^ing  pas-^ivc  riU'tinn,  t'rictioi],  nn<l 
dou-ht'!*.  Slmuld  the  musi-lt's  he-  very  flan-iil  mid  w:i.<ti'd,  f'>rotblc  cxtensinn 
mav  li-uvt:  II  (wniiancntly  wcaki-rud  limb,  nvcr  wliich  thi-  pntifiit  bus  Inst  the 
piiWfr  of  flexion.  In  such  cu-ts.  I  liuvc  fixiinl  ;rr:idu:il  extt-n.-^iur),  iriiide  by 
mean!'  nf  im  iiiiirultir  splint,  artt'>l  iipim  by  a  nit<-li<'t-a))jiHnilus,  thf  s:<t'<'st 
n>t-aiii'  <'f  n-iit'iring  the  utility  of"  tlie  arm.  If  tbf  aiikyliuti--^  be  ussi'mis.  the 
b>-n'-p  yliould  I>c  rrs«>ctC'd,  a  wt'dgt'-shaix'd  pii'rc  bt'ing  .lann  out,  and  :i  lal^e 
joint  allowed  tn  furm. 


fi02 


DEPORU1T1B8. 


2.  The  biceps  niur.  br  ilx  t-t'iitrunion,  nccuv'ii  u  jwrmiinent  0'  « 
arm.  TtiJK  coiitnit*tion  oflhe  hiit'^pe  way  he  liyf>terirnl  nr  rhi-uuii..  .  4 
liTHLf  rii-ul,  ot-ciirriii};  in  yi)iiu<;  wtiiiit-n.  ii  refiiiircx  thi>  itnlinarr  ooiMlitulMaal 
tniiLiiHtm  nf  UyML^na;  ^Iiduiil  this  fail  in  rrmnviu^  it,  rxlcntioa  wimj  \m 
niaili-.  utirlcr  clilorolurtii,  AUt)  the  nrm  kppt  lu  the  8trxii;ht  |i>*ilii>u  for  ■  tint. 
When  it  is  rheuiimlic,  or  oCorgntiic  cliarerter.  mnl  peniinticnt,  i»*vtioo  "ftbi 
tRTtiloti  and  itfl  sponcurosia  dirt  be  practiced,  due  care  bring  tak^D  uf  tkt 
nrtpry  and  nerve.  This  <i|)«nilioo  ie  moit  MlVly  done  b;  iutroducioe  tk 
lenotiinie  lo  the  iuDcr  side  of  the  tendon,  etipping  it  under,  and  mtiitifr  » 
n-nrd^  and  oiitnnrds ;  the  arterv  being  guarded  and  piuhed  lo  tht  inocr  mi 
bv  the  presBure  of  the  U^i't  toreiiDgcr. 

3.  The  foreiirni  may  be  fnrcihk  pronatod  and  flexed,  u  the  rcralt  aT 
chronic  influn)nmli»n  uf  tho  radio-tiuniiial  arlicuintixD.  Ilvn  fonjbb 
supination  and  cxlcneiuo,  undor  ohliiroform.  is  the  beat  rtmedy. 

4.  The  forcnrn)  may  be  bent  on  the  arm,  in  conana^ucv  of  ibe  rnDiimdino 
of  the  eicolrix  of  a  burn  alun}:  Uie  itiotde  of  the  limb.  Id  thta  caw,  the 
ptafttic  operation  dfocrilMHl  nt  pnjje  ■187,  ritl.  i.,  muel  bv  prartistvl. 

Ankylosis  of  the  Arm  in  the  Straight  Poaitfofi  ia  a  i^mdiiioo  of  ttrj 
seriouM  ■iii.-unvfnit.'tiL'e,  ihe  lini)>  bving  alniuet  uselcM  for  all  ortlinary  purpWM 


^ 


rit-  Kt. — OoBtrttelioB  *f  SuplavMn  it  Fonsna  mI  BsMaMM  of  Um  Kaaa. 

at  life.     lu  ai<>^  of  tlii*  kind,  tlio  treatiueat  lo  hv  udnptnl  itiiwt  il( 
upon  whether  the  ankyiu«iir  be  fibrous  or  usaenus.     If  it  w  libruue.  boai 
ftrni.  (be  furrnrm  mav  aJvuys  rt>actily  be  brought  iniu  n  rcetaogvlar  p'lalL 
by  flexion  under  ebionifijrni,  and  the  niubihtr  ol  the  joint  mmr  theOi 
inipn}?!.^!  or  restored  by  passive  moliuu,  Im'tiou,  uod  doUehrK     If  il 
uBseuuB,  a  ueilgc  uf  boue  must   be  reiuuved,  atid  Lbe  caeo  treated  a* 


fig.  tSt — Caniraodm  or  Tlutm  ib^  Vi-tttun  of  tb»  HrimI. 

ordinary  la»tao<w  of  exHsion  nf  the  elbow,  with  a  view  of  e^tabtbihiDi:  a 
falfte  joint. 

Aeqaired  CoDtraotion  of  the  Mnseles  of  the  Forearm  implicatiac  ths 
Hand  if.  ixTMtxDnllv  inrt  with  in  udull.i.  I  have  M^n  it  io  twrt  ^tppodlir 
cundilions ;  that  of  f'orcibte  extension  {  Fii;.  fi'J'J  '.  and  ibnt  of  fnrcibtr  llexir« 
and  proaatiuii  (Fig.  G'23).     In  iKilb  tosttmn-*  it  apf<(-nre<I  tu  bavr  been  tW 


m 


CLL'B-HAND  —  DUPUYTBKN'S   CONTRACTION.  503 

ivsiilt  i'f  exci-Mive  u^  i>f  certain  niust'Ies;  in  tlic  first  case  in  wriiiginjj;  out 
cl"th»**.  in  ihi-  iilliiT  ill  cutting;  with  vt-ry  heavy  shwu-f.  In  ihi-  ca,-'*'  nl'  tlcxion 
atiiJ  priioait'iu,  it  whs  interotitinti;  to  ob^rve  that,  whoii  the  lin^erd  weru  ex- 
tfOilvH.  the  wrist  hcoanic  tlext'il,  am)  when  the  wrist  wun  exteiuleii  the  tinkers 
be^amt:-  Iteut  !□■  In  thet»e  otueachan^nfcK-cuimtiou,  friction  and  };aK-ani:jin, 
with  the  n!<e  of  a  straijilit  ajilint,  were  a<lvuntage<)Qsly  n^ortui)  to,  a  cure 
bein'j  evenluully  eHi.'cte<). 

Panklyiii  of'  the  Extensor*  and  Supinators,  owing  to  injury  of  the 
niui«cuK>-^|iirdl  utrve  vonsei|uent  ou  fracture  of  the  liunierus,  with  or  without 
tiiDic  coDtraclimi  uf  the  l]exor»  and  pronators,  liaa  hecn  tieacribed  at  page  565, 
T-i   i. 

Club-hand. —  A  deformity  resembling  club-foot  ia  occasionally,  though 
raroiy.  met  with  io  the  hand.  The  contraction  may  occur  in  two  direetiona; 
either  in  the  M-nse  of  preternatural  Hexion,  or  in  tliat  of  abnormal  fxtenaion 
t'l'  the  nteniber.  It  has  been  deacril)e<l  by  Cruveilhier,  Voillerniier,  and 
Saiith,  of  Dublin.  In  mo»t  of  the  case^  that  have  been  met  with,  there  was 
a  cvrtain  amount  of  deformity  of  the  lower  end  of  the  radius,  with  congenital 
di»)< Krat i> >n  of  the  wrist;  and  in  Smith's  case  there  waa  an  accessory  semi- 
hinar  l>ime  iu  the  carpus.  Little,  if  anything,  can  be  done  by  surgery  tor 
the  relief  of  lltid  deformity  ;  though  some  benefit  might  po^ibly  result  from 
the  .(ivi.*i'in  "f  any  tendon!*  that  were  preternaturally  tensi'. 

Arthritis  Deformans  or  Eheamatoid  Arthritis  of  the  hand  is  a  common 
atfeciion.  In  thin  eumlitioii.  the  fingers  which  are  thickened  and  etiffened 
art'  parlially  l>ent  towards  the  palm,  and  at  the  same  time  turned  towards 
ih-^  ulnar  ^ide.  The  articulations  are  swollen,  and  in  the  earlier  stages  pain- 
ful. The  didt^ase  rarely  occurs  before  middle  age.  It  its  more  common  in 
ehlerlv  {x^'iple,  and  especially  those  of  the  laboring  class,  whose  hands  have 
been  inucli  e\piK!>ed  to  the  weather,  with  the  fingers  bent  as  in  liohltng  reins 
or  acriculturai  implements.     The  deformity  is  [R-rmanent  and  incurable. 

Contraction  of  the  Fingers. — One  or  more  fingers  may  l>e  bent  in  con- 
w^uence  of  injury  of  the  flexor  tendtmit ;  the  skin  and  tiiscial  structures  of 
the  palm  remaining  sound  with  the  exception  of  some  cicatricial  tissue. 
Such  a  miitniction  is  incurable,  as  a  portion  of  the  tendon  has  probably 
si  -ujherl  away.  In  the  true  digital  contraL'tion,  commonly  calleil  Ihiinn/lren'if 
riii.friftHiu,  hs  pathology  having  been  pointe<l  out  by  that  great  Surgeon  in 
1  >!'_'.  the  tend  ms  and  their  sheaths  are  unafl'ected,  the  deformity  bi'ing  due 
t'l  «'li:iii^e:«  taking  place  in  the  fascial  structures  outi^ide  them.  Jlost  coni- 
ni-Niy  this  CMnimciices  in  the  little  finger,  and  thence  gradually  extenrls  to 
th"  rill;:  ami  middle  fingers,  which  become  so  forcibly  and  firmly  curved  in- 
wards, iliat  their  extension  is  not  praotieabie.  This  fieformity  results  usually 
fr-iii  fn-ipient  and  eoutinued  [iressure  on  iho  palm  of  the  hand,  as  in  leaning 
I •II  a  r  •und-euded  stick  in  walking,  or  in  those  trades  in  which  nn  insiruiiient 
i-  pri-s!u-il  into  the  hollow  of  the  hand,  it  occurs,  however,  in  |ht.-ihi>  in  (he 
prime  of  life  without  any  ap|>an'iit  exciting  cMiise.  In  sudi  eases  1  have 
aittavs  t'nunil  it  assucialed  with  a  rheumalie  or  g'<uty  dialhi'sis.     <  >n  cxainin- 

ilJJ  the  i-'lltracled  fingers,  prujerlillg  rii|ge>  will  lie  fell  eXielldillg  Irorn  the 
puMii  til  tiii-ir  anterior  aspects ;  and  on  •-iideav"riii;,;  tostraii^hleii  tlimi,  tlu'Si* 
ridj'.-  will  be  tiiunil  to  become  ."t  ret  clie<  I,  :i[id  the  palmar  l:i>cia  ti>  be  ninlered 
trii-.-  Tiie  .-kin  covering  iIhm-  fascial  riilg";-  is  at  tirsl  i'lvr,  Imt  aflt  r  a  time 
lii'.-..ni*'»'  adip.-rent  to  them.  Sd  tirndy  are  the  liii;rers  contracted,  tlial  by  no 
etf'Tt  ('an  tliev  be  extended. 

i'ii'hfl--iu. — T"  l)u]>nylren  we  i>we  nur  knowleilge  of  the  true  pulli  ilniry 
••t'  tin^*-r  c'ntraeiliin.-'.  lie  fuuml  on  dir-.ecllnv;  a  liatid  whieli  wa^  tli<  ^eat 
of  tiif  di-*':i.*e,that  after  the  reTimval  nl'the^kiii.  nhiih  wn.-i  ImiM-anil  llieiiil, 
the  (iintractioii  nmtinued  as  betore,  and  this,  therefore,  eould  n-'t  be  its  seat : 


604 


llEt'OllUITlia. 


that  tlie  putmiir  fawin  which  wns  vxpoeed,  was  tensv  and  ■borteovd.  wbilit 
frotii  rlif  lourr  Bfl|)i>rt  Noiiii!  conl-like  pmlonpalioofl  pnatod  tip  bjr  tiumiitti 
the  tiii^'i-re;  and  ihat  uheii  )hpi<e  were  divided,  the  cdotrMtion  wnn  i«n«- 
iliatf^ly  rvninviHl,  thn  tpiidniiii.  the  Imnee,  mid  the  jiiiiit«  bcinff  [MiHVctlTanva^ 
He  coitsidrreil  theee  tibrmi?  dints  to  be  di>,'it»l  pmhinRatian^  of  tbr  palnar 
fascia,  and  conseqtifntlr  lookixl  iimin  this  nienihruue  nn  ibc  •«!  of  tU 
diseusp.  <_ioyrnnd,  whiiiins  nirefully  diasocted  hnodji  nffcclH)  io  thia  v>r, 
Btaim  that  those  fibnmfl  cordri,  vtilcfi  he  Inoks  upon  an  tbo  eeat  of  Uw  afln- 
tioiii  aro  not  prolongalinns  of  the  palmar  TaAcia,  but  are  ligameniAua  ttrafr 
turcs  that  cxtFod  from  ltd  Miprrticml  aspect  to  the  thcalh*  of  tht  Aeur 
tcndijDs,  into  which  they  arc  inbertN]  oppusitc  thv  M>iMr>d  phalaox ;  bMag 
formed  by  hyportmphy  of  bnndd  of  subculanooUA  connective  liatub  whiea 
naturnlly  cxi»t  in  this  ^ituatliin.  X^owwcr  this  ntay  be,  iJte  <mH  MBtatM 
cerlain  ihal  iho  Hcxor  tendons  hare  nulhiii);  to  dn  with  ibut  n-  >  if 

finjctT  cimtrauli'in,  but  that  it  b  due  eniir(>ly  toflbntutt  eorda  irot  lal 

diviiiiotis  of  thf  palmar  I'fljicia ;  and  tm  AdnniA  bm  poiutttl  nut.  r 
uf  tbeve  dtgtlnl  prolon^itliiHiH  of  the  ftuviii  into  ihu  )Mfri>«leuni  <<; 
phnlntix  reudily  explains  ihi-  ilrHwiuj'  down  of  tlial  boue. 

Tfie  /'iujrNwt«uri.'ii8c-9<if  dijjilal  ciinLrtii.'tion,«<i  far  na  tht'deforniily  tt  aaa> 
oenied,  is  obviuoo,  aud  require!  no  conimeitt ;  ft  far  a«  tli«  irauw**  ia  nan 
cenied,  it  u  noL  n  ea«y.  Is  it  tendiunni  or  Ducinl  ?  Wlim  tr-nditHmt,  ikm 
oontructi-d  teiidoD  can  be  followed  up  to  mid  nlrove  the  wrict  m»  a  tfotrnml; 
tlie  palmar  etructurea  being  healthy,  AVhen/'iwiW,  the  tendmi  ranooi  im 
clearly  deliaecl,  hut  the  palmar  Kructuree  are  driu<\  tliiukcuod,  and  iacnr- 
pofHU'd  together,  furmin|;  distinct  rid^'fl  and  vuld. 

Thi»  true  di>:tuil  ooiitniulii>i)  Diiial  not  be  eoaPounded  with  tlwl  ''arlhritii 
dcfitrtiiuiia,"  which  oltcu  diiitortj>  the  tveu ther-buatcn  hand«  of  lahorioj;  amm 
and  eailore.  In  these  cw:^cs  all  the  tniiiom  are  bent  inwardp,  ami  ninm>r  loa 
twitittd  to  the  ulnar  aidu,  bo  ihnt  the  hand  preiuuild  a  claw-like  appomiMa, 
the  tniHohief  evidently  uttci-ljiig  the  joinlit. 

Treatment. —The  treatment  of  digital  contractionn  is  purely  merhaaidil 
and  opcrntive.  The  priigre«  of  the  dbraae  may  I>«  retanird,  atKl 
benefit  riiitAined  by  the  \iw  of  tini?F>r-f;plint9  npptiol  to  thp  dofial  aafwrt,! 
provided  with  elnMic  traoU^ni.  The  kind  of  o[ieratlou  must  be  dt9etmA 
by  the  pathoto^ieal  eau*e  of  thfi  diwaAc.  A*  it  ii  nnw  known  ti^  be  dtM  la 
ba^tal  rbanKeti,  the  tendon  and  ita  nheath  miiiit  nr>t  Im'  tniieheil,  hut  the  eo*- 
traeterl  tlrnetur<«  outside  I  hem  must  Im*  cut  aenMM.  This  enDHiolii.  when  the 
deformity  is  iilii^ht  and  n>c«ot,  in  dividinf;  each  tense  dij^ital  fascial  pntlciog*- 
tt<Hi  by  a  sulMUtaneons  ineinion.  Thic  oboutd  lie  done  oppiMiie  thv  aroai^ 
])hnlanx,  wlnre  it  n  UHtiully  moat  tense;  but,  if  th^  other  fia^rjiuota  ha 
aHeelod,  n  M>pnrHle  sevlion  may  be  required  opfsi^ite  each  pbalaux.  TW 
Hurgi-on  niu"t  ■»•  careful  not  t'l  mrry  U'li  iiieiviniiK  or  puDctoir*  lim  dvrply 
into  iht^  pnliii,  lt«t  lh«  stjfterlii'iiil  piiliiinr  tircb  or  oue  of  itf  Krsnrhai  m 
Hividi'^l.     Tiie  guide  to  the  (.-^ounifUoiineiK  id*  lliii<  digital  pr  ;i«  fma 

(h«  palmar  (n#(;ia  in  the  trnn*trr*r jlr^inu  fiJd  in  the  fMlm.  1 
baa  p»inl<Ml  out^-Wirrreii-inda  exnetir  with  the  line  of  the  mrtacarfK^I 
laofienl  iirliculalions,  and  is  of  counie  wcil  in  advance  of  the  tn\ 
palmar  un-b.  By  keeping  the  higlie»t  innttimu  near  bi  thin  line,  no  tlaagar 
to  this  artery  need  be  Iviiroil.  Sbuulil  it  Ih*  hmnd  to  be  imnoaible  ta 
■tmighten  tlm  fingur»  with  eucb  liinitv<l  inrisinn*,  or  abould  In*  dtm  ba 
6rmly  ndhfn'nt  to  the  subjacent  fibrous  band,  it  has  been  recnmtncaiM  la 
make  a  rmrial  incision  through  the  nkiu,  tii  dissect  the  ttap  back,  dirUa 
or  disKvtolfthe  faiirini  bands  fnmi  the  obcaths  i>r  the  lendr>n«,  aadalnughm 
the  fingers.  At  the  Hrxor  u-iiHons  arr  not  nnmarily  affVctcil,  iktj  onHt 
Dol  be  divided.  After  the  o|K'nLtiim,  the  hiuiJ  should  be  placed  on  adii 
BpVuit  and  the  fiogerv  kept  extemtcd. 


CONGENITAL   DEFOBUITIES   OF    FINGERS   AN1>    HAND.      505 


Fig.  624.— Dupu,vtreii>  Cun- 
tractiun  (after  Ailami). 


Adamp,  recognizing  ihe  true  pathology  of  thia  affection  (Fig.  624),  baa 
devisel  and  practised  a  suceeesftil  means  of  reiiie- 
driu;;  it  Ity  subcutaneous  operation.  He  justly 
deprecam  in  such  cases  all  operation  by  oi>en 
wound.  The  i>lan  adopted  by  Adnnis  consists  in 
making  multiple  subcutaoeoud  divisionit  of  the 
fiucia  and  its  digital    protungalions.     For  this 

[turpoH^  be  um«  the  smallest  possible  tenotome — 
iltle  larger  than  a  cntaract-necdie;  with  this 
mstrtiment,  al>«>ut  four  punctures  and  subcu- 
tADeoua  incisions  are  made  to  each  finger,  not 
operating  on  more  than  one  or  two  fingers  at  a 
time.  The  first  puncture  ia  made  in  the  palm 
ja»t  above  the  transverse  flexion-crease  atapoint 
where  thetkin  is  least  a<niercnl.  By  the  second 
puncture,  the  same  cord  should  be  divide<l  be- 
tween the  flexion-crease  and  the  web  of  the 
fingere.  The  third  and  fourth  puuctures  should 
be  made  so  as  to  diviile  the  digital  prolongations 
of  the  fascia,  care  being  taken  not  to  wound  the 
digital  ves8i.'l8  or  nerves.  Immediate  extension 
it  then  made,  and  the  lingers  kept  straight  on 
a  f>addet1  metal  splint. 

C'jutructioH  or  bend  of  the  Finger  bachcardu  is  of  very  rare  occurrence.  I 
have  seen  only  one  sudi  ease,  in  a  lady  in  whom  the  little  finger  of  one  hand 
had  a  crescentic  curve  backwards;  tbc  ring-finger  was  also  slightly  affected. 
This  condition,  which  was  [MTiiinnent  for  many  years,  olwtinately  resisting 
all  treatment,  mcchunit-al  and  constitutional,  appeared  to  bo  due  to  chronic 
neuritis  of  the  cords  of  the  brachial  plexus,  coUi^eijuent  on  a  fall  on  the  back 
of  the  head  and  neck. 
Con^nital  Deformities  of  the  Fingers  and  Hand  are  fmjuently  met  with. 
1.  The  mitut  conmion  form  consists  in  a  Snpemamerary  Finger  or  Fingers. 
Tbe^e  an:  of  several  different  kinds.  There  i,",  in  the  first  place,  that  form 
of  ^'.i|icriiumerary  finger  in  winch  the  adde<l  digit  ap|>enr.'ii  to  ho  .siniplv  a 
Ofiniiuuation  of  the  natural  scries,  so  that  tliere  arc  six  fingers  instead  of  five. 
Sevi-n  have  been  met  with  ;  and  Murunil  dfjcribcrt  a  hand  having  a  thumb 
auil  fix  well-formed  though  soinewliat  shortened  fingers.  The  supernumerary 
tingi-r  is  u.*ually  atrophied  and  shorter  than  the  rest.  It  i,»  very  common  in 
theitf-  cases  [o  find  both  hund«i  ci|ually  provided  wiib  additional  fingerti,  and 
the  ft-et  with  one  or  more  supernumerary  tavf. 

-.  The  Thumb  is  liable  to  two  malformations — a  .•jupcniumerary  one  Iw-ing 
in  stimr-  <iise!*  addetl ;  in  others,  the  <ligit  being  bifiil.  In  the  pupernuiiierarv 
thiitiib  I  Fig. 'i'J.'i).  it  will  usually  be  found  that  there  are  two  small  anrl 
del'irnieii  phalanges;  in  the  bitid  one,  there  is  one  .•'mall  anci  mulfornicd 
{■haUnx  in  each  extremity,  the  two  lH.'ing  artieulatod  with  the  proximal 
phalanx. 

:;.  riu-  third  variety  of  deformity  consists  in  the  development  of  a  mi/ier- 
nNinemrifjliifjrr  tm  the  idnar  side  of  the  hand,  so  as  to  eon:ititute  a  small  and 
def- irmed  additional  little  fingi'r.  .VII  the-so  variptit>s  of  deformity  of  the 
fingers  are  more  or  less  hereditary,  ami  may  very  easily  l>e  rt-muvcd  bv 
oiit-ration,  wliieh  is  simjile  and  ptTfi'clly  safe,  llic  su|)ernomi'raiy  finger 
bein;;  disurlieulated  at  its  bii.-e.  It  is  ln'itiT  to  do  tliis  at  as  early  an  age  as 
)>ra>>iblf;    n"  gixHl  can  pohslhlv  come  ot'  ilehiy. 

4.  There  is  a  rare  variety  of  eonj:tiiital  defornnty  of  the  hand  and  fingera, 
in  which  the  fingers  are  sujiernumerary,  in  con  set]  lie  nee  of  a  deep  liij'ureutioa. 
of'  llie  hand. 


506 


DEFORUITIES. 


0.  In  sr>iDO  rare  ciueji,  aa  in  Chnt  trfim  whioh  ih«  Bnoeiad  drawifli 
d'ld)  wn»  tttkvn,  two  liantU  up|>var  to  bu  fiiMnI  into  ooe.     in  tb( 
fi|H'niti<>n  ctiQ  be  iulvaQlag«ouslv  pnictis«d. 

BmiJps  lliete,  rarioua  othnr  kiu^U  uf  tM>n(^nttal  dcfurroUjr  of  tb«l 
nre  rnvl  with.  Cue  or  ni-jre  fi(ig«r»  may  be  (>relorniitiirail_r  lonir.  or  i 
rtiHH}-  Hltoft,  tUivk,  or  atro^jbieil ;  or  one  tingur  mny  be  cntiralr  ab«eDt. 


Pi|t.  <>!&. — Bup«niuiB»rBf/  ThMtab. 


Tig.  AM — Appkraal  F«*Im  mt  | 


The  BCi'")in(niiiyiup  dmwitiff*  (Fig*.  6*27  lutiX  G'Jii  I  ar*  iwrrect  Mp 
of  (I  rviiiarkttlilo  tli^toniiity  of  tliu  hands  in  ■  child  that  wan  titider  my 
aonitt  yeani  ngu.     Thv  linguns  appear  l'>  have  sufr<!riHl  iu  •■>»»<  iii*t'>*- 
plete,  in  othen  parlial,  amptilatiou  in  utertr.     They  are  mark-  : 
trauBverte  auloi ;  nthvm  ore  ithortcnwl,  atid  terinioate  in  n>utidni 
wtLh  a  uurruw  pedicle  cuunrcting  them  with  the  pruximni  phalnnx. 


/ 


An*4t  of  Dnr<Jep««al  af  Tiagan, 
Pll.  «37.— Uft  Uaail.  Tif. «».— JU«H  1 

Webbing  of  the  Fingara  is  Mvaainoally  met  with.     Tn  tht* 
eutniMv^iiB  ix^iitum  uniitw  cmtlcuntts  floj^vri.     Scifflittmci  thr  ma}f»r 
Cumtiijfd  tit  one 'lii;lliil  ii)t«r«{Micfi.  and  ihrn  (l  ifl  UMiAllythai  b^twi 
Index  and  midillf  finjj*-™.     In  other  cuaft*  it  orcupiM  tw"  -ir  all  thi 
apai>c«.     Tlir*  vtfU  u  II  tolerahlv  thick   teiilum  nf  ikkin,  aart^tw  at  tt 
bmador  ahov/<.     [t  may  exli>i)i1   thr  Hhutt*  Ipnijth  nf  tbo  llngcra,  or^ 
piirtinn.     The  wfb  duflt  not  intorlvn'  with  the  in.ivemcnttf  of  tbfl   fioi 
fl4>xi<m  or  «'Xt<'iHi<in. 

Thj«  drrorniiiy  is  rradily  remtflicl  bynprratioa.     The  web  may  bei 
in  diflVnjnt  way*.     The  |>Ian  that  I  have  alway*  »ucc«w(\illy  adnj 
ablfl  ID  aepaniUDg  Ibe  Sngcnt  widely,  and  thi-n  tmltiug  Uirou|;)i  tiM  w| 


WZBBIHQ    OP   THS    FINGERS. 


507 


id  Iree  edfre.  keeping  accurately  to  the  middle  line  as  far  as  the  base  of  the 
fin^r. making  the  inciaioii  longer  on  the  dorsal  than  un  the  palmar  aspect; 
orihe web  may  be  transfixed  at  the  baae,  and  the  incision  made  forwards, 
^ime  Sur^reons  transfix  the  base  with  a  ligature  or  wire,  and,  bringing  it 
onrthe  free  edge,  gradually  tighten  it,  and  m  divide  the  abnormal  bond  of 
unii'D.  The  objection  to  this  jimceBs  is  that  it  is  slow  and  painful.  Afler 
tiit  divisioD  of  the  web,  the  hand  should  be  put  on  a  splint,  and  a  piece  of 
lint  interpostnl  between  the  separated  fingers  during  the  whole  process  of 
unii>n,  $<i  as  to  prevent  any  chance  of  re-adhmon. 

In  order  to  prevent  the  tendency  to  gradual  union  of  the  raw  durfaces 
Kivatiriug  fnjm  the  angle  between  the  fingers  towunis  the  tip,  it  has  been 
Mi^fylfd.  as  a  preliminary  step,  to  make  a  puncture  through   the  web,  at 
the  base  uf  the  space  between  the  fingers,  and  to  pass  through  this  a  piece 
oJ'plaji  rod  or  metal,  which  may  be  worn   until  the  wound  thus  made  is 
completely  covered  by  epithelium,  the  piece  of  glass  acting  like  an  ear-ring 
Mtheiobuie  of  the  ear.     When  this  healing  is  complete,  the  web  maybe 
("t  lip  without  risk  of  re-union  proceeding  from  the  angle  between  the  fingers. 
When  the  septum  is  very  dense,  the  following  operation,  invented  by  Didot, 
*>f  Liiye.  mav  be  advantageously  practiced.     Supposing  the  index  and  mid- 
dle tioger  to  be  webbed,  the  following  would  be  the  procedure  to  be  adopted, 
*hi('li  is  of  course  equally  applicable  to  any  of  tlie  other  fingertj.     1.  The 
^urpeiin  makes  an  incision  along  the  median  line  of  the  palmar  aspect  of 
'be  index  finger,  extending  the  whole  length  of  the  web.     2.  Two  small 
_ti»njverse  incisions  are  now  niniie  at  the  up[H.-r  and  lower  ends  of  this  long- 
'Kidinal  iucinon,  extending  from  it  to  the  ends  of  the  web.     3.  The  rectan- 
fTuIarflap  thus  defined  is  dissected  back  as  thick  as  possible,  so  that  its  base 
Corresponds  to  the  mid-line  of  the  web.     4.  A  corresponding  longitudinal 


/■ 


^) 


■« 


.r' 


:■} 


'5-  '^"!'.— I>ia)traiii    ft    Fi»iiii    in    '>|ierHtl<>D    fi>r 
Webbril  Tiogtr,  •rith  thick  i-rjilum. 


Fit;.  1^30.— n.  Tbe  liiieK  uf  ()i«  txu  in- 
L'iiiiuna  uniting,  fo  a.*  ti>  itiviile  tbe 
Wch  nnrt  tciTo  ft  Fl>i)>  nn  vnoli  »iile. 
b.  Tlie  i'\n\>«  detnpheil  rniio  the  ct|)- 
|)iii'it«>  Kingtr;  to  thuce  to  nhioh  (hey 
ure  aiihrrent.  <■.  Tlic  FlnpH  H|>[i1ieil 
to  ilio  Kin>;eri>,  iini)  I'uveritii;  in  the 
riiw  Hnd  exfiuscil  yurtuuen. 


"'*''>iiiii  if  now  made  along  the  dorsal  siirfiice  of  the  iniddlf  finger,  but  comes 

•^ttitT  further  down  on  the  Imiid.     The  two  Irnnsvri^e  incisions  at  its  up}>er 

^'1  lower  ends  are  next  made  ;  the  flap  thus  dt'fineil  is  disH'cted  liiick,  and 

Wn  t[,^  knife  n'aehes  the  mid-line  of  ihc  wch  the  two  fingt-rt'  will  In-  fmind 

-*  '*  H'fmmtcd.     o.  The  next  ami  liL-t  sifp  ^>i'  the  opiTation  is  to  wrup  each 

*P  round  thf  raw  surliicc  of  the  fingt-r  to  wliioh  it  continues  to  be  uitaclied, 

"''  to  fix  it  ill  fitu  by  three  or  four  points  uf  suture.     Thus  the  raw  surface 

'^  tht;  index  finger  will  Iw  i-overtd  by  the  flap  tiiken  fnnii    the  dnrsuin  i>f 

*  Dii'idle,  and  ci'ce  Vfrmi,  ii»  is  wen  in  t lie  accoiiipiiiiyilig  diagruiii '  Fig.  *>'2'.t). 

*u  the  Bccompuuving  cut  (Fig.  (i:;i)  i,  traiiaverce  sections  of  the  fingers  are 

^''*n. 


509 


DBFOHailTIES. 


DEPORMITUy  or  THE  LKQ  Ain>  FOOT. 

Knock-knee.— The  tlc-runiiity  termed  Qena  Valgnn.  KntMik  or  X'^ML 
usually  utri-ctK  Iniib  itxtrtiiuitic«,  Ibougli  it  ia  (.'cnvrally  monr  futlr  dcvcliifM 
in  ouv  ttiaii  in  the  other.  lu  it  the  knee  forms  the  apex  of  m  iriant;)*-,  iki 
Imlm  of  nbicli  wuult)  be  reprcMOtetl  by  a  tine  drawn  fruio  the  uuchaoM  lu 
the  uutcr  ankle.  Kniick-kuee  ariwa  at  twn  ppriixla  of  life;  Sim,  darng 
early  cliildbocxl,  when  it  ia  uatialty  tbc  rrault  »f  rickcta.  and  ia  bnm  In- 
i)Ut>ntly  eonjiiiiied  with  aoitio  curviilure  of  the  lione»  of  the  lef; ;  and  flBonndljTi 
abuut  piilMTly.  wtien  it  in  dtie  to  relaxation  of  the  ti     "<  ?  b  fi^ 

quenily  the  result  of  carrying  heavy  weighia.     At  thU  ,  i-'D  «a»- 

joineil  with  weak  ankles  hikI  nplay  fnot.  Iti  many  eaaea  Uiu  Qatauil  tiwirtai 
foot  is  priibably  (he  primary  aflW-tion.  Ruck  titatea  that  oal  of  HI 
wliirh  III'  exantlnod,  IT  originatetl  about  the  |>eriiHl  of  the  fir«t 
and  200  U'tween  that  a^e  and  the  ITxb  or  IMtb  year.  Bihdc  occup»UoaB 
Mid  t»  prt'ilisp'i^e  to  it.  Hiiiilhs  being  eejieoially  liable  tn  the  diifwt.  I^ 
wlialwver  way  the  dcfurniity  arides  there  i«  relaxation  nr  ittn4c:lila|i  ct  iW 
inleninl  laternt  ligament;  the  bioepa,  the  exLemal  lateral  It^atnt-nl,  aitd 
ol\en  the  vutu«  exlernus  nre  tenae;  and  the  (mtetlH  U  Ibrown  ttutwanl*.  Ifl 
castM  whieb  artae  directly  from  vrealcu(«8  and  relaxation  of  ibe  li^^oMWla, 
Littlu  states  that  a  distiucl  )pi\\  often  of  coiisirlvrablu  width,  may  )w  Ml  b»> 
twuen  the  iitnvr  «i(le  of  the  head  of  the  tibia  and  the  femur.  Knxn  an  mrtjr 
period  in  the  rickety  form,  and  at  a  Inler  atiitjw  in  CMett  of  aimpla  Tvlaxatjirfi 
ol  tbe  liganienlfi.  the  buiiw  beeuiue  altered  inform.  The  internal  ruodrU 
19  elongnted,  s'tnieti mes,  according;  to  MiieeurL'U,  to  the  extent  uf  an  inrh.  U 
is  evident  that  in  kn<»rk-kiiee  the  pressure  in  standing  would  bo  »'inirwkal 
IwBeaed  on  the  inner  side,  the  weig'hl  being  unduly  thrown  UfxiD  tbi*  oatar 
condyle.  It  is  believe<l  that  us  the  reeult  of  this  the  growth  of  tbr  osMr 
condyle  ia  arrested,  and  that  of  the  inner  is  cxag){erat«d.  The  Imgth 
of  the  inner  eoodyle  is  uut  uc<<oni|tauie<l  by  a  correspucding  imrrrvm  in 
a ntero- posterior  diameter,  eousequently  when  the  knee  ia  Sexed  the  defiirat^ 

diiuippearx.  In  eomc  ceM«  the  lowrriag  u 
the  inner  condyle  iti  dne  too  rirketr  mrr*  ia 
the  femur  immerlialely  aboTr  the  artimlar 
end.  In  extreme  casta  of  knttck-kofe  t^ 
juint  is  ohen  capable  nf  Bome  deKTf*  (if  iiw- 
exlenBion,  the  leg  at  the  ntme  u*iic  mtaliaK 
out.  ward  a. 

Treatment — The  treatment  coniiitB,  to  %ht 
sltghtM*  cniM,  in  Bpi>lyin(;  an  apparaliu  am- 
aUting  of  a  vcll-pAddfl  iron  Mem  abittg 
outside  of  the  leg  nod  thigb;  thia 
extend  fn^m  the  Irikcbanter  to  iIia  outer 
being  fixed  to  a  pelvic  band  at  ibe  upp^e 
pan,  and  into  a  boot  helow  (Ft|^  GUI). 
Where  it  corresprutds  ii>  ihe  kow  it  alwaliil 

be  pfividcd  with  a  hioL"'    "■■'  -' '■'  ^•-•rr  a 

broad  well-i-adiled  olrap  i  ler 

«idc,  liver  ibe  inotr  sidi.-  <ii  m*-  j i.  mvi  •!• 

tflc-lied  by  hucklea  to  Ibe  upprr  part  i»f  tSe 

Bl*-iii,  in  aneh  A  way  that  by  Itk'htenioti  tlifW  tbr 

kufe  mav  \n<  drawn  outwnnla.  Tbii  iip|Mnitus 

ri».«l.-A|.I»r.i«fo,  «|„.u|.|  li  i^itwtantly  worn  for  ti=  -  :t»; 

*•'  and,  if  pniptrly  adapted,  may  eil  ra. 

When  the  deformity  it>  of  ohl  Btanding,  and  the  purl*  about  tbtt  •rutrr 

of  Uie  jrdnt  very  tcuiw:,  the  bieepa  tcodou  may  retjulrv  divivioo.     lu 


aBK0    VALGUM  — TKKATMKNT. 


509 


thu.  care  must  be  taken  not  to  injure  the  external  popliteal  nerve.  In  Bome 
cases  the  vastus  externus  and  contiguous  portion  of  the  fascia  lata  also  may 
be  advantageously  divided,  and  the  apparatus  then  applied  as  directed. 

Id  thuae  easee  in  which  the  alteration  in  the  bones  is  such  that  there  ts  no 
hope  t>f  restoring  the  limb  to  its  natural  poeitioo  by  the  simple  means  above 
(wcribcd,  the  patient  must  be  submitted  to  some  ofKrative  procedure,  or  left 
to  eodure  his  defurmity  unrelieved. 

During  the  last  few  years  numerous  methods  have  l>een  devised,  with  the 
object  of  straightening  the  limb.  The  simplest  of  these  is  that  of  Delore,  of 
LyoDii.  It  consists  simply  in  forcibly  straightening  the  limb;  the  leg  being 
extended,  the  Sui^^n  places  his  knee  againet  the  prominent  inner  condyle, 
and  grasping  the  ankle  in  one  hand  and  the  upper  part  of  the  femur  in  the 
otber,  he  gradually  applies  sufficient  force  to  bring  the  limb  straight.  He 
eoDtiuues  the  force  from  five  minutes  to  half  an  hour,  till  the  object  ia 
attaiued.  The  limb  at  last  yields,  a 
teDsation  nf  something  tearing  being 
felt.  Delore  states  that  the  lower  epi- 
physis of  the  femur  is  separated,  but 
what  actually  takes  place  is  somewhat 
QDcertaiD,  and  must  be  left  to  chance. 
This  tuethdd  of  treatment  has  been 
very  succeeslul  in  its  inventor's  hands, 
bat  iu  this  country  it  has  not  yielded 
results  equal  to  those  obtained  by 
•iitise^>tic  osteotomy. 

Antueptic  of  teotomy  has  for  its  ob- 
ject the  restoration  of  the  lengthened 
inner  iroudyle  to  its  normal  level.  It 
u  iaip(««ible  here  to  do  more  than 
mention  many  of  the  methtxls  that 
have  been  employed  with  this  object. 
Id  1875,  Annanilale  opened  the  joint 
and  reniovetJ  the  prominent  portion  of 
the  inner  condyle  with  the  saw.  This 
bold  o[ieratiim  was  completely  suc- 
ceMful,  but  since  the  iutro<)uctiou  of 
simpler  uiethixls  it  has  not  been  re- 
pealed. In  It^m,  Ogi<ton  performed, 
fur  the  Gn't  limc,  the  oiHraiitm  of 
sawing  otf  the  inner  condyle  obliquely 
by  means  of  nu  Adams's  saw  '  Fig. 
otlS',  iiitniduL-e^l  obliquely  thnmgh  a 
puncture  made  iu  the  skin  abuve  the 
ioner  ^.tmdyle.  In  1878,  Macewen 
niotlifiurl  the  operatiou  by  removing  a 
weilge-shaiNHl  piece  of  brme  in  the 
line  <if  O^lon';)  saw  cut,  but  without 
[«nelrating  so  deeply  as  the  articular 
cartilage,  and  Reeves  at  the  same 
time  eu)^evted  dividing  the  condyle 
with  a  chisel  stopping  just  :>hort  of  the 
cartila}^.     In  1878.  Barweli,  rogurd- 

ing  the  def'trmity  not  merely  us  n  lengthening  of  the  inner  condyle,  hut  asnn 
•ibliquity  of  tlie 'whole  lower  epiiiliysis,  (liviiU-<l  tim  iouiur  by  a  chiw-l  a  little 
above  the  epiphysis  from  the  outer  side,  and  subsequently  after  some  weeks 


Fij;.  A:12.  — Kaock-knee.   a.  Fig.  r<;).t.— Mic- 
line  of  diviiiiiin  in  Mac-        cwco'i  Cbircl. 
ew«n'!i  o]ieritiion.     b.  in 
iJ^FluD'f  u|>crnliun. 


^10 


:poRMins8. 


or 


(]ivi<I«<l  (lie  tiliiu  antl  (ibiilatn  thptuimr  way  iibnittiine  inrli  hc-lriw  r! 
flurliiit-!!).     ijU'lly,  Miu'ewcii  iiilr<xliUH-tl  tli*-  iiietliml  'kf  )|ivt<liii|;  tli' 
imni»liuU-ly  nliove  the  epi|>hy.<fii!i,  uml,  Mt  tlie  niv»cut  timo,  lJii»  nivlfa>«l 
alnitifiL  iiiiivtTKally   a<li)ple>i  in  [irolerciK-«  to  all  oth«r».     It  Iiil*  ii>r  jrrai 
mivaiiUjje  of  beiug  »impli>  nod  ea*y  ->('  [K'rrornmnce,  free  fnmi  -4 

of  uol  iitinlicatUiK  either  tho  epipliysis  vr  the  joitiU  The  oimth;..  .,  .-  .i.« 
tifrfiiriiifd.  The  Itmh  ithouli)  be  IkkI  i*ii  il«  miirr  «i<l«  on  a  luif;  nf  «e4  mmL 
While  (he  litiib  if  extrmle<t  «  ]inint  i*  twkcii  elii^htty  iibuve  lh*>  ivvcl  of  lb* 
upper  iniirKin  vf  the  i)ntt;llH,  aixl  a  luci(;itu<linal  iiici«ioo  i»  uuuJe  id  fnMit  id 
the  ivudoii  uf  thv  Rtltiuctor  magtiu«.  tlic  iiiid)ll«  of  thv  iaciMuD  c>»rTc»M<oduK 
tu  ihnl  poiuU  Thtt  l«ugth  uf  the  incisi-^n  is  ttli^litly  grvater  tbau  Ibc  brmdt£ 
uf  th«  thMel  to  hv  u»vd.     The  bvuIih'I  must  be  carm'd  liir* '  '  :hf 

buue.     Th«  cliisel  ia  thcu  iu«i-rteil  tiiid  turuwl,  bo  (hat  its  i.ii     .  -  at 

ri^'ht  Hn;j;lve  (<■  ihu  iiiciBioii  uud  tu  the  vhult  uf  the  feniur.    lliu  Itiuuc  M  U»4 

divideij   U>T  liuire  thim  two-thirds  of  ita  thii'knese,  the  chieel  hrjn?  taktajt  

aud  out  of  the  wuiiiid  ua  little  aa  puaaible.     The  eut  10  f  i^BiAt^^fl 

iwrullfl  «r  the  ardculur  Hurfni-e  uf  ihi*  fetour.  which  will    '  <iUip|H 

(hull  'iiatuml.  owiD};  to  the  abnoriiiKl  leiit:th  of  the  luaer  <MJO<lylp.  Tht 
auterior  and  pimterior  luyert  of  (Miiipucl  tti«ue  iiiusl  mil  be  ue^lecUxI,  aari 
when  rht)*e]Itug  ihu  |Mwtfriitr  extra  cautiou  muet  he  ii#e<l  \m  the  ekimi 
ehoulil  he  drii'eit  iiitii  tliu  popliteal  vuHaeU.  When  twu-thinU  of  the  btxie  hivi 
been  ilivided  the  nMiiaitidur  is  fractured.  If  the  patirat  be  fully  rrawa.  aad 
the  buiie  of  ^onw  mw,  two  or  thn-e  ehidels  muy  lie  need  »iiect»iiviTf ,  the  fifst 
being  the  (hickesl.  The  operalion  Dlioiild  be  perf<>rrned  with  nil  anti»ef4ir 
precnuiiimH.  ami  an  aii(is«pttcdreijiing  applied  allcr  it.  Maceweo  hu  alwift 
etuplnvt^l  the  carbolic  sprar  and  the  eflrbulic'  j^iuzp  dtrMin^  Nn  intium 
bIiouM  be  put  into  the  wound  unlcfi)  il  is  ofuniisuiil  jtixe.    The  '{  ajr 

be  left  iinehiiDKed  fur  one  or  two  wcuka,  unleaa  »yutw  dischur^ii^  »\i--  ■■  4 

under  it,  ait  i(  iiinv  do  at  the  end  of  the  6rat  iwc-iiLv-fotir  hinink  Alin  lix 
operation  the  linib  may  be  pliiced  ou  any  convenient  »plint  fur  th«  ftn>t  ^y 
or  two,  until  it  is  aeeu  if  the  dro««ling^e4|ui^eschu^^inc,a^t■r  which  a  plaat«^ 
pf-Paris  tiniidx}£e  ehnutd  lie  nppliLtl.  The  age  at  wbii'h  the  (ipvrati«)ll  ikiwlll 
be  pertormeil  haa  been  the  iuhject  of  mocb  iliHerence  of  npiniOD.  KsPfff*- 
encv  haa  th»wn  that  if  done  t'xi  early  relnpse  ia  wry  likely  t'l  tak«  phw 
Atf  a  rnle  it  should  Dot  he  jierlornied  in  children  under  ten.  IJerurc  llut  ut 
thv  deformity  cRn  UBually  be  ctjrrecte«l  by  proper  npparatua,  n- ':  -'  'v  fuccitw 
straighlcning  not  carried  to  the  extent  of  acpRralioo  uf  lh<-  '  *.    Tbf 

malts  of  the  operntioD  have  been  extremely  sutirfactory.     In  i  ->"<.>  >lac«w« 
bad  opernted  on  'J'JO  imtieota  for  knoek-kDce,  preaentiof!  'Mi7  limb*  fur  Inat 
meat.     Id  addition  to  these  he  had  ofiemte^l  on  64  putientA  <  tU4  litatM), 
bowdejfa  O^nu  varum  i,  40  pntietits  (HU  limbs  i.  f<ir  anterior  tibial 
from  rirkeia:  one  for  aiikylofeia  of  the  hip.  nod  five  for  ankyloaia 
koee.    Thue,  nutiaeptlc  usLeotoniy  tiRd  been  (lerlorroed  OD  557  li«lH.i 
of  these  the  boms  had  bceo  divided  in  mure  thAo  one  place,  ao  ihu  in  t 
330  paiienia  no  lew  (bun  >i-io  M.>pamte  (wteoioruiea  bad  been  cairiHl  out.    I 
only  eight  of  theec  cases  did  the  wound  fail  to  heal  by  first  iDitQii\>a,  wiik 
out  suppuration.    No  paiieoi  died  from  the  operation,  aud  only  ■)•• 
ft.  one  from  diphlheria,  one  from  luhennilnr  tncningitia.  and  uii' 
monta.  which  had  eommeuced  before  the  operatiuu  wna  dont 
having  been  o|>cmied  nu  imiuediau.-ly  after  admiaaioD.     Thi-%- 
wrrr  in  no  M^nx-  tubKUlUDeoua,  the  wound  in  every  code  wu- 
quarlcm  of  an   inch   in    length,  und  nir  entemi   freely  )' 
'nii-«'  riKolt*,  tlnTcrjre,  oftiinot  hut  be  taken  lu  Imporiani  c\iilin':i>  ■.! 
Value  <if  (lir;  anlUH.'|>tic  treatment. 


CONTRACTION    OP   THE    KNEE-JOINT.  fill 

Cmtraetion  of  the  Xnee-joint — Contractioo  of  the  knee-joint  is  one  of  the 
iD^«t  <iiatrt-K<ii)g  (teluriuities  to  which  th«  hiiiimii  i'rume  is  liable.  If  it  be 
feverv,  the  k-g  ia  beot  at  nearly,  or  [lerhaps  at  quite,  a  right  angle  with  the 
thigh.  It  ia  tixed  in  thi^  poHitioo,  eit  that  the  patient  cannot  [lut  the  aole  of 
the  fttot,  uor  even  the  points  of  the  tot'»,  to  the  gntuud  ;  hence  the  limb  be- 
comes UM-tefti  for  tbe  purpose  of  progreeeion,  anj,  from  want  of  exercise, 
atrophies.  Hut  a  leg  wilh  a  badly  contracted  kiii;e  in  worse  than  ueetess — it 
K  a  pieitive  iui'unibmnce;  for,  aa  the  lijut  cannot  be  brought  titiriy  to  the 
gniuud,  the  limb  pn>Ject»  behind  in  a  most  awkward  manner,  swaying  as  the 
body  moves  round,  constantly  in  the  way,  and  liable  to  injury.  From  want 
of  exercise,  the  nutrition  of  the  limb  becunies  impaired,  the  foot  is  usually 
cold,  the  circulation  in  it  is  languid,  and  the  toes  become  liable  to  chilblains 
and  truublesume  ulceration. 

In  the  less  severe  forms  of  contracted  knee,  the  iuconveoience,  though 
not  -Mj  great  ad  that  just  described,  ia  very  con:jiderable ;  lor,  aa  tbe  patient 
can  nevvr  bring  the  beel  or  sole  to  the  ground,  be  re^^la  insecurely  on  the 
tipe  of  hi^  t«H-f,  and  walks  but  uneteadily  with  the  aid  of  a  trrutcb  or  stick. 

Vtirietiee. — This  delurmity  may  be  of  two  kinds.  1.  It  may  couBiat  of 
umple  Hfxion  of  the  leg  on  tbe  thigh,  at  a  greater  or  less  angle,  and  with 
mure  or  less  mobility,  according  to  the  degree  of  ankylosis.  li.  In  addition 
to  this,  there  may  be  horizontal  diapiacement  of  the  bones,  tlie  bead  of  the 
tibia  being  thrown  backwards,  the  lemur  and  patella  projecting  more  than 
u  natural. 

Id  examining  a  case  of  contraction  of  the  knee-joint,  the  patient  should 
be  place<l  on  his  lisci',  with  ibe  thigh  extended.  The  teg  on  llie  atlecled  side 
will  ihcn  l>e  raised  more  or  less  i)er[)endieularly,  and  the  amount  of  contrac- 
tion may  be  judged  of  by  the  angle  that  it  Ibrma  with  the  thigh.  The  de- 
gree of  niiibiliiy  also  mar  readily  be  ascertained,  lu  this  way  a  more  cor- 
rect idea  uf  the  amount  of  contraction  can  be  obtained  than  by  examining 
the  {tativnt  whilst  lying  on  the  back,  wlien,  in  conaetjuence  of  the  thigh 
being  Hexed  on  the  abdomen,  the  extent  of  the  angular  deforndly  cannot  be 
au  well  determined. 

(<iiij'(i'. — Contraction  of  the  knee-joint  may  nrise  from  a  great  variety  of 
[tatholngical  couditiuna.  ^mie  of  tbei^e  are  altogetlier  external  to  the  joint, 
Deing  stated  in  tbe  nerves  or  nmscles  of  tbe  limb;  whilst  oi Iters,  and  the 
majority,  consist  in  sonic  morbid  change  that  lias  taken  place  within  the 
joint  ilrelf  in  ita  ligamentoua  or  osseous  structures.  As  the  contnitlion  de- 
pend:' on  tuch  Very  varied  causes,  tlie  Tnutment,  having  reference  to  the 
cau>e  as  Well  ap  to  the  actual  morbid  conditions,  must  be  equally  cliversified. 

Contraction  irom  Ifervoas  Irritation  is  usimliy  associated  with  general 
hvirleria.  of  which  it  is  but  a  loeal  symptom,  and  commonly  occurs  in  girls 
■ml  yiiuni;  women.  In  tliis  form  ol  cuniractinn  there  is  no  evidence  of  dis- 
ea.*o  within  the  joint;  no  redness,  ^welliii}:,  or  other  ^i;:n  of  infiamnntlion  ; 
but  tlitre  are  great  pain  and  tendernt  ss  abuut  it.  This  [laiii,  as  ii^ual,  in  hys- 
terica! casi-».  is  sU|>erlii.'ial  ami  eutiiiieous.  It  is  not  contiiied  to  the  articulu- 
lion.  but  radiates  to  some  ilL-tunce  U'Vond  it.  -Viiy  attempt  at  straightening 
the  limb  n>>t  only  greatly  iiicrea^'ea  the  pain,  but  also  calls  the  iiil|<iiidng 
ruuicle.'^  into  sucb  tiircihle  action  that  it  is  iiniiossible  to  improve  the  posi- 
tii^n.  These  io<-al  ^ylnptoI^lS  are  coniiecltd  with  the  (irdiiiaiy  si;;ns  of  a 
hyett-rieai  teiiij>erament,  with  spinal  irritation,  and  often  with  uterine  de- 
nuirement. 

The  Tri'itiiu:t,l  of  these  cases  iA'  htj'ii  rivil  I'liulfii-tinn  of  the  kute  is  simple. 
Th'-  tir-t  tiling;  to  be  done  i.-*  to  striii;:hleu  the  liiid).  This  can  he  elfeeted 
only  bv  put  tin;;  the  patient  under  the  inllueiice  of  an  aniesllu'lic,  when,  all 
KOeiiiilily  i>eing  suspended,  the  muscular  opposition,  which  is  partly  volun- 


512 


DBrOBMlTlES. 


tAry,  and  nn  (loiil)t  In  some  metuure  reflex,  U  do  Inos^r  ciiT  arlino, 

and  tlie  liuib  lulls  ot'ito  uwo  accord  iiltii>.«t  into  fl  ftmght  |  t  mhttk 

it  must  be  reUiined  by  meaos  of  a  buck  spliDl,  k'et  the  rt-trucLi'-ii  necur  wilil 
reCurning  couscioueoeM ;  and  then,  tlie  hysterical  eoDiiiiiuD  Im^jdi  nmuvirf 
by  treutuieut  cnlculRted  to  tra|)ruTQ  the  geiieroJ  health,  the  tCDdimcy  lu  tha 
returu  ul'  the  dfforoiity  will  be  obviated. 

We  occasiouully  eee  ooutractiou  uf  the  kaec  from  ipumodio  actioa  of  iht 
haiuAtrii)^,  pruduced  by  some  irritation  applied  tu  the  nerve*  at  a  dii 
from  the  part.  Just  as  tpoioi  nf  the  iiiteruHl  rectus  muscle  uf  the  en  «_ 
eions  K<(uiiit,  so  long  as  the  Irritation  that  iftviai  rise  lo  the  ifMHm  Cuts; 
there  may  be  sjiafiia  nf  the  liaiiutringH,  with  cuntraoiioa  of  thw  ktM»  a*  a 
uousequcntf. 

UiKt  cimruDuly,  however,  the  Joiot  itself  is  at  fault,  cither  lo  fiiiiaii|iwiw 
uf  subacute  iiiftiinininlitm  within  it,  or  uf  the  permanent  cban;^  iodocM  hjr 
fiinner  iiil1amtiiat<»ry  altunkA. 

Contraotioii  from  Inflammatioo  of  the  Xaee.— In  inflummn'  'b« 

kiip^,  tht^  [miiertt  naturally  iinil  inotinclively  places  the  liiub  i.,  ii.t. 

flexed  |Mr<iiiitn,  n»  helnj;  that  in  which  there  19  U-axI  ien»iitii  rxrrimvd  ua 
the  8(riicliirf«  thnt  CDter  into  th«  Joltit.  and  r>iii!>e>iuently  that  which  is 
moM  congenial  to  his  fcfltn^.  This  poi^iiion.  which  i9>  immcdinirly  aaiaunl 
on  the  uccnrrcnc«  of  acute  and  active  iiiDatiimntion  in  the  joint,  otniM  mi 
more  gradually  in  casM  of  subacute  inHammatiim ;  and  her«  the  symptom 
of  dbuaite  in  the  joint  mny  be  »o  »lt)^ht  that  the  contraction  may  be  oto* 
siderod  the  chief  nilment,  and  engnies  Um  exclusively  the  Surgeon's  attentioo. 

Chrooio  Contraction. — The  ovxt  vluss  uf  oifes  that  we  have  i<i  coouder 
ore  thocu  of  II  more  chn>oic  and  intractable  kind,  lasting  oAeo  f'^r  yeaA 
dependent  upon  structural  leeiuiis  ot'u  deep  nud  im|MirlMUt  character  in  uhI 
around  the  joint,  and  nx|uiring  very  active  surgical  interfereiicv  for  their 
cure.  Those  chronic  forma  of  cunlractvl  kuoo  ap|>enr  t"  niugv  themselw 
tu  thrvc  iliatinct  varieties,  being  de|)endvut  ou:  1,  Cui)«olidaltoa  nod  Cos- 
traction  of  the  Ligunieutuus  Structures  in  or  aruiiiid  the  joint ;  'J,  iVrtDaneol 
Coutraction  of  tim  Mum'Ii-s,  with  or  without  the  last-natne«l  uoudilioa  :  aod, 
S,  0«eoaa  Ankyloeiif.  K.tch  of  these  varieties  will  re<|uire  sp[>arale  vuo- 
tideratino,  »»  ciu-h  deinande  a  a))ecinl  mode  of  trentinent  fur  its  curv. 

1.  Tbise  ca9«4  nf  c-imtractton  of  the  kneo  that  depend  on  OnutlidaUtm  ijf 
tAf  LitjamrnUnu  Structures  \u  and  aruuud  the  joint,  reaulliog  frura  tanorr 
tntltiinniatory  ultncks.  are  not  unlv  the  most  aumenttie,  but  the  a»i«t  rosdily 
atuenablB  to  treatment.  When  tli«  slructurve  outside  the  joint,  toch  as  tbs 
capsule  and  ligaments,  arc  the  parts  chicOv  nffectetl,  the  intlHrnnisli'in  has 
usually  been  of  a  rheumniic  character.  When  the  int^-mal  structures  bars 
been  diwrgniiited,  and  fibrous  bands  have  formeil  within  the  joint,  tfat 
infiammntiou  has  generally  been  ttrumiHis.  In  these  cases  the  kn*«; 
usually  fixe<l  at  or  near  a  right  angle,  and  11  capable  of  bat  vt-rr  limit 
motion — to  such  a  degree  only,  lo  mo#t  iuatanu'^.  as  will  allow  ihr  f..,*) 
move  through  two  or  three  inches.  The  hnmstring  n)iiscle»  arv  not  ti 
nnlea  tbc  knee  is  extended  to  its  ntm<)«t;  and,  iDuecil,  in  sodw  casks  thrt 
tn  flaccid,  and  feel  soft.  Not  tiiifrequently  the  teg  can  be  exlewM  op  to 
a  cvrtniti  point  with  as  much  frceiloni  as  in  tbe  natural  state,  aad  tM 
further  movement  is  checke^l  by  a  sudden  stop.  If  this  b«  not  drpciKUaft 
on  tbe  tibia  coming  into  contact  with  an  nnkyloscd  patella,  it  i«  nwii^ta 
shortening  of  the  Mganirnt  of  Winslow.  or  of  the  anterior  crucial  tignimaiti 
or  to  the  lonnati"a  of  ailheaions  within  the  joint.  In  this  form  of  c.>atrae> 
tion,  the  knee  is  often  much  distorted,  in  conwqnencv  of  the  i-  '  '  :h« 
tibia  Iteintf  partially  dislocated  beckwnr>t«,  the  femur  havini^  its  a'.  d 

~  ~    or  MM  00  ouo  side,  most  commonly  inwards,  ounatitutiug  a  land  uf 


TREATMENT  OT    CONTRACTION  OF  THB  KNBB.     513 

genu  valgum.  In  fact,  in  theae  cases  the  distortion  of  the  limb  is  of  a  three- 
fold character ;  there  are,  1,  contraction  in  the  angular  direction  backwards ; 
2,  diaptacement  of  the  head  of  the  tibia  backwards  from  the  lower  end  of  the 
femur,  which  projects  considerably  forwards  ;  and,  3,  rotation  of  the  leg  and 
foot  outwards.  The  angular  contraction  is  dependent  upon  adhesions  in  the 
joint,  and  on  the  gradual  tendency  to  flexion  that  all  indatned  joints  assume. 
The  partial  dislocation  backwards  is  dependent  on  softening  and  consequent 
relaxation  of  the  posterior  crucial  ligament,  and  partly,  also,  of  the  liga- 
mentum  patellss  or  of  the  lateral  ligaments.  When  the  head  of  the  tibiii  is 
displaced  backwards,  it  will  sometimes  be  fountl  that  the  Hgaraentum  patellse 
has  been  either  partially  absorbed,  and  thus  weakened,  or  that  it  ia  elon- 
gated, the  patella  being  drawn  upwards  or  to  one  side.  In  either  way,  the 
action  of  the  extensor  muscles  of  the  thigh  upon  the  head  of  the  tibia  ia 
weakened;  and  that  bone,  being  consequently  brought  under  the  influence 
of  the  hamstrings,  which  also  act  more  advantageously  in  the  flexed  position, 
is  drawn  backwards  (Fig.  634).     In  those  cases  in  which  there  is  lateral 


Fig.  6.34. — Chronia  Contraction  of  Knee-jnint ;  Ilsiid  si'  TiLii.i  iiiuffn  backwards 

rotation  of  the  tibia,  the  faulty  position  arose  either  from  the  attitude  that 
limb  was  allowed  to  assume  during  the  progress  of  the  disease  in  the  joint, 
or  the  leg  was  rotated  outwanls  by  the  action  of  the  biceps  overcoming  that 
of  the  inner  hamstrings. 

When  the  knee  has  been  chronically  contracted  for  some  length  of  time, 
the  ligamentum  posticum  becomes  pennjinently  shortened,  from  adhesion  of 
the  sides  of  the  folds  into  which  it  is  thrown  by  relaxation.  And  a  similar 
shortening  takes  place  also  in  the  anterior  crucial  ligament  when  it  is  re- 
laxed by  displacement  of  the  head  of  the  tibia  backwards.  Hence  the 
condition  of  these  ligaments  ofTi^rs  the  chief  obstacle  to  extension. 

Treatment  of  Contraction  of  the  Knee. — Extension  of  the  limb  will  prove 
sufficient  when  there  is  simple  angular  contraction.  Tins  may  be  done  either 
gradually  by  means  of  the  screw-splint  behind  the  knee,  or  forcibly  and  at 
once,  under  the  influence  of  aoEcsthetics.  I  prefer  the  latter  method,  not 
only  aa  being  the  speediest,  but  as  being  perfectly  safe  and  effectual.  The 
mode  of  effecting  forcible  extension  is  na  follows:  The  patient  being  fully 
under  the  influence  of  an  anresthetic,  and  lying  on  his  face,  the  Surgeon, 
standing  above  him,  seizes  the  foot  of  the  afflicted  limb  with  one  hand,  whilst 
with  the  other  he  steadies  the  limb  ju^t  above  the  knee.  He  now  extends 
the  leg  gradually  but  forcibly ;  as  it  comes  forwards,  the  bands  of  adhesion 
in  and  around  the  joint  will  be  felt  and  heard  to  give  way  with  loud  snaps 
and  cracks,  distinctly  audible  at  soine  distance.  Should  there  be  much 
resistance  within  the  joint,  the  surgeon  may  apply  his  own  knee  or  elbow  to 
VOL.  II. — 33 


614 


tiCKOHHITllCB. 


tb«  U|}per  tturfnce,  anti  thus  iDcrfafie  tlie  forc«  with  wliicli  thv  liiiili  t»  trtni 
upoa.  lu  lliitt  uav,  I  Imvc  never  I'uuDd  uuy  cu&trarliuDS  of  the  kitiii 
uudcr  cuusiiierntiuu  able  tu  reeUt  the  Sur^t-im  h  i-Qiirta,  iiur  nuy  tlitliculi 
rfll-ttiiig  at  uiicv  llic  extoiiaiuQ  ut  tlic  liuib.  Nor  liuvc  1  ever  fwu  aujr 
ranecquL'iiLVft  n-ifuli:  iuiivvd.  il  in  i!ur[>riiuiig  Ki  what  au  anHwot  nf  fnraa 
juiui  tiiut  litt£  Im'U  ci)iilrucLi'<l  iVir  uuy  leugth  of  time  niav  br  aubj 
wittiout  iiiconvfiiienct!.  lu  tbe«o  chmd  il  vruuM  npprar  a*  if  the  tji 
oitfmbmne  l<«t  its  luidcncr  tu  iufluniu.  juei  ii»  Ih  tm  cmk  with  trroua 
branes  that  haw.  bevii  the  kpui  of  clinnic  iitflamnintioD  jind  it»  cniWMaaNsa. 
Beyond  sitme  pain  for  a  few  days,  and  slight  tii-nt,  ensilT  Mibdocd  pjt  teii 
evapriratinE;  lntion»,  I  have  never  seen  any  ill-reeiilts  nrW;  bul  care  mmL 
betakeo  tnai  no  inHiimnmlory  action  \b  pv>inf;  nn  wiihin  the  jniot  et  tbi 
time  of  this  mHitipulnlion,  lor,  if  mich  action  were  prMtcot.  the  «[>«mia* 
would  ccrtainlf  be  followed  by  injurious  results.    Alter  eilenaiMi  hiibMi 


K 


y 


Pt(,  lOft  — Ka»*-Jutnl  artcr 
ItiUBiinn'  llfla<lnfTtblB 
IhrnwD  Hachwaida. 


IVttlInn  att«>  t:*t*R»>.<n  af  TiS 
InMUd  Knn  JnlKt. 


made,  tk«  limb  should  be  fixed  nti  a  long  s|>Hnt.  wt-tl  fwddMl,  ur  ■•* 
Thoniai'ii  koeeniplint.sonie  «Ta|K>raitiig  lutioun  applied,  and  tbe  pstirstlM' 
in  bill  for  H  f«iN  UayK,  afler  whleh,  with  the  aid  of  ■  itarehed  handag^bU 
m&T  walk  abotil. 

^bcn  the  triple  diflpUcetnent  which  haa  already  hem  rvfrrnnl  lo  rxitfi' 


TSEATUENT  OF  CONTRACTION  OF  THE  KNEE.    515 

Tis.,  BDgular  contraction,  dieplacenieot  of  the  bead  of  the  tibia  backwards, 
uhI  rutMtioa  of  the  limb  outwards — simple  exteii^sioii  is  no  longer  Buthcient 
lu  renwtly  the  deformity.  In  these  cases  the  liariistring  tendons  often  require 
division,  generally  ou  both  sides — sometiinoit  only  the  external  one;  and 
exten>iuu  may  then  lie  eHeeted,  either  forcibly,  or  by  tbc  gradual  and  sluw 
■ctioD  of  rack  aud  pinion  apparatus.  Wbon  extensiitn  ia  eomplele,  the 
bsckward  displacement  of  the  head  of  the  tibia  may  Ktill  occaoion  ooniitder- 
ftbte  del<>rmity  and  weakneKS  of  the  limb  (I''ig.  0-'!~i).  Thia  condition  is  l>e:it 
remnve^i  by  the  use  of  the  instrument  of  which  the  sketch  on  the  preceiiing 
page  '.F'g.  0.>l>)  is  a  g(K)d  representation  ;  il  was  designed  and  consiructeil  by 
that  f  xcvJleiit  surgical  mechanician,  Mr.  liigg.  The  dittgram  represents  a 
limb  with  the  tibia  tlii^placed  backwards,  the  angular  contraction  having 
been  remedied.  In  the  centres  of  the  lower  end  of  the  thigh-btme  and  of 
the  heatl  uf  the  tibia,  two  letters  (X  and  Z  i  are  placed  to  designate  the  axis 
of  each  bimy  bead,  l>eneath  and  above  which  the  displaced  j'liut  has  formed 
its  abnormal  axis.  The  dotted  lines  rcprf^ent  the  leverage  formed  by  the 
cylindrical  surface  of  the  tibia  and  tliigb-bone.  The  arnivvg  are  placed  in 
such  a  direction  as  the  bones  would  take  in  re:;timing  their  normal  position. 
It  Mill  readily  he  seen  that  any  instrument  ciipable  of  acting  in  the  mecbaDi- 
cat  •lirt-ction>  shown  by  the  armws,  Would  not  only  accomplish  the  restora- 
lii>n  iif  the  jiiint,  but  extend,  if  contracted,  the  extremities  uf  both  lemur  and 
tibia. 

An  additional  advantage  that  this  instrument  possesses  over  any  other 
with  which  I  am  acipiainted,  is  the  application  cif  spring-power,  by  means  of 
which  di-xion  of  the  knee  la'comes  an  element  towunls  the  restoration  of  its 
utility.  Instead  of  muscular  action  being  arrested,  and  atrophy  of  the  limb 
Win;;  tbu:;  priKliiced,  movement  is  conducive  to  the  perfect  action  of  the 
appiiraliis;  so  that  the  patient  experiences  l>ul  little  inconvenience  from  its 
u^-.  ail  [he  ordinary  jiositions  assunie<l  by  the  knee  in  walking,  sitting,  or 
standing  being  preserved. 

By  this  form  of  apparatus,  then,  three  important  points  are  secured  :  viz., 
replaii-nietit  of  the  head  of  the  tibia,  extension  of  the  angle  of  the  leg,  aud 
Irt-f  Niiisi'iilar  action  during  the  |)eriod  of  treatment. 

lu  Vvj.  (i-!'i,  A  and  H  arc  two  levers,  eompi'scil  of  metal,  corres[>i)nding 
in  their  ■iin-ciinn  to  the  [icrpendicnlur  |i<<siiion  of  the  tliigh-hone  and  tibia, 
I'  and  I)  are  iwn  axes,  jilaccd  exactly  cuin'i'idciit  with  the  centrec-of  the 
ariiciihir  end:' iif  the  bune".  Kami  Fare  twn  pow*'rfu!  s[»rinj|p<,  acting  in 
i.jip.  -in;;  dirt  ction.'* ;  viz..  in  thi>sc  indicate*)  Uv  the  arrows  in  Fig.  (i."i").  Thus 
1-  iirt,-.-v- ilic  lever  I»  in  a  forward  direction,  bemirig  the  end  of  ibe  tibia 
I'xruard.  wbil.-^i  K  i)ns?es  tbc  lever  A  in  a  backward  direction,  bearing  ilie 
end  "f  the  ihigh-bonc  backward.  As  ('  and  Dare  t'ouiid  acting  above  and 
Ih-I'-w  the  aeiual  axi.-<  <d' the  knee-joint,  they  nuitually  inllucnce  the  |»iint 
t'irn;ed  by  the  a]ip<»ition  of  the  heads  of  the  tibia  and  thigh-bnne ;  and  as 
it  ha:-  alnady  been  explained  that  the  thlL'b-bniM'  nally  olleis  a  ttxcd  resist- 
an<'<-,  aiiil  the  tibia  moves  beneath  it,  llie  head  of  the  latter  lionc  i.i  brought 
f-irward  iti  a  semicircular  dire<-tioii  consi'i|iient  on  the  upper  centre  <  ( ' '  being 
a  lixed  p'iiit.  and  the  lower  centre  i  Di  rolaltti::  itrmind  it.  (.>  is  an  el:i:-lic 
knet-cap;  II,  a  padded  plate.  When  the  liLMninHs  are  tense,  there  is  a 
ebaiii.-*-  I'l"  pri^K-ing  the  anterior  surliice  ot'  the  tibia  again^t  llie  p<^^lcrior 
surlai'f  i.f  the  tbigh-bone.  Tins  is  readily  ubvialed  by  li:iving  tlic  >lialt  A  ■ 
iijadf  III  tlougate,  wbcn  the  ceiitie  iCi.biiDL:  a  little  Inhered,  pu>lH>  the 
l«ver  I!  downwards,  carrying  llie  tibia  \\ilh  it,  and  thus  >cpiiraiing  the 
<«M-itii4  ^(irtiiees  of  the  JMint. 

'Z,  The  next  class  uf  casis  of  cuniracted  knee  that  we  have  to  cmsider  is 
that  in  hIiicIi  the  li'tmttriiKj*  'ire  Voufrudcil,  either  alone  or   in   adclitimi  to 


61 G 


DSFORMITICS. 


thoee  rmilts  of  rlironic  in fia minatory  action  wiibin  the  juint  thai  haw  jut 
been  ilescribixl.  In  tlit^o  caws  tlic  hamsiriii^  will  b«  Tnunil  (o  be  liKtit;  twt, 
in  proporliim  as  lbL>  le^  i»  extended  on  the  ihi^fb,  llioy  will  In-i^onitr  nittrt 
itaat,  until  at  Inst  alt  lurtlior  cxl^n&ion  ii  re&u>ioti,  afiuarfuily  I>t  ibcir  uw 
lion,  niii)  not  hy  uiiv  ttuiMin  i-Ia-ck  or  »tMp  wilhio  lb»  jnint  ItM^lfT 

DivisioD  of  the  Hunatilng  Tendons  U  iti  itMtuarv  etuir^  a>  .;ifir.1«  m 
ii[tpnttiiin    fl.<i  any  in  aiirgory,  ui)atlond(-<l  by  any  iliAleuUy,  [  :  ilv 

Hiir^poR  introduce  the  t«tiotome  Rll1M^  b>  tlie  it(1et»l'lbt  (endtio  it.  ._■.  ...^..^4. 
nod  rut  iti  a  direction  from  tbc  popIil«nl  Mpeci  Ltiwank  ibc  itkin.  Tbe  uaie 
btiiiis(r)ii}f  will  tuiii&lly  tte  found  to  be  tbc  tnosL  k-luc,  atir)  pbnuld  fini  br 
■liviilt'<l.  Ill  tlijii)^  tliiH,  tbe  itenincal  nerrc  iiiigbt  ap|ivar  to  bv  !ii  •l«b(«r; 
but  thin  may  l>e  uvniilMt  by  keepiitj^  the  Riile  uf  l)ii<  iriKtlorttf  ^>  ''  .i»4 
tbe  inner  i^lu^  ol   the  bicejm  trntloii.  tlK*!)  tiirnliijj  lbi<  i?ilf;e  mil  -  'S 

|uii»e<)  (Ifciily  eri<>ii)!li.  The  «vruiteti(lint>>ii*^  tiuxl  n-<)iMn^  divui'ia.  Tbr 
]K-iiiirii>*iiil>riii)(>^i]8  iK'«<l  IK' I  often  be  citt  Her<««.  Aftrr  tbt*  (liviF>i>n  uf  ii« 
tviiituiiit,  Ifiiee  nponcurolic  luitiiia  will  not  iii)lV>.*>i»*;ntly  Iw  found  U*  Mntefc 
aloti^  onv  or  IkiIIi  »idi.-».  nr  ((crbapfl  down  tbu  rrntrc  of  ihtt  [M>iiliirat  ipKV. 
Tbia  inity  b-mt  to  ilic  iiU>n  ou  Ihu  part  of  the  Sur^'(.-<»u  tb»t  \iv  baa  not  ^rly 
cut  tlio  teniluiib  Kcrofs;  but  this  is  «n  error.  Tlif  bnnil"  alluded  to  mn  n*- 
ilensed  ftlinrp-eilgod  pn(lungKti"ii»  of  tbc  fstvUx  lam,  f<)rtn»l  during  the  iwrij^ 
of  eotitni<tion  uf  the  joint  by  tliu  «briiikiM(!  and  thivkeiiing  ol  thift  oi**- 
hnuiouB  exiMiiuion.  Sitcb  oondeiiBations  uh  three  had  better  be  lefl  V9- 
|i>iu'lied,  aa  ihey  will  readily  sireteb  nut  under  i;rn<lual  extension,  itr  be  np- 
tnre«I  by  foreible  trurtion  of  the  limb-  If.  on  tlie  (rfher  banil,  tlie  i^r]^« 
be  tempt4vl  by  their  apparently  Fiiperfirial  and  rnfe  p^wition  to  pmcred  la 
ibelr  division,  he  inny  be  brought  nmre  cloH'ly  into  coniarl  wttb  lb#  po]fi- 
leal  V4«.<u>1h  than  ie.  deainilde  or  fnl'e.  In  these  cases,  the  nnatnmieal  rrlaiima 
of  pnriA  tire  Ml  much  nltereil  by  tlie  narrowing  i>f  ihe  popliteal  -fweo  aad 
by  tbe  pnijecilon  of  the  head  of  tbe  tibia  bat■kwa^l».  or  by  ii»  1  i 
lion,  that  rbe  Siir^nn  in  unable  to  cati'utate  with  Autbeient  nickels 
position  of  (he  larve  vceaela  and  nerve*  in  (be  neifjltitorb-oxl  »!  wbirb  htk 
about  to  net ;  and  na  may  lbu»i  injure  <^ne  or  other  of  ibi-ne  at  a  time  «ba 
he  ttiinko  that  be  ifi  opemcintj:  at  a  xafe  dtHtanec  trom  them. 

Afler  <livi»ionof  tbe  hnni^trinK",  lh«  knee  d<M-« not  ninimitnly  en...-  r».iti1r 
into  the  Btmtght  poAttinn,  owin^  to  the  Khorlening  of  the  piiM|*-ri  <  t; 

and  ^raihinl  exteni>ion,  by  meioA  of  pniper  ap{Miratii«,  will  Im-  >..j.,ii^<  m 
overeonip  thii  and  to  itlretrb  ibe  adheninitti  within  and  anxind  tbr  joiDL 

Contraction  with  lateral  Dinplacement  ia  not  unfrei|uriitly  mrt  with,  h 
ihtw  ra?vB  tho  knee  is  contrat-led  more  i>r  lew  in  the  ani;iil«r  din^ction  ;  bol. 
in  Miblilion  l<i  thi#.  tbe  loner  end  of  th«  ibigh-boni*  isdirrcled  tnwarda  omI 
jx-rhapH  enmewhal  foruanlo,  and  the  libia  iv  rotnUil  <Kitw-Rr<ta,  carrying  Ik* 
ti<ol  with  it.  There  la  ibue  a  triple  ileforinity — i)n;;ulnr,  nie^al,  and  tot*- 
lorr.  I  bclic-ve  the  aiigtilnr  to  he  (he  prtniai^  det'-rmily.  and  tbr  amid 
Bii<l  r^'lntory  lo  Iw  ee<iindary  In  tlii«,  arising  partly  t'rrim  the  rfliirla  uf  th" 
patient  lo  nalk  by  noting  on  the  point  of  the  gn-nl  toe,  anil  tbmwiar  Iha 
thi(;h  iiiwnrdf  in  onler  lovffrvt  this,  and  partly  tmni  Chv  action  of  iha  MeafB 
Tututing  tbe  \fg  oulwarde>. 

Tlw  3Wjttmriit  o(  thew  riwrs  is  not  very  satisfartory.  Tba  ofaalacle  to  \h» 
Kftorntinn  of  the  normal  pot^ilion  nf  the  Joint  is  Hcpfodent,  ao  far  aa  tW 
angular  rontmetion  is  concerned,  on  »hnrlriiing  of  tbe  liganientun  poMioum, 
aoil  tbe  rolntory  dirplucrnient  is  kept  up  and  rendered  intractable  by  «hurt* 
aning  of  the  anteriur  crurial  ligament.  Merv  extension  of  the  llrab.wbMlier 
graijual  or  fiirred,  may  counteract  the  angular  deformity;  but  )t  aiti  Ml 
Ivniy  leave  the  utber  difipjacemeola  aninflnenced,  but  may  aetually  tnerraM 
the  diiplaccnient  of  the  tibia  backwards  and  the  rotation  uf  ibe  teg  uotwardi. 


OSBEOUS    ANKYLOSIS    OP    THE    KKKE. 


517 


A  leg-anil-thtgh  splint,  such  as  U  shown  in  Fi<r.  63(),  but  having,  instead  of 
the  spriag^.  a  rack -and- pinion  apparatus  working  tni  three  centres,  so  as  to 
exteDil  the  limb,  abJuc-t  the  knee,  and  rotate  the  leg  iiiwiird^,  is  the  only  con- 
trivance hj  which  this  dei'ormity  can  be  counteracted,  and  the  Htub  restored 
to  shape. 

lo  reference  to  the  treatment  of  these  varitms  deformities  of  the  extremi- 
lin,  it  may  be  stated  generally  that  it  is  mucli  easier  to  rectify  faulty  posi- 
tiuD  than  to  restore  mobility.  The  first  may  alwavs  be  done  by  the  varioma 
meaos  that  have  been  enumerated ;  the  latter  can  be  ettectcd  only.  If  at  nil, 
by  lung-coutioued  efforts  on  the  part  of  the  Surgc<ui,  by  passive  motion, 
frictions.  shamptMiini;,  etc.,  aide<l  by  properly  constructed  apparatus. 

In  ankylosis  of  the  knee,  after  extension  has  been  made,  and  the  limb 
hroupht  struijrht,  the  <)ueetioii  arises  as  to  whether  mobility  of  the  Joint 
ihouid  be  encouraged,  or  the  limb  kept  straight  and  made  stiff.  The  answer 
to  thU  Question  wilt  greatly  depend  on  conditions  of  the  muscles  of  the 
thi^h.  If  the  quadriceps  extensor  exhibits  electric  irritability,  then,  if  the 
state  of  the  joint  admit  it,  motion  may  be  attem[)te<).  If  the  muscle  be  insen- 
sible to  the  stimnlui*,  then  the  joint  had  best  be  kept  stiff*. 

3.  Osseons  Ankyloiii  of  the  Knee  is  not  of  very  frequent  occurrence.  It 
is  ustially  the  result  ai'  traumatic  intlaiiitiiation  of  the  joint.  If  the  limb  be 
straiichl.  no  operation  will  be  advisable;  if  it  he  bent,9»  that  the  patient 
cannot  put  the  foot  to  the  ground,  the  only  remedy  will  be  an  operation. 
Bhea  Barton,  of  Piiiladelphia,  in  IHIJo,  proposed  an  operation  for  restoring 
the  straight  ixisitiuu  of  the  limb  in 
cases  of  complete  osseous  ankylosis  A 

of  the  knee-joint  with  angular  de- 
formity. The  proceeding  oonsists  in 
excising  a  wedge-shaped  piece  of  the 
shaft  uf  the  femur  above  the  con- 
dyles, not  inclu()ii)<>  the  whole  diam- 
eter of  the  bone,  then  fracturing  the 
undivided  portion,  and  so  bringing 
the  limb  into  a  straight  |ti tuition. 
Birch,  of  New  York,  in  1«44,  modi- 
fied this  operation  by  sawing  out  h 
wedjK-shaiu'd  portion,  con:»isling  of 
ihecitnilyktjof  the  femur,  the  piUcltii, 
and  the  head  of  the  til)i».  .Accord- 
ing to  <iroA>,  these  two  o[>oratiiiitd 
have  U-en  done  in  all  in  21  case^,  of 
which  -1  proved  fatal  by  pya'miii.  lu 
one  c:i>i-,  that  tif  Heil,  the  fcuniral 
artery  bad  l<i  be  lied  fur  sciondary 
ht^iuorrhngr  fr<oii  the  popliteal  on  the 
fifteenth  day  ;  but  tlie  p:)tii'nt  njaili> 
an  exifllenl  recovery  with  a  ust-t'iil 
limb.  Bniinard.  of  Cliicagu,  in  1^.14,  propusi  d  u  sinipk'  and  le.ss  sevcrt- 
lueth'wl  tiiari  cither  of  the  ab.ivc,  f.ir  tin-  remi.lyiii:;  nf  iinguhir  o.-sfous  aiikv- 
hn-ia  of  the  kniT,  It  consi-ited  in  drillinL:  tiii'  Icruur  ^lubcntiiiieouslv  and 
then  fracturiiiir  the  bone.  This  opcarii.ii  wa^.  lirst  d.>ni'  bv  P.irirni'isl  in 
l**'*!).  and  eini'L-  ihen  ba>»  hi'Pii  sucfosstully  practiM'd  bv  Itrainiird.  (Ir.i;'!'.  and 
uthfn<,  who  have  extcndtrd  it  to  .-ubculanrons  pfilWration  of  tin-  jnint  ami  to 
separation  of  the  patella. 

The  drill  nseil  for  this  operation  cinisists  ..f  a  i-tei'l  jihafl  41  inelus  long, 
fitted  with  a  solid  and  roun<led  handle  '  l-'ig.  i\.)~  .     'VUv  jxiint  i^  !th  of  an 


Kiz-  r,:;:,— Drill  r.r 
Aiikvlii-eii  Kiii-f. 


VlK-  'l"".— llrill  r>ir  Au- 
kTl«.<i.*<l  Jiiiiit. 


£18 


DKFORHtTIES. 


la 

1 

tidP 


iucl)  ill  breadth,  and  bat  on  cnrh  i>i<k>  nii  oblique  gntovp  wiili  cuuioj;  adftfh 
8u  ihal  it  acts  as  a  pmge  as  well  us  a  ilrill.  TUe  intm<ir  of  th«  nblitaralal 
artii-tilalion  is  rearh(-il  bv  niiikltifT  lit)  itimioii  nliout  half  «o  iiK'h  loojt  <« 
lUf  uuUir  side  of  the  limb,  at  tliv  line  of  jiincliim  Iteiwwn  Ihe  .s.'^  Ivl"  •< 
llif  iVmiir  mill  the  tibia.    The  ilrill  h  Llicn  workeil  ihroiigh,  iinli  ->■ 

Iw  fc>lt  miller  the  iiitfgnment^  on  the  o[tprKj)ie  Btde  uf  the  limb.  •  >i>-  .i^r.ii>> 
ment  muiA  m^w  be  worked  in  such  n  iiintitn'r  H8  to  br«ak  duwn  ihe  •«•«•« 
iidhf-iuoii^  between  the  loimir  iiiid  the  tibin  on  the  uiu'  bund,  aod  ibv  Mtelli 
on  the  MlhfT.  The  imlcDa  is  toitictimeM  best  Imisrried  by  u^-in^  ibe  drill  a»a 
lever.  Whon  the  bniies  have  heeii  Mifficieiitly  )wrfnnilLi)  in  didtrctil  dil«^- 
linnsi,  the  linib  must  he  extended,  ivjii'ii  the  retnninint;  iiivotua  er«UMed«H 
will  sive  wuv  with  a  erackiit;;  n»iso.  The  wotiiid  in  the  intef^timnit  b  tlm 
rloM-d  with  stiver  autuicA  nod  {idl'Mtimt,  mid  the  limb  laid  on  n  |>ill<#T.  la 
three  or  four  day*t  it  may  be  put  in  a  Molnlyre  !.idiiit,iind  j:riidu«l  rxut. 
praetisfii,  the  uilt  part*  i>»»!Hcriorly  *l<(ivly  yieidinjr.  B>'iiy  niii"n  will 
titke  place;  but  it  in  n  deciited  K«lvanla)ie  nheu  the  limb  tft  iiliirfi>r  \\.r  k: 
not  U>  be  qiiile  straight,  but  i>li)ihtly  flexed,  so  that  the  leg  may  be  abuul 
inch  «borter  Ihan  Ihe  onnoitile  limb. 

This  operation.it  will  be  seen,  is  in  maoT  rcipects  wpvriort"  !l-—  nf 
BnrtoD  and  Buek ;  for  whilst  briiigioii  the  limb  into  nn  rtiiinlK  «»• 

tioQ.  it  does  hi  by  a  comparatively  etight  and  j>ubcutiine«iis  priK-mnrr.  unat- 
tended bj  any  danger  of  hemorrhage  tit  of  compliciitinnf  nri>ini{  fnjin  ao 
extensive  open  wound..  The  nine  ea»ee  in  which  it  lias  been  d'Mic  freir  all 
ftuereNifui.  These  various  perfuratiu};  operations  apjtear  hitherto- In  havt 
been  eiiufliied  [o  the  knee-joint,  llul  tlu-re  can  be  little  dtiobt  lliat  tbv; 
iiii|>lii  advaniflge'iusly  bo  extended  lo  other  joints  atlecKsl  by  iMMmra  aoky* 
ln^t».  more  portieularly  iu  the  bi]>.  lu  nn^ular  eoiitmelion  >if  the  kaw' 
j'liot  with  dL^hH-alioii  of  the  llhin  bnckwarda,  Volkuiann  ha»  correelMl  tfa* 
dol'itrmity.  by  culling  acn^es  the  femur  iuet  ahovo  the  condylrc,  and  in  naa 
enae  bv  dolui-  the  sanio  to  the  tihia  juBt  bchiw  iU  head.  This  he  mnaraeorf* 
to  h«<donc  with  n  ehincl,  the  wound  being  dreawd  autisepiieallr. 

AiikyloMs  of  the  knee  in  the  ttmight pot'ttion  interferea  comfMinitirpIr  littla 
with  the  utility  of  the  timb.  It  i»,  however,  desirable,  wbeu  rnkeilnthle,  u 
restore  the  mobility  of  the  joint  The  piwaibility  uf  doing  thu  will  d«peflHl 
nn  the  degree  of  ankyloMt^.  If  thi*  I»e  oMeouii,  or  even  if  deoaelr  fihrtntf, 
little  fan  Ik-  d'ine  ;  btit  if  the  ri;;idity  deiM-nd  rhiefly  on  coudcoBaiinn  »4 
onjMtule,  nnd  fibniid  indiirHtioti  otitiiirle  tlie  joint,  Uiueh  may  be  ttSett^ 
the  UM>  of  pro|K'rlv  con;<troi.-tefl  np|)nrntiis.  Thifi  should  Ive  of  two  tt 
1.  A  l«-;;-[iiiii-thich  piece  securely  Inee^l  on  to  tbv  limb,  having  an  nn*tilar 
joint  <>p|M)»i(e  the  knc«,  and  connecte*!  ivwterinrly  liya»tri  ;  -nl. 

ennited  India-rublier,  tlu'  elnfttic  lcii»i<tu  of  which  i»  ct>ii»ii<  _  tn 

uvcrcotne  the  «(rniphtciied  limb  by  fleiiog  it  barkwanU;  nml.  ^,  ■  •imilar 
apparatuic,  with  ratk  an<)  pinion,  innetid  of  eltistif,  by  which  tb«  knrr  e»a 
b«  f  ireibly  tlexeiJ  once  at  lenut  in  the  day. 

Aokylusis  of  Ihe  kuee  in  the  anyt'lar  posUUm  forvanU,  to  that  lh<-  l#c  li 
ovpr-extended  iip<>n  the  tbigb.  h  very  ntr«.  Iridreft.  1  an  ar<iuainlrd  witlt 
only  three  pretwmtiona  iUutitruliiiir  this  defurmitv — one  in  the  tnnaruro  nf 
University  (Tollege.  one  in  that  of  Ht.  Thomas's 'llueptlat,  and  nnnibertX' 
hibiled  by  Adaraa  in  ihe  pHtholngtral  SK-it<ty.  frotn  ■  limb  ampautcd  by 
(ininl.  ot' (.'anada.  in  which  Lbib  eonditiim  orrurretl  to  a  ytmag  man  as* 
conwuieiici'  of  a  wound  of  (he  juiiil  r-ome  yeiir-*  jTevioiisIv. 

Deforntitiea  of  the  Bonn  of  the  Lower  Limb  Iron  ftickaU.— The  •!» 
tortioiu  of  the  Itotieu  of  the  leg  arising  fnun  ricketa  bavc  already  bavn 
alludti)  tu  in  the  ehaptrr  on  diaeaaea  of  lioiir.  It  is  ne«dlaaa  here  to  do  moit 
than  mention  that  antiseptic  osteotomy  hai  been  applird  of  latf  yean  whh 


irtntf, 


CLUB-rOOT — TALIPES    EQUINDS.  519 

great  aucceea  to  the  treatment  of  these  deformities.  It  is  seldom  that  aDj 
operatioQ  bevfind  that  already  described  for  kaock-knee  is  required  in  the 
femur.  In  the  tibia  the  curve  is  most  commonly  outwards  and  forwards, 
nfteD  to  such  an  extent  as  seriously  to  cripple  the  patient.  In  these  cases  a 
wedge-shaped  piece  of  bone  is  often  removed  from  the  most  prominent  part 
of  the  curve,  but  as  good  a  result  can  usually  he  obtained  by  simple  division 
tif  the  b<me  hy  the  chisel  and  mallet,  used  in  the  same  way  as  in  the  opera- 
lion  f^ir  kn<x;k-knee.  If  necessary,  the  same  bone  may  be  divided  in  more 
than  one  place,  either  simultaneously,  or  the  second  operation  may  be  de- 
ferred till  the  patient  has  recovered  from  the  first.  In  complicated  cases  of 
kn'X^k-knee  with  rickety  curves  of  the  femur  and  tibia,  Macewen  has  per- 
formeil  as  many  as  ten  osteotomies  simultaneously  on  the  same  patient.  If 
proper  antiseptic  precautions  are  adopted,  the  danger  of  these  operations  is 
very  drght,  as  may  be  seen  from  the  result  of  .Macewen's  practice  (p.  510). 

CLfB-FOcJT. — Deformities  of  the  foot  may  aflect  either  one  or  both  of  the 
extremities.  They  may  be  congenital  or  acquired,  and  may  occur  in  either 
sex.  but  appear  to  be  more  common  amongst  boys  than  girls.  There  are  four 
primar\-  varieties  of  club-foot  and  two  secondary  <mes.  Of  the  faur  primary 
f»mis.  In  two  the  defiirmity  i»  in  the  anterfH posterior  direction,  in  the  sense 
of  tlexioD  and  nf  extension  :  Talipes  Eqninas,  in  which  the  hoel  is  drawn  up 
and  the  toe*  pointed  downwanls:  and  its  antithesis,  Talipes  CalcaneoB,  in 
which  the  heel  is  pointe^l  downwards  and  the  t'uot  au<l  toes  drawn  up.  In 
the  remaining  two  forms  the  deformity  is  lateral,  the  foot  being  adducted 
and  twi0te<l  inwanis  in  Talipes  Tarns,  and  abducted  nml  twisted  outwards 
in  Talipes  Valg:ai.  The  tuur  primary  forms  «f  chib-foot  correspond  with 
and  are  dependent  on  a  permanent  condition  of  one  or  other  of  the  four 
simple  movements  of  which  the  fiiot  is  susceptible  at  the  ankle-joint. 

Thus  in  Taiiiies  Kquinus  the  foot  is  extended,  the  heel  being  raised,  and 
the  dorsum  ))ointing  downwards  in  a  line  more  or  less  direct  with  that  of  the 
anterior  part  of  the  leg.  This  i»  due  to  perniiinent  contraction  of  those 
musoles  that  are  inserted  into  the  oh  calois  tlirough  the  medium  of  the  tendo 
Achillis.  In  Talipes  (.'alcaneu.-*  the  foot  i»  drawn  up  and  the  heel  depressed, 
^>  that  the  dorsum  forms  an  un^le  more  or  le^s  acutt;  with  tlie  front  of  the 
W-s.  Here  the  tibialis  anticu's  is  tlic  iiitii»cle  chiftty  iit  fault.  In  Tali|>e8 
Varui*  the  foot  is  adducted  forcibly,  and  the  inner  side  of  the  sole  raised 
Diimetimes  to  a  right  angle  with  the  ground  ;  this  is  due  priuoipully  to  the 
C'tmbined  action  of  the  tibialis  [)osticu?i  and  tibialis  anticus;  and  in  Tali]>es 
Val;:u!<  we  have  the  converse — abduction  of  the  lliot,  and  raising  of  the  outer 
Hde  of  the  sole,  due  to  the  at-tioii  of  the  ]HTon«'i. 

Resides  thecc  four  primary  forms,  thfrc  are  two  peeondary  varioties  of 
'-lub'foot:  Talipes  Equino-Tams,  it>  whit^'h  tht;  heel  is  raised  and  the  foot 
drawn  inwanis,  and  Talipes  Calcaneo-valgus.  in  which  the  liot-d  is  drawn 
d-'wn  ami  the  fiH)t  turned  out.  Tin-  TnHpi-'*  K'juiiiti"  and  PurtM  are  com- 
ni"Mly  ass^H-iatcd.  bi-causc  in  tliiw  tiirrns  the  tlvxor  and  addiiclor  muscles, 
vi/..  thi-  ^-trin::  iiiiis<'li-s  of  the  call'  and  llie  til)i:ilis  pustiL-iir!,  thosf  that  are 
s-iipplitr-l  by  tlif  |»n.t<'riiir  til)ial  nerve,  are  <'ontraftfil.  .\gain,  the  Tn/ipm 
t  •ili-.iuruj'  and  V'lf^iuf  are  associated,  bfcausi^  in  thit;.'  tin'  exu-uj-or  ami  the 
ptTiHval  muscles,  ihosf  supplli-d  hy  tin-  rxiciaal  popliteal  nerve,  an'  the  scat 
■  >f  omtraction.  In  some  forms  of  club-tout,  t'spi-ciaMy  in  tin?  varus  and 
^jiiin>>-varu.s.  it  will  be  found  that  the  musch's  antaL;oiiistii-  to  those  that  an* 
cuntrai'ti-d  are  in  a  state  of  atro|ihv  and  defective  iiiiicrvatiini — in  this  ease 
th*-  -xtens  ir*  on  the  anterior  part  of  the  le;:  ami  tlie  piTomi.  In  sueh 
in-tano-M  a*  these,  electricity  hecomrs  an  im]'ortatii  adjiinc't  to  (he  more 
■liri-«-tIy  liiirgical  and  meehaiiica!  treatiiieut. 

In  infants  with  talipes,  Sayrc  begins  treatment  at  once,  as  soon  as  i>o.^sible 


IHITIE8. 


I 

tndriMj 


M 


afUT  birth,  li)-  driiwinf;  iheiboiiDto  (HNtiiion.    When  tbn  b  doocvftl 
<|ui[e  white  hiiiI  l>lo.Mlleaa.    The  traniuii  muAt  then  he  dbcaaiiatwd. ' 
be  iftiuiiifil  ngnin  in  a  very  ehtai  titue,  noil  m  refiefltefl.     A^er  a  liwi 
liiiih   iiiAv  he  fixo^  in  nri'iter  (inciitoQ  hy  tho  a|iplir«tiaii  aiKt  ti 
iilniitfrft;  niid   ihua  if  tne  lAlifrf'it  be  mil  cured,  it  nmy  vtty  earlj 
l»e  milch  nnieliornled  mid  remlerf^  more  tit  for  ojienilive  trrmtaietit. 

Ptithohgiciil  Chnngr*. — On  tli^ftectin^  a  timl  ntrcrti'd  bv  tnlipCM,  \l 
\tv  s*H'ii  thnl'  l»il  litllt?  nlu-ratioi)  hiw  lak^ii  iiln<:e  in  ibe  (■<iii(nti><ti  »l'  tho  bu 
III  »iiiiitf  |>ri']>Hrftltiiii«  i>t'  ihiM  kiixl  uliicn  iirtr  in  ibr  i'nivrr*ilv  C*'|: 
Mnariini,  ihix;  iirij  neiirly  iniriiitil  '  Kij^H.  <>40,  Ii44>.  Iml 
et^iiiiiub  itiii)  fiiii-nnvuB,  th^v  areM'ttrtvl^'  if  tit  all  tdlLTvil;  liul  : 
if  cif  i)I(t  8tnti>JiDgt  ihv  natrngaluK  will  goiiLTally  b«  founil  atr»f»iiM«l. 
jiurliculurly  iiUtut  its  hvait,  wliich  luay  It  somewhat  twitted,  aari 
navicular  Htid  ciilmid  buties  will  \w  iweu  u>  hnvc  uuil(>r);i<De  finitar  dMlf 
The  lignmentfl  arc  nvcuuinrily  fftmivwbat  altrivd  in  rhape,  bring  levfrthi 
oD  the  convexity,  ami  aburtened  un  the  cuurnvity  nf  the  fuMt :  the  dirrd 
of  the  teiidoun  \s  altered,  and  the  niuteJw,  ool  only  of  tlic  /uot,  but  vl 
leg  Rod  ibiffh,  are  geoerally  atrophiitl  from  dinue,  so  that  thv  Bmb  in 
CIBC8  ia  Milhcred  and  shortened;  indeed,  hn  great  nn  iaeiimLnuKii  ■>; 
oecttMonallv  beoome  under  these  circunislances,  that  nniputatioa  of  thi 
may  be  iusisted  i>u  by  the  patient,  and  with  prupriety  be  perfurawd  by 
Surffeon. 

Talipes  Equiniu  ia  charncterixed  by  elevation  of  the  hed,  «ad  iCMiaa 
the  it^udu  Achillifl.    Id  eligbt  caM's  the  heel  may  merely  beraiaedft&«, 


Hit-  ^*-  Ti>ll|M« 
B<|itti«*. 


above  the  grtiuiid,  and  it  will  be  fuuitd  on  examination  that  il  cam 
ibrwanls  to  an  aruto  »t  rren  In  a  ri^lit  an^le  nilb  the  le^.     lu  s 
the  f'Mit  may  tie  rxtvndwl  in  nt-arly  a  »trai(rht  Uoe  with  th^  b 
I  pativniuntk*  di  hi*  l"*^,  whicli  art-  (ilHccd  nt  h  ni;ht  anjle  lt> 
fciy.  tH").     In  tbi»  drftiriiiily  then.*  is  on  lateral  displai-vnu-nU 
THmplin,  it  is  never  t-i)n^<>nitiil.     It  nxial  iN^niniuiity  ariw  frim 
of  the  oervoue  Bvvtvm  during  tcrthing.     In  adiilln.  aa  well  aa  ii 
may  txnne  on  fmni  tuuie  dtseaHf,  nieh  as  an  ubverw  in  the  calf  o 


l^f.  6<«.— ItoKM  In  T«{| 


TALIPES    CALCANEUS. 


521 


which  the  gastrocnemius  muscle  is  crippled,  shortened,  and  contracled.  It 
»  the  mnst  important,  and  at  tlie  same  time  llie  ximplest  in  itself,  of  all  the 
forms  of  cluh-fuot;  it  commouly  coniplicBteii  T.  varus. 

Tbe  IVeatment  consists  lu  dividing  the  lerido  Aehillis,  and  bringing  the  heel 
veil  down.  The  tendo  Ashillin  is  bei^t  divided  about  an  inch  above  its  iuscr- 
tiuo  into  the  us  calcis.  The  limb  should  be  placed  on  ite  outer  side.  The 
Miifltant  then  relaxes  the  tendon  Elightly  while  the  Surgeon  slides  a  tenotonie 
beneatb  it  frum  the  inner  side ;  the  assistant  then  makes  the  tendon  tense,  and 
the  SurgeoQ  proceeds  to  divide  it,  u>ing  the  knitv  as  a  lever,  the  fulcrum 
being  the  edge  of  the  uiatleolus.  Tlie  Surgeon  must  keep 
the  lingers  of  his  lefl  hand  on  the  tendon  to  leel  that  the 
knife  does  not  approauh  the  skin  too  closely.  As  thescc- 
tiou  proceeds,  lie  will  hear  the  tendon  creaking  as  its 
fibres  are  successively  cut  through.  The  division  may  be 
safely  made  from  the  cutaneous  surface  if  it  be  preferred. 
The  tendon  must  be  made  tense,  and  the  {K>int  of  the 
tenotome  entered  tlirough  the  skin  close  to  its  anterior 
surface;    the    foot   is    tlien    fully    extended,   while    the 


Fiiltl.^AppkntuarnrateBftcr  Fig.  042.— Talipea  Cklcancui, 

f>\finva  ul  Tcoilo  AehlUi*  for 
P'filjtic  Ei(UtDU». 

^^■D  pinches  up  the  skin,  and  pnsses  the  tenotome  between  it  and  the 
JW'l-n.  He  then  turns  the  edge  nf  the  knife  to  the  tendim,  while  the  Ussictant 
lurcilily  Hexes  the  ankle.  Xo  sawiug  or  free  rutting  is  remiired  if  the  knife 
~feWen  entered  sutHoieutly  far  fdrwardt*.  With  ordinary  care,  there  is  no 
'ws'if  ffounding  the  piisierior  tibitit  artery. 

In  cii^eii  in  which  the  <letormity  is  due  to  pnriilysis  of  the  tibialis  anticus 
*'?'|fxltn*»r8  iif  the  t<*es.  a  coudilion  very  frenueullv  met  with  as  the  result 
"*  iiitkatile  jtarulysix,  the  apparatus  reprfscnted  in  Fig.  )>41  fitted  to  a  bout, 
''ll  br  fmiiid  (»f  great  use  in  ])reventing  the  return  of  the  contraction  atUT 
'''fWi.ii  .if  tlie  tendon. 

Ttlipn  Calcaneus  is  a  nire  variety  of  c)ul>-t'iut.  In  it  the  heel  im 
I'*'i'r(T(iefJ.  the  toes  and  anterior  j)art  ui'  the  timt  being  elevat^nl  i  Fig,  (U'J); 
"  I*  ufually,  I  believe.  cong«>nitnl — in  one  case  under  my  care,  hiiivevfr,  that 
'''^*  jrirl  twelve  yeiirs  of  age,  it  was  Heijuired.  It  arist-:'  from  etintrnction  of 
^*  I'llt-ustire  conseijUint  u|Kin  hva  <if  pnwirr  in  tl»'  tiexor;-.  It  is  sometimes 
*"*'  with  in  caw*  of  spina  liitida. 

TrtatnuHt. — In  order  to  bring  down  tlic  foot,  tlie  tibialis  antieiis.  the  exten- 

*^  C)iuiniuniii.  the  exten.-'or  poHliis,  and  the  peroneus  tcrtiiis  K'lidons.  may 

iJ'  fofpjire  to  U'  divided  as  tln-y  p:i?s  ovfr  the  dorsum;  a  straight  sjilint 

-'Uld  then  be  applied,  and  the  foot  dniwu  down  to  it.     A  minor  degree  of 


522 


IlEKOHMtTIEB. 


this  nflvcli'>n  cooeisu  in  n  peculiar  pnjection  upimrfit  of  ou«  m>  twn  of  lia 
t<io«.  nH«"ci»U.'<l  with  »<jinB  U'uiiiui)  mI'  the  cxlcusor  tcndims;  hy  -I-  "^ii^ 

aud   ket.>|iiii)^  thv  r-M)!  on  it  tliit  «]>litil,  lliu  'Icforiiiily  tnay  ci>rntr  <^ 

rectcil.     Ill  suiiiv  cttBvs.  tinivevtr,  llie  Uk  ia  au  iinmnuvnt.  aii'l  tli  i  -m 

ihk-s  nre  M)Uff/.ei)  un<ler  it  in  bucIi  n  manner,  that  tlip  ftxH  ie  cr»ti^  -  r^^ 
|il(.-().  nml  uin|iiitKCt'tn  of  tlie  ilisiiliiwil  iligit  u  mjuirctl  id  onicr  tn  rcMM 
Uie  tuiliLy  of  the  nivmbpr. 

Talipes  Tanu.— In  this  ilfronnitv  thv  fotil  if  iwSstHl  inwnrdB,  tb«  inaer 
siili*  of  iIh*  M'ie  iti  raieeil.  aiitl  the  stile  is  cnntmctt.'d  ;  the  paticiii  nalkiD^  oa 
the  oDtiT  Me  tit  tlie  Toot,  n-lii>re  tbe  skin  cnverio,^  the  tarsal  eod  i>f  Ibt  i6k 
moiat4tt?al  iHUm.nneii  litfomra  exn^oivply  flen»e  and  firm,  anil  a  t>urM  >«c» 
fliuDully  furma  (Fig.  643  ^     In  most  (.-oses  (here  ii>  Butiie  elt-vstioa  of  ibc  kfd, 


ric-  012.— Talipw  Vuvi. 


ih*>  afTvction  paruking  •omewhrit  t>f  tlic  chaniclcr  of  ta)ipr5  rqiiinw.  It  i* 
the  ntMt  fiimnmn  liinn  of  c«»Oj:  'Tinity.  I»nth  f*«t  '■  1 1  bW" 

larlyaflcctoi^rTHii^t  may  bflif  n  ijil.ilr|ienfl^nton  lu:  panljii* 

of  ifie  fxlfiiK'-ni,  ami  lliMl  »  otVii  limn^l  to  one  f-KiL 

Tlie  Tffjtmeut  cinti^ta  in  the  euceeuive  tUviiioD  uf  the  teadoai  ofw 
libiiilia  noticus  au't  tibiiLli»  p»«ticu9.  which  arc  the  luuiclos  principal'*  >K 
fault.  AfWr  LheHO  bavobeen  cutncross.  tb«  t«tido  AehillisBhoiil'l  ^"'  ■V.vl.W; 
but  itsMctiouibould  be  ma<le  laauaa  it  steadioa  tbe  fort,  and  t)<'  ''■" 

tbe  diviiii«>r)  of  tbe  tibial  teodiiaii.     Same  Surgeoui  delay  di»t- i  '•** 

t«ado  Achillts  fur  suuiu  weeka,  till  the  Inieral  (liflplacetiwnt  of  xhv  fnotkv 
Iwvn  rtMue'iied.  In  most  caiM  th«  pluutnr  iiutcin  ii  coDtnotcd.  aad  itqwf* 
di%'i^|iiii  wherever  it  feels  Len«  and  pnijeoiiii),'.  la  the  mcUo«  of  tba  tibialit 
pusticus  iL-ridiin  lx?hin<l  iho  ankle,  ihi'ra  is  tnucfa  daogwr  of  woowlmg  (b» 
ptioturior  tibial  lu-UTy,  which  li««  ciIom;  U>  it. 

Tbe  beat  way  u>  avoid  tbia  veaaol  Is,  ae  Taraplla  reaommeada,  to 
the  (tbeaih  with  a  nhnrp  tenotome  intmdueed  elnae  to  tlw  tibw,  Imi 
ii)>iivi'  the  matlooliis.  In  tKi>  iiiliilt  or  vouiie:  cliililrcn  poet  tbe  Bf>e  of  in 
n  srn&ll  point  of  lionc  run  bn  l'»]t  in  this  )fitunti->n,  which  marlu  tba 
limit  iif  thn  ffHKive  in  thi'  mallntilux  in  wliirh  the  ti^ndon  Ilea.  The 
•biiiilil  Im?  mailo  ahiivi>  this,  othorwiiie  th«  kuift-  i^uitnut  be  poaied  u 
tendon.  Aftrr  the  Mli(>ath  hoH  thiift  b^n  opened  by  a  puncturv,  a  blunt  IMd- 
t(*tac  u  ininiductNl,  cam  bcio^  tnkf-n  not  lo  ute.  mi  much  (••■  ^-  :-'  '-•  V';*tiil 
lhn>ux'>  the  ithral-h  on  the  o[i|>iu)il«  oi'le.     Tlit*  li-nil<m  i»  lli  •  tW 

nunnl  wny.      If  Ihr  n|wmlii>n  h*  [»orf.irnn.il  l^i  bi>th  np  tli'  .f  nrtnt 

\imffi*  di^fitnruni  will  he  iliTidc*!  with  Ihc  t«ndun  of  thn  liai  'Lit!i]a,ba( 


TREATUENT   OF   TALIPES    VARUS. 


523 


ttiii  u  a  matter  of  little  moment.  Unless-  great  care  be  tnken  in  cutting 
thnnghthe  tendo  Achillix,  there  is  also  some  risk  uf  wounding  the  artery; 
at,  in  hail  cases  ut'  varus,  these  two  structures  lie  close  together,  the  tendo 
Achilli*  being  drawn  out  of  the  niediiin  line  towards  the  inner  ankle.  Indeed, 
in  mte  instance  I  have  seen  the  |>o6terior  tihinl  artery  punctured  during  the 
dimoD  of  this  tendon,  or  rather  in  an  attempt  to  divide  some  tense  bands 
thit  ItT  beneath  it ;  the  bleeding,  which  was  very  free  and  in  a  full  jet,  was, 
bwever,  readily  stopped  by  pressure,  no  bad  consequences  resulting.     The 


I'xg.  QIj. — KeUtiiin  <if  Tenilun  >livii)R<l  in  Bijuinii-varus. 

*  Tibati*  Puftlcua.     }'uinl  nt  nhioh  cut.  a  Abiliictor  Pnllii'ifi. 

I  Flexor  L'lM^ua  Ihgiroruin.  ii  G.ilenyor  T<iin)iui>  PolliL'iti. 

r  Tcn-lo  Arhilli*.      Point  nt  which  cut.  l  Pn-terior  Tihinl  Artery, 

n  Fte.i'ir  L'inKUs  Polliri*.  k  I^>^Ierill^  Tihial  Xerrp. 

R  Tibialif  Anticu*.     Point  nt  which  l'UI.  i.  I'nrt  i>f  Annular  Li;;ftiiient. 

r   Plantar  F.i'cia.  m  Snplii-nii  Vein. 

fTnper  plan  of  treatment,  when  such  .in  accident  occurs,  is,  when  the  artery 
■  menrly  punctured,  to  cut  it  coriiplctoly  acropH,  and  then  to  «I'ply  fir'n 
pKnure  by  means  of  a  pad  and  bimdit^'O  <iver  the  l>leedin>;  orifice.  Taniplin 
itaint  that  he  hHf>  <>een  no  ill-eflectfi  t'ollnw  this  n'-i-i<lrnt.  If  n  circuniiicribed 
ftlse  anr-nrism  form,  it  must  be  laid  opcn.tlie  clutu  turned  mil,  and  the  vossel 
tie4.  No  extension  f»f  the  font  should  l>e  ]in!cti.-iod  fur  sdiik'  lime  iu  such 
cmiie*,  Icpt  the  cna^iilum  be  di^iturhcd. 

The  tihiali:<  iiuticu}!  niuiit  lie  dividi>d  ut  tlie  p'liut  mnrki'd  in  Fit:.  <>4~>. 
Th<>  tenotome  niu^t  be  pn^ised  fmrn  the  outfr  side  to  avoid  any  ri^k  of 
wouo'ling  th«^  domnl  artery  of  the  foot. 

In  ordinary  eases  of  vanis,  niter  a  Inp-se  of  four  or  five  diiys,  Scarjia's  or 


6-M 


nORMlTlSS. 


IJuIu'b  flhiie,  or  Aveling's  tuUvprt  (Fig.  646).  a  most  (uMnirtus  nnil  uaeM 
iusirmiieiil,  itUiiwiiig  every  movement  npopssary  iu  cIuli-ii>ot,  mav  be  ap- 
plied; or  the  fool  may  be  well  iibiJiicled  by  moans  of  a  wowleu  ttjjlint,  fixed 
tu  the  uuter  side  of  the  leg,  and  provided  with  |>ej^,  so  placed  tliut  lite  toes 
cau  be  drawu  U)),  aud  the  foot  well  turaed  out,  by  rollers  and  tapc«  attached 
to  tliem. 

In  Bome  cn^s  the  foot  may  ndvantageuusly  be  put  up  in  pliut^r  nf  PurU. 
Ill  order  to  do  ihtd,  it  u  tiritt  bandtigt^d  with  a  narrow  flanuel  roller.  The 
nssutant  thcQ  grasps  tlic  leg  tinnly  abovt^  the  ankle,  while  he  hulHa  tlic  foot 
ill  u  nearly  as  pnasible  the  normal  iinsitiun  by  a  narrow  loop  of  bandage 
IMUwd  round  the  ball  of  the  great  toe,  and  held  to  the  outer  tide.      The 


Fig.  Aiit.— AratlBg'*  Ta1U«rt. 

K latter  i*  then  npplii^il,  and  the  foot  held  in  position  till  it  has  ut.     The 
andage  should  he  chuiigud  about  every  two  we«kis,  the  foot  being  each  time 
drawn  a  UlLle  more  into  its  proper  position. 

Iu  epile  of  all  (.rvatnient,  however,  a  cousiilerable  proportion  of  caM«  of 
omgeaitBl  tiilipeH  equiuo-varus  are  at  [ni«t  ontv  piirlially  relieved.  In  such 
oases,  as  the  ohiUl  grows  up  the  muscles  fuU  to  ilevelop.  und  the  bone* 
become  altered  in  form  fo  as  to  adapt  them  to  their  nhu'irmal  pD«iliun.  Iu 
Bueh  extreme  anil  incurable  cases,  various  operations  have  been  ree<>innieuded 
to  enable  the  patient  to  bring  the  sole  of  his  foot  to  the  ground.  Many  years 
ago,  Little  suggeisted  the  removal  of  the  cubuid  in  order  to  assist  in  over- 
coming the  adduction  of  the  anterior  part  of  the  foot.  This  operation  -Kaa 
Ecrformed  with  sucoc:^  hy  Solly,  in  IS'i?,  but  did  not  come  into  geueral  um. 
9  1872,  Lund,  of  Mnntifieatcr,  removcil  the  astragalus  from  each  foot  of  a 
child,  with  the  result,  of  obtaining  considerable  improvement  in  the  pneition 
of  the  feet.  In  187G,  R.  Davy  repeated  the  operation  In  several  cases. 
obtaioiDg  good  rc-^ults,  but  was  not  able  t'>  di.spense  with  prolonged  use  nf 
Apparatus  afterwards.  In  18"(i,  IhiviesCi^lley  rc<^>rdcd  a  case  in  whi<*h  be 
removed  a  we>lge  ithnpcd  piece  of  the  tarsm  of  sufficient  »\l«  to  allow  of  the 
anterior  part  of  the  fool  bein>'  brought  into  a  straight  lino  with  the  nostcrior. 
The  o|>ertilir>n  was  pi-rfitrmed  by  a  long  iueislon  on  the  outer  side  of  iho  fool 
from  the  middle  of  the  os  culcia  to  the  middle  of  tlie  fifth  melatar^l  bone. 
From  the  middle  of  this  another  was  carried  acmes  part  of  the  dorsum. 
The  cuboid  was  first  romovei),  after  which  a  wedge-shaped  portion  of  the 
taraus  wai  removed  "  without  paving  any  regard  t*)  its  artieuJaiions."  The 
bouiw  removed  includfd  the  whole  cuboid,  parts  of  the  os  calcis,  of  llie  three 
euueifiirm  bnneii,  nearly  ail  the  scaphoid,  and  a  part  of  the  head  of  the  a«- 
tfagabm.  This  op<.-rtttion  ban  been  repeats]  hy  It.  Davy  and  others  with 
the  niiK*t  flatiiifiiciiiry  renults-  In  Davius-CVtlley'a  case,  the  patient  could 
jump  and  hop  six  mouths  after  the  oiKinitiun.    If  the  hfrcl  is  much  drawu 


i 


I 


FLAT    FOOT. 


525 


■p,tbe  tendo  Achillis  can  be  divided  after  the  oi»ratinn.  Davies-Colley 
fijood  the  ni<wt  cunveaieDt  appuratu^i,  during  the  early  part  of  tlie  after- 
trntment,  t<>  be  "  a  back-splint  exteiuiirig  fnirn  the  middle  of  the  thigh  to 
vithiD  ftHir  inches  of  tlie  heel.  To  the  distal  eii*l  of  this  wm  fastened  a 
tn»r«ree  bar  of  wood,  terminating  on  either  eide  in  short  upright  bars,  to 
vbirh  the  forepart  of  the  foot  wdh  attached  by  means  of  elrap|)iiig." 

TUipei  Val^QB  (Fig.  (UTj  is  the  antithesis  to  varus.  It  is  not  m  frer^uent 
adefnrniity  as  the  other  varieties  of  club-foot.  It  commonly  affects  only  one 
Mtreniity,  and  is  occasionally  congenital.  True  valgus  arises  sometimes 
fpm  onitraction  of  the  peronei,  but  more  commonly  from  paralysis  of  their 
iip]»neDl?.  The  fiMit  is  everted,  the  arch  is  obliterated,  so  that  the  sole 
feonifs  flattened.  The  anterior  part  of  the  foot  is  displaced  outwards  at 
theralnineo-cuboirl  and  astr:igalo-!>capboid  articulation,  and  the  scaphoid  is 
panially  dislocated  outwards,  so  that  the  lieiid  of  the  astragalus  projects  at 
ihe  inner  side  of  the  foot.  The  toes  and  anterior  part  of  the  foot  are  ofh-n 
ni^t^i  jrt  OS  to  Constitute  the  variety  termed  talcaneo- valgum.  The  most 
mirkeil  forms  of  thid  variety  are  met  with  when  the  muscles  of  the  calf,  the 
libialii  pneticu?,  and  the  flexors  of  the  tucs  are  paralyzeil.  The  projection 
nfthchfel  backwards  is  obliterated,  and  the 
"uter  si>le  of  the  foot  curved  round  so  that  the 
little  |iie  \i  approximated  to  the  point  of  the 
berl. 

I«  extreme  cases  of  calcaneo-valgns,  the 
>ri.-h<if  the  foot  is  sometimes  increased,  the  heel 
^\\yj:  [vijiiieil  down,  and  the  foot  sharply  bent 
■t  the  tniiif^-eri^  medio-tarsal  articulation,  so 
«  If  liriiif;  the  toes  to  the  gnmnd. 

Trfttrnvnt.  —  In  the  earlier  stages  of  ac- 
qaireil  talipes  valgus,  the  deliirmity  may  often 
I*  wmediwJ  by  putting  the  patient  under  the 
ioflueDce  uf  an  anusthetic,  forcibly  drawing 
tlw  fik)i  inwards  so  as  to  overct)me  the  tension 
»f  the  peninei  muscles,  fixing  it  in  a  Dupuy- 
inti't  splint,  and  afterwards  rt'Storiiig  the  arch 
of  the  t'ljot  by  a  convex  sole  in  the  shoo. 

In  ihe  more  iinifirmed  cases,  the  treatment  cnnsist.'*  in  the  division  of  the 
teoij'tix  iif  the  pcrmeus  Inngus  and  brcvi.-,  lu'liind  the  outer  ankle;  and  of 
thfttnf  the  fXteiMor  coninuinis  on  the  dorsum,  i^carpa's  shoe  may  then  be 
ippHeii.  and  the  art'h  r(f  the  foot  restored  by  wearing  n  pad  under  the  sole 
fiir  *".!i)e  (.'cin^idtrable  time. 

^t  or  Splay  Foot.  Spurious  Talipes  Valgus  is  a  condition  frequently 
"l^f  "itii  in  y>iiin;r  adults.  It  iti  [■rtdi'^post'd  to  bv  tlio^^e  constituti<mal  con- 
'liii-Bs  that  have  already  been  d-x-rihcd  as  favuriiig  the  duvflopincut  of 
ftt^ituru  <if  the  ."pinc.  l)ut  the  dctenuiiiin;:  cnu.-'c  is  nins't  i'ntjiiently  o%"fr- 
iityiip  of  t|)c  f(x>t  fnim  long-eniitiniU'd  i^tuiidiiig.  nnd  from  carrying  heavy 
**iKht8,  (ir  from  a  slovenly  h;iltit  of  wnlking  liy  sliding  rather  than  r:ii:Jiiig 
'"V't,  iir  twisting  the  fnol  rt'»  as  tf»  prtKf  upuri  the  iniu-r  fide,  tiirls  "f  u 
Icniitrairo  l>[-ing  allowed  to  carry  inlitiiiH,  buyH  ^ot  t<i  heavy  work  beycmd 
'heifftn-ogth,  :<ho{vi>nys  aiitl  gii'l.'i  nK-ri.'ilt  si|y  kcjit  upon  their  feet  for  too 
■"•O.'  hutirs.  will  early  develop  thi^  def.irniiiv.  When  both  feet  :ire  allectt'd, 
"i*reij  Usually  knock-knee  us  well.  The  dijiease  i:^  due  to  a  wenkiie:!-!  of  the 
*U(cIw  in  the  »"ili;  of  the  tliot,  and  to  nlaxatiun  of  the  ligaiiiriit.-*  by  which 
!''*«rch  i<>  muintained,  er^]H'eially  the  li^Mmenlutn  loiigiim  |)Uinlii',  :ind  the 
JDitrinr  calraiieo-navicular  ligament.  As  tlie  rcMilt  of  tliis,  tlie  arch  of  the 
'''"'I>  gradually  ninka.so  that  the  sole  becomes  perfectly  Ihit.     As  the  ilii:(.ase 


Fig.  r.JT.— Talipes  Valguii. 


£26 


DEFOKUITIES. 


atlvanca,  a  tcuduucy  (o  eTereion  >^f  Iho  fout  lakra  place.  At  Uie  nuMtun* 
uwiu^'  ti.t  flattening;  <Jt]t  of  the  arcli.  Ihu  inut-r  eitlu  of  liie  fuut  bw— 
Ivu^tlivia-U,  wliilu  tiie  uutt-T  liide,  Mliicb  is  uuturally  but  al'iKbllj'  inM.! 
but  lilllf  altvreil.  lu  conw-QUvocu  of  thU,  tbu  iiiil«rior  part  uf  ibe  faul  il 
rn>uL  uf  tJiv  luiiJiii-tantal  articulaiiun  is  tliwplatt'd  uutnarda.  Tb«  iwyfcwl 
u  liius  |iartlir'  t)ii#l<H*alt:il  fntin  ihf  hea<l  of  llie  a#tru);ulut,  whirb  prHfecli  M 
the  inutr^idu  ol'  the  fuuL,  ami  beinj;  f>r<.«^'il  Ujioit,  U  ofWn  a  sMumef  ntA 
paiu.  The  tnui^vt^ree  ligameiittmn  Mruclures  ihut  bitnl  lt';;«-thfr  llt«  bataoT 
ihe  metiilureni  bones  at  thvir  tli^ititl  t'ritU,  become  w('ali<-ni.-(l  aod  ■iratdMil, 
Thu  eoiisci]iii-tict>  of  thu  i»,  that  th*.-  ^il  lows  iu  I'lasticity,  bo<.-omr>  •liuflioi, 
and  tbi'  fuut  L-aiiily  tinw  in  walking. 

The  Tre<itnu-Ht  cousiuli.  In  the  firet  place,  in  improving  the  gmeral  boltV, 
and  rcitiovint;  the  cautctf  o(  ovcr-tnliguc  i>r  Mniin  in  the  foot,  withoiil  nhick 
8uri;ical  treatmttit  will  be  unnvuiliiig.  Thu  anterior  {tart  of  the  fiiol  tMjr 
be  atrapp^KJ  firmly  with  ntaater  aprua<l  on  wa^hlenlh^r  The  b<ifiu  mual  W 
carefully  att^mk-d  to.  Ttiey  miut  bo  widt  at  the  t'xa  and  the  horl,  ma«t  W 
large  aud  iimde  to  extend  <in  ibe  iuner  side  to  a  [Mjiut  f>p|>riaitc  ibc  ntiiJJU  «f 
the  fooL  The  Ixfot  luiiat  be  lilte<l  with  the  6i>callcd  "  ■urKteal  miIv,'  llut  m, 
to  aajr,  a  pad  ntuat  be  placetl  inside  to  !tup|Hirl  tho  arcb.  Thia  inunt  be  lawk 
vf  cork,  or  belter  still  of  india-rubber,  und  must  not  be  too  »tilf  or  t*">  lanca 
The  upper  lenlben  of  the  bout  iriuit  be  Btrons.  reach  well  above  the  aakk 
and  be  Jaeed  firmly.  If  the  feet  are  habitually  cold,  tbey  mual  be  nibM 
twice  a  day  with  salt  aud  water  and  warmly  clutbetl.  Tliim  miMiiMaiiiwIlj' 
•utBce  at  least  to  arreat  Lb«  progress  of  the  deftrrmity.  In  very  extreiM  csM 
it  may  powibly  be  neoesMry  tu  apply  an  iron  aimiiar  to  that  rvpnvnilad  ■ 
Fig.  ha,  but  without  the  spring  for  flexing;  the  ankle.  Thia  ia,  btiwrrvr, 
aeldatu  rctiuiri-d,  and  i^houhl  atuays  he  avoidtd  if  (xiMiible.  A  lifbt  ttt^ 
ajiriog  may  ftouietiiuf*  be  fitted  iu  tho  aide  of  iho  boot  in  aucb  a  wa;  ula 
direct  tho  foot  gll|,'btly  iuwarda. 

Hollow  Club-foot — Aa  in  the  baud,  so  in  the  foot,  the  lalcrtMat  matAm 
noi  only  iiiovL'  the  toes  lattTullv,  hut  powurfultv  ilex  the  llrei  nbalaagoLat 
the  eatiit;  lime  that  they  extemf  the  lael  two.  In  jwralyaia  uf  uumt  mman, 
aud  uf  the  sliitn  fli!.tor  and  adductor  of  the  great  tue,  tbe  toca  aauin  tfc* 
onDstniiued  [KieiLiou  of  a  claw,  i.  e.,  the  (irst  phulanj^  arc  extrnded  opaa  tSa 
nieUitarsul  btnied,  aud  the  lost  two  plialuDiiTn  fle^^ed  iiptiu  the  firo.    Tkil 

flrM  ri»c-  to  a  variety  of  clulvfoot  which  Duohunnt^  calU  '*  hollow  eia«-f<ML' 
bis  is  oAen  complicated  by  paralysis  or  atrophy  of  some  of  ibe  muaclexf 
the  Ifg,  giving  rise  to  vurious  uKuiciatrd  forms  cf  club-fool. 

The  actvoopanviii^  drawing  {^'^fi-  ^-i^''  sbow»,  l^t,  lIiiiI  (hr  dni  phaUan 
are  cxtendcil  nlnnrtt  to  the  i^iiiit  of  being  AubUixttU-d  ujM.n  the  head  nf  um 
uielncar|Mil  bono,  wbiUt  tbe  last  phalanees  are  flex<.-4l  un»u  the  lir»t  and  for* 
lbu«  a  vUm  ;  2'!,  thnl  the  curve  of  tlie  planlar  arcli  i»  ''*in!>i-)efab1y  ta- 
creaaeil-     The  origin  of  tliis  hollow  cUw-foot  or  p«»  cnvus 

"When   the  iuteruwvous  uiuselw  are  panilyt«d  or  nti    .■  cic 

contraction  of  tlie  mu«clv«  which  extcod  the  lirot  phnlnii|;«»  and  thr. 
niueclm  which  flex  thv  ta»t  phulnn},'i.-»  beiug  no  bm^er  opjioscd.  ibe  c   l 
«x>ndilion  of  the  luea  gradually  becomes  au);meuted.     The  {Mricrior  nxtmat' 
liva  of  the  fint  pbaliuigve  are  fluhluxute>l  u|>oii  the  heads  of  tbe  naetalafaU 
bonea ;  iben  the  curve  of  Ibc  plaulHr  arch  becomes  iucreaaed  and  tUe  piaaiar  ' 
faacia  ehurleued ;    then  certain  artieulaliou*  and  their   Hgattieiila  noiaa 
defornie^l.  aa  in  alt  club-feeu"    The  mecliauiem  is  exactly  the  auae  aa  that 
uf  the  similar  dueaie  iu  the  liaiid. 

This  disease  makes  Biundiii^'  mid  walking  very  painful  when  hm  prole«giil:| 
f^ir  this  n.*apin,  that  from  thu   jtusitiou  of  tbe  UH'I  and   fnim  Ibe  inctraMd 
arch  uf  tlte  fcMl,  ibe  wbule  preaauri!  in  walking  h  hotiui  tipoD  the  b«<i 


HOLLOW    CLAW-FOOT — PATUOLOGY.  527 

apootheakiD  covering  the  uniiaturally  prominent  heads  of  the  metatarsal 
buBti,  wbich  latter  become  tender  iu  con&cqiience,  especially  that  over  the 
gRtttoe. 

In  the  case  from  which  the  drawing  was  made,  the  disease  was  congenital, 
but  (till  Dot  trtiublc  the  patient  till  he  was  ti'n  years  old.  When  be  was 
apprenticed,  a  lung  walk  always  gave  him  pain,  and  at  last  he  was  obliged 
to  lie  up  about  one  week  iu  every  month  to  get  rid  of  hia  pains.  Both  feet 
wereiliected,  but  the  letl  much  less  than  the  right.  By  galvanic  examina- 
tioD,  irritability  was  found  to  be  entirely  lost  in  the  right  intero&sei  and  very 
much  diminished  in  the  left. 

ThediKsse  is  always  accotn[iaiiied  by  a  tendency  to  talipes  equino-vanis, 
**  thit  ii  to  (ay,  the  tlexiou  of  the  foot  upon  the  leg  during  walking  is  iocom- 


Fig.  O-IS. — HuIIdw  Claw-fout,  pen  i^htuv. 

plete,  lod  during  this  flexir)n  of  the  foot  the  tibialis  anticus  (flexor  adductor) 
BMi  I  predominance  of  action  over  the  extensor  tongus  digitoruni  (flexor 
■adabduclor  of  the  foot)  ;  or,  in  other  words,  <iuriiig  tlexion  the  sole  of  the 
^M  ii  turned  slightly  inwards  and  the  dorsum  outwards."  This  is  accountcil 
fi>'  by  cimsidering  the  unfavorable  conditions  in  which  the  long  extensor  of 
thetiwais  placed  after  paralysis  of  the  iiiteros^ei.  Tlic  inferior  attachment 
of  this  muscle  is  upim  a  movable  point,  the  po8tcri<)r  and  superior  extremities 
oithesfoiind  and  ungual  phalanges.  The  tendency  to  extension  is  counter- 
acted by  the  interossei,  which  serve  to  give  n  (ixed  jioint  for  the  extensor 
l"ti|n]sili^it<iruiu  to  act  from,  when  flexing  the  foot  ut  the  ankle.  But  whiii 
^**  museles  are  paralyzed,  the  nttnchnient  of  the  extensor  communis  digi- 
Ifrtiim  becomes  very  movable,  and  wo  then  see  ut  the  mumeut  of  flexion  of 
jlwfi»otup<»n  the  leg,  that  the  Hrst  phalanges  are  drawn  back  even  more  than 
wfiire  upfju  ibe  metatarsal  bones,  at  the  same  time  dvpreaning  the  heads  of 
ifc*  biines.  The  action  of  the  long  extensor  as  a  flexor  niid  nbduetor  of  the 
'"t  it  thus  much  weakened,  and  this  leads  to  a  predomiiuiiice  in  the  action  nf 
tbe  tibialis  anticus  (flexor  an<l  ad<tuctor  of  the  foot',  in  consequence  of  wliiih 
■  mild  liirm  of  varus  is  produced  flccom|muied  by  some  raising  of  the  heel, 
due  to  imperfect  fle.vion  of  the  ankle-joint. 

To  sum  up:  this  variety  of  hollow  foot  'pied  ereux)  in  produced  by  an 
nag^rated  bikI  continued  action  of  the  exieii^orii  of  the  flist  phalanges  of 
liie  toes— extensor  communis  digitoriiru  and  extene-or  pniitrin."  )>ollii'is,  follow- 
iDgon  a  weakness  or  feebleness  of  their  nntagoiiisis — the  ioten'jsei,  adductor, 

and  short  flexor  of  the  great  toe.     t.'onseqiicntly  any  excess  of  ad  ion  of  tht-at; 

■anie  extens4)r  muscles,  whatever  may  be  its  citu?i',  onght  to  produce  exactly 

identical  results. 
The  kn  fwledge  of  this  fact  explain;*  the  ori;;iii  of  tho  h  >llo\v.>d  claw-foot 

thMt  we  see  produced  in  talipes  eqiiinus,  when  the  long  extensor  of  the  toes 


528 


DBFOBMITIES. 


has  preierved  its  voluntary  contractility ;  and  it  will  be  as  well  here  shortly 
to  cuDsider  the  cause  of  the  ajteratiuii  iu  the  foot  in  talipes  e<]iiinu».  Aa 
soon  as  the  talipes  comnienccs  to  oppose  the  flexiuD  of  the  foot  upoQ  the  leg, 
the  opposing  muscles  net  nith  iocreased  vigor  to  prevent  the  deformity. 
This  leade  10  an  abnormal  extension  of  the  Orst  phalanges  of  the  t>jes  (vi 
vhicli  the  extensor  Imigtia  uuii  extensor  pollicis  are  iiftaclied ),  and  iihiiiialely 
lo  a  subluxation  of  llie«'  phulnii},'C»  upon  iho  dorsal  surfBceg  of  the  heads  of 
iho  metatarsal  boucs.  Kvc-ry  attempt  ai  Hexion  then  deprestteu  iho  beads  of 
the  iiH'Uiimnl  holies  into  the  sole  of  lIio  foot,  so  increasiog  the  plauiar  arch. 
This  in  Nioiit  inarkeil  in  ihc  great  toe.  Tlte  tiinic  force  of  the  aiitagoniiits  10 
the  exu'nsiire  is  unable  to  withstand  the  exaggerated  action  uf  the  l(>ug 
extensitrs. 

That  llin  mechaniiim  here  given  is  ci)rrect.  may  Im)  shown  by  the  following 
fact :  In  a  wi'll-niarkeil  mm  of  a  patient  aflltcled  with  a  "  hotlow  elaw-footeil 
equitiu.1"  Lj^ritll^  plf^d  crc-ux  ei]iiiii.<,  wc  Hhoiihl  see  that  any  attnnpt  to  Hex  the 
foot  at  the  luikle  lead!*  only  tii  further  exteii-4ton  iif  the  toes,  which  hi-rome 
^drawn  hack  over  the  headit  of  the  nielainntal  hones,  pre^iiii^  them  rtown  and 
increistng  the  arch  of  the  foot.  Hence,  so  far  from  any  raising  of  the 
extreinitv  of  the  foot  taking  place,  it  is  rather  itepresse<]. 

Tlic  Treatment  of  this  eomlilion  most  be  condoctt-d  on  two  priitciples: 
I.  The  stimiilftlior  of  the  [mralyztd  interossoi,  adductor,  and  short  flexor  of 
the  toe  hy  means  of  farndiuition ;  and  2.  The  divisiou  of  the  tendons  of 
tho0«  m\)wles  which  by  their  tonic  contraction  n)aii)tain  and  increase  the 
deformity.  Those  which  I  have  usunllv  found  it  necessary  to  divide  are  the 
extmiwir  of  Ihe  great  toe,  the  teiido  Aciiillis.  and  in  addition  to  these  a  rery 
light  band  of  the  inner  division  of  the  plantar  frt»cia.  The  Scar|>a's  8h<»c  that 
is  used  aiU'r  the  oin^rnlicn  i«Houi<l  have  liiriges  jicross  the  middle  and  Ite  pro- 
vided with  a  rack-and- pinion  moveiiieut,  ho  that  the  deprvsaed  beads  uf  the 
luetatarsal  boni's  nmy  be  raiaed  bv  t)ie  anterior  lialf  of  the  sole.  In  souie  uf 
>tbe  slighter  cutes  tlie  instrument  here  represented  (Fig.  649)  may  be  uswl  tu 
obtain  tlie  exltiided  position  of  the  toes  without  dtvisiun  of  tiie  tendons. 


Wg.  040.— Af<]wratui  fof  obtnlnios  ExtcDtloD  <rf  To«  wUbanl  DUUIan  at  TtiKtoiiA. 

Contraction  of  One  Toe  is  not  of  unfrcquent  occnrrcncc.  Id  this  com- 
plaint the  proximal  phalanx  is  either  on  its  normal  level  or  slightly  drawn 
up:  the  two  distal  are  bent  down  nt  un  acute  angle,  the  iipex  of  whieb  is 
formed  by  the  articnlatioD  of  the  first  with  the  second.  This  cintraclion 
more  commonly  atfeets  llie  second  tn^e,  ia  often  synimcirical  in  the  two  feet, 
and  is  frequently  a  stiurcc  of  great  inconvenience,  and  even  i«rmauent  lame* 
ueas.    It  appears  to  be  due  to  contractiou  of  the  digital  prolungatioD  of  the 


WEAK    ANKLES. 


529 


flntar  bicU,  and  is  beet  remedied  by  dividiDg  this  subcutaneously  opposite 
the  lower  part  of  the  second  phalauz,  and  theu  straighteoing  the  toe. 

I^OBiiBeruy  and  Webbed  Toes  are  sometimes  met  with.    It  is  compara- 
firdy  seldom,  however,  that  any  operative  interference  is  required  in  these 
^ould  it  be,  the  remarks  that  have  been  made  at  pages  506  and  507, 


Congenital  Ujpartrophj  of  Tom  and  Foot. 
Fig.  450. — PUnUr  Aspsot.        Fig.  6S1. — DorasI  Aapcot. 

ii  Rference  to  the  treatment  of  these  conditions  in  the  hand,  are  equally 
•Wliaible  here. 

t)«(eBital  HTpertrophy  of  the  Toes  and  Foot,  as  represented  in  Figs. 
tSO  ud  051,  occasionally  occurs.  This  malformation  is  of  necessity  in- 
cmUe. 

Wetk  AnUea  not  uncommonly  occur  in  rickety  children;  the  ligaments 
^g  relaxed,  the  joints  appearing  to  be  swollen,  and  the  child  being  unable 
tonlk  or  stand  without  great  difficulty.  In  these  circumstances,  attention 
to  tbe  state  of  the  general  health,  douching  with  saltwater,  with  the  applica- 
tioB  of  ao  elastic  India-rubber  bandage  round  the  ankle,  or  the  use  of  light 
manpporta,  will  be  found  most  useful. 


TOL.  II.— 84 


DISEASES  OF   REGIONS. 


CHAPTER   LV. 

CI3EA8ES  OP  THE  HEAD  AND  XBCK. 


DIBEASBg  OF  THE  8CAI.P  AXD  8KUL1- 

The  Scftlp  in  subject  to  all  tlios«  euri^ical  di«ca»4^  that  aflect  the  cummoD 
integument  uf  tli«l>ody.  But  it  i»  umre  than  any  utiifr  part  of  the  surface 
liable  to  two  liiwased,  %'iz.,  Altifrumatuu«  Cyets  and  Ntevi.  Tlieee  bare 
alreatlv  been  »t>  fully  trcateiJ  of  (CyatB,  p.  'SM,  vn).  i.;  Nwvi,  p.  953,  »oI.  i.; 
nnd  p.  d'i,  vol.  ii.'*  that  their  (les^-'riptiun  here  ivunld  leaii  to  utrediew  repeti- 
tion. 

Fachydernifttoas  Tumor  of  the  Scalp  or  MollDtcnm  Fibrosun  (vol.  i. 
p.  944),  This  diaeaae,  of  extrernelr  rare  occurrence,  wa«  first  deocribed  by 
Jobu  Bell.     It  wa$  tinrt  named  and  fully  described  by  Valentine  Mutt  as 

I'tirhtjiiertmlofxle,  more  recently 
by  Vircliuw  ae  Fibrvma  MoUwt- 
cum.  The  accompany ing  cut 
(Fig.  6-'J2)t  taken  from  a  patient 
H-hiLt  io  America,  who  was  atU'r- 
wiirdt^isucccs&fullv  o[>craLcd  on  by 
W.Siuke&,iu  l>ubliii, iiivt-^ammd 
repfLKt-ntiition  of  the  di^cuM*. 

T1r'«c  tumors  arc  neither  pain- 
ful nor  itaiigen^uft,  hut  their 
weight  and  the  dcriirmity  occo- 
aiuuerl  by  tlicm  render  their  re- 
mnviil  desirable. 

Trtaimcni. — The  removal  of 
thia  tumor  may  be  effected  by  the 
ligature  or  the  knife,  roiiook 
has  succcflflfully  extirpated  one 
by  the  former,  W.  Slokea  by  the 
lattrr  method.  Hut  the  operation 
in  not  without  dan^r.  Id  iSlokea's 
ns.451.— Pachfdenaatoiu  Tboi^t  »f  tlwfi«al|i.       casethchninorrhaj^c  wnsdeM:ril>ed 

a»  terrific,  nearly  crifltln^  the 
patieul  hid  life,  and  had  to  be  arrfftcd  by  the  cautery.  St^'koA  etntes  that 
ID  (he  wbulv  cuurec  of  liis  experience  lie  had  never  »een  such  copious  and 
uncontrollable  "  weeping"  bemorrhafje  ;  it  came  from  every  potot  of  the  cut 
surface. 

Fofigiu  of  the  Dura  Kater. — Bometimea  without  external  or  apparent 
cause,  at  other  tituui  in  cuQaeijiieuoe  of  a  blow  or  fall,  a  Fungou*  Tumor 


rtTNOOa    OF   TBK    8KDLL. 


f«lrt  of  the  dun  iiinter,  usually  nil  the  top  of  the  head  or 

lOOtof  tbe  paritfUU  regions.  A^  it  iacreawji  in  iite,  il  produces  ubforfitina 
'tiMikull  cuvcriag  it;  the  bone  becomes  tlitu  and  expanded,  and  cracklci 
!f«rchmvoL  uti  ]ire<6ure,  M>n]etirui«  not  being  raised  above  iu  proper 
J,  but  nion;  usually  being  pmtht'^l  up  by  the  pressure  of  the  growth 
lb,  vhich  at  last  protrucJuii  undiT  the  itcalp.  3Iorc  ui>uBtly,  this  per 
of  the  skull  is  emdual ;  but  in  Boinc  cutfta  it  would  iippear  tu  have 
rtpid,  the  fim  ititiniatioa  of  disease  that  the  paiii-nt  liud  being  the 
M«  of  a  tumor  under  the  scalp.  When  the  Mcull  in  porfonited,  the 
,  edgm  of  the  circular  opening  cau  be  distinctly  felt ;  and  the  tumor 
ikch  pruuudes  puJBBtu  di«tincctv,  aa  raav  be  proved  both  by  the  fiager  and 

htiaUgf. — The  uKlure  of  tl>e»e  tumont  19  eomewbat  uncertain,  an  suf1ioi<?ut 
a  km  Out  yet  heen  recnrtleil  with  an  accurate  niicrotic<>pi(.-]il  de»criptioii 
dwgMwtb;  but  it  i*  pmbable  tbat  in  the  majority  of  ca»e»  they  are 
i-ar  ftpiadle-celled  sarroniala  springing  fnim  the  outer  layers  of  the 
hnat,  wbtcb  furnui  Uie  intemnl  p^riimleum  of  the  skull, 
i^^jtaa*.— Syi»piijm*rtfi;erebraldi8turbauce — doublevixiuo,  optic  neuritii^ 
III  t^bt.  dealot«!<,  or  epileptic  tits,  with  f]x«d  pain  in  the  bead — ufually 
^r  a  cotuiderable  time  the  exlerual  appcArauoe  of  the  tumor.  In 
>fir«cwci,Do  such  aymplums  have  iudicaled  liic  existence  of  iatra* 
lU  diieaie;  and  the  tirst  evidence  uf  the  diseiM!  has  be«u  the  sudden 
fninuiuo  of  a  puUatiug  tumor  through  the  skull.  If  the  tumor  be  ci>in- 
Pnwil.  egsahell  orackbug  of  the  expamltxl  aud  thiuueil  cranial  hoava  will 
Ufrii,uiii,  if  aiLcmpta  be  made  tu  piub  il  buck  uuilitr  the  iHmei),  giildin4!M, 
^tcnpt.  and  convul«iitui>  an'  prxluced.  As  the  diseaae  makes  pnigreiai,  duatb 
«**S|Kralyau  and  uima  dU|>crvoiieii. 
IratMn/. — The  result  of  the  treatment  of  fungus  of  the  dura  mater  is  not 
■Jatii&ctory  ;  yet,  aa  the  diseuM  appears  lik  nc  almost  of  neoeesity  fat%l 
<■  [fft  M  itat*ll,  siimntliiag  nhoul-t  l)e  attempted — not,  however,  until  the 
Uour  htta  fairly  ap[H-areil  tlimugb  the  brnies.  The  scalp  covering  it  ahimid 
Wuirand  back  by  a  crucial  inci>iioij,  and  the  tum.)r  exp-eed.  The  aiierture 
vt^fthull  thriiugh  which  it  is  protruded  may  then,  If  necessary,  be  enlnrgetl 
^  tkt  ue  of  the  trephine  or  Hey's  «aw,  so  as  f>  lay  bare  the  full  extent  of 
^lamur,  which  mu«l  then  be  carefully  dlssectod  away  fn>m  thedum  ninter, 
''t  am  in  which  the  o|)eniti<in  wa*  being  perform^  bj'  Vulkmaon,  the 
pMHaiiliml  fntm  liic  eat  rant.'«  of  air  during  inspiralioa  through  an  accidental 
■iWiluf  (lie  lorit;i(i|riiua)  itinus. 
'■■Ills  of  the  Skull  hIso  may  occur.  This  term  has  betn  applied  to  any 
■  hagatin;;  luntur  apriii^iug  primsrily  fmm  the  vault  of  the  akull.  The 
Vwth  may  epnng  fruni  beneath  the  periosteum,  when  it  is  usually  n  amiill 
^ti  otlled  or  a  spindle-celled  aarcoina,  or  fnim  the  dipltte  when  it  is  most 
*^Aunly  myeloid.  It  gives  rise  to  a  sniooth  ovoid  tumor  ou  the  head, 
**diiaay  or  may  nut  pulsate.  If  it  .ojiiings  from  the  diploc  it  is  uouallr 
**■**■!  by  a  thin  lavt-r  i>f  booe,  wbicb  gives  the  sensation  of  egg-shell 
*'*i'klia| ;  wben  it  iNsuhfwriiMleal.  it  not  uncommonly  contains  a  framework 
*<  intfTular  siiicula  of  boue.  As  the  diMiase  progresses  it  usually  perforates 
**  ■kail,  aatj  comes  into  ronlacl  nith  the  durm  mater.  It  is  then  very 
*^\i  to  delcraiine  whether  il  amee  fn)m  that  membrane,  nr  merely  inipli- 
**l"l  it  by  uxltfnsiott.  These  tumors  may  become  multiple,  nod  after  a  lime 
^  Mluwnl  by  aei-xMidary  visceral  growths.  I  have  twice  seen  the  liver 
""^■larily  aHfcU-il  in  ihia  way,  di'AiVi  nMuliing  without  cerebral  dtslurbsnce 
^""nioirstinal  hrmnrrlingn  and  e-xhaustion.  The  only  trt^inieni  pAasible  It 
'^■Tsl  iif  the  griiwth,  but  this  ta  accompanied  by  c-in^idcmble  danger,  not 
""J  UQ  aci.-t>unt  of  the  |M*rfitratioD  of  the  skull  and  implication  of  tlie  dura 


532 


DISEASES   OP   THE    BEAD   AKD   NECK. 


luater,  but  from  their  extreme  vaBcularity.  In  n  caee  of  tbU  ktn<l,  which  I 
bad  an  opportunity  of  seeing  many  ytun  ago,  the  growth  was  ■ucoessCully 
removed  by  B.  PmUipe. 

Secondary  sarconinln  and  carcinomala  are  alao  occneionolljr  met  with  in 
Ihe  bones  nf  the  Ekiill.  In  a  cnsie  recorded  by  Morris  a  ff^w  ytnrs  ngo,  a 
large  piili^ating  tumor  of  the  skull  was  fuuiid  to  pretient  tJie  gtrucltire  of  the 
thyroid  gland,  and  was  Hp|>iirenttv  secondary  tnan  eulurgerneut  of  that  biidy, 
Tliree  or  liiur  similar  oases  buve  been  recorded  by  other  Surgeons. 

Hernia  Cerebri,  nrit^ing  rroin  ^ound  or  uh-erfiiiou  of  the  dura  mater,  has 
lieeii  iilri-iiily  <lc?critH*d  \/fti  %*ol.  i.i, 

Congfenital  Hernia  of  the  Membranes  of  the  Brain  it*  f>onietime»  met  Vbith 
in  ilie  form  of  Meningocele  or  of  Encephalooele.  ]ri  ihu  f(>rm»^r,  the  pro- 
truded aar  la  filUd  ttiLh  Uuid :  in  the  bitter,  il  caulaina  aUo  perebrHl  nub- 
etnnee.  Tlie  diagnoaia  beiwc-eii  tlies*  two  coiidilifiua  is  generally  diffieult; 
and  ill  of  little  practical  ini[Hirtuneo.  The  diseaee  if  usually  speedily  fatal. 
Z.  Luureiiee  finila  that,  uf  -Hi  inslimeea  in  wliieh  il  oecnrrei],  21  were  malei>, 
IS  females  ;  that  the  protrnsioD  may  vury  from  the  siie  of  a  pea  to  that  of  a 
tumor  exceeding  th?  ehild's  head;  and  that  the  oeeiput  is  its  chief  seat — of 
7ft  cases.  -"iH  being  in  thin  situation.  The  hernia  may  occur  at  wveral  other 
p(iint.o.  It  hflft  been  »ecn  projpciirg  through  the  anterinr  fonlanelle.  In  thifl 
situation  i\.  ban  moDt  frequently  undergone  Hpoiitaneonn  cure  aiithefontanelle 
closed.  Numerous  cnses  have  been  recorded  in  which  it  projected  ihrongh  a 
deficiency  in  the  region  of  the  cribriform  plate  into  the  nnsal  fiv>.*ie,  or  for- 
wiirdfl  into  the  face  at  the  r^^nl.  of  the  nn^e,  the  nasal  process  and  the  neigh* 
boring  parts  of  ihe  frontal  bone  being  deficient.  I<ichteiih«rg  bus  recorded 
a  ca»e  in  which  it  projected  from  the  Imim^  of  the  skull  into  the  plierynx. 
Id  Lb(8«  UQComraoQ  situntions,  the  gwelling  niny  be  mistaken  for  a  polypus. 
In  six  of  the  cases  collected  by  Z.  Laurence,  the  eubjects  of  this  luulforma- 
tion  reached  an  adult  age;  in  nil  ibe  renmining  caeea  they  died  curly,  or 
were  stillborn.  Hurgery  oflerv  little  in  these  cases;  thuugh  in  one  instance 
Paget  used  iujectioci  of  iodine  with  success;  and  in  another,  where  stoughing 
of  n  portion  of  the  tumor  was  luktng  place,  Annaudalc  applte*!  ii  ligature  to 
the  peduncle,  and  removed  the  liniior,  the  child  recovering  completely  in 
spite  of  au  attack  of  meiisles.  In  another  case,  the  portion  of  brain  was 
sliced  off.  the  patient  i^urviviug. 

Tapping  the  Head, — This  operation  has  occaatonally  been  performed  in 
chrome  hydr(Hi;]'hHlu»,  but  bo  far  without  much  benefit.  It  is  soroetimw 
conjoined  with  prersure  l)y  means  of  au  eluetic  Imndage.  Il  is  applicable 
only  to  those  cjises  in  which,  from  theearly  agvof  the  child,  or  the  imperfect 
'oesificntiou  of  the  dtRtemlecl  ekulL  it  is  poeisible  to  compress  tlie  head  by  a 
moderate  degree  of  pressure.  The  operation  is  l>est  performed  by  menos  of 
the  aspirator.  A  tine  needle  may  be  pushed  through  the  anterior  tontanetle 
or  the  coronal  suture,  avoiding  the  middle  line  for  fear  of  wounding  the 
longitudinal  sinus.  The  iustniment  should  be  directed  away  from  the  middle 
line  so  OS  to  penetrate  the  lateral  ventricle,  and  thus  to  evaeunte  a  portion  of 
the  contained  serum.  There  shrmld  be  no  vacuum  in  the  needle  when  it  is 
inlrodufod,  but  when  it  has  penetrnted  deeply  enough  to  reach  the  ventricle, 
the  piston  of  the  aspirator  may  be  slowly  rniacd,  so  ns  to  withdraw  the  6itid 
(tramially,  and  not  to  disturb  the  circulati<m  through  the  hrain.  After  a 
moderate  <)uantily  of  fluid  has  been  wiihdniwn.  the  small  aperture  should 
l>e  closed  with  a  strip  of  planter,  and  an  elastic  biindnge  should  be  applied 
rounri  the  head  so  as  to  compress  and  to  confine  the  bones.  It  in  ncarcely 
necessnry  tn  olinervc  that  the  proguasiii  in  these  cases  is  not  of  a  very  favor- 
able character. 


APFKCTIONS    OP    EXTERNAL    EAR    AND    MKATUS.  538 


DISEASES  OF  TUE   EAR. 

AFFECTION'S  OF  THE  EXTERNAL  EaR  AND  MbATUS. — MalfomiatiOIlS  Cpf 

tklnbule  ure  nut  uiicominoii.  Absence  of  the  pinna  or  such  deforniily  na 
eunplelelr  (o  close  the  meatus  has  aUo  been  met  with.  Hypertrophy  of  the 
cilrrotl  ear  is  sonietimea  met  with  in  idiots;  and  in  gouty  sul>jcct«.  Tophi, 
firfioity  Concretions,  are  occagionalty  deposited  in  it.  Paget,  Bruck,  ami 
Vuzetti  liare  do.-icribcd  a  Fibrooi  Tumor  that  occaeioiially  forms  in  the 
lobule  of  the  ear  from  the  irritation  produced  by  pierciug  it,  as  "  one  of  the 
pcniliin  attached  to  the  barbarism  of  ear-rings."  These  tumors  are  semi- 
■uli^ant,  like  the  warty  growths  of  cicatrices;  and,  after  excision — tbeir 
mlr  treatment — are  somewhat  apt  to  return. 

Bloody  Tamors,  or  Hsmatomata,  are  occasionally  developed  without 
apptreut  cause  in  the  external  ear  of  the  insane  ur  idiots,  and  are  not  un- 
cgmmon  in  other  patients  as  the  result  of  injury.  They  may  attain  a  large 
«w,tD(i  are  ofteu  multiple.  Unless  they  become  inflamed,  I  think  it  better 
bi  leave  them  untouched,  when  they  will  gradually  be  absorbed.  If  inflamed, 
Uiev  mu«t  be  opened. 

Senmaof  the  External  Ear,  sometimes  extending  into  the  external  meatus, 
b  a  Common  affection.  It  occurs  in  srrofulouij  cbililren,  and  in  gouty  adults. 
The  cnnstilutiunal  treatment  must  be  conducted  on  ordinary  principles; 
lortlly  the  application  of  glycerine  of  borax  or  of  boracic  acid  ointment,  to 
•biirh  a  email  quantity  of  extract  of  belladonna  may  be  added,  will  be  found 
Dii«t  useful. 

Concretions  in  the  Meatus. — We  not  uncommonly  find  that  the  meatus 
Oecumes  blocked  up  by  accumulations  of  wax,  dark,  indurated,  and  pipe- 
like, or  forming  bulls  and  masses  that  lie  in  contact  with  the  membrana 
tTtnpui.    These  occur  chiefly  in  individuuls  of  the  bilioso-phlcgmatic  tem- 
peranient.  and  are  a  common  source  of  temporary  deafuess  among  young 
pO'ple.    They  not  only  materiiilly  impair  the  sense  of  hearing,  but  are  very 
apt  [.» give  rise  to  muses  in  the  head,  and  to  crackling  sensations  im  opening 
■^•J  shutting  the  mouth.     Their  prest'uce  is  licfst  ascertained  by  examination 
•"o  a  well-cimstructed  ear-sjH'culum.     Tlie   Trenim'^iit  of  these  concretions 
<>>Di'i«ts  in  softening  the  wax  by  the  introduction  of  a  little  glycerine  into 
5  *  *'ar  for  a  few  nightti.  and  then  repeatedly  washing  out  the  meatus  by  the 
"'J5''tri>n  nf  tepid  soap  and  water,  thrown  in  with  a  large  syringe;  as  the 
'Ju'd  regurgitate.-!  from  the  membrana  tympani,  it  will  ut  length  bring  awuy 
*ij  and  hardene<l  ceruminous  m;is?es, 

^ckening  of  the  Cnticle.— Occasionally  the  cuticle  of  the  external 
-  '^lu:',  an<l  that  covering  the  membrana  tympani,  bc-.-omes  thickened  and 
^■t*nited.  assuming  a  dull  white  appearance.  This  is  commonly  a  result  of 
*/**ma,  and  may  give  rise  to  some  degree  of  deafnct's.  In  these  circum- 
**«*.  glycerine,  citrine  ointment,  or  solution  of  nitrate  of  silver,  will  be 
^^iil  in  restoring  the  healthy  condition  of  the  part. 

Pi^oilf  or  Follicular  ubs(Tes:ji'^  ure  not  uncommon  in  the  external  meatus. 

U^y   may  arise    ns  a   compticatinii  kA'  cc/.ciiia,  or  as  the  lonscijuence  of 

^lating  dii'charges  from  tiie  middle  car.     The  Trfulnu-nl  is  to  apply  hot 

"•^^nlations  to  the  ear,  and,  if  the  lti>il  i-an  be  seen,  rclivf  Tnay  oHen  be  given 

^.^rtincturinu  it  with  a  small  knife. 

l^iffose  Inflammation  of  the  Meatus,  or  Otitis  Externa,  is  nHi>>t  common  in 

'  Idn-u.  and  may  occur  from  a  viiricty  of  causes,  uriiiint:>'  which  arc  mea.-'lcs 

%<vrl<'t  fever,  eczema  or  injuries.      In  sumc  cases  the  iiillanirmui<>n  iill'ects 

^  periosteum,  and  in  all,  unless  it  lie  checked  early,  it  leinls  to  impliiate 

'^   membrana  tympani.     The  syiii[itoms  arc  rcdni^s  and  swelling,  mure  or 


684 


DISEASES   or   TSB    HEAD   AND   NECK. 


less  completely  closing  the  auditory  cannt,  \r\th  iolen^e  pain,  nggmvatri]  ia 
many  aiecs  by  odv  moveoieDt  of  the  jnw.  After  a  time  b  purulent  tliaehar^ 
cftca)K*s,  wheu  some  reiief  usually  follows,  The  <lii«C'nse  may  assume  b  rhn>iiic 
form  with  ilisclmrge  from  the  ear.  forming  one  of  the  varieti»-»  of  (itnrrhd-a. 
Id  oilier  cases  abscess  fnrniK,  wliieh  may  lead  to  disease  of  the  btiiiy  walls 
of  the  csoul.  [ii  (iomo  cnrtt's  the  ranal  beconiM  clowd  by  ilic  swetlinp,  and 
jwrfonitifm  of  the  nienihrana  tymnani  may  lake  place.  TIk-  IWatment  m 
tlic  earlv  ttagcs  oontiietii  nC  kfcluR  lu-hinil  ihe  eiir,  follottcd  by  hot  toinenta- 
lions.  If  su[ipur»tinn  ihrpatpun,  the  pus  must  be  lei  niit  early  by  a  free 
incihi'iD  made  (lee-ply  to  the  bone  wilb  a  hTie  knife  parsed  into  tbe  meatus, 

Ezostoies. —  Small  exoplosen  oceatiioiinllv  form  in  ihe  ear,  springing  frv^m 
the  bony  part  of  the  external  inealun.  Tbew  may  tanee  dealnen*  by  rom- 
pletety  omtructiiiK  th(>  catial.  They  have  been  iiticeepitlnlly  treated  by 
Malben-fion,  of  New  York,  Field,  Ualby,  and  others,  by  meaua  of  the 
American  denial  drill. 

Periosteal  Thickenings,  also,  th«  result  nf  syphiltB,  are  occasionally  met 
Vritb,     These  usually  dittappear  under  iodide  of  pota^ium. 

DieE^sE£  OF  TUE  MiPDt.E  Kab. — It  IS  iuipus«ible  io  a  work  of  Ibis  kind 
to  give  more  tlian  tiic  briefest  possible  deseription  of  the  methods  of  exam* 
iuiug  the  luiddle  ear.  and  of  die  alll-eii<<i]s  (u  Mliicii  it  ia  liable ;  for  fuller 
iuforiuatiou  the  slutleut  must  refer  to  spiTiul  works. 

Method  of  Examination. — For  csauiniing  the  ujenibraiia  tyiiipaui  or  tym* 
panuru  from  Ihu  niLiiluK.  the  ur<liuury  filver  ear  apeeuluin  nlll  be  fouud  ae 
ellieieni  as  any  of  the  moreeoinpIiciUid  iti^irunienleFonieliiriee  reennirueuded. 
Tlie  light  must  he  thnmii  doi\u  it  hy  a  coneave  n^irror  ttmilur  In  that  used 
lor  the  laryngosco|fC.  If  in-eeHsary,  ihe  ear  muel  firat  Im:  t-arefulty  rleaned 
by  syringing,  and  aflerwurtia  dried  by  meaus  of  ennill  pieces  of  alworbent 
i^oiil  twisted  round  the  end  tif  ii  bit  of  wbiilt-liono  or  woiid.  The  metnbraiio 
in  heellh  \»  of  a  hluiith-gray  color,  and  the  handle  of  the  mulleiis  can  be 
Been  crowing  it  from  above  dnn-nw&rds  and  slightly  backwards,  lerndnaliDg 
a  little  Wvond  ita  middle.  The  membrane  Is  set  at  an  angle  of  4ft  degrees 
with  the  lionr  of  tbe  meatus;  hut.  owing  to  its  concavity  looking  otitwards, 
a  Hmnll  triangular  part  below  and  slightly  in  front  of  the  end  of  the  handle 
of  the  malleus  reHects  bank  the  light  to  the  eye  of  the  obaerver.  and  thus 
appears  na  a  bright  .'tptit.  The  poinia  to  be  observed  in  examining  the  mem- 
brane are  its  degree  of  opacity,  its  color,  and  decree  of  vn^culariiy;  its 
curvature,  whether  loo  concave,  or  convex  and  bulging;  and  the  presence 
or  absence  of  performion. 

The  instrument  known  as  PoUizcr't  trng  is  of  great  value  in  examining  the 
condition  of  tlie  Ku^lucbiitu  tube  and  the  iiiiddle  ear.  It  eon^lMa  of  n  thick 
India-rubber  bag  with  a  blunt  nniile,  and  b  u^ed  thus:  the  noxzleis  ineerled 
into  one  nostril,  aud  IxUh  noetrila  are  then  Niueexed  betuet-u  Ibe  finger  and 
thumb,  sn  8s  eftieieully  to  close  the  anterior  naree ;  tbe  patient  then  takea  a 
amall  quantity  of  water  into  the  mouth  and  holds  it  till  directed  to  swallow; 
at  the  monicut  he  swaDowa  tbe  bag  is  Bijueeiced,  and  tbe  upper  part  of  the 
pharynx  above  the  aolt  palate  ia  tbut>  distended  with  air.  and  an  al  Ibe  same 
time  tbe  Euolacriian  tubeci  are  opeue^l  by  the  act  of  swalloivinjc.  the  air  ^l^hes 
into  the  cavity  of  Ihe  tympanum.  While  thic  is  being  <lone,  the  Surgeon 
eonnecte  h'\s  ear  with  that  of  the  pntifuL  by  means  of  an  India-rubber  tube 
about  three  feet  in  length,  wilb  an  ear-piece  at  each  end.  He  thus  heafj- 
distinctly  the  effect  produced  by  the  dislenlion  of  the  cavity  of  the  tym- 
panum. Tbe  cavity  uf  the  tympanum  can  usually  be  distended  equally  well 
if  the  patient  cl'Kies  the  mouth  and  pinches  ibe  uoalrils.  and  then  ma'kcs  a 
force<l  eifort  of  expiration.  The  fulloning  are  the  chief  faela  teamed  from 
Uiia  mode  of  investigation  :    In  healtb,  the  Sui^con  hears  the  air  enter  tlio 


VABIETIES   or   CATABBB    OF    KIDDLK    EAB. 


535 


Ivmpaniim  antl  impiiijrf  on  llie  n>(^iiihrnne  nil!i  a  ^hnrp  ctk-k,  i^iiinitliig  lo 
the  patic-iiL  Hi)  a  loud  cnu'li.      If  llio  Kti8lii>.']i)aii  tiilit^  is  rlnseil  by  ^wclliii^  or 

{ila)[j£wi  witli  insipisqjatiil  pus  or  iiiir'us,  also  tillitij!  the  tyriipamim.  ihi*  will 
le  eniirely  wanliti^.  U'  th»-  caviiy  is  filled  »il)i  hMincioiin  iiuu-ii»  or  rimco- 
punili'iii  Hull],  a  crftrkliiifi,  liiilililin^KOumi  will  Iw  lieard  b*illi  liy  tlio  Siirjjeoii 
utiii  the  pAtifiit  a»  ibc  air  ^titvrs  tbu  cavity.  If  lite  uivmbrnuu  i»  perloniled 
«»<!  Uie  l^uslwcbiau  tul)«  pervious,  the  &ir  will  be  b<r»rd  paaiiug  tliruugb  the 
sp«rUire. 

Thv  Eiulfichian  0:Uheter  in  useful  in  Lrvutiocut  riiLlior  thuu  iu  (liugiio«£. 
Ic  oittUiitils  ol'a  small  metal  or  vulcaiiiti?  tube  ubout  six  iucliesin  leu^tli,  irllh 
*tli);l)t  cur^'e  at  oue  eiid  and  expniided  at  the  other  to  rvcvive  the  uoxsle  of 
tbe  ernall  lodia-rubb^r  bag  used  for  injeclitig  fluids  ur  air.  Oti  the  large 
eod  ia  a  riug  to  show  the  piHiUiun  of  the  point  while  it  is  in  (he  uose.  It  la 
(bus  pawfd  :  the  concavity  of  the  curve  being  turned  towanls  the  tloor  of 
the  Daoal  fiuuMi,  m)  thai  the  point  may  not  hitch  agatujit  tbe  turbinate  b'jnea, 
tlie  catheter  ia  paased  backwarda  thro\]gh  the  no.'ie  til)  it  touches  the  pf«terior 
wall  uf  the  pharynx.  It  is  then  withdravrn  about  half  an  inch,  and  ii.-^  pnint 
directed  outwanis  and  slij^hlly  upwanls  af^ninst  tbe  orifice  r>f  the  Knslnchian 
tiibe.  The  Hur^^tton,  having  bia  ear  connected  wilh  thai  of  tbe  patient  hr 
the  India-ruhher  luh?  before  described,  can  then  ascertain  whether  the 
catheter  is  in  tbe  tube  or  not  hy  blowing  eoiuc  air  through  il  from  a  gniall 
ladia-Dihber  bag. 

Jo  unler  t4)  aacertam  the  degree  of  hearing,  n  watch  or  tuning-furk  is 
commonly  used.  The  distance  from  tbe  ear  at  n'hich  ibe  ticking  of  ibe 
watch  can  he  heard  k  generally  taken  m  the  iudicntion  of  tbe  degree  of 
drafneea.  ff  the  vibrating  tuning-fork  or  the  wutch  be  pressed  against  tbe 
v«<rteK,  in  hi-allh  it  is  hoard  equally  well  in  the  two  car«;  if  one  meatus  or 
oae  Kurit^cliiaii  tul)e  be  bliickeil,  the  Miund  will  he  heard  more  loudly  in  the 
affected  ear;  if  th«  wiund  ciinnot  li«  heard  wilh  the  instrument  iu  lbi« 
|M«itioD,  or  ))«  heard  very  im{ierfectly,  the  deaf'iie>i!>  ie  due  to  disease  of  tbe 
oervou.s  apparatus  of  tlie  ear. 

The  diseii«>(t  of  the  middle  ear  are  commonly  clawed  under  the  following 
besdtngH:  .Simple  Mucous  Catarrh  and  Purulent  C^itarrh,  and  each  of  these 
is  divided  into  acute  and  chr«inlc. 

Simple  Aciit«  Catarrh  is  usually  associated  with  catarrhal  affections  of 
the  pharynx,  and  is  most  coniiiiun  in  children.  Il  i«  chanu;terizeii  by  acute 
hrpervmia  and  swelling  of  llie  mucous  meinbrane  with  increased  secretion  of 
raucus.  Difiiculty  of  hearing  is  an  «arly  symptuiii.  and  iu  some  cases  there  ia 
iDlenw  earache  radialiuj'  ovur  the  eidu  of  the  bead.  Nutsoa  and  throbbing 
in  the  ear  are  aeldotu  amcnt.  Kxuuiinntioii  of  the  ear  kIiuws  the  external 
meatua  clear,  some  redoees  of  the  meml)ranu  tyiiipuni.  wilb  bulging  iu  mme 
auce.  If  left  unrelievcil,  the  membrane  occaaiouuily  perforntce,  after  which 
care  lakes  place  and  thci  aperture  ht^atit.  or  the  disease  may  iHMTume  chrouic. 
Tbe  Treatmrnl  iu  mild  <:aHwcim.aiijLtt  ttt'  the  upplieatioii  of  k■Cl:hc^  l>cliiutl  llie 
ear,  and  hot  fumvntnltaiiH  externally.  At  the  lianic  time  the  air  t-bould  be 
bluwu  into  the  tympanum  at  intt^rvalH  liy  meiuiit  of  I*alit»T'a  bag:  the 
mucus  will  usually  iiji-upn  wlit^n  the  uir  rcgurgiluteti  from  tbe  cavity.  If 
there  is  much  bulging  ami  acute  piiin,  relief  e-an  be  (ditaiiicd  more  I'urely, 
and  the  risk  of  permanent  damage  to  the  ear  avoided  by  puurturing  the 
menibmne  by  means  of  a  smdll  lancet-shaped  knife  spcH'iHlly  constructed 
fiir  this  puqinw,  or  a  cataract  needle.  ThLt  ofieralion  is  easy  of  imrform- 
ance  ;  the  speculum  having  been  pa-ised,  and  a  good  view  of  the  nu^mbranc 
obtained,  ibe  puncture  is  if  be  made  at  the  lower  part  of  tbe  membrane  be- 
hind the  handle  of  the  malleus.  The  mucns  may  then  he  hlonii  out  by 
meaoi  of  air-douches  from  Politzer'a  bag,  or  through  the  Eustachian  cutbe- 


586 


DISEASES   OF   TBE    nEAD    AND    KECK. 


tcr.  The  opfration  w  iiBUjilIy  followed  by  complete  relief,  and  the  iiniall 
puncture  siH>ii  heals,  leaving  ihe  hearing  iintmpaired. 

Chronio  Non-pnmlent  Catarrh  h  a  \cry  roninion  <!ia«ft8<^  nnd  a  frequent 
cAiLie  of  (ieafnewj.  Twn  ^-arinics  arc  liencrih^-d — the  dry  and  moLtt.  Dry 
cnlarrh  ie  ii  term  applJei)  to  n  chronii?  inflniiinkation  of  the  nuicmix  mem- 
hrnne  iinacompanieil  by  any  excess  of  nerrelii'ii.  It  leads  Ut  thick^iiiii^  of 
the  niiiC'UH  luenihrnne,  attil  finslly  caue4>8  deafness  from  iniDiubility  of  the 
osiiioWii.  In  moUt  calnrrh  lh«Te  nre  Bnetliiig  anil  hv|>«nt;iiiia  with  excev^ive 
^ecreLiuii,  It  ollen  alfecl^  the  Eut^lachian  t(il>e  (.-hivflVi  and  niay  I^ad  to  its 
cninlmclinn  ur  ch«tirf.  If  thi»  takt^  plnce,  the  air  id  Ihe  lyriipnnurn  »<M>n 
bvconiea  ntiKoihetl,  and  the  nieinbraiiv  becocne^  nbiionnally  concavf*.  Noiee« 
in  the  cars  Mini  ucca^ionnl  [iniii  aru  coiiiiiiiiii.  It  ii;  must  c<immoiily  arao- 
cialeil  with  pharyiigt-fti  eatarrii.  Tliis  coutlilion  ia  the  comriion  cause  of  »o. 
oullt-d  J:^U8tachiau  or  thri>at  di-nfiiOMj.  Thv  trvutineul  of  ehruuic  (.'utBrrh  it 
usuulJy  not  vtry  eatisfaclory.  The  ^vneral  health  luuiit  be  utlvnd«d  to,  and 
the  catarrh  of  the  phuryttx  relieved  hy  u»triiigent  applications,  as  nitrate  of 
Ditver,  gtyceriiie  of  lutiiiin,  etc.  At  tlie  namo  tiiiit:  thu  air  nintit  he  hhiim 
into  the  tynipMtiiim  ut  inttn'aiK  by  I'iilitzer'b  buj:,  thi;  Knt^uchian  ralbeler, 
nr  bv  forced  expiration  with  the  noKlrits  olored.  My  ihis  nieans  the  alrain 
on  the  nieiiihrune  i»  retiercd  and  the  innciiti  allowed  to  ei^'npe.  Antringent 
injei-ttonfl  into  the  tynipununi  by  means  of  iho  OHtheter  have  been  uited,  but 
their  iM-rielit  ii^  hoiiH'whal  iint^erLiiin. 

Acot4  Fumlent  Catarrh  i»  ooiiinionly  ueeqnela  of  Hcarlet  fever  or  luen^les. 
The  Ryinplonm  may  be  aeiite  like  Ibow  of  the  acute  Donpnnilent  form 
already  described,  or  (K^rtoralinn  of  the  nteciihrHUu  may  occur  vvilhont  any 
acute  Bymptomij  having  nitinifettterl  themttelvei^.  the  tirst  symptom  lieing  the 
diechnrge  from  the  ear.  Aller  the  pns  hiifl  thus  foniid  exit  the  opening  tu 
the  niendmitie  mny  close  und  tvwvery  t^ke  place,  but  in  acrofutnus  children 
the  supnumtion  may  become  chronic.  It  is  very  important  in  nil  caaea  of 
scarlet  tever  or  mcnalee,  especially  in  scrofuloua  children,  to  keep  a  careful 
watch  on  the  ear,  as  in  many  cases  the  complete  destruction  of  the  mom* 
bnma  tvmpiini  and  lo^  of  the  o^iclcs  might  he  prevented  by  early  incision. 

Chroiiio  runilent  Catarrh  may  ari^c  as  a  sequel  of  acute  inllnramation  of 
the  middle  ear,  or  a^.  the  result  of  extension  from  without  in  diffuse  infiam- 
malion  of  the  meatus.  In  these  eases  the  memhrnna  trmpflni  is  always  per- 
foratcd.  The  symptoms  are  merely  la^  ordulneiu  of  hearin;.',  with  a  chronic 
muoo-purulcnt  discharge  from  the  ear,  often  having  an  extremely  oflen&ive 
■mell.  The  consefjuences  of  purulent  catarrh  nre  frequently  serious,  and 
coiiietimcs  fatal.  If  unchecked,  the  disease  mny  lend  to  nccroatsof  thcBmall 
bones,  or  to  Iheir  l>ecomiiig  ankyiosed  and  tixed  by  ndheniona  to  euvh  an  ex- 
tent as  to  be  useieaH.  The  diwaee  probably  in  all  caaes  extends  into  the 
mastoid  ctWn,  and  here  the  discharge  may  accumulale  and  decompose.  Ow- 
ing to  the  irregularity  of  the  cavities  it  may  not  find  a  sufficientexil.aud  an 
nbccesB  of  the  msHtoid  process  may  form,  gradually  perforating  the  bone  and 
■ppeariog  benralh  the  skin.  Otries  or  uecrtxtis  of  portions  of  the  temporal 
bone  is  a  consequence  of  grealer  gravity.  When  this  takcp  place  pus  may 
form  within  the  skull  between  the  dura  mater  and  the  bone.  This  mny  be 
followed  by  dilluse  septic  meuingilio,  or  by  (hn)mbusi»  of  the  lateral  sinut, 
with  sulieequent  ttol'teiiing  and  d<!<iiitegration  of  the  clot,  giving  rise  to  em- 
bolic pyiemia.  Lc«s  commonly  an  abscess  forms  in  the  temporo-sphenoidal 
lobe  of  the  brain.  In  rare  canes  lutal  septic  Infection  may  take  place  with- 
out any  disease  of  the  bone  being  found  after  death.  The  symptoms  of 
these  various  complications  present  nothing  peculiar  and  need  no  detailed 
detu-riptiou.  In  strumous  children  enlargement  and  separation  of  the  glands 
behind  the  jaw  is  a  common  complication. 


OTOBBB<EA — POLTPUS.  587 

In  the  Tivatment  of  chroDic  punileDt  catarrh  of  the  middle  ear,  the  mbcd- 
liil  objects  aimed  at  are  complete  removal  of  the  purulent  secretion  as  soon 
■  itlbrmt,  and  prevention  of  its  decomposition.  As  the  secretion  dimin- 
iiktattriogent  applications  may  be  used  to  hasten  its  cessation.  The  removal 
tf  tk  porulent  secretion  is  effected  chiefly  by  frequent  syringing  of  the  ear, 
nd  \>j  blowing  through  the  cavity  either  by  Politzer's  apparatus,  the  cathe- 
kr.ariiinple  ^rced  expiration.  The  syringe  must  not  be  used  too  forcibly, 
ftpcdillT  if  the  opening  in  the  membrane  is  large.  Hinton  recommended 
tHl  IB  fndia-rubber  ball  syringe  with  a  uipple-like  nozzle  completely  filling 
theeiteroal  meatus,  should  be  used,  by  means  of  which  the  fluid  may  w 
■■detoflow  through  the  ear  into  the  pharynx.  This  should  be  done  with 
■taldy  gentle  pressure.  If  too  much  force  be  used,  it  causes  giddiness  or 
UstncM.  The  head  should  be  held  forwards,  so  that  the  fluid  that  enten 
ihepbarTDx  may  pass  out  at  the  nose.  Decomposition  is  prevented  by  the 
IK  itf  iDtiseptic  solutions,  the  best  being  Condy's  fluid,  chloride  of  ziuc  (gr. 
j*oS)>ora  concentrated  solution  of  boracic  acid.  Afler  the  ear  has  been 
■fii^ed  the  meatus  should  be  carefully  dried  with  cotton-wool.  In  many 
MM  great  beneflt  is  obtained  from  blowing  into  it  a  small  quantity  of  iodo- 
fim. 

Ilidn  this  treatment  the  discharge  in  most  cases  gradually  ceases,  and 
■tlasil  be  too  large,  the  opening  in  the  membrane  heals.  Id  exceptional 
eaw  io  which  there  is  insufficient  exit  for  the  discharge  it  may  be  necessary 
Id  enlarge  the  opening  in  the  tympanic  membrane  to  allow  of  more  perfect 
*fcwiiagof  the  cavity. 

Tb«  complieatione  of  chronic  purulent  catarrh  must  be  prevented  if  pos- 

■^  bj  the  above  treatment,     ^ecnsis  of  the  petrous  portion  of  the  tem- 

pnl  iMne,  meningitis,  intracranial  suppuration  and  pysemia,  when  they  arise, 

**  beyond  the  reach  of  treatment.     Necneis  of  the  mastoid  process  is  leas 

•fwous;  the  sequestrum  may  separate  and  be  removed  by  the  meatus  or 

"'^enitlly.    If  there  is  pain,  redness,  and  cedema  over  the  process,  indicating 

P'^tsip  pus  in  the  mastoid  cells,  trephining  is  sometimes  reauired.     It  is 

^'v  necessary  to  use  a  trephine  when  the  bone  is  very  hard.    As  a  rule,  the 

^^f  layers  can  be  cut  away  with  a  small  gouge,  after  which  the  mastoid 

^^  CSD  be  broken  into  with  a  strong  probe.     The  opening  should  be  made 

^9ttirter  to  half  an  inch  behind  the  attachment  of  the  auricle,  and  on  a  level 

^^  the  upper  margin  of  the  external  meatus.     The  instrument  must  be 

?^Tted  inwanls  and  slightly  forwards.     The  operation  must  be  performed 

•    *«*  great  caution,  to  avoid  any  risk  of  wounding  the  dura  mater  or  the 

**»al  einus.    This  operation  must  be  reserved  for  cases  in  which  the  paiu, 

*lling.  and  tenderness  over  the  process  lasting  for  some  time  clearly  indi- 

^^^  an  accumulation  of  pus.    If  carefully  performed,  it  can  do  no  harm  and 

^*|^do  much  good. 

,~X*lie  constitutional  treatment  consists  in  the  administration  of  cod-Hver  oil, 
^*^,  and  tonics,  as  the  case  may  require. 

^Jtoirlicea. — This  is  merely  a  name  for  muco-purulent  discharge  from  the 
T"*"-  As  already  pointed  out,  it  may  ariiie  from  diffuse  inflammation  of 
i^  external  meatus,  fntm  badly  treated  abscess  of  the  meatus,  from  catarrh 
^  the  middle  ear  with  perforation  of  the  menibrana  tympani,  and  from  dis- 
J^*  of  the  jietrous  portion  of  the  temporal  bcmeor  mastoid  process.  Disease 
■  the  hones  of  the  ear  is  very  rarely  primary,  l>eing  almost  always  a  sccon- 
'^vy  cdDwnuence  of  disease  of  the  mucous  membrane.  The  treatment  has 
***u  alrea<ly  described. 

_^  ••lyptii. — Polypi  of  the  ear,  in  the  great  majority  of  cases,  spring  from 
***•  trniinnura,  and  project  through  an  ojiening  in  the  membrana  in  cases  of 
^^runic  aural  catarrh.    They  are  rarely  met  with  springing  from  the  external 


588 


DiaBAses  or  the  hsad  Ayi>  necc. 


meatiiA.  Thf^r  arc  usually  hard  anH  flesihy-tnokinf;,  thnngh  Aoniclimeii  Ml 
ami  ff^lntinoui),  as  in  the  ii<mp;  Knmetinu^  perlunculntiNl,  bill  at  itthi-rH  situuied 
on  »  hntail  has^p.  They  prodiire  seriims  tnconvenieiice  by  obiilruclin^  the  ex- 
ternal enr,  and  require  ti>  be  twisted  off  by  inpHn.'^  of  fofce|w.  or,  if  too 
6raily  Hued  fur  tbU,  eut  nif  with  uri-^^ura  or  k  wire  i>iiftre;  aAer  which  means 
must  Uff  ukfii  to  cure  tlie  jmrulenl  aitarrli    upou  wliicb  the  growlU  ia 

Nerroiu  CeaftiMi  u  recogniKed  by  the  absence  of  the  symptonifl  of  any 
of  tlie  foreiioiiiy  disewtes,  or  of  Ihe  history  of  their  occurrence,  and  by  the 
fact  that  a  vibritttiiK  ttmiiig-fork  i«  either  uot  bvnrd  at  all  or  iruperl'ecily 
bean)  when  it  it  placed  u|kiu  the  vertex  or  betweeu  the  teeth.  A^  it  ia  ni>t 
Huieuitble  U)  eurgival  treatiiieut,  it  is  ueedleva  to  diacusa  here  its  causes  or 
|)Utl)ulogy. 

ni8IUSG8  Of  THK  KOSE. 

ExTRitNAi.  ArpRcrmNs  op  tiik  NoriK.^Aene  Rosacea  U  an  afTfcrion  of 
the  nkiu  nf  the  notie,  iti  many  raM^  diBtinrtly  rrtiiiltin^f  from  alcoholic  excess, 
in  nthern,  eapceially  in  women,  being  apparently  connected  with  cbrnnic 
dysnepaia.  It  commences  as  a  red  spot  nn  wliich  dilnied  cnpillAries  are 
visible,  and  e)clendn  gradually  over  the  whole  tip  of  the  noM  and  often  in  the 
ndjac:enl  |Mirts  of  the  face.  At  first  the  sebaceous  rolMcles  are  not  affected, 
but  hiier  on  they  usually  become  enlartp-d,  niakinn  the  surface  more  or  less 
tiilierculntcd.  Rome  thickenin^r  of  the  skin  uaitnily  occurs  at  this  atn^e.  The 
Ireaimfnt  consists  in  correcting  evil  habits  in  driiikinu;  or  ealiu;;,  and  atten- 
tion to  tliedigestitrn  and  general  health.  LucaHy.iodideof  sulphur ointruent 
is  useful. 

Lipoma  Nasi  is  a  chronic  hypertrophy  of  the  cutaDeoiis  and  subcntnneoiu 
Hlruc{un.>s.  lurming  a  large  reddiifh-blue,  vattculiir-looking,  soft,  tremulous, 


/ 


Pi(.  U).— LipDinM  qj  Uott  btitotv  Operation. 


Pig.  AS4.— SMoe  NoM  ftftar  Opcrattoa. 


anil  lobulati'd  niaas,  enveh>ping  the  end  of  the  nme,  and  prtxlucinf!  i^xt 
defiirniily  of  it.  There  are  all  degrees  of  this  disease,  from  mere  rUibbir  _ 
the  enil  of  the  organ,  to  the  formation  of  a  set  nf  pendulnuB  lobular  tumors 
Btlacheil  lit  it.  The  sebaceous  glands  arc  greatly  enlarged  in  ihia  disease, 
often  reaching  the  size  of  smalt  peas.  The  patient's  appearance  may  be 
greatly  impntvetl  by  the  removal  of  these  growths,  as  i«  shown  in  Figs.  G33, 
GA4,  taken  from  a  patient  operated  on  by  M.  Itcck.    This  may  be  done 


DISBASSS    or    TB£    KASAL    CAVITY. 


539 


reailil-p  enough  by  making  an  inrwlnn  (inwn  the  fuc«iiil  line  to  the  niarcarti- 
]ag«s,  and  iticn  diasectiiii;  cl)«  li)M>iiin  olf  these  on  L-ach  eldv;  e»\>vviH\  care, 
'  bowever.  l>ettie  tHk^ri  in  iloin};  tlii?  not  Ut  ourmac^i  u|Hin  th<?  U'<»(ril.  TIiib  ib 
but  avmiliHl  by  i1ire*^-t'rii);  Nn  ii^Mlaiit  to  kfc|>  his  linjivr  in  it  whil4>  the  dimec- 
noo  i»  bein^  t>r»a*>cut«<l,  »<>  llnil  ho  niny  warn  the  Surgeon  of  the  too  near 
ftppr'>«ch  of  the  kuifv.     Thi;  »urJ"nfL*  is  thtn  Iffl.  to  granulate  and  ficatrijK!. 

Lnpu,  Epithelioma,  Rodent  T71c«r.  and  Tertiary  Syphilitic  TJIceration 
are  all  comuiuu  in  the  nuse.  Lupus  cispeciiLlly  may  he  Inoket]  umm  aa 
atnioBt  specially  aflecting  thJHorgau.  destroyiugune  or  IxUh  alw.  liie  columna, 
*r  perhajw  the  whole  ol"  ibe  ntitt.  The  cotibiderution  of  the  nature  and  treats 
BM-iK  nf  thi-se  aflVctiona  in  tbia  situation  presents  nothing  special  (tee  Chapter 
XXJtVII,  vol.  i.):  but  the  eure  of  the  deforroiliep  iniliiced  by  thcin,  which 
ti  full  uf  interest  to  the  Surgeon,  will  be  conHidfred  in  dotail  when  wl-  epiiib 
«f  the  plastic  nperattona  that  are  pr&cti.'wd  on  the  fara. 

Vlcen  and  Fiisures,  of  a  Ires  aerious  character,  though  very  painful  and 

c^runic,  often  ocnir  at  the  angle  of  the  ala  and  aeptum,  or  bclwf^u  thv  ala 

stiU  lip.     Their  Tretttment  consists  in  tduchiog  Lhi-m  from  lime  to  tinio  with 

u/trate  nf  silver,  or  in  ihe  application  every  night  of  white  preripitutc  or 

eitriDe  ointment;  at  the  same  time,  that  the  general  health  \»  attended  to, 

Bftod  tUeBlreugth  restored,  by  iheadminiglratiun  ofirim,  hnrk.  and  liarAnpartlla. 

AKVKtTHJSs  OF  TUK  Nasai.  Cavity.    Examination  of  the  Vasal  Cavity. — 

7"!  i«  nasal  cavitv  may  be  esaminc-d  from  the  front  by  ni«an«  of  the  niiaal 

';>o-c:ulum  (Fig.  655).     This  is  iutrwluccd  ao  as  to  dilute  the  ni^Atril,  and  a 


li 


^i 


Tig.  US.— Na»1  8|i««iiluB). 


Flf.  Bin — FrUpttcl't  NaMt  P|iwaIiiio. 


Strong  light  is  thpn  rhrowii  In  by  mennn  i>f  the  laryngoecopic  mirror.  The 
sppculum  nhown  in  Kig.  tj.'it;,  will  be  fimnd  vfry  cMivenient,  aa  it  docs  not 
rwjuire  holding,  end  t!iu»  lenv<-«  the  Surg^'on'st  hnuiU  free.  _  The  p<wU-rior 
nare#  can  be  examined  by  the  laryngoscope,  the  mirrur  being  held  in  the  re- 
Ttrwd  |K«iiton.  The  patWnt  ie  placed  in  the  »anie  position  m  for  examining 
the  larynx  ise**  I'iiK-aeei*  of  the  l^irynxi,  but  the  tougue  is  not  drnwu  out. 
The  uvula  i»  llieu  driiwu  loruard  with  a  small  L-urved  apatiila.or  the  patient 
ttiay  be  told  to  breathe  out.  The  mirror  is  then  iniK-rted  till  it  is  chwc  to  or 
touched  the  posterior  wall  of  the  pharynx.    The;  handle  may  be  slightly  beilt 


640 


DISSABES    OP    THE    UKAD    AND    KKCC. 


with  the  concavity  of  tb«  eurve  towards  the  t«niruo.    Thn  mrlhnd  of  «xi^ 
nntiun,  or  p'letenor  rhinnsaiijj',  ns  it  is  t«rrr>oil,  in  difficult,  odiI  it  ■• 
thai  mui-h  ia  IvarntM]  from  it.     The  pixstvrinr  narvs  can  be  vuutiUNd 
di|!)(iilly  l>v  (inK'^iiii;  tin-  fingiT  beliind  llie  Hoft  |wlalc. 

Deviation  of  the  Septum.—This  rimy  In-  the  result  of  injury  w 
malfiintintion.  It  is  tieidmiiatf  nny  iiiipiirtanue, hul  should  it  vn'tal  Inaadkm 
ftxtent  MB  t<)  nbatnict  nne  nnotril  it  inny  he  mrcmnry  tn  rvmnlr  the  ilafunoit; 
hy  o|>enilinn.  This  may  be  done  by  forcibly  bi-ndin^  th«  tcfitam  ialit 
ilB  )in>p4>r  pttNti'm  hv  some  blunt  instrument  paa-teti  up  lh«  ntatrtl,  SbnaM 
this  be  itnpowible.  the  part  of  the  ciirtilape  oltftrurtint;  the  nottril  nay  bv 
cut  away,  care  being  taken  not  to  remove  m  much  an  to  cauM  nakbf  m  «f 
tfa«  nnsp. 

Chronic  Catarrh,  in  the  form  of  a  thin  wmerr  miKHiu*  iliiK>bar|pe.  taalac 
for  mniiv  iDonthst,  U  ocr&aionallv  met  with,  timre   parfirularly   in   ywag^ 
women,  independently  of  anv  Btrucluml  diseHse  of  the  itiuenii*  membi 
The  Ti'Mtment  of  lliii  aflertion  condint/i  Id   the  emtdovmml  'if  toniw 
nieann  cnlciititt^  to  strenirthen  the  ovuteiii  (irttiTully,  and  tbi- I'lt-al  af 
tion  of  n!>trin(ft>t)ts,  Buch  ««  tannin,  chlorldn  of  zinc,  etc.    But  under  aBjr| 
of  li-entmetil  thiH  nfffolioti  is  apt  to  prove  rehrllinuf. 

FotUoolar  Hypertrophy. — Meyer,  of  diH-nhajren,  ha»  d<««Tib»d  acwait 
tino  QccAfiioutillT  met  with  in  itrunioue  ehil<lreu.  in  which  Ihrrv  w  a  ^rMnl 
overgrowth  of  the  cloeed  lymphatic  fullioles  situated  about  th«  pnftrriv 
narvfl  and  upper  part  of  the  pharyox.  It  Icttdj  to  mure  nr  !«  annptrti 
obiitruction  of  the  [>n«ierior  nare^.  aiir)  is  often  nccom|tanii'd  by  dranN* 
The  condition  can  be  recognized  by  the  ntunl  Lone  of  the  voice,  the  »tnprii)tB 
of  the  nose,  nod  by  the  enlarged  follicles  beiii)j;  fell  with  the  ii'  ■••J 

behind   the  eoft   palate.       !S[eycr   recoiniuentU   thnl   the    enlot.  !* 

should  ]w  Bcra|>ei)  awnr  by  means  of  a  rioged-ehaped  knife  k:l  in  a 
handle,  which  rnn  bt>  pai>)te4l  through  the  nwtril  and  guiJeil  by  the  ' 
behind  llio  c.n  iinliiH'. 

Watery  DiBoharge  from  the  Hose.— i^ir  .Tauii*8  Facet  baa  recnnlcri  a  tmm 
in  which  a  ch-ar  walervHuid  of  ii  cpccilic  gmvliy  of  10<)4.  oonlainioitamo* 
of  albumen  and  a  ronHiderabln  quantity  of  rhtitridecifurfiium  flowed  >tfi>iily 
at  the  rale  of  a  dntp  every  five  or  r\x  st-oonds  from  the  left,  oo^lril.  Tfcflhild 
exactly  n-ai'inblerl  orrehrt»'«pinal  fluid.  Following  the  practice  nf  Sr  Ben- 
jamin Hrodle  in  a  vimiUr  case.  Sir  jAme*  ra^ct  adiiiiniAti^red  ntlpbal* 
of  xinr  intrrnnllr,  and  injected  the  nostril  uilh  a  tuduiion  nf  Uie  caBMMl^ 
manee,  nnd  under  this  trenlinent  the  diiu-hnrire  cenjuxl.  The  tat  (HV 
mem-rd  ttx  nionthi*  Hf1<>r  a  severe  blow  on  the  forchesd.  Tlit*  |tal{eiit  w*** 
qurntly  died  of  meiiin^^ilio.  the  iuflammAtion  beiuft  must  ntarkril  abuil  tn* 
umler  i^iirfnce  of  the  Inintnt  lobe«,  but  no  eomniunirallon  mm  found  betn*^* 
the  niiiial  f<iK<c  and  the  «ubar»chuoid  ifmce,  In  the  left  autrum,  bi*«rt**- 
wew  found  two  broH'l-hiweil  |K>)y)xud  ynmtha  which  Sir  Jattx*  PiS*^ 
believeii  tn  have  been  the  source  of  the  diwliiirjje.  _^ 

Otaoa. —  By  the  term  oswun  i»  nieaut  a  chronic  muc<»-iiuroVnt  di*ri*»lf* 
fniin  thr  noee.  having  n  peculiar  and  uiost  ofli/iiaive  enirll.     It  may  ari*  ** 
some  capes  without  evident  cause,  uud    is  ihcn   called   timfJe:     but   b*^ 
rommonly  it  is  due  to  MvphUiiic  or  ttrumov*  diveaw  in  the  nii»i'  f-«.*:r,  aoTlJ^^ 
[Minitvl  by  ulccralion  of  the  niucuue  membrane  oriivcroia  o:  -.     T  _ 

trcttment  neeewarily  variea  with  the  cauM!  of  the  iliaeaM.-,  iil,!  •<.,.,  be  ^ 
cuMiil  with  the  aflVcliiins  that  vive  rise  to  it.  but  from  whalrvpr  caiiee  it  **^ 
arise  the  nuf»I  cavity  mu(>t  be  thoroughly  waaliiHl  out  twice  a  dii'      '  '     -  * 
remove  the  otffndivp  diyclmrge.     Tins  can  Ih>  (lone  efficiently  <i 
of  the  "  luuo^  (/ouM«."     This  coiiHislH  of  an  India-niblicr  i    '  ' 

feet  long,  loocw  cud  of  which  h  fixed  a  nipple  like  nozzle  t 


pstxn  pAlBK  u  caireu  DMckworUa  uguioat  Uie  puetenor  wan  ol  IM 
But!  shuts  ufl  tliu  aasal  part  ut'  that  cavity;  the  fluid,  thprulurc, 
.  ttl  tbe  u]ipo»it«  uintril.  thus  wiishing  uut  butb  uual  caviliifB  auU  the 
le  pfaaryax  above  the  »Ai  jialnte.  The  fiutd  ueed  should  cutitaiu 
neptii-,  IS  CoDdy's  tliiid,  (.-iiloride  ut  zioc  (gr.  j  to  .^>;  a  coucen- 
lotiuo  nt  boracic  acid,  ur  sulphate  of  sloe  (gr.  ij  to  .\|>  After  the 
been  Ihoroughly  cleaned,  (i.  V.  i'oure  recumiueods  the  tulliiwiug 
)  bo  lakeo  as  uiulf:  blborate  of  soda,  DJtrale  ol'  bieoiuth,  ^  3}; 
a  of  quinine,  gr.  x;  ioduform,  gr.  v.  The  snuff  may  be  oscd  two 
iaa  a  day,  care  being  taken  to  vra^h  it  out  (horuugbly  eoch  day 
nual  douche. 

Ousna. — A  very  fetid  di'M'hargo  from  the  nose  mil)  oocnsiunally 

delioata  or  atrunioua  chiidn-n  while  cutting  their  tceih,  aud  may 

far  BCTcral  yean.     It  may  orige  also  after  one  uf  the  nouie  ttpecibu 

wdslly  soarlatinaormcuelea.    ^metimcs  it  occurs  ni  a  latt-r  period, 

vonwn.    The  macous  membrane  is  swollen  aud  lod,  but  the  dtaeaae 

CMaHly  attended  by  ulceratiou,  although  thii  may  talcv  ptact-  if  the 

large  ta  allowed  lu' accumulate.    The  Trmtment  confiiaia  iu  the  u#e 

lal  duuebe,  aAcr  which  «i>me  astringent  apiilieaiion  may  be  applied, 

t  of  taaoia  will  often  be  found  of  great  use.     It  may  be  applit»l  by 

a  eautel't-bair  pencil  thrt>ugh  the  noatrila,  and  iti  moat  ca^es  it  is 

alio  to  paw  a  hmg  bruxh  nn  a  bent  stem  from  the  luoutb  behind  tb« 

tt,  SO  as  to  reach  the  upjter  part  of  the  pharrnx  aud  the  [Kjeterior 

11  Tfxin^  cliildreu  the  teeth  aud  stoniaoli  riiuijl  be  attended  lu. 

I  fhickening  of  the  Schoeiderian  Membrane. — The  mucous  ojeni- 

the  nuee  is  not  untrequenlty  chruuicnily  iudaoied,  especially  iu 

children:    that  portion  of  the  luembraue  covering  the  turbtnute 

mning  thick,  toll,  and  vascular,  and  pnfjectiog  like  a  broad  fringe 

r  surface.     It  ia  usually  of  a  bright  red  color,  and  coverH  with 

«ritb'<ut  offctaive  odor.     This  encllitig  at  all  limes  pruduLts  buuf- 

a  peculiar  iotoniuiou  uf  vmce,  but  iticn-asoi  in  wet  weather,  and 

becoiiie  an  great  hs  wriously  u*  olwlrutt  the  breathing. 

I  oecasionalTy  forms  either  in  the  mumus  membrane  or  on  the  sep- 

Uius  may  lead  tn  necmia  of  the  cartilugra  and  bones,  separation 

|tttrning  of  the  nose,  depreasion  of  its  bridge^  and  great  deliirmity. 


A.ll._-J  i»....__.^.  ___.__-. I _ 


,k:ii.^. 


542 


PISBABBS    OF    THE    HEAD    ASV    NXCK. 


ease  af  Uie  antrum,  aod  escBpe  of  morbid  secretion  from  this  into  the  cant^ 
of  ilie  misc. 

The  TretiUneiU  nl"  these  conditions  must  be  cnnducted  by  the  use  of  the 
nasiil  douche,  followed  by  the  application  of  solution  of  nitrate  of  silver, 
eulphale  of  copper,  bichloride  of  mercur;-,  one  to  two  pTiina  to  the  imuce;  or 
black-wash.  Theanuif  nbore  mentioned  will  often  Iw  found  very  uiH>fiil.  In 
eyphilitie  cases  the  general  treatment  of  syjihilis  must  be  carried  out,  iodide 
of  potussium  or  mercury  being  administered  according  to  the  condition  of 
the  patient.  In  atrumous  cnsefl,  cod-liver  oil  and  iodide  of  iron  are  moat 
useful.     When  necrosis  occurs,  it  niuat  be  treated  rta  described  below. 

Necrosis  not  uufreijucntly  occurs  in  the  Ioo«e  bony  structures  lying  in  tbe 
nasal  foi^ai  or  in  the  nasal  bones  themselves.  In  these  cases  the  septum  nasi 
pftrticipHtc-s  in  the  morbid  proc«aa,  and  commonly  aeparatea  or  is  perforated. 

Kfcn*is  may  occur  in  these  situations  cither  as  the  result  of  syphilis,  the 
abuse  uf  mercury,  or  from  external  injury.  I  have,  however,  seen  cases, 
more  particuljirly  iu  women  and  childrtw,  which  are  not  referable  to  any  of 
thes«  t'HUsws,  or,  indeed,  to  any  other  external  exciting  cause,  and  in  which 
scrofula  was  probably  the  occasion  of  tbe  disea«e. 

The  presence  of  necrosli  may  be  suspected  from  the  great  fetor  that  infects 
tbe  breath — the  characteristic  odor  of  dead  bone  being  emitted,  but  in  an 
excessive  degree;  and  its  existence  may  always  be  positively  determined  by 
exploratiou  of  the  nasal  cavities  wilh  a  probe. 

The  Treatment  is  simple,  and  must  be  conducted  on  ordioarr  medical  and 
surgical  principles.  It  the  general  health  be  impaired,  or  if  the  diseam  b« 
specific,  appropriiitc  alternative  constitutional  treatment  mutt  be  adopted. 
The  fetor  may  be  lessenetl  by  the  nasal  douche  and  aniiseptic  applications. 
So  soon  a^  the  bane  is  htoaened,  it  must  be  extracted  with  p')lypU3  forceps, 
coming  away  in  soft,  black,  crnmUling,  (iJfenHivc  masw^.  There  is  often 
abundant  hemDrrhage  itfler  this  extracti'm,  but  I  have  only  once  seen  serious 
trouble  result  from  this  raiLw.  Tbe  patient,  who  waa  of  intemperate  habits, 
sulTuriNl  fnmi  extenetve  deftructinn  of  the  hiird  palate  end  bonce  of  tbe  nose. 
An  alteitipt  was  made  ti)  remove  a  tietgupslnim  when  a  sudden  gush  uf  blood 
took  place  which  rapidly  pnived  fatal,  partly  by  entering  the  lungs  and 
partly  frotn  syncope.  If  hemorrhage  occurs,  plugging  will  iu  most  cases 
easily  arrest  it. 

In  cases  of  obstinate  nwena  in  which  necrosis  is  suspected,  or  in  which  the 
sequestra  »innot  be  removed  by  the  nostril,  Kouge,  of  I.Jius»nne,  recom- 
mends that  the  nasal  cavity  should  be  opened  by  an  inci-^ion  made  from  the 
mouth  at  the  reflection  of  the  mucous  membrane  from  the  gums  tn  the  upper 
lip.  The  rftrlilnges  are  sepftrated.  and  the  septum  cut  thmujrb  wilh  ntning 
scissors  tmfficiently  to  allnw  the  npfter  lip  and  nose  to  Iw  pulled  upwanis  for 
a  sufficient  distance  thoruughly  to  expose  the  nasal  cavity.  By  removing 
se'piestra  in  tJiis  way.  Rouge  cured  several  cases  of  most  olwtinnte  oz«ena. 
Atter  the  operation  the  nose  is  replaced,  and  no  scar  or  other  deformity 
results. 

Calculi,  <.r  RhinoUthi,  are  occasionallv  met  %vlth  in  the  nasal  fa-ssie,  where 
they  simulate  fureigii  ividies,  sud  may  iceep  up  considerable  irritation  and 
offensive  discharge;  and  here  extraction  may  be  practised  with  a  pair  of 
forcejJS.  But  sometimes  they  are  situated  under  the  mucous  membrniie.  In 
two  cases  I  have  dissected  round  calcareous  botlies  of  this  kind,  of  about  the 
sJM  of  cherry  •atones,  from  under  tbe  mucous  membraae  of  the  ala  of  the 
Dustril  in  children. 

Bptstaxil,  or  bleeding  from  the  none,  is  \'ery  common  in  children  and  in 
young  people  about  the  nge  uf  puberty,  more  particularly  in  girls,  aittece- 
denlly  to  tbe  menstrual  period;  it  may  either  be  active  or  passive,  but  b  mvt 


DiaiASKS   or   THB   NASAL  CAVITT — KPISTAXIS. 


548 


I'tanllj  dqwndeot  un  ct)og«fiti<iD  of  the  mucous  menibruae.  But  iu  the  ailult 
lit  Mara  ■eriou8,  ami  it  may  Llien  be  aesociiitttl  with  und  itepemlent  on  two 
r*ppuBte  coDilitioo8 — either  on  a  Btatt*  of  jilrthoni  nilh  tentlcnc-r  to  cerc- 
ioH^ifstiuo.  urooaa  anainic  and  cnvhectic  state,  in  which  the  blood  tsthio, 
laililvaDat  voagulate  rc-iulily.  Iu  the  tirBt  condiliun  the  episuix'u  is  nltcn 
naoMtcd  with  congwltou  ut  the  liver,  und,  when  uccurriug  iu  tlic  }'ouDg 
mi  |4tt^oric,  it  U  ottcn  o  iwluiary  relief  to  the  syeteni.  But  when  occurring 
bathectir,  anirmir,  and  cspetiully  agod  pe<ipte,  it  bcoumes  of  very  serious 
Baamt;  and  in  such  circumstances  the  luta  uf  blood  may  be  so  cnntinuou* 
■Kicupioii*  that,  uulvM  active  means  be  adopted,  a  fatal  tcrminatiuD  may 
(•■L  Whrn  rpiataxts  pr<)V€«  fatal,  it  i»  by  its  conetant  rcciirren(-e.  Iu 
tin*  caw*,  I  tx^livve,  the  naMil  iu-iiuirrhflge  is  always  aasocialt^d  Mith  a 
WvkOHluwn  and  unhealthy  state ul' the  ci>RPtttution,  dependent  upou  cli runic 
nawnil  miMchiel.  ntjiecially  chronic  Brighl'a  diw8«e,  with  the  contracted 
kithiry  aod  cirrhuMia  ut  the  liver.  T!ii>  wuntt  and  mwt  inlrartahle  caitn  that 
I  iiivHvn  have  be«n  connected  with  hepatic  disease  and  jnuntlioe.  E[)i»- 
tutaii  la  •ume  cases  Bwucialed  with  purpura;  more  rarely  it  occurs  iu 
fabcau  Mifleriog  froai  biemopbilia.  It  la  eoinetimes  a  promiuent  eymptom 
»  wtmna  uf  lh«  bono  of  the  nu«e. 

TnatmaU. — Kpiataxis  muat  not  be  treated  limply  aa  a  local  disease  of  the 
BOR.  h  ia  OBually  uuly  a  ^ymptum  of  si>me  LMmstitutioaal  couditiim  or 
titcmldtBiaiBa  Umt  n-quirva  remetlying  bcfure  the  hcmurrhagv  can  be  ex- 
potid  to  oeaae.  Hence  it  is  ol' the  hntt  iiupiprtaoce  to  treat  on  ordinary 
■M^ieal  [HiodpteB  thnoA  states  of  plethora  or  cachexy  wiLli  which  it  may  be 
— inind,  or  U)(»i<  conilitiotii!  of  diet-aae  of  liver  ur  uf  kidney  that  are  met 
aii^  IB  peraoDs  sufTrrlng  from  iu 

iaywoK  people,  otherwise  healthy,  and  in  Hiifrhtrr  casea,  epistaxis  mar 
muMalylw  urreflted  bj  the  eniplnyment  of  oniinary  domestic  means,  such 
■Slliit  kpplicatiun  of  cftid  ti>  the  nape  of  the  utnrk  and  forehead;  and  iti 
mum  may  be  prevented  by  the  we  of  ]>urgBttve«,  or  by  attention  lo  the 
piWkrrTgulnliou  of  the  menrtrual  fonciion. 

iH  [Jrjbotic  Mlultsthe  flow  should  unt  l>e  loo  suddenly  checked,  especially 
d  liw  pulw  b«  very  hard  iind  iuromprcAsible.  Should  it  prove  vfry 
Blxuklknt,  dry  cupping  between  the  nhooldfrf,  and  the  application  of  an  ici^ 
DMiiiihf  forehead,  with  rt^t,  will  be  re<(uirfd. 

Uiniemic  and  cachectic  subjects,  and  in  old  people,  the  hemorrhage  is 

^^  tttendMl  by  dangerous  consequences,  and  requires  the  use  of  active 

■KuuTes  !■        ■  ■     ■•.iression.     In  thei»e  cni-es  the  following  plan  ehouid  be 

'B*!'^*      '  '  should  hv  ruisvd,  an   icc-biig  applied  to  tht  forehi-ad, 

^^■0|>ltte  rrai  and  ijuietu<Ie  fujuiii^d.  and  giillic  acid  in  leu  grain  do«>es,  or 

■liiTlrachm  duses  of  liie  tincture  of  crg<il,  adriiiuiBU'red  at  frecjuent  intervals. 

*^fi^  the  bletdiug  ttill  be  profuH.*  and  coutinuoua,  a  current  of  iced  water 

J^J  be  made  to  How  through  the  ni»e  by  uicana  uf  the  nasal  douche,  or  the 

Ulcn(,rnf  the  nuM  may  be  Bpougt^l  out  with  a  solution  of  perchlortde  of 

J^QOor  unnio.     If^Lhis  do  not  aumce.  it  will  become  necessary  to  plug  one 

■mtrils.     this  is  beet  done  by  means  uf  a  plug  of  prepared  sfninge, 

t^4|uilt  orn  piece  of  gum  catheter  passed  through  It  Icir  brealliing 

fWid  soakeil  in  a  sulution  of  perchloride  uf  iron. 

^  ^—.Jthe  hemorrhage  Ktill  itmtinue,  the  blood  paniiig  back  into  the 

^'^Mt,  Bud    (irrhatM    bi-ing  swallowed,   the  posterior  nam  require  Lo    be 

•^U||Rd  as  wril.     This  operation  should,  however,  be  deferred  until  it  btt*. 

****•  aJiwiilutrly  neccANtry  for  ihe  preservation  of  life.    Plugs  in  the  fv«<teri< 

S*^**  '  '■'*'■  soft  pMlatf  areaauurce  of"  very  great  diolrcM  to  mi 

^^l^ii.  .  ".ns  will  rapitlly  wear  out  the  povers  of  life  by  in;.       .       y 

*^  brratliiug  and  sleep.     I  lietieve  that  by  attention  to  proper  coostuu* 


644 


uissASKa  or  TU£  hkau  asd  mxcc. 


tioonl  anij  by  pcreevcmnce  id  other  aoJ  milder  IocaI  lremta)«Dl  pi 
the  p«ie|(rriur  uiirvs  iiinj  (xmiroonly  be  avoiJvtl,  Whrii  abMolutrlv 
il  b  b(wl  (bine  by  t-nrrying  a  lori^  |>t«ce  of  ttiroii^  wbiji-cartJ  aJon^ 
of  ibe  ii'iso  ijirtiu^'li  tbe  fnielwrii.r  narw  inUi  tbi'  |iharynx,  by 
Ik'lliK'tjV  (tuumi  (l-'i^ij.  057 1.  or,  if  ihia  b«  ni»t  at  baiid,  by  ibryafiiiia- 
lliruii^li  ttu  ulualk-  caljieu-r,  ami  carrying  iIiih  idio  ihv  (iharyns.  lh4 
ifae  ciird  aa  il  npitears  li«biiul  th*.'  ^nit  [xilatr.  ami  ilmwiDj^  It  thrwy 
the  mouth,  at  tiiw  Bame  time  lliai  tlif  mtbek-r  is  taken  »ut  of  tht-  tK% 
ih'u  »ay  till?  elriii]^  will  (mn  tbnxigb  the  tif^t?,  n>iiiid  tbe  hark  of 
palate,  iolM  and  iben  out  of  tbe  moutli  (,Fig.t>fid>.    To  thecrat/«of 


Ftg.  SAT.— B«ll«eq'*  SmiBiI. 


of  MiMa'*  9««i<l. 


of  ntrtng  ibat  hanga  out  betirern  ibe  Uft,  a  jiltigof  liot.al)>>ot  tbi> 
6n!t  joint  «if  the  th<inib,  or,  (xltcr  still,  a  jiicce  of  contprcH«?il  M-'Dg 
be  firmly  tier] ;  this  is  then  ilranu  up  into  the  posterior  nans  by  n 
the  end  nf  tbe  ligature  that  bangs  fnrni  tbe  miae,  being  guid«<t  in  ttl 
behind  the  palate  by  tbe  fiugerv  introduced  int^i  the  moutb.  When  t 
iag  has  t-eiuied,  it  may  reaiiily  be  witbdrano  by  meant  of  tbe  *tl 
bangs  out  of  the  mouth.  As  (he  epiBtuxl*  in  very  apt  t^  recur,  it 
precaution  when  tbe  plug  is  n!m>jTed  from  bchiud  tbe  palate,  to  Ira 
of  *tring  in  the  nosQ  anamnutb,  which  niny  be  knotted  and  Qxrd 
of  jilnMer  behind  the  ear.  In  lhi»  wny  the  plug  mny,  if  ocewioo  i 
reailily  replaced  nilhoul  the  Deccsfily  of  reintroducing  the  aound  « 
througb  the  ooae,  which  is  often  a  troublesome  opcmtioQ. 

■H'Moius  of  rut:  hxaxl  romx, 

foLTfXm. — Tiimoranf  verv  dUTerfQl  «raotur«  and  com,  ___ 
vltli  in  the  noetiiU;  am)  to  Mlloftbi-w  uriijch  |«imeM  tbccomomn 
of  being  {leadulou*  and  blncUiiig  up  iIk-w  pnnafiec.the  tMin 
Tbua  tturgenns  commonly  s|M-ak  of  the  Hmign,  llie  Soyi,  tbe  ttrla 
AfvCQW  f*o(w.  nfl  well  M  ibe  S'irramaioug  ^<T  i-/r*Av.  and  the  Mnh'jnf^ 
Tbff  term,  nowever.  ■boiihl  pnuwrly  t»e  c'nfineif  lo  a  mU  and  | 
mucous  growth;  the  fleoby  and  mnlignnnt  polypi  bving  mcrr  ra 
fibnmii,  mvoloid,  or  other  sarcomalonii  tumoni,  springitig  from  tiia 
tht  naaal  iimm,  or  firom  tha  etbmotdnl  and  sphenoidal  cflb. 


The  true  KaoQai  Haial  Polyp  is  a  soft,  rooijt,  gelalioous  tumor,  of  a 

paTMb-yelloHF  culur  when  iiid|f(^tl  iu  the  nasal  f(ta«u!;  hut  nrhcD  it  descends 

Ufllbe  aoterinr  uar«id,  or  bcyom)  tht^iti,  ami  is  cxptUMl  to  the  air,  it  becomes 

of  I redrlish-brown  or  purpit*  tint,  and  s«)mcwhat  shrivdlod  on  thn  jiurbc«. 

liiiusialljr  lobulated,  pedunculated,  or  bottle-shaped  ;  and  not  rery  vascular 

a])i  at  ibe  rixit,  whcrt*  it  is  perinfalnl  by  thin-walled  veaseb  that  bleed 

y  4in  the  iili}>htcKt  touch.     In  structure  it  ift  Doft  and  homogeoeous  tn  the 

liij  fye-     If  cot  acrum  and  »r|ueexed,  a  larjre  (juiintiir  of  thin  fluid  thms 

I,  and  lh«  maM  becomes  reduce<l  to  a  eiipall  proporliuii  ut'  it»  originul 

i.    Mucyus  )>oljrpi  are  furtned  by  an  ov-tfryrowth  ol"  the  iducoub  «u«1  sub- 

tiMue  of  tbe  noee.    They  are  oovvred  completely  by  luucouu  tueiu- 

kriuv  with  ciliated  epithelium,  ihv  cilia  of  which  luay  b«  aeeu   in  nctiv« 

iii/txBmt  uiiiler  ttio  njicnwcope  utter  removal.    The  uiucuue  uiembruue  may 

wmv  nut  coalain  glau<U;  occasional  I  y  tbt*  surfaco  t»  pitted  by  the  uriGeei 

it^wia  of  cuDsiderablv  siie.     The  tissue  which  luruia  ih«  bulk  of  the 

Umf  is  ct>mpuae<l  nf  delicate  bands  of  connective  li^Hue  wparaletl  from 

■datJier  bjr  au  abundaol  mucous  duid.    Amongst  the  fibrv^  are  ruimenius 

■ililiUKr  nmnded  nr  presentiiij^  the  stellate  tiirni  fouml  in  true  mucous 

tlMB  (see  Myxoma,  vol.  i.  p.  ^i'tl.  Vi^.  :i77).    The  whole  raasi^  i»  abundaotly 

Mfpried  by  mseb.     Ocrstuonally  polypi  are  found,  growing  fniui  the  tower 

put  of  the  nam,  covered  with  lemeltHteil  epithelium.     The  (uraor  mny 

ttn  Trum  any  point  of  the  aurftice  of  the  turhinati-  and  ethmoid  boned,  and 

m'mitmi,  tfaoogh  very  rarely,  lieen  obwrved  to  project  tnro  the  now  from 

^  ftuatal  nnuan  and  antrum.     I'olypi  ni(»c  frequently  grow  from  the 

■iUkipongy  bone,  sometimes  from  the  inferior  turbinate  hone,  and  in  rare 

omaikey  are  said  to  have  been  seen  springing  from  the  roof  of  the  nareti, 

^oner  from  the  septum.     The  polypi  are  usually  numerous  and  of  all 

;  at  they  ioereaat.*  tbey  commonly  exteod  t'urwards  into  the  anterior 

but,  when  large,  tbey  may  be  se«n  lu  reach  into  the  pbaryux,  bang- 

Mrdoan  behind  thu  palate. 

SfrnfOoms. — The  E>Tritp(om9  occasioned  by  the  preseacc  of  nesal  polypi  dt- 

p>4uD  the  interlcrcDCP  nith  respiration  and  speech  w hi cb  ther  occnnoo. 

Bovnadaa  through  the  a(Tecte<l  n<.i0tril  is  impeded,  the  patient  being  unable 

■nUiiw  through  it  when  directed  to  do  au;  and  his  speech  is  thick  and  uasaL 

^Wttin  auudhog  and  mucus  discbarge  from  the  nostril:  and  all  ibwa 

■^•ptwna  ar«  worae  in  damp  than  io  drv  weather.     On  exniuiuing  the  inta* 

nnsaf  the  now.  by  opcniuiL'  ll<c  iir'.^tril  widid^    with  the  forcejia  or  naikl 

^^IvB  'Fig.  fioij  I,  and  then  directing  the  patient  to  blow  down,  the  lower 

^i/ibc  pulvp  muv  he  dJatinctiy  Hcen.  and.  if  liit^,  will  dcBcciid  to  a  level 

'^''  oreret)  beyouJ  the  nasal  tt|H'rturc.     Hy  ihti  intrmluction  of  a  probe, 

and  extent  of  the  tumor,  together  with  th<^  position  of  its  pedicle, 

readily  aart-rtuiucl.     Aa  it  gmus,  it  impreasis  chaagua  ou  the  shafw 

boring  bonra,  pnxluring  expanmoii  and  tlnttening  of  the  now;  and 

ing  with  the  diiw  of  team  down  the  nasal  iluct,  occusionn  a  watery 

*^nf  tim  ey««,  which,  together  with  the  change  of  shape  in  the  feauim, 

**^  the  peeuliar  chumclrr  of  voice  anil  respiration,  enable*  the  Surgeon  ai 

**^la  rtc'fgntw  th<?  nature  of  his  p.itii-iii'ii  diwiwc-    Polvpi  occur  chietly  in 

^f*l^  adoliH  nfirr  the  axe  of  putK*rly ;  hut  they  nre  not  unfrequcutly  met 

^4  at  later  perii«l»  of  life. 

/TlMtr  (.htuet  are  ttry  obscure.    Most  comnKmly  Ihey  are  referred  either  to 
^Mwr  or  lo  ■  pndongcd  aitarrh.    They  are  more  common  in  women  than  in 

^^^HhiMML — 1.  Mucous  nwal  poljpi  may  be  distinguislied  from  rMraniL 
^HVMay  af  M«  miuvuj  membranv  emxrin^  the  i^mt^y  bvttr*.  by  the  absence 
^  tW  bUcr  *if  any  pedunculated  growth  artnind  which  u  probe  can  be  passed. 


544 


DISEASES    OP   TEE   HEAD    AND   XECE. 


tional  nnd  liy  pcraeTpraiK^  in  othrr  ami  milder  IooaI  trcntmenL  p1»^G;in);i 
the  pi«tcrior  niires  niav  coramcmly  be  aroiderl.  When  nbxoluiely  r<f|uired 
it  is  best  «](iiie  by  airrying  a  long  piece  of  sLronj^  wliip-cnrd  atniijr  tlie  fluor 
of  the  na<ie  throiijtU  the  poNlerior  naren  into  t1n>  phnrynx,  by  means  of 
Bellocq'ff  sound  (Kig.  fi-'i?),  or,  if  ihi-t  he  lint  at  hniid,  bv  llireadiug  the  coni 
through  4n  elastic  catheter,  hihI  c»rryiii^  thtx  into  thi;  phnryiix,  then  feixiag 
tiie  curd  as  it  a|i|>eani  beliiiid  the  «(>tt  pnlnte,  Rni(  drawitig  it  lurwardii  intij 
the  iiioutli,  at  the  sanie  time  Ihut  the  catheter  ia  tukeu  uiit  of  the  uij«tnl.  In 
thia  way  the  string  will  ]mait  UirtKigh  the  nooe,  muud  the  back  of  the  soft 
palate,  into  aud  then  out  (.if  the  mouth  (Fig.  058).    Tu  tbe  centre  of  the  pietw 


I 


■r  V 


■Ah  vi; 


Vlf.  e&7.— B«ll»Mi'a  Sodod. 


Fig.  AM — UUgrnoi  of  nagging  tb«  Nwcbll  lij  uMa* 
of  B«IliM<)'i  Scuad. 


of  String  th»l  huiijL'B  out  between  the  lipi,  a  pluf;  of  liot,  about  tbe  eise  of  the 
6nit  juiuL  of  the  tnunib,  ur,  better  still,  a  piece  of  coniprrssed  smoge,  ehvmld 
be  firmly  lied  ;  this  is  then  draun  tip  iutu  tbe  posterior  nares  ny  pulliog  on 
tbe  end  <)f  the  ligature  that  hangs  frum  the  nose,  being  jfUJded  in  its  pB8sag:e 
behind  the  palate  by  the  lingers  introduced  into  the  mouth.  When  the  ble«I« 
ing  has  ceatted,  it  miiy  reiidiJy  be  Mithdrawn  by  meitiis  of  tbe  string  that 
baugB  nut  of  the  ni<3Utr).  As  the  epislaxU  is  %'ery  apt  U^  recur,  it  i»  >  wise 
precaution  when  tlie  plug  is  removed  fruni  behind  the  palate,  tn  leave  a  loop 
of  string  in  the  nose  and  mi)utJi,  which  may  be  knnlteil  and  fixed  by  a  slip 
of  plnflter  behind  the  ear.  In  ibis  way  the  plug  may,  if  occasion  occur,  bfl 
readily  replaced  without  the  neecntiiy  of  reintroducing  the  sound  or  catheter 
through  the  noee,  which  is  oflen  a  inmbloBome  operatiop. 


TLIblOES  OF  TBE  KA8AL  FOEBJR. 

PoLTPrs. — Tumors  of  very  different  Mrnctures  and  composition  are  Tnet 
with  in  the  no^iiiln  :  and  to  all  of  thexe  which  pnpseM  the  common  characters 
of  being  poudulous  and  hlorlttng  up  these  pawingeo,  the  term  /Vi/ypiutA  given. 
Thus  Sargeoue  cimmonly  speak  nf  ibe  Briti^i,  the  Sofi,  the  Gr/n/i'woM*.  or 
Murvut  Polfp,  as  well  as  the  Sirrumatov»  or  i'lfthy,ant\  tbe  MotlgnoMt  Pitlyp. 
Tbe  term,  however,  should  pn^perty  be  eouBned  to  a  soft  and  pendulous 
mucous  growth;  tbe  fleshy  and  n>aligtiaut  polypi  being  mere  varielies  of 
6brou8,  myeloid,  or  other  sarcomatous  tumors,  springing  from  the  booes  in 
tbe  uasal  l^iesoe,  or  from  tbe  ethmoidal  aod  spheuuidul  cells. 


J 


MDOOUS    JiASKh    POLTPirs. 


545 


Tl)«  true  KncoDS  Hasal  Polyp  h  a  aofl,  moi«t,  g«latinou8  tumur,  of  a 
gray ivli-vel low  culur  wheu  luJgeil  in  the  untial  I'uMte  ;  l>ut  wlieu  it  ciwccnds 
iulc  llie  anterior  nsroa,  or  beyutxl  them,  and  is  exposed  Ui  the  air,  it  beconies 
of  a  reddish- brown  or  purple  tint,  and  quniewhut  shrivelleiL  uu  th«  surface. 
It  is  usually  lobulated,  pedunculattil,  *<r  buttk'-shaped  ;  aud  not  very  va-tculnr 
except  at  loe  root,  where  it  is  iieruiealed  by  thin-wniled  vessels  that  bleed 
&eely  ou  the  8liglitei>t  touch,  la  structure  il  is  sot\  and  honiugeneoiis  tu  the 
naked  eye.  If  cut  acrws  and  ^(gueezcd,  a  large  quantity  of  thin  fluid  flows 
fmiti  it,  and  tlie  niHsg  becomeii  reduced  U>  a  ^nmll  proportiou  of  its  origtuo) 
hulk.  Mucous  polypi  are  formed  by  an  overgrowth  of  the  mucous  nn*!  sul> 
IDUCOU8  tt8«uc  of  the  iiiise.  They  are  covercil  completely  by  mucous  mem- 
brane with  eiliated  eiiitheliuni,  the  cilia  of  which  may  be  ^cn  in  ncUvfi 
movemerii  under  the  microacope  alUr  remirval.  The  mucous  luembrune  may 
or  may  not  contain  ^dami^ ;  nccosioually  tbc  surface  is  pitted  by  tlic  orili<^ea 
of  tflanda  nf  ameideruble  size.  The  ttattuu  wlildi  forms  the  bulk  of  the 
tumor  is  composed  nf  delicate  hande  of  coniitctivc  tissue  separated  from 
each  other  by  an  ahundnnt  mucous  fluid.  Amongst  the  fibres  arc  numerous 
cells  either  rounded  or  protcnting  the  stellate  tiirm  Ibund  in  true  niucouA 
dsue  (see  Myxoma,  vol.  i.  p.  iir)l,  Vi^.  .ill}.  The  whole  mans  is  abundantly 
snpplied  hy  vemels.  Occasionally  polypi  ar<?  found,  growine  fnmi  the  lower 
part  of  ih'e  narK>,  covereil  with  leafwllaterl  epithelium.  The  tumor  may 
grow  from  any  point  of  the  giirfiti-e  of  the  turbinate  and  ethmoid  boneii,  and 
na*  indeed,  tlmn^li  vprv  fHrely,  been  observed  to  project  into  the  nose  from 
the  fniotftl  siniisi^  and  aiitrurH.  Polypi  most  fre<]uently  grow  from  the 
middle  ajMingy  bone,  sometime.'*  from  tbc  inferior  turbinnlc  bone,  and  in  rare 
Cfl«ea  they  are  said  to  have  been  s**ii  springing  from  itte  roof  of  the  tiares, 
but  never  from  the  septum.  The  polypi  are  usually  numerous  and  of  all 
sizes;  us  they  increase  ibey  commonly  extend  lorwurds  into  the  auterior 
jiares,  but,  wlieu  large,  they  may  be  seen  tu  reach  into  thi;  pharynx,  hang- 
ing down  behind  tbo  palate. 

Symptoms. — The  symptoms  occasioned  by  the  presence  of  nasal  polypi  de- 
pend on  the  interference  wilh  respiration  aud  speet-h  which  they  occasion. 
iKespinition  thnmgb  theaHccled  n»!>tril  is  impetled.the  patieut  b«ing  tinablo 
to  blow  through  it  when  iiirect>,id  to  do  so  ;  aud  IiIk  speech  is  thick  and  nut>ul. 
There  are  enulfting  and  niuc<iiii!i  discharge  from  the  nu^tril :  and  nil  these 
symptoms  are  worse  iu  damp  than  in  dry  weather.  On  examining  the  inte- 
rior of  the  nose,  by  openiu;.'  (he  iin.=tril  widflv  wilh  the  force|)e  or  nasi^l 
«(iMuluin  (  Fig.  Or^tii,  and  then  directing  the  patient  to  blow  down,  the  lower 
«nd  of  the  polvp  mav  he  distinctly  scon.  and.  if  Inri^e,  will  deecetid  to  a  level 
'wilh  or  even  beyond  ibe  nasal  aperture.  By  the  introduction  of  a  probe, 
»lie  iiae  and  extent  of  ihe  tumor,  together  wilh  the  position  of  its  pedicle, 
may  be  readily  ascertained.  As  it  grnu-a,  it  impresKt'S  changes  on  the  ^hape 
«f  neighboring  bones,  producing  expansion  and  flattening  of  the  nose ;  and 
interfering  with  the  flow  of  tears  down  tbo  nasal  duet,  occasions  a  watery 
«tiue  of  the  eyes,  which,  together  with  the  change  of  shaiie  in  the  features, 
vnd  the  peculiar  character  of  voice  and  respiration,  enables  tbc  Surgeon  at 
«iuoe  to  recf^rniite  the  nature  of  his  palienl's  disease.  Polypi  occur  chictly  in 
^■«jng  adolla  after  the  ace  of  puberty  ;  but  they  are  not  unfrequcntly  met 
■*i(li  at  Inter  periods  of  life. 

Their  (Jau»f*  are  very  obscure.  Mo«t  commonly  they  are  referred  either  to 
a  blow  or  to  a  prolonge<l  catarrh.  Tbey  are  loore  common  in.  women  than  in 
Xiien. 

[}iittfno«\$. — 1.  Mucous   n^Mil    [''^l>l'i  u»iy   ot  dislitigui.'.hed   from  ("Ancimit 
thickminy  of  (he  mucim$  mmf^runr.  cifrvrituj  the  'poiufj   bou^f,  l)y  t!ie  ab»«ence 
intlielatterof  any  pedunculated  growth  uruuud  whicb  n  probe  can  be  passed, 
VOL.  II.— SS 


646 


DISEASES    OF    THE    QBAS    AND    KXOIT. 


by  the  florid  red  di:imc'l«r  of  llie  thickened  iiierahmuv.  and  by  the  facL  that 
the  eubji'Ctn  ol'  this  thickeiiin});  are  almost  invariably  xlruranuB  children.  2. 
la  ai>aiw«'t  of  the  tcpluta,  llie  hii<t<iry  <iJ'  the  ca^p,  and  the  fart  <il'  the  [x>lyp 
never  hiding  attacht;d  to  ihi^  jiart  of  the  nofie,  will  tstahlifh  the  diignoeis. 
S.  There  is  a  ppcniiar  maiformation,  consisting  in  a  den'iati'on  of  the  Mjtttan  l« 
[me  i»i(ip,  that  may  nt  tiret  he  a  little  puKzUiig ;  but  here  the  exatninatton  of 
both  niipirilrt.  ana  the  HJnctivery  of  »  depression  of  <iiie  siile  of  the  eeptum 
corresptimiing  in  the  pmjection  on  the  other,  will  rcvt^l  the  Inie  nntnre  of 
the  case.  4.  The  jSAwiw  ajid  maiit/nani  (umordof  the  no»tril  will  be  loiind  to 
differ  euffitiently  in  consistence  nuc!  apnearnnce  from  the  ordinary  polypi  to 
prevent  their  l>eiDg  confounded  with  tnem  in  many  cases;  yet  in  some  id- 
ttlnnces  much  care  will  be  required  in  coming  to  a  definite  opiniun  as  to 
their  true  nature,  o.  In  one  recorded  case  n  meningoeeie  pn^ectiiig  into  the 
naaal  cavity  was  mistaken  for  a  polypus. 

Treatment. — The  spontaneous  separation  and  expulsion  of  nasal  polypi  is 
of  mre  occurrence.  I  have,  however,  seen  one  case  in  which,  alWr  the 
aniduouti  one  of  chloridp  of  litic  injection?,  tt  very  copious  dischnrge  of  large 
aluugby  polypoid  rnaMes  tuok  pUct  truiii  oneuoatril  which  had  been  blocked 
up  by  them  for  iiiuuy  months  previously,  and  from  which  they  had  even  de- 
ocentled  into  the  pharynx. 

Nasal  polypi  may  generally  be  most  reiidily  removed  by  avulsion  with 
forcepo ;  occasionally,  Imt  mrely,  when  they  are  very  large,  with  a  broad 
base,  and  esfwcially  when  they  extend  into  the  thront,  they  require  the  appli- 
cation of  the  ligature.  In  removing  these  growths  by  the  forcepf,  instru- 
ments of  good  length  but  very  slender  construction  should  be  used. — thoM 
generally  sold  are  too  thick;  the  interior  of  the  blades  should  be  properly 
serrated,  and  have  a  longitudinal  groove,  an  that  the  root  of  the  tumor  may 
be  tightly  grasped.  The  patient  should  be  made  to  sii  on  h  rather  Iutt  chair; 
and,  88  there  is  generally  a  good  deal  of  hleetliiig,  a  towel  ithould  be  pinned 
over  hi^  clotlit'S,  and  a  bti^in  placetl  before  him  lo  receive  the  blond  and  expec- 
torated mailers.  The  Surgeon  then,  having  at^cerinined  by  the  iutrottuction  of 
a  prr»be,  or  by  means  of  the  binilea  of  the  lonreiis,  thu  Bituuiinii  ol  the  pedicle 
of  the  polymii^.  gra»|H  thin  linuly  und  pulla  it  ulf  with  n  iwistins;  mi>vement 
of  the  liand.  He  procemlit  in  thi«  manner,  twisting  off  rather  than  pulliug 
away  polyp  al^er  {>i>Iyp,  until  tho  whole  of  the  noatrit  i*  cleareii,  which  may 
be  ascerliiined  by  exatiunntion.  Hn<]  by  ilirccting  the  patient  to  coninreas  the 
Mund  ami  to  blow  through  the  alfected  »iile  of  the  nose.  The  nieeding, 
which  is  often  very  free,  stops  on  the  application  of  cold  naier.  At  about 
the  end  of  n  fortnizht  the  pntient  slionld  be  eYamined  again,  as  it  not  qd- 
frequently  happens  that  .small  polypi,  which  had  been  prevented  from  de- 
scending into  the  nnrts  by  the  presence  ol'  the  larger  ones,  now  come  down 
and  r^-qulre  removal.  These  procedures  numt  be  had  recourse  to  from  time 
to  time,  until  nil  lendencv  to  fresh  formations  of  this  kind  baa  ceased. 

The  Ugtdurr.  is  required  chiefly  for  ihaie  polypi  that  jtnas  into  the  pharynx 
through  the  postcrii.r  nares.  They  may  best  be  tied  by  passing  a  liwp  of 
strong  whipcord,  bv  means  of  n  double  canula,  through  the  nose;  and  ineo, 
aflcr  expanding  t^e  nm>se  round  the  tumor  in  the  throat,  and  making  it 
grasp  its  pedicle,  knotting  it  lightly.  In  gome  inslmices  ibe  {M>ly[>i  attsio  a 
great  St £e,  producing  abanrplioii  of  the  nasal  bones,  and  of  the  nasal  process 
of  the  su|<erior  iimxilla,  In  such  cases  it  may  be  necessary,  in  order  to 
extract  them,  to  slit  up  (he  nose,  and  clip  away  with  forceps  the  osaeous 
■surface  from  which  they  spring. 

Tibrous  Polypus.    Jfaso-pharjnijgeal  Tumor. — The  term  fibrous  nolypos 

s  applied  ti)  a  iibrotua  epringing.  in  exceediug£y  rare  cases  from  the  peri* 

osteum  of  the  bones  entering  int^>  the  walls  of  the  nasal  cavity,  but  mor« 


KASO-PHABTNOEAL   TUMORS. 


547 


ilr  frnm  tho  bup  nf  the  skuti,  especlnllr  from  the  basilar  process  of 
ipitnl  b'>ne  an'l  tUe  un>)er  siirfnce  o(  the  body  nf  the  sphenoid. 
'))imai  polypus  it  ti  difteBM!  of  earlr  life,  seldom  comrnenciot;  bef-ire  thp 
rar  or  H(^er  thr  twentieth.  A»  ihe  tumor  incrcucs  iu  «\te  it  grii<l- 
ll«  the  upji^r  part  of  ili«!  pharynx,  and  extends  into  the  posterior  jMirl 
,1  cavity,  llt^  ourfaw!  is  lohuiated  au-l  covered  by  riiiioww  (ucm- 
b  firm  ami  r«irtirij;  t<t  the  touch.  Iu  the  earlier  singes  it»  form 
linean  be  wcerlJiiiteH  *'nly  by  digital  «xamiiin.liim  from  the  ramith.  the 
bciag  passed  up  behimj  the  »'}ft  palate.  In  the  later  tfUigus  the  tumor 
seen  frotti  the  noatrils,  and  iiiuv  appenr  below  the  sufl  palate,  push- 
forward  and  wriously  iuterlenng  with  deglutition,  and  finally  with 
intiun.  Thcw  tuniurs  blevd  freely,  and  mny  even  be  fatal  directly  from 
cf  Mood.  Micrtofopic  examinatioo  ahuws  that  they  are  compoewl  uf 
ibwttB  tissue,  with  a  varying  number  (»f  flattened  ur  oat-shaped  cells  beln-een 
tfc«  fibre*.  They  usually  contain  larjre.  tortuous,  dilated  vcMels,  which  form 
nprpMBiDeot  a  Ipaturc  in  their  structure  that  it  hait  mmetitups  berti  eug- 
fatal  to  tfrni  the  gnwlb  fifiroiuiffioma.  When  these  veesele  are  opened  hy 
■kBaiiiin.  '-r  in  an  openiliou  for  removal  of  the  growth,  they  bleed  exoef?J- 
i^ijr  frvrly,  l»einp  unable  to  oootract  Of  retract,  owing  to  the  density  of  the 
Mnoture  in  which  they  He. 

The  ffamatU  is  extremely  unfavorable.     If  Icfl  unrelieve<l,  they  always 
■Wimtri  »toner  or  later,  either  by  hemorrhage  or  asphyxia. 

IV  TMoiment  cfmsiste  in  their  remnviil  whenever  ihis  is  possible.  When 
ttttUKir  it  {•cduiiculalcd  it  mav  be  possible  to  pnss  ihi?  loop. of  a  galvanic 
tWMr  nr  of  a  common  wire  irorasenr  round  the  pedicle  fn>m  the  nose. 
UBb,  however,  seldom  practicable.  Elcctr^dysis  is  said  to  have  been  8uc> 
■rtlly  oorH  in  the  destruction  ol  lbc«e  tumor^  but  its  efficacy  is  somewhat 
A^fttl.  The  metliod  generally  rec<ignixed  ab  being  most  generally  appli- 
ID  the  preMnt  day,  \a  removal  hy  means  of  Paquelin's  rccl-hot  knife; 
iftiirder  bi  dc  tli)#.  it  ii  neceasary  to  ezpoM  the  tumor  folly,  and  several 
P'wbImivc  bo<-n  su^geslod  of  doiog  this,  of  which  the  following  are  Ihe  most 
Wortiot.  WboQ  aay  cutting  pTnn  h  adupteH.  it  in  always  saler,  as  great 
■Mrrfaagv  tnmj  be  expected,  t^  do  a  prclimiunry  tracheotomy  and  to  plug 
IJMtnclKfi  with  Trcudcleobiirg's  obturator,  or  in  pmsa  a  large  apODge  into 
ynx,  otherwise  death  may  be  cauaed  by  entrance  of  bluod  Into  the 

l^ir  William  I^Jiwreuce  exposed  the  nnsal  foaste  for  the  removal 
^*typi  by  carrying  an  incisi'to  round  (he  nose,  eommenciug  uu  one  side 
Kiaienul  to  the  lachrrinul  sac  and  terminating  at  the  aaiue  point  ou  the 
^Wade,  pMaiaj;  below  heiween  the  aln  nasi  and  the  upper  lip.  The  atw 
•■••uu  thro  w^jMraled  from  the  boue  and  iho  nasal  pniccss  of  the  superior 
■Utik  divided  IU  the  incision  with  cutting- pliers.  The  eeplnm  being  then 
the  niMH  wus  turned  upwards  towards  the  forehcKd.  The  nasal 
itTJs  ihiu  very  fully  fxpi<fteil,  and  the  space  obtained  iimy  in  some  casvs 
for  ihe  removal  of  a  iioso-pharyngeal  tumor  of  conaidenkble 

(ftr  rtr      "       '■  11  somewhat  similar  operation,  but  curries  his  incision 
'■Uisnpp»-  i.in,  commencing  at  the  ala  on  one  siile,  pn.<uting  up  the 

■|**f  I  '.■!  lb©  let'cl  of  the  lower  margin  of  the  orbit,  then  acniwi  the 

*id|i>  2  <  11  the  opposite  side,  terminating  at  the  ala.     The  iifuuit  bonea 

''dtbeDaml  process  of  tlte  superior  mnxilla.so  far  as  it  is  coocernwl  in  the 
[^fcc.are  th^-o  cut  thnogh  with  a  fine  «iw  nnd  the  ii.ne  turned  downwnrda. 
7 'li^h  the  upper  part  of  the  na^al  cavity  is  very  fully  expu«eil.  In  b<jth 
^^  DwtboH*  the  Doee  \a  replaced  after  the  operatiuo,  and  very  little  de- 
'•••lir  renilta. 


54B 


DISBASBS   OF   THE    HK&D   AHU   XBOK. 


I  CM 


Rouge's  operntioa  (]>.  5^4)  niiglit,  in  some  cbms,  giT*  luffieiiini 
the  oaaal  envily. 

Mnnnc,  nf  AvignoQ,  to  ITll,  oltempted  to  n»cb  llicM  tumors  fran  (btf 
itioutli  by  dividing  the  toil  psUte.  N^Iaton  rxletuU  tho  oiirruion  lint:  • 
l^llI«vc^M^  incision  is  firet  made  acrcm  the  hnnl  poiate  at  the  Ivirriaf  tki 
iiecond  liicuRpid  tcctli ;  from  th«  middle  df  this  a  Mcood  iocimtti  it  carrM 
biickw«rd»,  dividing  the  and  mructiires  of  the  bard  palate  uti  tb»  aft 
palate.  Br  means  of  the  p^rimteal  elevator  and  nc'imoni,  tb«  two  Aafia  tlta* 
formed  arc  separated  from  the  hone  and  turned  donnwnrdi  and  oaiwank, 
nut  (if  the  U'ny.  The  expose<l  part  of  the  hard  palate  fx  thrn  rnmoved  wiifc 
a  ohioet  and  mallet,  and  thus  the  postf^rior  part  of  the  naaal  cavUv  Mtd 
upper  part  of  the  pharynx  are  brotighi  very  fully  into  view.  After 
oiMTftii'Mi.  the  tlapa  are  united  by  ^uiurea.  an  in  th»  opcraiioa  for  ono, 
cleft  pnliile. 

O'liiplele  removal  of  the  aup^rior  niRxilla  by  Symt>,  Flaiih«-rt,  nod  gthctii 
ha«  been  ndopted  tw  a  preliminary  utep  to  remui'al  of  (he  titimuN  lumor 
of  uiiii^ual  size.     l>Aii)|:enbeck  ainl  (itnera  hav«  ])erf(inTi«9d  partial  n 
of  llie  np|ier  jaw,  ivilli  rcijlactrnieiit  of  the  bone  atter  tfa«  tJir«nition. 
prooe«dinjj8  are  more  fiilly  deM)rib(*d  in  Chapter  LVIi. 

All  these  (»)>cniti<jn8  arc  more  or  Ivsa  ditiicult  and  dungcrous,  ma6  abaaU 
nut  bo  undertaken  unlcea  the  tumor  Uirvntcnii  dcatii  fn>u  ilaaueorfivM 
IiKSB  of  bliKjd,  or  shows  evident  signs  of  netivc  growth.  A 
Le  Fort,  fibrous  {Milypi  tend  bi  ceiue  growing  with  the  growth  of  tiw 
and  pnrtiiil  dwtroctioti  of  the  lumtir  br  cuuLerizalioD  or  eJectrQlyiis 
^onif'timt-it  sur(H-«-d  in  nrrtfiling  the  further  progreaa  f>f  the  gnmib. 

Kalignaat  Nasal  Tnmon.  -There  i^  a  remarkable,  as  yat  iiiiiliiilllwl 
and  to  mr  ttu?xplic»li)e,  ooniierlion  Ix-tween  thi^  urittnarr  ben^n  ■■■!  poly^ 
pu6  and  ttininra  of  a  Min*omalou9  or  rjinr<>rou)i  rhnracler,  de¥»lofii»g  as  a. 
■equence  of  the  extmclion  of  ihe|Hilyp  in  the  lartre  cavities  and  ioiMnmmam 
fissarea  in  the  vicinity  of  the  narcA.  1  have  wveral  times  bmo  ia  duUnK 
and  vnnnf*  aduttH  tiiniom  of  the  alHive-mrnttnneH  rharmctsr  dcvalttpl^f 
rapi<(ly  in  the  orbit,  the  sphenoidal  cells,  or  liehind  the  snpt-rior  tuuilla, 
alter  the  extraction  of  pertectlraod  anatomically  benign  nasal  polypi.  TW 
qucfttioDS  to  be  dolved  are  these :  Are  tbeae  tumor?  tbr  rrsuji  of  ibe  irriia* 
lioo  of  the  operation  of  extrnctionf  or  are  lb«y  tbr  priaiary  d^^-"  '''o( 
concealei^l  and  undevelii|)ed  in  the  deep  cavities  of  thi>  face,  the  >  ••I 

[wlyp  bt;inft  wcondary  in  reality,  though  more  appari^t.  and  cntut^juesE  <m 
the  irrilHtion  ^  up  by  the  [fraver  aixi  yet  latent  tunfir?  In  wbatorer  way 
future  investigator*  may  auiivt-r  this,  the  fact  reninins  certain,  that  a  odo- 
nectiou  dues  exist  between  the  two  forms  of  disease.  I  have  •ereiml  tiiMs 
ubMrved  it. 

TumoiB  of  rapid  growth,  malignatit  hi  their  course  (sometimes  «alM  a» 
lignauL  polypuB).  either  epithelioma  or  sarcoma,  occasionally  turmpriaarilt 
in  the  midille  of  the  nasal  cavity  or  about  ibe  posterior  narea.  Imt  gnw 
rapidly,  with  great  expansion  of  the  bones,  much  discharge,  olkas  lUsai 
tciuiive  DHJu.  and  bleeding,  (be  hemorrhage  Iniing  often  fxecwInL  Tbsr 
Bttaek  children  and  persons  advanced  in  lite.  A  tumor  of  thin  kind  may  m 
developed  in  difll-rvnt  situations.  Thus,  in  some  case*,  it  extends  taui  ibf 
pharynx  behind  the  nofl  palute  :  tn  others  (t  has  a  tvntlency  to  pms  agliaw 
alwnrb,  and  protrudo  through  liie  naral  or  lachrymal  bone*,  nroalanio^  tib- 
stniclion  of  the  nrntril,  direrg«*nce  and  prntruxion  of  tlm  evcl«II.  with  ita- 
lurbance  of  vision,  and  i^vere  ni'iirnlgir  (xiins  in  ibc  head  i:'  '  "  'ft 

(.'lairtio  tumor  that  projecia  at  the  inner  ttide  of  the  urbic.  ft-  >;« 

nniie  and  r>ome  littk'  dt»Liiore  down  upon  the  chetrk,  ub~  >- 

iug  the  bones  on  which  it  lies,  and  giving  rise  to  8cc>.i.       .  --t 


NASO'ORBITAL    TOUORS. 


MP 


ehiiw  its  true  uati 


Tben  dweMot,  Mpft* 


'  tk  ugk  of  the  jaw,  will  sooo 

rUIr  vbpD  oocorriiitr  in  yuung  [>eo[ile,  speedily  pruve  fatal.  Death  mif 
•oenrin  TariouB  irnrs.  acvordiag  to  the  imture  of'  the  growth  and  the  diroc- 
Uoaof  ilB  dereJdpfuent;  by  cxhaostiou  fmin  henii>rrhage  ;  by  the  implica- 
ifaa  af  tin  brmio  aud  iu  membmuea;  bv  Hgphvxia:  or  bv  coDstitulionnI 
Mloy. 

twnaiL — It  ia  seldom  thot  aoythiDg  very  eflbctual  or  pennancDt  cad  be 

im  fay  o[KfmtioD  ;  and  U  should  be  borne  iu  miiitl,  that  some  of  the  molig- 

Mat  growths  which  projeot  itiu>  the  nostrils  take  ihtir  origin  from  tfacephe- 

aaiiu  i>r  etltrnoulal  eelU,  or  even  from  within  the  cranium,  and  that  the 

mmi  pitriion  is  ouly  the  externai  protrusloD,  an  it  were,  of  a  deeply  aeated 

tnor.    Sbiiuld    the   tumor  be  alow  to    iU  growth,   with   an   aWence  uf 

MBidary  depuaiu,  thv  Surgeon  mar  eodcflvor  to  ejElirpate  it  by  laying 

llw  «ide  uf  the  fnci!  frei>ly,  making  aa  iDci^ton  from  the  inner  ao^le  of 

uttQ  the  aide  of  tlit^  unae,  ituit  then  acroaei  the  cheek,  diasecling  up 

Itular  Dap.  ciitlinK  ncnvB  the  sujitirior  maxilla  above  the  line  of  the 

with  a  narruw-bladed  saw  and  cutting  pliers,  and  then  in  a  simitar 

1  iadi  the  (trliit  beyond  and  through  the  nasal  bones,  and  the  nasal  pro- 

ibe  superi'lr  iiinxillii  alMve  the  tumor,  and  ihuit  extirpating  the 

lo  thii<  operaii'  'U  tlieix-  h  'iften  free  bleeding,  which  may  be  arrested 

■ytfce  aetttnl  eautfry,  and  by  pludgets  of  lint  soaked  iu  the  perchloride  of 

'fM.  «liii-h  have  the  additi'iual  atlvnntago  uf  deatruying  uuy  portions  of  the 

"■Mr left  bebtod  in  the  irrt*guliir  and  cellular  caviiies  of  (hi^  rei*ioa.     In 

■*W  own  it  may  be  |M»»ible  to  expocte  the  lumur  i^ultioicurly  by  Ollicr's  nr 

I'VRaer'a  oprmtion.     Whenever  the  ui>per  part  of  the  jdiaryux  ia  free,  it 

i^U  be  plugcml  licfure  ismimencing  the  opcrntiuu  by  a  «pimge  [tafwd  be- 

liiUtkeRoft  imlatt',  and  in  the  way  already  de^criheil  ip.  544).     It  mii»t 

>«  be  loo  large,  lent  it  push  the  soft  palate  forwards  uguiuat  the  lungue  and 

■■nfe  reap] ration. 

Vuo-erbital  Tninors  are  growths  that,  rommcncing  in  the  upi>er  part  of 
ibr  oual  {,am»  or  In  iho  ethmoidHl  eellit,  iwrforate  evoiiiually  the  ihiu  inner 
**ij  of  the  urbit  and  expand  into  the  in- 
line of  that   cavity,  diAplacing  the  eye 
finarda,  downwardn.  or  oulivnnls,  lit  two, 
fntlimn  io  all  three  of  lh«^e  directions. 
VwM  tfotWn  bui  littli'  if  At  nil  disturbed. 
Ike  Ditatril  ••»  tb<<  altered  »ii\e  it.  ble«-kt>d 
by  a  {Mdy[»-id  gr«wth.      But  the  out- 
•>f  the  cii[wn<ir  miixilla  and  of  the 
pahMv  ia  normal,  ni>  pnilvctioD  of  the 
ID  whole  or  in  ptirt.  lieiiig  i»«rcepti- 
lo  fart,  ihf  diainisc  and  th«  deformity 
ocvd    by  it  occupies    a    part  of  the 
wbirh    ia    al>o%*e    a   hurixonlal    line 
ocfxaw  the  rheuk   on  a  level  with 
opprr  nr  uriiital  bonlur  of  the  supe- 
iIIb.      The  diaeaae  alwaya  ctmi- 
wmmen   primarily  in  the  m»e  or  in  the  Pf(,  m9.— !fuo-orbaal  Tuai*r. 

caritaa  crintjgur>uii  to  it.     The  cxtfni-ion 
iu»  ihe  nrbit  may  not  occur  Tor  many  niontha  after  its  primary  de%'eIoiimenL 

Ehrnrv  nt  all  pvricMlBol'  life,  from  nariy  chililhuud  tocunimencing  old  age. 
■rm  ii  may  prment  the  ordinary  chamt-Urs  uf  beuign  ua^al  polypus. 
li  naiitved,  n^'urs  mpitlly,  ia  Hi;iiin  removed,  with  much  hemorrhage, 
ibcn  the  orbital  impticatiun  is  developed, 
ke  iJiofftiMu  of  the  Daao-orbital  frt>m  the  na bo- pharyngeal  tumor  may 


550 


DISEASES   OF   TB£   HEAD   AND   VTCK. 


be  mnde  hv  observing  the  diaplacrmeiit  of  tbe  oycbiill  aud  obeeiice  of  all 
tumor  behind  the  sntl  palate  iu  the  first  case ;  whilst,  in  ihe  other,  the  naso- 
pharyngeal, the  orbit  ia  intuct,  the  upper  part  of  the  pharynx  bcin^  occu- 
pied by  a  nioi'hid  growth,  nnd  the  Buperinr  maxilla  poisaihl?  pushed  b4idilj 
iorwarda  or  to  one  aide.  In  the  nosoorbital  minor,  the  defurmity  ia  above 
the  horunnlal  line,  uf  the  upper  edfjc  of  the  superior  maxilla ;  in  the  aa«o- 
phnn-nj^oal,  it  is  below  this. 

The  nature  of  the  tumor  varies.  It  is  usually  a  lar^e  or  loiall  spiodle- 
oellcd  sareuma,  hut  it  may  be  epilhcflioamtous. 

Trealmtiit. — The  operation  fi>r  the  removal  of  uaao-orbilal  tumor  may  be 
done  an  fullons.  Ao  ineUiou  tthouUI  be  made  from  the  niot  of  Ihe  unw, 
dirfctly  dowD  along  the  i>ide  aud  louinl  iht!  ala.RouH  to  open  the  nanal  cavity. 
The  Hofk  parlH  on  tht  orlHtal  aide  of  ihlit  rut  are  then  ititi:>ei.-ted  down  into 
tlie  orbil.  One  blade  of  a  rutting  plier*  being  paMsed  into  the  noMe,  along 
the  outer  border  of  the  naMil  bone,  the  articulation  between  this  aiiit  the 
uatial  proce!)s  of  tbe  BUperiL>r  maxilla  is  cul  through.  Ad  oblique  cut  up- 
wnnls  should  then  be  mode  across  the  na^ul  process  uf  the  superior  maxilla 
deeply  into  the  orbit,  the  cut  bones  widely  sepnratcd,  and  the  uuse  turned 
completely  over  to  the  souud  side  of  the  (ave.  The  lumor  at  the  ua«al  eidc 
uf  the  urbit  may  now  bt>  felt,  the  eye  being  held  to  the  outer  side  aud  pru- 
tectcil  with  u  retractor.  The  orbital  tumor  iiiny  now  be  euueleale<l  ^tilli  tbe 
liuger  and  curved  8ci»!ori«.  The  i)4«tril  is  then  cleared  by  means  of  [mlypuB- 
forcepi".  The  bleeding  should  be  uirc-Bltd  by  plugging;  and,  alter  all  the 
murbiil  growth  has  been  fairly  extirpated,  tlie  u'we  should  he  pufche<l  back 
and  uii'uldfd  into  shape.  The  viiX  jmrl*  are  then  brought  Ufgelher  with  a 
fbw  poiiiCn  uf  suture.  As  iu  all  ifimtlar  o])eralii>U!i,  the  posterior  tmrcs  miittt 
be  plugged  lo  prevent  the  blood  liiidiug  its  way  into  Ihc  trachea. 

OcrtiHionnlly  the  diwaae  has  extended  into  the  inlegiinients  at  the  Inner 
angle  <if  the  eye.  Then  the  operation  becumca  more  ooniplicnted.  The  fol- 
lowing cases,  operflted  mi  by  me  Hi  Uiiivereity  College  Ucepilal,  are  good 
illiistrntions  of  this  nperntion. 

Tlie  fipBicase  waa  oneof  epithelioma,  springing  deeply  from  tlieethtnnjdiLl 
cells,  passing  out  through  the  lachrytiml  bone  and  the  orbital  plate  of  the 
ethmoid  into  the  orbit,  blocking  up  the  right  nnetril.  and  extenrling  some 
way  down  the  cheek,  overlying  iheHU|>enor  loHxilln.  It  whs  growing  rapidly 
in  a  woman  44  years  of  age,  and  required  exlen^ve  removal  of  tbe  boDjr 
Btnicturesin  the  situfltion  from  which  it  sprang. 

The  next  cHse  was  one  of  a  womnti  64  yean*  oP  age.  in  whom  a  sarcoma 
developed  witli  >;reat  mpidii y  iu  the  cilutitioti  of  the  lachrymal  sac,  invading 
the  ni«e  and  orbit,  and  dei>tn>yiog  ihe  upper  and  inner  part  of  the  su^wrior 
maxillary  bone.  The  eye  wfot  pii<hi-<l  oulwnrdt<,  Ihe  eyelids  bec-am«  impli- 
cated in  their  uiittal  third,  and  an  ulcerati'd  ojteiiiiiK  formeil  over  the  centra 
uf  the  tumor.  Its  growth  was  aLlended  by  very  !>ever«  tensive  pain.  Tbe 
operation  consisted  in  disaeolin^  away  the  dise.n«ed  part  of  the  tulegumeot, 
including  the  nasal  third  of  i^nvU  eyelid,  then  turning  down  a  Bap  from  tbe 
elicek  aud  cutting  away  with  pliers  the  osseous  structures,  iucliiding  the 
inner  part  of  the  floor  of  the  orbit,  a  considerable  portion  of  tbe  Buperior 
maxilla,  and  paii  of  the  ii;js»1  bones.  In  order  to  repair  iho  gap  inatle  by 
the  removal  of  diseased  skin  at  th*>  side  of  the  irnse  ami  by  tbe  removal  of 
so  large  ■  portion  of  the  eyelids,  a  Hap  of  integument  was  disaeete*!  olT  the 
bridge  of  trie  n«»ee  and  glided  over  the  aperture,  to  the  edges  of  which  and 
to  the  eyelids  it  whs  fixed  by  metallic  sutures.  Good  union  took  place,  nnd 
the  patient  made  an  excellent  recovery.  Tbe  immediate  etlect  of  the  opera- 
tion in  lH>th  these  ca»ea  was  to  relieve  tbe  patient  of  tbe  agonizing  pain, 


SALIVARY   FTSTUtA, 


651 


OK-aAionei]  by  the  leusion  io  the  bones  of  the  face  produced  by 

cif  the  lumor. 

BokI)  biw  (It^cribed  a  case,  in  which  th«  pAiieot,  a  inaa  ae«d  78,  had  a 

Biti|[tiuit  tiimiir  i>f  the  aizie  ufaftst,  occupy iog  Lhe  raidiilc  of  the  fare.     'I'he 

nptutni)  at  lhe  cnii)menc>emeDl  were  ih'Mse  of  nuaal  polypus.     Iti  reriitivtng 

I,  il  «M  nccemary  to  cut  chne  tn  tht*  cribriform  plate  o(  the  BthmoiU  btinr, 

IfeJufar  ha«k   ax  the   posterior  nurea.      A   (lap  of  skin  was  traospUot^il 

tna  i1  nl,  unl  (ki  much  U>  (ortu  a  new  nose  m  to  cover  iu  th«  cavity 

Ml     i       .         lit  wad  able  lu  I«ave  tbc  hospiUil  iu  a  few  weeks. 

diuauiaj  FapiUoma. — 1  have  once  met  with  this  funo  of  growth  in  the 
ual  ruse*  iu  a  la>ly  itubi  sixty.  It  sprung  from  the  mofof  the  nas»t  cavity, 
I  ud  funned  a  tuoss  tiluckiug  the  noetrils  and  projecting  into  eavh  orbit 
I  lucrallT.  Much  relief  was  obtuiiied  for  a  time  by  renioviaf  lhe  pmicctiug 
)«rt  >/tbv  tuoior  by  avaUiuu  with  poly[us  forceps,  hut  tbe  growth  snou 
^^Tiarnnl.  A  secttod  operBtion  was  performed,  but  death  took  place  oo  the 
^Bknl  lUy  fnKD  septic  meniugitls.  The  post-mortem  exannoation  showed 
^RUltlM  aribriforiu  plate  had  been  ab^>rbefl  by  the  prcwuro  of  the  growth, 
^KvUfk  kad  come  directly  in  contact  with  lhe  dura  mater.  Tbe  cauae  of 
'^Juli  «ra»  a  small  rem  in  tbe  menihrnae.  The  tumor  was  papillary  in 
rtradora,  and  cvorod  with  nou-cilixted  CDlumnnr  epithelium,  bcction^  of 
^  gniwth  under  the  niioroacupe  clueelr  reeembled  those  of  papillary 
pnib  from  the  Pwlum.  The  effect  prodtMcd  by  the  growth  on  the  eur- 
xnariiaf  parta  aceiued  merely  the  recall  of  pfessuro  and  Dot  of  infiltration, 
*Wi|UoUy  the  t*rouih  may  b«:  regarded  rather  as  a  papilluma  than  a 
^■bsiair  #piibe)i>>nia. 

Tu  Fhontal  St.vmEs,  though  rarely,  are  occuioaally  the  Bc>At  of  disease. 

WoM  may  form  hero,  wtib  much  pain  aud  expauiiiuti,  and  pi-i^ibly  caries 

*^>iiar  anterior  wall,  attended  by  tbe  local  sigu»  uf  iuHantntation  and  by 

^M(tr  (if  ouneomitant    iutlamiuatiuo  of  tbo  niettibranev  of  the  brain.     In 

'Vth  dreunutancca  il  may  be  pntpor  for  the  Surgeon  to  remove  by  a  (tmall 

*'"pliiM  the  anterior  wall  of  the  tinug.  and  thus  give  exit  to  the  retained 

^^    tn  other  iuilances,  agntn,  the  anterior  wall  of  the  sinus  may  be  aecrused 

H^''  p«rfofBled,  the  a[>erture  being  fell  under  a  puHy  tumor  of  tbe  scalp. 

™)^g«»  sl«o  the  trepbinu  is  required.    Distention  With  serous  flaid  also  has 

^^  dsBcnbed  as  liRving  oocuritd   in  soiue  coses.     There  are  a  few  cates 

^iBBnlsd  in  Kirgical  wriUogs  of  Polypi  springing  from  these  BiDUses,  and 

^NJiag  tbetr  way  duwn  into  the  nutse  atlcr  producing  expansion  of  it  oad 

***■<&  inounveaience.     Mere  likt'vsbe,  the  propriety  of  trephining  and  so  es- 

^^iliny  tiw  niurbid  niaiti  would  buve  to  be  considercil. 


DISEASES  OP  TflE  CUEKK8. 

^*IW  cbiH' dboues  niel  with  iu  the  cheeks  arc,  Ntevi  (p.  061,  Athcro- 
^^fcail  Cvsts  fToI.  i.  p.  1131 1,  SubcutaneouH  Sirnmous  Abslieesefl  (vol.  ].  p. 
>H  r.  Primary  Svphitltic  SoreH  (vol.  i.  p.  1014  -,  Tirtiiiry  Syphilitic  l-lcerfl 
>L  L  p.  lWi>S\  Lupus  (vol.  i,  p.  10*;:ii,  Epithelioma  (vol.  i.  p.  1I!M)'.  and 
Uteer  i.V'*!-  ■>.  p-vtft).     The  synipu^ms  and  treatment  of  all  these 
have  alri^dy  netrn  describeil.     On  the  innrr  surface  of  tbe  cheek 
cyst*,  which  can  easily  l)e  diswectH  (nit  fri>ai  the  inside,  are  not 
imofi.      ICpitiietinma   nlso   is  not  rari\      Mnlignnnl  tnmora  aHectlnc 
I  wluUe  thickuess  uf  the  cheek  can  seldom  be  operated  on  with  any  ad* 

'ialiTtry  Fistula. — One  of  the  most  troublesome  surgical  aifections  situ* 

lu  thi-  check  b  Saiitvty  I'iMuta,  t>ccurriDg  in  cou^wtpieuce  uf  injury, 

or  ojMtrntiuo,  by  which  the  pnrulid  ghuid  or  duct  has  been  opeued, 


afi2 


mSEASES   OF   THE    IISAD    AND   NECK. 


an  ait  In  cauxe  a  trickling  <ji*  saliva  thnmph  the  externni  nperturr  made  into 
it.     TliH  Rave  of  salivii  in  ihe^  cases  is  ulivnys  to  a  great  fxtriit  and  oftco  , 
eiiltrely  Interniictent,  reaxing  in  the  interval  betwe«a  mcale  and  hocoroiiig  i 
very  abiinclant  during  maslication.  i 

The  Treafjt\€Ht  h  by  no  meaiiB  satiefactory,  the  attempt  at  union  nf  the  ' 
opening  in  llie  cheek  being  fruHratcd  hy  tlic  escapi^  of  saliva  through  it. 
If  the  fistnlft  be  vor)'  Brnall  and  ret-eut,  the  i-Icctric  oautfiry  may  b*-  empToyod 
with  Bucceag ;  or  the  external  ajierturc  tuuched  from  lime  to  time  with  a 
pointed  fttickof  nitrate  of  silver.  Should  theftc  meann  fnll,  the  6atuln  having 
become  chronic,  operative  measure*  wil!  be  refjuired.  The  closure  of  an  old 
salivary  fistula  in  llic  che(-k  is  a  very  troublesome  matter.  In  these  catea  | 
Che  Stenouian  duct  appears  to  bi^  nbstructed  or  partially  cK^ed;  and  it  is 
uselcM  to  attempt  to  occlude  the  ojiening  in  the  cheek  until  a  proper  aperture 
ibr  the  c«cape  of  the  nalivn  ba^  heen  made  into  the  mouth  ;  the  e^rape  of  a 
fov  dro)M  of  saliva  through  the  li.sliilaii.'a  njiening  rendering  the  attempt  to 
cloK  it  completely  nugatory.  Tbe  plan  of  treatment  wbicit  I  have  tiiunH  to 
answer  best  is  a  moditication  of  Deaaull'^.  It  consists  in  |m»sing  a  biurU 
hydrocele  trocar  into  the  fistula  in  the  cheek,  pushing  this  obliquely  for- 
wards and  inwards  into  the  moutb,  as  nearly  as  possible  iu  the  direction  of 
the  parotid  d\ici.  withdrawing  the  slilet,  and  then  iwseiug  a  sniull  silk  seton 
through  the  canula,  bo  as  to  bring  one  end  out  of  tlio  mouth,  and  the  other 
through  the  fistula  in  the  check.  The  ciinula  is  then  withdrawn,  and  the 
seton  tied  lousely.  It  should  be  left  in  for  about  three  weeks,  so  as  to  estab- 
liah  a  sinus  inu>  the  mouth.  U  is  then  to  be  cut  and  witbdruwn,  and  ibo  i 
sinus  in  tlif  moutb  kcju  pait-nt  hy  the  daily  intrmtuction  of  a  probe,  by  leav- 
ing a  emu  II  |)i(!i-tMirguru  cutbcler  iu  it,  or,  if  iiehow  mnuh  disiXH^iliou  to  cloee,  | 
by  the.  introduiuiou  of  u  lumiiiariu  tent.  In  this  wuy  the  ntlivii  Is  diverted 
from  the  exteninl  oj)ening  and  nmile  to  fluw  into  the  mouth,  The  exlernal 
aperture  in  the  cheek  may  now  be  closed  by  touching  its  edges  wiih  a  potntetl 
stick  of  niirnte  of  .'silver  or  the  galvanic  cautery;  or,  if  large,  they  mny  be 
pared  and  stitched  together. 

UlSB.tflGS  OP  THE  Lira. 

Congenital  Kalformation  of  the  Lips  m  of  common  occurrence.  Con- 
yeniUU  t'vntntciiuii,  or  even  conipltte  cluoiire  of  ibe  orilice  of  the  mouth,  baa 
been  met  with  at  birth;  such  a  uondition  must  be  remedied,  according  to 
circumstaucea,  by  the  skill  of  the  t^iirgeou.  The  opposite  condition  ia  also 
oocasiimally  ob(«ervL>d,  the  opening  of  the  mouth  extending  on  one  side  loo 
far  into  the  cbeck.comiLituling  the  L-oudition  known  oi  Macroatomti,  It  must 
be  remedied  by  u  jiluDtii;  ()[)erutii)n.  Hy  fur  the  juust  <.H)mmon  mulformation. 
however,  is  the  condition  termed  Harelip,  which  will  be  noticed  iu  detail  in 
the  rhapter  on  the  I'lantic  Snrgvry  of  iliu  Fuuc  and  ML>ut]i. 

Hypertrophy  to  n  great  ex  lent  occjiMonatly  occurt  in  either  or  in  both  lips. 
It  i.-i  cHpt'ciiilly  coniniDn  in  the  upper  lip  in  ecrofuhjuii  cliildri'U,  forming  tne 
condition  ktiown  att  "Btrumouti  Up."  it  \s  nlten  of  an  wduiuutoue  character, 
being  kept  up  by  the  Irrilalion  of  fiesnreii  or  crackit;  if  wi,  Uiu«o  muet  be 
eureo,  when  the  size  of  the  lip  wilt  gradually  diminit^h.  HumclimL-s,  how- 
ever, it  becomes  permanent,  c<mtinuing  alUr  the  cure  of  the  lisBure ;  iu  tbiae 
circumstances  it  maybe  neressiary  lu  excise  an  elliptical  |H>rlionuf  tliunmcous 
tnembrane  of  the  lip  in  a  horizontal  direction,  and  then  Iu  bnng  the  edges 
together  by  means  of  sutures  or  pine. 

ulceration  is  not  unfrcijuently  met  with  on  the  prcilabtnm,  frequently  of 
a  simple  character,  though  chninic.  It  is  oAen  dependent  on  a  di.4onlered 
state  of  the  digestive  organs.    It  will  comtnonly  yield  to  the  application  nf 


DISBAdE   &r  THB   MPS — XPITHKLIOHA. 


558 


i 


ws. 


nitnite  of  ailrer,  to  proper  couslituLiooal  trcitmeul,  baviog  fur  ile  object  llie 
ioiprovvueul  of  the  tligci>Lii)U,  aud  iu  vury  chronic  cases  lo  ibe  admin istratiou 
of  ihe  pr«pnratiiiiii!  of  Hrituuic. 

"SzitOMij  Syphilitic  Sores,  communicated  bj  ki»ine.  are  by  do  means  tin* 
oouiiuou  ou  the  lijiH.  Tlieir  |H-culiur  charaetftr  bus  Irei-u  aireadv  de^ribcfl 
(vol.  i.  p.  \y)U\ 

CjTBtl  and  £teotile  Tamors.— The  lipit  may  Ih-  the  wat  of  cysts  and  erenile 
tDtnorv,  rccjuiritip  exlirpation  by  the  knifis  »r  lignliiru.  In  <tealing  with 
these,  1  he  Kurgeim  niiint.  be  ^ided  by  the  circinnatunoeH  of  the  iiidiviiliial 
Cftiie;  hut  be  shniiM,  if  prKMible,  nvoid  rutting  throiifrb  the  whole  ibickneat 
of  ibe  lip;  and,  if  I'^rnpi^Ued  to  do  m,  he  naist  net  «5  will  Iw  ileHcribed  in 
UKaktn^  of  cancer  of  t-bis  reKinn.  (See  next  page-)  These  gniwtbs  most 
Ret]uently  ocriir  on  the  Inwer  lip. 

Cy^  are  usually  sninll  nn<i  tmnspnrc-'nt,  with  tliin  walU,  contHining  a 
j^airy  6traw-colore<l  fluid.  These-  ahould  alwnya  be  disBtcled  out;  mere 
icxcisinn  of  a  puriioti  nf  the  wall  bciug  followed  by  rcenrr^nee  of  the  disense. 

iVixvi  of  the  lip  are  usually  of  an  iictivu  cburacler,  and  may  either  be 
txcised.if  of  niodenite  extent  and  implieHling  th«  whole  thickness  of  the  lip; 
or,  if  of  Inrjfc  aize  and  projecting  front  [be  nuicoua  surfaw,  they  may  cw 
nafely  tignture.1  (p,  'J8).     I  Iiave  bad 
under  my  eiir*;  several  cases  of  Sibpus 
of    the    up}>er    lip,   implicnlin^    the 
whole  aulwlaueu  of  Ibe  |>urt,  and  have 
successfully  removed  llieiu  by  tbe  re- 
ted   application  of   poiuasa   cum 
«8lc«. 

Warty  Growths  are  common  on 
ibe  lip,  and  are  apt  after  cxi^Uhg 
ktiue  time  to  become  epiibeliotna- 
lou9.  Honietimeecriisl&ofepttheliuTii. 
forming  hornlike  pnijeetious,  nre  de- 
veloped on  the  eurltioe.  Tbey  arc 
best  treated  by  early  removal,  uo 
local  appltealioii  beiu^'  of  niufh  uae, 
and  the  danger  of  their  hecomin;; 
Qialt^naiK  being  verv  conriderahle. 

Epithelioma.  —  Ttic  ticructure  of 
epitbclionm  has  beeu  m  fully  ile- 
(cribcfl  ut  p.  !l!^t,  vid  i.,  that  it  need  not  detain  us  here.  Tbe  ancximpanying 
cut  (Fig.  660)  is  a  gnod  ittustration  of  the  microscopic  characters  unually 
presented  by  it  in  the  face  and  lips. 

Epitbclinmn  of  the  lip  comniencei;  either  aj»  a  warty  growth,  which  gmdu- 
ally  nlceratee,  or  as  an  indurated  crack  uv  fiMinre,  the  ed^efi  of  whieh  have 
a  tendency  to  spread.  Tbe  ituhmaxillnry  lymphatic  glands  lend  lo  become 
tarly  involved;  and  the  dinea^e  may  eventually  prove  fatal  by  the  pain, 
exhaufilioD,  and  conRtitniional  irritation  thi)»  induced.  T^ip-epithelioma 
almost  invariably  ocelli's  in  men,  and  in  the  lower  lip — I  have  never  met 
with  a  case  affecting  the  lower  lip  of  a  woman.  It  >9  met  vitb  after  tbe 
middle  period  of  life.  Of  twenty  consecutive  cases  in  which  I  have  operated, 
aod  of  which  1  liave  notes,  thirteen  were  above  sixty,  and  six  between  fifty 
snd  sixty  year*  of  age;  in  one  case  only  did  the  disease  occur  under  thirty. 
'fhut  disenite  is  at  first  entirety  IochI,  idieii  being  induced  by  itonte  irritation, 
W  by  a  rugged  broken  tooth,  or  by  smoking  a  clKy-pii>e ;  and  wlien  removed 
it  doe*  not.  I  l»elieve,  very  commonly  recur.  At  least,  of  the  very  many 
patients  that  have  been  ojierated  upuu  at  UEiivvrsity  College  Hospital,  I 
have  kuowD  but  few  tn  return  with  a  recurruuce  of  ibe  dieenae;  1  eanuot, 


■'J' 


Pig.  S(0.— 8««it«Q  or  an  Sphli«lloiiia  at  tb« 
Papa,  ■hnninif  tlin  Kptlhallal  Colli  jianclnl- 
iog  intu  (he  lulwlB.iii'a  af  llie  true  Skia. 


561 


DIBKASES    OF    TH8    HEAD    A] 


NKOK. 


therefor*,  but  come  to  the  oooclusion  that  the  0]X'nili(in  for  ejiithelioma  6f 
the  luw«r  li[i  frer|ueDtly  rlUs  the  putieal  pertoAueiitly  of  bu  itisvtiau. 

W'lieti  return  does  t»k(.>  place,  it  is  ngl  always  to  the  cu-atrix  or  in  th«  ftitja- 
oent  filnnds.  I  have  vevo  revurreoee  at  the  Husle  of  the  mouth  aiid  ioi^ide 
the  clieek  of  the  side  opposite  to  that  oa  which  the  primary  dlBcue  had 
declared  itself  and  beea  removed, aod  thisQot  till  three  or  four  yeare  altcr(h« 
operatioD.     lo  these  caees  the  tuiuor  was  prolnibly  a  fresh  primary  growth. 

Wtieti  the  glands  are  eolar^d,  the  adviAabilitj  of  nperatiDg  will  depend 
upon  the  extent  of  the  glfindular  imnlicntion.  It  must  be  remembereil  that 
the  internal  orn^Rng  are  atlcclcd  in  epilhelloRin  only  in  exceptional  casvs.  nnd 
thu»  we  luuy  hupc  uoeasioimlly  to  cure  the  patient  permanently  even  uAer 
implication  of  the  lymphatic  glauds.     If  merely  ihe  eubniaxillnry  lymphatic 


Vtg.  401.— Exl*n>iv«  Witrtjr  EpUlitlivnia. 
u(  Lb  41  Li|>. 


Fig.  4C2.— I.ina*  of  IiMntion  (••r  Itvaoavlng 

V-»fa>>p*<l  Pi»c««f  Lip- 


([lands  are  enlarged,  they  fihould  be  fully  exposed  by  a  curved  incision  car- 
ried from  near  the  symphyRiH  to  the  level  of  tlie  hyuid  bone  and  back  to  the 
edge  of  tlie  sieruo-manlnid.  The  farral  artvry  and  veiii  will  probably  be 
(lividt^l ;  find  goinetioies  it  is  necessary  to  remove  the  Kiibmnxillary  [{land, 
which  Qiay  be  implicated   by  extension  froiu  the  neii^hhoring  lymphatic 


Tig.  M8.^f{pUh*UoiRH  of  Li>w«r  Lip: 
Linei  of  Inciitos. 


Fig.  BIM.^Lip  utter  HmhovaI  uf 
Bpillicliuui*. 


plands.  A  ^lund  must  be  suupht  fur,  also,  between  the  gcnio-hyoid  muscle*. 
If  enlarged  ghmdn  ain  he  felt  beueuth  the  bturutMuiuitugd,  it  is  belter  not  to 
oiterHte^  m  tliera!  can  seldom  ha  safely  reuiuved  owing  to  their  adbeeiou  to 
the  ramliil  sheath. 

If  the  glands  are  extensively  luiherent  to  the  shin,  then  no  opermlluD  should 
be  attempted. 

Operation. — When  onpc  the  true  nutiire  oJ  the  dispnse  had  been  lucer* 
laioed.  the  operalii>n  should  be  performed  with  as  little  deluv  as  pos^ble; 
bnt,  before  it  i^  dine,  it  i.-t  well  that  any  very  prominent  or  "broken  tooth 
should  be  removed,  and  the  tartar  cleaned  away  from  the  incisors.     The 


riSEASB   or   TOB   PASOTID   OLAND— KUXP8. 


fiU 


j  optntloii  rrijiiin-ti  to  be  Mmetrhnt  modiftM),  Act^ording  U>  llio  situation  un<l 
titnit«rtbr  afTi-i^iou  (Fig.  64!.'}).  If  this  Iw  tnlvrably  Itmilcd.  a  V-ehapcd 
'  nt,eit«-niling  wiil«]r  routiil  i(,  anf]  carried  ODfticiently  luw  to  include  any 
!  iB4«iat<'d  pndi>tig»ti(jo  nf  the  aKgnrltenta,  bIiouIH  be  practised ;  the  edges  of 
I  ^  cat  •lioulil  tlieo  be  bmught  together  by  two  harelip  pins  with  a  twisted 
laatn;  m  io  tbe  caw  of  a  simple  harelip.  When  the  diseaM  ocoupiet  a 
iRMiiluKble  UiDgituHioal  exl*'iit,  but  dqe»  not  dip  down  very  deeply,  a  slice 
^thf  lip  tlKKild  be  shaved  off,  iacludiDg  the  whole  of  the  morbid  structure ; 


\ 


V 


-^V^ 


J. 


J 


Yif.  IKIH.— KptthalUiaMi  of  l<ow«i  Up  iofolrlnf 
>)»«,  fnoooMhlllj  T«nut*d.   (Utatb.) 


kd  it  n  ofU'O  flurpri<fitig.  in  theM  circumstances,  to  nbservt^  how  the  ti5«ues 
tl>c  lip  will  ^pt-cdily  nae  to  their  naiurnl   level,  thus  prcvenliui;  niiy 
'Icrial  daformity  from  being  left  (Fig.  titi-l).     In  jM>me  rase*  ihe  diseaBe 
■pni  »  aqiinre  surface,  aitd  iheu  it  is  ncoc&uiry  tn  exciso  a  porliim  of  the 
bao  lliifl  ifi  done,  a  eon^idoniblu  gap  is  Ictt,  ref)uirii)g  lo  he  tilieil  by 
jlaatic  tijtcrntiiffi  of  the  Iclud  that  will  be  cuniiiden^i  in  a  «uhg!n|iienl 
^r^  which  niay  be  most  coDveuieutly  done  at  the  time  wlieii  thv  t- xri?ion 
{"rfiimwil.    When  tbe  diaeoasnceum  at  the  angleof  ihe  inuulli.  it  iiKaitinev 
•*w»  intnictahlc  character  than  wbeu   Htffcting  the  free  |«rt  of  th«  lip. 
XataoM  ojjeriLtiiin — llml  of  fr*e  t-xcision  — may  Ite  applied  to  it  here  sib  lii 
r  cue,  hut  Hitb  Icm  pri>d[>eL't  of  succeM.     Should  the  di^a«n  be  as 
as  io  Fig.  &io,  the  lioos  of  inctsiou  most  be  so  planned  ait  com* 
,   ^  fr  to  nirriiuD'l  and  to  i«<jlaic  iU 

■'  -  tiealb  has  very  auecejafully  extended  this  operation  to  cases  in  which 

(j  *  t^DceJ  r.f  the  Itp  had  invaded  the  gum,  and  had  involved  Uie  lower  jaw. 

l^'^iDuving  a  iHiriiou  nf  the  iinplii'ated  bone,  together  with  tbe  dloeiuie,  in 

^r*  *Wl  parts.    Fig.  iUi6  gives  a  gucnl  idea  uf  tbe  cases  lo  which  this  u[>eratiuii 

StpUcable. 

DIBFOSD  OP  T1IE  rAUCniD  ULAMD. 

^omps  er  Parotitis  is  an  acute  Rpccific  disease,  the  local  msnift^lalioQ 

^hich  ia  iiiHnmniatinn  uf  the  piroiid  and  uiiueiimes  of  the  other  salivary 

It  is  commoD  in  chiliircn,  though  it  not  unfttt^ueully  ucuun  ux 


656 


niSBASBS   OP   THE    HEAD    A.HD   NKCK. 


adullB.     U  it)  highly  infectious,  aad  frv^^ixuatiy  epidemic;  nod,  u  la  thcadbv 
Bcute  spcciliu  ()l«eAAP:s,  oae  attack  f^uiTally  pmlecttt  the  [wBrnt  rratn  Ut 
dtseaso  for  the  rc-M  of  hb  life.     Jt  has  bo  itiouluitive  p«ri<><J  of  frcn  im 
vmIu  to  tw<-'Dly-two  tlare,  but  threes  wenks  'n  the  rkhI  oommon  titM.    \\ 
eommeaeoi  usually  with  i^onie  febrile  ttisturbauce  and  mnlaiw  lutin|(  ibaol 
twenty-fuur  hoiin,  but  this  may  be  iranting.     At  the  ooil  df  (Jiaf  trmr  >M 
parotid  gland  bccomcit  8wollcii,  stiff,  and  puiuful ;  iho  xwellio^  rontinim  t» 
iii^reiLie  till  about  tho  fourth  day,  at  which  time  it  rcnches  from  Ibn  tygooa 
it>  the  angle  of  thi*  jaw.     The  su'tdlen  socia  |uin>tidia  can  uiuatly  b*  dearly 
fflt  over  the  iiiaMst-t^r  and  forma  a  valuabli.-  diagiinAtic  ngo,  dimtnguiaktiif 
parolilis  frmn  iiitliiniinatioii  uf  the  lymphatic  glands  Ix^hiiid  the  jaH'.    f^Mta 
tlie  Hwtillinjj  iR  at  ila  height,  inn^liattion  in  extrpio^ly  pniufut.     Than  ii 
usually  elevation  of  tempcralurc,  reaching  lO^"  F.  or  UJ:i'*  F.     \Vhi>&  om 
^land  be^ina  Ui  subttide  that  on  tbi.-  o|>|»r9ilr  t^ide  UMiiHtly  be^'in^  t->  mmcU  aai 
nins  tho  aame  courac,  but  occnsi»n»ily  bulh  glanda  awnil  iiinHiltanarnuit. 
Sup|>u ration  rarvly,  if  ev^r.  taket  place,  uuI«m)  it  be  id  tha  lyiiiphalir  elwx'i* 
of   tht>  ueigbborbuiMi.     At  tho  {Mirotid    aft*eL-tiiiQ    lubiidea.    but  MjuidiiBa 
aimuUanLM)usly  with  it,  iadamiuatiuD  of  the  te&ticle  iu  llie  male  ur  the  bmK, 
labia,  or  ovarv  lu  the  lemalc  may  take  plaw.     The«c  so-tMilled  mttutaam 
are  very  rare  m  cliildreo.     The  orchilia  is  frequently  fullowctl  by  putial  ar 
onmpli:tc-  atropby  of  the  tealicle  ;  but  lurtuiiaiely,  aa  'tb«  dtMoae  acnroely  ever 
affeclt)  Wlh  aidus,  Ktvrilily  mruly  rcsuhs.    lullamuaiion  of  the  miunbraiisal 
tbp  brain  hiia  btwn  uaid  to  have  been  met  with  ai>  a  complication  •>(  mu 
Tbp  Tnalmrnl  of  ibij*  nli'fction  ia  ttitiiplt>.     If  it  b*.-  aeviTi-.  tin.-  apphr 
of  h'it  foniontaliniitt  ami  the  adiuiuiairaiiou  of  iwltuea,  luid  when  the  ai 
is  nil  tli4>  dedine,  friclious  with  raiupbonited  oil,  will  hapten  ita  raolfl' 
Thp  orrbitia  must  bu  iri-ated  with  btii  fuiiii'nlatinns  and  mt. 

ToiBDn. — Tumon  of  the  pamiid  gland  itivelf  are  not  ho  frrqamt  aj 
growth*  Bitunt«<l  upon  it  or  in  its  vinnity.    The  tumors  loet  with  io  tUa 

region  mar  be  simple  or  malif^ouit.  The 
aimjde  tumor»  met  with  iu  ihia  nfian 
mnrt  frequently  pn-aent  ft  f*«-uliar  rtnw- 
turtt  ntrely  met  with  in  any  ((iber  f«n 
of  the  IwhIv.  They  consist  of  mixed 
carlilii{;e,  flbniua  tiasue.  ami  niuf««a 
tiMue,  to  which  i«  of^i-n  ^*  UD«loUr 
tiwue,  ii»i>ertrctly  res*  i  >•  slnjo 

ture  of  a  rHwmooe  gland.  When  wiall 
they  arc  firm,  and  aoniewliat  elastic  ti> 
the  feel,  smooth  or  slightly  lultulaledna 
the  surface  au<l  freely  movable  on  tka 
pariB  beutnth.  As  they  increaiK'  in 
fluetuaiing  areas  become  pcrcvp^ 
often  projecting  above  the  rest  of  tli« 
growth.  These  may  be  actual  erat* 
cnutaining  a  glairy  fluid  ftrrmed  by 
mucmi'  tonenirig  uf  the  rartila^e.  or 
Ihey  may  lie  due  to  the  j»n-*mr»  */  a 
man  of  getatiuoiis  tlnme.  pmeDtiag 
under  the  mlcnMoope  the  lynical  branetied  ndix  and  mucoua  intemOnUr 
Bulwtancu  of  ■  myxoma.  Theee  tnmor*  grow  slowly,  often  taking  wtmj 
yeara  tu  reach  the  r\t^.  of  a  walnut,  but  at  any  time  they  may  take  iti  artiTe 
growth  and  reach  a  large  sixe  tn  a  conifuinitively  abort  lime,  \v  van 

aa  large  aa  a  cocoaout;  the  skin  c^iveriiiu  them  then  iMOtmea  :<  »>< 

adherent,  and  not  unfreiiueotly  a  nciwotK  uf  vcioa  coven  lb«  maaa.     f  bt* 


|rt(.  UT.— T«mcir  uf  P»«il'l,  Xatt  Do*p1]r 
SMIad  Tor  RaMtarsl. 


DIAOXOSIS    OF    PAROTID    TUMORS. 


557 


growtbe  frequeutly  send  prolongations  under  the  ramus  of  the  lower  jaw,  and 
theo  occupy  the  whole  of  the  apace  between  its  angle  and  th«  mastoid 
pnicess;  when  flroily  bound  down,  they  involve  the  bloodvefKls  aod  nervea 
ID  this  important  region,  coming  into  relatton  with  the  styloid  prooees  and  its 
musclfg,  with  the  iiucrnul  m  well  as  the  exlernRl  cnrotid,  and  even  pressing 
upon  the  phnrvux  and  pnijeeling  inti»  the  fauces,  as  was  the  cu^e  with  the 
patient,  from  w)iotii  the  uunexcd  cut  (Fij;.  6Ij7  i  was  taken.  In  i^uch  ca«eii  as 
these  the  deep  relations  nf  the  titnior  are  so  intricate,  iniporbint,  mid  exten- 
aire,  that  nr>  openition  fnr  its  renKtval  can  he  uudcrlal^eii.  and  the  nalient 
erentually  ilies,  usually  In  consequence  of  dUturbnucc  of  the  cerebrnl  circu* 


V-r^ 


//' 


Vtg.  tSS.^ttimpU  Tuiuor  of  Paiotid. 


Fig.  fi&9.— SiiapleTuinur  of  l*arotlil:    KmU  Via*. 


lalion,  or  nf  compression  of  the  pharynx  and  larynx;  or  Ihe  skin  may 
At  last  heo<ime  adherent  anil  jjive  way,  profnsc  heniorrhape  afterwards  taking 
|>lacr  from  the  ulrerntin^  tnmor.  In  conseitiiencf  of  the  lar^e  size  that  these 
tumors  may  ultain,  they  have  a.  tendency  to  produce  atrophy  of  the  pamtiil. 
BDd  often,  hy  interfering  with  the  cerehrnl  circulation,  occasion  varions  con- 
gesltre  0ympt«iiii»  abuiit  the  Ijrnin.  Besides  the  ordinary  "  pamltd  tumor" 
pure  (.-artila^iuiiue ^ninths  Hrenul  unci>riimnn,nnd  more  rarely  purulibn>nmta 
antl  inyxoninia  are  met  with.  Cyate.  except  nt  secondary  funnatiiine  in  solid 
tumora,  (ire  very  rare, 

MalJffnanl  Tumort  of  the  parotid  »re  of  moderately  frequent  occurrence. 
They  are  imnt  commonly  sut^  glandular  cancers  lencephnloid),  but  scirrhus 
has  been  met  with  in  tbi«  eituation.  They  spring  from  the  gland  iCself  and 
nnt  frurn  the  nlnicturei9sLi[»erticinl  to  it  bb  ts  the  case  with  the  pimple  growths. 
They  present  the  ordinary  rapid  growth  of  such  tiimors ;  they  are  (rum  the 
firet  fixed  and  deeply  seated,  and  early  implicate  the  skin. 

.SpindlcK-elled  and'  round-celled  ^urccmials  are  wccasionnlly  met  with  in  this 
region,  epriuging  from  the  boueu  or  fascire.  They  grow  rapidly  an<l  impli- 
cAte  the  surroiindiitg  parts,  and  as  a  rule  force  their  way  into  che  pharynx. 
The  distinction  between  ibeae  and  the  true  cancers  cannot  always  be  made 
during  life. 

Dio^HOfia, — It  ifl  of  great  importance  to  effect  the  diugnttsip  between  the 
non-malignant  and  the  malignant  varietiee  of  tumors  in  the  parotid  r^ioa. 


tf; 


668 


DISEASES   OP   THE   HEAD    XSV    NKCK, 


In  the  umplr  tumon  there  ih  ulways  mnhility ;  tinrl,  allhoiiKh  the  nttackaiDll 
mny  )>e  di-ep,  the  nkin  h  nnttiivolve^l  (o  any  ext>-til~  Tlir  •milinr  ui  \h9  vaam 
is  iiAually  well  ilelined.Htiiare,  am)  fmmewhnL  toliiitated.  Th(»  pro|(ma  o(  Iki 
gruwth  M  very  »lr>w,  often  occupying  many  yenn  Hcrnm  it  altaina  any  mft- 
8i<ler«))le  bulk,  h»  in  the  annexed  cn\»  4.Fic».  06$,  tJ'^U),  rrpn-Mnlioi;  a  tumK 
of  oixieeii  yenrs'  staudiiig  which  I  oxeiMro.  In  the  Mnii^nnnl  i}r..<.-'i..  ti..rf 
is  no  nii)Kility.  hut  the  mnw  ii*  »»li<liy  fixed ;  \X»  outline  ii  ill-  ''t« 

skin  ttH>D  aMUtiir^  a  rcil'li^h  purpl«  color,  i«  brawny,  aod  pr(«ei>t-  uk-  imuaI 
characters  iuHicutive  of  8ubjac-«ot  niali^iiatil  actioa.  Wheti  Ibeae  lanwa 
are  enwpiuiloUl,  they  jjruw  with  cousideruhle  rapidity,  feel  9»fl  sitd  pulpf, 
aud  are  rounded  und  ill'de(iDe<i  iu  their  oulliue.  esjieeially  under  the  cAriM 
by  the  ramus  of  the  jaw. 

The  lymphatic  ginttd.  which  Hea  Just  iu  front  of  the  neck  of  ike  loirer)a*, 
ami  tliose  eupvrliciul  to  tbe  panHid,  nheii  chronically  eulerireii,  roar  otkta 
clu»ely  reeenible  a  eimple  parotid  Luuior.  Their  luiibitity  is  uaually  tov  thaa 
that  of  the  eiraple  parotid  tumor,  and  they  are  slightly  teudvr  whra  pnaacd 
u)Mjii,  ami  it  is  very  wMtim  tlmt  a  single  glanH  in  aneoliKl.  Occaairtoallr, 
however,  it  rosy  be  inipoasihie  to  make  a  certain  diognaata  till  the  tamnr  h 
removed. 

Trtntment. — In  the  treatment  of  these  tumors,  extirpation  in  oreeaimrilT 
the  only  courw  that  can  be  adopted;  and  thin  shouh)  r«nainly  diA  tl* 
atiemplJxl  if  the  disease  be  niali«:nanl;  for.  as  it  tvouht  be  imprwtiblt  U 
remove  its  deeper  at  tacit  men  t«,  the  gntwth  u>  u  certainty  would  aprcdilr  r(> 
turn.  Even  if  the  draense  be  of  a  simple  character,  rare  mtt«l  br  (akea  thai 
every  iobule  and  pndongnlion  be  extirpated;  for,  if  aity  be  left,  howtifsf 
smail,  it  will  without  •lnubt  become  the  nuetent  of  a  new  tttmor.  lo  r** 
moving  lumora  io  this  situation,  the  superKcial  incidtous  should  Ih-  free,  $*d 
either  longitudinal  or  eruoial,  m  that  the  whole  mntA  may  br  fairly  i-xp<mA, 
It  i^  uot  wiȣ  to  remove  integument,  however  redundant  tlii^ 
to  be,  ualosA  it  have  undergone  intiliration,  incorporation  with  0  - 
change  of  atruciure;  aud  rveu  then  as  Hltle  aa  pouible  should  b*  lak«R 
away.  The  librous  or  aponeurotic  inve^tmealB  of  ih«  tumor  muM  be  U 
uiKucd,  and  the  edge  of  the  knife  niu»t  theu  be  directed  again*!  it.  and 
diaaeclioD  carried  ou  from  below  upwardi,  or  from  behtod  hirwardi.  ax  I 
une  diviaion  of  the  blowlTeteola  iupplring  ic  majr  be  eul£cieot  After  the 
tanior  has  been  well  linjieued  by  the  (Jivisioa  of  lovettiag  faaeui  and  iitrae- 
lurofl  4and  it  is  surprising  how  movable  it  oAeu  becomea  after  IhtB  lia*  brca 
dune,  though  it  may  previouilvappeer  to  hav'cincorpi>rated  aomewbataolii  ' 
with  the  Hubjaecnt  tisuMt  iialtould  be  taken  hold  of  bv  the  hand  ora  h 
double  hook,  and  drawn  well  forwanls  whitet  the  deopdiMectluD  la  baing 
ried  on.  In  prosecuting  this,  the  Surgeon  muBt  particularly  piard  mgaiuA 
\roun<ling  the  lemp'iro- maxillary  artery  and  tlie  facial  nerve,  which  arweape- 
cialty  exjxKHHl  lo  injury.  In  i»ome  ca4e>i  the  division  of  thoe  rannnt  ha 
avoided,  a<!  they  are  incorporated  in  the  maa^  that  a  undi-r^pitn;*  nrmovaL 
Thv  hemorrhage  will  then  of  ooarac  be  ahumlnnt,  but  may  ui^ually  ho  imm^ 
diatety  nrrvsteil  by  the  ligature  of  the  divided  artery  ;  tndved,  in  mnat  MM* 
the  bleedinj;  is  prolute,  owing  to  the  unavoidable  ivrclion  of  nutrient  tm eh 
and  of  largo  subciitnneoiui  veinA,  but  may  genemlly  Im-  rraddy  arrated  by 
Ijgalnrc  and  preuure.  In  nxint  tnstHnoea,  how«^rr,  by  kn-piai;  the  ntjcv  uf 
the  knife  mrefnlly  again.tt  the  tumor,  and  hy  drawing  it  well  forwanl,  tn  a« 
to  IiM#en  it  in  il»  Hr«-<>lur  Ihil  at  eiich  stroke  of  the  Kulpel,  rrmova]  tif  tbe 
morbid  mam  may  1m<  eHV-rti-d  without  the  division  of  any  in)|H>rLant  v««Bd 
or  nervi?.      II.  \»  "t  more  con«<-<jueni-('  to  avoid  a  wound  ol'il'  <!ura  nr 

of  the  ehief  brnnchec  of  tho  |)e«  nnsennua,  than  even  of  tht  inaatl* 

Jary  artery;  at  incurable  paralysis  of  the  face  would  rrault  frwa  audi  aa 


^ 


DISEASES   or   THE   ITECK  — CTSTS. 


559 


injurv.  Injury  to  this  nerve  is  hwl  nrnidiNl  hy  Hwsecting  nut  the  lumur  by 
inciainus  parallel  to  its  mnin  trunk  nnH  cliirl  hronrheR,  and  especially  hy 
dmwiag  the  ina«  well  forwnr^l,  nnd  directinp  ihe  knife  tnwnrdft  it. 

If  the  tumnr,  thnnt^h  nnn-mnlij^iiflnt,  have  heen  allnwed  to  ntiain  an  ennr* 
mous  iiize,  developing  at  il<)  <)ef>]ier  iitlnchmenls  as  well  as  etiperfieinny,  with 
large  lot>eK  lying  Uehiitd  niui  iiikder  Ihe  ihthiih  of  Ilic  jaw,  in  cl<fe  relation 
nritli  the  pharynx,  the  internal  carotid,  and  jugular  vein,  it  Mill  not  be  pru> 
dent  to  atieinjit  ilx  renxivnl. 

Ezciaion  of  the  Parotid  Olftnd  itself  is  occaeionally  spokeu  of,  but  h  very 
rarely  "Jooe.  I  believe  that  in  nioKt  cnees  iti  whieh  it  is  slated  that  wmpleli 
removal  of  this  glauii  !ui«  heen  acciinijdished,  tutnoreoverlviuj:  ami  coniprvw- 
iog  it  have  beeu  nii«lakeu  for  it.  Godlee,  in  one  caee  iu  L'uiv«niity  Cullegu 
Hoepitnl,  completely  removed  the  gland  for  an  iuliltrating  growth.  The 
operation  nas  tediuus  and  rJiHicult,  nud  tbe  facial  nerve  and  carotid  artery 
were  necessarily  dividvl.  The  wound  heated  well,  but  the  growth  returned 
and  ultimately  proved  fatal, 


: 


DISEASES  OF  THE  JTECK. 

Congenital  FistaleB  in  the  Heck  or  Br&nchial  Fiattils  are  of  very  rare 
necurrencc.  They  artae  iVom  imperfect  closure  of  one  of  the  branehial 
clffta,  nxwt  comiiionly  the  lowest  (sec  Fig.  365,  vol.  i.  p.  038"!.  The  fistula 
npeua  on  the  ^kin  near  the  aternnl  origin  of  the  9terno-inu^tni{l.  It  is  lined 
vith  mucoua  rnenibrane  nnd  diitchnrges  a  small  qunniity  of  nincnus  fluid.  A 
fine  probe  can  uhuuIIv  W-  pa«;4t'd  a  cousirjerablc  distance  upwnnl:«  townrdtf  the 
byoid  bone,  and,  in  rare  <•«»<>!>,  can  he  made  to  enter  the  phftrynx.  Similar 
congenital  5stulec  have  been  met  with  in  the  middle  line  of  the  neck.  As 
they  cause  no  inconvenience,  they  are  better  left  alune  a»  it  is  impiiwible  to 
cloee  the  whole  track,  and  obliterali<in  of  the  orifice  would  probably  be  fol- 
luwe<l  by  the  dilalalicm  i>f  the  remainder  into  a  cyet. 

Cyitic  Tamors  in  the  Neck.— Six  varieties  of  cysts  are  met  with  in  the 
neck  :  1,  the  congenital  ttinitilociilar  cyxts  or  cystic  hygrimia;  2.  unilocular 
■erous  cysts  or  hydrocele  of  lEte  neck  ;  ^,  blood-cysts ;  4,  deep  atheruttmtous 
cytta;  6,  bursal  i-vst*  ;  nml,  ft,  troe  hydatid  cvsts. 

1.  The  Congenital  Multilocnlar  Cysts  or  bystic  Hygromata  are  usually 
aitunted  in  the  iiiid<lle  line  in  the  iiubcutaneous  tixsue  iti  front  of  the  Iriichea, 
whvre  they  may  attuin  u  good  size.  Tbeir  enppoeed  origin  and  their  struc- 
lure  liKv«  been  alrvatly  described  (vol.  i.  p.  939.)  If  not  too  large  or  loo 
deejdv  attached,  they  may  be  removed. 

'2.  *rhe  ITnilocuJar  Seroas  Cyst  or  Hydrocele  of  the  Neck  ii  of  Bdnicwhai 

doubtful  origin,  but  they  ure  uii^uuUy  suppu&ed  tit  nnsv  in  t-pare^  Ivlt  hy  the 

imperfect  closure  of  the  branchial  clefllB.     These  tumurij  nere  accurately 

(lescrilmi  hy  Mauiioir  and  I'hillipn.     They  may  be  congenital,  but  more 

tmmmnnly  appear  in  children  or  early  adult  life.     The  cyst  is  usually  situnte<l 

in  the  posterior  inferior  iriatigle,  but  hat  bi'eu  met  with  also  in  I'rnnt  of  the 

Btemo-mafltoid  between  that  niuKcle  and  the  jaw,  forming  a  rounded  tumor, 

sronQth,  tense,  and  elii!<lic,  anil  fillcl  with  a  yillownr  chocolate-colored  «eroufi 

Huid,     It  may  Httniii  so  large  a  nize  an  to  intertere  with  dcgiutiliun  and  rea- 

pirntion.     The  largest  I  have  seen  waa  of  the  size  of  un  orange?.     The  ek'm 

covering  this  tumor  is  not  discolored,  in  «nme  caccH  id'  niitnral  thickncM,  in 

others  tbin  and  expanded,  so  as  to  give  a  bladder-like  apjiearance  to  the 

growth. 

The  Treatment  of  this  tumor  consists  in  tapping,  when  complete  collnpae 
of  the  cyst  takes  place:  it  however  !?oon  fills  again.  A  permanent  cure 
may  be  effected  by  injection  with  iodine,  or  by  passing  a  leton  ncroas.    It  is 


6B0 


M3EA8ES   OF   THE    HI 


r»   XKCK. 


uhiikIIv  itnpr>ssiblc  to  diwcct  it  out  owing  to  the  depth  of  ita  attachments 
and  the  thmtii.'ea  of  its  n-al). 

3.  Blood-cyst  or  Hsmatocele  of  the  KecL — Thia  mny  be  merely  one  of 
the  cyals  just  described  into  which  hemorrhage  hi«  accidentally  taken  place. 
The  true  blood-cysts,  however,  arc  much  morw  ucrioua;  when  puncloreil  pure 
blood  e>ca)>eH,  Noinetinicii  ulmMtt  urterial  in  lint,  and  even  if  the  cyst  be 
emptied  it  »)>eedily  filU  again.  They  have  been  met  with  in  clo8c  conneo 
lion  with  the  great  vemeLi  of  the  neck.  Their  origin  ia  uol  certainly  known, 
but  wmie  have  Hiip[KitM>d  them  to  originate  from  a  c^'^t-likc  dilatation  of  one 
of  the  large  veins  of  the  neck.  In  others  no  communication  has  been  found 
willi  liny  large  ve9»el«.  I>ttt  the  lining  membrane  was  highly  votculnr.  The 
'J're^tlauiit  c-i>ii))i8[H  in  puncturing  the  cy»t  with  a  Kne  trtK'ar  and  injecting 
iodine  or  percbloriiitf  i>f  irnn.  If  the  <-y»t  t-ouhl  be  partially  emptied  by 
preiwtire,  ttliowiiig  ooimutiicalinn  with  a  large  vein,  this  would  evidently 
not  be  jtt^tiliahle.  Giiy  has  »iicces»fully  ilifl»ecte<!  one  out,  which  lay  in  clo«e 
contact  «illi  [he  iftrnlitl  »h<-;ith. 

■I.  Deep  Atheromatous  Cyiti  are  very  rare.  They  are  of  congenital  origin, 
and  arise  from  tncluiiion  of  a  fold  of  ekiu  during  clieuie  of  the  branchial 
clulli!  ;_vol.  i.  p.  y38}.  Their  niuBt  common  situaiionB  arc  below  the  jaw.  in 
the  middle  line  |>uehiug  upnardu  beiicutli  the  tongue  nod  along  the  anterior 
border  of  ibu  sleruu-niantoid.  The  only  Treatment  eougi«ta  in  directing 
them  out.  The  operation  may  be  very  ilifiieult.  owing  to  the  relations  of 
the  cyet-wall  to  the  large  vcaacls  and  other  important  parts. 

'}.  The  Bursal  CyitB  occur  in  the  middle  line  alHiut  the  hyoid  bone  aud 
the  frutii  of  the  larynx.  Thuy  have  already  been  described  with  diseases 
of  burwi'  (p.  4»(M. 

0.  Trae  Hydatid  Cysti  Nornettmca  form  iu  tlie  neck.  A  woman  was  under 
my  care  at  the  Hviflpitiil  f.ir  a  hydatiil  tumor  of  the  liver,  which  I  ia|ippd ; 
■even  years  «rterwar<l9  ehe  presented  herself  with  a  thin-walled  elastic 
aemi-transparent  tumor  in  the  ptiaterior  interior  triangle  of  the  neck,  about 
the  alee  of  an  urnnge.  Tins  I  tapped,  end  found  it  to  contain  clear  serous 
Huid  with  the  remains  of  echinococci.  In  another  case,  that  of  a  lad  aged 
about  18,  otherwise  healthy,  I  removed  a  hydatid  tumor  as  large  as  a  shad- 
dock from  the  nape  of  the  neck,  where  it  was  deeply  seated  under  the  trape- 
zius, grawiujT  apparently  from  the  Bubstnnce  <jf  the  complexus  or  splenius 
cnplliii  muscles,  and  Iving  close  upon  thecerviodl  spine  and  the  occipital  lione. 

Solid  Tumors  of  ttie  Veck. — Patty  tnmora  and  the  various  formb  of  hut- 
coma,  may  occur  in  the  subcutaneous  tissue  nnd  fa^'in  of  the  neck  as  else- 
where, but  ihey  prt^seiit  nollnug  B[iecial.  The  of-<.-k  ia  the  favorite  seal  of 
lymjjhadeiHMDa.  the  lumorB  in  this  situation  otlen  reachiug  an  enormous  sire, 
so  as  to  endanger  life  l)y  their  pressure.  In  tliesubmaxiilary  region,  tumors 
are  occueionally  met  with  airniltir  in  character  t<j  the  parotid  tumor  already 
descril>e<l.     The  aubtnuxillary  glaud  itself  is  mreiy  the  seal  of  diiense. 

Tumors  in  the»e  »ituntion»  may  occasionallv  attain  a  consldtfrsbK-  size,  aud 
if  beneath  the  fascia,  may  extend  deeply.  In  some  cases  when  the  integu- 
ments and  auperftcial  structures  coverlug  the  growth  are  divided,  it  may  be 
isolated  with  sufficient  facility,  its  hxity  being  in  a  great  measure  due  Xa*  its 
being  bound  down  by  the  investing  iti«:itt  rather  than  to  its  having  con- 
trocted  deep  adhesions.  Occasionally,  though  rarely,  a  slow-growing  simple 
tomor  develops  deeply  in  the  anterior  triaugte  of  the  neck,  lying  between 
the  Btcrnn-maatoid,  the  trachea,  and  the  pharynx,  pn»ibly  even  under  the 
carotid  sheath,  with  the  artery  pushed  on  one  side,  or  even  ruimiug  over  the 
anterior  convexity  nf  the  growth.  In  such  caaes,  the  question  o?  removn! 
requires  f>  be  approached  with  the  utm<ut  cautiou.  If  the  tumor  be  movs- 
ble  above  the  vessels,  ii  may  generally  be  taken  out;  if  it  lie  below  the 


THVROID — 001' 


5GI 


1,  even  though  not  fixed  lo  the  «pine,  lis  extirpation  is  not  pmciicable. 
ire  determining  ii|»n  the  removal  ut'  a  Mimor  Mtnnled  in  one  of  tlie  tri- 
anftle*  of  the  neck,  it  in  indee*!  always  very  neceM^nry  thnt  a  diom^nosis  of  its 
jiftture  be  etiected,  finrl  thnt  some  opiuion  be  funned  uf  the  probable  extent 

:  of  ii»  deep  attach menis. 

Tbe  Kret  pviut  tu  secertaiu  ts  whether  it  be  simple  or  matigoant.  ]f  sira* 
pie,  it  will  iiBually  have  been  uinuy  y«an  in  gruwing;  it  will  be  hard  but 

.  flOl  atuajr,  lobulate*!  vr  iKtmewhat  s(|uai-v-aUu|K.*d  ;  tiie  patient's  general  heulth 
being  gowi.  It  will  genemUy  be  fuuud  tu  Ih5  movable,  though  uut  jierlmps 
tu  any  greut  extent,  luid  will  prest^ut  uu  eigii  of  iiivorporutiou  tritli  uvigb- 
boring  slruclureK.     If  it  be  8upcrlii.-tnl,  the  tibrea  of  the  plutyeuiu  will  nut 

.appear  to  spread  over  it,  and  the  eteruo-mustoid  muBclu  may  be  Iniced  to 
oae  side  of  or  bel<>w  it.  In  such  circuiii!>tHue(.'2>,  removal  of  tbe  tutuor  muv 
be  uotlertaken  by  noy  Surtfeou  pueuesaiiig  a  fair  share  of  aoat'indail  kaonl- 
edge  utid  manual  skill,  with  every  proapeeC  '••(  success,  ilut  if  the  tuiuor 
be  of  stony  hardness,  have  implica.ted  the  skin, and  be  iriiraovablB,  the  whole 
bend  being  moved  on  any  attempt  at  drawing  it  ai-itle,  if  il  Iw  lll-delined 
oDiIer  the  jaw  and  ear,  or  rapidly  gron-lng.snfl  and  pulpy  to  the  f<?el,  deeply 
leateil  under  the  angle  of  the  jnw,  evidently  below  the  piaty^ma  and  deep 

;  liseia  of  the  neck,  and  ptissibly  beneath  the  eteruu-mnsloid,  then  no  altempc 
St  extirpation  aliuuld  be  undertaken,  as  the  ma^cmiid  either  not  Ite  removed 
with  nflfety,  or,  if  it  were  bv  any  possibility  extirpated,  the  nlreaily  existing 
contamination  of  the  neignhuring  porta  would  certainly  lead  (o  a  epeedy 
recurrenoc  of  the  diseatie. 

In  removing  tubmnxUtary  Utnutra,  a  free  RtiperfiL'ial  incieinn  nearly  parallel 
to  tbe  margin  of  the  lower  jaw,  but  beloiv  thi^,  will  usunlly  allow  ready  ex- 
tirpation of  the  ma^g.  In  tfaeee  operations  the  facial  artery  is  generally  suf* 
ficiently  under  cover  of  the  bone  to  escape  injury,  but  there  may  be',  and 
UMliilly  is.  tree  VfOiius  ht-niarrhiige. 

Congenital  Tomor  or  Induration  of  the  Stemo-maatoid. — These  terms 
IK  applied  to  a  ditTuic  thickening  and  iuditniLiiin  of  the  slerno-mastoid, 
■fleeting  eJpe<:iBlly  its  lower  and  sternal  part,  occasionally  met  with  in 
infanta.  It  ii  observed  cither  at  birth  or  Hhurtly  alter.  It  disappears  afler 
a  few  K'eekn  ur  months  without  any  special  treatment.  Its  nature  is  tome- 
nhat  uncertain;  it  has  been  attributed  to  injury  during  birth,  eitjM'cinlJy  in 
case*  of  breech-presentation;  Bryant  considers  it  iuHsmmntory ;  Holmes  i> 
Inclined  to  reganl  it  tw  a  c-otigentta)  hypertrophy  ;  and  by  others,  it  has  been 
referred  t<<  syphilis.  In  a  case  recorded  hy  F.  Taylor,  in  which  the  swelling 
Was  examiued  alYcr  death,  it  was  found  to  be  due  to  u  new  growth  of  Bbroui 
tiauc  between  the  bundles  of  muscular  HbreH.  The  child  was  syphilitic,  and 
tiic  case  was  alito  one  of  breech-pre«eutation  at  birth. 

Diffate  OeUoUtis  of  the  Heck.  Ludwig's  Angina  has  been  described  in 
vol.  i.  at  p.  Bd'l. 

DTBEASE9  OF  THB  THYROID  GLAKD. 

The  thyroid  gland  b  subject  tuvarioun  simple  chronic  entargements,  which 

oonunuoly  go  by  the  name  of  Hronehocxle  or  Goitre.     The  thyroid  gland  is 

leompoeeduT  closed  veaicles,  lined  by  a  single  layer  of  cubical  I'pichelium, 

[coDtsining  a  clear  albumimms   fluid.     The  veeiele;)  are  held  together  by 

^veolar  titttue,  supporting  nnmerons  vessels  of  considerable  slee.     Vircbow 

Ibaa  shown  th»t  all  furai^  of  hronchocele  commence  by  a  true  hypertrophy  of 

llbe  glaod-subitance.  but  as  the  enlargement  progresses,  one  ur  other  of  the 

[coDiCiCuent  elements  of  the  ghtnd  may  increase  out  of  proportion  to  the 

gthert.     If  all  the  coa:itituent9  ctniinue  to  increase   equally,  the  simple 

bronchocele  results;  if  the  coutenta  of  the  vcaiclea  accumulate,  unduly  dis- 

VOL.  II. — 90 


662 


IlISBASBS   OF   TIlS    HEAD    AND   KBOK. 


tending  tbe  mritia,  the  diseiM  Baumw  the  rnrni  Icnnwn  u  rjidc  tiiwihi 
celt:  V«r)'  oimmonly  there  19  a  J^retii  iiK-rfuct^  iil'  ll)»'  t'lltrouH  tnRw;ferWi| 
Ute  FitirouK  HronehttrvU,  and  nct-aAinnHlly  ;>nMit  ililntntiun  uf  tbv  iumIi 
Uikt>A|»]flce-wiih.iunplc  hy|>i^rlrii[ih)r  of  tlitr  n-iiiiiiiuii);  Btriictumuf  tbrfbtiJ. 
forn>in]{  the  Pttiiating  Iltotiekorfie.  Sfcoixlury  chad);**  nix*  ut«T  n/tiHj 
Uie  fctrii^'tiire  of  the  tumor.  Of  Uie»e  the  iiuisl  cnmcut'O  is  m  siiK-Mti'<i_fl  4 
11  gtlstiiiou*  colloid  material  lor  the  albumiunus  fluid  uormally  tbi 

veMolfff  (if  tlic  Kltnd.  Calriticatiuo  «1m>  t»  conimnu  both  in  th«  »»iin  •>  lii 
cj'sU  ill  cystic  broDchocele,  and  in  Uie  manea  of  libroua  tiwue  iu  \hm  Sbrnv 
guttre. 

The  CAWKeiof  broucbocele  haveb««u  much  diaciuaed,  buth  |iiiifiiiiwilli 
and  p«i[>ularly.  Thv  most  |ji.-iierNlIy  received  belief  ia,  that  tbe  di*e—  • 
dirticlly  occaifiuued  by  acme  iiiiiiurity  id,  or  peculiarity  uf.  tbe  tiattf  tlM 
the  palieola  drink;  and  it  has  t>een  «uj)pi«ed  tbut  water  rumiaj  ikiw^ 
chalk  or  iimeatoue  ie  pHrltcuiarly  apt  to  oceani'^u  broucbocule  \a  ttoe— Ify. 
and  that  uiiter  resulting  from  melted  buoh  ia  im  tHt'tsiouitig  nune  iB&rtlll^ 
land.  Itiit  llieite  iileaf  are  groumlle^.  Hard  waleriHdrunk  largdv  ia  llil 
country  in  dietrictH  where  nu  bronchoccle  occum,  and  mki*  water  ^  vent 
UB«1  in  Switzerland ;  sprtn^-waier  of  the  purt«t  kind  only  being  dmak.  b 
would  apncar  llint  air  ami  locality  have  much  ninre  to  do  w\\h  tlm  ocemtfM 
of  hroneiiocele  than  water.  In  mtMintainoue  cuuntriea  the  dfavnr  nmni 
almost  PDtirely  anion^t  the  inlmbitania  of  valleys,  wlier«  the  air  i»  taiia\.  taA 
BtagDnnl ;  the  inhahitauta,  eBpecinlly  of  rolleya  that  run  mirth  sad  wotA, 
into  \^hic'h  the  sun  does  not  penetrate  reaility.or  for  many  hniirt  in  ifccdif. 
which  arc  always  in  the  shade  of  neighboring  and  overhanging  mtmataiM, 
arc  csjiecially  prone  to  iu  Thisi»  well  knuuii  tn  be  the  case  in  Awitarrbtti 
wfatre  iheduease  is  endemic;  so  also  in  Inr^r  l  n  nn.  it  m  1  iin  1  liii  flu  anii<i|pt 
the  poor  who  live  in  cellars  and  kitchens,  or  dump,  ill-vriitilntrd  *trMteui 
courln.  When  it  is  met  with  in  the  ricbrr  claMcfl,  it  U  fuund  niamlv  a  ~ 
children  and  voung  people  shut  up  in  flchool-rooni*  or  dt-voted  to  a 
and  indoor  life,  unnatural  and  prejudicial.  It  in  rarely,  if  rrrr.  bm4  « 
amvogvt  those  who  lead  open-air  and  active  live*.  Bad  food  and  low  livi^ 
no  doubt  conduce  to  it.  The  tendency  is  probably  bereditarr  in  wQn%<mim\ 
when  aaaooiated  with  idiocy,  onnNtiluting (hat  wretched  roaditiua  **  rrHtBkuB.' 
it  ondoubtedly  is  so.  Every  race  of  men  is  liable  to  braochtxvlr,  and  it 
occurs  in  all  latitudee  front  the  Arctic  region  \n  the  tropica.  Tbiii  Fraaklis 
found  broDchocelc  amongvt  tbe  inhabitants  of  tbe  polar  rt|putM,  and  >liuift 
Fark  amongst  those  gf  tbe  interior  of  Africflu  in  tbia  oountrj  it  is  mmI 
eonimon  in  Derbyshire,  and  has  ontuequoDtly  roocived  the  tmma  of  **  Dm^ 
Aire  ntek."     It  ia  moat  fre«pient  nnionget  women. 

&TMPTOMB  AKD  VAKtCTiLs.    Sinpu  Hypertrophy. —The  ibyrDH 
may  be  aimply  hypcrtrophinl,  and  may  Iticu  atuin  a  oooiidam'  ll 

forini  B  smooth  rcunded  tumor,  mnintaintiig    mure  or  leas  ai>  il» 

form  uf  the  normal  glund,  though  fre(|ueotIy  tbe  enlargement  on  <>oe  sid*» 
greater  than  that  on  the  other.  It  is  soft  and  clastic  tu  the  ftvl  ^ml  noins 
up  and  di>wn  with  the  trachea  during  deglutition.     In  tbo  n<.  '  ■»■ 

sliiuci:*  iu  England,  the  tumur  is  uf  but  very  moderate  ntt,  n  >  ,-  ai 

firnt  as  a  uien  fblnoB  and  uniform  rounded  enlurgrnirnt  of  '  >«■, 

until  perhaps,  by  the  pre»urcuf  the  gMWth  conlined  beliini.  >...-  h 
mafttoid  miisrlr  and  under  tbe  deep  tUMia  uf  the  nerk,  thv  vuic* 
omnkiiigRnd  bumh,  and  resiiiration  and  ilcj^lutitiim  acriMt&lr  aflimML 
ia  Mddoiii  thul  the  brunclKK't'it'  dtolorta  the  ulruetumnf  th»  nfcit  InuoeMiW; 
but  this  niuy  ha]i|H-n.     Tliua  I  have  seen  the  InryiiK  ami  intcheB  paabad 
OOtnpletely  over  tu  the  lefl,  furming  a  lung  cuuvviity  in  that  di 


TREATMENT   OF  GOITRE. 


56S 


whilst  the  carotid  ibetitfa  oo  the  right  aide  wna  thrust  behind  the  sterao- 
luutoid  muscle. 

There  is  a  remarkable  conDectloD  betweea  tumors  of  ihe  thyroid  glaml  of 
this  kiad,  aod  a  general  aoiemic  c>iDditi'ii]  of  the  evstem.  In  L<>odnii 
Diithiog  is  more  conimon  IhoD  to  tiod  a  certain  degree  of  bronchocele  in  pule 
aod  bloodlees  women  and  girls;  indeed,  so  frequent  is  the  ooincidence  thitt 
it  is  tiDpoHible  Dot  to  regard  it  in  the  light  of  cause  aod  cHecU 

The  imineDse  lohulated  tumors  htiugiug  from  iho  forepart  of  the  neck. 
which  nre  met  wiih  lu  various  disiricta  of  this  country  and  of  the  Conlineat, 
more  especially  in  the  valleys  of  the  Alps,  in  which  the  disease  is  aiifl  has 
been  epidemic  for  ages,'  usually  belong  tu  the  fibrous  varivtv  of  hronchocele. 

Fibrous  Bronohocele. — This  form  coiumcnccs  as  siuiiilc  hypertrophy,  hut 
OS  ilie  tumor  iiiL-rtitJit-^  iu  tite  it  loses  its  solY  elastic  i'mi  aod  beeomes  dense 
aud  indurated ;  at  the  aanic  tiriic  its  form  often  chan);cs,  bccomiDg  more 
irregular  and  lubulated.  The  pnt»iiirivHrec!tB  uf  the  fibrous  bronchncele 
are  more  eerere  than  those  of  the  simple  fttnn,  owing  in  the  greater  density 
of  its  structure.  Kupiration  may  be  greatly  impelled,  at  tint  only  during 
exertiun,  but,  when  the  gri>wth  reaches  a  considerable  size,  during  reel  also. 
Occasionally  the  tumor  may  exteml  below  under  the  sternum,  and  the 
pmaure-aigus  then  become  more  serious.  Deglutition  is  seldom  seriously 
mterferol  with. 

Gjrstio  BrODchooele  is  due  to  the  development  of  C3r9ta  in  the  anhstance  of 
the  enlarged  gland.     These  cysts  may  be  single  or  multiple.     When  single 
or  of  large  size,  oa  in    Pig.  670,  Uiey  usually  ontain   clear  serous  fluid. 
When  multiple,  they  are  tilled  wilb  colloid  t-uhstnnce,  oi* 
with  a  tluid   that  preaenla    the  ordinary  charnctent  of  ^ 

altered  bliMxl,  being  dark,  gniniotis,  or  like  eofTec-grouDds, 
Olid  liave  often  cuuliHoitt-rdike  excresceucea  projecting 
into  llit'ir  iuterior, 

Paltating  Bronchoc«le  is  oocasioually  met  with.  The 
puleatiuu,  which  is  eeoentric  and  distensile,  is  synchronous 
with  the  heart'e  aetion.  and  evidently  due  to  the  vascular 
character  of  the  tumor  itseltl  This  form  of  broncbocele 
ia  sometimes  conjoined  with  the  cystic.  When  it  ia  con- 
fined U)  one  lobe  only,  care  munt  be  taken  not  to  cuufound 
the  beatings  with  those  of  carotid  aneuriam;  a  mistake 
which  I  have  known  to  occur.  The  diagnosis  of  the  two 
aBeclious  hob  been  adverted  to  at  p.  U*l,  vol.  ii. 

TKKAT.Mt;sr.— The  treatnieut  of  bronohocele  must  vary 
Accurdiug  to  the  »'\ze  and  character  of  the  tumor,  and  the 
ouiulituLional  condition  asi^icialed  with  it.  When  small, 
aod  usuciated  with  antemia,  and  of  compnmlively  recent 
jfiwrnatiun,  it  is  best  treated  by  improving  the  general 
oonditioD  of  the  patient.  This  may  he  done  in  vnrl(»U8 
ways — by  the  administration  iif  good  food ;  by  change  of 
air  from  a  low  and  damp  to  an  elevated  and  dry  and  hcjiithv  situatioo. 
The  change  to  a  higher  and  drier  and  more  airy  lr)c&lity  has  neen  much 
insisted  on  by  thuae  who  have  i^tudied  the  disease  iu  those  valleys  of  Swilzer- 
laod  in  whicli  it  is  endemic;  and  Lstablijthmcnis  have  been  erected  several 
th€»uauud  feet  above  the  level  ol  the  sea,  on  mountain-tops,  with  the  view  oi 
curing  patients  thus  affected.  Guggcnbilhl  has  been  particularly  succi-.«#ful 
in  these  emloavora.  In  towns,  tlu-  patient,  if  living  on  the  basement  (ioor, 
ahoulJ  be  moved  to  the  upper  story,  if  possible,  and  should  be  encouraged 


Quia  luinidum  Gutiur  mimtur  In  Alpibui? 


I' 


I 


Flf.  670.  —  OTit  or 
Tbyrald,  ooBtslD- 
ing  eloftr  Scront 
Fluid. 


D1SKA3ES    OF    TBE    HKJltf    Alft)    HKCR. 


in  hubilKiif  outdoor  rather  than  of  scdeiilarv  oriixImiromifialiaiK. 

tlie«e  hrgirnic  rccasurcs,  which  nrc  of  ibc  "firirt  ImportBiK-f   ^^-  'tf^^** 

h«  trcaleil  nirdif-nllv  \yy  the  ndminisl ration  of  jrnn,  rtp 

inlcrtifllly.  and  the  vxtertial  flppltontiuit  <ii  Ittditie  or  i-f  in....,: 

metit.     )»dt^,  in  the  enh  hronchnrcle  oorurnnfr  In  novmtr  femftlr*,  Itvm  ■ 

tif  the  uinioM  •erviit,  nnd  acts  nltntist  sb  n  i-ppcifir. 

In  bfonchocplM  of  liirge  tite,  hnrcl,  ind  unconneriH  with  aniMsU,  tk 
chiff  r<>liAiiro  in  |i>  hr  plnocd  on  the  frrr  nnd  conlinuouK  uh*  of  ia4int  ieit«T- 
nally  Af)  well  iw  exlernnlly.  Thf  iodide  of  pntaMinm  !»  th«  hr«l  *'<r«  n 
nhuh  1o  nivc  ihe  ii-diiie  internnlly.     Th^  iiunntily  of  ihia  m- ■  -dd 

be  ||;r«i!ii«lly  inrreated.  until  fnjui  20  to  TiO  |:;niu>ti  arc  givfii  ■•  i 

day,  either  alone,  in  milk,  or  in  (yimbinalion  «iilli  ^>nii^  prf|ian  -  it, 

the  iodide  iit  pnit«ahly  tlif  b«il.    Bill  iron  i»  very  iief«-F»»r\  in  a:    i  rnir 

funnt-  uf  the  di**-***.  Itxlidt-  nf  leail  nnd  0)m(nnin<l  iodiiie  r.ininiMi:  r.  .■  >■ 
used  »ith  advantage.  It  has  been  recoiimietjde<t  by  Mouat  ihKt  il--  i  >  -it  < 
of  mercury  ointment  (lU  grs.  to  the  ounce)  should  be  ««ll  c  M 

WTeml  dayi;  and  theu,  the  tumor  being  I'nTcred  with  it,  tliFj::;  .  M 

Ih!  rxjMwe^  tu  the  Mronfc  heal  of  a  niid*day  luniuier  sun.  Th:-  ■■■.''.<.■  \4 
tn-aiuieut,  «hich  it  »nid  to  have  been  exfreiueJy  tucctwiul  in  luilm,  iiu  M 
tictn  trit'd  in  thiH  country  tn  a  sufficient  exleni  to  ennblc  an  opicioti  ta  b 
fonntd  of  ilit  merits.  In  some  iiislant-te^r<WNr«  lias  brrn  ol  uie,  rfjralllj 
in  rniijuni'liou  with  ihc  iodine  iniinvlicue;  thoufih  il  is  nf>l  !<o  ra*T  d  i|iplf 
ibifl  mcanfi,  and  no  nmsiilerable  detne  ol'  it  can  he  Immc,  nn  »■  ■  i  'W 

iccreai^l  dilfirulty  nf  ri-ifi)ir»liiiri  tlial  ia  ihuB  nrranioned.     ]n  i-i  > 

pmaioD  exerciei'd  U|Hjn  llie  tumor  hy  ihe  eiemaninnltiid  mUFclet  \a  t<Mft 
these  roBCfl  is  bo  roni^idLTsble  that  it  berometi  nerrrfary  In  divide  iti  tfWiB 
mbcutaneously,  in  onlerto  relieve  the  trachea  from  the  ronfltrietka  toirUA 
it  if  Bubjecterf.  When  thu  tumor  is  rhiefly  cyetic,  the  fluid  cootrnti  MfW 
drawn  i>fl'  hy  tnp|>ing,  and  an  endeavor  may  be  made  to  cauar  ib^mllt* 
close  by  inducing  inflammntion  in  iheni  by  the  injection  of  tttirtar«nf  wAi'^ 
The  fluid  that  nows  from  the  cyst  19  ofiVn  darttly  stained  with  blood,  ot 
occ<«iooal)y  pure  blood  may  eM?npe  in  coi»iilenible  quantitiea  ftvm 
puncture.  Morell  Mnckeuzir  advises  the  injection  of  the  cyet  wHh 
chloride  of  inm  to  cheek  the  flow  of  blood  that  often  talcrfl  plac« 
cyal  wall.  He  recommends  ihal  the  cy*t  he  ttipprd  with  a  t 
cauula  ;  after  the  fluid  h«»  e*cw(>ed,  a  itiduiion  of  percl'  f  i 

ji  of  water)  \*  injectfd  ;  the  cnniila  i«  ihtn  plugj>ed  ai  till  at] 

Hon  is  e»tabli«lied,  after  which  it  may  l>e  withdrawn  iuid  n  dr«jn»{_ 
substituted.  When  bronchocele  i»  very  larpe.  and  v«ry  chronic.  it>  a' 
tiou  cannot.  I  think,  he  expected  to  be  brought  abtntt  by  Iheve  or  aoy 
nieaii.i;  and  the  tjuevtion  then  arifca  as  to  the  propriety  of  having  rr 
to  operalive  interlereucv.  The  inlro<Iuclion  of  n  feton  acr,«»  th«  lu 
ueesnioaully  attended  by  beneiicial  resulte.  This  opiTatioD.  however, 
unaccompanied  by  danger;  a  patient  in  the  ndgbborhoMi  of  I^otxl 
wbum  il  nas  being  pertumied  some  years  ng<»,  loat  hit  life  by  i*—  —^ 
of  air  into  a  vein  uhich  waa  accidentally  puncturrd  at  the  rooi 

Injection  of  Tioeture  of  Iodine  into  the  Kulwiancn  of  the  gUii't  i-  i 
a)end<r<l  by  Ititlroih  in  ca»t'ftof  simple  hypertrophy.    In  Rbrooa  b 
he  dot-n  not  advise  il,  an  they  are  oOen  permealnl  by  very  large  blood 
The  iodine  \si  injerl«-4l  hy  means  nf  an  ordinary  hypodermie  ty tinge, 
ten  minimti  iHTirigibmwn  in  at  a  time.    The  o^MTaiion  may  berepnUHl 
ur  threi-  time:*  a  week,  according  to  the  elfect. 

Injection  of  Perchlorlde  of  Iron,  by  nieuns  of  the  gyringv  flgtircd  ml ,. 
vol.  li.,  might  bu  <il  H-rvicc  in  8«nie  caaet  of  very  vascular  and  puUal 
bruach(.K.-el« ;  but  it  Es  not  without  the  special  danger  of  fonnlug  •  plof 


IX0I9IOK    OF   THE   TRTROID   BODY. 


565 


Intltin.  anil  rapiillv  fatal  cmholUm  ninv  fallow  iu  use.     A  &ul 


if  llii?  ktnii 


fact  bftor 


rdefl.     1 1 


'.  iiutance  Di  pubatmfi 
Kluwele  in  vtWtch  I  einpluved  it.  nllhoui^h  miich  Uval  in  Dn  in  mat  ion  anil 
detp ■rali.'J  »uppurftiioti  wertr  iiiituc«^  bjr  it.  the;  palieol  was  in  the  eud 
nwtcriallv  Im^iii  lid-l. 

Ligainre  of  the  Thyroid  Arteriei  has  boeo  practbed  by  gome  .^urceoo*. 
wiiii,  it  i»  st^t*"!.  8  cerl«i»  ilc^ree  «>f  siiccew.     The  difficulties  anrl  dnnjrer  of 

i*> --fi-iii,  th«  iiQcvrlJiiiity  ofiU)  r«aull». »nd  lb«  midiii<>M  wiili  which  the 

qiplr  Wituld  be  f<(rward«d  lu  the  tumur  rp>tii  other  eourcts,  hnvo 

tu».>i  II  i.<  Iw  but  JKtlc  rc8<>rl4Ml  to  b_v  Hurgcous  uftbe  present  du}'.     Iu  utie 

■>f  puUaliu};  brDUcbooelt!  to  ubich  1  liB<i  rt'CuurMt  lu  this  trvatiuviil,  no 

i:  rt:Ttult*-.i  froiii  i|. 

tuisjoo  of  the  Tbyrvid  Body.— Itfiux.  Warren,  Greene,  and  olhere,  bav9 

wwwfully  vxtiriMited  lar^  broni.-h'K.*(;l€«.  but  th^ae  openicions  must  iw  looked 

ifna  u  allugvtb«r  the  excvptioD  iu  ihe  treatment  of  the  dLieaiit;:  and  jilsIoucim 

■HoutaiDly  not  nlU-n  met  with  in  this  country  in  which  a  .Surtfe^ju  vrould 

lUik  it  prnpcr  to  tuiilerlake  so  serious  b  procedure  for  an  adectiou  that 

bMMeonarily  mortal.    Ctam,  however.  occa»)iinally  occur  in  which,  fnmi 

(MMrr  iko  the  tnicbeu.  nwtpbsKUS.  and  ju^fiilar  vein,  the  dYsptiiea  is  so  cx- 

MTe.the  draphaeia  and  vertigo  so  serious,  that  there  is  no  escape  from 

dwJi  tzc«p(  by  the  rem<n-al   of  the  lumor.     Of  all  the  methods  for  the 

WDml  of  ei)lar|j;cd  thyroid  gland,  P.  H.  Wauoo's  operation  is  pnibably  the 

■fat io  execution,  and  most  Katisracftrv  in  rMults.    It  is  done  ns  follows:    A. 

Iimmdmon  is  made  in  ihe  mesial  line  from  the  upper  to  the  lower  end  of 

|4iti(iii.ir.  the  fiii^-ia  Wiat;  *a  freely  opened  as  the  sktn ;    but  the  delicate 

Ifcnil  invnittur-nl  «f  thr  thyroid  ;;land,  which  i»  a  proKmjpition  of  ibeiilienLh 

tfllu  iliymid  ve«cU,  ah^iuld  tie  left  intact.     The  VMseU  on  each  sidt-  of  the 

toUtf,  iiup<Ti.ir  and   inftTinr  thyroid,  are  then  to  be  Mcuroly    lijoiturcd 

niii  their  »bcath,  by  pacing  an  nneumm-upedlc  round  ibis,  and  tying 

iMtM  •TtoAMr.     U  in  of  the  tirat  importaiii;''  Lb;tt  (he  vt^ucld  be  tieil  in  ana 

•ilk  thiif  •lii-Hthin;:  ««(t<.'ploiie;  for,  a«  Watson  truly  ob»erv«i,  if  tbi*  be  mit 

*<i*.tbcy  will  be  found  V*  W  so  frngile  as  lo  risk  being  cut  through  by  the 

^iihiiw,     After  ligdture  of  the  fuur  sets  of  supplying  veMels.  the  areolar 

■fMileof  the  thyroid  should  be  opened  by  being  scmtched  thn>ugh  in  tlio 

Miial  line,  aud  the  maas  removed  with  care  and  delicacy,  all  attachment* 

Wii{dirid«d  by  blunt-iminted  vcisaors.    The  principal  danger,  bcaidet  the 

WMrriiBge.  would  probably  eonsiHt  in  the  adhesion  of  the  tumor  to  th» 

*^lloflJi«  vwaelH.  iu->r«  )Mirlieittarty  the  internal  jugular  vein.     In  one 

■viefiirred  to  bv  W.  GrtM-ne.  liiix  vcsmI  was  wounded. 

fVAHor  K'H'hrr.  i>f  IWrne,  living  iu  a  gottmus  country,  has  prnlmbly  per- 

[m«h|  |b»  <>|>eraiiiiii  of  exfisi'in  of  hn)nL'boeelo  more  fretfuently  than  any 

''*W8trgw>a.     He  hoi^  ills'*  hi-t!n  eualilcd  to  study  the  utrt-cu  of  thv  o]>«?ra- 

^«tbe  afUirhL-altb  of  the  pntieiiU.  and  hi^  ohservuttonit  iu  thi^  nwpt'ct 

''iMonat  alike  in  tbv  phy<iiologist,  the  aurguon,  und  the  iMithoIogidt. 

tiuna  mav,  ind(Nf<l,  bt*  nignrlml  uf.  physi'dttgical  t!X|kTimeulH  no  the 

thetbtrroid  IhmIv,  on  which  they  ihmw  nmi-h  light;  and  as  (mlhologirjil 

^Vekca  ioUt  thr  nature  of  that  remjirkable  iliapjue  Briit  deocribetl  by  Sir 

"■  Gull— "Mvxtrdeffla" — in  whirb  atniphy  of  the  thrrold  is  an  imiiorlnnt 

"»"-   - :.lir.' 

Iiaii  partially  or  wholly  excised  tlie  thymid  Ijody  in  10]  tnnn;  of 

.    -•  !..■  Mu  abit  Ui  trai?c  the  after-raindi lions  in  2^  cn»-*  iif  partial,  and  in 

^^^tm  of  Uitnl  fKtirpatitut  of  ihiii  origin.      In   nont-.  uf  the  rnites  of  pnrlial 

'''^i*'  I  'tfriumtlMn  nf  y<-ncral  liraltb  n'i|.ir*-jihW,     Of  ih«  IH  cwa 

^t#,,,.  ,,  io  (WD  only   wm  ihvtv  un  clmiiuc   fur  tb«   wmfvc  with 

^K^rl  lalim  K«uenil  hntlth,  and  it  was  most  remarkable,  that  in  ouuoftbeae 


DISEASES   or   THE    HEAD   AKD    MKCE. 

ra«eB  a  vicBriouB  hvpcrlrophy  f»f  a  Bmall  at-renon'  thyroirf  body  ImhI 
plfiC€,  whilst  in  llic  nihcr  n  rrlurn  of  tlii?  jirjUru  Imi)  inkile  iu  appnuaAi 

In  nil  ttkp  K-niBining  IB  cases  of  luial  L'xtirfiiKitui,  lunrt-  or  loB  ■! 
sigliti  of  ilemnjfvmFnt  of  gencrat  h^altli  wtrc  uiaiiiff»t.  Thij  dei 
wa^  of  a  progretiaive  chnnirlfr,  hciug'inorc  nolin-abic  In  the  oldr«(, 
in  the  more  recent  c»9ca  that  had  been  oporain)  uu.  Vntfrtitt  Koehet  it- 
scrihi-e  llie  Rjinjitomn  (hnt  mani/fslod  thpnuwivt-s  u  ticeurriufr  in  iht-  Mkw- 
ini;  onler.  K^me  time  af^er  leavini;  tlie  hmpilnl  a  »eniif  of  falipic,  tawilwdp. 
anH  wearinPNi  wnii  experienced  in  the  Hnilw,  with  (inf:frin\f  jinitit  is  ike  am 
and  le^».  A  itensation  of  coldness  vorni  «»•  suppriulded,  r*{)rctnllT  in  t^ 
hantiM  and  feet,  wliit'h  p»t\»  in  th«  uiiiler  In'CHine  hliiUb-ivd  atnl  r«l<l,  tUi- 
blainM  iimkiiig  their  appfarancif.     Th<?  nientnl   aclivtiy  •!■ '  '     ltioti|l< 

and  »|ieech  became  »\»v.    The  movementi.  ^enerallr  were  >     _  _  nltKm 

was  no  inipNiriuent  of  the  menial  powvr«.  Swellini;  of  the  UiUt,  lt«l  w»^ 
especially  of  the  face,  nou  began  to  take  plan.*.  The  ryrtirla  Ixpcaixe  ihiek- 
ened  and  iyujcwhat  traue['»renl.  and  ihw  vxtTeTOion  of  the  cniotrtiaatf 
idiiilic.  Hand)!,  face,  and  abdomen  awulled.  Th*'  fkin  Iml  iia  elaatiniy  mJ_ 
became  dry.  Thu  huir  fell  off.  In  more  deTetoivcd  cnan  aunvita  ucnii 
In  tboBc  VRBna  in  which  the  growtli  of  the  iMNly  n-an  incoinplrtr,  ttiia 
retanleil  in  h  very  marfccfl  manner.  Ju  some  inaiaocn  dyipliapia,  lieadMilb 
and  jjiddiness  were  met  with. 

Theae  symptoma.  it  will  be  observed,  are  identical  with  thoen  of  " 
dema:"  not  one  in  absent  Ibat  w  met  wilh  in  that  (liaeBM-.  not  noe  i> 
The  imly  ex|ilanalion  that  can  !«■  given  of  the  idenlity  "f  the  aymptiim 
lowing  total  extirpation  of  ihe  ihTntid  b«Mly  an  dewrilw^d  l»r  K<>ehe», 
th(«e  of  niyxuHletna,  as  deacrlbefl  hy  ituil  and  (_>rd.  in  that  the  iioe 
logical  condili'm  coniiiinn  to  both,  viz,,  ahieiive  of  the  thyruid  Itody,* 
cause  of  the  symploniB. 

Escialon  of   the   lethmaa  of  the  thyroid  hiui   Ite^n    rec<M 
Tillaiix  Bft  n  nienns  of  cure  in  certain  CB«e  t^f  bronchi ►ceV.  ^h- 
rmerfltiou  Win^;  to  learl  to  atrophy  of  the  cnlarffrd  luleral  hi 
Tillaux  in  Pari»,  and  Sydui-y  Jiine«  in  thitt  countrr.  have  yi  ■  .'^ 

rations  eiuccerafally  in  several  cases.  Tbf  oiitratioo  ooimiMii  in  »xi>ratuf  li* 
isthmus  by  a  median  incifion,  parainir  a  double  lijiPitMn'  thruu|:h  it  at  rilkr 
end,  tying  them  tightly,  and  then  excising  the  inter*-r»inp  pnrtioD.  S  J*** 
advises  that  the  wounu  should  be  well  drained.  Tbe  raults  appear  Iv  km 
been  very  wlisfartory,  but  the  principle  on  which  it  i»  nbtaiDcd  b  wrtaWf 
very  nb-tcnre. 

Acute  Broncbocelt  is  a  very  diflereot  diveaae  fwm  the  ebrmio  fi** 
It  is  of  rare  occurrence,  but  has  been  met  with  both  sporadicmlly  andr)^ 
demicany.  and  in  young  cubjccfs.  In  this  form  of  the  all^tipa  tbe  Ikf^ 
R^Iand  undergoes  rapid  cnlargenicut.  attaiuiug  l>.>  the  pile  of  the  Sst  er  iafl" 
tn  the  course  nf  a  few  days  or  werki).  Both  l'>bes  and  the  istbaios  In*'** 
sfTcctrd.  Owing  lo  (he  rapid  cnlnrgcnicni  of  the  ihvroid  bodr,  tbeCucliof^ 
neck  covering  it  docs  not  stretch  with  ^uttii-ieni  rajuilily ;  ana  ibe  ni— ■[Mlf 
b  that  the  euojacent  T>artr.  na  the  trachea,  become  eom|tft«sed,Bi»  iWl  i>tt>* 
dyspn4Pa  sets  in,  and  death  from  asphyxia  may  result  in  the  ctnirw  nf  •  ^ 
days  or  veeka.  It  is  (Mffimit  in  these  cases  lo  know  how  lo  saTe  the  pMaati 
for  tracheotomy  by  the  ordinary  luelhoila  may  be  iaipnieticublcowiatlsd' 
naoner  in  which  the  tumor  dips  down  behind  the  Mcruum.  In  fuefc  o*^ 
tapoiof^  the  tumor  in  diflercnt  plncea,  ond  iho  division  of  the  bsciaef  iM 
DecK  covering  it,  mnv  give  relief,  and  afford  time  for  the  aciluB  of  i»ai(4i*i 
Ifihik  faiU  anri  deatli  ix  imminent  from  AMphyxia,  t«-     ■  •  '  '-  ■rs«'|** 

to  till*  Surgeon,  either  the  ivthuus  munt  In-  divided  u-  .r  niaw* 

Hoe,  Paquelin's  red-hot  knife  )>etng  used  to  limit  thi;  hviuw4rh«^  «r  1^ 


iifi 


VALIGXANT    0EOWTir3    OF    THE    THTROID. 


667 


taryux  may  he  opeueil.  the  cricoid  cartjltt^v  being  ilivideil  and  n  lon^^  canula 
or  a  callieitir  lie  (tasBi'ii  dowiiwanU  pasi  llie  olistriicunn.  The  latur  mttliod 
ha^  Wen  Dtit^'cet^tully  adupltHl  by  Konig,  who  hits  invented  a  apefial  rnriula 
fur  puch  raae?.  In  Iii:^  case  the  tube  Ua<l  to  be  passed  nearly  five  iuehee 
(lownwariiH  before  air  entered  friwly  tlimugh  it. 

Exophthalmic  Qoitre.  Graves's  Biaease. — In  pncttue  wc  not  uncom* 
nintily  ol>!tt]rve  a  triple  clinicul  coinbiuation,  of  anaemia,  ex»nhtha1mo8,  and 
brmitihocele ;  and  the  connection  of  these  hoji  been  coinnienieii  on  by  Graves, 
Beaedow,  Sirbel,  White  CoDper,  Aran,  Begbi«,  and  numerouft  oilier  prac- 
titiuners.  Exophthalmic  guHn  ie  almcieL  excluBtrely  met  with  in  women  in 
juung  Oflnlt  life.  It  comnicoec^  with  ana:<miA  and  noma  men-itriiul  dinLurb- 
ance.  These  are  accoTii[uLnied  by  palpitatiun  and  irref^lar  action  of  the 
I  heart;  often  with  connidtrablf  breuthleMmena.  Knlar^eniuut  of  the  thyroid 
eland  soon  f<j1Iow8,  which  may  asumne  the  form  of  the  piilHatiiig  brnnchocele. 
At  the  saiiiL-  time  that  thin  ^Uiid  enlarge*,  pnitruaion  of  the  eyebalU  hecotnea 
a  marked  symptom.  In  extreme  caiitea  the  exnnhthalnioa  may  he  »i>  great 
that  the  lids  cannot  properly  cover  the  eyeballa,  and  in6ammatioQ  of  the 
conjunctiva  and  cornea  may  result;  except  from  ibis  cause,  however,  ihere 
ia  no  ailection  of  virion.  The  disease  may  steadily  increase  and  death  take 
pUce  from  mtuv  intercurrenl  dUeaee  or  general  M'asiiug,  more  rarely  from 
proBuri!  of  the  enlarged  gland  on  the  tracben.  In  oiherca^cs  the  symptoms 
nuiy  gradually  subside  and  the  palieot  recover.  The  exact  nature  of  the 
'ItieiHse  is  unknown.  Shingleton  Smith  baa  described  changes  in  the  cervical 
vympBlhelic  gani^lia.  which  he  is  inclined  to  rigard  as  ibt;  i-auao  of  the  dis- 
ease. The  ganglia  showed  an  increase  of  counccjlivu  tissue  with  atrophy  of 
the  ganglionic  cells. 

The  tnatimni  consists  in  rest,  tlio  admioislratiuu  nf  iron  and  aloetic 
purgatives. 

Malignant  Tumors  of  the  Thyroid  Body.— KauH'man,  in  l><T!t,  puhlinhcd 
a  paptT  ui  wliirli  lie  rtcordpd  ■Hi  rasec.  partly  his  own  and  partly  collpcteil, 
ofinialiguant  tumur  nf  the  thyroid  liody;  of  thcj^e  '*'i  were  carcinoma,  and  7 
sarcooia.  In  every  case  the  malignnat  tnmor  originated  in  a  gland  already 
afii!ctiH]  by  tihrimic  bronchocele.  The  tnmora  nsiinlly  nffecled  one  lobe  only, 
buL  in  a  lew  cases  the  whole  gland  was  implicated.  The  cancerous  tumors 
were  oharacicriied  by  rapid  gMwth.  Infiltration  of  neighboring  atructurea, 
and  airly  iofeclion  of  the  lymphatic  glands  and  internal  organs.  In  six 
euee,  senmdary  tumors  formed  In  the  bonea.  The  tumor  was  in  all  coses 
soft  in  cousiste'nce,  and  micrtscoplc  examination  showed  that  the  morbid 
growth  ron)inenc<-d  by  prulifcralictn  of  the  normal  cells  of  the  gland,  the  new 
C«IU  tint  tilling  the  spaces  and  then  biirntwing  inln  the  surrounding  {larls  in 
columua.  Thi-c^dU  were  in  mu»t  cases  pulygituul,  but  in  une  the  Hpac««  were 
lined  with  cylindrical  epithelium. 

The  sarcmaia  were  rouud-celletl,  spindle-celled,  and  mixed.  In  one  case 
the  growth  perforated  iho  trai.heM.  aud  in  all  secondary  tumors  appeared,  in 
ihrve  caaes  in  the  lympl)alic  gUndd. 

A  special  form  of  malignant  tumor  of  the  thyroid  body  has  been  met  with 
in  a  few  recorded  cases  in  which  the  secondary  tumors  closely  resembled  the 
Dornial  thyroid  body  in  structure.  Theae  were  Hmt  described  by  0>hnheim, 
and  cases  have  been  recorded  by  Morris,  Waringtoti  Ilaward,  and  Neumann. 
Ia  all  these  the  lymphatic  gUiida  were  atfected.  and  pulsating  growths 
appeared  in  the  bones. 

The  thyroid  body  is  also  sometimes  itnpHcaCed  by  malignant  surcumatft 
springing  from  the  structures  in  its  neighborhood,  and  by  epithelioma  of  the 
(Mopb^us  or  larynx.  It  is  very  rarely  ihe  seat  of  secondary  malignant 
growths. 


568      UlSBABES    OF    THB    JAWS    AND    THKIK    A  J^  I'L'N  II  A  n  E3. 


CHAPTER    LVI. 

DISEASES  OF  THE  JAWS  AND  THKIR  APPENDAGES. 


msnASES  OF  THE  r.UMS  AND  AI.VF.ni.AR  PRrWEMIS. 

Absoeae  of  the  Oami.  Alveol&r  Abeoeu  or  Oamboil,  ie  of  very  fre(]uenc 
occurr«iiee,  fn>iu  llie  irrimiioii  uf  decayed  u-elh.  Tlie  ciininiun  guailHiil 
foru»  at  tlie  edge  ol'  (he  ),'Utii  aud  is  quite  au|KTliciaI ;  it  is  at  once  relieved 
by  puucluriiigil  wirli  a  luucet.  A  nmrt  tnmbk'S'Jine  Curm  oi*Blveol8ralj*ce» 
istbatwliicli  d(;vi-tu|i»  in  ruiiiioctinii  uiUi  liic  fmig  of  n  tuoth,  usunlly  trariuus 
hutoccaBioiially  apparently  lifiililiy.  The  pns  flirnw  at  the  fxireoiity  ol'  Uie 
fang,  the  alrcoliis  btin^  uhmirbnl  anmnd  it,  s<i  that  a  tiniu))  ahBcevs-eavity  ts 
hullowfd  out  ilccp  in  the  hour.  The  pus  mar  find  hs  way  tmt  alune  the  tooth, 
pointing  at  the  marf^in  nf  the  gum,  but  not  unfrcqueully,  especialty  in  tbc 
molar  or  bicuspid  tcetli  it  perfiiratp«  the  com|iflrt  tissue  ot  the  jaw-bonf  and 
tornis  nn  ah»w.-w«  deeply  iiofltcd  below  the  rt-flictiim  of  the  nau-oua  moiubrane 
from  the  guin  t"  the  lip  or  chet-k.  This  \»  aci-oiiipanied  hy  Ciinsidt-rablt'SivoII- 
ing  f>f  tbc  face  und  m-vere  puin.  The  nacnre  of  thesw^^lling  is  recogiiized  by 
ila  bi-iiig  tirmtv  fixed  tn  the  jhw.  By  a  free  and  early  incisiiiD  and  extruetiioi 
of  the  di<ieBBe(i  tonlh  the  pus  rciny  be  let  nut  into  tbc  mouth  and  imiuediale 
relief  obtnineri,  but  ttotuticDniinoidy  in  the  lower  jaw  ibe  alnceoa  opens  exler- 
Dally  near  ilie  angle  aud  n  iroublc-ayiue  sluus  may  W  left,  which  refuiM  to 
bwil  until  thv  n(!i;ctcd  tijolh  is  rfcuioved.  In  the  upper  ja«'  the  pua  may 
biirruwbcuwitblhu  palate,  btrming  nn  abscess  in  the  ruof  uf  the  timulh  wbicb 
<>cca»iuimlly  leads  to  iieciDsis  of  n  portion  uf  the  b<jue.  To  prevent  this 
eucli  abt-ccbsetf  should  be  o[H;ned  early  uud  (he  di8ea»ed  tuulb  iiimiediaiely 
exlractvfi. 

Spongy  Onnig,  soiuetiiaes  acoi>iDpanied  by  ulceration,  may  (u.'cur  as  the 
result  uf  frcurvy,  ur  Jruni  the  adniiuiBtraliuu  of  mercury'.  If  the  conditJoD 
be  due  to  scurvy,  it  is  ijuickly  relieved  by  atteuliou  Ut  diet,  frei»b  I'ruil  and 
vegelublcb  being  freely  supplied.  The  nitiuth  may  be  wiubed  at  the  »4uine 
tiiue  with  an  aluui-gargle.  Such  cases  are  nut  uiicomniou  aiuoug  the  I'eiunlf 
poor  uf  large  cities  whose  fund  convititK  chiefly  uf  bread  aud  tea.  In  mer* 
curial  wiliralion  a  stmng  aUim-^argle  will  be  tiiund  the  best  remcily. 

In  Bcnifuloufl  ill-fed  children  a  xftotig^  eorniifiim  of  the  yum»  with  -uleerotioH 
and  ft'lor  of  the  breath  is  Bomeliiiiet;  met  with.  The  ulcere  are  covered  on 
the  Burfaee  with  a  firay  sUiugb.  The  caueeof  ibii  coiidilion  ih  often  uhaeure. 
It  must  be  tn>aleil  by  loni.t*,  cml-Iiver  oil  and  imn.  aud  by  chloride  of  pot- 
aeh.adminiBtercd  iuternaljy  lu  very  yuung  child  reu,  or  UEted  as  a  gargle  wneu 
poeulile. 

InflainmRtinn  of  thegnms  during  teething  must  be  relieve<l  hy  lancing. 

Simple  Hypertrophy  of  the  Otinu,  in  the  lurm  of  a  (K-»du|i<uR  inured  out^ 
growth  overlapping  the  tf-cth  is  occttsioDally  met  with  iu  younj^  children. 
The  cause  of  the  rundiiion  is  uocerUiin,  bni  it  is  reniarkablc  ihiii  llu' children 
in  all  reci>rdc-d  chscs  were  deficient  in  intellect.  In  ii  case  of  this  kind  under 
my  care  I  freely  removed  the  growth  with  the  scalpel  ami  twiUMirs.  It  wae 
found  to  Consist  of  the  onlinary  structure  of  the  guni»,  wilb  fine  fibrous 
fltraoa  containing  much  glflnd'tiHtie ;  the  papillie  on  tb«  surface  were  very 
large,  and  covered  by  unusually  thick  epitbcliura.    At  the  time  of  the  opera- 


t>ISEASBS   OF   THE    OUMS  —  I 


569 


tkin  the  cliild  wne  *2i  yean  of  agt.     Fivd  yciire  aflerwartie  the  lute  John 

3((irrsy  oxhibiu-d  tliia  (Mtlient  antl  lii«  younger  hrulher  And  eielfr  at  the 

^c^iticu-ChirurijtcAi  Soc'iHy  (Trans,  vol.  Ivi.).     The  growth  hnd  relurnefl  and 

<he  two  youDgvr  cbiUlrt^n  w«re  sintilMrly  ktTected.     Thty  -were  all  the  fiiil>> 

jectsof  tumun  uf  the  skiuoftbe  LAtureof  mulluscuiu  tibn)eiiiii  und  peculiar 

euIm^eitKats  of  the  liugens  mid  toe«,  uud  wero  «ll  uf  weak  iiitvllect,     No 

«.^UM  c<iuld  be  found  tur  the  diseiiee  b«yuDd  lb«  Aicl  thai  th«  pHreotn  w«re 

fint  cousios.     C  Heuth  rectMuiueuds  lu  suub  caant  Lhut  the  ttlveular  burder 

tfhnuld  Iw  removed  nitb  the  gniwtb. 

Spoilt  U  a  tumor  sprlugiug  Irom  the  periusteuui  uod  edge  uf  the  ulveuluH, 
stnd  impliciitiDg  tbe  ie»e<)us  walla  uf  the  i>ui:kets ;  it  gruuii  up  belweeu  and 
Ju<«eOfi  the  neighboring  teeth,  which  it  ilibplacee  uud  «uve]o|ie  in  its  strui*- 
ture.  It  is  uf  [wo  kiude;  vimplc  uud  mnlignant.  Tb»  HlmpU  Kftutiif  ia  a 
tibriup  tumor;  the  term  Maiii^nant  £/iulijt  is  applied  to  a  myeloid  tumor 
^pnn^in>;  from  the  nlveolur  burder  of  the  jaw,  and  ii  u  eooietimes  exteuded 
tAi  rpithr-ii<ii)ia  of  the  gun. 

Simple  Epulis  in  most  frequently  met  with  in  tbe  lower  jav  (Fig.  671). 
I  imve,  bowovor,  aecn  aeverni  instances  of  its  epringiig  '*"'"'>  t'"'  ulveidar 
btvder  of  the  upper  jaw  (Fig.  ti72}.    U  appears  to  be  ooca^ioned  cbiefiy  by 


t  t 


S  '^^  ti'i^ 


Pi|.«ri.~EriaHior  Lo»ar 


bancing  ilowo  >o  m  lo  ovwiBp 
lb«  Lo«»r  Jww. 


*^*  irntattoQ  of  decayed  stumps,  and  hence  iK-ciirs  more  frequenlty  in  oon- 

I  *^tiiJii  with  the  niohir  than  with  die  iiicinor  teeth.     Although  thia  disease 

***  ocvasiuDully  inifn  seen  in  children,  it  seldom  occuni  bef'-ro  the  adult  a]^, 

^■'id  may  be  developed  eren  up  h>  an  advanced  [wriud  of  life.     It  is  et-eii  as 

•((■n  iimon^  frmalca  as  malps.     A  fibruus  epulis  ap[)ear»  a»  a  red,  BmiMilh, 

^^*i(l  lobulatod  tumor,  at  first  hard  and  winl-ehnstic,  like  tho  urdlnarj' *itnio- 

'4rt'  of  ttie  gum,  but  after  a  time  iileerutinjf  ou  llit-  surface,  with  a  puruleut 

^Vaanious  diacbar^e.     The  libroiis  epulii)  t>prhtpi  J'roui  the  pfrioateum,  and 

*^jaie!iniM  cotitaius  mpiciila  of  bone.    It  is  coverwl  by  a  thin  layer  of  mucous 

JWatment  of  fiimpte  fibrous  epulis  eonaielo  in  the  removal  of  tlie  whole  of 
*  lie  iaiu«.  If  it  be  very  «nall  and  superlieial,  the  growth  alone  may  be  re- 
**>uved  uud  tbe  aurfttce  from  which  it  springs  scraped  with  a  gouge,  iiy  thia 
*^ieiiiis  it  luay  occneiouully  be  cured,  but  more  commonly,  as  it  evinces  a 
^'real  teiideuey  to  rcproduuCiun,  it  must  not  be  simply  sliavcd  olf  but  the 
l»«rtiou  of  the  alveolar  border  from  which  it  springs  must  be  removed  as 


570      blSBASES   01 


Jaws  and  TUKin  appenoagu. 


w«lt ;  uoIpjw  lliio  be  done,  thf  ^Towth  will  to  «  oertainlv  )ir  r«-tiro4neML   la 


all  orditmry  vtv«s  'if  simple  epulis,  ihe  removiil  may  i>v  drme  trus  llw  i 
of  the  (uoulh  U'ilhnut  the  neccseity  i>f  leaking  an^  idcMoiw  |lin«|!b  tki 
cbeck.  lu  very  large  RiiiHee  of  epulis  extcndiug  inwnnb  the  nuuii»,  it  mif 
be  mmamrr  eillicr  to  cany  ao  incutoo  from  Iho  angle  of  tb«  ommiIIi  <!««»■ 
wards  aod  xutwiirde,  or  to  dtnoct  up  the  cheek  frtint  the  hnoft,  and  tha 
cxp<i»c  itic  dttw'ASc  fully.  Iq  performing  iJie  iiperatioo,  tbo  ilrM  thitw  U  W 
donu  u  lu  cxtmcL  u  to«>th  on  eacli  cide  of  thr  luiimri  a  cue  miMC  Im«  b 
madf  wiUi  n  «a«t  tlirougb  the  alveoli  uf  ihp  tr^h  that  have  bem  retrntdt 
dnirii  L<>  n  Irvid  with  the  bam  of  llio  j^rowtb.  In  dolni;  thi(>.  ran  aaaibt 
lakfii  not  to  cut  l<Ht  near  the  r<'m»iiiinf;  UTtb,  lest  (be  nU-enli  beupnurfaA 
their  Riip|iort  lo«i.  If  the  tumor  Iki  lar>;e,  il  ni»y  Ih>  nr«i'«»4irr  o  ••«  <k*^l 
htii  the  ImAo  of  tbt'  lii««>r  jaw  Klmuld.  whpnovf'r  pr»rtimhl<>,  he  leA  tolart.lH 
wbolf  of  iu  Kul)8lHn('<>  not  hnin^  mivin  (hr<tii<:h,»o  thai.  th<tuf;h  a  etmaidtnkh 
[lortil^n  of  hone  Im>  ri-niovetl,  vft  (lit*  Ifngth  of  the  \avr  may  U>  pnttmL 
For  thii^  )iiir|)iiep  Hcy'a  anw  should  oot  be  UM-d.  as  It  is  a  niinrlitijE  bntn- 
meul.  diffi<nilt  to  mnnai^  in  lliU  ■ttnatina ;  but  n  ntrai^hf  and  «iiir-li«ekHf 
«w.  wilh  an  deep  a  hlftde  aa  the  mouth  will  oonvonit^tiily  admit,  will  tttttMoi 

niiiet  nwful  {Fig.  (WW).    Tin*  epnlii*,  inrludod  hotwei-n  two  verti--'  wir 

now,  if  liimHil.lto  removed  with  cMw-culliiij;  furcopa,  and  the  M"  i*i 

by  (ilnang  a  plug  in  the  wound  nml  cortipritwtiig  it  a(;ain»l  Ihc  -.i-nu  •■.  U* 
upfter  jnw  )>y  ineMUB  of  a  hiin<U^t>  parsed  under  the  rbin.  If  iIh*  oMtlii  W 
largo,  a  hoHjiiinlHl  out  »hoiild  l>e  made  ahing  the  hunr*  alKiot  mtitway  MMfll 
the  atveolutf  and  the  ba^,  by  menos  of  Ilcy's  Miw ;  and.  nlWr  (W  Un»lM 
bteii  |K-nt.-tnit«d  to  II  Bulhcieiit  depth,  the  binile  of  the  cni»w-<-i  '  -i« 

niiiy  he  lixed  iu  thit<  cut,  and  the  iliBf.-«Hed  |inrt  th<-n  remnvv).  ^ 

be  «  spouting  dental  artery,  it  may  he  ut-ceMary  t'>  apply  a  n-  I  •< 

(he  perchloride  of  iron,  in  onler  to  Hrrvtit  its  Mevling.     The  civ  "11 

Bpecdily  granulate  ;  and  the  cavity  tille  up  nith  fibniun  tiaiue.     I  a 

for  the  removnl  of  epulta  is  n  very«afeune.    Of  28  C8»t«  C(illef't>  '  i'^ 

ins'in  from  ilitftrent  ]..'mdon  Hoepitnln.  only  one  waa  filial,  fr<Tm  prirnna. 

JtaU^nant  Epolia. — By  thtH  term  if<  cnmmonlr  mtnnt  a  mveloid  Mnaa* 
of  the  alveolnr  bonier,  but  it  ia  (K-caeionHlly  extemled  to  cpttueliooui  o^  A* 

int. 

SJyriaiti  Snreoma  of  (he  Alirotar  Border  forma  a  nofl  purpliih,  very  vaMvIV 

mor,  growing  rapldlr  ami  speedily  recurring  after  re-moral,  unlni  tbi  i^ 
ci«ioD8  are  carried  wiJelv  beyond  the  growth.  Il  oceiira  principally,  «i(u 
■9  my  observation  goes,  in  malc^  adviinced  in  life,  Them?  tumon  mfk** 
the  Mine  opemliiin  A9  th«  simple  epulis;  and.  as  much  hemtirriiaee  ohmII; 
follows  their  removnt.  n  red-ho[  iron  mast  be  applied  lAthe  bli<Mlili|[niT4ttf 
If  a  m&li|;naul  epulis  be  very  larfre.  it  may  be  necMMrr  tn  revnnt  a  pMiii> 
of  the  whole  (hickneaa  uf  the  bone,  through  an  external  incitioD,  as  will  ^ 
drflr'rihod  in  the  section  on  li^xcision  of  the  lyiwer  Jaw. 

Eplthetioma  of  the  Ohio  is  not  common.  It  pntaeDta  tbe  nnllDSiyfW' 
aetera  of  cpitht-tiat  eanevr.  £l  is  distinguished  from  myelt4H  aamiiM  lif 
its  flat  surfaee,  its  early  ulceratioa,  the  cTerte^l  edge  of  the  ulcer,  sn^  1* 
cnmpani lively  slight  tendeoey  Xo  fungale.  In  the  Inter  stage*  the  onixhlV 
ing    lymphatic    glands    t»ecomv   enlarged.      tn   the    lower   ja*  wbiia  tW 

growth  peuelrates  the  compact   bone,  it  exicnds   wideW   in   tf-.     ''-^ 

linue.     In  the  np[M>r  jaw  it  may  invade  the  uutrum,  ami  compi  ''*' 

Ottvity.  Tlje  treatment  is  li»  remo^-e  the  growth  freely  with  a  •>-wi'i*o«fc 
portioo  of  the  bone  on  each  lide  of  iL  In  the  urper  jaw.  if  the  fiwrtk  ill* 
the  antrum,  it  may  be  oe«egsanr  to  remove  the  wliule  or  a  grrmt  part  of  ik* 
upper  niaxillu. 


ITRCROSIS    or    TBK    JAWS. 


571 


Hmtoui  of  the  Jkw  is  commoDly  the  eS'pct  nf  IiIowe,  of  culivation  bv 
inertury,  of  syphilis.  <pf  fever,  or  of  expoaure  to  the  fumes  uf  phoiihorus.  I 
have,  hnvever.  Been  the  rlueiue  oocur  idiopnthtmlly  in  othfrwitit-  lu-nlthy 
eiibject*.  without  nny  flgilgnable  cause.  In  this  way  1  have  wpn  the  wbola 
of  the  BlvenlBP  process  of  the  upper  jnw  erfoHate  in  a  young  lady,  nlherwtae 
|>er(ectly  healthy ;  anti  I  hnve  several  tinifis  had  uccssion  to  remove  larj^ 
portioDB  of  the  lower  jnw — in  one  mm  more  than  half  of  the  bone — for 
neorom  that  could  nut  be  referred  to  any  of  the  ca\i<«efl  mentioned  nhove,  or 
iodeed  to  aof  aaBignahle  rea»aD.  The  diseaBc  bcfcinB  with  deeply  seated  pain 
TMfmblin^ inveterate  toothache,  which  nothing  will  allay  ;  the  gums  beoonio 
BWolltrn;  the- lec-lh  are  tou^ned,  and  evenlaally  dmp  out.  Bef<>re  they  dn 
so.  however,  pus  uauallv  welli)  up  ihrouinh  the  alveoli.  Absceues  form  in- 
side the  mouth  and  un^cr  the  auglea  of  the  jaw,  bavinp  fialulous  npeninRS 
tfcrOQgh  which  bare  btme  is  reached  by  the  probe.  The  general  health 
•affera  greatly,  more  so  than  in  nerrooln  gencrntly,  di>ubtle«d  in  couflequence 
*f  the  pativnl  awftllowing  aoine  of  the  pu*  fn-m  the  dead  bone. 

NecpifiB  of  the  jaws,  arising  from  the  inhalalions  of  the  fumes  of  phn«« 
phortiB  during  the  inanufiiciure  of  lucifer  matches,  first  noticed  hy  ly^rinser, 
at  Vienna,  bae  been  eBijevially  described  by  Vuu  Bibra  and  Geist,  who  bad 
xhundaut  <ipportunittev  of  observing  tlic  disease  at  the  large  manufactorleB 
at  XurembtTg.  This  Lnoifer  match  dlieate  wa«  some  years  ago  very  fre- 
<}ueuC,  but,  in  conitcquence  of  the  adoption  of  precautionary  nieH»ur«t,  n 
now  much  m'>re  rarely  tuet  with.  It  consisti*  in  nceroeie  of  the  jttn^  and  is 
attended  by  ibe  Hviuptuiuo  Hbove  di.«cribe«l,  but  in  a  more  !*evere  degree  and 
an  acute  form,  The  aflocicd  bouc  undervooii  a  remarkable  change,  awum- 
ing  the  i>on>uii  uspcct  iiud  grav  culur  of  dirty  puinicc-^t'iiie.  B>»th  jaws  are 
«<iualty  liable  tu  be  atleeted ;  but  communlv  mw  only  at  u  ttnte  is  dJKttwd ; 
the  whole  of  the  bone  may  die  and  be  separated.  Thusj  of  51  cases  observed 
ItT  Von  Ribra,  both  jaws  were  affected  in  five  insunoes  only— the  upper 
aionn  in  21  cases,  the  lower  in  25.  According  to  I^ngenbeck,  the  nvcal 
<li«ease  is  preceded  in  many  instancea  by  general  FympioriB  <»f  phoj^pborns- 
poisoning ;  and  there  is  a  conaideruble  amount  of  bony  deposit  from  perjo*- 
litis.  e-Qorosing  the  necroacd  b»ne.  It  has  been  believed  that  workmen  having 
Muod  teeth  are  not  easily  if  at  all  influenced  by  the  ftimes,  and  that  the 
phosphorus  ai*t9  through  carious  teeth  :  but  Langenlteck  has  oheerved  that 
the  teeth  have  lieen  ixiund  in  0R.4e3  of  the  dlseflse. 

The  diitgnQsin  of  neoroeia  of  the  lower  jaw.  »  usually  nnnccompanied  hy 
aty  difficulty.  In  the  upper  jaw,  esiieeiaily  when  limited  toihe  palaul  prn- 
ceu,  it  niny  rii-Sftiible  epitbeliociia  io  tb<f  raised  aud  everted  edges  of  tlie  ulcer 
in  the  hani  jmlate  and  the  spongy  feel  con]muiiicat«d  to  the  probe  by  the 
dead  bt'ue. 

Trfnimettt — The  treatment  of  nerrofis  oflhe  jaws  presents  nothing  special. 
The  rtrmoval  of  the  ee^pieetra  should  be  etfecteii  hn  far  a«  practicable  thr<iugh 
the  interior  of  the  mouth,  by  free  incisions  thntugh  the  ijumit. 

In  the  Mj7j>er  jaw,  where  the  iiecmeis  seldotn  extends  beyond  the  alveolar 
bonier  or  ibe  palatal  process,  this  may  always  readily  Ih-  done. 

In  the  Awrrr  jaw,  the  nuestinu  as  U)  whether  the  dead  boue  should  be  ex- 
tracted thnitigb  the  inside  of  the  mouth,  or  by  incision  from  without  through 
the  cheek,  will  be  determined  partly  by  the  pcisition  wf  the  ainust'S  and  partly 
by  the  situation  and  extent  of  the  bone  affected.  This  may  in  a  great 
nieasFure  be  asecrtaiticd  by  the  situation  of  the  ainuscH  leading  dowu  to  it. 
If  these  be  id  the  cheek,  or  in  the  side  of  the  neck,  or  under  the  angle  of 
theJBW.it  is  usually  an  indication  that,  if  the  nholc  of  ttie  corree|>(>uding 
nunus  or  body  of  the  bone  be  not  involved,  ihe  posterior  and  outer  [wrls 
are  certainly  affected ;  and,  in  these  cireumstancca,  extrocttoo  of  th«  sequea- 


i 


572      lilBBASBS    OP   THE    JAWS    AND   TKEIR    APFENDAOCS. 

trum  ii  beet  efTecteil  br  opeoiog  up  the  liatian  {)ankll«l  to  ibe  Uo«  of  th» 
)«w,  and  removing  the  Decrnsed  boue  in  the  iifiunl  wur.  The  JBcidnt  fct 
this  purpoeeaeorl  DotuftuaUy  be  very  extonaivo.  If  the  opcnUiua  baddajvd, 
in  aoonraaaoo  with  those  priDci|ile8  that  guide  us  id  the  maaagMNcat^tf 
n«ero«Hl  bono  ^eiicrally,  until  tho  Bequestrum  is  (]iiii«  Ioom,  it  aay  nanallff 
be  rfndiljr  PXlrarted.  in  whole  or  in  pieces,  throu^'b  an  openiafr  tlut  nl 
leave  but  n  BmatI  cicatrix.  By  such  operations  aa  tb«e.  the  waole  nf  ik 
lower  jaw  has  been  extracted  piecemeal  at  intervals  in  a  state  of  sccnaa, 
first  oD  UDO  and  then  no  tho  other  gidc.  Carnochun  has  rcmovad  tho  wbnk 
of  the  oecroBcd  lower  i&w  at  one  operalioo.disftrtiouiatiog  6m  one  aad  Am 
the  other  coDdylc  in  toe  usual  way. 

If,  however.' there  be  no  external  abaceas  or  siaiu— if  iho  jtnm  ban  hi« 
looMDed  and  perforated,  with  a  ragged  portiou  of  •cqiH'struDi  prnjartiwii 
through  it  into  tho  cavity  of  ihc  roouih,  Uteii  no  exteroal  inciiiflOi  will  b 
required,  but  the  dead  b<)ue  nmy  be  ri>adily  removed  from  within  At  laoML 
Larjce  portions  of  ihu  jaw  mur  thus  be  rcinovGd.  1  bAVe  taken  awaytht 
whole  of  tht*  ramus  uilh  its  proceMCs.  vulirely  thrnutih  the  i^ms,  •illml 
any  external  inciaiuu  :  nml,  iu  a  uugro.  the  wbule  of  the  boue  io  a  tlstr^ 
necnjais  bu  thus  been  rvmuvt;d  lu  Be)»arat«  pieces,  by  I'erry.  through  Uitit- 
aidu  of  the  ttiuuth. 

Iteproduetion  of  the  Jato  after  RemovoL — The  amount  of  t^^>-n,<nt'u^  et 
bout*  will  depend  gretitly  u|Km  xUv  state  ttt  the  |>eriosteum  bvfor'  tl 

of  the  «v<|ucatni.     If  this  be  heullhy.  and  if  new  bouu  have  alitwi;  • — •! 


tig.  m. — V««tl'*  Cm*  of  PbMfbiMvt'ftMru*!)  «(  •itllrv  Lwar  J*«. 


prior  to  yperation,  a  very  perfect  roproductlon  «if  tb*?  piirtion*  of  j 
may  tflkp  plncf ;  in  (lu-l,  fumplete  reiiriMlueliun  of  Ihc  *>  I 
juw.  h'uly.  mnii,  nnd  epipbvMr*,  ibou^fi  In  n  iwimewhnt  ru'l. 
pprrtTt  f'^rm  mtiy  follow  ii-s  rfinnvnl  fnr  jilM>!i>h"ru«  nccnms.     In 
of  llio  Ik-IIevije  H'*pilnl.  Xew  York.  \V<.iid  showed  nw  IW'>  ;; 
of  llip  Ufcnwl  lower  jaw,  renmveil  by  him  for  ph(Mph-M 
girl  nlxiut  1'.' (Fig.  n7;{).     She  diwl  <i|' l>r*iiHli5cafc  llm- 
<i|HTati"U :  an<l  In  the  same  collectioti  is  ber  cranium  with  a 
Inwer  jaw.  omsiiitin};  of  lui  etitin*  aemicirclr  of  Iwine,  abnut    V)'- 
d(H>]i,  with  all  llip  (■pipbyscs.     This  uui<]uc  and   mint  Uv 
already  been  described,  and  the  rrgoaerated  bone  flgurni  i  r  i^^ 


««rwni»< 


SUPPURATION    Oy  THK    AKTPUW. 

It  tlie.  periosteum  must  have  been  preserved  entire,  nnd  thue  led  to  tim 
reproduction  of  the  bone.  Should  uo  new  bone  have  formed  before  the 
operation,  a  denae  fibroid  cirDtrieial  Btnieturc  will  replnco  the  lost  bone. 


I 


DIBEASEB  OP  TilE  ANTRUH  AND   CTFEH  JAW. 

Our  present  knuwledge  of  the  operative  procedures  necessary  for  the 
renmval  iif  diiH-a&e&  of  ilie  jaue,  is  due  chiefiy  to  the  labors  of  tienftoul,  of 
Liars,  aud  of  Untuo.  i^ir  W.  Ferguaeoii  greatlj  distinguished  himself  in 
tbht  tield  uf  surgery,  aud  siiuplifieil  and  cxlejiJed  it  much  iu  its  operative 
department;  and  C  Heath  hue  madr,  iuijiortunt  contribuliona  t4)  its  lileru- 
lure.  O'Shaugbnessy  ni^,  who  hus  hud  initny  opportunities  of  wituectBiug 
tbfse  sHevlioiis  amongst  the  natives  of  Indin,  buB  added  much  to  our  ac- 
quaiuiaDce  nitb  their  pallmlogy  aud  treatment. 

The  various  lar^e  and  irr<-);ulttr  eavities  that  lie  amongst  the  bones  of  the 
face  may  bveotue  the  seat  cf  dii^ense,  primarily  originaliog  citber  iu  the 
mucous  membrane  by  whii-b  they  are  lined,  or  in  the  oeecous  structures  that 
compf«c  thi-ir  uatU.  In  tbi»  way  the  fruntal  )>iiiuses,  the  ctbmnidnl  aud 
sphenoidal  cells,  nnd  the  iiniruni,  may  either  be  scata  of  chronic  inHumnia- 
tiiiQ  of  their  muuoUH  HuingR.  with  moie  or  lees  profuMi  muco-purulent  dis- 
charge ;  or  the  mucous  membrauc  may  take  on  more  ;«erioua  organic  dioeose. 
Tbu*  epithelioma  may  develop  in  it,  and  alter  distending  the  cavity  in 
«hii.-h  It  originnlty  formed,  nitty  thin  and  destroy  its  nasettus  walls;  and. 
ihoN  papsing  outwards  into  other  fiiuations  about  the  face  and  the  base  of 
iIk  skull,  where  it  is  freed  fnipi  the  pressure  of  surrounding  bone,  it  may 
take  upon  itself  greatly  increa.wd  development,  blocking  up  mucousi  cannls, 
as  the  note  and  the  lachrymal  tiac  and  ducts,  displacing  tbceye,  aud  produc- 
iiifjgreiit  disfigurement  of  the  side  of  the  face.  Thtrsc  secundary  onigruwths, 
from  Ibe  mpidily  of  ibeir  urireslraiiied  developmetit.  nud  the  amount  of 
deformity  ao'l  JiFlres*  wbtcb  they  occasion,  may  rradily  be  mistnken  for  tbe 
primary  ilisL'aee,  the  real  Bturting-jioiut  of  which  will  often  be  lound  iu  a 
<le«9|>vr  uud  more  limited  lLK.'4ility.  Tbe  boiiea  constituting  tbe  walls  of  tbeH> 
facial  i-Hvitit^,  or  the  periosteum  covering  tlieni,  may  aUu  beeoiuu  the  urigi- 
Bsl  seats  of  mtirbid  growths,  more  purticulnrlv  uf  eucbuudrouiu,  uud  mye- 
loid aptu die-celled  or  rouud-eelled  sarcoma.  These  run  a  eimiliir  course  Co 
the  growths  originuting  iu  the  mucous  membruues. 

Slipparation  u  the  ADtrum. — tjuppuration  may  take  p]ac«  in  the  antrum  ; 
it  is  usually  excited  by  curius  of  ouu  of  the  teeth,  Ibe  fangs  of  which  come 
m  cli«e  relation  with  tbe  euvily,  viz.,  the  Hret  and  second  molar,  the  bicuspid. 
Slid  tbe  canine.  It  ocL-asinnally  iirittes  from  injury.  Jt  is  usually  uecom- 
panied  nt  brat  by  dec[i-mmted  lu^hing,  throbbing,  or  liincinating  pain  in  the 
liioe.  The  pua  ae  it  Ibrnii-  will  Honieliniea  overflow,  as  it  were,  into  the  nos- 
tril thruugb  the  aperture  iniu  the  midille  f'oi^a,  and  then  may  keep  up  con- 
stant irritatioD,  with  much  fetur  in  the  nostrils.  When  this  takes  place  tbe 
patient  is  coneoious  of  an  nnpk'HHant  gmell,  but  according  to  Heath  this  is 
noi  perceptible  to  other  people  115  it  h  in  oziena.  In  niher  cumes,  it  drains 
through  the  socket  of  a  tooth  into  tbe  niouib  ;  and  in  other  instHiicee  again, 
but  much  le^  commonly,  il8  exit  being  prevented,  it  gives  rise  to  enlarge- 
mcnt  of  the  cheek,  the  soft  piii'id  of  which  become  brawny  aud  inflamed, 
and  tbe  bones  expanded,  so  that  at  last  they  are  thinned  to  such  un  extent 
that,  aa  in  drojtay  of  the  cavity,  they  crackle  when  pressed  upon.  Auy  por- 
tioo  of  the  wall  of  the  cavity — the  orbital,  buccal,  palatal,  or  nnsal — may 
thug  be  cxponded  and  0uclu&tion  be  felt  tbrouph  it;  and,  the  laohrymal 
duct  being  commonly  obstructed,  tbe  eye  on  the  aHecttd  side  becomes  watery. 
Id  some  caaea  abscess  of  the  antrum  bu  been  followed  by  loss  of  sight  id 


574     DISBASES   OP   THE   JAWB    AND    TBBIR    APPKNDA0B8. 


tlie  ere  of  the  snrue  side.    Tempornrj  blmdaese  U  cot  uocouimoD  wh«o  tbe 
fluur  i>f  tJie  orbit  in  raised  by  llic  pus. 

SVeatmeftl. — Tliu  irvairucut  of  ibin  coodittoD  cunsiiU  iu  liie  cxtrncLiao  of 
any  carimi?  touLli  t>ciitvd  iu  tlie  Jici^'liborbood  of  tlic  iiutrum ;  or,  if  ibe 
tectb  be*  all  souuii,  iu  tli«  rcuiuval  uf  the  scctiud  molar,  the  f»Dg«  of  which 
coiue  iuto  cluee  rclailou  to,  aud  froqticutly  perforate  tlie  liottnm  of,  thi!  oavity. 
Id  ihtg  way  an  exit  may  1>g  giwii  t*>  thv  mattcir;  hut  b«  it  will  DittdiwJiargB 
ttaetf  i<u<Kmi'titly  freely,  the  aulrura  must  be  o|)cue(l  through  the  alveolus,  or 
thmugb  thu  c-aniitu  fnesa  unHer  the  check,  nroviiled  it  be  much  expanded  in 
this  eihiatioD,  ao  that  its  ravity  can  be  eaatty  reached.  The  perforation  into 
the  aiiirura  may  readily  he  made,  or  the  siwket  of  the  touth  enlargcil,  by 
mnuiA  of  one  uf  ihe  forma  of  antrum-jterfoniLor  ht^re  represented  (Fi^  674, 
67&,  676j,  ur  a  carpenter's  gimlet,  aa  recommende<l  by  FerguasoD.     As  the 


Fl(;.  tU.  Fig.  6;4.  Fig.  676. 

TftrteuR  farins  of  Anirnm-[^tformtor. 

matter  draias  away,  the  cavity  irill  gradually  contract,  and  the  deformitr 
thus  be  removed.  Il  a  well  not  to  attempt  to  perforate  in  the  site  of  teeth 
thai  have  been  extracLud  fitr  Bome  time,  as  here  the  bone  l»econie»  unduly 
couaulidated,  auii  the  attempt  to  reach  the  cavity  ia  conaequentlr  likely  tu 
fail.  The  matter  that  is  diHcharged  is  often  very  offenftiye,  or'it"  may  be 
tliiuk  and  paaty  from  the  abeorplion  of  ita  wntcry  parts.  Afl«r  llie  ajM^rture 
hfu  been  made,  the  oavily  Rliould  be  ayringed  out  with  tepid  water,  and  the 
alrnite  of  the  cheek  gradually  reatored  l>j-  pressure. 

Cyite  of  the  Antrom  of  Dropsy  of  the  Aittram.~TD  this  dw«i»o  the 
antrum  becomes  elowlv  distended  with  a  fluid,  in  some  case«  glairy  and 
luucoua  to  character.  like  the  contenu  of  a  ranula  or  (janglion,  in  nihera  thin, 
brownish,  and  fcroua,  oontaining  cholesktorine.  It  was  formerly  b«lieved  that 
thiswcdition  wa**  in  mme  inslanceaat  teaatdueto  obstruction  of  llivapertur* 
leading  from  th«  antrum  to  the  noao,  but  it  is  now  ^neralty  ackiiuwl.dged 
that  in  all  ca»e«  it  reBuIts  from  the  fornialion  of  a  cvslic  tumor  »priiigiiig 
from  the  luucutia  membrane  lining  the  cavity.  In  auch  cases  the  ac»;un)ula- 
tioD  of  fluid  may  after  a  time  cause  expanaion  aud  tbinuing  of  the  oeseous 


CTST8   OB    DSOPST   Of   THE   ANTBCJI. 


675 


•f 


7 


Flf.  077.— C;iti«  TtiBor  of 
AnuVMi. 


trails  of  tbe  cavity.  The  cbeek  a  rendered  round  and  pmtninenl — «  pain- 
letF^  imlDleut  KinieiHStic  tumor  ft>rDiiDg  in  it  and  protruding  it  outwurdH, 
and  giving  Hk  to  the  egg-shell  or  parchment'like  crackling  uu  preeaure 
(Fig.  (JT7j.  The  flour  of  the  orbit  or  the  roof  of  tbe  inoutb  may  be  cag»ed 
to  bulge,  and  the  nasal  cavity  tnaj  be  encroached  up«)n. 

Tivalment. — Tbe  operauoD  of  "cathcteriziog  the  aotrum,"  founded  on  an 
errooeotu  idea  as  to  tbe  nature  of  iliu  di^efue, 
ms  formrrlr  recommenduU,  but  was  n«^ver 
■Ueoded  by  nay  benotil  to  the  patieut.  The 
ooly  rfGeitLi  trvntiueiit  coii^iiits  in  opening  the 
tDtrum  fn>m  without:  ihia  is  dnue  witliuui 
iocifeiu^'  tbe  lipe  or  wouudin^  the  fare,  by 
thrusting  u  trocar  aud  (.■aiitila  into  the  luuat 
thioued  and  expanded  part  uf  the  tumor  under 
tbo  cheek ;  or.  if  iieeeeaary,  by  die>>f(:[iug  up 
iJie  cheek  from  the  gum,  and  thus  making  uu 
opcniug  into  the  travity  of  the  antrum  with  a 
Btn)itg  jmir  of  aciasoni  or  a  perforator,  through 
ltd  uiusl  expundtd  and  thinnest  part,  so  a«  to 
allow  the  iliwharge  tiieacnpe  freely.  In  order 
ta  prevent  a  rmccumulation  of  the  Huid,  it 
iriil  be  better  to  cut  away  a  small  [Xirtion  of 
the  thin  and  expanded  unll  of  the  autrum, 
and  thu.<i  to  e»lahli.4h  a  [)«rmBneDl  aperture  in 
it,  through  wliicli  it  iiiu»t  be  syringetl  out  daily 
with  Botut^  nniL'teptie  solution,  ttucli  as  Colidy  • 

fluid,  until  all  discharge  ccflMs.  The  best  instrument  for  thlii  purpose  in  that 
rvcommcuded  by  Heath,  conaisting  of  a  couimon  KuatttcLiinn  cntiieler,  tu 
utiicii  an  lu'iia-rubbiT  bull  is  fitted  Co  contalu  the  Quid  to  bti  lujected. 

Folypas  of  the  ABtrtim. — Mucoua  polypi  are  ticcaaionally  met  with  in  the 
aoLruiu,  but  they  give  nw  to  no  lymptorns  uuleea  they  reach  u  size  sufficient 
tu  cause  disteutiou  of  the  cavity.  They  then  n)t«C  cooinioniy  c«ub«  absurp* 
tioo  of  the  inner  wall  and  pmject  into  the  nasal  cavity,  froni  which  they  have 
been  succesatully  removed  by  forceps. 

DABtig^rouB  Cysts.— The»e  may,  according  to  Christopher  Heath,  occur 
in  either  jaw.  They  arUe  in  coiineciion  with  teeth  whicii  from  m^me  cause 
have  been  retained  iu  ttie  jaw.  They  arc  almost  invariably  connected  with 
the  periDBUent  teeth.  Tonics  bclievM  iliiit  they  arise  from  the  excessive  for- 
mation around  a  retained  tooth  of  a  Huid  which  is  normally  fiuuid  After  the 
oompltie  development  of  the  enamel,  between  it  and  the  i<oft  tii>3ues  invest- 
ing it.  The  tooth  is  not  uiifreqitently  found  tu  be  inverted.  The  cysts  may 
occur  ai  any  nge,  but  are  miut  ciiinmon  in  young  adulla.  In  the  up])er  jaw 
ihej'  nmy  (brm  cysts  in  the  antrum.  In  the  lower  jaw,  they  form  jtrominent 
isolated  tuniore.  They  have  been  mistaken  for  solid  tumors,  ami  the  jaw 
has  in  coast>(]uenoc  been  partially  rcninved.  Occasionally  Ihey  mav  supjtu- 
nue.  Ueutb  nienttous  aluo  dentinal  tumorn,  i.e.,  irregular  maases  ot  dentine 
growing  from  a  tooth  and  forming  tumors  of  the  jaw;  but  they  seem  very 
rare.  The  treatment  constats  in  cutting  away  u  part  of  the  wall  of  the  cyst 
and  removing  the  retained  tooth.  Tbe  subsequent  treuttoent  is  tbe  same  aa 
that  of  ey»t  uf  the  antrum. 

.Solid  Trajoittt  of  various  kinds  may  take  their  oriein  from  the  superior 
niaxiilft  or  its  immediate  neighborhoo<l.  Generally  oy  the  lime  the  case 
Comv»  under  ohmrrvalixn,  it  't»  impoMible  to  say  with  cerliiinly  in  what  part 
ar  liwiue  it  UKik  iL«  origin — whether  it  began  in  the  up|>er  jaw,  or  spread  into 


i 


576      DISEASES   or   THB   JAWS    ASD   THBIR    APPBNUAOBS. 


it  from  contiguous  structures.    The  following  ure  the  chief  tumon  met  wiA 
ia  tliia  rcghiu. 

Fibroma. — Thii  is  nnt  uncommnn  springing  from  the  periosteum,  and 
cither  Ailing  the  antrum  or  projecting  Irom  the  ulvonlor  border.  It  grows 
bIovfIj,  ami  has  no  tendency  to  iotuct  the  surrouutling  tiwuH,  but  wh«n 
springing  from  the  antrum  it  causes  grailual  ab»urptii>u  of  the  surrounding 
hone,  and  forces  lis  way  into  the  neighlniring  iinuses  and  cavitieii,  or  projects 
fornanU  on  the  fuce,  numetimes  forming  a  tumor  of  considerable  size. 

Enchondroma.  —  Pure  enchondronm  is  uncommon;  its  general  mode  of 
growth,  HUi)  the  ap|>earani:-e  it  gives  ri»e  to  are  similar  to  those  of  tihronia. 

Olteoma. — Bony  groHtli;*  aru  occasionally  met  with  filling  the  antrum  and 
CALuing  a  projection  forwards  on  the  cheek.  They  are  composed  of  tiMUe 
having  the  normal  structure  of  Uone,  and  somewhat  denser  in  structure  than 
ordinary  cancellous  tissue.  They  increase  slowly  ami  painlewly.  A  caseof 
this  kind  occurring  iu  a  young  woman,  aged  '£&,  was  recently  in  Univertily 
Cullege  Iliwipitnl,  under  the  care  of  C.  llealh.  It  formed  a  cnnetderable 
prujeciiou  on  the  face,  and  had  been  growing  for  ten  yeare.  Pedunculated 
groMtiia  have  been  wet  witli  growing  from  the  uuter  surface  of  the  bone,  oDii 
Biill  more  rarely  ivury-liko  tuiuora  have  been  fuund  iu  the  eume  sttuatioo. 

VaBoulaT  Tamon. — Listou  removed  a.  tumor  irom  ihe  maxillary  rvgiuo, 
which  iu  section  presented  the  appearuucc  of  erectile  tissue.  Thu  (i[>ecimeu 
is  now  iu  the  Museum  uf  Univcnity  College.  The  section  cloeely  rueemblea 
that  of  the  corpus  cavermwum  pcuis. 

Sarcomata  of  various  kinds  arc  of  frei^uent  occurrence  in  the  upper  jaw. 
(iriifinating  iu  the  maxilla  itself,  or  in  the  surrounding  buuce.  Spiudle-celle<l 
iinu  rtmnd-ceiled  sarcoma,  iu  sniuc  cnseg  undergoing  jiartial  ueaiticalitm,  and 
in  others  developing  into  cartilage,  arc  the  variutied  chiefly  met  with.  They 
form  soft,  rnpiiily  growing  tumors,  idlen  im])licaiing  the  surrounding  ports 
anil  pUBhing  into  the  neighl>nring  cavities  friun  an  early  period.  They  are 
extremely  vascular,  so  much  eo  that  in  rare  casea  they  puli-ate  distioctly. 
When  tbey  project  into  the  nose  they  form  polypoid  maMea,  bleeding  readily 
and  obatructing  the  fossic.  If  they  spring  from  behind  the  maxilln,  they  not 
unfrequenily  peuctrace  the  craninl  cavity,  either  from  the  orbit  or  by  means 
of  the  foramina  in  the  hnse  of  the  skull.  Myeloid  sarcoma  occurs  in  young 
adult  life  chiefly  in  the  alveolar  border  of  the  bone.  In  other  parts  it  ia 
exirtmely  rare. 

Epithelioma  is  far  from  uncommon.  It  may,  as  before  stated,  spring  from 
the  gum  and  gienetralc  the  antrum,  or  it  may  originate  in  the  mucous  mem- 
briiue  of  the  antrum  or  iiusat  fossie.  It  forms  a  soil,  rapidly  growing  tumor, 
infiltrating  the  surrounding  parts.  It  very  early  spreads  into  the  irregular 
cavities  iu  the  neighhorhowl  of  the  upiter  jaw,  and  thus  i«  very  apt  to  i-ecur 
after  apparently  complete  removal.  Ihe  fi>rm  nitwl  commonly  met  with  is 
the  oquamouB  epithelioma  spreading  from  the  hard  palate  or  guiu,  but 
columnar  or  tubular  epithelioma  originating  iu  the  antrum  or  tu  the  nasal 
foas;e  is  also  met  with. 

Situation  and  Symptoms  of  Tnmon  in  the  Eegion  of  the  Upper  Jaw. — 
Sarcomatous  tumors  occaaionally  spring  fnmi  the  surface  of  the  malar  bune, 
pushing  forward  the  cheek,  spreading  into  the  mouth,  and  involving,  with 
greater  or  less  rajiiditv,  according  Co  their  maliguHney,  the  soA  structures 
of  the  face,  and  occiutiuually  the  lymphatic  glands  under  the  jaw.  They 
are  usually  rapid  in  growth.  soR  and  elastic  to  the  feel,  irregular  in  oultinc, 
and  only  aecondurily  implicate  the  superior  maxilla  and  tlie  neighboring 
cavities. 

The  various  growths  that  are  connected  with,  or  spring  from,  the  peri- 
osteum or  mucous  membrane  of  the  antrum,  in  growing  gradually  expand 


DlAGVOSia   OP   TUMORS   OF   THE    UPPER    JAW.  577 

(liliU)  tli«  wmllg  of  the  cavity,  nreseing  the  bones  outwanls,  thinutng 

n,kO(l  giving  rim  in  a  considerahlo  outward  proj^wtion  of  one  side  of  the 

^Um  Ulterior  surface  oftbo  superior  mnsilla  hcing;  the  psrt  that  usual ly 

iImMi  to  the  outward  prcaeare.     The  tuuior  thiu  formed  is  f^nerally 

Mouli,  nrand,  or  orul,  slii^hlly  IoImhI,  perhaps,  more  oftpecially  if  BhrmiR, 

■<1  hat  b  mmay  oaecs  a  icodcncy  to  haog  dovnwarda,  so  as  to  overlap  the 

nvvr  jiw  to  A  ccrUiio  cxicDi.     Am  it  g^ruws,  it  eucroocboe  more  or  leu  upon 

ftiiv  lUiiciurca  ly'mg  in  ibo  viciuity  of  the  antrum.    Thus,  it  pushes  down 

[tbf  |a!atp,  caiuiug  considctable  swelling  in  ihcroof  of  the  lunuEti;  displaces 

liHalrcolar  procea^es  and  teeth,  giving  rise  to  irregularity  in  their  outliue, 

■d  Usdiag  to  proiect  into  and  occupy  chu  alveolus.    It  may  eocmach  upou 

lb  wiiit,  oecauaaing  epiphora,  impairment  of  visiion,  and  displacement  of 

thi  tnball.      As  the  tuoinr  eolar^^,  it  r)b))tructs  the  nasal  cavity,  and. 

Mniaiilg  back  into  the  pharynx,  iuterferea  with  respiration  and  degtutitioa, 

■MlaHBcUmea  oooasions  severe  epistaxia.     When  it  is  of  a  malijjiiaiil  char- 

aiur, ohMruotion  uf  the  nasal  ftntta  will  he  fuund  to  be  one  of  its  enrlteaC 

■fB^lasdiDg  lu  the  suspicioo  of  nasal  [>olypus;    but  the  true  and  more 

■■isoi  oature  of  tiie  digeaso  will  be  revciileil  by  the  iuiegumcuis  becoming 

■ntnd,  the  gums  implicated,  and,  perhaps,  the  submaxillary  lymphatic 

|)uiU(;Bl«rgi^l. 

Bi^ffDOsis. — la  ib«  diagnosis  of  then  turaors  growing  id  the  upper  jaw, 
then  sn  three  priucipal  points  to  be  altendcfl  to:  I,  to  disLiuguish  the 
pMth  froui  duid  Hucumulaiiuu ;  2,  to  detcruiiuti  whether  it  be  simple  or 
M%Baoi :  and,  3.  to  ascertain  its  primarv  smL 

,  t  la  Buking  the  diagnosis  fn>m  jtuitl  aeaanulaUon  m  the  antmin.  the 
^■7  of  the  case,  and  the  unifi)rui  enlargemfnt  nf  the  cavity  withonc 
'^■^'ted  projectioQ  beynud  any  part  of  it:4  walls,  the  elasticity,  and  even 
wAtttioa.  that  may.  afler  a  lime,  be  detected,  more  particularly  towards 
w*iler  side  of  the  swell! nti^,  am)  at  the  junction  of  the  mucous  mfmbrane 
*  4t  idteek  aod  the  gum,  will  enable  the  Surgeon  tn  determine  that  it  is 
■•  S)lid.  But  in  many  cnses  that  is  nnt  PiiHirient;  and  it  l>ccomc3  neces- 
■Uf  (unuke  an  fitploratory  puncture  by  means  of  the  perfiiralor,  through 
■■sr  other  of  the  mnre  tliinned  and  expnnded  p*rts  already  indicat«4l, 
Iwtbautd  never  be  omitted  io  cases  of  doubt ;  for  it  has  happened  even  to 
■■,(nd  a  Surgeon  as  frensou!  that,  atler  making  incisions  through  the  cheek. 
■»«  ikr  view  of  extirpating  the  tumor,  the  bones  were  found  to  he  expanded. 
"T  Ko  soiral  ahsceas,  and  that,  consequently,  the  operation  had  been  under* 
••keD  udoeoesaarily. 

^  In  dstermiuiog  whether  the  growth  be  timjUe  or  mnlignatil,  the  Surgeon* 
™»*«p*rieni'W  much  difliculty,  so  long  us  it  is  confined  to  the  cavity  vt'  the 
uitVBi;  tint,  when  ooeu  it  baa  perforated  and  {wsevd  beyond  its  nails,  thifr 
P*M  a  Muily  Kilvetl.  Vet,  even  whilst  the  tumor  is  still  confined  within> 
Aluttmiti.  much  light  may  be  thrown  upon  its  nature  by  atteutiuu  to  the 
•WWity-if  its  gniwtii;  the  greater  thia  is,  toe  more  reason  there  is  tosuspnct 
'■■tk  u  loali^noot.  Too  much  impnrlaace,  however,  muat  not  be  attached 
''tkh  sigu;  for  though,  as  a  general  rule,  tibrous,  cartilagiuoua,  and  bouy 
')'*WiBay  jnrmse  less  rapidly  than  the  malij^nant,  yet  they  may  attain  a 
|[^[|nat  balk  io  a  short  space  of  time.  The  age  of  the  patient  is  of  com* 
P'l'Bvtljr  liiilc  valoc  in  the  diagnosis.  I  think,  however,  that,  as  a  general 
™^*tiiple  tumors  rnotv  frvqueotly  occur  in  the  young,  whilst  the  raalig- 
^'Intim  of  the  affection  are  more  rommonly  met  with  at  the  middle  ur 
*"'**«rf  periods  of  life.  It  is  of  much  inifturtanoe,  in  n  diagnostic  point  of 
*^>  (0  uaaiufl  the  oooditiuo  of  the  submaxillary  glands.  When  the  dis- 
**^  b  aaUgDmat,  they  often  become  enlarged,  ana  indurated  at  an  early 
f*^   la  a  case  under  ray  care,  the  muignant  character  of  a  tumor, 

VliL.  IL— »7 


578    DISEASES  or  the  jaws  and  their  appendages. 


wbilfll  still  in  the  nntruni,  whs  detprmioed  hy  the  fact  of  tbere  bciag  a  long 
chain  ut'inilurnt^l  iyinphutic  f^innda  lyiug  under  the  aogle  of  the  lower  jaw, 
where  thcv  hud  hec4.ii\ie  eecoodarily  oHeetcd  bv  abaorptiou,  before  ibe  bono 
had  been  perf'uratcd  by  the  growth,  ll  must  be  remembered,  however,  thai 
many  uf  the  sarcomata  whieh  run  an  esarDtially  maligoant  course,  iii filtrating 
aurrounding  purm  aud  recurriug  in  internal  orgnns,  may  ut  no  time  aHecE 
the  lymphatic  inlands.  When  one«  a  nialignunt  tuuior  bna  passed  bey 
the  eiivity  of  the  autrum,  and  i«  thus  relieved  from  the  preMiiro  uf  ita  wall 
it  grows  with  great  rapidity,  and,  where  it  eun  he  felt  under  the  ikio,  ta  per- 
ceived to  lie  Btift  and  elaaiic.  luninuitting  it4eJf  exteoiively  anit>ngst  the 
bonea  uf  the  face  and  idtull,  it  creep:*  through  the  foramina  and  finurea,  and 
encroachea  greatly  on  the  nanal  cavity  and  orbit;  itn  early  protniiiion  into 
tbene  ravities  is  evpt^Ially  c-harHcterialic  of  malignaooy.  It  impliitateti  the 
integiimeiit5  uf  the  cheek,  with  an  inflnnimatory  ivdenia,  and  the  Mift  otruc- 
turem  witliin  the  mouth,  iinil  lhi'oW!<  uui  sjirouting  mawe»  in  tiif«e  several 
silUBlioitf),  which  present  all  the  characters  of  the  true  maligiiHMl  liiiigut). 

3.  A  jwiDt  of  very  great  impurtAuce  iu  relation  to  openitive  iutcrtereuce 
is  lo  determine  the  jiriamrtf  teal  of  Ok  tumor;  whether  it  spring  from  the 
cuvity  of  the  antrum,  from  the  malar  bone,  or  from  behind  the  auperiur 

maxilla  iu  the  jiterygivmaxiUary  fi 
When  it  epriugs  from  the  interior  of 
antrum,  the  buccal,orbital,  Dasal.  or  psl 
walla  of  that  cavity  arc  expanded,  und 
Hue  of  teeth  is  rendered  irregular.  When 
the  tutui>r  primarily  Buring8lrom  the mo/ar 
bone  i  Fig.  Sim,  it  pushes  forward  Uie  cheek 
into  a  8'ijucwhat  eouieal  pruiuiauuce,  aud 
dipH  down  into  the  month  between  the 
cuniF!  and  the  Boft  ctnictures  of  the  face. 
It  does  not  involve  the  palate,  or  niter  the 
line  of  the  leech  :  but  rather  spreads  over 
the  bimes,  atii)  involrea  the  covering  soft 
parta  by  ooniinuity  of  tissue,  without  any 
definite  anatomical  di^posirion.  Aa  the 
tumor  incrf^Hctes  in  size,  it  will  implicate 
the  anterior  wail  of  the  antrum,  and  thua 
seeonilarily  projects  into  thai  cavity. 
When  the  disease  develops  primarily  6«> 
hind  the  guperior  maxilUt,  between  il  and 
the  great  ain  or  the  pterygoid  procesa  of 
the  sphenoid,  the  upper  jaw-bone  is  simply  pushttJ  boilily  tnrwanls,  there 
being  little,  if  any,  deformity  in  ita  ontline,  the  lioe  of  tewtb  not  being  di»< 
placed,  nor  the  wall^  of  the  antrum— palatal,  nasal,  ur  orbiial^-expanded. 
Vet  it  niuHt  be  burne  in  mind  that  the  difficulty  of  diagnosis  is  greativ 
increased  by  the  fact  that  a  tuuior,  th<mgli  not  originating  in  the  antrum, 
may  find  its  way  at  an  early  |)crii>d  of  its  gruwth  into  this  cavity,  or  may 
[HISS  into  the  orbit  through  the  spheno-ninxillary  <i»ure,  and  may  make  its 
war  forwanls  amiin;^t  the  bonos  of  the  fuce,  jwrtly  by  creeping  through, 
ana  partly  by  absorbing  aud  displacing  them. 

Trtntment. —  In  llie  treatment  of  tumor  of  the  upper  jaw  and  antrum, 
nothing  can  be  done  except  to  extirpate  the  growth  ;  and  it  ii>  consequently 
of  great  iiiijtortanue  to  diBliaguteh  those  forms  of  the  disease  iu  which  au 
operation  can  be  undertaken  with  safety,  aud  with  a  fair  chaDoe  of  success, 
from  those  in  which  none  should  be  performed.  The  points  to  bo  considered 
are :  1,  whether  the  tumor  is  beaign  or  maliguaut ;  %  if  it  be  benign,  whether 


Ptg.  078.— MAllgnam  Dii«A*«  or  Unlar 
Best  not  vuMftbU  tvr  optration. 


TRXITKEKT   OF   TDUORS   OP   THK    UPPER   JJlW. 


579 


mn  frnin  the  aalruRi  (ir  ^prto^  frum  bfh'md  the  BUpcriur  muxilla;  or, 
d  \l  ta  malif^not,  nhoitier  it  has  pajwcd  the  boundaries  of  the  anlrurn. 
Win  Itir  tumor,  iiprliiging  from  the  antrum,  U  of  a  nimplc  character,  the 
diiMiesbouhl  he  removed,  together  with  the  whole  of  the  sufwrior  maxilla; 
dw  tuuiir,  «'haleTer  site  it  han  attained,  beinj;  generally  encapauled,  and  the 
knOB F iijaoded  and  ahaorbed  around  it ;  mi  thai  it  is  well  botindod,  and  docA 
5'il  itajilicttte  iieii:hbi>ring  parts.  Here,  a?  Linton  justly  obsenres,  no  nib- 
ut  tfnihhinK  operatioM,  but  free  excudon  of  the  whole  mnae,  should  be 
:i>ea.  When  the  tumor  spring  from  tbe  spheno-maxilUry  or  ptorygo 
lillarr  f-wstt,  pui^biiig  the  bone**  of  the  *ide  of  the  face  forward*,  aa 
nitifl  should  uut  bo  li^j'btly  undertaken,  ajt  it  is  doubtful,  ia  mauv  ca»e«, 
tlie  .Surgeon  cmi  rnt«rfcre  with  «uy  proein^cl  «>f  auccees.  fehould, 
,  tbv  tumor  bv  simplv.  the  putivut's  iK-nlth  Iw  guixl,  aud  an  opvratiou 
ltd  expeiii(;ut,  the  tumor  cuu  be  nmcliod  ouly  by  exciMng  ihu  upp«r 
ja«,»ltGii  it  may  cither  be  reruovcd  nltaoh«d  to  tlint  bone,  or  it  may  bvextir- 
paud  Inm  tbe  cavity  in  which  it  litr«  bvhiud  it.  ^?u^h  an  oiK-nitiuu,  impli* 
eatiag  ai  U  dues  tbe  baae  of  the  ekull,  may  be  followed  by  dfuth  from  shock 
totttnenroua  centres,  as  I  saw  hapiten  in  a  {mttent  of  l.istun's  thus  o[i«raled 
Vftm;  or,  iovolvioe  the  iotemal  maxillary  artery,  may  be  attended  by  very. 
frvfim  and  irouhUBonw  bemurrliage.  \^hen  once  a  malij^ant  gniwtli  uf 
thiipart  haa  pawed  beyond  the  oBseoufl  boundaries  of  tbe  antrum,  the  ques- 
ti(«  of  rcmomi  beoooies  rery  aitmplicate<l.  In  rufvrence  to  this  point,  I 
tbiok  Uiat  it  may  be  stated  generally  that,  if  the  cheek  l>e  freely  movable 
QWtJMlumnr,  and  the  Btibmaxiilary  glands  unntTected,  the  operation  mav 
btprweeded  with.  Rut,  if  it  have  advanced  so  far  as  to  implicate  the  soft 
tttMBm  of  the  check,  with  enlargement  of  the  Buhrnaxillary  glands,  it  is 
OM^f  wile  nnr  prudent  to  interfere  with  It  by  operation:  lu  infiliratloa 
■iU  tiave  taken  place  more  widely  thim  the  knife  can  reach,  and  Bpeody 
nnrreiwa  mudt  of  oeceauty  eani*.  So  lung  as  it  is  contAined  wtthiu  this 
ovitjr.  vbcre,  indeed,  it  is  often  iuposMble  lo  asceruio,  until  after  removal, 
*•  tnie  fialure  of  tbe  affection,  it  may  be 
*'<M«I,  provided  the  glands  in  the  neck 
•••^frpatJy  enlnrged.  If  they  bo  much 
wphmttd,  ovcD  though  the  walU  of  the 
■trs*  be  not  pvrfMnile^t,  it  is  wronjt  to 
i^lnttn,  *»  a  coro  bv  operative  pnicediire 
■*»  W  bopelcM.  WLenever  tbe  wft  struc- 
tatn^f  the  cbeek  are  involved  w  aa  bo 
f^n  partial  exciaioQ  with  the  luioor,  no 
fwation  ibcrald  bo  performotl;  na  it  cau- 
IM  t«  eompletely  extirpated,  and  will 
^•dtly  recur  in  ihe  cii-airix,  When  the 
^p^MJaw  ou  biiih  -tiiiei)  i»  uDiwtvd,  ns  aome- 
Ww.  ihougli  nirely.  haa  ha|ipeDe«l,  it  m 
m    ^—  that  the  tumor  cauoot  be  removed 

^^^■Ubonh  ox  the  TrixR  .Tau-. — The 
^^^^^^Bbat  have  been  pravtis*^^  for  ibe 
^^^^PWff  tunmrs  ipringitig  from  the  up- 
^ja«»f«  '.f  thrrc  ViniU.     They  niiifeiAt  of: 

,l.Sr-  ■  .  ,,(■  ihp  Tumor;  2,  Partial  Kxruion  of  the  Superior  Maxilla; 

]'\tsUi  Removal  with  or  without  llu-  M!ilar  Boue. 
..I'.i'iiK  iin  thr  up|M:r  jaw,  the  ^>urgeon  will  n-ijuire  strong  eutlinj; 
tHo  or  three  nnrruw-btudoil  oiiwn,  with  handles  aot  at  diOcrent 
f'^^n.ioii  having  movable  backs  (Fig.  iiHii). 


■w^'r'^V^ 


^^ 


V\g.  S7B.— M*ltfn*at  Tunrnr  *r  tb« 
li'i'lMr  Jaw,  inrolrinf  Itw  wbola  of 
Iha  nans*  ol  Iba  Vaoa;  no)  BtlwIU 
tlaf  or  O^ntlka. 


580      niBBASBB    OP    THB   JAWS   AND    TBBtR    AFPBSDA0B4. 

I .  BcoopiDg  oot  the  Tumor.  —The  practice  or  tuwiping  ont  tmnon  tf  lb 
■ntriini,  alter  turning  up  llio  cheek  from  the  anieriur  mrfBOt  of  tbenpM 
TDHxilln,  U  one  on  the  pnjprifi;  of  whii-h  there  Is  a  dtflrrenM  of  muu 
smoiig  r^urgcons.  hibum,  vrhtm*  cxpvru-ucs^  in  the*e  dUeafte*  wta  In  lui  dl^ 
nnrivsllcd,  denouDccd  kII  "grubbing"  operalioas ;  and  ^jtne  •Lr(>n|[;lf  Sm^ 


^  Kg.  lUtQ.— Skw  with  Movabla  BmIi,  for  OptrtUoo*  •*  lb*  J»m: 

proved  of  the  practice.  But  other  Surgeoos,  wbow  view*  %m  Uib  ivbjeet 
eutiiled  to  tbo  bi^bnt  rtvpcot,  advocate  and  practise  tbia  pnxmliiiii. 
rajr  own  part,  I  luuk  upuu  the  practice  as  uiucicDtific  io  priiiripltp  aad 
BStrous  ID  its  results.  It  is  applicable  qdIv  to  the  soAer  kinds  irf  lunon; 
and  these  arc  cbiell^  sarcutuata.  Hov  I  bold  it  to  be  iotpueeiblc  br  googta^ 
antopiiig,  Rhiftelliiig,  or  svniuiug,  to  extirjutte  these  completely  fran  nj 
bone  in  which  they  may  hv  aovvluped.  It  is  itn^Mwible  iti  this  way  fiuriy  b 
go  beyond  ihe  limils  of  the  disrase  into  bealiby  »tructum«.  Tiaiiiii  thtt 
appear  and  feel  sound,  are  in  roalliy  iofihraiod ;  ami  hrnre  ipeedy  near 
tcnee  takes  place.  Thb  has  happciicd  in  ivcrr  mse  in  whidi  I  have  «n 
this  operation  prnrttti^'d  :  ntid  the  recurrent  is  worvp  in  all  Its  fntttun — Baft 
rapid,  mure  luxurinnt,  mure  malignant — than  the  primary  disesae.     In  fad, 

there  is  no  rensim  why,  in  ititcratioiuiia  tht 
jaws,  we  should  depart  from  that  prlDcifik 
whirh  in  tWiind  neceaiary  io  'tprrtttiub*  >m 
olhfr  part*  for  the  removal  uf  roaligauA 
growths,  of  beins;  gidded  in  tfar  rxttntaC 
the  removal  by  tne  aoatouiical  buundam 
of  the  part  adViried,  and  nwC  by  %b*  affft- 
rent  extent  of  diwDsnl  otructiirr.  It  laiaa 
to  me  tu  be  an  reawmnble  to  vcoop  a  By*- 
loid  or  a  mali);oHiit  liiniur  uot  of  the  MM 
of  the  tibia  iiwteiid  nf  nmpulatiog  tlM  »$■ 
fecte<l  btintf,  as  it  is  li>  Fcrnpr  tl  out  of  lln 
antruii),  instead  uf  ex liqwtiiigtbtt  tapcrisr 
mHxilJK. 

2.  PartfalExoiatOQof tba6«ptncrMat< 

Lita. — Altlinugh    I   dn  not  oooiidar  iht 

scuoping  away  uf  the  tutoor  from  ihs  aft- 

trum  to  be  a  pmper  or  Airgtcal  proecdua, 

1  would  nnt  adviwate  the  removal  nfmtn 

uf  tbe  iKtnrs  of  ibo  face  than  is  afaaulaiely 

peoesary  (or  the  oomplete  exiirpAtiaa  uif 

the  diseaae,  man  npecially  when  iliaA  is 

not  malignant.    The  dbease  mav  be  limited  eitlierio  tho  upper  or  toiW 

liiwtT  part  of  the  superior  maxilla.     In  theae  eaaes,  the  praiiiMt  tk  Sir  W. 

Fei;gtiasoa  has  led  lo  great  odvaoces  in  our  method  of  remoTiikf  aMck  diseait 


^ 


Itg.  Ml.— liaM  of  loritloD  !■  Lliion'* 
0|NnH««  br  BkiiW««  of  l.'ppcr  J>v. 


CO»?LBTB   KX0I8IOX   OP    THB   UPPKB    JAW. 


S81 


iilh  ihe  lemst  possible  dufi^urenicnt  tad  the  leut  loss  of  bone.  Witli  ro- 
'|)Hillu  tht:  exMronl  int-uimia  in  those  cast^,  FerguaeoD  has  shown  thst  they 
dWa  need  to  be  but  vttry  limitod  ;  ull  tbut  is  Dcceaaary  b«iug  a  cut  front  the 
ta^f  of  the  mouth  upwanla  ao«l  outw«r<l«  through  the  checic,  or,  in  other 
OMi,  B  ttitt  through  toe  upper  lip  in  the  ni<»ial  line,  the  kitifo  hetni^  cnrried 
■Uax  the  aide  uf  the  euturona  into  the  utwirit.  By  these  simple  iocisioni, 
lloiimtiDniiobed  Surgeon  ha«  ahown,  nufBcirnl.  relaxBtion  nf  part«  rnn  he 
Dbtua«d  for  the  excision  nf  the  greater  part  of  ihe  anperinr  maiillary  bone. 
ToaoiM  oues,  the  malar  bone  and  floor  of  the  orbit  will  be  foimd  to  bfli 
Mt»l.  Wh«ii  tbi«  hap{>eii»,  they  should  both  be  l«fi ;  nnd  with  thii  view, 
■ftn  l^  cheek  hfui  been  iucijwd,  aa  jiut  described,  a  deep  huriviDtal  j;ruov« 
■Jboaid  be  made  with  a  narrow  slraijiht- backed  saw  lieluw  ib«  orbit,  drrectly 
Hnalrom  the  na«»l  pnK->-x«  of  tho  nrnxilUry  to  the  «dj^  of  the  maUr 
WiL  The  fortep*  Dhnuld  now  be  applied  8o  as  tu  cut  dowawtirdv  aud  uut- 
twlifrom  Uie  end  uf  ihiii  incision,  and  thua  to  sever  the  couoecliuu  betweea 
lUnptrtor  raaxitia  and  the  lunlar  bone.  They  are  theu  to  cut  along  the 
fnonlhst  haa  been  Lraoed  liorixontallr  Hith  the  saw,  nue  blade  cutting 
nrntbtosraa  aloDg  tbu:  and.  lastly,  tfie  alvotilue  and  hard  iiulale  huvtt  to 
UiSvided.  This  ia  beet  done  ntWr  tiie  cztracliim  of  ono  of  the  i-enlral  in- 
onn,  by  paaaing  a  oarruw-blaikd  saw  into  Ute  uutcrior  nans  aud  cMtling 
^Kion  tkniugfa  tha  alveolus;  ihu  remaimter  of  the  eettion  being  com|ilet9d 
^BtUb  (Im  fitroepa.  Or  the  pruoeedicie  may  be  reverted,  and  the  cut  made 
^VwNBtht  iDOUlii  up  towortlii  thi;  u\u^  cavity.  ?>houM  the  diseaae  inipltoatei 
V'Chhlytte  up|ier  orbital  anil  niiHal  {KirtionH  of  the  bone,  leaving  the  cheekj 
~  aatlranf  of  tbe  ninuLh  »i>und,  another  moditiiuition  of  the  operation  may  ba 
Bodfrlikea  by  carrying  the  knife  from  the  nn.'^al  process  down  the  side  of' 
tWme  and  from  the  noptril  HcroaB  the  rheek,  dissecting  up  the  flap  thua 
fcnori.  The  palpebral  ligament  munt  then  he  out  through,  and  the  fat  of 
l^achil  pushed  upwanln  and  held  on  one  side  with  a  copper  spatula,  which 
alUivnau!  time  proiecta  the  eye  from  injury.  The  naail  proce^  of  thesup^ 
riw  uuilhir}'  hone  is  then  cut  through  from  the  lower  and  inner  part  of  th6j 
*tfni  into  tiie  nrwte  ;  the  saw  is  carried  from  the  anterior  oares  acn«8  the  aupe- 
nuruuilta  hIkivv  its  alveolar  process  and  from  the  outer  end  of  this  a  per- 
pwBcular  ciit  U  carried  upwartls  into  the  orbit  towards  it«  outer  angle  so  ai 
tontud  backward*  into  the  «|iheno-maxillary  fiwure.  The  cutliDg-pIiera 
*n  then  carried  atoug  these  tiues  of  incision  so  as  to  Uxxwa  the  bone  com- 
pltltly  and  the  detacmd  portion  is  then  lided  out  by  means  of  a  curved 
Pfriwiwl  elcval'-r. 

S-  Quiplete  Bxciaioa  of  the  Upper  Jaw, — The  operation  of  excisioa  of 

w  *lnJc  of  the  upper  jaw.  tOKethtr  with  the  nialnr  bone,  for  tumor  of  tba 

•WRun,  Ntw  first  projioeed  by  Lizara  iu  18JG ;  tltough  Gensoul,  of  Lyons,  wa« 

«•  firtt  Surgi-oo  by  whom  the  operation  was  actually  performed,  in  May, 

^'^^  Since  tbeo.  it  has  been  repeatedly  practised  ;  and  tlie  oaiiies  of  Liato'n 

B*M  lif  KcrKUoion  are  insepHrably  connected  with  it,  for  the  skill  with  which 

Hp7^*'c  devised,  and  the  h<dduei«  with  which  they  have  carried  out  ibe 

^HjPlifte]«  of  its  itcrformance. 

^*r^*  patient  should  l>e  placed  in  a  recumbent  position  with  the  heiid  and 

^^M«»  well  raised  by  pillown,  opposite  a  good  licht.     The  Surgeon  stands 

1  ''M  on  the  same  side  as  the  b'tite  to  be  reniovoi,  bat  during  the  sawing 

l^*i||  fioil  It  oonvenient  to  sinnd  always  nn  the  right  side,  retnrning  to  the 

to  '*r  that  be  the  afllK-ted  side,  during  the  final  stages  of  the  of»enilinn. 

T^*'*rfbagc  doring  ihc  operation  in  one  of  the  chief  difficultic*,  not  only 

|i^'J*&eaaat  id'  the    actual   lo»  of  bloojl  that  may    Uilto  plu-e,  but  from 

jjjj^*«k  rf  asphyxia  from  the  hlo.id  fiurljng  its  way  into  the  larynx.     lo 

^^^  fn  prcmai  thb  accident  the  throAt  muat  be  fre<|uently  wiped  out 


582     03SEA8KS   OP  THE   J AW^AH^THbT^AFPIWOAOIS. 

diiriog  tliv  openitidn  nith  springes  fixed  u()on  proper  holders.  Annftndalc 
hiis  ri^cuiuiiieuded  that  the  nperation  should  be  done  with  the  pulteiit'ii  heiid 
hncrging  over  the  eud  <>l'  tfa«  table,  so  that  aujr  blood  that  rune  backwardii 
nifty  acciinjiilate  in  tbe  upper  part  of  the  pharyox,  wheooe  it  am  be  rcmovwi 
I'runi  time  to  time  with  ii  sponge.  This  poeitiou,  however,  tends  to  nggniviite 
the  hemorrhage,  and  iti  not  to  be  reconHiiended  vhen  tbe  tumor  is  very  vu- 
cular.  It  will  olteu  be  found  useful  to  plug  tbe  posterior  nareswith  a  gcxid- 
sized  sponge  passed  behind  the  soft  nalale  in  the  nay  already  described,  be- 
fore  ccimmencing  the  o]>crnlion.  Thi^  lenda  to  push  the  soil  palate  forwards, 
and  may  embarniss  the  brralhiug.  Should  tbib  hap[>eD.  n  large  tube  of  Kume 
kind,  Kuch  as  a  lithotomy  tube,  niav  be  [Mi^etl  hetwei'n  the  root  of  ihe  tongue 
and  the  eofl,  palnle,  through  wIul-I)  n^pirntion  cm\  be  readily  earned  on. 
During  tbe  operation  a  gDOu-siU'd  )i|Hinge,Hllai'bed  ton  piece  of  siring,  may  be 
placed  ill  the  mouth  oii  tbe  nde  on  whicli  the  oiieration  is  bcin^  performed, 
eare  being  taken  to  leave  a  eufljrieiit  t^pHce  fur  the  paaaage  uf  nir  in  respira- 
tiou.  It  must  be  remi- inhered,  that  ihi;  piitieiU  iUh-x  not  require  the  whole 
mouth  to  brenthc  through,  and  if  it  he  carefully  manageil,  a  great  part  of 
the  envily  may  be  filled  with  a  sponge  during  the  operation.  In  this  nay, 
in  ordinary  coses,  this  operation  may  Iw  performwi  without  a  drop  of  blood 
ptiHing  down  the  throat.  If  the  tumor  be  very  large  and  vascular,  and 
much  nemorrhnge  in  expected,  it  maybe  ndvisabie  to  ndopt  more  efficient 
tneaus  to  prevent  the  risk  of  asphyxia.  Thia  danger  maybe  entirely  avoided 
by  the  method  devised  by  TrPHfteUnhurg,  and  adopted  hy  lj«ngenbfL'k,  in 
cases  of  operation  about  the  jaw.i,  palate,  or  [iharynx,  in  which  serious  hem- 
orrhage is  anticipated.    The  patient  having  been  placed  under  the  influenoe 


Fi){.  AS2.— Tr<iii<)cl«nbarft't  Tr«eIiMi-Uttipnn. 

1.  The  Tracfaea  Lulie  ami  ColUr  Blijktl;  inllRteii.         S.  The  Inh»tins  Puiwel. 

i.  Til*  Inamiog  Bottle  attMhsd  1«  lb*  Callu  on  TnctiW-laba. 


of  chloroform,  tracheotomy  is  [>erformed  in  the  usual  way  above  the  thyroid 
bodv.  A  trachea-lube  fitted  with  a  hollow  India-rubber  collar  (Fig.  6o2, 1) 
u  tliea  introduced,  and  tbe  inhalation  of  the  aaaisthetie  vapor  carried 
on  through  it  by  attnching,  by  tneant  of  an  India-rubber  tube,  a  funnel  con- 
taining a  sponge  i  Fig.  09:^,  2j.  When  the  burgeon  is  about  to  oommeace 
bis  operation,  the  eollnr  is  in0atcd  by  means  of  the  ladia-ruhber  ball  at- 
tached (.Fig.  662,  3^ ;  the  cflect  being  to  close  iho  trauhtia  round  tbe  tube, 
and  thus  to  cut  off  all  posaibility  of  blood  finding  its  way  down  tbe  larynx 


eOMPLKTK   BXCISIOS    Or   THB   OPPXR   JAW. 


583 


Um  braBflii  ind  fttruells.    AAcr  the  up(>rauon  h  compk-tod,  the  "trni-hca- 

m"  it  ri-rnoviHJ,  noJ  on  ordinary  trachcu-tubc  is  suluiitiUed  and  re- 

w  loog  u  it  may  he  thought  nccenarjr.     If  this  Apparatus  be  not  Rt 

bB4,tb»  iWirM  rcflull  tnay  be  equally  well  obtained  by  performing  n  pre- 

faniMiT  larTDgoioray  and  then  piUftginji;  the  pharynx  irtth  a  large  sponge, 

«Uck  cAii  1m>  withiiniwQ  lu  sutoa  an  ihe  operation   u  over.     Mncewen  haa 

taggetud,  that  instead  of  opening  the  larynx  or  trarhon  a  tnlie 

!  hm  pMM«)  from  thn  moulh  thr<Mii^h  the  gloitin  and  tho  pharynx,  the 

lingof  thft  ^lottifi  being  then  plugged  with  a  spange.    Thie  be  hag 

illy  dMHi  in  ^-evenl  r»m^.     The  tube  ithould  be  of  gum  ela»tic,  and 

lid  oomaiKNid  U)  about  a  N<>.  ll>  or  12  KngliJ^h  catheter.     It  »  pawed 

littmlucing  the  finger  into  ibe  ntoutli  a»d  deprf»«ing  the-  c<[iighitti«<>ii  the 

tn^pH,  BsH  •!>  gtiiding  the  lube  i>v«r  the  back  of  th«  linger  into  the  larynx. 

Aipatif«t'*  ht»d  should  be  tfaruwo  iioniewhat  backwards  while  the  tube  is 


ng.  HI.— KseiaUiB  of  l'pp*r  Jkw  hj  Linorn'*  If aibod. 


I*  nrdrr  bt  dimint^  the  InM  of  blond  ttn  far  na  pomible,  the  facial  artery 
*^  W  canpTMaed  during  the  early  tncisittnti,  iind  all  bleeding  iTMeli  must 

Ti^rt  iij  nifT inrriii rn  rnrrijui  iniPiicliiitely  they  are  diviili><l. 

Tke  part*  tn  nc  rrmfivtsi  mii»l  be  fairly  cxpoeoi)  by  raiding  a  Hup  froni 
~*ck»i>ll  Thin  ninv  bo  ftuhinni^l  in  vnrtouii  wuys  (itec  Kigs.  (JMI,  »►>>:{,  Gt^A). 
■*<  r  ',  U  ifafl  method  adopted  by  Li»toti,  will  oecaaionally  be 

■^<1  ■  •  -  -lit  vhc'rQthe  lumor  is  very  largi?  '.Fig.  llBl  i: 

'*tbe  lirvt  aUm«,  tb«  central   incuor  tooth  on  the  diaenwd  side  having 


684       UISEASES    OF    TIIK    JAWH    AND    TBBIB    APrCMbAOU. 


b««u  «x traded,  tlie  poiut  of  abuluurr  is  entered  o|)|M)iiile  tlt«  «il*rn»lnci> 
lar  pro(.-cM  nt'  tiio  fruaUil  bnue,  hikI  i^arriod  with  a  KiuiLnrculmr  wmttf  iM 
ibe  augk  of  ihe  luoiUh.  From  iIh;  u]iiH>r  cud  »f  llti«  iuuiaioo,  a  eoi 
DUG  iiitiii  iu  Ifnglli  majr  bo  narrieil  altiufc  titt-  iyf^>niti.  AtiiKbcr  iadi 
niadu  frtim  tliv  ntittal  pmorw  ol'  the  Hu)ieriiir  lunkillnrv  boDt^,  dnwo  lo  iW  all 
uf  tilt!  ouet*,  ruumi  tlie  iita,  whirli  it  dvlavhn,  and  thniugh  (be  crnirc  -t  ik 
U|)]K!r  lip  iuti)  the  iiiutilb.  Thi?  flap  thufi  fiirmed  ta  diescciiHl  upwrnrli  aatil 
UiH  margin  of  ihe  orbit  Is  trathed  i  V'tg.  683) ;  the  mift  porta  are  ihaa  cut- 
full;  Kjmrated  from  ihe  floor  of  thin  cavity,  aod  drawn  upwanb  byaound 
copper  Hpatula,  which  protects  them  and  ihe  ginbp  of  the  eye. 

Or  the  line  of  incision  by  external  flan  i.Fi|;.  ft84)  mnr  be  ailopcal  ia  ila 
following  way.  The  point  of  the  knife  ta  entered  oppomte  ibe  ianer  aa|b 
of  the  eye,  and  carried  down  the  side  of  the  nosr,  niund  the  ■!■,  emI  ihnagk 
the  centre  of  the  upper  lip.  Another  incision  is  now  mnde  in  a  boriMMUil 
direction  betow  the  orbit,  by  entering  the  point  of  llie  knife  wbera  tliefal 
incision  coniniencc<l,nnd  cnrryin^  it  directlT  outwards  in  the  line  uf  juoetlfl 
of  the  lower  eyelid  with  ihe  chetk.  along  tne  edge  of  tbe  nrbit  u  (araa  tkt 
zygoma.  The  Hap  thus  formed  u  tbruwn  ixilKanU.  Tbie  tJiie  of  iB^^Jm 
bns  lliegreatadvniilage  over  the  one  repreaenied  tti  Fig.  fi-Sl.  that  tbe  ■«««« 

and  nerve*  of  tbe  face  are  cut  nfar  tiwir 
terminations,  and  not  thniogh  ibeir  lawf 
branchf«.  This  line  of  incixioD,  tu  wA 
C.  HeHlb  givui  thv  preft-reDce.  u  ommI  Mil- 
able  to  all  luniofv  uf  urUiBory  cixe. 

Hie  next  step  in  tbe  opvratioo  coBBtf»ii 
Ihe  division  uf  tbe  bunet.  Tbiai*  beildow 
with  a  jaw-eaw  and  ftna^  euUiug  fJi«t 
Tbe  central  incisor  tooth  » tnA  exlrtdel 
un  ttie  side  uu  which  thv  jaw  U  to  bf  >*■ 
moved.  The  jaWMLw  CFig.  GSO)  v  ^ 
pushed  into  the  nuetril  parallel  t<t  ibe  htr^ 
palate,  lu  point  must  not  be  directnl  tp- 
wards  for  fear  of  injuring  tba  eribrilnf" 
plate.  Tbe  suw  is  then  carried  ttmHifth  ikt 
alveolar  border  and  tbe  palaie  prueanx' 
the  superior  raaxilU  and  polate  booM.ol* 
ling  tbrongh  the  alveolus  of  tbe  inciiorlM 

has  been  cxtrnrtcd.  Noinctsion ■  *^"«i» 

with  a  knife  tbrmigh  thf  «>»;  "' 

the  h»rd  jwlate,  ns  they  arr  divj'i'-'i  r*'l»l* 
and  wiib  leas  htmorrhagi--  by  ibo  saw.  Oi" 
miut  be  taken  not  to  mw  m  far  a>  In  i^jsn 
the  tod  palate.  A  amalltT  saw  is  i^ 
taken,  and  the  nas«I  procew  divided  at  tbe  level  of  the  lower  margin  <4^ 
urbit,  »•■  IhnL  the  |MWiterit>r  extreinilv  of  the  niciDioD  nball  c<irn*puod  lo^ 
line  of  the  artivulatioti  Ifelweeii  tbe  Mifierior  maxillary  and  the  •ckat*'' 
boiiw.  Tbe  mv/  is  tbi-n  aimed  through  the  malar  booe  in  tudi  a  (dirrcO^ 
■a  ti)  reach  Uie  anterior  extremity  of  the  spbeoo>iiuuiiU8r]r  fiagon.  U"* 
lumor  impliratc»  tbe  malar  b«ne  exti:zuiively,  lbs  argoma  nmM  ba  ^*^^ 
and  aniiiber  eaw-cut  carried  fnjm  tbe  apbeoo-mazi&ary  flaara  ihroagb  ^ 
fnintnl  procew  of  tbe  malar  br>nc. 

The  cutting-pliers  are  now  iipplicd  &nl  to  the  malar  bcme  and  B«zt  to  **j 
naaal  prncess.  (.)nr  binde  of  ibe  biiiit>-fiin?e|M  'the  flat  oide  bciD|c  dir***** 
to  the  s-Hind  bonei  is  then  put  intn  the  nnne.  thr  mhvr  in  the  tnoutb  io 
line  of  the  saw-cut  already  made.     As  the  bladee  ar«  cloMd  the 


m 


t 


I 


k'if.  n^l.— Ua««r  liicUion  In  Et«i*- 
IQO  of  Uta  L'p|i«r  Jaw  bj  Kilarnal 
Ftap. 


COMPL&fB  BXOIStOV  OT  THE  OPPBR  JAW — BBBDLT8.      585 


tBctioD  of  the  furcefM  furc««  the  bono  outwards  aud  fractures  itB  posterior 
<  BttachmeuU.     Uulees  tlic  bony  slructurc-e  arc  cxtcusively  (ieetro,ved  by  the 
tumor,  the  line  of  fracture  ruiin  auriwa  the  asucudiug  process  of  the  palate 
boue  aud  ifao  middle  part  of  Lho  twu  plcryi^iiil  plates,  the  articulation  be- 
Itweeu  the  superior  iimxiltary  Bill!  the  pululu  boue,  aud  bclweeu  the  tuber* 
jnity  of  the  palniii  boue  and  the  pterypiid  platPH  being  to(j  lirra  to  yield. 
^Tbe  boQc  being  now  coinpletetv  twtpiirated  fnmi  iu;  uaiwctuti  attiiohincnt^,  the 
i£urgcoD  seized  il  iu  iho  "  lion  forrefM"  with  his  left  hntid  utid  wri^nchee  it 
tdowuvrardx  and  outwiinlti,  while  he  nit-i  ewuy  the  »i)lt  piihile  fntm  iln  atlach- 
|lDcnt  tti  tlie  bone,  cure  bein^  taken  not  ti>  cut  it  thrmij^h  verticully.     If 
iai  thi»  eta^  the  iKi|>erior  maxillary  nerve  in  seen,  it  muHt  he  rut  through. 
The  }>ar(8  of  the  pterygiiid  musclw  attached  to  the  portions*  of  the  ptery- 
goid plalea  that  are  removed  ran  l>r  tnrn  thniu^h  irith  a  Hltle  hc<]p  fmni 
the«uil|>el  nr  aciaiore.     If  the  bone  is  too  much  broken  up  )iy  the  tumor 
Iu  Ite  held  by  the  lion  forceps,  it  can  usually  be  drawn  forwards  by  the  fin- 
geTB.    Aa  anon  as  the  bone  cornea  out,  a  dry  sponge  must  be  forced  into  the 
cavity  to  arrest  hemorrhajje.  while  the  inniith  and  fauc*9  are  cleared  of  blood, 
and  the  i>atient,  who  at  this)  stn^e  has  often  partly  regained  conscious ne«9, 
is  again  brought  under  the  inlluence  of  tlie  anaesthetic.     Hemorrhage  from 
the  terminal  branches  of  the  internal  maxillary  must  thin  be  arrested  by 
the  actual  cautery,  or,  if  poiwible,  by  ligature.     When  all  bteedtng  has  cen^eo, 
the  whole  cavity  niu»t  be  ciirefutly  examined,  »iid  auy  remaiuing  fragmenls 
of  the  growth  must  b.e  removed  either  with  HcisHura  ur  with  Paqiielin'ii  cau- 
tery.    If  the  whole  growth  is  undoubtedly  removed,  the  cavitv   is  then 
lotubed  with  a  solution  of  clitoride  of  zinc  (gr.  40  lo  .y),  care  being  taken 
that  oone  of  the  fluid  passes  down  the  tbnmt.     It  elmuld  then  be  sprinkle*! 
vith  io<(uf<irrn  in  cry»tuls,  and  liie  cliwk  Ha|>  laid  ilown.     If  there  is  any 
doubt  about  the  eompietc  removu.1  of  the  gn^wlh.  Heath  reconimends  that 
laume  t)trip!»  of  liut  spread  with  chloride  of  uuc  paste  i^houbl  be  laid  ld  the 
cavity.     8(iipe  pieoea  of  dry  Uul  may  be  placed  over  these  to  prevent  any 
of  the  paste  &uding  it8  way  Into  tlie  throat.     The  flap  must  be  retained  in 
sUu  by  strong  luetalHc  sutures  or  harelip  pins  through  the  Up,  and  by  finer 
auturea  of  catgut,  horse-hair,  or  silk,  along   the  other  lines  of  iucisioti. 
However  much  the  ekio  may  have  been  stretched  and  thinned,  none  should 
be  removetl  unless  it  has  been  actually  incorporated  in,  or  iolihrated  by  the 
tumor.     Tbe  aller-treatment  consists  in  syringing  th(.>  cavitv  out  daily  with 
Coody's  Quid  and  water,  and  sprinkling  the  raw  surface  with  a  little  ludo- 
by  means  of  a  camel's  hair  peueil.     There  is  nothiug  so  efficient  as 
furm  in  the  preventinu  of  deconiptK^iLiou  in  these  caacs,  and  by  its  use 
the  danger  of  eeptic  poisoning  or  sojitic  pneumonia  if  greatly  diminished. 
Atler  cii'strimtiou  is  complete,  the  patient  ih  fitted  with  a  proper  obturator, 
iaad  the  deformity  rc-aulting  is  fur  le^  thau  might  have  been  anticipated. 
Besolts. — Tbe  reisult  of  operations  for  the  removal   of  the  upper  jaw  is 
very  satisfactory,  so  iar  as  the  operation  ittwlf  i9  couecrned.     Though  moat 
serious,  the  operation  is  not  very  dangcnnia.    Of  17  consecutive  cases  col- 
lected by  Hutchinson  as  having  been  practised  in  the  London  Hospitals,  it 
WM  BuccQwful  io  14  ;  and  of  16  cases  (10  of  total  and  6  of  partial  removal) 
done  by  Esmarch,  13  were  suceeaaful  {viz.,  8  of  the  former  and  5  of  tho 
latter),     So  far  as  recurrence  of  tho  dist-'nsc  is  concerned,  all  will  depend  on 
the  nature  of  the  tumnr,  and  tbe  extent  of  iht  operatiiui.     If  the  diseaiic  he 
malignaut  or  even  myeloirl,  speedy  recurrence  will  certainly  eoMue  if  partial 
exci«aD  or  soKiping  be  prartiacd.     Xothing,  indeed,  can  be  mnre  disastrous 
than  the  result  of  partial  operations  in  the«e  cases.     Even  though  the  whole 
niuxilla  be  excised,  the  inciitioiui  t)eing  carried  wide  of  the  diaease,  rccur- 
loe  is  th«  almoat    invariable  rule,  though  the  more  complete  operation 


$S6      DISBASES    OP    TUB    JAWS    AND    THEIR    APPENDAOBS. 

securaB  loDger  imniuoity.  Tbc  linbility  tu  recurrenco  is  rvmarkable  id  these 
CDHs,  wh&n  we  cunsMcr  how  tctMlatcl  thu  ui)|>cr  jaw  is,  beiug  buuudwl  oa  three 
eiiles  by  tho  tmviiiutf  uf  tijc  luouth.  tioflo,  aiiil  orbit,  and  bow  coiuplt:u;lv  it  can 
be  excised.  Il  is,  I  bdiuvc,  ruuinty  duo  t't  two  causes — oarly  ini)ili(ati<ju  of 
tbo  siifl  pnrls,  and  extension  oi  the  raim.^hii!!'  llimngli  the  fissures  aod  siouses 
behind  tho  bone.  These  rcciirrcrnt-  iiialijriiant  growthsi,  after  removal  uf  the 
primary  tumor,  dn  mil  admit  ^if  exlirpatini). 

Wliun  Lhc  itimor  is  beuign,  the  result  is  iiiivt  sattefhctory,  and  the  cure 
usually  cnmpl<?te. 

Tomors  that  spriug  from  bshind  the  Saperior  Maxilla  have  already  been 
adv«?rtpd  tn  in  i<prakin^  of  na»o-pbnryiigpfl.l  tumnrs  (p.  .17'*},  nnd  in  dti«ru8- 
sing  the  ilia^iinKb  nf  tnnnvm  of  the  upper  jaw  (p,  f}!!).  They  may  j^iw  from 
the  ajilicn'-id  bune.  or  from  Bome  of  ihp  deep  cavilieB  lying  betwwii  il,  the 
palate  hones,  and  the  pthmoid,  oonstitming  various  f  trmn  of  naflo-pharyngeal. 
palatine,  or  naati-pnlntine  polypi.  Kormerly  these  tnmnrs  were  either  left 
untouched,  or  were  extirpated  together  with  the  superior  maxilla  or  after  Its 
removal.  Of  late  years  varinuH  oftoraliuns  have  been  devt«?d  without  the 
neceisitv  of  removing  that  btme,  tvhieh  is  either  turned  up.  down,  or  on  one 
eide.  The  hv<  nperaliim  on  the  whole  for  thc-lr  n-movnl  is  Langenbeclc's 
Osteoplastic  Section  of  the  Superior  Maxilla,  with  ili^placeracnt  of  that 

bom-.  Thi;  6ruL  operation  wan  (RTforined  in  1?*59.  Up  to  1877,  Lnngenbeck 
bad  performed  it  13  times,  uilb  10  complete  cures  and  3  deaths.  Il  has 
been  jjerfurmed  iu  Germany  alim  br  Eaniitrch,  Wagner,  Simon,  Nugsbaum, 
and  Billroth.  The  last  two  performed  it  for  removal  of  the  superior  maxil- 
lary uer%-«  for  neuralgia.  Iu  America  it  has  been  performed  twice  b?  Che*- 
ver.  In  one  ease,  it  was  done  tor  removal  of  a  tumor  growing  from  the  body 
of  the  sphenoid  bone;  the  tumor  recurred,  and  the  operation  was  repeated  at 
the  end  of  eleven  months,  with  perfivt  success.  In  the  other  case,  both  bones 
were  displaced  at  the  iiame  operation ;  but  the  patient  died  on  the  Hfth  day  of 
"  prostration  with  excitement."  In  Lnngenbeck's  first  operation,  the  incision 
was  made  from  the  middle  of  the  nn»il  eniiucnee  of  tlie  frontal  bone  towards 
the  right,  over  the  na^nl  proce^  of  the  superior  maxilla  and  downwania 
to  the  ala  of  the  nose.  The  edge  of  the  wound  were  dissected  up  so  as  to 
expose  the  whole  nasal  proce^  and  the  nasal  bone,  the  ]H!rio6teum  remaiuing 
untouched.  The  cflrliln^inous  pontou  nf  the  nose  was  separated  from  its 
bony  attachmenU.  The  nasal  hone  was  then  cut  through  with  bone-forcepe, 
dose  to  the  septum,  and  upwards  as  far  as  the  frontal  bono ;  by  a  second  cut 
the  nasal  process  of  the  superior  maxillary  was  divided  into  the  antrum. 
The  cut  ended  where  the  nasal  process  of  the  superior  ninxillnry  bone  forms 
the  lower  border  of  the  orbit.  The  upper  part  of  the  nasal  process  of  the 
superior  maxillary  and  the  nasal  bono  were  then  priwid  up  and  were  turned 
on  to  the  forehead,  being  still  atbicbed  by  periosteum  and  rauci.us  membrane. 
The  nose  was  then  fully  opened,  and  the  polypufi  was  removed.  The  bonos 
were  then  replaewl  and  supported  in  position  by  a  plug  of  charpie.  The 
wound  healetl  rv^adily,  and  there  wan  no  exfoliatinii  of  bone.  Langeobeck's 
second  iif>crution  wa-i  undertaken  for  a  tumor  .springing  from  behind  the 
superior  maxillary  bone  in  the  pterygo-ra axillary  fossa.  Two  incisions  were 
made ;  the  first  began  at  the  insertion  of  the  ale  nasi  and  ran  atone  the  lower 
bonier  of  the  malar  l>one,  describing  an  arch  with  the  ennvexity  downwards 
and  terminating  at  the  middle  of  the  icygoma;  the  second  began  at  the  nasal 
notch  of  the  frontal  bone,  and,  following  the  lower  margin  nf  the  orbit,  crossed 
the  frontal  proce^of  the  superior  maxillary  hone,  and  joinei)  the  lower  incision 
at  itR  outer  extremity.  The  soft  parts  were  not  di«iected  up.  The  lower 
incistou  WHS  theu  carried  to  the  bone,  and  the  masseler  diiweeted  from  its 
attachment  to  the  malar  boue.     By  depressiug  the  lower  jaw  so  as  to  remove 


OTSTS    OP    THK    LOWBK    JAW, 


587 


ibtMroamd  prooeiB  ool  uf  the  war.  Ihe  fioj^er  cmild  be  forced  ia  front  of 
iktaaterwr  burder  of  the  t«m)Hinif  muscle  iulu  tht-  BpbviKMimxillary  fo>»a, 
viiaeh  WM  dtial«d  by  the  tumor,  iDto  the  otce  tbrougb  tiie  Bphvc^-palttlino 
ftiiMa.  A  oarmw  mw  mu  dow  poaaed  along  tbe  finger — iui  point  b«ias 
fMBCted  hj  tlie  forefiDger  of  tbe  left  band  introduced  Into  the  noetril — aoa 
tent  vti  made  dirertly  forwards  through  tb?  ascending  process  of  tbe  painte 
kaetrnl  tbr  butly  of  the  Buiterhir  mnxillary  bone,  acroea  tlie  cavity  of  tbe 
tolfWD.  parallel  to  tbe  hard  pnliite  and  immediutoly  above  it,  terminating  at 
ibesatrriur  nari^.  The  uppL-r  incision  wait  now  deepened,  and  the  00ft  parts 
«CR  mtkd  frimi  the  floor  of  the  urbit  and  from  tbe  angle  between  tbe  syguma 
tai  \bt  malar  l>ouf?;  itnd,  the  saw  being  again  inlrotlaced,  a  cut  was  made 
tlimgh  th*  malar  bone  into  the  spheno-maxillary  finure,  and  llienee  aertiss 
AtkurtKf  lh<r  orbit  nn  far  as  tiie  latbrymal  bone.  The  wetlge- shaped  piece 
tflWwfwrinr  iiuixillitry  bone  inrludtxl  between  these  cut«  wa^  now  attached 
udv  W  Its  otnueoticnit  with  tbe  uasal  and  frontal  Ixmi-fl,  and  by  the  soft 
ftn  mTcring  it,  which  were  untouched.  Ry  introducing  an  clcviitor  into 
t^nil  in  lUt:  malar  btine,  tbit  wltolo  piece  was  lilWI  up,  Wndlug  upon  its 
■lUfbiwnt  to  tb«  nasal  and  frontnl  bone*  as  upon  a  binge,  unlit  it  was  com- 
ply lomrd  inwards  and  upwards  over  the  opjKwite  wide  of  the  face.  The 
^U'D'ir.  «birlt  was  found  to  have  extensive  connections  in  the  pterygo-maxil- 
'-"■  r<  ^i..u,  was  Duw  removed.  The  bone  was  then  replaced,  and  the  woond 
'  -"■'(.  On  the  tilth  day,  the  greater  part  of  tbe  wound  was  healed  ;  on  the 
'  'u^aUi  the  nnuud  bad  comp^lcly  healed,  and  no  mobilitv  could  bo  felt  in 

0|ti(ri  and  Lawntuee'a  opentioos,  which  arc  adapted  specially  to  tamore 
**  *fc«Daa>l  fiNMB,  have  been  already  doscribed. 

DtB^XBBi  Of  TUK  IX>WER  JAW. 

^  Afcic—  la  the  Lower  Jaw. — Chronic  abacewca,  causing  "exponnoo  of  the 
"f'Hi,''  baT«  been  met  with  in  the  lower  jaw.  They  may  arise  in  conneeltiin 
J*"h  the  &ng  of  a  diwiaarid  tooth,  or  from  Buppuraiion  of  a  den  ligeroua  cyst. 
'^  Um  iball  of  bon«  surrounding  the  put  be  very  dense,  they  may  reaemble 
^'■4  Mmnn.    Thtir  trenimtnt  pr«»entA  nothing  peculiar. 

A««le  8«pt>u-tttiTe  Periostitis  is  occasiouully  met  with  in  the>  lowvr  jaw. 

'^  probablr  is  de|>endeut  on  carious  ireth,  but  the  immediate  chum  seems 

'^*u«Uy  to  be  exp<j»urt!  to  cold,  ouch  as  riding  in  a  jlruin  facing  an  n|H>n  win- 

'*•*'•■.     The  dtsesEC  ia  characterized  by  rapid  swelling,  wilh   teustttu   and 

"^^lii*  -       '    ■  ■•  vkio.     A  larjjv  HlMf.'f*«  c|uickly  forma,  surrounding  the  b^ne, 

■^i*!  i  to  <>ou  (tide.  »b.jut  ihe  angle.     The  swelling  extend*  down- 

*^*>ls  itilo  tiwf  neck,  and  tt^ndi  to  point  externally.     On  o|»e»ing  Ihe  abtoe« 

*    l«rge  )Mirt  of  the  b<>ue  can  be  fell  bare  and  denuded  of  its  periosteum. 

'*      IJm  pas  be  let  uut  early,  fre«  drainage    provided,  nod    <leeom position 

P^'^raited,  no  oernaiis  may  tiike  place.     U  \»  usually  necesenry  w  make  the 

^^*iiiiin  rxli*mally,  as  tlie  pus  extendii  too  far  in  the  neck  to  allow  of  sufB- 

C  drainafrT>  hnne  provided  fniu  within  tbe  mouth. 

MfMU  of  the  Lower  Jaw  has  been  already  dowribed  (p.  d71). 

ors  of  the  Loner  Jaw. — Tbo  lower  jaw  ia  a  i^)mmon  seat  of  tumon. 
KjnJU.  Mitrhiti  tyttrmmn  of  the  alveidor  boriler,  Eyithtlioma  «/  ihe 

.  implimting  tbo  boiin,  nnd    lirntigrrmia  Ct/flt.  have  been  already  do- 

^^wSUd  with  Eiimon  of  the  alveolar  hordcrsand  of  the  iipficr  maxilla;  they 

^■■ti,  binvavnr,  all  nmre  eommon  in  the  lower  Jaw  than  in  the  uppsr. 
^      Vina  <f  the  Lower  Jaw. — Sing/i^  ^!f^*,  containing  a  glairy  or  murotu 
Pi**  a4  in  which  bhnttwt^Trine  eryHtalH  are  nAeo  Men,  art>  not  uncommon  in  the 
*^'*^er  ja«.     Tb«y  cattse  a  painless,  aIow  «nlargeineiit  of  a  limited  {mrtion  of 


£88     DISEASES    or    the    jaws    and   T1I8IH    APPENDAGES. 


the  boae.  At  fii^t  the  fluid  ie  iturrouudcti  by  a  boIuI  bony  wall,  thi 
whicb  no  fluctuation  can  be  fe.lt,  and  in  this  stage  they  have  been  nii&tnken 
for  solid  tumors.  Ae  the  wall  becomes  thinner,  fluctuation  and  cgg-ehelt 
crackling;  can  be  felt.  They  originate  in  connection  witb  a  tooth,  but  their 
mode  of  origin  is  not  very  clear.  Sometimes  in  extracting  a  painful  loolh  a 
small  cyst,  seldom  nioi-e  than  a  quarter  of  an  inch  in  diameter,  '\s  found 
Attached  to  a  fang.  These  cyst«  are  developed  beneath  the  periosteum  of 
the  fang,  and  hence  have  been  termed  periosteal  cysia.  Tomes  believes  thoy 
are  of  inflammatAry  origin,  and  the  fact  that  their  contcnta  have  the  ap- 
pearance of  inApiuatcd  pit«  bears  out  the  view.  Whether  the  single  cysts 
are  of  a  oimilnr  origin  is  not  certain. 

AfuUUociilar  (ytfs,  which  have  aUo  been  described  under  the  nam«8  of 
cyfttic  narcoma,  adenoma,  and  Bbro-cj'fltic  tumors  of  the  jaw,  althoufrh  oc- 
cBMonally  met  with  in  the  upper  jaw,  are  infinitely  more  common  in  the 
lower.  These  tiimnrs  are  of  sinw  growth,  but  may  reach  a  great  sixe  ;  ihcy 
are  composed  of  cyst»  varying  in  size,  imd  having  more  or  \gss  solid  matter 
between  them.  The  walls  of  the  cysla  are  ftumetim«s  thin  and  membranou*, 
somelitucs  computed  of  tissue,  appearing  to  the  naked  eye  ae  fibrous  tiaaw, 
while  ill  other  cases  bony  lumellie  enter  largely  iato  their  composition,  to 
thai  on  pressure  they  occasionally  communicate  the  semi-crepitHUt  eensalioa 
peculiar  to  cyetio  expaosiuos  of  osseous  structures.  The  fluid  cunlaioed  in 
these  cysts  is  viscid,  and  usually  semi-transparent,  yellowish  or  bloody. 
Most  (ummouly  Lhe»e  tumors  run  a  simple  course  but  occasionally  tbey  have 
beeu  kiiowu  to  recur  alter  remuvnl  and  infect  surruunding  parts.  The 
origiuof  these  cysts  formed  the  subject  of  a  most  iuleresling  lecture  delivered 
by  F.S.Eve  at  iho  Royal  College  of  Surgecms.  lie  cunfirmcd  the  face 
already  noted  by  several  observers,  that  the  solid  part  of  these  tumors  is 
composed  of  irregular,  branching  (roIuniu.-<  of  Htmtll  round  e]iilh(!lial  c«IU 
resembling  those  in  the  decpt-r  layers  of  tht;  epithelium  of  the  gtini,  uml  sur- 
rounded by  a  fibniuH  stroma.  In  name  caxv-K  tbu  ciiliu  at  the  circumference 
were  columnar.  The  oysia  are  formed  by  coUrud  degeneration  n{  the  epi- 
thelial cells.  Eve  believes  that  he  ban  ilemiin»traleii  that  the  oohimns  of 
cells  are  formed  by  an  ingri)wlh  of  the  epithelium  of  the  gnm,  ami  that  the 
starting-point  of  the  HiHeage  is  ofUm  the  irritutimi  caused  by  a  diseased  tooth. 
Falkson  and  Bryk,  on  the  contrary,  believe  that  in  nome  cases  at  least  these 
cysts  have  their  origin  in  a  persistence  of  a  portion  of  the  epithelium  form- 
ing the  enamel  organ  of  the  developing  teetb.  They  found  their  opinion 
upon  the  resemblance  of  the  epithelium  cells  and  the  ctmtents  of  the  smaller 
spaces  to  those  observed  in  the  enamel  organ.  The  ijup^lion  of  the  origin 
of  the  tumors  cannot  be  considered  tn  be  finally  determined.  That  tbey  are 
in  snmt;  way  connected  with  the  teeth  i;*  liighly  probable,  as  they  always 
start  fn-in  tia*  ueighbrirh-mil  of  the  nlveidar  bonier. 

Fibromata  and  Chondromata  are  met  with  in  the  lower  jaw,  and  spring 
either  fnuu  the  pn-riijalmim  or  fri_>n»  the  centre  of  the  bone.  They  resemble 
similar  |{ron'iht<  c']«*where,  »ud  present  nothing  peculiar. 

Osteomata  of  both  forms,  tnt!>  cancellous  and  ivory  exostosis,  are  wet 
witb  in  (he  lower  jaw  ;  it  is  in  fact  one  of  the  most  commoD  Mats  of  the  latter 
affection. 

Odontoma. — This  is  not  properly  a  tuntor  of  the  jaw,  but  it  is  roost  con- 
veniently menliooed  here,  as  closely  simulating  disetM  of  the  bone.  An 
odoQioroa  is  the  result  of  some  peculiar  mudficatioa  in  the  growth  of  a  tooth, 
revulting  in  the  formation  of  au  irregular  mass  of  dental  iJiteues  of  no  definite 
ifaape.  Tomes  describee  one  n.-move(l  by  Sir  W.  Fergusson  as  being  "  cum- 
poaeil  of  enamel,  dentine,  and  buae  derived  from  calcification  of  remnants 
of  the  dentine  pulp,  thrown  together  without  any  definite  arraugemeuU' 


EXCISION   OP   TBE    LOWER   iXW. 


fiSd 


to  H«ath,  only  8  erne*  have  been  recorded,  all  Id  the  lower  jaw. 

tUMor  eao  bo  rcaiov'ed  if  its  Dulure  is  recognized  without  inking  awnr 

aojrof  the  jaw-bono.  Outgrowths  from  the  fangs  of  fully  developed  teeth 
nwiMifd  of  dcDtioe  and  cement  are  not  uucrtminou,  forming  the  eo-onlled 
vanjr  teeth,  but  tfacee  are  seldom  of  aufiicieiit  eitie  to  be  uf  any  surgical 


Itnaauta  of  variona  kinds  form  a  considerable  proportion  of  tumora  of 

tlwlnwerjaw.    Myeloid,  spindie-cellcd,  and  round-celled  sarcomala  are  all 

met  Kith.    The  ftr^l  in  always  centrnl.  the  last  two  may  be  periaeteal  or 

cnual.    Ctioodrifying  ur  uMifyiDg  Barcomala  are  occaaioDalfy  met  with. 

^henyeluid  tumor  uiually  ruu»  a  limple  course,  the  otlicr  forms  are  fre* 

weatly  malignant.     The  mode  of  gruwih  uf  these  tumors  and  the  symptoms 

WT  giTC  rise  U>  are  the  lutiDe  as  in  other  purls. 

DiajFiKwU. — In  the  lower,  as  in  the  upjier  jaw,  it  is  of  great  importance  to 

the  simple  fruiii  the  malignant  aflectioos ;  as  in  the  litLtcr  form  uf 

an  operation  is  sometimes  not  advisable,  the  toft  livsues  around  the 

iog  implicated  to  such  an  exteut  as  not  to  admit  of  removal,  and 

(oeDtly  not  uf  the  full  aud  complete  extirpHtiuu  of  the  disease.     The 

iMllpMUit  tumors  may  geaeratly  be  readily  delected  bv  the  rapidity  of  their 

Etb,  hy  ibrir  pulpy  ur  elastic  character,  and  by  inAltJalioii  «(  neighbor- 
parts,  with  early  adbesioo  to  the  skiu  aud  impllratioa  of  tbe  glandi 
■  the  jaw. 
TrmlmeHt. — Tbe  trvstraent  of  tumors  of  the  lower  jaw  depends  in  a  great 
iMwn  upon  tbe  clinracter  of  the  growth.     In  siogle  cyets  uf  moderate  size, 
*itlitkin  walls  and  but  little  solid  tissue  around  the  cysts,  tbe  bent  moilo 
of  tneatuent  consists  in  cutting  dowu  through  the  gum  on  the  expanded 
pivtioe  of  bone,  opening  the  ryst  by  means  of  tbe  antrum-perf'irator,  small 
h^kbe,  or  rutting  pliers,  according  la  its  sice  and  the  ihtcknefs  of  iu 
™ll;  letting  out  the  contnined  fluid  ;  and  then,  by  intniducing  a  plug  of 
'*il<  eauetog  tbe  cavity  in  gmnulate  from  the  bottom,  nnd  gradually  to  con- 
*"<*.    Whi'n  the  cysts  are  so  large  that  ihey  have  di-elroyed  the  integrity  of 
.^boae,  or  wht^n  they  areaisociaicd  with  a  large  quantity  of  solid  iJMue,  as 
^fhl  true  multilocnlar  cysts,  eicision  of  the  diseased  bone  must  be  practiK^. 
'^K  otto,  is  the  only  plan  of  treatment  that  can  be  bad  recourse  to  in  other 
P^Uis  in  this  b.>ne. 

^^wliioB  of  the  Lower  Jaw.— The  operation  of  excisloit  of  a  portion  of 
!~*  lower  jaw  for  tumor  of  that  bone  waa  first  performed  by  Deadrick,  of 
''it>npr*.  in  ISIO,  and  not,  as  {«  genernlly  but  erroneously  supposed,  by 
ivtreti.  As  the  growths  for  Khich  this  operation  is  performed  are 
•ituatrd  between  the  svm|ihysta  and  the  angle  of  the  bone,  seldom 
\t>n  tteyond  the  middle  liue,  the  operatinn  is  generally  limited  to  one 
the  face,  lu  sumv  instancet,  however,  the  tumor  may  encruHch  to  far 
may  be  necewsry  fi  remove  more  thun  the  half  of  the  bone;  and  ia 
■aeo,  again,  though  of  very  rare  uccurrvnce,  the  whole  of  tbe  boue  baa 
dlauticnlBted. 
.  -  .'ben  tbe  turaor  is  uf  moderate  size,  uud  is  situiUed  about  injt/miy  betveen 
1^  tnpkftia  and  angU  of  the  juw,  it  may  Ik  reached  by  making  a  wmituDar 
*^>Boa  of  sufHcirnt  length  under  the  lower  edge  of  the  boue.  and  carrying 
•*  anUrrior  extremity  of  it  well  forward  U|mmi  the  chin,  but  not  dividing  the 
■"^^r  lip,  if  it  can  be  avoiiled,  nor  cutting  into  the  angle  of  the  mnuib ;  then 
7**MctiDg  up  the  flap  thus  formed,  and  carrying  the  knife  cautiously  along 
^'^  i&wr  Me  of  the  jaw,  00  as  to  detach  the  mucous  membrane  of  the  mouth 
***^  the  Dylohyoid  muscle  to  a  sufficient  extent.  In  doing  this,  the  hemor- 
^■wii  oncn  Tery profuse;  the  bleeding  from  the  facial  artery  is  particn- 
ferdbtc,  the  blood  being  thrown  in  a  larger  and  stronger  jet  than 


500     D1SRASK3    OP   THK   JAWS   AND   TREItl    APPSyOAGKi. 

would  m<(>m  p^xsible  fniin  the  aiza  nf  th'>  veswi.  Hie  hemorrliage  ilMdl  k 
at  nave  iMntrnllei)  by  tlic  applicalionof  ligHiurea  to  both  enili  of  Uw bMhy 
art<^ry,  niiil  tn  any  ulher  pointd  fnun  which  it  iit  ubiiiutntit.  UhlnMllwH 
done,  Uift  Hll«r-«iefM  ut'the  i>j>orii(i[.Hi  will  be  rendfiY-d  muph  mon-  tiH*fvT**ai 
rliltiuull.     One  ut'  the  leelb  un  enrb  ^idu  of  the  timmr  hikvinii  Ih-  -It 

drnwi),  the  jnw  iiiiiat  now  bu  id^ply   iiutcbtsl   tbn)ii)i;h   thnr  m  Ji 

biwe  wilh  a  tiMrrnw  Atrunj;- hacked   mw,  and  out  thr>iU}[h  with  {'  »■ 

]>l»t«lr  dividod  wilh  the  »«w.    Aft*r  the  fnigiinrDl  cjI'  diw»B«i  i>  i* 

attach»l   tumnr,  hiw   bc-ca    rvmovcd,  ami  all    bliwiliug  Yearl-  -  ti 

aecured,  thi>  Sap  of  cheek  should  be  laid  dnwo  smoothly,  and  n-u..;.. ..  -  ntt 
b?  m««iii  of  harelip  pine.  Occaaionally  the  dental  artery  in  tbv  tat  jn 
gives  trouble:  the  hemorrhage  froni  this  source  tony  be  checkrd  hr  ttwsfflt- 
cation  of  a  piece  of  solid  pcrchlortde  of  iron,  nr  by  toacbiog  it  witb  lb» 
actual  cautery.  The  patient  roust  at  tirst  be  fcxl  with  alop,  whiefa  ibaaU  W 
8Ucke<l  ill  through  a  tube.  At  n  later  period,  when  aottrintiia  ii  Mil 
advanced,  the  t««th  i<hoitld  be  tied  togfilier  with  etrong  silver  viivi  art 
silver  cap  should  bp  Htterl  ujton  tho  tocth  of  the  two  ]>ortiuiif  of  bocwtliBtcii 
left,  and  attached  by  an  clajtic  spring  to  Routhor  ailver  cap  put  Od  Unarf' 
tbo  upper  jflw,  bo  as  to  prevent  the  displacement  that  wfwld  nthenriae  oewria 
tlie  008110?  fraj^mL-nt.  Union  titkei  placo  after  a  time  by  fibmiM  tiamtey  irkiila 
beoonies  sufficiontly  dense  to  lunke  toe  jaw  strong  and  uaefLil. 


/ 


PtS.  «Si.— Eidtt<n  of  Uw«r  Jk*.    Soft  9mrU  RMmA, 

In  thoae  c&tn  in  which  th«  (umor  tfieroaehe*  tqiati  the  anjfft  amd  r 
the  jaw,  it  t»  uimatly  iK-ltt^r  tu  rruiuve  iho  bone  at  tite  orticalaliaB  oo 
aSc-ctcd  si'lr  ;  for,  if  the  articular  end  inrludiiij;  the  curDDoid  pracm  htl 
it  will  be  displaced  fomants  nut)  upwnrds  by  ihc.  action  of  ib«  teAiponU 
external  pterygoid  mu»clv»t  and  be  a  aourcc  qI'  nnch  iuc<>nvetit«t>re  and  I 
tation  to  the  pnUent,  DoC  compeomtw)  by  any  cormponding  utility.    In  i' 


oonaequent 
,  And  ihe  orwr&tiou  niny  bo  pcHVirtued  in  the  lutlowing  war.  The 
vtiuit'i  bead  mun  lie  allowed  to  fall  a  liltlu  backwards  ao  that  ihechiD  majr 
n  wll  rmiard  from  iho  chest.  Au  iutmon  is  then  msdc,  c-oiutueocing  near 
tbe  ffTrnphr^is,  pusing  along  tbt->  under  tturfact  of  the  bodv  of  tho  jaw  bh  far 
■  ibie  tkng\e  and  then  upwards  at  tho  posterior  border  of  the  miuua  oa  for  aa 
tfw  level  of  tho  lubult^  of  the  ear.  If  the  tumor  bo  %-ery  large,  it  mar  be 
aHHBarr  to  make  an  incision  upwards  towards  the  lip  from  the  anterior  end 
4f  Ihkt  jukt  iDcutioned  or  even  to  dUtdethe  lipconipletelr,  hut  this  should  be 
irMdnf  if  paMiible.     The  facial  arterr  and  vein  are  wuundet)  in  the  first  in- 


and  must  be  at  mut  »eeure<l.  Th«  flap  n  then  raided  and  the  mucous 
abrmnedividtrd  alun^  il8  reH^ctiuii  from  the  cheek.  If  the  tumor  ianimple, 
Am  Mar  be  partly  dune  with  a  |NTi<v>tfnl  elevator,  the  perioeleiim  being  saved 
<Wtc  ic  cat]  be  safely  taken  fruiii  over  the  luuiitr.  Tlit;  kuite  is  then  carried 
Uiifed  the  jaw  in  frout  of  the  tumor,  separating  the  nivluhyoid  and  dividing 
4»  koooas  mt-iiibraMe  in  the  Uoor  of  the  mouth,  core  Wiug  taken  not  to  cut 
■**jtlH  |ivni<ihY«id  and  gvutohyogluwua  uiuscles,  uuletn  the  eituatiou  of  tlie 
■mmt  h  such  that  thii;  cannot  b«  avoided.  If  these  musclet)  are  nev««Harily 
'iriM,  ■  thick  ligatun;  should  be  passed  through  the  end  of  the  tongue, 
*^idi  nust  be  drawn  forwarda  bv  an  anisuut,  lest  it  full  backwanis  into  the 


^f  .4M-— Bidi)»D  of  Lower  Jaw.    Ui*atUc«IktlaB  of  (^adyU. 


It  and  thus  threaten  or  evtn  occasion  JuffiKntron.  aa  hss  happened  to 
3n*  of  eminence  \ni\h  in  France  and  in  Aniericn.  The  jnw  liuving  l>een 
uo  b'llh  aidfa  in  front  uf  the  tumor,  tl)v  iiK-iw^r  lootli  must  be  Jmuu 
fcfct  pifiul  wbire  it  \a  intende'l  to  divide  the  bone,  and  the  saw  ■  Fig.  6Sn> 
The  iwctioD  sbuuld  be  completed  with  the  aaw.  ns  if  the  Uwe> 
I  be  ut««l  s  jasg^il  '■Ig®  *>'!  pr«>l>Ably  bo  left  The  jaw  ia  then 
.-■fritter  by  the  fingc™  or  lo  the  J  ion-fur  cepe,  and  forcibly  dcpre«*etl  and 
S^Pt*D  sgmewhat  outwards,  while  the  cheek  Hap  is  pulled  upwards  so  as  V7 
^^rH  ^  comiuiid  pniceu  into  view  with  Ihe  altacnment  of  the  temporal 


I  tlie  juint,  care  matt  be  Imid  bhI 
the  nnius  give  wbt,  hAviiii  km 


692      DISRASE.S    OP    THK    JAWS    AND    THKIH    APPKSDAOKI, 

niuBcle,  which  must  be  divided.  If,  aa  eometimra  happens,  tbb  csuutoi  W 
easily  reached,  the  coroiioid  proceea  maf  b«  cut  ibroujrh  with  a  ■«  aa4 
muoveii  HtXorwnrds.  As  snoa  an  lh«  iMnin  in  fr««d  frum  ilie  ifiuioiralmvcli 
it  limy  be  drawn  more  outwards  and  iLa  inner  »ide  cimrerl  l'r\>iii  thr  iDlriMl 
pterygoid,  aire  being  takvii  to  ki^ep  the  Mf^t  nf  tlie  kiut'e  turn«-il  Ui-»Mt6t  tW 
booe  t<i  Hvoid  the  submaxillary  gland  and  the  lingual  nerv«-,  IaMIt,  fay 
forcibly  dcpre^ing  the  bone  the  cundyk  isdi^locatt^l;  tlieextrmal  ntetyftH 
u  divided  by  a  touch  of  the  knife,  and  the  b«>iiett»en  conint  avmr  .  I'Il'.  ^V 
buriug  this  stage  of  the  o|>enilinD  care  inunl  Ih.-  taken  not  i  '-'•a 

iiiteruul  maxillary  artery,  which  lies  cliNse  tu  the  neck  of  the  t^'t  '  4 

uud  the  ioternal  lateral  li^^meot.    If  the  boue  be  twisltMl  too  oiu'  "^ 

the  coudyle  wdl  jihw  uuder  the  artery,  which  is  then  turn  tbr>'u{;ii  ">  ujt 
Should  the  artery  be  divided,  it  luiist  he  ligatured,  or,  if  it  be  rat  TvrydoM 
to  the  main  trunk,  it  may  he  uecv»«ry  to  tie  that  immediately  beluw  tliepiial 
at  which  it  divides  ioto  the  temporal  and  internal  tuaxillarr.  lo  dcpiiBaif 
the  bone  to  reach  the  temporal  muecle  and 
to  nse  too  much  force,  test  it  happen  iliat 

weakcDed  by  the  diaense;  this  accident  causcBs  good  deal  of  difficulty  Id  di^ 
articulation,  which  can  be  flccompliBhed  only  by  aeizing  the  frs^Miil  left 
behind  in  necroBis  furwpa,  ibua  dragging  it  lurwarda,  and  thtro  dividisK  tk» 
rauBcle  and  caitaule.  When  the  opcraiiun  U  oornpletcd,  ihc  raw  aa.tftn 
ahould  be  touencd  with  a  soluliua  of  chloride  of  uoc  and  ipnnkled  villi 
iodoform.  The  flup  ia  then  brought  down  and  secured  with  iuturcittt  ibiis- 
age-tube  being  iuwried  at  the  lower  and  posterior  angle  of  the  woomL  If 
the  sympbysia  have  been  remo%-ed,  the  rtMt  of  the  tongue  ranot  be  itilcM 
liirwardH  and  the  ligature  through  lu  tip  ruuM  be  rotoined  for  a  few  dayitiO 
all  danger  of  it»  falling  backward*  into  the  pharynx  ia  iMUaetl, •■> lltot  iinaf 
be  drawn  forward  if  necessity  arlHe*.  When  cicatrluttiuQ  b  QOOtplMC,  t 
deuMt  niH»s  (if  tiltrou*  tiuue  i»  formed  in  Uie  place  of  the  jaw,  ood  obiu|«im* 
lively  little  derormity  retult*. 

Di»EAet»  oy  THK  Tkmporo-maxh.i.aby  ABTirt'i.ATrox. — Tb«  ariiculo- 
tjnti  of  the  Jaw,  though  le^  frequently  diseaied  than  intjal  other  joioU,  t> 
liable  to  the  siime  aflectioui  at  eiiuilur  parts  elaewherc  Ohronic  HblMMttt 
Arthritu  ut  the  tcmponhiuaxillary  articulatiuu  haa  been  already  dcaertbeit 
(p.  t}57).  AcQte  Arthritu,  terminating  in  destruction  of  tb«  joint  aad 
tibrouB  or  obbcoue  uukylueis,  moat  comuioiily  occurs  in  coDsequeDc*  of  dioBooe 
of  the  middle  ear  in  scarlet  fever.  Accontiug  to  A.  K.  iJarktr,  who  Wa 
specially  cnlled  attention  to  this  form  uf  dtseosv,  it  is  met  with  alin>»t  excio' 
lively  in  children,  and  is  due  to  the  persistcuce  of  a  hiatu*  in  that  i«rt  ol 
the  tynipanic  plate  furming  the  Aoor  of  Uie  meatus  and  the  roof  of  the 
urticulatiiin.  This  hiatua  U  always  present  in  infancy,  and  amy  nmatii  ia 
adult  lile.  The  disease  may  result, also,  from  necroeis  of  the  bone  Id  chradi 
■uppurative  inflammation  of  the  middle  ear  al\rr  fcven.  The  syniMooMafi 
thoM  met  with  in  oilitr  jxinis — acute  [win,  redness,  ewrtling,  and  ui«  tanm^ 
tloo  of  absceaaefl  di.->elinrging  either  im  the  cheek  or  by  the  mr.  Tbe  IfcM' 
mcDt  consists  in  rc»t  and  o|»ening  the  ahscessra.  Ankylosis  of  the  Jaw  may 
be  Hbrous  urv*t»ou>^.    It  necessarily,  even  if  afl^tiog  "iit-  t>i<lc  only,  pfwesu 


i 


mMBlicHlinti.  If  fibrous,  it  may  bo  treated  by  fotrtbly  opening  the 
under  chloniform  by  means  of  a  MTcw-gng.  or  of  an  apparmtita  tpeelaUy 
constructed  for  Ibe  purpose,  after  which  n  wedge  may  Iw  pln«.-«i  bi-lweeo  the 
tcetb  to  keep  them  apart.  This  treatment  i»  |>aiuriil,and  ha*  !•>  '•"  r>'<— ^t««l 
at  intervals  for  vome  time,  lest  the  articulation  become  again  '  It 

b  not  usually  very  satisfactory.  Spanton  hue  Biicceedwi  In  i.i--..i.  i»g  a 
better  mull  by  dividing  the  ubruus  bands  in  the  arliculnlioa  or  mmu  «f 
a  tenotome  paved  into  it     In  lirm  fibrous  ankyluab  in  which  utbcr. 


I 


CLOSURK    OF    THE    JAVV8. 


503 


liBve  failed,  or  in  osseous  aakylosU,  the  only  treatment  likely  to  be  followcil 
by  ^lod  resulls  is  excUiou  of  the  cunclyle  of  the  jaw.  Ttib  is  bt-si  dime  by 
»a  incision  carried  alont,'  the  luwcr  border  of  the  sy^xtiia  fmiu  immediately 
in  front  oi'tlie  car,  avoiding  the  teiii])<tral  artery,  to  tlie  maliir  buuc.  Fnim 
the  middle  of  ibis,  a  short  vcriicat  iuciHi<iu  may  his  curried  diiWDwanls,  for 
about  threo-quarien!  <d'  au  inch,  ilividin^  the  sltia  and  fnt  only.  The  viaa- 
aeter  is  then  separated  frtxu  the  zyf^orautii':  aroh  as  far  m  it  i»  expoaiH^l  by  the 
scalpel  and  perioeteal  elevator,  i'he  neck  of  the  bone  io  thus  fully  exposed, 
and  tuui<t  be  carefully  cli-un»l  with  a  narrow  elevator,  keeping  close  to  the 
buoe  so  aa  tii  avoid  injurinj^  the  facial  nerve  or  internal  maxillary  artery. 
The  oeck  of  the  iHtno  is  then  ilivided  with  a  narrow  chiael.  After  this,  if 
le  ankylosis  ii  tibmud,  it  may  be  jmmible  to  lever  the  comlyle  out  with  an 

Bvator;  if  it  is  iwseous.a  aecond  section  of  the  bone  must  be  made  with  the 
ii»fl  inimctlialely  helow  the  zygnma.  This  operation  has  I>een  suocessfully 
(performed  by  Duvies-Colley,  Heath,  nnd  others.  The  result  \a  Visually  very 
BBlisfactory.  Humphry,  of  Cambridge,  also  successfully  removed  the  con- 
dyle, in  19>'i6,  for  rheumatoid  arthritic. 

Enlargement  of  the  Condyle  of  the  Jaw  in  a  rare  condition  occasioually 
m^l  Kith.  There  is  great  and  irrt-gidar  incrvage  in  size  of  the  condyle, 
apparently  due  (o  the  formation  of  o^ifying  cnrtiliigiuouH  uutgrunths  similar 
to  those  of  rbeuniHloid  arthritic.  lu  a  catw  of  tlii«  kiud  reconled  by  Adams, 
utber  jiiints  were  similarly  Nffected.  In  two  other  casee  recorded  by  McCarthy 
and  Heath,  thert-  were  no  signs  of  general  articular  nllectiou.  In  Heath's 
cai*  the  chin  was  thrown  over  lo  the  opposite  side,  and  great  deformity 
reaulte<t.  The  diwnsvd  condyle  waseuccwwi'ully  removed.  It  measured  one 
inch  and  tfin-e-cpmrttrs  from  before  back  and  one  inch  across.  The  im- 
pnivt.-ment  in  the  appearance  of  tho  patient  auii  the  utility  of  the  jaw  was 
very  marked. 

Closure  of  the  Jaws. — SpasmotHe  closure  of  the  jawa,  lasting  weeks  or 
months,  and  ft'tvo  accompanied  by  considerable  pain,  is  not  an  uncommon 
ranili  of  reteniion  of  ihe  wisdom  tooth,  either  from  faulty  position,  or  from 
the  second  molar  uoi  allowing  room  for  it  to  reach  the  surface.  It  occurs 
between  the  sgea  of  20  and  <i5,  at  the  period  at  which  the  wisdom  tooth 
should  be  cut.  ('Idorolbrm  must  be  administered,  and  the  mouth  gagged 
open,  The»euoud  molar  must  then  be  extracted  to  give  rootn  fur  the  wisaom 
looih,  after  which  the  symptoms  at  onee  subside. 

yermaneni  Clature  of  Ihe  Jaws  may  be  due  lo  ankylosis  of  the  joint,  as 
already  described.  It  is  perhaps,  however,  mure  cfjinnionly  the  reault  of 
contraction  of  cicntricos,  renulling  from  cancrum  oris,  or  from  gangrenous 
nonuuilia  folloiriug  the  excesairc  adrainifitratiim  nf  mercury,  or,  more  rarely, 
horn  exiensiTe  nceroBia.  When  the  mu«ms  membrane  has  been  destroyrd 
by  ulceration  from  the  one  alveolar  border  Ut  the  other,  the  resulting  cicatrix 
bmds  the  jaws  m  firmly  together,  that  not  only  is  movement  iiupoasihle,  but 
itte  iu.<ii<lc  of  the  cheek  i«  in  such  cli«e  contact  with  the  teeth  that  there  is 
siaircely  rotmi  lo  pass  a  director  between  them.  Under  th&so  circumstances 
it  is  evident  that  little  can  be  done  Co  relieve  the  patient  from  within  the 
inoaih.  I)iviginn  of  the  cicatrix,  followefl  hy  forcible  extension,  baa  been 
recommended  and  pnictised,  but  never  with  any  good  result.  As  the  raw 
surface  heals,  the  coiiLrflction  necesiMirilv  recurs,  and  the  last  state  of  the 
patient  is  much  the  snmc  as  the  first.  If  the  bitnd  were  very  narrow,  and 
bmJDiy  mucous  membrane  existed  on  each  side,  which  coulrl  be  drawn  in  by 
eontniution  of  the  sore  in  healing  while  the  moiitli  vuu  gagged  opeu,»r>tue 
benefit  might  re»ult,  but  practicutly  such  a.  cotiditi>in  is  never  met  witti. 
Variou?  attempts  ut  plastic  "peratn-iuti.  similar  to  Un^se  performed  for  faulty 
cicatricve  in  the  skin,  have  been  sujjgeated  and  attempted,  but  an  good  result 
VOL.  ti  — 38 


594 


PLASTIC    SUBOEBY    OF    THE    PACE    ANIf    MOUTH. 


bw  been  oblfliued.  In  order  to  relieve  this  diatrewing  deformity,  Esmarch, 
of  Kiel,  in  1^C»5,  su^geot^nl  divisiun  <>!'  th«  jaw  and  Ihe  forniHtion  of  a  lalav 
joint  in  front  ul'  the  cicutrjgial  lianils.  AlK>ut  llie  same  time,  Hizzoli,  of 
B«>l»gua,  maife  a  similar  Buggesttoti.  In  ICi/zuli's  nielhod,  tlie  jaw  in  »imp\y 
divided  frum  wilbiii  the  innuth  hy  a  jmir  <if  etrung  cutting  plien ;  in 
ICamarcli's  uperatiun.  a  wedgc-siiuped  pit;ce  of  tinae,  with  thf!  aiwx  towards 
thv  alveolar  border,  is  removed  by  a  saw  fmro  an  incision  made  from  outside 
at  tbe  lower  border  of  the  jaw.  The  performance  of  the  opnralion  is  »utB- 
cientlv  easy,  but  conbiderablc  difBcuhy  is  found  in  maintaining  tbe  muTu- 
ment  Wtween  tbe  fragmeiilB  eHer  t-icatnzation  ia  complete.  The  tendency 
to  reunion  by  bone,  or  by  Hbnius  tissue, bo  dense  as  to  prevent  all  movement. 
is  certainly  less  when  a  couj^iderable  piece  of  the  jaw  is  removed.  C.  Healb, 
who  was  one  of  Ibe  first  Lo  |)ertbrn)  tbe  operation  iu  ibis  couniry,  expresea 
a  strong  preference  ior  K^innrch's  operation.  In  one  cnsc  o|>erated  on  by 
him  by  this  nicrliiMl,  iu  I'^04,  the  pnlient  «qb  funud  to  have  good  use  of  the 
sound  m\e  of  tbe  jaw  in  1K80,  The  wedge  of  bone  removed  mimured  seven- 
eigbiha  of  an  iiicii  at  the  lower  border. 


* 


chapte;r  lvii. 

PLASTIC  SHRGEKV  OP  THK  FACE  AND  MOHTH. 

By  Plastic  or  Eepaiative  Surgery  is  meant  tbe  performance  of  operations 
fnr  the  repair  of  delicienuies  in  structure,  whetlier  resulting  from  injury, 
from  diieflHe,  or  from  nmUormation. 

Il  bus  been  long  known  that  porlimis  of  the  l>odv  may  retain  sutficleiiL 
vitntity  to  become  again  uitherout,  whi-n  attached  hy  but  a  very  narrow 
tongue  uf  tissue  to  the  pan  from  which  they  have  tieen  till  but  separated. 
This  has  oflcu  been  observed  iu  iujuricB  of  the  tiace  and  fingers,  ])ortians  of 
which  have  been  atino^l  completely  severed,  and  yet  have  united  again  i>n 
being  replaced.  But  there  is  a  sutlieicut  nundier  of  cadch  on  record  lu  show 
that  certain  parts,  when  completely  separated,  may,  after  being  replacetl, 
again  become  adherent.  The  mn«t  remarkable  instances  of  thia  kind  are 
those  which  are  related  by  Hoffacher,  and  attested  by  Chelius  and  Vetpeau. 
HofTacher  was  oflicinlly  appointed  toaltend  &»  Surgeon  nl  the  duels  which 
were  then,  as  now,  frequent  amongst  the  stodcnls  al  HeidolWrg;  and,  as  at 
tbem:  encounters  broad-swords  were  u.sed,  he  bnd  an  oppi)rtitnity  of  ^leeing  a 
considerable  number  of  inci-ied  wounds,  and  has  relat<_n)  no  fewer  than  six- 
teen cases  in  which  portions  of  the  nose,  lips,  or  chin  had  been  sliced  oflT, 
and,  being  put  on  again,  contracted  adhesions.  An)onc;st  the  niOBt  remark- 
able of  these,  is  one  in  which  the  end  of  the  niise  was  sliced  ofl'by  a  cut  with 
tbe  broad-sword,  and  fell  under  a  chest  of  drawers;  il  was  nni  found  for 
acme  time,  but,  on  being  recovered  aud  washed,  was  stilcbed  nn,  and  became 
firmly  allached.  In  another  inttlauce,  a  dog  that  was  in  tbe  room  snapped 
up  the  detached  portion  of  tbe  organ  as  it  fell  to  tbe  ground,  but  tbe  nose, 
being  immediately  taken  out  of  Uie  animal's  moutb  aud  put  on  ugain  and 
Btitcbed,  Ijecame  firmly  fixed. 

in  order  that  union  should  take  jilaec  between  parts  that  have  be«u  sepa- 


METHODS   KMPLOYKD   tl 


•LABTIO   SVROSKY. 


595 


ipleldr  or  neRrlr  so,  nod  ibv  n^st  of  the  bu<ly.  it  u  Decessary  that 
'  tufl  SDit  vascular,  uml  inure  e8[»eciAlly  ihaL  their  structure  be  of  a 
lowgeiMOtia  character,  such  as  is  oiet  with  ia  the  tissues  of  the  face ;  ^^llere 
MT«i7  large  hltwdvcsK^lfi,  oervra,  tuiidune,  or  bun»  are  found.  It  ts  lh« 
■■e  in  iita^lic  upcratiiius,  which  succeed  hcHt  under  Bimilar  conditioue  of 
UMi,an<l  which  are  roiiduoted  uii  the  same  [irinciple  asaaaUeraptatuuiou 
ntpBTtially  scven^l  structure. 

b  b  priodpally  ftir  deformities  and  loss  of  the  noae  and  tip  that  plastic 
»pwitioos  are  of  much  strvice:  ihuy  may.  however,  on-Htiionnlly  Ite  had 
neoaiM  m  in  other  eiluati'md.  as  ahoul  the  cheeks  and  eyelids,  but  seldom 
vitbui  equal  amount  of  aucc^'^e.  Reference  has  already  ^eeo  niade(p.842, 
fnl  L)  b}  the  iterforinnnce  of  platftio  operaliuns  on  the  perineum.  In  the 
pnrtict  of  this  very  interesting  branch  of  Burf^^ry,  there  is  much  opportunity 
IW  the diiplay  of  miinuul  dexterity.  On  this. indeed,  almost  the  whole succcM 
•flbtoDerati'tii  de|ieiid9:  and  n  vnst  dctil  ninv  be  dune  in  npparently  the  moai 
n|nwuiiog  cases  Ity  skill  and  patieuee.  In  these  operative  procedurea  the 
iMNafKerrea,  Dtettetibach,  Lintuu,  Syme.  Fergussun,  S^-dillot,  B.  Langen- 
beek,  JiJwrt,  and  \Volf«,  <lt«ei'vediy  take  the  Iir«t  rank. 

lo  perftriiiiiig  the  variuuB  plastic  n|>erationB  live  methods  have  been  em- 

plwbL    la  the  first,  the  tlap  of  skin  thnt  is  intemled  to  repair  the  Inst 

Nnetiir^  is  trun>plaat)x|  from  a  distant  pnrt,  as  the  arm.     This  operation, 

BBifcloCTHl  by  the  Italian  Surge<in,  TaRliacotius.  in  the  sixteenth  ceutury. 

UdbeBoe  commonly  c«lle«l  by  hi«  name,  has  in  a  great  measure  fallen  into 

'■BK.uD  account  of  the  ditliculty  of  Its  execution,  and  the  great  iincertaioty 

|>f  obtuDiug  a  suoceosful  reaulU     The  Komd  plan,  which  has  heeti  recently 

iMnrfaonl  by  Wolfe,  of  Qlasgow,  consist:^  in  the  transplantation  of  a  piece 

■Tuia  of  cuttsiderable  size  from  one  part  of  the  l>idy  to  another,  the  trans- 

f^Vcd  portion  being  completely  separated  at  the  lime  of  the  ujieration, 

''UWtnully  frecl  from  every  trace  of  subcutaneous  fat  with  a  pair  of  sharp 

''I  >ci«i>rB.     The  third  plan  consiats  in  trnnsulanting  the  reparative  struo- 

tore  from  some  part  in  the  neighborhood  of  itic  organ  to  be  repaired  ;  the 

**'*)  from  the  forehead,  for  instance,  being  used  for  the  formation  of  a  now 

•■•r  that  from  tiic  chin  for  tho  reeluration  of  a  lust  lip.     This  procedure* ' 

'jl*^  seems  first  to  have  been  adopted  by  the  natives  of  India  iu  restoriog 

^  Ion  of  the  nii«e,  is  the  method  that  is  luusi  commonly  employed  in  thia 

^■MitfT  ID  pluiic  operaiioos  on  the  faee.    Tho  fourlh  method  consists  in 

^(^mu  the  skin  by  a  pmceas  of  subcutaticous  section  tn  some  distance 

*'^fld  Hie  part  ui  be  repaired,  and  then  drawing  it  forvarda  with  or  with- 

^y  iaa-Mioii  through  Its  substance.     This  gliding  operation  ts  fhietly  prac- 

^^d  fiiT  the  cl-isure  of  listnlous  o)>enings.     The  fifth  method  in  eio[iloyetl  iu 

^4mi  wlM*rc  an  abnormal  tissure  exists  in  a  (lart.     In  cotuists  in  bringing 

'^lK**hcr  and  uniting  the  edgea  of  the  fissure,  after  baring  pared  them  evenly, 

^Ma  to  expiwe  tbcir  vascular  aurfaees. 

^Htflioti  in  plAvtic  ojM-raiions  should  take  place  by  the  first  inte.ution, 
jMiaxiM  this,  howpver.  fail  front  any  accideotal  circutnslaacea,  the  Surgeon 
"^^  nrit  dt-spair;  ns  the  parts  may  unite  by  granulation,  iu  a  very  Batisfac 

r-  -'■  •  -"fnpleie  manner. 
•T  union  t(»  be  eSeeted.  it  is  necessary  that  the  edges  bo  clearly 
cut,  su  as  to  ailjust  themselves  nccuratelv  to  oae  another.     This 
^'  l<e  must  skiinilly  ctfeetcd  iiy  making  tlic-  mcisiou  in  the  part  that 

**  a»  rrcvive  the  flap  someivhal  oblitiue  or  bevelled,  thus  securing  a  more 
*^ania  adaptatioa  of  the  edges. 

the  flap  has  been  formed  and  the  part  in  which  it  Is  to  be  trana- 
praperly  parad,  the  operation  ehoiild  be  delayed  a  few  minutes  until , 


596 


i'LASTIC   SDROERY    Of   TUB    FACE    ANU    XOtrTH. 


I 


all  blee<1)ng  ha*  cca>«4).     Tliin  U  (tf  nmcti  imporUnce,  a*  the  int«qintiUaB4 
It  Inyer  of  cuttgulated  bl«>od  will  tiiit«riail}'  interlere  witli  union. 

Id  bringing  the  parts  iut»  appoeitiou,  grefti  care  must  be  takra  that  »> 
undue  tractioD  or  coastrictioQ  be  oxercia&il,  lest  ibcir  uirculatiuu  )m  touf- 
hred  villi,  aud  their  vitality  be  euilaugvri'd. 

The  parLt)  niaj*  be  maintained  lo  apiKnition  by  flutnm,  ctilloilkn, 'ir  tk 
npplicatioo  uf  a  strip  of  iainglan  pliwii-r.  Tb«  Butiin-s  sbimld  be  a*  Hm  it 
puMible,  introduced  with  a  ftniall  ncvdlc.  and  kuoUfHl  on  Um  aoiuHl  pana 
HiirMfbair,  fine  ratgut,  or  «ilkH'oroi-giiL  will  be  fuutul  ilie  boa  Bwlmk 
uboru  there  U  no  strain  on  the  BUtun-s  ;  tthoutd  ihrrti  tinavoIdaUy  bt  «■■ 
strain  li  deep  metalttc  Mhdi  shuulrl  be  |An»prl  to  rolici-e  ih"  ffnvr  nam 
Occasionaily  iiiin^lip  [>ins  may  advantageciut)ly  l»e  uned.      ■  t*  «oU#- 

dion,  where  applii-ablf,  i^  of  gn'al  ailvanln^  In  plaBtic  »i>  -  it 

only  secures  ndheoion,  but.  by  exoluding  the  air.  Iea»em  the  chaaee  of 

[turation.  If  the  wound  is  Inrge,  is  must  not  bf  couinleiely  cAverfd  by 
iidiiiii  lest  dim^barges  an-umulau)  beiii-ftUi  ihi?  flap.  In  surae  part*  in  « 
the  wound  ie  iiiuidicned  by  the  »ocr«tit>n  of  K>mf  he ighburiiijE  inimMii 
braiic  aiul  cannot  be  kt'pt  dry,  as  in  the  eyelids,  uW  iMtranc  «ri<l  Itnl  •< 
boracic  acid  oit)tQ)ent  will  Im  found  the  be»t  application  :  in  ••(her  parte 
atK»rbeiil  induform  or  aalicyltc  wrxd  may  be  applii*<l,  a  attiall  pi«nr  fi  lb* 
"  prutecUve*'  oil-silk  being  placed  next  the  wound  lit  prevent  U  from  rtictt- 
inc.     Tbu  woo]  may  be  fixed  in  (KMitiou  by  collwlion. 

For  a  pla«lic  procedure  to  «ucc«4>d,  it  i«  alisoliiii-ly  necnaarylbat  ooBmrbid 
pntoees  Iw  goiog  on  iu  the  «eat  «f  upemtion  ;  mid  not  only  that  nocM  bvatfv- 
ally  iu  pnigrem,  but  that  all  have  ceuseil  I'^r  etmiv  «-no!ii>leraHle  lime.  Tbi> 
i*  more  pnrlicularly  the  ca»e  when  the  det'oriuily,  f')r  (he  remevlying  of  wbich 
it  is  pracUfie<l,  ban  resulted  fn>iu  eyphililie  uli-erntion.  In  9oeh  ^■efl^  it  ■ 
neccaeary  to  see  that  the  conatitutiou  is  sound,  ns  well  as  that  all  local  A- 
aue  has  been  erailicated  ;  utherwise  the  irritation  of  the  oprrati(ia  mlfb&ait 
it  up  Bgaia,  and  ihe  new  Sap  might  be  invadeil  and  destroyed.  Fnim 
of  inis  precaution,  i  have  amn  than  once  seen  disapfv^intment  renilL  W! 
■n  operation,  as  on  the  nnge  or  lip,  is  performed  fnr  epithelioma  or 
ulcer,  ablation  of  the  morbid  part  may  bo  done  at  the  moment  of  oi 
—the  sHeolion  iH-ing  a  local  one ;  when  for  struma  nr  syphilid,  the  di 
eonstitutional.and  care  roust  be  taken  thai  all  morbid  action  baa  ibomuibly 
and  cunipleiely  ceased.  As  a  general  rule.  pia«lic  opcratioDs  pnetJsnl  br 
the  repair  of  mutilations  from  injury,  or  of  coDgVDital  defioirnciev,  arv  aan 
tiicc«^ful  than  those  that  are  performed  attcr  diaeasov 

No  rouliue  system  of  treatntent  aliould  be  adopted;  but  a  f<-w  dan  nf 
re»i.  gootl  diet,  and  a  dose  or  tMl^  of  aperient  medicine,  fn;;  '  '-^ 

before  the  operation  ift  prtjci>edtrd  with.     In  the  aftertreatu    .  <■< 

a  notiriMhing  but  itn»liiiiuliiting  regiineti  nhvuild  be  otwrviml. 

Faulty  Cicatrices  nlMiii  Uir  fnce  and  uM-k  ni\j-ii  orcAsion  much  defnrtnily 
and  annoynuee,  ami  may  re<^uire  u  ptaxlie  i>)>eni(ioii  for  UiHr  retDOvaL 
Thoee  rcMiltiug  from  huriu  bavu  almuly  beru  roiuuilcml  n>  nl>n  thof 
treatment  (Vol.  i.  j>.  ;J«-1.  ri  wj.),     Wlien  due  to  other  cm  a*  lbs 

uoskiilbl  opening  of  strumous  nlMi>esee«,  or  the  healiug  of  »  -^    llrt 

orgniiuf  of  gunjiowiler  emtmldeil  tn  them,  bring  pucken  ..d- 

hvrent.  or  disiM>loreil,  mucli  may  bo  done  by  pro{MT  eurgieal  n]n>] 
ihi*  tliviigureuient  they  occasion.  This  is  lust  dnno  hv  dtssmii 
olennlv.  then  ioiwpuing  the  Mlgiv  of  tho  cut  by  running  the  |> 
scalpel  under  the  skin,  ft  that  they  may  Ik*  lin>ugbt  together  w .  k- 

rrintr.  and  theu  iniiiiiig  them  by  lueaiis  of  horveliair  or  One  ratj^ut  i4iu)ri 
by  a  ruuiul  wwiuu-ueedle. 


BURUW'S   OPKBATION  — BLBPHABOPLASTY. 


697 


Bvrew'i  Operation. — A  plastic  operation  specially  suited  for  the  repair  of 

deformity  consequent  on  the  removal  of  morbid  growths  from  the  cheeks 

■ad  other  parts  of  the  face,  has  been  introduced  by  Burow,  a  Polish  Surgeon. 

uid  wiccessfully  performed  and  described  by  Stokes  (Fig.  687).    The  steps 

are  u  fullows.    The  growth  to  be  removed  is  included  in  three  incisions,  1, 

2,  3;  and  the  integuments  from  which  it  spring  are  then  carefully  dissected 

(4r,  leaving  a  raw  triangle,  the  apex  of  which  ia  on  one,  the  base  on  the  other 

Mde  of  the  tumor.     The  incision  1,  4.  3,  is  then  carried  outwards  to  5,  8,  7, 

M  that  the  whole  distance  from  1  to  7  is  exactly  three  times  that  of  the  base 

of  the  raw  surface;  a  second  triangle,  5,  6,  7,  ia  then  made,  having  its  base 

on  the  outer  third  of  this  horizontal  incision.     The  two  triangles  must  be  of 

«)utl  size,  and  the  integuments  are  dissected  off,  o,  6, 7.     There  are  thus  two 

iViurtkces  to  be  covered  in.    This  is  done  by  diesecting  up  carefully  the 

■ipi  1,  5,  6,  and  2,  3,  7.     When  this  ia  done,  the  points  1  and  3,  and  5  and 

7>  are  respectively  drawn  together,  each  by  one  suture,  and  the  two  raw 

triangular  surfiicea  are  thus  covered  in. 

Plutic  operatidDsuf  various  kinds  are  frequently  performed  on  the  eyelids. 

Jtopbaroplaaty,  or  the  operation  by  which  the  eyelids  are  repaired,  is 

ocanooally  required  for  loss  of  substance — the  result  of  wounda,  cicatrices, 

r    operations.    It  ia  less  satisfactory  in  ita  results  than  most  of  the  other 


^^SL!.'"ii»"'''j*^!?^ 


T^B-  K1, — LInuof  Ineiiion  Id  Bnrow'a  Operatlun.  Fig.  6iS. — Openiliun  fur  Repair  uf 

Eyelid ;    {a)    Gliding    Method ; 
(£)  rwiating  Method. 

plastic  procedures  about  the  face  ;  yet  it  may,  iu  some  cases,  improve  luateri- 

*1W  the  patient's  appearance. 

When  the  upper  eyelid  requires  repair,  the  flap  ia  taken  from  the  forehead  ; 
™n  it  in  the  lower  lid,  from  the  cheek  or  temple.  This  operaticm  may  be 
perfurmed  by  the  gliding  method,  by  twifltinw  a  flap  into  its  new  situation,  or 
^7  tnDapluntation  of  a  piece  of  skin.  By  the  gliding  method,  a  triangular 
^P  it  cut  and  partially  detached  ( Fig.  688,  a),  and  then  drawn  gently  for- 
^n]g  until  it,  corresponds  to  and  litis  up  the  gap  that  requires  repair,  when 
''■there  fixed  by  a  few  points  of  suture.  When  the  twisting  method  is 
"".(•toyed,  au  ovai  flap  ia  detached  ( Fig.  688,  6),  except  its  [K-dicle,  and 
t»i»ted  down,  to  be  planted  (m  the  raw  surface. 

Occt(li>ual|v  ueither  of  these  methods  is  applicable;  and  then  the  pw- 
*™ure  that  I  suc^cessfully  adopted  in  a  case  of  which  the  aiinexe<l  cut 
'*'K- 681)^9  a  representation,  may  l>e  followed.  In  this  case,  which  was 
'Mlof»  |a,iy  ^f]i(j  hmi  rectjived  a  aovere  mutilation  of  the  face  by  thi^  tx- 
pltattiQof  n  giiijjer-becr  bottle,  there  was  a  deep  ami  hard  cicatrix  aero?::  the 
.'**'■  eyelid,  causing  depression  and  eversion  of  it.^  outer  portiiin,  and  mllie- 
""0  of  thf  inner  part  to  the  ball  of  the  eye.  After  dividing  the  nillic.-ions 
"IC  reaiuviug  the  cicatrix,  I  made  a  semilunar  incision  «>  as  to  disjcet  up 


L698 


PLASTIC   aUBHEBT   OF   TffE    FACE    AND   UOCTB. 


the  eyelid,  and  then  fised  h  hf  points  of  suture  in  ita  new  situalion.  w ben  it 
bcoBnie  firtuly  adherent  (FiK>  0110),  and  scarce  any  apparc-Dt  dcforniity  was 
left.  lu  another  very  simnRr  cfiae,  in  which  a  girt  was  bitten  ihriiugh 
the  Inwer  pyeliil  by  a  doe,  a  similar  operation  was  practised  with  euuallT 
good  results.  In  both  these  caacs,  the  eyeball,  having  been  injured,  hail 
Womc  nirophicd,  with  opacity  of  the  cornea.  But,  when  an  artificial  eye 
was  a(iju»teJ  (o  the  shrunken  globe,  the  appearance  of  the  patient  was  moat 
sntisffiv'tory. 

Restoration  of  the  lower  eyelid  iu  extreme  ectropion  by  ooraplele  trana- 
plontation  of  a  piece  of  skin  was  introduced  by  Wolfe,  of  Glangow,  in  187.5. 
ainee  which  time  it  has  been  repeatedly  perforiited  with  Huccetti.  The  opera- 
tion is  thus  perfornicd  :  the  eyelid  in  first  freed  from  the  nhnnrinal  iiitualiim 
iutu  which  it  has  been  dravin  until  its  fre«  border  can  he  bniughl  in  contact 
with  the  upper  lid,  the  two  lida  tlien  being  tied  together  by  eutureti  piisa!>ed 
ihruugh  them.  An  accurate  pattern  nf  ihe  raw  aur^ce  to  becuvered  is  then 
taken,  nud  a  Hsp  of  «ki»  u  raib(;d  fmm  the  forearm  curreajiouding  in  ebajw, 
but  N  little  larger  to  allow  for  HhriokiDg.  The  under  j^urlace  of  the  flap  Is 
then  frved  fnim  every  veslige  of  sLibcutaneous  titauc  with  a  jiair  of  flat  thmrp 


Pig.  0^0.— LvwtrEyaliildvfiiravdb^Cioiiiii.  Fff.  fl9i>.— Lo»ar  Bjrvtid  »(t«r  OpKrntiou. 

adttors,  so  as  to  have  a  white  appearance.  It  is  then  applied  to  the  raw 
aurface  and  united  to  the  surrounding  skin  by  fine  »ilk  sutures.  A  dredsing 
of  warm  wcl  b.iracic  acid  liut  rnav  then  he  applied  and  covered  by  guua- 
perchn  tissue  and  cotton-wool.  About  a  furtni.irht  after  the  npernlinn,  after 
the  (tap  has  become  firmlv  adherent,  the  sutures  uniling  Ihe  Itdn  mav  be 
removed  and  the  eye  allowtd  to  ojM'n.  In  a  case  suoocssfullv  orn'rated  nn 
by  Wolfe,  the  ovaf  piece  of  skin  transplanted  measured  two  incnee  by  one 
and  a  (juarter.  U  united  by  fir^t  iulenlion,  without  even  desquamation  of 
the  cuticle  taking  place. 


PI.AKTIC  HL-RCERT  OP  THE  NOeB. 


I 


RniNOPi.ASTlc  Opi:batio>>  are  occasionally  required  for  the  restoraU 
of  llic  lorm  of  the  nnsc,  which  has  beeu  destroyed  by  injury  or  disc: 
This  branch  of  plastic  surgery  has  lung  received  much  attention,  and  has 
been  reduced  to  dti-tincl  rules.  Either  the  entire  uoae,  or  a  portion  of  it, 
ninv  deinnnd  uperalion. 

Colniniia.—Whcn  the  columns  and  a  portion  of  the  aeptum  are  destroyed, 
a  large  gap  iati-ll  al  tlic  nn«ul  npiTlure;  and.  the  noec  becoming  tlatleue*!  in 
coniie(|ucnec  of  ils  tip  falling  iu,  great  deformity  necessarily  results.  Tbe 
upper  lip  uIbo,  loping  ihiit  amount  of  support  which  it  receivea  from  the 
coliimna,  hecomca  pendutoup,  nnyccling,  and  Ihii-kcned  at  iJie  end.  thus 
adding  to  tlic  dicfigiirem4'nt.  1  tie  ri*liiratiun  of  ilic  columna  is  eHcclcd  from 
thiH  tliirkciu'd  ami  prominent  ii[)iM'r  lip,  which,  by  l>eing  reduced  in  size,  ia 
rendereil  far  mon>  ^shapely.  The  operation  ciiueiEla  in  cuitiug  through  tlte 
Trhole  length  of  the  lip  from  above  downwanis  on  each  side  of  the  lueaial 


R3CST0KAT10H   OF   THE   KKTIHG    NDSX. 


leare  a  longtie  about  ooe>tliird  of  an  inch  in  wiJth.  Thin  ts. 
ap:  aad  iu  eu>U  beiu^  well  pared,  and  ibe  umlvr  surfaco  of  tfa« 
4  ibe  nuK  pnj[>erly  rrtuliciiLiI,  it  in  fixed  l>y  rauaiisuf  a  fmu  tiarulip  pin 
twilled  Bulure,  which  should  be  left  in  for  uboul  four  days.  Uuioii  taKea 
yian  ia  a  few  days :  but  uutil  (his  is  firm,  the  uuw  ciiluniun  inuat  be  properly 
mffurttd  with  narruw  iiriyra  uf  plusLcr  fixed  tn  the  chi-f  k  i)tt  each  Hidf.  No 
uaUng  uTthU  ainall  llaptu  rvi|uin.>d,as  the  niunmsBiirfHoe  Bp««4lily  biicoiiKyi 
CUlUMuut,  and  vier.  rcnJ.  The  diviiiitm  in  the  ii[i|K'r  lip  miiHt  lie  tretUed  in 
tbtauDe  wav  na  an  ordinary  hurelip,  and  tinite^  irillxnit  difKculiy,  tefviening 
inally  tbc>  rleliirmity  in  thli  pari. 

11a. — When  one  ala  only  U  deficient,  the  net  of  the  nnse  bein^  snnod, 
DMttf  tkree  proeeoKS  may  be  ndopted  to  remedy  the  Hcforniitr.  L  When 
■  Mail  pnrtwa  imly  of  the  free  bonier  of  the  tip  has  been  lost,  an  incision 
AduM  Im  moile  i  Fig.  6i)l)  across  the  noae,  and  the  remnini  of  the  nla  and 
t  pNtiiJO  of  the  naflal  integument  thu9  marke<l  out  diaaected  down,  and 
Mudwd  to  the  end  of  the  organ.  In  this  way  a  very  excellent  result  may 
bBahuInnl. 

1  [f  the  \n»i  of  mibstance  be  greater,  a  flap  of  »kin,  of  the  proper  shapA 
IB  iHtMc  (he  defiintiity,  may  he  niiw_-«l  from  the  cheek,  applied  to  the  pre- 
TiwJr  par^ii  pilj;«'n  of  the  [«»rl  re-^uiriog  it,  and  fixed 
tkaeby  a  few  (>oim»  of  fine  suture. 
^3^  If  the  lod  of  the  eubstance  of  the  ala  be  very  cm- 
*iilBiWe-,  or  if  it  extend  to  a  part  of  the  b«Kly  of  the 
■■Mitlieo  it  ia  mure  eHicieutly  reetored  by  bringing  a 
l<«|  nirrow   (lap  from  the  forulieutl  in  a  w»y  that  will 
JHualtBiely  be  duicribed.     Iu  the  ruajurity  of  ca^-s,  the 
'wnclion  of  the  ala  and  uf  the  body  uf  the  nuee  is  bo 
Msiderable.  that  other  plans,  to  be  presently  described, 
w»iwuifir«I  f.<r  the  re[»air  of  the  deforuiilv. 

fcltft  Sow.— Fur  the  restoration  of  t^e  entire  nose. 
^^pfiscetlurM  have  been  employed:  viz.,  1,  the  Taglia- 
O^io  Operaliiin  :  'J,  the  Indian  Opemtion. 

h  The  TagUacotian  Operation  cnnsiiU  in  taking  the 
■4(000011  and  areolar  li^vnc  r^)uired  for  the  repair  of 
^MoC]gan  fnmi  the  iniitde  of  the  arm.     Here  a  llap 

"  lent  extent  is  to  be  marked  out  and  diiLv>ao<l  up  with  in  suhjncent 
tiame,  leaving  it  men^'ly  attached  to  the  limb  hv  a  root  nt  iia  distal 
So  aitrnipt  »t  fixing  this  flap  to  ih(<<  nrvie  ahould  \h)  made  for  at  leaat 
it^hi,  during  which  time  it  »h<>uld  be  kept  upon  n  piece  of  net  lint. 
•»4tlk>wcd  to  thicken,  granulate,  and  become  vagcular,  so  aa  to  Bt  it»clf  for 
*^fc«i»a  to  the  new  Mirfn<.-<>  to  whit-h  it  i«  to  he  applied.  The  remains  of 
»*  irformeil  no»»  having  then  been  properly  pared  and  the  flap  shai>ed. 
^7  Bnut,  after  all  bleeding  has  ceawil,  Im;  pro|ierly  ndjustiHl  and  6xed  to 
H^  Baotbar  by  point*  of  HUltn-e.  The  nnii  mu»t  then  be  vlonely  uttaehed  to 
^  hiaii,  BO  «»  to  be  aa  nearly  as  pu«sibte  immovable.  At  the  end  of  about 
'**^T*,  wben  adheaiooi  have  taken  place,  the  connecting  me<lium  niny  bo 
^*cnB.and  the  part  Idi  to  be  eup|>urtL-d  by  thu  vitality  which  it  mar 
*"  ~  ^n  tb«  new  surface  to  which  it  is  now  attach^'d.  This  process  ia  com- 
,.  '"I'ly  ialdoin  had  recourse  lu,  for  obvious  reasone.  The  uncertainty  of 
*'**'»minB  tAe  ritatily  to  iht-  tlap,  thu  extreme  terlitiu.«nc?B  of  the  pnilonged 
*'"'*'*iofa  poaitioo  in  whicli  it  ia  uccewsry  to  keep  the  (Hitient.  and  th# 
P*U  diffiflaUy  of  guarding  against  movenienlHof  tlte  nrm,  cajH-cially  during 
r'9>*ad  which,  bowever  slight  and  involuntary,  would  be  Hutlicient  to  di»< 
?*  "^ion  between  the  o|ipiiBed  aurlacce,  aud  occasion  the  failure  of  th« 
•'■WtMi,  baTfi  eauaed  Lhi«  plan  of  prucedure  to  fall  into  dttuie;  and  it  i« 


^ 


Fi|.  Ml.— lltliei«aar 
or  AU  ar  So**. 


>riinBi. 


600 


PLASTIO   SITRGBBY  09   THB    PAOB    AXD   MOUTH. 


now.  I  believe,  uoivcreally  aLnndniieil  by  Surgeuns  in  this  cuuntrv.  bavioff 
bceti  repiaced  by  llio  inorv  ctrtaiu  jjrurctlurc,  wliiili  will  now  be  t^cBcribed, 
of  borniwin^  the  ekiii  ti»r  ihv  new  uom!  fruiti  ihe  ibrebead. 

2.  Thf  Indian  Operatioo,  :i  kiif)wlo(l>.'i->  of  wliicb  was  bnmgbt  to  this 
country  by  (.'arpin,*  in  ltS14,  in  KxiniiiK^lr  HucciWilul  in  its  rfisulta,  tbfKJixh 
rei]iiirit)|;  a  pHwl  ileal  of  tiU'cty  fiir  tlH  jintper  exoriition.  The  (i|H'nilivo 
proreibiri'fi  n>()iiire<i  by  this  mi^lbixl  nrf  tutmewlmr  nomplrx,  and  niiiy  run- 
veniently  be  divided  into  thrc*^  dt!<Ltn(-t  Mn^fia:  !,  the  Di.awction  of  the  Flap 
from  the  h'lirebciid,  and  iIh  AMarhnicnt.  to  its  new  ^itiiniinn  ;  2,  the  Separa- 
tion of  the  li'int  of  tbe  Flap  wliere  it  is  tiirripd  down  from  the  Forehead, 
and  thp  Formalinn  of  a  proper  Bridge  to  the  Noec;  S,  the  Formation  of  the 
Columnn  Na^i. 

1.  Formation  and  Attachment  of  the  Flap.— Id  the  shaping  of  the  finp, 
eare  nui&t  he  taken  that  it  is  of  sufficient  ciio :  aa  during  the  afler-pmrt  of 
the  irontment  it  often  has  a  tendency  to  shrive),  and  more  inconvenienrc 
usually  resuliii  from  its  not  having  originally  been  made  large  eaoiigh,  than 
the  reverie.  The  sIkv  «<]«ptcd  In  the  particular  face  may  bwl  be  judgwl  of 
by  moulding  a  thin  piece  of  gutta-pen.'ba  to  the  nose,  then  flattening  it  out 
by  dipping  it  io  hot  water,  and  u»ing  tbit  as  the  guide  for  marking  the  out- 
line of  (he  flap  oiKin  ttie  forehead.  Tbia  should  be  traced  with  liucture  of 
iotline,  which  will  not  be  w!tslii*d  off  sn  readily  at  ink  by  the  flow  of  blood, 
nbicb  in  oi\vu  nitber  free.  Tliia  flnp should  beof  thesl>ape!>hown  in  Fig.  6-)'J, 
taking  care  that  it  h  rather  BquaiD  at  the  angle?,  and  not  too  much  rounded 

off.     The  size  will  neeeasarily  *ary  ao- 

^  . cording  to  the  cliaracler  of  the  cnuote- 

\,^_„,.--"  JW*  ^     nance,  and  the  extent  of  Idbb  that  baa  to 

be  repaired.      When  the   whole  of  the 

3  /  y      now  rt'()uin»  rwLoration,    it   h   usually 

^,'  y       necessary  to  make  it  aliout  two  and  a 

/  jf^  lialf  to  three  inrhea  in  length,  by  about 

'         -^  tliu  Bnme  in  width  at  the  liroadeBl  jmrt. 

It  may  either  be  taken  fn)m  tiie  middle 

XI  \|  of  the  forehead,  or  obiittuely  from  one 

side ;  if  the  latter,  the  right  side  hi  the 

most  convenient.    It  must  now  be  d'n- 

aecled  off  the  forehead ;  in  doing  tbia, 

care  mual  be  taken  to  cut  the  fla|>  ai 

thiek  n^  possible,  eapccially  at   its  root 

l>etu'een  the  eyebruws.     Il  most  KtM>  be 

liut   little   handlijd,  And,   above  all,   not 


Pig.  0K_I>iftKnuD  »r  >*1a|>  in  Rhinv- 


ninchcl,  eilh^fr  with    tingere  or  furi'Vpa. 
The  diwecti'io  should   be  comnienfwd  at 


tlie  ro«it,  90  that  the  outline  may  not  be  obscured  by  blooti;  and  this  part 
ibould  be  lefl  long,  in  order  to  admit  aflerwurd^  of  a  very  gradual  and  ea«y 
twiit.  Io  order  to  facilitate  thin,  it  is  desirable  also  to  make  the  inciaion  on 
the  right  side  a  little  lower  thau  that  on  the  left.  Aller  the  f]ap  has  been 
raiiMxt  throughout  the  whole  of  ita  extent,  pressure  should  be  applied  to  the 
forehead  by  means  of  a  sponge,  with  a  view  of  arresting  the  bleeding,  before 
tbe  next  atop  is  taken.  This  coiiini^ts  in  paring  the  surface  and  edges  of  the 
■lump  of  tb«  uose,  and  removing  the  integuments  from  it  in  such  a  way  as 
Co  leave  a  Lriangular  raw  surfuco.  In  doiug  this,  care  must  be  taken — whilst 
a  gooil  base  of  aitachment  i'^  left — nut  to  remove  the  psrts  too  widely,  lest 
the  cheeks  hh<^uld  retract,  and  ttalten  out  the  nose.  The  tntegumenli^  also 
■huuld  be  disfi<i!ied  awny  iu  such  a  manner  aa  to  form  a  deep  groove  Hhelv- 
lag  inwards,  so  us  to  receive  and  bold  the  ilap  more  securely  and  with  Im 


RBiyOPLjLSTr — APTES-TSEATUENT. 


601 


■nrimtBg  of  ifac  fdgiv.  The  fi|>rraiion  mu»t  now  hp  discnntinuM  fur  li 
(n  ninuu^  until  nil  lilrcdJn^  h&s  CH.-R>teit.  ami  th»  ml  Hurtarex  liare  liirrnnie 
(Und:  ihU  |Miint  is  of  i^real  iin|M)rluiK-e  in  KMruritif;  direct  niUmion,  ami 
miM  be  carefttlly  stlcniiflil  to.  Th<^  lilrpilin^  Imving  b^n  arrttitnl  by  ei- 
pmieto  the  Mir,  iind  hy  tbr  tomion  ralht-r  lliao  the  ligature  of  anv  8pi>ut- 
tof  branrh,  the  flap  from  the  for^'hcRd  should  be  hrmighL  down  hy  a  twist 
friia  \»h  tA  riftht,  and  attaoheil  by  a  (ev  \mnu  of  fino  »uliire  on  tncb  eidn 
ta  iIm  Mlf^  of  tbo  incision,  amund  the  uatial  aperture.  A  plalfiet  of  mtfl 
Knt,  >ir  wiiaI  grrcAncd  with  carbolic  oit,  thuiiM  now  l>«  g<>nlly  insinuRtod 
anJrt  the  flap,  the  lower  pnrt  of  the  incision  in  the  furchea/J  drawn  ti^'thtr 
In  a  [kTiint  of  autiirf ,  but  not  Bo  aiti  t(i  t-■m^t^ict  lh«  nx>i  in  any  wav.  nm)  the 
roiull  the  exposed  eorface  covered  with  soniv  »impli>  dn-wing.  I'lic  parts 
«ill  lliru  pmsi'Dt  liie  np|M-«rauc«  nf  Fig.  *>*J4,  taken  from  a  patJuiit  *if  mine 
tfedsvitler  ih^  opi-nilioii.  Fijf.  61)^  rvprmtiiitH  the  defurniity  for  whit-h 
ibo^ntifu  wnH  prrtorruvd.  The  |>utieut  8buuld  be  put  tn  bed  with  apiew 
<4  bit  lint  laid  over  tho  whole  of  tbt;  j'uoe,  so  as  to  maintain  it»  temperature; 
•ad,  if  it  Itv  winter,  be  muxt  be  plitced  in  u  rouni  that  is  well  warmer!  day 
n4&>f[ttt  The  diet  fur  the  lir»t  lew  days  should  be  simple,  but  abumlant, 
nontB^  chiefly  of  outritiouK  stops, 

tkcircBBiuics  must  not  be  disturlwd  fur  three  days;  by  this  time,  if  all 
P>  »fJl,  tbo  flap  will  be  fitund  mimewhnt  tumid,  warm,  and  acn^itive,  but 
!■>)•  ia  i»l(ir.    The  pliigin  lhemi»e 


*ul  Mw  require  chancing,  lest  it 

*  nndcred  uHennive    by  the  dis- 

^)pa;hi«t(hdrHwnland  Ihesub- 

'(''(iliin  of  anniher  muat  be  dooe 

*'(b  the  greatest   gentleneM,  the 

^'^pmt  bMrin^  In  mind  that  any 

**■>«•  pmnirc  or  traction  may  d^ 

"^y  adhesions,  and  prove  fatal  to 

^  ritality  nf  the  Hap.     If  the 

^Utm  prnduofi  no  irritation,  they 

^J  b»  left  in  till  tho  fifth  or  rixttl 

^T.  by  which  time  adhesion  will 

w>  ..i-.,i,'.    -...rfect.  aud  they  may 

cut  and  withilrawo. 


4 


A_ 


plrvn^'thena  and  the 


Fif.    MS.  — If-       Fl(.  evi.— X««  MofO.  4mf 
fnm»i  KoM-  aAtr  OfHStlaa. 

T>t«nty  of  the  flap  ioipruvee,  it  must 
"•  •Je«al«l  by  puitinj:  uNdemeath  it  a  larger  plujf  of  tint ;  for  whieb.  after 
*  «i«ie.  mat  be  miUliiuted  a  small  gulta-i»ercha  tube  inoHlde*!  to  tlie  figure 
^  the  tiutde  of  the  nose.  (Kdeina  of  a  «umeivhfit  ftoHd  character  is  apt  to 
ua  ID  tbe  flap,  givin}*  it  a  white  api>earance  ;  but  Lhi»  'i»  of  little 
■nt,  and  will  gradually  subside  as  the  circnlalion  thrnufrh  it  I>ec<kmea 
aclitely  catabliuhe*!.'  The  flap  jtradually  becomes  thicker  and  firmer, 
ling  i^utVrBniilaliona  from  its  under  surfac-.  which  eveulually  b*x-<)mea 
••**«l»d  by  epiiheJium.  The  wound  on  the  fureheaii  nnwt  lie  drei»ed  like  an 
**4iufy  ulcex,  and  be  well  touched  with  nitrate  of  silver  fr*>m  time  to  time, 
*«»  i«Rire  it*  ixnlrsrtioii.  It  URnally  cicatrix's  with  great  rewliDcM,  and 
^••»ei  r»marknhly  litllt;  deformitv. 

—  IspumtioD  of  the  Eoot  of  the  Flap.— Tbii>  may  be  done  about  a  nionlb 
*''«tbe  flap  ha*  ben-n  fai^hioned.  when  its  vaBCuhiriiy,  through  U*  lateral 
^'I'^Ajim.  «dl  !»  perfwlcd.     The  liirfcion  of  the  nwl  ia  best  done  by  paas- 
'"Ra  ■arn.W'bladed  hiMoury  under  the  twUt,  aud  cutting  upwards  towanb 
^  ejrvliniwii.  '  ■  u  wwlge-ahapod  portion  uf  the  soft  {mriB,  su  aa  to 

■■^easiDooil.  I     ^*r  bridge. 


602 


I'LASTIO   STTROKBT    OF   THE    FAOK    AND   MOUTH. 


:t.  Formation  of  the  Colamna  Nasi. — Tht>  aiKiition  of  th«  cnlumoa  U 
Duw  hII  ihal  i^  waiiLe'l  to  niuke  tli'^  tit'sv  complete.  Tbis  must  be  mndti  frutn 
th«  upper  lip,  pcrlmps  at  the  same  time  wh«ii  the  bridge  is  fashttnie*) ;  anil 
it  niHj  be  cut  attd  fixed  in  the  way  that  has  be^ii- already  described  io  epeak- 
iug  of  the  re«toralioD  of  this  feature,  the  interior  of  the  apex  of  the  new 
ooee  having  been  well  pared  to  receii-e  it.  The  cnlumna  muat  be  well  sup- 
ported by  meaiu  of  a  narrow  atrip  of  plaeter  pawing  from  one  cheek  io  the 
other, and  usually  requires  a  goud  deal  of  fashioning  before  it  ia  perfect;  in- 
deed, this  18  the  part  of  the  o|KT(ition  that  I  have  found  always  luost  trou- 
blesome, and  requiring  niust:  Attention. 

The  new  nose  must  (roniiuuu  to  be  supported  from  beneath,  for  Bome 
monthe  after  itK  lurmatioii.  by  pluf^  of  lint  or  small  gutta-jiercha  tubes,  as  it 
will  evince  a  ji^reat  ttindvncv  to  uimtrsct  and  to  alter  in  its  general  outline 
and  shape;  becomiu^,  if  tliu  Sur^i-ou  bo  not  cnrefiil,  either  depressed  or 
dumpy.  The  gotmitiiliiy  of  thi;  new  no»ii  is  entirely  dci'troved  for  a  ti toe 
alier  (he  divisiim  of  thu  hridj^c ;  but  il  slowly  returns  from  nil  8ide8,appear- 
ing  first  in  the  neighborhood  of  the  tt<ih«?^ion8  bttween  it  nod  the  cnoeks. 
then  near  the  columna,  next  in  the  bridge,  and  thus  the  or|;an  nt  lost  has  its 
sensntion  restored;  for  tliia,  however,  several  months  will  usually  be  re- 
quin>d.  and  the  part  in  whirh  it  returns  lost  of  all  is  its  central  portiou. 

The  annexed  outs  (Pigs.  695,696)  give  a  very  fuithful  rcpreeentAtion  of  a 


^ 


^ 


M/l 


Fif.  IBA. — P«li«Dt  b«ton  Hhinopt«aiio 
O]i«r»lloii. 


Fig,  tM. — Saqiv  PhUmiI  tuin*  biobUm 
•rtar  Opualloti, 


patient  on  whom  I  operated,  before  and  after  the  reetoratiim  of  the  lost 
uri^n. 

The  Biict-eas  of  the  case  will  depeuJ  very  greatly  up<>n  tb«  minute  atten- 
tion which  the  Surgeon  hcstown  on  the  detaiU  «f  the  uperatinu.  and  «u  the 
care  which  be  tuke«  in  the  afttT-trcntment.  During  the  oi^rratiou,  the  chief 
pointJj  to  be  attended  to  arc,  that  the  Hap  be  mude  of  euflicient  size,  that  ull 
oozing  has  censed  before  the  cut  edges  are  brought  iuU^>  cuutact,  and  that 
no  tenKiim  or  constriction  be  excroiiied.  A  principal  source  uf  failure  in 
the  operation,  or  in  the  result  so  far  as  concerns  the  afUr-ap|>earaDce  of  the 
patient,  is  gangrene  n(  the  flap,  in  whole  nr  iu  jmrt,  arising  from  the  rm>t 
beinjr  tnn  narrow  or  loo  lightly  twisted,  or  from  the  flap  being  too  rougbiy 
handled  in  its  dissection.  So  also,  if  it  be  cut  too  email  and  not  properly 
Biipportcd  a.Vrwords,  the  result  will  not  be  very  satisfactory.    Other  acct- 


riBTULOVa   OPENINGS  TOROUOH    TBX    IC19AI.    BONES.      60S 


Aatooeouionnlly  hoppra ;  iluis,  erysipelas  mav  occur  early,  deetnijinf;  ih« 

tilility  of  the  flap,  nr  ounip  on  at  a  Inler  perinii,  nuipinp;  ihf  iifw  tuiw  to 

rinjlfa  ODdrr  the  Bturk  i»r  itiflnrnmntion,  wnirti  it  ha»  not  FiiHiricnl  vilnlily 

kmbt,  u  banpciieH  in  one  of  Linton's  enrlicr  cnses;  or  the  n<ev  mute  may 

W  drrtroyf^I  ny  «  rrlurn  uf  the  liiptw  Htiii-lt  pro%'cd  (icalructive  to  the  old 

ix».    HpRHirrhaj^v  *iiKt  muy  oci'iir  from  un<)ernt-Hlh  tlio  ttn}>.     In  tbe  ln»t 

at»  of^nled  <iD  by  Lislon  iu»t  bi^furc  hi»  <)out)i.  nud  mIiicIi  was  complfted 

W  Mttrtun  at  Vntvcr>ity  dllcge  I!(i*t>ital,  lipnmrrh«(,'C  to  tlie  extt-ut  i^f  more 

'^"  1  (tint  look  pl»«'  «m  the  ulnth  diiy.  witbout  any  evident  caufto,  from 

'■  flap,  and  could  hv  arr^eled  only  by  ptugfjiti};.     Fiirlher,  tb«r  op*r»- 

I  <-t  williout  tin  danger*.     DieflenbHclt  luet  two  pativnls  out  of  six  on 

>  o|ieruted  in  Par'w,  their  ounBtituiiuUB  laving  probably  beco  io  an 

Uf-     r  /  ■-■  ^ta^e. 

1  !  lion  IIP  ju8l  dcitribed  will  usually  be  utieuded  by  very  sHUAfac- 

im  fuuiL-.     Of  late  yt-ur*  Boiiie  mudificaliona  bave  l>Lf  u  inln^diiced  into  it. 

TbuUinjftnbetk  recuiumends  (hat  the  periosleiim  fihuuld  be  cliwecled  up 

fritu  tbe  fpiutal  buD«  together  with  the  skin-flnp,  iu  order  that,  by  the  sfler- 

<ln''!"-iinfTil  'if  MAtrous  tMsue,  n  firmer  and  belter  orgao  should  be  leA.     It 

^'  riii  by  iM>me  Surgeouf  that  exposure  of  the  CroDlal  bone,  by 

•■' ,,    _         !t«  [>eriisteum,  would  probably  tw  followed  by  necniBbt.     Ex- 

Pt^nn  has,  however,  shovn  that  thb  frar  is  groundlesg,  is,  indeed,  might 

MVtbecD  fnfffrrrd  from  analogoua  pondilions  oiXen  obeerrcd  io  injurieg  of 

^  btad,  in  which  large  portions  of  the  perirrsnium  may  be  detnchett  with- 

*""  tbe  ezpnued  hone  l<«ing  it«  vitality.     But  it  appears  to  me  that  there  are 

■'^  wriiiUK  objcciicns  to  "  Ojtoo-rhinoplaBty,"  and  that  it  is  an  unnecea- 

*T  nwnplicaiinn  of  tbe  opcrraliiiu  to  turn  down  the  pericranium  iu  the  nasal 

5*P,  tilt  two  n-anons.     FJret.  the  perieranium  is  very  firmly  attached  to  the 

?***,  attd  Very  Im»fly  to  tbt  intrfi;u mental  »truriurea,  which  glide  over  iL 

'^»tB  the  lu-rif  it  i»  ii»L  drt»(-hr<l  without  ditticulty  and  a  certain  amount  of 

'p'A'  'Oiich  iu  vitality  is  likely  to  be  tnipnired  to  Ao  (rreal  a  degree 

^^i  '.  be  of  no  oervire  at  a  fWne-prtMluciug  orf,;an  iu  the  i»ew  noae, 

''^  Mirultl  Dot  impn>!>ably,  when  twi^teil  diiwn.  »liiU);h  I'mni  inftufBcient  vas- 

f*U»f  ••[.ply,     S,■^^.lldly.  even  if  the  pericranial  liuiuy  of  the  new  niwe  mere 

^  rvtaio  its  booe>prttducing  p»wer,  it  •eenut  to  me  titat  an  oaMoiit  layer  inside 

*^*t  urfmn  would  rather  bo  a  diMtdvantage  tbnn  of  »er>'ice,  and  would  cer- 

^«iIt  expuas  it  to  greater  riik  of  fracture  and  other  injury  than  if  such 

"*^uie  material  aa  a  thin  aliell  of  bona  did  not  enter  into  its  compoeitioD. 

Tht  optraliou  prat-tiaed  by  Oilier  appears  to  me  to  be  Icm  nappy  tbin 
^<^«y  of  that  execUent  Hurgeou'e  eugfiestions.  It  consiits  in  cutting  donn 
'^%  Mual  procets  of  the  lufierior  luaxilla,  and  then  beodiug  it  acroee  so  as 
J**  tanm  ■  kind  uf  bridge,  on  which  Iu  sustain  the  tegu men K^ pericranial 
'^Lp  deflerte^l  from  thu  fort-head,  lint  by  doing  this  the  lateral  i>u|))>iirl«  to 
***■  hridse  of  llie  new  nuee  arc  removed,  oud  nccnwts  of  tbe  bent  ur  rather 
*«xiImb  ingmcnt  of  bone,  which  has  actually  occurrctl,  is  nut  an  unlikely 

ShcHikl  tlia  opentinn  fail,  or  if  from  any  reason  it  Is  not  advisabltt  to 
■VtfllifC  it,  tbe  palirnl  may  hr  liLtcd  with  n  painti'd  vuli-nntie  nose,  attached 
^■^  yiifiiJaa,  by  whlrh  the  delurmity  Ih  xtu»t  iffirienily  ronn^aled. 

'VmtiC'O  Oi'KKiNtui  TiMioiiiin  TilK  Nahai.  H<»ii>  leading  into  the  In- 
I^VKritf  the  uiMtril*  arr  occmttotmlly  tiii-t  wiOi.  ^ucb  a{terture«  as  these  are, 
p^ilwin.  bi-st  cliMtl  by  (laring  the  ed^es,  and  then  bringing  forwanl  a  Bap 
**'*  xiitbboring  piktn  tty  ihr  gli'litg  oiHrmiion.  In  attme  rate*  of  tbin  kinil, 
P'l^afw  luay  br  rr«|uire»l,  in  which  Uie  Surgeon  may  ditplay  much  in- 
S**««itT  an«l  Iwntrfit  bis  |wttpnL  grmtiy.  Tbe  cuts  represent  a  oa»p  many 
T^^n  «Dre  under  my  care,  lirfore  and  the  day  after  operation,  in  which  t 


i 


S04 


PLASTIO   BURQERY    OP    TUG    TACVi    AND    UOCTU. 


Urge  aperture  into  the  siile  of  the  m»c,  rcsultiuj,'  from  aecrout  of  ihe  U 
■laial  bone  consequent  on  scarlatinu  (Fik-  C^T).  whs  «uccenfully  clwed  br  a 
flap  of  skin  taken  from  the  forelifad  by  tlic  twUtiiif;  jimcccB  (Pig.  698^  The 
patieol,  who  was  a  child  at  the  lime  ut*  Ihc  operation,  has  eiucc  grown  into  a 
comely  woman,  presenting  Bcaroely  a  trace  uf  the  operation. 


^ 


Fig.  697. — Ofolag  I  nta  Acil«rl4t  }f«rM. 


Flj.  OT«— Opening  l«tn  Aniociw 


OpERATlo.v  FOR  Depreaard  Xose. — Sometime*  the  nose  is  depressed  and 
flattened  in  conwffuencfi  of  iKe  toss  of  tin;  t'Brlil«^'*'R,  vomer,  and  Bepium, 
though  chc  external  (mrti  reniniii  viitire.  Uietfenbacli  han  propnced  a  plan  for 
raising  it  by  «litlin){  it  loii^itiniinslly  iato  thrw  piffcen;  fliKM^<'tinf!  the  Intoral 
slips  from  the  o^Kenus  attachriMfnls ;  paring  the  vAg^i  to  sucli  an  extent  tbnt 
they  overlap,  and  ^litchiii);  thi^in  together;  then  brinj^ing  the  whole  organ 
forwards  hy  pushing  lont;  hartdip  piiisi  across  iUi  bnse,  m  na  to  etcvat«  and 
narrt>w  it*  attachments,  willed  are  brought  rnorv  into  the  mesial  line.  For* 
gusaon  has  inipruv«il  tliia  proci-dure  Ijy  not  siitlint;  the  no»e  down,  hut  dia* 
Bccting  it  away  fnnii  the  bouw  from  within  the  uiwstril.anrl  then  pushing  long 
steel -pointed  oilver  needles  ncrosa  from  olieek  l*)  chvek,  and  twiAting  their 
ends  over  perforatcil  piews  of  sole-leather,  through  which  they  had  pre- 
Tiimaly  been  passed,  itius  lirint^ing  the  wh>>te  organ  bodily  forwards.  The 
columna  is  next  t'ushiuned  in  (hu  way  which  hns  already  been  dcawribed  ;  and 
the  noae  is  completed. 


PLAOTIC  SVBOXRT  OP  THE  LIPS. 


•wHakklip. — By  harelip  is  meant  a  congenital  pcrfwudiciilnr  liastire  or 
ntaires  ihrough  the  upix^r  !ip,  the  rewilt  of  an  arre:!t  of  development. 
Wilhoui  going  into  the  details  of  the  devehipm^'nt  of  the  face,  the  mode  of 
origin  of  harelip,  clefl  palate,  nnd  coogetiitAl  irnmiverde  hasure  of  Ihe  cheek?, 
or  macros loma,  mav  be  made  clear  hy  recalling  the  main  features  of  the  pro- 
cess. Tbo  fai-e  is  develofied  parity  from  a  ceiitni!  process,  the  fronlo-nnaal 
plato,  descending  from  tlie  iVotit  of  the  cmnluTu  between  tlie  ocular  vesicles. 
From  this  are  developed  Ihe  promiutfuL  |uirl  of  the  noti«,  the  aeptum  nasi,  the 
Columna,  Uie  central  part  of  the  iipi>cr  lip.  und  the  intermaxillary"  bone  witii 
the  incisor  teeth.    The  remainder  of  the  faw  above  the  line  of  the  itiwer  jaw 


I 


d 


HARELIP. 


605 


iideTd<^ed  from  a  lateral  procesi  on  each  side,  the  Buperior  maxillary  plate, 
Mcb  giiuJaally  grows  forwards  till  it  coalesceB  with  the  vertical  process  just 
atBtiwed.  From  these  processes  are  developed  the  cheeks  aud  ttie  whole  of 
lb  nperior  maxillary  booe,  except  the  part  of  the  palate  corresponding  to 
dtt  indaur  teeth,  which,  ae  already  stated,  is  formed  from  the  frooto-Dasal 
plate.  The  lower  jaw,  and  the  soft  parts  covering  it,  are  formed  from  similar 
proeasee,  the  inferior  maxillary  plates  advaacing  from  each  side  and  coalesc- 
■|in  the  middle  line.  The  superior  and  inferior  maxillary  plates  coalesce 
uetch  aide,  leaving  the  open  space  of  the  mouth  in  the  middle  line.  The 
lim  in  which  these  various  processes  unite  are  roughly  indicated  in  the  dia- 

Cn  on  p.  938,  vol.  '%.  The  mode  of  origin  of  the  various  deforniities  of  the 
!  it,  therefore,  evidenL  If  one  maxillary  plate  fails  to  unite  with  thenaso- 
ftoatal  in  front,  a  cleft  will  be  left  through  the  upper  lip  on  one  side  of  the 
aiddle  line,  forming  a  single  harelip.  If  both  plates  fail  to  unite  a  double 
knlip  results,  and  the  intermaxillary  bone  may  be  left  adherent  to  the  tip 
«f  the  Dose  and  septum  nasi.  If  at  the  same  time  the  development  of  the 
BHO-froDtal  process  is  arrested,  we  get  the  rare  condition  of  a  wide  gap  in 
the  middle  line  with  absence  of  the  incisor  portion  of  the  superior  maxilla. 
If  the  anterior  parts  unite,  but  development  is  arrested  posteriorly,  cleft 


■^ 


FIf .  «»,— Single  Hnrcli)). 


Fl|.  ;00.— OrdiDkr;  Double 
Haralip. 


Fif.  TOl.— OrdiD&r;  Doable 
Harelip.    6ide  View. 


P>Ute  results,  the  fissure  being  single,  and  in  the  middle  line  as  far  as  the 
PWtrior  part  of  the  premaxillary  bone.  If  the  arrest  of  development 
■more  complete,  the  fissure  may  e.\tend  to  the  lip,  deviating  in  front  from 
"*  middle  line  aa  it  pa9i>es  between  the  main  part  of  the  sujwrior  maxillary 
fW  the  premaxillary  bone.  If  both  sides  fiiil  to  unite  completely,  the  fissure 
"ttQgle  behiad  and  double  in  fnmt,  passing  on  each  side  of  the  intermnxil 
^Tbone.  In  exceedingly  rare  cases  the  fissure  of  the  harelip  has  been 
"•"extending  upwards  on  one  si'le  of  tht;  niwte  townnis  the  eye.  Maurostoma 
^Congenital  transverse  fissure  of  the  checks  rcsntts  from  arrested  union  of 
"•Wjieriur  and  inferior  lonxillary  |)lates. 

'•■ito  Harelip  is  by  far  llie  most  common  deformity  (Tig.  fl99).     In  it 
^■Bciial  side  of  the  gap  is  usually  rounded ;  the  outer  edge  is  flattened ; 


606 


FLASTIC   SURGKEtr    OF   TQK    FACE    AND    UOUTU. 


ftnd  Lhe  frwiitim  at  the  an^te  is  lou^  finti  subcutftiieoiift.  It  moKt  fn^quently, 
■o  far  tt»  I  ImvH  oii»erve<),  occun  up^m  the  Ull  Hide.  Whtfii  double  (Fi^.  700, 
701),  the  f»»ure  in  ufWu  <let;p«r  ou  oue  aidt'  thuii  wu  the  oilier,  nml  usually 
exteuda  itttii  the  u(i«lrtl,  aiid  is  Ksaociiit«d  with  cleft  |>ul»te;  thuugh  ^niie* 
timefl  it  aUipe  »hort  of  thi«.  In  Lbeae  CMJten  the  nw«  is  usimlly  flutt«tie(i  antl 
expnaded,  aod  beln-eeu  the  lissuns  there  is  ulwair's  a  ceuLrat  or  median 
lobule,  coiisLsting  <if  the  iuterniaxillnry  bunes  io  o  rutlitneutary  coaiiiliuu; 
to  tliid  a  triun]fi]lar  labial  noijuie  is  commoolr  attached.  In  many  cases  thia 
is  pushed  forwardo,  oud  tttted  on  its  baae,  su  that  the  alveolar  border  prnjecta 
furwnrds.  SDiuetimea  the  projection  is  wt  oonsiilerable  tbat  it  Ls  attached  to 
the  tip  of  the  iiose. 

Median  fisson  is  bo  rare  that  there  are  scarcely  any  authentic  cases  of  it 
in  the  records  uf  surgery.  Delahaye,  however,  menliona  one  instance  at* 
mesial  fissure  of  the  upper  Up  with  two  lateral  fissures,  and  Nicati  has 
dMcribed  one  id  the  lower  lip,  the  only  case  of  the  kind  that  I  have  met 
with  oa  record. 

The  tissurc,  when  single,  may  be  confined  to  the  lip;  but  in  the  majority 
of  oa^c*  il  extends  to  the  alveolus  of  the  upper  jaw.  Kiving  rise  to  a  deep 
notch  between  the  outer  incisor  and  the  caulue  tooth.  When  it  i«  double,  the 
four  incisors,  usually  ioiperfeclly  and  irreeulurly  deveJoped,  are  included  in 
the  central  intcrniaxilhiry  tubercle.  Meckel  and  Nieaii  have  described  a 
rare  form  of  hiircUp,  iu  which  ihe  fissure  corri'aponds  to  the  line  of  junction 
between  the  central  acid  lateral  iucisor*.  In  many  casei  ihe  fissure  extends 
back  into  the  palate;  this  more  frequently  happens 
when  the  harelip  ia  double,  and  in  thcec  cases 
every  variety  of  pahitAl  deformity  is  met  with 
(Fig.  702  L 

Age  for  Operation. — The  cure  of  harelip  can  be 
eHecied  only  by  a  properly  conducted  operation. 
In  the  |>err>jrm»nce  of  lhi!<,  the  tirst  point  that  bat 
to  be  deleriiiined  is  the  »g«  at  which  it  should  be 
done.  Ou  this  there  Ims  l)een,  and  is  still,  a  >;ikk1 
deni  of  didrreiice  of  opiuioii.  Suryeous  neiien»lly 
are,  huwever,  I  think,  agreed  that  k  ie  better  not  to 
perform  the  uiKTatioii  during'  dentition;  at  all 
cveuts  tiut  during  the  cuttiug  of  the  incisor  teeth, 
whL-n  there  is  mucb  local  excileiiieut  and  general 
irritability  uf  the  nervoua  avBleni;  but  they  are 
not  agreed  uj^  tu  whether  it  suouhl  Ik-  done  Dcfore 
or  after  dentition.  In  support  of  the  opinion  that  it  is  mure  prudent  to  wait 
until  after  tliis  |M?riod,  it  is  alleged  that  very  young  iiifiinis  are  e«pccinlly 
liable  to  convulsions;  that  the  performance  of  rip^ralioiipon  them  is  trouble- 
some; Hud  that  it  interferes  with  suckling.  These  statements,  however,  are 
not  supporied  by  what  we  meet  with  iu  practice.  There  is  no  evidence 
to  sh'jw  that  there  is  any  danger  in  upeniting  during  early  infancy:  ou  ibe 
contrary,  very  young  children,  ihnse  but  a  few  weeks  or  months  old.  bear 
operations  remarkably  well.  I  have  refwatetlly  operateil  at  these  tender 
agw,  not  only  (or  harelip,  hut  fur  hernia,  the  removal  of  tumors  and  nievi, 
tue  division  of  tendons,  etc.,  and  Imve  never  seen  any  Iwd  result  follow. 
Btisidoj  this,  the  performance  of  the  operation  Is  easier  at  a  very  early  age 
than  when  the  chihl  haa  reached  il»  first  or  second  year;  when,  ita  intelli- 
gence being  more  developed,  it  know^  u-hat  it  has  to  suffer,  and  screams  and 
fltntggtes  more  than  a  very  young  infant  doea,  whenever  it  sees  the  Surgeon, 
or  when  he  makes  an  attempt  in  examine  the  witund  or  dresaings>.  AAer 
the  operation,  also,  the  child  will,  when  young,  take  to  the  breast  without 
difficulty  and  with  the  greAtest  avidity.    The  act  of  suction  is  advantageous. 


Pig.  70S.-.- 


J  n<K  in 


Donbk  Harvlip,  Mil  Ctaft 
PklkU. 


OPERATION    rOR    IIARELII'. 


607 


•■  ia  U  the  eiflca  uf  itie  iacUioa  nte  more  cluwly  comprencd  aad  brought 

together.     At  wry  drlv  ngva,  udiou  uI'  ttic  wuund  takev  plac«  niib  great 

RMdtocM  au')  »t.>ii(litv  :  nud,  as  iiu  tiine  has  bit-u  given  fur  ifae  rtst  of  the 

tcKluraa  lu  bvciituc  dielurud,  Llit^rc  will  uut  b«  lliat  pfrniaDcnl  tindfiiiiig  uud 

ilclumiil,v  of  ibtf  fan  v;liicli  U  ajit  to  conlinue  after  the  bnrelip  t»  curvd,  if 

dba  opcratinu  bt  lieferrvdio  a  rtiurv  a«lvHiired  age.    Furthme  vnrioUH  rvaMUia 

I  Bgive  with  Duboiv,  KerguseuD,  and  Biilrlier,  that  the  <]|>eration  had  beet 

W  perfortned  esirly ;  ifptjwible,  at  abtiut  the  sixth  week  after  birth,  or  frora 

ikn  lo  (he  ibircl  motilb.  which   may.  1  thitik,  l>«  cnaeidered  the  time  of 

d«eth«B  lor  ihiu  pntcediire.     Al  (his  time  the  vilalily  of  the  child  i«  good, 

wA.  the  tisBOPa  are  not  m  lacerable  a»  nt  an  earlier  age.     The  operation  may 

■Ur  be  perfi)rine<l  at  a  much  earlier  period  in  single  than   in  double 

Wraip;  and  ibe  grealt;r  the  deformity,  the  more  marked  the  intrrtnaxillary 

p«jtrti;>u,  the  wiM-r  will  it  be  to  deler  operation,  which  not  ooly  bcciimec 

botajiogly  aevere  with  the  extent  of  the  deformity,  but  after  I  he  pc-rfomi- 

wm  (if  which  the  traction  on  the  pina  beoontea  too  great  for  the  tender 

Ibarsto  aiutaio.     Should  circunislancea  require  i I,  however,  th<;  operation 

>i|;lit  be  duoe  at  a  much  earlier  period  than  that  advised  above.     Thnu,  at 

li*  urjTot  •ulicitaii.jiio  of  the  parcnta,  I  have  pirtormtd  it  within  the  firtt 

ItfntT.fltur  boum  alter  birth,  and  several  time»  during  the  first  week.     But 

tf  tli>M  Terr  earlv  dajra  of  life  the  o{«ration  is  not  without  danger;  th« 

'itlity  nf  the  child  is  oflen  feeble,  it  suffers  greatly  from  the  loss  of  even  a 

***;  foimll  tjuanlitv  of  blood,  and  the  tiwuee  are  su  lacenible  that  tliera  b. 

P**t  dangvr  of  ikc  pins  or  stitches  cutting  out.    X  would,  iberefon^  doc 

*^*in  ita  performance  then. 

.  't  is  KBTcvly  necestsrv  tr>  observe  that,  as  uuion  by  the  firat  intention  is 
***»«]  mt,  the  uperalion  should  not  be  undertaken  unless  the  health  beguod; 
''^  ccnainly  nul  if  the  child,  at  whatever  a^e.  have  but  recently  recovered 
*^^  lofmiik-fl,  ^cHrlei  fever,  or  other  infantile  disease. 

Operfttion  for  H&relip. — lu  the  treulment  of  hnrelip,  ihc-rc  are  three  main 
Jpi«|js  lu  bf  kvpt  in  view:  1.  The  procuring  of  Unii^n  by  Firet  Inttniion  of 
'^*  CBt  tdem  of  ilie  Fieeure:  2.  Ihe  Preveniion,  as  far  as  jKieeible,  of  Ue- 
">*viky  during  the  iirucece  of  Uniou  ;  and,3.  The  Avoidance  of  all  Traction 
"**  the  line  of  iuciMoo  dial  may  interfere  with  ihc«e  remlu. 

Tbcae  priuciplt-a  of  iM-atnieni  are  carried  out  by  paring  the  edge*  of  the 
■^urc  freely,  liriugiug  them  Hither  by  means  of  the  twisted  or  interrupted 
'uture.atKi  uking  off  all  tension  by  meani  of  strips  of  plaster  and  the  cheek- 
^uiiipr«««ir.  The  American  "rubber-plaster"  will  he  found  invnlimble. 
&ui  thf.  detaiU  of  the  treatment  vary  so  much,  according  as  ihe  liDsure  is 
Ma^lc  or  ilouble,  or  cnnipticAtcd  by  more  or  less  projection  of  the  inter- 
■mj.Ularir  purtioo.  that  the  steps  of  each  operation  require  to  he  Mparntely 

Sift^  Hknlip. — The  operation  for  tingle  harelip  is  performed  in  the 
KlUa«iug  WRV.  The  child  having  been  well  pinned  in  u  jttck-towel  that 
*^>'MIm»  it  tightly,  the  Burgeon,  silling  down,  placeK  his  feet  on  a  Rt<M>l  so  as 
tck  raJM  thrni ;  and.  cov<:-riug  his  kneea  witli  apiece  of  mackinlosh  cloth, 
tMkJdi  the  child's  bvnd  firiuly  between  them.  Bleeding  from  the  coronary 
■**fj  of  (h«  lip  may  be  prvvente<l  (Fig.  703),  either  by  an  anistant  or  the 
^*U|Me  gnspiag  ihe  lip  between  his  forefinger  and  thumb,  or  by  comprrss- 
*^tln  lipwiUi  tne  tittle  contrivance  here  figured,  which  consists  of  ordinary 
'^*V*rori'epa  cooverlefl  ititu  n  comprceaor  by  having  a  vulcanized  India- 
'v^Wr  ring  slipped  over  lite  hnndtts.  This  will  be  found  lo  be  invaluable  in 
'?**'>^  opermtious  about  the  face  and  juws.  Tlie  lower  this  ring  is  drawn 
r***!!.  lite  tiglitfr  will  the  forceps  grip.  The  Surgeon  find  freely  diviilee  the 
^^lum  and  all  meinbrauous  cuumxLtuna  between  the  angle  uf  ihe  clefi  and 


608 


PtASTIC   SCTROERV    OF   TUB    PACE    AKD   UOVtU. 


th«  gam  of  tho  upper  jaw,  and  then,  pultlng  the  lip  on  the  stretch  bv  acizing 
the  extreme  edge  of  (he  clel'i  with  a  pair  of  artery-forceps  or  a  tcDacutum,  ho 
pares  the  edges  of  the  clel^  by  transnxion  with  a  narrow-blufied  bistoury,  or 
fine  sealpe),  frum  above  downwards,  first  on  one  aide, 
.  \  ,  then  on  the  other;  takinir  care  that  the  incisions  unite 
f-  "-\^*\  neatly  and  cleanly  above  (he  iipiter  angle  of  the  liMiure, 
I  ^    *  which  nutst  be  well  cut  out ;  am)  that  (hey  extend  suffi- 

ciently far  outwards  to  ctit  away  the  rounded  portion  nf 
the  prolabium  which  fortii»>  the  side  of  (he  baae  of  the 
fifsure.  The  incision  on  each  aide  luust  be  curved  %vith 
the  concavity  (nwardn  the  fissure  (Fig.  708),  to  (hat  by 
bringing  (he  two  curves  into  a  stmi^ht  line  a  ilighl  pro- 
jection of  the  nrolnbiunn  at  the  point  uf  union  flhnll  be 
produced.  If  this  be  not  dune,  a  notch  will  be  lell  whea 
the  lip  is  healed.  Carie  should  be  taken  thai  enough  i* 
cut  away;  there  ia  more  danger  usually  of  taking  too 
little  than  too  much. 

Fine  harelip  pins,  made  uf  soA.  iron  wire,  with  hardeued 
pniDia,  should  then  bf  deeply  inlri>diired  through  tho  lip 
(mm  one  side  of  the  tiaiurk-  to  the  ortier.  Th^  pina  ehoulvl 
be  entertid  a(  about  a  qunrtKr  nf  an  inch  from  the  pared 
edge  on  one  aide,  aiifl  brought  out  at  acorrtvpindiiig  point 
on  the  other;  curu  b^intr  taken  that. though  tney  are  imseed 
deeply,  the  niu<-uue  membrane  is  not  transfixed  ;  if  it  be, 
it  will  be  dmibk'd  into  the  woTind.and  (huH  inberfere  with 
nnion.     Two  pine  are  nsnaily  inquired  ;  If  the  child  he 

e  yeare  old,  and  the  tiwiure  very  long,  three  may  be  used.     The  lower  pin 

KJiould  be  iatroduced  first  underneath  or  ihrotigh  the  cut  coronary  mrtery,  in 
Buch  A  way  that  its  pressure  may  stop  the  bleeding  from  this  voMcl,  which  is 
often  rather  free.  In  passing  this  pin,  great  care  should  be  taken  to  bring 
the  opposite  sides  of  the  figure  well  into  contact,  ao  as  (o  be  on  a  level  below, 
(hat  no  irregularity  may  be  left  in  the  prolabium.  The  iwtsted  suture  is  then 
apptieil  in  the  usual  way  I  Fig.  70-1),  first  round  the  lower  pin,  and  then  round 
tb«  upper  one  i»epara(c  thread?,  however,  being  used  for  each);  and,  lastly. 


Ftg.  ;0.t.  —  Bl>»tie 
Ci»apr«Morapplit<l 
•T«r  Coreasry  Ar- 
•rj. 


Plf.;*f,— AppliMtion  ofTwUtad  Sutar«. 


Vig.  Tlf5.— AppIloaiiM  ol  i'lni 
■nd  Suiurw  la  lUrtllp. 


the  two  are  tiniterl  by  a  few  cniss-turns,  m  as  to  press  down  and  support  ihe 
whole  length  of  the  fiasure  H-'ig.  105).  In  anplyiitK  (he  twi8te<l  stuture.  the 
Surgeon  nuiBt  be  careful,  whilst  drawin^lhi'  ediictp  diwely  into  apposition,  not 
to  apply  the  threo'ls  t"o  tightly,  le^t  alondshin^'-  result;  and  in  crnesing  them 
fn>ni  one  pin  to  the  olber,  great  caution  most  \w  used  not  to  draw  the  two 
pins  togelher  horizontally,  lest  puckering  of  ihc  line  of  union  lake  place. 
The  pins  are  then  cut  short,  (be  whole  is  coated  with  u  layer  of  collixiiou, 
and  a  piece  of  plaster  is  put  under  the  ends  of  the  pins  to  prevent  exroria- 
tinn  ot  the  skin.  In  addition  to  the  pins  and  twisted  suture,  I  invariably 
introduce  one  iminl  of  interrupted  suture  through  the  inucmis  membrane  ol* 
the  lower  part  of  the  fiiiuro,  just  ioaide  the  mouth;  nud  I  look  opou  this  a>i 


OPEBATION    rOR   BABSLIP. 

importance  in  preventing  th«  notching,  which  is  otherwise  very  apt 
r,  iti  c>inse(|U«iice  uf  that  portion  of  the  Jnci^iou  between  the  lower 
iwd  thv  e<lge  of  the  lip  tM.'iii);  kvpt  open  by  the  child  iu  eucking,  or  »n>- 
niinK  its  t^jnguo  Hgain^t  )L  At  the  c^nd  of  from  7*2  to  Oti  hourv,  Hccoruiue 
iih*-  agv  iif  the  child,  the  piu  should  hv  withdriiMn,  or  it  may  b«  runiovea 
b*  k  Ei-utli-  mtnlory  niovemeiH,  in  ituch  «  wsy  thiil  the  cut  end  di»eii  ur^t 
Vw'ir  lui.-i?nit>;  the  aperlure  in  the  lip.  The  thrvJitU,  iuuLte<l  together  with 
Mmifttinn  and  n  little  blood,  ff^riii  »  pmd  crust,  which  may  l>e  left  on  Cor 
U"  IT  thre«  days  longer,  and  then  allowed  to  separate  of  iteelf ;  tlie  lew  auy 
entUlhat  form  over  the  line  of  incision  are  interfered  with,  the  better  will 
tbiiwult  nnially  be.  The  lip  may,  if  thought  desirable.  l»e  eupporte<l  by  a 
Americnn  rubber  or  other  ndhe&ivc  planter,  which  should,  indeed, 
lued  for  about  a  fortnight  afu-r  the  operation,  so  ns  to  prevent 
.--„  of  the  cicatrix  and  notching  of  its  tower  part.  The  point  of 
BpHd  mture  may  be  left  in  for  nbout  four  days.  It  sometimes,  though 
nnrir, happciu  in  single  harelip  that  the  inlcrmRxillurv  portion  b  so  large 
ud  projecting,  that  there  ia  difficulty  in  bringing  the  lateral  segments 
ttpner  aver  it.  Should  thia  be  the  case,  the  better  plan  ie  to  notch  it  at  its 
klrenlar  border  on  the  side  that  is  not  flaeured.  and  then  Co  break  it  back  fw 
utomnove  all  projection.  If  the  fiHurc  be  wide,  and  the  child  re^tleee,  bo 
Uh  tttefe  Kb  danger  of  the  part«  being  dragged  upon  during  ita  screaming 
verjmg,  it  la  a  very  gotui  plan  to  apply  the  spring  check-eom pressor,  in- 
vustl  br  Hain»by,  here  ropreieutefl  slack  (Fig.  706).  It  must  At  tho  child 
Mniely,  anii  coiumnnly  require*  to  be  made  specially  fiir  the  case.  If  it 
>  III  obtainable,  the  cheeks  may  he  drawn  togetner  by  a  piece  of  muslin  cut 
■  Mtu  form  a  lar^e  rounded  piece  in  each  cheek  conueele<l  by  a  narrotr 
*ripoferthe  lip.  This  must  be  applies!  while  the 
vmu  are  prwswl  together  with  the  tingers  and 
MUdowD  with  colIiHlion.  American  rubber-pla«t«r 
aai  i_  ....f.tieil  in  the  *ame  way. 

c  fiesure  doe^  tM>l  extend  tlinmgli  the  lip 

'  raiit'u  reutmniendeil  by  N6taLon  wilfbe  found 

'  i  u'  nii«i  uxtvlk'ut  results.    The  mode  of  per- 

ir-iiic.^  il  is  fully  explained  by  the  accompanyiog 

B'joble  Harelip. — Tho  ofwralion  for  dunble  hare- 
j;' 1*  [Krr>'riiii'd  on  the  same  princjjile  oa  that  for 
li'  "iiii-if  r-Tiu  of  the  disease,  via.,  of  pnMiinng 
'iui'ii  hv  Billxi-ion  between  the  opposite  surfaces. 
T^'j  ilitl^rt  iirr-  in  the  operaUau  oouista  chirlly  in 
^jit)^>  nith  ibe  iniermetOftte  portioo  of  the  lip  and 
^vcht,  .  Fig.  T<1»  I.  The  management  of  the  intermaxillary  proeea  must 
^  kourJing  to  ita  site  and  d^ree  of  pruje<ction.    If  it  be  small  and  mdi- 


Pl(.  TSC— nar«i)t>  t  Siitimc 
Ob  Mk  -wn  fn—mr. 


^ 


Ftf.  7*T.— Ittlst*n'i  Op«r»Uaa  for  pkrlUI  lUrwII^ 

,  or  fixed  to  the  tip  of  the  nose,  as  in  Fig.  709,  it  should  bo  cnt  off 
sippeni,  as  it  would  prevent  the  lateral  segmcjita  from  eomiag  into 
101.  u—99 


610 


PLASTIC   eDBOEBT    OF   THE   FACK    AN1»    MOLTB. 


proper  appoittioD.    Me«t  commonly,  when  tliis  ii  done,  tliere  b  6m  al 
«T«D  dangerous  lileeiling  from  a  il^otnl  nrUTy  'leep  in  the  boiw.  «hkk  bi; 
require  to  U'  touched  wJlti  h  rcii-hot  umile  tir  vb* 
bel'ure  tli»  livriiurrhniie   frotu  it  witi    rvmu-.     Tr  lU 
Otfutrtttiiitoniiaxilliu'y  [HirlionlvUr^rn' 
it  nmy  be  bvot  or  l>ruk«u  buck  by  »;j-.;.^   , — f. 
cuver«d  with  vulcaoiz*^  India-rubber.     Fcrin>*4 
huwevvr,  puiiitnl  out  tlial  if  this  b^-  liooe  tii^ 
tet-tb  CDiitaiiieU  in  llii*  iatiu'iuitxillurY  |>ir- 
it'  thi-y  ilevelop  Ht  all,  pruject  bftckwrnnb  ili>    il« 
roof  uf  tbf  niiiutb,  hh  the  bojie  Li  txti  ftuiiM  am 
ii»  Diirmiil  PititiittnH,  liul  mther  rntateft  oa  ':i 
viinte  ftxiii,  iJieelt'iHliT  iifck  ulinchinp  it  to  !! 
bcin^  bent  u|K)U  itM-lf.     llcv. 
Ihst  ill  all  vM»<-s  it  is  liettvr  t<. 
lo  DtienipL  lo  t'urce  <ir  Itend  ii  tntu  >  a 

If  it  be  large  and    uul    pnijt-clinc.  tl  , '™ 

ebould  be  well  pared  on  carM  suTf,  and  inaAtd 
by  the  harvlip  dim,  and  thtu  be  inl4'rp<w«l  hrtwM 
and  unitctl  tn  tne  pared  lateral  aurfacr*;  iadiwii.  c 
ia  Blu*a}-s  ad%'isablc  nnt  to  rcroove  thia.  qdIm  it  k 
mukwnRlly  Mlnatcd,  aa  la  Fig.  iif&.  Wbu  ilii 
Ictl,  though  the  union  may  nnt  ■ppi'ar  f)uil«iuin^ 
feet  and  uniform  as  it  would  if  ihr  Uli.fiil  baJM 
had  bei^ii  directly  unilvd,  yet  cvdiiumllr  Lb«  am 
will  turn  out  iK'ttvr ;  the  ceulral  {»>rli<>n  bwoBBBf 
developed,  mid  lormint;  the  natural  menial  pn^/rcv^ 
of  the  lip,  whirb  i-  K)«l  wlicu  the  lateral  h7t\yr*Ui 
directly  united.     In  •>ime  of  tht'*e  (.-ax-  it 

U  re<.iuired   in   ptnuiiiu^    the  itii-ivioti?      .  ib< 

inlroduutioD  of  the  ^uliirtw.     The  ctiitrai  piirtiwtt 
raoat  advaDtafic»u»ly  pared  in  a  »oui(>what  oi>uvuc  uiauuer,  vti  that  tbe  fm^ 
cut  edgCB  of  the  Interal  b&lven  are  more  accunttdy  liLt«d  upuu  it.    SbaaVl 
■a  often  bappcns  in  aingle  aa  woll  as  in  double  liareJip,  utia  »(  th»  lalm* 
aagmeoU  be  tied  down  to  tbe  gum  and  aWeulu»  by  a  duubliag  uf  uum^ 
membraoc,  tbi«  miut  be  freely  divided,  aiid  tbe  portion  uf  lip.  with  p^ 
bapa  the  correspond iiij;  ala  of  the  iinac,  freely  disnerted  up  from  the  ia*M«t 
etructurca,  8u  aa  to  udiiiit  uf  its  being  uiovihI  funaanlB  witboui  too  bm^ 
traction  being  put  U]Kin  it. 

Id  tfaueo  i-aeea  in  which  the  intermaxillary   portion  it  prni 
Bttarbeil  to  and  fu»ed  with  tbe  columnn  of  the  noae,  as  in  FiffL.  709 
I  have  (itrfiirmeii  the  following  opcmiinn  with  grnat  kuctmi. 

1.  The  triaii^Milar  Hap  of  skin  covering  the  intertnaxillary  ptution  k  di 
aecleil  np  a»  thick  aa  pomihie,     2.  The  intermnxillary  prooMi  ia  ibi 
awnr  at  ita  rcMit,  which  is  small  anil  pedunculnt^^l,  vicb  a  p«r  of  « 
3.  The  edgeti  of  the  lateral  fi.'nnrea  are  then  pared  in  thr  u«tal  vay.    4. 
free  lower  marpn»  of  the  [laretl  edges  are  brought  toc*'lhcJ-  by  finf 
pin  and  tvri»t(^  suture,     o.  The  leaf-shapctl  Sun  ht  invn  laid  down  io 

Inangular  hollow  Itfl  above  the  pin,  and  relaii)e<l  llion-  '■  -    ■ -  '■■-     -    '•« 

of  silver  tinliire  on  each  didc.  the  gap  ]ma^  thus  comp 

Treatment  ^y  Simple  Sntnre. — During  Mfverst  yeam  i  TLtvc  i-.-r-a  lo 
habit  of  treating  harvlip  of  all   kinds,  double  aa  w«)l  aa  eiof^le.  with 
simple  iiitt-rruplt:d  suture  alone,  without  u«int;  any  piu>.    I  haw  in  Ibk 
Irtuted  moat  BUccesafuUy  many  caseo  io  childrvu,  wboae  ag«B  have 
from  a  few  days  to  four  yvajt,  with  most  ntia&ctory  malls,  and  vkli 


Fif.  ToK— OpMBtioD  Tor 
Doabt*  l[>r<ll|>.  Hight 
•ilia  «r  Ulp  ilrnwii  ilo«B 
b;  Jliiriiig-hrtuk  Fmcvp*  t 
liHiK  narrow  Knifi  ctil*r«4 
kl  Mttilti  ilolUd  liao 
■lioas    4ir«etlMt   of    tit  a 

]a«W«Bf. 


OPBRATION    FOR    DOUBLE    HARELIP.  Gil 

nkrkiog  of  the  lip  than  I  have  ever  seen  attend  union  by  means  of  the 
twuted  suture.  I  prefer  the  simple  to  the  twisted  suture  as  beinr  equally 
Mlie,  more  simple,  and  followed  by  less  scarring  of  the  lip,  provided  the  case 
be  not  too  complicated,  nor  associated  with  very  wide  fissure  in  the  palate, 
DF  with  great  projection  of  the  intermaxillary  bones.  lu  these  circum- 
■tancei!,  the  pins  should  be  preierred. 

When  the  fissure  is  single,  the  edges,  having  been  pared  in  the  usual  way, 
•booM  be  bn>nght  together  by  two  points  of  suture  ;  the  tirst  passed  deeply 
near  the  free  edge,  and  io  such  a  way  as  to  compress  the  cut  coronary  artery ; 
the  other  nearer  the  uasal  angle.     These  sutures  should  ,be  of  thick  well- 


fi|. :n.— DoabI*  lUrvlip;  Inter-  Fij:.  7llt.-  Double  lliireli]i :  I'nijetting 

■ulUarj  Portion  fixed  to  Noaa.  Intermix  ill  nrj-  IWlion. 

■Ufld  dentist's  twist  that  will  not  cut  out  too  readily,  or,  what  is  better,  of 
■Inr  wire.  A  point  of  fine  interrupted  suture  i>luiuld  then  be  inserted 
tkoQ^h  the  mucous  membrane  inside  the  lip.  The  tip  may  then  be  sup- 
poned  by  two  narrow  stripe  of  plaster,  oue  placed  between  the  sutures,  the 
Mber  between  the  upper  suture-and  the  nose.  On  the  third  day  the  upper 
Mtnre  should  be  taken  out,  but  the  tower  oue  may  be  left  in  for  a  day  or 
tto  longer,  when  it  and  the  one  through  the  mucous  membrane  may  be  re- 
■OTcd  together,  unless  the  latter  have  already  cut  it.i  way  out.  If  silver 
"irewiures  be  used,  they  may  be  lefl  in  for  six  or  seven  days  without  pro- 
•liiriDg  irritation.  The  lip  must  then  be  supported  tor  »  tew  days  with  a 
wip  »f  ptaater. 

_  Id  the  ca.se  of  double  harelip  the  same  plan  is  to  bo  adopted,  first  on  one 
Bde, then  on  the  other;  but  here,  hs  the  gitps  ari.-  wider,  aud  the  tension, 
joore  particularly  when  the  iutermaxiilary  [inimim-iicc  is  very  projecting, 
"•[H  tij  lie  nmsiilerable,  it  is  nocer«ary  ti)  support  the  cheeks,  and  thus  to 
["Jvent  undue  traction  on  the  stitches,  by  moans  of  tlie  check-compressor 
{i\  TO*})  or  pro[>erly  applied  plaster.  In  this  way  all  risk  of  the  stitches 
nilting  out  before  union  is  completed  Is  nvniiied  ;  an  excellent  ami  solid 
!*ioiiwill  speedily  be  obtained  even  in  ciises  of  double  harelip,  with  some 
•otertnaxillary  pnijcction  and  fissured  palate. 

The  operation  occasionallv  fails.  Tlie  probability  of  the  occurrence  of 
U^b  in  untoward  event  is,  however,  greatly  diiiiini.-«h<'d  by  the  use  of  the 
™*<k-com|)re88or.  It  may,  however,  happen  cither  in  c(in^ei|ueiut'  nf  the 
*'ld'i  health  being  in  an  unsatisfactory  state,  so  a-  to  prevent  union  by  the 
^intention;  or  in  consecjuence  of  the  pins  having  In'on  withdrawn  too 
*"?.  before  secure  cohesion  has  been  effreted.  In  such  circumstances  as 
r***.  »n  attempt  might  be  made  to  unite  the  granulating  edges  by  the  re- 
^trodnction  of  the  pins  or  sutures,  anil  by  finiilv  fixing  the  lip  by  means 
"*  the  check-<»>mpresBor  or  plaster  applied  as  above  described.     Such  at- 


61£ 


PLASTIC  SUROERT   OF   THE    FACE   AND   HOVTB. 


i-tenipU,  however,  rarely  Bucoccd  ;  shoiilti  they  not  do  so,  it  will  uKually  ba 
found  most  pnictent  ta  wait  at  least  a  inontli  before  taking  any  further  slcpa, 
and  then  to  p&rt  the  edges  nfresh  and  repeat  the  original  operation. 

C-Oxr.EsrTAi.  TiiANSVEiiBE  FisBiiREi*  OF  THE  Chekes,  extending  ftom 
the  angle  of  (he  mouth  to  the  anterior  bnrder  of  the  masaeter  or  up  towards 
the  malar  bone,  are  occaiiional  ly  nuet  with,  and  have  been  specially  deitcribed 
b)'  Klein  ami  Xit-ati.  Their  mode  nf  ori);in  hua  be«n  already  referred  to 
(p.  014).  In  thi^se  maifurmatiiins,  whirh  are  of  extremely  rare  occurrence, 
the  «ar  on  the  nllected  side  if  imperfectly  developefl.  An  hiu  be«n  QUwrved 
by  Ffrgii^emi,  ih^trH^iis  is  detached  from  the  auricle,  and  in  fixed  to  tb6 
cheek,  where  il  furnis  a  small  loboluted  apfwndage.     The  external  ear  Jten- 

[Crully  is  nmlforineii.  the  helix  being  twisted  and  curled  inward*,  These  tual- 
^ruiatious  reijuire  Ui  be  trtuted  on  exactly  the  ^nme  principles,  and  wilh  the 
same  attention  tu  detaiU,  «j*  harelip ;  union  between  the  jwred  edgee  being 
efiected  by  means  of  harelip  tiine  and  the  twisted  suture. 

Oii;ii,opLA8T\". — fiimule  pluBtic  "iK;rali<'U»  are  commoulv  pracliaed  on  the 
lower  lip  Ibr  the  rcoioval  of  epiihc-liuma,  by  cutting  out  a  V-ehaped  piec«of 
the  lip,  including  tbc  wholu  Jiei'aecd  eiruciiirc,  and  llivu  bringing  together 
the  upjHisite  sidee  of  ibc  incision  hv  harelip  pins.  TtiefC  operationi;  hare 
already  been  drecribed  and  tiguruil  ui  p.  o54,  vol.  ii.     Wa  ehall  coni^ider 

.here  ttiose  caees  In  which  il.  becomes  uecc^iFary  tu  repair  more  or  lees  exteo- 
tive  loss  of  subBtBUce  in  tlio  labial  i^tructurcis.  The  rettttjration  of  &  portion 
of  the  lip  that  ha^  been  destroyed  by  accident  or  digease,  is  not  fio  readily 
efTecleil  a»  ihat  of  the  nuec ;  yet  a  giKnl  deal  may  h(.'  done  to  remove  the  <le- 
Ibrmity.  The  plan  origiEiully  icitrodiu^'d  by  Clinpart  ruBoisla.  when  it  is  the 
lower  lip  that  ie  deformed,  in  carrying  an  incision  each  side  of  the  diseaaed 
portion  of  the  lip  vertically  dfjwnwanis  belnw  the  jaw,  for  a  greater  or  leal 
distance  according  to  the  amount  to  be  removed,  even  if  necessary  as  far  na 
the  hyoid  bone.    The  diseased  pan  of  the  lin  is  then  removed  by  a  trans- 

.  vcrsc'incision  below  it.    The  square  Bap  marRed  out  by  the  two  vertical  in- 
aioua  is  then  detached  from  above  downwaids.     It  is  then  brought  up,  ood 

'fixed  to  llie  pared  edges  of  the  remaining  portion  of  the  }ip  by  points  of 
luture;  the  head  being  kept  properly  inclined,  in  order  Ht  prevent  undue 
tenoinn.    After  sufficient  union  has  taken  place  to  preserve  the  vitality  of 


mX 


,^G&iw^ 


ClM>l0|>l«*tj. 


Fif.  7IS.^IiKi'tiiunR  and  SnturM  In 
Cbeil<i)-]K4l}'. 


tlie  tliip,  its  lower  altachment  may  be  divided.  This  operation  is  not  usually 
Vf:ry  sal  iofactory  iu  its  results,  as  the  ucw  llap  ia  apt  to  beoome  uHlematoua 
and  iuverlL-d  at  the  edge,  or  the  flow  uf  saliva  may  interlere  wilh  proper 
uniiui.  In  thoee  caees  m  which  the  greater  pr>rtion  of  the  lower  lip  has  been 
excised  for  i>anceri>ufi  diaenee  ailbctJng  ita  upper  margin,  another  procedure 
for  the  rvDtoraiion  of  the  deformity  coaslata  in  a  modification  of  the  plan 
Teoommended  by  Serres ;  and  from  thia  I  have  derived  excellent  results,  aa 
in  the  case  which  is  here  represented  (V'lg.  71 1).  The  objeci  of  the  opera- 
tion is  to  raise  the  lower  lip  to  a  level  with  the  inciaor  Leclh.    An  incision 


BnCHANAN'3   OFBBATION — SYHE'S    UETHOD. 


613 


■boot  three^uartara  of  an  inch  id  length,  is  made  directly  outwards  from 
the  angle  of  the  mouth,  on  each  side,  into  the  cheek ;  from  the  extremity  of 
thii,tcut  is  carried  obliquely  dowuwarda  on  to  the  upper  margin  of  the 
lower  lip,  80  as  to  excise  the  iDcliide<i  triangular  piece;  the  lower  lip  is  then 
diaaected  away  from  the  jaw,  from  the  iuside  of  the  mouth,  and  a  V-fhaped 
piece  18  taken  out  of  its  centre.  By  means  of  a  harelip  piu  ou  each  aide, 
aodt  point  of  suture,  the  iucisious  in  the  angle  of  the  mouth  are  brought 
aecumelr  tO)i;ether;  and  in  the  same  way  the  vertical  one,  in  the  centre,  is 
Qoited  iTig.  712).  In  this  way  the  whole  of  the  lower  lip  is  raised,  and 
brou^t  more  forwards.  If  care  have  been  taken  in  removing  the  cancer 
from  the  edge  of  the  lip,  to  leave  the  mucous  membrane  rather  long  (which 
agy  akays  be  done,  when  the  skin  is  affected  to  a  greater  extent  than  it),  a 
0x)d  prolabium  may  be  formed,  and  the  restoration  effected  with  but  little 
wfnrinity. 

Buchaoati,  of  Glasgow,  as  far  back  as  1841,  published  an  account  of  a 
nKthod  for  restoring  the  lower  Itp  when  atfected  by  extensive  cancerous 
dwate,  which  leaves  most  satisfactory  results.  The  accompanying  6gures 
illmtnte  the  kind  of  case  in  which  Buchanan's  operation  is  applicable,  the 
liociuf  incision  required,  and  the  appearance  presented  by  the  chin  and  lip 
>fter  the  disease  has  been  removed,  and  the  Haps  braught  into  proper 
ipp-wiion. 

the  steps  of  the  operation  are  simple,  and  the  result  is  excellent.  The 
diaetwd  part  of  the  lower  Hp  is  first  remove<]  by  an  elliptical  incision  (Fig. 
•  13,ABAt.  An  incision,  B  c,  is  then  carried  downwards  and  outwards 
ODcicb  side  of  the  chin  ;  and  another  inci:<ion,  c  n,  upwards  and  outwards 
pvallel  to,  and  corresponding  in  length  to,  a  ii.     The  Haps  formed  by  these 


lip.  71..  Fit'.  "'*■  Fig.  ria. 

Builianan'*  0)>erntioD  for  the  Re.-'lur.itiDii  of  tlio  Liner  Lip. 

incijiuna  are  represented  in  Fijr.  714.  They  are  detiu-hed  from  their  sub- 
.jiceni  conneotionA ;  and  the  whole  is  ruiscd  uiiwanl.*!,  so  that  the  curved 
■ncifion,  .\  b,  comes  into  a  horiz'tntnl  line.  nni\  is  made  to  constitute  the 
""ir^nn  of  the  new  lip;  (he  secondary  inci:*ioris,  ii  i',  coming  together  in  a 
'^ftical  directii>n,  in  which  thev  are  retaiiiod  by  twijited  and  interrupted 
wturM'Fip.  7ir>i. 

^yine  rcci*mmendcd  a  somewhat  ditTcrciit  iii'iilo  of  operatin<r.  Instead  of 
the  ioi-i^iiim^  c-  i>  boing  nuido.  tho#e  marked  u  v  arc  carrit'd  onwanU  f  )r  some 
dtftSDco  in  a  direction  curviii^r  dnwiiwardfl  and  mitwards,  so  tlint  ttiev  ter- 
"iinateil  b(>low  the  angles  of  the  jaw.  The  thips  so  f  u-med  nm  raised  and 
^ited  in  the  middle  line,  as  in  Ilnchanaii's  optTatinn,  the  /^-shaped  imrtinn 
wikiii  abi.ve  the  «'hiu  serving  to  maintain  thorn  in  jiKsition  and  prevent 
|wir  sliding  downward.-*.  Tlie  long  curved  inriaion?;  onahlc  tliis  to  bi'  done 
•*  Werelv  stretching  the  convex  fdircs  nf  tlio  tliips,  without  siifficiontlv  dis- 
P'aciDj;  them  to  prevent  their  readily  meeting  tho  r-unravi'  cilirt's  of  inter- 
'*iiing  skin,  and  being  united  to  them  hv  sutura*.  N'o  surtiice  i:<,  therefore, 
■•ft  to  granulate,  and  the  whole  wound  heals  by  the  tirst  intention. 


614 


PLASTIC   SUROSnY    OF    TUB    PACE    ANI>    KODTU. 


Id  iwrr<>rmiug  tfaia  operntiou,  it  is  eMWotial  to  riocmb  that  tW  ittdinv 
iliould  be  fiitHcittiilly  free,  bo  that  the  flspB  muy  be  bniugfat  iota  poilU 
without  tetiBion.     If  the  chin  be  removed  as  well  u  tbc  lowor  lip,  it  Bcoaa 


Fig-  Til.— J'ywe'i  utilhiMl  uf  r**U)riD( 
tba  IiAw«r  Lip.     Uiim  of  Inelilvn 


Fig.  "ir. — Sj»»'»  ni*lliii4  g(  ■■ 


very  difficult  to  restore  the  loǤ,  as  there  w  no  6xe<)  [M>int  behiw  ttiMtppnti 
the  new  lip,  which  c«osci)ucntly  icnd^  to  ajnli  downwanLi. 


PLA8TIC  StTROKKT  OF  THE  rALATK. 

Varioue  degr^ce  of  coogenit«l  ilet<irmtly  mtT  occur  in  the  |>ftlate  and  onii: 
tbui<tLv  uvula  alone  niay  bv  bifid:  orlbt^clvft  may  cxtt-tid  tbrjiJ^b  thcf^rahr 
part  ur  the  uliulc  of  ihe  i)'>ft  palatt* ;  ur  tbi.'  Iianl  palate  may  lip  divided  M 
well  (Fig.  71^);  nud,  ItiBlly,  thu  aeparatinn  iiibv  vxtcud   T  '  -  i»- 

tegunicntn  of  the  face,  jiruduviug  eiugU*  or  double  harplip  X%t 

soil  palatL'  and  uvula  art-  not  unrroijuvully  elcfl  witl'iut  ibe  b»i\i  (Miiftitt  bdaE 
diviik'il ;  ami,  in  aortic  very  ran-  ira^tv.  ihu  lip  and  th^-  hard  palate  are  finrarM 
williiiiit  the  Bofl  Iwiuf;  flfti.  The  mode  uf  orijjio  of  these  defunniliM  hn 
aln'adr  \wfn  dt-t^cribcd  i  p.  0^)^). 

Thfsf  malforniHtion!  uc-ot-Afarily  give  rise  to  ^n^at  tnconveaieDCVv  ^  iottt- 
feriog  with  deglutition,  and  rtrndcring  speech  nahsl  and  imperfecL     k)nii^ 

the  Bwuliowin^  of  fluttU^  there  h  •  ImiiImkt  M 

regurgitation  ibroujrh  the  noae.  t*- *■  '^h  it 

ii4-<*iui>tnally  pn-veoteil  by  the  u-  '.nb 

of  ihc  Lsl^t^  of  tho  fi<i^ure  to  thr-  .'^. 

An  infaut  born  with  a  clt^A  fw  >'«^ 

•urily  iinnhlc  to»U(-l<.  nnd  uuleaa  carttuiij  M 
l>v  Imiid  will  Miuu  peririh.  It  mnM  h<  frx)  wdrlv 
<ni  milk,  the  mtiibfr'* 
which  may  he  drawn  i-  > 
inteml  to  tha  child.  Tlw  It-cdiox  UNty  b« 
by  s  prnpi>rlT  c^HMtrurtrd  lioiiit'.  fniai  wloeb 
the  milk  will  flow  slonly  withriul  ibc  aeoi 
sity  of  Huckini;  on  the  pari  nf  tb«  ciiild;  l^i 
Qiiist  be  filted  with  an  ludia.rablKr  ubs^ 
which  must  bfi  poshed  well  to  the  back  of  tin 
pharynx  at  the  milk  is  given.  Id  the  abieoct  of  a  bottle  thv  t-hilil  B*y  bi 
very  efbcieutly  fi-d  by  means  of  a  tcaipoon. 

Uutil  ■  fi-w  ytnn  uf^t,  (Iiik  nr>eration  wu  always  deferred  nntil  the  fmtiaU: 
had  attained  the  ago  to  uoderitAnd  the  necaaiti'  of  Rmaininf  qokc  dari>f 


'{ 


Fif.  ((S.—  Mkuit  .if   l|*r.]  >nil 


BTAPHYLORAPHT. 


615 


U»  |iraM»diQ|;,  and  vu  able  to  contnil  his  movem^itU,  at  suocem  depeiicJed 
faignat  moaiore  ajkoa  his  remniiiin^  ptfrfectly  iranqiiil  mid  iir(>n<lr  diiriog 
ihtmeeMu^  nanipuUtions,  which  are  ot'a  tediouB  and  (»r.)lmcl*d  chnrncWr; 
aadupoahbaMloliu^  tho  Siirgemi  hvopenmi;  liiit  nKjiith.aad  n»t  atni^^liog 
tkriiig  tbe  iulnxluvtioii  of  instrumonUi.  Cholorofuroi  was  ocvor  adiiiinis- 
Vml,  fmnt  lilt  f<rar  that  ^iiHocatim)  iiiigbt  bo  oaut>>cd  by  the  blood  Irotn  Uip 
4ptr»tkm.  which  it>  alwRVB  HhuiidaDt,  euicntig  ihu  uir-iNiesai^.  lu  1^69, 
Kwrer.  Tb»mu  Smilh,  of  !>i.  Barthnlniijcw's  II»«piLu],  <ieinc>natraii'd  tltal 
with  mtper  care  aitnstb«tics  may  bv  witl'ly  nduiiniittered,  aiid  at  the  same 
tiswmi  invcntel  a  iuo«t  ia^niou»  ^•;,  by  riH-niie  of  which  thv  |>atii;nt*B 
Muthean  b<>  ke|it  widely  <>i>eQ  without  thv  Surj^i^tn  heini;  iiitprfcri^d  with 
tJtlKr  by  tht?  httiid«  orawtiaumts  or  ibe  inBtnim^Qi  itsplf.  By  the  hcl|)i.)rthi9 
|ig,ain  ibe  luliuiniAlratioii  of  rhlorofurm,  the  rtpt>ratiim  can  now  hv  per- 
nrwd  at  any  ap^ ;  hut  ag  the  bleeding  \a  nlwn>'A  very  free,  it  b  advi.'^jible 
Mtnittetnpt  il  id  too  yaung  children.  At  the  ageuf  ihref  it  may  be  Mifcly 
Oifattltca,  and  the  advantage  of  having  it  done  mfore  tbe  child  ha?  learned 
tofpak  Is  very  great. 

nAnfYUSBAi-iiv. — The  operation  fiir  the  cure  of  a  cleft  in  the  eoft  palate 

■■jrlMMid  In  have  Iwen  inlmdiiced  by  Kitiix;  for  aUhouehse\t!ral  attempts 

•1  tlia  care  of  lli)t>  detormily  had  bc^^n  m»d«  by  Surgeons  before  hif  time,  yet 

Wta«  the  fint  lo  eHlAbliiih  Staphyloraphy  as  n  distinct  o|>onitioa.     Many 

■idiftcatidnf  iif  Roux'«  plan  have  been  pracliseit  by  Von  Orife,  W»rreu, 

DMftobaeh.  Linton,  and  othen),  in  order  to  render  it  more  etuty  of  execution, 

W4  cntAiu  ill  il«  reaultJi,  and  especially  by  making  ii]ci»on«  through  the 

pitt*  ta  M  U'  take  off  the  traction  on  the  Mtitures;  hut  to  Fergueaon  waa 

■W  tile  merit  of  inlmducing  a  new  principle  of  treatment  in  ibe  opemtiou, 

^^  iIm  application  of  nirotoruy  to  il,  thus  panilyr.iDg  the  movements  of  the 

■Mdni  tif  the  palate.     IVrgussou  tvaa  of  opinion  that  the  great  cause  of 

■Bore  io  these  operations  mis  the  mobility  of  the  parts,  and  the  tracttoa 

••Wciwjd  by  the  nio»cI«!,  principally  the  levat*)r  palnti  and  the  palato-phnryo- 

ff*.  m  the  line  I'f  union  ;  in  ortler  to  obviate  this,  he  conceived  the  idea  of 

ihtwe  muBclep.     Before  t-'ergussi'u  laid  down  the  priocipiea  of  chb 

it  ia  true  that  various  cute  had  been  made  in  the  palate  Dydifferoot 

niih  the  view  of  taking  off  the  tension  after  the  sutures  were  tied. 

:1enbach.  I'ancoost,  Liiitun.  and  .S^illot,  all  recumiDead  that  the 

n  the  Mitrhrv  ehonld  be  lesaened  by  longtiudical  incisions  iu  the 

.il.  ,..  ndnhim  rnlali.     Mottnucr  pmc- 

^■1  Kiveral  small  incisi«n»  fnr  this  pur- 

'■  "         nl    Sluitn    Warren    divider!    the 

I'illar  nf  the  faueeg  ami  the  al- 

*^cuiuuita  of  tbe  palate  lo  the  posterinr 

yWt  enmtnz  nearer  than  any  previous 

^Hntor  to  FcrguasoD'a  niethml.     Tb<«e 

jy^rationa.  boweter,  were  done  almmt  at 

■*I»liaiard,  and  tu  an  r'nipiritiil  way,  wilh- 

?*■*■  tl»ei*e»^iliMtiofativ  ilL-tiuct  principle 

^^»n:  iiividveii  id  tbpiii. 

Orvration. — The  |Hilii--nt  t*  placed  in  the 
f  t>"«>lit>ti,  the  fjtirgetin  stundintf 
'-'('•,    Tbe  gag  is  then  inserted, 
>  ailniiniRien-*],  or  if  the  |m- 
^^  _t  t"^  ic  '    ■■'■••'  th«  gajr  may  he  IntHTted 
■*«p»iwr-v.-  -11  1^  indMce«l.     The  gngri'[>- 
^^feMilMl  in  the  acr<-[iM>anying  drawing  (Fig.  719)  is  a  mndificalJon  'tf  T> 
^*aiilb'B,  inrentcil  by  WoihI.    Il  can  bo  atljusted  to  fit  any  patient  by  mora 
^V'  Um  widely  aeparaliug  the  two  halves. 


J 


h 


Bmitli'i  Uag. 


610 


PLASTIC   8DBaKR¥    OP   TBR   rACB   JIVD    MOUTH, 


iHg.    70I*.  —  Opanllon    Tor 
DonUv   lUr-lif.      ItlHbt 

■ill*  of   Lip   UraMti  dawn 

long  DAtTaii  K  iiife  *Eit«r»il 
«l  ■nsU;  ilollctt  line 
•bow I  illfwtimi  of  Ibf 
laelaEont. 


proper  ftppopitioo.    Most  commnnly,  when  iWis  u  Hone,  there  b 
even  duigerous  lileedin^'  from  a  dt^nm)  nrtiTv  d^p  in  itie  Im: 
require  lo  bo  touclied  willi  a  red-hot 
bcl'ure  ihc  beiunrrbiigc  ftoro  it  will 
ocniniruilcniiAxillary  portion  be  UrKc ami  { 
it  niay  be  bent  or  brukou  back  bv  stroti 
covered  with  vulmoiusl  Iiiilia-rubuirr.     !>' 
hawcvcr,  poinU'il  nut  that  if  thia  be  diine  t 
teeth  coniaiticd  in  the  iatf^rmaxillury  |xii 
if  ihoy   develup  at  all,  pniject   luirkwanb 
roiif  <if  ihtf  niiiulb,  an  tlie  bone  ■>  not   ^. 
itii  uiirnial  Mliiutum,  but  rather  mUtlnl 
veme  Rxi>,  lb«  j>l<^ui)vr  ti«i.>k  nltttrbinfr  i 
hfiiii;  Iwnl  ujtiiH  ilwlf.     IIcm  •  •    » 

that  in  all  ca***  il  ii  brtt^r  to  -o( 

U)  altf  nipt  to  turc«  ur  l>en<]  it  iniu  »  bcw 
If  it  be  large  and  nut  projiviinf;,  tli«  ■ 
DbuulU  bv  well  pan.il  nii  t-mU  h'nlv,  nud  tl 
by  the  baivtip  pina,  niid  ttiun  be  inicrpuHiJ 
and  united  lo  tiic  jmrt-tl  Iiiifnil  aurfttas;  b 
IB  alunyif  adviettblv  nut  to  rt-niuve  ibia,  unk 
awkwardly  mtuali'd.  at  in  Vig.  701).  W| 
left,  tlifiUfib  thv  uuiuu  may  nut  appi'ar  quil 
feet  »nd  uniform  ue  it  uould  if  tlit>  lal<^r« 
bad  been  rtirwtly  nuileil.  yrt  evriilitalty 
will  Hini  out  iM'lltr;  the  cpnlral  iHtriiun 
il<>vp|(>]H;d,  nnd  forming  ibt-naliiral  mt-9iial 
nf  iho  lip.  whirl)  is  Iimt  wln^n  tbe  laXTnt 
directly  united.  In  Aumciif  thf*i,'  t-aM** 
ii  reoinrni  in  plnnniti^  the  int-iMona, 
inlrtiiiiirtiiin  of  the  iMitiirfs.  Tbi-  ct-n 
moat  advantaftcoualy  pnrfd  in  AtuinicwbaL  oinvtix  niannt-r,  bu 
cat  edgn  of  the  lateral  bnlveft  nro  mono  arcnmtrly  fitted  n)>on  iL. 
M  otttra  happenn  in  tingle  »»  well  na  in  double  liurvlip,  one  of  1 
aegnif^nta  bo  tied  down  lu  the  ^m  and  ftlvfutitfl  by  a  iloubling  i 
membrane,  this  mu^t  he  freely  divided,  and  the  pnrljon  of  Up, 
bajM  the  correapAndini;  alu  of  the  nf«e,  frc«ly  dimecte<l  up  fmm  I 
8tTuctMr68.  BO  as  l<i  ouniiL  uf  ita  being  moved  forwarda  witiwat 
traction  being  put  upon  iL 

In  tJioee  uaaea  in  which  tbe  iDtcmuutitlary  portion  U  pr 
attached  to  and  fused  with  the  c-olumua  uf  the  none,  aa  in  Kigm. 
X  hnvv  [icrfornied  tbe  following  uperatiuQ  with  groat  raecaM. 

1.  The  triangular  dap  uf  skin  coreriug  the  intcrinaxillaiy 

■eeted  up  oa  Uiick  aa  possible.  2.  Tbe  intermaxillary  procvia  ii 
awav  at  ita  root,  which  is  email  and  pedunculated,  with  a  pair  n 
3.  "fhe  edges  uf  the  lateral  Samirea  are  iben  pared  in  the  usoal  vhay 
free  lower  margioiof  the  pared  edgt*  are  bruught  tugother  br  on 
pin  nod  twisted  Buturo.  5.  The  loaffthaped  flap  ia  tnoi  Ijuif 
triangular  hollow  left  above  the  pin,  and  retainra  there  bv  one 
of  silver  sutnre  on  each  side,  the  ^p  bein;^  thuB  eonpleCely 

Treatmeat  l^y  Simple  Sutnrv.— ]>uring  Bcvorol  ytun  I  haw 
habit  uf  treating  harelip  of  alt   kinds,  double  aa  well  aa  ua^f^ 
ilmple  iaterruptcd  milurc  alone,  without  OBing  any  pina.    t  hai 
tre&ted  moat  aaeoeaaAilly  many  oaaea  in  children,  whoM  ag«a 
fVom  a  few  dayi  to  four  yeoia,  with  mnat  uiiijd^iory  rtaulta.  ao' 


m 


OPBBATION    FOR    DOUBLE    HARELIP.  611 

B&rking  of  the  lip  thao  I  have  ever  seen  attend  uoion  by  means  of  the 
Voted  Buture.  I  prefer  the  simple  to  the  twisted  suture  as  being  equally 
■ft,  more  aimple,  and  followed  by  less  scarring  of  the  lip,  provided  the  case 
>  not  too  complicated,  uor  associated  with  very  wide  fissure  iu  the  palate, 
'  with  great  projection  of  the  intermaxillary  bouee.  In  these  circum- 
Moes,  the  pins  should  be  preferred. 

When  the  fissure  is  single,  the  edges,  having  been  pared  in  the  usual  war, 
oald  be  brought  together  by  two  points  of  suture;  the  first  passed  deeply 
ar  the  free  edge,  and  in  such  a  way  as  Ui  compress  the  cut  coronary  artery ; 
e  other  nearer  the  nasal  angle.    These  sutures  should  Jie  of  thick  well- 


't|.nt.—DonbI«  Harelip;  Inter-  Fig.  710.- Double  Hiire1i|i ;  ProjecliDg 

■UiUarj  Portion  fixed  to  Noie.  JnternikxilUrj  Portiun. 

nsti  dentist's  twist  that  will  not  cut  out  too  readily,  or,  what  is  better,  of 
>lw  wire.  A  point  of  fine  interrupted  suture  !«hould  then  be  inserted 
I^gh  the  mucous  membrane  inside  the  lip.  The  lip  may  then  be  sup- 
p(*tM  by  two  narrow  strips  of  plaster,  one  placed  between  the  sutures,  the 
Xkr  between  the  upper  suture-aud  the  nose.  On  the  third  day  the  upper 
"ton  should  be  taken  out,  but  the  lower  one  may  be  left  in  for  a  day  or 
*o  longer,  when  it  and  the  one  through  the  mucous  membrane  may  be  re- 
nored  tt^ther,  unless  the  latter  have  already  cut  its  way  out.  If  silver 
'iie  sutures  be  used,  they  may  be  left  in  for  six  or  seven  days  without  pro- 
iDciog  irritatiuD.  The  lip  must  then  be  supported  for  u  few  days  with  a 
trip  of  plaster. 

In  the  case  of  double  harelip  the  same  plan  is  to  bo  adopted,  first  on  one 
>(^,  then  on  the  other;  but  here,  us  the  gajts  are  wider,  aud  the  tension. 
Kit  particularly  when  the  iutcrmaxillarv  proniiuence  is  very  projecting, 

■pt  to  lie  considerable,  it  is  necessary  to  support  the  cheeks,  and  thus  to 
itvent  undue  traction  on  the  stitches,  by  means  of  the  check-compressor 
'ig,  70(i)  or  proi>erly  applied  plaster.  In  this  way  all  risk  of  the  stitches 
tting  out  before  union  is  completed  is  avoided ;  un  excellent  and  solid 
ion  will  speedily  be  obtained  even  iu  cases  of  double  harelip,  with  some 
xrmaxiUary  projection  and  fi.isured  palate. 

The  operation  occasionally  fails.  The  prolmbility  of  the  occurrence  of 
;h  an  untoward  event  is,  however,  greatly  diminished  by  the  use  of  the 
Bek-com pressor.  It  may,  however,  happen  citlivr  in  consequence  of  tlie 
ild't  health  being  in  an  unsatisfactory  state,  so  a-^  to  prevent  union  by  the 
It  intention ;  or  in  consequence  of  the  pins  having  been  withdrawn  too 
•ij,  before  secure  cohesion  has  been  effected.  In  such  circunuatances  as 
■e,  an  attempt  might  be  made  to  unite  the  granulating  edges  by  the  rc- 
rodaction  of  the  pina  or  sutures,  and  by  firmly  fixing  tlic  lip  by  means 
the  check-compressor  or  plaster  applied  as  above  <lcscribed.     Such  at- 


612 


PLABTTO   StrROXRT   OP   TflK    FACE    A»D   HOCTB. 


cem|ttit.  liowpver,  nirely  aucreetl ;  should  llicr  not  dn  m,  it  will  aMnllyl 
found  inncit  prudent  trt  «ujc  at  least  a  mouth  before  taking  an;  furtliirM| 
and  tlicn  (o  pare  the  rdgM  nfmh  and  repeat  the  original  npfratioo. 

(.'0N<;KXITAI-    TKANitVERKE   FlMITRFJI   OK    TIIK   <'lll:l^Ji.4,    «Wr'lii^  '•  ■ 

the  angle  of  the  mouth  to  the  anterior  border  of  the  mameter  or  <. 
the  mfliar  bone,  are  occajtionalty  met  irith,  and  have  beca  aneeialljr  immn 
by  Klein  and  Nimti.  Tlieir  mode  of  origin  has  been  alrMdy  r«fan4 
(p.  CM).  In  iheite  ma  1  forma lionD,  «hifh  are  of  ftxtremetv  tmn  nooofia 
the  eftr  on  tlie  all«oie<l  side  ie  impertcclly  developed.  AiLm  bwa  otew 
by  Fi-rguiwon,  tli^trKfjue  is  detarlit'd  from  thv  auricle,  and  i»  lixr«l  lal 
cbvfk,  K'livre  it  luruib  a  ^niall  lubuiHied  appendage.  The  «xti-nial  car  gi 
erallj'  is  uiHlturiiicd,  the  helix  being  tnii^ted  and  curlnt  invMnlVk  IImswh 
forwatioue  rtniuire  to  be  trealol  on  fXMctly  the  ^aine  pniK'iptn,  and  vithi 
eanie  atti-uticu  lo  dftatU,  a»  bar«lip;  union  betne^ii  th«  patwl  edge*  b<i 
ellccted  by  uicaue  ut  Imrelip  pine  nod  the  Iwietmt  suture. 

Cuuixji'LASTY. — Sintpte  plaBtiu  u|>enitiotui  are  cnnini<mly  pmctiacd  tis 
lower  lip  for  the  retuoval  uf  cpitliciiuum,  by  culting  out  a  V-^'"'"-'  "^ 
the  lip,  including  ibe  wliule  di^'aned  structure,  and  ibrn  bn;  ,«li 

the  opposite  uidea  of  the  ineiiiiun  by  harulin  piua.  Tfaae  ujK-ratt.<iui  fa 
already  been  de9cril>ed  and  figured  at  p.  064,  vol.  ii.  We  shall  oaati 
here  tnofee  cswa  in  wliich  it  beconiep  necvteary  tii  rvjiair  more  or  law  ixt 
Bive  Iw^  uf  eubelaoee  in  the  laliiiil  structures.  The  rertonuioo  nf  a  port 
of  the  lip  that  h«?  been  deetniyed  by  acciilent  or  tltaeaM,  is  not  M  rmd 
effected  as  that  of  the  none ;  yet  a  good  deal  mar  be  done  t>i  r«CDOT«  Um 
fiMloity.  The  plan  originally  irtrriduced  by  Cbopart  ronsiata,  wfaro  it  a  I 
lower  lip  that  is  derormed,  in  carrj'ing  an  incLiion  each  side  of  the  diaM 

Sortion  of  the  lip  vortically  downwarne  hrlow  the  jnw,  for  ■  grtttcrcrl 
islancc  according  to  the  amount  to  be  removed,  rven  if  necci^vy  M  ftr 
the  byoid  bone.  The  diseased  part  of  the  lip  is  then  removed  bystn 
Terse  inetfliou  below  it.  The  anuare  fiap  mnrKed  out  by  the  two  rMtieal  i 
ci«iuui  id  then  detached  from  above  dowDwaads.  It  in  then  broaxbt  up,  ^ 
fixed  to  the  iwrr-d  4*<lge«  of  the"  remaining  portion  of  the  lir  ''  "t* 
tuture;  the  head  being  kept  properly  inclined,  id  order  to  nd 

tenntni.    AA«r  aufiicient  union  hat  taken  place  to  presenre  tor  i  \i*niy 


Hg.  TIL— 14UM  •!  Intdiiso  la 
C1i«n«|>li*(j. 


fig.  riS,— iBcttUw*  k«4  i«t«n*  » 

I 


the  flap,  il«  lower  ntlaehment  may  be  divided.    Thi»  operalios  in  ant  i 
very  salinfiirlnry  in  ila  re*utu,  as  the  new  flap  is  npt  in  Ix-cme  <nlf 
and  invertMl  at  the  edge,  or  the  flow  of  saliva  maj'  interfere  «ith 
UDloa.     In  ibowe  cnses  in  which  the  greater  portion  of  thv  lower  lip  hM  h 
^ excised  fur  cnnrerouK  diseflse  afft.'^litig  ita  upjicr  mm  !ber  prMnl 

jr  ll>e  rexlorntion  of  ihe  dotormily  cunsints  in  a  i  >a  of  tbe  p 

reeonimvnded  by  i^rn-ii ;  and  from  t.bi«  I  have  deriiKl  i^ttlknt  rvulla 
in  the  case  which  is  here  represented  (,Fig.  711).     The  object  uf  tlw 
lion  is  to  raise  the  luwer  lip  to  a  level  with  the  incisor  tei*ih.    Aa 


bitchanan's  operation — syme's  method. 


61S 


iboot  tiiree-qu&rten  of  an  inch  in  length,  ia  made  directly  outwards  from 
tbeugle  of  the  mouth,  on  each  side,  into  the  cheek  ;  from  the  extremity  of 
tbiiitcutis  carried  obliquely  downwards  on  to  the  upper  margin  of  the 
lover  lip,  so  as  to  excise  the  included  triangular  piece ;  the  lower  lip  is  then 
diiKcled  awaj  from  the  jaw,  from  the  inside  uf  the  mouth,  and  a  V-shaped 
piece  u  taken  out  of  its  centre.  By  means  of  a  harelip  pin  on  each  side, 
tod  a  point  of  suture,  the  incisions  in  the  angle  of  the  mouth  are  brought 
•OTritely  tofiether;  and  in  the  same  way  the  vertical  one,  in  the  centre,  is 
anited  (Fig.  712).  In  this  way  the  whole  of  the  lower  tip  is  raised,  and 
brouf^ht  more  forwards.  If  care  have  been  taken  in  removing  the  cancer 
tron  the  edge  of  the  lip,  to  leave  the  mucous  membrane  rather  long  (which 
■ut  alvays  be  done,  when  the  skin  is  affected  to  a  greater  extent  than  it),  a 
pnd  prolsbium  may  be  formed,  and  the  restoration  effected  with  but  little 
<fcfi>roiity. 

Buchanan,  of  Glasgow,  as  far  back  as  1841.  published  an  account  of  a 
Method  for  restoring  the  lower  lip  when  affected  by  extensive  cancerous 
^uease,  which  leaves  niiwt  satisfactory  result*.  The  nccorapanying  figures 
i'lustrate  the  kind  of  case  in  which  Buchanan's  operation  U  applicable,  the 
JiDes  of  incision  required,  and  the  appearance  prtMcntiM]  by  the  chin  and  lip 
*ft«r  the  disease  has  been  removed,  and  the  Aitjis  brought  into  proper 
'PP"i6ltiyn. 

,  The  steps  of  the  oiieration  are  simple,  and  the  result  is  excellent.  The 
^Oeased  part  of  the  lower  lip  is  first  removed  by  an  elliptical  incision  (Fig. 
'^3,  ABAi.  An  incision,  II  c,  ia  then  carried  downwards  and  outwards 
*">  each  side  of  the  chin  ;  ami  another  incision,  c  n,  upwards  and  outwards 
P*r«llel  to.  and  corresponding  in  length  to,  a  it.     The  Aapa  formed  by  these 


Fijr.  :i-.  Fi^'.  Tl*.  Fig.  71 J. 

Bu'ih&tian'i  0|>eriitioD  for  the  He 'tor. it  ion  iif  the  l.'ini-r  1.i|). 

|nei.*ii>ns  are  represented  in  Fig.  714.  They  are  detached  from  their  sub- 
jacHfDt  tfmnectiuns ;  an<l  the  whole  is  raised  ii[)Wiirds,  so  that  the  curved 
int-wioii,  A  B,  comeu  into  a  horizontal  line,  and  is  miidc  to  constitute  the 
'*»a.r;:in  of  the  new  lip:  the  spcondiiry  incisinris,  n  c,  canning  together  in  a 
vertical  direction,  in  which  thev  are  retaini'd  bv  twisted  nod  interrupted 
lUturPs-Fig.  715>. 

!^yme  recumni'^ndcd  n  somewhat  difftTont  ni'idu  of  op(?ratin<r.     Iiiiitead  of 

iHe  ioi'iaion^  c  i>  beinir  niiidc,  those  iiiarkotl  it  c  are  carried  onwards  for  some 

duuDce  in  a  directiun  curving  downwanln  and  outwards,  so  tliat  thev  tcr- 

ninkleil  bt>low  the  unglt-s  of  the  jaw.     The  (laps  so  formed  arc  raised  and 

oniiwl  in  the  middle  line,  us  in  Ituchanan's  o[n'ratiun,  the  y\-sliapi'd  portion 

of  (kin  ahiivc  the  chin  serving  to  inuiniain  them  in  ]>nsiti<ii)  and  )>reveiit 

™ir  sliding  downwants.     The  long  ciirvoii  incitiinirt  i-iiiihU'  tliis  tu  ho  done 

•Y^creiv  stretching  the  convex  edires  of  the  flaps,  without  sntiieientlv  dls- 

paciD)!  them  to  prevent  their  readily  meeting  the  eoiiejive  edires  nf  inter- 

jwingikiD,  and  being  united  to  them  by  sutures.     No  siirtjiee  is,  thercfon% 

'"tlo  granulate,  and  ttie  wdiole  wound  heals  by  the  first  intentiim. 


«14 


PLASTIC   SUROEnY    OF    TIIK    PACK    AND    MOUTR. 


In  performing  tbb  operation,  it  ie  cwoiitiwl  to  luco--  ^el 

Bhoiila  hv  ftithciently  Tree,  «>  thiil  tlie  llu|>s  may  b«  bi  >:ii 

withoQt  tension.    If  the  chin  he  reatored  lu  w«ll  ns  the  Juwvr  tip,  it 


(i^^, 


Itia  LoBw  I.ip.     L.tBM  gf  Inclaloit, 


Fl|'  TIT,— A/Bv'i  nMbikJ  af  r*M«rl« 
tb«  Irowcr  Lip.   Op»r»ll<ai  i 


very  difficult  to  refitnre  the  Iom,  aa  there  is  do  Bxed  point  brJow 
t.he  new  li[>,  which  coaMM)tieDU}'  teoda  lo  sink  dowowartb. 


rbijR 


PLAarif  HVROGUV  OF  THE  PAt^TE, 

Viiriouedegreefluf  conjivnitMl  deformity  may  occur  in  the  palate  aadl 
thus  the  uvuliioloite  may  be  bilid  ;  orthecI<^fl  majexlrml  tlir'-' 
part  or  iho  whutu  of  thv  soft  palutc ;  or  the  hunl  patnlc  mi>- 
well  (Fig.  lis);  and,  lually.  Int.'  separatioD  nutv  fxtcnd  forv 
tecutnentB  of  the  lacv,  produeiiig  muglc  or  iluubte  linirlip    )  1 

8(itl  palate  »ni]  uvitln  are  not  uufretgueutty  cleA  williout  the  h.->  he 

divided:  aiid.inwmie  very  rare  ear-e't.  the  lip  iind  the  hard  \<a.  ■  -*u 

without  ihe  sofl  being  eleii.     The  mude  uf  urigin  uf  ibcse  derunaitM 
alrvady  been  dftcribfd  ;  p.  C04). 

These  mairormHiione  u(-ct■ti.^nrily  pivv  rise  to  gn'M  incouvenieocK,  by  ia< 
ftriog  with  deglutition,  and  n'mli-rinf;  speech  nnKil  and  im[H>rftNl      t'^-r 

the  Hwullimiug  of  lluifln.  Lberv  i>  a  t- 
regurjfitalion  thr<>ui;h  ibe  u<>»e.  tbMU;^>i  t.nr 
uccnxiunully  prevealed  by  ibe  apiiroximal 
of  the  edges  of  the  fisuure  in  tlie  wad  nalab 
An  infant  bom  wilii  a  cleA  polat«  m  hm 
aarily  uuoble  l»  vuL-lc.and  unlcM  oarrluJIy 
by  hiind  will  e>>un  perish.  It  nii)«(  Kf  fpti  mJ 
on   milk,  ihf   n»o(htr'~  |> 

nhioli  nmy  hn  drawn  fir 

i*tcr<-d  toibi-child.      I 
by  tt  properlr  iMnrtni' 
the  milk  will  6<>w  «b)wly  witbotit  itie  on 
»ily  of  sucking  on  thv  part  of  tb«  rliiM;  i 
muvt    be    6ll(>(J    with  an   Imlia-nibbcr   tu 
which  nuist  be  piubtil  well  ir*  the  back  of 
pharynx  an  the  milk  is  given.     Id  the  abaencii  of  a  bottle  ibv  child  OHJ 
vrrr  efficiently  fed  by  meanfi  of  a  teaapoon. 

Catil  B  fen  years  ago,  the  operoiiou  wa*  alwaya  deferred  until  Lh«  pati 
bad  Htuined  i^e  age  to  undemaod  tbe  neeeaity  of  renuiniag  quid  dofi 


8«n  I'aUig. 


SOBAPHT. 


6lfi 


[lb  pnendhig,  and  wts  able  to  rontn)!  his  movitnii-nts,  ns  RiK^rpfn  Hpprnded 
tmiRAt  neftaure  a|uin  Ii'm  rpnininin;:!  perttrtly  tranqtiit  ami  ^te»iiy  during 
ihtMHMary  manipulati'in^.  whii^li  nre  of  a  tedious  and  prolrn«led  chnrncMr; 
llpm  hu  aMLHlin^  tlif^  Snrgemi  hy  nppiiin^  liiii  month,  and  Dot  dtru^jgling 
the  intniduriiiin  of  itiiitnimciiLa.  ('hnlortiforin  was  never  xdiiiinis* 
"nun  tlie  fear  thni  siilfocftLion  nriif;ht  be  onui*ed  hy  ihe  hlorxl  from  tho 
Mmn,  which  is  aIwhys  abnndaiit,  entering  the  airpA^siigcs.  In  ll$69, 
iivtrtr,  Thoniat  Smith,  of  t?t.  liariholoiuewV  I|iwi>itii),  demonstrated  CliaC 
liifa  pr(>per  t-are  tinie^lbetica  may  W  eafvly  adininislered,  and  at  the  «ame 
|W  ioreot^t  a  tmwl  iug«uioiii>  gag,  ijy  oieaiis  oi'  whidt  the  |Mitieul'a 
^"lon  hv  kept  widely  opeo  witliuut  the  Surgeon  Iwiiig  inlerferud  with 
'ky  tbe  ban'U  ufaiwtstttuts  ur  the  iu«trumeuL  itself.  By  the  helpuf  tbia 
Mud  th«  adiuii)ji>tnitiou  of  i-Iilurjt'oru),  the  uperatiuu  can  now  be  per- 
■nKd  at  HDV  age:  hut  a«  the  bieediog  is  always  very  free,  it  is  advinable 
Mb)alt«inpt  it  in  t'lo  young  elnldreo.  At- the  age  of  three  it  miiy  be  »kfeW 
ofatakeQ.and  thr  ndvnntage  of  having  it  done  before  the  child  haa  learned 
IBi|wk  u  very  j^reat. 

inipmrLORAlliY. — The  o|«'miiim  ftir  the  cure  of  a  cleft  in  the  sofi,  palate 

■nr  tie  Mid  tu  have  bf-en  intnidiiivd  by  K'inx;  for  although  several  Hitempts 

It  itip  cure  nf  lhi&  deformity  hail  been  made  by  Surgeons  before  hi*  time,  yet 

it  iu  the  finut  to  eeilahlish  Staphyioraphy  as  n  <li:4tinm  operation.     Many 

todiHrations  of  Roux'fl  plan  have  Itepu  i>racti?ed  by  Von  Grafe,  Warren, 

I^irfftnharh,  lji«|on.arid  others,  in  order  to  render  it  more  easy  of  exeeutioo, 

jtO'l  nrisin  in  iti<  resiilti<,  and  especially  by  making  iucision^  thnsugh  tfa« 

rnklp  tn  as  to  take  iifT  the  traction  on  the  sutured ;  but  to  Fcrgusson  vaa 

'flu  iIm>  tocrit  of  intnwiucing  u  now  principle  of  treat meut  in  the  operation, 

*ia,lJH  application  of  nivotoniy  to  it,  thus  paralyzing  the  muvement^  of  the 

(Backs  (if  iho  palatA.     Fergu&iion  was  of  opinion  that  the  great  caitsA  of 

Aflm  b  theac  operations  whs  the  mobility  of  the  |>art»,  ami  the  iraclioo 

WBdMsd  by  the  mu»fW,  principally  the  levator  palnii  and  the  [>alato-pharyn- 

Cn^oo  the  lino  of  union  ;  in  order  to  obviate  this,  he  cono^ived  lIir  idea  of 

•rtiof  these  muscles.     Before  Ferpuw-m  laid  down  the  principlee  of  thia 

9intii.iD,it  18  tni«lhat  various  cute  had  been  made  in  the  palate  ur  different 

Rii»i.,n.  H-tth  the  view  of  taking  off  the  l^usiin  after  the  euturw  were  tied. 

>'nbach.  Pancoael.  Liston,  and  S^iillot,  ntl  recommend  that  the 

'■■- I'  the  atilches  should  be  lessened  by  longitudinal  iocisioDa  in  the 

^i-m  pendulum  nalati.     Metluuer  prac- 
'  'Lil  imall  iucinionB  lor  thi#  pur- 

Ma»<jn    Warren   divide<l    the 
■f'tri  jf  pillar  of  the  fauceg  and  the  at- 
Cirlin><-f)i9  of  the  palate  to  the  [umierior 
ing  nearer  than  nuy  previi' 
.    FiTgu«»oiiV  im'ih<«i.     Th-  - 
however,  were  ilone  almoft  at 
.ind  in  an  empirii-ul  way.  wiih- 
^^nitionof  any  diiitinct  prinriple 
'■    .  ,,..  uvcd  in  thwiii. 

OpmtiaiL — The  patient  i*  placed  in  lh« 
'•owi' — •  — 'Mon,  ihr  Surgeon  ^landiuij 
■•M*  Tlie(tng  M  theu  inwrlwl, 

lorni  ndminiMiTeil.or  if  iIh^  pa- 
oUf  the  a>tii  may  be  inM-rtetl 
ittoia  hi  imluc-t-d.     The  ung  re|»« 
io  the  aceoiii|>nnying  driiwiug  i  Fig.  719)  b  a  modiRcatioa  of  T. 
'i,  tBTvatol  by  Wood.     It  eon  be  adjusted  to  fit  any  patient  by  m^tra 
^Um  widely  aefNLratiiig  the  two  hatveik 


rig.  ri*.— WM4'i  M->aisiuiii<i*v( 

Smitti't  Oi(. 


616 


PLASTIC   SUBOIBY    OV    THE    FACE   ASb    MODTB. 


Id  the  operntiun  »s  p«rfurmcd  bv  FerKUMon,  Uicr«  ftr?  fotir  (tiiUsci  (Cm 
L  The  mtueJe*  of  Ute  paiate  "re  iJivifien,  by  pOBSiog  a  currrd  ImoifiW 
knife  tlirouKli  Ibe  (isaure  belitml  ibe  vi:Ium,  loitlwar  bctvrcra  iu  altaekarM 
to  the  liunf  paliite  aud  the  fn-e  lllB^^iD,  ond  sbuut  Imlt-way  lKit«nA  lli 
T^lum  anil  ihueuil  of  tbt>  Kiislachiaii  tube,  by  ciiUiii;;  di^eplj  iritb  tbrpiitt 
of  tbe  kuife  in  tbls  eitualiuii,  tfae  levator  pslati  i»  dividml.  Tbe  aratiil 
theu  Mtzwl  auil  drawn  biruards,  do  as  Ui  pul  liia  piMti'riiir  |»illar  of  tbe  fcua 
on  the  Htretch.  wbich  is  u>  be  snipped  acrtw*  so  aa  lo  divide  the  |MUaiD-|ifaaij» 
ecus.  The  aiUerior  pillur.  tbe  iialaUvf^IoanM,  may  ihen  be  notdwd  ■  i 
similar  way.  %  Tbe  mtxt  blep  in  tbe  operation  oonaista  in  fMrtMf  Ai  eift 
of  thf  fijmtre  from  above  downwards^  by  means  i)f  a  abar|>-painlcd  biilnan. 
This  is  best  tloue  by  wising  tJie  lower  end  of  the  uvula,  nutting  il  obh 
stretch,  and  ctiLliii?  ftn<t  imona  side  and  then  txn  the  other.  leaviDK  tbeaB|k 
of  uoiuD  to  be  allerwiinia  renKi%'ed.  A  piece  of  'u-v  tixe<l  in  a  boUcf  MF 
then  be  applied  to  the  wound  to  uheek  the  henHHrhajfe,  while  the  &MCi  M 
Ircuuently  cleare^l  of  bloul  and  mucus  by  meBii>  of  sponge*  on  tpH*- 
holders.  3.  When  tbe  bleeding  is  arretted,  tbe  Surgfwi  nnic««<I«  to  m 
next  step,  that  of  introducinrf  the  tulurtm.  The  best  niiiterial  f>tr  thoe  ia.  b 
must  cases,  fine  silver  wire  or  silkworm  gut.  Catgut  i»  nbacirhcd  tfn  rraiST 
and  19  apt  t<i  yield  before  tinion  is  cx)inple(e.  (?ilk.  «bich  wa«  f'lnri.'Tlt  iml 
cnitnnt  be  retained  beyuod  a  fewday»,  as  it  exeites  too  murb  irr 
•oaked  in  deciimjMieing  Huitbi.  Huree-bntr  will  be  fiiiind  nveful  m- 
UTula,  but  U  not  strong  enouf^b  for  the  other  piirte  of  tbe  pnlntc.  ^'' 
are  umially  introduced  by  a  tubular  neodle  ^pecinlty  ouMtructeii  i-.-i  iih-  {•l^ 
poee,  from  which  tbe  wire  is  protruded  by  a  cniall  wherl  at  tba  lowar  mi 
In  the  absence  of  thiti  apparatus  they  tuny  be  very  rvtidiiy  na»od  asibllu**. 
a  common  tioivui!  uee^ile  i?  threaded  with  a  loop  of  fine  silk ;  this  is  nasMl 
throujjb  the  right  aide  of  the  clefl  and  drnwn  out  at  the  moutli.  AMsiltf 
loop  ia  then  jtfmrl  on  the  left  side.  The  ri^bi  loop  is  then  pawrd  Ifaw^ 
the  left,  which  is  withdrawn,  carryiog  the  tir^i  loop  with  it  thmngh  (Im  M 
side  of  tbe  palate.  There  is  thus  a  double  ligature  passed  bckm  tfcaiM 
having  two  tree  endfe  oo  tbe  rl^i^bl  aide  and  n  loop  uo  tbs  left.  A  fine  b*^ 
ie  tlien  made  with  a  pair  of  diweeting  forceps  on  a  piece  nf  wire;  Oat  * 
booked  into  the  loop,  wbieb  is  then  withdrawn,  carrying  tb«  wire  witk  '■ 
across  thu  cleft.  Tbia  prucoedinjr,  though  it  seema  rather  ciiitipli/Kt«l  is* 
written  deiarriiiiion,  can  be  oarried  out  with  great  caae  ami  rapidiiy;  tf' 

the  Qfodic  being  passed  on  both  sides  from  oefjre  bodcwardK,  '^ "^it* 

can  be  inserted  more  aceuratelv  and  eveulr  than  when  no  ■<!  >* 

passed  fVom  Ikchlnd.    In  tying  tbe  knots,  great  care  *bi>uld  li< 
no  undue  trarljoD  be  rxt-rcised  ui)ou  the  parts ;  tu  fa«t,  ibe  lue  . .  t 
is  not  to  draw,  but  siinply  in  hoid,  tbe  parl»  tot;i>tber;  tbp  di\ 
muarlm  btu  (.^uH-d  these  to  be  relaxed,  »>  timl  thrv  hung  Jnwi: 
merely  require  to  be  held  in  u|ijKMiliiiu  by  tbe  Mutureau     Ti^     ;<  ■.' 
next  i>e  put  to  be<l,  and  every  cure  tnkm  in  uvoid  snv  hiik-i -<  m 
IHilalr.      He  nhoubl  l>e  re»triitt-d  to  tluid  but  Hooi  -1  for  a  few  limf  "^ 

and  (hould  be  dire<.-teil  t<>  Hwallow  lliin  with  n^  li:  ■■  nv  p^wablswa^^^ 

iodeeil  should  oi»t  be  allowed  anything  »itltd  until  complete  union  baa  tak^^^ 
place.  ^|>enking  muxt  be  strictly  f'^rbiddcn  uutjl  uni'>a  is  cuupleie.  -'^** 
Tke  HMtesthouid  be  Irfi  in /or  »nrrui  days;  and.  iii'li.''.-<l.  not  be  disliirbed^^^ 
lone  as  ihey  pru<lutv  no  irritation.  Tbey  uetially  ri.t)uire  rrmoiral  by  t^^'[ 
uigbtb  or  tenth  day.  but  occnsionally  may  be  left  with  ailvantage  for  m>^^^ 
lime  longer;  they  sh<>uM  then  be  cut  across  with  soisson  and  drawa  o^"*** 
thfl  upper  ofw  0rsL,  the  middle  next,  and  the  lower  one  last.  Should  ihuiu  si» 
be  any  aperture  leSi  in  the  palate,  where  uaiou  bu  not  lakes  place,  ihk  m^^ 


TJBANOPLASTY. 


617 


be  eloaed  by  touching  it  vrith  a  point  of  nitrate  of  silver,  or  the  tbermo- 
cuteiy. 
The  voice  in  these  cases  does  not  usually  recover  its  natural  tone  after  tfae 

rUOD,  although  in  some  cases  it  may.  The  nasal  or  "  Punch-like"  voice 
u  often  left  afler  operations,  ap|>earB  to  arise  from  two  causes.  The 
lint  tithe  mere  habit  of  faulty  articulation,  and  this  can  be  corrected  by 
cuefiil  instruction  in  elocution.  The  second,  which  is  much  more  diiBcuft 
to  deal  with,  arises  from  a  mechanical  conilition,  and  is  dependent  on  the 
coDtnction  upwiards  of  the  palate  along  the  line  of  the  cicatrix,  so  that  the 
nlum  becomes  unable  to  shut  off  the  posterior  nares  from  the  pharynx. 
MiKoi  hu  proposed  to  remedy  this  condition  by  dividing  the  soft  palate 
perpendicularly  on  each  side,  so  as  to  leave  a  square  and  mobile  central 
up. 

la  dividing  the  levator  palati.  Pollock  adopts  a  different  practice  from 
ihtt  of  FerguBson.  Instead  of  cutting  from  behind,  he  passes  a  ligature 
ittrough  the  curtain  of  the  soft  palate  so  as  to  control  it  and  draw  it  for- 
*udi;  then,  pushing  a  narrow-bladed  knife  through  the  soft  palate  to  the 
iuergiUe  of  the  hamular  process,  he  readily  divides  the  muscular  fibres  by 
ninog  the  handle  and  depressing  the  point.  This  mctliod  of  dividing  the 
Icninr  palati,  which  is  analogous  to  the  plan  employed  and  depicted  by 
SWillot  (Figs.  720,  721,  722),  appears  to  be  more  simple  and  easy  of  execu- 


tig.  7-:v. 


8'''Jillnt''  I  l{jcrnti<iii  fur  Sla)iliv1orn)ihj. 


KiS.  722. 


Eion  than  the  division  of  thn  iiiu?ck':<  of  the  velum  from  behind.  The  gap 
Chat  is  left  closex  witliout  difficulty  by  grniuilatioti,  and  seems  stilt  more  to 
^ke  off  ten:<iiiu  from  the  pnrt^. 

In  S'lme  cai^es  in  which  the  clrfl  i.<  limited  to  the  soft  palate,  which  is  how- 
ever otherwise  well  developed,  sn  that  diiriiif;  atteiii])tod  dejrhitition  witli  the 
mituth  oix-n  the  two  side^  o("  the  li?i»ure  nifet  to  a  eoii^^idernbie  extent,  divi- 
lifiD  'if  the  iHuscles  may  be  di.'i|H-i).-'od  with,  «n<l  two  (loop  cutiires  <>('  tiiii-ker 
trir*"  intr-Klured  to  relieve  tlio  stniifi  mi  tlie  liner  slitclies.  The  dec|>BtiteliC3 
may  !»■  retiioved  on  the  t'niirlli  ur  f'riih  ihiy. 

l'KAXOri..\sTV.— Fissures  of  the  Hard  Palate  nre  iisuiiily  clo-id  by  nii'iins 
iif  "  iibiuriitor*"  mnde  of  l'oIiI,  viil<';Miitt',  ur  ivoiv.  To  Wnrnn,  I't'  li.'htnu,  is 
untloubtHiIly  due  the  merit  of  liaviiii:  Ikcii  the  tiriit  to  clur^e  thtgc  lis^iirvS'  by 
a  surgical  o|>er»tion.  The  oprrutiini  wii-*  first  brmiyht  bofnrc  the  i'mlission 
in  this  oiuntry  by  Avery  mid  .■iiil>siiiin'iitly  liy  I'olloek,  wbii  have  iiiviiited 
Some  very  ingenious  iii.itnniitnlH  fur  ils  inajier  jut  forma  nee.  Warren 
(tperaied  by  dissecting  the  soil  tisi^ues  tVom  the  palat.il  areh  In-tneen  the 


618 


PLASTIC   aUBUKRV   OF   THK   PACE   ASU    ICODTH. 


maretu  of  tlie  cteA  and  tbe  edge  of  the  gum,  and  tbeo  uniting  them  in  the 
midule  liue  by  iiicaas  of  8titcbe«  in  tlic  e^unic  wrv  a^  in  ti^surc*!  «oll  palate. 

If  tiiG  &tvh  of  the  palate  be  very  lii^h,  tUerc  tuay  be  suliicieDl  tissue  to 
raotil  io  the  middle  line  nbcu  sepRrutcd  front  llic  bouc  and  allowed  to  banR 
dowi),  bill  it  ii!  better  not  tu  Lruxt  to  tbii.  but  to  iimkc  a  free  iDciiioD  on  each 
aide.  Tlio  <i|»'ratiou  ia  iH-rforaiL-d  lu  ilie  followiuj;  way  in  a  ease  of  com- 
plt>lc  irlvfl  of  ttki- liHrd  palaio.  An  iiiciHion  Ls  luiidn  from  near  tlie  canioe 
UMitli  |i»ru]Icl  tu  the  aiveoUir  niur<;iM  iiiid  ulxmi  u  ttiinl  of  au  iiicii.  or  itm. 
interniil  to  ii,  reactiiii;:  b»ckwaril»  to  a  little  beyond  the'  last  niular.  A 
M!t»)tid  incision  is  tlieu  madu  iilunf;  the  edgH  of  the  cleft,  at  thu  junction  of 
the  uiisat  and  {>alntul  mucous  ineiuliranra.  Thid  ineixion  must  be  carried 
bBtrkwardM  into  the  Hitl  pulatt',  from  which  a  strip  of  iuu«»iis  membrane  must 
be  reiiwu'eil,  as  in  ihu  ii[»eration  for  clnKure  nf  clefta,  impliailin;;  that  [>ari 
only.  The  enfl  Htrurtun>fi  cfivering  the  hitnl  palate  are  then  raiR-U  fnun  the 
bane}i  with  a  curvt-d  |i(>rioHtral  elevator,  shaped  someivhut  like  an  unmiriatn 
needle.  In  fact,  if  ihe  pnipcir  insttrunient  be  nnt  at  hand,  a  fitriing  aneumui 
needle  will  aiiswer  ihr-  ptirp.i»e  admirably.  The  periiwteum  should  be  miseil 
with  the  flap  as  compt.-iely  an  possible.  Lnnyenl>eck  point*^  out.  that  if 
this  he  dune,  not  only  are  the  tlaps  thicker  and  stronger,  but  they  may 
eventually  throw  out  iMDe,  and  thus  nii.>re  elHcieutly  cloiie  tlie  ^ap  in  the 
hard  palate.  In  raiding  tbo  Qa|ie,  care  must  he  taken  to  avoid  th<i!i>e  jmints 
aotenorly  and,  if  pi)«Mihle,  pu»tf^rinrly,  where  the  UiooJve«8cU  and  nerves 
enter.  Another  point  of  equal  importance,  as  poiut^l  out  by  Thomiis  Smith, 
is  to  gepiiratc  the  atUicbnifut  «f  the  eofl  palate  to  the  hard  with  a  eharp 
in»truinent — either  a  pair  of  j»ci»or«  or  a  kuit'e,  beut  at  a  coovenient  angle. 
If  All  attempt  he  madt^  tu  tear  this  through  with  the  elevator,  the  parts  will 
be  M)  bruiseil  that  union  by  tinit  intention  will  not  take  place  even  if  »km(Th> 
iittf  be  avoided.  When  these  structures  have  beeu  well  loosened  on  each 
siue,  the  covering  of  the  palate  will  be  found  to  lianj;  donn  na  u  curtain 
from  the  vault  uf  the  mouth — the  two  purt^  coming  into  apposition  olong 
the  meeiul  lini'.  or  poi<»ibly  overlapping.  The  eil^es  are  then  broujrhl  into 
app<j«ition  by  muina  of  wire  etitures  inCnxluced  as  before  drscriht'd  and 
without  any  drag;;ing.  On  thii)  point  great  care  is  neceesary.  lu  eaoea  ia 
which  the  Hajxt  do  not  nK:et  readily,  one  or  more  deep  sutures  of  ihioker 
wire  may  be  in>ft*rtcd  further  fntui  the  eil<;i'i-,  so  ai>  to  ndieve  the  strain  uu 
the  finer  .stitrlits;  or,  if  neccsHJiry,  the  init  ral  imrisiima  maybe  continued 
back  some  way  iiiU)  the  aoh  palate.  The  hemorrhage  during,'  the  operation 
w  usually  rather  free,  but  may  Ihj  arresieil  by  a  Ci-vr  minutes'  pressure  on 
the  blee4ling  ]K>iut  with  a  piece  of  dry  sponge.  The  patient  b  eoufiued  to 
bed  for  Mivcrnl  daTH.  and  sllowe<1  an  abundant,  but  Huid  or  pulpy  diet. 
Uuiou,  if  it  take  place,  will  usually  be  found  to  be  perfect  at  the  end  of  a 
week.  The  wire  sutures  need  not  be  removed  for  a  month  or  six  weeks. 
Id  fact,  it  iit  nnich  aafcr  to  retain  iht^ni  until  healing;  ift  eiimpleto.  uot  only 
in  the  middle  line  hut  in  the  two  lateral  wonndu  an  well,  othern-iee  the  con- 
Erneti'ms  of  ihc  granulations  ra  hcaliufir  ta\i.c»  place  may  tear  open  the  young 
cicatrix  in  thn  mirldle  line. 

Seeondury  homurrhagv?  nf  a  somewhat  aerioug  character  haa  been  kouvn 
to  occur  after  thi.**  operation.  In  one  ca^  of  this  kind,  Howard  Mar^h  mits 
ceasfully  nrrested  the  bleeding  by  plugging  the  posterior  palatine  eaual  with 
a  piece  of  wood. 

Sir  William  Fergiofloo  suggested  a  niodiHcation  of  the  operation,  in  which 
an  incision  was  niaite  on  ench  eidc  of  thv  flt^ure,  and  the  bone  divided 
longitudinally  with  a  chiiM-1,  the  two  edgve  bfing  then  force^l  into  contact. 
AllhoU(;h  ill  hia  own  liundB  **inw  enticiaetory  reaulie  were  obtained  by  this 
laethoil,  further  expcrteuue  has  led  to  the  abaudoument  uf  this  operation  as 


DISKASKS   or   THE   TONGUE — UACRO-OLOSSIA.  619 

brioK  ID  no  way  superior  to  tbat  already  described,  and  being  somewhat 
titble  to  be  followed  by  tiecrosiB  of  the  divided  bone. 

Itvai  formerly  advised  by  some  Surgeons,  uot  to  undertake  the  closure 
of  the  bard  and  soft  p&latc  at  the  same  time,  but  it  is  now  generally  recog- 
mwl  tbat  nothing  is  gained  by  dividing  the  o|it;r»tion  into  two  parts. 

Saccest  will  very  much  depend  on  the  pro[>er  selection  of  case».  Fergusson 
eoiwdered  that  about  one-half  of  the  fissures  of  tlie  hard  palate  ailoiit  of 
nccnsful  oneration.  If  the  cleft  be  very  wide,  a  welt-constructeil  obturator 
will  probably  give  more  relief  to  the  patient  than  any  operative  procedure. 
Id  act,  at  the  present  time.  Dental  ourgeons  have  brought  the  obturators 
for  cleft  jialate  to  such  perfection  that  it  is  a  question  whether  any  adult 
vlio  i(  io  a  positioD  to  pay  the  necessarily  heavy  cost  of  such  aii  instrument, 
■Iwald  be  advised  to  submit  to  operative  interference. 

Pkkforation  of  the  Hard  Palate. — Perforations  of  the  hard  palate, 
G(Mei)Deot  on  necrosis  of  the  bones,  the  result  of  syphilis  or  injury,  are  not 
amnuble  to  surgical  treatment.  In  such  cases,  a  well-fitting  obturator  will 
ntoMeBectuallT  remedv  the  inconvenience. 


CHAPTER    LVIII. 

DISEASES  OF  THE  MOUTH  AND  TIIKOAT. 
DISEASES   OF   THE   TONGUE. 

ToxcrE-TlE. —  Infants  and  even  adults  are  said  to  be  io)igue-tie<i,  when 

^  fneaum  lingusc  is  shorter  than  usual,  causing  the  end  uf  tlie  tongue  to 

^■lightly  bilid.  depressed,  an<l  fixed. so  that  it  cannot  be  protruded  beyond 

^  iocifors.     If  this  malformation  be  considerable,  suckling  and  distinct 

"ticulatiou  may  be  interfere<l  with  ;  and  then  division  of  tiio  fold  becomes 

•*«a«iry,  which  may  readily  be  done  by  snipping  it  across  with  a  pair  of 

'^Dd-end&l  scissors.     In  this  o[ierminn,  the  risk  of  wounding  the  ranine 

"Vries.  that  is  sometimes  spoken  of.  may  be  avoided  by  keeping  the  point 

•*»  (he  scissors  downwanis  towards  the  floor  of  the  mouth. 

livi'llKTItOPIIY  AND  rKOI-Al'Sl  S  ol'  TilK  T(1M  iT  i;  i  HI  MA<'tt»>-(;l.i>OIA  Is 
'*o«*inDally  met  with,  either  as  a  eongenital  or  iic'ijinred  condition.  Of  1I;1 
pMe*  Collected  by  A.  E.  Barker,  in  only  ;!;t  wiis  it  apparently  aniuired,  and 
In  ni«t  of  these  it  apjwared  at  a  very  early  age.  In  this  comlitiun,  llie 
tonpie  hdls  out  of  the  mouth  with  constant  dril)l)ling  uf  yalivii,  is  greatly 
•*flllen,  of  a  purpfufh  color,  but  somewhat  dry.  If  the  swelling  have  existed 
"*'  » long  time,  it  may  give  rise  to  defoniiity  nt'  the  teeth,  and  of  the  alveolus 
**»  tie  lower  jaw,  which  is  pushed  forwardr'.  The  protruded  tongue  is  liable 
y*  "ttacks  uf  subacute  inflammalioii.  which  lead  to  its  still  further  imreas- 
^(jin  size.     The  Patholotjtf  of  this  conilition  w;!."  tii-st  clearly  pointed  nut  l»y 

•  'rthow.  There  is  a  great  overgrowth  of  the  inler-'titiul  connective  tissue 
*"j  '^*  tongue,  and  in  this  tissue  are  fouml  dilated  tyni))halic  vessels  of  con- 

j"*rable  size,  and  spaces  filled  with  lymphoi.i  ci'lU.     U  presents,  therefore,  a 

"f^  analitgy  to  elephantiasis.     In  nianvcasc.i  the  dilated  lytiiphatics  f'urm 

^  iitiportaDtsn  element  in  the  new  lisMif,  that  tlie  disease  has  been  termed 


620 


DISEASES    OP   TU£    MOOTH    AND   THBOAT. 


fwl 


rig.  TS-t.— Ilj'iwrlrnrbr   and    Tro. 
U|>««i  «f  Tuai[<iB  In  a  bojr. 


by  some  writen  "  lyinphangioms  of  tbo  toogue."  to  tha  Trmimat  4 
thu  diiiease  prcMure  ha»  been  attempted  by  stnippinK  ihp  pnitraJti><  fwi. 
but  without  beocfiu  Exculou  of  a  porliijin  of  th«  tiiugne  by  tk»  ki^ 
•cinors,  or  lienuour  u  tba  only  efficient  remedy  for  Uw  dmram,     to 

OA»es  tlie  r«tiwv«l  nf  »  V-*hsfwd  |Hmi 
giT«  th«  bmt  reautl.  Thb  ixpantMo  «ai 
suooewfully  iwrfurmud  by  C  Bealli  u,  Ua 
case  from  vrbkb  the  Hcconipaoytas  dn«n| 
WMUkeu  (Ktg.  723 «. 

IXt-LAMUATIOK      or      THE    TuKOim,   fli 

Gi/MsiTi!},  ic  tKtt  B  common  aBlwitiMa.  TW 
raoiit  CAimmuii  form  »  tUal  whk'b  ar»»  bw 
immoderate  aii'l  iujudiviuua  ailiaiBiiUMM^ 
mercury.  lu  thip  thvtongur  beoataeafnHiT 
iwollen;  it  maj'  hang  from  tbe  ut>au,  vn 
profuse  ilisohargc  of  mIivb  at>d  inabUi^ 
thu  jiart  <tf  thtf  putit-iii  to  sirmllow  or 
nud  ixThapH  a  lhroBl«nii)|^  of 
Tlio  aides  nre  iiinrkt'tl  br  d«p  Im 
the  tiM^th,  in  which  aAdr  a  time 
may  form.  Acute  f^busitis  with  gnM 
of  the  organ  ocemtlonally  twcura  aflftr 
and  more  ramly  without  any  apparani  a- 
citing  (!ftUM>.  In  thU  form  tbrr<-  {■  toft 
pain  with  considrrubJp  fcbriln  dirioriMwa 
Tbe  tongue  iwdU  rapidly,  to  that  io  a  !■> 
hours  it  may  reach  Kuch  a'  lite  ••  to  thnaua 
^^fTncati'iri.  The  dytipnrpa  may  bv  due  1t>  the  olwtruction  caused  br  lb 
rolleu  totiKue,  or  to  cxtt^nsinn  nf  ih«  <i>(lfmft  to  llie  KrYt4vut>«pi, 
filldeof  muc<iUB  mcmbnuie.  Tbe  inflainmalion  may  <-ud  in  rc*<>lut' 
npidly  to  the  formation  «if  put.  Th.-  Trfilmmt  uf  t;l<*aitiij  rartr*  wi 
oatlM  and  tbe  tli^i^ree  nf  4He|lin]^^  It'  of  nK>r<;uri»l  "ripiti,  i 
the  CtUM,  and  ihf  ndiiiiiiiittrntiiii)  iit'  tmliiu'  |)urpilivf9>  nii*!   -  "  tf 

pi>ta«b  gargle,  wilt  uiiunliy  armt  tht*  pr');!n'«»  "f  the  iollnnimatiMn.  ll'tk 
swelling  be  very  KTe%.\,  mure  evperiully  in  ibv  idiipputbie  fortu  of  tbe 
tbe  only  efficient  trtsimeut  cmwJBli)  in  making  a  lon^  and  frt«  fueiikNi 
tbe  dorsum  of  tbe  t^iugue  on  each  tide  of  tht*  rupbv,  which  giT<n 
immediate  relief  by  tUe  escuja'  of  bIiH>d  and  infillmtcd  lluiila.  I  bare  Mi 
a  imti«nt.  who  was  ui.*arlr  KuironiLod  by  \\\v  immrnM  aixe  of  bta  loaM 
relievcil  at  m\w  by  such  incisions,  and  nearly  wkII  in  the  ooaraa  of  aa^ 
hours  aflerwanU. 

AmrRw  OF  THi:  ToNtiDR,  though  rare,  oceulonnlly  occurs.  I  haTs  ^ 
seTt'rnl  indtjiun«  of  iu  Tbe  alisertw  formn  a  flmnll,  deeply  vi^ted,  rta^irtr* 
Arm  tumor,  wlnrh  (uimetimes  frain  slightly  miivnblc,  and  prnfota  an 
firinl  diMMhirnli'>ti.  There  in  nodiaeolorntinn  or  othrr  rhnnge  in  tl^ 
mcmbmne  or  epilhflium  (if  the  tongue.  The  wiiliti  iif  thfee  glnMsl 
are  very  thick  nud  denite ;  lieuce  thn  diMSM  may.  anleM  can  ba  taki 
eaitly  miHUkcn  fcr  solid  tnmoni.  The  ahaeea  is  alwajrs  rerycbrootc. 
the  liability  to  crn^ir  in  djn^'nin^iA  in  incrrsMd.  It  is  commooly  teal*^  at  t1 
cigu  and  lowanl*  thu  anterior  imrt  of  (he  tongue,  but  it  fit»>-  ■--- 
middle  of  the  lo^gu(^  A  buy  vtnh  iince  bniugbt  to  me  with  nn  ' 
of  slow  gnjwib.  and  of  hIiouI  the  niw  of  a  umiill  plum.  *■'■  .tjiIv 

tbe  centre  of  lh<-'  tnngtm  ;  on  puncturiog  it.  about  half  ai'  bwC^ 

pus  was  let  out,  aftvr  which  the  ryat  «|Hwilily  ulrwed.  Tliv  irf^tmutmt 
mtoin  niakinua  Inngitudioal  tnci»iiiu  iuiu  tht;  absoeaa.  In  ill  laiis  nf  i 
in  diagnosis,  this  should  be  duue  before  any  utber  operation  is  uadc 


I  Ml 
'ttbl 


fnv^ 


OHSONIO   SUrEBPlClAL   OLOSSITIS — LBtrcOrLAEI A. 


ChROSIC  firPF-KFlCIAL  GLO^TTrft— rSOBIASIft  OR  laiTHYOMS  OF  THE 
ToyoCE — Lel'COPLAKIa.— Uiidtr  Ibt-at?  oames  h  iliseuseiJ  cunttitiou  of  the 
UiDKue  has  hwa  dmcribed  which  it  far  from  uacnmmoo  iu  t-hiit  oountr^  and 
in  France,  but  it  is  said  to  he  much  luse  fret^uent  m  Uerroau^'.  The  Oiwuue 
GODSisU  esKolially  uf  a  chrgnic  iDtlamtiiatioii  uf  the  mucous  membnine  of 
tbe  toogoe.  Iu  the  earliest  eUgeb  there  is  hyperemia  of  the  papiliv,  with 
some  swelling.  If  seen  at  this  jteriod  the  nmcuus  membraae  presents  red 
jwtcbes,  usudII}'  limited  to  the  dureum  of  tlie  toogiie,  but  occasioDally  ap- 
pearing Mmultaaeously  no  tbe  cheeks,  and  pa.'^iiig  through  the  saiDe  stages 
ibere  as  dd  the  tODgue.  It  cuu  be  recognized  ciearjy  only  after  the  muciius 
moDibraiie  hu  be^  thoroughly  dried  with  a  towel.     Thii*  inuel  uever  be 

f  omitted,  for  uolces  tbe  eurface  is  well  dried  it  h  impoir^ible  to  obecrvc  necu- 
ntety  ibe  conditiou  of  the  papilla'  nod  epithelium.  A&  the  diseiise  ndvaiictv, 
sna 
iopei 
male 
n«ai 
Snhn 


ansxoneive  growth  of  epilhelium  takes  place  over  the  swollen  papillir.    The 


fOperficwl  layers  uf  ocll^  beciimc  hi>rny  mid  opaque,  the  oeighbariDg  sputa 
leaea,BiKl  thus  white  patches  of  cou^idernble  size  form  ou,  the  niucuus 
^nmubrmii*,  from  which  appearuDcc  the  name  of  leueoplakia  was  suggested  by 
Sobwimmer  for  the  disease.  As  the  disease  advances,  microecopic  cxamiua- 
tion  shows  that  the  papiDoj  and  the  superficial  parte  of  the  corium  preiscnt 
'|he  ordioaiy  signs  of  chrr^nic  iuflarunmtion,  the  vessels  are  dilated  aod  the 
'nirrouuding  tiKues  infiltrated  with  smtill  round  cells.  The  next  stage  in  cho 
process  is  cJiaractcrizod  by  atrophy  of  the  papillae.  The  opaque  pstchca  then 
iMcomc  perfectly  smooth.  Iu  this  sts^e  the  surface  of  the  fiuguc  is  some- 
what iuaurated,  having  upon  its  surface  smoorh  patches  of  a  dcud-whiic  color, 
irregular  in  shape,  atid  varying  in  size  from  thnt  of  a  split  pea  to  an  inch  in 
diameter.  This  coudition  closely  resembles  the  appearance  of  pKoriasis  uf 
the  palms  of  the  bonds,  and  frnni  this  rcscmhltincc  has  been  termed  pitoriaxU 
UJ  Ihe  lungxte.  When  tlie  di>te«we  h»8  reached  this  stage,  cracks,  H«>nre*,  or 
•uperfieiHl  ulcers  niny  form  in  the  o[ia(]i)e  patches)-  The  ulceration  takes 
place  loiwtly  by  an  exaj^^emliMii  uf  tl>e  process  already  described.  At  »uiue 
point,  i»»*tibly  as  the  result  of  injury,  the  small  round  cells  become  incrensed 
ID  Dumber  br  ini^rmtiuu  fniin  the  ve*«e)s,  tbe  epitbeliuin  becutiies  loowued 
aod  is  rubboft  uH'  by  llie  movemeuts  of  (he  tuugue,  nud  a  raw  surface  is  thus 
lett,  from  which  ulceration  luay  f;rudunlly  extend.  A  ujorc  serious  result  is 
the  supirrveutiou  of  e|iithelion>a,  whiuU  is  a  couimuu  terDiiuatiun  of  the  dis- 
eaee.  Microscopic  exHrntuatiuu  of  a  touguv  iu  which  this  Js  takiug  place 
may  show  all  the  stn^^es  uf  the  disease  iu  ouu  eectiou  :  at  the  niar^iu  of  the 
patch  will  l>e  culnrged  |nt|itllw  cuvL'red  wilh  a  thick  layer  uf  epilhelium; 
iiE^rer  ihe  ventre  the  pupiihe  have  dibapfK'ared,  thecoriuiu  being  covered  by 
a  thick  layer  of  epitlH-linm,  the  greater  purl  of  whit?h  is  coiii|H>Ked  of  Uat- 
teaud  horny  sailer :  ucsir  the  centre  the  cflls  of  the  rete  mucobiiin  are  hwu 
to  be  gniwiug  anlvtly  and  forming  cilumiit^  which  force  their  way  into  the 
spaces  of  the  Bubmucous  tii^ut;,  and  further  on,  amongHt  the  mufcular  fibres. 
These  columns  are  surrounded  by  the  zone  of  small  ctdl-iufiltration  always 
aeea  at  the  edge  of  a  growing  cHUC>er. 

VBri<iU8  modificalions  of  the  nroce-M  above  described  may  lie  met  with; 
thus,  in  some  cases  tbe  gntwth  of  epithelium  is  lera  abundant,  so  that  lutitead 
of  the  formation  of  white  ptitches,  the  surface  of  the  tongue  l)eoome»  smooth, 
Ted,  and  shining,  giving  riee  to  the  condition  known  as  the  "glazed  red 
tangxie"  In  other  cases  the  growth  of  epithelium  may  be  very  excessive, 
forming  thick  scaly  masses  on  the  surface,  from  which  this  variety  has  been 
tcrnacd  iehthyoins  of  the  tonyve.  These  forms,  though  differing  in  detail,  are 
essentially  the  same  pnthologically. 

All  forms  of  the  diBCflS(^  nre  accompanied  by  some  dteoomfort,  though 
usually  no  actual  pain.     The  tongue  is  tender,  so  that  the  patient  cnanot 


622 


DIBEASBS  OF   THE    MOUTH    AND   TBBOAT. 


take  muBtnrd.nr^iDcs  or  drink  hoi  fliiids.    TbciippM^h  marbeooiMd^^ 
lispiDg  or  iniiiaiinpt.     The  durnliou  is  very  indotiuilp.     Id  Btmiecimhfl^ 
grtmeB  olowiy  for  nifinj  yennt.at  Ina  bcooiuing  stationnrT  and  anin|  A» 
patient  bui  little  iiicoDVPnieoce.     lu  i.nlicr«  ulcernlJtiD  may  take  ptu» 
a  fvwjreare.    Thciuvn«oDol'epUbcliomH  may  itfour  aft«rteDorM«ii 
yean,  and  iu  miiDy  cosm  Ibc  paticut  cscnpce  altugciLfr.    Th«  amteiaf 
disease  arc  unt  iilways  to  be  clearly  flBcrrtaio«d.    The  earlier  Hrilmbdimd 
it  tu  be  iiivariablj  an  efffect  of  ayphilis,  but  ibere  apcmfi  no  di»'-'  '^i'  ''^■ 
view  cflniMii  be  maintained.    A.  K.  Borkt-r  hua  paid  gn-al  an- 
«tibiect,  anil    to  bin  valuable  artii;le  on  lli6  "  DiM-jiMm  of  fbr    Ion, 
Ii<imi(!«'i)    S*f*t€m  of  Surgery  I   Wimbl    refer  thn    inuier  Tor    mom 
iiiT'irniHtioi)  limn  cnn  be  ^Jvpri  h^rtf.     Ho  liAx  i^tlleirted  fniti 
110<-it!*<*  of  cbrunic  siiiM-rfieiai  jiliM^ilifl.     Of  ibew.  UH  i. 
Mnd  ll  in  females.     Of  the  lUl  cii»«'t^  in  malr?t,  A.*)  ii(1<-ct*,il  tin-   : 
Z'i  tlie  t'ingu«  hikI  clieek*;  V2  ibe  lijw  iinil  cluH-k*;  1  lli«*  Iianl  [■  ■ 
4  tln'  m-nt  was  not  ineiuioned.     Of  tbe  110  pnlieiUtt.  -I'-i  hml  t>;riji  - 
eyjiliilis,  and  lU  oertaiuly  bad  not;  in  tlic  rettiainin^;  vitBn  v  vn^  : 
llicfucl  Uinluvarlvoitc-tbird  of  tbopaticuti'hadituir<r>n-*l  ff 

«ug^'i«t  Lbal,  tbougli  uol  tbc  Hitv  cauae,  it  may  form  an  imp  i  l-l: ■. .. 

the  prodnctiun  of  the  diiK-iuie.  The  diH<n^<■  vm  Hseoctnteii  with  (woriaM  <r 
eczema  in  G  of  Iturker'ti  ranee,  and  with  syphilitic  psorJnaia  id  '1.  It  haiahi 
been  seen  aiwociatctl  with  ichthyoaiH  oftiiv  tliin.  la  T')  caao  evklewcia 
given  HB  to  smuking.  Only  4|iatiet)tsdid  noteniokc,  while  46  arr  nid  talaff 
ioiliilj^d  in  the  h»bit  Iopxcpfk.  SmokinKmay.lhfrvfore,  lie  rairlvmosdoid 
to  exert  »ome  influence  «n  the  orrtirrenceof  the  dtsettie.  Oinmu!  dpfif^ 
rihI  habitual  9|>irit-drinking  are  atftn  nappoeed  in  act  aa  prrdiafinaiiiy  nai^ 
That  dyspepsia  should  take  a  p«rt  in  iu  cauntion  is  not  mirpriutijr.  u  il  ii 
well  known  t/)  every  smoker  that  the  tongue  becomes  aore  mori-  nrailily  atm 
*■  the  stomach  13  ont  of  order." 

Tbc  Pro^Dogin  ia  atwaya  bad  as  Ui  cure.  Of  the  ItO  caaca  rreortlcd  bf 
Barker  the  di^ajw  ended  in  epithelioma  iu  i3.  Tlie  averagv  durstloo  of  tw 
disease  t>cfore  this  took  place  wii»  14  yeMrs.  Hiicb  vaan  must  be  cardklly 
watched  fur  the  earlier  aigns  uf  the  iuva«oD  of  epithvlioma,  aa  by  IMT 
removal  only  can  the  patient  be  saved. 

The  TVeatment  it  not  iwnally  very  satiafnclorr-  If  there  if  any  erii*** 
of  syphilis  the  patient  must  be  treated  for  that  *)i»eaae.  SmokinR,  the  uw^ 
spirits,  and  h<>t  condiments  must  be  prohibited.  Locally,  before  ulcvratim^ 
taken  place,  Barker  recommends  frequent  washing  of  the  aioutb  with  ■  t^ 
tioD  of  bioarbonate  of  soda  (ffe.  xx  to  .^).  The  application  of  stroovcauriv 
to  the  diseased  surface  does  nothing  but  harm.  Ifsimploul'.'  '  '  L^utk* 
place,  a  solution  of  bichloride  of  mercury  (gr.  ii  to  ,5J)  apj'  :,:■  dr*" 

tongue  with  a  cnmol'^-bair  pencil  twice  a  day  will  often  be  mm"! 

uaenil.     lu  eliief  value  Ib  as  an  untiseptic,  a«  the  furfiteo  ui     >.  <  ria>^ 

lu  become  very  foul. 

Orni.R  Sri'KitriciAi.  Affectimw*  op  Tirn ToNOtTE. — Varltioa  utlwmf^' 
Rcial  afreciioiu  of  the  tougiio  are  commonly  met  nith.     The  ^mall  lao^ 
whitish  pfltchcti  or  aphthn  met  with  so  commonly  oa  the  roult  "f  . 
and  thrash  lieloug  rather  to  medicine  than  to  surgery,  and   : 
de«cribe<i  here.     A  pci'ultar  wandering  rash  which  haa  ^n  dn^ 
the  name  of  "lichenoid  of  the  tongue"  by  flubler,  hast)cmr&i 
Ui  bv  Itarker  in  tbU  country,  who  suggested  for  it  the  namx  ot     -  uma^* 
migrani."     It  is  cbararterizttl  by  the  appearance  on  the  tnneue  «f  tn^' 
circK'l*  or  cr«ri»rentic  bands  of  lightcolorH  rash,  wbtdi  rni      ' 
trifugaJly  over  lliv  tongue.     Il  causes  some  >taIivalion  ami  ii 


i^riBSI 


TUBERCULAR    ULCBB — GUMUA    OF    TONGUE.  623 

tpptreDtly  due  to  the  presenco  of  a  parasite.  The  disease  riiiia  a  chronic 
eooise,  aoil  no  treatment  seems  to  have  any  effect  upon  it. 

Kmple  TTlceration  is  not  uncummonly  met  with  upon  the  side  of  the 
tongue  usually  op[>o8ite  to  the  molar  teeth,  most  commonly  dependent  on  irri- 
tilioD  of  sharp  projecting  stumps.  These  ulcers  cause  considerable  pain  in 
eitiag  aiid  sjMraking;  they  are  red  on  the  surface,  with  slightly  ntif-ed  but  not 
enrt«d  edges,  and  the  base  is  free  from  induration.  They  are  thus  easily 
dictinguished  from  epithelioma.  They  readily  heal  if  the  oltending  tooth  is 
fillol,  atopped,  or  removed. 

Tobercnlar  Ulcer  of  the  Tongae. — Tubercular  ulceration  of  the  tongue  was 
firrt  noticed  by  Portal,  and  has  been  since  accunitely  described  by  Riiyuaud 
ud  Netlupil  and  others.  It  is  not  common,  but  occurs  with  sufficient  fre- 
<{atacy  to  justify  a  desc-ription  here.  It  commences  as  a  minute  white  spot, 
orervhich  the  mucous  membrniic  gives  way  and  a  small  quantity  of  puri- 
htm  matter  escaftea,  leaving  an  excavation  which  gradually  extends. 
Sioilir  spots  appear  round  about,  and  the  sores  thus  formed  may  coalesce, 
£>nniiig  a  larger  irregular  ulcer  with  a  yelluwisli,  uneven  euHucc,  and 
ilighlly  indurated  base.  They  occur  usually  at  the  anterior  part  of  the 
toogueat  the  edges  or  on  the  under  surface,  vorr  rarely  on  the  dorsum.  It 
itwtremely  painful.  These  ulcers  commonly  appear  in  advanced  pulmo- 
urr  phthisis,  but  may  occur  before  the  lung  symptoms  become  marked. 
Sedopil  has  microscopically  demonstrated  the  presence  of  tui>ercle  in  these 
lone.  In  a  case  under  the  care  of  Godlce,  the  tubercle  bacillus  was 
detected  in  the  base  of  the  ulcer.  In  another,  recorded  by  Jioyd,  it  was  not 
fiMiud.  The  treatment  consists  in  the  ap])lication  of  morphia  and  glycerine 
to  relieve  the  pain.  If  the  patient  is  in  a  state  to  .^^tand  an  operation,  the 
■ore  may  be  scraped  with  a  sharp  sjwon  and  dressed  with  iixloform,  or 
tke  whole  sore  may  be  dissected  out.  .Some  ctficicut  treatment  may  become 
otraurv  to  relieve  the  pain,  which  may  be  so  great  as  almost  to  prevent  the 
puieut  teeding. 

Syphilitic  Affectioss  of  tiik  Toxcik. — The  following  are  the  chief 
iTphilitic  affections  met  with  in  the  tongue:  primary  soTei  (vol.  i.  p.  1045), 
wee  in;  very  rare  and  present  nothing  peculiar;  in  the  early  secondary  stage 
papula  are  not  uncommon  ;  later  ou  irnutll  siiperjicidl  tileera  mav  occur;  and 
Uier nill ytiviircj^  with  thickened  epitholiutn  around  them  may  lie  met  with; 
■Wow  tuhereU's  are  more  rare.  In  the  tertiary  stage  the  juitient  may  suffer 
'ram  fiMureti  and  superficial  ulcers  eindlar  to  tluit<c  already  mentioned,  fn)m 
f^wiic  superficial  glostiti*  with  Irucoplnkia,  from  diffttve  iiidiiriidon  of  the 
(Vg>D,  and  from  yiimiiuiUi,  These  have  already  been  di-i-eribed  in  the  chapter 
w  ??yj>hilid  i,vol.  i.  p.  lOUfii,  and  the  gummata  alone  need  be  further 
refrrreil  to  here. 

Syphilitic  OnnLmata  are  not  unconinion  in  the  tongue.  A  gumma  forma 
<* irregular  iri'liirat^Mi  mass  impcrfoclly  cirruiiiscribcd,  and  of  roundeil  shape 
Htuatcd  deeply  in  the  riub)<tance  of  the  organ.  It  may  occur  at  any  part  of 
wtungue,  but  it  ir^  perhaps  iiio^t  frequently  situated  near  the  dorsum,  some- 
"■■Kain  the  ndddle  line,  a  i^ituatiou  in  which  i-]>itlK'lioma  is  very  rarely  found. 
«  omitDences  distinctly  l)encath  the  :*urface,  the  mucous  membrane  ciivering 
".beinnat  fin>t  unaltered.  As  it  approaches  the  surface  the  muci>us  membrane 
■•womeB  adherent  to  it,  and  dusky  red  in  color.  Under  proijcr  treatment 
''* growth  may  disappear,  but  iro<iuenily  it  sol'tens;  the  inucnus  membrane 
"'« it  then  gives  way  and  a  ragged  cavity  i.--  exposed,  iti  which  the  remains 
^  the  gumma  are  seen  as  an  adherent  i-lnugli,  rc:?>:'tnl>ling  wet  waslidcather 
"I  appearance.  If  the  gumma  is  watched  Irmu  the  beginning,  an<l  presents 
w  typical  course  and  appearances  above  described,  there  can  ite  little  difii- 
Nty  ID  ila  iliagnosifl.     If,  however,  it  be  ^een  for  the  first  time  atk-r  the 


624 


inaKABES    OF*   THK    HOUTO    AND    TUROAT. 


otutracteriBtic  slough  bus  seimrntetl,  the  foul  cuvtty  that  is  l«fl  nuy  ctoal^ 
reeenilile  an  iipitheliotiin.  It'  there  iK  ^'nat  iloutit,  s  piem  of  U>«  iloar  ifWip 
of  the  nicer  mny  be  removed  and  examined  niion%copiat]ly,  wbm  tbaHii 
□attire  of  the  dii^ase  can  usually  be  detcirmined. 

The  'Preaiment  contiii^B  in  the  admiDistmiion  of  large  d<—  of  kifidirf 
potassium,  sud  if  that  produces  no  effect  mercurr  maj  be  l^^raB.  If  lit 
gumma  8ofl«DS  nud  ulcerates,  the  same  onnstitutiunal  tmttnrat  miM  be  oa- 
tiaued  and  the  aore  dressed  with  ind<if<i7-ni. 

TuHoiu  OP  THE  To^ut'B.  FapUlomatA. — Hmall  wans  arv  auwiii— 
formed  on  the  tongac  and  are  eaflily  rL-moved  vith  aoiaaon.  WartTfmatta 
of  tai^gor  size  arc  occfuionally  met  with  composed  of  large  papill*  aaftnf 
the  cod  or  Aide  of  the  tougue.  Those  must  alwayi  be  nnrdM  with  laapjcia, 
for  epithelioma  may  a«6ume  thi^  form,  or  if  Uie  growtn  it  at  fint  rfafkil 
tendascMiu  t»  liocome  malidnaiit- 

Vbttu  and  Anearism  by  Anaaiomosii  are  but  rarely  aMO  in  the  to»m 
and  when  met  with  would  require  xx^  be  treated  on  the  aaiDe  pcindplM  IM 
guide  UB  iti  the  maDngement  of  tliu  diiteaiite  etiwwhere.  A  TCiy  reouHttUt 
liulaoce  of  ail  erectile  tumor  of  atevoid  character  afTcctiug  the  tonpiMcu» 
uader  luy  care,  iu  v  hJeh  the  whule  of  the  free  extreuiity  nf  the  wna  vw 
ioiplicuied  iu  the  morhid  growth,  pre»eDtin}:  a  club-t)hai>ed  «od.  whieb  piv 
trudc^l  Itetweeu  the  teeth  sad  lips  of  the  patient,  a  girl  about  lb  r^  >  ■■•>»  "k 

Id  these  cases  Image,  of  Bury  ~-'  -^^ 

Wbad  very  judiuioUBir  arreste<i  c  i:^ 

^  the  disease,  am)  had  produced   '  <e 

of  the  tnass,  by  tbu  introductiDn  ct  Mv«a 
which   were  worn   for  some   moatfaa;  s84 
when  tiie  child  subi»eque9t]y  cune  niKltr 
care,  the  chief  incuHTeaienco   Uiat 
resulied  from  iuterference  viUi  qiaeebr 
the  <lefuriiiitv  uecueioned  by  lb«  byveffl^ 
phied  and  ufougnlwl  at^an  iPlg.  434}.    If 
mcHikS   of   the  i^cniMtir  I   reraoTrd  all  iW* 
redunilant  tiNtiic^,  nnd  so  rrdocrd  thaUfW 
to  itis  normal  length  anil  breadth. 
A  form  of  very  viwr-ular  hjeal  b 
may  ocenr  in  the  umgue  at  a  In^ 
life,  which  may  M^rhapii  be  \tc*i 
theae  growths.     The  <iuu>of  whiil^ 
A  fcooo  represen tuition  waft  of  this  kisd   H 
oocurr^  !n  a  lady  about  50  years  of  age,  and  pulnateil  tttruotflr.    Tbtfi** 
«Me  WH«  conliiit^i  to  the  anterior  half  of  the  tongue,  which  I  'swjiiMifcBy 
rentovf^l  wiih  ttie  ccraM'ur, 

Cystic  TamorR  of  the  Tongue. — Two  forma  of  cyit  have  bw«  tsrt  wiik  i* 
tbe  tongue,  titiii<itid»,  whirh  are  extn<mely  mre,  and  mwviu  tyaU. 

tlneouM  C'yiUf  seldom  reach  any  large  xiKe.     Tbey  li«  iiuiu«^ta|oiy  h»sw 
the  macoua  membrane,  usual  ly  on  the  dorsum  or  at  uoe  side.    Tbey  ney  ^ 
•0  teoM  as  to  reaeoiblo  eolid  growths    Chronic  ahiicewM  which  era 
aoBally  found  m  the  tongue  cannot  with  cvrtainiy  be  distiDgobbed 
muooua  cysts  till  the  ttuid  has  been  lot  out  by  a  puncture.    The 
A  XDDOOUS  cyst  consists  in  dissecting  it  out  if  pcniblc.    If  this  eaasdi  be 
it  wilt  usually  sulfiee  to  punetan.'  the  cyst  and  >ppiy  *  atroag 
chloride  of  eiuc  to  the  interior, 

Pibroiu  Ttunon  have  been  met  with  in  the  tongue,  but  an 
rare.    Should  siuch  a  growth  be  met  with,  it  may  readily  be  reaored 
drawing  the  tongue  forwards  by  means  of  a  book  or  piece  of  whi 


Tmicii«. 


nisllif 

Am 


CANCZK    OF   TUB   TOSQUK. 


kt 


I  pttKd  timiugfa  its  tip,  uDit  ihcm  difsooting  it  out.  Anj  bleedlnj;  that  occurs 
BWV  be  arrpdlet)  by  liffiiture,  nr  by  piuuing  a  suture  by  mnnDS  of  a  curved  or 
concserew  ocedle  acroM  tbe  g»\>  in  thn  course  of  the  diriiled  ves<ielA,  and  l.hu» 
closiog  the  aperture  at  the  !)am<>  tim«>  th»t  the  v(«scl<i  are  compressed. 

CjtsrER  oi'  THK  TuNoL'K- — Epithelioma  is  the  tiirmot'canfer  met  with  in 
the  tongue.  Scirrhai  was  tumi^rly  rlcK'ril)«cl  an  ht^'utfi  coinnioii,  anil  ue  are 
Uul  nnw  ill  »  jMisiiioii  to  deny  tliat   it  inay  occur,  4^|i4'(-ialiy   it'  the  jrmwth 


eommeticf^  in  Un^  floor  of  the  mouth,  »nd  arise*  ixi^sibly  iVoui  ihp  Hubliii;'ual 
gland,     ll  i«  honever  90  rare, 
«crii>iug  cancer  of  tbe  tungue. 


gland,     ll  i«  honever  90  rare,  (bat  it  utxsl  uol  be  furlli^r  coDi-idt-red  in  de- 


Kpilbelioma  alrri(.i«t  alnuys  coiutueucee  ou  the  edge,  uaually  at  the  middle 
thinJ.  ext**Mdini,'  back  U>  the  antfriur  pillar  of  tbe  tauce*,  but  it  nmy  occur 
at  the  tip  of  tbe  t«.'nj,'ue.  in  the  floor  i-j"  tlie  mouth,  yr,  iu  rare  cases,  on  the 
dorsum.  It  MKi»t  uBUuUy  occuni  in  individunia  between  Ibe  «Ke«  of  40  and 
60,  It  in  more  rre<juent  in  invn  than  in  women  ;  accor«.liug  to  Barker,  iu  the 
proportion  of  *i47  to  4(>.  It  may  develop  without  any  evident  cautw  in  per- 
wos  who  arc  otherwise  perfectly  healthy,  whoae  teeih  are  Hound,  and  iu  »  hoiii 
there  bun  been  nu  precxi^litig  diM>a»e  of  the  tongue ;  but  mofit  coninmnly  it 
occura  in  conaeijueiice  of  h>cal  irrilatinn,  as  from  the  abrasion  pnKJiiced  by 
broken  tooth.  Iu  other  cam's,  as  before  pointwl  out,  it  in  preceiie<l  t'orfiome 
yean!  by  jworiania  or  other  chronic  disease  of  the  nuicfHis  meii)brarie  ( p.  fi21 ). 
It  may  ariee  in  an  old  syidiilitic  crack  or  unhealed  lisflure.  If  it  appear  in 
an  otherwise  healthy  Uingne.  as  a  tubercle  or  warty  growth,  this  Is  usually 
flat,  induralcd.  and  of  a  piirpliah-red  cidor.  ^'rndually  runninp  into  ulcera- 
tion :  if  aii  a  tii^^iire,  this  from  the  cominencentent  lias  an  indurated  base,  a 
foul  eurface.  and  a  caMou:^  e^lge.  As  the  ulceration  extendi,  n  chasm  wttb 
> averted  edge^and  ragged  ei' Lea,  and  a  el oiighv  surface  that  cannot  lie  cleansed, 
smdually  forma  over  a  widely  imiuraled  baac  ;  there  arc  great  fetor  of  tbe 
brealh,  and  prufuM  salivation  ;  and,  as  the  diflea»c  progreanes,  implieatiun  of 
the  mueou§  membraDe  and  of  the  Htnictiireii  of  tlie  tluor  of  the  mouth,  and 
of  the  glands  under  tbe  jaw  and  in  Lhe  neck,  taken  place.  Soiuetimea  the 
whole  tua«i  of  the  organ  i»  iiitiltrated  by  the  cancerouH  growth,  becoming  gen- 
erally hard,  nodulale^l,  ulcerated,  an<l  in  some  pariK  covered  by  thin  n^j  i.'ira- 
^trices,  and  in  otberti  by  foul  puUy-like  acciimmnlationA  of  epithelium,  Tbe 
lin  ia  very  severe  in  mo^t  ciitiei>;  every  movement  of  the  organ  in  articula- 
tion, iitiistication,  or  deglutition  caiint^  great  ^^uH'ering.  The  friction  or  com- 
IpresaiuD  by  neighboring  teeth,  tlm  jiroluse  >4alivation,  all  aggravate  the 
patient's  «)i!ilrei>!i  in  ibia  most  agonizing  dii^eaHe.  Tbe  paiu  is  not  confined 
to  tbe  tongue,  but  runs  tbrougli  all  tbe  branches  of  the  tilth  nerve  over  ihe 
Bide  and  crown  of  the  head,  to  the  face  and  the  ear.  The  lymphnlio  glanda 
'under  the  jaw  usually  becuiHC  iuvolvcd  at  an  early  period;  though  the  dis- 
|«ajemayexist  forayearor  two  without  their  becoming  implicated.  Cachexy 
It  last  hupcrveuea,  and  the  pnticuL  dica  from  the  coujoioed  effects  uf  oxliauit- 
tioa.  irritation,  elarvatiou,  and  poisuniug  of  the  system. 

There  are  three  cuuditiun«  iu  cancer  of  l-he  tongue  thai  are  of  serioua 

import,  and  thai  may,  eingly  or  in  conjuniTtion.  lead  to  a  falul  tenninalion. 

!.  Tbe  puiu  not  only  weant  out  tbe  iiaticnl  by  depriving  liiin  of  retnt  nnil 

«omturt  iu  life,  but,  being  greally  aggnivaicd  by  maiitit-aLion  {ind  deglutition, 

<wu8e»  him  to  avoid  tUem  avii*,  and  hence  leada  to  a  pmcevs  of  grndnul  Btar- 

valiou,  either  by  liti>  abi^taining  fnim  food  aliogelher,  or  taking  a  li([nid  and 

linnutriliout)  diet,  becaiiite  ii  i»  mon>  en.iily  Hwalloui'd  than  .■'olid  and  tnore 

tmifaeiantial  meat.     '2.  The  profuse  ^nlivaiion  tend^i  ntill  further  t/i  exhaust 

ilbe  jiHiient ;  and  -i.  Tbe  occurrence  of  hemorrhage,  when  the  dit^ea;^  bus 

erodeil  S4)  deeply  as  to  open  up  one  of  the  larger  branches  or  irunk  of  the 

lingual  artery,  may,  by  repeated  recurrence  or  by  sudden  gush,  destroy  life. 

VOL.  II. — ID 


e? 


I>I3EA8E8   or   THE    MOUTU    X3tU   THROAT. 


If  caoccr  of  the  luoguc  be  allowed  in  run  iU  nutural  cmirK-  uabilMaarf 
bv  ojwration,  ii<jtbiti|j  chd  «xceed  the  niuwry  uftLe  jifltk-al'i  d«ilb,  bnff^ 
about  aa  it  is  by  pain,  atarTaliou,  and  bcmorrhagc.     Wbni  ibo  patkotm 
by  recurrence  uf  the  dievasc  after  reiuoval.  he  has  probably  obuin   '  -  ~' 
niootba  of  iuiniunily  fruai  luffcriug.     The  fatnt  UTuiinatiuD  iipui\ 
place  from  recurrence  id  the  glaada  of  ibi>  ueck.  iccKDiUry  aromtm  isik* 
vitcera  being  rare,  as  in  epilheiioDia  of  other  iwrle.    The  eBiarsvd  nrri^ 
glaods  gradually  reach  the  ckiu,  eonen,  aud  brvak  down.  iMViag  foal  an- 
ties,  ODd  Itic  pnlitnLffrndiiallydiee exhausted  from  pain, and  potaunrdbi^ 
abeorplion  ot  ibe  decomiiueiog  dlM-liargte.     Smuftiiuti  iho  mtar^  gMsdl 
push  into  I  he  pharynx,  ob«lrui-tiii^  biah  ilc^iutiiit'ii  aud  reapinilioa.    lilill 
ae  a  rule,  il'  rfcurreiire  io  tho  mouth  can  Ih>  avoiilL<d,  ihc'  ni<Hlt  of  dcalhh 
far  catiicr  iliao  when  tlircrcly  due  lo  ibe  primary  diiMWbe  io  ihi*  tiogML, 

DiagnosU. — The  diagiioais  of  cpithi-lionm  ul  the  um^i!  to  ii«  adnaerf 
Blagi-ti  i»  uetmtiv  easy  ciitiugh  ;  the  derii  foul  uli<vr  on  one  aide  of  lb«  tciO|ai. 
the  pain,  the  fixity  of  thu  organ  ami  the  cnlargrRK'nt  of  ibe  lTn|)liitic 
glands  make  the  nature  of  lh«  dixcaso  unniiatakable.  At  tbb  penod,  bo*' 
ever,  little  can  be  dune  to  cure  the  patient  or  even  lo  relieve  bitu.  Tu  bti/ 
any  iwrvice  t<i  the  patient,  the  din){niiaiii  must  be  mode  early,  while  tlw^ 
eaite  i»  »till  localized,  and  an  oporalion  can  ho  uiidi^rtakcu  wiili  aorM  pl» 
pert  of  jiiving  lasting  or  (wriiiunent  relief.  Syphiiitie  utcmition.  mith  aa  M- 
durated  h«ftc,  c^mimonly  clowly  n-Aeinblcs  cancer  of  Uie  Iftiyufi  •nrfuKly, 
indeed,  that  it  i«  only  with  f^ent  difficulty  that  the  d.ngn<-  'fvL 

Tbte,  howe%*er,  may  liPiierslly  be  accompiUhed   by  iiliwr»ii  _  .'bf 

litic  ulct-r  i»  elwiinaled,  irregular,  tUt^  not  rapiilly  <*xtrii(l,  Btni  w>  swuciw 
with  other  evidetit-ce  ol  eoiutilotiooal  8y|ihil»;  uhik-  the  ranccn>a«  ulttf  • 
of  n  mure  circular  shape,  has  hard  aud  everted  edgea,  i»  mitrr  painful,  ud 
sprvudd  with  greater  rapidity.  The  Jttnueiice  ul»o  of  irralntvnt  irill  aftirk 
Unio  throw  light  upon  the  nature  of  the  dievaee. 

The  diugnoeis  between  the  gyphililic  gumma  and  connr  it  nf"*  '.mi-.^iR 
here  lliv  duration  of  the  direaM!  and  the  coexisleacn  of  ciiuittitii 
must  Ik)  taken  intu  nccouui.     It  is  nliHi  of  much  moment  lo  aik  .> 
eitUBtioQ  of  th«  tumor;  tbo  syphilitic  gumma  being  almoct  in^ari^' 
with  deeply  in  the  subetauee  ot  the  organ,  nhilel  the  cmaeerooa  gr«ii>" 
commonly  iwali><)  at  ilH  edgrs  or  tip.     Il  lou^i.  hunever,  he  rpmutabtrad  tbl 
ft  U-iigue  which  bsf  long  been  the  scat  id'  thi^e  mtirbid  changci  in  ike*** 
of  ibickening   of  ita  epithelJuui   and   uk-eralioD  of  its  muci>u«  DrnbilK. 
which  are  coiooion  8e<]uel:o  of  syphilis,  may  at   length  Uecume   adpctod  ^ 
trite  epithelioma,  the  tongue  being  nmullaneously  Htrtrittl  by  Imth  daeimt- 

In  all  caan  of  grave  tloubt,  it  is  bntler  nut  to  wait  till  ibe  odvaarr  uf  tW 
ilbrinw  rendera  tbe  nature  uf  the  growth  evident.  The  reini>val  of  a  aaii^ 
■ud  8ut>erfiuial  portion  of  the  tongue  h  an  o)>enttioD  eo  kitoplr  aod  m>  ft<^ 
from  aanger  that  il  may  be  undertaken  without  heaitalion  for  a  •InikN' 
sore  upon  the  tongue,  while  if  the  diACBHe  l>e  IrA  till  Uie  glanilv  an- 
nol  only  ore  the  nt:e*t*tiry  operative  prooe/lurea  for  ila  removal  u>  ^ 
Mri<»us,  but  the  ho[K-)>  of  giving  even  prolaugeil  relief  arc  very  amaU 

TrMtment. —  In  the  trentment  of  caocer  of  th«  tongue,  n  '' 
utterly  uscleM.cxwpt  sh  pnllialives  of  pain.  No  tneoaurri  i 
chance  of  cure,  or  even  of  pmlongntioii  of  life,  except  the  ctimpltU  nm^ 
of  the  diai'flHcil  »trocturcs,  and  thiH  it  is  by  no  riieana  evoy  to  ocrvmplli^  " 
Uh>  ooceroits  infiltnttion  often  vxlendo  much  further  thiiD  at  fint  *|f^ 
poanng  deeply  hrtwii-n  the  muM-uliir  fasciculi  and  plan**,  into  tb*  rM<" 
the  tongue.  In  ibrw  deep  canceroos  alTectinnt  llicre  ia  unally  f^ 
eDlargeoinit  of  the  glanda  under  the  jaw  with  infiUralion  of  tha  Boar  «J  ** 


1^ 


0PBBATI0S3   POB   CAHCIB    Of   TONGtf«. 

mouth  and  neigli boring  aofl  parts  to  aueh  an  extent  afl  to  render  it  ioi possible 
to  eicise  or  in  any  other  way  remove  ihc  whole  ot'  the  die(:a,0c. 

There  are  two  upcralionft  occnftiounlly  praotiseil,  having  for  tht-ir  object  to 
palliate  the  ftuffering  or  to  retard  the  jirogroM  of  the  diseaao,  viz.,  Dtviwon 
of  the  (]!u8tatur^'  Nerve,  antl  Ligature  of  tht-  Lingual  Artery. 

Division  of  tte  Sensory  Nerve  of  the  Tongue. —Scrtioo  of  the  guitat^iry 
branch  of  the  filth  nerve  was  lirst  |.rojH«s«_'d  and  practiit«<l  by  niJlnii,  willi 
the  view  of  relieving  the  pttiu  of  the  caDcen'MU  tilot-r,  retarding  the  progress 
of  the  diaea^,  lewit'nitig  the  profuM  salivation,  and  enabling  the  Surgeon  to 
apply  ligatures  for  the  removal  of  the  cancer  t»  a  p»t-i  that  lm»  bei^n  deprived 
of  all  aenaihilily.  Thl.^  ojienition,  which  Moure  rc|>e:it(d  Nevenil  times,  nod 
lo  which  be  specially  drew  the  attention  of  the  I'rol'iwiiou,  undoubtedly 
■ccotuplitbefl  the  olijcctK  for  uhich  Itiltou  originalty  propwed  and  practised 
it;  more  especially  no  far  ax  relief  of  pain  and  tliiuiimtion  of  *ativatJon  are 
concerned.  Anil  it  dest^rvea  to  be  coUHidei'ed  as  one  of  the  moat  et!ic>ent 
EDiMJes  of  relief  tu  the  Giiffering  produced  by  cancer  of  the  tongue,  in  all 
cases  in  which  an  operation  for  the  removal  of  the  disease  is  not  desirable 
or  practicable. 

Division  of  the  gosUtory  nerce  may  be  douo  in  two  ways;  one  originally 
employed  by  Ilikoo,  the  other  ttdupteil  by  Moure.  Both  opuratious  consist 
in  dividing  the  guxtaiory  nerve  in  that  part  of  its  uourtic  which  extends  from 
its  eniergcuce  liclwei;n  the  iutcrniil  pterygoid  niuaele  aod  the  jaw  to  the 
puiut  where  it  cuterH  the  tougue.  Opposite  t<>  the  second  molar  touth,  the 
nerve  lie*  umler  the  iinjcmts  membrane  of  the  floor  uf  the  mouth.  There  it 
can  be  eaailv  reached  by  the  ilivisiou  of  the  mucous  membrane  covering  it, 
when  it  nillbe  foumJ  clueu  hehiud  the  Kuhliiigual  gland.  It  may  be  raised 
by  ft  blunt  book,  seen,  and  divided.  It  wan  in  tliis  tiituatiou  thiLt  Hilton 
pracliaenl  iia  aection.  The  advaninge  of  this  choice  of  place  i».  that  the 
nerve  can  be  seen  and  its  divitiion  thuK  rendered  certain.  The  disadvantages 
are,  that  tlie  gtiiilea  to  the  apnt  are  not  <]ut(e  certain  ;  that  the  cut  h  apt  to 
be  obecured  by  hemorrhage ;  ami  thai,  when  the  disense  has  exteinleii  to  the 
Boiir  of  the  mouTh.  the  operation  is  inapplicable.  Mnore  consefjuenily 
recoinmeniled.  and  in  five  casee  practised.  Kcctinti  of  the  nerve  further  back. 
The  guide  to  it  in  this  situation  is  thi-  laift  molar  Un)ih  ;  nnd  a  line  drain-o 
from  the  middle  of  the  crown  of  the  tooth  lo  the  angle  of  the  jaw  will  crow 
the  nerve  in  the  exact  place  where  it  shonld  be  cut.  The  nerve  lies  uhuut 
balf  an  inch  (mm  the  tooth,  between  it  iinri  the  anterior  pillar  of  the  fauces, 
parallel  to  but  behind  and  bc-l»w  ihe  hu!|:ing  alveolar  ridge,  which  can  be 
lielt  iu  the  luwer  juw  usceiidiitg  lowxriU  tto-  thin  coronoid  pmce^.  Hy  enter- 
ing the  (Hiint  of  u  knife,  tliL'refi>re,  into  the  mucous  memhraue  uf  the  mouth, 
tbree.<]uarti;rs  of  an  inch  behind  aD<l  boluw  the  laH  molar  tuolh,  nnd  cutting 
down  to  the  hone,  the  nt>r%'e  muel  li¥  dividc<l.  Moore  advises  that  for  tbia 
purpose  a  curved  blst^iury  be  used,  m»  tlie  projection  of  the  alveolar  ridge 
itouhl  protect  the  nerve  fnim  a  slniight  blade.  The  good  effect  of  the 
Operation  ■»  iDslantaneous;  pain  ceases  in  the  tongue,  ear,  face,  and  head, 
and  the  flow  of  saliva  is  greatly  diminished  ;  and  the  relief  is  couliiiuuuB,  fur 
it  does  nut  appear  that  the  nerve  reunites. 

Ligature  of  the  Lingual  Artery  may  be  re()uir«d  to  restrain  profuse 
hemorrhage  from  an  uicemled  cancer  of  the  tongue.  This  operation  has 
been  prautised  also  with  the  view  of  starving  the  morbid  growth  and  thus 
retarding  ila  development.  That  it  does  so  fi>r  a  short  period  is  undoubtedly 
the  case,  hut  that  il  does  so  permanently  is  u  fallacy.  This  ojiemtiou  has 
been  recommended  for  these  purposes  bv  Domaniuay, and  bus  been  performed 
iu  this  country  by  Moore  and  O.  lleatli. 

The  lingual  artery  may  be  exposed  and  tied  in  the  following  manner: 


d        ^ 


DISKASES   OF   TKK    MOUTH   AND    TOBOAT. 


The  artery  id  reached  with  mopt  certninty  in  ihe  rliffiistric  Iriaofle  i 
Deck,  where  it  liev  benesth  the  liyifghwsuH  muvcle.    A  mrvnl  iy 
from  abntit  ouu  finger's  hrvuJtli  external  lo  theevruptiyaii  nn  '' 
t»  iho  grent  oomu  of  the  Itvuid  bone,  anrl  protnngrd  iipwmril-  ... 
angle  uf  the  jaw,  will  expoM*  the  Inwer  border  of  the  ^tihtnnKill 
In  fat  »ulijec-tB,  or  when  ihe  partx  nri^  onoHen,  the  inriaioii  mirvtl 
full  length  ulmve  meiHioned,  hut  nnder  iirdiniirT  circuniBdinrTP 
ciirtaile<i  by  aWitt  half  rd  inch  at  each  end.     The  Hrvt  itiei'fr-n  <n*E 
akin.euper^cial  fapela,  and  plnlrtnin,  expociag  the  strong  Inrctacorrni 
submaxillary  j;lan<i.     If  the  inclvioD  be  carried  too  far  baekw«rdt,tbil 

vein  uill  be  divltlcd.     The  deep  faeeia  niuat  now  h«  opene^l.  Bad  

niaxillarT  gland  raised  aud  drawn  ujiwards  towsnla  thv  jaw.  Tht  UoMi 
of  the  diga»[ric  then  coDica  into  view,  and  a  apace  is  axpoiM  boowlrd  Mp* 
and  externally  bv  the  curved  lendun  uf  the  liiguatrir,  internally  bylWEnt 
edge  of  I  he  niylo-liyoid,and  above  by  the  ninth  nerve  aeconijiauied  byaiad 
vetn.  The  floor  of  the  epnce  is  formed  by  the  imrt  of  the  hyo-gltiBOt  aH^ 
ing  from  the  great  eornu  of  iho  byoid  bone.  The  fibre*  of  the  bye-glaas 
IUU81  now  bo  picked  ujt  carefully  in  (hU  Bpaee,  and  divided  horwiniBf. 
irbcn  the  lingual  arlcry  will  come  at  once  into  view  (Fig.  725}.    Ouvmit 


fig.  Tti. — LIgatarm  of  LlRgtuI  AH*rj. 

be  taben  while  ezpoeing'lhc  artery  not  to  cut  too  deeply,  aa  lib  i 
fVnm  the  muenUB  membrane  of  the  pharynx  merely  hy  a  ttm  flbm'  „f 
middle  roneirictor.    Someliiiiea  lb*  aiyltf-hyoid  ligBRieot  cwmcs  i 
it  may  t»e  recognized  at  onec  by  il«  patting  upward)^  and  outwards,  w......  ^: 

artery  ii  directed  upwards  and  inwanla.  Hhuulil  it  be  H>en,  il  may  ha  ori 
»«  a  guide  to  the  artery  nhich  patveii  betw«-<-n  it  and  ibo  hvo-gtMaaa.  ] 
mre  oaaea  the  artery  lies  with  the  ninth  nerve  suprrlirial  to  lIm  Tjo^ltaMJ 
in  whi<-b  Rilnnlion  it  must  be  nought  if  not  found  In  iu  projier  pliM.  J 
»Ji  EHATinM*  ON  TUK  ToNcirr. — Thf  opernlionn  that  art*  prartWul  ••o  a 
tongue  when  it  U  affcctvii  by  rarirrr  tiiniiist   in    removal  af  a  !  ' 

organ  unly.nr  its  rumpletu  i-xiirpation  ti«mi  the  hyuiil  h-'n*"  m  ■ 
itilualiort  of  ibe  ■liM'nK  and  the  oxirnt  to  wliit'h  t\^- 

I'nleM  tlw  diw^'c  cwi  be  ri-ry  fully  »T)d  freely  extifj 

attempt  aity  o}>eratioB,  for  io  do  organ  it  there  a  greater  teotkncy  to  raca 


OPBitATlOKa    FOB   CAXCKR   Of  TONGUB. 


629 


rOHCe  of  cancer  lli«n  iu  the  tongue.  When  the  diMMe  extenila  to  the  fluor 
of  llic  rooutli,  in]pltcaL«'«  the  urclies  of  the  pftUte,  or  hue  largely  infiltrated 
Ihe  submaxillnry  Ijrtupbatic  glands,  t)ie  propriety  of  operstiug  becomes  very 
doulitful.  Eveu  under  Llit;^  otrcuniataiicfs,  however,  extensive  uperatiom 
bare  been  perfortntid  nitli  at  least  temporary  benefit  iu  sutue  cases.  Iu  deter* 
minia^  the  questioa  ol'  uperatiuj,',  uiuch  will  depend  ujiou  the  conditioa  of 


n$.  Tlfl— Appliealion  o(  Scittt-gmg.  Oh«ekTaUiM)U>r,  kad  Wblpeord,  In  0)iM«tiftti> 

of  til  a  ToD^D. 

the  patient.  If  he  be  otherwise  in  gi>o(l  hcaUh,  though  suffering  greatly 
from  the  palo  of  the  cancer,  aud  if  llie  secondary  allcciioQ  be  limited  to  the 
glands  below  the  jaw,  whit^h  can  be  remuvud  witliuul  ditliciUtv,  an  operation 
may  be  uudertakeu.  If  lie  be  greatly  exhausted  by  puiti  uuil  want  uf  food, 
and  more  eepeciatty  if  the  j^lauda  uuaer  the  stern ii- mastoid  are  enlarged,  ea 
operation  would  at  the  best  give  very  temporary  relief,  and  would  be  very 
likely  to  be  direirtly  fatal. 

Iq  alt  operationa  u[Mi)t  the  tongue,  three  precautions  must  be  taken;  1,  to 
prevGOt  llie  pativnl  from  biting  it;  2,  to  expose  it  thoroughly;  and,  .S,  to 
Veep  it  under  eontrol.  TKe  fint  object  is 
altaiueil  by  placing  an  etHoient  gag  be* 
tweeu  the  teeth  on  the  side  oppr«ite  to  the 
•oat  of  operation.  The  Bcrew-gog  i  Fig. 
T2ii*  limy  l>e  lifted  in  some  caaes,  but  it  ia 
raiJier  apt  ti>  slip.  FergiiaBon's '  Fig.  727 ) 
ur  Whitfhead's  gag  i  Fig.  ~'2S)  will  be 
found  mure  efficient,  Fergiiioon's  \i  vcir 
ditficult  ta  keep  in  position  when  the  bncEt 
teeth  are  wanting,  a»  it  teml^  t>i  slip  li^r- 
wanht.     Whitehead'*  gag  may  then  be  of 

service,  but  it  also  is  uncertiiin  if  the  front  Via.  TIT.— F«rgtuMa'«  Oag. 

teeth  are  wanting.     Efficient  gauging  is 

voe  of  the  Tuo«t  e:^eeulial  parts  of  all  uperations  on  the  tongue,  aud  in  all 
coses  it  is  belter  to  entrust  the  gag  tu  an  assistunt,  whuse  hoIv  duly  slinli  b« 
to  see  tlint  it  ditee  not  elip.  The  Bli|>piug  of  the  gag  and  the  nudtluti  closure 
of  the  iitouth  nl  H.  crilicul  point  in  the  operation  may  necesttitattf  a  »udden 
perfurnioiicc  of  laryugotomy,  or  may  even  c*»t  the  patient  bis  lilc.  If  the 
patient  l>e  efiicii-utly  guggi^d,  ihe  jet  of  bloud  from  a  divided  lingual  will 
usuiilly  be  thrown  uul  of  the  mouth,  and  cause  bul  little  trouble.  If  u  gag 
be  uueii  which  acts  ou  one  side  only,  the  tongue  rauut  be  fully  exposed  l)y  a 
cheek-rvtraolor  (Fig.  72l»)  applied  on  the  opposite  aide.  During  tlie  opera- 
tion the  iDUgue  must  be  ooiurulled  by  a  strong  whipcord  ligature  passeil 
through  it  about  an  inch  from  its  tip.  If  only  a  einiall  portion  of  the  ante- 
rior p«rt  is  to  be  removed,  a  eingle  thread  will  suffice.  In  removing  half 
the  tongue  two  ligatures  must  be  passed,  one  on  each  aide  of  the  middle  line, 


DISEASES   OP   THE   UOtJTH    AND   THKOAT. 


■o  as  to  control  not  only  the  part  to  bo  romoved,  bot  the  nntaininK  panik^ 
io  that  t1]C  fttump  mar  be  nrawu  Ibrwardi  at  the  rm)  of  th«  npcrttMlB 
arrc«t  hcmorrhogc.  When  a  portion  only  of  the  (onguo  i»  t»  b*  raUHfnts 
ninv  b«  iliine  bv  tho  lii^iitun-,  thi.-  f'crasour,  the  knife,  or  th«  ffrii»on>  Wka 
extirpatiuti  of  the  whole  orti»n  U  <lfc-i<led  upon,  thv  li^turi*  is  i>«it  appliciMc 

¥oT  the  purpose  of  operation  th«t<<i)|fu«  may  bt.'  dividtit  intn  ibrpc  re|p<«, 
viz..  the  anlfrinr  thir<l,  the  ceutral  liilt^nil  |H)rti(>ti,  and  tht;  (njttvrior  i*n. 

Exoision  of  a  small  part  of  the  Tongue  luay  r«a<ti)y  and  safely  W  ii» 
when  th«  free  nnterior  portion  ouly  in  di»i!a»e<l,  or  Hh«n  it  u  xuty  Mifxrto- 
nlly  aflectei)  at  its  side  or  back  jMirt.  The  patteot  havinj;  bv«tj  iri^iiri  tki 
tongue  it)  secured  by  passing  a  tbr«ad  through  it.     It  u  tltvii  dra«o  tdl 


forward  while  the  lingual  artery  h  atmpreMwd  in  the  way  refyimctrotM  b^ 
C.  Heath.     To  do  this  the  forehuger  is  pHN>»-d  over  the  dm--  ■  wigo* 

till  it  tuuchea  the  epi^lottia  ;  it  i«  then  turuvtl  t>>nunl»  thu  ^:  '^lidi  Ik* 

artvry  is  lu  be  cuinpreewd.  and  hooked  loriiMy  upwaril*  a^mu  ihc  )>*• 
The  di»ense<i  portion  of  the  U'Ujfue  is  then  ditwcteil  nut  with  n  N-a-'i*..  or 
st'iwors.  and  furcepe-     If  the  artery  be  well  oinipri-wi-d,  the  oprr  •« 

pmctioally  bloudlew.  Ou  rerunviog  the  pressure  iht;  bcmorr]ia]|iL  t  .:.  ,  ..n 
profuse,  but  the  larger  vet«ela  are  eabily  ligatured,  and  tlie  txttiug  vtllioxo 
cease  <m  the  applivuliou  of  iee. 

Strangulation  of  the  dit^niH-d  maw  by  meatis  nf  thf  Ligature  was  foranly 
much  mure  oiiiptoyed  than  al  the  pre^nl  day,  and  it*  iiiilr<->I  dov  icIdtaH 
odopU'd,  on  ■et'otuit  of  the  pain  thai  attends  and  the  fi-tur  that  fnllon  its 
use.  If,  however,  th<'  Hur^eon  hv  singlehandrd  or  unprovided  «ilb  mil' 
worthy  aaeiKlanis,  or  if  heniorrhngu  is  much  to  be  lean-fl,  this  mrans  n^ 
etJll  Itc  employed. 

For  the  purp<i4o  of  this  operation  strong  tliick  saddler's  whipcord  ii  the 
best,  a»  it  doca  not  readily  cut  through  the  toll  and  brittle  tlanBflftbs 


/> 


n^ptn,  which  will  be  ihp  esse  if  the  small  comprewM  coni  hwhiIIv  mM  b' 

the  inMrtimont  makers  Iw  uwd,     There  is  liillr  dan^-t' 

after  I  bill  nperstion;  and  itie  \m\ti  sod  i-tilipe^joenl  -l. 

much  lew  iliRii  niijiht  be  i'X[»ected.     The  pnln  may  I"  -■'■'' 

uf  Ibe  t!U»1atorr  nerve  prit-r  to  the  applic-.-itti.ii  of  the    i. 

The  lifHilnre  is  passed  by  means  of  an  ortlifmry  oa5Vu»- needle,  or,  wba^ 
Ofteu  more  conrenieDt,  a  corkM:r«w-»>-^>lle  iMirve«l  i-n  th»*  side  as  well  a# 


EXCISION    or    TONGUE. 


681 


the  point  (Fig,  729).  Iii  many  CMf»,  the  plan  described  f»r  tying  flat  nrevi 
will  be  found  the  moat  criDvenienl  cniHiK  of  paaaing  the  whipo<jrJ  round  iho 
ouiccr  of  the  t'lngue  (  Fiji.  I'Sd).  In  whatevLTway  the  lignturca  are  applied, 
care  ghijuid  be  titkcn  ta  ^tass  them  throiij^h  the  heallhy  fiMue  of  the  organ 
wide  of  the  dinenae,  mid  theynhould  thru  be  tied  very  Lif;htly,<iuaato  atniugle 
the  mass  eSectuaily.  Tlii^  may  then  he  cut  away  by  »(•!•«:>»,  bo  as  tn 
dimtoUb  the  rjuanlily  of  sliiu^h  that  wmthl  othcrwiM-  hv  Icrd  In  the  mouth. 
Strolling  of  the  touttue,  fallowed  by  ratlier  proriioe  Haliratioii  and  felor  of 
Ibe  broalh  attends  tbU  operatian  ;  but  lh«  mau,  if  pmperly  constricted,  will 


r 


J 


Xi^- 


Pig.  ItO. — A|rplic>li>iii  uf  Ligsliir«  to  CoiMieT  of  Anlriior  Pkrl  at  TABgg*. 

Bgb  away  In  a  few  daya,  leaviug  a  large  gan  that  readily  (ills  by  (:runu- 
latioii.  WliCD  the  dtsciute  extvudfd  m  far  baoK  that  il  udiiM  u»l  n^adily  be 
readied  from  tbu  muuth,  (ylnt^uet,  Ariiutt.  and  othuiv  eut'iteeiierl  in  stran.i^liiij; 
it  by  making  au  iiicution  iti  the  hynid  n>gtoii,  between  thn  geniodivo'id 
nuficleir,  carrying  the  HgalureA  liy  niennfi  of  lun;;  nt-edlefl  through  iIik  liofle 
of  the  tongue,  and  then  drawing  them  tight  tlirongh  the  aperture  iu  the 
npok.snas  to  constrict  the  rllsensed  ma.*s.  This  melhifd  of  operating  was 
rarely  micces-ifiil  and  has  h»ng  be^^n  abandoned. 

Excision  of  the  Whole  or  of  a  Large  Portion  of  the  Ton^e.— This  opera- 
titm  may  brr  perfirnied  in  limr  wnys.  1.  Frr>t»  the  ini*!!]?  of  the  motillj, 
withiMii  nnv  external  inciainns.  2.  By  the  submeiital  mrthrvd,  ihrougli  llic 
myh»-hy"tn  space.  3.  By  the  biiooal  method,  a  free  tncic>ian  being  made 
through  the  clieek ;  ond  4.  By  division  of  the  lower  lip  sTid  jaw. 

The  excision  of  ihe  whole  tongue /n>m  the  interior  of  the  mouth  \a  moat 
eaaily  pert'ormed  by  means  of  the  i^crnaeur,  and  it  is  to  the  introduction  of 
this  instrument  into  eurglcal  practice  by  Cbassaignac  thai  we  owe  loo  great 
extent  the  adpfluee  nmde  iti  this  operation  during  the  last  thirty  yean. 
Tbera  are  many  methods  by  which  this  o[>cralion  may  be  [wrformed,  the 
diflisreuce  iu  the  minor  details  l)«itis  dependent  on  the  extent  ami  HJluation 
of  the  cancer,  and  the  amount  of  ti;ngiie  that  coiimjciuently  re^jutres  extirpa- 
tion, The  following  plan  is  that  mosl-  usually  adopted,  and  will  h>e  found 
effectual  and  e:ife  in  ttie  vast  majority  of  cases. 

The  gag  having  been  applie^l,  the  end  of  the  tongue  should  be  secured 
with  o  piece  of  whipcord  and  well  drawn  forwards  and  upwards.  The 
Surgeon  then  cul»  acrow  the  fruenuni  by  treans  of  itlrong  curved  scissors, 
and  divides  succesiively  the  iiiswrtionsof  the  gcnio-byoid  and  genio-hyo- 
glonal  mu»ule«  into  the  lower  jiiw,  cutting  freely  back ivardu  so  as  to  liberate 
the  base  of  the  tongue.  He  doiv  ffiipe  aurot«  the  reilectioD  of  the  mucous 
membrane  of  the  floor  of  the  Diutith  from  the  lower  j»w,  and  then,  laying 
aside  the  scissors,  sepnratea  widely  with  hia  iiugere  the  b<isc  of  the  tongue 
from  these  part^.  As  ho  doea  this  the  asaislant,  who  has  cliarge  of  the  whip- 
cord ligature,  draws  the  tongue  well  forwtird?,  and  it  comea  bodily  out 
between  tho  lips.    If  the  anterior  pillar  of  the  fauces  offer  auy  obstado  it 


632 


DISKASBS   OF   THB    MOUTH    AW   TiiBOAT. 


inay  besnipiwd  ioro»,  and  tlie  wire  of  the  tcrawur  mar  ibm  be  *|ifiiil 
wull  rutiiiil  inc  liiick  >>f  the  iirgan,  ihc  sliaA,  beiiie  preawcj  up  uoiler  ikshac 
of  the  tdiicu*^-     I*  the  wire  hiivc  n  U'ndeiicy  to  »li|i  forwanl-  ■■  'WUt 

hook  ehould  bo  pua«p<l  in  front  of  it  into  the  h»sQ  of  tli<  -,i  ai  u 

iteadj  it  and  ptvvpnt  ii9  slipping.  By  uow  workiug  it  sluwiy,  lii«  *kiJk 
orgjkn  can  he  removed  iviihont  homiirrbtiB;e. 

Nunncloy,  of  Ix^ds,  dtvi-ed  nri  ingciiionfi  mode  of  tpplring  tbe  itiwmm 
»a  a.i  to  remove  por(iou«  nf  ihc  longnc,  or,  indwHi,  the  wfioif  orgmn.  uhr 
hack  as  the  hyoid  bone.  Thi«  o|>pniti(in  coRsiMn  in  p(i«iiig  the  rhan 
^riueur  through  tbe  centre  of  tnc  mylo-hyoid  e(uicc  by  mraiu  of  u  -..^ 
nhapetl  needle,  about  41  inches  long  and  as  brond  aa  a  butoury  blade.  Bf 
ibU  uefclle  the  chain  t*  broH(;bt  into  the  mouth  clo»e  to  thc>  Irrnum.  Tm 
or  three  curved  And  slronj;  harelip  pins  are  now  paf»e«)  d<¥tdy  inU>th«toa^, 
oblifpiel)'.  I>«hind  the  tteat  of  the  di»ea»e.  their  points  betn^  made  U'  pr(j«t 
forwardij  below  ibeorgHu.no  as  to  prevent  the  chain  from  itipiiinB.  Tb> 
loop  i^  tiowgrxduully  tightened,  aud  the  tODgUtt  w  cut  oribavcdoil  obli^ndf 
frum  behind  forwarue. 

Two  ^craeeura  were  Buccewfulljr  owd  by  ChaBaaignac  iu  removing  pTti-'O 
of  Lbo  louguc.    Wlieu  the  diaeaie  ooouf^  onljr  untt  side,  and  it  ii  out  ibuufit 

OMMBBarj  to  cut  away  the  wholr  bnadli  <f 
the  organ,  two  instrumeutj)  are  rcQutn<). 
which,  M  Cfaafisnignac  rt>pn<»ent«  iVi. 
mUBt  b«  pacBcil  thrmgh  the  sulvtaoLv  : 
toDsuc  in  oppoeite  direirtions,  aa  aa  to  iaibrit 
aaddetach  tlie  diarased  portHm.  The  oprn- 
liou  Rtay,  however,  he  prrformi-d  morfa  aort 
niptdty  nnd  m^ily  hytplittint;  (he  tooirwii 
the  middle  line  by  means  of  a  knife  or  a  piir 
of  wciwiirH.  As  Morrant  Baker  haa  •[w*i»llf 
IMiintcrl  nut,  an  incision,  if  make  accanni*)!  ■ 
the  middle  Hnr.  i»  almost  bl>kodle»  tW 
incixion  can  be  wfely  cnrried  backwanh  > 
far  Hft  ttie  root  of  the  tonuue,  and  the  !«f«i*' 
lion  of  the  diseased  half  of  the  vrpiu  aod  f^ 
application  of  (he  frcraaeur  arc  much  froli- 
tated  by  «>  <loing. 

The  following  |K>int«  mi»t  Iw  atleifW*'' 
iu  removing;  largfo  |H>rliutiB  of  tbe  timj^tit  W 
means  of  the  ^crasettr.  The  wire  ah'Mild  be  thick.  If  tou  thin,  it  cuisaln'^ 
as  readily  a«  a  knife,  and  the  lingual  arteriea  will  certainly  anom  sod 
the  ligature.  The  instrumcnl  ohould  be  worked  vcrv  alnwlT,  in  order 
time  may  bo  given  for  the  vewela  to  contract.  Aa  an  adJitional 
agaim>t  hemorrhage,  a  atroug  ligature  should  bu  applied  behind  tbe 
juat  before  it  tintilly  cwIe  through  the  Ungual  artery. 

The  wire  ccruM-ur'  Fig.  7:^2  i  will  be  found  lietter  than  the  rhain-iDitraaeO^ 
Tbe  fjrm  uf  wire  beat  suited  to  tbe  iiiotrument  is  strong  piano-wtre.     It  wi" 
be  found  better  lo  atuch  one  end  only  tn  the  movable  iiart  of  ihv  it 
menl,  the  iither  l>eing  lwi,i(ed  rotind  the  handle,  aa  in  toe  flgure.     It  tb^ 
cut^  by  B  t*low  sawing    movement    and  divides  the  roafeU    m<>r<     .>ijr/l 
Middledorpra  galvanic  cautery  waa  much  utied  a  few  years  ago  :  >i 

on  the  tongue  (Fig.  73^1.     By  working  thia  nlowlr,  and  not  I 

Clatioiim  wire  bevond  a  r«l  beat,  the  tongue  may  be  removeil  i| 

MS  of  a  drop  o^  bloix].     This  1  have  done  in  inreral  caae*  i  t| 

whole  tongue  required  removal,  from  the  Inride  of  the  mtruth.  -.t 

exUraa)  wound.    The  galvanic  cautery  cute  mure  rapidly  ibaa  tbr  ii 


\ 


Vlg.  TXL— Two  SorsMiir*  *(ipllftU 
t»  Ouww  of  Taagit. 


XXCI9IQN    OF   CANCER   OF   TONGUE:    UY    gCBASEUR.      688 

instrBmeot.  and  it  waft  at  first  hoped  that  it?  u»«  wouM  con^id^riiblT  simplify 
the  operatioa.  Kxperieuce  ban,  huwever,  Bhowti  that  llie  cimrtvd  Mirince 
lefl  by  iKe  pflB»age  ol'  (he  hot  wire  heals  more  eluwly,  wUh  more  ilbchat^e 
aad  sloughing,  than  that  k'l\  liy  the  ^craeeur.  HecoiidHry  beniorrhage  hus 
occurred,  moreover,  in  a  considemble  nunilxT  of  cii»ee  al^er  ile  iiee.  It  whs 
urved  as  another  odvantnge  attendiog  its  employment,  that  a  charred  surface 
od&rs  a  burner  to  the  aheorption  of  ecptic  matter,  but  the  fallacy  of  thia 
idea  has  been  demoD«tratea  by  experimental  iovesttgatioDS    oD    animals. 


Pig.  73X.— wire  Bi>r«Mui  f«r  Remo**!  of  Tongu*. 

The  iostrument  hm,  therefore,  be^ui  obandoned  almost  univcrsallv,  moet 
Surfce<^Dtt  preferring  the  wire  icraBcur  in  those  cases  in  uhich  tlie  scusors  or 
knife  eannut  he  snfely  cmptoyc<l. 

In  1877,  W.  Whitehead,  of  MflnchcBter,  successfully  removed  the  whole 
tongue  through  th'e  m.'>uth  with  scinors,  and  aincc  then  the  opcmtiuii  has 
becu  repealed  in  n  large  number  of  oa»e«  with  exoellent  resulu.  Thia  opera- 
tioD  i»  conducted  as  fultowe  :  The  mouth  in  efficiently  gagged,  and  a  double 


K 


F1|.  Tits.— QAlt-niiie  Barumr. 

ligature  passed  through  tho  tip  of  the  tongue.  The  a^istant  in  charge  of 
this  is  directed  to  maintniu  tlii-DUgliout  the  operation  a  steady  Lraetiou  up- 
wards and  forwards.  The  i>pci-ali)r  L-omineDcea  hy  dividing  all  the  attacii- 
raeots  of  the  tongue  to  the  jaw  and  to  the  pillarc  of  the  fiiucix  with  an 
ordinary  {)air  of  straight  sejtwoi-e.  Tho  iuu)>ric»  nttarhed  to  tlic  base  iiflhc 
tongue  are  then  cut  aiTu««  by  a  sen**  nf  tuecemve  iJiort  rriipa  nf  the  tfelwMiri*. 
until  tile  entire  tongue  ii^  Kvparaled  in  the  plane  of  the  Inferior  border  of  the 
loner  jaw  as  tar  buck  an  iIil  ^ufety  of  the  epiglottis  will  permit.  Any  ves- 
sels requiring  tortioii  are  tnif^tetl  at  dividcil.  but  a  niutiictil'B  jiretiKurf  with  a 
aioall  piece  of  aponge,  held  in  H|ionge-lorr't')itn,  t^ufficiH  tenipDnirity,  if  not 
nermancutiy,  tu  arnxL  any  bli'ediiig.  A  t^ingle  loop  of  pitk  h  then  put^td 
by  a  long  needle  ihrmigh  the  remniiiH  »f  the  ginfiso-epigloltidean  fuld  of 
mucous  membrane,  an  a  nieiin.s  of  drawing  forwanttn  the  floor  of  the  month 
should  secondary  hemorrhnge  Hike  place.  Thi?  may  be  withdrawn  on  the 
second  day.  The  heinorrlmge  iti  this  mdlind  of  operating  it;  raucb  leM  than 
woulil  be  experled.  Whitehead  nfalt^  that  in  two  cases  he  removed  the 
wbule  tongue  without  twisting  a  single  veaeel.     Treves  and  others  have, 


G34 


DISKASXS   OF   TBK    MOtTTlt    AND   TOSOAT. 


however,  met  with  very  trniiblfBome  hpmnrrhaRe  during  rh- '-     '- 

A  ]iap4T  rrait  l>efore  the  IliKTiiatiuiinl  MedU-al  f'lHiKfnM  <■: 

recordei)  iwenijr-ei^hl  casea  in  which  the  nprmiioa  had  been  [Kriurmca.  <rn> 

only  thre«  d«ithB,  two  of  which  orciirrpd  at  a  remote  period  aft«  lb 

operation. 

If  nnly  half  the  tongue  i«  alfectfd.  it  may  be  renored  by  aeiman  fat  At 
Mmo  way,  At'nr  havJii;;  been  eplit  In  the  iniilille  llnf. 

Whfn  lh«-  llrMir  of  iho  mouth  '»  iingiliuilt^l  in  chu  illiwu^,  n'-i  opantMB 
thrttn^h  the  iinnith  ahoiihl  be  nt.t6mpt«(i:  om  ii  in  im|iuM>it>[  rdCRUW 

extirpnt*^  rhf  tvhoK*  of  thv  diiwaae  In  thi«  «Itii(il!'in,  nn<i  |i-i-'  .'ntti'n 

will  ho  fiiltuwrtnl  nnly  hv  rHftitl  rccurri^nc^f  Mud  incn^AMH)  artiviCy  uf  J^mtof* 
ro«nL  Blight  tinlargeinent  of  the  j^laods  unJtr  the  jaw  ab'Kilil  out  U  My 
bar  to  thi'  operntiuQ,  provi^le<l  the  disease  !•«  limited,  and  the  ciBrtitatiM 
gooii.  If  not  too  much  eohirifvd,  thti  glands  may  itv  rxc>a«^l  at  ti>«  mm 
time  with  the  disease  of  the  tongiiu  ;  or  if  thfy  li«  so  slij^litly  cnUrgvd  nv* 
be  ecarculy  r«ouguizabie,  thvy  iimy  bu  left,  warn  thry  will  porbap  «(ii»idt 
without  the  noceadty  of  <>|>eriiliun,  as  thtrir  ealarx<?n)«nl  may  niMafatr  W 
d«|iendfnt  upon  simple  irritation;  shouhl  tbey  cnnliDue  iDdufmlea, ibvr  ■»; 
readily  hv.  reiiinvpd  at  a  [■uh6i>r|iit>nt  jHTiiMl. 

BabmeotaJ  Operation  for  Excision  of  Tongue.— Hcjmnli.  of  Vhrn,  pab> 
UkIilm].  in  I'^SS.  a  (te-soription  of  a  mi'lhufi  by  which  thu  whole  Umgam  sbcM 
be  6uci:eaarully  removed.  The  plan  that  he  prunueed  wa»  mt  fullewi:  Aa 
incifiion  of  a  semilunar  tihnpc  waf^  ninclcalon^  the  lincof  the  Inmr  jaw,b^p»- 
nint;  near  one  nofile  and  t«rniiDalin),'  eloee  to  the  other.  A  pecyaoiliiafar 
iDcieion  woa  oirrit^  from  the  eetitrc  of  this  line  imfnedialely  under  Uwckii 
Co  the  hyoid  bone  (Fig.  7S4).    In  making  this  wmilunar  inctsioo,  cart  aoK 


l^g.TSi.— Ubm  «f  Inebloa  la  IttcixiU'i 
0|Mr*ll<in. 


Fig,  Tia.— Tmfaa  4n«»  om  bMi 


J  taken  not  to  wound  the  fiicial  artery  on  fither  aide.     The  trank  J  tk* 

tread  lihould  \m-  prolecit'd  hy  ihc  tlnurr  of  nii  n»»iMnnt  w  tl  fiirw*  tMnii^ 

lower  jaw,  and  the  intri^ion  nhouUI  \*v  c'ltitined  witKin  the  • 

two  facinU.     The  IriHii^iilnr  fltifix  of  t>kin  f<irtiKHl  in  t\u- 

arr  di»m>cteil  htick,  anil  iIm- rniiAch"!  and  myl<»]iy>>if( - 

Tli«io  m«i»l  l»e  *iirc»'i'*ivcly  divided  ;  thf  ant*'ri>ir  lu'tli' 

cut  acfiae.  the  myh>-hy.>iJ  mimcle  dividL-d  Iniiifverculy  nl  it*  ■ 

and  (he  Altachments  of  the  genio-hyoidei  and  geuitHhyugloM  m.  . 


EXCIBIOH    OF   TONOUB — BOGOAL    OPBRATION. 


fl35 


tdetaclicd  rn)iu  the  lower  jaw  bj  a  Tew  toui^Iiee  nF  tlic  iti^ulitel,  au<]  b;  eepa- 
niiag  with  the  tiiiKerB  the  mucous  mi'tiibniiu!  ol'  t)i(^  tloiir  nf  lliu  iiiuuili.  An 
uporluru  is  then  made  iuU]  this  by  [m»tuiig  the  »nil[iel  thnugli  it,  and  its 
rvUectioii  fnim  the  itit^idpnt'  the  Iowit  jmw  is  ilividptl  as  far  haclc  an  the  outer 
■U}Hf«  ol'  the  exlernal  incisinn.  The  nubmaxillHry  ^Initda  are  |iu»herl  lutide, 
and  the  tip  of  the  tongue  bcin^  seized  with  a  strong  hook  or  vulwlluin-fiirccpfl, 
the  or^n  is  drmrn  out  to  its  full  extent  an  to  the  anterior  part,  nf  ihe  neck, 
between  the  jaw  niid  the  hyoid  bone  (Fig.  73.")).  when  the  whole  nf  it  may 
be  rentftvetl  close  to  its  nltflchmenti  to  the  latter  hone  by  means  '-f  the  knife 
orlbe^cmaeur.  The  latter  ingtrunieDt  is  to  be  preferred,  as  its  use  ia  Btl ended 
hrlfM  hemnrrhafcc  thnn  follows  that  of  the  knife.  It  will  orcasionalty  be 
found  that  the  nnterior  pillar  of  the  fauoea  is  aoniovhat  in  the  war  of  the 
ftpplicntiiin  of  the  ioMtninient.  Should  this  be  iuoonveniently  so,  it  may  be 
■nipped  acro^a  before  the  wire  of  the  ^oraseur  is  applied.  By  means  of  this 
ofkeratioD,  which  I  have  several  llmoa  perfurmed,  the  whole  of  the  tongue  may 
be  shaved  off  clean  from  the  bsK  of  the  cpislotii^  and  hjoid  bone.  After 
the  removal  of  the  tonffue  the  hemorrhRgu  will  usiially  be  found  to  be  trilling; 
but  should  one  or  other  nf  the  linniial  arteries  bleed,  it  may  readily  be  Mired 
and  li^tured.  The  line  of  incision  in  the  skin  munt  then  be  etitched  op,  a 
jpxmI  sized  drainage-tube  being  inserted  at  the  lower  end  of  the  vertical 
iaciBton. 

K«jcher,  of  Berne,  believing  that  the  best  hope  of  giving  prolonged  relief 
or  poesibly  perniauently  curing  the  patient,  lies  in  a  complete  removal  in 
every  case  of  the  lymphatic  glands  below  the  jaw  simultaneously  with  the 
diaeafted  part  nf  the  tongue,  has  introduced  a  method  of  operatinir  wiiich  in 
bis  hands  has  been  attended  by  n  cuusidenible  degree  of  succew.  lie  makes  a 
free  external  incision,  commencing  s  little  below  the  lobule  of  the  ear  and  ron- 
ning  downwiirdK  along  the  anterior  bonier  of  the  i>tornamnatoid  u>  the  level 
oftEe  great  cornu  of  the  hyoid  bone;  from  thin  an  incision  ia  carried  forwards 
Dearly  to  thu  bivly  of  the  hyoid  bone,  ami  then  upwards  along  the  line  of  the 
flntcrtor  belly  of  the  digatitric  ti>  the  jaw.  The  ftaji  thus  maVked  out  is 
turned  upunnls  over  the  faoe.     Tim  lingual  artery  is  then  tied  before  it 

fiiaea  beneath  the  hroftlosBUfl.  Hy  a  pmoem  of  careful  diBsection,  all  the 
ymphaiic  glands  are  remove«l  from  the  region  ex|MMed  bv  the  wound.  In 
an  doing  the  enrotid  tiheath  will  he  exposed,  tut  one  gland  always  lies  ui>od  tt 
doee  to  the  sle nut- mastoid.  The  facial  nrrery  and  vein  will  be  divide^!,  and 
mast  Ite  secure<l  hy  Mgnture.  (t  i^  uitually  necessary  to  remove  the  anb- 
maxillnry  and  sublingual  glands,  which  otherwise  are  somewhat  in  the  way. 
Some  lyniphalic  gInndH,  bniching  the  inner  surface  of  the  inw,  lietween  It 
and  the  6ublinnual  glnnd,  inufit  be  nought  for  and  removed.  The  mylo-hyoid 
rauftcle  and  the  mucous  ini^mbmne  of  the  mouth  are  now  fully  e.xpoaed,  and 
must  V>e  carefully  divideil,  when  the  i«ide  of  the  Mngue  u>  ite  very  root  cornea 
into  view.  If  only  one  aide  ]»  atl'ected,  the  tongue  may  now  Ik-  split  down 
tbft  middle  line  from  the  month,  ami  the  base  cut  through  from  the  external 
wound.  Kucber  recommends  a  preliminary  tracheotomy  and  plugging  the 
pharynx  during  the  ofwralioo.  In  fourteen  cnaem  0(>erat«d  on  by  himwlf  hy 
this  method  only  one  [Nitieut  died,  fn>m  secondary  hemorrhage  from  the 
trachet>tomy  wound.  Id  H  recuiTonee  of  the  iti^ease  took  place,  1  die«t  a 
year  atler  nf  pneumonia,  aa<l  4  remsined  well  ut  14  mouth*,  5,  5,  and  ti} 
years  atWr  the  operation.  The  <>i>vnitiun  is  a  bold  one,  and  reijuires  skill 
and  patience  in  jta  performance;  but  the  danger  does  not  mem  txj  Ite  great, 
and  the  results  ore  such  na  t"  eucournge  further  itltempte  in  the  same 
direction. 

The  Buccal  Operation. — Furneaux  Jurdau  has  introduced  an  operation 
wbieb  consislB  in  dividing  the  cheek  on  the  aSecied  side  backwards  as  far  an 


C86 


UISBASBS    OF    THE    MOUTH     ANP    THBOAT. 


the  ramus  of  llie  jiiw,  care  being  taken  to  go  below  the  paroUil  duel.  The 
tongue  h  then  ac\t^  in  the  u^iial  way.  nnil  cut  off  by  two  ^rasfuni  wurkeii 
BiniulUineiiti^ly.  the  chain  of  one  dividing  the  orgnn  trsnsven<ely  cl«8e  tu  the 
pilhirs  of  the  ffliiL-eii,  that  of  the  other  severing  the  ti^eues  al-tiig  the  floor  of 
the  moulh.  I  have  performed  this  operation  in  one  ca^  of  unilnlprat  c-uiicer 
of  the  tongue,  and  fnunil  that  lh«oi^ncoutd  rcAtlily  berenehed.commiiniteJ, 
and  ft  portion  n-moveii  through  u  gap  in  the  check.  After  the  operation  \i 
coneluded.  ihin  is  ehtned  hy  (Hiturc«. 

Exoision  of  Ton^ne  after  Bivisioii  of  the  Lower  Jaw. — Sedillot,  of  Htras- 
burg,  ilt-Btribeii,  in  1855,  a  tiuahixl  of  removing  the  whole  of  the  tongue, 
which  he  Atatof)  Ihnt  he  hud  practiced  for  B»me  y«ara  with  mewm.  The 
operation  coniiiiilA  in  making  a  vertical  spclion  through  the  lover  lip,  sawing 
ihroogh  the  inferior  maxilla  at  il«  »yniphyNia,  separating  the  l>onc  on  eitch 
Hide,  drawing  the  tongue  fcjiHard  and  removing  it.  (n  perf^^rming  this 
operation,  its  inventor  reconimendu  that  the  section  of  the  lotver  lip  should 

be  made  carefully  through  the  median 
liue,  aod  carried  acroH  the  chin  as  far 
down  as  the  hyoid  bune.  Thei  lower 
jaw  is  then  utwn  through  at  ita  sym- 
physis. In  order  to  fix  the  Iwnw  more 
accurately  after  the  operatiou.  ho  n- 
commends  that,  instead  uf  making  one 
vertical  inciiiou.lwooblique  cuts  should 
be  practised  with  the  saw  in  this  shxpo 
^ ,  Ki>  as  to  form  a  triangle,  the  noiol 
of  which  corresiwuds  to  the  middle  of 
the  body  of  the  bimc,  »o  that  the  two 
oppix^ite  fiiden  may  be  locked  together 
afler  the  removal  of  the  tongue.  Be- 
fore Bnwing  the  bone  it  may  be  drilled 
on  each  side  half  an  inch  from  the 
edge  of  the  int«'nded  incision  ihwugh 
it.  After  having  dividetl  the  lower 
jaw,  the  tnusclee  connecting  it  tu  the 
tongue  shi>iild  be  cut  acn>86  and  the 
mucons  me^nbrane  f  >rming  the  f1iK>r  uf 
the  mouth  detached  from  the  bone,  the 
two  sidca  of  which  are  drawn  aaunder; 
and  the  tongue  then  removed  from  the 
byoid  bone  by  a  stroke  of  the  knife,  or 
gmdualtv  snipped  through  with  mcis* 
Bors.  The  lingual  arteries  bleed  freely, 
aod  mu»l  be  at  once  secureil.  Fidd«, 
of  Jamaica,  recommends  that  the  arterr  be  divided  and  tied,  6rst  on  one  elde 
and  then  on  the  other,  »o  as  to  avoid  dangerous  hemorrhage.  The  opp>^te 
•idef  of  the  jnw  bone  are  then  brought  together,  and  held  in  pu!filion  by  wire 
twisted  round  the  teeth,  or  pamed  thn>ugh  a  hole  ilnlled  on  each  xide  before 
the  division  of  the  boue.  If  Scdiliot'n  angular  cut  be  adopletl,  the  hoofr 
may  he  kept  in  filw  much  more  easily  than  if  the  vertical  incision  to  which 
he  first  of  all  had  recourse,  and  which  is  commonly  adopted  in  this  country, 
be  practised.  The  incision  in  the  lower  Hp  must  be  uuiteil  in  the  usual  way 
by  harelip  pins  or  sutures.  This  operation  was  first  done  in  this  country  by 
Syme  nnd  Nuuneley,  and  has  of  late  years  been  very  extensively  prnctis^  by 
many  Surgeons.     By  it  the  whole  tongue  can  be  freely  exposed  and  cat  uut 


>Y^ 


S 


tj 


PJg.  7M,— Ramovkl  of  ToBfue  hy  Divialon 
«l  Li>««r  Jaw  knd  Eoruenr- 


1 


i 


i 


IXCISION  OyTOWOUE — ACCTPBNT9  AFTER  OPERATIOX.      937 


fmm  its  deepest  attnchmenU.     It'  it  be  preferred,  the  ^craseiir  rutty  he  ap- 
plipH  when  ihe  tongue  has  het-n  fiitly  cxposfd  (Fig.  (-iS). 

RemorthsLge  dunng  Excisioo  of  the  Tongue  is  ihc  only  serinue  danger 
of  tbo  operuiiuu,  tmd  m  Uiag  fta  tlie  mouLh  is  thoroughly  gugged  cvt'u  (lite 
need  cnuse  no  anxiety.  11' only  a  part  uf  the  longiie  U  heiug  rctntiTed,  hem- 
urrfaage  may  be  immcdiaicly  ttrrc»ti.-fl  by  drawiug  the  tip  well  out  <>t  tiie 
iDoath  1^  tbc  ligAture  through  it  and  compre^ing  the  liugunl  n^uioMt  the 
jaw  by  the  nifihwi  alreiuly  dosoribc-d.  The  pharynx  niust  tb*u  lie  ihor- 
uughly  cicaucd  with  j(|i.>iigea  on  spimge- holder*.  When  this  is  diin<*  the 
■MiaiaiJt  relAXt«  bU  tingcr,  and  the  bleeding  point  can  u.iii»ily  1>«  aeiMd 
withoui  dtttifulty  in  a  pair  of  foreipreMure  tbrce[M.  It  the  whide  tongue 
hare  heoo  removed,  the  stump  nuul  be  hooked  furKard  with  the  fl>refiuger 
and  «(-txt.-d  in  a  pair  of  vuIhcIIuoi  Turceps  uhilc  the  artery  ix  cuiiipre«eed  an 
before  deseril>«d.  lu  tying  the  lingual  artery,  a»  the  tinsupM  ai-e  brittle,  it  if 
belter  to  include  Mime  ot  the  surrounding  atrtictnre.  The  ligature  may 
Uieu  he  cut  Abort.  The  most  teriuiis  accident  is  when  the  gag  alijM  while 
tne  lieiiivrrhage  is  going  on.  In  a  case  of  ihis  kind  1  had  tu  perfurm 
laryogotomy,  us  a  ccaguluni  formed  in  the  pharynx  before  the  Tcosel  could 
be  secured.  Tlie  patient  made  a  good  recovery,  dying  two  yean  afler  the 
openiliou  from  the  recurrence  of  the  disease  in  the  luug  nud  in  one  of  the 
tocc 

OosUig  of  blood  may  usually  be  arrested  by  ice,  or  if  it  be  more  tbao 
usamlly  Iree  the  bleeding  poiut  may  be  touched  with  Putjueliu's  nnitery  or 
p«rehloride  of  iruu,  but  thi«  should  be  avoided  if  pai>eiblr,  as  it  interleree 
with  the  healing  of  the  wouud. 

If  very  free  hciiK^rrhage  is  expected,  it  may  be  advi^ablo  in  some  cases  to 
perform  u  pretiminiiry  tnuhootomy  and  lo  intniducc  Trvndv  leu  burg's  ohlu- 
nttor  or  (o  plug  the  pharynx  with  a  sponge. 

After-trealment. — The  chief  irouhle  in  the  aller-trentnienl  is  to  keep  the 
mouch  free  from  decomposing  diitcbargett.  Various  means  have  been  tried 
for  this,  chlorinate^l  giir^ks,  Aanilaa,  terebene,  Omdyn  Huid,  etc.,  but  nothing 
Bpproachea  iodoform  in  clticiency.  It  should  be  anpHetl  in  the  form  of  cry»- 
laid  (not  precipitatetl  i  immediately  alter  the  operation.  Hubsequently  a»ma]l 
quantity  may  be  sprinkleil  over  the  raw  Hurface  daily  tty  means  of  a  cametV 
hair  pencil.  The  mouth  may  lie  washed  nt  interval.-)  alter  the  firdt  thirty-six 
hiiui«  with  a  weak  solution  of  pfirmaii^annte  of  potash.  Ice  may  l»c  sucked 
at  intervals  for  the  Hmt  few  dnys,  if  it  l)e  found  grateful  (o  the  patient.  A 
tendency  to  dyspna-n  is  sometimes  niHuifesled  alter  the  <iperniion,  owing  to 
the  stump  of  the  tongue  fallin-:  backivards.  This  ia  rcnit'ili^il  by  opening 
the  mouth  and  drawing  the  »tunip  forwards.  If  It  occurs  frefjuently,  a 
thread  muat  be  pawed  through  the  «tump  and  retHineil,  for  a  few  days.  If 
only  a  part  of  th**  tongue  ha%-e  bviH\  reirjoved,  the  patient  will  bo  able  lo 
snatlow  tiiirly  well  atlvr  the  first  few  hours,  but  if  the  whole  organ  have 
been  taken  away  he  must  t>«  fed  by  vnemala,  ur  through  an  India-rubber 
tabu  pasaed  down  the  umophngus,  for  the  lir«t  three  or  tour  days.  There  is 
ofleo  trouble  from  proluse  Mitivation  for  two  or  three  week»,  owing  to  the 
patient  being  unable  to  bwuIIow  tlie  viscid  saliva  excreted  from  the  wounded 
and  irritated  glands.  This  is  lu-st  controlled  by  alum  and  pyreihruni 
gargles. 

Accidents  after  the  Operation. — .Secondary  hemorrhRgc*  may  occur  about 
the  tiflh  or  sixth  day.  especially  uller  the  galvanic  cautery.  The  free  ^uae 
of  lee  or  a  t<pray  douche  of  ice-cold  wnier  niuy  arrest  it  if  it  be  elighu  If 
IVee  and  a^erial,  perchloride  of  iron  or  ihe  actual  cautery  may  be  re<|uired. 
If  this  fail,  the  lingual  may  be  ligatureil  above  ihehyoid  bone  unlett«  that  hats 
beaa  already  done  as  a  preliminary  8t«p  to  the  operation.    Sfpticfecer,  teptie 


im 


ass 


DlfiEXaES   OF    TBE    MOCTH    AKD   TBBOAT. 


pououtnff,  nnd  »tjttic  iufeetion 


[irevcnIfO  hy  avoiding  whenever  poMible 
leave  a  slou^liing  nui'tace,  and  by  the  free 
use  »r  ioiiofunn  ju  itie  after-ti-uatnieiit,  Si^ptic  ptieumuuia  due  tu  the  inhala- 
lion  of  rie<xini  posing  mailer  from  llit?  floor  of  ilie  mouth  isuoommnn  caitsieof 
dentil  in  exeUiou  ot  llie  toiigtic,  tis  in  ctil-tliroat  und  .timtlar  injuries'.  It  U 
characterised  by  scattered  ]Mit<.'l)e«  of  broucliopueumonia,  mpiilly  ending  ia 
breaking  down  of  the  lunji-ti»»ue.  .Somelime*,  aitpareotly  by  t^xtetuiou 
from  tbeue  cetitrvB,  large  arvHs  of  iimg-liwutj  m»y  be^Mime  yangreuou*.  Thw 
very  fntal  cuiu{>licuti<ju  is  bi-et  uvuidvii  by  the  luw  of  iudofurro  atid  by  drjiio- 
age  from  Iho  Buor  of  the  uioulh  in  cmefs  of  removal  of  the  eutire  ti^ugue. 
A.  E.Ji»rkerBUgge«ledaud8UC'<.-fNrully  pnictised  iu«ev«ralca»eca[>reliiuiuar}' 
tracheotomy.  Aftt-r  the  opuratiou  the  pa(iei)l  wn«  made  to  breathe  by  the 
tracheal  upeuiDg  utitil  the  luoulh  bud  biicome  clean.  The  iutroductiou  of 
iodoform  has,  buvrever,  eu  efHcii^iitly  prevtiutvd  septic  proceMCB  iu  these  caM« 
tbat  tracheotomy  is  now  rarely  ri'tjuired. 

Comparison  of  the  Uethods  of  Operating:. — Iu  iuslituiiug  a  compariaoD 
btilneeii  the  <liHcr(^nt  nieihodn  <pf  dcaliii};  Vrilh  caucer  of  the  ioii;:ue  ii  nhould 
bu  uiidenjL<iiHl  thiiL  tliv  uanie  plan  of  trealtueiit  in  not  eijuiilly  applicable  Iu 
all  cawit,  hut  that,  one  or  other  t<hoijld  ite  adopted  a<.-(^>rding  to  the  Bize, 
situation,  and  extent  of  the  cancerous  mafs.  If  this  be  small  and  Biluateil  at 
the  lip,  Lhie  i>onion  of  the  i)r};an  may  Ite  I'MKily  and  t^utely  exciseiL  If 
Bitualisii  towanis  the  flide  so  us  to  re<]iiire  ihe  removal  of  perha]ie  the  anterior 
third  of  one  Bide  uf  the  orgnn,  it  may  be  best  done  by  splitting  the  Loague 
and  exciBiog  the  dbeased  part  by  the  ccraseiir  or  Bciasun,  and  the  game 
iDethtnlg  are  equally  applicable  when  half  the  organ  ha?  to  be  removed.  If 
the  {kosterior  i>art  beei]|>erlicially  affected,  the  dibeai^e  may  be  cut  out  and  ihc 
buccal  operation  will  then,  in  same  caee»,  \te  found  to  expose  the  jMri  most 
fully.  If  the  organ  bo  *>  deeply  alfeclod  that  the  whole  re<|uire»  extirpation, 
it  can  be  done  from  the  mouth  by  ibe  Ccrasfur  or  by  Wbitehead's  method. 
In  some  cases  it  will  be  found  most  convenient  to  split  the  tongue  and  remove 
the  halvrfl  separately.  If  the  Door  of  the  mouth  i»  implicated  recount  niu»t 
l>e  had  to  S^diltut's  operation  of  divistou  of  (he  l'>trGr  lip  and  Jaw  iu  tlie 
miildlc  Hue.  If  it  19  intended  to  remove  the  ^^tanda  below  the  jaw,  Ko<.-ker'8 
metliod  wiil  be  touod  the  beat.  VVhicbcver  m^lhotl  be  adopted,  Ihe  6Ubliu- 
gual  gland  should  always  be  removed  either  witli  the  tongue  ur  by  soiaion 
alter  the  main  part  of  the  diseaie  has  been  taken  away,  a$  there  ar*  eoiue 
aiuall  lymphatic  glands  buried  in  its  sulisLance  which  ar«  often  an  early  t«U 
of  secondary  infection. 

BitutU. — The  prognosis  in  coooer  of  ibe  tODgue  is  always  bad.  Tbe 
uufortuDBte  victim  ot  this  most  terrible  disease  is  almost  inevitably  dustinul 
sooner  or  later  to  fall  a  sacrifice  Lo  it.  Hemoval  of  the  diseased  organ  in 
part  or  in  whole  may  relieve  for  a  time,  but  verir  rarely  does  more  than  this, 
fhe  more  acute  the  cancer,  the  more  rapid  will  be  ite  recurrence,  cither 
locally  or  in  the  glands.  A.  E.  Darker,  who  hna  most  cnrclully  inveKtigated 
thiii  point,  dales  that  out  of  170  cases  collected  from  various  buurces  he  could 
outy  find  17  in  which  recurrence  did  uot  take  place  under  one  year ;  and  in 
ihc  whole  of  medical  literature  he  could  meet  with  the  reconl  of  only  \'l 
cases  iu  which  the  patient  had  remained  free  from  recurrunoe  Ibr  a  aufficieoi 
length  of  lime  to  justify  the  hope  tluU  he  was  permanently  relieved  of  the 
disettse.  One  of  ibe  ju<wt  successful  cases  on  rei;urd  woh  operated  on  by 
O.  Heath.  The  cancer  was  situated  near  the  fncnuni  adhering  to  the  jaw, 
and  extending  upwards  iuto  the  suhstauev  of  the  tongue.  The  whole  inciaur 
portion  of  the  lower  jaw  and  the  auu-rior  half  of  the  tongue  with  the  corre- 
sponding part  of  the  Huor  of  Ihe  mouth  were  removed  in  one  piece.    The 


I 


i 


DISEASES   or   THE   TLOOB   OF  THE  MOUTH. 


689 


operalion  wao  performed  more  than  ten  years  ago,  and  the  pati>pnt  i«  still 
alive  aoil  in  gtxxl  health. 

Tbi^  niortAliLy  ilireclly  dus  to  the  operation  in  roiuiderable,  but  not  very 
hifch. 

Barkor  haa  collected  218  oiRea  from  TaiiDiis  aources,  and  finds  that  the 
deaih-rate  is  lii.!)  jier  cenU  It  U  imtisfaclory,  however,  to  note  thnt  ol'  late 
vears  it  han  ctMiBiilembly  dimiiiivliptj.  TIiuh,  at  Univer^ly  t_Vi]|ft;(*  Huiipilal 
88  caven  wer*!  nperal^d  uii  lieLweeu  11^71  niiil  I'^Ml,  nt"  Ilicse  lU  ilifd ;  'It)  of 
tliene  operHlion.''  uere  peri'ortiieil  l»flore  IK77,aiicl  ol'  the»«H  died,  Hl)ik'  urihe 
18  nince  ihat  date  oul/  2  died.  The  diiuiiiivlied  <lealh-tHle  »eem»  to  be  due 
in  (Mtrt  lit  least  to  the  more  succenwfVil  prevention  ot'<lecoiikp<.isition  by  the  uae 
of  iodoform.  The  recor«]s  of  exaeiuii  of  ihn  tou^iie  «re  so  far  from  saliif 
fueiiiry,  lliat  »«ume  Surgeons  have  doubted  the  prupriely  of  perlyrtuiog  the 
ojierntion  ;  but  when  we  retnember  the  terrible  late  of  the  patient  if  iJie  dis- 
ea*«  be  allowed  to  run  its  coiinse,  iiiid  that  caeea  of  apparent  cure,  although 
exceptional,  are  unl  unknown,  it  cannot  be  denied  that  the  operation  ia 
not  only  justifiable  but  advi»id>le.  The  ho[>e  uf  tnipniveraent  in  the  reftulls 
Kcnift  to  lie  liDit  in  early  r<!;>ognition  of  the  disease,  fc  that  it  may  be  removed 
jbefore  tlie  glands  are  alfected ;  and,  secondly,  if  tliis  periuil  lie  jiacBcd,  in 
ifree  removal  of  the  disea»eil  organ  with  the  whole  of  the  lyinphiilic  glandti, 
which  reevire  lymph  IVoin  it,  it  this  be  pi;M<ible.  The  fact  that  ejtilhelionia 
tehlorn  recurs  in  the  vibi-vni.  eucotiragea  ub  to  ntteinpl  the  removal  of  ihs 
~  ded  glauda  whenever  their  Bituatiun  is  itueh  that  ibe  operation  can  be 

^Iv  underlaken. 

Eflect  of  the  Eemoval  of  the  Tongue  on  Speech.— Altlum^h  diHttnctneee 
of  artit-ultiiiou  ]a  nec't't«'&ri I y  alfti'led  for  a  lime  by  them;  openilioiis  on  the 
tongue,  yet  it  is  ttsnally  restore^l  when  only  the  aiUerior  third  or  half  is 
removed;  the  tissue  of  the  organ  recovering  its  normal  mobility  with  re- 
iniarkable  facility,  and,  iDdeed,  appearing  to  po^arss  a  very  considerable 
reparative  power,  and  to  be  L'apable  r>f  reproduction  to  some  extent.  Even 
after  removal  of  the  whole  uf  the  tongue,  the  power  of  deglulilioa  i$ 
preserved,  and  that  of  arlicululi<-n,  although  at  first  Botiiewhai  imperfect, 
eventually  relunia,  »o  that  the  patient  is  able  to  speak  so  diitlinctly  that 
•irangcra  would  nut  be  awart-  of  the  loss  he  had  suBinined.  Amongst  the 
torlnn:-*  to  which  Christian  marlyrs  were  subjeclc*]  in  the  early  aacs,  and  the 
puuishmtnia  whifh  have  been  inflii-ted  on  heretics,  "cuttiDg  out  the  tongue" 
vui  one  of  the  most  barbaroun.  Marlyrologists,  in  describing  this  horrible 
niutiiatioD,  have  remarked  with  wonder,  that,  although  it  was  practised  with 
the  view  of  depriving  thesufferera  of  the  p<»wer  uf  speech,  yet  it  uiUu  failed 
ID  its  eH'ect,  and  thu»e  who  had  been  subjefteil  to  it  were  enabled  to  speak 
afterwiinis  as  plainly  as  before.  This  tbey  liare  attributed  to  direct  mira- 
culous iDterveution.  13ut,  as  modern  Surgery  has  shown  that  the  power  of 
Seecb  returns  equally,  whether  a  caucerous  tongue  have  been  extirpated  by 
e  kaife  of  the  .Surgeon,  or  a  heretical  tongue  by  that  of  the  executioner, 
We  mu»t  look  upon  tuc  return  of  speech  rather  as  n  physiological  fact,  than 
as  a  miracle  specially  wrought  for  the  benefit  of  thuse  mutilated  in  and  for 
the  propagation  of  the  true  fnilh. 

DiHEAHiiB  OK  THE  Floor  oftui:  Hot-'Tti. — Solid  Tumor*  arc  occasionally 
met  with  in  this  li^g'wu.  £p\theHoiiui  being  the  tuust  coaimoa.  Adenoma  ultn 
in  couneetion  with  the  Balivarv  glands  may  occur.  Nrevi  also  have  been 
otteorved  in  ihif'  eituation.  "i'hei^c  tumors  require  removal  by  irregular 
oijerationa,  varying  according  to  the  size  and  situation  of  the  growth.  Fur 
tiiese  procecdiiigii  uo  Kpeelal  directions  ran  be  given.  In  remiiving  ^uch 
tuiuorv  UB  th<sc,  when  siiuiiied  under  or  by  the  side  of  the  tongue,  the  knife 
must  necessarily  be  used  with  much  caution.     It  must,  huwevor,  be  boiue  in 


DISEASES   OP   TQE    UOtTTB    AND   TDROAT. 

mind  thai,  if  thesi?  growths  cnniiot  be  reached  fViiii)  Ihe  moiile  of  (Ueib^l. 
thoy  may  be  got  lU l>y  iiicisinii  through  the  Jiiyln-hjoid  region,  wbvn  Um 
is  but  B  slight  thicl[»c8t!  of  §t*i\  parts  between  tht)  etirlorv  and  the  Ikwi 
the  mouth. 

Cyatio  Xamon  in  the  Floor  of  the  Xoath  may  occur  unrU r  liim  (km' 
1,  Knniilfl  ;  2,  Ctingonital  iK-rmoitI  Cm ;  snil,  '■'>,  Bum!  I'ysta. 

1.  Bannla.— A  globulnr  swelling,  semi-tninjtpiin'nt,  cvidratl,r  ctmtalBai 
flui<).  nm)  often  nttainlng  the  bIzc  of  a  wiilmit  or  »  plf«fon*ii  rgg,  m»jh 
situated  un<ier  th<^  tongue,  puibing  thii  orgAD  upvnrH*  and  bnckvirdk, ibI 
consequently  interferiog  with  deglutitiim  and  speech  (Fig.  737).    TWwUi 


Vif. 'J7.— lUniiU;    InlcudlMllaB  «»(  gctoo. 

of  tbe  ejBt  are  usually  tfaio,  with  »niRlI  t»h1s  ratniAriogoa  Ibcn;  in**' 
tents  are  glairy  and  unlike  ealiva.  Thii!f»rm  of  roouw  U  tuwdljHld  i<>W> 
dtlniation  of  Wharton's  duct;  but  there  i«  no  proof  of  the  dhmfe  bc^Dftftkii 
nnturv,  nor  is  it  very  cosy  to  undorMnnd  how  no  sninll  a  Huct  can  he  iUitJ 
to  H  largo  a  size  ns  is  occndionaHy  attnined  by  thr-ac  lomorf.  which  aemM 
Bomo  cneci  nl  least,  mther  tn  ooDniai  of  independent  cr^ttc  *'r.rm»tina»,«^ 
■8  commonly  occur  in  connection  with  other  tk-crctir  sod  ia  t*** 

p»irlj«  of  the  mouth.     And  thtt  riew  of  the  caoe  i«  fii.  ..i  by  tfaelMt 

that  these  globular  cystic  tuniora  containing  glairy  tliiid  may  occur  in  1^ 
fuhntnnce  of  the  tongue  Jtself,  far  away  from  nny  nalivary  duct. 

Murrant  Bnkcr,  who  hu  tnverligntt^l  tbe  connection  iN-twcfo  raftak  w 
the  Whttrtoniuo  duct,  find*  that,  in  «»«  of  ranula.  Whuf'  "'-  ''"^  i»^»* 
free,  without  any  allcmtton  in  vlxcaud  that  wtiva  may  \-  lagfr* 

it,  A  probe  |MUMed  into  tht  duel  i«  iteparatt^i  from  thi-  uiTjt;iii  oyiiM* 
nieinbraiioui  wait,  showing  clearly  that  the  duct  and  Uit  ranula  d-j  Dot  c**^ 
niunicate.  I  have,  however,  lately  aeen  a  vmc  in  which  a  ranula  r**'^ 
from  a  wound  of  the  Soor  of  the  mouth,  in  the  «iluBtiim  of  tho  WbannM* 
duct,  Tbe  wound  wan  caused  by  tbe  accidental  slipping  of  a  pair  of  l"**^ 
forceps  during  cxtrRctirm  of  the  Bnrt  mL>lar  tooth.  As  the  *<"'.)B'1  b«W  • 
ranuin  furmeif.  the  cf-iitcuis  of  which  were  ihifk  and  mi  ■dsIW*' 

Mcrclion  of  tbe  submaxillnry  glaurt.     It  ullimaiely  rear.  -i»  •■'  •" 

plover's  egg.     That  this  tumor  was  fonnvd  by  an  nccumulaiioD  of  the 
lion  of  tbe  submaiillary  gland,  (hen?  l'Uii  be  no  dimhi ;  but  it  b  (jails  f 


DiaSASKS    OP   THB   PALATB. 


641 


ble  tbat  the  collection  formed  in  the  submucous  tiwue,  and  that  it  was  not 
enclosed  in  no  actual  dilatatiou  of  the  WliartoDina  duct. 

The  IVfofmrnf  of  this  form  of  rauula  cousUls  either  ju  passing  a  seton 
through  its  walb,  so  that  coDtracLiou  luay  lake  place  ou  this  (Fig.  7U7 ) ;  or 
else  in  the  excision  of  n  largo  portion  of  (lie  anieriur  wall  uf  the  ctisI,  the 
remainder  c<^ntmciin^,  until  it  at  lost  h^>ociMiie8  obliterated, 

2.  The  Coagenital  Dermoid  Cyst. — Thit;  rare  iVirii)  of  cyet  is  met  niih  in 
the  middle  line.  It  most  comnumly  forms  a  ant'lliuj;,  |»rojeuting  into  the 
raoatb  beneath  the  tongue,  and  aleo  appt-ariii;,'  on  iho  notk.  In  a  case  of  ihia 
kind  under  my  cure,  the  coiitenl*  ftliwely  rfwjinhlcd  cn'miiohof^  in  appeRt- 
aiii-e.  nnd  were  conipoBed  of  epillivliat  scales  and  liitty  matter  (aee  als4i  vol. 
i.  p.9:i.Sj.  Thc^e  vyaxs  may  be  diesectel  out  fnmi  the  mouth  ur  by  au  exter- 
nal incision  iu  the  middle  Itno  between  the  rhin  and  tlir;  hyoid  hone.  Tlie 
operali'in  is  irnMhltDome  ami  iimy  be  armmpnnied  by  free  hleediii}^. 

3.  Burial  Cyst. — This  is  lielievcil  to  arien  frimi  fnliirgenn-uL  nf  ihc  bnraa 
above  the  hyoid  bone  between  the  gfnin-hynidei  and  gcriio-hyo-gln^i.  It 
prDJocla  usually  more  dintinrtly  in  the  neck  thnn  into  the  mouth,  nnd  thus 
iiirmd  a  larg;c  tumor,  snfk  or  elnettir,  and  memi-tluctuating,  occupying,  perhaps, 
all  the  spscc  between  the  symphysiix  nnd  the  livoid  bone.  It  mny  attuin  the 
titt  of  an  orange.  The  tumor  is  best  treated  hy  making  a  free  incision  into 
it,  from  the  mouth  if  possible,  and  wiping  out  the  cavity  with  chloride  of 
rinc  (gr.  40  to  .y  of  water),  after  which  a  drainage-tube'  may  hp-  inserted. 
If  the  tumor  is  more  Mi|»erficial  exlern»lly,  ihe  same  treatmeni  may  be  ciir- 
rie*l  out  from  the  outside.  It  is  nut  jKWible  in  most  cases  to  diseect  the  cyst 
out,  as  its  wall  is  thin  and  its  connections  deep  and  importiint. 

Kai.ivary  Caix^via  arc  occnsionally  met  with  in  connection  with  the  sub* 
lingual,  stibmaxiltnry.  iind  pnnitid  glniid;«.  They  are  most  common  in  the 
sublingual  gland,  aud  will  theu  be  louml  to  ha  situated  in  the  Wimrtouiaa 
duct.  Fnjui  this  situation  I  have  two  or  thrte  times  removed  them,  (.tross 
mtutions  a  case  ofnalculus  in  the  duct  of  the  submaxillary  gland.  Wherever 
occurring,  they  uhstruct  the  duct  aad  produce  retention  of  saliva  tn  it. 
U«nv«,  when  the  aulivary  glands  become  actively  secreting,  as  at  meal-timea, 
Ihe  calculus,  by  preventing  the  escape  of  the  ailJvary  Huiii,  causes  digten- 
tion  of  the  gland,  with  paio  and  tenderness,  rendering  mastication  dif&cult. 
The  TVifofmerJ  is  simple.  It  consists  in  dividing  tlie  mucous  membrane 
I  over  llie  calculus  aud  then  extraccing  it  with  forceps.  The  largest  irhich  I 
I  Jiavti  removed  was  of  the  size  uf  a  small  danisou-stonc;  it  was  loose  la 
I       Wharton's  duct. 


DffiRASBS  OP  TUB  PALATE,  UVL'l^,  AND  TONSII^. 


IlARt>  Palate. — The  hard  palate  i»  liable  to  neerosi^.  usually  the  result 
cif  syphilis  or  scrofula,  hut  occasionally  ariatng  from  a  subperiosteal  ahset-ss, 
■starting  from  a  diseased  tuoth.  The«o  ctndiliona  have  already  been  aufli- 
«:ieDtly  (lewribed  in  the  chapter  on  Diseaseo  r-f  the  Jaws.  Epithelioma  ia 
«)rca»i<>nBlly  met  with  nflecliug  the  bard  palate,  hut  it  is  far  from  coiimion. 
J!>n^Ju>mirvma,  yil/mnit,  aud  varioutfonm  of  Sarcoma  have  also  been  met  with 
in  this  region. 

Soft  1*alate.— The  nioct  common  distase  cf  the  soft  palate  is  fyphilitie 
tileerxitioH  (vol.  i.  p.  1067).  KpUhdioma  is  occasioually  met  with  in  this 
Imrt,  but  mure  conitnoiily  the  palate  is  affected  by  extension  from  the  pillar 
«^f  the  luuces  or  the  root  of  the  t'>ngue.  Adenoma  is,  jierhap,  the  most  com- 
■non  tumor  in  this  region.  It  b  hard,  smooth,  painless,  and,  being  encnjwuk'U, 
la  readily  shelled  out  from  a  single  incit>iou.  A  few  years  ago,  C  Ileulb 
Vol.  11,-41 


642 


DISEASES    OP    THE    MOUTU    AND    TQUOAT. 


successfully  removed  a  tumor  of  this  kind  mcnauriag  about  cue  iodi 
lialf  in  fliamotor. 

Uvui^.  Elongation  of  the  tXrala.— The  uvula  occasionally  bcfsnutDg 
elougfttuil  auil  Imu^iu^  •hnvn  iuio  iJiu.jilmryux,  eo  m  lo  touch  the  i->ptglo| 
niitl  sensitive  uiticiu^  luiiuhrunv  in  its  iiviffhliurbood,  given  rise  Ut 
irritation  of  liii!  luui-c:^,  atui  to  »  ucklhig  or  fijiadnKidic  cough,  wbioh  can^ 
cun-H  iiu]y  hj  reiuuvhig  the  jiendtilouB  bmly.  This  little  opemliiin  may  be 
readily  done  hy  seizing  tlie  end  of  the  uvula  with  a  pair  nf  pnlypus-forcepe. 
and  snipping  it  iirrotw  near  tlio  root  with  a  long  pairof  eciaih)rs.  It  is  belter 
not  to  remove  the  whole  of  the  uvula.  If  thiv  lie  dune,  thniat-irritiitioii  tii 
apt  to  coiitiune.  1  have  been  most  patiftfieil  with  the  result  of  those  rawfl  in 
wtiich  a  Btunip  from  a  r)tmrter  to  the  third  of  nn  inch  in  length  haa  been 
left.  Tor  Bonie  venrB  I  have  Iteen  in  ihe  habit  of  uring 
a  pair  of  "  vulftellnui-sciseora"  (Fig.  738).  by  which  the 
uvula  \a  cut  nfT  at  the  eame  mamrnl  thai  it  is  seized, 
lhu5  rendering  the  operation  easier  and  lees  irritating  to 
tlie  pnlieot.  A  very  ingenious  An>er)cim  inglnimetit, 
conH«litig  of  a  |>air  of  forceps  and  »oii«ore  ciimbiued, 
may  be  employed  with  the  same  view;  bv  clueing  the 
handles  of  thi«  instrunieiit  the  uvula  h  &rt,t  seized,  and 
is  then  ininiedifttelv  cut  acn*s  (.Fig-  7-19J. 

ToN9i[.«.  Toiunlitia  or  Qniiisy.^Tbe  tonsils  are  DOt 
ui)fret|uer)tly  the  M-al  «if  di«euiw,  becoming  inflamed  or 
lieriTiHiieulty  enlai^d.  Whtn  iiiHamed,  ibev  beooiue 
swollen  and  red,  with  much  pnin  in  Ihe  side  ot  the  n«ck 
and  var,  increased  by  any  attempt  al  swallowing  ;  there 
is  usuiiily  rallicr  a  prufuiw  iiecreLion  »f  saliva,  and  a  g'wd 
ileal  of  fiwelliug  under  the  angles  of  the  jaws ;  the  tongue 
is  much  coated  with  thick  pasty  mucus,  and  the  voice  is 
thick  and  naesl.  The  disease  comes  on  suddenly,  often 
accompanied  by  high  fever,  chills,  and  occa^ioDallr  even 
delirium.  The  tbermnmeier  frequently  rises  to  l(ict°,  or 
even  higher.  In  Mm«  cases,  a  trace  of  albumen  may  be  found  in  the  urine. 
Tonsillitis  is  oilen  caused  bv  exposure  to  impure  air,  such  as  results  from  the 
escape  of  sewer-^ss  into  a  Jiouse,  and  it  is  not  uncommon  amongst  the  rca)* 
dcuia  in  hoapiuils.     It  may  be  mistaken  for  dlpbtberia.  scarlet  fever,  or 


Fl(.  739.— ValHllum- 
•elNOrft 


Pig.  TS0.— ForMf  t-nlnora. 

erysipelas  of  the  faucca.  From  diphtheria  it  is  dislingutahcd  by  the  absence 
of  exudation.  The  mucous  secretion  from  the  tonnil  may  Ktmcwhat  resemble 
diphtheritic  exudation,  but  it  is  readily  dixtingoi^hed  by  its  want  of  adher- 
ence, as  it  in  easily  removed  with  a  camelVbair  pencil.  From  scarlet  feirer, 
tonsillitis  i*-  di«tin;iniphpd  by  the  absence  of  the  red  tongue,  and  by  the  pcd- 
nesa  of  the  throat  Winj;  purple  in  tinl^  and  limited  to  the  tonsils  nnd  tlicir 
immediate  neighborhood,  ana  later  on  by  the  absence  of  raah.     From  ery- 


KKLAROBMENT    07   TKB   TOITSILS. 


648 


nf  tbe  fnuoes  il  ia  more  diffiviill  to  diiitiiigiii.^h.  but  it  will  iisuhIIt  be 
I  ibai  the  Kdunc  is  durk«r  in  tial  nud  \ie»  <\\ffu»eii  ihnn  in  ervei|H;laB, 
llkmii  \em  oe^lemittdus  ewt^llini;,  and  an  tendency-  to  the  eupi'rveotioQ 
rdfipaoA  fnim  tnlema  glultidiB.     Dttre  u  miao  len  (glandular  ealar^iueot 
•I  liw  Riigle  or  the  jaw. 

IV  Jywtment  shnald  nivays  be  commcniwl  by  b  ^^oud  pur)^;  ■  ualomel 
lldeoloc^nih  yiill  will  be  fimnd  most  i>ffii*iiciitui<  it*  it  can  l>e  taken.  This 
il  r>lt'i«r(l  by  the  appllL-Aliitn  nf  fonu-ntutitm^.  thv  inhHiiition  ofthu  steam  of 
^••t  ttat'-r,  and  low  diti,  which  need  sctirLvly  be  cnforeeil,  on  account  ol'  the 
Jilfirtilty  and  pain  in  AwnllowiDj:.  D"  (lie  momli  onu  he  opened,  much  relief 
my  be  jri\-«i  by  •CBfitVing  the  toitsib  with  a  prohc-p')iiiu*d  biMoury;  and, 
if  ih«ocw  r-rni.  it  shoulil  l»e  opeucl  ctiHy  with  a  giim-!ancrt.  The  iohalatinn 
ut  ihi-  >tiMtii  frrnn  a  pint  of  hoiliug  witMr,  to  wbiob   ha*  Itocn  added  n  tea* 

rxDiul  <'t  rr4>»^»te  or  carbolic  acid,  will  often  give  much  comfort  by  allaying 
frtor  mI*  thp  bre*lh. 
BnlufeoeDt  of  the  Tomils. — There  are  two  dii>tinct  fornu  of  chronic 
rat  of  the  toDsilp.     In  one.  tb«9«  organs  become  increased  in  fize  in 
beat  thy  children  in  coxiK<]\ieDQe  of  repenttd  attacks  of  injiam  motion, 
'  eapeciaily  <>r  diphtheria,  scarlet  fever,  and  measles.     In  the  second 
D,  the  enlargement  is  due  to  a  trua  h^crtrophy  of  the  normal  itructurei 
'  toQiil.    The  lymphatic  rollicloe  are  enlnrgcd  and  increneed  in  niimhcr. 
Itbt  ooooeclive  tissue  between  them  ia  a».tn*  abundant  and  denser  tlnui 
unL    Tbe  crypta  are  deepened  and  are  died  wiih  an  abundant  mucous 
ion.     In  rare  eaaee,  oalcarcous  eoDcreiioiiB  may  be  found  in  the  dilated 
irrplL    Thii   fi.nn  of  enlarfrement  may   be  cijmplicat»-*d   by  the  dfecl*  of 
Muued  Htuckfl  of  inflammation. 

Wbea  Uiv  tt>n*iU  art;  i-hn>utcally  enlarged,  one  usually  anfTi^n  to  a  some- 
vUt  ^reaicr  extent  than  the  other.  The  condition  is  ubvinUH  on  0|i«:nine 
iW  OhHith  and  di-prmiing  the  t.on;:ue  mi  tat  to  cxp<iae  tbo  fauces  fairly,  una 
OBKitbe  miiitakt>n  fir  any  otlur  morbid  atnle. 

_  la  Dbvnir  infiammiilory  enhrrjrmml  die  umsiU  are  red,  rongrau>d,  and  wry 
isbk,  under  ihe  induenocorslight  cnuses,  to  violent  attacks  of  acute  iufUitu- 
■Uim  vlib  ulceration  or  alMwcwt. 

U  tknmie  hypertrojihtf  the  tonnil  prewnta  diirer<>nt  rbararter^ ;  !t  Is  large, 
'hIim  pa]«.  hard,  (mrMiih,  and  »emi-el antic.  This  dti*<>B.«e  is  one  which  occur* 
to  dtilttrf ti  and  you n IT  jK^rv^ms  who  have  a  general  tendency  to  fttrumous 
AciiiiM  of  tlti^  mim>u<i  mi'iiihranes.  M(-i»t  commonly  it  ileveloiMi  willioul 
**J  tniitnahle  ur  r\i  "ise,  iisually  commeiiciiiji  vt  five  or  six  yenrii  of 

*p.Bn<(  cmdimllv  n  _   op  to  puberty,  a  pcriml  whi-n   ihe  iuncti"ual 

[•^iTr  itcsl,  nod  when  tli'-y  are  mout  «ipo»<nl  to  irri- 

"Il  ,  ■    .  "•pccially  scarlatina  and  measles.    When  once 

[■M  Unmh  hare  eniargcl,  th«y  become  a  oou  rce  of  i^ri-at  inconvenieucc  nud 
r^iKQ  aerioUB  deraajfeuieut  of  health.  The  child  io  liable  to  nttnck»  of 
"'sBtution  of  the  throat,  the  tousile  thi*n  becoming  oongesleil.  greatly 
**'i'Kfc,aitd  readily  running  into  ulceration  orvuppuraliou.  lu  conaequence 
TthtN  repealed  attacks  uf  inllaraniatioii,  the  eulargeinenl  of  tite  tuaailo 
■**ns.  they  become  indursi«<),  ruj.^ged-|ookin,L'.  and  nwlutulwl,  nmjecting 
*'tir«anU  into  the  fauce*.  and  5timotimee  even  fHichitig  each  otoer  below 
'**  VTula.  Rapiration.  arlicnlation.  and  deglutition  are  uow  aerioualy 
'•■rferjd  with.  Tbe  mumuii  iiiembrHnt^  of  the  ufse  and  eyea  are  offcen 
w^oicaUy  cuugvitnl,  and  there  is  an  iiiereaaed  necretiou.  from  the  bock  of 
***  throat  and  nave.  uJ*  thick.  tMioeiouit,  nnbealthy,  or  fetid  miicuH,  tbe 
••■Jlwiag  nf  which  ia  dclelerioii».  Thi;  child  mnnot  ulifp  without  iiiorinjr, 
"^  ti  apt  Ut  start  up  with  a  filling  of  atiKocation  :  th«*  voice  lnHMnien  thick 
^  kmitj :  Um  atnae  of  hearing  U  blunt«?d ;  and,  partly  from  the  incipient 


fe 


644 


B1SBASB8    OP   TBB    MOUTH    AND   THBOAT. 


deoibeii?,  partly  from  the  tlifficulty  of  brcfltfaiog.  causing  the  child  tn  keep 
ita  moulh  liiilt'-opon,  tlii>  muDtviiauce  aseumes  a  peculiar,  racuDt,  gciiii-idioUc 
exprewioD,  wliicn  ia  very  clmiacterisiic  of  the  aavimetd  6Uik<'«  of  tlie  diseaae. 
The  moat  ecrioue  i-ilcvt  ia  Llie  iui{H:'dinii'iit  to  iusiiiraiiuu,  which  iu  tho  more 
chrooic  aud  sevorc  lorins  ol'  ciilargc-d  toDeils  will  ^;  to  such  an  exteul  aa  to 
prcvcuL  the  full  iiidiLtiou  uf  the  luuj;>«,  and  thufi  occaiuoD  a  permaneut  flat- 
Mning  and  cniilractiim  of  tho  chest,  imperfect  afraiitm  uf  the  bhiod,  and  an 
iateri'ercoco  with  general  nutntinii. 


Hff.  T«).--Tua*ll-K(iillotlM 


Fig.  T41.— TMiril^uillMlne 
■IidL 


Fig,  Tt3— ToBtU- 
giiitloUn*,  Willi 
Hooka  (I*  mIu 
Tuutil. 


The  IWofniCTi*  of  chronic  enlarRenientof  the  tonsitfl  vrill  vary  acconling  to 
the  agt  of  the  child,  and  ibc  dejiree  nnd  kind  of  hypertrophy  and  indura- 
tion nf  iheiMj  organs.  In  the  earlier  ntid  sligliter  formu  of  the  discnw,  the 
enlargenivnt  of  the  tunsib  may  gmduAliy  »idisid«  as  thv  child  grows  oltler 
and  stronger;  and  it  is  ucll  not  to  be  in  too  great  a  hurry  to  excise  the  tooaila 
ID  young  children,  but  rather  to  adopt  a  course  of  const ituUoual  treatment 
with  th«  v'lvvr  to  the  improvement  of  the  KAneral  health,  by  means  that  are 
onltnarily  had  recourse  to  in  th«  niatingetneut  of  xtrutna.  The  internal  nse 
of  into,  and  the  local  applicaliou  of  the  tincture  of  iodine,  of  nitraiP  of  silver, 
or  of  burnt  aiuin.  are  occasionally  serviceable.  In  the  majority  of  instmicee, 
however,  the  disease  *ill  not  Ije  materiallr  influenced  by  any  therapeutic 
mcan^  that  may  be  adopted  :  and  tu  the  eulargemeut,  continuing  or  iorreaa- 
ing,  gives  rise  to  difficulty  in  reapiratioa,  and  thus  interferes  with  the  due 


UAhiaSAST    TUMOH8   OP   TRB   TOSrsILB. 


645 


lintioQ  of  ihe  blood  io  tiie  limgv.  and  iiuf>aini  the  child's  speecli,  it 

tDecesMry  to  rvmove  that  purliuu  of  tbegruwtli  which  projects  b«yi)iid 

trdi»  of  the  palata    This  iiiny  l>eBt  be  iloiie  by  the  unituary  luosil- 

kllucinp.    TiiP  rin)(  uf  tht.-  iiiatruiiii'-ut  betog  paatwd  uver  the  lunior,  tha 

lavi  blade  »  pui^lied  r(irwan]»,  aud  ihue  a  eliuc  uf  the  projecting  part  of 

LUe|Tu«th  is  reutuved.     Ju  some  caM<ti  dilHouliy  is  experteuced  in  oriuging 

me  tfoisil  fairly  into  tlie  rin^  of  the  iustriinient ;  this  may  be  obviated  hj  I 

Lfovins  it  ihrouE^b  with  a  vulfellum  nr  double  h<>tik.  and  iiideeilr  io  some  uf 

t|k  laaclunea  BoliJ  for  liw.  puriHKM;.  a  douMe  hunk  h  Hlltiche<l.  which,  being 

tnliolo  the  Kinail,  dran-s  it  forwiird^  before  it  is  sliced  urt'(Fiip(.  740-742). 

Ii  performing  this  o|ieralitm  it  is  heat  for  the  S(irg<><iu  to  amnd  bc-hiiid  the 

■lliBt,  more  partictdarly  in  etcising  the  right  tonsil,  as  ho  cnu  thtu  look, 

wllcr  inli'  the  moutli  and  have  more  command  over  the  head ;  or  he  may 

mat  in  front,  and  uw  the  left  baud  f'>r  ibc  right  tMii^il,  aod  vice  vtr»i  i  Fig. 

'4Sy   Should  a  guillotine  not  be  at  hand,  the  tonsil  may  be  removed  by 


?lf.  TU.— aranrsl  of  RishI  T-xnil  witb  lad  UidiI. 

■inif  k  witli  a  vulaellum,  drawing  it  forw&rda,  and  then  taking  off  a  slice  with 
*  pmbv-pointai  bistoury,  the  baae  of  the  blade  of  which  should  be  wrapped 
JJ'ad  with  a  pieee  of  plaster,  to  prevent  its  woundiD);  the  lon;rue.  In  ei- 
(■■<B|;tiw>  tonsil  in  this  way,  care  raiut  be  taken  to  cut  from  below  upwards 
■*<luinnls  towar*U  the  mwial  liae,  and  on  no  account  to  turn  tht*  cdg«  of 
I"*  knife  outwanh.  lest  the  internal  carotid  artery  be  endungL-red.  The 
JiWiiilia^  that  follitwit  tbU  oiicratioQ  is  umially  verv  trifling;  but  it  may 
"MSetefltly  abundaul  In  euJan);er  the  {nitieiil's  life.  In  such  cates,  ic« 
'^l^lic  acid  wdl  uitunlly  arrest  the  blneiling.  In  one  case,  I  found  a  gargle 
"■(pirits  of  turtieutinu  sUMmndeil  in  mucilage  otfuctual  after  all  oilier  meitu* 
WltilMl. 

u  In*  been  slated  by  some  that  excision  of  the  tonsil  is  liable  to  lie  fol* 
■••i  b r  wttut  (if  d»?veliipineut  of  the  testes.  This  I  have  never  ob«erved. 
^t  K  ii  iKawible  lliat  I'li largemeiit  of  the  tonsils  to  fuch  an  extent  us  to  in)- 
P^nspiratiuu,  and  cuisequeutly  to  interfere  with  nutrition,  mar  lessen  the 
•■•  ^veiiipment  ol"  the  genoralive  or  any  other  organs  of  the  body. 

VtUgaaot  Tomort  of  the  ToniU  are'occasioDnily  met  u-ith,  but  are  not 
^MwL  The  umeil  readily  bue<imcs  implicated  iu  epithrliorua  springing 
••tfce  pillars  of  the  fuucca  or  lh«  root  of  iho  t'lUgoe,  but  is  very  rarely 
~*PniBary  aoal  uf  the  discauH'.  .Miwt  of  the  primary  tumnrstd  tlif  louhil 
^^bem  tkaeribn)  as  scirrlinuj  or  eucephalniil,  but  it  ia  iluubtful  wli<>tber 
*"*■  a;Jrrhu>  ever  camtnencn  in  thia  situati'ui.  The  s<tf\  "eucephuloid  " 
^'■'napiwBr  to  hava  been  in  mnet  cases  lyniphomata  or  Irmpho-aarcumnta. 
^  ■NlifBant  growths  in  this  n^oo  the  diaesae  apeedily  extends  to  the 


616 


DISEASES    OFT] 


UOUTH    AXl 


'HKOAT. 


■  A 


piUaw  fif  the  fftuc**,  the  |jliarj'nx,  and  ldwupIb  la  tbc  fUwir  -if  tht  kmuL 
the  i^IhikIs  uikIct  iho  aii|;lo  bpcwine  intjilicatpil,  fxlvnaive  iDfilfrslim  "f  i 
branii}'  charncit-r  tnkcs  place  in  aii<l  ar<iiiii<)  thru),  the  swalluwioi;  hrniH 
vxireiiiely  paiDful  und  ilitficutl.  rf9pirHtt»u  is  imiJOiled,  l)i«  nluurjoi  s»l 
jnlnle  ItrcfDit-  itm^'ftli U  uuil  )(iad<'(l  wUh  vtETid  niura«,  and  the  ptlWM 
evcDtuatly  (lii.>e  iu  a  distrvsoing  maouvr,  partly  from  etarmijun,  p«nl]rfr* 
coDftiilutioiiul  cuulHtiiination. 

Surgery,  as  a  rule.  ftVvm  the  m^aiw  otily  of  relieF  in  tlieae  aail  (■((»    li 
tme  nwo  111'  H  Kiill  tnHli>;nant  Liiiuor  of  llie  ti)rit<il.  nhicli  woa  uwltfr  m*  nn 
I  ohuiiiHrd  eonie  teiniMtmry  ftdi-nnltip;?  by  rvimivinj!  portmnft  of  lUe  •oft  pr» 
jeclii!^  and  very  vn>tciilar  (rrowlh  hy  iiienns  uf  lh»-  f<Ta«eur.     HhrtaH  ik 
itiiiior  lie  eo  siliiatpil  thnt  iht-ro  scorns  n  ii(v»il.ility  of  rr-nmvinp  il.  it  miT  b 
hniiight  more  fully  within  rent-h  by  <lividiiig  the  cb»t'k.  as  in  iHe  huatl 
(i|K>riiii()n  for  rcnmval  of  Ihe  tongue.     I'ouIib  re<N>nimtnrU  an  iDri*»->0  &n« 
(he  allele  of  i\w  niotith  to  the  angle  of  the  juw,  divUion  trf  the  }*imt  with  i 
«aw,  and  wide  separation  of  the  two  parlfi,  uy  which  the  lnosil  U  v>  - 
pletely  oxpoMffi.    Opvrvltone  in  ihtBrfgitiii  arir  bwl  nirritd  out  with  t'-' 
not  knife.      The  rvMilts  of  att«inpta  of  tbia  kint),  altb<'i]|th  ni>t  v. 
coiirti^ng,  have  Imwo  sufficient  to  »hi>vt  that  it  i»  ptiwible  In  rprT>  ■•  •■ 
with  the  pillan  of  the  fauc?9  and  the  nifighbi^ring  ]>iirt>  of  th' 
soft  palate  without  fatal  cmsequeni-es  ensuiny.     It  is  probablr,:!.'  . 
if  performed  isulficiently  early  rouch  heoelit  might  fnllow  oprraii  r 
wlected  cates. 

DUEASiai  OP  THE  PHABTKX. 

Sypllilltio  AfFeotioni  of  the  Pharynx  have  heoii  nln  ril^l   T»i.L 

p.  KHm).     The  i-iiijse<jUenoc8  of  extun^ive  ^vpbilitir  ul.  ;ii.iv  KumT 

tie  alluded  tn  here,  an  they  ooeUfiiouitlly  cafi  iVir  surgical  inlfrft-nfvr  Si 
the  ulcers  heal,  the  pharynx  may  poolract  so  that  ilrglulllion  U-f<tiiir»  il* 
cult,  lliiidft  only  ht'iug  able  ti>  \m»».  Iu  Hiirb  cflAi'4  some  rclitrf  nity  nra* 
sinnally  Iw  given  by  cnrefiil  diviijir.iD  of  mme  of  tbe  tight  cicstrictaJ  haak 
which  narrow  the  fnure»,  followed  by  the  noaaage  of  l>otigie9.  t^oawtianalli' 
FofV  italate  becomes  adherent  to  tbe  posterior  wall  of  the  pbBryDl.ffjn[ii*tr^ 
abutting  off  the  oaeal  cavity.  For  tbia  conditioD  nothing  can  b«  dont,  ai  ■( 
ia  imposaible  to  aet  the  aofl  palate  fipM,  and  an  opening  througb  it  wwM  **iS 
add  to  the  fiatient'sdbtconifort. 

ErysipelatouB  Pharyngitis  iioecuiioDalty  met  with,  accompari'    '  * '  j^v* 
oont-lituiinunl  ditttirbauoe ;  it  ia  beat  treat4Hl  by  the  applicatioi 
aoluiion  of  uiirate  of  silver,  the  use  of  emollient  ^>on;lca.  and  the  lai 
udminiKtralion  of  nmiuoQin.  with  bark,  siimulani^.  ana  support.     If  it 
a  IcihIlui'v  to  ntu  to  iilou;:biiif:,  ibe  intt-rmil  udminifecrntiou  of  lb*  aiiai 
acidit,  Mitfi  hark  and  KtiiniiluDlv.  llie  nitntie  of  silver  lotion,  and  ohl 
ganlt^  are  UEcful.     Suuielinics  abBcesB  fornix  in  the  aubatanee  of  iba 
ann  then  rrquireii  to  he  opened  with  a  narrow-bladed  bittoury. 

Absoeai  (H-msionaliy  foriiw  in  ibu  areolar  tiiauis  bchiatl  ilia  pharrn^ 
bettvcfti  the  vertebral  rolumn  and  iu  ponterior  wall,  which  ia  coaMqacatly 
puahed  forward  an  ni  to  tieclude  the  pnatorior  uar«,  giving  riai-  tu  a  pMatiar 
natal  intonntion  of  voice,  if  the  ahaces*  be  iiiiuuted  high ;  if  low  down,  iha 
oonih-qiienrc>s  are  more  wrinus,  oa  it  may  interf<--r«  with  rc«pimtion  by 
ing  upon  the  u[>|M>r  pari  of  the  larynx,  Tbi«  kind  of  ab*cnw  ia  oAaa 
necied  with  iliKeiiae  of  the  lionea  at  the  ha.«-  of  the  akull,  or  nf  iIm 
cervical  vertehrie.     In  nuiny  cnac«,  if  lef)  tn  ilitelf,  il  .       '  '   '  aril 

the  iiiucoufl  membrane  inl"  tht;  luoijtb  ;  but  in  otliera  it  i.Jtf 

tli«  attfruo-mastoid  muaclea  into  tbe  forepart  of  the  neck.     U)  e^^tluriAg  the 


A 


8TBICTUBE   OF   THE   CBSOPHAOITS. 

IX  with  the  finger,  which  may  rtaflilybc  done,  tenaion  and  fluctualioD 
igh  ila  piwcrior  wall  may  caeilv  bo  raailc  out. 
la  these  <•&&&»  the  TnmtmeHl  cnnaists  simply  in  Irtling  out  the  nintter  by 
■  punctiiriug  the  teiiftc  raerahnme  covering  it.     This  may  be  done  bv  means  of 
nharp-poinlfid  bisNiiiry  properly  prolectwl,  the  oniinary  abBceas-knife.  or  a 
pharyogotome  (Fig.  744).     'Hie  pii»  let  out  w  unually  o&^Dsivc,  even  though 


il- 


the  biiaes  be  nut  affected.     If  there  is  reason  to  believe  the  abscess  a  cod- 

Inected  with  disease  of  (he  cervical  spine,  an  Hllompt  should  he  made  to  open 

externally,  as  described  in  thv  OiaplLTon  DiseiiMW  of  l)ie  8])iiiv. 

Tamon  ore  occau-ionully  met  with   in   llie   pual-pliAryiigual  an>u1ar  tis»ue, 

eiviug  ri»e  to  the  sainv  Mwelliug,  dilfictilty  io  reapirutiou  and  deglutition,  iind 

fMtei-al    pritjectiijii,  u*  occur  in   abauess  of  this  region.     These  gruwtliB  aru 

lly  ninlignKiiC,  and  speedily  prove  fatal.     Po/i/pi  tn  the  pliHrynx  usually 

down  from  the  Dasnl  caviti^n,  but  «oniotiniet!  spriug  from  the  inside  of 

canal  on  one  or  other  of  its  inargius.     They  are  usually,  when  truly 

pharyngeal,  of  a  malignant  charauler,  and  grow  with  great  rapidity.     Tlie 

tisea  of  thti  part  are  necee«Hriiy  inturferetl  with,  and  di-ath  may  eventually 

IfCKuk  from  iiltstructinu  to  deglutition  aud  respirutiuti.     The  socallecl  /i6rt>U4 

fpolrfptu  projecting  from  the  base  of  the  ekull  into  the  pharynx  htm  be«Q 

I  alreadv  de^ribed,  [k  040.     JCjAlbetloma  of  the  pharynx  has  occasioually  boeD 

met  with  (Fig.  745).     This  t'i>rD)  of  the  disease,  which  b  of  rare  occurreDoe, 

does  Dol  ditfer  from  simitar  growths  elsewhere. 

STtUCrUttE  OF  TUK  OSOPHAliDB. 

All  diMMea  of  the  o>ftophagus  have  a  tendency  to  oonvtriot  and  eventnatty 
to  occlude  its  paiwage,  and  hence  arc  oomrtinnly  described  as  Strictures  of 
it  In  Some  instanres,  the  cnmitrietion  of  the  osophagus  may  he  of  a  purely 
nervfiuji  or  tjttumodic  character;  hut  iti  the  majority  of  in»taiices  it  in  the 
result  either  of  fihrouft  or  nf  cancenniH  inliltratitm  of  the  w:tlls  of  the  cnnal, 
sod  is  then  termed  organic  stricture.  The  simple  uou-muHguaut  or  fibrous 
stricture  is  in  most  instances  eventually  tlie  scat  of  an  epithelioma,  and 
fceoce  appears  to  he  more  rare  than  in  reality  it  is,  as  it  is  seldom  met  with 
after  death  in  its  simple  form,  f^cirrhous  cancer  may  implicate  the  oesopha- 
gus as  it  C'uters  the  stomach,  and  sarcomatous  gronrtlis  of  various  kitids  may 
arise  in  its  ueigbborhood  and  involve  its  coats. 

The  great  feature  of  lusophiigesil  stricture  is  difficulty  of  deglutition;  but 
dysphagia  may  arise  from  many  niusca  bcsidiM  ics«>phageul  stricture.  Ilencti 
its  diaguoi^i^  in  in  the  liigho»^t  liegree  importaut. 

Ojnditions  PuoBCirisn  DysmAGlA  I>;uki'eni>enti.v  opSrRtcrn^KH — 
There  are  at  Ica^l  eight  dilfcrcnt  couditious  met  with  in  the  nock  and  chest 
capable  of  giving  ripe  to  dyt>phagia  by  compressiug  llie  tusophagua,  iiulepen- 
dwitlv  of  any  slriciurc  of  ibnt  iranal. 

1.  iTiunors  connected  with  the  Pharynx. — Pittiiiig  out  of  ronsidpratlon 
tumors  of  the  toiiJ^ila,  whirh  would  always  be  readily  discovered, /jn/imtM  of 
the  pharynx  may  hang  down  and  offer  o  I  ml  ructions  to  the  passage  of  food. 
Tn  all  polypoid  growths  connected  with  the  pharynx  (which  are  exceedingly 
fare)  the  nature,  connections,  etc.,  of  llie  growth  may  !)e  made  out  by  draw- 


648  DI6EABBS   OP    THE    MOUTH    AXD   THBOAT. 

iug  tbe  tongue  nell  forward,  keeping  U  fixed  with  th«  loDgue-BpntuIa.  na< 
paceing  tlic  fiuger  well  dowu  beluDd  the  ruol  of  the  orgnn  ;  tite  punrviix  can 
tbui«  be  cxii|i>n-d,  eveo  below  the  root  of  tbe  epiglottic,  without  mueli  ditfi- 
culty.  Abtcejis  tiiay  exinl  betweeu  llic  pnelerior  wall  «if  the  pburyux  and  llie 
spine,  fwetiibly  ari»iug  fruiii  caries  <if  the  ccrvicnl  vcrtebise;  or  a  potl-pharyn- 
geal  Uimor,  a«.  fur  iofeUinee,  a  Barconiiitinii)  growth,  may  he  developed  from 
the  hodiea  of  the  vertchrtc,  uiid  puxb  the  pharynx  fornarile.  Toe  eye  is 
oflen  deceived  ii)  iliexc  casm,  fuilin;^  to  dcti-ct  the  cxittteuce  of  an  eularf;c- 
ment  at  the  back  of  the  pharyux ;  but  the  finger  readily  reon^nisca  it.  In 
the  rai^v  of  abscesfl  there  is  flnctuatitin,  ami  tbu  dy^pliagia  uill  bo  removed 
by  opening  the  abi»-ei>»  aod  Icttini:  niil  tJio  e<mtem»;  unil  thb  aolid,  or  aemi- 
solid  aiid  mi\,  ur  otIitT  t'cfl  uf  a  tumor  iu  thltt  »itiiatiun  will  lead  to  a  very 
probal)le  rueiw  as  to  it^  natiirt>. 

2.  Uorbid  ConditionB  of  tbe  Laryiut.  — (Kittnm  ahnnt  the  bark  of  the 
epiglottiit,  or  chroiiii:  u'dcina,  nlrfration,  nnil  thickening  of  the  mucous  mem- 
bran<<i  there,  dependent  upon  ttyphiliii  or  tubercle  ')r  n-deina  about  the  rima 
glotliHis,  may  eive  rise  to  a  tendency  for  liquids  to  pans  inln  the  air-pa<»ftgeA, 
and  thu!)  oecaiiliin  a  .4eririu9  impediment  in  .twallotvin^,  the  difficnily  being 
attended  wilh  a  feeling  of  !i|>H.'<m  and  Miflocntirm.  By  |iaDsing  the  finger 
down  behind  the  jvwitnf  the  tongue,  the  slate  of  tbe  pftn>  cnn  someiinies  lie  felt, 
and  the  actual  condition  can  be  readily  asoertained  hy  th«  use  of  the  laryngo- 
»ciipc;  hut  the  combination  of  dysphagia  with  a  8iifT:>cntive  lit,  and  lhe»e 
prttbably  as^iiciftted  with  laryngeal  cough,  are  tbe  chief  pviuta  to  be  attended 
to  in  the  diagnosis. 

A.  Tamers  in  the  Heck  outside  the  (EsophBgiiB. — Enlarged  glands  or  a 
carotid  aneuri^ni,  developing  posleriorly.  ws  Im*  Iwen  known  to  occur  with 
the  internal  carotid  arltry;  or  a  tumor  cminectfil  with  llie  ihyroiil  body, 
tightly  bound  down  by  the  gtemomaetoid  musclea  aud  cervical  fascia,  may, 
by  preseing  on  the  imsopliagiiB,  give  rise  to  dyephagia.  In  all  cagea  where 
that  symptom  is  complained  of,  the  neck  ehonid  be  examined  carefully  for 
tnmon}.  which  will  generally  he  very  readily  detected,  especially  where  the 
difficuky  liai<  cxtiited  t»r  Home  time,  and  the  peraon  has  bccume  much  emaci- 
ated fpfni  dfticient  ucuru'httienl. 

4.  Aneurism  of  the  Innominate  Actery.— When  this  diseaw  has  risen  into 
tbe  rout  of  the  neck  it  is  easily  recognizable;  but  iu  certain  caBcs  it  develops 
first  in  a  direction  backnarde,  and  then  one  of  the  earlier  ayniptoms  i»  dye- 
phagin.  Indeed,  the  patient  may  suffer  but  Httle  from  any  other  eymptuni, 
and  may  apply  to  the  Surgeon  for  relief  from  it  alone,  quite  uucon^cioua  of 
the  cxiMenee  of  any  serious  disea^.  The  diagnuMa  will  be  eHl'ctod  by  care- 
ful attention  to  the  srmploms  described  at  pp.  180-18?,  vol.  i^  In  such  a 
ca^,  much  danger  might  be  incurred  by  at  once  putting  an  instrument  into 
the  osophagus,  under  the  impremon  that  stricture  existed  ;  fur  tbe  point  of 
tbe  bougie,  or  whatever  instrument  might  be  used,  niighl  perforate  the  aac  of 
the  aneurism,  and  i>o  give  rise  to  instant  death. 

5.  Aneurism  of  the  Aorta,  whether  of  the  fusiform  or  the  sacculated 
variety,  may  gi%'e  ri»e  ut  ditliculty  of  deglutition  by  pressure  on  the  gullet. 
In  this  case,  also,  there  is  great  danger  of  the  aueuriiimal  sac  being  pierced 
by  an  iostrumcnt  passed  down  for  the  purpose  of  ascertaining  the  cxietenoe 
of  slricnirc,  Tho  presence  of  the  symptoms  of  iutmthuradc  aneurism, 
dpBcrihed  at  pp.  !7;1-177,  vol.  ii.,  will  determine  the  diagnosis. 

I).  Intrathoracic  Tumors,  such  a^  enlarged  brt^iichial  glands,  saroomatons 
antl  other  groutlis,  developed  from  the  thoracic  ^plne  into  the  posterior  mcdi- 
a»tinoin,  may  oomprcsn  the  iH»opbagua.  In  such  caaea  the  diagnosis  is  very 
dilhcult.  It  id  difticult  enough  to  tlelermine  tl>e  exiatence  of  a  lumor,  hut 
still  more  so  to  distinguish  it  from  an  aneurism  undergoing  consolidation ;  but 


IMPACTION    or    A    PORBIOy   BODT   IN  THB    ODLTjETP.      649 


I 


dulncsB  on  pereussiou,  and  dyspoa^a  with  Jvrplia^in,  together  with  fixed  paiu 
in  or  to  ooe  tide  ot  the  spiue,  with  ueural^ia  duwu  the  anus  <»r  up  the  side 
of  the  bead,  and  a  Taricose  coudition  of  the  supcrGcial  veius  of  the  chest, 
are  tb«  iigns  on  which  we  place  our  chief  reliance  iii  diagiioBJug  the  exist- 
ence of  K  tumor.  Indeed,  in  the  diafiiioBia  of  ancurii'mof  the  norta  and  of 
iDedinKtiDal  luniitr,  I  iouk  upon  the  ctmibiiiation  of  dv^piiira  with  dy^phuf^ia, 
and  fixed  wcarinf;  pain  ht-luecn  thtr  ehtiulilcn>.  mot  the  jiri-atL-t^liuiptiriiince. 

7.  Diilocation  of  the  Sternal  £od  of  the  Clavicle  Backwards,  nlitihi-r 
merely  u  siinpli-  lii-Iiwiitiuji,  or  pnidinH-d  in  cuusiKjiiiiifU  of  txn'««ivc  curva- 
ture of  the  xpiiii',  itiuy  ^ivt?  rhv.  Id  ilittiniUy  of  [iej^iiicitioii.  Of  the  latter 
kind  then!  is  at  leufl  one  cbm-  on  ri'cunl,  which  is  nurrnte<l  hy  f^ir  Amltry 
Coujier.  in  which  thn  flfrnul  end  of  ihi;  clavicle  hy  its  prcssiiff  ho  oIh 
atructcd  the  pay-nipe  of  fitixl,  that  the  fmtient  was  hronj^ht  inlo  a  condition  of 
extreme  danger.  The  Surgeon,  un<k!r  whone  pnre  the  patient  was,  very  skil- 
fully and  credilahly  sjiweii  throuj;h  and  detached  the  internal  end  of  the 
clavicle,  and  thus  relieved  his  patient  from  the  Imminent  danger  in  which 
she  was  placed. 

8.  Impaction  of  a  Foreign  Body  in  the  OnlleL — If  a  ninn  swallow  such 
a  thing  an  a  iwt.f.  of  niutton-hune,  or  the  i^etling^  of  artificial  teeth,  it  gener* 
ally  lies  acriBi>  the  j;uUel  in  such  a  manner  as  to  Ite  easily  felt  hy  the  Siir- 

Cm  on  pAJiainj;  it  pruhnii^;;  hut  there  are  other  coxee  in  which  a  foreign 
ly  hec(>me»  sn  loo^jed  in  the  caual  as  to  escajw  detection  and  removal. 
Some  years  a;;o  I  was  requested  to  see  a  )mtient  who  was  said  to  have  swal- 
Invretl  a  piece  of  );utln-[>(^rchtt.  He  had,  it  appearetl,  in  cousequcucit  of 
havin;;  lo«t  several  ti^tli.  eadeavurt'd  to  construct  an  urtifiL-iul  mut-ticatory 
ap[iarutus  fi^ir  himself,  which  had  become  lnone,  and  he  had  accidentally  i<w»I- 
lowed  it.  A  few  dayj^  afterwards,  finding  that  dcgiutitiou  coutinued  di(H- 
cult,  he  cnnaulted  ft  very  able  .Surgeon,  who  carefully  examined  him;  but, 
Dot  detectiug  any  fiireign  body,  he  considered  that  the  piece  of  g^uttn-perchn 
had  passed  tuto  the  stomach,  and  that  the  tesophagus  had  been  scra|>ed  by 
it  in  its  passage  down.  Inability  to  swallow  solids  came  on.  I  saw  him  six 
mouths  afterwards.  The  question  then  was,  whether  the  foreij;n  body  was 
Btill  im|iacteil  in  the  a?supha{*us,  or  whether  the  symptoms  aroee  from  damage 
inflicted  on  tliaL  tube.  I  examined  the  a'sophapus  mcpst  carefully,  but  ftiiled, 
ae  other  Sut^eons  hiul  ])revioitsly  done,  to  discover  the  existence  of  uuy 
foreign  l»ody.  1  tliout^hl  that  the  (eeophagus  had  been  injured  in  some  way, 
and  that  pi-ohably  epithtlinma  was  developing;,  and  would,  sooner  or  later, 
prove  fnul.  One  <lay,  while  at  dinner,  the  puiieul  suddenly  vomited  a  largo 
uuHutity  of  blood,  atid  fell  dimn  di-iid.  t>n  exaniinutton  after  death,  wo 
found  that  the  piece  nf  ^utta-nerchii  had  furmo^l  for  ildclf  a  bed  in  the  wall 
of  the  iwophaffUB,  lyiiiK  paruflcl  with  the  inside  of  the  tube,  and  that  the 
ulceration  of  the  mucou-*  nicinbranc  caused  by  Its  presence  had  opened  some 
•MsojihaKeal  vessel — which,  we  could  not  aBcertuin  (it  was  not,  however, 
either  the  oaniUd  artery  or  thejujjular  vein) — thus  giving  rise  to  the  copious 
and  sudden  hemorrhage  which  hacl  caused  the  patient's  death.  The  surface 
of  the  gutta-percha  which  looked  into  the  (pjiophagus,  being  constantly 
covered  and  smoothed  over  by  mucus,  and  being  protected,  as  it  were,  hy  a 
rim  of  swollen  mucnus  membrane  all  around  it,  hud  allowed  the  probang  to 
paes  easily  without  iu  presence  being  detected. 

These,  so  far  as  my  experience  goes,  are  the  eight  conditions  which  are 
likely  to  simulate  stricture  of  the  lesophagus ;  and  such  are  the  p<tint4  to  he 
Aticndcil  to  in  the  diajjiiosis  of  these  affectiona  from  each  other.  With  regani 
to  the  diagnneiis  of  titricture  from  tbe^e  conditions,  the  process  ■»>  rnthfr  a 
negative  than  an  nUirniHtive  one,  proving  the  absence  of  tumor,  aneurism, 
etc.    The  conclusion  that  the  difliculty  of  deglutition  can  ariM  from  no 


650 


DISEASES   OP   THE    MOUTH    AXD   THKOAT. 


other  CAUM  than  strictaro  is  ftrrivcd  at  by  »  prrwflM  of  exc! 

•ituatioD  anil  extfiii  of  t)i(<  striclure  ar«  ucert«med  by  cvi".:  .      » 

gum-«Ia!'tlc  vBtliKer  or  b»i«gie. 

FoKJt"  OF  f^TBiCfURK. — There  are  Ihrw  fonoB  of  thja  Bflk'tion  whMi'il 
in  tiKtvHirv  l'>  liijuiiifiuiflh  froni  each  other,  inaarauch  h>  thvv  <lilf^r  cr*^tli 
ID  the  tii'xfe  of  treiiinitMit,  uml  in  Ihe  ultimate  result.  Tlie^r  nn> — 1.  H^t- 
t«rit-at  or  8[i«6in«Klii.'.Slricturf ;  '.i.  FibrousSlricture;  3.  IVni-rroufStrirtHR. 

1.  Hyattrieal  or  Spftsmodic  Stricture  i«  met  with  diieHy  in  younfr  ta«ha 
uuder  tnTnty-Rve,  llioiiifh  it  may  orrur  lu  much  nldnr  penman  of  ibe  hy» 
tertcal  temp^'miucot.  It  in  powihle  fnr  it  tn  iMMnir  w!th>iiit  ovltlrnt  frguae 
diseaM  or  chungo  i>f'  hdv  kind.  Btit  I  believe  that  tlir  Hni|ilf'  Ktiil  pan)  at' 
complicAlod  hyi»tt'ri(;iil  Btriciure  is  of  very  rare  oocurrenre.  In  (be 
of  iDsUinrea  it  will  uDdniibtedty  be  fotinil  to  be  de}ieii'leni  Dpnti  aooM 
rhaup;  of  ^lrup|iirt\  tiii)«l  comniritily  of  a  simple  kind,  f>ufh  as  ebrnote 
Hitfuiniuiou  of  ihfi  i>harvD|^i\l  muoiiia  membniDn,  ulovrativ^  abraaloo  rfi 
nr  fitllicular  iuflammatidu  about  the  opigtottiti  and  posterior  part  of 
lan,'ux.  The  diantae  In  mnny  rases  is  mppoacd  tn  ha  dMiMldent  •« 
have  be^n  nccnHonet)  by  the  ^watlowiof;  nf  mme  fin'isn  UhIv,  a»  ■  A«b-bi«i, 
bead,  brittle,  etc.,  whioh  after  manv  mnntha  in  »till  tlinu|rht  in  he  tmpMiai 
This  it  nlmoAt  alway'it  erronenua.  The  forei)^  body  mav  harf  iMyn  aval* 
lovM,  and  may  hav^  been  the  slnrtinft-poinL  of  the'  stiffht  {tidamtnatiiie  it 
ulireration  thnt  oceaainnfl  the  dy^pha^na,  hot  it  baa  loni;  ftince  iliBaprrflrwI. 
leavinjj  merely  a  ««^rie»  of  trotihteanme  crtnuetjiieiices  in  ilfi  imin.  Tbe  oh- 
Hlriic-lion  'm  f^nerally  hifrh  up  in  the  pharynx,  rather  (linu  in  lh«>  ■i<»>^t>hat«; 
bfin}!  pr«idiic(Kl  by  the  conlraolion  uf  the  oiMmtrirlor  iiui8clc».  Tb«  dj*- 
pha^iia  i*  int4-riiiitt«-nt ;  ythvu  the  patient'^  mia<]  b  iilhiwt-'l  (•>  'Iw^M  loiifrO 
the  Hlfeulion,  and  she  beei>nie>^  anxious  alxiut  il.  (ben  ihv  di''  'jrnitlf 
incn-H4C<l  ;  whilst  at  oilier  (iinrH.  when  her  Ihi'ui'htfl  an-  ■  I'nwB  It 
foml  piu^tfCT)  cnsily.  It  will  \tv  (tuiml  n\M>,  in  llu-w  rii»-#.  that  on  «tiftnptiti( 
to  pnw  II  prolmitg  or  largt)  bougit;,  ite  pnigros  will  nt  Hr«t  Ix?  n«t«tr<t,  twt. 
by  piitivntty  uud  g«ntly  preesing  dowu  upon  the  atricture.  th*  inatramial 

will  fi^HUl  \H138  i'nHily. 

2.  Fibrous  Striotare.— Then*  are  two  kin<U  of  nreanio  ntrictant  nt  tha 
u«ophagiui  —namely,  the  fibroim  and  the  {^iicenuR.  llrtwem  thrNP  the  dlap- 
niMt9  in  often  verv  diltirull;  Hlricturen  nrigiimlly  Bhrniin  Bumdimrf  bmHnbiE 
the  fleal  nf  u.  mitlignnnt  (p'owth  ;  while  othcr-i  eontinuv  fibrous  to  the  «vil. 
The  JihniUH  mricture  is  ai-arpely  ever  idiopalhir.  U  may.  p^w-ihly.  ari» 
fnirn  rnnlrartinn  of  the  wnir  lolY  hy  a  nyphililio  ulnr;  hm  it  alni<Kt  iaraii- 
nhly  originates  from  the  ciii)trri/.«tion  of  the  interior  of  the  nsophaRoa  hy 
the  iiccidrnuil  or  aiiiridnl  .iwiillnwing  of  nome  ctrr-wvr  iluid.  acid  or  alu> 
line,  a^  the  Htrong  miiipral  ncidi>  or  soap-leyi.  by  which  the  mnr^^aa  mil 
bnuM  ia  destroyed,  chnrred  as  it  were,  nnd  a  ricalrix  as  of  a  bom 
Thifl  gradually  contraotjt  till  at  la.'it  almoat  total  oocliMion  of  the  gullal 
ensue.  The  otiolngy,  in  fact,  is  an  important  element  in  the  diagDfaia,lir« 
fibrous  stricture  being  alniiiAt  JDvariably  the  direct  reirult  of  eeeharfitie  artkia, 
the  cancerous  oceurring  without  aaaignnble  nUM,  or  being  referrti)  tn  tutM 
alight  form  of  local  irritation.  Generally,  on  pawing  an  iif>">-'  -r->  «« 
find  tbat  in  the  «implL>  or  (ibrous  striclure  it  gn«a  amoolhly,  ■<  ao 
aeunaliim  of  roughufos,  no  fwling  of  lacerating  its  way,  or  a*  if  ■  i  i  n-r-  [liv- 
ing over  an  ulceratei)  Hurfare;  no  bliKMl  ftillowa  it«  withdrawal,  and  the 
patient  do^-ti  not  brintc  up  pii«,  or  blood,  thniinh  there  may  he  <«»{^au*  ni 
diwbarg^.  Then-  in  no  tnntt-rlal  rnlHr^zvniL-tit  of  (be  neck,  tt"  ««<-lllii 
the  oervii-al  i^lnudu,  no  »igii  i»f  tin-  mnffmuii  (■n^'hfiiu.  The  fibro«u  ri«ai 
vial  fitrictiire  mar  owur  at  uoy  part  of  tbe  (t«t>pb8|{us.  It  is  uaually  Mlv- 
atwl  towards  the  middle. 


TmKATHBKT   Or   8TRICTITBE    Of   THE   ESOPHAGUS.      051 


S.  CanceroBs  Strictoro. — Cttncf-r  Id  the  nvophugiis  alvuv^  aanumm  the 
Ibrm  of  rpiltit'lixnia.  It  is  9i<uHt«H  iHiially  hij^n  up,  must  oiiiiraoiilv  rather 
in  ihr  phsrmi  tlmn  the  giill<>(.  imiiinliBtety  iH-htnil  the  larynx.  Hetwecn 
ihiit  p^iint  noH  the  caniiac  orilicr  cancer  i.-»  tnurh  mnre  rar<;.  At  the  car- 
diac orttiix*  tlto  •i-«i>]<liii|^us  iiiH)'  bvojriie  iiiipliciilfii  iii  caiu-er,  tisually  »pir* 
ritotu,  CMiHiiPiiciri;;  in  the  Btumacli.  In  the  mntlKnanL  »lrii'liir«.  it'  nn  in* 
»trt]ii«i.l  Im>  fkaKM-il,  it  amniD  (o  paw  uver  a  rooffh  an>l  ulcerated  surface, 
<-'  ■  -liDg,  and  the  pntiont  cui^-hs  up  blmxl,  nr  MoikI  and  pu«,  mixed 

•  1         1  sbreda  of  tiwii^— I'uiKiitioiis  nil  iudicutiii);  a  lottt  nf  8uh«(aiioe 

y  -  T+'»>.  There  i«  aiN).  wnneliniM.  an  ovuid  or  e|i>nj;al#<l  8w«llinf{  at  th« 
r'^4  iif  the  D«wk;  ih*-  neighlmrinp  n'""''"  '"^>'  '•*'  «fit'Cte<l  ;  ibtre  may  Iw 
cKOcerotu  tumom  i^lMwherv ;  auU  tli^  tympU'^ms  "f  lh«  cancerous  cachexia 
BHkv  he  priMeot.  The  vptMrial  causea  of  cauccr  vf  thu  (wophagu^  are  nut 
iuKiwit. 

TH^i.\TMK5r  — The  tr?iit.mt!nt  nf  stricture  of  the  (raophagva  will  d«|M*iid 
■p-<n  (iF<  tintiin^  In  the  hi/ftrrie-il  vcritty,  the  occasional  introUuotiuu  of  a 
f :  hagii^lMHigie,  the  application  of  belladonna  to  tb«  Ufck,  and 

B<-  trualmcQt     ^.'cnerally. 

irno,  aJt-cucs,  diiucheff,  and  divertii)],; 
tluf  piuit-tit'B  mind  fmm  her  niahidy, 
■retb»  mcanalohc  iinplovcd.  In  svich 
faiii.  fiiiiTiiil  haa  ven*  aifvnntBCo»iii(ly 
esphiyird  largr  iUmr*  of  a^nfutidn. 

Tb^  tn-fitmeni  of  orguiio  strictare 
i*  m'trr  dtffirull.  In  it,  care  shfuild  be 
lAkaa  that  the  txiticni  livfs  rhiedy 
MMl  nutriliiuit  flrtpn,  or  ii[Min  meat 
t&at  bat  b«ra  wril  chnpwd  op,  tu 
largrr  frapmeniaanrapt  t'}))(tiim«  int- 
partrti  al  '  '\'..nstrii-tion.    The 

dilCculiv  ■  iition  will.  hi>w*?ver, 

gnuluallv  uicmiAa-,  tlit^  patit^ut  l>eing 
tu>t  anablr  to  i-wallnw  lu.lidH.  (lien  be- 
ittg  reduced  in  pulpy  fmHl,  and  at  In^t 
10  liqaidk.  After  a.  time,  he  nil)  nut 
•na  be  able  to  avrallow  tbt« :  ami  then 
it  beeomn  oewsMiry  for  thu  Surgeon  Ui 
ftcd  bim  by  ibe  iniriMluetiun  of  a  gum- 
«batic  «ub«l«r  through  the  Htrirture, 
and  iba  lojvctiua  of  a  »iilBrifnt  ipiau- 
lUj' of  liquid  ur  aeuii-pullao-ouii  noiir- 
ilmaatil  into  the  i>t<<niarb  twice  a  day. 
After  a  frw  ir<>i-k<<,  the  irrilatioi)  in- 
dgcrd  br  the  rrjH-ntPil  inmHliU'lir.n  of 
tW  nlbeu-r  will  rrndfr  ila  paiMfce 
morr  and  morr  diilirull,  nniil  at  laMit 
ba«au«  impoaiihle  let  get  it  through 
IW  rontlrirliim.  The  patient  may 
Mill  b^  kepi  alivo  *br  »>roe  wtcki  b/nutritire  euemaUi.  but  at  la»t  die«  of 
Mamltiro.  Ktrti  in  cHnc«ruua  stricture  of  the  a-suphagiw,  dntlh  seldom 
Mnin  by  wv".ndan.'  depneit^,  nr  by  cmslitutional  eouuiniination.  but  in  the 
Way  jtM  [-Miiiiie))  out  In  M>me  raaea  the  dieeah*  cxlenda  to  the  pnaterfor 
ptrt  i.f  ibf  larynx,  the  miici.Uf  membniue  overing  the  arytjeaoid  cartllagn 
ud  tlM  vpiybiiiis  bcooRM*  itivulved,  laryngeal  stridor  and  djrspnon  enaue, 


i>r    PlMrjrai    uai 


iKtoptekf  tu  oftBHaf  S  trial  ur*. 


tj.'>2 


DISEASES   OV    THE    HOOTH    AK1>   THROAT. 


aad   il(;ALb  may  ro^iilt  from  Inrynj^nl  Hpasro,  unltos  lifs  b«  pralMgttl  kj 
irochpotomy,  whicli  in  many  ctt»(»  becumea  nec«*»ary. 

Surli  19  the  niUerable  course  an*)  tcrmioAtiou  of  an  '>f}ruitc  •triclun«ri^ 
iS40pKAj{i)^-  Hilt  lticriui>4(i<in  uuw  preienuiUclf,  Oau  notbiox  beiintwlwcM 
or  even  urresi  iIiim  ilis«i-«'e* 

The  PalliatiTe  Treetmeoc  that  is  usuiilly  m4)opt«(l  Id  UiaMrH-»  '•••'•■•(• 
In  ttie  iaLrodiiutioo  of  ltiHi;jieit.  ttnd  au  tUUTOjil  tliuft  t»  dilaU'  i 
exactly  m  in  the  nue  uf  a  consthctiuu  uf  tli«  ur«Uira.     la  p-*-  .  >»« 

gi«e  into  tlie  stricturcd  part  ^f  the  te»>pbague.  ihvru  is,  I  iica  » 

gtXKl  <lvnl  uf  dilficully  iu  niakiii;;  th**  puiul  of  the  inaCrumeui  ciit'ir  ;Il«u^ 
ruwetl  purtiun  v\'  llie  cutiul.  Tliid  is  more  |Nirlicularly  tho  caw  nhfli  li» 
cuitalrii-li'iri  iiiiiiuitMicea  HUililL'iily  ;  lliu  u'Mipliauua,  ub  \-  :'i«cbn, 

being  iJiUK'il  inUi  n  puucli-like  wiu  aUovv  it,  iu  whieli  ih  -  Mp, 

atiJ  the  villi  of  clii>  instrument  to  Un  urrtated,  and  at  ibu  b»iu>iu  •.!  Mbici  > 
narrow  orifiw  exists,  lemlinjj  into  th«  luwer  puriion  of  the  c.-iri-jl.  In  ll"* 
oaaee,  ruuch  |Mitieuce  an<l  care  may  b«  requiruU  iu  uvfi^ 
Beeidn  the  onlinarv  ililntatioD  by  gruduatly  inorrnttiti;.-  n  - 
menu  tued,  I  have  in  ^ooie  casm  seen  temporary  bmietit  nuult  from  ihf  ii» 
of  a  catheter,  Rurrouadc)  by  a  tube  of  viilcanieed  lti>iia-rubl>t>r,  whidi  tA- 
mitten]  nf  dilatalion  by  the  iujecLioD  of  water  nr  air  when  iatniduncd  tlirmsi 
the  ^Iricliiro;  or  from  the  empluynicnt  of  a  tubular  inatriiaient,  Uv  pMuni;> 
long  aniall-aizcd  bL>ugie  thntujtb  the  cuD8tricliun,  and  thra  ^Jippin^  a  jcu'U' 
eliMtic  catheter  with  a  rounded  terminal  a|)eriure  o\'er  it.  It  ia  nrttUaat** 
observe  thai.  In  the  treatment  of  atrioiure  of  tlie  cuAophagua  wtlJi  b<Mei(K,M 
force  should  be  uwd,  leat  the  iralis  of  the  canal  be  (lerforaleil. 

From  UiCM  mcaiu  temmrary  relief  may  result  in  Mnii'  fmir»\  but  ouico 
ruapbageal  «lrieiure  be  tnus  cured?     I  iJclitve  not.     If  the  Mrictun  tm 
ordinaritv  libntna,  ta  in  the  urethra,  permanent  relief  mii^ht  {xMihly  beM- 
nectcd.    lluL  thia  form  of  «i?:!i<>phBgeal  onstriclion  is  compuralivelv  rari*;  iMt 
tf  the  disease  can  be  maile  out  to  be  mali^fuunl,  but  litile  goorf,  oiid  bu«* 
probably  much  harm,  wilt  result  from  the  irritation  of  dilalitig  in«train«&M' 
We  may.  therefore,  employ  dilatation  as  a  means  of  temporary  brorfii,!**' 
not  with  the  hope  of  etfecting  a  cure.     Should  tho  stricture  nt  lart  b(w«»' 
so  tight  as  no  longer  t*)  allow  -the  catheter  to  b«  pUKd.  and  fowl  Ut  ht  Aw^ 
injected  into  the  stomnch.  the  putivnt  must  inevitably  die  of  iaaoitioo.  aal«^* 
kept  alive  by  nutritive  enemata.     Uy  them  raoaiu  1  hav«  Icoown  hh  iif^v 
longed,  by  a  frail  tenure  it  il  true,  for  many  wwkt.     In  such  caeca  it  ■•  a^E> 
interesting  pliysiolo|;icnl  faot  that,  although  the  patients  toft/  oootiau*  \*\ 
nioderntely  well  n>>uri«hvd.  and  du  not  fool  the  puigi  of  hanser,  tbef  i 
excessively  from  thirst. 

Unit  aurjfury  no  resource  in  Ihoee  caaea  in  which  the  stricture  bat  bww*** 
impormeabic,  and  in  which  neither  food  can  be  swallowed  nor  a  iMhtt^sf 
passed,  and  in  which,  »mRer|uently,  the  moat  miserable  deatb.  doub  brttA'- 
vatioii.  t!t  impt^nding?     In  nurh  cueea  it  has  been  proposed  by  Sediflot.  " 
open  the  -itomarh,  hy  an  inet-iou  through  the  abilominal  walls,  tail  ttt'i' 
din-cLly  inlnxluce  fitud  into  the  organ.     To  tbia  operation  fc^^Uttit  i^an  i'*' 
name  of  Oiutroiliimif. 

Operation  of  Gucroitomj. — The  object  of  the  operation  is  to  upm  th* 
ntomatOi,  atid  U*  make,  a  fiAtutnU!!  oiicning  in  that  part  of  it  which  is  iMIBiaU.'' 
in  <xjnlact  with  ihn  alMlominal  wall,  and  uncovfnNl  by  the  riba.    Tbei^V' 
tion  onitifils  of  three  atii;;!^:  1.  Tiie  exposure  of  the  •toniach ;  2.  I'-***' 
hcsion  to  ihe  lifui  of  the  incidioo  iti  the  abdominal  wall ;  3.  The  nul  '■ 
ao  opiiniiii;  into  it.     The  area  to  b*-  exp^e^d  i»  not  Inrgi-,  and  r')rr>-i'"'' 
externally  to  l\n-  i-nrlilagas  of  the  eighth,  uinili,  and  tx-jith   ril«  ;  nUik'r  *"'' 
internally  it  is  bounded  by  the  lower  edge  of  the  Hvcr,     la  the-  r<>uin^'"' 


iROSTOJfT. 


653 


slale  of  the  stomach  the  pylorus  lies  imniedi(it*ly  to  the  right  of  the  nii<lill6 
line ;  it  is  advisnhlo,  iheret'urc,  to  make  iho.  inciitton  as  far  to  the  left  iik  ctiti 
omvcnieolly  be  dune.  St^dillot  divided  the  abdominal  wb)1  hy  a  crucial 
iDcUioa,  each  limb  ttC  whieh  whs  Hboutan  inch  and  a  half  in  longth.  Further 
experience  has  ehowii  thnt  eo  lar^  an  incision  is  not  ncce^^HrV'  Labb& 
reeommenda  an  incision  abont  an  inch  nnd  a  quarter  to  an  inch  and  n  Imlf 
in  length,  parallel  to  the  left  cwtal  cartilages,  nnd  one  Anger's  breadth  from 
their  borders,  terminating  below  nt  an  imaginary  line  drawn  botwcen  the 
moBt  prominent  points  of  the  convexitiea  of  the  two  ninth  cartlhigea.  This 
incision  will  be  found  to  divide  a  ftw  fibres  of  the  external  obliqut-  und  notch 
the  edgo  of  the  rectiiii;  beneath  this  in  ibe  expansion  from  tlu'  internal 
oblique  and  the  upper  BhrcK  of  the  tramtversalia,  under  which  lie  the  trans- 
Tcrsalts  fascia  and  the  ptriloncutu.  .  Howse  prefer*  a  vertic-al  iiieision  nt 
abttut  the  same  level,  ptuning  throufth  the  i>uter  fibres  of  ihe  rectus,  whivh 
will  afterwards  exert  a  sphincler-like  action  on  the  opening.  In  whichever 
way  the  abdominal  wnll  i^  divided,  all  bleeding  nuiHt  be  carcfutly  nrri'Med 
before  the  peritoneal  cavity  ia  opened.  On  dividing  the  periloneuni  the 
stomach  may  present  at  the  wound,  and  may  be  grasped  with  the  fingers  und 
drawn  out.  If  it  is  not  at  once  seen,  the  finger  mUKl  be  introduced  and  the 
lower  border  of  the  liver  feJt  for  immeJialely,  below  which  wilt  be  the 
stomach.  When  the  stomach  is  felt,  it  may  be  drawn  up  into  the  wound  by 
the  tiugers,  if  po«eible,  if  not,  bv  a  pair  of  riug-furceps;  vuleellum-fi<rcep» 
niuit  oil  no  nccdunt  be  used.  If  the  oinentum  presents  in  the  wound,  it 
ahoald  be  drawn  gently  downwards  until  the  sctininch  cnmes  into  view.  The 
only  viKus  which  can  bo  mistaken  for  the  lilonmch  ie  the  Iransvei-ee  colon, 
ihc  leil  end  of  which  immediately  before  the  gpliciiic  ourvalure  niny  proM^nt 
in  the  wound,  Tlie  stomach  can  be  recognized  by  the  lliickm-»s  of  ila  walls 
Hud  the  extent  and  tsmnothi !(>•<»  of  its  HUrlarre.  The  next  ntep  is  to  oecun-  it 
la  the  Oftcning.  Thin  is  iw«i  done  hy  curholized  ttilk  f<ulnrefl  |)aR)ed  through 
the  eeniU!*  un<t  mufcular  roat  only.  This  itf  eai>ily  acmmpltHhpd  hy  j^enlly 
pinching  the  ciiat»  of  the  nlonmch  between  the  titiger  and  thumb,  when  ihe 
niucouR  cnui  will  lie  felt  to  nlip  away,  leaving  the  other  two  in  the  graep  of 
the  tiugiTB.  The  flitches  mitHt  be  paived  fintt  through  a  gond  thtf-k  jiiece  of 
the  t(t<)n)ai.-h,  then  throngh  the  peritoneum,  which  shonld  be  drawn  a  Httle 
forward  by  fon-cps,  ami  then  through  the  skin  and  Iht,  missing  the  muHciiiar 
tissue  of  f  he  Abdominal  wall.  In  ihiswny  theseroussurfaces  will  he  brought 
very  accurately  in  contact.  All  the  stitches  must  be  passed  before  any  are 
tightenefl ;  they  must  be  not  more  ihnn  one-sixth  of  bd  inch  apart,  and  must 
be  so  arrangefl  tts  to  enctose  a  circnhir  urea  of  the  slomach  wall  about  the 
aiij^  of  a  shilling.  Finally  the  slttchesare  tightcm^d  and  the  wound  dressed, 
with  pro]H"r  At4ention  to  the  prevention  of  decom|«>»ition.  The  patient  must 
(>e  nirtirished  for  the  next  four  or.  If  jHjssible.  five  days  by  nutritive  euenmtu 
By  that  lime  the  atoiiiacli  will  have  K>rnieil  lirni  adin-aiona,  and  may  be  safely 
Opened.  This  is  done  hy  passing  n  narrow  scalpel  through  Iho  adherent 
portion  of  the-  stomach,  antl  niakiug  nu  nneniog  large  enmigh  to  admit  a 
No,  lU  catheter,  into  wliirh  an  Itidi»'rubljer  lui>e,  htted  with  a  Bhield  or  a 
i^niall  tracheotomy  tube,  may  ho  [laMcd  ;  the  orifice  of  which  may  he  closeii 
with  a  o>rk.  At  firat  only  milk  or  pancr^itlzed  fond  should  l>e  intnxiuced, 
but,  »i  the  stomach  becomes  stronger,  uiiuced  meat,  bread, aud  other  food 
may  be  used. 

Tlie  chief  danger  of  tho  operation  is  peritonitis,  but  Ihe  risk  of  this  hns 
been  very  greatly  dinjiuished,  (iral  1>y  the  adoption  of  the  ineLhod  of  ojierat- 
ing  iu  two  slagee,  and  secondly  by  the  uee  of  anticepticB.  The  ttdvaritage  of 
delaying  the  opening  till  lirni  adJsesiouB  have  formed  ia  clearly  ahown  by  the 
statistics  published   by   C.  L.  Vitringa,  who  has  collected  altogether  the 


664 


PISEASES   OF  THE    UOUTH    AKO  THBOAT. 


r«con1ii  of  155  eaten  of  gutroatoray.  From  thaw  be  fhrnn  iKat  befaa  lU 
iatroductioD  uf  antiaeplic  ircatmvut  65  per  ccut.  of  chc  |>uitctii«  ofwriUdM 
died  directly  from  tbe  operaliou,  hut  a'm<x  that  perio«l  i)>>  '  rut*  b» 

been  reduced  to  27  per  cent.     II'  lUv  antiseptic  caavM  arv  ■:  :u  Ub« 

ID  wliicli  the  opening  wat  made  into  ttie  ett-much  at  llu^  liruc  >'l  :Uk  xpmiM 
Hud  tliuH;  in  vrliich  Jt  vru  delayed  till  adtie«tuiis  had  luriitnl,  nr  find  tbt 
deatb-rnte  was  r)&  per  ceut.  in  tlie  furiner  aod  only  li-'>  p**r  i*vui-  ta  tb* 
latter.  la  tiiauy  cases,  although  ilie  patient  due«  imt  die  dim-lly  Irun  ik 
opemlioii,  lilo  is  but  lillle  prolonged  by  il,  oa  tbc  atomacii  awna  oaahb  to 
resume  ila  functions.  Thbt  nioel  coinniuolv  baa  happened  In  caaea  of  aia^ 
notit  Ettricture.  in  which  ibe  ujieraiioa  ba«  beeti  defcrrtxl  llll  the  fiatirot  ua 
the  la»l  stage  of  cshauntiou.  lu  nil  ca«es  of  malignant  etritrturv  ihe  aut 
that  can  be  obtained  by  gascruattiniy  ia  Uie  prohmgatiitn  of  a  procaricM  a- 
Isieuce  which  muAl  in  a  few  weeks  or  monilut  be  cut  xhtirt  by  lit'-  ir-'-V—*.^ 
progreBS  of  tiie  rliaeaae.  In  xuch  cAaee  the  advantagt-A  andtbcd 
operation  should  be  laid  fairly  bi-fnre  the  patient^  but  it  ie  Dot  tht  may  m  t» 
SurtfpoD  to  ur^e  hitii  m  tuhniii  in  it. 

There  ui,  however,  one  clam  ot  (BMphageal  atriclurfit  which  are  nf  tlieakv 
ohatinate  character,  and  rapidly  fntal  by  limplr  ncclusixii  tif  ttu'  tube,  aid- 
out  Any  letiilency  to  tualijjnanty.     Those  are  the  r-rmer net imw  tJiai  tv*vk 
friim  the  jtwallowiii^  uf  oorri*ivf  liiiuitU,  whether  atid  «»r  alkaline.     Itt  «r4 
cages  a«  Lhette,  in  which  speedy  deain  by  Atarvution  ia  inevitable.  I  iln 
Burgeon  is  jtiitified   in  adviifiog    the  opemtinti.      la  a  caM?  of   <1<|    - 
operated  on  by  Trendelenburg,  the  iiatii-nt  wao  aliv«  and  well  louny  tMn 
after  the  uperaliuu.     lie  took  fo<Ml  by  maaticaliog  it  Lliomughly  aoii  ili* 
blowing  it  from  bia  mouth  into  th«  atouiacb  through  a  lub«  fitted  t»  lie 
oauuln. 

In  inany  cases  a  good  deal  of  trouble  haa  b««a  occasioneii  aAcr  tbeeptf*- 
lioD  bv  the  escape  of  gastric  juice  from  the  tistnla.  Tbb  cnuaia  gnat  inic*- 
lioD  of  the  surrouuding  skin  appiireiitly  by  a  proceee  of  digeatioo.  It  k  ho^ 
avoided  by  nut  making  u  larger  opening  than  in  nlieohitely  niiwary.  l*~ 
the  vertical  incision  adopted  by  Hois-se  the  .«|)hini-U'r-likc  notioo  of  tbr  &hr 
of  the  rectus  tends  in  great  me-anure  to  prerent  tbia  wmplioation. 
the  ekin  bemuie  sore  it  may  be  relieved  by  being  waabeti  with  an 
aolutioD  and  protected  by  vaseline. 


DIB&UB8  or  mit  LAKVKX. 

The  larynx  may  b*  the  seat  of  a  great  variety  <>f  morbid 
Acute  (edematous,  and   fullicular  iulUiiirruaion ;    iilcrmtions  and 
thickeningB  of  the  mucous  meniliniue;    iiiflaoimalton  aoil  nccrea 
Carlilagee;  and  the  foriuatiua  of  turnout  or  jiolypuid  growLlia  in  ila  ■ 
may  all  occur. 

LAHYN'iioscYiPE. — It  ta  of  the  utmost  importance  id  ibe  diasDoaia,  aad  . 
the  proper  tniatmenl  of  theee  affectione,  tliat  a  view  should  Mr  ohlaioad  of  ^ 
the  parts  (hnt  are  the  sent  of  disease.     Tbia  con  be  dvDr  oo)/  by 
the  Larynyoicope.  ^^ 

The  intriKluction  of  this  instrument  into  practice  and  Its  perfeetJoa  hS^ 
been  a  work  of  time. 

It  npp4iir»  ti»  have  bei-n  tnvenle^l  and  Hret  u»pil  in  1820,  by  Bk 
whn.  under  the  term  "Glotliscope,"  dci^cribed  an  ioaLruiBClu  eousltt 
small  mirror  fixed  to  a  wire  ebank,  which,  being  plaoed  a^iu- 
whiUt    the   longue  was    held  down,  enablct!    hitu  to  view  lb< 
upper  part  of  the  larynx  ;  more  ci>pccially  when  he  illuiniiialiHl  ttt<-»>- 
bj  throwiog  reflected  light  upon  ihem  troui  a  mirror  held  in  bi»  UA 


m 


USE   OF    LAHTNGOSCOPK. 


655 


Trouaeeau,  and  Avery,  all  made  attempts  ia  the  same  direction.  But 
he  celebrated  singer  Garcia,  who,  by  throwing  the  sun'a  raya  into  the 
f  his  mouth  from  a  mirror  held  in  his  left  band,  and  then  introducing 
st*8  reflector  into  bis  mouth,  saw  the  image  of  his  own  laryaz  and 
1  ita  movements  in  the  reflection  of  the  looking-glass.  Hitherto,  how- 
arjogoscopy  had  not  been  employed  in  the  Htudy  and  diagnosis  of 
B  of  the  larynx,  and  it  is  undoubtedly  to  Czermak  that  the  merit  is 

haviDg  been  the  first  to  make  this  application  of  the  art. 


Fig.  746. — Metbod  of  uiing  tb«  LaryngOMOp*  with  Reflector. 

taryngoteope  essentially  consists  of  two  instruments,  a  reflector  (Fig. 
rhich  may  be  attached  by  a  spectacle-frame  or  an  elastic  band  to  the 
o'a  forehead,  and  a  mirror  (rig.  747 j,  which  is  held  in  hid  right  or 
od,  according  to  circumstances. 

mode  of  application  and  of  use  is  extremely  simple,  and  is  illustrated 
.  746.  The  patient  sits  with  his  back  to  a  good  light;  that  of  the  sun 
>ry  well  if  it  can  be  obtained,  but  usually  artiiicial  light  has  to  be 


"\ 


Fig.  747.— Tbroat  Mirror. 


red.  Thip  may  be  obtained  from  a  moderator  or  paniffin  lamp.  The 
if  the  lamp  shouhi  l>e  a  little  al)ove  the  level  of  the  patient's  ear.  The 
o,  facing  the  light,  arranges  the  reflector  in  such  a  way  that,  whilst 
e  and  the  patient  are  in  essy  positions,  a  well-definod  circle  of  light 
the  patient's  mouth.  If,  as  in  many  arrangcnienls,  the  reflector  be 
3e  eye  of  the  t^urgeon,  he  must  so  place  it  that  he  sees  clearly  through 
iC  iu  t!ie  centre,  ami  can  cim^piiuontly  employ  both  eves  in  examining 
■oat.  The  patient  now  having  the  liead  very  slightly  inclined  biuk- 
ipens  his  mouth  and  puis  out  lii#  tongue.  The  Surgeon  grnsjts  the  tip 
.ongue  geutiv  between  the  fnri'finfrer  and  thumb  of  liia  Icil  hand,  covered 
luth  or  pock ct-hani) kerchief.     He  must  be  careful  not  to  drag  ou  the 


056 


DISEASES   OP   THK    HOUTH    AND   TUROAT. 


tongae,  hut  mercljr  to  hold  it  steady;  and  this  ia  heat  ocmmptlabM  hi  nmu; 
tb«  forefinger  oit  the  patient's  chin.  He  now  talcM  the  noftll  mirrfr  um 
warms  it  ovut  the  lntn|i,  ?o  tliut  the  iHttieiit'a  hrvalh  mar  not  <  -  '  :  it 

HDil  obscure  the  imiij;i.'  ol'  tliw  Inr^nx.     Hn%'ing  warm«l   it   (;i  '/ 

clouc)  of  condense'l  nKiistnn-  from  ihe  lamp  tliuMpm-Hr.  he  t  ii 

own  check  tu  1'kv\  tliiit  it  ib  not  too  hot,  and  tlit^n  mlr<Mlui.'<  -  ■*• 

ing  war.  The  hamlle  Imitig  heh)  like  a  pen,  ami  rall)«r  to  Tb*^  irit  n4«  4 
the  patient's  ttiuuth,  the  mirror  is  pasveil  in  careriilly,  hnviDg  it*  mtUn* 
nanillel  to  the  dontum  uf  the  tongue,  until  the  tip  of  thr  uvuln  ir»is  ua  'at 
back,  and  is  pu9he«l  alightly  backwards  aud  upwanji  by  it  i.^arv  luart  I* 
taken,  iti  doing  tliis.  that  the  reflecting  surface  don  not  tnucb  tbcfantjtw. 
nod  so  become  dirtietl,  and  that  the  mirror  ta  not  puacd  ao  Air  at  hi  bM 
the  back  of  the  phar}'nx,  which  in  must  patients  would  cauic  aoeibrtri 
swallowing.  The  mirror  being  in  the  poeiiion  above  dncribed,  tba  SgffKs 
will,  if  he  see  anything,  view  the  back  uf  the  pharynx  reflected  oa  ii>  ns' 
face ;  but,  by  gently  and  steadily  raisin"  his  hand,  to  M  to  render  tb*  KfW 
formed  by  lhe«irfaco  uf  the  niirrur  with  the  potieot'e  body  ab'>ut  balfanfirt 
angle,  he  will  bring  the  o|>eniDg  of  the  glullis  into  view.  By  rainsc  ibi 
hand  still  a  little  further,  he  can  examine  the  eplgluula  and  the  pxjI  <ii  U» 
tongue.  It  must  be  remembered  that  the  image  thua  produced  ia  rmtid  ii 
the  nntero-poateriur  direction,  the  pans  that  ap[>ear  anterior  on  the  ninw 
beine  really  piMtcnor;  white  in  the  tntnaverse  direction  there  ia  DoranniL 

When  tlie  Hurgeon  requires  both  hands,  oi  in  the  applieatioa  of  aaiii'* 
or  in  the  remnyal  of  growths  or  foreign  bodies,  the  p^Lticot  must  Iw  aiidedt 
hold  his  own  li>nguc,  or  it  must  be  held  by  an  avaistaut.  The  Surpma  dm 
holiI»  the  Kinnll  uarrur  in  hij  left  hand,  and  thtt  iiittrum<Tot  he  !•  uaiii|  in  tbi 
throut  in  his  righL  f^tmetimes  all  view  of  th«  larynx  u  oliMureil  br  tht 
patient  ohatinatfly  arching  the  luligue  in  the  iimttlli.  It  mii«t  ibeii  he  hfU 
down  by  n  ttpaVtila.     In  wiint;  paliciils,  the  faur<'«  nre  so   ^'  '     that  iIm 

aiighleat  touch  causes  violent  retching.     This  itmy  Iw  allo)  ■  llftriaa 

for  a  short  tiuie  before  the  lnryng(«co])e  is  einpluyed,     Thr  Ji<iii  o* 

bromide  of  jxilat^iuui  for  n  few  days  in  full  d>iin  is  faaid  to  '  .      iW 

sensibility  of  the  fnuoes.  but  its  action  is  not  certain. 

LAltVNtitTls. — Inflammation  of  the  Inryriic  occurs  both  in  adulu  aa4 
children,  though  mure  commonly  in  tlic  former,  frnni  e«]H«ure  to  cx>Ui,t* 
th«  inlbctiou  of  eryaipotas,  and  vurinua  other  causes.  It  rliir.'r*  .-vHiiniUly 
from  the  croup  of  chtldreu.  which  is  atlcndetl  by  an  alhui"  ■<«. 

and  sprvads  uownwards  into  the  bronchi;  whiUt  in  lar\iii.<'>3  ^.><i- 
surh  efl'uaion,  and  the  diaeam  Is  confined  to  the  Inryns  iiaelf.     Liai_ 
may  nuL  only  he  of  an  actilc  or  chronic  kind,  but  the  acnte  (ortn  lil 
pn<eents  Iwn  ilistlnct  varieties,  according  to  the  parts  ailerteil.  tW 
from  which  it  arises,  and  the  condition  of  cnnstiiuiioa  in  whi<'h  il  (w 
iu  one.  the  true  Acate  Catarrhal  Laryng^itia,  the  iDflantmati«n  a 
chiefly  in  the  mucous  raenihrane;  in  the  other,  the  (BdeaatOU 
the  atti'ciion  eitenda  to  the  Bubmucitus  areolar  tiaaue»  villiin  anJ  an>ai 
larvnx. 

In  nil  inflammatory  afleetioDt  of  the  larynx,  whether  actit«  nr  i'hn«ic| 
there  in  danger  to  life  ;  the  rima  gloltiiliD,  timt  n»rr->w  chink  II 
nil  the  air  dntined  for  respiration  inu.^t  ent^-r,  l>ecoiiu-s  n'adily  < 
asphrKia  conse((Ut-nlly  reiulla.  This  may  hnppru  cither  hv  tl. 
lo<«e  fi>ld*  of  mtto^iK  nicmhrane  about  the  upjwr  oftetiiiig  o^  ih' 
membranous  exudation  upon  the  vocal  onU,  or  by  the  occum  ■  i«« 

in  the  larynx.     Ittdvtd,  there  is  tisunllr  more  or  loss  apaam  i>  *'- 

all  the  acute  inllamnialory  affections  of  this  part  of  tho  alr-tu* 
ipsam,  being  superadded  tualrea<ly  existing  niecbanicftlnocluii<.>D,  Liiibriiv'ti;; 


TARIETIK8   OF   AODTB  lARTXQlTIS, 


657 


proves  fatal.  These  Inryogeal  spaanis  do  not  at  first  recur  (>ft«oer  ttian  at 
lDt«rval«of  half  an  hour  or  an  bour;  but,  at  the  diseose  advances,  tliey  be- 
come more  frequent,  nod  in  any  one  of  them  the  patient  may  be  carried  off*. 
It  is  of  importance  to  bear  in  mind  that  death  may  occur  in  theee  eases, 
although  a  considerable  portion  of  the  cavity  of  the  larynx  continue  free. 
Thua  Cheyne  states  ihnt  there  arc  always  in  croup  at  least  three-eighths  of 
the  glottis  open  for  the  (ratisniiBsion  of  nir.and  that  death  must  consequently 
resuTt  from  some  cause  oilier  thnu  mere  me<-hanicnl  obstruction.  This  tree- 
dom  from  permanent  (W'clusicm  commonly  occurs  in  cases  of  Inryngitia;  and 
the  inimeaiate  cause  of  death  in  the  niojorily  of  instances  apfieors  to  be 
spasm,  ci>nji>inecl  with  defrclivc  Bricrializatioa  of  the  bluocl,  which  ciiuscs 
coDpc^tion  ')f  the  Jim,p»  ami  tMnvuIaiona. 

Acate  Catarrhal  Laryngitii  may  arise  fmm  exposure  to  culd,  fVom  violent 
airnins  of  ihc  vocal  apjiarntus,  or  Iriiin  exlcnsinn  i>f  raiarrh  fn»ni  lliii  ii'i^e  or 
pharynx.  It  ts  most  nimnion  in  ndutt  mnUs,  but  may  occur  in  children. 
One  attack  predispriees  to  another.  The  mucous  membrane  only  lieirg 
affected,  the  symptoma  are  not  indicative  of  such  early  and  intensi!  inter- 
ference with  rospiratinu  as  is  met  with  in  the  o^dematnus  firm  of  the  di!)ea5P. 
These  are  dryness  of  the  tliroat  and  hoarseness,  with  pain  varying  fnjni  mere 
dckliag  to  a  severe  sen.<ie  of  constriction.  Occasionally  there  are  pain  Bn<l 
tenderness  on  pressing  npnn  itie  larynx,  more  pspccially  about  the  pomum 
Adami.  The  voice  is  at  fir^t  harsh  and  rnufrh,  then  stridulons,  and  finally 
may  be  completely  lost ;  there  may  besonip  pain  and  diffitully  in  deRhiliiioii, 
In  simple  catarrhal  larynpitis  there  is  rarely  any  serious  Hyspiio>a  or  Dpnsm, 
but  in  children  there  may  he  c<jnsi<lerable  difiirulty  in  respiration,  esiiecially 
if  the  fi;iotli9  becomes  covered  with  dried  mncus  durinij  sleep.  There  la 
expectoration  of  frothy  mnctis,  ^umetimcs  linged  with  blood,  and  the  act  of 
coitgbinif  is  nccomjiauie'I  bv  uoneidenibic  paiu.  With  tlic  taryugoscupe  the 
iuteusely  injected  state  ui"  the  mucous  membrane  of  the  larynx  can  be  seen  ; 
but  this  is  not  accottipliabed  withimt  difficulty,  partly  fn»m  the  irritability 
of  the  fauces,  ami  partly  from  the  large  amount  of  tenacious  mucus  which 
nsuallv  surrounds  the  glottis.  In  very  severe  cases  the  infiamniation  may 
extend  to  the  eubmucus  tissue,  and  be  accompanit'd  by  exudation  into  the 
louse  areolar  tissue,  ami  the  symptoms  Ibeu  gradually  merge  into  those  of 
tbe  cedematous  form  of  laryugitis  to  be  prcsi-utly  described. 

Treattnfnl. — The  pHtieDt  abould  be  placed  in  a  warm  almoephere,  which 
should  be  kept  moist  bv  steam  carrieu  into  the  mum  from  Ihu  s|jout  of  a 
k«ttle.  This  is  es)}ecial1y  important  in  children,  to  prevent  the  drying  of 
the  mucus  rhirln^  sileep.  Hot  fomentations  may  be  applied  tn  the  throat, 
and  the  patient  should  lie  made  to  inhale  the  ateam  fmm  a  pint  of  boiling 
water,  tu  which  a  tea-tpoonfit!  nf  compound  tinclnre  of  benzoin  ha.'^  been 
adde<l.  A  free  pur^  will  he  usually  Ton  ml  useful  at  the  i>nsi?tof  the  attack, 
and  should  there  be  much  pain  and  coii^li,  small  dneeB  of  opium  should  bo 
adminiBtered.  Should  flyniptoms  of  dyeimn>ii  appear,  indicating  a  temJency 
for  the  inflammation  to  assume  the  tpdemataiie  form,  more  aclive  measures 
must  be  aduoted,  which  will  be  describeri  with  that  aftection. 

Aoate  (EaematoUB  Laryngitis  may  arise  m  an  tniensiiicRtion  of  simple 
catarrhal  inflammation,  as  an  independent  afTectiim  by  extension  I'mni 
Deighlxiring  partis,  or  na  a  complication  of  various  rhrouic  aH'ectlons  of  the 
larynx.  In  ninny  cases  it  seems  to  be  distinctly  erysipelatous  in  character, 
ixjctjrring  as  the  result  of  exposure  to  the  impure  air  nr  crowded  hospital?,  to 
lae«er-gaa,  or  to  the  specific  infection  of  erysipelas.  In  fact,  it  appears  to  be 
at  timea  epidemic,  and  in  its  pathological  conditions  to  resemble  closely 
phlegmonous  ervsipelns  of  the  part,  the  mucous  membrane  becoming  red, 
palpy.  and  swolfeo,  and  the  submucous  tissue  infiltrated  with  sero-purulcut 
VOL.  II. — 42 


6d8 


DISEASES   OF   THE    MOUTH    AND   THROAT. 


fiuid.  <Kdemnt<iUB  Inryngitia  is  occaoiunally  met  with  in  fw'  - 
JD  Bcnrtei  fever,  nnd  it  is  |ireiiUp<iBed  to  in  some  cwivi  liy  Hr  . 
Il  IB  most  pommonly  met  with  in  adiiltii,  being  vrrv  nn>  Ui 
eighteen.  The  ^ymptom^  nre  ii«u»lly  wpII  marked,  llir  tiiii(Ti>  •>  - 
duaky,  oDdewollcD  ;  difficulty  in  ewnllowin^ia  often  an  orly  md  pwnn— 
Byiii|)l4)m,  nud  coiuinuce  thmughunt;  d^-d[>t)ccJl,  often  uf  a  tpMmodtr  cW- 
actcr,  llitu  opprare.  the  Ii[»  l}«tr<)tiiiog  In-id,  the  D'MritB  dilaivd,  tbo  fmuttrn 
paid  and  bedewed  with  perepirntinD,  the  eyes  watery  and  bloofUboi,  aad  tW 
rcdpiraiory  muscles  arc  calkd  into  violent  Hciion  ;  japing  effuri*  at  bnaiW 
ing  mid  sudden  fiu  of  increased  difficulty  in  inspiring  come  on ;  aiiht  mm 
tiuio,  the  pulse  is  feeble,  though  it  eoDtinuoA  rapid ;  and.  unlcH  cffianiW 
relieve<l.  the  patient  will  sp^eiiilr  sink  The  voire  is  at  firfet  boafM.baiii 
■p04>4lily  luaL,  and  there  niny  be  8t>roo  tendemeH  about  the  Ixeyux.  TW 
dynpna-a  h  uaually  peculiar  in  character  in  the  iutervala  between  tbaipaHi 
In»i>>rHiii<n  is  always  more  or  leas  difficult,  (u  the  swollen  aMlenainas  pun 
fall  h>g*-llier  in  a  ralve-like  manner  over  the  opening  uf  the  {jltrflit.  Eipiia< 
tiou,  on  the  other  hnnd,  may  be  comparatively  cdbv.  Thv  fatal  rcMil  il 
freijuvutly  due  directly  to  spnam.  The  apaems  come  on  early,  umj  arc  fwy 
apt  to  be  brought  on  l>y  speaking  or  vwalluwing ;  but,  im  the  diM-aM>  adnata, 
the  tlyspnTfl  becomes  more  contiuuuuv,  until  stupor  at  leniith  supenW^ 
and  speedily  terminatei  in  death.  There  Is  UMiully  welUniarknl  r«^ttdi» 
turbauw.  If  the  finger  be  passed  over  the  buck  of  the  ti>i)gue,  llxrifi^ 
swulleu  epiglottis  may  be  clearly  felt.  l,aryng<«c<ipiu  essminalitM)  ttnisi 
the  epiglolits  forming  a  red,  semi-transparent  mil.  usually  Iwut  upm  iti^ir 
tfmnsverM^ly.  It  may  completely  conetal  the  )>arts  beneath,  hul  in  nMf 
GAMS  the  icdematjous  nrytieuu-epigloltidean  t'<'l<ls  nmy  bv  mtu  on  each  tidt- 
II  is  mreir  poacible  to  obtain  a  viuw  of  the  otrdi*. 

The  maenuUous  infiltration  in  this  form  of  laryngitis  tt  cuaSoed  (*V(^ 
pally  t*)  the  stihmucotts  areolar  tii<eue  around  the  ttpiglutxis,  in  the  arytan*- 
ei>i<;l<>uidcan  foido,  and  over  llio  aryiicunid  carlilagva.  In  thase  silDOtMas 
the  I'lMtiK  ia  distended  with  an  abundant  infl»mniati>ry  exuiUiIuB.«f  ■• 
opalescent  iippearanoe,  so  that  the  swollen  mcnibranr  may  almmtf  cnnnkilsl* 
occlude  tbe  rims  glottidis  <.Fig.  Tift).  It  i«  a  patbok^ 
cal  fact  of  much  importance,  cliat  the  rlTuaioa  Dtwf 
extends  below  the  true  vocal  cords,  being  liiniml  at  l^ 
point  by  the  direct  adhesion  of  tbe  mucous  oMtahnw 
to  the  subjacent  fibmus  tissue,  without  tbe  intenaia* 
of  any  loose  areolar  liji«ue. 

Diagaoai*. —  It  is  of  ffTMt  imporunee  to  nnf>i> 
cpdeniatous  laryngitiii  early,  and  n-rt  li  '        :    '  «iO 

simple  catarrhal  intlniiiiiiMliuu.     Tti4>  i  •  e 

the  greateHt  ii»e  in  arriviui;  at  a  •'"  -  >.     It  i 

aomewhat  dilticult  to  une  in  thrse  1 1  \  if  tlwri 

be  much  dyapiicea,  but  iiupiH<«iiig  »- > 
xinnce  be  obtained  of  the  oiMTiini,'  of  t 
dition  depicted  in  Fig.  •' 

lu  aildiliiin  to  this,  tbe  ( ,     <      i- 

tba  aflection,  the  early  ilye|iuuf!a,  and  tUte  duskr  tvoUrt 
faueca  will  fioint  tu  ibo  a-dcmatous  variely. 

Trmlment. —  The  treatmtut  should   be  antipfalofiitM 

rig-  7U.— (Edimaor    though  in  many  casca  the  ennstitutitin  will  not  be» 

tli<D(oi(l*.  HL'tive  measuMw.      Leechiug  under  tb*  )awa  aad 

the  liirynx.      In  some  easrs  acnnite,  aDtimoor,  nf  i 

might  be  of  use,  but  very  nllrn  the  invofinn  of  tbe  infUramatton  ts  so 

that  Ucrnl  meaoB  must  be  relied  upon  rather  than  rnniftlntin— I     !■ 


CUUONIC    LARYNGITIS. 


icarficatlon  with  n  hurnin-knife,  or  with  a  8hurt>-p(iiat4Kl   bistourv, 

wilb  plaeu-r  tn  wilhiii  a  quarter  uf  an  incli  of  iu  piiint,  v'\l]  lie 

Cnml  Uw  Minflt  ready  mc^n^  nf  unloailiti);  the  inRItmlvil  tiiiiobUH  niiiiiltraiic 

The  ofwriitiuti  nf  M-3ir)lle4ilu>D  may  be  more  at'cunitely  perfurtiied  l>y  uaiug 

tti-  I.irt  ii>j^i(l  Uncel,  wliiUt  the*  glottis  is  brought  ioio  view  by  the  uft«  of  the 

l.>  i|M>.     If  iMi  iiii<trum«:ni  h«>  iit  hand,  the  swollen  mucous  niembrAue 

u>-,<  "•-  viHcicnlly  »caritit^l  with  tho  foredngernnil  notched  with  a  {uir  u( 

•riMora.     Atler  tbia,  inhalations  of  the  ateam  from  a  pint  of  but  wator  to 

wtiicb  tweuty  dmitf  of  carhoHc  ai-id  or  a  drachm  of  compound  tliii-ture  nf 

brtixtiiii  Umn  \nva  addeti,  will  be  found  lo  fipve  most  relief.     Hot  fonientationa 

!'.'.  -    I  •[■IttHl  cxteniullv  nnd  I'l-et^nently  chan((e<l-     In  the  early  8tN^»  ice 

t  .ivt-n,  but  alttT  the  »welliii]|;  l)a«  comuieoved  (>teaniii)(;  ibf  ihront 

v'M  more  rvlief.      If,  Dutwitliataudiii^  these  rt^miHlied,  the  ditliL'uity 

.1*11  ivtutiiium  to  iucrtrsse,  the  u-indpipe  uiust  be  ojwni^i  beforu  tiiw 

1    Itrmii  Iwf'iinu   irrctricvwUly  eujfijrged.      Alter  the  |irop(rr  t-niphiy- 

:iv  Dieaiis  that  biivi;  buvn  indii.-ate<l  unU  their  failurv.  ibu  Ivse  uvlay 

le  tn  opvuiug  the  alr-passa^  through  ihu  crico-thyroid  tuembraue,  the 

-    I.  r.     The  'Surgv*in  eliuuld  uot  wait  uutil  exlretne  and  cuotiuuous  dysp- 

D>ra  has  wt  iu;  this  may  never  occur,  the  difficulty  in  breathing  beina 

nubrr  *pBi>miKlic  than  Oduiiniious,  and  in  uue  nf  the  ttpaffms  of  dyspnu^  Itle 

lamy  vuddi-nly  becoaio  extinct.     The  lungn  may  Wcome  falallv  congei>ted,  if 

tW  Jitficuliy  iu  breathing  be  allowed  U)  continue  too  long.      The  operntioa 

■lidf  hut  little  to  Lhrpnticnt'N  danger,  but  the  incre-n-'^ed  ri»k  is  immense  if  it 

b>  <Splii3rrd  tu  UD  advanced  {wrlod.     I  can  truly  nay  that  I  have  seen  several 

can*  lual  Uy  delaying  ihu  performance  of  the  operation,  hut  never  one  by 

opgraiiog  too  early.     When  once  dy^pno-a  wiib  laryngeal  ftpnsm  hii.^  fairly 

Ml  in,  tvttj  moment  is  precious. and  the  patient  may  at  any  time  be  carried 

od*  by  tkt  recurrence  of  the  sfxiainodic  seJEuree.     The  patient  dix^  not  die 

mdualJy  aiphyxiatod.  but  \a  suddenly  seised  with  a  Bpmm  that  terminaieiA 

Ml  exuiaaoe.     Maoeveo  hia  lUggesled  thnt  instead  uf  performing  truche- 

oinaiy  a  larRc  catheter  should  be  pas«ed  thruugh  the  larynx  from  the  mouth. 

II*  kai  sucocvfully  adupte<l  this  in  one  case,  retaining  the  eaibeter  with 

MirprMingly  liltl«  inconvenionoe  to  the  patient  till  the  cciiouia  bad  subaided. 

If  the  a>d«maU>Ud  laryngitis  become  chronic,  sloughing  and  putrid  sup- 

•'-■:'•  ■'  iif  ib«  MibtuucuUB  areolar  tiwue  may  occur,  as  in  phlegmonoui 

-  of  utiier  |>arli>  of  the  ImkIv,  and  the  |>alieut  may  die  partly  from 

C';  ^;  x>»  aud  |>artly  from  tvphoid  ayuptonu,  with  putridity  of  the  breath 

ii.,l  tuouLh.     In  llineeoavethe  adminiBtralion  of  etimuliiulaand  tonics,  more 

M-iy  poft-wineand  bark,  with  frws  f  ponging  of  the  part  with  a  stnmg 

:  nilrat«  uf  silvvr,  will  bir  tirgenlly  rt^^uired. 

Triiumatic  Laryacitia  from  !cahU,  crrosive  fluids,  etc..  haa  already  been 

■  Iiu<li^  111.     It  Usually  nasumea  the  a-dcniatous  form,  and  re<juiret  the  auoe 

tr«a>»cttU 

Cnaoxic  LABTXcann. — The  larynx  ta  liable  to  various  chronic  diwuM  of 
m  MTtiiuB  chankL-ti-r,  some  of  which  are  iucuruble,  leaving  a  permanent  ini- 
pAirmmt  of  the  vocal  and  other  functiona  of  the  larynx.  Chronic  laryngitis 
*•  Ufuallj  divided  into  three  varieties,  .Simple  or  Catarrhal,  Syphtlltii;,  and 
"^  '''  If.  .\ll  furnut  give  riJic  to  inierfcreuoe  with  the  voice,  and  dome  to 
•r  i-uniplct«  loM  nf  vrilnc. 

Clmiiiie  Laryngiitii.— This  aflcdinn  is  cnmmoa  amoDgst  ibose  wbn 

1-  fXt-rt  the  voice,  nnd  from  ita  frt^uency  ninongst  clergymen  is 

;i5  the  Ctergynan't  Throat;  it  is  also  of  frequent  occuf 

I  ni.  but  may  be  met  with  in  all  claases  of  ibe  comrouoitr. 

.:  u  itio  rrault  of  a  phtviutu  attack  of  acute  laryngitis  and  it 

:  Eo  by  gout  and  alcoholic  exoeeses.     The  voice  at  DrU  becomes 


■r,.i_... 


INJSOTION   OF   N1TRA.TS   OF   SILVER. 


661 


Dtimber  of  caaes.  Hijme  oT  il«  H(lvt>Rati»,  htiwevor,  not  content  with  curing 
io  tilts  nay  cliBeaae  that  is  visiblv  Mialnd  in  the  thnkat,  alate  that  tlit;  morbid 
oomiiiiiin  extends  down  the  traclipa  into  the  brmichi,  atitl  itiat  it  is  neceasary 
to  follow  it  in  tfiPse  siluations.  Tliey  «(ri-i)riHnj;ly  upcak  of  paaeiuir  thfi  pro- 
bang  or  brush  between  nml  heyonil  the  vocal  curds,  and  at' spongmg  and 
mopping  out  ihe  inurior  of  the  larynx  anri  the  lower  parl3  of  the  alr-ttihe, 
ami  of  applying  thn  i-austic  Bolutinn  to  them,  as  if  this  were  a  prnoee-iling 
that  could  be  ailopted  with  as  little  difficulty  as  passing  the  xpongc  into  the 
Dares.  I  monot  believe,  however,  that  this  practice,  though  cnmmonly 
spoken  about  and  professedly  employwi,  is  ever  in  reality  carried  out. 

The  utmost  that  can  be  done  is  that,  guided  by  the  laryngoscofte,  a  small 
brush  may  be  momentarily  poaaed  between  the  vocal  cord?,  but  the  spasm 
10  caused  renders  it  impossible  to  do  more.  Other  instruments  have  also 
bero  passed  beyond  the  true  cords,  and  warty  growths  have  been  in  this 
irty  removed  from  the  cords  themselves;  but  the  nioraeni  they  are  touched, 
ipasm  oct^urs.  The  most  that  can  be  done  is  a  sudden  touch  of  a  brush  or 
match  with  a  forceps  or  liiH>p  of  wire>  Any  mor«  deliberate  procneding  is 
inipijMibltf. 

Inhalation  of  the  Kitrste  of  Silver  in  Powder  is  ijcyanionally  useful  in 
cases  in  which  the  fuiliclea  about  the  opening  of  the  glottis  are  much  e»- 
lari^ed.  It  is  miMt  conveniently  done  by  mixing  it,  lO  proper  prupiirtinny, 
with  some  innncudue  impalpable  pnwiler,  such  as  ground  and  dried  sugar. 
The  strength  may  vary,  one  part  of  nitrate  of  silver  being  mixed  with 
twelve,  sixteen,  or  tweaty  of  sugar.  A  small  quantity  of  the  powder  so 
prepared  ehould  be  put  into  the  end  of  a  thick  glass  tube,  which  has  been 
bent  nearly  at  right  angles  about  one  inch  from  its  extremity.  The  Siir- 
^on,  placing  K\»  finger  over  the  orliice  of  the  straight  part  tif  the  lube, 
carries  the  bent  cod  behind  the  tongue,  over  the  epigloitis;  he  thea  direct* 
t-he  patient  to  make  a  sudden  inspiration,  and  at  the  niomcut  of  hie  doing  so 
take^  away  his  thumb,  so  as  tu  allow  the  powder  to  be  drawn  nut  of  the 
tulxt  and  into  the  air-pue?iage«  along  with  the  current  i)f  inspired  air.  In 
l.bit^  way  the  nitrate  of  Btlvar  may,  in  some  case*,  he  very  eunvcnifutly 
■spplii'd  10  the  nliole  of  tlic  afTucted  mucous  surfaces  without  the  irritation 
{iro<iu{?(-d  l)y  llie  friciimi  of  the  (iivinge. 

Injection  of  the  Solution  of  Nitrate  of  Silver  may  easily  bo  done  by 
luf-aus  of  the  inetrunient  that  is  here  didlueated  {,Fig.  75U),  and  which  I 


I 


Fig-  TM.— Larjufenl  Sfringv. 


lave  bad  condtnictfid  for  this  purpcwe.  It  consists  of  a  stiver  tube,  perfor- 
ated at  the  «^nd.  and  having  &  ^mall  pintim  moving  in  it  with  a  sponge  at* 
lached  to  its  lower  stirfnc*.  The  inntrumi'nt  is  charged  by  dipping  the  end 
In  the  solution,  and  then  drawing  hack  the  piston-rod.  It  is  then  passed 
ibUt  the  pharynx,  or  V»etween  the  lijis  fif  the  ghittis.  and  the  fluid  is  injected 
iat4;  the  air-pasj-agcs  or  upon  the  inflftmed  Biirlafys  in  a  iiuinl>er  of  fine 
streams,  by  puphing  •[own  the  piston  and  ci>m preying  iheKponge.  By  nu'Sris 
of  this  /'iryiijfru/  infrini/f  the  nitrnte  of  silver  can  be  ajiplieil  l<»  any  part  of 
the  pharyux  without  irritating  the  teii<ler  mucous  nicii)brani<  by  the  contact 
of  a  rough  boily  ;  and,  by  applying  its  nunitle  to  or  between  the  Ii]i8  of  the 
glottis,  the  fluid  may  b«  readily  thrown  down  into  the  inlermr  of  the  larynx 
with  the  greatest  certainty  and  ease.     In  those  coses  in  which  it  ts  wished 


«62 


DISEASES   OF   THE    HOUTn    AXt)  THROAT. 


to  apply  the  »n]utioD  of  the  nitrate  of  pilver  to  the  mirpwMgr,  I  pmU 
{irrfer  using  thia  umple  instrument  to  the  ordinirr  updn^e  nr  ln«k,lk 
tnerv  nivBflure  of  which  Qpon  a  tender  mucoiii  lurfncv  mny  \k  m  wuam4 
irriiHiinn.    When  the  mueous  memhrnrie  behinil  ilic  tvIuiu.  nr  th*t  tiT  iW 

Cogu-rior  narra.  is  nffected.  ihe  8o|iili<>n  mnj'  rvjiflilr  be  npnlinl  U)  ikcw  |wu 
y  luniiii^  the  rnd  of  ihc  iDdinimenl  upwnrtl8.iiutl  then  iDJectiag  itirim!* 
on  til  ihc  fldiM!terl  gurftiL'cs. 

In  whatever  way  tiic  caustic  i»  uaetl,  iu  appticntina  ahouM  ht  v^tiM 
about  every  acconH  vr  [hinl  liar,  in  order  to  in^uie  ila  full  *0iwtL  In  s"* 
iDelanoea,  however,  ndvAotagea  may  be  obuiDid  hy  unnfr  it  ewrr  tUy;  b 
otherii.  n^aiu,  a  lonc^r  inrerval  ia  required  Utan  that  juit  auied. 

Syphilitic  Laryngitis.— AreordiDg  to  Maeltenzie,  avphiliiic  ditfeuaihm 
about  '.i  per  ccitt.  nf  all  strL>ctiouA  t)f  the  larynx.  In  ttii)  ^rly  casolkMi- 
tMl*  itag«  of  ayphilJH,  alight  hyperemia,  with  a  liltl»  hoart«ncM.  m  o«t  ■•- 
common,  but  it  h  usuhIIv  «>  »li|tbt  om  to  peafc  unDotit«i.  In  the  In* 
•fcomlary  tiaut*,  condylumala  or  moc«)UH  tub*- ri-lni  mny  be  met  with.  TWy 
can  Iw  recogniwxl  only  by  the  laryneow:"!*.  by  uieHnn  of  wbirh  tbry  ranw 
avva  fiirniinj:  smooth  grsyiith  elevation*,  ueunlly  on  tlie  iMiiiilnttia  or  ttw  iaM' 
arytunmiil  fold  uf  mufjua  mentbraae.     These  may  Iw  followi^il  !-  '  ^=1 

ule^-rnlion.     The    most  ti'mnion  aud  moot  uharuclerivtic  of  i!  n 

aftedii'iis  of  the  larynx  are  thuM  owt  with   iu  the  tertiary  Mlint'^  "l  (U 
di^eaM*.     The  pathological  cttHDg«s  obwrvrd  are  the  iHiro«  as  in  other  fni^ 
— diffuse  overgrowth  ut  the  conueclice  tiasue  or  guinmamuf  iofilirali"a.i>" 
the  fonnatiou  of  i»ilaie<)  guminuta.    Tho8uhsequenttioAeiiiu;:ul'ihr  guniw^ 
gives  rise  to  wide-fiprendini;.  doittrticlivc  ulrerution,  and  should  die 
reeover  and  the  ulcers  heal,  eicniricial  unit racUui)  follows,  aoBicUmn  in 
an  extent  as  almost  to  close  the  opening  of  the  larynx.     Th^  patt* 
afti'Cted  are  ustially  the  epiglollia  nod  the  nryurtio  epislotiidraa  £>liia, 
trum  these  iHiinia  the  ulceration  extc-nda  inwards  lonanli'  tfaeglolUiL    T 
tinica  the  diatinei  gummaia  may  lie  iw«n  as  pale  yt-llowinh  Hevatiara  ta 
mtK-tiUH  membrane,  ami  ahould  MtAi>ning  and  ulcerulion  fnllov,  U)«  jc]~ 
adherent  slough  may  poMibly  he  rrcoi;niZ4>d.     SyphiMtie  uU-rratlon  sot 
commonly  leads  to  complete  destruction  of  the  epiglottis,  and  in  tb« 
stages  necrosis  of  the  cartilHgr'i  iVequmtly  occum.     Thb  dta»aa«  ta 
amnciated  with  similar  olrernlion  in  iho  pharynx.     The  symptoma  ar* 
of  chronic  laryngitis,  with  miioo<punitent  expectoratinn  and  gradaat  V 
voice.     (trAdiinlly  increnNing  ilyNpno-a  \i  not  uncommna  fnim  ouoirmclma 
the  opening  of  the  glottis. 

/.>t((jHM«i#.— Syphilitic  ulceration  of  the  larynx  is  re«i>gDiwd  by  ibo  hiib>5T 
of  tiTphilic  and  the  j-reoence  of  other  manifi'i^lHtiiinK  id  the  disrate,  by  t 
rigidity  of  the  aHeuteit  ti**ue»,  by  the  early  nHVrtionof  the  rpij:l>'fii.  il;.- 1- 
gray  surface  of  the  ulcers,  or  tlie  preaetioe  of  ailherent  y*-llow  ■;■  k* 

the  fact  that  the  ulceration  coiiinieaces  iu  the  jwriphr'nil  jmrts,  .....  -( ■■» 
towanU  the  cetilral,     The  rapidity  with  which  the  drstnictioo  uf  twu* 
take  placr  serves  to  distinguish  it  from  epilht-liitma. 

Treatmenl. — The  u«ual  (tmslituti'fnnl  Irealmeut  of  ayphllia  must  be  adi' 
adupteil.  Locally  a  solution  uf  bichloride  of  mercury  fgr.  rj  to  j^).  mm 
applied  with  a  ationge  or  brutih,  or  a  p re [ui ration  of  half  that  strragth  i 
»  a  spray.  Iodoform  mixi-rl  vtiih  twice  its  bulk  of  sian-h  may  w  U 
iDlo  the  larynx  by  the  method  .already  riescrihed,  or  hy  nitttns  id  the  bjbm^' 
instrument  conitlrurled  fur  tins  |)iirp'»e.  Whi-n  healing  m  taking  p^ 
nitrate  of  siU-er  may  be  of  use,  hut  it  is  nolsu  rfticnciousas  inslinpte  ehh'H 
laryngitis.  Should  the  dyspntva  beooinc  a  marked  araifitoia,  UadHoio^ 
must  be  pcrfurmrd. 


OOMPLICATIONa   OF   CHRONIC   LARTKQITI9. 


663 


m 


Tabercular  Laryngitit  in  nsimllj*  met  with  nnly  in  ndvant'ed  HiseBee  of 
the  lun<^,  but  itccosionally  it  U  tlie  c-nrliest  sign  of  phlhisii?.  am:!  the  iliscase 
may  run  ili^  (.fiurse  anil  termiuute  fntully  without  the  limge  bfinf^eifleiiiiivelj 
affected.  This  variety  is  Bometiraes  Bpnken  nf  aa  fMiyngenl  Phthm^  The 
earliest  sympt'iniB  are  merely  those  of  chniiiip  laryngitis.  A^  it  nHvniires 
the  roice  is  Wt,  there  is  ccinntaut  cough,  with  frothy  tuuco-purulent  expect- 
oration nnd  great  pain.  Degtiitilion  beeomrs  gradually  more  and  nutre 
painful,  till  at  last  llic  patient  oan  Aciircelv  hcindiioed  to  bwaIIow,  and  death 
takea  place  gradnallv  from  cxbnu^tiou.  LnryngiMeopic  exaruinntinn  may  at 
first  show  but  little,  nut  before  long  a  peculiar  swelling  \%  ohserved  in  the 
mucous  mend)rai)e  covering  the  arytamuid  cartilagM  and  the  nei^-libtiring 
parts  of  the  aryl»n<>-epigli'ttideDn  folda.  This  gives  rise  to  two  pyrifnrio 
swellinga  of  aiiflStient  sizl'  u>  tneul  in  the-  midille  line  pusreriorly.  li  i;*  ihia 
»wol1en  masa  projecting  backwunis  ihat  oaiiix^  the  pain  and  dilfn-iiltr  m 
■walliiwing.  Xumeruns  Hiiiall  iilcem  thcti  apfM-ar,  tir^t  in  the  rentiul  partd, 
and  Bubsequentiy  extending  to  the  peripheral.  The  under  »iirf'a«  of  the 
epiglottis  may  be  early  atTected.  These  ulcers  gradually  cuHlesce  and  extend, 
forming  crennluted  sorea,  destroying  the  vocal  corda  and  ueighburiug  parts. 
There  is  seldom  serious  dyapaoea,  as  the  soroe  have  no  teudency  to  heul  nnd 
contract.  In  the  later  stages,  if  the  jjatient  survive  sufBciently  long,  necrosis 
of  tile  cartilages  may  take  place. 

The  Dia^otig  is  made  by  the  presence  of  dii^ase  of  the  lungs,  the  pecu- 
liar swelling  over  the  arylicnoid  curtilage!-,  by  the  inuliiplicity  of  the  ulcers 
and  their  coniparativcly  eupt.'rDciHl  uliHraetcr,  and  by  the  fact  that  they 
appear  tirst  in  the  cculral  i»arle  of  the  larynx  and  spread  towards  the  pen- 
pheral. 

The  Treatment  of  this  uQeutiou  belong  rather  to  the  physician  than  the 
Surgeon,  I/ical  treatment  ran  at  ttioat  give  sonic  slight  relief.  Mafken/io 
recommetidR  i^Hitliin^  inlmlalmn»,  such  as  the  conipt^tinil  tincture  of  benr.oiTi, 
cr  the  inKUtHation  ot  oneeightb  of  a  grain  of  Jtmrphia  diluted  with  hlnrch. 
twice  n  day.  The  dyapmea  m  rarely  Huch  as  to  nec^'twiuite  trachentomy.  If 
the  inahilily  to  swallow,  partly  from  pain  ami  partly  fmm  the  food  finding  its 
vayinto  th«  laryns,  become  i?uch  ti»  to  t-breaten  death  from  starvation,  the 
patient  may  \w  tt'<kwltbon(  diffiniltv  by  an  it^sophiigc-al  tube. 

Complications  of  Chronic  Laryngitis.— In  all  rasex  of  chronic  laryngilts 
there  is  a  tendency  to  acute  hifiammatinn  itiiperveinngon  the  chronic  di^-caxo. 
The  affection  may  then  pnive  fatal  by  the  inilitction  of  iprlenia  glottiditi, 
often  coming  on  with  great  rapidity.  Se-fro^U  of  the  (_hrtitii()ea  of  the 
Lntynr  in  nxist  commnnly  a  complication  of  the  more  advanced  Dtagea  of 
tuhercnlnr  laryngitis,  and  lc*s  frei|iiontly  of  gypbililic  diseasw-.  It  baa  been 
known  in  rare  cases  to  foUow  typhoid  fever,  and  still  more  rarely  tn  occur 
without  any  evident  caoito.  It  gives  riiic  to  copious  expeclorai.ioi>  of  Urge 
quantities  of  fetid  |>uriform  sputa,  »d>en  streaked  with  h]oi>il,  and  occa- 
sionally Containing  massorn  of  necrosed  and  usiinlly  calcified  cartilage.  In 
many  cartes  alwcesH-s  form  outride  the  tube,  and  after  much  irrtlaliim  and 
diairesa  o|>en  externally;  and  tint  nn frequently  they  are  mot  with  U*  such 
•a  extent,  as  to  undermine  nnd  dus'irganiM;  the  greater  portion  of  the  ti^iiea 
of  the  aolvrior  part  of  lb«  neck.  Where  they  correspond  to  the  necnu^cd 
patches  of  oirtitage.  they  give  rise  lo  iierial  fistula>,  tlirough  which  bubbles 
of  air  escape  during  resjiiraliou.  TracheoloHiy  is  sortielinitB  retjuJrtd  in 
these  cases. 

In  cueev  of  long  standing  au'l  incurable  turyngeal  disease,  either  syphilitic 
Or  tuliercular,  it  has  been  pnipoet-il  by  Bryant  lo  perfortti  traubetilomy  «ith 
Chu  view  of  giving  the  diseased  organ  rest,  and  thus  giving  time  and  ojipor- 
tuDity  for  the  iuflnnied  and  ulcerated  mucoua  luembrano  to  heal ;  thcojiera- 


6t!4 


l)iaEAa&»    OF    TtiK    UOVTU    AND    TUhOAT. 


tion  being  tverforoi^d  liere,  uot  for  llie  relief  of  laryngeal  oltstriiclioii,  or 
the  view  nf  rejcuin^  tli«  patiotil  from  im)ieii<]ing  death  from  Hsphyxis,  but 
with  ibe  object  of  iiidiug  utlier  ciiralive  nieana  in  au  otii*rwi«e  iiitrwcliible 
dbeit^e.  Thi»  ^ug'tfvifti'iu  Hp]H.-Mrs  tu  be  ruua(lc*()  on  ^imuil  [iath>>lo;!)c«l  pna- 
ciplcs,  «uti  is  of  (wculiar  ituportHHce  wheu  wfc  couaitlerthut  |Mitieiil(«  niifTuriDg 
frou  cbrouiti  laryngeal  dideuse  arv  uever  eafc  from  tlic  Buddt;ii  BU)wrveutiuo 
of  avletiiagloLliilis.  Whenever  acute  iuflsuimmiou  supervcuesia  Ibeee  otBev, 
with  a  tviideuey  to  ceiletim  about  llie  i^luttio,  the  pmieot  should  be  narrowly 
watched,  m  he  may  readiiy  be  cnrried  ofl  by  the  sudden  BwelHng  of  the  Irps 
of  the  riiiia,  or  by  lb«  buperventiou  of  spa»iu.  la  caiiaiof  this  kiod,  the  nir- 
pauage  may  have  to  be  npeue<l  to  allow  reepiratiou  to  be  carried  on ;  and 
tbie  iiperation  oiuat  not  be  delayed  until  the  patient  falls  into  au  asphyxial 
condition. 

Nkkvoub  Akfixtiuns  or  thk  Lakysx  occur  both  in  children  and  in 
adults,  lu  children  the  nffeclion,  cutninonly  called  Spasmodic  Croup,  cunies 
<m  Buddcnlr  and  runt:  it»  c'>ur»e  Kith  great  rnpidiiy.  The  child  19  aeizt^. 
often  witliiiut  previous  warning',  with  difGoutty  in  brpathin};.  usee  violent 
efi'iirlB  to  ineptre,  becomes  l)lack  in  the  face  aud  convuli^etl,  mid  has  iu  rare 
cases  lieen  known  to  die  before  anything  caii  be  done  fi^r  his  relief;  but 
ordlnnrily  he  capes  atid  gHS|>e  ^\,  few  timei>,  anil  eveutually  recovers  himself 
vith  a  loi)g.  deep-drawn  whoo|)ing  in^piratton.  In  eases  uf  this  kind,  the 
Treatment  at  the  time  of  the  lit  cotisista  in  dashing  eotd  water  in  the  face,  in 
exposing  the  body  to  a  current  of  cold  airland  iti  using  friction  lo  the 
extremities.  If  nspbyxia  occur,  artificitil  respiration  must  be  kept  up  either 
through  an  opening  made  in  the  windpipe  or  by  the  mouth. 

In  the  aduh,  these  spasmodic  affections  of  the  larynx  may  come  on  either 
from  pure  hysteria,  or  from  irriialiou  of  the  laryngeal  nerves  by  the  preaaure 
of  tuiDors  or  aneuriHmH  upon  them.  Iu  other  instuueeK,  tliey  arise  Irooi  the 
nn^cncit  of  some  local  iniianinmlory  mischief  about  the  ^luttifi.  In  the 
nyi'Ierical  form  of  the  atfectioii  the  ordinary  remedies  fi>r  hrsEeria,  to;;elher 
with  cold  douches,  will  be  of  enMrntial  service.  In  »onie  coses,  however,  the 
obstruction  to  respiration  is  so  great,  that  the  burgeon  may  think  it  neit;*- 
sary  to  hnve  recourse  to  i^perallon.  When  the  di«ea.'>e  ariseii  from  irrilntion 
of  the  trunks  of  the  nervp«,  ituch  a  procedure  may  give  Jelief,  but  the  ucca- 
sioning  chu««  is  usually  in  il>elf  of  a  fatal  charncter. 

Paralysis  of  the  Larynx,  eiilier  unilateml  or  bilateral,  is  occaaionally 
met  with.  When  unilateral,  it  arirtes  usually  from  preasure  on  the  recurrent 
Ittryugeal  nerve  by  an  aneurism  or  other  tumor.  The  abductor  muscles  of 
Iho' cords  arc  UHiially  allected  first.  The  vocal  cord  ou  the  atfected  »ide  then 
fDoiaiiis  stationary  in  the  adducted  pusitiou.  If  only  one  side  is  aifected,  it 
caufiea  some  aUeruttim  iu  the  voice,  but  no  serious  dyspuoia.  If  bulb  sides 
arc  affected  from  any  cuu^e,  serious  dyspuuta  results,  necessitating  trache- 
otomy for  its  relief.  Many  other  forms  of  parutyeis  of  Ute  muscles  of  the 
larynx  are  met  with,  but  their  ounsidcratton  belongs  rather  to  the  physician 
than  the  Surgeim. 

Ti:M(ikh  or  THE  L.VRY.NX.  Simple  Tumors. — PnpiUomata  form  the  rooet 
common  xitnple  tumors  of  the  lur)ux.  They  appear  as  caulifiower-lik« 
gniwths  of  all  sizca  up  to  that  of  a  waluuL  They  may  be  single  and  {wdun- 
culated,  or  multiplt-  and  F«Mile.  spreading  widely  over  the  upper  opening  of 
the  glottis.  Their  most  common  seat  of  origin  is  the  vocal  cords.  They  are 
met  with  at  any  age,  hut  are  nuiro  common  afler  thirty  than  before.  Id 
rtnicturc  they  resemble  similar  gmwthe  elsewhere,  being  compnecd  of  pro- 
cessCii  of  vfl-scular  connective  tii^uu  covered  with  a  layer  of  epithelium.  The 
epithelium  is  that  normal  to  the  part,  being,  a£  a  rule,  stjuamous.  though 
columnar  epithelium  is  said  to  have  been  occasionally  ot»orv«d.    Fibrvmain 


^ 


TUUORS   OP   THE   LARYNX. 

ire  much  lees  cotumtin.  They  form  mniiLlftd  or  smtHttlil)-  lobulaled  ptitluo- 
cutaied  growths,  8|)riii|j;ii)p  iiDUally  i'niiii  thu  neighborhood  of  the  vtx-jil  <t)nl)<. 
Tbey  arc  aliwwt  iuvariably  eiiigle.  They  are  componed  at'  onliuarv  librotia 
tiaue,  coverisl  with  u  K^uamouii  epjlheliuin.  Myxoma,  Lipnnui,  anil  yarvoid 
Tamor$  liavu  lieeii  met  with,  hut  are  of  t^xtrmne  rnrily.  i)/»t»  Hriatng  from 
rctontiou  of  llie  oecrBlioii  of  iht'  niiicouK  plancU  ocoasioiiHlly  develop  in  the 
nei;^h borhouti  uf  the  epii^lottii}  or  fiilKct  voeiil  vonU.  They  form  smooth, 
shiniii;;,  rounfled  jirojectiont*.  l^ohiput  of  the  Larynx  in  a  term  npjtlied  to 
auv  ^iiuiple  iwduiictiliitpr!  ^rowlh,  hiuI  hat*  tin  pathoh:ij;ic»l  Hignilientic;^. 

Tlie  simple  tumors  of  the  larynx  cause  alteration  in  the  voice,  alight 
eou);h.  ili»r*omrort,  and  dyapmeA.  varying  in  degree  wilh  the  site  of  the 
gniwth.  Their  true  nature  can  be  recrtgnizcd  only  by  careful  exnmiDHlioa 
with  the  laryngh^cope. 

Trnttmrnt. — Thewe  growths  miiy  be  removed  by  one  of  two  nielhods — the 
eado-  or  the  ectri-larytigeal.  There  appears  to  be  a  general  consenMiB  of 
opinion  amoiige>t  Urrngologists  that  the  endn-lnryngenl  methix)  should  aln-aya 
be  attempted  in  tb*;  txnl  inslance.  Should  it  fail,  then  (he  larynx  mtir  b« 
opened  and  the  growth  removeil  frniii  without.  The  eudu-taryn){eul  method 
conabits  in  removing'  the  growth  [hmuyh  the  glutlis  by  meuua  of  inntruoieats 


Pig.  'SI.^Entla-krjnganl  Poraap*. 

specially  dcsigtiwl  for  the  purpose,  guided  by  the  laryngnscopo.  The  instru- 
mentt  mrwt  commimly  unoti  are  furct-i«.  by  which  the  grow Ih  can  be  »ei/.cd 
and  lorn  from  iu'dttaehmeiilif;  but  in  some  vaeoe,  especially  whiu  the 
growth  ia  oi'mtme  Hiee  and  distinctly  peduneulute,  wire  snares  or  erniill  icra- 
spiirfl  may  be  of  Utw?.  In  some  caaea,  the  deatruction  of  tlie  growth  mar  be 
bronght  about  by  nimply  cru)«hitig  it  with  n  8trimg  pair  of  forceps.  Thc-ae 
operations  require  nractiee  both  cm  the  port  of  the  patient  and  the  Surgeon. 
The  patient  mi»t  be  taught  to  keep  steady,  to  hold  hia  own  tongue,  and  to 
tolerate  the  presence  of  the  instrument,  tor  this  purpose,  it  is  often  neees* 
aary  {<>  train  him  for  a  week  or  two  before  any  real  attempt  ia  made  to 
remove  the  growth.  The  smaller  papillary  growths  will  sometimes  disappear 
under  the  application  of  nitrate  of  silver;  in  such  caacs,  therefore,  the  Hur- 
ge«>n  shoulrt  not  he  in  a  hurry  to  attempt  operative  interference.  The 
aecompaoying  drawings  iTigs,  IHI,  "r>2,  TJi.T)  ahow  various  forms  of  foreeps 
which  may  be  used  in  these  operations. 

Should  tbe  end n- laryngeal  operation  fail  or  be  impossible,  the  growth 
muAt  be  removed  by  an  ecto-lnryngenl  operntion.  Maekenzie  lays  it  down 
n»  n  cardinal  rule  that  no  operation  of  this  kind  should  be  undertaken  unlew 
there  is  rlunger  to  life  from  dyapncea  or  dysphagia. 

The  operntion  most  commonly  performed  is  that  known  as  Thyrotomy. 
It  la  advisable  in  mc«t  cases  to  perform  a  preliminary  trBchenl^jiny  «lx)i)t  a 
fortuight  Itefure  undertaking  the  removal  of  the  tumor.  When  the  patient 
faaa  quite  recovered  frum  thie,  and  feeie  no  further  disicomforl  from  the  tube. 


666 


DISBASC3   or   THE   VOOTH    AXD   TUKUAT. 


tbrrotomy  may  bo  underukfti.      Thf>  opemtJon  u  lhu« 

inciaidii  h  rn»<le  Hc^iiritMly  iu  tho  middle  line  frora  the  thy 

cricoid  ctirtil»^.     T)w  cnrtilngo  is  1li4?ii  CAr«fiil[r  drrKli^l  wuh  h  xaiK>«. 

if  it  Iw  oc»iti(.-«i,  willi  a  tine  wiw.     The  aim  nre  tbco  h»*lti  »\mf  nidi  Muni 

hooki,  and  Ihu  interior  of  the  Inrynv  i«  fully  expcifted.     A  »'  ' 

iponge  n>ay  Ihoii  be  jMuwed  into  the  trachea  «o  aa  to  plug  tl"- ' 

tne  tube,  le«t  blood  sliuuld  pan  into  the  tiingo.    The  m 

then  be  removwl  willi  (tciasors,  and  the  nurfaee  from  whicti  u  tr."  i...  -« 

wilh  nitrate  of  diver.    Alter  all  bleediuf;  has  ceajKd,  ibf  ■j>'>n}fv  is  reiw"*^. 

and  the  parts  accuratfly  Untught  t«gether.  and  the  Inu-heu  t«il»'  l*  rrt«ii*l 

until  the  fMitient  can  breathe  through  the  glottu  with  eiute.     Macteuue  lti< 


nf.  7S3. — Bnd«-l»rMCMl  Karo*|M. 


tig,  7iS,~ZmAa-\»rjmgmal  FwvapA, 


pninUhcal  tbe  rdsulla  of  -18  dues,  collected  fniin  viiri<Hi.i  -^^'iiri^-t-.     Of  ili 
cL^t^t  [»er  cent.  di««l,  in  :il,*2fi  p^r  ceuL  tlie  np^ratiou  ua-i  I'<ll<>U(<i  ^v 
B'Mt«at  dyK|>ciiiMi,  reipitrtng  the  u«e  of  tbe  cuuula,  and  oulj  li^  per 
mtilted  in  »  iK'rrect  c.nrv. 

Tumor*  ulf>%lini;  the  upper  opening  "(  the  ^lirftia  or  the  epij^luttu  hi' 
alif"  bevu  remiivifll  by  a  trutisvenu*  iumion  iu  the  thyro-hyuid  it.Ai-. 
pii^tue  retximimjude  that  the  incision  sh'tuld  be  made  ali^nc  ih. 
of  the  byoiJ  bmc,  partially  divi'Ung  tbe  iteruo-hyciid  and  -: — 
niiinctc*  and  the  thyro-byoid  nienibnine,    Tlie  bend  beinij  thntwn  writ  tuc 
•uffivieDl  «itiiur  may  ibua  lie  oblitine*!  to  allow  of  removal  "f  '^—  — *'  'U.^ 
or  a  tumor  Bitualttl  iu  iu  imtuediAtu  uriiihbiirhcK)d.     Tbi*  ■ 
nidom  be  rpqiiire'l.  as  simple  growths  iu  ibis  region  caa  osuallv  iw  rcini 
from  tbe  ni  >uih. 

Kalignant  Tonors  of  Uie  Larynx.— Roth  true  caruiooma  and  »a 
are  iiifi  willi  in  th(>  larynx,  but  tbe  former  Ih  far  m»re  «>in>n)>tn.     Tb»  Iprtf 
of  (mn-irimtin  nit't  with  !!•  almost  invariably  miunni'  "u    Culu' 

epiLbeliomn  has,  hiiiv<-vi-r.  Imeo  observed,  and  tfn  ibir  cmneer 

■aid  to  have  been  «een.    When  aarcomaoocars  in  the  larynx  it  ta  mcMeo 


J 


VAMOXANT   TUMOBS   OP  THE    LARYKI. 


667 


Flj. 


7&4.— K|<llb«ii>iiu« 


la 


I 


tDonly  spindte-celled,  lees  frequently  roimd-celled  ^r  mixed.  Rtitlin.  who 
fans  collet-led  tliv  reuords  of  2^1  esses  of  wrcomn.  »uit*8  thai  hnlt"  the  cflaes 
were  »i»iu(ilc-celled.  MaligDant  growtliu  in  the  larynx  may  he  intrinBic  t»r 
BXlriLsiu,  llmt  18  to  say.  tlicy  may  consuieoce  in  the  interior  of  the  Inrjni, 
•rapriiij;  iVuni  i>urrounilinj;  parts  an*!  seeondnrily  iuvnde  it.    All  mnliijiiant 

Smwiha  in  this  re;:ion  tend  to  aasunic  a.  papillary  fyrra  (Fig.  (■j4i,  ihiHijrli 
ley  are  rarely  pnlypnid.  Thty  are  nu«t  eoinnionly  single.  The  aympti'nia 
they  give  riee  to  arc  ihcwe  of  interrcreneo  with 
S[ieecii  and  n.«iiir»Li(in,  with  mme  cough  and  ex- 
ipeetoration,  oflt-n  mixi^d  with  liloo^l.  In  the:  carri- 
liomat4>u»  growth  the  gliindtt  are  I'arly  afli-ecptl. 
The  Bituaiiiin  of  ihi*  tumor  anri  ito  f^\r.v  are  uHimlly 
deterniiueil  without  difhcnity  hy  the  faryng<l(il.'o|^e; 
but  it  ia  not  e«!>y  in  many  rneeH  lu  detrrniine  Ih? 
nature  of  the  growth.  I'Vir  ihb  purpnt-e  a  piece  O'f 
the  growth  can  sonielimes  be  removed  with  the 
laryniiPfll  forceps,  and  submitted  to  micr««copic  ex- 
amination. Death  in  such  case*  ie  neceMftrily  io- 
rv'ilahle,  either  by  asphyxia  or  by  conetitutiouitl 
infection,  if  the  niw-aae  he  left  to  ron  it«  course; 
and  up  to  a  cuniparativcly  recent  [w-rtod  the  .Sur- 
Eevu  had  no  olhi-r  (iieans  of  pnilon^ing  life  thao 
by  the  perforiiinnee  of  tracht'otnmy.  Of  Jale  yean,  however,  Operntire 
&ur^ery  ba^  aildcil  exiirpattou  of  the  entire  larynx  to  its  other  triuniphH. 

Extirpation  of  the  Larynx. — Kxcisiuu  of  the  larynx,  or  ^Hryoj/eri'/wiy,  in 
part  IT  iu  whulc  hua  b^vn  soiut^'whnt  ext<.-ii8ivety  practiced  of  late  yenr». 
The  Ilr^l  case  iu  which  thiefurtniihibleoperatiou  was  uuderlaketi  wax  thitl  of 
a  mao  'So  years  of  age  affected  with  pyphiiitic  steuosia  of  the  larynx.  Ur.  1'. 
Heron  Watson  iu  t^fit! excised  the  larynx,  in  thia  csee  the  patient  dying  three 
■weeke  arterwards  of  pDcuniouia.  In  1873,  fJillroth  operated  in  a  case  of  car- 
cinoma of  the  larynx.  The  palieni  survived  the  operation,  but  died  in  a  f«w 
months  from  recurrence  of  inc  diaen^.  .Since  this  time  the  operation  has 
'lieen  frequentiv  practi.'<ed.  Dr.  Snlis  Cohen  haa  collected  the  details  of  05 
«aKS  of  complete  extirpation  of  the  larynx.  Tlic  practicability  of  the 
vpemtioD  without  canein^  the  death  of  the  patient  baa  been  fully  demon- 
atraled. 

The  dieeasea  for  which  the  larynx  has  been  extirpated  arc  chiefly  sarcoma 
and  epithelioma.  Of  the  ti-'j  cases  in  Dr.  Cohen's  tables,  the  operation  was 
«oly  done  in  4  for  non-ninligaant  diseose,  in  5  for  sarcoma,  and  in  the  re- 
jnaioing  56  for  carcinoma. 

Of  the  4  nonnifllignaut  cases  2  died.  Tho  6  in  which  the  opemlion 
•was  done  for  sarcoma  all  recoverefl.  And  2.  tlioee  of  Bottini,  of  Turin,  and 
Cnselli,  of  Rfffgio-Kniclia,  wore  alive  61  and  2  years  rcspeciivclv  after  the 
operation.  Tneec  caiee  arc  the  more  remarlcablc,  as  in  Boiiini's  the  man 
not  only  recovered,  but  was  able  to  return  to  his  work  ns  a  postman  and 
walk  eight  milw  a  dav.  In  Caselli's  case  the  sarcoma  extended  far  beyond 
Ihe  larynx,  ami  ihiR  Surgeon  ncci-rdingly  performed  iho  i-i-markable  opera- 
tion of  extirpating  not  only  the  larjux  but  a  portion  of  the  pharynx,  the 
base  of  the  tongue,  the  soft  palate  and  tonsils.  The  patient,  a  girl  of  19, 
was  alive  and  well  two  years  alYrr  Ihi-t  nioitt  formiilable  procedure.  These 
two  esKea  are  the  roost  succeMsfuI  tux  record,  for, aaC-ohen  moat  truly  obflervea, 
the  hisU»ry  of  ih«  remaining  56  prtscnla  a  much  more  gloomy  account.  Of 
these  5C  no  Ipsa  than  42  died  either  from  tlip  direct  effecla  of  the  operation 
or  from  rapid  recurrence  of  the  di»caae — 14  only  recovering,  and  of  tbeee 


668 


DiaBASBS    OF    THE    MOUTH    AND    THROAT. 


only  B  Imvc  bct'n  reporlcd  as  alive  ouu  year  «ir  luoro  after  the  operntioo. 
Tl  oiiL  of  thu  42  tleutbs  occurred  wiltiiu  itic  Grst  fortniv'lit.  chiefly  froui 
shiick  nii<l  imeumoDin.  Itniui^it,  piicuiti'iiiia  ap[iL'ar8  tu  bv  Lbe  great  Quoger 
fliiring  tlic  curtiur  [leriot]  atWr  laryii^fctxiiiy.  But  itic  ioflucDOQ  uf  shock 
is  nl8t>  a)i|mrL>iit  in  tltL<  ileiitti-ratu,  ainl  tliitt  is  not  eurprisiug  wiieu  wo  reflect 
tliat  many  of  tlt(»e  ripcrationti  uccu]iieil  frum  outi  Ut  Lurtw  huurs  in  tlioir  per- 
ttirniancc. 

Tlinie  rcjiulut  are  liy  im  nieans  encniirajFlnf^.  There  would  appear  to  be 
BOtDC  pmspcct  nf  atlvaniaf^e  from  larytt^^cnmy  iu  certain  ctia^,  eepecially 
irhen  the  dtnease  u  rcrD^nizeri  early  ami  ia  incriiisic,  aad  more  ea[»eciatly  if 
it  ifl  Rarcnmatima.  In  extrinfiic  nialigtiant  in3(>uBe  cf  thu  organ  it  id  very 
doubtful  wlifther  it  ifl  n  justiliahlc  |inirf<lur«.  ]ii  siii'h  casni  there  is  not 
only  the  imminent  rii^li  of  a  ilirfMrtly  fatai  result,  hut  the  abetitute  vertaiuty 
of  a  PiH-edy  recurrence  of  thr  iliseaKe. 

LHrvnpccli>mv.  indecfl,  appears  to  offtT  no  advantages  over  tracheotomy 
in  sncft  cased,  liy  trachwitomy  the  patient  is  !'ave<l  fr*im  the  danger  of  im- 
mediate 9uffi)cation  witli  Utile  risk  t<»  life,  and  hii»  pubsequeni  existence  will 
probably  endure  as  long  a»  it  would  in  the  face  of  the  inevitably  speedy 
recurrence  uf  the  Cfircinoma  after  complete  extirpation  of  the  larynx.  The 
operation  \i  clearly  oriju^tifiaMc  when  (he  cervical  glands  are  widely  iropli- 
caled,  »o  as  not  to  admit  of  thonaigh  rentuval. 

The  operation  mn^t  be  varied  Komevrhat  according  Ut  the  extent  of  the 
disease,  hut  the  folluwtng  plan  recorn nreiided  by  Foulis  is  applicable  to  most 
cases.  A  vertical  incision  nui»t  be  made  accurately  in  the  middle  line  from 
the  body  of  the  hyoid  bone  to  the  second  ring  of  the  trachea.  The  sort 
partj*  are  ibcn  to  be  turn*-d  ofl'  (he  larvnx.  all  bleedini;  ve*.*el»  being  liga- 
tured ns  they  are  cut.  Wht-n  the  laryux  in  fully  ex[Hj*ed  and  all  bleetliDg 
■rrestwl,  the  ericoid  cartilage  \<  drawn  fo^^va^tid  with  a  nliarp  honk  and  the 
traefacu  divided,  care  being  taken  not  to  wuund  the  u»ophagUB.  The  trachea 
is  tlieti  a(  otice  pluggeil  uiLb  a  large  vulcanite  or  leaden  tube,  slightly  cuni- 
cal  in  shape  and  completely  lilliog  the  piusage.  i^evenil  such  tubeti  of  dif- 
ferent iiizefi  should  be  at  hand.  The  taryiix  is  then  dranit  fumnnlif  and 
Beparaled  from  the  rpsophague  and  the  lower  part  of  the  pharynx,  the  e*lge 
of  Ihe  knife  being  carefully  tumeil  t')wards  the  parts  to  be  removed.  When 
alt  hemorrbajje  has  ceased  the  wound  may  be  partly  clwe<l.  the  lube  Wing 
retained  in  the  trachea.  In  the  afUr-treatmeut  the  patient  must  be  fed  by 
means  rif  a  tube  passed  down  the  <esopbagUB.  When  the  wound  has  con- 
tracted Uussenbauer's  artificial  larynx,  containing  a  reed  for  the  pnaluctiua 
of  vocal  sounds,  may  be  introduced.  If  the  disease  is  nut  found  to  be  so 
extensive  as  was  expected,  part  uf  the  larynx  may  be  eaveil,  as,  for  example, 
the  upper  port  of  tne  thyroid  cartilage. 


OPENINO  TUK   WINDPIPE  IN   MEMBRAXOtlS  LARTNQITia.     669 


CHAPTER    LIX. 


OPEItATIONS  ON  THE  AIR-TUBK  AND  ON  TBE  COEST. 


LABYNOOTOMT  JkJSD  TBACHEOTOMY. 

The  •windpipe  may  require  to  be  opened  to  allow  the  formntinn  of  a  tem- 
porary bremhiiig  aperture,  in  consefjtienee  of  obfltruciiiin  of  the  larynx  by 
causes  thnt  nre  9|>eedily  removuble;  or  it  mny  be  neceaeary  to  estnlilish  a 

SBrnianent  opening  in  the  air-paesflge  in  titose  forms  of  ehronic  laryngenl 
isesae,  in  which  tno  obetniction  depends  upon  alicrations  of  structure  which 
we  not  reniediiible. 

Anions  the  conditions  requiring  1emf)orary  aptrture,  may  he  meuti^med  all 
acute  inflaniiualory  aflecliims  of  the  larynx  tbal  give  ri»e  to  obslruclive 
(edema  of  the  giuttis ;  also  traumatic  conditions,  such  as  the  impaction  of 
ina««s  of  fwod  in  the  gullet,  indutitig  asphyxia,  iind  not  capable  of  bting 
ini mediately  removed  ;  scalds  of  the  rinia  glottidis  ;  the  presence  of  Jbretgn 
budiM!  in  the  air-pn»age;  and  cedema  of  the  glottis  frgm  wounds  of  tl]« 
Ihyrtvhyoid  membrane. 

The  eetablishmeiit  of  a  permanmt  apertuTe  in  the  air-psseage  is  especially 
required  in  chronic  diseases  of  the  larynx,  attended  by  tbiclcening  of  the 
lUGous  m^jnibraue,  by  ahacess,  or  by  neenji-is  of  ihn  cartilages — in  fact,  by 
ill  such  conditions  as  cause  obatructii'a  not  admitting  uf  removal ;  bo  albo, 
in  citses  of  epithelioma  or  ^ariy  growth  of  the  larynx,  a  permsoetit  open* 
iog  below  the  obslrueled  point  may  be  required- 
Opening  th«  Windpipe  in  HembranouB  Laryngitis. — By  membranous 
laryngitis  is  meant  any  form  of  inHamniAtiLiQ  of  the  larynx,  aeeontpeDied 
by  a  c'>aguUb]e  exudation  frum  the  niucoua  membrane,  forming  a  false 
membrane  upon  it,  whether  diphtheritic  or  not  It  ia  not  the  place  here  to 
enter  into  the  di8[)uted  point  of  the  identity  of  croup  anil  diphiherin.  The 
exhaustive  report  of  the  able  committee  appointed  hy  the  Medico  C'hirurgi- 
cal  Society  in  the  year  1879  clearly  demons  rales  the  fact  that  inilammatiun 
'  the  mucous  mcmhrane  of  the  larynx  with  membranous  exudation  amv 
isc,  not  only  ua  a  result  of  diphtheritic  coumgion,  but  as  nn  accompnni- 
Bnt  of  measles,  scarlatina,  or  lyphoiit,  and  occasionally  from  "various 
ctdental  musca  of  irritation — the  inbalalion  of  hot  water  or  slenm,  the 
itact  of  acids,  the  presence  of  foreign  bodiis,  and  a  cut  throat. "  It  seems 
sibic  also  that  asimilar  condition  may  arise  from  simple  exposure  to  cold. 
To  all  these  cases  the  tirm  inembranous  laryngitis  may  be  indiscriminately 
ipplied,  as  it  merely  expresses  an  anHtomical  fact  without  implying  any 
theory.  The  committee  made  the  excellent  t-uggestion  that  croup  should  l>e 
used  merely  as  a  clitiiful  terra  implying  laryngeal  obstruction,  occurring 
with  febrile  symptoms  in  children,  nud  not  as  indicating  a  special  disease,  of 
the  existence  of  which  there  ia  no  definite  evidence.  When  the  disease  ia 
evidently  zymotic,  and  when  the  larynx  ia  affected  by  extension  from  the 
throat,  the  tf-rm  "diphtheria"  is  applied  to  it  by  common  consent.  M<^m- 
branoua  laryngititi,  from  whatever  cause  arising,  is  a  most  fatal  disease 
in  childhood,  at  least  90  per  cent,  of  those  attacked  dying,  and  a  conniderHblt 
proportion  of  the  minority  that  escape  owing  their  lives  to  the  performance 
of  tracheotomy.     In  acute  catarrhal  laryngitis,  unattended  by  membranous 


fi70 


OrBRATIOXS   ON    THK    AIR-TOBK 


■  a   CHEST. 


exudation,  trnchootom^  is  scarcely  ever  needed,  the  diieait  yklSac  b 
milder  iii«lli»d>i  of  treatmeat. 

The  qiicflti>m  »a  U>wlietber  the  wtadpipe  shnuM  be  opened  in  isrnibniBi« 
laryneitif  ha*  l«*o  much  discuued.  Wtre  the  fiiseaw  litnile*!  to  ibr  Ur)«, 
BQil  iliil  death  result  from  simple  Ittn'ti^enl  ultstnietioti,  therv  i""ul'l  •cmn»i» 
have  arisen  anr  fiueatiun  at  to  ihe  pmpriety  of  imrlortniug  the  'tperutiulL  Birt 
iD  the  grt^at  nittji>rity  of  casea  of  all  kiods.  aod  In  al  I  thr«e  of  tymi-tic  ^)ri^ 
there  are  two  distinct  sources  of  danger:  1,  that  aruing  Iruoi  aapbTU 
dept:uilent  on  laryogeal  obstructiou ;  and,  2,  that  m  hich  is  due  to  the  rTttw 
of  intlaruRintJon  behjw  the  larynx  into  the  hronchi  and  lunga.  iiy  tneJMt- 
loDiy  we  can  doubtless  remuvc  so  mnch  of  iho  dnnj^r  u  nmm  6mb  lb 
laryngeal  obetruclioD ;  but  we  canuat  remove  that  which  la  depeodaat  m  iW 
ofU'U  eunconiitaot  bronchu-pncuruunia.  Id  fact,  the  quealion  ■■  tu  the  |a- 
forninncc  of  Irocheotomy  in  these  cues  niu»L  be  aiuHorcd  by  the  lauutrf 
Iaryo|{eal  obstructioo  aud  the  ext«Dl  ut'  pulmonary  i[upliciiiii>u.  If  (b 
child  be  io  danger  of  death  from  laryngeal  obetrucuun  anil  apaata,  tindf 
tracheotuiiiy  nil!  undoubtedly  reecue  it  from  this  immediate  danger,  uJ 
will  he  a.  pM|>er  o[terutioQ;  buc  if  extenaivo  broQcbopueum^^nU  tlraaih 
exist,  it  will  be  wor»e  than  uselesi,  and  should  on  do  account  Ik  fmuaML 
Id  caaea  in  which  the  diiieaio  ia  uvidcntly  true  Uiiditberia,  and  iheae  umbalt- 
edly  fiirju  iho  viut  majority,  there  is  vta  aui>tlier  danger.  The  wiAdjdfe 
nay  he  opened,  and  the  imniediate  Oi-currcuoe  uP  death  from  atpiifxii 
warded  oA',  but  the  zymotic  diseaae  remains  uuJ  niiu  itit  citup»-  '>"-  tMil>ii 
ultitimtelr,  in  a  large  proportion  of  cases,  dyliij;  of  exbauai  '!« 

aequelie  of  the  dueatte.  Even  though  the  relief  aflbr<)e«]  by  i.|kiiiu->u  W 
only  tein|>orary  in  the  majority  of  caaes,  yet  it  is  ubviounly  proftrr  when  ik 
dau^r  from  Inrynxeal  ai^phyxia  is  iniiuinent,  Uiat  the  Surgeon  ahouidraaa 
tlie  |MtlienL  from  inittitnt  peril,  and  give  him  hts  only  chance  of  |iruk>Qf;tl^ C 
pr«iM?rviug  life  by  ofteuinjj  the  windpipe. 

It  ha:t  be«n  very  justly  observed  by  Sir  W.  Jeuoer  that  by  o|«atlt  ite 
wiudpi|i«  in  these  cases,  we  twve  the  patient  from  »>  terrtbln  n  death  ••  Alt 
by  asphyxia;  aud.  even  if  life  be  ultimately  extinguished  by  the  diMaai, 
toiuiiorary  en^v  will  have  been  atforded,  and  death  will  onjur  in  alcM'i'' 
trrMin};  manner;  and  that,  if  only  one  lifu  iu  a  huudred  oiold  in  this  Mfb 
BAVed,  we  should  be  justilied  in  having  recuuraa  to  tJic  uperatiuu.  Sil  W- 
Jeuuer  has  made  the  important  observaiioQ,  that  if  the  Uryux  W  9* 
ioraiJed  by  Uto  end  of  the  Hrst  week  of  diphtheria,  an  aa  to  require  thi  wll^ 
pijie  to  be  oiH-ued,  laryngeal  obetrucliou  rarely,  if  ever,  occurs. 

I  have  freijuently  (terAirmed  tbo  operation  myself,  though  rarely  with  iln" 
male  BUcocae,  and  thij  1  lielieve  is  Ow  pcneral  experience  of  ot!  -  -■ —  « 
The  operation  was  strongly  advocated  in  Franca,  mora   pui  ''1 

Trousseau,  many  yeara  ug<i,  when  it  waa  regarded  tees  favomuij  iti  U*<|' 
euuntry.  But  even  in  Paris  it  was  nut  a  very  suooeaanil  pr'M:>e<tur«;  thoa  ^ 
apiK-ars  that,  at  the  Hospital  for  6iek  Children  in  that  • '  f>cT«ii<3* 

was  iH^rfornteil  in  21S  eaaee  iu  Gv«  years,  and  that  oi'  il  .  iTva" 

curv'i.     I'nlttia  we  assume  that  the  disease,  aa  occurring  in  Vntta,  w  ilJftK 
from  that  we  meet  with  here,  it  may  fairly  be  duubt«d  uhether  nn  ttpantt^ 
which  in   iu   ilAelf  ibuigerous  c<>uM   havt  been  IKCMsary  in   many  uf  ih' 
instance?),  and  whether  a  larue  proportion  of  th4  ckildrvn  niighl  [hi4  b*- 
r«covi^re<l  under  ontinnry  medical  treatment  and  without  hating  raooana 
surgical  i>i»emtion.  j] 

The  pn-ipriety,  or  rather  the  neoeaeity,  of  Uio  operation  bring  now  uoit^^ 
sally  rec<>gtiiu-<l,  il  remains  to  omsider  the  imlicatluna  f'>r  prrf^mnisiE      i 
TrtMjjptfeau  strongly  advocated  early  tracheotomy  before  oollaMp  of  tb*  lo^ 
Iwd  taken  place  to  any  extent,  or  the  patient  had  baoffiM  «3uuwtfld  by  t^ 


NBCK881TY    FOH    PROMPTITUDE.  671 

•triiegle  for  breatli;  and  ootliin^'  is  more  ccrtuiu  tlmii  lliat  ihc  0|>eratit>n  ie 
rarely  eucc-c^ful  if  pcrl'urini'cl  in  extranu.  h  way  be  lukt-n  as  a  rule  that, 
wbeu  ibe  voiov  i«  Uml  or  uvarly  )<i»t,  aud  llicrt  is  cviilout  Inrynfrnil  obt-lriic- 
tiuu  ^odutilly  tucrcvfiio^,  tlic  kodult  irui-lKMliinir  ia  |ipri'i>rnii-n  the  belief. 
The  (Trgrvc  ui' obetrucliuu  is  I'Mimultid  by  tlm  rrcivijiuri  ol'  tlii-  rhipt^Mit-HllB 
during  iu»|)initiiii].  IJ'  the  luwer  ribti  ami  tpi^tiiiisrrium  eiiilc  in  uilh  each 
iDSiiinilory  tSiin,  it.  is  wiitiT  nol  U)  doiiiy  the  uperuliim. 

The  {inH^|»tc(  of  euving  life  atWr  npeuing  the  wind)ii|>e  in  cases  nf  diphthe- 
ritic asphyxia  will  greatly  depend  iipim  the  age  of  the  patient.  Under  two 
or  even  ihree  years  of  age,  reetiTery  is  cxtrtniply  rare :  as  age  ailviinoes.  the 
chance  of  life  proportionately  iiirreaecft,  and  in  adiills  the  pr<i(ipeet  of 
rreoTery  is  considerable.  In  many  cases  the  paiifnt  will  gpt  great  tempornry 
bewtfii  from  the  operatian.and  will  appear  in  be  doing  well  lor  eeveral  days, 
perhaps  for  eight,  ten,  or  fourteen;  and  then,  lo  the  great  disappoinimentof 
the  Surge<in.  ne  will  die,  not  from  the  ctfects  of  the  operalicn.  hut  from 
bliMMl-fvoiitiining  or  from  exteiiEilivn  of  the  dii^rHw  (<i  ihe  bronchi  and  lungs. 

In  other  forms  of  laryngeal  obBtruction  nut  dejiendt-nt  un  luenibranntis 
larj'Dgiti*,  there  can  be  no  question  iis  to  the  prupriity  of  the  opernlion.  No 
patient  oiiglit  ever  to  be  allowed  to  die  Ironi  simple  laryngeal  ubvtruction, 
whetlier  that  be  8|>R8inijdic  or  de[»endent  on  organic  dim-aiie.  wilhnut  an 
attempt  being  made  l«>  save  life  by  opening  the  windpijjv.  It  is  hs  uuper* 
miMible  for  a  Surgeon  to  allow  n  paliei:t  to  die  of  Inryngcal  asphyxia 
without  au  attempt  at  relief  by  opening  the  windpijie,  even  thdugb  life 
arpear  t>  be  extinct,  as  it  would  be  to  let  him  die  of  heniorrhiige  without 
Btieinplint;  (■•  conirul  the  bleeding  vcfxel. 

Beeesaity  far  Fromptittide. — When  it  has  been  deterniiced  to  opeu  the 
wiiidpijM-  liir  ncnte  dii!e«He,  more  espL-eially  euperveiiing  on  chronic  luryngitis, 
the  lew  lieliiy  there  la  in  having  recourse  to  operation,  the  better;  as  the 
patient  may  ut  any  moment  be  eei»;d  with  larj-ugeul  vpatiti],  and  be  carried 
o£  The  oi>erBtioii  ought  always,  however,  to  be  coiupleted.  even  though  the 
patient  have  apparently  expired  before  the  windpipe  lias  been  opened  :  fur 
reauscitalion  may.  even  in  these  extreme  cnaee,  be  cfTecled  by  iiitilicial 
respiration.  WHen  life  hangs  vn  so  slender  a  thread  ae  it  does  in  urgent 
cues  of  luryugeat  obslructiun,  the  lirst  touch  of  the  knife  niay  cause  a 
spumodic  seizure  that  may  give  rise  to  apparent  death.  It  has  twice  hap- 
peoed  la  me  to  operate  under  such  circuiiiplances,  and  in  both  cases  to  be  for- 
tunate enough  to  save  the  patient's  life.  I  was  called  muny  years  ago  to  an 
elderly  woman  who  was  apparently  dying  from  the  supervention  of  acute 
upon  chronic  laryngeal  diseoee.  1  loat  no  time  in  making  an  incision  into 
thecrico-thyroid  menihrauc,  but  at  the  flrsl  touch  of  the  knife  slic  stink  back, 
apparealty  dead.  I  inimciliiUely  coW|)Icled  the  operntinn.  and  introduced 
a  large  silver  tube,  through  which  the  lungs  were  influtcil;  in  the  course  nf 
afcw  minutes,  voluntary  rMoirution  recommenced,  and  the  patient  eventually 
recovered.  She  has  never,  nuwcver,  been  able  to  breathe  without  the  silver 
tube,  which  ^he  wears  in  her  wiudpi|ie  up  to  the  pret>eut  lime.  In  another 
CBie  ID  which  1  was  hastily  summoned  by  my  friend  Mr.  Tweed,  I  found  the 
patient,  a  young  woman,  \a  the  lost  stage  of  asphyxia  from  aeuie  disea.'ie  of 
the  larynx.  I  immediately  proceeded  to  operate.  As  the  patient's  neck  was 
ebon  and  thick,  and  the  veins  cxccastvcly  turgid,  there  wmi  profuse  hemor- 
rhage  on  the  first  Incision  being  made;  white  we  were  waiting  a  minute  or 
two  until  this  would  cease  before  nf>eniiig  the  windpipe,  the  patient  fell  back 
and  aoperently  expired.  I  lout  no  time  in  plunging  the  scalpel  into  the 
crico-tJiyroid  meniUntne,  nnd  cutting  down  through  the  cricoid  cartilage,  BO 
Bs  to  make  a  free  aperlure  into  the  air-pa»sage.  On  endeavoring  to  set  up 
irUficial  respiration,  [  found  lite  air-pB&sagfii  clogged  with  iaspissated  mucus, 


672 


Ol'KRATIONS    OS    THE    AIB-TUBlf    AND    OUKST. 


which  )irevmtu-<l  flie  cntrHtice  of  air  Into  ihc  luiifff ;  Uw  liff  of  •  (r\viv- 
cn'-itLuru  lining  ut  ataku,  and  ileitouik'nl  uu  Lbe  iinmciliatf  ntiJ  Atll  tsubltilh 
ment  of  HrtiHriAl  reApiratioii,  I  felt  that  there  wik  nnlr  one  thing  to  t»to« 
— to  enipiy  the  chest  of  the  nialtors  loadiof;  il,  iind  that  thii  mtMl  b*  iim 
iiKlftntane<iiix)y.  I  arennHin/U*  applied  my  lipti  t<>  the  wouii<l,  Abd  Klck«J 
out  tlire(<  nr  four  nioi)thfiii»of  hlnod  and  niiiciitt,  when  I  had  th«  aaiiatJMUN 
tatee  that  air  ouuid  be  made  to  enter  the  Itinga.  Aftor  artificial  reftfitstMs 
had  been  kept  up  for  some  time,  the  heart  bej^xD  feebly  to  art,  th«  be* 
became  lea*  livid,  and  the  circulation  waa  rec«tabltabed;  lbe  {iftlient  ttttt- 
ually  (lid  well,  ami  i«  now  alive  and  iu  jfood  health. 

UPERATtoN8. — In  opening  the  witKlpipe  the  Surgeon  h&i  tbe  t\i<ion£ 
two  MitiiHtidiis  iu  which  he  may  make  the  nperiure;  eitbvr  io  the  an«» 
thyroid  nienibraiiv  by  Jiaryngototaj,  or  in  some  p«rt  of  the  tmchea  b* 
Tracheotomjr.  Be«idee  lbe««  tmi  c>tHl>li'<lie>lo)>eratiuti»,ii«)iocSurppumlia«i 
perfonuvd  n  ihinl — Laryn^-trftcheotomy,  l>y  u{tetiitig  th*T  i;nco^yrtU 
iiK'iiibniuc,  and  divtdiii(;  the  cricoid  cartilage  with  the  U[(per  riop«tW 
trachea. 

Wliichcvcr  0]K'mliiin  in  pcrformcil,  so  anon  as  iho  windpipe  ia  ept9Nd.(b* 

Iiaiivut  is  sein^l  wiih  an  uttucknf  atiaom  and  cimruli*ive  eougfa,  often  sttcoM 
ly  mucli  iilru;!gling  and  (iiKlrem.  uiiritig  which  the  whistling  nccannatd  ftr 
tlie  pubfling  111  the  uir  thnmgh  the  new  paetuige  is  very  loud  aoil  VBukm. 
Thu  patifiit,  however,  wxm  rccuvera,  and  then  brealhca  natanUly  tfldcHly. 
the  aigns  of  asphyxia  di5ani>e&nng. 

The  wiQd[>itw  may  require  Ui  be  opened  either  by  iBrrngntoniror  tncki^ 
tomy  tor  the  following  c<inditions  {L  =^  I<arytigDtcimy ;  T  =  TracoMfiMiy;: 

1.  Acute  laryngitis  with  ledenia  of  the  glottis  io  the  adult  (.  L). 

2.  Chronic  oedema  of  the  glottis  with  nulfucating  epaami  <.Lt. 

3.  Hvphililic  or  other  ulcerations  of  the  glottis  with  chronic  oidcaia  {IX 

4.  Membrnnous  laryngitis  in  children  (1). 

5.  Mcmbrunoufl  laryngitis  in  adults  (L). 

6.  Necrosis  of  the  cartila^  of  the  larynx  with  obttroetive  tbidteaiB|rf 
(isauca  'T  or  L). 

7.  Epithelioma  of  the  epiglottis  aod  other  growths  obstructiuif  the  )vj^ 
geal  oriltce  (L). 

8.  Tumon  in  the  larynx  ^L). 
!l.  i^cahi  uf  glottis  by  boiling  wst«r  or  aoidi  (T  or  L,  acoardiBC  to  if*^ 

patient). 

10.  KoreigD  bodiee  impacted  in  the  larynx  (L). 

11.  Foreign  body  in  the  trachea  or  broui-bus  (.T). 

12.  Xmi>actioQ  of  fureign  suhatancei  in  the  phaiynx  (T). 

13.  ^Vi>phyxia  from  any  cause  by  which  the  glottis  is  mecbanicalljr 
(T  or  L.  according  to  the  age  of  the  patient ). 

14.  Act'idenla  in  operations  about  ttte  head  and  face  by  which  Uoad 
cumuIaLrrt  in  ihc  pharynx  {h). 

15.  At-  a  preiiniiiiHry  step  In  certain  operations  uo  the  boDM  of  ihf 
attended  by  niurh  hemorrhage  (T). 

If).  Lnryngejil  Apium  <ir  TiaralyaEs  fmm  campresalnn  of  the  fsfciriar  Urjr^ 
geal  nerve  hy  aortic  aneuriam  (L). 

I-.ARYX>i(>TOMY  Ifl  AH  co^v  operfltlnn.  The  crico-thymld  owmttraM 
almiwt  sulvctitanconii,  nnd  mny  rcndity  lie  reached  hy  nukincr  a  rerttcMl  i  _ 
cif)iiin  in  the  me«ia1  line,  b^-tween  the  ■tcnio-hyuid,  about  an  Incli  in  ieuti 
and  then  a  cmei  cut  through  the  menibrane  with  an  ordinary  scalprl.  Tia 
uir-piuMage  harini;  thus  been  (i{M-ned.  n  silver  tube,  curved  vu  the  flat,  ma  ; 
be  readily  iDtnxlijeetl  and  retained  by  ia)»n  around  the  neck.  The  ■« 
Iroubleaume  result  that  can  occur  in  this  opermlioo  is  tbt  wwtid  of 


PBRFORHAI 


EXCHBOTOMT. 


67d 


■rterr.  the  crico-thyrnid  branch  nf  tlic  muperior  Lhyroiil  which  cromm  iho 
inemDrBUe.  I  bavo  never  bccd  any  trouble  arise  from  thi*^ ;  but,  ehould  it 
DPour,  tbv  hemorrhage  would  rcudilj*  be  arretted  by  the  appticatiou  of  pres- 
Jure  or  ligatnre. 

In  ooaL-ii  of  extreme  urgency,  it  is  rccommcndcfl  by  aomc  Surgcona  that 
iBryugnturny  he  performed  by  a  traiiRverte  instead  of  by  a  tongiludinal  cue 
through  the  au jK-rticial  utructurea  in  urcler  to  save  time.  In  tbiit  opinion  I  tlo 
Hot  agrM;  little  if  any  time  i»  naved,  and  peril  may  enHUe  by  cutting  acrou 
the  branchea  of  the  anterinr  jugular  veins — ^thiiti  leading,  as  I  have  iieen,  to 
proftue  hemorrbage,  e<pially  embarrasAing  and  dangerous.  There  in,  more- 
over, soma  risk  of  the  iVtrniatiDu  of  an  aorial  li^tiila.  In  all  caiiesi  the  longi- 
tudinal cut  answeni  perfectly,  and  ihecrico-thyroid  membrane  can  be  opened 
by  it  in  le^  than  tive  seconds. 

Tit*CH(X)Ti:>Mv  oon^istfi  in  making  an  oftening  intoaome  part  of  the  tracb^A, 
by  exposing  the  lube  and  culling  acni:w  two  ur  three  rinjp*. 

There  are  three  giluatiuns  in  which  the  trachen.  may  be  oj>ened ;  above, 
underueatli.aod  bcluw  ilie  ieiboiusof  ilic  thyroid  budy,  which  usually  ero«sc-8 
the  air-tube  oppueito  its  wcond  and  third  rings.  Above  the  ieihums,  the 
trachea  is  comperaiively  iup«rficial,  being  covered  merely  by  the  skin  and 
niperficial  fascia,  the  deep  fascia,  and  the  Hlcniu-hyoid  nmecles.  Beneatli  the 
nusclea  will  be  fuuud  a  atning  fascia,  whieli  uumea  downwarda  in  front  of  the 
laryox  from  the  hyoid  bone  and  dividtealxivu  the  tliyroid  body,  cuctosing  ita 
ifCnraos  between  it^  lw»  iayeni.  This  faacia  is  of  some  im)K)rtHUce,  ua  it  h 
diiiicult  to  puidi  the  i»thniUH  ilnwuwarde  m  as  to  expotie  the  u)1|K.t  rings  of  the 
trachea  without  nntching  itiix  irBiiKversnIy.  Helnw  the  thyroid  glainl  the 
trachea  recedes  from  the  surface  am)  i.'^  overlapped  by  tlie  sterno-hyoid  and 
■teruo-tbyniid  niuM-les,  beneath  nhich  Ih  aome  tonBe  areolar  liatjue  in  which 
lie  the  inferior  thyroid  plexus  of  veins,  which  are  of  large  size,  together  witb 
isome  tracheal  branches  t'rom  the  inferior  thyroid  artery,  and  in  rare  caseaan 
irregular  arterial  branch  a?eeud:«  trom  the  aorta  in  frt:int  of  the  tmchea  Co 
the  thyroid  body — the  tbyroideaima.  Beneath  the  deep  fascia  but  super- 
ficial to  the  muactea  on  each  aide,  lie  the  anterior  jugular  veins.  Those  arc 
variable  in  siie,  become  larger  below,  and  aomelimea  communicate  by  a  branch- 
crowing  the  line  of  the  tracheotomy  wound.  The  carotid  arioriea  also  are  in 
close  relation  to  the  trachea  on  each  aide,  being  more  capecially  in  danger 
at  the  lower  part  of  the  neck.  Opposite  the  episternal  Dotch,  the  windpipe 
is  crossed  by  the  left  innominate  vein,  which  has  been  seen  by  Macilivain 
lying  high  at  the  very  point  where  tracheotomy  ia  usually  performe.].  A 
glance  at  these  important  relations  will  sutliee  in  indicate  the  difheully  that 
niu»t  in  many  c««8  occur  in  expoNiug  and  opening  the  trachea.  This  diffi- 
culty ia  greatly  increaeed  when  the  veins  of  the  neck  have  become  turgid  in. 
consequence  of  the  pulmonic  obstruction.  It  will  be  seen  also  that  the  trachea 
i»  lew  covered,  anti  m»y  consecjuenlly  be  much  more  readily  reached  above, 
than  Iwlow.  the  i»llimu9  of  the  thyruid  gland.  Though  some  Surgeons,  ai 
Velpeau,  for  instance,  have  recommended  the  opeuing  Xi}  be  made  in  the 
loiter  |>art  of  the  tube,  no  advantage  whatever  is  gained  br  ao  doing,  whiUt 
the  difficulties  of  the  operation  are  very  eeriously  increased;  and  in  practice 
it  is  alm'»t  invariably  opened  at  its  upper  part,  usually  through  the  hm  and 
second  rings. 

Thv  patient  should,  if  pix^ible,  be  placed  on  a  table  in  a  good  light.  In 
operating  on  ao  adult,  it  will  be  found  sufficient  iu  most  cases  to  supjiort  the 
pstientH  shoulders  with  pillows,  while  the  head  iia  thrown  as  mueli  buck  as 
practicable.  In  cliildren,a  ^miill  firm  pillow  muat  be  placed  under  the  neck, 
so  OS  to  throw  the  trachea  ad  muith  forwards  a*  inaaibh.  A  stocking  itlutled 
tightly  with  t^iwclij  will  utiually  bo  found  to  uuswer  the  pur|ioec  admirably. 
Vol.  II.— 43 


674 


OTERATtONS   ON    THJC    AIR-TCBK    AM*   CIIE»T. 


An  Hwi^tant  !;hiiitlil  be  iM>nlf?<l  iilntTr  lliP  hrud  nf  ihr  pHlirnl ;  i( 
hold  l\w  head  axenfly  uilh  lii:<  vM'l^tn,  while  uilh  a  hlunl  h*K>lc  ir> 
draviA  the  wouud  oiM"!!  Hiirinj;  itif  i<fM?r»tii)n.    At  thr  *tinii>  hi  >  'i'  ^    i-'  ^  ' 
the  chin  exaclly  in  the  tniddfe  lim-  tii  serve,  a*  a.  (fiiiihr  ti>  th)*  -ut , 
bonk«  must  never  be  eiitrii^tM  to  soptirate  ii)wt«iliiiit8,  nii  ihcy  •' 
dig|ilace  ihe  wouuti  Intni  the  middle  line.     Il'  another  nnutant  -  , 
may  give  the  nnitatbeljc  siid  s|xini;e  the  wound.     Tb»  -Surjr^ftiu  Maii> 
n);nt»ide  nf  the  jMilient. 

If  il  Ix-  tuteDdi:d  to  0{>eu  the  trachvn  above  th«  ietbmua  of  tli«  tlivr 
thv  incisiou  iuii«l  l>c  cijn)iii«iicvd  tit  the  ii|>|>er  bnrdrr  ut*  the  cricoid  < 
Bud  currJLil  duwnwards  directly  in  thv  iniilJIt-  line  fur  au  ioub  \t*  an  ' 
B  half,  nccurJing  (o  the  aav  and  »iz<-  ut'  the  [mtieni  and  tht^  aruouiu  nl  !u' 
cutMueous  ful.     After  ilividin^  the  inU'tftinii'iil^.  ibo  iottrrul  txtofro  ti> 
Bl«rn<>-hyoid  muscles  inuat  be  tuuud.tilid  tliLve  <iraw*u  Bpnrt.     Ativ  vl-;u(1&91 
pretwut  theuifclvi'B  eliuuld  be  avuidi'd  ub  cttrefiilly  ait  )V)«ible.  aod  bvM  >« 
ant)  aide  bv  the  Hsciatnul,  uhu  has  t-harjfv  nf  ihu  hluut  hu«>lui.     After  tb«  ottir 
cliv  bavu  bi'vti  drawn  H)Hirt.  ihi^  it«tliiiiu»  tt(  iUt-  tliyruid  hndy  niiun  iamrifff, 
Biid  abuvv  it  is  ihe  ratx-ia  that  Humxirl-s  il  and  ruvi^m  tbe  trarht-a.    Th*  ifi 
border  uf  tht;  rncoid  carlilu^e  Htioubl  iheti  lie  fell  fnr;  it  no  be  nccfxtd 
bj  its  forming  a  flight  prY^jccittin  tibttve  tht*  k-vid  of  the  tnchcs,  wbidifM 
be  rtfudily  felt  witb  the  iinger-nail.     If  the  [utrt*  are  well  in  view,  tbrtn^n 
may  Iw  U>Jtl  expowd  by  Lhe  pbiii  reeonii»eudt-<l  by  Heme.     The  layrrnf  iwna 
in  front  of  the  trachpa  which  supports  the  ii!Lbmiis  in  picknl  up  «ilb  ■  jaif 


W 


y 


=v. 


r" 


"  N 


^ 


Fig.  7U.— 0|i«raUoa  of  Jntbmtnmtj. 

of  furcepi  at  the  lower  \t»tfier  of  the  cHcriid  cartilnue.  and  carrfuHy  ^^^^ 
transversely  for  a  diatunce  aiiHieient  to  adtnil  the  bnnttk-  '-f  ?*■•  m^I^ 
benenth  il,  bv  luennii  uf  which  the  iHlhmi»  i»  pti>>bnl  dtmoK    -  '-''' 

upjier  three  ruiK*  of  the  trachea  clearly  ex|>»i«Ml.  The  traehr.i 
fixed  Kith  a  sharp  lnHik  and  drawn  foruanl^  to  Rt^'sdr  it  nbi' 
is  niad^.  It  \»  iitnially  rerorDiucndrd  to  inwrt  the  hook  in  tbr  ii:i'>-i>i' — ^ 
Inauied lately  behiw  thu  cricoid  (.-arliluec,  but  the  pluti  devtat  <1  by  J.  Mi^*v 
will  bu  found  mare  couvonieut.  in  thio,  the  li(H>k  ia  ioairitod  BfaiiRil  aa  n^^. 
of  an  iiifh  froio  tbe  middle  line  |>arullcl  to  thv  inlmdcd  Inciawo,  ia  f^*^ 
beio)i  iiinde  to  reappear  mi  us  to  puncture  ibe  irarhra  in  two  plam.  aiil  ' 
get  a  firm  hold  on  it.  The  opi-nmg  ill  ihf  irnclua  i»  iben  made,  the  kf** 
oeiuK  heltl  hy  the  blatli-  al>'>ut  hiilf  an  inch  rnxn  ile  puint,  »o  " 
poniblo  to  trouetix  the  irnchen  and  punrtum  the  irvuphagus. 
must  be  made  fnim  below  upwards,  and  rh^uld  inrlude  aUnut  thnrr  n 
tbe  traoheiL  The  tube  mav  now  be  rudly  iiiM-rtpd  by  drawing  one  tip  ._ 
npentag  wfll  forward^  witli  the  hook  that  bat  been  tnaertcd  juirBlM  U» 


VIFPICULTIES   AND   ACCIDENTS   IN   TRACHEOTOMY,      675 

iil«  the  other  is  depressed  with  the  end  of  the  tuhe.  If  this  be  done,  it 
p8  Id  without  any  difficulty.  It  must  then  be  retained  by  tapes  rouad 
e  neck. 

If  the  trachea  is  to  be  opened  below  the  isthmus  of  the  thyroid  body,  the 
cbion  muHtconimence  immediately  below  the  cricoid  cartilage,  and  be  car- 
ad  dowuwanis  for  at  least  au  inch  and  a  half.  The  muscles  are  exposed 
id  flepanitt;d  aa  in  the  previous  operation.  In  this  ailuatioo  the  sterno- 
yroids  will  probably  come  into  view  after  the  Bterno-hyoids  have  been 
mwD  aside,  The  isthmus,  having  been  exposed,  must  be  drawn  upwards 
ith  a  blunt  hook.  At  this  stage  of  the  operation,  the  large  veins  forming 
K  inferior  thyroid  plexus  mu^t  be  carefully  avoided,  and  if  the  wound  be 
Hy  deep,  it  is  safer  to  use  the  scalpel  to  a  limited  extent, dilating  the  deeper 
uts  of  the  wound  with  its  handle  or  with  a  director.  In  young  children 
he  thymus  gland  will  appear  in  the  lower  part  of  the  incision,  and  require 
Abe  pudhed  downwards. 

Opening  the  trachea  beneath  the  isthmus  is  seldom  necessary,  but  should  it 
be  aaavoidable,  the  tissue  of  the  thyroid  body  may  be  divided  with  hut  little 
bleeding  if  the  knife  be  kept  accurately  to  the  middle  line.  Laryngo-traehe- 
ifaxjr,  in  which  the  cricoid  cartilage  is  divided  with  one  or  two  of  the  upper 
ri»pof  the  trachea,  is  occasionally  performed  intentionally,  but  more  often 
ModeDtallv,  in  young  children,  the  cricoid  being  mistaken  for  a  ring  of  the 
inehea.  'the  accident,  if  such  it  can  be  called,  is  not  productive  of  any 
injory  to  the  patient 

The  question  as  to  the  lafety  of  the  administration  of  chloroform  in  these 
<)[wntiunj  often  occurs.  I  believe  that  it  may  always  be  given  safely  except 
ucawn  of  extreme  syncopal  asphyxia,  where,  as  sensibility  no  longer  exists, 
It  u  UDoece^ary.  Laryngeal  inflammation  and  obstruction  are  always  asso- 
o»t«d  with  so  much  spasm,  more  particularly  in  children,  that  it  will  oft«n 
be  fnund  that  the  patient  respires  more  easily  and  fully  whilst  under  the 
uifluenee  of  chlorolorm  than  before  lis  inhalation  was  commenced  ;  and,  as 
the  aoxjihesia  materially  facilitates  the  operation  by  doing  away  with  his 
*ntliing3  and  strugglings,  I  invariably  have  recourse  to  it  when  I  perform 
''tcbeotomy  on  children.  In  laryngotoray  in  the  adult  it  does  not  appear  to 
**  tn  l)e  necessary. 

Diffieolttea  and  Accidents. — This  operation  is  often  attended  by  extreme 
wfiiculty,  and  not  unfrequentty  by  much  danger. 

The  difficulties  (wcurring  in  traclieotomy  are  chiefly  referable  to  four  heads : 
'■  Difliculty  in  Exposing  the  Trachea;  2.  Profuse  Hemorrhage;  .1.  Diffi- 
""'•y  in  Oi>eniHg  the  Trachea ;  and,  4.  Trouble  in  Introducing  the  Trachea- 
lobe. 

1.  The  Dij^ctdlij  in  Krpoi*ing  the  Trachea  increase.^  greatly  as  the  incisions 
JPproach  the  sternum,  and  is  especially  great  in  litout.  short-necked  persons. 
^^  want  of  an  assistant  to  hold  the  wouml  open  adds  greatly  to  the  diffi- 
•'ty  of  the  operation.  This  may.  however,  he  (tvercume  by  the  use  of  the 
iScoious  "Auttimatic  Retractor"  devised  by  K,  \V.  Parker  (Fig.  7d()), 
•**  accidents  in  this  part  of  the  operation  arise  very  commonly  from  taking 
'*  guides  incorrectly.  In  their  anxiety  to  upon  tlie  trachea  above  the  tliy- 
'*d  hotly,  yimiig  opcratfirs  are  apt  to  make  the  inci^iuu!)  too  high.  The 
'■Oom  Adumi  of  a  young  child,  especially  when  overed  by  much  fat,  is 
^t*cety  to  he  telt,  and  the  liyoid  bone  is  t)i.<mi  tiiiics  mi:4takcn  for  it.     Owing 

Ibis  error,  I  have  more  than  once  seen  the  thyroid  cartilage  partly  divided, 
^  in  one  case  an  ojiening  made  even  in  the  tliyro-hyoid  space.  The  inis- 
^^  is  avoided  by  taking  the  sternal  notch  lis  the  guide,  and  making  the 
^iaion  iu  a  chiid  reach  to  abnut  a  Anger's  hroaiith  aliove  it.     Insufficiency 

^e  iocidiou  is  a  frequeut  source  of  difficulty.      Kven  iu  the  smallest 


OFERATIOi 


THK    Ain-TUBE    AND   CHEST. 


children  it  ehonld  never  be  Iws  than  one  inch  in  leiiclli.  Deviation  fn 
thu  luidiile  line  i«  n  common  cause  of  acciHent,  teadinj;  to  woutiJs  af  thT 
tlijroiil  body  or  even  of  the  carutid  artery,  or  to  great  iliffirulty  in  liinHug 
the  trachea.  It  niuv  be  llie  Ihult  of  ttie  ft9tii*lflnt,  who  should  keep  the  chin 
exactly  iu  the  middle  line  8B  a  guide  to  the  Burgeon.  In  very  young  chil- 
dreu  an  iiiexi>erivuced  tiseiKtaul  way  even  draw  the  trachea  on  one  side  with 
the  bluut  houk. 


...--r^— "^^^=*^" 


Ftg. 7SB, 


-AalftQUtlo  R«lraoU9r. 


2.  The;  Hemorrhage  nmy  occur  cicher  from  arteries,  Inim  veina,  ur  from 
the  thyniid  glitnd.  Arterial  hetiLnrrhage  ia  le^  frequent  and  Lroubleeoiue 
than  the  bleeding  frniii  other  HOtirces.  When  it  (H^curH,  it  hii)))ienii  chiefly 
from  the  wuunil  of  tu>me  anomalous  hruQcli,  or  from  thai  of  the  tiuiall  tra- 
cheal veasels.  Uefiault  han,  however,  mentioned  a  fatal  caw,  in  which  death 
at-oee  from  a  wound  nf  the  carotid.  Tlie  arlerinl  anastomosis  of  the  isthmus 
of  the  thymid  binly  may,  if  this  part  he  enlarged,  nrctt»ion  Home  difficiilty  in 
the  performance  of  the  oneralion  :  Inil  the  main  (source  uf  dauger  tn  uiii|UCB- 
lionnbly  the  vmoutf  bleedmg.  Not  only  are  the  plexuaes  of  veiuK  of  lurge 
size,  more  pariicularly  where  they  cover  the  lower  part  of  the  trachea,  but 
ther  hecomc  immeoflcly  gorged  by  the  asphyxia  that  necegallatea  the  0|>cra- 
tion.  Hctice,  when  they  are  wounded,  the  bleeding  may  he  so  abundaDl  a< 
■carcely  to  be  conlrollaule,  and  may  very  greatly  retard  the  after-ateps  of 
the  operation.  Many  Surgeons  of  authority  in  those  matters  advise  that  th« 
windpipe  should  not  be  opened  until  all,  or  nearly  all,  the  bleeding  has 
ceased  :  lest  the  blood,  entering  the  bronchi  and  lungs  through  the  aperture, 
aaphyxiate  the  patient.  But  in  thi«  way  much  valuable  time  may  be  cun- 
aunied,  and  the  patient  may  be  fatally  exhausted  by  a  tedioua  and  proloDget) 
operation,  and  by  the  Iobb  of  an  unnocegaarily  large  quantity  of  blood.  The 
hemorrhage  in  this  operation  is  almost  entirely  veuous,  and  is,  in  a  great 
measure,  depeudeot  on  the  distention  uf  the  veins  of  the  neck,  which  occurs 
iu  aepbyxia  as  the  result  of  the  accumulation  of  blood  in  the  right  cavities 
of  the  heHrt,  citnaeiuent  upon  the  obstructed  circulation  through  the  lungs; 
and  the  bleeding  will  continue  so  long  as  that  ubatructii.m  remains  uouuved. 
But  as  the  reHpiratory  procees  is  reestablished,  thii<  obstruction  to  tbe  pul- 
monic circulaliou  liimiDisliee,  the  cardiac  cavities  become  unloaded,  tbe 
venous  turgescence  of  the  neck  subsides,  and  the  hemorrhage  proportionately 
lessens.  This  I  have  repeatedly  found  in  asphyxia  urtitiuially  induced  in 
animals;  and  1  have  olten  seen  it  in  the  huui«u  subject,  iu  casos  in  which  it 
has  become  necessary  to  open  tbe  windpipe  at  once,  without  waitiog  to 
arrest  hemorrhage.  Hence,  except  in  tho«e  instances  in  wbieh  an  arterial 
twig  or  large  veunut*  tnink  bus  been  wounded,  and  which  must  of  ooune  be 
■ecured,  the  occurrence  of  bleeding,  though  tolerably  smart,  need  not  doler 
tbe  Hurgeon  from  opening  the  windpipe ;  as  the  relief  afforded  to  respiration 
will  induce  a  corresponding  and  rapid  diminution  in  the  venous  turgefroence 
oi'  the  neck,  anrl  iu  the  consenuent  flow  of  blood  from  the  wound. 

It  is  iniportaut  to  bear  in  mmd  that  the  risk  of  bcoiorrbagc  is  not  entirely 
avoided  by  the  use  of  blunt  instrumcota.    The  veins  are  very  thin-walled 


OiPPIOULTIBS   AWn   AOOinENTS   IK   TRACHEOTOMY.      677 

ami  eaBily  torn,  ami  I  have  seen  very  tniu)>leti:)iii(!  ttleuiliii};  uauseil  iu  thU 
nay  hy  thi*  incAUtiuus  one  of  a  director.  Th<^  <]ifficiilLit»  amiu^  fruui  lieinor- 
rliftge  are  verj'  grontly  tncr^sised  hy  an  InEiiHuuent  inoifiioii.  There  b  eeli]<un 
any  trouble  iu  arresting  llie  blee<ling  if  the  wminde«l  vessel  can  be  clearly 
Been.  Sir  Spencer  WeUB'a  forcipreaeiire  forc<?(»B  will  be  I'lmml  irivfthiable 
under  these  circumstnDces,  as  the  vessel  can  lie  aeiaed  and  the  fun-eiw  left 
attached  till  the  operation  is  completed.  Hhould  blood  aociilentally  enter 
the  trachea  in  »aA^  ijunntities  a.;  to  ihrenten  911  tl'u cation,  it  must  be  ancked 
out  either  by  the  month  applied  to  the  tube,  or  by  an  aspirator  lube  passed 
down  the  trachea.  As  in  diphtheria  it  is  ertremely  flaiii.'eroHs  to  suck  the 
tube,  it  is  aJvl-table,  when  performing  tracheotomy,  always  to  have  an 
upirai4jr  at  hand  in  casc  of  nee<l. 

3.  Another  difHoulty  in  tmcheotomy  ftomctimea  attends  the  prncesa  uf 
Opesisg  the  Trachea  dfler  it  is  exposed.  In  consequence  of  the  convulsive 
breathing  of  \h^  patient,  the  stcrDo-moatoids  arc  put  upon  the  stretch,  thus 


Fig.  »7.— Tnoheirbooli  DirMtor. 

iDcreaeiac  considcnibly  the  depth  of  the  wound  in  the  ucck;  and,  at  each 
short  ana  gat^pirig  ^el^])i ration,  the  air-tube  is  rupiilly  jerked  up  and  down, 
appFunchiu^  to  and  receilin<^  from  the  surGice  iu  BU[-h  a  way  that  the  scalpel 
cannot  Imi  thruht  into  it  nith  »itVty.  In  order  to  do  thin  with  the  least  riak, 
a  ebarft-poioteil  hook  should  be  passed  between  two  of  the  riu^s,  and  the 
tnlw.  being  thus  fixed,  opened  by  cutting  upwards  (Fig.  75.1 1.  Or  the  hoiok, 
being  grooved  along  its  eoovcxitv,  as  Edwards  recommends  (Fig.  7.'>7).  is  to 
be  introdnccd  under  the  cricoid  cartilage,  and  the  air-tube  pulled  np  and 
opened  by  sliding  the  scalpel  along  the  groove  of  this  hook-director.    I 


Fi(.  TSS. — Cutttng  TfmIih-IiooIc. 

have  found  it  advantageous  in  uoine  case*  to  open  the  trachea  with  a  cutting 
h<iok,  such  OS  is  liere  repn-tuun-d  l.Fig.  758j.  Ky  iijeann  of  an  inHlruuieul  of 
this  kind,  the  trachea  i»  first  iixed  ai]<l  then  divided  withuut  danger  to  the 
putieoU 

The  ooiy  accident  likely  to  huppi-n  at  this  aCage  of  the  operation  itt  wound 
of  the  oosophagua.  ThiM  is  aviiidud  by  hleadying  the  wri.'it  on  the  sternum 
white  makiuk'  the  incision,  hy  drau-ing  ihe  trachea  well  forward  with  the 
sharp  hook,  uud  by  holding  thu  knife  hy  the  blade  s>i  that  not  more  tliau 
balf  au  inch  projects  beyond  llie  Knger  and  ihunih.  I  have  heard  of  a  cH«e 
in  which,  fur  want  of  theK«  |irecautii»n»,  not  only  was  the  oN^ophagus  wounded 
but  at  the  p'Mt-iiitirtem  examination  the  mark  of  the  knife  was  found  upon 
the  btHJics  of  three  of  the  cervical  vert«hrie. 

4.  .\fter  the  t^a<^hea  has  hpen  opened,  the  next  point  ia  to  Introdaoe  a 
proper  Tabe.  In  doing  this,  Rpecial  cnre  must  be  taken  not  to  pu*h  the 
lull*;  into  a  sort  of  poiich  which  always  exisU  at  the  lower  angle  of  the 
wound.  Itetwef-n  the  trachea  and  the  deep  fascia  of  the  neck.  Thijt  error  is 
Dot  only  cnibarraesing  in  the  highest  degree  to  the  .Surgonn,  but  dangeroua 
to  the  patient  by  the  delay  it  occasions,  by  the  coiuprc^ion  exercised  on  the 


k 


678 


OPERATIO.VS   ON    TUB    AIR-TUBE   AMD   CHii8T. 


trachea  litlow  tlic  opening  iolo  it,  niirl  by  ihe  surtion  of  \AonA  into  the  aper- 
ture in  tilt-  flirtubt'.  ]t  is  bc-*t  avuidcil  by  expanding  llie  Lracbcal  opening 
wilh  iho  flilttliir  (Fi};.  761 »,  oiul  paeaing  thp  tub*  lietween  the  hladea  of  that 
irBiruiiiCLi,  or  by  ailopliuj:  the  moihod  nlrcady  described  of  inwrting  the 
sharp  huidc  parallel  to  the  Liue  of  inriHiim  imtead  of  above  it.  Id  pitfwing 
the  luW  lull)  the  trachea  some  diflitiilly  may  W-  experieuc«d,  owiug  U^  the 
elaslioity  of  the  nides  of  the  iuciMon  in  the  windpipe,  in  conscqutfuce  of 
which  i>no  of  th«[ii  ia  apt  to  be  doubled  in  uii(l«i:  llie  end  uf  the  iuetruineDt. 
Tlii*  may  be  avoided  by  intnidiiclDg  the  ^Imrp  book  iu  ihe  inauiier  iletjcribed 
above,  or  by  the  use  of  Fuller's  bivalve  tube  introduced  clused  (Fig.  Tot)), 
and  then  expanded  liy  ulipping  a  oanula  into  it  (Fig,  760).  If  the  liugK  of 
ihi;  trachea  be  very  rigid  and  tinyieldiii^,  the  ailver  tube   may  must  couve- 


r. 


»».— BlTftlra  TiiVt 
d»Md. 


rig.  76«.— BivklTo  Tube  With 
CanulK  iBtrodnceil. 


Ifig.  TOI.— TncbtA-iUlittur. 


niently  be  introHuoed  by  expanding  the  incUioti  by  means  of  the  trachcn- 
forccps  [Fig.  761),  and  tlien  pauiug  it  between  or  under  their  blades. 

8ome  ^urgcoDB  prefer,  inetend  of  the  scalpel,  to  open  the  trachea  with 
cutting  forceps,  or  with  a  trocar  carrying  n  cnnula  in  the  shape  of  a 
trochea-tubc,  which  is  then  left  in  the  air-paaaage ;  those  initruments,  though 
ingenious  and  in  some  respects  useful,  do  not  npp^ftr  (o  me  to  be  so  snfe  or 
ea^v  of  niRtiat'cment,  especially  in  children,  as  tne  soal|tcl  and  Iruchea-hook. 

Trachea*tTibei  flhould  be  nf  euth  a  calibre  throughout  as  t«>  admit  pf  rea- 
piration  being  carried  on  through  them,  without  Hny  effort  on  ihe  [»art  of  the 
patient.  Many  of  those  that  are  tu  be  met  with  in  the  iuslrument-makerv' 
shop!?,  though  very  wide  at  (he  mouth,  are  far  ttto  narrow  and  contrscled  at 
the  lontr  a}>ertiire  to  allow  a  free  and  unimpeded  paasage  for  the  air  of  ree- 
piratton,  being  iiiiide  very  conical  in  order  lo  admit  of  easy  introduction, 
and  to  occlude  the  opening  in  the  windpipe  completely,  so  as  to  jirevcnt  the 
•otry  of  any  blood  by  the  aide  of  the  tube.  The  disadvanta^je  attending 
this  mode  of  construction  mav  in  a  great  degree  be  remedied  by  having  a 
longitudinal  opening  like  the  large  eye  of  a  catheter  cut  in  the  aide  of  the 
tube,  immediately  above  the  inferior  aperture. 

One  great  dithculty  which  the  Surgeon  has  to  meet  in  cnsee  of  tracheotomy 
or  laryngotomy,  is  to  keep  Ihe  tube  from  being  clogged  and  obstructed  by 
mucus.  It  is  nenally  slated  that  ihc  tube  mav  be  kept  clear  by  the  occa- 
sional introduction  of  a  feather,  of  a  piece  tt(  sponge  fixed  to  a  slick,  or  a 
hit  (if  lint  wrapiHid  round  a  probe.  In  this  way  it  is  true  that  Ihe  frothy 
mucus  that  collects  Jo  the  tube  may  bo  readily  enough  cleared      #ay  ;  but 


FOBHS    OF    TRACHEA-TL'BES. 


679 


this  Hmple  ueaDS  will  in  very  many  cases  be  found  to  be  quite  ineffectual  in 
removiDg  uiotber  kind  of  mucus  that  in  certaia  conditions  rapidly  accumu- 
lates to  a  considerable  extent  within  the  tube.    On  examining  a  trachea- 
hibe  that  bas  been  worn  tor  but  a  tew  hours,  it  will  be  found  that  its  inte- 
rior  becomes  gradually  lined  by  a  coating  of  dry,  gummy,  and  very  tena- 
cioua  mucus,  which  is  so  firmly  adherent  to  tbe  metal  that  it  must  be  de- 
tmched  br  means  of  a  peu-knite  or  |>oiiited  prube;  or,  what  is  better,  by 
pouring  Doiiing  water  through  the  tube.    This  tenacious  mucus,  collecting 
u  largest  quantity  at  the  interior  aperture,  and  at  the  curve  of  the  trachea- 
tube,  mar  olock  up  its  calibre  to  a  very  great  and  dangerous  extent,  whilst 
tfa«  mouth  of  the  tube  appears  to  be  perfectly  jwrvious  and  free.     Though 
SeatheiB  and  pieces  of  stick  armed  with  siwnge  or  lint  have  been  introduced 
from  time  to  time,  these,  passing  over  this  dry  mucus,  are  quite  unable  to 
detach  it  from  the  side  of  the  tube,  and  bring  away  merely  the  sputa  and 
more  frothy  mucus. 

Obie  ileviseil  a  very  simple  means  to  remedy  this  inconvenience.  It  con- 
mU  in  the  trachea-tube  being  made  of  uni'tbnu  calibre  throughout,  and 
kiting  an  interior  tube  accurately  fitted  to  it,  and  projecting  about  one- 
dgbth  of  an  inch  beyond  the  lower  extremity  of  the  outer  tube.  It  is  in 
IM  projection  of  the  internal  tube  beyond  the  lower  end  of  the  external  one 
tint  the  great  utility  of  this  contrivance  consists.  If  the  two  tubes  be  of 
ibe  nme  len;;th,  or  still  more,  if  the  innermost  tube  be  tbe  shorter,  a  plug  of 
nncQR  may  be  left  at  the  end  of  the  outer  canula,  ou  the  withdrawal  of  the 
buertube.  But  if  this  be  the  longer  of  the  two,  the  end  of  the  outer  tube 
will  beefibctually  cleared  every  time  it  is  withdrawn,  which  may  be  done  as 


'V- '(!.— TrMbek-tube,  Siil«  view. 


Fig.  Til".— Trnphea-tiibe. 
Krunt  view. 


Fit;.  70-). — Liir;n- 
g»3\  lube. 


''"W  as  an V  mucus  collects,  without  in  tbe  sliirhest  degree  disturbing  the 

P*ti*ol.    The  two  IiiIhs  are  fixed  by  means  of  n  button,  attufht'd  to  the  edge 

™  tbe  outer  one  (Fig".  7t>2.  7(>;i  >.'  The  biviilve  tRirbca-tulK;  ( Figs.  759, 

'oO)  ig  cnnstrurled  on  the  same  ]trinciji]t',  th<'  inrn'r  tube  bi-iiig  limgor  than 

Ueuuter;  and  it  po»s(-*<«'s  the  iKMitiimiil  aiiviintagi'  of  iM-inir  rwidily  re- 

Wural  fur  the  purp(»?os  of  cloimin;:.  and  as  cHsity  n-piacod,     AVhrii  us<'d  for 

■jj'ynpjtoiny,  the  tube  may  coiivniit'iitlv  be  nirviti  on  the  flat  (Fijr.  7ii4  t ; 

'Oe  liin^t  (liamrlt^r  l)pi»<r  lateral   iiisteail  <•(  aiilfni-[)iist('riiir,  thus  being 

***ptiii  to  the  form  nf  tlit-  aptTtiiro  in  tbn  cricn-ihyniiil  mciubraue. 

_   'i  sometinn'H  bapfteiis  that,  in  cunM-tiin-nci'  nt'  xhv  tube  hcciuiiirig  dotnohed 

J-,    *  the  filiield,  it  »li|xi  into  the  tracbca.  uIhti*  it  act:*  as  ii  foivi^rn  boilv. 

^^*f9  of  this  kin<l  liiivo  bo.-n  rchui-d  by  Walti-rs.  and  by  J.  \V.  Ol-'Ii-.     The 

lloval  (,f  jj|,j  tubes  wai*  etfei-led  liy  riieaiis  of  forceps.     For  tbe  prevention 

r     'Uch  an  accidt'Dt,  it  has  iK-eii  riiigi:est<-d  that  the  traehca-tube  should  be 

''**>e<J  in  one  i>iece,  inutead  of  in  two  pieces  soldered  together. 


ehMtDiky-tnlM. 


OPERATIONS    ON    THE    AIR-TOBB    AND    CUEST, 

When  a  inicliott-lube  bua  been  wurn  for  any  leogtb  of  tim^,  it  will  timM 
always  be  foiiiul  that  ulceralina  bas  taiceo  place  in  tbe  tracbra  at  kiow  jam 
M  tbe  refiult  of  pressure.  Tbc  discliargc  from  Uiia  al»niijD£  H)rbf*.ui 
the  iiicrcneect  fiecrclion  oaused  by  the  acoumpanjiu^'  irriutiuu.  ailil  matlf  ti 
the  difficulty  ex|ieripiiced  in  keeping  the  lube  frum  bc<!OQiiii{  ebMed.  T» 
overcome  ini-^c^  ditBcutlicA,  Murrnut  Haker  ha&  eroploTcd  a  tahe  awliri 
India-rubber,  siicb  aii  i.i  umhI  iu  tbe  iiinnururturc  of  the  lodia-rubber  orfiw- 
t«r.  It  ban  sufficient  rjjzidity  to  prevent  itx  OdllaiMiDZ,  btit  n^i  •ofGnMU 
i;ive  ri^  U*  irritation  or  to  eause  ub-erfltion.     It  is  to  &«  in '  -  '  nAtf  tht 

iirat  tweuty'f"ur  Injur*,  a  uiiver  tube  being  us«v!  iill  iben.  ■  iailific, 

i>ut  tbe  ease  witb  wbic)>  it  can  be  removed  nud  reiatnylui-M  u  an  fnM, 
ibal  tbere  is  no  diflit-utty  in  keeping'  ji  clean  ;  in  fact,  the  iiritailoB  f» 
duoed  in  s»  duing  i#  said  to  be  less  ibnn  that  caused  by  tbe  mmnval  of  tW 
inner  tube  uf  uny  urdiiiary  double   tracb«a-lu)>e.     Baker  bat  found,  fna 

cx|>erience  in  a  couiiiderable  uundier  of  ra#n,  lltti  it 
^^^^^^^^^^  is  worn  witb  much  gr«alw  cunfurt  to  the  pdtietii  ihaa 
A^^^^^kfH      u  tube. 

PI^^^^^BB  K.  W.  Purkcr  baa  pointcil  out  that  tlw  DlnntM 

^  caused  by  tbe  point  of  the  cuinula  is  in  gnat  — in 

^K  due  to  the  fact  tbnt  the  ordinary  qunrter-eircle  ta)« 

■  do  nut  correepund  witb  tbe  unlural  direction  ot  tkt 

H  traebea  ;  bu  bafi  therefore  derised  an  angular  tabvti 

V  (ivercume  tbiit  difficulty.     It  is  fitted  with  tfacmonU* 

collar  invented   by   Itoger,  of  Paris,   whtob  will  I" 

fiiunil  to  l]e  more  comfortnble  to  the  |mtieitt  liiu  ■ 

rik.'i<I  Hhiebl. 

Traclieotoniy  in  Children  h  never  eaav,  and  Is  at  timea  n  dangenoi  efott 
tioD.  The  dittieulty  of  the  operation  aruee  more  ftartirutarlT  in  infimuia^ 
very  young  cbil.lren  from  tne  ahortncM  of  tbe  ueck.  and  the  depth  •*! 
small  size  of  tbe  tracbea.  Before  the  age  of  ]iul>erty,  tbia  tab«  is  analti 
thickly  covers)  by  a  quantity  of  loose  granular  fat,  cttDtaining  maoT  niaa 
and  is  of  small  size,  ao  that  a  slight  deviation  of  tbe  inrisina  to  «m  ad* 
may  readily  lead  the  Surj^a  astray,  and  into  dangerous  pnutimitT  «iu 
the  canitid  arteries).  The  danger  of  lh«  0|M^ralii>n  re«ulls  fn.>ro  tb«  EiTf* 
size  of  the  venous  plexuses  in  cmoectina  with  tbe  lhyri>id  b«t«ly.  In  fr 
forming  ibis  operation  in  young  subjetis,  chloroform  obould  nlway*  b»  ti- 
ministered.  This  maybe  done  with  i^afoty,  even  tbutigh  Ibi-  mi«t  ar^i 
asphyxia  l>e  present;  tbe  tlitKculty  of  respiraliou,  beiui*  in  a  gmt  tamfo* 
spasmtKlic,  is  rclier«d  bv  the  aoiwtliettc.  If  L-hlun>f>imi  be  not  gtrsa,  ll* 
struggles  of  tbe  child  »-ill  seriously  cmbarmsB  tbe  I'liemt'ir.  Tbe  daag* 
and  difficulties  of  tbe  opemlion  are  avoided  only  by  nttmtioo  lo  tlw  aJri* 
already  given,  to  keep  accurately  to  the  middle'  line,  ti>  avutd  upcratfof  i"' 
high,  niifttaking  the  nyoid  boue  for  tbe  ponium  Adami,  Ut  nakc  a  ft*" 
«oough  incision,  and  above  all  to  avoid  nee<lle«  hurry  in  css<a  in  n^ 
asphyxia  is  not  immiuent,  and  to  do  tbe  operation  bv  a  csrrfiil  provtf  *" 
dissection,  rather  than  by  irregular  lemring  with  blunt  instninMBla. 

Comparison  of  Traoheotomjr  and  Larjngotomy.— On  comimring  tnc^ 
tomy.  as  ordinarily  pertbrmetl,  with  larrogolooiy.  I  think  tbera  no  ba  li*^ 
doubt  tbat  the  Burgeon  nhould  give  the  prefereocr.  in  all  OHi  wb0i  1^  *" 
practii-able.  Ui  (be  latter  operation,  on  account  of  its  grtalar  limptif**^ 
safety,  and  rapidity.  When  the  windpipe  ts  to  be  opened  for  tb*  estntf^ 
of  a  foreigu  body,  trachf^otl>nly  shoulrl  be  performed  in  piefertflw  to  If^ 
gotomy,  AS  the  latter  operation  does  not  provide  a  nufficicnl  openlag  ftir 
•xpolsion  or  cxiraction.  In  children  the  larnix  is  ao  little  derelopiid.  cf 
tamobeotamy  iqua  alvaya  be  done.     Iti  all  caiM  in  which  the  ofaatnicdai* 


COMPARISON  OF  TRACHEOTOMY  AND  L AB YXGOTOM Y.      681 


nspiration  is  produced  hy  tnflaniraatory  elTusion  into  the  i>ii)bmncoU!<  nreolar 
lUBUe,  or  flodema  glottidis,  wlietlier  dejiendent  upun  idii>[>utliic  or  prj-sipela- 
1008  laryngitis,  or  chronic  diwftse  of  the  larynx,  or  u[>oa  the  irritHtion  and 
inflanimalion  excited  by  swallowiuy  boiling  wRtet  or  the  stronger  acids,  in 
IDT  opinion,  laryn^^tl>Iny  h  ihe  operulion  tliiit  ulifniKI  he  preferred  in  the 
adult ;  and  this  upiijioQ  is  based  ou  the  following  reawjus. 

1.  A»  in  laryii^nitoniy  the  nir-tube  is  always  open  below  the  gi.«t  of  oh- 
ttruclion.  there  cau  be  uo  necesiity  to  make  uu  aperture  further  from  the 
seat  of  duiease.  lo  laryngitis  whether  that  afjectiou  assume  the  acute  or 
the  chronic  character,  the  ubstructiuu  to  breathing  is  iu  a  great  measure 
mechanical,  and  depends  upuu  the  iuGltrntiuu  of  the  submucous  are^^lar 
tissue  of  the  laryux,  and  partly  of  the  large  plane  uf  this  tissue,  wliicli  lies 
iM^hind  tbe  laryux,  and  whieh,  by  expaudiag,  as  it  were,  into  the  pharynx, 
obstructs  (leglutiliou,  hihI  atlerwunlti,  by  the  extension  of  this  swelling  and 
infiltration  to  the  lips  of  the  glottic  and  the  interior  uf  the  larynx,  causes  an 
iui)>ediiueut  to  the  entrance  of  ait  into  the  bronchi.  But,  as  has  htfcn  pointed 
out  by  Sir  Prcficott  Hewett,  this  subnuicous  areolar  tissue  terminates  at  the 
true  vocal  cords,  where  the  mucoue  membrane  hecnmes  directly  applied  to 
the  subjacent  fibrouB  structures;  the  Bwelling  and  consequent  mechanical 
impedinifut  are  hence  confined  to  the  limits  of  the  thyroid  cartilage,  and 
auy  oiK*ning  made  below  ihis  will  clear  the  lowest  limit  of  the  disease,  which 
is  always  accurately  and  aEmoet  malhemalically  bounded  below  by  the  vocal 
uorda.  Hence  an  aperture  iu  the  crico-tbyroidiuembmaeis  quite  as eflhctual 
aa  oue  in  the  trachea. 

2.  Laryogotomy  is  a  far  safer  operation  than  tracheotomy.  On  this  point 
I  need  scarcely  dwell ;  a  glance  at  the  anatomv  of  the  parte  concerned  will 
be  sufficient  lo  establish  it.  The  crico-thyrLti(i  membrane  is  nearly  subcu- 
taneous, and  no  parts  of  importance  can  lie  wounded  In  opening  it,  it'  we 
except  the  small  crieo-thyrfiid  artery  which  cr<««ca  it,  and  which  might  he 
cut  acroM,  but  from  which  I  have  never  seen  any  trouble  aris*.  The 
trachea,  on  the  contrary,  in  not  otdy  deeply  seated,  hut  covered  by  a  large 
plexus  of  bloodvcsaeU,  which  when  rendt^red  tiirgiil  by  the  asphyxiated 
condition  that  exi»t.s  when  an  operation  is  requtrefl,  pours  ivut  a  large 
quantity  of  dark  blood,  and  thus  fteriotmly  embarn(«4>«  and  delays  the  Surgeon 
at  a  time  when  the  life  of  the  patient  depends  on  the  speedy  admisaioo  of  air 
to  bis  lungB. 

3.  Laryngotomy  can  l>e  much  more  quickly  performed  than  tracheotomy. 
This  I  look  upon  as  an  inestimable  advantage  in  many  of  the  cases  requiring 
operation  ;  a  few  seconds  more  or  less  being  suHiciont  to  turn  the  balance 
either  in  favor  of  life  or  of  death.  The  rapidity  with  which  laryngeal  ob- 
struction— partly  mechanical  and  partly  from  spaem — sets  in,  is  sometimes 
•ogivat,  more  particularly  when  au  acute  intlurumation  superveneFinu  chronic 
disease  of  the  larynx,  that  life  may  be  cxtiuguished  before  the  SSnrgeon  has 
tiine  to  open  the  windpipe,  if  ho  endeavor  to  do  so  by  tracheotomy.  In 
extreme  oases,  as  where  tne  lunga  have  beeume  slowly  engorged,  the  action 
of  the  heart  is  already  enfeebled,  and  a  suddcu  spasm  occurring  at  the 
glottis,  will  at  once  place  the  patient  beyond  recovery.  But  even  though 
iuie  appear  for  the  moment  oxtiucL,  it  is  llie  imperative  duty  of  the  -Surgeon 
to  open  the  air-paesage  a*  speedily  as  poiwibie.  and  tii  endeavor,  by  means  cl 
artincial  respiration,  to  reiaill  the  tlickcring  fi|Mi.rk ;  and  It  is  impossible  to 
experience  a  greater  satisfhction  in  the  excrciiw  uf  our  profession,  or  to 
witness  a  greater  triumph  of  art,  than  in  thuii  nnatching  a  patient  out  of  the 
verr  jawa  of  death. 

An  objection  has  been  urged  to  laryngotomy  in  these  caets,  that  it  does 
not  allow  the  patient  to  wear  a  tube  without  much  irritation  being  induced 


632 


OPERATlOKa    ON    TllK    AtR-TL'»E    AND   CHXST. 


Tbii.  however,  I  have  not  found  to  be  th«  cam  in  mj  practiee.  I  hm  tai 
patients  who  bftve  voro  silrcr  tubf«  in  this  sitURtioit  n  oonsidenbk  ivaW 
of  years,  in  one  cote  a»  luauy  tut  twelve,  and  in  whom  no  ipeoiAl  urilHlaw 
hsB  l>evn  occasiutit^  by  tbviu, 

Tbe  coudiliuud  wliich  iivoe^aitatu  ao  u[>e(iin};  in  lh«  windpipe,  and  Um  4fitffr 
lion  u'lapte'i  to  i^cb,  have  bwn  already  jtivtu  i  p.  G72). 

After-treatment  of  Laryngotomy  and  Tracheotomy. — In  all  cmm  ifttr 


the  windpipe  h»s  btii'ii  opened,  tht*  nntient  ohoulU  Iw  pluc^xl  id  a  w«ll-iraf*nd 
nwm.  the  air  of  ^^bivh  niumhl  )>e  kept  luoJst  by  means  of  sicam.  A  Ab 
piece  1)1'  niu»lin  folded  two  or  thrat*  times  may  bu  laid  over  the  oftuafd 
the  tube  to  exclude  duel.  If  tbe  operation  have  Iweu  iNrrforiiieU  for  mm 
temporary  obstruction  of  the  glottis,  auch  ais  Uie  impactioo  of  a  foreign  Mj. 
tbe  tube  may  hv  taken  out  as  soon  as  tbe  cause  is  removed,  an]  the  wnai 
allowed  to  heal  by  granulation. 

Tbe  aj  ler- treatment  of  iraeheotomy  for  mejnbranoui  litrynff it  is  reqaina  apidll 
alteuiiou,  as  the  euccew  uf  ibe  operatiim  depends  ainiutt  eatireljr  upa  iL 
The  objects  in  view  are,  Ist,  lo  pmvide  a  warm  iimisi  aln)i*pb«re,  to  anirli 
diminish  as  far  as  possible  thv  ri^k  of  hroochitia ;  'ii,  tu  keep  the  tabs  d^ 
and  free  ;  Sil,  to  hu^tL-n  the  sejMinitiou  of  tbe  mcmbraoa  and  Itnrit  ita  txM» 
sion  ;  and,  4tb.  to  ramove  the  tube  at  the  earliest  pnnibtc  p^rioil. 

A  tcirtH  maut  aino^iJure  is  beet  pruridcd  by  plaeiD^  iKl-  cWM  to  a  W 
over  whiob  a  sort  of  tent  of  sheets  is  reared,  supportMl  l»y  jfircir*  uf  Islb  * 
iron  nitachcd  to  the  legs  of  the  bedstead.  One  side  «!'  t  hi«  it^'ot  mtut  W  hdt 
open,  and  ibniug^h  thU  opening  a  currt^ni  of  steam  must  he  intrudoml  ba 
a  kettle,  to  the  uoczle  uf  which  a  tin  tube  is  attacheiL  The  b*«t  appantoi 
for  ibis  purpose  ia  the  "croup-keltic,"  invuited  by  R.  W.  I'arker,  aW 
supplies  a  current  of  warm  air  mixed  with  the  steam,  thus  rlBcienllT  Bsit- 
taming  ventilation  as  well  as  warmth  and  moisturo.  By  il«  dm«m  tbe  KB- 
perature  can  be  easily  reKulate«l,  •>  that  ibere  u  little  rnk  of  weKkcnisf  ihr 
child  hy  over-heating.  2.  The  titbe  mtut  Ue  kept  r/m»i  by  freuueotlr  nass^ 
iug  the  inner  part  and  waxbiof;  it  with  warm  wattrr  nod  cleaitior  tha  bait 
with  a  feather.  If  it  is  caked  inside  with  dried  mucus,  this  will  be  naflf 
removed  by  a  solution  of  carboaateofaoda.    A/ter<'<  '   dsTth«MM> 

tube  also  may  be  removed  and  cleaned  once  awry  I^'  .r  houn.  tb 

ptttWDt  must  be  coosiaatly  watched  day  and  oiu;bt.  uuu  any  bhmk  tt* 
■ppeara  at  the  orifice  of  (he  tube  during  ctforts  al  voujjhiuK  louai  bavlH 
away  with  a  sponge.     -I.  To  hasten  the  tepamiiun  of  Urn  mwmkrmnt  wmikp* 


vent  its  extetmon  various  subeluices 


be  admiuistond  by  lahfttsH* 


Dtnl  iM  txletmon  various  subeluices  may  be  admiuntand  uv  mhUsw- 
Acting  on  tbo  theory  that  the  formation  of  the  membrane  is  dcpendcol  ;* 
the  micrococci  which  arc  invariably  found  in  it,  i{uiuine,  rsrhoUr  srti 
creasole  and  eucalyptuii  inliatationa  have  been  rcoommt^ndi'd.  QBWif 
acid.  i-renMtU*,  and  cuculyptns  oil  may  be  adminiMi-rvtl  by  midiu^  a  fr«  dmf* 
tu  the  wau-r  in  the  keltic,  from  which  Uie  steam  ut  being  aupplind.  t^uis^^ 
may  be  given  hy  mennet  of  a  xpruy  from  a  8iegel'a  appnralua,  the  aolBW 
qbmI  containing  abotil  four  graine  to  the  oiinoe.  tSi)lventa  may  be  OM^* 
the  same  way  to  soften  the  membrane  ;  the  best  of  these  it  cnrbooalo  utf  •» 
(gr.  XX  lo  ,^t.  lactic  acid  hIao  bnn  been  recomnumdcd,  but  it  dott*** 
Bccni  Ut  be  wiiK-rior  to  the  »*i«ln  JM«]iition.  Th(*o  auhslnnrv*  in  »pr«T  omi^ 
used  every  two  or  three  hours,  the  child  t>clng  wrapprtl  in  a  martaldaho^ 
at  (be  time  to  bv.iM  wi'iiinp  ihf  rloilic*.  It.  W.  Pwrkrr,  hdirvilMC  *^ J* 
oil  CMM-s  iif  mvnihmnoiH  Inrynj-itiji  the  rtiM*sSr  in  at  tir»t  Inrnl.  anfTlhatt" 
general  eympt»nis  are  doc  to  th<?  alwjrption  of  the  unb'  darf** 

the  liMnil  pntcj^fw,  iiiaiuls  very  stroiij;!)'  <jii  the  n9C«a»ity  of  f  I  .     inws*^ 

both  nt  thv  time  of  the  opomtion  and  afterwards.  Uefun-  ill^•  r  ■'.•:■  ihf  (■** 
bo  rvc>jniiiicuils  that  tiie  iueUiou  iu  the  trachea  should  hv.  Uuiu  v{>ca  *** 


683 

hooka  or  B  dilator,  while  all  lupmbrane  withiD  reach  is  rpmovpd  hy  mpans 
uf  a  fealher  wliich  lius  boon  previously  smiked  in  a  solution  of  carbonate 
of  nxitL.  In  ordtr  to  clear  ihc  larynx  llit  fcutbcr  may  be  passed  iipwarHii 
int4)  the  mouth.  Tbie  apparoutly  severe  treatment  ha»  in  his  hands  proved 
Tcry  successful,  no  fewer  thaii  8  out  of  16  casea  thus  treated  having  re- 
covered. 
4.  The  removal  of  the  tube  ahotild  alwayn  he  accomplished  ag  ncftn   ag 

Keihie.  It  is  otten  difficult  to  delcmiine  when  thin  can  l>e  xal'ely  done. 
■ny  tulieia  are  made  with  an  opening  at  the  upper  [inrl^  mi  that  the  patency 
of  the  glottis  can  be  aHcertaineil  hr  ]>la('ing  the  linger  over  t)ie  external 
npeoing  and  observing  the  efleet.  The  return  of  tlie  voice,  more  or  lew  jwr- 
fectly.  when  the  nuter  0[>enin]{  is  closed,  i^  UHualty  a  sipii  that  the  t»il«;  may 
l>e  »afely  removed.  In  rare  cases  there  ii>  niiich  delay  in  ;;vlliiiy  rid  of  the 
tube,  owing  to  a  |)erKi>itence  of  the  larynjjeal  ol«tnjcti(»ti.  Thi*  may  Ihj  iliie 
to  adhe»iune  in  (lie  larynx,  winch  may  be  brnken  down  by  an  inelniiiiient 
pwocd  iipwat^ie  from  the  uonnd.  In  other  oamea  it  seems  to  result  from 
paralyxis  of  the  laryngeal  muscles.  Cictilricial  ci»itraelii>n  in  the  cite  uf  thti 
opening  in  the  trachea  is  a  rare  eimiplicatiuu.  In  uiuat  cases  the  tube  can  be 
remuved  without  ill-ctlect  iu  about  a  week. 

The  f(«diug  <ir  the  patient  must  not  be  iieglecLed,  even  if  nmoidcrHhle 
pcrsuaaiiiu  be  necessary  to  make  tlie  child  KwulJnw.  Food  shoulil  he  given 
mhouC  every  two  lumrs,  and  eotl  soliils  will  often  he  taken  more  eueily  thiin 
liquids. 

.SUROTCAI.  OFERATtOKS    ON   THE  CHEST. 

Tappino  the  Plei.'ral  Cavity. — The  operaiiun  of  Tapping  the  Pleural 
Cavity  i^  ri't|uiret]  in  caees  of  hydroth<irax,  enipyeina,  and  h:emoih<irax. 
The  point  nf  wlertion  is  a  «pot  in  the  fifth  intereodtal  anace  on  the  laternl 
mclian  line.  Thi»  point  is  crn!»ed  by 'a  line  drawn  horizontally  round  the 
liody  fn>m  the  nipple  to  the  spine. 

As  it  is  (if  great  importance  in  cases  of  Ayrfro/Aomr  to  exclude  the  air  from 
the  pleural  hic  the  opemtion  is  now  almost  invariably  peiforraed  hy  the 
upirHCnr.  The  original  aspirator,  as  invented  by  Oieulaioy,  slightly  modified 
(Fig.  03,  vol,  i.  p.  '2.*i4  ).  will  he  fonnil  the  most  convenient  instrument,  as  it 
can  be  convertc-il  into  a  siphon  at  will.  The  ordinary  hoUle-nsiiirator  (Fig. 
766)  will,  however,  usually  answer  the  purpose  well  enougii.  The  air 
liaving  been  exhausted  from  the  hottle  by  means  of  the  air-pump,  and  the 
etu|>o<M'k  closed,  the  chest  is  lapped  in  the  way  to  bo  presently  dcKcrilx'd  with 
\hv  a^pirator-trocnr;  and  the  cock  in  its  side  In-iug  turned  ou,  the  lluiii 
rusher!  iritu  the  exhausted  bottle  tu  till  up  the  vacuum. 

Other  iustruments  also  hare  been  designed  for  the  purpuae  of  preventing 
the  entrance  of  uirdTiring  the  operation.  t)f  these  the  two  most  efficient  are 
the  " pistoit'lnoar"  i  Fig.  T'lT),  or  Thoiii]Mon'9  "glpli'jji-lrorar"  i  Fig.  7*»^». 

If  the  *'  piston-trocar  '"  (Fig.  767  )  be  used,  the  tap  ahoiild  be  cIo9<M  a.*  the 
stylet  ia  withdrawn,  and  nn  India-rubber  ti)l)e  attached  to  the  end  of  the 
canula.  The  lap  Ix'ing  then  opt;neil,  the  Huid  tlonq  along  this  into  a  vessel 
wiotaining  a  I  in  20  solution  ol  carbolic  acid.  If  the  sipbon-trfcar  be  used 
the  fluid  is  allowed  to  run  "H'  by  the  elastic  tube,  the  end  l>eing  in  the  same 
wav  imraeroed  in  »n  antiseptic  solution. 

In  the  absence  of  all  special  instruments,  the  chest  mav  be  safely  tapped 
with  n  common  trocar  hy  the  simple  method  suggested  by  Key  bard.  A  piece 
nf  thick  linen  or  cotton  rag  free  from  holes  is  nmdc  into  a  runnel,  the  nnr- 
row  end  of  which  is  tied  tightly  r*iiind  the  cnnula  inimedinlelv  below  its 
expanded  end.  The  funnel  \a  then  thoroughly  soaked  in  rarbolic  oil  (1  in 
10).    When  the  trocar  is  withdrawn  the  funnel  of  oiled  rag  hangs  dowu 


684 


OPBRATIOyS    ON    TUB    AIK-TUHK    XVU   OBSST. 


fruiQ  Uic  end  of  the  canula,  am)  turves  to  direct  the  fluid  ioto  a  t«m1UI 
to  rccE^tvc  it,  itnd  at  llie  sanit'  lime  it  furma  bd  efficittil  tkItc  wfaieh  pnntt 
the  pnlraDrc  ot'  air  duniif;  iuspirtttion. 

Whatever  plan  he  iirtoptcd,  the  aide  of  the  ebeit.  the  uperaLor'tf  lual^nl 
all  inslrumutitJi  uvd  rauAt  be  carefiillv  wfldhed  in  a  aolulKiD  of  eartkoficiai 


K" 


Fig.  T«a.— T>|ipii>g  the  CttMt  b;  Ui«  lloll]a.>«f.irKlar. 

(1  in  40).  The  lower  bonier  of  the  sixth  rib  is  then  felt  fur.  and  if  i  tmor 
is  being  used,  a  Hmnll  inoinion  may  be  made  thro(i)(h  the  akiu,  paralld  u  *• 
io  the  mid-axillary  line.  The  fioiol  choaen  should  cormpttiul  b)  ihm  inww 
between  two  digitnlitme  of  the  a^rratue  ma^nufi.  If  the  aapiralar  M  t"**! 
nted,  nn  inrtsiun  is  required.  The  «kin  is  then  drawn  tjpwnraa  till  tbvf*" 
choseo  in  the  akin  o>:irretpotidt  to  the  ttpper  border  of  the  rib,  and  tbi  f* 


Kg.  Tn^PUliMHlraau  for  Tap|>litf  tb«  CkmiL, 


of  the  trocar  U  theo  alippod  over  ita  maipD  and  tbnut  aharplr  and  i"^ 
inlo  the  pleural  mo,  so  aa  In  make  sure  uf  (tenotralinfc  the  ihidicnvt  f^J^ 
aor)  any  layer  of  falao  membrane,  which  if  tbt-  iiulrumcoi  wrrr  f^ 
aluwlr  on,  might  bo  thrust  before  IL     By  tliiu  pasiog  the  trocar  iiMnwM'v 


BITROICAL   TBKATMSHT    OP    EUFYBUA. 


685 


16  rib  any  risk  of  woundiop;  th«  iDtercoetal  artery  or  nerve  is  avoided, 
r  draviog  up  the  akiu  before  so  doing  the  Buperficial  opening  nnd 
the  intercoetal  muscles  and  pleura  do  not  correspond,  and  thus  the 
'  the  trocar  is  efficiently  closed.  After  the  withdrawal  of  the  caoula 
etare  is  covered  with  wtrae  dry  cotton-wool  and  collodion,  or  by  a 
adhesive  plaster,  and  will  usually  unite  without  trouble.  After  tap- 
B  lung  will  expand  and  fill  up  the  cavity  previously  occupied  by 

i  aspirator  is  used,  the  details  described  in  vol.  i.  p.  253,  must  be 
I  to.  It  must  be  remembered  that  when  the  vacuum  is  moderately 
^e  lung  is  being  expanded  by  the  pressure  of  the  atmosphere  witn 


Pig.  768. — Tftpjiicig  ibe  Cheit  bj  the  Siphon -trocar. 

■qnal  to  fifteen  pounds  to  the  square  inch.  This  may  possibly  cause 
iury  by  rupture  of  adhesions,  and  even  cause  hemorrhage  from  the 
.f,  therefore,  the  patient  complains  of  severe  pain  after  a  certain 
of  fluid  has  been  withdrawn,  the  operation  must  be  at  ouce  brought 
d,  and  repeated  after  an  interval  of  a  day  or  two,  if  necessary. 
mportance  of  antiseptic  precautions  such  ns  have  been  described 
Ten  in  a  simple  case  of  hydrolhorax,  is  very  great.  If  they  are 
arried  out,  tapping  may  be  repeated  several  tin)€s  without  evil  result ; 
lid  they  be  neglected,  the  hydrutliorax  is  very  prune  to  become  con- 
Dto  empyema. 

sal  Treatment  of  Empyema. — When  the  fluid  in  the  chest  is  puru- 
is  generally  acknowledged  that  the  patient's  chance  of  recovery  is 
41,  except  by  surgical  interference.  The  consideration  of  general 
m  indicating  the  presence  of  pus  in  the  pleura  belongs  to  medicine 
lan  to  lurgery,  and  need  not  be  discussed  here.     In  all  cases  of  doubt 


686 


Ol'KRATIONS   ON    THE    AIU-TVBE    AND    CRUT. 


ibe  JiagnoeU  may  bo  reiidtly  tuatlc  by  moflii^  of  Lhe  upiraUir.    TW  fitm 
of  pus  hariii);  bocii  itt^tcrniincJ,  ihLTo  dboulij  bc>  att  ilvlay  in  rtmenna^ 
Tlie  t«iU);«>r  il  is  Itft,  ihc  mnre  liniily  lhe  luug  be4.^aine*  bouwl  ilos*; 
odhmioiiti,  luicl  the  probabiiiLy  of  its  [icrli^ct  cx[nui»li>n  becomrs  \cm. 
uver,  the  ]iii9  mnv  burniw  twyonit  llic  limiu  nf  tlic  tilvunil  i-avitT, 
it»  way  tliiMnunnU  into  tlie  iliac  fnMa,  or  inure  rarrly  into  t)"    -<^''l  > 
cavity,  iirid  ibus  aitd  greatly  to  the  gravity  of  llie  on*-     tr. 
|>i>rii(»u  of  cft*e9  empyema  may  be  cured  by  aimpti-naptratkin.    It 
tlivrefore,  always  tuiitlempt  this  before  j>r>>c«e<lin};  (o  ifae  unerTit:<  <t    '    poi- 
iuj;  tlie  pitfura  by  aa  external  jttciisiun.     If  aRer  willidruwiDK  tb«  diii<  lit* 
U-tiiperAture  t'allit,  the  general  »yinpli>mt  improve,  aijil  the  fluid  rwicwB 
Iat«.-e  shiwly,  naptratiou  may  be  re)H-iite<l  with  nime  bupa  uf  •uooem    It 
iiutvever,  thv  relief  te  very  oli^'ht  aut)  teiu{xjrnry.  it  is  niavr  at  mir  tonfn 
the  pleuru  and  draiu  th«  cavity. 

Tliti  uperalioi)  'if  opeuiug  tlie  pleuru  fur  etupyeniH,  tboiigfa  ooe  uf  the  mm 
aiicit.'iil  Id  surgery,  whb  until  reevntty  so  UDUliBlnclury  iu  iia  raMilUtfat  d 
wuH  reanrleil  tti '>iily  in  the  liut  t.-xtrviiiity.  Tlieruial  result  Lbat  aa  frvquad* 
folUin-td  WH8  due  to  septic  fever  and  ]trul(iii^'ed  HUppuratiuo  niDsnamait  aptt 
iiii[K?rrect  drniiiBge  atid  dei.-xtmpueitiuil  nf  the  retmtiei)  Huid.  Wiui  Uw  rin 
of  prevenliiig  the  accumulation  of  pua  and  diminisibin);  tlic  rok  of  Mflit 
p(>iiH>t)iiig  GiHwltl'lhiw  mill  De  Morgati  adopted  llie  uoe  of  OiaaMictiut  dnm- 
age  tubed  witb  couuiderable  advantage;  but  it  was  auL  until  the  inlralaettia 
of  t-tiicietit  fliili;<epti<:  treatment  lliat  the  uperaii'-n  became  millT  mIi  aa4 
9Ucce<aful.  In  diacuMing  the  opemlitin  the  fullowiiig  point*  have  lo  he  aa- 
sideretl:  1.  The  best  point  for  making  the  o])eTiiiig;  2.  The  motbodof  mdtii| 
it;  3.  The  furni  of  tube;  4.  The  dreaeiing  and  aftcr-trr-atmeot;  A.  Tb  ft- 
moval  of  the  tube;  6.  The  resiUtj  ;  and  7.  The  wibsciucat  tnumtttdih 
cavity  i>houid  the  lung  fail  to  expand. 

1,  The  l/t'tt  point  for  the  openitiQ  'ut  the  Mibjcct  of  cnnfid.  r^ntttrf 

opinion.     Mauy  Sur^jeons.  lollowiii^  the  ordinary  rule  of  <<  *:  k)anv 

at  its  nioat  dependent  pan,  make  the  incitioo  ba  far  back  and    -  ■  » 

pOMible,  lhe  point  ehoeen  being  either  immediately  bektn  iir  a  ;  ^3t 

of  the  uoijie  of  the  scapula,  iu  the  seventh,  or  even  as  lour  at  tbc  niatliiaW 
oostal  apace.     The  advantages  of  this  Bitualioo  are,  however,  very  ■*  i^tfcl 

A  patient  stilferiug  from  empyema  usually  doei  not  lie  flat  upon 
but  incliued  towards  the  affecteil  side,  to  aa  to  allow  tbc  frccai  p(«»i'»*  i'-: 
for  the  Boiiud  Lung.     Au  o|<ening  in  tlie  mid-axillary  line  will  tharafcwW 
more  dependent  while  the  patient  is  confined  to  tied,  aud  at  IcaMWt^nOf  M 
when  hL'  is  iu  the  erect  nosilioa.     H'^reover,  tlie  ribs  (nwieritirtT  liatt* 
together,  making  it  difficult  Ui  in»ert  the  tube,  and  are  thickly  oaravdnillt 
luuselet,  neccsitiialiag  a  longer  incisiou  and  more  diioumfort  to  iJm  |iitM 
afivr  the  operation.     Another  nnd  niorv  aerious  ubjectiuo  b  that  at  tM  !■( 
expuoda  it  flrsl  Comes  in  ountiii-l  with  the  cheat  walla  puatcriorly.  ibt  M 
pleural  surfaces  mcetlug  last  in  rr>>nt  of  the  mid-axillary  line     An 
made  too  far  back  is  liable  t/i  become  curly  overlapped  by  the  eX', 
luug.  and  drainage  is  thu^  seriously  iiiterfured  with,  or  a  sinu*  difleall  t* 
heal  may  be  left  runnio;;  Tirw^ird^  tu'wdrdd  the  anterior  part  of  the  elMal.  I* 
HUMS  in  which  the  expantioa  of  the  lung  i^  imperfect  the  diaplirtgn  ■>? 
rise  up  and  obstruct  tlie  opening  If  it  be  mule  trMt  htw. 

John  Manhatl  hai  pointed  oul  that  immediately  outsido  and  bel««l^ 
junction  of  the  fifth  rib  with  its  rnriilage.  i«  a  point  In  th«  cbr*(  willf^ 
which,  from  the  oomiiamilve  absence  »f  auppijaeent  muM-Irt,  th«  p)is9 
but  slightly  sup]M>ried  citurnally,  and  through  ihi*  be  brlirvr*  an  enpytf  . 
teii'bi  naturally  to  point     Tbia  point  is  ab'tvc  the  origin  of  ttir  KXl(t>* 
oblique,  external  to  the  insertion  of  ibe  revlua  and  iaterool  Iu  the  ori|* 


SURGICAL    TREATHXKT   OF   EVPTBnA. 

the  iieiTHtUB  ma^us.  It  is  covered  by  the  outer  eJge  of  the  pectoriilia  niujor, 
anil  in  bvycjiid  the  anterior  limit  of  the  external  interciwtal  muscle.  Thai  an 
•pipyema  may  pertbrate  the  chest  at  this  Bpot  ifl  UDdoubted,  hut  accnrding  to 
iD(«t  aiithorilieii  it  teuds  to  point  higher  up  in  the  ikcoikI  or  third  space. 
Uarehall,  arguing  fmni  the  excellent  requite  that  usually  follow  the  opeuiug 
of  au  empytriuu  poiiiling  in  front,  euggeets  that  the  npeniug  should  iilwaye 
be  made  oo  the  thio  pxint  above  nienuoned.  The  only  objection  to  this  in 
that  the  ribe  are  ^mic^vbiit  cl()^«r  tog^lher  here  than  they  arc  a  little  i'urtlicr 
back.  The  liictb  udduced  by  Mitr^htill  may,  however,  be  said  to  demonstrate 
that  openings  mudc  far  back  and  low  down  do  not  present  the  advHuiagrs 
usually  a»!<ii!ncd  to  ihuiu,  and  thuL  Ltctcr  results  will  prolmbly  be  nltnincd 
br  Diakiug  the  incieioit  mure  nearly  over  that  )>art  of  the  cavity  which  itt 
tuc  last  to  bo  closed  by  the  ez|mueioa  of  [he  luu^'.  The  space  bc-iweeu  tjic 
filth  and  gixth  ribs,  an  inch  to  an  inch  iiiid  a  halt'  in  iWmt  of  the  iiiid-axillay 
line,  will  probubly  be  liiund  iliu  hei^t  iit  uioki  cases.  The  ititcrvul  bctuccn 
the  ribts  is  wide  enough  here  to  admit  n  large  lube  readily,  the  co\'oriiig  of 
toil  purls  is  not  too  thick,  and  the  druinagu  obtuJned  is  efficient,  and  there 
is  liule  risk  uf  the  opening  hecuming  obittrurtcd  cither  bv  the  etpundiiig 
long  or  the  diaphragm.  In  cnsca  of  localized  empyema  the  inciaiun  must, 
of  cour«*,  l»c  made  over  the  collection  nf  pun. 

2.  The  mftkad  of  ttptraiiiiff.  The  operation  should  be  performed  with  the 
■irictedt  Mnti.Hcpiiir  precnkitionn,  including,  if  po»$ilde,  the  carbolic  spray, 
which  ailds  greatly  to  the  certainly  of  preventiti);  putre^iction,  as  it  is  almost 
itaponiblc  to  prevent  the  entrance  of  air  during  hispinilion.  tf  the  opening 
ia  made  in  the  fiflli  jtpace,  it  Li  not  necpsiiary  in  ordinary  rafter  Lo  remove  a 
nurtion  of  a  rib.  The  ini-iniiin  should  be  made  about  an  inch  and  a  half  in 
length  p:trallel  to  the  upper  border  of  the  ,«ixth  rib,  exposing  it  clearly- 
Any  supi-rtiviul  vrasvl  that  hiecdo  may  then  he  svuurvd.  The  iutercoslul 
iDUSctvi)  nud  |>]euru  «re  thcu  punctured  with  tiie  scalpel,  guided  by  the  left 
forvGnger  iu  the  Kuuud.  iiumi->liHlely  iihuve  the  rib.  so  as  tu  avoid  the  inter- 
cvctal  artery.  The  blade  of  the  kuife  must  be  [Mirallvl  tu  the  rib.  A  pair 
of  drvi9siu'^-tbrcc[is  may  tbeu  be  introduced  and  the  wouud  etrutchud  by 
clpHudiug  the  blades,  after  which  the  tube  may  be  at  once  lUBerled. 

If  the  opening  is  luiide  further  back,  or  IE,  from  |>artiai  absorption  of  the 
6uid  part  ui  ihe  pus,  the  ritm  have  falleu  together  so  as  lo  leave  an  iiieuffi- 
cieot  space  for  tiie  introdueti'Hi  of  the  tube,  a  piece  of  the  rib  muet  be 
removed.  Some  Surgeons  prefer  always  to  remove  a  portion  of  rib,  aetiertiug 
that  by  this  means  a  lietter  opening  is  provided,  but  in  the  mujonty  of  cases 
it  dues  not  hcem  lo  be  neceMary.  Should  it  be  required,  the  iiperation  is 
thus  perlitrmed.  An  incii<ion  from  two  to  three  inches  lu  k'Dgth  ia  made 
directly  upon  th«  rib,  the  i^erioateum  of  which  mnt^t  be  divided  in  the  long 
axis  of  the  hone.  The  wound  is  then  held  wi<lely  open  with  the  blunt  honks, 
aufi  the  perifK^teum  stripped  from  the  exposed  part  of  the  rib  with  an 
etevntor.  which  must  not  be  too  sharp.  I*>'o  difficulty  will  be  founil  in  turu- 
iog  the  intercoi^tal  artery  out  of  its  groove  at  the  lower  border.  A  curved 
elevator  or  a  bKmd,  tial  direclor  is  then  passed  completely  under  the  rib 
from  below  upwards,  ami  the  bone  divided  in  two  places  with  a  saw  or 
properly  constructed  bone-forceps,  and  about  one  inch  of  its  leogth  removed. 
The  iileura  should  not  be  wounded  up  to  this  stage  in  the  opiratiitn.  All 
blceaiug  having  been  arrested,  the  pleura  may  be  opened  and  the  tube 
in!ertc«r  If  it  be  preferred,  the  oj^ralion  may  be  |>erfiirnied  by  a  T-»baped 
incision,  but  this  ut^ually  presents  no  udvanln^'c  over  the  simple  longitudinal. 
The  removal  of  a  pleeu  of  rib  is  not  accompanied  by  any  difteuky  or  dniiger. 
Nccr.rtia  rarely  fallows,  not  more  often,  ap[»arently,  than  after  the  simple 
insertion  of  a  tube  between  the  ribs.     Kew  botic  rapidly  forms  from  the 


1 


688 


OPERATIOKS   OX   THE    AIR-TVBK   A^U    CUK9T. 


I 


perioKtcimi,  aurl,  nftcr  a  time,  the  c-ontinriityuf  the  rib  is  rcf torrtl,  (u»l  mi^^ 
tinii^  a  n)]i»8  ol'  buoe  5118  the  iutercdslHl  »f>act«.  The  niwration  tumy,  \^*t* 
fijrv,  Iw  uudertaken  without  hetitatioD  whenever  it  seema  lit  offrr  llw  aliilMI 
sdvanUge. 

S.  The  Tuhe,  The  orciiimr}-  ludia-ruhbcr  (lmiiinge>tube  kbould  ktW*!, 
but  care  uiuat  be  taken  thai  ihere  i*  no  b«l«  iu  Ihe  j«irtc"r"-'"-'"li"/'"lW 
cheat  wails,  as  gnmulatiuiis  are  apt  to  eproul  up  into  i'  'W 

lumeo.  Il  must  bo  provided  with  a«hiel<l.  le»l  il  slip  into  (■"  ,■ 
The  best  iurtn  is.thul  suggested  by  K.  B.  Baxter.  It  is  thus  i 
the  middle  ut'u  piece  ufahett  liidiB-nibber.  about  a  sixteenth  vi  ml.  incd  luxi, 
and  one  inch  and  a  hall'tu  iwu  iuclits  B<juar«,  a  ruiiud  hute  is  cut  urtbeowt 
iiw  ai  the  drainage- til  be.  The  lube  ia  theu  [HUued  tbruU){b  for  ft  sufficRst 
diit&uce,  and  sjilit  iuto  tuur  jiie<.-eB  ttulTicitiiily  luag  lu  reach  to  the  fmt 
coraerB  uf  the  shield,  tu  wbidi  they  are  nttarhed  bjr  mlver  wirv.  Tk* 
remainder  ol'thu  tube  ua  the  other  bide  of  the  shield  muet  have  bulncutie 
it  at  ioicrvaU,  as  iu  an  ordinary  drainage-tube.  The  tulw  must  vmr^  ia 
diameter  with  the  aiw  of  the  palient.  It  slmuld  alnnys  be  nit  Imrve  aicu 
oonvenieiitly  be  paased  initwcen  the  rib»,  but,  as  the  dUchar^'  itmaa,t 
smaller  eiie  may  be  subtstituted.  It  need  never  be  mitrc  than  t«o  or  tJm 
ioches  in  leuglh.  Mothing  ia  gained  by  putting  eight  or  nioe  'mAmttoim 
into  the  ptoura;  it  caoDut  dUck  the  fluid  uut,  aud  nnty  caiMs  Mfdhs 
irritjitiun. 

4.  The  drttinff  and  afier-iraUment.  The  mMl  officieflt  drcMioff  h  cuiA 
gauze.  Should  it  cauiu!  irritaiinu,  eucalyptus  gauxe  may  be  aBoitlmrtfa 
iC    Should  this  not  he  at  band,  nn  «tflcivut  abior^  :  .       Vaul> 

of  aalicylic  nr  ii»do form- wool,  card^il  •lAJtum  nr  <-  :  'tA  «itk 

a  piece  of  oile^l  silk,  nr  some  other  ini]x;rni<  il:.  inituiial,  i.>  I'fcVral  lis 
discharge  from  Auaking  Lbrough  too  «>>on  m[i|>  -h-  (io'  wound.  The  drt^^g 
should  be  conducted  under  the  carbolic  sprHv,  but.  il'  tbi*  cauu<it  beiltWi 
the  entrance  of  impure  air  cno  b«  prevented  with  a  little  cuv.  by  cuRritf 
the  opening  immediately  with  a  piece  of  rag  •oake^d  in  some  autiMptic  lib- 
tioo  as  the  drawing  ia  lemovcd.aud  draniog  it  out  again  froai  uodwUtt 
fVesb  dressing  as  it  is  applied.  For  the  iint  liiw  days  daily  drssrinp^ 
required,  but  the  iolervala  may  bo  gradually  iuetvaced.  It  is  seldom  a<ln*' 
able  tu  leave  it  for  mure  thao  a  week,  even  if  uu  diicliargv  appeanatlte 
edge.  Iu  ordinary  cases  uotbiog  is  gained  by  washing  out  Ihs  eavitf  ^ 
auiieeptic  nululious,  a  proceeding  which  has  tieeu  known  to  cauMi  smlila 
death  in  more  than  ou«  caao,  an  aocideoL  the  ctiuaa  uf  which  is  tjuiu  i^ 
known. 

r>.  The maova/ o^ Me ht&e.    The  tima  at  which  the  In'  id  bt  rtaon^ 

ia  oiVen  a  difficult  point  Ut  dotcrniino.     When  the  d^-.  ..  c^oia  |)antf 

serous  and  vury  small  in  amount,  the  tulu^  may  iit  lirsi  U-  ohurlenad  till  <l * 
juflt  lung  enough  to  retain  its  po«sitio».  It  b  th«n  olWii  fnrtwd  otx  kj  (^ 
gnuulations,  or  by  the  expanding  lung.  It  ia  well  (o  •xarainu  th«  <ai^ 
oarvrully  with  a  prdw  bclort;  removing  the  tube,  ns  the  apacn  anclnadM 
be  larger  than  would  be  Hupp>HU-d,  from  the  amount  of  duthar^  &  Ml 
as  n  distinct  cavity  remaiim,  the  tulw  »houhl  he  rrtatnrd.  I-  --t.-iit"-"  a|^ 
cially  if  the  opening  has  not  been  deferre«l  too  long.thn  w<  '  ■* 

allowed  tn  clu«e  alVer  about  a  month.  In  adults,  in  whuot  •-t.^<.%>\-.-t>  «>  -^ 
lung  is  oflen  IcM  perfect,  and  wh<i«e  cbo't-wnlUare  tiMi  rijod  tusink  tB,>>'f 
iDODths  usually  elapee  before  the  cavity  is  cloM^tl.  and  io  sotnc  nantsoH'*' 
rMfiverr  never  takra  ptucu.  Long  niousts,  wry  in>ublt*oai*  to  httl.  an^ 
casioually  left,  Tbew)  rommonly  arise  l'n>m  -ijieiHug  t"*'  far  Ixiek  uf  losl** 
down,  or  fruui  the  pruloogud  rutentiou  of  tubis  of  m-MJttsa  leugtK. 

0.  The  rent/iEs  of  the  operation  for  empyema  are  usually  as  ■atJslatiuiy'** 


flTIES. 


* 


u  tliey  were  formerlj  unHttUfartorr.  In  chilitren,  ftipecifilly  if  tlie  lipalth  U 
otherwise  good,  ivcuvfry  is  the  rule.  The  temperature  falls  )mme<1late]y 
after  tlie  op^rniinn,  und  iinlfss  some  cnniplication  occurs  «el<loiii  ri^es  syftin. 
If  the  nperalion  be  not  too  long  <I<-1ati*(I,  complete  «rx|>9iiitiiun  of  the  lung 
usoally  takes  place.  Thi«  is  tHect«>]  by  the  gntdual  udhe»iou  of  ihe  twu 
pleural  8nrfao««  to  each  utiier,  cuiuiueuciug  iu  Lue  augle  of  rvtlectiuu  Irum  the 
cbe»t-wnll8  |4>  the  liiug. 

Oj>eratiuu  fvr  empiftma  without  antittptic  precimtiona  may  occaiiiouBlly  be 
nece««iiry  when  the  mvaus  uf  proper  (rtfaliueut  an:  uot  ubrtiiuublu.  The 
Surgeun  oiiiBt  then  ruly  va  (nvAom  of  draiuuge,  by  ivfaich  it  niuy  he  possible 
»d  far  to  reduL-e  the  ({uautity  of  dvcumpueable  matter  io  the  chi>st,  that  the 
dwv  of  septic  pntduclE  uLeorbed  by  the  patient  ehall  nut  be  suflicieat  tt^>  cause 
KriouK  e"n&titulii<nul  dlsturbaace.  Thiu  nbject  is  beat  attaioe*!  either  by 
biakiog  II  free  incieinn  «>mc  inches  in  lengih  betneeti  two  ribs,  or  by  the 
insertion  of  two  tubes,  one  in  the  or^linary  tiiuatioo,  and  one  at  the  lowest 
posaible  point  in  the  pleura.  The  second  opening  way  be  made  upon  a  curved 
pnibe  passed  in  at  iha  up|ter  wouud. 

7.  In  coses  in  which  the  cavity  coDtinuea  ofLer  many  moolli^,  or  even 
MS,  to  discharge,  showing  nu  signs  of  diminieliing  either  by  cuntraclioii  of 
the  cfaestrwalls  or  expBtu>ion  of  the  lung,  the  operniiou  of  division  of  the  riba 
corresponding  to  the  unclosed  space,  or  of  removal  of  an  inch  or  more  of  hone 
from  each,  has  been  often  attended  with  satisfactory  resulld  iu  ninny  caecA. 
The  operniiou  can  be  done  ns  already  dcscrihcdj  portions  of  two  ribs  being 
removed  from  each  incision. 


^raus. 


TAPPIM)    PUUHOSARY    CAVITIES. 


The  openition  of  tapping  vomlcte  in  the  luugs  in  phlhisirid  pntients  could 
Cut  b«  duue  with  cerlaiuly  luilil  the  diiigutieis  of  the  existence  auci  precise 
■eat  uf  Buch  cuviliee  could  be  uccurattily  determined  by  auscultation;  for, 
prior  to  X^mnec's  time,  the  physician  could  uot  diiifcnose  u  pulniumiry 
Cftvity  from  a  circumscribed  empyema  coiuniuuicating  with  the  lung.  Hence 
ibe  aceuunis  of  such  an  operation  given  by  the  older  writers  on  medicine  from 
the  days  of  Hippocrates  down  to  the  present  century  must  be  received  with 
scepticism.  Hut  that  the  idea  had  suggested  itself  at  an  early  period  to 
medical  pracliuoners  uf  treating  pulrnouury  cavities  by  incisiuD  ur  tapping, 
there  can  be  no  doubt;  for,  i\iihoui  going  tmck  to  the  earlier  medical  wrilerv, 
»e  hud  Dr.  Ihirry,  iu  1727,  recommending  that  phthifieal  cavilie!<  should  be 
opeuetl,  \(i(h  the  view  of  giving  a  direct  exit  to  the  combined  miitter[<,  and 
thus,  hy  avoiding  violent  jmroxysms  nf  cough,  that  the  purls  may  be  kept  ut 
rvet,  and  be  more  likely  to  undergo  a  cure.  The  prop'usnl  rcccivetl  little 
altenlion,  and  the  practice — if  ever  adopted  by  others  than  Barry— died  out, 
until,  in  ]fiiiii,  it  "nas  revived  by  an  empiric  of  the  name  iif  Kiirnadge,  who 
appear?  to  have  Tflp[x.'d  the  chei^t  on  several  ocension^  in  order  Io  lei  out  pua 
from  4^nvitie8  in  Ihe  lungs.  In  \ii4a  a  most  abl«  young  burgeon— Slorks — 
performed  thi>!  operation  with  i^ucceas,  and  with  advantage  to  the  jiaticnt,  in 
a  ease  of  Dr.  Hn^ttiiigs.  Htorks  opernleil  by  makioe  a  long  incision  upi>n  the 
upper  border  of  a  rib,  and  then  op'i-ning  up  the  cavity  by  means  of  a  pair  of 
forceps,  inserting  a  caiuila  to  allow-  of  the  cscope  of  the  contenta.  This  case 
attracted  little  attention  at  llie  lime,  and  the  operation  again  died  out.  Of 
late  yeai-s,  howevfr,  it  haa  be*n  revived,  and  Mowler,  of  Greifi(wa]<I,  has  been 
more  especially  at^ive  in  m  resuacitution.  Moslcr  not  only  tapped,  but 
iajected  the  cavitien  with  disinfectant  eolutionj. 

In  A  case  of  Dr.  The*Miorc  William*  I  operated  by  Siorka'a  mctho«l.     The 
patient,  a  gentleman  21  yean  of  age,  had  an  enormoua  cavity  at  the  base  of 
vot.  II.— 44 


6flO 


OPBRATtONS    ON    THE    AlB-TlTBK    AND   CHXST. 


Ui(!  Wi\  lung.  The  discharge  from  tliin  kha  nut  nntr  profnae,  bM  mm 
horribly  ot!4>Dsive;  the  paLiRnt  being  unnble,  eVfU  by  ihe  inu«t  violtni  tui 
couliDtietl  ptiroxyunfl  or  couj^b,  to  empty  tbe  cavity;  a  l*rK*  quftlHilJ  4f 
decompoAe^l  miico-pus  was  alvrayA  pren^nt  in  it.  I  niadr  nn  iofjaioe  lA  iht 
upper  bonier  of  Ibe  aeventb  rib  in  the  la tf  ml  nir«ial  linr.  aod  patlitwk 
Urge  trocar  and  caniila  thtxiugh  the  mxIIi  iiitercn«lal  s[>aFe^  pntionttA  «it^ 
difHctilty  ftome  very  condensed  ttioue,  probably  thick«ued  (iK'iira  ■»>!  fibnni 
luop,  and  then  penetrated  the  cavity.  Jffnrly  two  pialit  of  roi:-  •-  tm 
dbcharfred,  aud  the  puticnl  derived  ^reat  relief;  the  eolith  di';.  mj 

iheu  entirely  diwtnja-ured.  The  cavity  was  waelied  out  with  dmnr  >."(mt'< 
fluid.  IiDiuediatifly  on  lh«  cavity  being  opeueil,  a  limited  pocumuhnm 
folli>wed  by  exleu»iv«  subcutaneous  etupby&enia.uccurrcd.  but  gnwtmtov* 
trouble  at  any  niunietit-  Tlii8  was  doubtlew  owiatc  to  a  {-•rlioo  nf  »>•■ 
adherent  plvurti  Imviuji;  l>e«u  iterfornted  at  tbe  Bpotetlecloi  '  . 

Tbe  patitut  was  ^Teutly  benetitvd  by  the  0|H;ratiuu.  uud  U\- 
ailer  ia  oumpamtivu  comfort. 

Dr.  repi>er.  of  rhiladelphia,  who  hoa  publbhed  an  esbfttnthre  uticbM 
this  Hubjert,  adoptn  a  difffrviil  pnH-eduri>.  He  tai»  the  rumioa  with  a  nail 
uinulu  uud  trocar  titted  to  a  syringe,  and  inje<-U  the  mvity  with  dUntii 
tincture  nf  iodine.  The  reeultsuf  hiapracttoe  have  iu  roaa/  ouai  bccaTs; 
encou  raging. 

Operation, — When  the  pulmonary  cavity  ii  def>ply  Heated,  more  myrBJally 
if  biigic,  the  operation  may  be  conducted  aa  follows:  Ad  aspirmttir-flfeikar 
sufficient  size  to  i>erniit  the  pasange  of  thick  pus,  having  been  thnnt  l^u^Q^ 
the  intercostal  Bpaci:,  opposite  to  the  scat  of  the  suppd^vtl  ntMocM,  will,  if  tC 
penetrate  the  onvity,  inmcate  by  tbe  eacape  of  pus  that  thi«  has  been  mcM. 
A  horiximtal  incision  nbout  two  inches  long  i«  then  niniii>  in  the iakfMltil 
space.    A  fuU-«izcd  flat  trocar  (Fig.  7i«i))  u  then  thnut  through  tbefdemttrf 


<^ 


Ft(.  T<ff.— TrovM  f«t  Tapianf  P«laMS«i7  Cktiltw. 

pulmonary  lieaue:  the  Bspiratoriieedlp,  whirb  boi  flenr«d  u  ft  guidf.  bo>l 
witlidrawu.     The  fnuula  of  the  irucnr.  of  silver  or  vulouiile,  ihoold  fc>n  * 
bmad  pliitc,  by  u  liicb  it  may  be  fasiencd  by  nrinpt  and  plaster  to  tbeckf^ 
wall.     An  free  drainage  of  the  cavity,  more  Mpet-iallv  if  it  be  buici**^ 
main  object  of  the  ofierntion,  this  may  be  aecured  by  le«viog  tbe  cmaolt  *" 
tbe  wound ;  or,  if  this  be  loo  short  lo  servo  as  a  free  drain,  il  tuay  bs  w^ 
drawn  and  a   rigid   tube  of  some  kind  rabsllluteil.     I  have  found  sfil*' 
fixed  dexible  proiiutie  catheter,  cut  of  proper  tenglh,  to  bo  the  m<M  v*^ 
Bbould  it  be  neccMury  to  o[ien  up  tht^  lu«g  vtilislautt.-  more  frMly.th* 
may  he*t  be  dune  by  nicanii  of  drCNiing  forcefw,  im  in  Hilton'*  plan  atf^f^ 
iog  deep  alM)re«t(«.     There  will   be  )e«o  danger  nf  bemtrrhagT  ihaa  u  * 
•cal|«l  be  UM^d.     No  nntiseptic*  are  nrt^led  when  the  oinl^ittJi  of  the  ttn^J 
are  alretuly  decompn«iog  ;  free  drainage  is  all  that  is  rvtiuimj ;  and  all*'' 
tiaeplics,  if  injecteo,  irritate  the  bronchi  and  luDg. 


TAPPING    TRK    PERICARDIUM. 


691 


W 


Should  empliyserua  occur,  as  I  have  seen  hap|)«n  very  extetisivcly,  at  the 
time  or  ll)«  o])er».tioD,  DC  apprebeusiuu  ueed  uri«e,  as  the  air  will  be  aUeorl>ed 
in  the  usual  way. 

If  the  iutercostal  space  is  too  oarrow  to  admit  the  trocar,  a  piece  of  rib 
BUT  be  removed  by  the  method  already  described. 

Tapping  tuk  FiiidLAitDiUM. — In  hydroi*  [iwicardii.altuudetl  with  iriiiiu- 
iKUt  daiiK^r  of  iJvutb  from  pressure,  il  »vill  be  uecrssar^'  to  tap  the  pericar- 
dinia.  This  uiay  be  liotiv  by  uiitkiiij;  uu  iiiciaiou  abuitl  halt'  au  iuoh  ju 
leti^h  through  the  akiu  and  aruulur  liseue  in  the  fitlh  iutt-rcustal  E[jacti,  in 
the  cardiac  rtgiuu,  utid  thi-ii  slowly  and  curelutly  iulroduciug  a  tine  triH-'ar 
at  that  poiut  where  percussion  and  autcultatiou  have  JndiciLtixl  the  greatest 
amouat  of  tiiiid.  The  trocar  ahould  be  passed  oblii{uely  ;  and,  as  souri  as  it 
appearv  to  have  vnlered  tlie  pericardium,  the  atylet  shoidd  be  bheuthed  and 
the  cauula  pushed  fumvards  until  the  serum  escapee. 

The  o[»eratiup  is,  however,  much  more  safely  done  with  the  aspirator. 
From  exju-rimente  made  on  the  dead  body,  Dieulafoy  i-onchules  that  it  may 
tie  performed  in  the  fuiirih  or  fiflh  lefl  interepnce.  the  titYh  heiiig  perhajw 
ipreferable,  as  il  Ib  nearer  the  apex  of  the  heart  and  i?  a  more  de))endeot 
Ntuatinn.  The  puncture  may  lie  ma<le  from  2  to  2^  incltef  from  lliC' left 
nargin  of  theeternum.  The  spot  having  been  aeleuted  atiould  be  nmrki^Ki 
with  ink.  If  the  [>atient  be  uuasarcoua,  the  interapace  must  be  determined 
by  carefully  pre^iii^  away  the  a'dcnia.  The  needle  to  be  employed  should 
Vary  with  the  case.  If  the  diiigunsi?  be  certain,  No.  2  (one  millimetre,  or 
roujfhiy  v*!;  inch  in  diameter^,  should  be  used;  but  if  the  dia^osift  liv  uu- 
certain.  Ao.  I,  half  ihid  bikc,  should  be  choacn.  ns  with  this  needle,  it  is  said, 
'the  heart  may  be  punctured  with  impunity.  The  best  form  of  aspirator  to 
nee  ia  one  such  us  is  rcpreacnted  in  Fi^'.  03,  as  needles  of  such  small  size  are 
t  to  be  pluf^^^l  writh  ttmall  flake*  of  lymph,  and  if  such  au  accident  (K^cl■r, 
ley  may  be  cleared  a};ain  by  reverain^  the  ayrtn^e  and  forcing  a  small 
luantity  of  fluid  bnck  into  the  pericardium.  Before  using  the  lupiralor,  it 
louh)  be  carefully  testerl  with  Home  carboHzed  water  tn  render  it  aseptic, 
and  to  see  that  the  needle  is  [wrvioiis.  and  the  whole  apparatus  in  unrking 
order.  A  vacuum  having  been  created  in  the  aiipiralor  by  drawini;  iMick 
and  6xing  the  piston,  the  needle  is  to  be  inserted  at  the  spot  determined  on. 
»xtn  as  the  opening  at  the  point  of  the  needle  is  onverfd,  the  8topcock 
leading  to  it  is  to  be  o]>ened,  so  that  the  vacuum  extends  into  the  ueeille; 
d  "  we  now  ndvaoce,  vacuum  in  hand,  iu  search  of  the  eflusion."  The 
e<lle  must  be  pushed  sluwly  and  carefully  onwards  iu  a  direction  upwards 
and  tuwarda  till  the  (luid  appears  iu  the  glan  tube  of  lliu  aspirator.  The 
monieut  this  oceun;  all  nutvembni  of  the  needle  must  cease,  and  it  uiUHt  lie 
held  steadily  an  long  iis  the  iluiil  cuutiuuea  to  flow.  Any  uiiuc(%i»iiry  move- 
luent  may  8crsl<!h  and  injure  the  iturface  of  the  heart.  If  the  tlow  cease 
suddenly,  as  if  from  nome  oli»tniction,  a  little  fluid  may  be  forced  hack  m 
abiive  etale<l,  to  clear  the  nee<ile.  Afler  withdrawing  the  m^edle  no  dre»t- 
ia  n!<]uir(2tl  to  the  niiiiute  punctun;.  Over  a  jiint  of  Butd  hat)  lieen  re- 
nted by  this  nieanin  at  one  ojieration.  In  iiiEerting  the  needle,  care  must 
taken  not  to  forcre  it  through  a  cokChI  lartilage,  or  a  small  plug  of  carti- 
lage may  be  cut  out  which  would  etfeclualty  close  ila  canal. 


692 


DISBASI 


■IIS    BREAST. 


CHAPTEU    LX. 


mSEASKS  OF  TIIK  BltEAST. 


By  Disease  of  the  Breast  u  luennt  hu  tfTvctiun  of  the  aiammary 
not  merely  of  the  mammary  gland.  These  djseaaes  may  occur  la  iha 
SB  well  M  ill  the  female.  They  iirv  uecesMrily  wore  rmjurot  iit  wtJl  m 
importatit  in  the  Intter.  the  ruiliiiieDlary  miiiuiuar)'  ^'lauU  of  Itic  mak  betw 
little  preUieposed  tu  eucli  uflectioiiB  in  cuiupnrtsou  to  the  bigbl^r  Avniufm 
and  active  orgnu  in  the  female. 

Disensfs  of  the  i>rea»r,  whfu  they  occur  in  the  female,  are  ttt  modi  [sieral 
to  the  8urg<>oii:  not  lOilv  od  aco>iiinl  nf  their  znett  mriety,  hut  frun  ik 
difficulties  attending  iheir  diugnneis,  and  fnim  tho  imjiortiintT  Aitacliio^k< 
the  quertion  of  uperative  interference  in  ouuucftlito  wiili  them. 

DigefiBCfi  of  the  hreaat  »eldiim  occur  before  pulx^rty,  being  mo*t  frrt"""  ■ 
met  with  either  during  laclation,  when  tb«  functianft  ul'  the  gland 
high  degree  uf  development;  or  lowiirda  ihe  tennination  of  mcnatras.  ■»' 
when  the  organ  is  necessarily  inSuencc-d  hr  the  <-hnnk'<-)i  thnt  arc  taking  (Jsff 
in  the  uterine  ayslcm.     But  there  ia  thia  iwportiint  ditli-n-nce  brtvMB  li< 
dbeasea  at  tbeae  different  p*,*riiid«  nf  life,  viz.,  that  in  tit*-  yituug  thvy  uv  tt 
a  flimplc,  in  the  oMer  wuman  frequently,  if  not  grneri*lly,  ut  a  nallgMU 
nature.     .Iu»l  before  or  at  puberty.  th«  hreaat  ix'cn!ii>mally  h«-f<<mr«  l,'ir«»r 
of  intlamntatioti  and  nUacirM ;   in  all  prohnhilily  ohId^;  t 
place  ill  it  in  c)^i)nPctioii  with  the  genrral  di^velopmetit  i>l    ' 
ayiitem.    Ai^  the  per)»d  of  pulwrty  Hppr<uiciie».  the  umats  uften  - 
hard,  knotty,  and  s<jaicwhat  pninlul,  indicative  uf  eome  oammiu...  . 
in  the  genenitive  iv^tcQi.     In  other  caccs  nguin.  a  precociuua  b«|- 
may  take  place,  Irequcntly  nilended  with   itevere  neural-.-'n    ]••    ' 
When  puberty  occurs,  the  breuslsiialurally  enlarge, and  olt' 
and  ucc-diiiouuily  odc  undergoes  a  certain  degree  of  h'  -    - 
greatly  iu  bulk  beyond  tiie  other.    These  variuUB  rh; 
alarm  iu  fenmlt-e,  caniuit  be  rvgarded  as  of  any  very  wri'iir  iniporiiUin,*» 
Btddiiin  ri-(|uire  mure  than  thu  »im]ilciil  surgieal  trt-nlmeiiL 


AyoHAMCB  OP  nKvojorMEirr. 

The  mammary  gland  is  Hubjevt  to  ct-rtaiii  :<i 
Thua,  in  >ome  inetaoces  it  has  bwu  found  t«  U 

Ci)*if>er  and  Frtirlep  both  relate  iustumt:*  iu  whii.h  ihu  iti^^iu  ma*  a-  ' 
veli)pe<l,  and  iu  which  the  ovariea  weri!  »I»(i  deficient.  A  iin.rr  rrmarksW' 
uniiiiiHly  ci)nBii>t«  in  th<'  development  of  u  numhi-rof  Sapemamcrarj  BliS* 
Hirkcil  haa  collected  fourteen  n'porled  ni?*!?,  in  which  iln-n:  w^re  nitJ»l^ 
twohrraiMa;  most  frequently  thi-re  is  hui  one  ffuprrininirrary  glaiwi.a'''' 
titnea  two ;  and  or-cnsiimiilly,  though  very  ntrfly,  ihrre  hnvr  (tcra  i»i4f*^ 
C4itiKtituting  quintuple  nintnmir.  Snpemnmerary  Nipples  have  itkt^^ 
been  fiiund  l<»  occur;  Iwn  in  each  breaot  have  l»*-<n  niet  with.  *  -  ••  '•"'■? 
duels  opining  iiimD  it.     M(i«i  Irequrntly  tb«  siipfrnumcrary  t>  *'' 

nleil  aomcwhcrc  lu  th«  nviglitHtrhotxl  ol  tho  aormal  iflaiH),  a*  uti  lui  aKL.--'' 


IRTHOPHT    or   TKK    BREAST. 


BdS 


I>art  of  the  tliomx ;  hhJ  where  four  are  developed,  they  have  been  found 
ptaoxl  in  two  paralki  rows,  one  above  the  other.  Occafliotmlly  they  huve 
ooeo  met  with  in  very  Btmnge  situations;  thus  they  have  beeu  seen  un  the 
outer  |wrt  of  the  Lhigb,  tti  the  BEruin.nnr]  on  the  back;  nnd  obildreu  are 
even  said  tu  have  been  suckled  by  these  abiiormal  breasts. 

VKVRXt.iil/L. 

STeural^a  of  the  Breast  ocrusiitnally  ocaini  to  so  severe  a  dejjree  as  to 
cim^lituLu  u  poHitivti  diKfamr,  either  in  p,irh  or  at  n  more  advanred  [leriocl  of 
life,  wlti-n  it  not  unfreijiiently  complicates  cither  more  serinns  HtiW-lions  nf 
ibia  <)rgan.  It  is  especially  apt  to  occur  in  young,  delicate,  uinnarried 
ft-males  of  the  hysterical  temperament,  though  it  is  often  met  with  in  strung, 
ruddy-Iookinp  women,  who  ure  perhaps  Hubject  to  nf  nralgic  imins  in  the  back, 
and  in  other  dtnationa.  Mi-st  cnmrnouly  the  catflmeuiti  will  be  fouorl  to  be 
irrefiular;  and  uterine  congestion,  inOamniAlion,  ulcerntioD,  or  displncement, 
will  iie.  discovered  on  examtuatiuu ;  indeed,  I  huve  scArcely  ever  failed  to 
detect  one  or  oUier  of  these  conditiooa  iu  the  uterus  in  caaee  of  neuralgic 
brenst. 

SjpapUtmg. — lo  neuralgia  of  the  breast,  the  raamraary  gland  may  h«  of  its 
normal  s'\ze  and  consistence;  but  in  j*«)me  iustanci'a  it  is  more  or  lew  indu- 
rated and  hypL-rlropliiwl,  owing  evidently  to  chronic  iuflammatory  ttiickeniug. 
There  are  always  muuh  geiiem!  paiu  and  aching, deeply  in  il«  substance,  with 
cutaneous  teiiderneM  of  it»  surface,  and  lancinating  or  radiating  aetisations 
that  extend  into  the  axiliH  and  down  the  arm.  These  painful  twusatiunn  are 
Ciinimonir  increased  befire  the  menstrua.1  period,  and  not  unfretjuently 
sUeraate  in  the  I  wo  breapta. 

DUt^ROfit. — The  diagnosis  of  this  affection  from  iDore  serious  niammBty 
tlisease  may  usually  he  etfL-eted  hy  attending  tu  the  ^uperScial  and  radiating 
character  irf  the  paio,  to  the  ncurotii:!  temperament  of  the  woman  in  whom  it 
occurjf.  to  its  ehihing  seat,  and  to  the  absence  of  uny  sign  of  organic  disease 
ill  the  breast  sutKeieiit  to  occasion  it. 

TnaimttU. — The  ireolmcTit  consists  es[>edinlly  iu  attention  to  the  cooditioD 
uf  the  uterine  organs;  unl(^  x\\h  he  doni>.  the  dit^euse  will  pro%'e  excessively 
rebellious  and  iniubloaoniL'  to  manage.  By  removing  bv  proper  rt^medies 
uy  utt^rine  irritaliou  that  nmy  he  f  >iiiid.  llii»  ulfeciiou  wifl  be  subdued  with 
for  greater  readiness  than  by  nny  purely  local  plan  of  ireaLmenl.  At  the 
■ame  ttnu!.  an li- hysterical  (-iiiHtitniional  rouH'di™  may  \w  employed;  the 
preparntions  of  iron  adminif'tererl,  when  necessary;  and  the  ln<*«l  pain 
relieved  hy  the  application  of  hslladoiina  and  opiate  plasters,  or  by  hypo- 
dermic injections  of  morphia. 


nVPERTROpnT. 

SuiFl-i:  llYt'SBTRornY  of  the  Brea»t  is  not  uofrequeutly  a8sociat«d  with 
very  severe  oeurulgiA  of  the  organ.  An  iucrease  in  size,  such  as  naturally 
takes  place  during  preguaucy,  botweeu  Ibe  fourth  and  uinth  mouths,  will 
Dccastonally  commeuee  at  puberty,  and  go  ou  uucil  the  orgnu  attains  an 
eourmous  bulk,  us  iu  Fig.  TUO,  which  rupre^cuts  the  breast  of  a  very  tbiu  girl 
Af  fifteen,  who  was  under  niv  care  for  this  conrlition.  In  some  cases  the 
br«>a;et  has  hecm  found  after  fleaih  to  weigh  as  much  ns  twenty  puundi? ;  and 
afWr  ruioovul.a  breast  of  titis  kind,  taki^n  froiii  a  young  woman  under 
thirty,  has  weighed  uo  lens  than  twelve  pounds,  being  entirely  composed  of 
its  nurniul  tissues,  gr(?iitly  lLypertn)phiud.  In  <nsea  of  by[)crtn>phy  both 
breaals  are  usually  affected,  though  one  is  commonly  more  so  than  the  other. 


694  DISBASKS    OP    THE    BXEAST. 

When  Rnt  thia  morbid  condition  commeDres.  the  lireitHt  prrmrrm  ill  ubI 
•bape.  tli«n(;li  it  is  increiueH  in  bulk  ;  luit  an  it  paliir}[(>*  U  gmduaUf  »r»- 
JecU  lorwBt^B,  drawiug  dowo  tbe  skin  of  the  thiMiIdpni,  of  the  tUt  of  tit 

cheM.  snd  rven  of  t)ie  back,  uti  imf 
V  ing  ilownuMntfl.  until,  u  iu  m  rate  bk»- 

tiuued  by  Bcrard,  It  hw  b«ro  kaon  t* 
j^       \\  /  reach  to  the  kiiwB. 

y^      ^   \J  TrentmenL—Tht  tre«lra«it  tif  r*:-*  -' 

/  4  fcctiou  u  very  «n»ati»fnclorT.     1 

ernl  health  niiut  b«  attciuled  (•',  an>i  i^ 
eudeavor  luny  b«  wade  to  «icit«  lun- 
tiou,  and  thus  t<>  unlirad  th«  rvtrU  of 
tbe  breaat  by  the  edipiuymrat  nf  |!alwi» 
gogue  retuvilii-s.  AiiiputatioQ  of  tin  ur- 
gau  should  put  be  ]«rforiD««i  id  Unh 
case),  uuleaa  th«  Krowtli  atuuii  wo  ffni  a 
mse  aa  tx)  render  lire  a  bunlra.  Tbta  ikt 
namnay  be  extirpated  with  liuletnnbb 
or  danger. 

ABNORMAL  COyplTirtNS  Or  TUC  UCTUl 
fWKKTIOX. 

Th«  lacteal  aecretion  ta  occaaioDally  ikf 
cause    of  abuorma)   <->  <<   in  ik 

breaat.     Tlni»  liit   mtli-  :.;iMr  a 

^  ^^  UfiH/Ufi/fimrji.a  (welvei'i  .urtiiOT. 

p^^  aRt^r  Meftiiiiifi;  it  lia*  ■  I*  ^'"^ 

^Jr^  knowti  to  Iwf  pfcrett^l  in  vh 

^  t)oni«  n-tiiHrkabta  iiiMlan<.'r«    , 

'^*  men.     In  utbfjr  iiisUinwa  ao"'".  "* 

flgg.  770-— .Slwtpi*  Ilrpartroplijr  of  BrMut     lurition,  ibcni  ia  a  luul  AbMBCe  .    " 
In  >  Qirl  Sftcaa  jtMri  old.  eitbiT  uwing   Lo  Want   i»f  tlcTcluf>i 

the  ^'laiul,  or  to  debility  on  Ihf 
the  mnthor.     The  oppueitc  condition  will  occaeinnally  ncciir,  and  a:: 
lin  Flow  of  Kilk  may  cuutiuue,  eei>ecially  in  hyfitiriral  fenmUa  l< 
the  child  ban  been  weuiit'<l.     In  nnch  ca^e?  nn  tbi-H*,  tbe  ^oioelffrHWn 
obecked  by  thv  application  of  thn  extract  of  belladtnina  t»  the  bnait,u>"" 
by  tbe  rmplnynicnt  of  toiiica,  an<l  the  ad miniat ration  of  acidit. 

LAtTK.M,  Ti  MOK. —  It  may  happen  durinj;  Inrtatinn  ilini  one  of  tk>h» 
tiferoua  ducta  Iwcimes  ohfitnicled,  either  by  il«  iH'ine  obtitermieri  by  ialHi- 
nation  or  occluded  by  the  deposit  in  it  of  n  amall  concrelioo — a  hotal 
ealeoloa.  In  eithtr  cane  the  walla  of  the  duct  may  be  cxpnndrd,  n  lliil  •> 
last  it  constitutea  a  moderatc-eized  cyst,  iluoluatin^'  on  presanre,  and  eTidfit|* 
containine;  fluid.  In  anme  caaefl.  the  lactenl  lumi>r  has  been  known  tn  iltiiB 
an  onormoUB  size.  Walpy  has  related  a  caie  in  which  Scarpa  ilrew  ef  "* 
poandflof  milk  by  tapping  a  cnnectinu  of  thb  kind.  Tbene  luiOMr*  VT 
axint  for  a  considerable  time.  Dupuytren  recinls  an  ioatanre  in  whtrb** 
bad  exiHt«<l  for  ten  monlba,  and  Oioper  one  of  a  year's  duration,  lul^ 
chrciuic  ca»e!t  the  milk  uitually  undergoes  ehuogra,  berominf;  t-fFauiy,  t^''^ 
and  oily;  and  in  aoine  injtancea  it  would  appear  to  I«n*e  a  -  '  '  '"* 
roaidue  by  tbe  atworplimi  of  i|e  watery  parts.  In  other  tni^tAi' 
apjieart  as  if  ilifTiive'l  through  the  ^uliatancc  of  the  gland  and  U>  'lucu.'^^ 
Htitutiog  a  Hpirngy  »emi  IlLirtuitting  tumor,  Velpeau  baa  pointed  nnl  '^ 
tbeae  lactaal  dejNHits  undergo  a  seriM  of  changof,  aunewhat  aimllar  Va  '^ 


INFLAUllJlTION    OF    THE    N'll'I-LK    AND    ABEOLA. 


695 


that  Lake  place  in  blood  thai  has  beeu  cxlravasuUH);  Itocotuiag  abi<irbod 
whully  or  in  jwn  iti  euiub  iusUiuccs,  hi  othfr»  rutimiii'tug  lluid,  aud  <jO(»istOD' 
ally  moomiug  (turrouatled  by  a  dieiinrt  tibroun  wall. 

Trtaimeal.^-lu  ibeae  caaen  the  tumor  may  bu  y^nl  rid  uf,  as  Sir  A.  Oxiper 
adviees.  by  inakiti^  an  ubiiiiiie  piincturu  from  tin;  uif>|il<^  towardii  it,  by 
meoiu  of  a  trni>»r  and  caniila,  so  that  n  fiHtiilouR  truck  may  be  let>,  aloog 
which  the  milk  is  [iiflrbarged  ;  the  child  being  at  th^  same  time  weaued,  so 
that  the  secretion  may  oeaae.  In  most  cases  it  is  better  to  make  an  opening 
through  the  skin  and  to  treat  the  cyst  by  drainage. 


I.VFl.AMMATIOJt  OF  THE  BKKA9T. 

In&ammatioD  of  the  BreasE  may  take  place  at  any  period  of  life.  In 
uew-bora  infant*  rodn^'K^,  ami  swelling  of  the  breast  is  fminetimes  observed, 
with  (ome  discbarge  from  the  nipplit?.  It  usuully  nuWiiles  without  auppura- 
tion  in  a  fe«  day*.  In  cbitilhimrl  it  ncciim  an  tbft  renult  of  acci<lental  cau>ieii, 
and  also  just  before  or  at  puberty.  It  is  !>ometime!i  met  with  in  bt.iyt  as  well 
Bi  ia  girle.  as  a  coneeqaeDce  of  the  geueral  developnieot  of  the  organs  of 
reproductiou.  In  these  cases  it  is  easily  subdued  by  the  application  of  glyo- 
erioe  and  belladouna  ointmeot.  Far  more  frequently  it  occurs  during  lacta- 
liuo  in  feeble  and  ana>aiic  women.  It  is  commonly  met  with  during  the  first 
mouth  or  two  after  the  birth  of  the  child,  and  seldom  occurs  duriug  wean- 
iag.  but  luay,  as  Nuun  haa  shown,  be  (be  couacqueuco  of  unduly  prolonged 
euckling,  and  ihusappenr  at  a  late  periml — tlic  leuth  or  eleventh  month, 
lullamaiation  may  allect  any  one  of  the  coneLiliit'iU:^  cf  which  the  breast  is 
comptwed,  and  may  be  limited  to  thig:  lhu«  it  may  take  place  in  the  nipple; 
ia  thL-  sulifutHueuus  arenlar  ttt^ene  lying  bclHcen  the  skin  aud  the  glaDU ;  in 
the  gland  it-<«<>If:  or  in  that  extenm^'p  plane  of  areolar  liKriiie  upon  whirh  the 
^land  TeMn.  and  which  tnlcrvene^  between  ic  and  the  pectoral  uim^t-bi.  Hut, 
althnugh  inflnmniation  commonly  nKecta  thoi't'  ditferent  partK,  iti  many  cHHCfl 
the  whole  of  the  breant  appears  to  he  involved,  and  no  distinct  implication  of 
anv  apccial  tissue  rain  he  ma'lc  out, 

tnnammation  of  tha  Nipple  and  Areola. — When  the  nippli-  and  areola 
are  inHamed.  these  parts  become  conical,  re^t,  and  swollen,  with  ninrh  pain, 
owing  to  the  density  of  tlic  subcutaneoDa  tissue  in  this  situation,  This  aflec- 
tion,  **  the  cracked  nipple"  of  nurses,  usually  occurs  at  an  early  period  of 
lactation  in  delicate  women,  and  eupcciHlly  with  the  first  child.  It  com- 
mencos  in  the  follicles  of  the  part,  being  accompanied  by  superficial  ulcera- 
tion, abrasion,  and  liMure^,  with  oozing  uf  a  small  ipiantily  of  thin  aero* 
piiriforni  Huifl.  Ther«  in  great  pain  during  suekliug — so  great, indeed,  an  to 
prevent  the  proper  cuutiriuaiice  oI'lliiB  act.  It  is  usually  altendet!  by  a  good 
deal  of  conslilutinnni  trritution.  In  some  instances,  the  fissured  state  of  the 
nipple  would  ap^ieiir  to  jirecede  the  setting  in  (if  ioilammatton  ;  in  other  cases 
the  inflammation  is  the  primary  cimdition.  In  wet-nnraes  the  pii»»ibility  of 
the  occurrence  of  a  primary  syphilitic  oore  comnuinicated  by  an  infant  suffer- 
iog  from  the  congenital  form  of  the  4li»eaoe  mii!>t  always  be  borne  in  mind. 

The  Treatmenl  is  a»  follows.  The  child  must  be  taken  from  tlie  affected 
breast,  both  for  its  own  sake  and  the  motherV.  the  milk  being  drawn  off  by 
meansof  a  breaet-pump  or  sucker.  The  general  health  must  beattended  to; 
tonicfl  given :  the  infant's  mouth  examined  f<>r  aphtha>.  which,  whether  as 
cause  or  us  effect,  are  common,  and  must  he  treated  ou  ordinary  medical  prin- 
ciples. If  the  nipple  be  not  fissured,  it  should  becovered  with  flexible  collo- 
dion, nr  ]>aiGted  with  an  ajitrlngcnt;  a  solution  of  nitrate  of  silver,  catechu, 
r  tanniu  a  the  best.  If  it  be  fissured,  a  pointed  stick  of  nitrate  of  silver 
masL  be  applied  to  the  bottom  of  the  crack  daily,  or,  if  deep,  ila  base  may  be 


696 


BISBASBS   OP    THE    BBBABT. 


flivideil  by  drawinff  a  lancet  aloD^;  it.  A  nipple  sblelil  through  «bt^  lb 
cliiltl  can  Bui>k,  will  often  be  fniintl  useful  in  pn-VfiitiD^  a  reeumuca  ate 
the  fiftfiiro  hill*  Ittvn  cuivil. 

Eczema  of  the  Nipple.^Tlic  nipple  nad  the  areola  are  uot  anennwNlf 
tho  M-iit  of  very  chrtniic  iind  obslinato  L-oxeinit.  The  cnipti'in  may  rttoul  U 
the  surrouudiug  ek'ia.  The  cauee  of  thin  cotxlilinn  is  iir>i  aIwatm  evidei)l.b«t 
io  some  cases  it  ii  the  prcrnre'irof  canccrof  the  brrnst.  It  not  utilra}neiill; 
attacka  both  sidcti.  The  Treaimmt  is,  u  a  rule,  rcry  iinMtbfeciorT.  iWit 
nipple  Diust  be  carefully  waahcd  with  tepid  wuier.  filyecrin*  'if  hoiai. 
boracic  acid  mntment  with  one  drachm  of  extract  of  bclladiHiiia  to  oA 
ounce,  carbnimle  of  lead  niiilmrnt,  iiiid  lead  lotion  may  be  trmt,  and  oAca 
are  of  iiM>.  Painting  the  intlrinie<l  area  occasionally  with  a  UroBg  aolalMa 
of  nitrate  of  nilver  nmy  aonictinm  prove  t>eiieAcial. 

Abcc«si  of  the  Areola  not  unfrequently  occum  io  noek'i- ^^ 

the  ordinary  1*1^11^  of  lix'al  iiitlamruation,  larn)iiiating  iu  <-<  -^ 

fiuration.  Thi*  jTrex/ifiTnl  ct>ntit»t«  iu  the  appljcation  of  WMnu  Ui-iia-lvMiaflr 
ead  l»iioD,  and  upvuin^  thv  aboLti*  early,  lu  d'-iD);  tbid  care  akwiM  b 
UkeD  that  the  cut  be  nmdv  fruiu  Lite  iwnire  tifthe  nifiple  i^wapialhccimt» 
ferenoe  t)f  the  areola,  eo  ait  uot  to  dividu  the  lactual  ducu. 

Binall  fiiiliuular  intlamiiiatioiig  aiid  abMcwea,  Taryiag  iu  aisa  fron  ■  pb'* 
head  u>  a  cherry,  an;  ctiiumon  iu  mitldle-aged  woroea,  iudopendcDlJy  of  kdfr 
tiun.  Thev  often  excile  aliinn.  and  occa»tou  frmie  yaun.  They  an  uMiltr 
readily  n;livved  by  belludonua  aud  glycerine  ur  wariu  lead  lutius,  fulbnd 
by  the  touch  of  the  point  of  a  lancuL 

lNPLAMM\Tin\'  OF  TilF.  HiiK.vsT,  which.  aa  it  f^nerally  m<runt  in  Hinaai 
mothcrv,  ami  lerminiitia  in  siippuralinn,  i;*  usually  calliil  Hilk  Ab«cfM«  WKf 
ncriir  in  ihree  niluHtinnit ;  I.  in  the  Suhnitflncouii  Areolar  Timur,  Sopnaifr 
mary  Abscess ;  2,  in  the  Gland  itM-lf.  Mammary  Absceas  ;  and  \\  id  ib( 
Arroiiir  TisMim  beLnt-en  the  Mammary  Gland  and  tbv  I'ectiinUii  M^jctf,  8tV 
mammary  Abscess. 

1.  laflammatioQ.  followed  by  Abscess,  of  tbe  Snbtmtaaeoiu  AnaUi 
Tissue  of  the  Breast,  thouf^h  conniinii  durlnj;  liKiutioo,  i>ci^-un  axm  fit- 
(juently  than  any  other  t'orm  of  itiHanuDutiou  in  thia  r«yii>n  at  <rth«r  p(ri«)i 
uf  life,  mort"  parciculnrly  abont  ihea^e  id' puberty.  \lx  svnip4(tnw  arc  lli>« 
uf  simple  acute  inilniiiitmtion,  ditK-riiij;  iu  no  wny  from  aWceas  of  tbb  kiiri 
in  other  i>itiiatioii»,  t-xo-pt  that  it  \»  »W»y%  rlintiactly  circumacrilwil. 

2.  Inflammation  of  the  Kammarjr  Gland  in  the  iu<«i  eiininoo  fora  ■■■ 
Willi.  It  ari-i'»  aliiH«t  nUays  iu  connection  with  lactation.  Of  22*  *■■ 
recorded  by  Nunn,  Bryuut,  and  Uillrotb.  lUl  occurred  during  auckliucll 
during  prugnaucy,  and  34  indvpeudeutly  of  tbcse  cnndilious.  It  li  a^ 
cuiumou  iu  priinipara',  Ihti  tendency  to  it  diminishing  with  each  coofiuuiSiM 
The  right  breast  ia  more  commonly  afTected  (huu  the  leA,and  neoaMaosUfll 
ia  double.  The  cauhb  of  the  iuUaiiinmtiou  are  by  nri  meaoa  certain.  It** 
been  suppoM-d  tu  be  due  to  obotrucLiou  of  a  duet,  and  such  an  explau^'* 
no  doubt  a  very  powiible  one,  but  there  ia  do  di-fiuite  evidrooe  iu  aotipalt" 
it.  The  fact  that  il  is  verv  frequeatly  precedi'd  by  ft  tore  aipfiw  a*" 
sugf^eftl  the  pomibiliiy  of  its  lacing  due  to  extension  fmin  lhi«,  eitner  kf  1^ 
lyniphatios  or  ducts.  It  m<iAt  coininonly  contnescea  durinir  tba  fin*  i*' 
weekit  after  tabor,  or.  if  that  (wri'Kl  be  paswil.  tnvards  the  eml  of  fHnbi^ 
laciation,  eacemlly  in  weakly  women.  Ilencc  it  i*  rrrv  coinnKMi  aaiM^ 
the  ptiurer  elasaei,  amongst  which  it  ia  not  rare  to  find  ctiiMrea  nf  fnm  f** 
to  tvru  years  old  stilt  al.  the  hreiibt.     It  ia  rarely  m«i  with  in  moiben  ■ho^ 

not  nurse  tfaelr  own  children,  a  fact  which,  as  Billnitfi   •  -r- \.  ..^em- 

what  oppoeud  Io  the  theory  that  iu  common  caoae  Is  '-  * 

of  milk.    The  whole  gland  is  rarely  alfectcd,  but  shouUt  u>o<  hkiij-'ii.ii  .'■'* 


m 


TASATH£KT    OF    UA1I»ARY    ABSCESSES. 


C07 


roe  tfl  (treat  swellinK  of  the  brfasl,  with  severe  aching  nnfl  lanrinalinj;  pain, 
and  much  conMitutiuiial  ilisIurbaiK-e,  witli  consiilomble  i>tf^vtilion  of  tt^niper- 
aiure.  Much  iiior«  i-mni'iiunly  one  lit1>e  only  iHTomt^  iuflnnieH,  moot  com- 
monly At  the  iKit«r  iir  low«r  liunlvr  oT  the  ^luud.  Tlie  local  itiirttft  are  th(!D 
profHirlioiiHlcJy  litnit«<l,  ami  uccaeignnlly  the  iiiflttnimatioD  sub«i(1(-0  withi)iit 
reachinfi;  Uic  «lftg«  uf  siippuratloD.  Aa  V»rl(»eaii  baa  jM)inteil  out,  one  lobule 
aAer  aDutfavr  may  become  itiBaiiiet),  wt  ihut  a  Bucctnioii  of  abeceMee  fnrma 
in  diSereul  puru  of  tbt*  glami.  As  the  lafliiruiuation  advances  to  eii))|)ura> 
(ioa.  the  ekiu  is  reddened,  aasumes  a  dusky  hue,  becomes  glaxcd,  haa  »  iiecu* 
liar  greasy  appearance,  and  piu  on  preesure.  When  raiilter  has  f.irtii'wl.  the 
leDsioD  of  the  eupertiuial  parte  with  a'deina  ami  fluetuution,  perhaps  drep* 
seated,  deicrniine  its  presence. 

'X  Inflammation  ia  the  Areolar  Tissue  between  the  Hamma  and  the 
Pectoral  Muscle  is  of  Itse  frequent  occurrenct;  than  the  other  llirniis  nf  niara- 
nmry  iotliuiuimtiun.  It  tiri^'s  in  eoiiie  coses  apparently  in  depend  en  tly  of 
BOjr  affection  of  the  gJand  itself;  l>ut  iti  mo«l  ca»ci,  as  Billroth  suff^^estR,  it  is 

frobnbly  due  toinQumniutiininiiii  HUppuraiion  of  a  deep  lobule  of  the  luamnm, 
n  whatever  way  it  arit^cd,  the  influminalion  djlfu^t-^  itself  over  ihc  whole  nf 
the  areolar  layer,  oud  ulmoat  ioviiriably  runs  into  ubseeas  with  cousidenible 
rapidity,  giviae  rise  to  severe  pain,  of  a  deep,  heavy,  and  throbbing  character, 
muob  iucrea^  by  moving  (he  arm  and  shoulder,  and  attended  by  Bwelling, 
OKlenia,  and  a  flight  red  blush  upon  Ihenkin.  The  breast  beconiee  prominent, 
and  is  conical  and  projeicting.  the  whole  ftrgun  being  pushed  forwards  by  the 
[>f«i*ure  from  behind ;  it  is  not  readily  movable  on  the  |)ccloml  muscles,  the 
subcutaneous  veins  become  engorged,  and  at  lant  nh<icew  forma.  It  is  not 
atwayi  easy  in  these  casts  to  determine  whether  supptinition  han  taken  place 
or  not,  the  depth  at  wldch  (hf.  pus  form<t  reiulerlng  it  imnoasiblc  In  the  early 
Uigee  to  detect  DuctUHtioii ;  ilit  pret^nt-e  may,  however,  ne  suspected  on  the 
occurrence  of  deep-rented  throbbing  jiain,  i«ul>ciiliineonf)  fndenia,  and  some 
superficial  rcdtiees.  The  »bocw»  iit  last  p-tiuts  nt  some  part  of  the  margin  of 
lh«  gluud,  usually  at  its  lower  and  outer  side,  to  which  p-)int  the  matter  Heenia 
Iv  gravitutv ;  alter  a  Lime,  howwer.  it  will  commonly  appear  lit  other  points 
of  the  circuuil'ereuce  of  the  gland,  beyond  which  it  always  extends,  •eldom, 
if  ever,  [wrforating  the  structure.  A  series  of  t^mr  or  five  itperlure*,  forming 
a  large  circle  round  the  margin  of  the  mamiuary  gland  niav  thus  form.  It 
very  commonly  happens  that  the  aj^ertures  throuf^U  which  the  pus  di** 
char^oa  ilaelfin  these  situations,  degenerate  into  sinuses,  by  no  iiK-aiis  easily 
closed. 

TreatmrnL — In  the  treatment  of  inflammation  and  absceas  of  the  breast 
OCCurriug  during  iaclutiori,  it  muat  he  borne  in  mind  (hat  we  have  not  a 
sthenic  iuflatiimatory  condition  in  rieal  with,  hut  thni  the  diseaae  almost 
invariably  hap|ienH  In  deliciite  anietiiic  women,  weakened  by  recent  iMirluri- 
tion.  It  i^,  llo-refore,  olivir>uB  thai  HnLiphloglstlc  meanH  of  an  active  nature 
are  not  admisbible;  and  the  be^t  plan  of  trealment  uppeare  to  consist  in 
keeping  up  the  strength  of  the  patient  by  proper  constitutional  nupport,  at 
the  same  liii.e  that  the  IuchI  inilammalion  is  checked  by  topical  antiphlo- 
gistic measures.  The  first  thing  to  he  <lone  is  tn  prevent,  if  pnestble.  the 
occurrence  of  euppuralion ;  if  this  can  be  accomplisheil.  whtuh  Is,  however, 
rarely  the  cnse,  much  will  be  gained.  In  order  to  etfect  this,  the  breaiit 
should  !)«  HUp]K)rted  in  a  sling,  bo  u;s  to  lessen  congestion  of  it ;  the  urnt  at 
the  oanie  time  l>eing  lixcil  t<<)  the  side,  in  order  to  prevent  traction  of  ihe 
(lectorals  and  movement  of  the  suhiuammary  areolar  tiuue.  If  the  patient's 
iitrenglh  be  gooil,  leeches  may  be  applieil.  but  these  are  rarely  roqnireil  nr 
a<lmi:uihle.  Hot  fomentiilioDs  should  be  assiduously  applied  from  the  tirst, 
and  Lbe  whole  breast  painted  with  equal  parl^  of  glycerine  and  extract  of 


DISEASES    OP    TUE    UUSAST. 

hellailonna ;  at  itip  flume  time  the  mitk  •boold  He  ilrairn  nff  bjr  BMatWi 
brejuit-puiDp  or  suokor,  the  chiki  being  put  to  the  JD&Ai>et«l  fanMi  «r 
weaned,  aod  an  occHsioaat  E^nliii)*  purimlive  o'lmiautfrvd.  Wkin  Nwan> 
tioti  in  impeniJiD^,  the  upplicatioo  of  IVimenUtiKTu  iiiiii  liii  i  iwiiiiiiw.  llw 
pntient  l>eiiig  aUnwcd  a  more  liberal  lupply  fitudurnhmeal,  witfa  s  nvJvili 
supply  of  malt  liquor;  aod,  bo  sooo  »  matter  cuu  b«  Mu  it  aboalil  IkmI 
down  iipoQ  sud  lot  out  by  au  a()erture  in  tbe  must  depeudcnt  p^Mlino.  1W 
iocuiou  must  always  be  in  a  lioe  radiating  fratu  tbe  oipple,  m  at  to  ami 
oeediculy  damnjting  theduotA.  It  ieof  sraat  iiupuriautt;  ttiat  Ifaa  puibmiil 
be  let  out  early,  by  an  .ipeuiog  into  the  loweat  |Nin  of  tiiu  ahaewa ■  A  gmd- 
sized  druinajw-tiihe  ahriuld  theu  be  inserted,  and  some  effldent  aotivflH 
dn^iii^  tipplied.  It'  ihivc  precautions  be  oot  lakeu.  tbf  fHJi  bunwn  ifi^, 
difTufiiii^;  tl^tf  through  the  arvolur  ttSHue,  under.  lM>vonil.  and  vnoad  lu 
gland,  iipi^iiin^  at  MM't-rnl  pointjt,  and  leaving  long  liHtn  V»  prHtntiaf 

th«  bn'iist  in  variomt  din^rlionii.    When  ?n|i[Hi ration  i.-  .  ..  tba  f*<tf  |^ 

Btrt'iigrh  rniisr  be  Aupporled  with  tonirs.  thn  mineral  ut-.iiU,  turk,  or  qvi^H 
BtininUnlA  may  be  given  an  required,  and  plmty  i>('  nourtxbmmi  Wp]4l 
Shinibl  Hinnses  form  in  a  case  of  mammnrr  ulwcf-M,  ihi-y  will  iimuIIt  Am 
if  the  child  be  weaned,  and  lactation  stoppeil.  Hhould  ihry  du|  ilnio,  (te 
employriieni  ofprrwiire  and  the  naa  orstiiiiulatinir  injectii>Di>,  with  aiutttia 
to  the  general  bejiltb,  will  usually  in  tjni^  bring  iihoiit  a  cure.  lDca«»«f 
submamnmry  nltscem,  the  incision  must  be  fr«e,  and  a  large  draioace-lals 
should  be  used.  Sinuses  of  au  intractable  kind  more  onrnmonl*'  '"''  •  tha 
than  tbe  other  f^irms  of  mammary  abtccM.    In  the  event  of  t4 

rebellious,  it  has  been  proposed  to  elit  them  up  hr  free  incv:^i"(i*  •,<--rim 
towards  the  nipple;  but  this  is  unneocssanly  sever?  practitx-,  and  na^I 
believe,  in  all  cases  be  avoided.  It  will  oAeu  bo  found  that  the  delM' ii 
hesiiug  is  due  partly  t<>  the  existence  of  a  cavity  lienralh  the  momim  «akA 
is  imperfectly  drained  by  the  siousee.  Uuder  these  ctrcunataan*.  tht 
orifiees  of  the  siuusee  should  be  enlarged  ttitli  a  knife,  and  the  Cracks  dilsu' 
with  Ibe  linger.  They  should  then  l>e  «^'m|H.<fl  Miib  a  sharp  s|>oi»i  to  rrawo* 
the  uiiht-allhy  gran u bit i-m-liaoue,  aller  whirh  they  aboiild  be  clcwied  witki 
piee«  of  sponge  aookeil  in  chloride  of  lino  aiduiion  (gr.  40  lu  3I  ■,  IwU  la  • 
pair  of  sinus-fureeps.  A  drainag^tube  should  then  oe  inaertrd  ialu  ifi 
and  gradually  shortened  at  ««cb  dreoaiug.  lu  some  casM  henliar  »  \** 
mot<^  by  the  intniiluetioQ  of  a  small  qaautity  of  liMliifomi.  Ttw  vnot 
suhmammary  sinuses  may  usually  be  speedily  made  to  cloae  br  tlui  IM^ 
ment. 

CtiKoNiLr  IspKAMMiTioif  OP  TOR  Brkast.  Chrooic  Iiit«nttUal  M»- 
titia. — A  form  of  chronic  iuterstilial  inflammnilon  of  the  brsaat,  aAcuH 
usually  only  a  limitetl  |»art  of  the  gland,  is  not  tineoRimonly  m«l  with  ia 
women  past  middle  life,  and  ii  of  great  iro|>orltinee  from  ibr  rfaettltlsaff  il 
bears  in  its  clinical  features  to  scirrhous  cancer.  Tbe  fooditHM  waifa* 
accuralely  described  by  Cruveilhier  under  tbe  name  of  flbr^ius  bodies ''odf]* 
fibreux  ■  in  the  breast ;  and  niuM  hi^  time  it  hiu  ri*ceivM  mnnr  nthrr  ■■■* 
SUcbasdiflusefihroniaor  hardelephantinsiij  Virrh-iu,),!,..!.  '«ftr<^ 

(Sir  A.  OM>f>er  I.  knotty  or  nmlulnr  induration  (Ilillrolh  -»»  rflfc* 

mamnin,  benign  induration,  etc.  "  Chr*>nic  lobular  inlcnitilial  martW'* 
however,  the  best  name  that  can  be  applied  to  it,  as  it  correctly  uidiali'l'' 
nature  of  tbe  aSeetinn. 

Tbe  pathological  nppeanmoea  are  rery  minutely  described  br  VirdioK  V 
the  earliest  stage,  which  ia  ertdently  inHammatory,  tbe  acini  and  JaCV** 
the  gland  show  no  change  beyond  a  slight  inoreiaw)  in  tbe  epitfaeliuia.  i** 
eunnei-tive  tissue  of  the  alfected  Inbule  l«  iafiltnted  with  aniall  nHi»dt«I|*^ 
which  are  most  numerous  in  the  immediate  neigfaborbMid  uf  lb*  aetai    ** 


CBROBTIC   IXFLAHMATION   07   THR   BRSAST. 


Lbe  Mcoud  stage  the  oew  cpIIb  undergo  development  into  ilense  fibrniis  tit^ue, 
like  thai  of  n  cicwtrix.  This  is  RrcotnpHnieil,  as  in  similiir  procerises  elee- 
where.  by  shrinking  of  the  tissne.  The  acini  and  ducts  in  the  ntft'cted  area 
ire  thus  pressed  upon.  The  epithelium  uiidergt>es  liitt}'  degeneration,  nnd 
Is  for  the  most  pnrl  absorbed,  and  thus  a  uumber  of  the  acini  are  finnlly 
obliterated.  Here  and  Eberc,  however,  small  reteniion-eysts  form,  chiefly 
from  the  duels  which  have  bt-en  constricted  in  ptnees  by  the  contracting 
fibi-oid  tissue,  while  ai  the  same  time  there  has  been  a  slight  increase  of 
secretion  owing  to  the  chronic  iiiflmnmntory  process  going  on  in  thcsur- 
ruunding  areolar  tiwiie.  These  cysU  acldom  reach  a  sijte  larger  than  that 
of  a  mufttard  seed,  owiog  to  the  density  of  the  tisHuc  by  wliieh  they  arc  sur- 
nmaded.  The  disease  is  very  coromimly  limited  to  a  single  hibulo  of  th« 
mamma.  Oocastonally,  however,  it  may  be  more  ditfused,  and  in  snob 
caMii,  when  the  Htage  of  nhrinking  is  renehed,  the  gland  may  become 
shrivelled  and  <>oiiHiderabty  reduced  in  size.  The  nipple  mar  Ite  retracted 
u  the  breast  shrinks,  thus  still  further  iucreflsing  the  reeeml^lance  to  atro- 
phic scirrhus. 

The  mtuet  of  the  condition  are  very  obscure.  It  is  trequeotly  aseoclated 
with  some  menstrual  disturbance,  bihI  is  nut  uncommonly  met  with  nt  the 
change  of  life.     It  is  must  common  in  women  \^hu  have  borne  children. 

Tbt  tymptotM  consist  of  the  gradual  formation  of  a  tough,  hard  ni>du1e 
in  th«  breast,  usually  situated  in  the  peripheral  part,  tolerably  clearly  cir- 
cuiDBcrlbeJ,  aud  of  roiiuileU  furni.  In  aim  it  may  vary  from  a  uiarblc  to  a 
pigeon's  egg,  seldom  being  larger.  It  n)uy  distinctly  increase  in  size  at  the 
itiL-n!>irual  periods,  and  dimiuiKh  lu  tlie  intervals.  lx»  surliiec  is  uAcn 
slightly  nodular,  tlic  notlulta  being  fortiie<l  by  the  aniall,  tense  cysts  already 
uii-utioued.  [fit  hv.  gruti|ied  ami  gently  pulle<l  upon  with  one  hand  while  the 
nipple  is  held  with  the  other,  no  aa  in  make  the  durr^  pa.<ving  from  it  tent^, 
il  can  easily  be  recogniitejl  that  it  is  part  of  the  mamma,  and  nnt  an  ianlatetl 
lURior.  On  pinching  up  the  skin  over  it.  a  dintple  may  form,  rh  the  areolar 
tisBUe  of  the  subcutnneoua  fat  is  continuous  wirh  that  penetrating  between 
the  lobules  of  the  mamma,  which  is  involved  in  the  interstitial  inflammation. 
A  similar  nodule  may  not  unfrequently  he  found  either  in  another  part  of 
^ibe  same  brca.'it  or  on  the  opposite  side.  The  disease  may  he  painless,  or 
'  aay  be  a-ssocimed  with  severe  neuralgia,  worse  during  the  menatrual  period. 
'In  the  early  stages  there  maybe  slight  tenderneas,  hut  this  Is  seldom  marked, 
and  is  often  wanting  when  shrinking  is  far  advanced.  There  may  in  some 
t^ftses  be  a  slight  enlargement  of  the  axillary  glands. 

The  diitifttoaiji  will  be  roiisidorcd  more  specially  with  reference  to  cancer 
and  adt^noma.  When  it  ociHirs  below  ihe  age  at  whii-h  cJiiic-er  is  met  with, 
its  recogiiittim  doi-s  not  as  a  t»\v  pr4.>«ont  great  ilifltculty-  From  adenoma  it 
is  distitigiiishetl  by  oln^erving  its  lenn  dt'liiied  tiiitline,  and  its  conneclioi)  with 
the  nipple,  showing  that  it  is  actually  an  Rltered  piece  of  the  mammary 
gland,  and  not  an  eitcap«uled  tumor.  If  more  than  one  lobule  Im  aflecled, 
tb«  diagno^iit  is  more  easy,  as  all  true  tumors  of  the  mamma  are  single. 
From  a  oininle  cyst  it  can  naually  be  dislinguishe^l  by  its  more  leatherr  feel 
nod  less  denned  outline,  but  the  •liugnoeis  is  n»t  ajwuyn  pnesible.  When 
from  the  age  of  the  patient,  the  multiplicity  of  the  tumore,  the  diiratluti  of 
the  disease,  or  from  its  geoeral  fealurea,  it  can  he  certainly  j^tated  that  il  is 
not  a  cancer,  it  may  be  left  to  tinie  to  determine  ita  nature,  but  should  there 
be  the  slightest  doubt  in  ihe  mind  of  the  Surgeon  that  it  is  malignnnt.  it  is 
his  duty  to  cut  deeply  into  it  without  delay,  and  remove  a  piece  for  micro* 
scopic  examination. 

^0  trealmetit  exerts  much  influence  on  the  progress  of  the  disease,  hut  this 
is  of  leae  consequence,  as  beyond  the  neuralgic  pain  sometimes  accompany- 


700 


D1SKASK5   OF   THE    UKKAST. 


hit;  it,  and  Iho  mpntnl  nnxiety  It  often  cnn^es  the  patirnt,  it  i<  a 

CAuse  any  inconvcnieiice-     BI!«tfriiij;,  )ir<ilitti|;t.-'i  imiotini;  Kiti<  md 

other  forms  of  rountiT-irritalioD.  priKiiicc  little  ur  no  rffrt-t.  tlcitwl>asn 
may  he  apiilie'l  tct  relieve  ihe  pnin.  Pre^mirr  tusr  piiMilily  l*n  of  (mtici  b 
•i»nie  ra^tM*.  Probably  tb«  caww  of  wcalled  adcucmis  rtr  caiirtr  coiwl  bt 
pressure  were  In  reality  ni«reiy  chrunically  iuflametl  lohulea.  ^tmaJd  it 
serionsly  aunoy  the  pHlieiil,  the  aflecteii  lobule  may  be  oafelr  retDorfd  If 
the  breast  i^  widely  airecleil.  uu  o^ierative  interference  elitnild  be  undertalivM. 
In  operating  in  lliefle  cjiwa  the  iucistuo  Hh'HiliI  he  placed  so  tliat  if  tbc  dii- 
ise  be  cancerous  the  whole  initinma  mar  be  removed. 

Chkomc  Autif:Ki»  uc  Tilt:  Ukkaot  may  ouunie  twu  fomu:  lii«  Di/mmJi, 
'and  the  Virvumtvrihfd  or  Kuc.v»t*d, 

Chrooic  Siffiued  Absceii  of  iliv  bretut  may  occur  at  all  tL^iem,  in  UtcMffti 
or  in  thf  innrried.  It  usually  iippcan  in  the  nuhniaoimary  amUar  tflH& 
often  without  any  estenial  oxcitiiii;  cuuhc,  but  as  a  ctiiumfueoce  of  iaipaind 
hetilth,  in  htrumous  or  caehectie  females,  and  ii  iiflen  ooauMtt^l  Mitb  titenw 
derangement.  It  may  attain  ii  very  larfj^  size,  and,  pttshinj;  ihr  maaiaiwi 
gland  funrards,  it  gives  the  hrcast  a  oonical,  pointed  sha[M)  Fliirtuatifl 
Btiim  liecomea  apparent,  and  the  ordinary  local  algos  nf  chntnic,  ncdd  arm- 
gentive  absce&t  diselnee  themselves.  <'brnnic  ahMSSBM  in  thb  ntualtoa  najr 
arit«e  aXw  in  eonnectJan  with  carirs  or  nccrons  nf  a  rib. 

The  TrtaUnent  uf  chronic  dlfl\i««l  abscess  of  the  breast  ottoMt*  \a  nakiai 
a  free  outlet  for  the  pus  in  a  depettdfot  siluntion.  keeping  it  frMvitJtl 
drainatre-tubc.  and  drewdng  it  by  some  eiBoicni  nntiseptir  mfth(Hl ;  it  ibt 

lie  linit-  tluit  l\if  f^oera!  health  i»  improved  with  iron  or  coii-Iirrr     ! 

Chronic  Encysted  Abscess  of  the  breawt  i*  a  diiM-aM*  of  k'r>-«t  )ni|> 
Tnoiimuch  a»  It  finitely  simulatM  vHrlous  lumora  in  llii':  ^r  •■•  iLLua 

so,  indeeil.  thai  it  \»  only  with  extreme  difhoulty  that  the  -i^       >  .effnrttd 

In  some  ea*«i.  Tho  breast  haa  id  numerou»  instanoM  bovo  aiiipuUKd  m 
the  supposition  of  its  beinn  lh«  s«al  of  tumor,  when  il  wasTiurnHy  ik««a 
of  a  very  chmnic  thick-walled  abaoeaa.  Thi:i  form  of  abacon  iMuatlyo*' 
menoes  as  the  result  of  pre^ancy,  whether  complete  partoritiuo  ur  aimat- 
rinjre  take  place :  aometimea  u  a  consequeooo  of  lacteal  iDflamnntioa,  ^ 
usually  without  any  injury  or  other  direct  local  cauae.  An  iaduralot  "^ 
lent  swelliut;  formH.  and  thb  mny  gradually  softcD  id  tlia  oeotrj :  b«t  ttt- 
luatinu  nuy  fur  a  luu^  time  be  very  indistinct,  and  even  abaeut,  twoc  (^ 
acured  by  the  thick  wall  of  indurated  tisdue,  eurroundiux  iha  «olttrtwi<' 
pin.  It  it)  owiu;;  to  the  dense  iutlnmmalury  iaduratiua  ui  the  aumMB^ 
tiMOM,  that  llie  chronic  encysted  nliscett  um  cointDonly  miaukm  foca*» 
tumor.  It  is  in  funeral  not  very  di«linclly  circumacrilitNl.  and  of  bulB"^ 
rate  niB^uitude  ;  ufler  u  time  it  renialutt  itlatioDary,  durintr  a  apaet  af  viT 
months,  or  but  tiliiu'ly  increjuK^  wilh  l>ut  little  pain;  il  ta  duC  oufiiytWiT 
attended  wilh  retrartinn  of  the  nipple. 

Diagnosis. — The  dinf^nooiH  of  this  form  of  abscns  ia  of  groat  iiDVMM*> 
inasmuch  as  it  him  not  unfre^iuently  been  exritfed  fnr  Iwaor  of  th»  mimL  * 
atn  actpiaioted  with  many  instanoca  in  which  thin  miatake  haa  beoaof^ 
mltlrd.  8iich  nn  error  may.  however,  ctnnmonly  be  artmled  by  attfBB* 
t')  the  following  points:  1,  that  the  existence  of  nn  abac«m  is  alm'Wt  isnri- 
ahly  |ir*4SNled  hy  i in prefrnation,  pnnurilinn,  «ir  miiic*rriai;e  ;  *1,  ''--i'  •*-'•  •• 
more  or  li*as  iixtema  of  the  subuutanooUA  nrrv>l«r  liMue  covrriti  •'* 

altliouKh  it  is  of  slow  liinuation  »nit  nithont  pntn,  it  is  not  diMioci'T  i-ir^ 
scribed,  hut  i;nwlually  fu»e«(  in  an  irre^fular  miinni:>r  into  Llie  ncielilMn* 
tiasuet;  4.  thst  it  is  not  freely  movable,  but  rather  in  :  -liih 

(MDt  parts;  and,  o,  that  uiasticitv,  or  even  deep  tlu..  be 

nualy  felt  at  one  part  of  it.    8buuld  there  be  the  leaat  duubt  is  tJM 


m 


OTSTS    OP    THB    BREAST. 

the  iiitrofluctiim  of  an  exploring  trocar,  hy  giving'  iwiie  to  a  drop  of  pus, 
will  always  delormiov  its  true  nature;  indeed,  thi« simple  means  of  diag- 
Doeiii  should  never  be  Degleclcd  in  any  eaac  in  which  there  is  rcMon  even  to 
niApecl  the  jMSiubiiity  of  the  apparent  tumor  of  the  breast  being  in  reality 
an  abaieett. 

IWatmmL — The  absctw  should  be  opened  as  soon  as  recogniKod,  and  if 
of  sufficient  siu;  a  drainn^-tube  ahniild  be  iiiiterleil.  Should  t\\e.  inti!f»  of 
indurntod  tii^AUe  surriiiMidiiig  the  piiH  be  very  Inr^^e  nud  dense,  a  free  iucUion 
carried  Lhriiu)ih  it  will  UMimlly  hnKteri  its  iliMipjit-arnikce. 

In  all  caM(9  of  rliruiiLp  aluce.^  of  the  breast,  but  more  particularly  in  the 
subiuaiiiniBry,  tlie  uriii  »huul<]  be  kept  Kt  perfect  rest  iu  »  )<liug  or  hnnilageiJ 
to  the  xide. 

TlUEKCLB  or  THK  Bkeast. — True  miliary  tubercle  has  nut  beeu  observed 
in  the  uuiiiniia.  C'ase««  have  beco  observed  dI  multiple  cavities  in  the  nianiinn 
with  vaiteou^  softening  ci^titenis,  but  tlie  evidence  tliitl  these  were  tubercular 
u  Hot  |«rf«:t.     BilJr^jth  quotes  one  such  case. 

STrmnTtc  Disease  of  tuc  Mamma.— Primary  8ore»  on  the  nipple  hav« 
alrmdy  iK-en  lueuliuucd.  Oammata  havu  been  deseribt'il  in  the  iiiamtna, 
and  a  few  caM»  rvvorded.  Uillrolh,  hunever,  d<i«i  iiol  regard  the  evidcuco 
of  llieir  wcurrunee  as  coucluaive.  There  ie  no  doubt  that  if  they  do  occur 
ibey  are  of  extreme  rarity. 

TX.ISIOBS  OF  THE  DHEABT. 

The  study  of  the  various  tumors  of  the  lemale  breast,  more  esperially  iti  a 
'diagnustie  point  of  view,  is  of  the  first  inipoitance  to  the  practiral  Surgeon ; 
for  though  it  might  be  supposed  that  it  would  be  easy,  if  not  to  recognize  tht; 
miouber  sbatles  of  palbolugiciil  d I Ui'reiKt;  betuecii  iiiurbld  groMths  so  euptr* 
[ficially  ftiluHted  ax  tb<>«e  ot  the.  niaiuuinry  gluud,at  nil  events  lo  r|iugni}!>u  [h« 
aialigtiiini  fi-i^iii  |b<;  uou-matiguaiit  Mllvctioiis  of  this  I'rguu,  yet  iu  practice 
nothing  is  more  diflicult  iu  many  casw  ;  and  it  not  uoly  r«<jiure»  great  k\\)v 
rieuce,  but  iiluKist  an  inttpuitle  uc<^uaiuUiucu  with  the  special  course  and 
syniptuius  of  each  [Mirticular  disease,  to  come  Iu  a  correct  conclusion  as  to  its 
natun;,  Kven  nitti  uli  the  light  which  experience  utid  a  careful  exaniinal-ion 
of  the  charactere  of  the  tuiuur  may  thruM  upon  the  uature  of  the  disease,  it 
will  be  iiuptMMiblc  f>;r  the  Surget^u  to  avoid  <jcea«Jiii]al  errors  iu  diagu*j&is. 

The  lir^t  thorough  cla^ilicution  of  the  diHi^reul  varieties  of  simple  tumors 
'lliat  develop  in  the  cuammary  gtuud  uas  mude  by  Sir  Astley  Cooper,  aud  this 
rimportatit  department  nf  ijnirgical  pnchology  was  suliceipipnUy  nuich  extended 
T  the  na=earcb<*  id'  Veliieau,  Kirkeit,  and  Paget.  Evince  the  inipnivenientJi 
ibe  inethiHU  of  investijration  have  led  to  a  nmre  (terteel  unatomical  eliis^i- 
ficatiou  of  tumors,  [he  contusion  ibal  formerly  curnitinrled  this  very  intricate 
subject  bus  been  lo  a  great  extent  cleared  up  by  ibe  labors  of  Vircliow,  llill- 
roih.  Grow,  and  others.  The  micri*(.'opic  characters  uf  the  various  tiinioTS 
uf  the  breast  are  imw  accurately  determined  and  gt'uernlly  agreed  ujiou,  but 
Confusion  still  remnlna  in  the  nonienclBlurc  which  time  u lone  ran  remove. 
Id  deecribing  the  various  tumors  uf  the  breast  I  sbitll  follow  the  order  ndoptcd 
in  the  chapter  oti  Tumors  iu  general. 


KON-MALIONAST  TUMORfl. 


Cms  OF  mK  Breast  are  of  common  occurrence.  They  t»ccur  either  as 
iwlciwrndent  tul^o^s,  or  in  conjunction  with  solid  j;rowth».  To  the  former 
clsis  belong  Uetention>cysls, Serous  Cysts,  and  I'arasitic  Cysts;  lo  the  Inllcr, 
the  cystJ  met  with  in  "cysto-sarcoiua, '  and  the  cysla  in  suit  sarcomata. 


702 


IIISSASE9    OF    TUK    BRSJkST. 


1.  Setantion*oyBti.— Tlicac  are  fominl  by  the  j^ndml  dilataliw  «f  ite 
acrini  or  i|ii(.-t^  ot'ttic-  nmiiiniary  fjland.  The  " gaUietoeete,"  aj ready  Jmtftti 
(p.  <S!)4  I.  iM^lon^'s  pro|-trly  to  this  da^  of  tumor.     Il  ui  produMM  MiMyby 

tion-cVAla  funne^l  in  (he  inanima  at  othur  timm  ticv^r  cttacain  nUk.  7W 
fluirl  that  distcnrU  them  \a  u-tually  thick,  iu)mclitiiai  aJmovt  niuoou*  ta  ■ffir 
ance,  and  uwuatly  nf  a  hnkwuisti-Tclltiw  or  liniwu  rntur,  and  tuuni  m  k* 
turhifl.  It  is  an  abnnrmal  secretion  fr»m  the  ulatultiMuv.  InralacMi^ 
the  sole  cause  of  the  comiilion  ia  nbstniclioo  of  a  iluct,  but  In  we  (Till  M 
■rtt  now  comtidering,  ahmirmal  secretion  i»  the  priiiinry  factur  io  tu«  pf^ 
duction  111"  the  diiifjise.  The  walls  <jf  lliew  cvnU  arc  conifuwnl  *4  a  laywil 
connective  tiMue  of  rariable  thiclcix^,  umtniniii^  usually  ati  alHinilaatt  «ap- 
ply  of  capillary  vewels.  Ttivy  are  linf<J  intvriially  by  a  layer  of  vph^rttaia, 
either  cuuical,  Bonu'whnl  rivtrniijling  Ihnt  of  ihe  normal  acini,  or  cuIbibbm, 
like  that  uf  th«  duct*.  Viirious  luudilicatiuiio  also  are  ui«(  with  whidi  aill 
be  dttcribed  IhIvt  »u. 

.\s  l>eforv  ntalofl,  cysts  of  thia  rlaaa  ar«  freriuoiitty  tnci  with  in  labqiarf 
Um  mamma  aflcwteJ  by  chrimic  inlerstilini  inflammuiinii  i  p.  61*8 >.  Thatm 
usually  multiple,  iiud  aeidom  reach  nnv  Krenl  Btze.  They  are  al«>  not  v> 
common  in  the  indurated  and  atroithieJ  breeata  of  old  womvo,  and  «te 
met  with  under  theae  circuinstancvs  nave  l»eeii  termed  "  invUaUott-vtit.' 

Keiention-rystfl  arising  hideiwiidently  of  these  couditiuns,  or  fMBlikr 
cyita  as  they  are  often  termexl.  nmy  be  multiple  or  single.  Aa  a  fp»nilua» 
pie  of  the  multiple  form  the  following  case  may  W  gtveo  :  A  youue  aaaa^ 
ried  woman,  in  order  to  quiet  a  bnhy  she  had  charge  nf.  put  il  ttwiiawlly 
to  her  breast.  This  was  followed  by  Dump  pain  and  nwelllng.  ud  a  iMi 
Telli)wi»h  Hittcharge  frini  the  nipple.  .S<>me  months  after,  on  (•samiaiatlbt 
bren8t.  a  number  of  small  i1u(!tunting  swollinRS,  the  largeat  abamt  tlwui*f 
a  bazel-nut,  could  be  felt  bcattercil  through  both  breasts.  Tbey  were  VMl 
distinct  in  the  neighborhood  of  the  areola.  The  dbcbarge  enntioDeS,  mJ 
wna  a  source  of  c>>n»idLTnblc  annoyance.  On  pressing  the  cv»ta  tikcir  ex- 
tent* were  easily  stjueened  out  through  the  nipple.  The  cnnrliiinn  nM^BtA 
unchanged  (or  about  two  yeani.  in  spite  of  belladonpa  and  other  cffftll 
remedies.  !?be  then  niarrie<l  and  became  pregnant.  Aa  the  bnaat  Mtaf|iA 
the  abnormal  discharge  gradoally  ceased,  and  aAer  berconfiaemat  A*Mi 
able  to  ouPK  her  child  without  difficulty. 

(single  c>'st«  of  the  same  nature  are  not  UDCommooly  met  witb,  aad  nff 
attain  a  coosiderable  size.  They  form  rounded  or  lobatatod  laoMiCi^tisaslT 
imf>erfectly  defiood  and  nainlcsH,  or  nearly  so.  When  tb«r  eoalcnCi  flU " 
squeezed  out  at  the  nipple  they  are  usually  soft  and  flfielnating.  SluMtM  tk 
duct  become  f«miplctely  or  partially  bloc^od  either  from  inflaminalMy  ia<l>' 
ration  nf  the  surrounding  tisaue,  or,  as  in  a  case  recorded  by  Bogeaa,  ktl 
small  papillary  growth  springing  up  in  its  interior,  the  cyst  iDcrma  ■** 
rapidly  in  si/e.and  beoomea  so  teoae  as  to  be  easily  miitak«a  for  ■  solid  tB«* 
The  vwxiA-%  of  these  oyats  are  anccrtaio.  Tbey  Mcm  nmally  to  arist  Cna 
some  injury  or  irritation  of  the  breast.  ButJin,  who  has  recently  puUiiW 
sotoe  interesting  obtorvations  on  these  cysts,  states  that  tbey  usually  «ieniraIIM 
ihirty-five,  in  women  who  have  borne  children,  and  in  ■rmrnl  caaea  tpp*" 
to  have  arisen  as  the  result  of  a  blow.  In  some  caaea  they  nay  po^My^ 
aasociated  with  some  uterine  afTection. 

Cysts  nf  this  kind  may  become  the  seat  of  fntroejn'ur  ffrowfAl,  enmpiap' ^ 
dclical«  branching  pn|>ilt»:,  covered  with  epithelium  of  the  ■ajsterharaiiif  ^ 
that  lining  the  ryul-wall.     The»e  may  at  last  citmpleiely  fill  ibe  i-xviiy 
verting  it  into  n  solid  tumor.     These  vascular  jiapills  reailily  blsed. 
have  probably  be«n  the  source  of  tb«  blooily  tluul  which  ho*  bcvo 


^ 


m^m 


SKROUa   AND    HYDATID    CYSTS. 


708 


E 


^  fioai  tha  nipjple  in  somo  of  thcAC  cmca.  It  ii  po^ible  that  th«fte 
nuy  bcoome  mahgniiDl,  and  b«  tb«  sUrting-poiut  of  a  f>eculiar  turm 
oT  caoc«r  wilh  colunnmr  «pitheliuni,  occaaioualt}'  met  witb  la  lh«  breaat,  to 
b«  sulMrquvotiy  fle«crii)«d. 
2-  S«rou«  Cy«U  of  the  Breast— Tb«tK  are  believed  lo  be  formed,  as  el»e- 
t  b;  ditaUliLiu  of  tbu  lyiiipb'HpHces  of  tbe  areolar  tinue.  tbe  wait  ot  th« 
iMlDg  furnied  of  the  lurroundiDg  cooDective  tissue  prened  bigetber 
•ubaetjuentlr  tbidcened  br  new  firowih.  The  evideuce  of  thU  mode  of 
irmrth  u  out  by  any  oieaaa  perfect,  but  it  aeems  the  ouly  poesible  expluua* 
OoB  nf  tbeir  atnicture.  Their  vralU  arc  compueed  of  delioatc  arenhir  Uasue, 
llMd  iateraally  with  flatleiied  eailothclial  cells  like  tbikoe  of  u  lymphatic 
IOkL  Tbe  contents  are  UBunlly  citar  yt.-ltou'i»h  serous  fluid,  but  niur  aoms- 
tUM9  be  bruwnisb  or  turbid,  from  ihc  udinixlurc  of  bluod.uod  iu  e^iitie  caaea 
ebolortenoe  is  present.  Tl)c«e  cysts  arc  u»ually  single,  sometimeB  tbey  are 
loeolunl  and  ID  other  cases  multiple.  Tbcy  are  Uttuully  al>out  tlie  aiz«  of  a 
ilbert  wbeD  first  noticed,  and  may  remain  small  for  a  great  leo^lfa  of  lime, 
kut  in  oUier  cases  tb«j  gradaally  increase  until  tbcy  may  contain  sereral 
(MDce«  of  fluid.  Tbcy  then  become  very  tense,  ao  much  so  in  fact  that 
floctuatton  is  no  longer  present. 
Unilocular  cysis  of  the  hreAst  oorafttnnaMr  attain  nn  immense  size,  at  the 
le  time  that  their  walls  remain  thin  and  supple.  In  the»e  cases  llie  skin 
rrin^  them  may  become  thinned  and  translucent,  constituting  tbe  condi* 
hicb  has  b«?n  termed  hydrocele  of  the  breatt. 
The  simple  serous  cysts  never  develop  iniracyctic  growths.  In  some  rare 
•cs  e»k-li'  .      r"  the  cyst-wall  has  been  olisvrveii. 

ft.  The  :  fifi  C>-l  is  extremely  rare,  but  hns  been  met  with  in  the 

■nntna.     'ihts  dimple  serous  cyst  was  described  by  8tr  A.  Cooper  uud«r  this 
a«»e. 

Tb*  IMaynotif  of  a  cyst  of  the  breast  mar  usually  be  eflecteil  by  feeling 
Use  globular  elatttic  tumor  under  the  skin  ;  tlie  maiuniary  gland  being  raov- 
abW  *nd  not  adherent  tu  any  of  the  adjacent  structures.     Cysts  being  con- 
Beetad  with  tbe  mammary  tissue  drag  upon  ibc  niptile  wlit-n  moved  away 
from  iu    Tbb  is  recoguiu-d  by  holding  the  nipple  lightly  while  the  tumor  is 
drmvn  away  with  tlie  other  hand,  when  the  uounectiou  between  them  will  be 
olmrlv  perceptible.    Iu  thuse  cases,  however,  in  which  tbe  tumur  lies  deeply, 
tlie  dmgtKwis  may  not  so  readily  be  made,  mure  especially  from  tumors  con- 
taining eyaia  or  tsancer.     In  fact,  nothing  is  more  easy  than  to  diagni^e  the 
true  aature  of  a  eupcrficiully  sealed,  lax-walled  cyat ;  nothing  is  more  ilifli- 
call  than  to  recognize  it  when  tenne  and  deeply  seated  towards  the  under 
■irfrce  of  the  niamniary  ^bind  I  Fig.  771 ) ;  for,  the  whole  thickness  of  the 
plasd  tntenrening  lietwcfu  the  i-yst  and  the  finger,  the  sense  of  elusiieity  is 
lost  and  a  »i>liil  feel  communicalnl.  which  may  readily  mislead  even  the 
xttH  rxpc-ricnred  Surpeon.     Whenever  tbe  !?urgeon  has  any  douht  about 
tha  cxiatence  of  fluid  in  a  lumor  of  the  breoi'l.  he  i^hotild  introduce  an  ex> 
iilarinf^  trocar;  when,  if  the  ilis«^n»e  be  cystic,  the  fluid  will  be  discharged. 
U  thv  tumor  prove  to  be  solid,  no    tlbconsequcncci  will  result  from  the 
UBipIc  puncture.     Several  instaucM  have  occurred  to  roe  in  which,  from  the 
«wi  <if  thii  simple  precaution,  very  excelleut  Surgeons  have  condemned  •• 
cancrr    -  • -■-•i.tn  of  the  breast,  which  proved  to  be  cystic-. 

T<'  ■:»  of  the  retention-cyst  from  the  simple  serous  c^'st  ia  not 

pOBttiir  ii[ii>^  Quid  can  be  sfjueeu^l  from  tbe  nipple,  a  condition  which  of 
eaaae  cannot  occur  in  tli«  eemus  cynt.  If  this  sign  be  wanting,  the  nature 
"t  tW  jiMBM  may  be  recoguiz^l  in  moat  rases  by  the  character  nf  the  fluid. 
n>*  true  hydatid  cyst  is  stj  rare  that  it  mav  be  practically  excluded  iu  making 
^  ^Ibgboaia.    It  may  be  recuguized  by  tiie  character  of  llie  fluid  withdrawn 


704 


DISBASXS    or  TIIK    BRKAtfT. 


on  puncture.     Tliij^  im  t-lenr,  C4)iitiiiniii^  nirtrty  tlip  fnintrct  trace  of  i 
una  hut  a  i^jicciflt  );r»vity  of  UMli  lu   10m4.     IIiMiklft*   maj'  powli 
found  iti  ii,     Without  piinclure  these  cysts  cannot  b«  i)iil)0)pt'Mbs4 
the  nther  loriiis. 

Trfatmcnl. — The  (r«atmu»t  <>{  cyMs  of  the  brmst  varies  arcnrijing  (o  llwir 
Dumber  nml  siiu>  aud  the  presence  or  alisctice  of  ititr»cy»l!'-  ".  — •!.*.  gasll 
multiplv  r«t4MilJi>n-cyst»  which  can  hv  eniptieH  through  lh>  -  fowtiaa 

require  uo  furthpr  tr«nlin«nt.  Bellndouna  or  «oine  form  ul  "  lofiMrTttaiMs 
may  be  applied  exteniHlly  in  the  hope  of  arreetio^  Iho  abaurmal  sMictieo. 
but  these  ineaDS  are  seldom  of  much  use.     Jf  the  cyst  is  larger  and  tmamt 


t^? 


Fl(.  TTI.^Br«ftft  laid  opvn  mtttr  r«B»u*Kl,  >bu«tag  Cj»t»  dav^lji 
Utuiil,  laUUkaa  foe  8«l(rli«>. 


mmtfi  la  Maaw) 


b«  emptied  by  prewure,  the  fluid  cootADta  may  be  Id  out  by  wadatrtt 
with  u  small  trr>car;  hut  a  cure  cannot  usually  he  rffectcd  in  tnii«iy.*> 
the  fluid  rfAccumuliitea.    Occasinnnllv  it  will  suppuraie  BDoDionoowIy.tf' 
is  tiius  got  rid  of.     If  the  tumor  be  einplti.  it  may  usually  ne  cored  iTf^ 
ing  it  by  r  Email  incisioo,  wipinj;  it  out  with  a  st'roDg  B>ilutina  of  Amimn 
xtnc  or  tincture  of  i>H)ine.  and  iosertin;;  a,  drainage-iDhc  under  an  aoliMft'' 
dn-minf*  for  a  few  •lays.     If  it  seem  to  bo  surrouDdrd  hr  induniled  msiaMiT 
li!«up,  it  U  nfccn  best  to  dissect  it  out  and  to  remove  it  with  the  lobaleoftV 
maniiiin  l<i  uhii-h  it  is  Htlachnl.     On  doing  this  it  will  otWn  b«  fM*A  A" 
the  cvft  ii>  Dot  )>ing1e  a*  was  at  lirst  «n|ipueed,  hut  that  several  saialbr  H^ 
are  pn-wnr  which  Imve  U*»  toncvaled  oy  the  larifiT  one.     If  the  eyK**" 
taia  intrs'-ystic  gr-ivi  ths.  it  sti^uld  l)c  coiiipleiiL-ty  rvniovfd  with  tlM  Mi|hhDr 
ing  jtart  of  the  ninnuiinry  ^land.     If  |he  cysli  are   niultiple.  ibcy  laMI  ^ 
treated  acoonlin};  to  circunintaoces.     Ifthvre  arv  but  Iwoor  thrve,  (beyy 
be  irealeil  un  if  eingk',  hut  if  very  numerous  there  U  nolhlog  tu  be  dM*!"* 
10  remove  the  breast  if  operative  iuterfereuce  is  deiimndeil. 

Lipoma. — I-Vtty  tumors  baveoccoaionuilybeeu  nietnith  !n  rlnM  artablAC 
tu  tliu  mamma,  so  as  to  simulate  «  tumor  of  the  gland  itself.     A  ItltW 


ADENO-riBKOMA — ADBNO-SABOOU  A. 


705 


fa]  examination  will  ueubIIv  onsble  the  Surgeon  to  ascertain  tliat  the  gland 
i»  not  implicated.  The  JVetttmeni  of  lbc»e  tumorB  prcwnla  oothiiig  |wcu- 
Itar. 

Fibroma. — Pure  fibroma  of  ihe  mararaa  is  very  rare.  One  case  only  Km 
occurred  in  Uuireniiy  Ctillege  liiutpilal  iu  the  laat  fifteen  yeant.  Ibe  patieut 
was  a  middle-aged  woman,  and  llic  tuinnr,  which  wn«  about  the  eizeut'  a 
hea'fe  egg,  wta  of  atony  tiuntna^.  It  was  Llimight  to  be  a  Bcirrhnus  cuncer, 
bat  as  there  was  some  dimbl,  u  de«p  incision  wn^  ninde  into  it  befure  remov- 
ing the  breast.  It  wax  found  tn  \k:  t^xcin^'lingly  dmite.  orenkeil  under  the 
knife,  anil  no  cuficiule  whh  recitgnized.  Ader  removal  of  the  breast,  it  vtat 
found  to  be  cli^rly  4l«fined  and  8iirniun<lnl  by  a  distinct  but  dense  cnp«ule 
from  wlii<;h  it  cnuld  Im>  dissected  nut,  leaving  the  inainniary  ti^ue  untouched. 
MicroBCopic  exntninntion  .'^howed  it  Xn  be  cc>mp<iecd  of  pure  dense  fibrous 
tissue,  without  n  tnire  of  glandular  structure. 

CbondroBa  and  Osteoma. — Tumors  of  the  breast  containing  cartilage 
have  been  recorded,  but  are  of  extreme  rarity,     Killnah  niontious  a  ease  of 

large  aarcomn  of  the  mamma  in  which  small  nodules  of  true  bono  were 
fi>unu. 

Adenoma,  Adcxofibroxa,  Adeso-sabcoma,  C\nro^xncoux.  ~  A 
group  of  tumors  closely  related  to  each  ntlier  pHtbol<>gtcally,  though  dilfcriog 
considerably  clinically,  are  included  uuder  these  natties.  The  eoaential 
'^tures  common  to  ail  are — first,  the  prtsenee  of  spaces,  either  flattened 
and  slit-like  or  forming  dinlinct  cysts,  tin«d  with  a  flmalt  cubical  epithe- 
lium, usually  in  wvernl  layeni  but  occaaiunMlly  single  (vol.  t.,  Fig».  ItRA, 
ti^4).  The  spaces  coatain  a  variable  amount  of  fluid,  in  wiine  cases  ju>  small 
in  amount  aj*  to  be  scarcely  recognizable,  in  others  disteinling  the  cavities 
ipto  well-niHrked  cysts,  seldom  excee<liug  an  inch  or  an  inch  and  a  hall'  in 
diameter.  The  bulk  of  ihc  tumor  it<  eompnaed  of  the  inler»lilial  ti^ue 
bvtweea  the  epitheliumdined  spaces.  This  tissue  varies  fpim  fully  developed 
fibrous  tissue  to  the  eimpluit  embryonic  tissue,  and  mar  preaent  every  stage 
between.  Thus  it  may  be  composed  of  small  spindle-cells  with  numerous 
fibres  between  them,  ot  imperfectly  developed  fibrous  tissue,  infiltrated  with 
small  ruuud  cells,  of  large  spiiidlc'cclls,  of  delicate  fibres  with  stellate  cella 
nnd  mucous  intercellular  substance,  or  of  various  combinations  of  these 
structures.  Lastly,  when  the  Hpu(*es  develop  into  cysts,  they  often  present 
iatracyslic  growths  of  great  aha  forming  the  most  marked  feature  of  the 
tumor.  These  growths  are  l^irmed  4)f  procegttes  of  the  interstitial  tiasut:  ot 
die  tumor  projecting  into  the  cyst,  and  are  covered  with  a  layer  of  epithelium. 
They  are  often  branched,  and  mar  in  iv>me  casce  comiik'U'Iy  fill  the  cavity 
into  which  they  grow.  They  may  nprout  from  all  slues  at  once,  and  then 
form  a  closely  packed  f.liaterl  mnsa.  without  any  clear  evidence  of  the  mode 
of  growth  remaining.  In  other  cases  a  ]>edunciilatcd  mass  springs  up  from 
a  single  p'>int  in  the  cyst-wall,  and  may  project  into  it,  still  surrounded  by  a 
certam  amount  of  fluid,  or  may  completely  fill  it,  displacing  the  fluid  and 
being  Aurrouiided  by  the  cyst-wall  as  by  a  capsule. 

In  whatever  way  the  tumor  growa  it  remains,  as  a  rule,  completely  sur- 
rounded by  a  cagtsule  of  areolar  tissue,  and  forms  no  tidhe^ons  to  the  sur- 
rnundins  paru  unless  it  be  allowed  to  reach  such  a  size  as  to  excite  inflam- 
mation by  the  prcesure  and  tension  it  exerts. 

Of  the  cau»es  and  mode  of  origin  of  these  growths  little  u  known.  Bill- 
roth state*  that  they  commence  by  an  overgrowth  of  the  connective  ttitaue 
■urrounding  the  acini  and  •tuct«.  But  whatever  point  they  may  commence 
In  it  is  evident  that  iu  their  suhse'iueiit  development  the  growth  of  the 
epithelium  is  as  essential  a  piirt  of  the  process  as  is  that  of  the  interstitial 
tiwue.  The  presence  of  the  epitbelium-liued  spaces  b  not  a  mere  accident 
rot.  ir,— 4fi 


706 


D[8EA8ES    OF    THE    BREi.8T. 


of  llie  growth  but  an  «Menli&l  feature  of  iL    Thaw  UiiBon  an  ifcgiliw 
property  termed  adeootnata. 

The  diflvreiicvs  in  snatomiral  structure  corretpond  t^ilcrmbljr  icmtUtf 
witli  the  varittliona  io  tlie  clioical  coiine  of  the  growth.  The  mtm  ptrtort 
is  the  dcT-elopiiient  of  the  JntentUial  fibroua  livue,  the  »lower  i»  tb«  p-«k 
of  tbe  luntor;  the  more  embr/oaic  the  tiasue.  the  more  rmpid  h  iu  orrfnm 
and  the-  greater  is  the  risk  of  ita  exteadiDg  beyond  its  capBuk.  U)filir«u*| 
Deighburiii)^'  (wrtf,  aud  recurring  iu  iuteraal  orgaoi,  lo  tact,  raool&f  lb 
Mwrm  of  a  uiali^uam  Mirconia;  a  lerrainniion  wliit-b  is,  bonrrcr,  ttrj  nn 
in  lhe«e  caseit.  It  not  unconinionlv  hap|K-ii«  that  the  lumnr  appemnfntM 
a  small  hard  nodule,  e^-idenily  witli  firm  l)bri>ui>  iiiterBtittiil  tiaiitc,  and  aaj 
remain  in  thin  Miiiu  for  nuioy  yean,  scarcely  inrn-axint;  in  UKe;  bnl  aAff 
middle  life  it  may  diiddenly  take  on  rapid  frrowili.  and  «ben  rciBDitd  m 
iDKTviitia)  fulte'tntire  will  pri>bably  oonaKt  of  Bpiodle-calla,  orof  MMH  tfw 
mort'  eniliryouic  form  nf  tissue. 

Tlir  brief  Bnaloiiiical  flketrh  above  given  will  sufficifnlW  etpliiD  ik 
various  names  beRtoweil  uivon  this  clnai  of  tumnni.  When  tiie  UiMutkii 
■low  growth  flud  lirni.  It  U  often  called  ihe  dintHt'e  JUammary  Tiravr,  iM 
name  originally  given  it  by  Sir  AiPtley  Cooper.  Abrroeihy.  Inita  ii#  »»• 
teniblatire  of  il'ie  Mrtinn  in  some  canes  t^  that  «if  the  psm.-rf'M.  irrti>MJ  n  Ux 
Pan^eatic  Sureoiua.  Vidal  termed  it  partial  or  /ofrwAir  liyprrlrtif>itf  tftit 
mttmrnu.  In  this  cuuntry  it  is  rao«|  commonly  lermeil  the  A*mfiU  Adimm. 
Th^  term  Adft-o  Jibrmna  is,  however,  that  which  mmt  cloaelr  dttnfcw  i» 
anntumical  •>(ructure.  and  is  undoubtedly  the  beet  (vol.  i.  p.  iM,  V\f,  Vft 
Wheu  the  intentilini  (i^ue  is  either  enihryniic  or  mid''  r^af}k 

priiDury  luodilicHtiouB  which  embryonic  tiwue  mauifesUs  n.  .  i  J.r^iiBHl 

iutu  hlirouit  tiiwue,  in  other  wonis,  when  it  corm{Mmds  to  ib«  rtructw 
eliaracteristic  of  H  enrconia,  the  lumur  is  calk-^l  nn  Admo-mrvamH  {v^i-i 
p.  \}o'i*.  h'iii.  ■iiiii,  Hud  when  stellate  eel  It)  are  found,  and  the  tumor  TifUl# 
squeezing  an  abundant  glair}'  uiucous  fluid,  il  is  uf^en  termed  Adttminf^ 
tarvoma.  When  cysld  lurra  u  marked  fenture  iu  the  groivth,  it  is  cvannalf 
termed  a  i^fio-aareoma  of  the  mnnimu,  but  other  lerma  are  also  appliadtoit 
ThuH  BrMlie  termeil  it  the>Srn>-cy«fi'c  Mranna.and  Paget  sugmtra  ths  SM* 
of  itlanduiar  praU/eroua  cytit.  '['he  term  C^-etiHwrcotna  originally  tuggMii 
by  J.  Mtiller  i^  so  generally  adopted,  that  it  is,  pi-rhapd.  most  oitimbfatl* 
nilhere  to  tl  for  clinical  purpomv,  therefore,  these  three  fonsa  vay  b 
described:  the  Adeno-fibroma.  Atlenomircoma,  and  Cysto-HsreoaM,  fffBW 
Iwring,  as  Uillroth  says,  that  from  a  pun;ly  nnntoniii-al  point  of  ritv, iW 
diffcrenon  between  thew  forms  is  verr  sliglit,  and  that  we  aboald  be  paisellT 
justified  in  considering  the  Adeno-fibroma  as  the  initial  ata^  of  ite  AM 
Ibrma. 

Tbe  Adeao-flbroma  ih  tbe  moat  eommoo  simple  tumor  of  tbe  brvMt   ^ 
Is  often  nllributed   to  blows,  Hqueezei,  or  lacteal  irritatitio,  and  h  alv^ 
invariably  met  with  in  youne  women  onder  thirty  years  of  ajce;  osullyi* 
women  othcrw is*  beahhy.     Il  is  ofWn  asaociated   with  the  byaferieal 
perameot,  and  connected  with,  if  not  depcitdent  on,  aterine  irrttaiMi 
•exual  excitement  of  an  irregular  kind.     This  tumor  it  generally  t4 
size  when  tint  perceived,  and  may  remain  stationary  for  many  yean:  «r 
may  slowly  iucreaite,  and  at  Insl  attain  a  considerable  bulk.     In  utbera 
may  very  rapidly  grow  to  a  great  site.     In  a  cose  on  which  I  opFnt«d 
yenra  ago,  the  tumor  had  continued  for  eighiecu  years  about  tbe  a' 
walnat,  Dut  in  tbe  course  of  six  months  it  iDcreaaed  lo  an  envrsMMS 
tnde,  and  on  removal  wetghwl  uearly  five  [>ounds. 

Thb  tutDor  usually  comntencfs  ns  a  small,   movable.  flDeljr  nod' 
growth,  atucbeil  by  a  |iedic]e  to  one  side  of  the  maninary  glaoa;  h  b 


LTMINr  OP  AUKXO-PIBROUA  AND  ADEXO-Sj 


I  A.  707 


lod  iaoDaprMnble,  often  appeam  iioluLed,  and  is  not  g^nernlly  palnru),  but 

ii  mtuunie  women  may  be  tlie  seat  uf  inteiwe  aeuralgic  |)nia ;  it  iDcreaiei 

ilfmlv.  wiibout  discoliirtog  ibc  ekio  or  becomiog  atcacbed  to  it.  and  is  fre- 

jmiily  Duuiy  rears  in  attaining  a  oioderate  size.    It  is  often  floating,  as  it 

^fcoi  in  tJw  substance  of  the  gland,  into  which  it  can  be  pushed  back.    This 

^nvr  la  someticBee  mtfttakcii  for  a  cancerous  growth,  aud  the  diugnosis  is 

«Acn  as  difficult  as  it  is  iaipurunt,  ttiuugh  in  many  cases  the  comparatiTa 

jooUi  of  the  )iati«ol,  the  mnbilitr  uf  the  inase,  the  abseacc  of  all  inipUcn- 

lioa  ai  the  skin  and  glamJH,  ami  its  accunitely  cireuinM-ribed  clmracter  wilt 

Ulcwe  its  true  nauin-,     Crala  and  chmaic  iutentitial  iuHammacioa  of  a 

lafanle  are  often  miHiakPn  ftir  adonnma.  and  in  many  caaes  the  diatioctloD  i« 

very  difficulu     The  ilia^mwis  is  made  by  the  more  aocurnie  circumscriptlott 

•f  ihc  fibro-aileDonm.  and  by  i[>t  licio^  unually  riearly  separable  from  the 

wininn.  and  not  connected  wiih  the  nipple  by  a  cord  nf  diiriA  which  can  be 

fck  on  drawing  the  tumor  away  from  the  nipple  while  that  ia  gently  held 

Wtwctn  the  finger  and  thumb. 

On  «Xiuninatiun  aller  removal,  an  adenoma  appean  to  be  irregularly 

lat«d,  ia  eucliwed  in  a  capsule  of  areolar  tiasiie,  and  its  cut  surface  is 

'  Ut  present  a  bluish-  or  grayish-while  color,  which  after  exposure  to  the 

;aHnnic»  a  njey  tint;  and  on  preMure,  drops  of  a  thick  mucous  or  aeroui 

'  arc  often  seen  to  cxud**.     On  examination  with  n  tens,  ila  loliated  struo 

ia  atien  v«rr  appareut,  i>o  much  so,  that  it  has  been  compared  by  Virchow 

the  section  of  a  cabliage.     This  is  mure  clearly  seen  atler  it  has  been  a 

4ty3  ID  DpiriL 

AitBlhMreoma. — An  nileno-Gbrnma,  ihoiigli  usually  very  chronic  in  its 

mar  at  tim«)  assume  cxtremv  rapidity  of  gr^twtb,  so  as  to  simulate 

loer.     This  huppcmi  usually  iu  tbuoe  cases  in  which  thu  tumor  has 

saed  in  a  quiesceut  state  from  an  early  period  up  to  about  the  middle  of 

in  cases  in  which  the  disease  develops  for  the  firet  time  between  the 

of  35  and  40  tt  may  grow  quickly  fn>m  the  tinsL     In  these  cases  it  will 

m  with  extreme  rapidity,  attaining  in  a  few  months  a  size  equal  to  that  of 

ooma-nut,  or  even  lar^r,  and  simulating  in  this  respect  the  progr«s  of  an 

ihaloid  tumor.     These  rapidly  growing  adeno-sarcomala  are  painlees. 

rale,  however  large,  continue  perfectly  movable,  free  from  de«p 

I, or  from  gtandutar  implication  ;  the  skin  covering  them  Is  healthy. 

and  unndherent,  the  nipple  projecting  usually  very  prominently. 

tuiDitr  itdclf  will  be  felt  to  be  notlulated,  mmi>elBBttc,  not  stony,  and 

151  rounikd  in  outline.    After  removal  its  section  is  lohulatcd  and  gtiaicn- 

■MneChing  resembling  a  mass  of  rice  or  aagojelly.  often  having  cy^ts 

Ltir'iOx'h  tu  substance. 

Mammar;  Tanor. — tt  occaaionnlly  happens  that  an  adeno-flbroroa 

the  svnt  or'  vt-ry  severe  and  paroxysmal  neuralgic  pains,  attended 

■ifc  nrf  eooiiidemble  cutaneous  scQAibiiity.  and  it  has  then  been  termed 

tWpafa^  mamntartf  ttanor.    This  condition  roost  froquontly  occurs  in  early 

K^ and  in  womni  nf  an  irritable  and  delicate  oonsiituEioQ;  it  ia  commonly 

>»fiatc»i  with  disorder  of  the  uterine  fbncUons,  the  paio  increasing  at  tbe 

WuBcnia)  periixls. 

TlMtmsat  of  Adeoo-flbroma  and  Adeno-s&rcoma. — If  the  tumor  be  firm 
**A  tauill,  uid  shows  110  tendency  to  further  increase,  it  may  be  let  alone, 
■•Ibi  it  bo  a  source  of  mental  disquiet  to  the  pHlienu  If  it  auume  tbe  form 
"^  ilie  painful  mammary  tumor,  the  treatment  must  have  special  refercDoe 
I^Uw  removal  of  the  neuralgic  condition.  This  is  commonly  best  eAotad 
"T^'n  intaroal  adroinistralii>n  of  alteratives  and  tonics,  more  ]Mirticularly 

C rations  of  Iron  and  zinc,  with  ciKl-liverotl  if  necessary;  and  by  the 
of  an  nintMnnl  of  belladonna  or  aconite  into  the  alfected  hreasL 


708 


DISEAaSS   OP   TBB    »BKA5T. 


Id  mnuTciiFCf  theiipnlicnrioDnf  a  few  leedits  from  tint^lo  time. afiKklilk 
tbo  vioiiiily  of  ihc  axilla,  will  lewrn  the  Dcuratgin  more  cflcctuatljr.  Hum 
mpm)!^  fail,  ihc  tumor  muit  be  removed. 

Adeno-fibromata  are  said  to  have  occanoSBllj  disappemd,  um)  !■  «■§ 
iosiBuooH  tn  have  boeo  Hptrntsneou^lj  nb^iirbi^  after  marrage  or  diiriBfipnf' 
Dimcy.    The  iuternni  Ddniioi&tratitui  nf  Flummer'a  pill  aod  ibe  cciwmm 
decoflioD  of  11I008,  and  the  external  applieation  of  leecbn.  feUowrd  by  At 
inunction  of  iodide  of  lead  oioimcnt,  and  the  emiiloymeni  of  pr< — ■■—  -■•^- 
by  means  of  Arnott's  slack  air-ciubion  or  by  Taiichuu's  plMO.nr 
have  caused  ibc  abBorplkm  of  tbp«e  tuooora.    Tanclinu'A  a|iparn:^>  iii^ki 
of  a  pad  tu  which  a  spiral  apriof;  ia  attached,  and  wrhieh,  Witi|:  riiDi|>rTMrd  bf 
a  proper  armngeiuriit  of  bandag«B acroM  Uic  cli«wt,  will  kcrp  up  a  *frBJT  *W 
continued  preMure  up/>n  the  tumor,     ll  ia  leM  expeoMvc  nml  rttmUr^-v 
than  tlie  air-compreMtor,  and  haii  the  advantafre,  that  it  i:)T! 
junction  with  abtorbent  uinlnienta,  whieh  ranmil  be  u»eil 
as  thf  {{iniAe  enteriiig  into  their  comnoaitiim  ilcstn^VH  the  n 
wbich  it  is  made.     I  have  i^mployca  thta  kind  nf  upparaii 
in  the  breast  with  great  adv»utage.     It  i«  probable,  huucver.  that  liinran 
nere  nut  true  adenomata,  but  indurated  lubulei  uf  the  hrvoft  due  t«  t^mait 
intcretitiat  iuflanimatioD,  a  oondilion  which  n-ns  formerly  not  d«H;  'fr 
Liuffuislied  from  adenoma.      There  is  nu  doubt  that  iho  cshv  uf  a»ialU 
caucer  cured  br  the  Mime  menus,  were  alio  in  mlily  lobulea  of  tW  maM 
indurated  by  ebruDiu  inQammntion. 

The  only  ellicieul  Lieatcncut  of  on  adeno-fibnima,  or  an  udtua-tmmmi,^ 
its  removal  hv  excieion.  In  doing  this  it  is  noi  nea^nrj  to  KNMiTfl  iW 
wholu  of  tlio  breiut,  but  it  will  be  ({uti«  tnfBctent  to  extirpate  the  tsav 
iuelf.  or  at  iht'  most  the  email  lobe  nf  the  miirnmnr)  nncaid  viA 

it.     Thi»  may  alhays  be  done  without  difficulty  by  n  ■  iiitai.    lat^ 

majority  nf  cmies,  aa  tni\a  ha  the  rap&ole  Mirmunding  tht  ttmior  ia  npaief.it 
can  be  «helled  r.ut  without  further  u^e  of  the  liniie.     Tlierv  are  uinlljrl* 
vesBelis  to  tic.     In  removine  a  liinior  of  ihic  kinij.  there  are  two  tluk  |ne 
tical   pointo  that  fihnuld,  it  pr^iiiltte,  he  attfoded  to.     1.  The  fUtoi  aWiU 
not  be  inriivd  through  ilK  whol<>  thicknoM,  no  an  to  open  up  the  arwIarW 
which  18  interiJoned  between  it  and  the  p«-ftoral  muwie,     II  it...  J-^aii* 
feret)  with,  infiltration  of  blood  or  o(  pUH  into  it  may  occur,  aoc 
may  form  under  the  hreast.  or  At  the  luwer  edge  of  the  ^laii'i  << 
tnnihleeome  consequences.     2.  The  wound  muht  not  he  i' 
shijuld  b«  very  th<iroughly  drained.     Unb-tw  this  he  dnae,  ttir  (UH-naijr*  li' 
retained,  and  if  alliiwe<)  to  deconipoee,  burniwiu}:  of  unhntlt^  utttMittr 
the  BubmariimHry  areolar  t  issue  w  ill  tnlce  place,  leading  to  aztMHlTl  Mff 
ration  behind  the  miimuiHry  glnnti,  i>tlen  cf  n  moet  IruitblawaM  wmI  Imh^ 
aharactcr. 

In  cares  of  adeno4arc<ima  which  have  been  allowed  lo  attaia  a  vwrUi:^ 
BSe  belbre  removnl,  it  will  genemlly  be  nvcv»ury  Id  eitirpate  the  « w4*  ** 
the  mammary  glaiiil,  which  will  bu  littiud  cither  invoiwi  in  the  taiMrtf~~ 
an  atrophied  hut  otburwiM;  henllhy  »tale.     It  is  surprising  with  wbal  ti 
tbeae  tumors  enn  utien  be  reumved .  even  when  they  have  reached  eiMM peaa^* 
in  weighL     They  mrely  Ibrm  any  deep  attachmentN  and  adbcTe  to  lie  lis* 
oolv  nbpD  the  tension  has  become  wt  ^reat  ob  to  M-t  up  iDflamUHUiaa. 

tfysto-sarccma. — These  tumors  are  eompoeed  of  deoM  white  khtthrtei  ^ 
foliati-sl    structure,  rcsemblinff  that  of  the  adeno-fibrona.      Thta 
studded  ihrouj^hout  with  a  number  of  etiiall  cysts,  varying  t&  mt 
pinVbcad  to  an  inch  sod  a  half  in  dinnieter,  and  uauallj  MfUBiBiac 
Quid.     The  larger  cysts  contain   lobulatcd,  branchinff.  intracyMie 
must  commonly  sprouting  from  one  side  only,  and  forming  padi 


CTSTO-SAHCOMA. 


709 


into  Uio  c*vitiee.  Thc«  ititrucvittic  gDwlhs  are  DOt  «lw»y« 
This  farm  of  tumor  b  oitiallf  met  witli  in  irt^men  of  Trora  thiny 
IB  lhirtT-6v«  yenr«  of  a-^,  nod  b  n(tea  auributed  ti)  injurv.  U  occurs  most 
fr«c|a«all7  to  wumcD  who  have  bnrne  children,  and  ii  possibly  a  rem:iie  coa- 
■qaeace  nf  some  indammatory  procean  occurring;  during  Inctalion.  On  ck- 
■ouaiDg  a  breaAt  affected  in  this  way,  >l  will  be  found  that  the  tumar  id  hard. 


Fig.  Ti2.— Cfttu-tareooiB  of  |lr*ut. 

Utrr,  idd  BiiHd  l«  the  feel;  on  careful  examination,  however,  its  surface 
HjTM  felt  to  be  finely  nudnlnted;  and.  (H-casiunally,  a  larger  cru  than 
il,  rQcogniie^)  br  its  tiUi^lic  ft^^l  aod  Klohulnr  shap»,  roar  b«  found  pn>- 
The  disease  is  hIdw  in  its  growth,  nod  does  not  implicate  the  adja- 
cvtaoeoUf  ijr  areolar  atnicturra ;  heuco,  th«  tunior  is  movable  on  tbe 
vral  mufclee.  and  the  nkin  is  u[iatlHche<l  to  it.  Tbe  axillary  glands, 
m  Dui  enlarged.  The  iii|>ple  will  usually  b«  fuund  to  be  normal  in 
*a  tbi|)r.  and  not  depreved.  If  one  of  tbe  larger  cysts  be  laid  open,  or  if 
tke|ireiiure  uf  the  iotracystic  growth  cauwa  inflammation  and  ulceration 
^  tU  tapiule,  this  may  at  last  hv  perforateil,  and  ii  funguus  mass  will  sprout 
t^rvtfh  it.  prcfeming  many  of  tbe  ordinarv  syiuptoms  of  a  maligaant 
pMrU);  being  irregular,  ilark-colurerl,  bleeiling  readily,  and  increasing 
Ofdly  to  lite.  When  i^ucb  changes  an  tlieiie  hare  taken  place,  the  tumor 
formidable  character,  and  will  rapidly  pmvi>  fatal  by  exhaustioa. 
krcoma  may  attain  an  imuieuse  raagnituile  and  wc'i;;hl.  They 
tntt  with  of  »ix.  eight,  or  even  twelve  pounds  weight ;  but  by  far 
jH|{eat  la  one  dcaeribed  by  Velpeau,  which  weighed  forty  pouods. 
*"  erentual  derelopntpnt  of  fungatiog  aarcomatona  tiaeue  In  these 
^■■ksi  must  Dot  be  0Terli>'>ke<l.  A  tumor  of  this  kind  may  remain  benign 
years,  and  remain  eo  geuernlly  throughout  the  greater  pr)rtion  of 
lure ;  yet  ailer  removal  "xifi  mrconrntous  manea  may  be  found  sprout- 
M  some  nf  the  cyita.  In  the  caiK>  from  which  the  drnwiogs  (Figs. 
a, 7*4  I  nrrff  taken,  the  tumor  hul  exi-oled  fur  more  than  twenty  years 
'  having  commenced  at  tbe  age  of  twentyn^lghl ;  but  alter 
TunK'tting  growths  were  ft>und  at  the  boituiu  uf  some  of  the 
Tb«  iX>D»tilution  was  uncoMUmiaatcd  throughout. 


710 


rBKASBS    or   TUB    BRXAST. 


There  is  do  TrfiUmfitt  for  tItMe  tumore  but  t*r\y  miii  < 
If  taken  vttrly  CDoiigb,  llio  mamma  can  uatiall)'  Ik*  mi\- 
growth  tias  pa«tiHl  a  tvrlaio  size,  tiiia  »  do  loDgcr  pcMiiblr. 

Baroonata  of  the  Breatt — Tlio  tnannnary  glaml  or  iis  immediate  ncifi- 
borhoiKl  is  a  freuui'iu  veat  of  aarcoma.  liy  far  tin.':  must  cDtnmoo  fi<m  wA 
wilb  is  llie  sjiiiidle-vcllvil  larcuiua,  luually  of  tlic  large-reJIvfl  i>p(!-  ^"ua^ 
limes  ifae  firmer  forms  uf  s|iiuillc-cplti'il  sancuma,  «itti  t>mall  cplltanilann- 
ing  amount  of  Hbruiia  stronia^llio  old  rwum-nt  tibmiil — w  met  m'v\  - 
region.  Small  rouml-cclled  sarcnma.  alveolar  MtriMma,  aud  f^t: 
anroonia,  am  also  met  Vi'ilU  la  ihia  regtnii,  tuit  nTv  all  rarr.  The  Urv'.un 
of  iheee  varioiin  foniiB  (if  eanwma  liaa  already  beeo  full/  deartibtil  in  tk 
chapter  mi  Tumora  (vol  i.  p.  95it). 


is- 


\. 


^^ 


^*- 


,/-- 


Fig.  Ti  3.— I!  tc«r>t*d  Vfftio  Tunar  of 
Braajt.  ot  to  jean*  daratioB. 


Fig.  771.— Tb«  iBWa  CjtUe  Twmm,  ikx  w^m 
Utar,  ailli  fiiniitln  aiiiiiwmai  |ii^'' 


Htvt  saromatn  of  the  brca»t  are  diPliDftly  eDCH^wult'd  br  alajt^uf  SWo 
tbeoe  ill  liw  t'srly  i^tagee  of  itieir  growth,  but  later  in%  tfirv  lead  u>i|)R>' 
beyond  thiH,  «tid  infiltrate  the  i7iirr«iitiilii)g  Mnicturea. 

SarcoriiHtu  are  difiictilt  to  di&tiiif;tiitih  from  the  softer  forma  ofate^ 
fibrotiiu.  and  are  praeticallr  indistinguishahle  from  the  adeno-Mrmaiata  lUI 
after  removal.  Usually',  iLej  develop  tn  women  after  thirty.  TImt  In 
•oft,  elastic  tumors,  smooth  on  the  i«urface,  and  uniformly  rouoifed  ar  fn' 
in  oulline.  They  may  be  deeply  btiried  in  the  uibMaace  of  thif  flttii.\^ 
more  frequently  "they  are  situated  at  one  ride.  Th»-y  nru  pnlitlnw  awl  aw^ 
able  over  the  pt^turalie  loajor  iititil  they  have  rvachiHl  a  nnmdmUf  <■*• 
aud  they  show  no  (eiidetiry  (o  infect  the  lymphatic  glnnds. 

Surootnata  hero,  us  eWwhere,  may  develop  cysts  in  ibeir  fubrta»e»fr* 
softening  or  from  hemorrhage.  Thene  accidental  cavitioi  muvt  not  he  <*** 
founded  with  the  cyota  of  a  cysto-sarcoma.  Somctima  (he  »hoIf  vtaf" 
may  be  so  soft  as  t«>  be  iDcltvtioguishablo  from  a  coll«otioTi  nf  fltji-l  In^ 
oaae  of  Ibis  kind  under  my  care,  a  amnll  punclur«  wai  n-  ^^ 

blood  escaped,  and  in  a  few  weeks  a  fuDgatinu  sareomatoUE  ^  '    ^ 

irom  the  opening.    The  breast  wna  removea,  and  the  growtb  wm  fowail 


htf 


711 


he  an  exceedingly  soft  Mrcrtma.  the  slructnre  fif  which  wm  to  a  grejit  extent 
broken  down  by  neroorrbRge.    The«e  tuniora  present  the  nine!  typical  exam- 
ple.4  nf  recurrent  sArciHimtA.     U  may  W  staled  hmadly,  tliAt  the  BofWr  the 
taronnia  tJie  more  mpiilly  will  it  recur.     la  une  cA«e,  lu  which  T  remuveil  k 
very  large  tumur  uf  this  kiuil,  weigliiug  about  fuur  j>ouude,  with  Che  whule 
of  the  involved  aad  iitn>pbied  mamuiary  glaud,  from  a  lady  furty  yeani  of 
age,  ia  IS52,  recurrence  touk  place  iu  1^1,  aud  again  in  1^1)3,  lt)64,  1865, 
and  1868.     The  recurrent  tumun  were  duveluped  at  some  little  distance 
frum  the  original  cicatrix,  aud  pruved  uu  careful  cxaniinatiuii  to  bu  oarcu- 
liialoua.     Thu  geucnil  health  ci>nliuueil  pcrftectly  good  throughout,  aud  there 
Ka«  uu  infection  of  the  lymphatic  glandei.     ii\»3  died  of  parulvsiii  sotue  yejira 
hflvi  the  latit  operation.     Iu  these  caeesi,  this  absence  nf  all  glandular  impli- 
oatioo  or  of  coDstitutinrial  atfectiou  from  secondary  growths  in  the  viscera 
will  indicate  the  beni^^ui  character  uf  the  diseoee;  the  peculiar  local  malig- 
naocy  nut  being  a.ss<iciated  with  any  tendency  to  general  infection.     Iu  such 
cades  as  theae,  the  tendency  to  recurrence  will  oileu  Kniduully  wear  itself 
out.  and  atber  several  operati'm^  have  been  performed  nt  intervnla  uf  moiiths, 
or  a  year  or  two,  the  di^n^e  will  ceii.se  to  be  reproduce)!,  and  a  cure  will  be 
thus  estAhlished.    The  result  is  not,  however,  always  so  favorable.    InsUinces 
are  not  wanting  iu  which  the  tendeucy  to  local  reproduction  of  the  tuircuniB 
lias  beeo  sti  active  that  it  outran  all  possibility  of  complete  extirpation,  and 
ereotually  destroyed  tlie   patient.      Moreover,  whenever  a  sarcoma  is  not 
only  exceedingly  rapid  in  its  growth,  but  recurs  after  removal,  suspicions  of 
^neral  malignancy  itot  unoaturally  arise,  as  two  of  the  most  frequent  and 
important  elements  of  snch  a  condition,  exuberant  ve^tative  activity  and 
local  return,  exist.     In  a  ca^  under  my  care  a  few  years  ago,  I  removed  a 
sarcoma  about  the  sizo  of  a  hea't^  egg  from  the  niamtna  of  a  middle-agod 
unmarried  lady.     The  tumm-  w»a  distinctly  en^apauled,  and  wan  eoiiily  dis- 
sected out.     It  wat)  iuift  in  structure,  and  yieldr^d  a  glairy  Auid  from  the  cut 
surface,  and   was    compniuxl   of  large  nvat    aud  spindle-aha|>cd  cells,   with 
ACaroely  any  intercelluhtr  sulwtanc^.     A  few   months  after,  Hve  ttniall,  si>ft 
tutnom  sprang  up  around  the  cicatrix.     The  whole  breast  was  then  removed, 
1>ut  the  patient  died  a  year  afterwards  from  a  large  secondary  growth  impli- 
cating the  sternum. 

The  iJiagno&U  of  sarcoma  of  the  manima  from  the  softer  forms  of  adeno* 
fibroma  and  adeno-sarcoma,  is  not  possible  in  many  cases  before  removal.  It 
may  be  suspected  when  the  tumor  is  uniform  in  outline,  free  from  ]i.>bulation, 
of  rapid  grt>wth,  and  citrrnnences  after  the  age  of  thirty-five.  From  cancer 
it  is  distiugutehcd  by  its  sofLucsj,  its  more  rapid  growth,  its  more  tJcQutte 
rCircuinscripLiou,  and  the  absence  of  glaudular  aJTection  aud  of  retraction  of 
^ibe  uipple.  Should  the  sarcoma  from  the  hrst  iuSltratu  the  surrounding 
180.  the  diagnosis  beconiuc!  much  oiore  difficult,  as  the  growth  closely 
'iVBembles  some  of  the  softer  iorms  of  cancer. 

The  Tir*iimeni  of  sarcoma  of  the  breast  is  early  aud  free  removal.  Nothing 
slse  can  be  of  the  alightcst  use.  Before  coiuuicuciug  thu  operutiuu,  it  is  welT 
to  obtain  the  patient's  cuu^ent  to  complete  removal  of  the  brcust  if  neces- 
sary. The  tumor  niiiy  then  be  cxposod  aud  dissected  out.  If  it  be  tirm  and 
distinctly  eucapsuled,  it  may  Ihi  removed  without  taking  away  the  whole 
Diamma.  the  cii[Mule,  if  pi»teiibte,  being  removed  with  it;  hut  Hiionld  it  be 
soft,  ill'dehned,  verj'  vascular,  it  is  safer  to  remove  the  whole  gland  nt  the 
aame  time.  Khonhl  rerurnmce  take  |tlace,  the  breast  must  bo  fully  reninved, 
and  the  iiperation  may  he  re|>eated  as  ofteu  ax  tonal  recurrence  takes  place, 
BO  long  as  there  'in  no  evidence  of  tiec^ondary  growths  in  the  vii>cem. 

BaB^ineous  Cysts  are  occnAionally  mia  with  in  the  mamma.  These  are 
of  TariouB  kinds.    As  before  stated,  reteotion-cysts  with  papillary  growths 


712 


DISEASES    or   THE    BABAST. 


within  tbem  may  become  filled  with  hloxl,  which  may  !>«•  «)iiMt«d  Ami IW 
nipple  br  praHire  on  the  tuniur.  Very  »un  HrcuuiBta,  iJaot,  am  h>  ■ 
brokeo  down  hy  hcniorrh^g^  iuto  their  eubtuuoe  u  ta  ha  —*— V—  fa 
blood-cyets.  A  peculiar  t'jrm  i<f  cnucer.  to  be  Hubwquently  dwcriW. ■ 
which  it  8cenj8  to  iirise  rullier  from  tlieducU  ihuu  tho  at-iui.  tuay  »lm  mtwm 
numerous  cysts  lillcd  with  bluod.  Luit,r,  auy  t'urui  of  ey$i  tamj  mem» 
filled  with  blood  u  the  result  of  aii  iujtiry. 

Foetal  Bemaim  have,  iu  eooic  rare  eases,  l>eeu  met  with  ia  tki  hnrnki 
Ihetc,  bnwcver,  are  ntliier  tnatterv  uf  paihological  eunueity  Uibd  otfgaiUai 
iru|Mirtanee. 

CANCEB  or  TUft:  BBF-Atrr. 

Glmidulnr  cancer,  that  is  to  tar,  cnnccr  the  rella  of  which  helaar  lo  Ai 
type  of  glundulnr  or  spheroidal  epithelium,  is  the  furm  CimimoDlT  (WMmd 
iti  the  niftmniH.  Its  three  varieties,  scirrhus,  encephnlijid,  aud  enlloi^ m 
met  with,  but  the  first  occurs  with  tnr  greater  frMjueuey  than  any  •-•f  lla 
otbvr  forms.  The  ei>ceplia]oi«l  furm  of  the  dweaae  occurs  with  viom  Ur- 
queiicy;  but  c-jtloid  is  very  rare.  Cancer  of  the  breast,  whatever  Ions  it 
amuuie,  is  in%'ariably  primary;  il  may  aSecl  one  lube  only  ur  b«  httttiatid 
into  the  whdiv  i^IhiiiI,  and  it  may  t-omroeucv  in  ur  Jiuiitpdialt^ly  bri»ralk  ite 
nipple,  or  BO  early  affect  the  skin  and  spread  so  niileW  in  It  as  to  apfMU is 
have  orifjinated  in  (bat  structure.  M«ct  frei|UeMtfy  one  breast  «al/ « 
aifected,  but  iu  some  caaet  both  are  implieale<l. 

Si'iRKRCt). — Scirrbus  b  the  f<irin  of  oaucer  which  is  commooly  net  aiUil 
the  breast.  Il  may  occur  in  several  ways  ;  either  affecting  the  uipple.iafft' 
eating  the  okto,  primarily  developiiig  to  the  form  of  an  inlra-inaanarr 
UlBHir,  or  infiltrating  the  whole  8ul)«tan<%  of  the  oi^^.  It  musC  mnmml 
emnmencet^  as  a  circumscribed  lumur  »f  small  siae,  at  (irtt,  pi-rhaps^nNW 
and  round,  hard  and  indolent  in  its  charucter,  with  Uttlu  ur  no  psia;  ki* 
readily  movable,  may  be  situale<l  in  one  loltc,  and  is  atlarhetl  prrhap*  !■•  tts 
real  of  the  gland  by  a  distinct  pedicle.  As  it  increasn  in  st<r,  il  bteaM* 
hard,  kn»bbed,  and  irrejjuliir.  perhajw  presenting  a  fiiu'lT  annular  Mi,wi 
becoming  tixe<)  to  the  gland  and  stibJRceut  parts.  When  the  dt*ca»cbi|iM 
as  scirrhous  infillniliuu  of  the  breui^t.  the  maaa  is  fmrn  ihe6r»l  bard,  raj^oL 
irn-fi^ular,  nnduliited.  and  heavy;  oAen  aonewhat  square  iu  shape,  aail  niiH 
accompanied  bv  udhetiona  to  the  skin  and  the  subjacent  pan*.  In  sths 
cases,  the  developraent  of  the  acirrhous  mass  ia  accnmpauicd  by  a  c-mt 
apondin^  atrophy  of  the  ninmrnary  gland,  which  beconjr«  shrivelled  aad  dil' 
ap[H'Ar<i  entirely.  In  v>me  instant-es,  rather  large  cytts  may  fiirm  in  eooweC' 
tion  with  the  scirrhous  mass.  In  a  woman,  whktoe  brenDt  I  onee  ntaonrlfttf 
what  was  supposed  to  he  cystic  tareoma.  but  which  proved  after  tb«  ofin*' 
tion  to  be  a  scirrhous  tumor,  the  maM  ccmtaiued  aevenl  ey>i- 
ohcrries,  tilled  wilb  dxrk  or  greenish  Huid,  and  projectinK  fnt" 
and  in  a  lady  under  my  care  for  acirrhos  of  the  breanl.  a  tunx  . 
a  pigtiiu's  egg,  containing  sanguinutenl  Hui<l,  formetl  uu  the  ».i    <  -  t 

tumor. 

As  the  swelling  increases  in  siae,  il  has  a  tendency  to  b«  omn  Ixcd  tu  thi 
Kubjanent  parts,  becoming  adherent  to  the  peeiorut  moidaa  and  iai3ne|wrafc< 
with  the  areolar  lieoue  ut  the  border  of  the  axilla.  The  Cumor  alinhmart 
to  Ibrm  a  distinct  rxteraal  projection,  and  beeumea  mora  Irmular  in  ahaf 
it  is  the  9eul  of  severe  pain.  mnr«  particularly  at  night ;  and  it  in  armt  m 
onvercd  by  n  plexne  of  blue  and  ailmeil  X'Hns.  The  urdinary  symp^at 
oanoeroas  cachexy  now  appear,  and  the  diseaas  ibca  Mokca  atill  man  taf 

The  tomor  may  in  tome  cnea  remain  for  a  great  toftk  of  tim»  vilte 


ECIBRUOUS    CANCER. 


7IS 


implicRtiaf;  Lbe  Skin;  tml  raoet  comiuooly,  after  it  hiu  exiBt«<l  for  a  few 
mtanthm,  W»  timut  becoiuea  more  or  lees  iavulvrd.  luBtcad  of  Iwing  Iixih 
•ad  normble  over  the  surface  of  llie  c^iDcer.  it  will  U*  found,  uu  being 
ptncbed  up  betwtvu  itiu  fiugvre,  to  dimplu  ut  utic  part,  where  it  tnsy  hif  felt 
u>  b«  altadied  lir  a  kind  of  oiiril-like  jinK-em  tit  ihu  tumnr  beneath  iu  After 
m  time,  that  jKirtion  ufthe  pkin  nliicli  firvt  befjitne  iixed  io  this  way  ai^iuiree 
a  retldiab  ar  {lurplish  oulur,  end  is  cnverefl  with  thia  scaly  epidermic  de8f|ua- 
mmiMO^utd  becnmea  permeated  by  a  oumber  of  small  ramifyiDg  vefliels. 
JL  cradt  or  fiamire  aveulually  fornu  in  this;  a  small  exudation  of  senua 
Aaid  take*  place,  which  dries  into  a  scab;  under  thia.  ulceration  seta  in, 
wbicfa  Wfeedilv  assumea  tbe  ordinary  chnracters  of  a  scirrhous  ulcer,  lisviDg 
bard.  eJevaietl,  and  everted  edfres,  a  gr&vish-grecn  or  foul  surface,  and  du- 
flharipag  a  <)iinntity  of  verv  fclid  pus.  Xu  some  cum-^  ulceratioD  may  take 
plaee  at  seventl  ptiints.  nnd  thu^  the  whole  surface  of  tbi)  breast  bcooroei 
eoavertcd  iDbi  one  iiumeose  chasm,  which  may  extend  even  up  into  the 
axilla. 

Tbe  ikin.  ulien  nfieclcd,  often  nssuiiios  a  nnl,  glazed,  hard,  and  brawny 
ebamcirr,  beiug  sbining,  and  as  if  greuy  upon  the  surface,  having  tt«  porvt 
colargMl,  and  fDvelupine  lbe  side 
of  lb*-  rfarvt  io  a  kind  of  otilf 
••  li'i  Cluing,  advmled  luunily  by 
L.'Au^-h  pain,  coasiderable  tedema 
tbv  arm,  and  an  agpiaraled 
of  constitutional  cachexy ; 
■lorstaon  at  last  takes  place  in 
ibii  hardened  raaH,  and  then 
■paadity  destroys  the  patient.  In 
MlHr  OMca.  the  cancerous  devcl- 
■paaat  items  to  expend  ita  en- 
aisy  ebivfly  upon  the  cutaneous 
AfUViuiH.  The  tumor  of  the 
ghod  IB  amall.  atrophic,  and  iiu-  ^J  I 

ptiww  the  nipple.  The  oance- 
iQOi  ukfiltrsiioo  mpiilly  ipraadi 
ni0  t2ie  iurrouodiuK  ioief^rooit, 
vUeh  becomea  early  ctiutaiui- 
■Bud,  asHiming  a  hard,  leathery  /{ 
ebaraeter,  ur  leeliofi  brawny  and 
brfltralfd :  otb*n  witbuut  liiscul- 
laaUati,  but  presenting  a  by))er- 
tni|ihM<I  ap[ifantuce,  the  pore* 
Waic    rblarfii-il,    and    tlie    Inter- 

rr«  brt»»*ii  tliem  iiirreaited. 
iiUirr  etLM*,  tbe  iutiltrated 
Aw  aMumra  a  bruwniKh  or  piirplitth  c'dor,  and  is  ci.>vered  by  ruugh  deaqua* 
ntllaK  crusts,  so  a»  to  rtrvenilile  tbe  Imrk  of  au  old  tree.  This  diseased 
■feteoT  tbe  iutecuioeuts  will  extend  very  widely,  without  ule«nition  or  fur- 
tWr  development  of  tbe  tumor  situRle<l  in  tbe  Klaud.  I  have  in  this  way 
•■■  tbe  ioteijumctita  of  the  whole  fnmt  of  the  chest.  frt>m  the  claviclea  to 
Wduv  lbe  mamma>,  and  from  one  axilla  Xa  the  other,  infiltrated,  hard,  and 
hatlmy.  of  a  brownti>h-r«d  color,  forming  a  etiiT  cuiraetf,  as  it  were,  but 
H-ithoii  ulceration.  This  condition  is  very  chronic;  and  it  is  remarkable 
ihai  iti  it  the  axillary  inlands  are  nut  infillmtetl,  or  lbe  oin><titutiuD  rendered 
mrteilio,  at  nearly  so  early  a  (teriod  as  when  tlte  disease  more  ezten^vdy 
^pKeaioi  tbe  mammary  glaud. 


i 


I. 


Ftf.  T7t.— UI(sntlB«  S«lrrhoiu  CuiMr  ot  Braatt- 


714 


DISEASES    or   THE    BREAST. 


Another  way  in  wbicb  the  Hkiii  becomci  inrolved  a  by  tltp  fimMtrai  «fi 
BoirrhouB  tubercle  or  Dtidule  in  it  ^)wartiB  the  outer  or  axillur  bonhr  tf  A* 
Duunma,  the  plaad  beneath  being  implicated  tn  but  n  limitMl  extrat.  Il  i 
[Ktlbable  that  in  these  cases  the  disease  commencrA  Id  an  ouUjriag  Infaak  d 
the  gtand  situated  immediately  beneath  the  skin.  Oocafcioo»lly  mill  I  mJild 
tubercles  Bprin;;  up  in  the  skin  around  the  spot  firat  tmplieiunL  Thtj  m 
of  n  retldJBfa-brown  ct>lur.  slightly  elevated,  spiootli  on  the  Mir&w,  awl  ivt 
bard.  By  the  oonleaccnce  of  theso  the  oonditiun  &buve  dMcribcd  of  ni^ 
sprcadio);  implication  of  the  akin  mav  ariie. 

The  Pain  is  in  many  cflBM  but  tri6]ug  in  the  early  Uaces  of  ib«  aftdiB: 
fto  much  M>,  iitdood,  that  it  U  the  tumur,  often  atoideutalTy  tiotMMl.ihat  Im 
excitea  alarm ;  as  it  inereaaea.  bowc-vi^r,  llie  ttutfi-riotf  bMomaa  wtcpit  mm 
particularly  at  night,  ia  greatly  autcraTaietl  by  baudling  th«  iiatatti  ■«, 
and  obioHy  extends  up  to  tb«  abuulder  and  duwu  the  artn.  Tb«  pain  uaalif 
becomes  moat  aeren-  about  tbc  time  when  the  «kiu  u  ti»t  ioiplicAlcd ;  hac» 
lb*  eutaniHiUN  iutiltniLiun  goed  on,  it  gradually  leaieiu,  owing  |»rolMblr  lAlki 
deatructi.m  uf  the  cutHueoui  nerveo. 

BetractiOD  of  the  Nipple  communly  comiiieni.-e!i  abnul  the  tame  tiloaUii 
the  skin  is  implicatetl.  Ic  i»  moitt  murke«1  in  tbo  atiMpbie  furra*  tjf  <•^ 
rbua.  It  is  due  to  the  shrinking  and  coutractioa  uf  lbt>  nlder  parti  uf  lb 
growth,  which  furios  go  characteriatic  a  feitture  of  »ctrrbii«  (voL  L  p.  ML 
As  this  takes  place  the  ducte  pauiog  from  the  affected  part  of  the  iplaailll 
the  nipple  become  dragged  ujkiu.  The  depreeaiou  may  uo  at  the  aim  tint 
increiii*ed  by  llie  projection  forwards  of  the  general  nuua  of  the  hnvf.* 
that  the  nipple  may  become  cnmpletely  buried.  This  sign  baa  rveeiml  aan 
iruporiance  than  it  deiterves  in  conueciiou  with  imncer,  as  it  dooa  Bol  Metf 
in  alt  catue  of  malignant  disease,  nod  ia  occaaioually  met  with  la  aaflt 
mammary  tumors. 

Tlio  AJcillary  Glands  ui^utilly  Leoomo  eulargol  early  in  thn  dMSM^M^ 
mav  attuiu  a  ^nutur  nirM  ilnin  thut  of  the  original  tuuiitr;  and  aa  oImiU- 
aminatiiiu  a  kind  of  induratcil  conl  muy  in  si»me  casea  be  lelt  axUndtM « 
tbc  course  of  the  lymphatic  vrsacls,  from  the  edge  of  the  pectontl  raHOlV 
the  axilla.  Aflcr  n  time,  the  supraclavifular  ^andu  may  likewiae  baoM* 
implicated.  In  fa^t,  the  whole  of  the  glandular  i^tructunw  in  tb»  ricioiiT 
of  the  ihonlder  undergo  cjkncerous  infiltration.  When  thin  b  tbw  naa.lli' 
pressure  upon  the  axillary  vein  may  occaaIoD  crdcma  of  tlw  arm  aod  baai 
The  glandular  iotiltntLion  u-itiftlly  increaies  rapidly  alV>r  the  »kiD  hisbr 
oome  implicated.  In  some  omeii.  when  the  glandji  heninte  atfiii.'tetl,  ihtckirf 
virulence  of  the  d!»ea«e  appears  to  expend  itftell'  ufion  tliein  ;  the  taonr  J 
tbe  breast  cetuing  to  enlarge,  or  even  naiiling,  wbiliit  the  aacoodftrv  ^iamtf 
tar  de|Nwit«  iu  the  axilla  beoome  gretttly  devehi|ied.  Il  ia  probably  Ul  lUi 
way  that  tbe  supposed  cases  of  priiaary  »virrhu«  of  ibe  axiiisry  gUa^i  bN> 
ariw-n. 

\^  tbe  ei-irrhuH  extendi,  it  may  gradually  implicate  tbe  nubjacvtit  iiomH 
arvHilar  tiiuue,  the  riba,  and  at  laitt  tbe  pleura,  ^ving  rise  awBtBallf* 
hydrothorax. 

'  All^T  liiu  atfeotion  of  the  lymphatic  giaoda.  asotuulary  grawtha  laafca  iW^ 
appcaninbo  in  the  Viiotra  and  other  parti  of  the  body.  The  p*''"' * 
which  this  takes  placu  varies  in  ditR-rt-ut  ea»ot.  Xt  a  rule,  it  mt'-  f-ifiM 
that  the  sofler  tbe  tumnr  aud  the  yuunger  the  patient  the  r;.  ^ 

visoera  be  implicaliMl.  The  must  eummun  seat  of  tbe  visonral  luiumi '  ^ 
liTar;  ader  ihat,  but  at  a  cunsiclenilili!  interval,  oiinias  tba  laa^aalll* 
thn  booea.  In  the  brain,  kidneys  and  other  organs  asooadafT  froethi''' 
ocouionalty  met  with,  hut  are  le»s  conimoo.  Amoog  tbe  bnua.  tbs  h"< 
the  ribs,  and  the  vcrtebne  are  perhaps  the  inost  fratjoaBtly  fMTWtfJ-    lo^ 


ENCSPHALOTD. 


715 


last  situation  it  cuuiteH  ilettth  by  develop tneiit  of  ai)[fular  curvature,  with 
iir€««ura  oil  the  t)]iiiiul  cunl.  lu  llie  long  buDee  it  gives  rise  to  epuiitaueoui 
iraclure. 

The  Conititation&l  Cachexy  is,  in  (he.  maJniitT  of  cobcs,  unt  preeeot  till 
nn^r  ulrcratmn  hm  titki^n  plnct*  or  setvinrlary  gmwths  have  fonin^d  in  the 
intenial  organs.  In  fnct,  in  a  very  largp  proportion  of  fufles  the  palieiilhas 
cnjnytHl  fxcfptionally  good  hcaltli.  »ntl  appears  perrectly  hpiitthv  in  other 
respecu  at  the  lime  the  lumnr  is  first  discnvpreii,  antt  may  remain  bo  till  it 
has  made  consiHerahle  progrpss.  'i'he  impliration  of  the  skin  ip  lutnaily  an 
epoch  of  peculiar  importance  io  seirrhue  of  the  hrenBt,  as  it  is  at  this  period 
that  the  pain  increases,  the  lymphatic  glands  become  infected,  and  the  con- 
stitution rtecomes  distinctly  poisoned. 

Duration. — The  duraiion  of  life  after  the  occurrence  of  scirrhiis  of  the 
breast  varies  greatly;  so  much  so,  that  ibe  disease  may  be  considered  na 
assnmiug  an  acute  nod  a  chronic  form.  The  acute  variety  occurs  princi- 
pally in  ruddy  and  plethoric  women,  and  commonly  proves  fatal  in  a  few 
^_  ntontlw.  In  those  who  are  of  a  more  fveble  and  delicate  coDSlitutiun,  the 
^^V^diseaM,  as  a  general  rule,  take«  n  slower  course.  Sir  A.  Cooper  stales  that 
^^"^  the  disease,  on  an  average,  is  fnim  twn  to  lliree  year?  in  growing,  and  fn>m 
1^  six  uiuntha  to  tno  ream  in  destroying  life  aft«r  Iwing  fully  formtHl.  In  this 
I  estimate,  which  is  probably  correct.  Wnlshe  agree?.  Paget  stateH  that  the 
I  average  duration  of  life  in  case»  in  wliich  Xhv  dineaoe  is  allowed  to  run  its 
I  Course  without  openilion  is  iour  years;  but  the  statistics  of  f^ibley  and  Vi>n 
L  Winiwarter  give  a  period  nf  ouly  fnmi  thirty-two  to  thirty-three  numtha. 
^^K  The  average  durnlion  of  life  in  cancer  of  the  breast  may  therefore  probably 
^^g  Im  estimated  at  about  three  Vfars.  As  a  generitl  rule,  the  progress  of  Hcir- 
rhua  ie  slower  in  ol<l  people,  in  whom  it  occasionally  gives  rise  to  n  kind  of 
atrophy  of  the  breast,  with  ahrinkiug  of  the  tumor.  There  are  many  in- 
amnces  on  record,  in  which  cancer  of  the  breast  is  said  to  biive  existed  for 
a  far  longer  iicriod  than  lliis ;  for  ten,  twelve,  or  even  twenty-five  years,  but 
there  must  always  be  a  doubt  as  to  the  correctness  of  the  diagaoeis  in  such 
ca»ee. 

Pathological  Strncture. — After  removal,  seirrhun  of  the  mamnm  presenla 
considoralik-  viirieiy  in  ap])enrauce.  In  the  majority  of  inauncee  it  occurs 
as  a  peculiarly  hard,  ktii>t)l)<!il,and  irregular  mup»,  creaking  und4.':r  the  knife, 
when  cut,  and  prcitcnting  on  section  a  grayieb  or  bluish-gray,  eemi-transpa- 
rtint  «urf«eii,  tnivorHed  in  various  directions  by  bands  of  a  rnorc  opaque 
chamcier,  and  exuding  on  preivuru  a  lliin  milky  juice.  The  section  has 
been  vory  aptly  compared  to  thnt  of  an  unriof  pear.  In  all  alow-growing 
hard  cancers  the  cut  Aiirface  becomes  distincfly  concave,  a  peculiarity  which 
distingniAhffl  them  from  all  other  tumors.  Id  anft  canrera  this  feature  ia 
wanting.  In  many  specimpn.s  masAos  of  an  opaque  appearance  and  yellow- 
ish tint  may  be  seen  in  the  midnt  nf  the  tumor.  These  are  the  reAult  of 
fatty  degeneration  of  the  scirrhoiifl  structure.  In  other  caaea.  again,  on 
prewing  the  ttimor,  small  dropA  of  a  thick  creamy  fluid  will  appear  to 
exude  at  various  pointi^.  Thi.'«  seems  to  be  the  inspissated  and  altered  siecre- 
tion  of  the  gland  retained  in  the  diiclA  CVsw  are  occasionally,  though 
rarely,  met  with  in  acirrhue  of  the  breaat ;  these  are  usually  small,  and  con- 
tain clear  fluid,  being  deeply  embeilded  in  the  snltstanee  of  the  tumor;  in 
other  cases  tliey  may  be  largv  and  globohir,  .tod  lille<l  with  a  bloody  or 
dark-green  lit^uid.  I'bv  [nicr'isc'opti.'jil  charHoters  of  scirrhue  uf  the  breast 
are  ^ucb  as  are  repre^nti.'d  iu  V'lffi.  'i*J>i  and  'i)W,  vol.  i. 

£NCEPnAi,oiD. — Formerly,  when  all  soft  earooniala  were  clawed  as  can- 
oere,  euceploiloid  uf  the  breiiet  was  described  ««  a  dtwuMj  of  raodurately  fre* 
4]ueut  occurrence.     Now  tbut  the  term  Is  strictly  limited  to  the  softer  and 


716 


DISBASKS    OP   THK    IIREAST, 


more  rapidly  growiDg  forms  of  glttoduliir  csucer  the  disease  cmnnnt  Kt  wJ 
tu  \.w  wimintiii.  No  sbarp  line  <-aii  be  drawn  lietweeo  acirrhiu  aod  aoom^ 
luid ;  wliut  oiiR  Hitrgeiiti  wtuild  lertn  n  Buft  fortn  nf  ncirrbita,  Boothtr  wmiA 
clatw  at)  encKphaluiil.  Fiilhi)l(>!;icallr  tliB  difTerenoe  liRtween  tb*  two  fbm 
ooiiBtfttH  ill  ttie  relative  nroportion  of  thti  fiintiiia  and  cell*.  The  gnatortfei 
pruportioi)  of  etroma,  ttie  linrder  the  luiuur.  In  the  eoftej'  fonoi  l^  «dl 
are.  as  a  rule,  larger.    (Fig.  400,  vul.  i.) 

Sod  glandular  cancer  iiaually  begins  deeply  in  the  auhetaner  nf  tbtbntf 
as  a  eotl  globnlar  tumor,  which  rapidly  increavee  in  bulk  and  inGltrmia  tht 
who)«  gland  ;  the  intf^ments  covering  it  nro  not  at  tint  adherNit.  bat  m 
usualiv  pushed  before  it,  nud  speedily  beoonie  permmtrd  by  a  lar^rniiaiAli 
oetwnrk  of  veins.  Id  some  cases  I  bare  seen  the  integumenis,  nrly  in  tbi 
dneaac,  o^demntous  and  iDtiam«d,  so  as  to  maflk  the  lubjaeMit  laaar.  Tht 
noass  at  tint  foels  ns  if  composed  nf  wveral  tofi  and  rounded  tamon,  vkid 
may  communicate  an  obscurely  fluciuatin^  aeoaation,  p«rhapa  caovBi  A* 
Burgeon  to  mistake  ihe  growth  for  a  crstic  fbrroaiioa  w  an  afaaefla;  viih 
which  It  i»  «ep«cially  apt  to  be  confuumjed  in  thon  caaea  (rare,  il  b  trMjli 
which  the  Mkiii  is  iiiflnmed  huiI  u-ilvmatouti.  The  breant  iintr  rapkUyMSMW 
a  very  pruminvnt  and  iMtnical  fortu;  thv  skin  covering  it  at  Its  iiMatpn}Mt> 
ing  part  becomes  thinned  and  redd«iit»l,and  al  last  give*  war.  leaviof  •  ll/(l 
circular  ulcer,  from  which  a  fuugoua  mau  of  gra.ytah  or  rvadisb'bnwo  imt 
Bpe«dily  sprouts  up,  with  n  goud  deal  of  discharge  of  a  foul,  bhioilr.  ai 
ofltmsive  cbamcter.  From  this,  disintegrated  ma»ea  are  uccaaiooally  d^ 
toobed  by  sluaghiag.  Implicatii>a  uf  the  glaodular  struclurea  in  the  vioiitf 
of  the  tumor,  toltowcd  by  constitutional  cachexy,  ocoun  in  tbii  aa  in  sdnki 
of  the  breast,  but  somewhat  earlier.  The  prugreaa  of  the  dbeaaa  is  tiwut 
extremely  rapid,  especially  in  palieiita  beluw  middle  life  aad  otberaM 
healthy. 

CoLlxilD  of  the  breaet  a  of  very  rare  occurrence.  Most  comnKMly  mI*  • 
part  of  the  tumor  has  undcivouti  degeneration,  the  remaiuder  preM^sjc  w 
ordinary  appearances  of  snit  or. hard  glandular  eanoer.     I  ha-  't* 

last  few  years  removed  two  very  typical  specimens  of  thia  form  "r  U 

hnth  cajie«  the  patients  were  past  middle  life.  The  perulinr  fraium  isaack 
case  was  that  though  the  tumor  hod  implieotcd  the  skin  and  fomtrd  a  fttd" 
nence  about  nn  inch  an<l  a  half  in  diamt-ter  and  projecting  nr^rlr  aa  fack 
above  the  anrfacc,  no  deep  ulceration  had  takea  place,  mir  wrn~  '^'  -'hvk 
afibcted.     A  section  of  the  breast  ahowctl,  in  the  greater  part  -ti«i 

a  enaine  alveolar  structure,  the  alveoli  being  distended  with  c»iimi<i  uiaUtf- 
The  groving  mitrgin  of  the  tumor  preaeatfiu  the  ordinary  appearasce  ^  IH 
ratiier  aofl  scirrhous  canc«r.  and  between  this  anrl  the  cv>ll(>«d  pMi  mrjf] 
intermediate  gradation  wao  rec»gnix«ble.  Tht-  nature  of  tba  gruwth*  «tfi 
oonfirmed  by  micr<«copic  examiaation.  i 

DucTf-CANrRR.    \'ii,ix}i-N  Cani  kr. — Under theae  oaniM haa htm  dtntilwd 
a  rare  form  of  tumor  which  inHltratM  surniiindiii;;  parts,  iolW'  ^-ii^ 

and  generaliu^  like  an  oniiuary  cancer,     it*  strui-ture  has  Ik-  .^Of 

descrilifd  hy  (_'umil  and  llanvi^r.  Tot  hi?  nikkiHl  evr  it  may  rewcohir  egoBplM  ■ 
Juid  canrer.aud  itx  iM--ctiun  ^-ieldj  an  abundant  milky  juioe,  bol  it  di0en  frn^ 
ordinary  canocr  in  prvseating  uumenms  aioall  cywis.  Bona  oaly  jusi  vbuhla 
tu  the  naked  eye,  and  othcrv  an  eighth  of  an  inch,  nr  even  more  in  diaoMHrJ 
In  s'>me  spocimens  ibew  cystji  are  tilled  with  bloi>d.  Micruaoupte  eaaauaa^ 
lioQ  ahuwa  it  tii  be  compinwd  of  a  well-formed  fibrou«  un>raa,  tnaiaima/M 
8|iaoes  lined  with  an  epithelium  tending  to  aosume  n  oolnBoar  form,  Om^ 
oata  TitlaaB  pmceasea  covennl  with  epithelium  prrtject  tWtm  tiiia  AraiiH  in 
the  ameea.  Theae  villi  ntntain  loopa  nf  dtdirale  mpillary  veMels  which  vie 
the  blood  ao  often  fouml  filling  the  spooea.    According  to  (.'omil  and  Ravnap* 


CAUSES   or   CAKCKR    OP   THB    BRSAST.  717 

ffrcBtcr  part  of  Uie  Btnall  ejug  ean  be  clnrlj  recognized  u  dilated  f^Ucto* 

M  ducti,iud  ihejr  are  of  opinion  tbiit  ihesi.- tumun  are  malignant  xri>wt)i8 

ioc  from  tbne  itmctureB.     Ad  befurct  poiuK-d  out,  villous  gn^wilis  inav 

in  rimple  glandDJar  cvste,  and  llic»e  may  bear  the  tame  relntion  tn  vil> 

Ima  cancer  that  the  eiiuple  papillary  pulypus  uf  the  rectutc  does  tocotuaioar 

■yitlidiiniia.     Wlwn  these  tumors  atlect  the  lyniphatic  glands  the  aeccMidarj 

owthfl  |>rv»t.'Ut  the  same  structure  as  the  priiuarj'. 

C&Bset  of  Cancer  of  the  Breast. — TIteve  are  oaually  extremely  obwure. 

&^  is  certainly  the  circuiuelaoL'ethat  has  I  he  moat  marked  influence  oo  the 

occurnsuce  of  nmnimary  cancer,  the  disease  being,  hb  is  well  knotrii,  almost 

iLirely  cotiSned  M  woineo;  yet  instances  of  this  affi-ctioo  in  the  mulv  br^u 

Hrittnatly  occur,     lis  peculiar  frequency  in  the  female  may  puseibly  be 

inecled  irith  tiie  grtat  and  sudden  alternatiunii  of  the  funcUunal  aiMJvity 

of  Uic  breaat  in  women.     The  changes  impre^frcd  upon  this  organ  at  piiberiy 

■ad  darloe  pregnancy,  the  various alteritiit ions  uhiuh  ilunder}coee,tlie  intlam- 

nmSory  aiKclion«  to  which  it  is  eubjert  during  laclaiimi.  the  frequent  irrita- 

uon  tn  which  u  is  espttfed  by  Bympnihieing  with  uttrim:  <l<>rangemfnt,  and 

ike  dlminuiioa  in  its  vital  activity  that  iakv»  place  at  Lhi-  change  of  life,  are 

Mlflcieoi  toexplaia  the  great  liability  iif  this  ur(:an  to  disease  generally :  and 

nar  oo«  imprubably  give  a  clue  to  the  reason  why  it  is  peculiarly  the  teat  of 

cancer  in  women. 

Jfft. — The  »ge  at  which  caoear  of  the  breast  most  frequently  occurs  ts 
bti««en  the  thirtieth  and  fiftieth  years.  According  to  Itirkelt,  it  is  moat 
conmooly  met  with  between  the  ages  of  forty-five  and  fiAy — a  period  of  life 
that  ii  popularly  looked  upon  as  specially  obnoxious  to  this  malady.  At 
lh(ae  age*,  cancer  of  the  breut  usuallv  atfects  the  form  of  scirrhus.  When 
itoeenn,  as  it  Jtey  rarelv  does,  in  early  life,  it  more  freoueotly  assumes  the 
tacephaliiid  character.  1  have,  however,  removed  a  scirrhous  breast  from  an 
Dsmarri^i  womau  twenty-three  years  of  age.  In  elderly  wuioeu  alsOfScirrhus 
»  U»e  prevalent  li>rm;  though  1  have  se«n  several  instances  of  eucephaloid 
at  as  advanced  period  of  lile,  one  case  iu  a  woman  upwards  of  seventy  veara 
of  ago.  Indeed,  raaeer  iu  either  form  may  aflect  this  or^jau  up  tu  the  fatcat 
INoioil  U>  which  life  is  prolongt.-d.  Married  women  are  suid  to  be  more  liable 
ikan  aJogla  ones  tu  cancer  of  the  breast;  it  may,  however,  fairly  be  doubted 
wbfftbvr  they  are  pruportioaalely  so;  aud  it  is  a  common  belief,  founded,  I 
think,  io  some  degree  un  truth,  that  (he  disease  is  nmet  uummun  in  women 

Kbo  have  Dot  borne  children. 
imjmria  inllicted  upon  the  breast,  such  as  blows,  stiurezes,  etc,  are  cota- 
aaly  refarrvd  tu,  and  arc  greatly  drcadeil  by  womeu,  as  the  causes  of  cancer, 
hat  tbry  mighl  be  su  in  eoubtitutious  otlierwise  pn-dispcised  to  the  affiMAJon, 
mn  not  afipcar  {mprohable;  and  that  tliey  are  so  iu  reality  in  many  cases, 
1  hava  mit  the  least  doubt.     The  nunilH?r  of  inFlanc«*a  that  have  fallen  under 
mj  aharrralion.  in  which  a  blow  or  squeeze  of  the  breast  has  speedily  been 
AithMMKl  by  the  appeamnre  of  a  rancenins  tumor  in  it,  leaves  no  doubt  what- 
ntroD  BIT  mind  of  the  truth  of  the  popular  belief  that  anociatfs  the  injury 
with  the  diseaK,  iu  the  relation  of  cause  utid  effect.     LaetMt  iitjtamumlions 
likewise  supposed  to  tend  to  the  production  of  cancer  of  the  breast.    Of 
dcicirine,  I  tnink  that  we  do  not  posseas  sufficient  proof;  though  it  appears 
gkly  probable  that  disturbance  of  iho  functions  of  the  organ  during  hu-ta- 
m  may  prpdii«|Hiw  to  the  nccurrcopc  of  this  disease. 
The  sD-ewlU'd  '■  EcMma"  of  the  Hippie  nns  first  de8cril)e<l  by  Sir  James 
""*  ■--  ^-  '■■  .'occasioiially  the  precur^-jrofcancer  of  the  breast.    The  nature 
y  n  and  itatfiiinrctiun  with  caocerof  the  breast  are  alike  obscure. 

ai>  iDM  wajs  by  which  Xha  latter  lusy  be  explitiiifd.     Thus  the  local 
<«nial  eciema  may  bv  the  primary  disease,  and,  travelling  up  the  epithelial 


718 


UI8SASB8    OP    THK    BSKAST. 


lining  of  the  laoteal  ilucts,  may  produce  clianK^  io  them  which 
Bnaliy  o  true  cnncer  of  the  oiamniftry  glauil.  But  there  ia  ubvionUra 
explBimtinii,  vis.,  that  the  primary  diwAse  is  eiluated  in  the  ■rini  vTtk 
gland,  llmt  wme  luodifieAlion  of  uulrilivc  or  struetural  change  takoi  fimi 
in  them  cither  prclimiunry  to,  or  of  the  nature  of,  etuicer.  Ui  ciaBM>(iMDtt 
of  which  their  i<ecretiou  becomes  unhealthy,  and  liial  thi*  mnrhtd  KcnbiB 
irriute:*  the  mucootituucouB  surface  with  whiuh  it  cora««  in  ctwaict.  TW 
this  cxplunntion  is  n  probable  one  would  appear  fmni  a  case  undsr  nroant 
in  which  u  Indy,  having  atrophic  adrrhua  of  the  right  mntonta,  eeciM 
afterted  by  ccwma  of  the  left  nipple.  After  a  time,  the  axilUrv  .fianA^o 
th^ — the  left  iide — becatne  canoenHU,  and  then  aome  iodur  V 

tected  in  the  left  mamma.    Here  it  seemed  probable  that  tfa«  pn •■  <..«Aa 

of  the  left  mamma  consUied  in  a  small  acirrhoua  inliltrmtion  *>(  it  wtoA 
8imultanei>uily  nr  almost  ao  gave  riae  to  ecxema  of  the  nipple  on  ooeti^aiBi 
alandular  infiltralion  on  the  other.  Any  nay,  perviueot  ecMma  of  r  tinl' 
m  a  middle-aged  woman  niuit  excite  the  graveit  apprebeDaiod  ai  apnbani 
preeurMir  or  concomitant  of  cancer  of  lh«  breBi>t. 

The  influence  of  Heredity  and  tbo  Otogrmhieai  Dittribution  i^tiii  Dimm 
have  been  already  autticieotly  diMuaed  in  we  chapter  uu  caacer  is  ffosil 
(vol.  i.  p.  974). 

Diagnoiis. — The  dia^oati  of  cancer  of  the  biwut  from  oCbaf  immm 
affecting  this  organ  U  of  the  Brat  im{>ortaDce.  and  ia  aitenJeil  by  aiiwifd 
ing  difficulties.  The  great  point  ie  to  determine  whether  tin  tanor  of  tk 
breaat  be  of  a  cancerous  character  or  not ;  that  the  &urg«ou  aboutd  go  btnad 
this,  matters  little  tn  practice — and,  indeed,  except  in  some  of  tbafbraiif 
cystic  dLaeaae  of  this  organ,  few  ))ra<-titiuuere  would  feel  didpoacd  laiailMnr 
to  carry  their  dingnneislwyond  thlfe  point.  Tbe  great  and  Hsential  difltal^ 
in  determining  the  nature  of  a  tumor  of  the  breast  consists  in  the  faa  of  th 
same  sl^iif'  being  raurc  or  less  common  to  nuiny  growtlu  in  this  nfWi  * 
hard,  circumscribed,  indolent  mass,  chronic  in  iu  prugreaa,  witli  a  uuuii 
nmitunt  of  pain,  being  the  usual  characteristics  prescuied  by  all  Kiliil  oa*' 
mary  tumors  ;  and  though.  In  nine  caaca  nut  of  ten,  a  tumor  pn-Mruliaglkv 
characters,  which  has  existed  for  ft  yp-ar  or  more  in  an  eldf  Hy  «ii'inan,ii^ 
has  resisted  ordinary  ah«orbent  ami  allcrativc  trpolment.  i>  M-irThoat,t« 
instances  of  the  reverse  occasionally  occur.  Nothing  can  brttrr  rxrtapui^ 
the  dltficulty  of  diagnnat<«  in  tumors  of  the  breast  ihsn  ibf  cin-urariaaa, 
which  is  not  unfre<)uently  witnessed,  that  after  the  removal  <if  lb«  Jiwajut 
Diasa.  its  section,  and  careful  examination,  Burgeons  of  equal  pxt-T;.-nrr  viU 
dtfler  as  to  whether  it  be  malignant  or  not,  and  to  what  class  >  < :  _•  tl 

should  be  referred ;  and,  indeeu,  in  many  of  tlieee  case*  it  is  ■lup-'^MMrV 
ascertain  its  precise  nature  without  having  recourse  to  micruscofwa)  a^ 
servation. 

It  is  extremely  difficult  to  lay  down  any  de6uit«  rulas  of  iliaga^ais  t>j[ 
which  the  (juestiou  us  to  tbe  malignancy  of  a  tumor  of  tbe  brMit  <»a  ' 
solved.    In  the  majority  of  cases  of  cys(>>  yrvu<fA  in  this  region,  tbcn  is  111 
difficulty ;  the  existence  of  cysts  of  euHicif.'nt  size  to  be  readily  felt  <r 
through  the  skiu  being  eeuerully  chnrn(.-tcristic  of  the  nun-mnliKiinnt 
gruwtTiB.     It  must  be  bume  in  mind,  honever,  that  caoea,  auoi  aa  om 
which  allusion  has  already  been   made,  may  occur,  in  whiob  oyito 
joinixl  with  cancerous  itovetopmcnt. 

The  dinguusis  between  eyttk  mrtvma  and  some  furms  oia/atie  mm 
breut  is  not  always  easy  ;  indeed,  it  may  be  impracticable  rxrepi  by 
Boopic  examination  after  removal.     I  have  had  in  the  Hospital  a 
filly-oinci  yean  of  age,  in  whose  breant  a  hani  tumor,  as  large  as  half 
orange,  had  existed  for  live  years;  it  was  porfeetly  and  fneely  OKtrakkv 


DIAQNOSIS    OF    CANCER. 


719 


conoect^  in  aoy  waj  with  the  akin  ;  th«re  was  no  retraction  of  the  nipple, 
aod  tn>  lancinating  pain.  On  its  upper  Bit!*?,  several  large  cysts  could  be 
felt,  and  K«a  through  the  skin.  On  examitialion  after  removal,  it  was  found 
to  be  cyatic  Bcirrhus,  with  large  cj-sts  of  the  size  of  cherries,  containiog 
bloody  and  yellow  fluid.  The  only  very  suepiciouB  circumetaaces  here  were 
the  Hge  of  the  patieotr  aod  the  exUtenoe  of  one  soiail  indurated  gland  in  the 
Bxitla. 

Id  these  cases  of  doubt,  the  safer  plan  is  always  lo  make  ac  exploratory 
puncture,  and,  if  necessary,  to  examine  under  the  micmscope  the  contenu 
witlidrawD  by  the  groove  in  the  needle  or  by  (be  trocar;  indeed,  if  (here  be 
the  slightest  doubt  aa  to  the  nature  of  the  tumor,  this  exploratory  puuctura 
ihould  never  be  omitted  before  its  removal  is  determined  upon.  I  have 
more  than  once  8«eii  tumors  which  had  been  positively  pronounced  to  be 
scirrhous,  and  fi>r  which  nmputuiion  of  the  hre&si.  had  been  recomnieuded, 
prove  lo  he  cysiic,  and  di&uppear  cBlirely  when  ihcir  coiitenis  were  witii- 
dniwii. 

Between  cancer  and  the  ordinary  toUd  i\tmor«  of  the  breast,  more  espe- 
cially the  adenoid  and  adeno-surcomttloua,  the  diognnsiH  ia  often  extremely 
difficult;  but  we  may  arrange  the  chief  aigna  of  the  two  forms  of  diecHSe  in 
distinct  groups,  that,  by  comparing  thcni  together,  the  differences  may  be 
more  clearly  seen.     {See  Tabic,  j 


Ad.  Moderately  bird,  nodulated,  irregu- 
lar In  ihspe ;  Dcrsainnally  mope  or 
lata  lol)«d;  distinctly  circumsorilwd; 
•umetiniGs  ei»tic  tn  parts. 

MoAifity.  Contiderable,  though  oecaslon. 
ally  ili*re  t>  a  deap  [jeduncuUited 
Ktiacbnt«nt, 


HCIRXHOUS    rCMOKS. 

Feel,  Of  itony  hardneea,knobl>y  aodiDdis* 
Unctly  cin;um«cribed,  or  aornvwhat 
aquara,  and  occupyinc  tbg  wLoId  of 
tee  aubflUitce  of  ibc  gland. 

Mobiiiitf.  At  Qrat,  coasiderablc,  but  eoon 
lost  from  adbuton  to  tbe  draper  ttruo 
luros  bv  a  broad  aiuicbm«iil. 


Skin,    or   th«  natural  color  throuffhoiit.  Skin.  Early  iinplicnt«d ;  al  Anl  dimpled, 
thuuf(h  thinned  and  expandea   witb  ibon  r^  or  |iiirple,  and  inoiliGrcaace 

tb«    tumor    lyin^   close    beneath    it.  bmwny  and  leailicr-like,  an   that  It 

ItuplicaUsd  uiily  lu  the  advanced  Btage  does  nut  admit  of  beina  pmtbed  up 

of  cyatic  sarcoma.  inf>  fi'lda  ;   or  nodulated;   purpk-red 

maanea  form  in  it. 


mpptt.  Uiually  not  retracted. 
VtintoJ  tKe  Skin.  Not  uiucb  dilated. 


TfippU.  Usually  ratracted. 

Veina  of  the  Skin.  Very  greally  dilated. 


Pain.  Often  moderata ;  if  tevere,  conUnii- 1  i^in.  Sarere  and  laiicinelinr,  especially  at 


ona,  or  of  a  neuralitic  cbarncier,  much 
Incrawad  by  handUng. 


nl|;ht  anerliundliriKi  and  when  tbeikin 
ia  Implicated,  but  ikh  condnuottt. 


Axillary  Otnndt.    Uf  uiuhI   liie,  or  but   v4ici7'inry  O/antft.  Krilnrfiod,  induiuled,arid 
allghtly  enlarged  and  novablc    Lym-  flzi-d.    Induruifd  icHf»  of  Ivmphntiti 

phattce  not  MlTecied  ;   iiijiraclaviculur  under  and  pMrnllei  to  t^nre  of  the  ptC' 


glasds  not  affec4«d. 
Ci»utUuiional  In/Kivm.  Nona. 


toral, iLretvhini: into th« axilla;  lupta- 
clavicular  glandi  enlarged. 


Conttiititumat    Otefitxy. 
vnncee. 


A*  diMn>e    ad- 


Tbe  coexistence  of  adenoma  and  carciuooia  in  tbe  same  breual  ia  exceed* 
ingly  rare,  though  a  case  has  been  recorded  by  Busbtun  Parker.  In  euch  a 
caie  tbe  diagnosis  must  Decesaarily  be  very  obacure. 


730 


DIBSASfiS    OF    THS    BBKAftT. 


The  diagnasie  of  cancer  of  the  bieul  from  rhron-ie 
of  ft  lobule  or  the  gUod  ia  oflen  extremi-iy  dittirult.  Both  dtMM  loajk 
CBtc  tlic  inammuiy  tii^uc,  ure  ill-dcflned,  hard,  nod  oflrn  nnluUr  iW 
pain  may  be  the  same  id  both,  and  tbey  may  occar  at  the  auna  ag«.  Iftb 
loflaroed  lobule  be  near  the  aurfac,  the  skin  mar  dimpin  over  it  «■  io  • 
cancer,  and  in  rare  caaea  there  may  be  an  eolnrge<J  gland  in  the-  axilla.  Ai 
a  rule,  however,  the  inflammatorr  indurati'in  ia  not  no  hard  aa  liMl  J 
cancer,  and  more  than  one  nodole  may  be  felt  perbapa  in  t»A  hwc 
whereas  a  prininry  scirrhus  ia  alwaya  nlngle.  In  the  later  Ma^.  vha 
cancer  haa  implicated  the  akin  and  gland*,  the  ditKculty  in  diagouaia  it  m 
lonf^r  present. 

A  similar  difficulty  often  ariaea  in  caaea  of  ekronta  tncytttd  a&«Mia.  Bm 
th«  distinct  relation  of  the  diaeaae  to  iiupreguaiion  and  the  pii^bt  <iitm 
alnooet  always  to  be  recognized  over  an  awceas  will  eerre  to  abow  tb*  aMan 
of  the  di»eaee. 

Rapidity  "/  tfrotcih,  aUhoiigb  alwaya  a  very  euajttcious  circunifltaM)*,  d^ 
Qiil  by  ilaelf  and  witliuut  other  signa  be  taken  aa  unequirocnl  aridflMlof 
iuMligiian(.-y  of  aclioD.  I  have  aeen  a  ao-called  "  chrunio  mammary  taaoi.* 
probably  a  suritima,  iucrvaae  from  the  aize  of  a  ben'a  egg  tu  that  of  the  tMi 
Dead  in  leas  than  six  months,  and  aflur  removal  not  proeot  Um  alighM 
evidence  of  malignant  iliseaae,  on  the  mnet  car«fal  eaaminatino. 

Hfrurrmee  after  revmval,  though  a  very  auapicioua  rircurnctance,  ia  byat 
means  a   proof  of   malignancy,      llapidly  grotring  sarcumain   nill  nrur. 
This  I  have  aeen  hapwn  five  times  in  a  lady,  olberwiae  in  j>- :  i. 

and  without  a  trace  of  malignant  disease  in  the  avatem  or  in  ib<.  ........  m 

p.  711).    Bo  also  the  recurring  fibroid  tumor  has  oeen  remand  rij^hiorm 
times  from  the  breast,  befure  its  complete  extirpation  hoa  baea  tflMiad. 

In  caaea  in  vrhicb,  aAer  carefully  applyinp  the  foregtHoe  princt(dM  af 
diagnosis,  the  Surgeon  is  still  unoertain.  he  may  feel  tempted  Ut  vait  nuQ 
time  clears  up  the  doubt  and  makes  the  naturo  of  the  dieoaae  eridesL  tif 
■o  doing  the  only  hope  of  mnterialiy  prolonging  the  patient*  life.  eb>AM  tka 
dtseaae  be  really  niiili^iiant,  u  luit.  In  the  prveent  day.  when  <Kir  uralmffl 
of  wouudv  is  so  far  perfected  that  u  aimple  incision  may  be  rvgarded  aa  Oai 
from  danger  and  aliu>wl  free  from  incmivifnitfuce,  it  is  the  Surgeao'a  (Ivty  I* 
cut  into  every  doubtful  tumor  which  may  by  any  powibility  be  a  caMA 
and  to  remove  a  piece  for  examination.  In  the  great  majority  of  oMMlkt 
naked  eye  a|>poarances  will  at  once  determine  the  question  wbetber  it  bt  I 
caneer  or  not,  but  should  there  still  be  doubt  a  scraping  or  a  anal)  fin^ 
ment  teased  out  with  needles  mar  be  put  under  a  micnaoipe,  vhiek  abooli 
be  at  hand  for  the  purpose,  and  it  is  very  rarely  indeed  that  any  dnubt  ejl 
then  remain.  lu  such  caaea  it  is  brtter  to  obtain  the  patienl'a  eoascDt  tei* 
whittcver  may  Iw  necessary  iKfure  making  the  examination,  ao  that  so  tia* 
may  be  bjst  and  the  whole  breoat  imnicdiaLely  excited  sboald  ft  pfWeiaki 
cancerous. 

Tki^^at-mekt. — In  caaea  of  cancer  of  the  breaat,  the  fint  qaMitoo  tbo^ 
pmeniB  itself  to  the  Burgeon  ia.  whether  any  plan  of  treatment  sboct  of  t^ 
removal  of  the  ttimor  holds  out  a  pruspcct  of  cure,  or  even  of  raliaT;  ao^ 
If  out.  whether  the  extirpation  of  Ibc  canoemiu  bresat  ein   be  andsfia^i^ 
with  the  proe])ect  of  ridding  the  jHiticni  of  an  otherwise  btal  dtieaas,  m  4^ 
leoit  of  prolonging  her  existence.     To  theao  questions  the   remarki  nwk  ^ 
p.  too:}  fi  *cq.,  vol.  i.,  on  the  general  treatment  of  cancer,  mar  be  cuosUer*^ 
applicable.     The  management  of  cancer  of  the  breaat,  however,  iovolvft   ^ 
many  special  cnnsidcratlona  iif  importaucc,  that  it  becomei  naecaaor;  i4i  o^^ 
aider  tu  bearings  somewhat  in  detail. 

No  consiiluUunal  means  appear  to  be  of  the  aligbiMt  awvic* 


iaaiiiitl^J 


TRCATUKNT    OF    CANCER — COMPRESSION.  721 

and  still  less  ia  removing,  caocerous  tumors  of  the  breast.  Tlie  advantages 
stateit  to  have  been  derived  from  the  use  of  araeuic,  cooiuin,  iron,  various 
preparations  of  mercury,  etc.,  have  uot  been  borne  out  by  exiwrience  ;  and, 
mdeetl,  it  may  be  stated  generally  that  these  and  nil  other  known  remedies 
*re  pertVftly  valueless  in  the  curative  treatment  ul'  this  diseajie. 

Compruiion  by  various  means,  whether  by  plasters,  as  employed  by 
Young:  by  agaric,  as  used  bvKecamier;  by  the  sprin;r.pa<ls  of  Tauchou  ; 
or  by  the  slack  air-cushion  of  Arnutt,  has  been  much  praised,  not  only  as  a 
palliatiTe,  but  as  a  curative  means  of  treatment  in  this  disease;  and  cases 
are  recorded — which,  however,  even  the  warmest  advocates  of  this  plan  of 
tnmtment  are  forced  to  admit  to  be  altogether  exceptional — in  which  the 
empluymeot  of  this  means  has  been  stated  to  have  ett'ectcit  a  complete  re- 
moval 4it'  the  tumor.  But,  although  I  am  not  pre[)nre<l  to  deny  that  indurated 
massei*  in  the  breast  may  have  become  absorbed  during  the  employment  of 
this  treatment  i,and  indeed  I  have  hud  occasion  to  observe  this  in  mr  own 
practice  I,  1  think  that  evidence  is  altogether  wanting  to  show  that  an  un- 
doubte«I  case  of  cancer  of  the  breast  has  ever  been  cured  by  this  moans. 
And.  iiotwithstRnding  the  high  authority  witli  which  Home  of  these  alleged 
cores  of  cancer  have  been  brought  before  the  pnifeesiiiu,  no  positive  proof 
fata  been  adduced  to  show  that  the  tumor  that  wh.-^  observed  wm  really  and 
truly  of  a  cancerous  character,  and  tliut  it  may  not  have  been  merely  the 
mult  uf  chronic  intlammatiou.  Every  priictical  Surgeon  well  knows  that 
it  is  utterly  impossible,  in  the  present  t>tate  of  science,  to  diaguot^e  in  many 
cMw  with  complete  certitinty  the  true  nature  of  a  tumor  of  the  breast,  and 
must  frequently  have  witnessed  cases  in  which,  after  extirpation,  the  morbid 
ffrowth  has  been  found  to  be  of  a  different  character  from  what  had  originally 
Deen  supposed.  I  am  acquainted  with  at  least  eight  or  ton  ca.He.s  in  which 
•oiue  of  the  moat  experienced  Surgeons,  bolh  in  this  country  and  in  I'aria, 
bavtf  amputated  the  breast  lor  supposed  scirrhus;  when,  at'ier  removal,  it 
was  found  simply  to  have  been  the  seat  of  a  chronic  abscess  with  very  dense 
walls.  And  with  regard  to  a  hard,  chnmic,  and  indolent  tumor  of  the 
breast,  few  Surgeons  will  hazard  a  positive  diiignoi-is  as  to  whether  it  is 
scirrhous  or  uot,  until  they  have  actually  seen  a  section  of  it.  For  these 
reaAHid.  it  is  impossible  not  to  receive  with  the  utmost  hesitation  the  cases 
of  supposed  cancer  of  the  breast  reporteil  m  ciirt><l  by  the  advocates  of  com- 
pression, and  not  to  suspect  that  the  cases  recorded  by  those  geiitlonioii  as 
instances  of  the  successful  omplnyment  of  this  phui  of  treatiiunt  may  have 
been  simple  chronic  indurations  of  the  breast  and  not  cancer. 

But,  though  there  is  no  evidence  before  the  pnitoi-sion  to  prove  the  ntility 
of  compression  as  a  cunilire  agent  iu  cancer  of  tbo  breast.  I  think  that,  when 
tMlctisetl  with  Arnott's  slack  air-cushion,  or  Tanclion's  spring-pad,  it  is  of 
conaiderahle  value  hs  a  ji'iifiuiiff  in  some  of  the  earlier  stages  of  this  disease 
ihould  the  patient  refuse  to  siil>tiiit  to  operalion  ;  tlu'u  il  may  uiiilotibtedly 
ocraeiouully  arrest  its  progress  tWr  a  time,  ■jiiniiiish  the  sizi-  of  the  swelling, 
■Dil  le»>en  the  violeniv  of  those  attacks  nt'  lancinating  pain  wliich  arc  so 
dutroiping  to  the  patient.  In  conjnnclioii  with  the  )>re.''siiri',  loiicli  relict'  to 
kuffi'riug  may  he  atlijrded  by  tlie  nsenf  lK'lliiil<'iiiia  plasters,  or  <if  atro|)ine  i>r 
acnuite  inunctions,  together  witli  tlie  internal  )'xliil>iti<>ii  nf  cnniiim  and  nior- 
phia.or  liy[>oderniic  injections  of  niorjihia  ami  atropine. 

Ill  the  advanced  stages  of  the  diMasr,  hov\<'ViT.  wlieii  the  skin  is  involved, 
the  pri.'«(<ure  is  often  unluantble,  iiUTia.-iiii:  llif  p:iin.  and  a<-ling  as  a  source 
t»f  irritation  to  the  patient.  In  some  cax'*  of  tin-  kiml,  in  whiili  tin-  slack 
air-cu»ln,iii  <><)iild  not  be  borne,  1  have  miii  irli.  I' atll-rd' d  by  ruiidcnite  pres- 
H"*!^  Kith  thick  layers  of  amadou,  snppoiiiil  l>v  itn  elastic  liaiidiiL'''.  btlta- 
ioDUA  or  coniuni  in  powder  being  du^te<l  mi  tl>"  iniieriniisl  layer  of  aniailou. 

TWL.  II.— 4fi 


722 


1IT3IA8E8   or   Tne    BltKABT. 


A  very  thin  gtitla-nrrcha  Bhifltl.  mmililf<)  to  the  part,  aoav  iMBlliaa  hi 
advaniflgeoiiiily  nppiied  [i%'er  this,  nnd  kvpt  nii  hy  turii5  iif  nn  dHMnltf. 
When  the  »kiii  U  implicni^i)  nnd  very  trndfr,  Llie  n{)|'  /  WlladNlft 

and  lead  lotion  is  otuw.    When  llie  di«e»i*e  Ims  run  m  i  i-«-fmted  Mifi. 

U)«  iiiterna)  iidminislmtioo  of  cotiium,  m  itt>  to  lilunt  Die  vrmubiliir,  aiutUf 
luciil  application  of  eur«ly[>lu«   oil  and  todororm  oinliiirnl,  katrarir  tni 
lotion,  and  solution  of  fNrrnian^nnti.'  «f  jKitauli,  to  Irwrii  thi-  Mor.  Viftitm 
with  til*  wat#ry  extract  of  opium  or  of  btflladonoa.  will  n-lief*.     Id  ~-;—' 
this  kind,  the  application  of  cauetice  line  been  gnnitlv  vauDlvd.  aoti  i 
of  the  dievniH.tJ  surface  luuy  t>e  oleaiiMrd  ■>r  rviiiovvtl  by  thvM  nni" 
employment  of  thd  vuriuuB  aiitiafj>lii.-  drfniiigs  (tiat  Br«  familiar  t><  - 
geoua  in  of  much  wrvice  in  Lh«  udvanix'd  atti):cR  of  ulc«r»! 
breast,  removing  fi'tor.  ami  IcoM-uiu^  thu  iatiaromatory  Jn 
by  the  der^>iu}»>^ilioa  of  the  dischat^es. 
'Caustics,  ti{i)>lied  iu  accordance  with  the  principles  laid  down  «< 
Tol.  i.,  mar  octranioually  be  advautaj^ualy  employed  in  tlie  tren' 
oaocer  of  the  lirenft.  or  when  ihp  patient  is  atanned  at  and  pivtivci;  ' 
to  i^iibniii  l'>  the  knife. 

Operation. ^Thc  consiitiitionnt  and  onlioary  local  unttment  nf  mirrt  J 
the  hroast  being  thus,  at  the  niri»t.  of  a  iialUative  chararier,  the  qii- 
operation  always  primnla  itself  at  Ihbl  The  ohjectg  pnipcan)  art,  i 
Brsl  plaoe,  by  the  extirpntion  nf  the  disenaed  hreatit.  to  previvt  fUf-r.- 
tiuDai  inreclioD,  and  thne  f>crmanenLly  to  free  ihu  pvtieui  froin  brr  wtv 
sarily  iatnl  aflectioit ;  nr,  failing  in  this,  to  relanl  the  prngrvM  nf  ibf  ti«- 
stitulional  infection,  and  thn»  at  Uftst  to  prolotig  existeo<x.  How  iu  tkw 
objects  arc- attflincfl  by  anipiilation  ol'  the  cancerous  bniisr  U  a  tuhjtcl  if 
iniportitnt  inquiry  to  the  .Surgeon.  The  o)«ration  hnit  Ut-n  dtaenaateuoNi 
by  many  excellent  pathi>l<>giMs ;  uuL  mt  much  from  any  inlrinsfc  daaiB  ll 
may  poeoeM,  for,  althriugh  occosinually  fxtnl  frum  erysi[irlK»  xr  wmt  &S0 
accidental  compliratinn,  lli^re  is  nolhtn^  sperinllv  haxurdous  ahncl  U:  9* 
from  its  Iteing  now,  as  formerly,  open  to  the  nlijertixn  of  suh^MtiBf  1^ 
patient  to  nunecnsary  pain,  all  suflvrinf;  dnrinj;  ilA  [>prf'orniancc  b*tl9f(*' 
vented  by  nnRSthetics,  and  little  incoDveuiencc  bcinK  rxprrimcrd  at  •>■■■- 
quent  dressings,  which  are  ububIIv  almost  painless;  hut  the  gmt  vhitcl^ 
lies  in  the  fear  that  the  disease  will  return  and  run  its  coursent  nipfdfy*^ 
tbc  operation  as  if  non*  hod  Usen  performsd,  In  aouM  omm  ptf*^  "** 
more  rapidly. 

Tliu  principal  points  in  oonnectioD  with  lb«  openit]<M>  appear  t«  rti^ 
theuitiolveB  into  two  questions:  I.  In  any  cnse  of  cancer  of  the  brsMt.  a^ 
oonstitutiuiial  infection  be  prevented  by  aniputaiiou  of  thai  orj^n ;  avt." 
Bo,  under  wlial  circumatRuees  ttill  this  tnoBl  prultably  happen*  i  A'lh-^*^ 
tbo  disease  may  eveutuatly  return  in  (he  purl  or  elM-wUcrf.  BMiy  oc-i 
arrtst  the  rapidity  of  ilie  f'utal  lenniualion  t     i  I  idt  p.  1002  ri  rrr 

To  the  first  qut«liou,  it  is  not  rosy  to  give  a  very  de6niu 
nlder  slatietica  upon  this  fioint  are  hut  nf  Uule  value,  for  i 
rttuuns:  Ut,  that  it  if>  only  comparniirely  recently  that  it  has  Ix' 
cirarlv  lodistiuffuish,  i-vru  atlcr  reriiovnl,  the  various  forms  >! 
of  indanimatory  induratuui  from  mncer ;  and,  2d,  that  tinlil 
recent  period  roust  Surftenns  have  conlenifd  themM-lvt^  with  r< 
diseased  mamma,  leaving  the  nxillnry  ^lAods  iiuloncht-d,  unii 
obviously  atrectetl.     Wo  may  thereftire  put  i>n  one  •it\f  the  aU'.  :  ^ 

who  ntittcA  that  out  of  KS  niiM^,  there  were  only  IH  rrlN|B>m  ■>  • 

those  ofM-mled  on  by  him  at  Irast  two  year*  hefor« ;  of  Air*,.  w^* 

who  aaw  no  recurrence  in  4  out  of  00;  of  Iloycr,  who  sai\>i- 


I 


TREATMEXT  OF  CAXCBR  BT  OPERATIOM. 


728 


ine,  who  Mved  none ;  of  Warren,  who  Mved  1  in  3 ;  and  Omper, 

Since  the  inlmdudion  nf  annesthetii-s,  and  roore  es^iecially  tince  the  re«nt 
improvement  in  the  trealnient  <>f  wound*,  llie  more  extenalve  removal  of  the 
at&eted  paru  ha»  been  largely  practiaeii  by  Lister,  Btoks.  Billroth,  Kitoter, 
ViilkniBiin,  atid  many  othwrs.  These  Hiirgecmi!  advoeate  Che  rcjuoval  of  the 
entire  mamnm,  with  «s  much  of  th«  akin  eoveriog  it  M  cuu  wnveuieutly  be 
lakcti  away,  together  with  the  axillary  glHtidi*,  even  when  tbew  are  oot 
ohvioiigly  affecled.  The  rvuuUx  oblaiucd  bu  far  by  thia  treulineut  have  been 
most  encouraging.  Thuo  Bauka  Iib«  [mbljghed  the  records  of  46  cases,  ten 
i>l'  vrhoru  were  alive  aud  free  froiu  rL*currcuc«  ut  periods  varying  from  two  to 
ten  yeare  allvr  the  openitiou,  and  in  live  mun<  no  recurrence  had  taken  place 
fnxii  ooe  to  Iwo  years 'afu'r  the  operation.  Kibter  states,  that  in  2fi  per 
cent,  of  the  patienls  openileil  nti  by  him,  no  rei:urrenoe  had  taken  place 
three  years  after  the  removal  of  the  breast.  Billroth  states  that  he  had 
tinder  obBervation  l^'I  caKes,  in  which  no  recurrence  had  tnken  place  within 
two  years  of  the  operation,  .'i  *if  which  had  remained  free  for  four  yeare 
and  upwards  and  4  more  for  more  than  three  years.  lu  almoat  all  of  these 
the  axillary  gland?  had  been  removed  either  at  the  same  lime  as  the  mamma 
or  in  a  subaeiiuctit  operation.  These  extensive  operations  under  the  modern 
■yttem  of  trealinjtj  wounds  heal  frequently  without  suppuration.  Some  stiff- 
Besa  of  the  arm  preventing  mnvemenie  above  the  level  of  ihe  Bhoiilder  is 
usually  left,  l)ul  ihi.'f  is  of  sninll  moment  if  a  greater  chunce  of  life  is  ;,'iven. 

The  inference  fairly  de^lucilile  from  these  casea  m  that  in  a  certain  pnipor- 
tiiin  of  cases  cancer  has  been  eH'ectunlly  removed  by  extirpation  of  the  breast, 
aod  that  the  proportion  of  the.'^e  casen  in  the  practice  of  any  particulnr  Sur- 
geon is  directJy  projwrtioued  to  the  freedom  with  which  he  remo^-ea  the  dis- 
eased Btructun^ 

As  to  the  )UN:nnd  quettinn — whether  as  a  general  rule  life  may  not  be 
pndong«fl  by  the  perturmanee  of  the  operation — wc  are  coufronled  with  the 
same  tnllncy  in  all  the  older  slatiAtic«.  Leroy  D'Etiolles,  Walshe,  </ooper, 
and  Brmlie,  were  all  oK  tlie  opinion  that  life  was  little  if  at  all  prolonged  by 
operation;  and  although  Velpeau,  C^illaway,  Brndie,  and  other  Surgeons 
recorded  cam^  in  which  the  pnlieiit  had  liv^d  rttany  years  afler  the  opera- 
tion, nn«t  of  them  were  ]>rohably  ra>efl  of  Baroma. 

The  nin«t  trustworthy  iitaCiintic?!)  tliat  ue  piiwseaa  on  the  relative  duration  of 
life  in  cases  of  cancer  nf  the  hreaM,  with  or  without  ojteration,  are  those 
collected  by  Sir  Jame*  Paget,  Morrnnt  Baker,  and  Sibley;  hut  even  these 
probably  include  some  eaties  of  rarcoma  under  the  name  of  encephaloid  cancer. 
Pugec  eialc8  ttint,  of  1 13  cases.  t>d  were  not  submitted  to  operation  ;  of  these 
the  Rveragi'duralioDof  life  waaa  little  more  than  -J &  months.  Of  47  operated 
on.  the  cor  respond  lag  average  wtis  also  a  little  more  than  4!)  niontus.  In 
the  firut  two  years  ol  the  disease,  the  proportion  of  deaths  was  much  lees  in 
those  operated  on  tbuu  iii  ihoeo  who  were  left — being  in  the  former  24  |»er 
oeuL,  in  the  latter  '■W  per  cquL  The  longest  duratioa  of  life  in  cases  oui 
openiictl  rm  wtis  I^  years  ,  in  those  operated  on.  a  little  more  than  12  years. 
Morram  Haker  tin<ls  that  in  84  cases  in  which  no  operation  was  performed, 
tJie  average  durntiou  of  life  was  43  months;  in  H'i  casc^  operated  on,  the 
avemge  was  66^  muntlis.  Sibley  linds  that  llio  average  duration  of  lite  in 
linoperate<l  cases  wuh  about  :V2  months  ;  whilst  in  thoae  suhjecled  to  amputa- 
tion of  the  brPHMt  it  reach^l  M  months.  Thus  it  will  be  seen  that,  inde- 
pendently of  the  possible  .'hances  of  a  complete  cure,  the  operation  holds 
out  the  proftnect  of  an  average  gain  of  ab{nu  a  year  and  a  half 

There  is,  however,  another  [mint  of  view  from  which  these  operations  may 
be  considered ;  for,  even  if  they  do  not  prolong  life,  they  may  greatly  im- 


lit 


DI8SA8ES    OF    THE    ttRRAST. 


prove  the  pQijcDt'H  condition,  and  place  her  iu  t  aUte  of  oonpanilinaaaiiffi 
during  (hi;  rpniHlnder  of  h«r  exiBteiire.  TIiub.  sh«  niaf  b»  tufTeritii;  •>  ksA 
pKtn  from  the  IdchI  HfTm^tion,  or,  if  the  cmxwr  lie  ukyrnt^I,  nmT  tw  *«  amk 
luiDoyed  br  the  fetor  of  th<*  discharses,  ihnt  she  mtiy  )><•  |>U»d  io  »  |H»tii»ii 
uf  far  greater  comfort  by  hnvitig  the  local  Hourcv  of  diMVM  atiJ  irnuiMi 

remored  ;  and,  ibough  »he  die  eTeiitually  of  cancer,  it  may  It-  -"' ^ 

1«H  luB^iof;  to  herself  nod  others  for  her  to  be  earricd  off  by  ■ 
aecondarr  gnmthe  io  lh«  luuga  or  liver,  tbati  to  b«  worn  out  i'l  ui<- jaip 
duKbarge,  and  hemorrhngfs,  of  ■  slowly  pn^renlvc  ulcfrratiDg 
raaniiiio. 
The  questioQ  as  tothoadvimbility  of  operatlno  in  any  given  eiMiif  i 


nf  the  breast  uannol,  bowover,  be  detorratoet)  by  abatraM  iMlholagieml 

ilatloi 


iag,  by  rcforonoe  to  scicntifio    principles,  or  by  ralculatloM 

gtuifiUcal  retulu.    Thu  .Surgeon  must  minutely  namiar  and  aumiiM))' 

weigh  ait  the  circum!>tnncrti  of  tliu  piirliciilnr  rase  belurr  hioi,  and  be  uM 

fmdeavor  to  di»lii>}:uit<h  thi»c  cnitv  in  which  the  ogiffslinu  may  p^aibly  W 

the  menns  of  pre5erving  or  prolonging  Hi*-,  from  thoae  id  tthich  xhfn-  m  a  i 

prn!ipo4*t  nf  iifl  being  of  any  aervior,  or  in  irhirb,  indeed,  it  nni»t  iii' 

liaaten  the  patient')*  death.     Whatever  the  value  of  dtatiiUini  mer  <• 

termining  tne  question,  whether  in  caws  of  canrer  of  the  brcA-t  c.  n>  ri  ^ 

the  operation  will  effect  a  cure  or  prolong  life,  they  are  not  equnf'. 

in  their  application  to  individual  caaes.    When  a  Kuritt-on  u 

hi*  opinion  renpeclinf;  the  propriety  of  amputatioK  the  breast  oi  lut  paor^^ 

before  him,  it  ie  not  eufhoient  for  him  to  be  able  to  riate  what  tb*  ^nrrtl 

R«ulL  of  tliA  o|)erHlion  iipay  be,  but  he  ituiet  be  able  too«(i»r> 

the  iiarticiilar  int^lHiice  under  cotifidi-ration  may  or  mmy  ii>  ' 

oas«,  exce|>tioiiHl.  iK-rhap»,  in  which  there  U  a  \» 

diaea»eulir<;l_v  fnnu  llu;  cyttem,  or  »L  all  evfutK    ■. 

•zisteuce.     lu  order  to  do  llii*.  it  i*  uecewary  to  fmienvor 

rules  that  may  guide  ue  rn  iseiecting  tho«v  cnwe  in  which  it       , 

be  wlvautageously  done,  and  in  aetting  aside  '•tberf  in  whieh  wv  know  ttet 

it  will  almost  to  a  nerlainty  hiuteii  the  j>atient'K  death.     And.  indeed,  ilv 

the  aliaenoe  uf  all  surli  coiuiiderutiuiie  in  general  slatiftical  invcatigatiMi 

into  Ute  raulla  uf  o|>eraliona  for  eanuer,  tJiat  deprivea  tbeja  uf  oiarb  «  Umt 

value  as  guidef<  in  artual  practice. 

Tbougn  nothing  can  Iw  more  uusurgical  or  improper  thnr  ''r  =r,:Ii»Bri» 
nale  extiriMitiun  of  cancerous  tiimoTSof  the  brenet  f'rxm  nil  ]  ibsM! 

present  them^etvcfi  in  whatever  stage  of  the  diM^r4> :  ami,  t>i'-'u;;ti  aactl  t 
practice  would  doiibtlea^  bp  followed  bv  re»ull-«  fully  as  d iMutrooa  ■■  thtf 
that  occurred  to  Mncthrlnnc,  Boyer.and'olheni,  yet  thero  can  be;  little  daaM 
that  a  Hurpeon  who  would  employ  a  certain  jtrineiple  of  M'tecfiuo. 
oblnin  a  very  diflercnt  and  a  far  more  eucccaiful  result  in  his  praitM*. 
U.  Brodie  very  clearly  and  <iucciDL-tly  pointod  out  the  moat  iiori-'rlaiil 
cumstanccs  hv  whieh  the  question  as  to  the  propriety  ot  o|ier  ' 
cases  sbould  be  drtermincH.  Hetbrc  doing  so,  he  verv  inxtU  i'; 
fact  that  in  many  c<i»e«  the  ciperation  may  fail,  and  thi 
thnoigh  the  negltgencv  of  Ihi.' Surgeon  in  leaving  {xirti 
iif  (he  tumor,  or  f-ontaminated  tJnuea,  and  tbnl  ll>< 
receive  diacretht  for  wbnt  is  iu  reality  the  fault  of  tor  -^urifr'u 
pvrfnrmetl  it. 

With  riifcrence  tu  opemiion,  cuuceroo»  'liseaMni  of  tb«  brraal  amy 
divided  into  tbre«  c\amtf*:    I.  Tb>i»-  in  wtii<-li  it  t»  the  dutv  oj  tb^Sai 
to  dist-oiinlentince  exetsiori;    'I.  Thoce  iu  which  the  !■•  lonl 

cxpeiliener ;  and,  'S.   Tiiuue  in  whlvb  it  is  Uiv  duty  xiS  • . 
mend  iL 


CASES   OP   OAVaBR   PATORABLB    FOB   OPKRATION.       726 


1.  Case*  unfit  for  Operstton. — This  claes  includes  cases  prwenlinji  the 
follnwine  coadltioiu:  a.  ^Lron^ly  marked  coaeliluiional  cachexv  ;  0.  DiwaM 
in  both  brea«t«;  c  Secoadnry  deposits  ia  iDternal  orgaas:  d.  Much  eulargv- 
meiit  vf  the  glands  uader,  and  tjspecially  of  thnse  abore,  the  clnvicl« ;  «. 
IKIeraa  of  the  hand  and  arm  fnitii  pressure  on  the  aiillfiry  vein ;  /.  Adhe- 
sion of  the  tiimar  to  the  rib.^  and  intercostal  muscles;  jr-  Hard,  brnwnr,  and 
ioGltnitekl  skin,  of  a  roddiah-hrowa  eolur.  having;  n  hard,  leathery  feel,  or  a 
greasy,  glaKt-d  nppeanincc;  A.  Uupid  fjrowch  of  the  tumor  in  a  patient  with 
a  strong  hereditiiry  wint:  i.  An  L-xtcnsivcly  ulcerated  and  funpiting  tumor, 
with  marked  r:>UHiituti<nml  ('n(.'bcxy. 

2.  Doubtfal  Cases. — ».  If  tlm  (miiont  he  agod,  weak,  aniBmic.  or  very  fat, 
and  the  tumor  lar^o,  it  i»  at-ldom  expedient  to  o|>entlv,  na  the  shock  may 
destroy  life.  L  When  tht-  «kin  'mi  miTeiy  dinipUwl  io  by  a  kind  of  pedicle 
paaeiag  from  the  tumor  u*  iu  nndtT  Burfains  an  operation  nmy  h«  performed, 
unless  other  clrcuniHtunci^  nhonlil  contrMintlirjiKi  it;  hut  in  such  cases  It  ts 
necessary  widely  &>  exciHc  the  inli^gmnonl  surrounding  tliti  ulinchfrd  point. 
The  canwr- cells,  as  I  have  mnrc  than  unrr  had  nccaninn  to  observe,  will  have 
dttfbscd  themwlrct  extcnaively  tliriiii;^li  rlir  neighboring  skin,  which,  tn  the 
uakctl  eye  and  to  the  touch,  biu  a  pertectly  healthy  »pp«nrAnc4>,  LhB  tumor 
being  surriHinileil  by  a  kind  of  halo  of  caniter-infiltrntion.  c.  When  there  Is 
but  moderate  enlargement  of  axillnry  glaodit,  which  are  ho  situated  a»  U* 
admit  of  removal,  the  operatiim  mav  he  performed,  d.  When  the  cancer  is 
ub^rated,  it  is  seldom  proper  to  >tperate;  hut,  if  all  other  conditions  be 
fa%'orable,  this  even  neerl  nut,  in  some  special  vni'e^,  he  a  bnr.  As  Sir  B. 
Brodie  has  pioinied  nut,  the  patient's  existence  may  sometime*  in  these  cases 
be  prolonged,  and  her  comr.irt  nintcrially  increased,  by  removing  the  dis- 
eased and  ulcerated  ma«^<i. 

Old  age  exerciees  a  material  iuBucnce  on  the  expediency  of  operating  for 
cancer  of  the  breast.  As  a  rule,  L  du  not  think  it  advisable  to  do  so  after 
seventy  years  of  age.  unless  the  distress  from  pain  or  the  discomfort  from 
%tid  ulceration  be  «<>  great  as  to  render  removal  at  any  risk  justi6able.  The 
danger  of  the  operation  is  greatly  increased  by  advanced  age,  more  eepeeinJly 
if  the  [Mtient  is  sUmt ;  and  if  recovery  take  place  the  expectancy  of  life  after 
seventy  would  not  be  materially,  if  at  all,  increased  by  the  extirpation  of  a 
disease  which  would  probably  lecnr  and  prove  fatal  within  twovearfl;  the 
more  so.  as  the  progress  uf  cancer  at  ndvance<l  age  is  often  very  slow. 

Frtgiuuicy  is  not  Meeessarily  a  liar  tn  the  perfortnnnce  of  any  necessary 
operation,  even  >if  amputation,  on  the  female  breast.  In  pregnant  women 
cancer  when  attacking  the  breast  becomes  verv  active,  hence  its  removal 
ehoulil  not  be  too  long  dclayeil.  if  nit  other  crrcumstaiices  are  fnvorahte. 
Rhould.  however,  the  sixth  or  seventh  month  be  reached,  it  might  be  as  well 
to  delay  the  operation  till  alter  rccovcrj'  from  parturition.  But  in  deciding 
this  question  much  will  depend  not  only  on  the  rapidity  of  the  growth  <d'  the 
tumor,  but  mi  the  rtize  of  the  brcaitt  and  the  moral  etfcct  of  ilie  oper-atinn. 

3.  Cases  favorable  for  Operation,— All  cases  of  cancer  of  the  breast  are 
favuralde  fir  operation  when  recognized  sufficiently  early,  provided  the 
patient  is  suffering  from  no  cmisLitutioDal  disease,  but  unfortunately,  either 
from  relJcencc  on  the  part  of  the  patient  or  hesitation  on  the  pnrt  of  the 
medical  attendant,  the  ijucstiou  of  operation  is  frequently  not  raised  until 
some  of  the  unfuvorable  conditi-ms  already  mentioned  have  apjipflrwl.  The 
exclusion  of  all  the  cases  in  which  this  has  hftppene<l,  will  necessarily  limit 
very  nuKerially  those  in  which  the  ofwrnlion  may  he  undertaken;  it  can, 
however,  he  performed  with  every  prospect  of  its  being  advantageous  to  the 
patient,  if  tbe  tumor  be  of  moderate  si se,  slow  or  nearly  stationary  in  its 
growth,  unoouncct»i  with  or  at  least  merely  attached  by  a  pedicle  of  the  skiti, 


726 


DISEASKS   OP    THE    BREAST. 


ID* I  0«f^ 


prelLy  (tKiinetly  oirfTUtnscribeil. movable  on  ttii-  •^ubjnrc-ut  parti, snd  Mlft* 
ulicatcd  by  gr^allj  <M)lar]:ed  glands  id  tlie  axillH  <>r  <-]rtfH(ier«.  Tke  paiMl 
lias  an  cppccially  finod  pnwpect  rtf  recovery,  atoordiflg  ta  Brudle,  if  tV 
dWase  hpi>ratc<)  In  liw  uipnle. 

Wbcn  once  a  tumor  of  Ine  brraftt  has  been  awrtrlaiDnl  lu  bt-  *t(  i«bcvi<«< 
ebamrler,  the  sootier  it  n  removed  the  heller,  uuIum  udo  <<r  <)"-  "•  ^'I 
rens<inB  ndverM  to  operation  lliat  bare  juat  been  aiirerlcd  U 
Ecery  ^^av's  tJelny  diniiou>he»  ibe   cbance  of  iMTiiiatietilly    r 
paiieDt.    The  diwaM  (for  rennous  Melcd  al  pp.  ()7&-0n],  wt  > 
tlie  early  stw^e»  ofteti  to  be  entirely  IirhI  ;  Ibere  it  m>  v\h'- 
tioual  iiifectiun,  but  if  tbe  upKratjun  be  deliiyeil  Ibr  rkii> 
iriipjiitit«l,  tbv  Hsillury  ^lituuB  eular^'e,  tuid  rnitevn'Ua  nn 
all  caeVK  of  euuctr  of  the  br<:url  tbe  wliote  uf  tliat  '•r^'i'li  '  ' 
r«inuvrd,  eepecial  care  bviue  laki'u  (but  uu  bile  ofmuniinart  -r 
bebiud;  and  aA«r  removal  tbe  under  Mirfarv  and  vdi;**  ot     lu 
to  be  carel'ully  exaiuineil,  to  discover  ubetber  lliv  cj^tirfwlion  lin»  btn> 
lilete.     Tlie  <)iie«li<in   of  (he  Biniuldiiiei-uii   removal  oj'   tbr   axillary  t^mU 
ju  every  cuhe  is  t>till  un  u|»eu  one,  but  ubeu  ive  ciiUBider  how  uimil»t»cl>«^ 
the  Hiiiinle  excision  of  the  glfliitl  iiftiitiUy  in.  it  ivrlainly  decervt-B  i  tmt 
When  ine  rnnrer  is  infiUralea,  the  whole  of  (he  brcatt  and  tbe  burrouaiJiiii 
cleIlllI^^ndiI>use  Btructuree  niitfl  be  very  freely  renioveil.  !■-  •>■"-  -  ■ '"• 
a  huhi  of  eaiicerout*  iufillraiion  around  the  iiitirniil  niiiM>,  Jo  i 
healthv.     Il  nmy  happen  that  ibe  minor,  espeeially  if  a>-iriii' 
ently  iMiIated.  and  situated  al  one  bonier  of  tbe  gland.  M-er<' 
(!(miieote<l  uilh  thai  structure.     Ilere  the  (jutstion  will  ai' 
the  whole  of  ihe  organ  rmght  to  be  removed  or  not.     In  d<  i 
tnu6t,  I  thiuk,  be  Kuide<l  by  the  pi-Bition  of  the  seirrhoua  m(u>  ixuii 
of  the  breast.     Toe  ranccr-intiltralii'm  proceeds  in  (he  euune  of  ; 
phalic  vessels.     If  the  eanrar  be  situatn)  ittwnrds  tbcsiemnl  tr  i 
ho«ever  isolated  it  mav  appear,  it  will  Ite  found  thnt  thr  nnu 
will  wriaioly  liave  hL-oonie  infiUratfd,  lyliiji  as  il  dtn  - 
man  and  the  lytnidiatics.     When,  however,tbe  tumor 
or  outer  border  ot  the  gland;  when  it  appears  to  bedrtncb* 
lying  rather  in  the nzilla  or  below  the  claviclr  than  in  c«'ii-   ■,:  .. 
gland  :  when  the  breast  itself  is  very  large  and  fnt.  but  healthy  to  ' 
without  harduew  or  retraction  of  the  uipple ;  when  tbrre  i«  oo  ■'/" 
of  deep  intiltnitioD — it  may  then  be  a  i^uealioD  whether  it  will 
prudent  to  extirpate  tbe  tumor  alviue,  uiih  tbe  adip<«c  bed  in  wnicn  ii  i" 
and  B  deep  i^licD  of  the  adjoining  uinnniinry  gland,  than  to  (•vrfnmi  tbe  ■>** 
aeriouB  ofHration  of  removing  (he  whole  o(  the  brcnit.     In  delrrmiaiMll* 
point  wo  must.  I  think,  be  voided  by  the  situation  of  ihc  tumor,  tlic  ml*' 
tho  breast,  and  tbe  size  of  that  ijr>:an.     It  the  tumor  be  distiDrtJy  asills'T* 
if  (lie  brcMt  loel  pt-rlectl^-  soft  and  healtby,  and  the  nipple  prujtef,  tlin*<* 
DO  rcn*iu  to  feiir  iniiltmiion  hy  eaucer  of  tbe  eentral  ana  Bteroal  pi>rlioH* 
lire  manimnry  j^tund.    I  have  found  on  careful  niicnecopieal  examinatiM*** 
bitaati  removed  Ibr  sctrrhua  at  the  axillary  burder,  thai  the  abuT«'BAM<* 
partsof  the  uland  wereentirclv  fret*  from  all  sign  of  dtseaae.    If  tbe 
l>o  small  and  shrunken,  the  wdolc  may  tx*  removed  without  any  Itww 
danger ;  if  it  be  very  large,  the  Surgeon  best  eonaulls  the  j-^'ir-r^''-  —■'-•¥ 
amply  removing  the  tumor  witb  a  deep  ived;t«*^  shaped  pic«-> 
portion  of  the  gland  ;  but  if  there  tie  aiiv  hardneM  or  (iu.i|>k> n*  n<>iu 
feel  abeut  tbe  mumnutry  glnnd,  if  the  hue  of  demarcali'tn  b<r|iatTn  il  ai 
the  tumor  be  not  defined,  and  particularly  if  the  [utlicul  b-     '  ibat  t 

operation   '\M  not  n   very  severe  one,  extirpation  of  the  wl 
MJgbt  eerlainly  to  b«  praclisril.     iluw«v«r  widely  the  part*  ar«  nawnJ, 


tm*«. 


AMPUTATION    OF   THE    BREAST..  727 

line  of  iocisioD  usually  comes  together  readily  and  evenly,  owing  to  the  laxity 
of  the  iDteeumeDta  id  the  mammary  region. 

I  have  observed  in  those  cases  in  wliiuh  it  becomes  necessary  to  extirpate 
Cumora  of  the  mammary  region,  without  removal  of  the  glaod,  that  erysipelas 
has  more  frequeotty  followed  the  ojieratiou  thau  when  the  glantl,  being 
affected,  has  re<)uirtd  removal. 

Batnm  of  Cancer  after  Operation  may  take  idnce  in  three  situations: 
in  the  cicatrix:  of  the  part  operated  upon,  in  tlic  neighburing  lymphatic 
elands;  or  in  some  internal  organ  or  distant  part.  When  cancer  recurs  in 
the  neigbborhooil  of  the  previously  affected  part,  it  is  pnibahly  owing  to  the 
cancer-cells  having  become  widely  dii>seminated  in  the  skin,  the  subcutaneous 
areolar  tissue  and  muscles,  or  neii^hboring  lymphatic  glands,  and  af^er  the 
removal  of  the  tumor  these  celU  becKine  the  germs  of  new  growths.  In  these 
circunutanccs  it  may  reour  in  the  ciciilrix  and  then  implicate  the  glands;  or 
in  the  glamls  without  the  cicatrix  having  been  jireviously  nffectttd.  In  local 
relapse  of  this  kind,  it  often  hap[)en8  that  the  disease,  so  re|)roduced,  runs  its 
eourae  more  rapidly  than  if  no  operation  had  been  iierfnrniitd ;  the  hypenumia 
Kt  up  in  the  part  during  the  healing  process  ap|>earing  to  give  augmented 
force  to  the  reproductive  energy  uf  the  cancerous  griiwth.  In  some  cases 
ilreiurDS  in  the  wound  even  before  cicatrization  is  completed,  the  surliice 
then  assuming  the  ordinary  character  of  the  cancerous  ulcer.  In  other  cases, 
the  cicatrix,  some  weeks  or  months  atlcr  it  is  i'uUy  formed,  uzssiimis  a  dufky  red 
or  purpli^fh  tinge,  becoming  hard,  stony,  and  uoduhitcd  at  |Miiiits;  these 
nodules  being  round  or  oval,  oilen  very  uumcrou:^,  and  varying  in  i>ize  from 
a  pin's  bead  to  a  pigeon's  egg,  studding  the  whole  length  and  breadth  of  the 
dcatrix,  and  at  last  running  into  true  cancerous  ulceration.  In  such  cir- 
cnmstaoces,  the  only  hope  of  prolonging  the  patient's  lite  lies  in  the  speedy 
cxcUton  of  the  whole  of  the  diseaiied  structures,  or  their  cxtirftation  by 
caiutics.  provided  there  be  no  deep  atftjctiun  of  the  glands,  nor  evidence  of 
internal  secondary  growths.  But  if  the  axillary  glands  be  much  enlarged, 
either  alone  or  together,  with  recurrent  discai^c  in  the  cicatri.t,  or  if  there  he 
■nr  sign  of  iutcrnal  cancer,  further  operation  will  lie  impn>[»er. 

Ampitation  of  tiik  BitKAsT. — The  question  of  amputation  of  the  breast 
ihould  always  be  raised  and  discussed  with  more  than  onlinary  regard  to  the 
freliiigs  of  the  patient.  A  woman  looks  upon  her  breast  as  alike  the  emblem 
ud  the  ornament  of  her  wottianhood.  She  shrinks  from  the  idea  of  ltd  being 
iffected  by  disease.  She  suffers  acutely  in  mind  when  it  is  invaded  by  tumor 
nf  any  kind ;  the  horrid  dreud  of  thai  disease  being  cancer  ever  haunts  her 
thoughts,  not  su  mucli  from  the  fear  of  the  po:<!«ibly  imiH'uding  operation, 
bat  rather  from  the  distress  of  mind,  in  many  easeii  amounting  to  a  sense  of 
haniiliation,  at  the  idea  of  the  mutilation  of  which  she  is  about  ti»  become 
the  vitrtini. 

The  o|)cration  for  the  removal  of  a  breast,  whether  affected  with  cancer  or 

vith  other  diseaae,  may  be  [KTloriiied  in  the  following  way:    The  patient 

ihoulil  lie  upon  a  table,  with  the  arm  hanging  over  the  side,  tied  down  or 

hehl  by  an  it>siiitaiit.     If  the  tumor  be  large,  and  the  lo:-s  of  blood  a  matter 

of  much  consequence,  another  assistant  slionid  eoinpress  tlie  subclavian  iirtery 

"H  the  lirsi  rib.     The  hemorrliage  will,  however,  depend  more  on  the  nature 

ihiii  on  the  size  of  the  tumor.     In  all  eanecrons  tumors,  but  esiM'eially  in 

the  eocephaloid,  it  is  considerable,  and    from  many  enhirgeii  vessels.     In 

•jnipic  tumors,  even  of  very  large  size,  it  i>  often  trivial.     I  have  removed  a 

WOiple  tumor  of  the  breast  of  many  poumis  weiLrht,  and  had  ti'  tic  onlv  one 

■P'^uting  viitwel.     Indeii],  nothing  indicaien  nmre  eornlu.-lvely  ihc  enormous 

•^'ivity  of  eancerouH  tumors,  tind  the  great  dniiii  they  must  exercise  upon 

"**  aysteni  generally,  than  the  large  size  and  great  iinndK^r  of  their  supply- 


'28 


UiSBASBS   OP    THE    BRKAST. 


iog  nrtrriee,  ronipaird  with  iboec  Boot  to  a  «impl<?  tumnr  mmoT  tlawi  kr^ 
tbun  (lif!  rualivMiuut  udo.  If  the  vmiu  about  tht>  part  b«  mod  dHwd, 
tnoiauivB  stiuuid  b<-  Lakou  to  nrtL-M  the  flow  r>f  h\<io<\  from  lh<n,  ■»  il  an 
soiiiclimea  bo  tlAnj^emusly  pmruso  :  indeed,  6<iu(h  rululM  tbe  cmw  nf  s  {himI 
who  dit^d  frttrn  tlib  tmaae  durtiiff  tb<r  operaiioti.  ]n  lit  emttamtmtMitmmm^ 
bcrof  for(-ipn--*iiurL-l'iir<-epA<ihi>iil(l  be  at  bund,  which  can  bo  left  BttaeM  l*Ai 
bicediiiy  vf^elii  until  more  ftermnncnt  mumi  of  uTMdl^  ibe  Iwaonklfi 
can  W  i-arriod  out  it*  ne^fiwir)-. 

Jn  lunpuinlinnR  of  ibe  brciwl  f»r  caucpr,  then-  tire  fiur  prindMl  iftd  vU 
pfiinlB  tliat  miii't  Iw  Hlti-iKit-d  lo:  ].  Ti»  remove  llw  ttbole  of  uw  gluil;  t 
To  rcmovf  tlm  nippier ;  ^.  To  rfmove  t)>e  »)cin  wiilelY.^v^ti  when  apparfM)^ 
fa(-aUby;  4.  To  cicnr  out  tbe  axilla  if  tberr  he  luiy  Kluiidular  cnlmqpaMn. 

The  (>penitii>i>  »boul<J  utwnvg  \>v  dout*  willi  uril)H.-ptic  pfMtatiUdMk  Hv 
whole  br«H)il.  side,  Rlid  nxillii  sbould  fiitit  be  thuroii^rlily  •"'  ''  MfbJB 

loLtito,  1  to  '20.      The  direction  of  tbi^  incUJon  thmu^li   li  .lONll  ■ 

varif^i)  by  tliflfrrtil  .Surj|;«<)Us ;  s^xuv  pivfcr  n  imn»v<-nM',  othro  n  |iri ticMtinlir 
one.     I  tbtiik  that  tin  dctiiiitc  pliiu  ebuuld  hv  fi>l|i>n<-d,  but  thr  dtrvcdoilf 
tbr  I'ut  Hindu  to  vary  accordiug  l»  lht>  sjliiatiuti  uml  fi»  "C  t)o>  igiuc»r,u4 
the  fini<iuiit  of  iuic^tinieiit  that  r(><iiiirM  removal.     In  nil  vmf*.  tbe  ntfjil* 
should  bf  included.     In  urdinarv  nitvis.  ta  n  t'fuc*ral  rulr.  I  prrfrr  an  uUh^ti 
incision  fulluwinfj  tbe  coun-«  of  tliv  fihrw  of  ibt-  jfrwit  pectoral  mu*^'-    "'' 
CDubk-8  tbe  Surgeon,  if  ueccfi&ary.  to  fxtrnd  ibc  cut  inti*  the  nxiV-:' 
reiuovnl  "f  fiilnrf^l  glaniU,  and.  aAvr  ciratnuttion,  allonx  tb'-  ~ 
of  tbi^  arm  witluiiit  iindui'  trarlion.     An  obiiqup  rlliptiral  im-j 
eiriil  ti-ngtb.  nmr  thus  h«  made,  fi rat  bt'low.and  nrxt  nlK)vo  tl>'-  -r 
U>  include  a  Bii^ctent  qtiaiitiiy  of  intcjjuoieut  (Fi|^.  TTtii.     In  -  :  '    -" 


Fljt.  n«.— pM)tl«n  ot  PiUtfii  la  AnpntotlM  -ol  Bnwt. 

where  tbe  nVia  a  somewhat  involved,  a  tramvunw  incitioti  mav  \m  laa^* 
addition  Ut  tliiK,  Ki>  ai4  to  iucludr  tbf  ufffcUwl  tiilft>iinifnl  iti  \'u  Vt^ 

uer.     Wlii.-ii  I  be  tumor  'n  very  Inrut'  aud  pr<iiiiiiii-ul,a  duuli.  >^  '**^^ 

uiny  very  {.'•'iiveuit'iilly  include  the  nipple  and  tbir  ni'wt  »u«^uM>u*paiV* 
thu  skill.  Tbo  divevliou  ehould  iht-ii  ih'  tteadily  farriv«l  dowa  t>»Uitf>c 
toral  inusvlv,  CTory  bleeding  vesaet  U'liig  iuiiticdiiitoly  veixrd  in  ftmipn*'''* 
forceps, aud  the  breast  ffiuoved  wilii  the  cellular  ImmI  iu  wfairb  it  lica.  WWi 
tbe  tumor  is  of  lar^  size,  aud  fapoclally  if  it  be  nf  ttniple  ohanrter,  tlH* 
part  of  llitf  ojieraiion  may  be  dune  very  pxpcdiliouily  by  drawiM  dnntta 
raaa  and  Unicbing  Ui«  areolar  tissue  with  the  Bcalpel.  whpn  ibe  vwilr  tav* 
will  peel  off  the  jieciorat  niuacle,  and  can  readily  bo  deiaebed.    AlUr  iW 


THiC   AXILLART  9I.AVP3.  729 

removnl  of  the  cliBcaaed  breast,  it  and  the  tumor,  ns  well  as  tho  whole  interior 
of  the  uoiiiid.  tiiUBt  be  caretally  exftiiiin^tl.  to  n^'orltiii)  that  nn  ?lici^  of 
murbi)]  tiiunchiivo  been  Icfl  behind  :  if  so,  tbcv  nuist  Iwl'rotly  cut  nut;  and  if, 
as  soraeliriioa  happens,  the  p-owlh  he  rather  tirraly  adherent  t'l  the  pectoral 
0nii*cle  or  Bubjttccnt  stnicturpn,  portions  of  th«*c  must  also  be  removed. 

Tbc  clciiriiig  out  of  the  axilla  ndds  greutly  to  the  severity  and  immedinle 
ilangcr  of  the  operation.  Bhuiild  there  be  enlarged  lymphatic  glands,  or 
should  the  Surgeon  adopt  th«  course  of  clearing  out  the  axilla  even  when 
dis«>tiM-d  glandit  cnnnot  be  felt,  this  may  be  done  by  extending  the  oblique 
iincij>iiin  upwards  aa  far  as  may  tje  necessary.  It  will  orten,  however,  he 
■Jjund  more  convenieot  to  perform  the  operation  in  the  following  way:  An 
oval  inciaion,  the  lonj{  diameter  of  wliich  ia  placed  Irnnsversety  In  the  trunk, 
may  be  made  to  include  the  hreiipt,  iind  ae  much  i<kin  aa  it  in  intended  to 
jRiove.  From  the  outer  eud  of  this  au  iuci*ion  may  be  tarried  to  the  outer 
iriler  of  the  axilla,  in  ibe  line  of  the  iutig  dtniiietirr  of  the  oval  inciaion. 
Another  incifeinu  is  curried  upwards  along  llic  anterii>r  border  of  the  axilla 
to  the  arm.  The  mamma  ia  then  removed  in  the  onlinury  way,  the  surface 
of  the  pcctoralia  major  heiiij:  carefully  cleflned.  Having  arrented  the  blee^l- 
ixig,  the  Huffruou  now  pmceeiU  to  remove  the  contenta  of  the  axilla  aa  c-jm- 
pleiely  as  poemble,  including  not  only  the  lynipbatic  glands,  but  the  fat 
Burrouudiag  ihem.     While  doing  this  the  bandngc  securing  the  arm  niuat  be 


n^.  TTT.— TbeUloD*  rt^slrtd  fat  tboHaglilr  eluiriitg  Asilla. 

I, and  the  limb  given  to  an  HseUlant,  who  muat  hold  it  in  the  positioo 
riDoet  convenient  to  the  Surjieon.  The  edge  of  the  peetoralis  major  may  be 
'clcaneti  with  the  Hi-alpul.  care  lieiug  lukeii  Ui  cxpoeo  nud  eleau  the  lower  pari 
of  the  pecL'iraliff  minor  nleo,  m  a  few  glanda  almost  invariably  lie  concenltnl 
hetwceQ  this  and  the  greut  peetoral.  and  may  be  easily  uvcrluokcd.  In  doing 
this  the  external  mamnmry  artery  will  be  dividdt.  The  contenla  nf-thc  axilla 
are  then  turned  cflrefiilly  over  to  the  poeteriur  )>ide  uf  the  s|)acc.  In  the 
lower  part  thin  may  safely  be  done  with  the  edge  of  the  ktiite.  but  at  the 
lUpper  part  the  handle  of  the  Rcntpel  and  the  fingers  F'bnuUI  be  um'd.nnd  any 
inds  which  are  met  with,  and  appear  to  contain  vcfuels  shotdd  be  tcolaipri, 
id  a  ligiitnre  pns-'ed  round  them,  after  which  they  may  be  divided  with 
Kira.  By  thus  working  carefully  at  the  upper  pnrt  of  the  axilla,  the  fat 
and  the  glands  contained  in  it  may  be  gafely  separated  from  the  great  vea- 


780 


uisBASsa  or  ru£  bkjcast. 


aels  which  arc  left  exfRiiteil  ufteu  i'ur  uut;  or  twu  iodioi.  FkakU;, 
luam  is  ilrawu  iluMiniards,  aud  sepHrntetJ  fntQi  tlie  pieteiiur  banter  cT  tk 
axilla,  cjire  he'm^  takuo  not  to  wouiitl  the  aub»c-u[>ulnr  arur^  and  vat )» 
wbicli  Lhu  «DlHrguil  ulari<Li  ura  snmeliiiuv  uillieri-iit.  HbouM  it  bs  Dtmagf 
to  iUvi<le  tlitse  Vf«MU.  they  iiiuitl  nuL  be  cut  tux  cUjwIy  to  iKj*  mata  Uiakk 
The  cniuplete  extirpation  of  (lie  nxillary  ^lanilj>  i(>  tiir  iinwt  ilit&ealt  fa/l^t 
tlie  operation,  but  by  jialieiit  anil  fnirt>ful  <]ii<^-ction  it  <.'aii  he  aaM^an^ 
pLulieJ.  If  th<>  enlarged  gItuirU  tlinl  are  rvuililr  [wrocpltl»l«  an  il^ 
removeil  wil  limit  iJip  fiit  mirrouiitiiiig  itivm,  n  tiumlM-r  of  umaller  riMdiaM 
sure  to  be  left  beliloH.  Wound  af  the  axillNrv  vein  ii  the  lU'wl  Ikavlf  aoi- 
dent  tu  uccur  in  remnving  daods  suated  high  up.  It  u«ially  ariMs  &«■ 
tearing  through  iotuc  stiMlT  brauch  ju»t  »:» it  enter*  th«  main  tn-^V  tit^ 
opcDiOft  be  very  smalt,  it  u  easily  SL-ourLH)  by  pinching  it  up,  ai  ,  » 

ligature  louiid  it  without  occ-lutlius  tbe  whole  vein.     Should  ii-r  w.^umi  hr 
nit>rcext(.-DBivo,  the  whole  veinshouhl  l>eti«il.    Rillnith  ftatrfl  that  be  ba*bU 


1I0M  followal, 
l«pao^  m 

i-'U  ID  the  nwa 
.  icgn,  lb'  \m\mat 
rifiuUiii*  iti 


occasion  to  do  tbii  nmre  than  ooctr,  iiud  that  no  cvd 
rarely  even  oedeiuH  of  the  arm.  The  anfcly  of  th> 
much,  however,  on  the  huccv»IuI  prcvfuliou  of  •!■ 
Should  the  injur««l  vein  be  bathed  in  d«o?uip<>- 
would  be  exposed  to  the  iinniiDent  dauger  oi  avptit: 
mill,  which  formerly  made  ^uiveoos  hesitate  to  apply  u  ligature  (■' 
Sotry  of  air  into  the  vein  u  a  dnnger  which  niuat  be  b'tme  ia  tund  vhw 
ramoving  glands  in  cluse  proximity  to  iu  It  is  best  av<Mded  br  earvfal  i^ 
Mction,  but  should  the  vciu  be  unavoithibly  in  danger,  an  luttilant  AmH 
place  hi^  tiager  on  it.  if  possible,  on  thu  csrdlae  side  of  tlie  expanl  ivl 
Wound  of  the  artery  b  uua'h  lam  cininiun.  It  is  must  likely  to  oceat  >"■ 
shaving  tbe  eubHcapular  branidi  away  m  closely  as  to  leave  a  dmilar  tft' 
turein  tliesideof  the  main  trunk,  lican  bcMt  be  avoided  by  n<*i  lakiacriivf 
instmmcols  in  tbi^  r«*giou.  Shimld  It  happen,  the  main  trunk  mau  HMt 
ou  each  aide  tif  Uiu  wound. 

The  njierdrfMtnij  of  ihe  wound  is  of  great  cinMqiKDoe.     A  vuBfldtM 
gapos  iu)iu<.'U»cIy  whilst  the  arm  han^A  tlonn.  will  tie  found  to  cliMe  villi tki 

Sreatofll  ease  when  the  arm  u  r^i^ied  and  laid  acroiu*  the  i-ht-at.     If  pruptrlr 
reaed,  the  patient  iniffi-r^  no  pain  during  the  healing  of  Ihr-  w  Hind,  vkin 
is  usually  complete  in  about  a  fortnight ;  thert-  li  no  eon-:  :    lisuH- 

ance  of  any  eoiiseouence,  and  the  dreA*itigs  neu<l  not  bu  di>'  .    ■.^<n.  |Lu 

twice  or  thrice.  8>inc  form  of  antiseptic  dre--wing  iihould  nlway>  Ik- spt'lBl- 
Tbe  plan  that  I  nnw  usually  adopt  la  aa  follows — nil  l>'"  .  <!liu-  "  •'xi*  uriat 
been  wcurcd  by  l^irai'io  or  by   ligature  with   fine-  •  jut-i* 

wiHiud  M  ihufjughly  washed  out  with  a  solution  of  oUi.. '->■  ..i  '  '^'' 

bolic  lotion.    The  etiges  are  then  to  l>«  br»u^ht  togwthw.     If  n.  " 

been  reinovral,  and  there  in  cjioaidcrablo  »tratn  in  npproxtmalr  '" 

•bould   be  done  by  lh«  introdueliou  of  one  or  two  deep  Ikm  -^ 

thick  wlver  wire.     The  viiivm  are  then  carefully  ailjimlwl.  ■•> 
■itiou  by  lueiiiut  of  ii  stirbcieut  number  of  iMiinls  ol  eiitnri 
or  catgut.     Kllicieul  drtiimgo  must  next  he  Heciireal  i- 
or  two  dniin4gu-tul>u»  ol  ^\h\-i  calibre  with  a  piece  >•; 
they  iiiiiy  not  Ih:  but  in  the  woiin<l.     If  them  in  a  iat 
axillary  bi^nler.  tbit  nmy  bo  piTtoraleil  ami  one  of  th* 
aud  tixo<l  in  tlie  hole.     A  large  and  thi>'k  layer  u(  i 

be  laid  over  the  wound  and  well  up  into  the  axilla,  w'j 

packed.  Over  thit  a  Btill  larger  and  thicker  layer  of  niieyhis  and  «* 
must  be  placed,  taking  in  the  Hhouhler  at:  I  clavicle. 

Tbia  ilreHsing  ahonid  be  mnfined  and  rtuppxrteil  by  uinu  nf  a  hulr  li^^' 
age  well  stitched  down.     U  need  not  be  diaturbed  for  aeVeral  dan—*  af^ 


AXILLO-UAMUABT    CANOEB. 


731 


or  more — unlcn  the  Lemueraturo  nefji  ubftve  100°  Fahr,  or  tho.  fli<icli»rKe 
Irom  the  wound  soaks  thruugh.  The  deop  silver  sutiirc^s  nhoitld  be  tiilcen 
out  about  the  <>ighth  or  tf^nth  day.  The  cat^iit  ktiloheft  itft^^n  Iteconie  ah- 
mrbed.  tf  niiL,  they  may  he.  picked  nut  when  the  wound  U  healed,  ^fter 
citraLri^Atinn  U  cimiplcte  the  |iari  should  he  kept  imvercd  with  o>ttoti-w(H>E 
Igr  HijTiie  nioiith?,  nni)  |h«  patient  catilinDe^l  nut  tu  iDuve  lh<;  Rriu  Ui*)  IVeely. 
In  must  cn««8  It  will  unite  by  th«  Itrst  iulention ;  for  owing  to  the  yivUliiiu 
Dulure  of  the  |>»rti<  in  this  situation,  the  lipe  of  the  cut  cuiue  into  vvry  good 
«pI><n^itiou,  even  thuugh  u  conaiderahle  maiMi  h»*  bet-u  reuioved.  By  huiuo  ic 
hiu  l>e«u  gup[>o««<J  timt  reliipg«  aC  vwxr  is  Itrm  liabio  to  take  place  if  the 
wound  unite  by  ^'rauiilatiou.thau  if  it  (H>nie  t<>^Ui«r  by  mure  sptredy  union  ; 
of  ihijt,  however,  thert  is  no  |>n>uf  with  which  1  ura  aci|uainl<xl. 

The  nwrt'tiily  Jrvm  umpudjliun  of  M?  brvist  wiw  nvvfr  very  oousiderahle. 
and  has  bit-u  ^rvatly  reduced  by  tbe  uiuderu  iinproveuienta  iu  tlie  treatment 
of  wounde.  The  circunistanced  that  chietiy  inlluiuce  it  are  the  nature  of 
the  lunior,  the  eiee  of  the  br<.'u»l,  uud  the  extent  of  iht;  luiisioa  into  the 
axilla.  The  upcrulion  is  nuu-h  more  dau);enui!i  when  |)erfi>rnifH]  for  the 
reiuuval  of  ranceniui^  than  of  biniple  tuniore  ;  and  the  danger  increai^ect  in 
pru[>ortion  t»  the  h-n;;tli  of  time  the  eaticcr  has  been  allowed  to  exifnt  before 
the  '>|»erulhin  is  unduruiken.  In  proportion  as  the  patient't*  general  beslth 
hae  become  undermine*]  by  the  curilinuance  of  the  malignniit  di^-ase,  so  the 
tendency  to  pyemia  and  ervuipelat^  increases.  Women  who  hare  etnall 
mamnue.  villi  lillle  fat.  bear  the  operation  heal.  The  diinj^r  of  the  opera* 
ti<ui  lit.  for  obvious  reaeoiii},  much  greater  in  wonieu  with  large  bren^ta,  in 
whom  the  ai-eolar  cisxue  i^  Ioade<l  with  conrse  yellow  fat.  In  these  repar»- 
tive  action  is  slow,  and  there  is  nuieh  tendency  tu  elnughing  and  to  crvsipe- 
Ibd.  T<afitly,  the  operation  becomes  dan;;en>ue  in  proporiiun  us  the  lumur  ia 
adberoDt  to  the  pectornl  niutM^le,  and  the  diMfctinn  reqiiirett  to  be  carried 
deeply  into  the  axilla  or  under  the  pectoral.  Th*  danger  here  in  threefold: 
I,  (rom  hemorrhage;  '2.  from  the  entry  of  air  into  a  vein  ;  and,  ."i.  from 
opening  up  the  deep  faiteia  of  the  flxifla.  anrl  the-  risk  of  the  occurrenre  of 
deep  cellulitis.  This  lust  danger  is  much  le^s  if  thfc  axilla  in  thoroughly 
clcanod  out  than  if  a  nmall  oi)«Miing  only  be  made  in  the  fascia  anti  the 
glands  torn  out  thniuj;h  this.  It  can  be  much  )e«4ened  by  the  proper  o»e  of 
arainnge  and  aiitineptic  dressing:).  When  death  follows  these  operatiotu  it 
is  moat  commonly  the  re«ull  of  erysijtclas  or  ttepticaemia. 

There  are  two  dangers  which  attend  exei«ion  of  the  breast  rather  more 
frnpiently  than  other  operations  ;  vix.,  1st,  &  congestive  form  of  pneumonia, 
not  dependent  on  any  blood-fwiiiODiDg,  but  arising  from  defective  aeration 
occasioned  by  the  breatliint;  being  Ghailow  and  restrained  either  by  tight 
bandaging  of  the  chest,  or  by  the  pniu  inditce*l  by  the  movement  of  the  chest 
vails  in  respiration  ;  and,  2d.  cardiac  thrombosis  extending  into  the  pulmu- 
oary  artery.  I  have  known  eevernt  inataiices  of  death  from  each  of  these 
cauees.  The  first  •lan;.'er  can  obviously  be  guarded  H;;uinsi;  IhesiTond  cauiiot. 

Axillo-mammary  Cancer  presents  some  peculiarities  that  dem.'r%'e  e|M.-ciul 
coDsi deration.  It  develojw  at  tbe  outer  and  upper  angle  of  the  mammary 
glaod  towards  it«  free  border,  so  that,  instead  of  ^rruwijju  into  ila  subftuncfl 
and  remaining  emhetldctl  in  it.  it  ton<la  t<>  |msli  mto  the  dirccliori  of  Ivm»1 
rraiftance  to  its  outgrowth,  aud  thus  to  extend  into  the  areolar  upace  at  the 
tower  border  of  the  axillary  edge  of  the  pcclihralis  major,  and  lie  bi-lwceii 
it  and  the  lattSi^imufl  dorai  muscle.  The  tumor  fi-cU  hanl  and  nodulnted,  and 
10  rounded  in  elm|M>,  rioiiiL'iimeM  it  apiiuira  to  be  ncanrely  altached  tu  the 
mammary  gland.  Kut  on  i-lottur  maniputation  it  will  he  fontid  to  extenrl 
deeply  into  its  KuheiaiH>a,  which  towanU  the  bai^e  of  the  tumor  feels  hard 
autf  thickened.  The  greater  portion  of  the  gland,  the  median  half  and 
much  of  the  lower  [lart,  will  continue  long  unaffected  by  canceroutt  infdtra- 


73S 


nisEASKs  or  thk  iirka»t. 


tinn.    The  nipple  ia  not  mtroclerl  until  a  verr  late  iMrintl  in  ihid  ttum 
ftUedM.     It  fttirl  t\w  arnola  priMPrvf  lti*>ir  iiormHl  uiirit-aRHKa. 
ih*"  filcio  ftbove  Ihom  Ka?  In-come  invtilvwl  am!  tlii>  Hxillarv  gl«n<t«  i 

Tlifi, manner  in  which  lit*  ^Iciii  i»  iinplicftiftl  Ami  Ihf  Bpn«*fimri-«-  it         

an*  |te(.iiliar  and  QhurxflorUtir.      It. hociint^ilnviiK-L-'l  far.-  -myftitt 

Wtiiw  ill  a  tratitvcTitp  rlin-clion  ai.  th«  upper  nixl  niiti-r  tnir<  •  uoimk 

whtTt"  there  i»  a  ti-«<l<"ucy  naliirally  to  a  fniil  ur  mm*?  in  ihr  inlvt^mML 
Thwre  the  akin  liwwimw  inlillralL"!  in  a  t rnunvr-nw  linf  nf  lianJ  KirrliiB.ra>l 
depr««M*il  Hnil  pnclcenffl  in,  with  tiiiirh  fet'lingnf  cnn»trirtion  BO'MifinHfh 
raiding  the  arm  from  the  sicIp.  'the  ilisra^e,  when  ouw  it  ha*  nwibid"* 
stiitfe,  will  iif  Rounw  make  nipiil  pmgrew  Itcith  locally  and  iMfnlititti 

That  th«!*e  ax lUo- mammary  cancen  arise  priinarilr  in  thp 
there  can  be  an  •loubt,  althimgli  their  mpid  (Ifvolopnufit  baToad  ha 
may,  at  first,  tmd  tn  the  suspivina  that  (hey  hnvr  mmtiH>Dml  oatwfe  It 

It  \f  idIv  towards  the  upper  and  outer  bonier  of  the  nauntam  llM  tfaa 
outi;r>»win^  ranc^i^  i^eem  tn  develop.  [  have  neror  wen  ibcn  U  tlw  ■■> 
or  lower  [inrt  of  the  glnnd.  unlcRs  the  wliuk-  of  tta  Btructan  had  beafia- 
vinualy  ioHltralod.  Tho  operation  in  thcBc  cneea  fthtaild  beMmpktanl 
ttinn>u;^h,  thc!  whole  organ  beiuv  removed,  howerer  healthy  the  a^vla 
arvila.  and  ^iiiie  portionb  of  il^  glnad-ntruclure  may  appear  in  he.  1W 
skin  alio  t^hould  be  vrideiv  removed  where  implieateil.  aiid  the  dlnciis 
carried  u  high  into  the  axilla  as  aafetv  will  penoit.  UnlcM  thiiTMifli  u- 
tirpation  be  prautiBed.  speedy  and  rapid  recurreace  will  msue.  lauks 
in  all  uperiitioD!  for  ditTused  cancer,  the  wnund  should  be  well  wuhal  ■! 
with  B  wlution  of  chloride  of  zino  [l  Co  20),  w  aa  to  deatroy  aay  acaUMl 
ocdla. 

DIBGAaiS  OF  TOR  MALE   BRKAi^. 

The  Kale  Breait  though  raruly  the  eeat  of  diaease,  may  oceaai<«aDr^ 
oome  aS^ected  in  a  somewhut  girailar  iiianoer  to  the  mammary  |*laadu^ib* 


c^' 


/ 


\ 


\ 


rt|.  n^.-aotrrhou  C^mett  tM  fk«  Mali  ttf«ML 

temalcu  (^^asee  have  been  recorded  In  which  ft  waa  hfpertrophud,  and  hi  *^ 
It  ha«  been  iIm  seat  of  an  nhtwrmal  aexretion  of  milk.     In  bnya  abomt  tb(  >r 


8IUPI.B    AXILLABT   TUMORS. 


7S8 


of  puberty  it  occaaionallv  becomes  the  seal  uf  aubarute  iiijtammution  oflcn 
attributed  to  o  blow,  'this  ia  b«%t  Ircati-il  bv  the  applicatlou  of  a  bcllu- 
doDua  plaster  spread  on  sole  leather  with  a  huiv  <-iit  throufjh  it  for  the  nippie. 
Chronic  interetUial  inJiammuUon,  with  nulurgctuiuit  ami  iiiduratiou  of  the 
rudimentary  tnaiuma  u  occa>iiiinatly  met  with,  kikI  if  u  eiiurro  of  niiieh 
aDiiuyanc«)  may  justify  llie  n^moval  of  the  ilLieaHcil  ^lund.  ()j«fii  and  eareo- 
mala  an  more  rare.  Srirrhov^  naneer  b  occaBituially  met  vtitli.  Tlio  at-com- 
paiiyiii^  (Iniwiug  (Fig.  77Hj  rt^prHHciilH  a  ciit=<!  of  tliis  kind  under  the  cart!  of 
C  Heath  iii  University  Oille^c  Hniipirul.  'I'tx^iee  growtlie  require  renxtval 
by  ihe  Humc  kind  of  operative  procedure  that  is  adopted  when  they  aflect 
the  female  hrtast,  thiiugli  of  a  less  extensive  character. 

AXri.LARY  TtTMailS. 

Chhoxic  Sthumoi-^  Disl'ahr  of  the  axillary  glands  U  occasionally  met 
iritb,  forming  a  \nTge  lubed  mnas  under  the  pectoral  muscle.  Such  a  tumor 
tin  Ihia  niay  easily  ami  safely  beeouelealed,  and  should  be  removed  if  it  have 
resisted  all  urdiuury  topical  aud  constitutional  treatineut.  U  will  be  found 
(o  Ih*  iutilirated  with  lulvercle. 

SiuFi.K  Tt'MOiw  <->f  various  kindv  are  met  with  in  the  axilla.  The  most 
L-oiiimon  are  lympl)aden<jmata  of  the  axillary  glands,  fatty  aod  fibrous 
Imnors. 

Lymphadenoma  of  the  Axillary  Olands  is  met  with  chiefly  in  youog 
women,  forming  u  smooth,  lobed  oiaits,  ui\eu  reaching  a  jfreat  size.     It  ia 


f 


y^ 


Fig.  77».— FlbroM  Tanior  in  JliUlft 
«C  a  V«aM>. 


Vig.  TM.— OamtTiiaiDr,  Ktimt  Via*. 


usuflllr  associnted  wilh  similar  tumors  elM-whcre.butoccasinnullyihe  ginnda 
*)f  ihc'axilia  lire  aioue  alfccted.  The  enlarged  glands  fr.rm  nn  attaclimenta 
loFiirroiiniiiiig  parts,  and  may  be  readily  removed  hy  enueIeation._ 

Fibromata  nre  wiroctimes  met  with  in  this  rej-Imi,  and  may  attain  a  great 
miigniinde.  A  tiltronid  furms  a  large,  emoolli,  r-unded  mnM,  Rtrelchinff  the 
miipclec  and  dicplitt-iuf;  the  vef*els  uud  nervec,  «»  in  Fjks.  77H  and  TfiO.  In 
this  case  ibe  lunior.  which  was  of  very  bIov,  growth,  devdi.iwd  between  the 
lerrotiifl  and  the  ribs,  etrelching  the  muucle  over  it  to  h»  to  lorni  a  I'petie*  of 
fnpaule  lo  it,  drawing  the  scapula  forwardp,  depreseing  the  chest-wall,  and 


784 


P1SIA38S    or   THK    imitAST. 


rtg.  ni.— braOBK  In  Axillft  of  m  Utn. 


drnwing  the  •ti! 
lo    iiImhiI    thm- 
cliiviclv.     Ill    rrniociRj; 
ubliftril  lit  UikciiMaf  »  j-- 
eX|iHit()nl  wrnilui  ae  !■?!!«■••  U» 

leol  rwuvrrj-.  ;>' 
difficulty  in  l>i>*.....  . 

SakcxiUaTji  of  rn  r 
met  with  in  llie  axilia  .n^  ■■■ 
8uch  luniun  rui;*bt.  in  tkm  ««tiT 
Btagi*.    be   diw    *    ■ 
ihey  cxivtid  hic-- 
ur  iiuplicntv   ibe  akiu  «i 
inflltratiun,  iliey  >bonlil,  I 
\w  left,  u  «ru    DPCfwary 
|miiciit  fnim  wbini  Fig.  7tlt 
ukcti.  ulicn-  the  ilse  of  iIn 
and  iiM  rounnrtiaiM  pcrehiM  ll» 
p()»ibiltly   nr   nprnliou.      1W 
n-tniival    aitiDot,    tofkrd.  at  agt 
itajfv.be  iindrnakf-u  witlwNilaNa 
danger.     Ill   dMMtioni  rr^/vm 
for  the  exttrpalinB  of  Mdi  i^n 
M  in  Fit*.  7KI .  I  ba*«  Kid  H  n- 
po*e  the  nxillanr  and  wlinj|d» 


Fif  TSI.^Lsfga  8w«on»  la  AxlDa  af  a  Maa. 

twmU  aud  their  accompanfiaff  u«nm.  Tha^mth  bciiif  mub 
what  widely  diaMmiBat«d.  It  if  difficult  to  b«  ccrtaiD  Chat  (he  wboiv 
rxiirpntc^l :'  heuce,  recurrenc*  ti  likely  apeedily  lo  tnkr  |>lacv. 


DISEASES  OF   THE  A 


MEN 


CHAPTER  I.XT. 


Ik  no  department  of  Surjjerv  lias  tliere  been  n  greater  advnnoe  during  llie 
lui  few  yenrn  tlinii  In  i)ie  Operative  Treatment  of  Diseaies  of  the  Abdominal 
Afid  Pelvic  Viscera.  Uui  u  ivw  Y(.'iLr!>  u^o  u  uuuini  of  lUi;  pcritoui'imi, 
itbelher  acciilciuul  or  tnti'UCiouut,  wan  rv},'iinio<l  uh  being  jiiuvitublv  itouutii- 
paoied  by  yrave  danger  in  life.  The  pi?r(l'fliiiii  dI'  iIh;  i>pi-ritli(iii  nf  ovari- 
otomy, witli  which  tile  name  of  Sir  H|K-ncur  Wells  iiiiiet  evur  be  iiiseiiambli^ 
aisuvmlcd,  led  ti>  a  more  tlionm^h  understamliiig  of  the  ciiu»es  »t  death, 
Bud  <!«tiil>ltiihcd  the  [>riiiciplea  which  alout!  can  guide  ua  lo  succOHi  ii)  opera- 
tive [iroi-eduree  uffef'ting  the  |>eritiinE>ul  cavity.  The  syeteniHlic  uiie  of  unlt- 
Kpti^-»,  further  put  at  ouf-conimiiiid  the  liest  means  of  preveiitiiif;  the  nmal 
cixtiiiiou  and  rai«t  Jatal  cimiplicatintifl  of  pt-riioneal  wound?,  mi  that  at  the 
prcaeai  time  opemtiona  on  thfe  abdominal  visuera  are  undertaken  with  lillle 
more  hesitation,  and  are  altetiiled  liy  iie  ^oik]  resultH,  an  lh<«e  of  eigual  mag- 
nitude in  any  other  part  of  the  body.  Before  proceeding  tu  the  dt-scripiion 
of  the  surgical  diseases  of  the  abdomen  aod  itieir  trcairnent,  it  will  bu  well 
to  consider  briefly  the  Bpccidl  dangers  common  to  all  abdominal  i>piTittiou», 
and  (he  principles  which  guide  u<>  in  avoiding  ihem. 

Operations  on  the  abdnincn,  with  wound  uf  the  peritoneum,  should  they 
prove  fatal,  u»uftlly  do  so  from  one  of  three  causes — septic  peritonitis  anil 
septiciemia.  ftlmck,  nr  b^mnrrhugt^. 

8«ptie  or  Diffiiae  Peritonitis  and  Septiofemia. — These  conditions  are  so 
closely  BMociiitcd  that  it  is  must  convtiiient  to  consider  tbeni  together. 
Until  recently  the  peritoneum  was  lielievcd  lo  pnjwfas  »onie  peculiar  ten- 
dency to  icflunmiution  which  rendered  a  wound  of  it  gpeciully  dai)gen>us; 
the  ioflaramatioD  spreading,  as  was  said,  by  contitiuity  of  tissue.  There  is 
nothing  to  juBtity  »uch  an  BEsumplion.  Tlie  peritoneum  becomes  inflamed 
under  the  same  conditioua  as  other  tiMUes,  the  process  is  the  same,  and,  as  io 
other  parts,  it  is  limited  to  ihc  area  upon  which  the  cau^e  it  ncting.  In  the 
preventinn  of  jteritoaitis  it  is  necevary.  therefore,  to  consider  the  causes  to 
which  it  is  due,  with  a  vie^v  of  excluding  them,  if  posaible. 

Certain  causes  of  infltimniation.  as  pointed  out  in  the  chapter  oil  the 
Process  of  Intlammation  (vol,  i.t  are,  frum  their  nature,  limited  io  action. 
To  these  belong  mechanical  injuries,  heat  and  cold,  and  the  action  of  those 
chemical  sulratances  which  cannot  increase  in  quaotity  in  the  living  body, 
such  u  mineral  acid«,  valine  cuustics,  and  the  like.  A  wound  of  the  peri- 
toneum, therefore,  gives  rUc  to  intlammation  limited  to  the  area  injured, 
and  unless  iMime  other  ctiusc  be  intrmluced  it  has  no  tendency  to  spread 
further.  In  inflanmiHtiou  of  the  periuxieurn,  as  in  all  other  membrsnce 
lining  cavities,  the  intlummatory  products  find  their  way  readily  lu  the  sur- 
face. If  the  proccjse  be  of  itullicient  intensitv,  nu  abundant  ciiagulable  exu- 
dation takc«  place ;  the  fibrin  entangling  wfiite  corpuscles  forms  a  layer  of 


736 


DISKASBB   OP   THE    ABUOMKN. 


"lympti"  DD  tlie  iDllnQic^l  surface,  and  the  #eruni  draiaa  away  UDlo  ti«  pn- 
UtDOdl  laivity.  Tlu-  in'rititnoum,  however,  fiuiii  iv<  iiitiniai«  ctuiMdidB  silk 
ilie  lyutphaiio  »yi^tL-iii.  is  poascned  of  the  paw«r  of  abwrpliuD  in  tkm  U{hai 
degree.  Hia  eeruiu  [loured  out  at  the  aeai  uf  inSumnuuion  if  ihcnAni^ 
stirbix)  will)  j^reat  rnpidit}*  by  the  healthy  part  of  the  nieubnuie,  aad  ula 
thu  quantity  be  very  conAidurable  tb«  euviiy  ta  kepi  dry.  The  exfaniMMi 
by  which  thiA  t-xtraanliaary  Bbftorbinff  p^iwer  ul'  tl»e  peritattMUn  hu  \»m 

deniotistraU'd  have  beeu  Already  olludei)  lii,  toI.  L  p.  827,     Th'- -'«1J» 

exudation  which  covern  the  intliuned  aurture  glattt  it  to  any  Am  ^^a 

ut'  iieriLiiiieiiiii,  aiid  adheiiiiins  art!  ibus  formed  which  iuH< 
va*>c'ulMnzed  and   iMi<lrr]^>  devtilMpiuenL  into  connective  i  , 

idbnttcid  U)  thuHj  oi^curnng  in  the  forniatiou  of  libruuit  tu-ut  in  tM 
uf  Ihf  u'uund.  Il  i»  by  thi»  proce^ti  (hut  adlitwious  form  In-tTKvii  in' 
ctA\»  of  iutMliue,  auil  that  ligalure)>,  ifittutca,  ntul  ottirr  Minplr  r»rvi|rB  bniha 
become  buried  H»d  eucapauled.  Il  funn»  nil  t«M'Mliul  part  of  tb«  uam-J 
all  woundt  of  (he  periloueuiu,  and  u  often  the  meana  uraavuii;  th«  imtmat't 
life  hy  prvvciitiuf^  {Krforatiou  uf  the  hoihitv  vieiTrtt,  or  ifae  niptntvafv^ 
lecUuue  uf  piiB  into  the  oiviLy  of  the  ahilonieii.  It  is  the  ubjert  of  tbti^ 
geun  til  exclude  all  thiiee  Eourcea  uf  irritaiiun  which  i-an  coovort  thi> 01111 
locniixed  iiillainiiiHliuu  into  a  difTuae  ur  8|>readin);  proceaa. 

The  catUMv  uf  apreadiii^  iiiSaBitnaLioiui,  a*  already  |K)iiit«!il  iMl  (nlLfi 
\9!>),  are  tlie  rheiuical  prtxlueUi  uf  prucecBW,  aualoji'uuB  iti  fcnusMtet 
taking  place  in  tlie  normal  HuiiU  uf  tlu"  lK>dy,oriii  inllntumati>ry  etiiiiiCiMi 
iir  utiier  rullectionB  uf  fluid.  Witlioui  n^ln  eiiceriu^c  iutu  the  i-vidnMe  l« 
aud  aguiiat  the  theory,  that  these  priHWwaea  are  ilir^i  i      '  irdi  apM  ik 

prcaeoce  of  niiertwcupic  orgnnisnia,  upon  which  the  .'  traataMttk 

fountled,  we  may  adopt  it  a»  a  hypothesis  tn  explain  the  pluitutineoa  iif  iqiic 
jierilonitia.  and  to  guide  ua  iu  the  prevention  of  thiH  faul  aMBplicath*.  Il 
will  be  rententlter^il  that  nc4V>rding  lu  thia  Iheury  two  cloMm  of  tmatilft- 
□isnta  exi^t,  the  pathogenic  or  apeeiSc  nrgnnisiu*  which  ran  i:ife<l  aad  ■» 
liply  in  the  living  tirxut^  and  bloi>il,and  ihc  iitMi'paili  -  M«6c,vkM 

gruw  only  in  dead    iimlter,  and  are  believetl  to  tie   ;  '  <>!  orliairf 

putrefactive  cbangei^     The  furmer  we  may  exelmlw  from  ■  ..n»fc*i 

fur  tbe  anke  of  simplicity,  alt^<>ugh  it  is  pue»dile  they  mu\  -.-.-  4  fUlh 
Um  ewisaiion  of  aoaw  casw  of  dilfun  peritoniiivw 

'  For  tbe  dovelopmcDt  of  wptic  prmwaseo  in  tho  peritounitn  two  cmifll^ 
I  oeoetMry :  firvu  tb«  pres«ace  of  iho  putreacible  matter,  aod.fec^iadlj.ik 

iDUict  of  the  ur^faiiiaruft  with  iL.  The  |iutrc»ciblo  ttiattvrii  famiilMil  hy^ 
liquiii  part  of  liic-  intlaminatory  cxudatioa,  or  by  oxtnTacatod  blwd.  "^ 
ur^niiiiatii^  itiay  retich  it  either  from  the  exteronl  woaod,  carrird  ia  kfri* 
Sur^^'vou'ii  hajiila,  the  fefiungeii,  the  ligatum,  or  br  ibe  ur ;  or  io  ihuK** 
iti  t^hich  the  gut  in  iiijkin^,  as  iu  rtniogulateU  iirriiia,  they  may  find  IkaJr 
way  from  the  inieriur  of  the  iuteatinu  Uirou);h  tbe  diseaaed  c«aiia»  Utka 
amount  of  the  inflaiiimatory  rxudutiuu  be  cvxupimiiively  amall,  il  10  w  n^ 
idly  abdorbeil  by  the  heuhhy  piirt  of  tlie  periloUL'uin  tlmt  no  dc 
talcra  place,  the  ftnit  roudiiion  of  tin-  procrm  being  waniJnif.  If  Um: 
of  exudutiuu  be  in  exevss  of  that  which  etin  be  al  unuenbaortieti,  an 


lattou  tnkea  plnc<-,  which  if  the  cauM-  of  puLrrfacliim  have  b«.i-n  atlniunl'' 

it, 'iM-edily  dcconiiRMM?*.     The  irritaiiun  produela  tif  !■■  --  - '-  - 

widely  diifuM-d,  nxu-itiu^t  inHniiiiiinlinii  wherever  tlic\ 

perittmeum  becotiu"^  nHrded.      At  the  winie  lime,  lh>-(.-  i-  * 

from  tbe  nhtMtrptiou  ol  ihc  chciuicnl  prixlnru  ut  ihe  (>ri'<  c  * 

lnr)(e  pnipurtion  of  cn^rn,  ibix  b  tht-  in>oi>      .         .  <f 

provo  tiittil  before  the  local  signs  of  penlui'  ^ 


BROOK — BC)IORRaA(}E. 


737 


•rnpfoms  are  those  alreadj  described  (vol.  L  p.  907)  of  acut«  septic 
p<.)i«oaii)g. 

It  doec  not  alwHj-u  happen  that  'Jiffonie  peritijiiitisoccunt  wheu  the  opening 
in  the  meiobrHne  c:>inaiuiiicste5  with  a  foul  wound.  Thus,  congested 
otneatum  iu  the  operation  for  strangulated  hernia  was  furtiierly  ligiitured 
%ith  a  piece  of  whi|)cord.  the  mass  being  cut  olf  and  the  stump  sail  ligature 
left  lying  in  an  opeo  wound  to  nhich  a  poultice  was  applied.  Uudcr  these 
circumstances,  septic  suppuration  neccttsarily  occurred,  nut  diffuiie  perit'^uitiB 
by  ao  means  invariably  followed.  Id  those  cnace,  there  wae  a  free  exit  for 
tbe  discharge  from  the  wound,  and  the  opening  into  the  peritoneal  cavity 
became  sealed  by  drm  intlanmiatory  exudation  in  the  firi^t  fmv  hours  before 
decomposition  ^et  in  in  discharges,  and  ihu»  the  danger  was  avorted.  This 
is,  however,  an  uncertain  barrier,  aud  these  exeepliuual  oaeea  do  not  justify 
us  in  neglecting  any  precaution  by  which  iho  close  contact  of  septic  pus  with 
the  peritoneal  caviiv  «iu  be  ovoided. 

The  prevention  of  septic  [jerilouitia  and  itti  conBc^iienocs  ia  carried  out  on 
two  principles:  firat,  by  the  use  of  aniiscplios  in  iueh  a  way  as  to  exclude 
any  living  organisms  from  the  cavity,  and,  secondly,  by  draining  the  cavity 
in  all  those  coses  in  which  an  amount  of  exudation  is  expected,  beyond  that 
which  will  be  immediately  reulMorbcd.  Considerable  ditfcrcucc  of  opinion 
exists  89  to  the  relative  value  of  these  methods,  xome  Surgeons  maintaining 
that,if  aiuiseptic^s  nre|iroperly  used, drainage  is  scarcely  ever  re^juircd;  and 
olhera  that,  if  the  peritoneal  cavity  be  thoroughly  cleansed  before  closing 
the  wound,  and  ilrainage  be  efficiently  employed,  antifleptic  applieatiuDB  are 
scarcely  necessary.  Tt  is  not  the  place  here  to  discuss  this  disputed  point. 
The  great  majnrlty  of  Surgeons  are  agreed  upon  the  value  of  ontiscntics  to  u 
certain  point,  the  u.'ie  of  ifie  carbolic  .'<pray  being  the  matter  chiefly  in  dis- 
pute, its  opponents  muinlaiu  that  it  iiicreasea  the  ^hock  by  cbil'liiig  the 
pati«iil,  that  wbeo  tbe  peritoneal  cavity  is  widely  open  there  is  considenible 
daogvr  of  carbolic  acid  pnieouiag,  and  that  with  ciireful  attention  to  other 
autit^e[itic  details  it  may  be  sately  dispensed  with.  Its  advocates  maiotatn 
that  by  careful  maoagemeDt  the  uhilliug  uf  tbe  body  and  the  enlrauce  uf  a 
dangerous  amount  of  carbolic  acid  into  the  periluoeum  are  easily  aruided, 
and  tbat  br  its  u»e  they  are  able  entirely  to  disj»iuse  with  drBiaag^ — which, 
tv  say  the  lea^t,  is  au  iucuuvenieoce — save  iu  a  few  exceptional  cases.  The 
point  must  atUI  be  couaidered  au  open  utie,  an  excellent  results  liitvc  bccu 
shown  both  by  those  who  use  the  t^piay  and  those  who  di.>  not.  Iu  tbuee 
UBS  iu  which  but  a  sinall  opening  is  made  int<i  the  |X'riloneuiti,  aud  it  is 
'  eoDsequently  impossible  to  clean  the  cavity  before  cloeing  the  wound,  and  in 
which,  moreover,  drainage  cannot  be  etlicientlv  carried  out,  h»  'm  ii|ierationif 
for  hernia,  tliere  can  be  ud  objection  to  using  tiie  spray,  especially  in  huHpital 
practice. 

Shock  is  a  common  cause  of  death  in  operations  upon  the  abdominal 
visceru.  It  probably  arines  chiefly  j'rnni  the  iojurv  done  to  the  large  sympa- 
thetic plexoses  in  connection  with  these  parts.  The  exposure  of  the  vigccra 
to  cold  aud  the  lues  of  blood  doubtless  aggravate  it  in  many  cases. 

Hemorrhagft  is  necessarily  a  source  of  danger  in  many  cases,  but  it  prcsenta 
nothing  requiring  special  consideration. 

The  following  are  the  general  rule*  applicable  to  all  ttbdominal  operationt  : 

1.  The  room  in  which  the  operation  is  to  be  performed  must  not  be  too 
cold,  especially  if  the  abdominal  cavity  is  to  be  widely  opened  and  the 

<  viscera  exposed. 

2.  In  those  cases  in  which  it  is  poaaiWc  to  do  so,  the  bowels  should  be 
Uioroughty  emptied  by  a  purgative  the  night  before,  and  au  enema  on  tbe 
day  of  the  operation. 

VOL.  II.— 47 


DISBASBS   or   THE    ABDOHKN. 


3.  In  all  operattoni  od  tlie  lower  hnlf  of  the  nbdomei),  the  bbAhr  ihiU 
be  cnnilied  by  a.  catheter  iuiiitwiiately  before  coniioenciog. 

4.  Thv  piiOout,  when  placed  upuo  the  labte,  sboald  m  w«rinlT  wnpfied 
up,  leflt  the  shock  be  increaaed  by  chilling  the  body.  If  the  n>ny  u^t^i» 
used,  the  body  must  be  covered  with  a  muckintoAh  cloth,  or  ■  toert  of  imW 
Btik  with  a  hole  cut  in  it,  through  which  the  region  of  the  opcraiioD  '»n- 
poeeA.  The  under  surface  of  this  may  be  sprcna  with  idhnire  plutrr  it 
one  inch  round  the  aperture  to  keop  it  in  poaitton. 

5.  The  instrutnenlH  and  sponges,  etc.,  and  the  hatidji  of  tb*  ^rgtoB  nl 
hifi  nmintaiitii  iuU5t  be  cleaned  and  disinfected  with  carbolic  arid,  ••  atmif 
described  (vol.  i.  p.  *262f.  Durin^f  the  operation,  nil  •^vKtRtu  tB«(  la 
iqueetcd  as  dry  aa  poMible,  a  tHiHied  towel  being  ii-  -*t 
datit!en>us  amount  of  carUdic  acid  b«  iolroduced  int"  :j, 
Tht-y  xhould  be  wasbeil  in  warm  carbulic  lotion  to  avoid  r                 -  yatu. 

(I.  Tliu  BiKingea  tbotild  be  counted  l>efure  and  atW  aoy  <.<^ ' :  _ .:  ^  la  aUA 
the)-  »r^  u^d  inside  the  abdoroinal  cavity. 

(.  All  hemorrhage  Irom  the  abdominal  wall  mmt  b«  amat«d  brfnntli 
pcrildneuQi  ia  opened. 

a.  li' during  tbe  operation  the  intestines  are  expowd,  they  thnaU  btUI 
on  one  side,  and  relaioeU  in  the  ubdumiuul  cavity  by  a  large,  Sai  qMft 
&r|uei-£eil  as  dry  a>  poeaihle  after  having  been  well  carmilimi 

Should  they  bo  exposed  catcraally,  as  in  operattuua  for  beniia,  iatHV- 
ceplioii.  t-tc,  or  escape  from  the  abduiiien.  ihuy  must  be  covered  with  alfas 
nig  hcvenit  fulds  thick,  wrung  out  of  a  warm  1  in  40  aolucioo  of  carWit 
arid. 

!t.  When  the  o|>eration  la  comptefol,  if  the  abdominal  esrity  barehiB 
openofi  sulfirtentlr  to  ndmit  the  bund,  it  roast  be  oleaoed  with  ipaaf* 
8i|uee7.cd  as  dry  k«  piwaible  and  paeaed  into  the  most  depeodent  puU  of  tka 
cavity,  one  atier  anollipr,  until  tbey  return  quite  clean.  Tbia  ii  a  maiim- 
portaiit  |>»rt  of  the  operation,  and  success  in  many  caaes  depondi  to  agnrt 
extent  upon  the  thoroughni'ss  with  which  it  is  done. 

ID.  In  closing  the  wound,  the  deep  stitche*,  which  should  b«  of  carbofi*! 
sUk.  nin»t  iucluoe  the  peritoneum,  so  that  the  serous  sorfni-es  shall  be  broafM 
dosely  in  coutact.  Toe  importance  of  this  in  securing'  primarv  aaioo  •■• 
deiiioiistraled  experi  men  laity  many  years  aeo  by  Sir  Sjwnwr  Wells.  \fba 
tbe  abduniinat  walls  aro  very  lax,  as  after  tne  removal  of  a  large  tasDr.ite 
atitc)iMi  may  be  made  to  catch  tbe  peritoneum,  tbe  apooeuroab  orib«elkrf 
the  mosclee,  and  the  skin  and  suocutaueoue  tiwue  missing  tbe  mueAlv 
fibres:  but  if  there  is  likely  to  b«  cousiderable  strain,  it  b  better  to  pMi^ 
decpstilchts  completely  tbn>ugh  tbe  abd'iminal  uell  about  three^oarttf* ^ 
an  inch  fr<>m  the  v^\f>K  of  the  wound.  Both  ends  of  the  deep  stitches  pari 
be  passed  from  withiu  the  abdomen  to  avoid  any  risk  of  puDctnriai  iW 
intestine.  All  the  deep  slitches  must  be  pacaed  before  any  are  tilUJU^i 
and  can  must  be  taken  white  this  is  bein^  done  nut  to  include  accMCSMltf 
a  knuckle  of  intestine  between  the  edges  of  the  wound  ur  oaderaHtX^ 
Alter  the  wound  has  been  brought  together,  tiner  stitehes  may  ba  pntii" 
bring  the  edge  of  the  skin  accurately  in  contact. 

11.  If  ii  bethought  necesaary  to  dniin  the  abilomen,  this  b  dooa  t?' 
large  tulMi  of  India-rubber  or  glaw  passed  into  the  miat  depcsdeat  pn<^ 
the  cavity  and  hnmght  out  at  the  lowest  anj^le  of  the  wmind.  Tbs  vM 
must  Itc  of  such  eiu!  that  all  fluid  shall  escape  readily  from  fL  IneBfi'* 
drainage  is  woree  thnn  none  at  all. 

12.  The  dressing  should  be  compMed  of  aome  efficient  antiseptic  nsMSif^ 
If  the  wound  is  completely  closed,  a  thin  layer  of  drvMing  is  snAcicsL  B 
it  be  ilniined,  a  thicker  mass  mttal  be  applied  to  absorb  ihe  diachaxy.  v 


[ 


operations  involTtng  the  auterior  wall  of  the  ahdomen,  the  dreaaing  is  mont 
fonvenientlv  kept  in  place  by  a  broad  band  of  strapping,  which  at  the  same 
time  siipporta  tlie  ahrloni<?i). 

13.  Alter  mo«t  ahilomiiial  operations  the  patient  should  he  kept  wlthont 
frxdl  for  from  twealy-luur  to  f'lriy-eijjlit.  Iioun^,  i.*v  in  some  cases  eviin  I'tn;;*r. 
A  6iiiall  quantity  of  iceil  «<xla-wattir  ur  barle^y-waier  may  be  given  lu  ailav 
tJiinit.  If  the  condition  uf  the  palienL  inakts  it  necesaary  u>  give  foiA, 
chickeo-liroth  or  ivaii  milk  and  ii<Hla<watttr  is  the  best,  given  in  small  quan- 
tilie«  at  intervals  uf  about  two  hotirei,  Small  luiLritive  enemata  are  ofieu 
useful.  lu  operatioD^  involving  tfae  intestine,  opium  is  often  ueoes^ary  to 
prevent  [wrielaltic  movement. 

H.  If  the  opcraliou  is  foHowe«l  by  a  high  temperature  du«  to  absorption 
of  inflaiiiointory  exu<latiou  from  the  peritocieucu,  an  ice-cap  may  bo  a]ip[ieii 
tn  the  head  as  recommended  by  Knuwsley  Thornton.  If  (hcfre  is  rvusun  t» 
belit'V«  that  the  perituni'uai  is  becoiniug  distended  with  lliiid,  the  patient 
may  sometimefi  he  ftave^l  by  inicniiig  one  end  of  the  wound  and  ini^urting  a 
lube  in  thivw  aifm  in  which  drainage  haa  tiut  been  adujiLeil  j'rom  the  lirKl. 

lu  all  ah<l(iminnl  opi^raliouH  xueucBS  will  greatly  depend  on  minute  atten- 
tion to  dftaite.  The  openitiou  must  hi!  L-arefully  considered  and  planned 
beforehand,  anil  evfrythtng  timt  can  poFsibly  hi?  required  must  lie  at  liaiifl. 
At  the  end  uf  u  severe  fijienilion  in  ihit;  region,  the  patient  U  n\\en  Hudering 
greatly  from  shook.  {Krhajm  hovering  Itetween  tile  and  death,  and  »  little 
needleae  delay  from  not  having  everything  n-ady  the  mompnt  it  is  wanletl, 
an  annereesary  exposure  uf  the  intestine  for  want  of  a  proiier  flat  sptinge  to 
reloiu  them,  or  a  lallure  io  aome  other  minor  detail,  may  juat  turn  the  scale 
against  bim. 

HKKXIA.     * 

Dy  Hernia,  in  its  wiiteat  sense,  is  meant  the  diaplacemcul  of  an  organ 
frum  the  cavity  in  which  it  is  uatunilly  cnulained.  by  being  protruded 
through  an  nl)normat  ur  accidental  opening  in  its  walls;  when,  however,  it 
eacapes  through  one  of  the  natural  r>utlets  of  the  part,  it  is  not  C(m!>idered 
heruiul.  Tbue.  the  protrusion  of  the  brain  through  an  aperture  in  the 
cnuiium,  or  of  the  lung  through  one  in  the  thoracic  walls,  or  of  a  portion 
of  iotestiue  through  the  abrlomiutil  parietes,  is  tcrmeil  a  hernia  of  the  organ  ; 
but  the  descent  of  the  bowel  through  the  anus  does  not  come  under  thia 
deeiguatioo.  Here,  however,  we  have  to  consider  only  the  hernial  prolru- 
sioDB  that  occur  fnim  the  abdomen — the  coraiuon  aituafion  of  thi8di!ea3e. 

A  hernia  may  occur  at  almost  any  part  of  the  abdominal  wall ;  though 
it  is  far  more  liable  to  do  so  in  some  aituationa  than  in  others,  being  com- 
monly met  with  at  those  poinld  where  the  muscular  and  tendinous  structures 
are  veakeoed  to  allow  the  pas^ge  of  the  spermatic  cord  in  the  male,  and  of 
the  round  ligament  in  the  temalc ;  or  fnr  the  trnosmis^ioQ  of  the  large 
veffiels  to  the  Jower  extremity  ;  hence  the  inguinal  and  crural  canala  are  the 
common  situations  of  this  dittease.  It  raav,  however,  occur  in  various  other 
mtuaiioDB,  as  at  the  umbilicus,  the  thyroid  foramen,  the  sciatic  notch,  in  the 
TSgiOB,  the  periaeum,  through  the  muscular  portions  of  the  abdominal  wall, 
the  diaphragm,  etc. 

SriiffTCRE  OF  A  HERNtA. — In  whatever  situation  it  occurs,  a  hernia  is 
CMDposed  of  a  Sac  nml  its  Coiitent«. 

The  Sao  is  the  jiroloiigatioD  <if  that  portion  of  thepcrilooeum  which  over- 
lies and  corresponds  to  the  ajKirturc  through  which  the  hernia  protrudes. 
It  is  io  all  cases  comp'ised  of  a  neek  and  a  hodt/. 

The  Keck  is  usually  narrowed,  though  In  some  old  herniie  it  becomes 


740 


HEKNIA, 


wiile  and  expmiileil ;  it  is  cuoiiuuiily  atiort,  cuueUtiu);  iadMfl  of  a  fsdlki 
ooo^trivLiitn  of  the  sac  in  thta  liiciiatioii,  u  hapneiix  in  nion^  fonM  nf  fcmnl 
hernia ;  but  in  other  t'nMtJ  it  is  elongultsl  aixf  narn)*r»l,  T1>p  nrrk  ul  lac 
hernial  hiic  uHually  heconira  gnai\y  lliicl(eiie<l  and  of  an  npaqve  ncl'T,  tn 
the  growth  of  lihn>i<l  tissue  in  or  n[>iin  it  from  the  irritalitin  to  which  i:  bii 
been  subjected  by  the  pressure  of  the  hernial  tumor  or  the  iruai!,  by  itm  r» 
oornoralioD  of  the  subserous  areolar  tissue  lying  externallT  in  it,  tv  by  lU 
nurkeriiig  ti^tber  of  its  folds,  which  have  bevn  comprcnwii  by  tbr  fl(>ftsn 
in  which  it  lies. 

The  Body  of  the  snc  is  usually  globular  or  pyriform.  eometimii  donlri 
and  cyiindriiiil :  it  may  vary  from  the  eixe  rif  n  rbrrry  to  ■  tomor  ■*  ^V 
u  the  hpiid.  When  recent,  it  is  iif-unlly  thin  and  iniPspareBl,  thaagh  a 
some  cases  it  liecome?  greatly  thickened,  having  nrbore«erat  rrmth  nmHf 
ing  in  it, and  being  nlmost  laminnird  in  structure;  tbb  tiespoeullf  tbncM* 
in  old  femoral  herniie.  In  other  iiutances,  howcver.it  becnraet  lAuiBi<Jai4 
atrophied  aa  the  tumor  expands,  so  that  the  conienro  heromc  visible  iliraick 
it.  Thia  iit  especially  the  ca»e  in  old  umbilical  heroiae,  in  «bich  I  ktn 
seen  it  as  thin  as  the  fiue«i  •juld- beater's  akin. 

The  sac,  though  usually  forming  a  f>erfect  incWure  lo  the  hcreol  (cft- 
lent«,  occasionally  constitutes  but  a  partial  invr^tniiut  tn  them.  »<«•  Ta^ 
ticuiarly  in  such  orgsus  as  the  civcum  or  bladder,  which  ar^  {>an'' ' 
covered  by  peritoneuro.    In  other  instances  it  may  lie  ruptured. nr  a\:  . 
abnent.     The  sac  is  absent  when  the  hernia  occurs  as  the  r*^ult  of  s  nit-i.- 
injur),  or  abscess  of  the  abduntiual  wall.  It  cannot  be  saiJ  lo  exi^l  ia  a'-n' 
genitui  bemia,  and  may  be  absent  in  ca<cal  and  in  uiuitjlical  hej-ni-*- 
rarely  a  double  hernial  sac  is   met  with,  one  being   protmde*!   i 
placed  behind  the  other.     There  are  instances  nf  three  aaet  oceiirrii|i^ 
gether ;  and  Sir  A.  Cooper  relates  a  case  in  which  six  were  met  with  in  tW 
same  [terson. 

The  abilominal  parietes  outside  the  sac  undergo  important  cIm&m.  TW 
aperture  through  which  the  hernia  protrudes  usually  D«cvarse!realar:B&(r 
a  time,  indurated  and  rounded  nl  the  edge,  and  p<ineiderablycBlaf]gnli«b<i 
situated  in  the  movable  portionf  of  the  abdominal  wall,  as  in  tlie  {D|ttfis) 
region,  it  becomes  disptared  in  old  herniie.  l>oing  dragired  dnwn  by  thc«(>{M 
of  the  protrusion^  usually  towards  the  mesial  line.     The  sufaaerros  witf 
tissue  alwavit  becomes  greatly  thickened,  often  indurattd,  so  as  to  iiiaUinW 
one  of  the  densest  investments  of  the  sac,  and,  in  somr?  old  e««rt  <if  Imi^ 
closely  to  resemble  omentum,     T)ie  more  superfictal 
intc^mont  and  fascia,  arc  much  clitngBl««l  and  stn-r 
not  unfrequcntly  hanging  in  folds ;  tbev  are  usaally  < ' 
have  been  long  worn,  they  become  thicxened  and  cond-,-  ..-    , ; 

of  the  pad, 

OoDtcnU. — The  content!  of  the  sac  vary  greatly;  arrry  «-u^„,  ..v.^Mt  ib 
pancreiiR  having  been  found  in  a  hernial  tumor.     Moat  fr< 
of  the  Small  InteMin*,  more  parlirnlfirly  of  the  Ileum,  is  ' 
tuHog  the  form  of  hernia  called  Eiit«roc«lfl.   The  Quantity  ' 
th«  aac  may  vary  from  a  small  accti'm  of  the  caJibre  of  <' 
diameter  Dtft  being  included,  to  a  coil  several  fc«t  in  lengt) , 
meaentery.     After  a  portion  of  the  intestine  has  once  dfariniUil,  i 
truded  part  tende  lo  increase  in  rjuantity:  until,  as  in  ionie  larre 
herniie.  the  greater  portion  has  been  known  to  lio  in  the  sac    T^ 
Intestine  a  rarely  found  in  a  hernia,  though  the  CKcam  is  oocaaiMi 
with.    When  intestine  has  been  long  protrudad,  ii  uaually  beoooi- 
CDOi],  nnrmwod,  grayish  uu  the  surfaoe,  and  BWre  or  Ina  dcnwg"' 
funciiuns.    The  corresponding  mesenlery  beonmca  thickened,  hj^ennfti^ 
and  vascular. 


II 


HTDBOCELR    OF    THE    HXPlflAL   SAO. 


Omenlum  is  oflen  fiminl  in  hernial  eucs,  totjetlier  with  iotesline :  but  is  not 
unfreiiuitiitly  niel  with  ulune,  coii^litiitirig  Eplplooele.  AHcr  hnviug  been 
i)riHru(le<l  fur  annie  time  it  becomve  thickt^oed,  brawn}*,  un<l  iHtninated,  losing 
il£  ordinary  uelluIi>adipoe<o  texture,  ami  liecoruing  indurated.  Its  veins 
usually  aBaume  a  Bomewhitt  varicose  t^nditiou ;  und  the  mass  of  omcolum 
becomefl  triangular,  the  apex  being  upwards  at  the  abdominal  nportiirc.  and 
the  base  below,  bn^ad  and  expanded.  In  some  coses  it  can  be  unfolded ;  in 
others,  it  h  matted  together  iobi)  a  cylindrical  mass.  Occnsionally  apertures 
form  in  it.  through  which  a  coil  of  intestine  may  protrude,  thua  becoming 
seoodnrily  strnngulatLvl  within  the  sac.  In  other  ii)f;tftneeg,  cym  are  met 
H'ith  in  itcontaiiilDii;  fluid.  When  intestine  and  omentum  t<»gethcrare  found 
in  ft  bemia,  the  disease  is  termed  iin  Entero-epiplocele  ;  and  in  thwc  cironin- 
Kanocs  the  omentum  usually  deseeudft  in  front  of  and  oceasionally  envelope 
the  intestine.  Besides  these,  the  ordinary  content*  of  bernlie,  the  sLumacb, 
liver,  spleen,  sigmoid  flexure  of  the  colon,  bladder,  uterus,  and  ovaries,  have 
all  been  found  in  them.  In  a  ciiee  described  by  Scaozoni,  tbe  gravid  uterus 
and  ovariMwere  enclosed  in  the  eac  of  nn  inguinal  hernia. 

Atlhenoju  commonly  form  witliin  the  sac  in  old-standing  cHses.  These 
may  lakt;  place  between  the  contained  vixcera  merely,  a^i  between  two  coils 
of  intestine,  or  between  the^e  aud  the  omentum;  or  they  may  form  between 
the  wall  of  the  nac  and  its  contents,  either  by  broad  band?,  or  else  by  bridg- 
ing acrooe  from  one  aide  to  the  other,  and  iuclositig  a  portion  of  the  viscera, 
lu  recent  cases  these  a(lhe8ioU!<  are  mfi,  and  muy  rentlily  be  brukeii  down; 
hut  when  of  longer  duration,  they  are  oflen  very  denoe,  and  are  especisllj 
firm  about  the  neck  of  Ihe  sac. 

Bei^ldes  the  viscera,  the  hernial  sac  always  contains  a  certain  quantity  of 
llHitf  secreted  by  and  lubricating  its  interior.  In  most  citpe-i,  this  is  iu  but 
im&ll  quantity ;  but  in  eotne  inslauces,  when  the  sac  \i  inflamed,  or  the  hernia 
ttrangulaied,  ii  very  cuusidcrable  bulk  of  liquid  has  bceti  met  with  ;  I  have 
ivcD  na  much  uk  a  pint  escape  from  a  large  liernin  in  an  old  man.  When 
■bundant,  in  stningulatcd  or  iniUtned  hernia,  it  ie 
generally  of  ii  bniwnish  color,  ihough  clear  and 
tntusptirunt;  It  is  met  with  iu  largc«t  quantities  in 
Inguiiml  hcniiEB. 

Hydrocele  of  the  Hernial  Sac. — In  some  instances 
the  fluid  bceumi^  coljecltil  in  a  kinil  of  cyi>t  within 
the  sac,  formed  by  tlu-  omenlum  coiitracting  adhe- 
sions Ui  its  upper  part,  and  leaving  Hpacu  bchiw  for 
the  Huid  l«  collect;  this  condition,  represtntcd  in 
the  annexed  drmiing  (Tig.  7M).  has  been  culled 
Hy<lnKti«  of  the  Ht^rnial  Saf,  ami  constitutes  a  some- 
what rare  form  of  disease.  The  fluid  is  often  in 
considerable  cjunntity;  in  a  carn^  whieli  I  tapped 
•ome  years  ago,  nearly  three  pints  of  dark-brown 
liquid  had  thus  Accumulated,  and  were  drawn  oC 

If  we  limit  the  term  hydroeeU  of  tJie  hernial  nae 
to  tbiMe  cflseA  in  which  there  is  a  slow  and  gradual 
accumulation  of  fluid  at  the  bottom  of  an  old  her- 
nial sac,  which  has  been  cut  ofl'  from  all  communi- 
cation with  the  [►eritoneuni  either  by  the  radical  cure  of  the  hernia,  or  by 
the  adhesion  of  intestine  or  omentum  to  the  upper  part  and  neck  of  the  sac, 
it  mu»t  be  considered  a  rare  disease;  and  hut  few  ca^es  are  recorded  by  sur- 
gical writen*.  Curlinu.in  his  work  on  the  TMtw,  states  that.during  hisoon- 
nection  with  the  Ivjndou  IL'spital,  be  saw  only  one  case;  and  ibe  only  olhera 
witb  which  I  am  acquainted,  besides  one  that  occurred  in  ray  own  practice, 


Vi7^ 


PlK-  7^:1.— IlUfrain  of  II jr- 
drocolB  at  Barolal  Sm. 


742 


HBRKIA. 


are  twn  rrlnled  by  PoU,  two  by  Pellrlaii,  one  by  Bojrr, 


Thif  A\ 


mst  not  bo  confounrled  with  tbi 


ren<v.      ihif  cli»te*<ie  must  not  bo  cont 
iu  whntt'ver  f^iinntUy,  in  stranfj^ulatetl  benila,  or  in  b^i-ni-ii  ^»- 

municjite  v/hh  the  prrilnnr-al  cavity.     It«  dislinguiiibin);  r>:<r..[.  .:>. 

oiulatiuii  of  fluid  iu  n  sac  that  has  been  cutoff  fmmall  comniunicalioa rntk 
the  cavity  of  ibp  jvritniifiini. 

Ad  Accumnlation  of  Ascitic  Fluid  in  a  Remial  Sac  may  oonir  «^ 
hcrtita  i«  o>iii|>liciile>l  wiih  dropsy  of  l}ie  neritoDeiim.  la  oor  — "  '  **iii 
kind  which  occurred  in  my  practice  at  Uiiivereily  CvUqgc  b 

bvruiu,  which  was  femoral,  in  a  womuii,  vtm  very  (JKbtly  atnitijfuiaiM,  m 
large  as  a  bbadduck,  very  tense,  with  distiuct  Suc-tuatiuii ;  tb«  ikiD  cot«n)i| 
it  being  niiicb  slretcbcd,  thiH  wit«  jNwuliarly  evident.  Ou  uficmini;  llic  mt, 
Riinl  UuwihI  iu  a  jet,  »»  if  a  bydrocclv  hu<l  been  fiuuc-turvl.  nn'l  abtiut  faa 
inciivH  nf  ctniugtt^  gut  wcr«  found  lying  ut  the  bottom  <  AA«r 

dividing  the  »trictur«,  scniutf  lluid  iu  larg<.'  [|utiutily  coutiiir  .4111  inm 

the  peritoneal  cavity  fur  uoveral  linuri)  rIut  (he  "W-nitii'ii. 

An  Accumalatiou  of  Fluid  in  a  Hernial  Sac  vhicb  has  been  obUt««tliil 
iU  neck  ix  occabiutially  met  with.  cbieJly  in  fbe  femnral  rejriou.  A  ouirf 
thin  kind  iK'ourreil  nut  long  Hf^o  in  ti'uiveftity  <.'<)lleg(3  HiapilaL  TW 
patit'ut.  a  miildle-a^l  woman,  wiu  suddenly  wixed  with  |raiD  in  tbc  sIn^ 
men  and  biltouH  vomiting.  On  examining  the  groin  a  t^UM!  muodHi  tuarv 
was  (oimd  in  the  region  of  a  femoral  hernia.  U  y,Qs  frr«  fn^m  iroirreM 
and  nudualetl  indti^llnctly.  On  cutting  down  ujiou  it.  (t  waa  ff>u»d  IjiWu 
old  bemini  sar  distenditl  »ith  dear  5>erou»  Huid,  but  wttb'nit  ii'>1id  rt<Biriib 
While  exnniining  the  ring  the  adhesions  at  the  neck  of  the  xac  gar*  nt. 
and  the  (inger  slipped  into  tlic  abdominal  cavitv.  The  vomiting  aa<l  jus 
[>roved  bo  have  Wen  nnthing  more  than  an  orcfinarr  "biliow  aUa«k.*iiJ 
the  |>nLient  speedilv  recovere*!. 

LcMsa  Foreign  Bodies  have  occasionally  bMo  met  with  inaiife  b«rot*laia 
They  arc  usufilty  rounded,  Bmoolti,  and  nroi ;  vary  in  aizc  fr«CD  a  pM  lo> 
cbr«tuut ;  nnd  are  mostly  single.  On  section,  tbey  are  fntind  U>  romit  ■•'■ 
fatty  centrnl  nneteus  with  a  tnminalcd  tibruu»  envelopv,  usually  of  r>:n*'i'- 
able  thicknevs.     They  ar«  appHn-utly  cnnipoeed  of  one  of  the  glan'^ 

ploicie,  wbicb  has  bec>m«  <(etnched,  fulleu  lotiae  idIq  the  pariUiacat ; 

and  bec<>me  envetope<l  in  tibriuouB  layers. 

SiGKif. — The  sigDi  of  bernin,  though  varying  cvDsid«rably  according U d* 
coDtentc  of  the  iao  and  the  cnuiMtiuo  in  which  it  ts  placed,  pnamt  ic  t^ 
cues  many  points  in  common.  There  U  an  elnngntetj  or  rounovd  turn*  t 
one  of  the  usual  abdomiunl  apertures,  hmader  below  than  above,  whmtt^ 
oAcn  narrowed  into  a  kind  of  neck.  The  swelling  usoaJly  incfMMi  ta  ii» 
when  ibe  patient  etandx,  holds  hJa  breath,  coughs,  or  mukm  mmtk  awiwlw 
exertion.  It  can  be  pushed  tiack  into  the  nbd>>men  on  pwnra.  Of  f* 
back  readily  if  the  patient  lie  d'>wn,  hut  rcappcnn  when  beatnadfapi  ^ 
coughing,  a  i4trong  and  distinct  impulse  may  bo  felt  in  it. 

When  the  hernia  is  altogether  Intestinal,  it  is  usually  imoolJi,  jpUfVC 
when  pressed  upon,  sumetirncs  tympanitic  and  rumbliug,  aail  naooiit  ^ 
pcrcuMJon.  It  may  be  rcinrued  into  the  cavitv  of  ibe  abduinffl  wiihs^ 
tinct  atlp  and  gurglo;  it  lins  a  Hcll-marked  impulse  on  coughotf,*^* 
usually  accompanied  bv  various  dvHpeplic  symptoms,  and  oftea  wnB  ^^ 
dragciix  uneasineaB.  Omental  Hernia  h  usually  soft  and  duugliy,  ntar*' 
ing  slowly  on  premure  Intu  the  abdomen,  feeling  irregular  an  ibcaai^ 
and  having  an  ill-de6ned  outline.  It  occurs  most  fr^^^uentlvoo  ibe  M*^ 
and  is  ran  in  infants,  in  whom  the  omentum  ia  short.  In  feitenK^paplM** 
there  is  a  combination  of  the  two  oonditioua  and  their  aigns .  but  that  ■■'' 


CAU8SS   07    nEBNIA — SEX  —  AQK. 


748 


m 


uxuttlly  so  unwrtaiii,  that  few  Surgeona  cure  to  pre^lict  before  o[>cning  Ihe 
sac  what  the  probnbie  nHti)r«  of  thu  conteuts  may  be, 

Ccecal  Hernia  aecTesMiril}'  occim  on  the  right  »ule  Dnly.  It  in  a  large, 
kijobby,  Hod  irreffular  tumor,  irreducible,  owing  to  thp  adhesions  omtractwl 
by  that  )H)rtiou  of  cwcuin  which  ia  uncovered  by  periloneum.  The  jiecu- 
iarily  uf  this  hernia  con-iisbs  iu  Che  sav  bein^  absent,  ur  aaly  partifil  in  the 
majority  of  eases,  the  perit^ineum  lieing  !>trlp|iod  utf  oa  the  gut  dem-euds. 
When  this  beruia  u  large,  and  partially  Invented  by  serous  menihraiie,  a  sac 
usually  exists  nt  ita  upper  aspect,  into  which  a  portion  of  itmall  inti-stine 
may  fall,  and  which  may  in  i«onie  casea  coneiitiitc  a  second  hernia  lying 
above  or  before  the  ciecal  one,  which  will  be  found  situated  at  the  posterior 
wall  when  ihii^  hernial  pouch  is  opened.  Occasionally  the  verniilbrm  appen- 
dix and  the  caput  cnli  are  found  in  the  gnc.  but  can  rarely  l>G  returned.  Die 
rule  of  cn>val  hernia  having  a  partinl  peritoneal  investiuciil  only,  does  not 
hold  good  in  all  ca^es;  and  in»>tancc8  have  occagioQ&lly  been  met  with  in 
which  Ibis  portion  of  interline  lay  in  a  distinct  sac. 

Hernia  of  the  Bladder  or  Cyitooele  is  very  rare;  and,  like  that  of  the 

CBJcuni,  18  usually  (;iielf*.«(!d  in  a  pnrtinl  peritoneal  invostmeut,  though  it  is 

Decewarily  *>.     South  atatca  that  there  U  a  preparation  at  St.  Thomas's 

'pital,  iu  which  the  fuudua  of  the  lilarldttr,  with  'H&  pcritont'al  covering, 

passed  into  a  dLttinct  sac.     In  soin<?  initanoos  the  cystoccic  in  nrcomiHi- 

ted  bv  an  ent*rocetc.     This  hernia  is  alway-i  irrcidiicil>Ie,  is  attended  by  a 

good  ifciil  of  difficulty  in  urinating,  with  varying  tension,  acci>rding  to  the 

uantity  of  fluid  contained  :  by  Br]iirpzing  it,  urine  may  be  forced  out  through 

le  urethra,  and  fluctuation  has  been  felt  in  it.     Urinnrv  calculi  hnvo  been 

rmed  in  the  tumor,  and  have  been  removed  by  incision  through  the  scrotum, 
or  have  ulcerates)  out, 

CAtrsES. — The  cHuxe*  of  hernia  are  usually  auHiciently  well  niarlted.  In 
•orne  in8tanc««  tlm  disease  is  conr/cnifn/,  ariHing  from  preternatural  patency 
of  the  abdominal  ajterturee  :  iu  other  cases,  it  occurs  at  a  laler  periixl  of  life, 
in  cou»ef|tience  of  Home /orct^^  effort,  na  lifting  a  heavy  weight,  jumping, 
Cout;htiig,  Btrnining  at  stool,  or  pussinj;  urine  through  a  tight  stricliire. 
Such  causea  u6  these  act  especially  in  tall  and  delicate  |>i^ople,  purlicularly 
in  those  who  have  a  natural  itl«|ioeilIon  to  weukneee  or  bul|;tug  of  lhe(;roiD8. 
The  disfdai.'emeiit  of  the  abdoiuinal  viscera  by  a  ^ainil  vlerfix,  will  aUo 
oecaxiouallr  give  rise  to  the  disease.  Ileruia  rreijuenily  results  fnjiu  a  com* 
hinntiuu  of  causes  ;  thus,  if  au  aged  person  of  feeble  build,  or  whose  ab<loin. 
inal  apertures  are  patent  in  consequence  of  rather  sudden  emaciation,  make  a 
violent  effiirl,  a  hernial  protrUHiou  is  vorv  apt  to  occur, 

AmoDgsc  the  moet  fre<(uent  Fredisposing  Caaiea  of  hernia,  are  twrtuiidy 
•ex,  Bgv,  and  occupatiim. 

Sex. — Men  arc  more  liable  to  thifi  di»ea>)e  than  women,  in  the  proportion 
of  attout  4  or  5  Ui  1.  Thus,  nccurding  t^i  .Mnlgaiguf;,  in  France,  nne  man  in 
thirteen  and  one  woman  in  fifty-two  um  the  Kubjcclti  of  hernia.  Itut,lhi>ngh 
men  are  more  genernlly  liable  to  hernia  than  women,  they  are  \^t»  so  to  rer- 
lain  form.4  of  the  di»ea'<e,  especially  to  the  femoral  and  unihijical.  U  is  to 
tht>  iuiruinjil  that  they  are  particularly  Buhject.  According  to  Inwrence, 
out  of  J*:i,. 'tH4  patients  who  appliwl  to  the  City  of  Tendon  Truss  Society, 
67.79H  were  malffl  and  l'i,78t{  female-^.  Of  4:i.2I4  applicant.^  at  the  same 
in.ttitution  duriti^  the  eight  years  lSfif>-lK(17,  lifi.lOl  were  males  and  7,053 
iemalca.  Of  thew  .'{4.7)^^  male^,  and  S.OS.'i  femalea  had  inguinal  hernia; 
1,373  males,  and  :t.'J(iH  femalea  had  femoral  hernia. 

Age  cTcrcises  a  very  material  influence  u|ion  the  frcrinency  of  hernia. 
Malgaif^nc,  who  has  carefully  investigated  this  subject,  finds  that  in  infancy 
the  disease  is  sufficiently  common,  owing  to  the  prevalence  of  congenital  in- 


744 


HERNIA. 


gniniil  buH  iinibilicnl  heniiie  at  this  pcrifx)  of  lifr;  nnd  thai,  in  thpfiTvtnr 
ttflor  birlii,  lionilu  occurs  in  tliv  [>ru|Kirticiii  of  1  in  vvry  'Jl  rhttdrvii.    Il 
(hen  p»ea  on  dccreaaing  in  rreijtiency,  ihcn-  iK-injj  ]  in  2f*  nt  thp  wcood  jmx. 
1  ia  :J7  at  Ibe  third  ytar ;  until,  at  th«  ihirtwulh  rtar,  it  hut  falVn  i- 1  tr 
77.     Shortly  aft«r  this,  its  frwjueucy  begins  to  rise  again,  ami 
progrfssivvly  iucreusing  imtil  the  cl(>«e  of  life  ;  thus,  at  th«  21-:^  ■- 
la  1  «t«e  in  32;  at  the  2>H\i  year.  I  id  21  ;  at  the  :)Iilh.  1  in  17:  at  r 
1  in  y ;  at  50,  1  in  G ;  fr«.ra  tK)  to  70,  ]  jn  4 ;  and  frtmi  70  to  7FV    ' 
women,  acoirding  to  Ma)gaiga«.  hvruia  tnoetfretiufnily  oocum  t 
to  the  .')Oih  ywifs.'     ^lal^aijriit's  fiv'ttrea  give  the  ngva  of  iho  nati^ny  *i^ 
they  caiue  undfr  his  ubei-rvaiiun.     KingUon  baa  iumtifpited  ur  qutuCiiH itf 
the  ugtf  ut  which  the  heniitt  ciouitneticed.    lie  ataies  that  ' 

5,659,  or  B0.8  |ier  cent.,  had  cummencttd  before  :C'>,  aud 
cent.,  after  that  age. 

TheleiideiiL-y  tobemta  is  often  hereditary,  and  congeuita]  brrolaJaeoniaa 
in  the  cbihlron  of  hernial  parents. 

Some  races  of  men  are  lem  subject  to  hernia  than  olbtrtB.  Thus  it  hia 
frr<iiK'Ut  in  the  negro  chnu  in  the  white  man,  except  id  the  ventral  fivm- 

Occnpattoo. — Thnee  occupations  in  which    the  iodSvidual  bi  L'xr>«i  i' 
violent  muscular  cflitrts,  more  particularly  of  an  intermitting  chart  : 
dispose  strongly  to  the  occurrence  of  hernia ;  and  in  theer  r-r^-^  •:• 
tendency  to  llie  disease  ia  tifteu  grcatlv  increased  by  the  : 
wearing  tight  girths  or  bells  round  the  waist,  which,  by  e-a: 
ilomen,  throw  the  whole  pressure  nf  the  ubiloiniaul  ci>atents  '  '.<■ 
regions.    Hernia  is  alao  comrunn  in  tui^n  such  a^  nulw:i 
aofdicrs,  artillery- men,  exposed  to  much  jotting  iu  iht-  upr 
right  fKiTiition. 

Other  Causes.— It  in  probable  alao  that  hemU  is  prediapoM^  to  bf  tki 
baight  nf  (lie  seatK  of  watcr-rl(i«ets  in  cumoiun  use.  lo  thv  natural  pmia 
Uaunicd  by  man  iu  iktVculirtn  the  femoral  amj  inguinal  ringa  and  tht'oaff 
part  of  the  abdrimt>n  nre  fluppi>rt(>d  by  the  Hoxed  thigh*,  wh^ma  «e  tk* 
ordinary  water-closet  seat  tlie  thighs  are  not  Hexed  much  beroad  a  hfta 
soglo.  and  the  support  is  consequently  touch  lc«  perJeci.  The  fntmtef 
with  which  hernia  appears  for  the  fint  time  or  become*  strvngulateH  '<"rt«r 
defeaitiou  wituld  Icmi  some  support  lo  this  view,  ilabilual  cvwtiv 
aprcdisp<»iog  cause  id  many  eases.  Kapid  eniaoiatiou  fruui  any  eau>T»i— 
uufret|uenlly  fullowcd  by  hernial  pnHruuoD. 

CoNuiTiotn  pBEBEXTLt)  BT  IIekma — ^Thc  oonUilioni  in  wbtck  ■  btn^i 
may  be  found  are  wry  vnriouii,  and  email  rarrespiindiDir  diffrrcacn  ia  iW 
result  and  trealraent  of  the  affectiou.     When  lir»t  fori'  r  beroi**** 

beanid  to  he  Incomplrtr,  being  fur  a  lime  reuiininl  w;  orificwrflfc* 

eanal  through  which  they  eveniuallv  protrude.  'Wheu  ihcy  have  pa^ 
altogether  bt-vitnil  the  ahdominni  waits,  ihey  are  euld  lu  be  Camplelt.i^ 
ihl«  ia  the  condition  in  wbicli  tbey  tin-  ut-ually  prtsentod  to  the  Sargooa.  A 
hernia  uniy  ulsii  be  KedwibU,  IrreductUr,  or  SiraMffaJatML 


RCDUCTOI.K  HERNIA. 

A  hcniia  is  commooly  at  Bnt  HeHveible ;  tltot  ia  In  aay.  it  inar  r^Wh  ■> 
]HjKhcil  hack  into  tint  cavity  of  the  abdorovii,  protruding  ag: 
[niirat  Btanihi  up,  holds  his  bruatb,  ur  awkes  any  csortioo,  n;  -  * 

'  TIvi  iriicrait^  in  the  tutUtie*  of  Ilrrnia  will  ind  )i.ii'?i  Iiir.in:,i.L;t^  Lt,  »» '*'*' 
<m.  I'V  A.   W«mhfr,  of  OImmr,  In  Vol.  M 

Ki         .      i.inin,'l»"(IM»l.  awl  In  "  H^jiurtoof  fnn. 


Uu.(i^  ftUU«  Amijr,  1870." 


ircihle  impulse  on  (uiughiiig.  Though  the  h<:riiiu  ooiiLcnle.  ia 
fare  rediiciblt!  into  the  abilometit  ihe  sui;  is  nut ;  it  aIniwL  iiuine- 
diBtcly  c»ntructfi  udheeinns  to  the  areolar  ttwiit!,  by  wbtch  it  is  lirmly  iixeA 
[u  its  new  t^ituatioii ;  though  in  aooie  cuaes,  as  we  shall  hereafter  see,  it  may 
be jiusbeil  l>Bck. 

The  4]uef?tioD  as  to  whether  ii  heniia  is  of  recent  origin  or  of  old  stan<1ing 
snnielimps  presents  itself  in  medico-legal  practice.  In  determining  thta  the 
fnllowins  pciinle  deserve  attention  :  1,  A  recent  hernia  resolting  from  injury 
is  attentied  with  pain— iisunlly  severe — from  lacernti.in  of  the  Btriirtiires  of 
the  nhdoniinni  wall.  2.  WhcD  oblique,  inguiual  or  fenmral.it  may  be  sinHJl, 
but  vhen  direct,  ioguinnl  or  ventral,  it  is  often  large  and  rounded,  the 
aperture  through  which  it  protrudes  being  irregular  and  wide.  3.  The 
nutrgins  nf  the  aperture  in  an  old  hernia  arc  mure  rounded  than  in  one  nf 
fcoent  formation.  4.  Bocent  hernia-  arc  inloiitinni,  not  omentnl.  S.  They 
are  readily  reducible ;  whilst  old  herniie  are  frequently  irreducible  in  whole 
or  in  part  and  omenlal.  6.  Atlcr  rcluctiun  the  sac  o^  a  recc-nthernia  when 
rolled  between  the  Hngers  will  feel  thinner  anil  softer  thnu  that  of  an  old 
one.  7.  Strangulation  may  occur  at  the  moment  of  prolruBiou  of  a  bernia. 
Hence,  alth-rugh  mure  fretjuent  in  old  than  in  recent  hurui:i^,  its  exixteiice 
docs  not  jiruve  Ihe  hernia  (o  be  old.  8.  In  old  hernia,  if  the  patient  has 
worn  a  trura,  there  will  usually  be  sigOHof  prewure,  nrof  chafing  of  the  «kin. 
Though  such  piunt>  may  be  eHaced  by  friction  with  the  handH. 

APPi.iCATtos  uf  Tkus'?, — In  the  Treatment  of  a  "reducible  hernia,  our 
object  ifl.  by  the  application  of  a  proper  trUM,  to  retain  the  protrusion  within 
the  cavity  of  the  aodonien.  In  order  to  do  this  the  patient  must  be  pro- 
Tide<l  with  a  proper  kind  of  truss,  adapted  to  the  partic\i]ar  nature  of  the 
hernia.  lu  umbilical  and  ventral  ruptures,  an  elastic  pad  ami  belt  may 
moat  conveniently  be  used.  In  w.'l(cting  tlur  truw,  care  should  be  taken  that 
the  spring  lie  of  proper  strength,  adaplwl  to  the  atze  and  ]»>wer  of  the  indi- 
vidual ;  UJid  that  it  ue  prti|ierly  ehaiiril,  »ii  that  it  does  not  touch  any  part  of 
the  abdominal  wall,  but  merely  l>ear»up(m  the  points  of  prc-sfurcend  counter- 
prvssure.  The  pad  ahuuld  he  convex,  firmly  HuRed,  and  of  suffideni  size 
tfi  press,  not  uuly  upon  the  external  a|H!rture,  but  upon  the  whole  length  of 
the  caiial.  Before  applying  the  truas,  the  hernia  murtl  Im  reduced,  by  placing 
the  imtirnt  in  thc<  recumheiit  poaitirtii.  relaxing  the  iinirii-.!es  by  bending  the 
thign  u|)on  the  abdumeu,  and  |irr»dng  tbe  tumor  back  in  the  ])ro|ier  dirco 
tion  ;  the  inini  Kliould  then  be  put  on,  ami  be  worn  during  the  whiilc  of  the 
ilay  ;  imlecd,  the  patient  should  nevnr  bo  allowed  toxtund  wil limit  wearing  it. 
At  night,  it  mav  either  be  left  off  altogether,  or  a  lighter  one  applied.  The 
patient  should  be  provided  with  a  "  bathing  "  triips,  that  is,  a  trusa  covered 
irith  India-rubber,  so  a»  to  rei>ii>t  the  action  of  the  water.  It  in  well  that  the 
ordinary  truM  be  covered  with  linen,  fto  that  the  leather  may  be  kept  clean 
and  unstained  by  perspiration  and  the  spring  fret:  from  rust.  In  itome  en!)e<i, 
the  skin  becomes  irritated  by  the  pressure  of  the  pad  ;  in  lhe«e  cireumstancwi, 
an  clastic  air-cushion  may  he  me<\,  or  the  parts  subjected  to  prejwure  may  be 
well  waahed  witli  cpirit-lotion.  The  truaa  may  be  known  to  fit  by  testing  it 
in  the  Ibllnwing  way.  The  patient  should  be  made  to  eit  down  on  the  edge 
of  a  chair,  and  then,  extending  his  legs,  opening  them  widely  and  bending 
the  body  furwarrls,  cough  several  time*.  If  the  hernia  do  not  now  slip  rlown 
behind  the  [rad,  we  may  b«  eure  that  the  truss  K  eliicieiil,  and  will  keep  the 
rupture  up  in  all  unlinary  cireumstaneeK. 

It  is  tite  ^?u^georl'e  duty  tu  tull  the  iiistrumeut-maker  what  f>rm  of  truss  is 
rtfjuired.aiid  toseelbattliL-in8lrumeuti!Hpp)ied  fultiU  its  object.  It  is  always 
better  for  the  itistruim-ul-mnker  tu  see  the  patient  aud  iiieuKuro  him  for  lli« 
Inttt,  but  ill  country  practice  this  ia  ofleu  impotuible,  and  (be  Surgeon  must 


745 


QBRNIA. 


Iheo  mcawiro  the  patient  himiieir  and  ordtr  the  roquind  tmCnwaL  1W 
roost  importnnt  measnrenieut  i^  the  circutnr«reo(m  of  tho  pdrii  llkai  wH- 
my  between  the  crest  of  the  itiiim  nod  the  trnchuiter  M>j<ir.  UflK  iMn> 
rae'ot-miikcn  HBT  that  this  is  all  they  reqiiirf>:  but  tn  ttiMin  uiHBMT.ilii 
better  to  send  aUt  the  exact  mcuduremeDt  Id  the  line  id  which  tiw  trv  m& 
lie,  coutmcncini;  at  the  ceutre  of  the  rior,  oiid  paniD^  rnuod  the  pelTiiai^ 
way  between  tlio  crest  of  the  ilium  and  the  trochnoter,  and  WmumuSuu 
the  riug  agaio.  Tho  Burgcoo  rnuat  also  iuform  the  iu«triinie9t*naktr«dtt 
Datu  re  of  tbe  hernia,  the  side  on  which  it  w  siiuaicd,  the  aiae  of  the  ria^ihi 
a((e,  »ex,  and  physical  power  of  tho  patieiiL  H«  muet  »tat*,  aim.  if  Itii 
occupaliun  U  uich  aa  to  necessitate  a  Bpriof;  of  more  than  urdinarT  Mrtncik 

IUdk-al  Cvrt.  of  IlBRXtA. — Vflriuiu  meani  have  b««D  lieriaid  w  etiiWr 
(o  elfL-L-i  the  radical  cure  of  a  reducible  benila.  The  onl*  pUn  thai  i*  p» 
fevlly  fric  friim  danger,  is  the  (Him|irMaiou  uf  a  well-made  truaa.  la  tW 
way,  uoi  uafrc(|uvutly,  th«  hcruiii!  i>f  iiituaU  beciKiir  ftidii-M'!*'  n!r«d;  tlM 
aainc  result,  huwever,  aeldoni  ocrunt  al  a  oKifeadvati^  iAl    la 

order  that  cuiiipreoaiuD  in  thia  way  tiiHy«occee>),)t  is  ii>  il  ahadi 

be  applied  not  only  U>  the  external  R|>erture  l}truu|^  whirb  ibi  infteit 
eaeapea.  bnt  to  the  whole  of  the  cnaal.  It  must  also  be  eu(iunu«-il  f'r  s  iitt 
couHiclerable  lime,  at  leoat  a  year  or  two;  and  care  should  )'-  M 

during  the  ireatiueot  the  rupture  ts  uoi  nllovred  to  dustvud.     I 
cornea  d'lwn,  any  good  that  may  have  been  drrive*!  is  urei^SKin 
with,  and  the  trentiucut  has  to  bvgin,  as  it  were,  anew.     ICwlivu' 
hernia  hy  tnuis-preasurQ  can  lie  cHln'ted  only  in  tJnxo  uasm  in  *  i 
abd<Hiiinul  u|>erturu  hus  been  lefl  enn^vnitnllr  weak  or  open.     ' ' 
to  he  hogHMl  lor  only  in  children   and  vrry  youn^  adult^  and 
two  coDgenitJil  fomiM  of  hernia — the  umbiliiTal  and  the  ingnitial. 
tinuoil  prvesure  of  tho  truas-puiL  in  thrae  casee  seems  Ut  dclfTniii. 
adliiviveprooemes  which  arc  neceeeury  for  lher,l(»ure  ofoitrof ;)' 
a|H.'rturea.     AfU>r  the  cure  h  hupjkhmnI  to  hare  tiepn  rflecied  in  i 
truiM  must  Iw  worn  tlir  a  very  et>nt«idemlile  length  of  time,  leM  by  as;  st- 
fijrtnhnte  moTf-mBnt  the  rupture  be  forced  down  again. 

The  Operations  th.it  have  been  derived  fur  the  radical  cure  of  befsHW 
■II  founded  on  one  of  three  principle*,  viz.,  the  excitation  of  surh  an  tiirtal 
of  perilonitiH  in  the  sac,  or  its  neck,  m  to  cause  it*  idiliternlion ;  il>r  plsip^ 
of  tbe  hernial  aperture  by  invagination  of  the  mc  and  subciiiaoMiu  tiMA 
or  the  complete  removal  or  invagination  of  the  sac  with  cloatini  nf  tk*  oaf 
by  snturea. 

If  the  aconmplishment  of  th«M  conditions  would  always  prevent  tb»  rwv- 
rence  of  the  ruplnre.the  radical  cure  might  fn^juentl'  ' 
it  18  inipiMiible  to  IikiIc  upon  the  agglutination  nf  thr  ' 
ol<»ure  of  llie  nbdouiiniil  B|)erLure.  or  even   tbe  rvm..\.»i  uj   ; 
aole  c'onriiti'ina  reipiirud.     To  nct^rimjilieli  the  radical  eurr,  it  ^ 
aarv  in  many  etuea  to  vfTvet  chuutrtm  in  the  »hnp<?  and  ■  ■  ■ 
nbi|i)niin»l  contents,  to  alter  the  size  < if  the  nhdomiDnl  c' 
to  modify  in  vari'ius  ways  many  ptinditiouR  indrpendi'-ntol  ; 
ci>nnpoli;d  with  the  hernial  protnipiou.     Slany  uf  lIic  raran 
by  which  obliteration  of  the  interior  of  the  sac  or  of  itJ'  neck  i- 

eflected   by  the    introduction    nf  causlirs,    bv  acarifi cation,  ^ ;4.  ■ 

injection  with  tincture  of  iodine,  are  attended  with  an  mueii  danfar  !<■> 
peritonitiK,  and  are  m  teMom  followed  by  good  reaulta,  that  their  omM^ 
tion  need  not  detain  ns  here. 

The  operations  that  are  now  pnujtiaed  for  the  radical  cnre  of  beraiaM* 
condiK-Ky]  on  three  pritioinnl  plana,  however  much  they  niaj  be  Tari(4  !■ 
their  details  by  the  ingenuity  of  particular  Surgwmi.  '  ^^^ 


nz] 


■8   OPTbATION    F< 


tADICAL   OOHE. 


747 


The  firfft  method  of  trcatm«nt  cuneiMs  of  invagfimttiiij;  fimply  »  fMirtidn  of 
ibfr  «onit4)ni,  Kali  fixing  it  iu  thv  inguiunl  cniinl,  wIutk  it  bt-mnit-n  n<lli('rvDt, 
And  8i>  occluties  the  apenurtt  of  exit.  Of  this  kind  of  uperKtion,  WuIzct'b  ia 
the  t>e»t  uxain|il«.  The  second  nii^thod  of  trrutriii^iil  cuueists  lii  excifiLg  a 
|M>rliuu  u^'ifae  iulejfumtfolal  BLriu'turi^,  aud  tbtiu,  by  uieuuB  uf  nuturea  altach- 
lug  th«iK<  uDil  the  deL-per  iHirta  together,  aud  thus  iendiog  to  thf>  ouo^olidatioD 
of  th«  cftoal.  Of  ibia,  Wood's  nperatioD  is  lh«  bust  examplt*.  Tbi;  tfaini 
method  coueiBta  nf  compltrtu  or  partial  ruriiuvHl  of  the  sac  and  cloeure  of  the 
ring  by  sutures.     The  toilowiug  are  the  detiiils  of  thuite  procvdiires. 

Wotxer'a  Operation. — The  Ute  <'.  W.  Wuizer,  of  tinau,  udoptefl  a  plan 
of  radically  curing  reducible  inguinul  herniie,  combining  ilie  two  priiiciplea 
oD  which  the  older  opemtious  were  founded,  viz..  the  aggluttimtiim  of  the 
neck  of  the  heraial  hbc  liy  the  excitation  of  iniluniniDtiou  iu  it,  and  the 
chwure  of  the  iuguiuul  canal  by  the  invagination  of  the  efrolum ;  and  he 
carried  out  these  objects  in  a  ealer  sud  more  f^ucceeahil  manner  than  by  any 
of  the  methods  previously  employed.  Ilia  plan  of  treatment  cont-itited  iu 
introducing  n  plug  uf  the  scrotum  into  the  iugninnl  canal,  nnd  fixing  it  there 
by  exciting  aubcsive  iiiHammatioii  iu  the  neck  uf  the  9bc.  The  (ieluila  of 
the  operatioD  aro  bb  followe :  The  patient  lying  on  bis  back,  and  the  hernia 
being  reduced,  the  t^urgcon  pushes  hie  iudes-fingcr  up  the  Inguinal  cannl  aa 
high  ae  the  internal  ring,  carrying  before,  it  a  cone  of  the  i>cr<>tHl  li^eiiee  :  a 
hollow  boxwood  cylinder,  about  four  inches  long  (Fig.  784,  C),  well  uiled, 


£ 


"^ 


C 


(• 


Tig.  TBI.— Wuucr'*  A]ip>r»iu«  for  IlAdicAl  Cura  of  llcrnlit. 

k  then  pusb&d  up  m  the  finger  U  withdrawn,  so  as  to  occupy  itA  plai-e  in  the 
inguinnl  canal.  Along  the  interior  of  this  cylinder  a  HexiMe  t<teel  needle, 
gilt  (A),  6xe4l  in  a  rimvable  handle,  is  then  jinnhed,  »n  m  Ut  Iraveme  the 
invaginaled  ecrotum,  the  hernial  »ac,  and  the  auterior  abilnrninal  wall, 
through  which  ita  potut  in  cau»e«l  to  protrude.  A  concave  boxwimd  eune  (B) 
i^  then  passed  over  the  projeoting  |ioint  of  the  needle,  and  fixed  by  the  other 
end  by  a  w-rew  apparatus  to  the  cylluder  (C),  eo  as  to  coiupreH  the  enclosed 
tiMueH.  The  apparatus  so  fixed  is  left  in  situ  for  six  or  eight  days;  whea, 
tonm  divcharge  being  eHtablixhed,  it  is  witbdrawu,  and  the  invaginated 
scrotal  plug  BUpjHirleil  by  lint  introduced  up  its  interior,  and  by  a  spiea 
baudnge  tightly  applied.  The  patit'ut  ii>  ke[tt  tjuiet  for  a  forlnigbt  longer, 
whfu  he  id  allowed  to  move  about,  wearing  a  lijibt  truae  for  ihrte  or  four 
inuDtba. 

Tbia  method  of  treatment  is  eaay  of  execution,  end  appears  to  have  been 
tnore  iiutve»aful  than  any  that  preceded  it.  Yet  it  is  opt-n  to  the  ubjcelions 
that  attend  all  plans  for  the  radical  cure  of  hernia,  vii.,  the  po^tiiblv  cxeita- 
tiiHi  uf  a  ilangerouH  amount  of  peritonitis,  and  the  want  of  udliitiii'n  hrtnecD 
the  lower  part  of  the  scrotal  plug  and  the  c'(irrc-8|>iindir)g  sidt;  of  the  inguinal 
canal  aud  ring,  and  consequent  taJlure  in  the  cunipU-te  occlutiion  ol'tbit  canal 
and  iu  the  radical  cure. 

So  far  as  tlie  fintt  objection  is  concerned,  I  believe  that  verj*  little  weight 
can  be  attached  to  it.    I  have  very  oflea  perfurmed  this  operation,  aud  have 


748 


RlfRNlA. 


never  seen  tlie  sligfitnt  evidence  of  n  dii^piMition  to  pn-itooMl  ialuwuha 
or  otiier  Io'-aI  niiDcliief,  except  abrjulon  Dl'tlif  akin  iii  mir  xrliraaMM.  Will 
n-AUcct  to  llic  »«ci>ni)  ulijcction,  there  can  be  tiu  iIkuIjI  lh«l  failur«>  an  bu 
uotrtHiueiit;  but  oii  the  other  liaitd  sucoemes  are  not  rarr,  and  1  hAt*  tun 
under  oWrrntioii  several  ca^es  in  which  a  complete  cur*  luu  n— tn^ 
although  several  vears,  frotu  two  to  nine,  have  eUjiMal  itmca  Uw  opmli«. 
It  is  oow  BCRrc«fy  ever  practised,  being  replaw:*!  by  W«jJ'»  wftrBtMa  <* 
Some  or'  the  variotm  piano  of  oluving  the  rin^  by  «utura«. 

Wood's  Operation. — lu  order  to  securv  tbs  more  cumplebe  oblit«nt»ifl  W 
the  canal,  and  c-spucially  Ihe  cohesiun  of  the  tnuer  aud  iiosltTiof  mlk,  J«te 
Wood  had  brought  forward  another  operation,  for  ihe  ^dlowtur  dwoiyliwa 
of  which  I  am  iudeUcvd  to  biiii.  The  principle  of  tht>  luctb'jd  omMH  it 
the  apuroximutiuu  of  Ihu  U'odiuouD  Htruclurve  foraiiu^  the  Uouodary  of  ih* 
beniial  canal,  by  the  applicattoa  of  a  Bubculuueoua  wirv  suture  tbrMflt  t 
puncture  in  the  sktn.  Id  applying  this  principle  toiujcuiaal  beflua.tai«il«r 
to  promote  the  adheiiion  of  the'tcndiuouasurfacw,  and  to  protect  lliewtiW 
cord  from  injurious  violence,  the  highly  vmicutar,  elastic,  and  t/Mj^  Cmmtl 
the  Hcroliini  ts  detached  subcutauetiiiBly  from  the  ■kiD,  tnuMfilaiiiad  bf  !»■ 
vaginatiuu  into  the  caual  and  held  there  by  nuturee  till  adbesitw  nmm  ti 
the  wrIIh  of  the  canal  and  to  the  spermatic  cord.  The  wirt*  i*  mn  applied  m 
to  ohiaiii  H  fair  hold  in  two  places  upon  the  «ructurt»  forminiir  the  pautm 
wall,  viz..  the  conjoined  Icodon  aud  Ihe  triangular  nponeurtwu ;  aad  icaia 
upon  Poiipnrt's  ligament  au<I  the  lower  portion  of  the  ■  :  ■-  '  ''  ■  - 
a|H)Uciiroiiis>  furtninj;  the  anterior  wall  of  the  canal.  Thi' ' 
is  to  close  also  the  external  abdominal  ring,  the  pillars  of  t^  ^.m;... 

in  its  grasp.    Br  the  cIom  adheaion  which  ia  thud  pmiii.  -vo  w 

poBt«rior  and  anterior  walls  of  the  canal,  the  former  is  ma>l<.  k»  .au  liif  t^ 
limb  of  a  valve  iti  preventing  the  descent  of  a  hernia  into  iIm  canaL  Tba 
a  pcrmftiH-nl  r«istiincc  to  the  reproduction  uf  the  rui»lur<^  Is  pwriial. 
which  renmin«oven  after  the  tein(n)rarily  trffuscd  lymph  ba«  b*rn  r**hn*W. 
The  impulnive  force  of  the  ab4l»minal  omtcntit  tending  to  protnidtf  at  tkc 
internal  Hug,  is  nsisteil  by  the  valve-like  action  of  tbw  pi«t«H4>r  wall,Ml 
is  not  able  to  exert  itself  upon  the  recently  formed  adbw..n«.  Tlw  am^ 
the  trun,  except  as  a  tem[)orary  adjunct  in  the  cure,  is  rcndomd  ouMi<t«*7 
by  this  operation. 

Operation. — The  patient  being  laid  on  his  back,  with  tho  tbaoUsntifl 
raiitcd,  and  the  pubes  and  scrotum  shaved,  the  bernin  mutt  br  ndao«lu' 
held  up  by  an  assistant  prcMioK  upon  ibc  lotoroal  opening.  Th«  wj***", 
standing  nt  that  side  of  the  potient  which  is  about  to  beopcralcd  M,Mhi 
with  u  »niatl  toiiotomy-knite,  an  incision  about  three  fourths  of  aa  lodk^ 
through  ttie  skin  of  the  iicrotuni  over  the  lower  pari  of  the  (UBor:  ■ff,!/*'' 
be  large,  about  two  and  n  half  inches  below  [be  pubic  spine.  Tbia  th*kH 
being  lUEi'rtcd  Hatwi^e  between  the  skin  and  the  fascia,  is  made  lo  Mf^" 
them  aniund  the  incision  over  an  area  of  about  a  tw(»'inc)i  circle;  sp*^ 
ceeding  which  tlie  Ioomi  attachinent  of  the  skin  easily  allows.  The  kp^'' 
the  putieut  should  next  be  drawn  up  towards  thvabilonien,  and  held  t'^;'^ 
so  ai  to  relax  the  structure  connected  with  Poupart's  ligam^oL  IWt^ 
finger  is  next  paved  through  the  opening  in  theiKin,  and  majteioinm*''' 
the  detached  lascta  through  the  external  ring  into  the  canal,  vhkli  if  ^ 
done  bv  using  the  right  hand  for  the  right  side,  and  riiv  rtrtJ,  keephif  t^ 
palm  dlrecteaforwanls.  The  invagination  of  the  faiicia  should  be  com  ■Mi*' 
mini  a*  low  a  point  as  the  cutnutMHi-  ineiition  will  permit.  «o  as  lo  fmk  (^ 
invaginaliiig  finger  ax  much  a»  poAiible  between  the  sac  uf  the  herais  ■** 
tite  a)KTiitntic-  conl.  When  the  finger  Is  in  the  oanal.  ita  (loitil  shoaM  rsM^ 
th%  internal  opening  of  the  hernia,  and  the  cord  should  be  dbdiietly  pi^ 


m 


WOO]>'u    OPERATION    FOR    RADICAL   CURB. 


749 


ceptible  to  it  nix)  protccl'eil  by  it.  The  iioinl.  of  ilie  Jing«r  will  (h^^n  be 
|)lac(;<l  beiiiud  the  liiwcr  bonier  of  the  itilernal  obtiijiie,  and  must  render  this 
piiipl  prymineiit  at  the  surfacK  by  being  houked  llinvanl.  The  Hnrgeon  will 
now  be  sensible  nf  the  edge  ol'  the  ciinjuined  [endim,  raised  in  relief  to  tlie 
iuuer  fride  of  the  invagioHlinjr  finger,  and  io  cuotact  with  its  radial  border. 
Next,  the  needle,  stout,  blunc-pointeiJ,  and  curved,  mnunte<l  un  a  strong 
handle,  is  U>  he  passed  along  the  radial  border  of  the  linger  as  far  ns  Jun 
beyond  the  extreme  joint,  at  ivhieh  point  it  ia  made  to  pass  through  the  oou- 
jciined  tendon  and  the  external  oblique  aiKmeurosis,  till  It  is  seen  to  raise  tbe 
skin,  which  is  then  to  be  drawn  upwards  and  inn-ards  as  far  as  pu^iblc 
before  the  needle  is  pushed  through  it.  Then  a  stout  cupper  wire,  silvered, 
about  two  feet  long,  and  bent  into  a  convenient  hmik  at  cuch  end,  is  hooked 
onto  the  eve  of  ihc  needle;  and  the  latter  is  withdrawn  and  unhotikcd, 
leaving  the  lower  end  of  the  wire  in  the  ecrotal  incision,  and  the  upper  end 
la  the  groin-puiicturc.  The  invHg^nating  iinger  is  then  plxccd  on  the  outer 
side  of  the  cord,  behind  Poupart's  ligament,  as  far  from  the  border  of  the 
external  ring  as  possible,  raising  the  ligiinjtMit  on  its  \wu\t.  The  needle  is 
then  poMed  alouj;  the  ulnar  bonier  of  the  tiuger,  and  pushed  throngb  the 
external  pillar  cioe«  to  Fnupart's  liganiEfut  uppueite  to  the  iDtemal  ring,  the 
akin  being  drawn  outwards  till  the  polutof  the  needle  appears  at  the  ibrmer 
puncture,  through  which  it  is  then  pushed.  The  upper  book  of  the  wire  is 
Lben  hooked  on  and  drawn  donn  with  the  needle  into  and  through  the 
scrotal  iucisioD.  Hext,  the  spermatic  cord  opposite  to  the  scrotal  incision  is 
to  b«  carefully  separated  from  the  sac  of  the  hernia  by  the  finger  and  thumb, 
placed  uiKta  the  skin  iu  the  same  manner  as  in  the  operation  for  ligatnring 
varicocele.  The  oeedle,  detached  again  from  the  wire,  iS  iheu  passed  into 
the  lower  angle  of  the  scrotal  incision,  and  made  to  traverse  the  tissues 
between  the  cord  and  the  hernial  sac.  wid  to  emerge  at  the  upper  angle  of 
the  incision.  The  inner  end  of  the  wire  is  then  hooked  on  to  ibe  needle  and 
drawn  with  it  aerusa  between  the  cord  and  aae.  A  little  care  must  here  be 
taken  toavoidany  kink  iu  the  wire,  which  must  be  drawn  down  until  the 
pan  which  rumaing  in  the  wound  ie  i|iii(e  straight.  The  ends  of  the  wire  are 
then  twisted  to  the  extent  of  tlirce  turns,  wbieb  it  will  be  fnuud  useful,  fur 
convenienco  iu  removing  tlic  wire,  always  to  make  in  the  same  direction. 
Traction  is  then  marlc  upon  thG  wire  loop  which  remains  Iu  the  gmin-pnncture. 
Tbta  will  he  found  to  iuvagiuate  the  sac  and  scrotal  fuKcia,  and  to  close  up 
tbe  pillar«  of  the  external  abdoinioal  ring.  The  loop  must  then  be  twisted 
by  llirc'fi  firm  turns  well  drawn  Into  the  grnin-puneture.  Then  the  long  ends 
of  the  wire,  being  cut  off  to  a  tjuitablc  length,  are  to  be  passed  together 
through  the  loop  bent  down  to  meet  them  and  hooked  on  to  it.  Under  the 
arch  tlms  formed  a  stout  pad  of  lint  h  placed,  and  the  whole  is  held  firmly 
by  a  apica  bandage. 

The  patiejit,  after  the  operation,  should  be  placed  in  bed  with  the  nlimilders 
well  raised  and  the  knees  bent  over  a  bolster.  Any  discharge  which  forms 
has  a  free  escape  ilownwards,  and  may  he  received  upim  a  sponge  steeped  in 
some  antineptic  fiiild.  The  i^orotuni  should  he  either  suspended  in  a  turn  of 
the  bandage,  or  kept  up  by  a  small  cushion  or  strap  of  plaster. 

The  wires  should  be  kept  in  from  fourteen  to  twenty-one  days,  according 
to  the  amount  of  solid  effusion  which  subsequently  oecnrs.  Any  pain  in 
the  abdomen  should  be  allayed  by  opiates  ana  fomeuta lions,  and  by  slack- 
ening or  removing  the  bandage  after  forty-eight  hours.  Pain  sometimes 
result*  from  iacluuiug  the  ilio-iuguiual  nerve,  which  must  not  be  uiietiikeu 
for  the  twin  of  perit-'uiiis, 

Wood  had  ui)  to  1872  operated  In  nearly  200  iostances,  and  e»liiuale<l  his 
suoceeaful  results  iu  cases  of  nil  degrees  of  severity  at  about  sixty-Sve  per 


7S0 


BKBNIA. 


cent.     Iq  younj;  pcrenim  the  resulta  have  been  atill  mmr  ' 

now  conrioci  the  operatina  to  patierits  below  the  ojn  i<i 

spedft]  uircuDUlnnoe*.    Thn«  deaths  have  reaultcd  rmm  pyvutisa: 

lonitU. 

An  iiigcriiiiiis  ontruLion,  much  the  same  in  principle  as  WitTMi'a,  ' 
lalely  dcvUcil  by  W.  Dtinnctt  Spanlon.     Afu-r  iuvofcinatini;   i  - 
the  subcutiineitus  tuAiic,  of  the  acrotiiRi  and  the  au- a*  in  W 
instmd  of  paMing  wires  he  inserts  an   instrument  like  a  c.n 
point  of  nhirli  is  inlnxluced  through  the  skin  at  the  up|>rr 
lD({uinal  cauttl.      By  rotnting  the  handle  thp  piiint  ^uideil  hr  int  rnj^r  in 
lb«  caDal,  vhich  nt  l)ie  i«>anie  time  protect*  thv  cunl.  ta  mail«  to  ytm^ 
imiif  the  sMrue  part«  at  an  pierced  by  the  needle  lu  W<mk)'*  npcmtii*  ■• 
well  as    the  invaginated  subcutane^^us   tietuf,  and    it    it    Rnallr   m»ii*  b 
euierfie  hI  the  incbtiuu  in  the  scruluin.     In  thi^  uny  lh>*  pn  r 
brou)jht  t'^>g*;llier  aud  held  in  ptwition.     The  instnimcnt  i-    ■ 
a  week,  till  some  inflamiuHtory  en-elliiit;  ia  perwptiblc  aniuud  il     Itii  t»- 
Blrumeul  (uubI  be  suited  U)  the  sixe  oi*  the  i>atiriil.     Vy  to  144'i,KMBlia 
bad  operated  on  51  com*  without  an  acciik-nt.  nod  Hiib   m<«t  mxmadmf 
results.    It  ia  esrwcially  adapted  v>  youug  subjects  with  revest  lMnii».a)*> 
dally  wheu  of  tli«  congeniul  variety. 

tiinco  the  iolroductiou  of  the  Bniiseptio  metho«l  of  treating  wmmKUi* 
old  operation  uf  cutting  ofl'  the  sac  has  been  revived  with  cnusjderabla  mm- 
cees.  lu  1871  Sir  Juaeph  Lister  reported  two  cases  in  which  he  had  art 
down  iipni)  H  hernial  sac,  and  clo6»]  the  ahilomiiial  opeubif;  wiib  mtpn 
BUturee.  This  method  of  operating  did  not,  however,  nod  much&mr,  ■ 
further  experienoe  showed  that  it  was  uncwruiin  in  its  r*aults.  DoriafilN 
last  few  yean  Annandnle,  Banks,  Ozerny,  and  nlherg.  have  pranisnl  ■ 
variety  of  operations  of  this  type,  of  which  the  following  are  the  cVwffcnoi: 
1.  Glflaing  the  inguinal  ring  by  Biiturftt  withmit  touchinir  the  h4*;  2.  [if*- 
lure  of  the  neck  of  the  aac  ;  3.  Buture  of  the  ring  with  inva^ittaii  >n  af  Die 
•ac;  4.  Ligature  of  the  sac  with  exciaicrn  uf  the  [>»rtioa  helow  tbt-  li^ttuR: 
and,  A.  Ligature  of  the  neck  of  the  sau,  excision  of  the  part  Ih-Ihw  the  iijs- 
tUre  and  suture  of  the  ring.  Of  these  various  (tptratloiu  tlx-  liul  hasprnn 
the  must  Bucceft^ftil,  and  is  the  nne  adopted  by  Annandalr,  H4oki,  mi 
Cxerny.  Banks  has  further  modified  it  by  u«ing  stn^ng  ailvfr  wire  tutsn 
to  cUwe  the  ring,  Itaring  them  to  heal  int«  the  wounrl ;  a  m-'-  ■•  ■■■■ ^"••nf 
founrl  frw  from  inconvenience,  nod  more  etfcclual  than  ^* 

opemtioD  for  inguinal  hernia  is  thus  {lerfornioil.  The  inrtoiKn  •mt^oiiA 
cummeuced  one  inch  above  the  cxlerual  ring,  anrl  carried  down  tf>  thv  l"**^ 
limit  of  the  sac.  Before  begiuDiog  to  clear  ibc  sac  not  it  must  bv  lhnrio|li'T 
exposed,  as  auy  attempt  to  pull  it  out  of  its  coverings  withoat  tn  dnhig  if 
likvly  to  be  fi>Mowed  by  suppuration.  In  old  incuinnl  hrniuv  totne  oir*U 
di«»«clinn  niuy  bo  re<juired  to  neimrale  the  sac  fn'm  the  tunica  vapioalnw^ 
from  (be  cord.  If  the  sac  can  be  completely  ••mplierl,  it  it  next  drawo^"™ 
uod  iii^ture<l  with  carb'ilized  silk  or  catgut  cloM-  to  the  ring.  The  IM^ 
is  then  pushed  into  the  inguinal  cnnat  and  tlie  pillars  of  the  exttnialiiBfr 
which  muHt  be  cleanly  exposed,  are  then  brought  together  with  ■trDOgi"* 
wirv,  li«ving  only  just  enough  room  for  the  |Maan  of  the  oird.  8bi^ 
there  bo  adherent  omentum,  the  sac  must  be  opaoen  and  the  nas 
in  wparate  pieces  if  large,  and  cut  off.  In  cmecs  of  oongvaiul 
aame  operation  may  be  performed,  but  the  sac  must  be  ctit  aernwi 
lower  port  ct'wed  with  suturcfl,  so  as  to  leave  a  tunica  vaginalis.  The 
operation  shoald  bo  perlormed  with  the  slrictcet  antiseptJo  praeaattealtl 
the  safety  of  the  patient  depends  in  great  measure  up<m  thbi 

A  similar  operaliou  li  practicable  in  other  fiirrai  oi  hernia.    Ia  naUttst 


[RREDVCll 


[BiriA — I 


•TOWS. 


751 


h^roise  the  ring  nmy  be  sutured  in  the  Mime  way  «a  in  &a  iiiguioHl,  but  in  a 
femomt  tbU  is  iriijiuiwiblf,  aud  removal  of  tde  »ac  with  ligutur^  ot  its  neck 
is  all  that  can  be  dooe. 

Tbe  results  of  this  opprattoD,  so  far  ta  the  life  »  concemetl,  are  very  good ; 
but  in  H  oonnderable  uuinber  of  caiieB  the  [latieot  has  not  b«en  able  to  dis- 
pense  with  Lb?  use  of  a  truss.  In  luauy  uf  these,  however,  the  hernia  which 
could  Dot  be  retained  id  the  abdomen  before  the  operation  nas  eai^ily  kept 
up  ai\pT  it.  There  it  do  doubt  that  euc-h  an  r)perati(m  csnnnt  be  devoid  of 
a  certaio  degree  of  danger.  It  should  iherefore  not  be  umlertaken  in  nnr 
case  iu  which  the  hernia  can  be  eat^iiy  controlled  by  a  trues.  When  this  ib 
Dot  the  ciue  it  piiibably  gives  the  patient  as  good  chance  of  relief,  or  poeai- 
blyof  cure,  as  any  other  method.  In  irreducible  heruiie  it  is  thecniy  avnil- 
•ble  mode  of  operating  should  interference  be  cunBidered  advietible.  In 
cases  of  stranguliited  hernin,  when  operative  interference  becomes  ueeeg^ary, 
many  surgeons  advise  that  the  operation  should  alnnys  be  compk-ti-d  by 
removing  the  sac  and  closing  the  nng,  unless  Hmeaperial  eircumstHueceucn 
as  the  exIiauBted  state  of  the  patient  or  his  great  age  renders  it  inadvisable. 

The  etnti^tical  results  published  by  Banks  arc  the  must  extensive  at  present 
before  the  profbsition.    Uc  htn  operated  on  the  iotlowing  hemiie,  uuc(>m- 

Slicated  by  atrangulation :  1  ventral,  1  umbilical,  2  inguinal,  with  un- 
esceoiicd  testicle,  11  inguinal,  and  ti  feniural.  Only  one  of  these  died, 
appareotly  from  causes  unconnected  with  the  operation.  He  also  completed 
the  opc-ration  for  strangulated  hernia  by  closing  the  ring  in  B  inguinal  and 
3  femoral  hcruiic,  only  one  of  which  icrmioated  fatally.  All  the  survivors 
were  either  cured  or  malerially  benefited  by  the  operatiou. 


IRREDUCIBLE  HERMIA. 

iRnEnccioi.E  Hersi.ii  are  usually  of  old  dale,  and  of  large  luze.  They 
generally  contain  u  ctinxidcrable  quantity  of  thickened  omentum,  aa  well  a» 
iotcaline  and  mesentery.  In  many  instances,  a  rupture  of  thiit  kind  is  partly 
reducible,  the  greater  portion  remaining  unreduced.  It  is  usually  the  gut 
which  slips  up,  and  the  omentum  that  cnnmit  be  returned. 

Caiuea  of  Irredticibility. — The  irreducibility  of  a  rupture  may  be  depen- 
dent on  either  its  shape,  on  the  existence  of  adhetiuTu,  or  un  its  viry  nature. 
If  the  sac  become  the  seat  itf  an  hour-glass  contractioo,  or  its  neck'  become 
elongateil  and  narrowed,  the  hernial  contents  may  continue  jK'nuauenlly 
protruding.  So  also,  the  expanded  condition  of  the  luwer  part  of  the 
onieDtum,  and  the  narrowing  of  its  neck,  may  prevent  a  return  of  the 
rupture.  Tbeexisiteuce  of  adhesions,  either  between  the  sau  and  iis  eontcniD, 
or  between  protruded  intestine  and  'imeutum,  will  commonly  render  a  hemiu 
irreducible;  and  most  frequently  these  are  Bssocialcd  with  cbaiigee  iu  the 
ihape  of  the  sac  or  of  the  omentum.  Ileruiie  of  the  c».>cum  and  bladder  can 
never  be  rc-turucd.  on  nccouutof  the  analouiical  couditiuDS,  to  which  rel'erenoe 
haa  already  been  made. 

Symptoms. — Au  irreducible  hernia  is  uiiually  a  f^uurce  of  great  iiicunveo- 
ience;  it  has  a  tendency  to  iDcrcasc  if  lell  to  iiacif,  until  at  last  it  may  con- 
tain, as  Id  sQDie  extreme  cases  it  has  been  ftiuud  tti  do.  the  greater  f)i>rtioa 
of  the  abdominal  vi^^era,  forming  on  enormous  tumor,  inconvenient  by  its 
aixe  and  weight,  in  which  the  penis  and  scrotum  are  buried.  £ven  when  the 
irreducible  hernia  is  of  small  size,  it  gives  rise  to  a  «4;ndation  of  weiikncMi  in 
the  part,  with  dragging  pains,  and  is  very  frequently  accompanied  by  ctdieky 
aeDsatioDS  and  dynpeplic  derangements.  The  patient  also,  tu  these  circum- 
atances,  is  in  a  stale  of  conoidiTable  danger  lest  the  rupture  become  striingu- 
lated  by  violent  efforts,  or  injured  and  intlamod  by  blows. 


752 


DBRKIA. 


Treatment— Fur  tht  nbove  troMiiA  it  u  ntctmuj  bM  Ottlf  to  |w«utii 
ru|>tiirc  of  tliid  kiixl  trim  external  riolentv,  but  to  cndMiMr  tf  fKniri-ni  ii* 
iucr«HS«  in  »iw>.     TIim  rowy  lit^t  Iw  ilon«  liy  I»*lling  llie  p«ti»n" 
with  a   lurg«  cniitiLvi?   pa<l,  wliicli   itu|i|>nrt#   aoil    |)nilKt«   it  : 
rupture  be  ni»t  uf  t<Ki  greiit  n  niztf  for  ttiv  nppttcattun  <jf  9ii<-!>  ;>ti  i.* 
It"  itif  mngatLiide  tie  verj"  waHidernlile,  it  iiiu^t  lie  pupjmri-'l  ^<j  n    >  ■ 
BUtfp^neory  baudnge.     Bransby  Oioper  bsa  recutunnfoHcMl  that  «rt 
sbuuld  be  made  to  onvert  the  irrcludble  into  a  reducible  I><ti.  1 »  i- . 
tbe  patient  la  bed  fur  wreral  weeks,  on  low  diet,  with  the  • 
tton  of  ice  Lo  tbe  tumor.     If  it  contains  much  (imeatiitu,  oii-.  ;•<■    |»......  - 

fat,  the  diet  may  be  regulate<l  accordinglv-  All  fund  rf^Dlaiuioc  ffoiidt* 
BUgor,  except  a  emuli  quautit}' of  bread,  aod  all  HlL*iL>britie  drinkaanM  UtUt 
biddeu.  The  patieot  must  be  fed  on  a  biudII  quiirititr  of  Iran  bbI  ■! 
grecD  vegecftbles.  At  tbc  enme  time  a  doee  of  blue  pill  and  *  mUin  po^ 
uvo  must  bs  given  occarinnallT.  nnd  I  have  advaalageouil;  adnaiiUM) 
iodide  of  ^xHaieium  to  promote  absorption  of  tbc  fat.  The  aeracaai,if  ^ 
hernia  be  inguioal,  must  bi>  rai^ttl  on  a  pillov,  and  the  foot  of  the  bed  m; 
alao  b«  clovatcd.    Taxis  may  be  alten)i>tod  <laily. 

B;  this jilau  I  linvo  seeii  vpr;  laree  irreducible  beraia  relurDcd  taatrr 
wockti.  If  the  patient  be  young  and  otherwiM  healthy,  tlie  queMiM  rfpr 
formiDg  the  operatimi  for  radtcul  cure  by  opening  the  hernia,  ilJMmty 
through  tlie  adbcsious,  removing  the  sec  nnd  Bewing  up  the  ftB|  aMfW 
considered.  Such  on  operation,  however,  ihuuld  not  be  raahly  dadmika 
if  the  lieruia  be  lar^c  and  the  patient  fuL 

Inflamed  Inrednoible  Hernia. — The  ooeurrence  of  infl-- - -•:  n  in  a 
irreducible  hernia  in  a  scrioiiii  complication,  utd  one  ibai :-  -^tru^c 

lation  very  clnMly.  When  this  complieatinn  iiocur«,  tb«  [luri  i>i-->m<»  i< 
tender,  and  painful;  there  ia  not  much  tcoxion  in  the  tumi-r,  «bW^  it 
•eldom  increased  beyond  itJ  usual  magnitude ;  thi^n:  i»  .'  :  '  pyrua 

and   (jvinptonis  of  |iericonit>fl  spreailing  from  the   vi'  :iJa0^ 

rupioiestet  in.  In  »ome  ca)i«s  there  w  vomitinj^ ;  '  a  r.  i.  ;  .uiuUBt,iai 
never  feculeut,  occurring  generally  early  in  the  <lir-ii.-v.  ^u-^':  r'<aafti»ffri»- 
eipUly  of  the  contenta  of  th«  stomaeh ;  being  apfMuvoU;  an  aftirt  etvattn 
to  get  rid  of  an  iudigctlible  moa).  If  there  w  oonwpatlott,  a*  fumOj 
haj)pen»  in  all  cares  of  ptiritonilti,  it  is  not  complete,  Batni  oocmmmI^ 
paseiug  per  ununi,  together  with  a  small  ijuantity  of  tluid  teem.  It  >  " 
iniportauiw  in  these  cases  toob8cr\'c  that  the  itiflamuiatino  cummcnetsilUa 
body  uf  tlw  snc,  and  extends  into  those  |iarla  of  tb«  abduroen  cliM  arc  «■* 
tiguous  U)  it«  neck  ;  tbc  guiftriu  and  iuicaiina]  deraogemcoia  being  wigiAify 
to  this  nmsiderftliiHi. 

Tlit<  'tVMt'ueiil  of  an  inHaraoil  Irredncihle  hernia  must  be  dlncMdhit^ 
peritonitia  which  attends  iL  The  application  of  IcMbeaover  the  «t  nrf 
its  neck,  and  the  administration  of  opium  or  hjrpid«ralc  iojkImH ^ 
morphia  if  l\w  vomiting  ronttnuee,  fillowed  by  hot  fnmrntatttia,wllk<in'^ 
nnliplititgislir  rrgimcn  and  rest,  will  usually  bjttiedily  subtiue  all  tiffltiH^ 
flam  mat  ion. 

IncaroeratAd  Hernia.— An  irreducible  bemia  oeras^nallr  iMeono  >^ 
strucl<-<l,  then  c<miiliiutini{  the  coudilion  termed  inc.:  '.rmi^  T^ 

oonditioii  ocL'um  prihci|)flilv  in  old  jHMiple,  (Vum  the  ac<:i  aof  ttaW* 

of  undigested  mattem,  Dticfi  as  clierry-otonet  or  tbc  remnini  uf  a  lari;4M*' 
of  cahbnge  or  apinucb,  in  an  iiogte  of  tlie  gut.  In  thnm  rase*  (h«i«  '»  n*" 
stipotioo,  with  eructation,  and  |K'rhiipB  occasiunal  vomiting.  Tber«  nrf^  ^ 
»oni»  dcj^ree  of  |win,  w<-ight,  or  uneasiness  about  iho  tunivr;  but  tii»rt)*>" 
tension  in  it  or  in  its  neck,  and  the  syroplums  altogatberaraof  a  chraaiclM 
eubaeutti  character. 


^ 


HEOBANISU    OF    STR  ANOULATION. 


768 


he  Treaimeitf  of  sucli  a  cue  as  tlib  should  consist  iu  tlio  adinlntstrattoa 
of  a  giiiNl  pur^^utivti  lujccitou  ;  the  compouud  culocyuUi  ettuiiia  b  the  best, 
lhn>wri  u[i  as  hi^^h  as  pwsiible  bv  means  uf  a  lung  tube.  Ice  may  then  be 
iipplitid  Ui  the  luiiKir  fur  abiiiu  hull'  au  liQur ;  and  the  laxia,  as  will  afterwards 
tie  dEacribefl,  iimy  be  used  under  chlt^ruforiu.  Tito  ice  may  be  omiLted  in 
thoaecaaeia  in  whit^h,  on  liaudlta^  Lhe  luitiDr,  (rurjriiiig  can  readily  be  felt; 
bul  the  tJixiii  (ihould  always  hi^  imud,  us  by  it  th^  iiK-arcenitrd  gut  maybe 
partially  emptied  of  it^  {>>nlont» ;  or  if  atiy  additional  prntnision  should 
nave  5tippe<l  down,  thitn  may  be  relumed.  After  tliene  means  have  been  em- 
ployed, an  active  piirgiitiv*?,  such  aH  a  full  duse  of  castor  oil  ora  cakmiel  and 
colocvnth  pill  mav  be  administered.     Hhnuhl  there  be  any  sif^of  inflamma- 


BTRASr.lLATBD   HRRNU. 


A  bemia  is  said  to  be  Strangulftted  when  a  portina  of  gut  or  omentum 
that  is  prutruded  is  so  lightly  cunstricled  that  it  caunot  be  returned  into  the 
abdomen  ;  havinu  its  functions  arrt-sted,  and,  if  not  relieved.  H]>eedity  ruuning 
into  gan^'rene.  This  condition  may  occur  at  all  periled  uf  life,  being  met 
with  in  iufauu  a  few  days  old,  and  in  ccntcuariaus.  It  eoiuuionly  arises  from 
a  suddeu  violent  efllirt,  by  which  a  fresh  portion  of  intestine  is  tlintibly  pro- 
truded into  u  previously  existing  hernia,  which  it  di«lcnda  to  such  a  degree 
oe  to  produce  struugLilutiou.  But,  chough  uld  bernito  are  ni'tre  subject  to 
ibis  eoudiliou  than  recent  ones,  it  may  occur  at  llic  very  firat  formatiou  of  a 
hernial  snulliug,  the  gut  bceoming  strangled  us  it  is  protruded.  There  are 
therefore  two  dintiiicl  kinds  of  strangutation.  One  may  be  said  to  be  of  a 
passive  kiud,  oneurriug  cbiefly  in  elderly  people,  the  subjects  of  old  and 
perhaps  irreiludhle  hernia;  which,  in  uo[i9('i|uetiice  uf  aunie  accidental  cir< 
curastance.  become  distended  by  the  descent  of  a  larger  portion  of  intestine 
than  usual,  and  tbix,  undergoing  constriction  and  comnresaion  at  the  neck  of 
the  sac.  gradually  becomes  strangulated.  The  other  Ititid  of  Btrangulatioa 
is  most  frequent  in  younger  individuals;  In  it  the  symptoms  are  more  active, 
the  bowel  becoming  protruded  in  consequence  uf  violent  exertion,  and  un- 
dergoing rapid  strangulation,  the  tension  of  the  parls  not  having  been  less< 
ened  by  the  previous  long  existence  of  an  irreducible  hernia. 

MEdiASisM  OK  .Stranolilation.— Strangulation  has  been  attributed 
either  to  a  spasmodic  action  of  the  walls  of  the  aperture  through  whi<?h  tbe 
hernia  protrudes,  or  to  changes  taking  place  iu  ttie  protruded  parts,  ttubse- 
■luent  lo  and  occasioned  by  their  constriction  by  the  tissues  external  to  thera. 
The  strangulatiou  cannot,  I  tbijik,  ever  be  regarded  with  justice  as  of  spas- 
modic character;  the  aperture  iu  the  abdominal  wall,  through  which  the 
hernia  eacapea,  being  tendinous  or  fibn^>us,  and  certainly  not  in  any  way  con- 
tractile, though  the  aclton  of  the  abdominal  muscles  may  undoubtedly  in- 
crease the  tension  of  its  sides.  The  continued  and  permanent  character  of 
the  straugulnlion  also,  when  once  it  has  taken  place,  would  disoountenauce 
this  opinion ;  those  forms  of  hernia,  indeed,  as  the  ventral,  which  occur  ia 
purely  uiuBculur  atructures,  are  very  rarely  Btratigulatdl.aud,  when  they  are 
BO.  the  constriction  is  generally  occasioned  by  the  formation  of  dense  ndven- 
titioua  bands  upon  or  within  tlie  sac,  and  not  by  any  muscular  agency. 

Slrangulatiou  is  characterized  by  congestion  of  tbe  protruded  parts,  in- 
duced by  the  con!<triction  to  which  they  are  subjected  ;  the  niechanisni  being 
as  follows.  A  knuckle  of  intestine,  or  piece  of  omentum,  ts  suddenly  pro- 
truded during  an  elTort  of  some  kind.  This  immediately  bi>comes  com- 
prencd  by  tbe  sides  of  the  narrow  aperture  through  which  it  has  escaped ; 
the  return  of  its  venous  blood  is  cousecjuently  interfered  with,  and  swelling 
VOL.  n. — 18 


n 


754 


HERNIA. 


P[{.  TI9,— S(Tleiut«  III  III*  Nvck 
«f  Uie  SbO,  IkiJ  DptB. 


And  odcma  rapidly  ensue,  culminatiiig  in  BtagnRtton  of  the  blood  iii ''    '' 
th(.'  contlricliijii  be  excessively  tiglil,  llie  wnlU  of  llu*  rinf;  twiof  ^■ 
anit  sliiirji,  the  part  lliHt  is  «u  Btningii1aiF<l  niav  Ik*  (Icprr - 
io  ihc  {i>uree  ot  n  lew  hoiirv.     II  tlif  i«tniiiguliitii>[i  Im*  I'--" 
cirrulutiiin  ii<  not  i-nlircly  arroaun],  tiio  ciiunecs  rhitr'  .■!  uUUaM- 

lion  jipowiily  Buperviiic.     In  proporli-^n  ««  the  (s>iigt  ^  .       fiientt,  lfc«i»- 

turn  <if'  the  protruilcti  pitrta  is  ncoenarily  rendered  more  ditllrull  bjdi 
increase  of  their  swelliujf. 

Skat  op  Strictuue, — The  ntriclurc  is  very  commonly  niiuatMl  outtUelW 
neck  of  the  sac.  In  the  tcndinoun  or  lignmenlous  Ktruclur««  •tirfmit>''>ii!'i) 
Dot  iinfrrquently  in  the  aliere*)  and  tbicketttM  siibneroua  arwUr  ti- 
otber  caHB,  and  indeed  with  ftreat  Irc^uenry.  it  ia  met  with  it>  *'• 
the  Mc  ii*clf  (Fig.  785 1,  which  is  narrowed,  elongated,  and  lul 

Btricted  by  lmn<la  ihitt  ure  incvr|>i>r;«i'<]  *iiu  l^ 
More  rarely  it  e\im  iu  the  body  <if  ibe  me. 
which  may  have  hmiiiiikxI  nii  h>iur-tila«  tlta^ 
Id  some  ca&ei,  it  ut.>uhl  apjfear  aii  if  Uili  far 
ticular  shape  were  owing  tu  an  old  bcnii  B■^ 
ing  b«i-u  pushed  dowo  bya  reomtoMabvftil 
The  8lri{:iur«  ie  BumuLimtv.  ihnugh  br  bi>  mttm 
fn:uuuutly,  met  uith  iotide  the  sar,  c<«HliD| 
of  bauds  of  adhcsinnn  atretrliini:  arnat  tba," 
uf  tho  iiiduratcii  eilge  of  an  ap«'nure  is  Ut 
omtiDluiii  tfaniugh  which  ■  pitrlion  of  tit  pt 
baa  slipped. 

IxtCAI,  KpPBCTS  op  fiTRANOriUTIOT.— Tht 
changes  Induced  in  the  strnngulatt^l  parttrmil 
frf)m  the  preraure  vf  ihr  ilrirturr.  nrnl  Ibtftw- 
eerjiient  interferencewilh  the  cirnilntitm  lknN|h 
them.  If  the  Btranculation  hi>  ariiic  that  rBf* 
tion  of  intestine  which  lira  '.<   ^  <  Ir  uifcr 

the  stricture  will  bcseeii  to  be  nipjied  or  mnrJic*!  br  n  u*,iw»- 

piooed  [wrtly  by  the  preaaure  to  which  it  liui>  b«;t'n  ttifyect  ;  srtlfl'J 

the  ewelliiig  of  the  congeste<l  linsuw  beyond  it,    Ths  «■  .taiBi* 

place  iu  the  protruded  Jnlvatine  rapidly  increa»e  in  pru|>nniou  to  itivdaf*- 
tjoo  of  lb«  BlrangulalidU.  The  tigblnvw  of  the  stricture  aud  the  aeiHOiM 
of  the  alraogulation  have,  however.even  more  tu  do  wiiJi  tlitw  chaDj^ti^B 
ita  duration.  I  have  seeD  the  bowel  tn  tightly  iiii>pe<l  ti<»f  ii..<:<'?i  tb 
atratigulation  had  existed  only  eight  houta  MbeQ  tite  •  i  '-f- 

foriui'd,  the  vitality  wai  loel  in  the  part  cooBtricted  (Kig.  7.'.  .  ct.-.  .»  -^ 
caaett  I  have  known  the  port  to  recover,  although  BtiunguIuLiuo  faaJb'^ 
for  five  or  six  dare. 

The  first  change  that  takea  place  in  the  protruded  pan*  intbecaM* 
■tmngulated  hernia  i»  their mri^esfion.    Thti>  u>  p^  '    lujariM 

from  the  fant  that  at  first  the  jireseurv  U  tvldom  -  ihetrt^ 

rial  Hiiw,  while  it  seriously  im|irdei>  that  ibrntj|^'h  llii:  vuiii>-  '-*' 

qucnee  of  this  ihcguLgrudtiiilly  swelle.  and  at  lafttth«*  arterial  tl  '^ 

itln.  The  gut  bcMtmrs  at  lirst  of  a  elnrut,  nuinme,  i.r  ptirplI«b'lifnwnMl^i 
aometlmes  ccchymnacd  on  the  Biirfu<-e,  with  thicki-ning  and  tttflenlD;  kit  A 
Cftttta  owing  to  rflVisioti  inio  their  sulvdtance.  At  the  Mtme  time  tbawrl*' 
cornea  distendi'd  with  fluid  poured  out  I'rnm  the  over  ditl^nd^d  «•-■»-!■  Mbn 
the  circulation  ia  completely  arrpatcd.    ThcvrpMtsof  any  nmen  -ay 

be  prvM-nt  in  the  sac  will  bo  almilarly  distended.     The  loterfi- 1  Uii 

drcalaiion  fieoe»»arily  leads  to  ■  pnigrcMivo  diminutino  of  \  hkA 

speedily  terminatn  in  gangrene  of  the  stniDgM  gut.    Tb«  ptiraonieM 


^mm 


LOOAL    BPPBCTS    OF    STKANOUL ATIOK. 


7-»5 


^^yta  lui 


inflammation  cannot  mBDifost  themselves  adcr  the  circulation  is  arrcalc*). 
Jo  fact,  in  ail  ca!*es  of  sevore  and  rapid  8iraujjiilaiiou  they  arc  vnlirely 
wanting:,  the  surtace  of  the  eul  beiug  free  from  lymph,  iiml  llic  tluid  iu  llie 
Me  pvriecily  clear  tliuiigli  ilurkly  Btaincd  with  hlwij.  Iu  the  vmon  uf  slow 
iBtrangiiltttion.  on  ibe  oilier  liami,  iu  wliicli  ihc  gm  is  att  loosely  held  tliat  i^ir- 
culalioii  conlinuca,  altbuugh  all  luuwage  of  iW'f*  is  arrtwtcd,  tlic  si^rnn  nf  in- 
fiaiiiinaLioQ  are  commouly  tiica  with.  In  Uicmo  chhiw  the  hi)wel  i»  dark  in 
cu]'>r,  though  Dot  DO  dark  ua  in  tnun;  acute  tilrau^ulatiini,  and  is  coated  here 
and  there  with  (tnkt-)'  of  lymph,  which  givi-  it  a  rouj^h  and  villnuB  Innk ;  the 
onieuLuui  has  a  uiitnewhat  nwy  tingo,  iiinl  thc^n'  in  intually  a  good  iIbuI  of  pale 
reddish  fluid  cnutainiug  t1ak«B  iif  lymph  in  thf?  ^ar.  Lt  is  thenretically  p<ie- 
sibic  that  iu  mnw  cn^tt^ri  the  ftrHn^nltiti^in  may  he  so  complete  and  )>udden 
thol  the  arterial  and  vciioun  tlow  would  he  flimultaneoualy  arn>6terl.  In  Huch 
a  cJiac  the  gut  would  \w  pale  and  the  aac  free  fnun  fluid.  Hin^^h  a  crpudition, 
if  il  tlivtt  occur,  is  of  intinJtn  rarity.  When  ganffrtine  ncrurn,  the  howel  loses 
ta  lustre  and  pojitth,  heci)n)in^  of  an  a^hy-^ray,  or  ilull-ltlack  color,  mift  and 
what  lac^rnhle.  !>ii  that  its  rofll«  rend'ilv  sv-parate  from  one  anothfr;  the 
aeroufi  membrane  espfcially  peelinn  iifl".  I^he  omentum  is  dnrk  purplish,  or 
of  a  kind  of  did!  yellowisli-yray ;  and  there  is  usually  a  coiit<ideral>ie  (piai)- 
tily  of  dark  turhid  ^^Tuni  in  the  wie,  the  whole  contents  of  wldeh  are  more 
or  less  oHeiisive.  ^tost  n^naily,  when  gangrene  occurs  in  n  strangulated 
rtipture,  inflammatiun  of  the  sac  and  its  coverings  Inkes  place,  accompanied, 
aXer  a  time,  by  a  reddish-bluc  or  congestt'd  Npfiearance  and  some  tenderness 
on  pressure;  and  if  ibe  [uirl  be  letl  unri^luced.eveutuHJIy  by  emphysematouM 
crackling.  If  the  case  \ne  left  witliotit  being  relieved,  gangrene  of  the  »kin 
will  at  last  take  place;  the  sac  giving  way,  arxl  the  fecal  matters  being  dis- 
charged til  rough  thesidU-nedand  dii^iutegraled  tissues.  In  such  circunistancea 
Bit  these — which,  however,  are  ver)'  rarely  met  with  at  the  present  day — the 

E patient  usually  ereiiiually  dies  of  eihnuslion  from  vomiting.  In  exceptional 
caees  peritonitis  may  be  tei  up  by  ulceration  and  perforation  of  the  gut  im- 
ne^iialely  above  Lhe  seat  of  stricture,  hut  in  the  ^Teat  majorilv  no  efiusion 
of  iecident  matter  takes  place  as  the  porliou  of  bowel  immediately  within 
the  atricture  becomes  adherent  to  the  wall  of  the  abdomen  and  the  neighbor- 
ing coils  of  intestine,  and  thus  fecal  exCravaealiou  is  prevented.  It  does  not 
follow  that  there  is  always  external  evidence  of  the  occurrence  of  gangrene 
within  the  sac;  and  ihc  bone]  is  frequently  nipped  to  such  an  extent  as  to 
prevent  its  regaining  its  vitality,  without  any  unusual  condition  being  pre* 
tented  until  the  sac  is  actually  laid  ofjcn  and  the  intestine  examined. 

The /futW  contained  in  the  hernial  sac  undergoes  changes  in  appearance 
an<I  chanicler,  corresponding  to  those  which  take  place  \n  the  strangled  gut. 
In  earlier  and  slighter  casi^fii  it  continucn  clear  and  but  inoderntely  abundant. 
8omtiimoi  the  quantity  iucrea'iefl  greatly  and  rapidly,  hut  more  oocuno.nlv 
lhe  chief  alteration  that  tiikca  place  is  in  its  ch/nyirter.  It.  becomes  reddish 
or  hroWD  in  color  from  tnimiiided  blood.  So'tnciimea  even  pure  blood  is 
fouml  in  the  snr,  and   I   hnvc  seen  the  protrmled   intestine  invested  with  a 

IJayer  of  coagultim.  If  gangrene  of  the  gut  take  place,  the  fluid  bt-comea 
nurbid,  dark,  and  ofll-niiivc.  Suppuration  in  the  sac  is  very  rare.  I  have  only 
wDCe  met  with  it  io  n  woniftii,  'Si  years  of  age,  three  months  pregnant,  who 
■Wail  auHering  from  an  acutely  strattgnlntM  femoral  hernia  of  sixty  hours 
doratioii.  In  that  case,  the  taxis  had  Wen  freely  used,  riiictuation  could 
be  lell  deeply,  there  was  difluM-d  doughy  infiltratiou  of  the  groin,  and  on 
opening  thv  »acit  was  loun^l  filled  with  dark  thick  pus — about  half  an  ounce; 
at  the  Iwttonj  of  which  lay  a  small  dveply  congeste"!  hut  not  gangrt-nous 
knuckle  of  inl««line,  which  was  replaced  after  the  division  of  a  very  slight 
■tricture.     The  pattern  recovered. 


756 


HBRXIA. 


Inflflmmation  of  the  Gat  aft«r  relief  of  8tr&a{fiiiAtion  occtin  hi'-. 

fivportiuu  tit'  au«8.  Il  line  l>evn  nlrtady  pnitilvil  nut  in  iKr  chx; 
uflumoiatiuu  i  vul.  i.  p.  Itf'l )  thut  llie  urrtvt  ol'  eirctiUiiun  ibrtiugh  i  jic;  <! 
tbeliviug  butly  [irodu(.-ea  dillurcoL  clTecbi  uccurdiiig  t>i  tiie  Imgtii  u(  tiutUit 
il  in  ki'jti  iij>.  If  the  urrcst  u  cuuiplete  and  uf  etilfiricut  ilurali'iu,  r^ufna 
mu  il),  »ut-l)  bloiiil  u«  till'  vostls  coolain  cu8){ulai<«.  oikI  un  irlivf  of  lU 
8trai)gtilati<iii  the  btuod  ie  utinbic  tu  emcr  tbe  <lvud  tinua.  If  tlM>  tnrottfl 
tbe  firculnliuu  has  \kvu  luatuluiuutl  fur  a  length  i»f  time  5iifTt--ii>ai  to  li***: 
Ibe  viLulity  iiftlm  pari  uutisiderably  but  uui  tt<  kill  it,  '  >  >  fnf  rtmg» 

lation  all  ibe  phenomena  of  inllummation  mauilrat  th'  ^  Thefwk 

become  engorged  with  blowl,  abundant  usudatiuD  takn  placfl  cmtnaf  ftW 
swelling  by  whieb  the  fuehle  cinulatinn  may  br  again  arn-»lfvi  ami  gampfm 
may  aet  in.     In  ulher  caaee  the  inllamiuaUon  tuny  fall  »hiiit  of  ilu«.  ha 
cuny,  ID  the  case  nf  the  intmtine,  be  ttufHcteat  loeusjM^Dd  tbe  fuDctinnt  i/ik 
affr(:tc<l  part  eo  tbat,  although  die  Htnmgulaiidn  in  reliwcd.  the  ohacradh* 
to  liie  passage  offecea  remains  for  aoineilaya,ur  even  till  death  n»altK  If  li> 
arrest  of  otrcalation  has  been  lean  ooroplvte  or  of  sbortcr  duratiim.  the  r»li>i 
of  strAttfTtilntiiin  iit  followed  by  lempcirary  bypprffiiiia,  ubich  •mhici  Mihiiila 
It  is  not  uticoiuiiion  in  tAtal  caitci*  to  6iiii  ihp  coil  of  iiitp'tin>>  fr*-^  fr*ini  r*f- 
grciie.  but  iwollr-n,  coven'd  with  «  ihirk  layer  uf  int' 
bxinj;  it  to  the  tieiKhboriii^  coiU,  viid  i-videotty  iursj  • 
function:*.     Tlili*  indnmniftlion  alitor  redtictioa  is  a  l'a<:it  ui  j 
ax  il  abows  lb4^  uece««ity  of  giving  tbe  gut  re«t,  n*  far  a*  j' 
strangulation  has  been  relieved,  by  the  aroidance  of  purgativea  or  irntaone 
foot). 

It  wiu  formerly  anunied  Ibat  in  all  races  of  pndongetl  vtraogubtiin  fw- 
eral  |ivritoQili»  scla  in.  Thia  aMUtoptidU  ia  uot  bonio  out  by  tbe  rtauh*  i' 
the  pual-iuurlem  examination  of  ctuN»  dying  of  unrelieved  straognlatioa.  J> 
such  oases,  aa  a  rule,  local  peritonilii)  a  found  at  tbv  xivck  of  tbe  mc,  bK  tt* 
menibraue  g(.>rierally  is  frre  frum  any  signs  of  inlliiniraatioo.  8Im^  ifr' 
flanimatioo  occur  it  is  always  slight,  and  aeems  to  be  ■eoowlarjr  la  «■)• 
inflammatioQ  of  the  niiK^tiis  membrane  of  the  iutestiDe  abtnrv  tiM  Mifcim 
which  in  too  many  cKsee  is  the  result  of  the  injudicioiu  iidadmKfmlMa  df 
purgatives. 


Btmitoiius. — The  sigua  and  armptontit  of  51  rangu lotion  ore  of  two  Hii" 
L  The  loeal  onee,  affecting  the  1  ouior ;  and,  2.  The  genaral  otiM,  ittfliUDda|f 
the  Cunstitiiliun. 

1.  Local  Sigoa. — The  tumor,  if  the  hernia  lie  an  old  one,  will  be  fiwnd  la 
lie  increased  in  eize;  or  it  mav  have  appearcK]  for  the  SnH  time.  At  thi 
moment  of  strangulation  it  wifl  (^ncrafly  be  found  to  l>e  har-^  >.,<.»  {tad 
rounded,  more  particularly  if  it  bo  an  eoterocole.  When,  bo*-  >r> 
nia  is  ia  a  great  measure  omenta),  it  is  not  unfroqucntly  soft  hu>i  •nmj^tiy, 
though  strangulated.  It  seldom  incfMuea  in  size  after  straoxulaUMi  hu 
uccurrod,  as  do  frosh  protrusion  can  take  place  below  the  «trii '  *  .il  I 
bare  known  it  to  be  greatly  augmented  in  bulk  afti^r  the  sintti.  .sd 
existed  fur  some  hours,  b}  thu  ctfusion  of  serum  ini<>  tbe  uc  11  :iii.i  buati 
have  previously  been  r«ilueii>lv,  it  can  no  lortf:*'r  b«>  pit  l>n«>k  ;  and  ibnte  ■ 
no  impulse  in  il  nur  increase  in  iuisixe  mi  v  -rmltaf 
the  transmission  of  tbe  shock  to  tlie  couleulc  tiu  >a*. 
as  pointed  out  by  Luke,  the  siluatinn  of  \\tc  KHf-  •ntn^mm  t» 
a»certaine<l  by  observing  ut  what  point  ibe  impu.  >  1:1  murt  eais 
therv  is  votixiiJenible  local  leiiderueat. 

2.  OoustitutiODal  Symptoms.— So  suoo  as  the  sLnuigulalioD  boa  ucenmd. 
inlestiliAl  iilutructii'U  takes  plBi«,  aud  the  patient  lunnimci  uweasT  ami  rmtt^ 
leas.    If  thu  cousiriciiou  he  of  au  active  charat!t«r,  ho  will  be  srinsl  with 


llODtriCATI03IS   OF  8TMPTOM5. 


TfiT 


ncMtc  pflin  ID  the  part,  which  Bpeetlity  eitetids  to  the  contiguous  portion  of 
itir  abiloiiien.  The  first  ihiii);  tli»t  hapjieiis  when  iiitealine  is  strantrulatcd, 
whether  a  lar^  coil  b«  conetricleil,  or  h  atnall  portion  only  of  the  cliarneter 
of  the  ^it  be  nipped,  is  »n  arretit  of  tho  perJBtaUic  movement  of  the  part 
implicated;  and  the  occurrence  of  obstruction  to  the  onward  counse  of  the 
iDt««tinal  cotitentd  is  followed  by  constipation,  Tomiting.  and  colicky  pains. 
The  CDnHtipalion  is  always  complete,  neither  feces  nor  flattis  passing  thruugh ; 
thu  bowels  iimy  sometimes  act  once  after  the  slrangiilation  ha&  uccurred  fnttn 
that  portion  which  lies  below  the  seat  of  constriction,  hut,  they  cannot,  of 
course,  empty  themeelves  thoroughly,  nor  from  above  the  strangled  part. 

Vomiting  usually  sets  in  early,  and  is  often  very  severe  end  continuous, 
with  much  relohing  and  gtraiiiin); ;  nl  fin^t  ttie  contents  of  the  stomach  are 
ejected,  with  some  bilious  matters,  bui  afterwardi!  ihe  vomiting  becomes 
leculeut  or  slercoraceous.  The  cause  of  feculent  vomiting  has  usually  been 
auppoeed  to  be  an  inverted  peristaltic  action  of  the  intestines.  Brinlon, 
fanwever,  opposed  this  tiiuc-hnnoreil  view,  luaialaiuing  that  the  peristaltic 
action  duitiuucfl  direct  an<l  causes  a  periphcrul  downward  current  as  far  hb 
the  obetructioD,  from  whit^h  point  a  central  upwurd  current  returnit  the 
contents  of  tho  intestine  tnwtirds  the  sb>macb.  The  quantity  brought  up  is 
often  very  largo  in  amount,  and  consists  not  only  of  tho  normal  contents  of 
the  intestine,  hut  of  an  abundant  sprrrtion  from  the  congested  and  imtutod 
mucous  membrane  above  the  obnrrurtinn.  It  is  greatly  incrc9J»cd  in  i)uaiiiity 
should  the  patient  have  tAken  a  purgative.  In  cases  of  prolonged  obstruc- 
tion it  is  somctimca  mixed  with  hiack  phreda  of  altered  blood,  indieating 
iDieose  congestion  of  the  mucous  membrane.  The  vomiting  is  attended  hy 
colicky  nuil  dragging  pains  about  the  navel.  'Hiefle  symptoms  nrc  moro 
BCTcrc  in  their  character  when  the  strangulation  is  acute,  than  when  it 
b  passive.  They  occur  equally  in  the  incomplete  and  the  complete  forms  of 
the  disease;  indeed,  it  not  unfretpiently  hap|»enN  that  the  hernial  tumor  may 
be  wi  small  as  tf>  have  eacH[»ed  ubservation,  tlie  occurrenee  of  the  above- 
mentioned  svmptoins  heinj:  the  Rnl  indicalion  of  the  probable  nature  of  the 
mtsfhief.  Hence,  it  is  well  always  to  examine  for  hernia  when  called  to  a 
patient  suddenly  seited  witlt  coufttipatiiju.  vomiting,  and  eoliclty  jmins,  even 
if  told  thai  no  tumor  exists. 

After  the  straiigulntiou  has  existed  for  som'e  time,  the  abdomen  becomes 
distended  and  tynipatiilic  with  much  pain  and  distn-«s.  The  puli*e  becomes 
(mall  and  rapid,  ftud  perhaps  iutennitteut ;  the  tongue  is  dry  ami  speedily 
becomes  brown;  the  countenance  is  pale,  anxious,  and  dragged.  The 
extremities  become  (-(dd.  congcHted.  and  rlaniiuy,  and  the  tumpcmlure  falls 
below  Dorniul.  When  gaiigrnne  nf  the  rupture  takes  plaee,  hiccup  usiially 
comes  on,  with  eudilen  t'i;s«ati<in  of  jiain  In  the  tumor,  and  iuterniitteut  puUe, 
ci'dd  sweaui,  pullur,  anxiety,  rapid  sinking  of  the  vital  poweni,  ueuully  with 
slight  delirium;  and  dciith  npeerlilv  (V[-ciin<. 

BlodiflcatiouB  of  Symptoms. — 'rho  symntomH  just  described  are  tlifiee 
whieh  are  usually  met  with  in  t^trangulated  hernia.  They  may,  however,  be 
aitMlifii-d  in  »tume  impttrlant  rnRpccti'. 

1.  There  may  be  little  or  no  tetihion  in  a  strangulated  hernia,  the  tumor 
continuing  soft  and  Inx  ;  this  is  eji]>eciHlly  the  <'a.He  when  tlie  henna  contains 
oraculuiu.  and  in  congenital  herniip  when  ntrangiilatpd.  It  may  occur  also  in 
the  (MHe  of  double  hcrni.'e  nn  the  same  aide,  in  ci>nHequpnce  of  the  miler  sac 
bring  empty,  or  merely  filled  with  Herum,  and  the  pcisicrior  one  being  pro- 
truded against  thixnud  strangulated,  but  its  tension  being  masked  by  the  lax 
state  of  the  outer  one. 

2.  Vomiting  someiiincs  dn«  not  take  nioce  from  first  to  last,  there  being  at 
most  a  little  retching;  at  other  times  tne  patient  vomits  once  or  twice,  and 


HERNIA. 


then  there  is  oo  recurrence  of  thU  sympLotn  sn  Innj;  rhIir  rMimInt  rgaWi.Ufi 
k«V)«  tfae  etomuch  empty;  but,  on  moring  or  diking  uouriktininil  nf  ui« 
kind,  even  fluitle,  it  ccimev  ou  aifuio,  tmd  tluis  Ihe  Suri^vm  nimy  fAnl  tu 
vymptoin ,  ehuuld  it  be  ueceewry  in  a  ritagmntic  jminl  ol'  virw. 

3.  Exteuaive  perit'^nitis.  with  copiouA  cHu-siiin  of  n  purifi^rni  tiqHvt.  wt 
occur  VFJthotit  nny  pnin,  lltit)  with   but  little  Icnilerneas  and   do  clni'       ' 
leniperuture;  the  anxitty  of  cijunlenaacc  and  oharpoew  of  pulM  '" 
only  Byniptoms  Ihiit  lend  to  a  suspicion  of  ita  eKi«(ence. 

4.  iX'Blh  iiiBV  result  from  exhiiu.>!lion  cousecjoent  no  vomitiDg,  wilbontur 
sign  of  gangrene  in  the  constricted  porLi'm  of  inteetine. 

DiACXoeis.— The  diiif^noets  of  atniugulaled  hernia  reqairai  Id  b<  ■>•)• 
from  the  fnllinvin*;  coniliiions  : 

1.  Obstructed  Irreducible  Hernia, — In  this  there  sre  no  »aat»  wymfttm, 
and  tfae  rupture  wilt  generally  be  found  to  be  a  larf^o  wv  of  old  ftudiif 
It  may  become  aomcwhat  teuee  and  swollen,  but  it  is  Dot  Icndfr  In  tw 
touch,  Hud  always  presents  a  certain  degree  of  iiiiputsc  on  Cftugbinif.  Tkn 
nifiy  bo  oonstipBtiriu;  hut  there  ii  no  vomiting,  or,  if  there  be  any,  it  b 
timjily  mueous  and  bilioim,  cotuifiting  of  the  eoiiients  of  the  Momarb.  lit 
speedy  resLoratioit  of  the  iuteeliiial  aciion.  by  ilie  treainient  alrraJy  toiii' 
cated  flB  prujier  in  these  cases,  will  remove  any  duubi  m  lo  the  nstmeof  tb 
aHecliun. 

'2.  Inflamed  Irrednoible  Hernia. — Here  there  are  f^^at  UnAtnem  ui 
pain  in  the  tumor,  with  pyrexia,  and  some  getierni  periloDitt»,  but  tkenbii 
vomiliug ;  or,  if  the  patient  have  vomited  once  or  Iwie*-,  he  tt'-e*  dm  rootiw 
to  do  fto  with  the  Mime  degree?  of  vioWnoc,  or  iti  ihe  mi:  iy,  m^ 

would  if  it  were  the  n-KuIt  of  Htrnnpuliilinn.     Again,  tfae  i  'OiiUl 

absolute  nm\  entire,  t>iit  l1iilii»  ami  liijuii)  I'nf*  will  u»uiilly  paaa. 

X  Oeneral  Pentonitii  conjoined  with  Hernia.— Uerv  tb«  di^pHw  ■ 
often  extremely  difficult,  especially  if  the  hentia  bet  an  irnHJuribir  om.  b 
tbew  case*,  however,  it  may  be  ubnerved  that  the  tteritirtittis  i*  auMt  imUam 
at  a  ditttance  from  the  sac;  that  there  will  be  iillle  or  u<>  TtiB3itilif.C 
if  there  be,  that  it  is  dimply  of  niucui!  and  the  contvnU  of  the  *loiMfh:  ui 
that  the  coDstipittiun  is  by  no  means  ub^liuate  or  iusurmouDlablr  by  onJintry 
means. 

•1.  lu  Doable  Hernia,  one  tumor  may  be  etrangnlatrd  and  the  otfatr  tA 
though  irreducible.  In  these  circuinttancos.  it  nmy  at  l)n>t  hr  a  liUl*^ 
cult  to  dc-termiuc  uhich  one  is  the  seat  uf  oun»trieit<>n.  This,  hunrrer.  MT 
be  asuertniuL-d  by  ubevrviug  greater  teneion  and  tendemeas  about  ihffBsdt* 
theslrangulaltsl  than  of  the  uneoii^irii;lr<l  faeniin. 

&.  The  eoeaifiince  of  Early  Pre^aacy,  i<r  a  threatened  Miseaxria|fh  n<* 
obscure  the  diagnmia,  iht-  Sur^'t-im  |»t<f^ilily  Iteiuk;  in  doobt  trbeibfr  <^ 
Toonting  la  dejirndent  on  the  Hiale  of  ihr  nt'erita  or  on  ihe  sitangnlatMa 
the  bcmia.  Here  it  may  be  Blaled  gem-nilly  ihat  the  vnmiling  of  prvfcaiMf 
Darer  becomee  slercorarcxnja;  that  iionetipHliou  is  not  complete,  flauutf*' 
feres  psaslDg ;  and  that  the  local  signs  of  strsogulaLtoB  an  wMially  at^ 
marked. 

Bnidca  tbeae  various  conditions  of  hernia,  which  may  b.  i  '  niti  «1A 
•trangutatioD,  there  are  other  tumor*  which  may  W  mi»  r  lUi^ 

ease ;  hut  iJiese  we  ehall  have  lo  oonsider  wbeu  epaaking  m  tue  special  iM 
of  hernia. 

TttKATMrrcT. — The  ireatnient  of  stntigolnled  hertjin  '•.-  ■   tW  ■■* 

important  dubjecfs  in  surgery.    The  olm'4-t  to  In*  ar(»m])li.-  .  r*ia>^ 

of  the  CiitiHrricti'in  from  the  Mranglnl  hernial  tumor.  Thi*  m  rliectrd  ritba 
by  the  Iteduction  uf  its  Couteuta  by  Taxis;  or  by  ttiv  Divicioa  of  tk> 
Strictura. 


TBEATMKNT   OF   SIR JlNflULATIOS— TAXI8. 


769 


Tixi».~The  mluctitm  of  the  hernia  is  effwted  by  ihp  eninh>rment  nf  the 

[u.  tty  which  lit  mfmni  Ihe  TnriuuA  iiianunl  priicedure^  eiiiplnrCHi  in  piilliD|r 

rupturr  hnrk.     Tlu<  laxi8,  wheo  pri>|H>rly  perftinn«<1,  is  seldom  Attentt<Hl 

ilUiT  ■vrioiw  lytnseijUMicvs  U>  lliu  pHtteal.     I  hnva  Ufv«ri»een  it  fullowt^  by 

i;   and  out  of  '2^)-*  cmiw  of  heniiM  re[M>rte4]  br  Ljiikp,  itn  linvlni;  Itc^ii 

ind  liy  taxis  in  the  L/rntlon    HtMpital,  none  di«<l.     In  the  HciMirts  of 

IrrnitY  Cill*n;«  Mi»pit«l  one  filial  c»»e  ia  recor-iwl  in  which  rU-ttrli  fniin 

prmtiim  ami  fMrrnrBtii'U  i»f  the  gnt  at  the  seal  of  nlricture  follnweil  reiliie* 

by  Utvis.     It  is  Dot  unFrcrguHntlj  f(>Uowe<l,  however,  by  il  riithi-r  ahnrp 

,of  |«eriLonili«,  which  might  probably,  io  some  instances,  prove  falnl ; 

flo»liince.  1  have  seen  it  fullowcl  by  very  abunclnnt  hemorrhage  fmrn 

the  hnwi-l.  pr>ibaMy  owing  to  the  rupture  of  some  of  the  conffesteil  vt-wels  of 
Uie  itran^flcil  porti>m  of  (he  gut.  Id  uving  the  taxis,  great  care  nhoiili]  in 
M  CBMv  beemploye<l,  nnd  no  undue  force  should  be  hud  reconree  to.  No 
cmn  e%~er  w  clffcttMl  by  violeocc  ;  the  resistance  «f  the  riti^  eanuot  be 
by  forcible  pressure:  and  a  vast  deal  of  harm  may  be  done  by 
ig  af^nst  It  the  t^ioder  and  iuflnmed  gut.  causinf;  ihtK  fi  n\*erlap. 
tho«  to  be  bruispd,  or  even,  |»erhaps,  torn.  Tho  taxU  shouhl  not  be 
^nhio^M  bcTitnd  half  bq  hour;  if  it  be  properly  employed  for  this  time, 
^B  brmia.  if  nHluciblv,  will  probably  go  back.  K  it  be  applied,  as  it  ntWn 
Hd  rery  impriperly  i*.  for  a  lengthened  period,  and  by  aereral  8ur^Ton9  in 
fpofaBioD.  the  protrudt^d  part  becomes  ecchyniused,  irritated,  and  )Ji?|>oH>d 
VMBflaumatioQ  ;  and  the  ehaocM  of  recovery  after  a  'ubaequent  opcratinn 
taiKh  te^^A^iied.  When  the  parts  arc-  raue})  Intlfliiic-d.  the  laxis  should  b« 
.-reat  caution  ;  and,  if  it  have  In^n  fairly  aud  fully  used  by 
u  II,  it  is  better  not  to  re|X!at  il.     When  ffiinnrene  ha*  ticturrea, 

taxi4  vlioiild  never  be  emphkyed,  as  tlie  puttin;;   biiirk  of  the   mortified 
iDt'i  thu  abdomen  urouid  be  fullune^I  by  extra vasotiun  of  feces  and  fatal 
>aiti«. 
[n  uaiii)!  the  taxli,  It  ihouM  b«  borne  in  mind  that  there  are  two  ohstactea 
[wirrcoiuv:    the  rrsistaoce  of  the  parts  around  tbv  rinif,  and  the  hulk  of 
tumor.     The  firet  may  be  somewhat  lessened  by  relaxing  ihe  alxlominal 
clva,  and  o^Dsequeutly  dimiuiijhiui;  the  tension  vxerotsvl  upon  the  tea- 
afierturea  oad  fascise  of  the  croiu.     In  order  to  elfecl  this,  the  patient 
lid  be  placed  io  a  proper  (KieiLioo,  the  body  beini;  bent  t'orwanls.  ibe 
jh  adiluelirtl  ond  oeiniflexcd  Ufxju  the  uUtomi-n  ;  the  Sorgoon  mny  then, 
,rmpl->yiiit;  f toady  prossure  uu  the  tumor,  endeavor  to  squeeze  I'Ut  sotne 
.  the  latuii  from  thi.'  tutran^lod  portion  i>f  iiitealiue.  nnd  thus  to  effect  its 
'  lelion.      Ill  diiin^;  thiA.  the  Deck  of  the  »»p  should  be  «t4-Hdi<>4l  by  the 
tlw  leA.  hand,  whiUt.  with  the  nirht  dprrnd  over  thi)  lumnr.  iba 
endeavirs  u*  punh  it  biirkwants,  uKiiij;  a  kin<l  of  kuearlin);  mnUna, 
a«timrs  in  the  tir^t  innlnnoe  dmwiri);  it  slightly  downwanU,  »•  aa  to 
in}clr>  it  fnim   the  neck  of  the  sac.     The  ilinn'tion  of  tho  pretture  is 
■ortaut :  it  diituld  alwavA  be  in  the  linn  i>f  the  deereni  of  tJie  lumor, 
mea»i>  may  Im3  eniphiyed  aa  anon  as  the  patient  in  seen  by  the  E^ur^mm, 
I,  by  steadily  rarryinK  (in  the  taxU  f^ir  a  few  minute,  he  will  perhaps 
tr  and  fe«-l  u  (;uri;li(i)r  in  the  tumor,  which  will  be  f>dlowed  by  its  imme- 
retiucli'iu.     If  tite  patient  Iw  thin,  and  the  outline  of  tfie  ft|>ertiire 
t>uj;b  which  the  hernia  e(iea[>e«  tolerably  denned,  the  protru<tiiin   may  be 
lurtil,  oiler  failure  of  (he  laxi»  in  the  i>rilitiHry  way.  by  pAHxin^  the  tip  of 
Goj(rr  or  ihe  nail  under  the  eilue  of  (lie  rini;,  nnd  piitlio);  this  liniily  and 
pibly  on  oue  side,  »>*  a*  to  steady  and  at  the  Hiiue  lime  dilate  it,  pr>-iuur4 
fcept  Mp  on  the  tuntor  with   the  other  hnmi.     ThtM  man<ruvn«  rati  bo 
nl  with  Hi'ire  fiicility  aud  succew  in  fenionil  hernia,  where  ihe  U|i|ter 
ibe  naphenouv  opvning  is  sharply  defmed,  but  may  also  succnufully 


780 


HZBNIA. 


be  liad  rccourae  to  in  iuguinal  and  umbilical  pralnivioDi.  In  mawciH 
reducttoii  upjicura  to  have  be«u  fac-iliUiltKl  by  plHcitig  llie  [wttivDt  on  bulmA 
BD<1  elioulik-ni,  and  rabing  the  binly  in  (he  rertival  |HMitiuo  wliilM  tW  ui> 
WOB  bein^::  employed.  Should,  however,  reduction  iiol  eUHie.  it  will  be  tlev- 
nble  to  have  rceourec  at  oucc  to  further  meiinB,  the  obji-rt  of  whWi  ifchj 
relaxing  the  muttoleit  and  lewcniug  the  bulk  of  the  tsmor,  to  nubblH 
hernia  to  be  rpduoefl. 

Auxiliary  Measures.— The  means  to  be  eniplnvptl  most  be  modified  uod- 
ing  to  the  «)ndition  of  the  Btrnngulation,  whether  it  be  n{  the  artit*  oi rf 
the  panivc  kind.  If  it  Ik  acute,  the  ]iatient  may  be  put  idLd  a  hixhiik 
where  he  may  rcmuin  for  twenty  minutps  or  hnlf  an  hnur.  or  nnlit  bvMi 
faint;  and,  whilst  he  is  in  th^  balh  in  (bin  conditinn,  the  taxi*  •h'-Qld  l» 
employed.     If  it  do  not   succeed,  he  should   be  tnkcu  I'P"'  "P  ™ 

hlunketit,  and  be  put  ftjily  nnder  the  influence  of  an    '  Vlht  » 

at  the  iirCKcnt  time  uoualty  ^iven,  hiil  in  Mime  ruses  i(  fn 
muHoular  relaxation.  ai)d  ehlorofi.rm  may  then  be  cui  - 
patient  ib  fully  ameRlhettxed,  t»x'w  may  W  Iricd  ou«^  nEnin.  >b'iuid  Atbi- 
fail,  operation  ratMt  be  JmnieiliRlely  jir«»ceedi-d  with.  No  ji;<«(nl  t%a  tf^iWj 
ronie  of  delay  in  these  e8M«,  and  re|teate<l  aiteniptK  at  laxb  kbould  l<r  tvf 
fully  avoided.  If  the  hernia  do  nut  admit  of  reduction  in  the  catIt  fta;;* '^ 
the  BtrangulatioD,  it  will  neceeaarilj  be  much  leu  likely  to  du  hi  wWa  tW 
part«.  squeezed  and  bruised  inucb  by  raoQipDlatioD,  wUi  bjave  bad  iLm 
ooaecstcd  condition  (rrcatty  iucrcased. 

When  ihe  Birangulalioo  is  of  a  paeeivc  ehanictcr.  lapenrenii)^  ^_  » .-n. 
io  an  old  hernia,  t)>|>ecially  of  inguinal  or  umbilical,  aud  occurrn 
or  elderly  people,  ullivr  meaiiuri*  niay,  in  excuptional  caws,  bo  aiiuj-Hrt  *'" 
the  view  of  lessening  the  bulk  of  the  tumrir,  which,  rather  than  lae  U mbO 
iif  the  paru,  oiWn  ihe  nhiuf  object  to  reduelinu.     lu  iiueb  circBOiluM 
e8[H-riiilly  uht-n  ibv  lumnr  is  tar^  and  not  vi'ry  tcn»e,  it  ia  well  In  ifiqaiff 
with  thi!  hot  bath,  which  has  ao*netIme«  a  tendency  |n  inerrane  any  naff^ 
tion  that  miiy  already  extHt  in  the  brain ;  I  have  in  more  than  one  chvmA 
a  fltrangiilaieit  niptiin;  enlarge  conMilerahly  after  the  enipl'-ymmt  ttf  tbt 
bath.     In  Hurh  caBes,  mure  lime  nmvsnfely  be  spent  in  alti-mm-  at  Tt-Atdi^ 
than  in  very  acutely  strangulated  hernia*.     It  is  a  useful  ;  <■  omt' 

inencc  the  treatment  by  the  aHniiDistnttion  of  «  large  i.  n-t,  ky 

emptying  tlie  lower  bowel,  will  alter  the  relali"«»of  theab-i  -BlHils. 

and  may  ninlerially  faeililate  the  reduction  nf  the  Innmr.      iii.  ^ 

is  one  of  gtuel  and  castor  oil,  with  some  spirit*  of  luriwutioc  m'\-  it 

should  be  injected  through  a  fullsiied  tul>e,  piua^-d  high  up  im-.  thr  ^ot, 
and  with  a  niiHlenite  degree  of  force.  In  admini^liTititr  it,  rarr  mnM  im 
taken  that  no  injor>'  be  done  lo  lb«  bow«l,     U  wnuhl  ■     <     '     '  -tx 

to  give  such  a  caution  as  this,  were  it  not  that  I  wa«  )^i'  <n 

•go,  by  two  very  excellent  practitioners,  to  rev  a  womitu   «•  M 

femoral  iicrnia,  to  whom  an  enema  of  about  two  quarts  ot   <  .aA 

been  ndminiatered  ;  and  as  this  had  uot  returuc<l,  and  did  n'>t  appear  to  baw 
gouc  up  the  ix^wel.  they  suspected  that  it  rmiat  have  jiasse*)  ou  t  of  tbe  rertaa 
into  the  Buriiiunding  areolar  tiotue.  A»  tbe  jKitient,  Iiwwever,  did  wi  auW 
to  be  auflering  tVom  this  cause,  and  as  the  symptoms  of  »tnuiptii^i'  r^  ^we 
urgent,  1  operated  on  the  hernia.     Death  euddvniy  iKvurre*)  Jf 

from  cxhttu^ion.  in  about  eight  hours;  and,  oo  examining  i'--  .  ■>  was 

found  that  the  rectum  had  Iteen  jwrtorateil,  and  tbe  fluid  v  -if^  ibr 

meao-reclum.  Be|MiratiMg  the  gut  from  tbe  ucrum,  wbeuce  ii   t.  !ed 

into  tbe  general  mibiHTitoneal  areolar  tjasua,  which  euntainetl  n  nt 


the  li<]uid;   aomt! 
cavity  alto. 


of   the  water  appearad  lo  have  cniervd  ib«  p«:rUi:^Bcal 


r 


PEBSISTBKCB    OF   SYMI-TOMa    AFTER    REDACTION.       761 


Id  the  large  heroic  of  old  people,  more  particularly  the  umbilical,  in 
wbicb  there  ia  a  ^ouii  deal  of  ilutue,  aflor  the  cuetua  has  beeu  adniitiistercd, 
a  bladder  of  ice  may  be  ajiplied  fur  three  or  four  boun)  with  excellent  ftket. 
Chloroform  may  tbei)  be  givcu,  aud  ilrn  (axis  uinplnyed  under  ile  iiifluciice. 
Of  late  years,  iudeed,  I  have  been  in  iiiosL  Ktmes  in  the  habit  uf  trustine 
almost  solely  tu  chlurulurm  as  a  relaxing  Bfretit,  and  have  rillen  diapensed 
with  the  use  uf  «tui  the  vrariii  liath.  If,  however,  this  can  be  RiiDvenicnlJy 
used  without  tmi  much  delay,  it  Hhinild  he  employetl.  After  this,  I  jint  the 
patient  at  ancu  under  ehhiniriirni,  and  ihen  trv  tiixiH  for  a  period  not  exretd- 
lug  half  an  hour;  if  ihia  fail,  tlie  njieration  i^Kontd  he  ilnne  without  niaking 
any  further  altetnpts  at  reduction,  which  are  not  only  useless,  but  tiijurioua 
by  hrui>iin^  the  protruded  parts. 

Al\er  taxis  has  been  fairly  employed  for  a  sufficient  time,  and  hnn  not  a»o- 
cNietlvtl  in  rednciDg  the  hernia,  the  ojwrntinn  must  be  proceeded  with.  There 
are  few  Surceonw  who  will  no!  at  ouce  acknowledge  the  Inilh  of  the  remark 
of  the  hite  Hey,  of  I^eds — llint  he  often  rt-grelled  perfornjinj;  this  operation 
Uk>  late,  but  never  having  done  it  too  early.  It  is  true  that  cases  are  i)cca- 
Bionally  recorded,  in  which,  after  four  or  five  days  of  treatment,  the  hr-rnla 
haa  gone  up ;  hut  it  ta  rery  rare  to  meet  with  such  cases  in  practice;  and,  in 
all  probability,  in  delayini;  the  operation  in  the  hope  of  lindin)'  one  such 
case,  the  lives  of  dot^emt  of  patients  would  be  saerilioed.  Luke  has  shown, 
as  the  result  of  the  experience  at  the  Loudon  Hospital,  that  the  ratio  of 
mortality  increases  greatly  in  proportion  to  the  length  of  lime  duriuj;  which 
the  strangulation  is  allowed  t>)  continue.  Of  09  canes  of  iitrnngulated  hernia 
Operated  upon  within  the  4U  hours  of  otran^ulation,  12  died,  ur  1  in  0,7  ; 
whilst  of  'M  cases  operate^l  on  atler  more  than  -l^^  hours  hait  elapsed,  L5  died. 
or  1  in  2.5.  Indee*l.  one  chief  reason  of  the  [greater  mortality  from  opera- 
tions for  hernia  in  hixtpital  than  In  private  practice,  probably  arises  from 
the  fact  that  much  valuable  time  ia  lre<)ueutly  consumed  before  assiittance 
is  sought,  or  in  fruitless  efforts  to  reduce  the  swelling  before  the  jmtienl's 
adniiacion.  ^'ot  only  is  time  lo^t  in  thie  way,  but  the  bowel  is  often  bruii^d 
aod  injuriously  s<)ueezcd,  so  that  the  Uiflamiuation  already  existing  in  it  is 
coiiatderably  increased.  Moreover,  at  tbo  pre^nt  time  the  improved  melhoda 
of  treating  wounds,  especially  thoec  iniplifating  the  ijcriloneuoi.  have  so  far 
diminiidicd  the  dangers  of  the  ojieratioo  that  the  great  reason  for  hesitation 
baa  been  removed.  The  morlality  in  operations  for  strangulated  hernia  per^ 
formed  withiu  tweniy-four  lumn  of  the  desecnt  nf  the  gui.  with  aiiliseptic 
precautions,  or  even  with  nimmoii  ntleutiim  to  uleanline^)!,  ia  m  small,  thai 
It  may  be  t^aid  to  lie  ultmii^t  iniMni'idcmhIe. 

Persistence  of  Symptoms  after  RBdnotion. — After  the  rednciion  of  the 
hernia,  the  gymptonw  of  Blninpnlation  may  continue  unahiited.  This  unlo- 
wnni  occurrence  may  arise  from  five  distinct  conditions :  \.  The  honiia  may 
hare  been  peduccH  in  ma«9  (nW*  Chapter  LXIf.i.  2.  An  inlernnl  strangu- 
lation has  exifitcil  within  the  due,  the  taxis  having  overcome  the  external 
Btricture,  but  failing  to  influence  that  within.  ^.  The  gut  may  have  been 
BO  severely  nipped  or  strangulated  fur  do  long  a  time,  that,  ati  soon  as  the  con- 
utrictiou  of  the  vcMel.4  ia  relieved,  the  phenomena  of  acute  inflammation 
manifest  themsetvea,  with  complete  arrest  of  peristaltic  movement.  Thia 
condition,  as  before  stated,  may  end  in  gangrene.  4.  The  sac  may  he  of  an 
hnur-glaw  shape,  lying  partly  within  the  abdomen  and  partly  outitide,  and  in 
the  apparent  reduction  the  gut  may  have  been  merely  ^i^neezed  from  the  out«r 
part  of  the  .lac  into  that  lying  within  the  cavity  of  the  abdomen,  6.  A 
second  hernia  may  exist  in  a  state  of  straugulation,  wldch  has  eiKaped 
detection. 

The  diaguoeia  of  these  several  oonditiooa  may  possibly  be  made  by  atteD' 


lER.VIA. 


tion  tn  the  fullowiii);  circumstance^!.     Tn  the  reiltuHon  iu  vmM  tfat  tiaarWl 
slippc'I  iiji  witliipuc  aoy  gurgle;  tlie  cuuaI  is  very  opeu,  aD<l  at>  tnadm 
cau  be  felt  iu  it,  but  a  rouatled  luiunr,  |i<j«»iblr  nt  tlin  ii|i|Kr  fMurt,  t«  oi*^ 
iug.     Id  the  owe  of  inleraal  adfiemotu  there  will  linvc  brra  u<i  gUTflM|^kl 
tho  caual  w  alill  filltil  by  the  isac;  the  nbdomiciftl  aiicrturaa  uv  M(fnw» 
naturallj|Mili'iitnuil  ilistiiicL     Iu  the  <»0e  uf  ef/^me  nippiny  anil  cJMrjwM 
inUniiimatiaii  uti<l  |>»nilvei«  nf  a  |Hirlt<iii  of  tbe  gut,  {furgllog  kiU  ban  krt 
felt  ami  bt'anl  iu  plfectiu;;  the  ttknU,  which  clma  i)i)t1)n|>|ri-n  jo  ritbrri'Tiki 
tilher  L'ttnililiiitid,  aud  thp  syuiptoitii*  of  inteslinni  i>l»tni<-ti-in  wilt  o<itbp()aM 
complptc.     The  vutiiiting  will  Umv  its  steronnceuuo  rliHrarlrr.  and  pwfcM^ 
eome  flatus  will  pun.     Au  hnitr-gUitt  aoe  is  met  will)  nnir  io  nld  isfihll 
ht^rni»,anil  appears  t>i  ariw  fn>m  a  pnrt'nl  reducttnu  iu  man.     Fuorowstf 
tbifl  bind  havo  iKvurred  in  Univernity  C-tllpj^e  H*kHpital  in  tb«  1*4  tvftrt 
veara.     In  each  uppntvnt  reduction  wasunttily  r(rt!Cti>r|,  with  ftli^l  cwtliil' 
The  pnttruttioii  readily  reap|itfar«d.  ami  was  easily  put  hark  agiM.    Tm 
nature  of  the  case  was  recognized  only  ofter  urxTaliwo  pcrfMrwIrt  ftr  j» 
ststi'nce  iif  «ytiipt'>m8  in  three  ciMe^,  nnd  after  aeaib  in  tlo-  Climii.     Id  f\i 
caw  of  llie  eoexiftenre  of  a  neromi  hrrnin  in  a  state  of  »(rftii_ 
of  Llie  eoutiniiniK'e  of  tlie  iymptonjs  may  he  asreriained  hv 
tion  of  the  ahilDiiiiniil  wnlU.     It  im  eapvcinlly  the  niexi 
femoral  with  »  lurge  umbilical  or  inguinal  hvriiia  thai  ■•  ayi  i.-'  i"  ><« 
lotikvl.     This  I  h»v«  seen  happen  in  a  very  fat  |icrw>n.    A  matt  waaadntlMJ 
inl"  University  O'llege  Hospital  with  ^trangulHleal  in^iiiiinl  bi-roim.     It  •» 
reduueJ  by  the  house-surgeon,  but  the  Brmpt"uiM  p^rnisU-d,  and  lh«  \»xwa 
diotl  unrelieveil,  there  being  u»  indieiitioo  for  upersliou. 
aniall  piee(.\  half  u  knuckle,  of  inte&tine  wiia  fouml  sinin^i: 
canal  tif  the  same  side.     The  patient  bciuR  extremely  fat.  (in- 
WM  not  deieeled,  and  could  not  he  reeiigniz^l  doriug  life.     Tl^ 
gn>in  sh'iiild  he  very  carefully  examined  in  all  lh«ie  cascii. 

The  Treatment  of  ihe^  diOureot  C4>udili'i08  t«  full  of  drlBinl^  1KtA4 
anxiety  to  the  8urgenn.  As  a  geueral  rule,  I  think  that  the  pniprr  pn^ 
in  all  cusra  when  the  svmptoma  of  stningulaUoD,  n>|iec>iallj  rtcmtficfM 
voruiling.  oootinuc  unretUvtd  and  undiminl»hed  in  MPtrity  for  aaoM  bvm 
after  Iho  apparent  reduclinn  of  the  hernia,  is  to  cni  dimn  nf*-: 'i— —a' 
expoM  the  aae.  and.  if  that  be  fiaind  still  sirictured.  divide  il: 
in  the  way  which  will  shortly  be  de«eriho>].  (Should  the  heroi>i  'v.  iw 
been  reduces]  "in  muM."  it  might  po?uiblr  Ite  fouud  that  a  email  knucihi" 
intt^ine  is  Mill  grip[HM|  at  the  inner  and  deeper  ring:  hut  fhnuld  tfaalf>* 
be  the  ca^,  it  will,  I  tiitok,  he  saft-r  not  to  push  any  expI<^ralioa  hrtv  th) 
ahdominal  cavity  iviih  the  view  of  diaouvoring  the  p'<*flhle  erUtran  «f  vv^ 
tieved  intorual  ntniiiiEulaiiou,  the  preaencc  of  which  woald  bo  bickly  yn^ 
lematiffll,  flod.  if  iTxinting,  c«iuM  acaroelv  admit  of  dise-ivcr)-.  TltsaAT*' 
wiser  plan  under  »tieli  eireuuistaocet  appean*  to  lie.  to  leare  ihe  muanA  •f*> 
with  a  liKhtdri>Miiui;  nvre  it,  and  to  fi,iv^  the  iiAliL'nt  the  ehaiicenf  tke  Aai** 
tiou  iif  an  arlififiul  nnuA  ou  theslouifliiQK  nf  toe  atrangulateil  ur  badly  ■ipp' 
knuukle  of  intestine;  a  result  that  I  havv  mon  than  onoo  wJlDcaed  ui^ 
the  fourth  ur  5fth  day.  tbe  patient  ultimately  recovering. 

Iu  jmmii  eases,  whera  llie  uippiug  of  tbe  atrangulaleil  lut^ioe  ha*  bi* 
severe,  yet  uot  sufficient  tn  arruit  [lermunently  the  iKTi^lallie  act)i«  i#tt 
dislroy  its  vitality,  c<ti)8ti|Hitiou  and  rrtehini;.  with  unuNea.  mar  enatifla*; 
and  the  tumor,  if  the  hernia  have  bna  small  aJi  '    ' 
ticularly  if  femoral }.  may  ooutinua  to  bo  felt,  tU- 
consisting  simply  of  the  thickenod  and  influmad  sau.  »uh  Kf 
la  these  circumeuinccs.wc  must  bo  careful  not  too|wratcv     1 
or  throe  uocasious,  aeen  an  omptjr  sac  operated  oo  to  tba  BBOidjraaei 


OPERATION    IN    WHICH    TBI   SAO   IS   OPBSED. 


: 


Burgooo  and  dnngcr  uf  ihc  pnlient.  The  mistake  may  be  avoided  by  observ- 
ing that  the  svniutotiiA  gradually  IrsApn  in  scvcrily  hy  naiLitig,  and  lliat  the 
lympeuitiii  eulinidw,  tho  abdomen  h^coiuing  flat  and  fiiip|)1c. 

Tiie  length  of  timo  during  wtdrh  thp  (;onf;ested  cnndilion  of  the  bowel 
will  continue  after  a  Alrangulatetl  portion  of  inle»iin*!  has  betn  reduced,  is 
Terv  L-ousidpralile.  In  h  cane  of  i4lniiit;ulnted  feniiiral  lu-rnin  which  was 
■(■me  time  af^n  iind^r  my  c»rv,  re<Iiir(ioi)  whji  eHirtii-il,  hul,  dliftn^tilaiiiin  re* 
ourriiijl  AC  Ihe  eiul  <jf  Iwi^lve  day^,  »■>  o|)eratii>ii  became  itecei»Hrr  ;  this  was 
perfnruifil,  aii<l  tiie  patient  died  on  tlie  eighth  day  after  it,  nr  ibo  twenty- 
fimt  fmiii  the  fin^l  strangiitntion.  On  exaiidii:«Uon.  (he  ^riinll  inli-stine  waa 
found  congested  in  lun  dl^ilinct  jwrliuns,  each  of  wliich  wiii«  almut  eight 
inches  in  leu^th;  several  feet  uf  healthy  gtit  interveninp  between  tKern. 
One  of  ihese  cougtsted  oortiuns  lay  opposite  the  wound,  and  was  evideully 
the  interline  thai  was  Inet  strangulated.  The  other  «iut  «lt"(j«-tlier  away 
from  Ihe  *eat  of  0(KTBt!uu.  but  was  equally  darkly  congested,  being  almost 
of  a  bkck  c(di>r,  and  wai^  elvarly  thai  purlioii  which  had  beeD  couetrictcd 
sonic  titue  previously;  and  which,  allhiingh  twenty  days  had  claf>»ed,  had 
oot  as  yet  recovered  iteelf.  When  a  ^cond  dirangulaleil  hernia  cxiale  it,  of 
counc,  luufit  either  be  reduced  by  the  taxia,  or  the  operation  pructiiied  ou  it 

OPERATION    FOB  STRAHOULATED  HIiRNIA. 

All  operntiong  for  hernia  should  be  performed  with  efficient  antipeplic  pre- 
cautioriii.  The  Surgcun  and  his  a^i^iaiits  niu^t  6rgt  eart'fidly  clean  their 
batidB  i,p.  2i>3,  vol,  I.],  and  the  s|>onges  nud  iii^tninienla  must  be  disinfected 
Ba  already  det>cnbed  [p.  66,  vol.  i,).  The  skin  of  the  {)alicnt  for  pome  die- 
lance  uround  the  seat  of  the  Incision  must  be  also  cleaned  and  difiinfecterl. 
The  carbolic  spray,  if  at  hand,  rnay  l>e  u»e<l,  as  experience  has  abundantly 
proved  thai  in  an  opernlinn  for  henda  it  never  does  any  harm,  find  in  the 
opinion  of  many  rxcetlenl  ^^nrgeons  it  in  an  additiniinl  neciirity  against  septic 
peritonitis;  F»|>ecially  an  in  ofieralimiH  fur  hernia  it  ia  impm^ible  to  clean  out 
the  cavity  should  any  blood  or  tliiid  from  the  oac  find  admiiiKion  to  It,  If  the 
apray  be  not  at  hand,  the  wnund  may  hf-  occawonally  irrigated  with  cnrholtc 
lotion  (1  in  -It^),  or  oilier  antiseptic  wiiution,  care  being  taken  that  the  tliiid 
does  Rot  pai>s  into  the  peritcmeal  cavity:  a  basin  of  carbolic  acid  lotion 
shdubl  Im^  III  hand,  into  which  the  >^urgeon  should  dip  hia  handa  before  io- 
trwlucing  the  linger  into  the  nl»[(ittiinal  cavity-  Should  a  coil  of  tnteotinc 
be  unavoidal>ly  exjiosed  for  any  length  of  lime,  it  may  l)«  covered  with  a 
piece  of  lineo  rag  soaked  in  o  warm  1  in  40  solution  of  carbolic  acid.  If 
the  patient  be  much  collapsed,  tlie  extremities  must  be  covered  with  warm 
blaukets.  and  no  more  uf  the  bodv  exposed  than  is  neceesary. 

The  operation  tor  slraugulateif  hernia  may  be  performed  in  twoway»; 
either  by  opening  the  «ac,  exposing  ita  t^oiiteuis.  and  dividing  the  etricture, 
wherever  It  is  sltiiaied./roni  wUhin;  or  it  may  be  done  by  dividing  the 
Btrieturc  ouiMtdc,  withont  ojH'iiing  the  aac.  lu  cither  cnae  the  great  object  of 
the  ujieratiou,  the  divi^^ion  of  the  Htricturo  by  the  knife,  is  the  same :  but  the 
luoile  in  which  it  is  effected  is  diHereiit.  We  shall  first  describe  the  opera- 
tion in  which  the  »:u:  iu  optueil ;  aiU-rwanlH  thai  in  which  it  i«  nut ;  and  then 
brlelly  compare  the  tvrn  procedures. 

Oi'KHATioN  IS  wHif  II  TiiK  Sap  IS  OPENED.  ExpoBure  of  the  Sao. — The 
patient  having  het>n  broiighl  to  the  eiljp'  of  the  bed,  or  placed  im  a  table  of 
ctmvenient  height,  the  bladtler  in  emptied,  aiirl  the  part«  thai  are  llie  seat  ot 
OfKration  are  shaved.  The  di.>tMei'tion  of  tlie  hernial  coveriiigj!  in  laren 
anatomically  arranged,  ih  never  iJone  at  an  operalion.  TheSnrge^m  ilifsccts, 
or  rather  cuts,  dotrn  to  the  aac,  then  turns  aitide  the  cuveriugs  as  a  whole. 


764 


HBRNIA. 


ad  dividefl  ttic  stricture.  Ho  proceeds  us  f  illows :  An  incttkia  of  nfttlaii 
tau^tb  is  made  nvor  tlio  nock  of  tbc  sac;  lliia  may  be  bMt  Arm*  br  piniUii 
up  a  fold  ol'  akin,  (lUfthiii;;  tbtr  s^-iilpcl  thnugb  iu  bMP  with  the  bvk  (i(lVi 
inslrunient  turned  tuwardii  the  hernia,  ■tid  uiea  cutting  upwurd*  i  Fie. TV' 
A  linear  iucisluu  is  thus  mule,  which  nmy  be  oxtrndiyl  nl  either  eod  if  bm»' 
eary ;  the  diMCCtlou  is  then  carried  t)ir<juf;h  the  BUpcrficial  faMom  utd  &lnlk 
the  scalpel  uid  forccpti.  tf  any  small  orterj  ipout  frMly,  it  had  hmtt  ki 
tied  at  once,  lest  tlie  hteeiliiig  ohAtruot  the  riow  of  the  part  id  the  Hk»> 
qucDt  steps  of  (lie  opcrution-     As  the  Surgttoa  approacnM  \h»  me^mm 


./■ 


y 


^ 


Fif.  78S,— Opanlloit  for  UwkU  ; 
J>lrM«B&ftk»Sktii. 


T\%.  TS7.— 4r«rati<M  \m  llwvWi  b 


caution  is  required,  pnrticularly  if  tb«  ttih«i<rouA  areolar  liMoa  b* 
opatgue,  and  liiiuinau.-<i.     TheHuiye<jn  must  pincli  this  up  with  the 
mak«  a  stnnll  incixion  into  it,  ii*tr\>iluc«  u  direvUT,  and  lay  it  op^o  apoa 
or  "11  the  finger  (Fig.  787).     If  it  be  thin  oud  nut  uiia^jue, -o  »»if.*+p4i 
V'eu  of  the  subjacent  |Mu-i8,  he  amy  dissect  it  througn  >»ii' 
baod.     In  this  way  he  prfcecils  until  the  sac  is  r«ache<l. 
knuwn  by  its  rouu'de«l  iind  Lenae  appearance,  its  Blnmcnt'^us  cbar»ct«r,  ts^ 
by  the  urburcsceul  arrangunivat  of  veaeels  ujitm  its  surfser.     Id  ^•bm'  i-xta 
the  ijurgvim  thinks  that  bo  has  reacjied  the  enc,  whcD  to  rtiiality  be  ) " 
come  upfiu  a  di>«p  layer  of  coodeneed  areolar  tissue  in  d<we  otintaci  - 
here  ihi>  ahsnnce  nf  all  appearaoce  of  veowls.  the  dull  nod  opaijuc  • '. 
of  the  tinxue  and  its  more  solid  feet,  tufcether  with  ihe  at»rnct^  ofth'- 1 
tension  lliai  in  uhnracteriscic  of  tJie  sac,  will  eoable  bim  tu  rrc<ietiii< 
statcof  tliinffft,     ]u  other  rases,  It  may  happen  that  the  vs^'  '•- 
flupurlii'ial  Nlructure»  art^  so  little  coodentted,  that  (he  Sur^'> 
the  oarlic^r  incibions  In-lore  be  ihinkit  he  has  reached  it. 
stances  a  portion  »r  the  ioteslioe  p^H^udin);  mijfbt  be  mi". 
This  iUii)forouB  error  may  be  avoided  by  uhservin^  '' 
and  hii^bly  polished  appearance  prcBMlte«l  by  the  ilar k  <  . 
absf^na^  of  arhor>-4c-ifnt   vessels,  and   the   ii<>n-«xUtencv 
betwp«>n  its  deeper  (Ktrtious  and  the  tissue*  upon  which  it  li' 
prematurely  opened,  the  €«ca|)6  of  Ouid  wilt  indicate  this;  and  it  oiasaan 
protrude,  the  icraiiukr  appearaji«e  aud  peculiar  feel  of  this  Liarae  will  u 
ooce  cause  iu  recot;niti»n. 

Opanin^  the  Sao. — The  sac,  having  been  exposed,  mast  be 
opened;   this  should  Ih>  done  towards  its  nuturior  aspe<U;   aiMl.  if 
•mall  uuo,  at  its  tower  jmrU     It  may  best  b«  dune,  if  tJiv  sim  b«  ii 


.Vb^arm 

r.«aiflbi 


DIVISION    OF    THE    8THICTUHK. 


iGft 


tense,  )>y  sciEing  u  pnrtiun  of  it  bi-tw^en  thf^  fingpr  mitt  tliumb,  and  tliiitt  ke\- 
iug  tbut  uu  iult8liii«  is  included;  n  aamll  portion  ot'tt  is  then  piiirlitil  u|i  Uy 
im  forcepe,  naii  an  u|K>iiin^  in  amiie  into  it  hy  cutting  a\mn  their  poinlf  witli 
the  edge  of  llie  seal  [ml  laiil  horizontallj'.  U  the  uac  be  very  teniji',  it  (.-annot 
Im!  piiK-hwl  up  in  thin  way,  anil  then  il  may  beat  be  i>[teneil  by  iiilnmlucing  th« 
poiiii  of  a  tine  honk  very  cautiously  into  ila  substance,  raisinj;  iin  a  portioo 
of  il  in  thki  way.  ami  then  making  an  aperture  into  it.  There  is  bttle  risk  of 
wounding  the  gut  in  doing  this;  for  the  tension  of  the  sac  arises  from  theeflb- 
tiotiufQu'u]  into  it,  which  will  be  interpriseJ  between  it  and  the  gut.  In  these 
ouee,  Uie  fluid  aomelimes  squirts  out  in  a  full  jet,  and  occasionally  in  h  very 
oonaiderable  quantity.  J  have  seen  at  least  a  pint  of  slightly  bloody  serum 
escape  on  opening  the  snc  of  uu  old  inguinal  hernia  ^bieh  had  become  elran- 
galated.  Most  frequently,  however,  there  is  nut  more  than  from  half  an 
ounce  to  an  ounce ;  and  sometimes  the  ipiantity  is  considerably  less  than  ibis. 
Sir  James  Paget  very  wiselv  atl.ichca  great  importance  to  the  character  and 
appearanceof  thef1ui<l  innfiftrnialsac;  if  ihitf  fluid  be  clear  and  ironspareut, 
of  a  y«lluw  tint  like  eeriim,  it  i«  a  good  sign,  as  prubabJy  no  great  amoant 


Fl(>  niS. — BfcHwl  Md  N*m*r  DIrtclor  on  wbicb  lb*  Sno  maj  b«  liiriilcd, 

of  ooBgeBtioQ  has  taken  place.  If  reddened  by  cxtravaaatiaDof  blood,  it  ie 
an  erideuue  of  iucrvOKi-d  coiigeetiou;  and  the  dt-cper  the  disouloration,  tho 
browner,  the  more  muJdy  the  lluid,  tlie  grtialcr  probaMy  has  beeu  the  change 
induced  iu  the  etraii^led  ptt^L^  by  the  c(ingc«lioi]  or  intlamiuation  re^ultijiK 
Irom  the  ittriucuru.  in  some  inntancen  >^i'arcely  any  Uuid  exisi^;  and  then  it 
hecnmnt  netrrssary  lo  proeeed  with  extreme  canricin  in  opening  theitHC,  aa  the 
gut  or  omennim  is  applie<l  citjsely  to  its  inner  wall.  In  such  cases  as  these, 
ihe  sac  is  not  unfrequently  sufficiently  translucent  to  eniible  the  Surgeon  to 
Bce  its  ooDtents  through  it:  and  he  should  then  open  it  opposite  to  the 
omentum,  or  to  any  small  muss  of  fat  which  he  may  observe  shining  through 
it.  The  opening,  when  once  made  into  the  sac,  may  be  extended  by  the 
introduction  of  a  broad  director  4  Fig.  7^8),  upon  which  )t  is  lo  be  slit  up  to 
a  jufficient  extent  to  atlow  the  exatninatiou  of  its  contents. 

DivlsioQ  of  the  Striotare. — The  next  point  in  the  operation  is  the  division 
of  the  stricture  ;  and  this  requires  considerable  care,  lest  injury  be  done  to  the 
neighboring  ]iarts  of  importance,  or  the  gut  be  wounded.  Vessels  and  struc- 
turec  in  the  vicinity  of  the  ntrieture  are  avoided  by  dividing  it  iu  a  proper 


Pl(.  TM.— HeraU-koIfe. 

direction,  in  accordance  with  onlinary  anatomical  considerations,  which  will 
be  described  when  we  oonie  to  speak  of  the  cpecial  ibrms  of  rupture.  All 
iojury  to  (he  intestine  is  prevented  by  introducing  ihe  index  finger  of  the  left 
band  up  to  the  seat  uf  stricture,  insinuating  the  iinger-uuil  underneath  it,  aod 
dividing  the  conatriction  by  means  of  a  heruia-kuife.  having  a  very  limited 
catting  edge  (Fig.  789).  If  a  director  be  used  lo  guide  the  knife,  "the  iutcs- 
tine  will  be  in  considerable  danger,  as  the  instrument  may  be  olid  uuilerthat 
portiou  of  it  which  lies  beneath  the  stricture;  or  the  len:se  gut,  curllug  oveE 


766 


HBBiriA. 


the  side  of  tbe  groove,  may  come  into  contact  wiLli  lh«  edfre  nf  tb«  itdk 
Tbuno  acuidi-tils  nrp  ureveiiled  hy  using  ilie  linger  oa  a  dtrertur,  idiI  ilif^^ 
the  liernin-kuil'e  ^  which  shuutd  nut  have  i^uiU'  eu  loog  a  {"^  ■'  uTiw 

usuhIIt  ninde)  aloii^  ihc  pulmar  surlaou  ul'  ihe  tiiigtT  up<  miIf  ■ 

reprv^i-Dled  iu  Fig.  79D):  th«  finger  scrvaB  In  ket'p  the  IwiwlI  uultil  llw*", 
aiid  ilflccu  any  part  that  may  be*  inlerpuaed  belueen  tb«3  edge  itf  tbr  kii> 
and  ihe  slricuire. 

During  tbe  division  of  the  Btricturo,  the  protrudio^  portiooa  of  IiNoii* 
must  be  protected  from  the  knife.    The  operator  may  ipread  kk  IdHori 


Pig.  TM.— Uods  of  g«ing  tk«  Haralk-knlfo. 

over  them  in  uticb  a  way  that  they  cannot  be  touched  hr  tht*  ttig^  tt  tfa 
instrument:  or  they  may  be  protected  by  an  atteutive  aou  careAil 

In  eome  ca«e«  the  stricture  i»  »a  tight  ihHt  it  i»  at  6rst  alrauM  in 
get  tlie  eilge  of  tbe  oail  underneath  it.  Tlieyurgeon  will,  bowr-.-- 
succeed  iu  doing  lo,  by  directing  his  R«ii>taol  to  draw  doun  it"  **■ 

line,  »■»  ns  t-J  lowwn  it,  tm  it  werv.  fpoui  uuderneath  the  »tricturc  ;  nc  »i.i  iM 
tiaufilly  buct-ved  in  passing  his  finger  up  iu  tho  middle  nf  the  cuit,  wbm-lkt 
Diesontvry  lies.  So  souu  as  tbe  bluut  cud  <if  tbe  bernia-kiufr  has  beeB|ii^ri 
uodcr  th«  stricture,  Its  sbirp  edg«  must  be  turned  up,  and  tb«  eaaHfiaM 
divided  in  a  prvper  dtredtun,  tu  a  very  limited  cxtoDt,  frotti  oaatighlfcw 
quarter  cd'  au  inch. 

Reduction.— The  iniestioe  and  omentum,  havioE  boen  oxan^ned,  nialW 
dealt  with  acciirdinti  to  the  crtndiiinn  iu  which  they  are  ftund:  oswO)* 
dwcribwl  at  pp.  7d9-77'i.  vol.  ii.     If  ihcBP  BtructureB  be  ^  brail*,' 

to  admit  <irrt<du'Jliun,  the  intestine  abuuld  first  of  all  be  n,'f^ Ihitavl 

be  dune  by  pushing  it  back  with  aa  mucli  ^ntleoess  M  poenible.  snd  dUdr 
by  using  the  index- fingers.  WheD  it  has  slipped  up  ioto  tbe  abdtMMO,lk 
omentum  must  be  nelurneil  in  tbe  Mme  way.  In  rvliiciot!  tbe  h«nuil  f^ 
tniBiiin.  after  the  Kac  hiu  been  laid  open,  care  ahunhl  be  taKen  that  the  w^ 
g\ns  of  this  are  firmly  held  down  by  meatM  of  a  pair  of  fitrcrpe;  lat  il 
together  with  its  cootenta,  be  returned  en  mtme,  the  stricture  being  ndirab^ 
After  re<)uct>on,  the  Surgeon  should  pass  his  finger  up  lolo'  ihe  nnnl  tkaa|^ 
whi<-h  tbt_-  hernia  hu  descended,  and  feel  that  all  b  olrar. 

Treatment  of  the  ftae. — There  is  no  nrceasity  to  close  the  opcviiv  in  tk 
sac  by  tuturea.  It  unites  reaillly  under  the  prrasure  of  the  dreslag.  IflM 
patient  be  y<»tug  and  healthy,  Hnd  not  too  exhausted  by  nreriuit*  rMiBKi 
the  it[«.Tati->n  mur  be  complete<l  by  ligature  of  the  oefit  of  the  »tf  •*■ 
Btrutig  oirlHitited  catgut  or  silk,  removal  of  the  body  of  ili<-  -m  »ii''  it^w 
inguinal  nr  umbilical  hernia)  suture  of  the  Bb<l<iniinal  "[  'i 

experience  U  renuired  before  it  can  bo  defiuitrly  stated  h"w  * I'* 

ceediiig  adds  I')  the  danger  of  the  operation.  Those  who  have  adutK^I  tl#fM 
highly  uf  it  and  advise  it  in  all  cases  iu  which  no  exceptional  cirniiarfli* 
render  it  inadmistible.  It  should  never  be  undertaken  except  m  tsm^*^ 
tion  with  efficient  antiseptic  treatment  during  and  aftsr  the  aptrmtiua. 


iMiii 


AFTER-TREATMKJJT    OF    THE    WOUND. 


767 


Treatment  of  the  Wound. — Aiier  ihe  fiperniion  is  complctet),  whetlier  ihe 
sac  Vie  reiiinvcd  or  iml,  the  wnuiiil  inunt  be  lir(>iij;)il  teif^t-ther  >iilh  sutures 
nod  H  oiitalt  ilrninage-tiibe  in^f  rt<>(l  at  the  lower  mi^rlc  ;  U  ia  then  ilrfi»84>().  itu 
onliniiry  principlpi«,  with  aome  lorm  nf  aiitii*pptic  diYssinR.  Curholir  kuuw, 
KKloIiiriu-wiHil,  snlifvlic  wool,  nr  nny  oilier  efncieiit  niili^-plic  iiiKteriiil  luiiy 
be  UH'd.  Il  iiiu»l  i>iirr(>und  the  woiiurl  lor  eotue  ditlniice,  und  a  (»id  uf  Ibe 
drtKeiug  should  be  placed  over  the  abduiuiiial  yptiiiug  tu  prtveut  the  pro- 
tniBiMn  of  ibe  b«ruiii  diiriog  a  fit  of  c-uu^hiug  or  u  muaculur  (■ITorC.  The 
tlrestiiDg  niuet  be  eecurird  by  a  buudngtf,  ovt-r  which  h  Biuglcr  lurti  of  vluetio 
webbuig  mil)'  be  ujtpHed,  ))iii!«iiig  uvi-r  the  Abdoiuiual  upciiiug  tn  act  ne  a 
truM.  CRre  must  l>e  taken,  ilmt  allbuugb  the  dre»ing  u  fiitnly  applied 
uoduf;  preenttrtt  18  uot  exerted,  le^t  it  iuterltre  uitb  druiuage  and  prevcot 
the  uuiou  ul  tiie  wouud.  This  is  pMrticularly  oeceeeHry  if  carbolic  gauze 
be  used,  n«  the  pad  it!  apt  lo  ciike  iucoasulid  luuea,  tapcciaily  if  the  tiiatvriul 
be  uut  of  Ihe  beet  iguaiity.  lu  ibe  absoiiL-e  of  other  dreHinge  a  pad  of  IJDt 
soaked  in  eurbulic  nil  (1  in  1(1 ',  or  isitiiple  dry  Jiot  ur  collon-wtiol  iiiuy  be 
used.  WaiiT  drcFsiiigBhouid  alwiiys  be  avoided.  In  nii»t  i-aees  the  wound 
beala  by  the  linst  inteutiiin.  Should  tiuppurnlion  occur  the  stitches  must  b« 
removed  and  a  ll^bt  uiitisepLic  dreF^xing  be  applied,  lest  the  pns,  not  finding 
a  ready  outlet,  may  cilher  be  diHuRed  between  the  muscular  planee  of  the 
alKJiiminal  n-ali,  occat^ioning  sloughing  or  the  formation  of  au  abecesB,  or 
return  into  the  peritoneal  cavity,  exciting  inilamniation  of  it, — a  rcfult 
which  I  have  mure  than  once  aeen  occur. 

AJler-treatniciit — The  patient  should  be  kept  quiet  In  be<l ;  a  dry  hot 
flannel  laid  over  the  abdomen,  and  the  leg  on  (he  affected  eide  bent  over  a 
pillow.  From  SO  to  40t»i.  of  laudjinutii  may  then  be  given,  nr  i  to  j  er.  of 
morphia  bypudermically.  If  the  atrnngulation  has  been  nf  very  »hort  dura- 
tion— under  24  h»nirs — and  the  gut  hut  little  congMled,  the  patient  may  be 
left  witbiiui  further  medical  trcainieni  until  the  Dowels  act  by  themiieive», 
unU-Ks  this  be  delayed  for  three  or  four  daya,  when  a  ca»t»r-oit  and  gruel 
enema  may  bu  given.  In  all  cases  iti  whloh  the  strangulation  was  of  ]on(;er 
duration  au<l  more  severe  the  bnwtU  must  be  kept  confined  by  fniall  dnees 
of  opium  till  the  fourth  day  at  leaat.  The  opium  tnay  then  he  dincontinned 
if  there  i»  no  abdomliial  teuderDCM  or  other  bad  symptom,  and  the  bowels 
allowed  to  act  naturally.  If  they  do  not  act  before  the  end  of  a  week,  and 
the  patient  i»  well  in  other  respects,  an  enema  may  be  given.  It  ie  of  very 
great  importancre  not  to  adminisler  any  purgatives  in  the»e  ctiM>p.  If  the 
mechanical  ol)structiou  has  been  removed,  the  bowels  will  he  sure  to  recover 
their  proper  functions;  though,  iti  consequence  of  the  gut  having  becti 
aeverely  constricted  and  almoflt  wounded  by  the  preemre  of  ihe  stricture,  it 
may  rei]uire  to  be  left  quiet  for  a  few  daya  before  it  con  recover  its  peris- 
laltiv  action,  TlieadmiuiBtrntiou  of  purgatives,  by  still  further  irritating  it, 
will  increuee  the  ri»k  of  inflammation  in  il.  and  ^lill  probably  do  much  harm. 
The  patient,  of  course,  must  be  kept  upon  the  timpkst  and  niopt  unirriinl- 
ing  diet — indeed,  be  should  be  allowea  only  barley-waler  and  ice  for  the 
first  day  or  two,  and  afterwards  some  beef-tea ;  hut  no  solid  food  must  bo 
givtn  till  the  boweta  have  acted,  and  at)  riek  of  peritonitis  hus  iiasscd. 

The  result  of  the  operation  for  strangulated  hernia  is  greatly  influenced 
by  thcuKe  of  the  patient;  the  reisnlt  being  very  raueii  mure  iavorable  in  the 
earlier  than  in  the  ituer  perlude  of  life.  Of  15  couieeulive  cases  ii|>erated 
on  at  Uriivcniilv  ('-olU-gQ  Hogpiial,  of  which  8  recovered  and  7  died,  tho 
avemge  age  of  iliu  fatal  casee  uas  23  yeara^grrater  ihon  that  of  the  auccna- 
fnl  onea.  Ohi'sity.  hIbo,  has  a  very  iinfavurnblc  etfi-ci.  The  depth  of  the 
wound  in  fut  people  adds  to  the  <l'ifficuliy  of  drainage,  and  the  diachargee, 


768 


DKHSIIA. 


if  fillowctl  (odecompoBO,  reatltljr  soak  into  the  lutiporttonal  GcDtlv te^ 
KDil  give  ruu  tu  (lilt'um*  culliililui  willi  flluiighing, 

AcvincNit)  AND  M<>iiiFii'ATioNa  of  rtiE  Oi'kkatioiv. — Tht  mwiilki 
linviug  iKvu  thus  (ivKCiibeil,  we  have  next  to  uuneider  io  detail  RrtuiMi- 
U«iim  atifnilii)^  it,  or  tniKliQimltuii!)  which  tnaT  he  rvt]uired ;  sodiMl^Enk- 
iiitis,  Aruiv  Kuu-riti».  iliH  MaiiHf^mpiit  uf  the  [uteatioe  aooacding  tt  ill 
cuDiliiiiiiiB,  thtf  .MHtmgfiiiKui  nf  Ailhesitim  aaU  of  Uie  OoMOUim,  'WeaattJ 
ibe  Iiiteeliae  ai)<l  nt'  Aru-rie?,  Sliiughiog  of  ibe  Hae,  ArtiScbl  AaH,al 
1-WaI  Ktiilulii. 

Peritonitis  aflsr  Oporation. — ^The  great  danger  tn  be  appr»b«M  iflv 
operations  ttir  hernia  is  the  superventioo  of  tiUffate  pfritonilU.  TUi  mi 
rarely  existtt  at  the  time  of  the  operation.  la  a  coinsiderahle  pniionuaW 
CEBea  it  arises  from  the  iatntduction  of  septic  matter  tutit  the  rmrttj  c4  Ik 
abdomen  frotn  the  wound  either  at  the  time  of  the  operatioo  or  at  a  hm 
period  should  e>eptio  suppuration  take  place.  In  other  cases  it  is  d^fMiint 
upiin  the  omditioD  of  the  cut  at  the  time  it  is  reduced.  Era  if  il  k 
HctuHlly  gangrenous  it  mar  Become  rapidly  surrounded  by  a  flriD  Uttkam^ 
tury  c-xudaliDn  uud  diBuae  intlamriiuliou  may  thus  be  prtrmtad.  Mm 
cummouly  ihie  fuils.  the  inB»Tiiiiiat)uu  extends  more  widely,  tb«  ^outitf  tf 
the  exudation  becuntos  90  great  that  thi-  healthy  part  of  tb«  pwitoBHB 
vuniiot  ab«ijrb  it  (i-iii«  p.^2$,  vol.  j.) ;  septic  change*  tbeo  tak«  ptaoalBtb 
accumulated  Hutd ;  the  irritating  pl^>ducts  itre  ditTused  widely  and  men' 
peritonitis  results.  When  the  gut  is  gangrenoui,  and  probably  if  it  at  ftrj 
acutely  iallumed  as  the  result  of  ao  long  stniDgulatioo,  the  nmiaadiir  ^ 
Hammation  of  the  peritoneum  roar  aaiume  a  septic  form,  th«  infeetion  tauf 
place  from  wiihiu  the  gut  The  nrst  cause  can  be  obviated  by  tkt  wm* 
antiseptics  during  the  operation,  but  it  ia  evident  that  thcM  eta  han  Hk^ 
flucDce  when  the  source  of  infection  comes  from  within  the  gut.  Tbtiyof 
tonu  of  peritonitia  may  asBumo  two  distinct  forma,  being  actmaad  •oiu.ir 
paaaiTO  and  latent. 

Anite  i'eritotiiiia  ia  commonly  met  with  in  atroog  and  roboit  pM|da^Mta^ 
wise  healthy,  who  are  the  uibject^  of  the  operation.  It  preaeota  ilie  «nKMff 
aymptoma  of  scuto  idiopathic  inflamotaiioa  of  th«  periuxneanL  T^mmw 
tendemoaa  of  a  ditfused  character,  with  loadDattng  paina.  Tbe  patieilii 
ou  bia  back,  with  htA  kneM  drawn  up,  baa  an  anxious  oountcBaDce,  •  tfikk, 
hordpulae,  a  dry  umgue,  and  much  inflantinaiory  fever;  tbe  royinumti 
priucipally  iburucic,  and  tympanitis  soon  cornea  on.  The  bowels  are  uaall^ 
ivmstipatcd,  thuuffh  ^metimed  irritated.  Vomiting  usually  furau  a  aaiM 
ayinpuim.  The  Trmtnenl  of  this  form  ia  beat  eoadacled  lir  the  adauiiMi* 
tion  of  opium.  A  pill  cuntaining  fir.  j  of  opium  may  be  given  aftrv  bonk 
or  sixth  hour.  If  the  patient  is  young  and  ttlrong,  gr.  j  of  calooa  AmU 
be  added,  and  toeches,  followed  by  hot  fotoentations.applwd  tu  theaUaB*- 
The  patient  luusil  be  confined  to  barley-water,  milk,  and  ic*.  %'b«  !*■ 
inlUiiiiiiiit»ry  action  in  subdued,  the  oonstipaliun  which  is  occsikiCtfd  hff  it 
will  be  i-elievixl  wiihotit  the  aeve«»ity  of  adininistenag  any  pnrttlivaa.  iW 
lyitipuuitii«  may  best  be  rcmured  by  tur|>cutiue  envtnata,  ao J  aay  lafkiD| 
teudiTUUM  by  the  upplicnliou  of  blisters. 

LnUni  or  J'iutive  I'tritoniiis  occurs  cliii.'By  in  old  people,  or  bl  waaU; 
aubjecte,  and  is  eapeciallr  apt  to  fulk>w  u|N>n  iiitlnminalion  of  tlia  iMMMf* 
and  \\a  ot>niH!(itK-ui  suppuration.  In  other  caaw  it  Mlawa  Uw  radosdM* 
iullamcd  or  gangreuims  guL  More  commonly  It  ia  lh«  omuBOOCOCw  af  ^ 
extension  of  unheallby  iiiflunimation  of  septic  or  inlecUva  ongin  fnoo  Ul 
wound  tu  the  pDrituiicum.  Thta  form  of  inflammation  la  very  apt  ta  i«e' 
in  uTDrcn)wded  or  unhealthy  boapitalB,  and  ia  pravented  by  the  a«tna  i—Wi 
hygienic  iind   local,  ai  pyKOaia,  septicvoiia,  and  the  allied  diteaao.    ll 


KANAOByBNT    OF    CONGESTED    INTESTINE.  769 

vaumllj  proves  rapidly  fatal,  the  patient  being  poisoDed  by  absorption  of  the 
pruduvta  of  the  unhealthy  pnicess  ;  dying,  in  fact,  of  acute  septic  puisonlng. 
In  hi«|>ital  patients  es|>cciany,  iu  U'h<in]  all  discatie  is  apt  to  assume  a  low 
ebsimcter,  thiu  inflamuiatiun  is  [>^utiarly  liable  to  occur.  In  suiue  iustances, 
it  Beui  in  without  the  appearance  of  any  marked  local  symptoms  of  iuflam- 
Bitttiun,  such  as  pain  or  uneasiness  in  the  abdomen  ;  but,  two  or  three  days 
after  the  operatioa,  the  patient  becomes. depresaeil,  with  a  quick  and  weak 
pulse,  an  anxious  countenance,  a  tumid  and  tympanitic  abdomen,  and  rapid 
uokiog  of  strength.  In  the  majority  of  cases,  however,  some  of  the  ordinary 
locml  signs  of  peritonitis  arc  present.  Alter  death,  the  abdominal  cavity 
vill  be  found  to  contain  a  qudntiiy  of  turbid  serous  fluid  mixed  with  flakes 
ftf  lymph  ;  in  many  instances  in  such  quantity  as  to  give  it  a  puriform  ap- 
pearance, and  not  uufrequently  matting  together  the  coils  of  intestine.  In 
the  Trealme»t,  it  is  uecesftiry  to  support  the  patient,  and  in  some  instaucea 
eveo  to  administer  stimulants,  such  as  ammonia,  the  brandy-and-egg  mixture, 
etc  Depleting  measures  of  all  kinds  are  quite  inadmissible:  and,  indeed, 
tbe  remedy  that  offers  the  most  prospect  of  benefit  to  the  patient  is  opium  la 
full  doses,  one  grain  being  given  every  third  or  fourth  hour  until  some  effect 
it  pruduced  upon  the  constitution.  At  the  same  time, 'turpentine  enemata 
Diay  be  administered,  with  the  view  of  removing  the  tympanitis,  which  is  a 
•oorce  of  much  distress  to  the  patient. 

Looalized  FezitonitiB  is  of  common  occurrence.  It  is  not  characterized 
hj  any  very  evident  symptoms  beyond  pain  and  tendernesd  at  some  point  of 
tbe  abdomen  near  the  seat  of  the  hernia.  It  is  must  corairionly  due  to  the 
eondition  of  the  gut  when  reduced,  and  is  often  couservative  iu  character. 
Thas  in  a  case  in  University  College  Hospital,  iu  which  the  patient  died  six 
days  after  the  o{)eration  from  brunchitis  and  emphysema,  the  part  of  tbe 
intestine  which  had  beeen  nipped  was  found  to  be  flrmly  adherent  to  the 
nrroundiug  coils  by  recent  inflammatory  exudation.  Opi>osite  the  seat  of 
•tricture  was  a  small  slough,  about  half  un  inch  in  diameter,  atlectiug  the 
wliiile. thickness  of  the  coats.  It  was  already  piirtly  separated,  and  had  the 
patient  nut  died  from  other  causes,  would  probably  have  been  thrown  off 
into  the  inteetine,  without  fecal  extravasation,  owing  to  the  firmness  of  the 
■orrounding  adhesions.  The  presence  of  the  signs  of  local  peritonitis  are  of 
importance  tmly  as  indicating  the  necessity  of  avoiding  purjcativea  or  even 
cneinata,  until  they  have  passed  nlf.  The  patient  must  be  kept  slightly  under 
tbe  influence  of  opium  to  maintniu  rest  of  the  inflamed  bowel  till  all  ten- 
dcroees  has  disappeare<i. 

Aevte  Cataixaal  Inflammation  of  the  mucous  membrane  of  the  intes- 
tioes,  or  acute  enteritis,  occaiiionally  follows  the  reduction  of  a  hernia,  and 
laar  prove  fatal.  In  this  condition  there  is  profuse  diarrhoea,  commencing 
very  soon  after  reduction.  The  stools  are  diirk-colored  from  admixture  of 
blood.  At  the  same  time  there  maybe  vomiting,  the  vomited  matter  also 
ooutsining  black  shreds  of  altered  bloixl.  It  is  never  stercoraceous.  Unless 
relief  be  obtained,  collapse  txxm  sets  in,  the  tcm|)cr;iture  becomes  subnormal, 
the  extremitiea  l>ecomc  cold,  and  death  ^imn  f  illnws. 

The  TrwUmettt  consists  in  the  uilministrutiun  of  morphia  in  repeated  small 
doles,  with  tbesubnitritte  of  bismuth.  Xoiiiiliil  fiK>d  muft  be  allowed.  Milk 
ud  •oda-wster,  or  barley-water,  or  carelully  prepared  chicken-broth  may  be 
gJTea.  ik-ef-tea  is  apt  to  Increase  the  diarrtiu'u.  Brandy  is  frecptently  of 
■errice.  both  as  a  stimulant  and  in  arrestiiiL'  the  diarrha^a. 

Kanagement  of  Congested  Intestine.— The  condition  in  which  the  c<m- 
teaU  of  the  sac  are  found  in  a  case  of  hernia,  detonntnea  greatly  the  course 
which  the  .Surgeim  should  pursue  after  liivisinn  of  the  stricture.     Must  fre- 
quently the  intestine  is  deeply  congested,  being  of  a  re<ldi&h-purple,  a  claret, 
TuL.  II. — 49 


770 


HERNIA. 


or  chooolite  color.  Tbii  enngMted  Mate  mupt  nut  bv>  conrouatM  vitli  pi- 
greoe  of  tbr  pnrt — a  ini^ake  uliich  might  tiapprn  if  tli«  Homai  vm  \» 
oaDteQt  hiineelf  with  judgiof?  of  the  coodition  of  the  bonel  li;  id  (■)■. 
However  il&rk  tliis  nioy  iw.  the  gut  cunnot  be  mid  tn  lie  ^ograammim 
as  it  ia  iKttisbeil  nnd  firm,  free  from  putrescent  odor,  imd  witboiit •  moil 
lingc.  In  i-OM-s  iu  which  there  io  much  rluobt  M  to  niii-ther  it>  viliiitTn* 
tioucB  or  uot,  it  has  been  proptteei)  to  wearily  ite  BUrfitce  l);{btJy  villi  ibt  pni 
of  a  lancet.  If  blood  fluw  fruiii  the  puucturc-s,  ifau  may  be  laltea  u  a  fnd 
of  iho  cuDtiouaDcc  of  tlie  vitality  of  the  part.  8ucb  a  prac«<liira  «tkk 
however,  in  cortaiul;  aLlended  by  some  degree  of  danger,  and  can  •rLAc*  U 
required. 

Wheu  the  iulf'AtiQO  !■  aierelr  coIl^e»ted,  honever  deeply,  tiw  rule  i*,(lM 
it  should   be  returned  ioto  the  cuvily  uf  the  abduaicu  in   tl»c  kr-i-  -f  r« 
ultimately   recoveriDg.     Thitt  it  will  generally  do  if  it  bave  tuA  ' 
much  handled  alter  the  «utc  ban  been  oitened  ;  DUtio  wrnir  ■— ^  ■'  -.  i.t.-^^ 
a  lew  days  atkr  Jc  has  beeo  reduced,  uii<l,  ihtr  fects  b«'ii)g ' :  tbraMk 

tbe  vrouod,  u  fecal  fistula  nill  be  t'oriued ;  thU  tuay  bnpjicu  ai  lau  ai  m 
eighth  ur  teutb  day  alter  ihe  ii[)erutii'D. 

Kanagement  of' Tightly  Conitricted  Intestine.— Wheu  tbe  islotiM  k« 
bocu  very  tit:htly  uipped  by  u  )>hur[>cd|>;ed  tttricture, »»  liiat  a  deep  mkm 
or  deprt-seiuu  \t  lell  uik>u  it,  it  seldom  recovers,  whether  the  wbtJe'/tk* 
cuil  of  guL  have  l>ecn  ihut)  atK.-cli'd,  ur  only  a  email  porttou  uf  i:a  diaiwitf. 
It  Id  rvmarkublo  hnw  very  (|utck)y  chaagc«  wbirh  are  iQcooipaubU  «U 
life  mHV  eii»ue  in  a  portion  of  gut  that  has  l>een  very  tightly  tiraBgaJairi. 
I  have  liiiown  a  coil  nf  intestine,  that  had  Ihh-ii  hut  etiiht  hourt  ■traa^tiltfed 
before  the  uperatton  was  pcrrfirinc<l,  «o  tightly  (YtnstrK-trd  as  not  to  rifMl 
ita  vitality  after  reductiou  (Fig.  791).     In  ftuih  nwra  the  patieni  imII; 

diee  of  peritonitis  in  tbe  cuune  <if  i  (« 
dayR  withdiii  tbe  b»weU  haviDg  adai 
alt  perietnltic  mntion  havtog  nemarilT 
been  annihilated  at  the  injurfd  iniai 
On  examination  after  deaib,  tbt  em- 
■tricti'd  inlrsltne  will  b*  found  tii  prarH 
all  the  appf^raii'  -^  hnpf 

of  a  btacti  or  a-  wii^stf 

having  Any  tloc<  <  .  pb  dffoiyi 

ui>i>n  lis  (urtHoe.  I  -.Mnayfciia 

nbundAnce'  in    the    i  ■  <i  park 

Fn'ni    the   verj'  unfn-  nm%  ^ 

tboae  meet  in  which  thrr*  baa  br<D  nf? 
light  nipping  of  the  |.r.."-.-;™1  l..»tl.« 
verv  caulioLig  prognu»i  'ij 

ami,  in  rv<lut:ing  tlie  ^^^  * 

uf  tlio  tlrictun-,  rar*  *b"  "* 

not  to  imsh  it  far  back  ioUiinrar*>"«^^ 
hut  to  Ubtc  it  near  the  iaorr  riaf*** 


fe   J^ 


tig.  Ztt.—Otat'*"*  **'  taUallB*  tmm 
Sinafulttiioa. 


that,  in  the  event  of  its  uhitnntely  giving  way,  there  may  be  \em  nifc*' 
feculent  extravuaiitioa  inu>  ihe  peritoneal  rnviiy.  In  ihnae  casts  ia  «t«ck 
the  nipping  baa  been  very  severe,  tbe  suIcuh  In-ing  distiodlT  aiaffcvd.w' 
tbe  iotestino  excenivety  dark  and  congr»<ti>d,  though  not  actually  pttgnnMa 
it  would,  I  think,  be  better,  ufler  dividing  the  ntricturr,  to  leave  ib*fal«^ 
aide  the  ring  tlinn  to  return  it ;  the  reduition  of  ioteatiDe  in  tbla  tfata  bdiC 
aliiinat  Invariably  followed  by  fatal  peritonitis. 

It  ia  important  t(>  obaerve  that  it  is  not  atwars  powibl«  to  letl  lartDi^ 
whether  the  gut  ia  pant  recovery  or  not,  for  intestine  vhidi  baa  been  mmiwf 


HANAOKUEVT   OF   OAXOREyoUS   INTESTIXE. 


m 


Dipped  may  not  be  tiMe  to  rpcover  ite  vitality,  nnd  witl  Tali  into  a  state  of 
BangreDCfifttr  being  nKlucedjUnd  may  not,  at  the  time  of  iucx|>r«iirc,  present 
the  characlere  of  putres-ccuee ;  thero  ia  no  fotor,  no  green  or  pulpy  appear- 
ance,  no  Iom  of  polii»ti,  uo  acpamtiun  ot'  peritoneum ;  it  is  simply  nt'  a  dark 
purple  or  niaronc  color,  and  that  it  has  been  lightly  nipped  is  evident  from 
the  sulcus  upon  it.  Thurt- arcnosi^iiB  of  gimgrune.  ainiply  bceausfl  nuflBcieol 
time  hai  not  elapsed  fur  piitrefiiotjuu  tu  set  in.  As,  when  a  pile  or  lurvuB 
has  been  tied,  though  vitality  lie  extinct  in  the  part,  which  in  !iw(i]|«>n  and 
purple,  some  time  must  elap»e  before  signs  of  pulresrence  niHuifc«t  Ihem- 
Mlve^,  Ml  it  may  hci  with  a  !(tric(urt<)  f^iil  which  has  ti>»t  iLi  vitality. 

Kaoag-ement  of  Qangrenoiu  Intestine.— When  the  intenline  i»  aetuatly 
gan^^renous,  the  iotegumentfl  covering  the  tumor  will  be  inKltmted,  brawny, 
and  duskily  congested,  aud  the  Htructures  imineilialely  overlying  the  tutc 
malted  tOf^ther;  the  «ac  will  contain  fetid,  dark-coloreii  .«erum  or  puB  ;  and 
the  aofteoed,  lacenible,  or  pulpy  UhiIc  of  the  protruded  part,  ilH  Ki»n  of  lti»lre, 
and  iieculiar  greeoiah- black  or  dark*^ray  coEor,  witl  oiuse  the  uatufe  of  the 
miBchief  to  be  readily  recoguiMd.  In  the  majority  of  cases  there  will  bo 
much  coostitutiooal  deprewion,  and  clnniniy  gktu.trnipaoitie  ahdoiaco.and 
brown  or  black  tongue;  but  in  Boiue  iuBtflnces  I  liave  knowu  all  theee 
ayniptoms  to  be  absent,  and  the  condiiitju  of  the  patieut  to  prc'Wi'nt  uo  very 
unfavorable  slate.  Suuie  dtlfereiice  of  opiuiou  L-xiela  an  V>  thu  proper  line 
of  practice  to  be  adopted  iu  Buch  eases.  Travtni  aud  Lawrence  hccui  to 
think  tliat  the  division  of  the  (Stricture  i«  uuneces»'Hry,  or  uiay  even  be  luju- 
riouB ;  while  Dupuytreu,  A.  CVioper,  nod  Key  (with  whom  I  eoueur  j  advitc 
that  it  should  be  doni.- :  that  the  stricture  slionld  bu  divided  in  the  usual 
way;  that  a  frei;  iueiiiidii  Hlnmld  then  bi;  made  into  the  pnitruded  portion  uf 
bowel,  wbiL-h  niubt  be  left  iinredueed,  ihi  as  to  all<iw  the  weapo  of  fe«t;  and 
the  wound  left  open  and  rovered  liy  a  poultice.  In  tlili*  way.  an  artificial 
auua  will  necessarily  be  formed,  throtigh  which  the  feculent  malttT  (inds 
exit-  The  gut  in  the  vicinity  of  the  stricture  ia  retained  in  hUu  by  niasst-s 
of  plaistic  exudation,  which  prevent  the  peritoneal  cnvity  from  being  opened. 
If  the  inteetine  should  already  have  given  way  before  the  operation  is  per- 
formed, the  stricture  muse  be  dividal,  and  the  part  then  \eh  unredni-ed,  care 
Wing  taken  to  interfere  as  little  as  possible  with  any  Hdhe.'tiona  or  oonnec- 
tiouB  lying  inside  the  neck  of  the  sac;  though  I  fully  agree  with  Key,  in 
thinking  that  the  danger  of  disturbing  them  bes  been  exaggerated. 

When  a  small  portion  of  the  bowel  only  is  gangrenous,  the  better  plan  is 
to  return  it  just  beyond  the  nioutb  of  the  sne,  without  laying  it  open;  but  it 
ilhould  not  be  |>u0he<l  any  diHtance  iutu  the  aivtty  of  the  abdnriieu  ;  ihe 
pressure  of  the  surrouudtng  piirts  will  prevent  t;xtruvii(>i>lii>ii.  Wlion  the 
sloUgb  eepftriik':^,  it  will  probably  be  dii!<.-liurgvd  iutu  the  cavity  of  tliv  iules- 
tine;  and  the  iii»frture  reoultitig  will  be  closed  by  the  adbesioua  that  extend 
between  it«  miir^iu  and  the  nbdouiiaal  wall. 

During  the  last  few  years,  the  operation  of  removing  the  gaugrenouB  por- 
tiou  of  the  got  and  uniting  the  ialeatine  by  suture,  on^iually  perforiueil  by 
JMefTenbacbiin  iHIJfi,  has  been  revive*!  and  repeatedly  ptrforniKfl  by  Hillroth, 
Czeniy,  Juilt&rd,  Madelung,  K.  Parker,  and  others.  Juillard,  in  1^91^,  pul>- 
lishe*!  44  eases,  collected  from  various  sources,  in  which  thin  operntiou  had 
been  performed  ;  of  these,  'I'i  died.  These  results  contrast  unfavorably  wilh 
those  of  the  same  operation  performed  for  the  relief  of  an  artificial  aiiuti  or 
fecal  liiitQla,  of  which  Juillnrd  records  2'i  cases  with  -^  deatlis.  lie  therefore 
recommendii  that  iu  all  eas€«  the  gut  sbuulii  first  be  treated  as  above 
dc»cribe<l,  nud  the  ullcmpt  to  unite  the  ends  delayed  for  two  or  three  weeks. 
By  this  time  the  patient,  if  he  survive,  will  have  gained  strength  ;  the  feval 
accumulation  iu  the  upper  part  of  the  gut  will  have  been  relieved,  and  the 


HBBKIA. 


opcrntion  will  altogcllicr  bo  jwrforrocd  under  more  favorable  circumstances. 
If  the  attempt  tti  remove  the  ^ungrcnoun  gut  be  made  at  the  time  of  the 
operatinn  for  rtlitf  of  atrangu latum,  the  conditiou  of  the  surrotindinR  parte 
is  in  nuiDV  cases  most  unfnvorablo,  dilfuftp  iuftaoimadun  olU*ii  exti'udiDg  for 
many  iucbes  armmd  the  sac.    Under  such  circumtiAncea  the  remora)  of  the 

Orenoua  gnt  would  evideutly  be  out  of  the  question.     The  operation  will 
eacrilwd  »uh»equeutly  with  removal  of  purlinua  of  the  gut  for  other 
cauiied. 

Hana^ement  of  Adheuoiu.^Thifi  varieii  aecording  lo  the  condition  of 
the  Ixiwt;!,  aiul  the  nuture  nud  HJtuatioii  of  the  bands.  A*  has  just  been 
rcinarkecl,  if  gangi^ne  be  prettent.eitpecial  care  must  be  tnken  nut  tn  disturb 
Any  c(>nnerti'in.>t  lliut  Imve  liei'it  torniptl  aliout  the  ueck  of  the  sac,  and  which 
conatilute  the  moitt  ctlW-ttml  Imrrier  B^aiii»l  feculent  extra vesatiuu.  When 
the  adhe.>)iim)i  Hre  rerent,  conKi^lin^  merely  nf  plaglic  matter,  in  whatever 
Ritualiiiu  they  exist,  they  may  readily  be  broken  down  with  the  fiiigeror  tht 
httodle  of  the  scalpel,  and  the  parts  iheu  returued.  When  of  old  elandibtf 
aud  deuse,  they  must  be  dealt  with  according  to  their  cunnectioDS.  Murt 
frequently  these  ad hcaions  occur  iu  the  shape  of  thickened  band?,  situated 
within  aud  Btrctching  acroex  the  neck  of  the  bbc.  Iu  other  cases,  they  may 
be  found  either  as  llTameutuut!  bauds,  or  as  broad  ttttnchmtuUi  connecting 
the  sac  with  its  contents,  aud  perlm|>s  tyiuy  llifte  together.  When  of  a 
narrow  and  constricted  form,  and  luorc  parlieulnrly  when  seated  in  the  ueck 
of  the  sac.  or  streicbiug  like  bridit*  acroja  ita  iutvriur.  they  may  readily  be 
divided  by  n  pr">bt'-puiuu<l  bistoury,  ur  the  beruiu-kuife.  If  they  cousist  of 
bruad  altachmentJ^,  they  niny  be  dissected  away,  by  a  liltte  careful  manipu- 
lation, from  the  purtti  iu  the  iu^id*'  of  [be  tav;  though,  if  the  adhesious  be 
very  extensive  aud  of  old  standing,  it  may  sonietinies  be  mure  prudent  tn 
dissect  away  that  portion  of  the  sac  which  is  in  connection  with  them,  or 
even  to  leave  them  untouched,  and  ihe  adherent  inteetine  or  omentum  unre- 
duced rather  than  to  emteavrir  to  separate  them.  They  may,  however,  attach 
ihemselves  in  such  situations  that  it  becomes  necessary  lo  divide  (hem ;  thus 
I  have,  in  a  case  of  congenital  hernia,  found  it  necrasarj  to  diFsect  away 
BOme  very  exteneive  and  wbltly  spread  adhesiuna  that  had  formed  between 
the  omenlum  and  the  testicle,  and  indeed  had  almost  completely  etiveloped 
that  organ. 

Internal  Adhetion»  bftwei-n  the  omentum  and  intestine  or  mesentery  orca- 
stnnnlly  exist,  consisting  usually  of  rather  iirm  bands  stretching  across  from 
onr>  part  to  the  other,  sometimes  connected  with  the  inner  wall  of  the  sac, 
but  111  otlier  eaM«  confinetl  to  its  contents.  A^  these  bands  may  constitute 
the  refti  »tricture,  continuiug  lo  etraogulate  the  gut  alter  the  division  of  the 
slniclures  outside  nud  iu  the  neck  of  the  eac,  tliey  miisl  necrH>»rily  be  di- 
vided. Tliis  operation  r«<]uir«»  great  csre,  lest  the  ueighhoring  iiite»Iiiie  be 
wounded.  It  is  best  dune  by  pm^sing  n  director  underuealji,  and  cutting  the 
bands  thmugh  with  a  probv-puiutefl  bistoury ;  or  if  this  cannot  be  done  on 
account  ot  their  coouectiuns,  tbey  must  be  seixed  with  forceps,  and  carefully 
ditsected  ufl'  the  gut.  In  a  case  of  large  inguinal  hernia,  etmlniniog  IwlU  gut 
and  omentum,  on  which  I  operated  some  years  ago,  1  found,  aHcr  dividing 
the  Mlrictorc,  aud  taking  hold  nf  the  omentum  in  unler  to  push  back  the  in- 
testine, that  this  could  not  bv  re^luced.  4Ju  searching  for  the  cause  of  diffi* 
culty.  aud  druwiog  the  mars  well  down,  I  fuun<l  high  up,  in  the  part  cnrre- 
spoudiiig  to  the  neck  of  the  sac,  a  narrow  band,  like  a  piece  of  whipcord, 
eiretchiiig  acn.'SB  from  tlie  omentum  to  the  mesentery  and  tirmly  tying  down 
Ihe  gut.  Uu  disecctiug  this  carefully  (hroueh.  the  cont^lricled  portion  of  in- 
testine Fubjacent  to  it  spmng  up  to  its  fuU  diameter,  and  was  then  very 
readily  reduced. 


SACS — CYSTS.  778 

Kmagement  of  Omentmn. — The  omentum  may  require  to  be  treated  in 
one  of  three  ways:  1.  It  may  be  returned  ;  2.  It  may  be  left  in  the  sac; 
3.  It  may  be  cut  off.  The  loethod  of  treatment  must  vary  according  to  the 
•Uteio  which  the  omentum  is  found.  If  it  be  small  in  quantity,  healthy  id 
ektrscter  though  congested,  and  apparently  recently  protruded,  nut  having 
udereoDe  thnee  changes  that  occur  in  it  when  it  has  been  a  long  time  in  a 
iKntial  sac,  it  should  be  reduced  afler  the  intestine  lias  been  put  back. 

If,  however,  ita  mass  be  very  large,  if  it  be  liypertrophicd,  indurated,  or 
otherwise  altered  in  structure,  or  if  it  be  closely  adherent  to  the  sac,  at  the 
nme  time  that  it  is  congested,  Surgeons  are  agreed  that  it  hIiouM  not  be  re* 
toned  into  the  abdominal  cavity ;  as  inflammation  of  it,  Epiploitis,  will 
pnbabty  set  in  and  terminate  fatally  with  effusion  into  the  peritoneal  sac. 
SoiUo,  if  the  omentum  be  in  targe  quantity,  and  have  become  inflamed  in 
Uienc,  it  should  not  be  returned  ;  as  the  inflammation  in  it  is  very  apt  to 
no  00  to  a  kind  of  sloughy  condition  of  the  whole  mass.  If  gangrenous, 
itriiould  certainly  not  be  reduced.  When  simply  hypertrophied  and  adhe- 
KBtto  the  sac,  but  without  evidence  of  inflammation,  it  may  be  lefl  in  the 
«c;  but,  in  many  of  the  cases  of  hy|>ertniphied,  and  in  all  cases  of  inflamed 
or  gangrenous  omentum,  the  best  practice  consists  in  cutting  off  the  mas^,  as 
rwommendeil  by  Sir  A.  Cooper  and  Lawrence.  If  it  be  left  in  the  sac,  in- 
Itinination  or  sloughing  of  it  will  occur,  and  the  patient  can  derive  no  cor- 
npundiog  advantage  to  the  danger  he  will  conaei[uently  run.  Ezcition  of 
Ike  mass  may  be  best  done  by  enclosing  the  neck  in  u  ligature  and  then  cat- 
tiBX  it  off  below  this.  The  ligature  may  be  of  carbolized  catgut  or  tine  car- 
bolned  silk.  If  the  mass  be  large  it  is  better  to  divide  it  into  several  pieces, 
■ltd  to  tie  each  separately.  The  ligatures  are  then  cut  short  and  allowed  to 
Ktraet  with  the  stump  of  the  omentum  into  the  abdomen.  If  the  omentum 
ktiMiffered  much  from  the  strangulation,  it  must  be  drawn  well  down,  so 
tlol  the  ligatures  may  be  applied  to  a  healthy  part.  If  carbnlized  catgut 
viilk  be  not  at  hand,  a  strong  double  ligature  of  whipcord  or  silk  niurit  be 
PiMd  through  the  neck  and  tied  securely  on  each  side,  the  moss  below  then 
Kioft  cut  off.  Aa  a  ligature  of  thia  kind  might  become  a  source  of  irrita- 
JKH)  if  it  were  drawn  into  the  peritoneal  cavity,  it  must  not  be  cut  short,  and 
■beDrlB  may  l>e  secured  to  a  piece  of  plaster  on  the  forepart  of  the  abdomen, 
to  prevent  retraction  of  the  stump  of  the  omentum.  I  have  frequently  cni- 
ployej  this  plan  with  excellent  etfl-ct.  The  cunstricled  stump  of  omentum 
ilooghs  away  in  a  few  days,  and  separates  wiih  the  ligature.  When  this 
PfWice  is  adopted,  the  w<iund  should  nut  be  closfd.  ami  must  t)e  lightly 
O'Wed.  The  ([uantity  of  omentum  that  is  cut  ofl'  varies  cnnsidvnibly ;  the 
^Xa  removed  usually  weighs  from  four  to  six  ounces,  l>ut  in  some  ingtances 
It  may  amount  {■>  a  pound  or  more. 

Sa(*nr  Apertures  are  occasionally  formed  in  the  <mientuni,  in  which  a 

Knuckle  of  intestine  mnv  become  oiiveluped,  or  by  the  miirgiii»  of  which  it 

litr  Ite  strangulated,     'these  envelopi';)  of  omentum  arotiud  the  gut.  which 

k»ve  been  especially  described   by  Sir  1'.  Ilcwetl,  miiy  occur  in  all  kinds  of 

Wmia.  at  letist  in  the  itigutonl.  the  feiii'inil,  :iiid  the  uDibilical,  and  somc- 

ttmcs  aLtjuire  a  large  size,  completely  shutting  in  the  got.     They  iip|)car  to 

hefiriiietl,  in  some  eases  at  leawl,  by  the  adlietiion  nf  the  i)]ip.isiie  cdgus  of 

flnatiog  layers  of  omentum  nrduiid  a  pii'ce  of  intestine,  whicli  thus  becoiiics 

included.     It  ii*  of  importance  to  lK>ar  in  miiul  thi>  pos^sitiility  of  thi-ir  exist- 

euce,  and  in  all  cases  to  unravel  iIh'  oincntuni  lit-lori'  rem  iving  it.  lot  it  con- 

Uio  a  knuckle  of  intestine,  which  niii:ht  be  wonn<U-(I  in  the  operation. 

C^U,  usually  containing  pcllufi.l  scrouii  tliiitl.  struw-colnred  or  redilenecl, 
bat  sometimes  Hlled  with  blood,  aro  oecasionaliy  met  with  in  the  omentiiiu. 
Ther  appear  to  be  formed  in  the  !<ame  way  as  the  sacif  containing  interline 


774 


HSRNIA. 


juit  dcflcribcd,  except  that  tltoy  are  eoclused  oo  all  side*,  ibrir  man  a» 
lentB  bc-iug  niortly  eiudatiuu«  iWin  the  pcritonenl  liniof  of  the  enL  Aif 
are  ^'lobiititr,  clnstio.  and  doselj  re^mblc  in  form  m  MudOe  of  ImiIm, 
uooH!tiouiu>;  uui  u  little  embarranmcut  to  the  Kurgcun  ;  by  a  cftnAd  emu- 
natiuD  and  uuravt-lling.  howover,  of  the  Mncutuiu,  tbtir  inie  utni*  «fll  U 
inado  out;  their  fluid  contents  may  then  bo  discharged,  and  Ummbmub 
deall  with  arronlitijt  Cti  the  rules  already  giveu. 

Wonnds  of  the  biteatine  may  accidentally  occur  at  iwn  perind*  of  Ibt 
operatiim ;  either  from  the  Surgeon  ctittinj;  tw)  frc«ly  duvo  tipoa  lh«  ■w.aid 
op«niii;r  this  before  he  is  aware  of  what   he  is  alKitit ;  or  eUv,  at  ihc  tint  tl 
the  diviition  nf  (h«  stricture,  fnim  a  tK>rtii.>D  of  the  t>tit  nhich  lie*  beooMliit 
Keltii)):  iiito  the  way  of  Ihe  trdye  of  the  kuife,  nod  li«-ii; 
hnit  kind  uf  Hccident  can  JiH|>pvt>  oidy  fmiti  n  certain    : 
but  it  vi  nut  always  su  ea»y  tu  uvuid  woinKJiug  the  ^ui,  ntuji  lUc  airk.'UiL  ii 
DO  light  thai  the  linger-oiiil  cjinnut  be  slipiKil  un<ler  it  ««  n  ;:ni'tt-  in  t^-  fcr?- 
nia-kuife.     In  caaes  of  thti*  kind,  a  very  narrow  dins;^Jr  i: 
ihia  is  a  mo»t  dangerous  in^triimvni.  us,  iu  jiasfeii)^  it  <1- ' 
uudcr  the  tight  etricture,  a  siuull  jK>rliiin  of  the  i£iit  may  curl  u; 
int4j  tho  griHivc,  Hiiil  thus  become  notched  by  the  knife  as  thij  . 
it.    Thift  nccidenl  huH  baiipK-'ni^l  to  the  beet  and  niual  carefiil  Sarvmxu.    La«- 
renre  rtdalea  two  cases  Inat  uccurred  to  him ;   aiid  Sir  A.  C«oprr,  Cl«|i*. 
Jobert,  and  Ijston,  have  all  met  with  it.    It  may  be  kuuwo  tn  havvurrumd 
by  the  bubbling  njt  uf  a  smiill  quantity  of  flatus  and  li(|uiil  fma  frua  U» 
bottom  of  the  incitiion.    The  IVrattumt  of  u  wound  of  the  f^t  muM  dtftai 
n|>oi)  its  size.     When  it  is  verv  small,  rteembling  ■  pimctuir  nthrt  tba* 
cut,  the  praclice  recoromendeif  by  Hir  A.  Cooper  should  be  silopied ;  tij;..  W 
teiie  the  margins  of  the  iDcisinn  with  a  pdir  of  furreiM.  and  tit  lie  a  fiar  lilL 
thread  tightly  around  them,  the  endsof  inhichfihoiild  then  be  cutoftaailiW 
gut  rcinrncd  into  the  abdominal  cavity.    Such  a  prmvetltng  at  ik'n  iamtH 
ap|>car  to  give  ri^  to  much,  if  to  any,  increase  ol  ilanv^r.     In  ■  am  ihH 
o'vurred  to  me  many  years  ago  at  the  Himpilul,  in  which,  owiog  Ulka* 
ces»ive  li^hlneM  of  the  stricture,  a  very  narrow  dirf-^tor   only  omU  bi 

Eaned  uudei  it,  the  gut  tmmedimelr  alnive  il  w»>  oolclml  aod  oMsedhM 
ind  of  piinctunsl  wound  ;  this  wok  tied  up  in  the  wny  mentiooeil,  asil  Mm 
the  death  of  the  patient,  which  took  place  ou  the  fourth  day  ■fb>-T  thf  nfirr 
tiou  from  gangrene  of  the  strangulaletl  portion  of  tMiwel,  tbr  aiik  tit*w* 
was  found  to  be  completely  enveloped  iu  a  mane  of  Srm  plutic  riiMUti* 
If  the  Wound  l»e  of  larger  itiite,  it  must  lie  cl>M>ed  by  Lcnib«rt'«  •uur»  rn  Im 
manner  dcgcribeil  in  the  chapter  on  Wounds  nf  the  Intf^tine  p,  M*2,  ril  t ! 
The  gut  niuBt  be  very  carefully  cleaned  with  some  anliseptio  ■olatvM  krf^ 
being  returned. 

Wound  of  one  of  the  Arteries  in  I  he  neighborbom)  of  the  no  ■'•tm^ 
duriug  the  division  of  the  stricture,  either  in  consequence  of  t>ytn*'  »*»«■«' 
iu  the  distribution  of  the  ve8»?l,  or  fn>ra  the  Surgeon  dividing  * 
wrong  direction.     This  accident  usually  bappooa  lo  the  epiga<-: 
obturator  artery;  and  Lawrence  hajB  collected  fourtccD  monlad  *■*" 
which  it  occurred.    The  rueult  in  these  hiis  been  verv  variooR:  ia  •ob*'* 
pattenu  have  died;   in  others,  after  much  los>  of  blood,  and  uuim^i* 
AiintneM,  the  bleeding  ceasefl  Bpontaovously.    The  proper  TimlmmUmj* 
certainly  consist  in  cutting  down  upon  um)  securing  the  bleediae  xm^  ^ 
the  event  of  the  Surgf4>ii  operaliiig  on  a  case  of  hcniia,  wiihoal  UfiB(  t** 
able  previouRlv  to  satisfy  himself  aa  to  its  precipe  character,  or  if  frnDi'.' 
CHUM,  in  dtvidiug  the  stricture,  he  have  reaaon  to  dread  the  prt^xinitT  'i  ** 
artery,  he  miiy  rairly  and  readily  divide  the  cou*trietion  with  a  knifr  i^ 
would  not  easily  cut  an  artery ;  and  he  will  find,  if  he  blunt  tb*  ttigt  of  t" 


ARTIFICIAL    ANUS — PATnOLOGY. 


775 


hernia-koife  by  drawiu;;  it  u%-er  llie  bai-U  nf  titu  scaI[Ht),  that  it  will  still  b« 
keen  euuugh  to  relluvu  the  i>Lraii),'ii(ati(>ii,  wliibt  it  will  puii])  belure  it  aay 
artery  that  iimy  hapiwa  to  he  in  tiiu  way. 

Sloagtung'  of  the  Boo  is  »i'  rare;  o(.-ni  rreiico,  aiitl,  wheit  it  happens,  is  cdiq- 
tuonly  uILi'uiIimI  hy  fatal  rt-Kultri;  it,  h  not.  hnwever,  ueceasnrily  so.  It  has 
ivi  \cc  hupin-netl  in  tny  practice ;  ami  in  hixh  OLHes  t\w.  patieut  rucoverod.  In 
an  old  WDrnnii  im  wiiom  [  opi?mleil  for  femoral  heriita  of  very  liir^  aize,  tho 
HLC  uluughi-d  awav.  i'xpot^ing  neArly  the  whole  of  Srarpii'i)  triangle  with 
atiiitMt  as  tniich  (iiKtinctness  aa  if  it  had  been  diasectetl ;  but,  ulthuii^h  in 
much  danger  for  h  time  from  an  acute  attack  of  perttonitia,  she  ultJiuately 
reoiiverpd. 

Axtiflci&l  Anns  aad  Feoal  FiattUa. — When  an  apertnre  exists  in  the  bowel 
by  which  the  whole  of  theinteBtinal  contents  escape  extetraliy,  ihe  condition 
is  dentiminnted  an  aHtficiat  amis.  When  hut  a  small  portion  ao  e8ca[>ee,  the 
greater  part  finding  lu  vay  through  the  natural  anus,  a  ftxat  JUhila  is  said 
to  exist  The  nuantity  of  feculent  discharge  ueceeaarliy  depends  upon  the 
extent  of  the  ae«trucliun  of  the  inteAliual  coat« ;  and  \la  character  on  the 
pnrt  of  the  gut  that  in  injured.  The  escape  takes  place  involuntarily,  and  U 
usually  continuous, 

Tliimconditiuu  may  itcciirin  several  way^  Thus  thi>  gut  may  he  accidentally 
wouudctl  duriut;  Che  operation,  and  the  fvcei  may  alU'rwunls  continue  to  he 
<lisrhar|fetl  Ihruugh  the  aperture  i<(»  made;  or  it  may  have  been  gangrenous, 
and  have  given  way  into  the  sac  before  the  operation  ;  or  the  fiurgeun  may 
have  iutenlitmally  laid  open  a  gangreuous  porttou  of  iuteatine,  «ii  as  to  facill* 
tale  the  eHcape  of  the  feces.  In  eunie  cases  in  which  the  bowel  has  been 
severely  nipped,  ttnd  is  dark  and  congested,  though  it  have  not  H<^^tually 
falleu  iutu  a  state  of  gangrene,  it  may  not  be  able  to  recover  il«elf  afier  its 
returt)  iuto  the  abdutninal  cavity,  but  will  ^ive  way  iti  the  course  of  three, 
four,  MX,  or  even  ten  days  ufttr  the  operation.  Id  these  qbsks,  a  small 
quantity  of  feculent  matter  ie  Brst  observed  in  the  dressings;  and  gradually 
a  greater  discharge  appears,  until  at  last  the  li&tulotie  opening  is  completely 
ealublished.  In  such  cuiies,  it  is  of  impon&ace  to  observe  that,  although  the 
bowel  givefl  way  within  the  pcritoucal  cavitv,  the  feces  do  not  become 
extmvBsated  Into  this,  hut  csc'}t|>o  uxternally.  This  important  eircumslaocc 
is  owing  to  the  fact  cff  tht;  portion  <it'  the  bowel  that  is  nip|>ed  losing  iljt  peris- 
taltic action,  and  cousefjucptly  remuiuitig  where  it  is  put  back ;  whilst  the 
parte  in  the  ueighburhood  iuflamc,  throw  nut  a  cimgulable  exudation,  and 
beoome  consolidated  to  each  other  und  to  the  parietal  peritoneum,  so  as  to 
include  the  gangrenous  portion  of  the  gut,  ami  coinplctcly  tu  circumscribe  it. 
It  (H  cunse(|uently  of  great  importaure,  in  caws  of  thia  kind,  not  in  any  way 
to  disturb  the  adhesions  that  have  formed  bctwccD  the  sides  of  the  aperture 
in  ihe  gut  and  the  neck  of  the  sac. 

The  /'o/Ao/oyy  o/vlrd/ciW/lfKW  is  commonly  aa  follows;  The  edges  of  the 
aperture  in  the  gut  become  tirmly  adherent  to  the  abdominal  wall;  and 
whether  the  whole  or  a  portion  <jn]y  of  the  calibre  of  the  intestine  lie  rleatroyed, 
the  apertures  of  the  upjier  and  lower  end,  though  at  first  Iving  alnin.it  in  a 
continuous  line,  soi^n  unite  at  a  more  or  lesA  acute  angle.  These  are  at  first 
simitar  in  size,  and  present  no  material  riitferenoes  in  shape  or  appearance: 
ftA  the  diiiea^  becomes  more  chrnoic,  they  gradually  alter  in  their  charactent; 
the  lower  aperture.  I>eing  no  longer  used  for  the  tranmmi&iinn  of  fece^,  grad- 
ually becomes  imrrower,  until  at  last  it  may  be  almost  completely  obliter- 
ated ;  whilnt  the  upfier  jjortion  of  intestine  becomes  dilated  in  consequence  of 
there  being  UHiiatly  sume  slight  obstruction  to  the  outward  pasaage  of  the 
fec«.  The  mesenteric  portiou,  opposite  the  aperture,  becomes  drawn  out 
into  a  kind  of  prolongation  or  spur,  tbe  full  Iiuportance  of  which  was  Brat 


776 


BEBNIA. 


pointed  out  bv  Dupuytreo.    Thi»  Bpur-lik«  prooew  pr*.I*.'r»  1->iwm«  (W( 
HiwrLurv*,  itu  J,  beliif^  (IvSected  by  tiie  |)«LS8ag«  of  I  lie  r  u  lut  i  («»- 

i)eiii;y  to  act  m  a  kiud  uf  vnlve.  nnd  tliiu  luuccludn  tlu:  v>iii.<  v  .i^Lo  Uit  !<)«« 
[Mirtioii  uf  th«  gut.    Tlie  iuti-);unii:im  iu  the  ueigiiburbuiK]  ufauch  inRivrun 
ta  thiR  utiii»]ly  btddinc  irritutud,  iriltanicd,  and  excoriutcd,  fruio  tbc  owimi 
psfi^np^  i»r  tti(-  fvve*  uvvT  iliL'iii.    In  eotuo  iMsax,  thn  luuctiiintnrmlinuivltsiaf 
the  e<lgeB  beouinra  everted,  iiud  ptiultn^;   und,  in  »tliere,  n  tni«  pnili^if 
the  gtit'lnkpB  place,  lur^'i!  |H)rti»uH  priiLrii<liii)f.     Au  nriiticUl  anw  hilh 
formed  in  thie  wny  never  undtreiwa  P|Mi»tiinc(.iiB  eyre.     BnrJdn  ihut  •hici 
is  the  ordinarr  romi  uf  artitirtnl  niiit^.  we  nniRl,  I  think,  roc«if^iii>  «i  Iwt 
two  other  varietim,  hiith  of  which  I  hiivr  met  In  prBClicf.     In  onf  of  tlinr, 
the  anele  formed  by  lh«  gut  i^  iidhen-nt  lu  the  tipper  MtrcraitT  of  tbtut 
which  nu  been  FCtiimed,  and  thus  lies  at  some  distance  ^tm  the  wir1u>,N 
that  the  feeni  matter  traverses  a  iimg  canal  before  it  michM  the  pstrnil 
aperture.     In  the  other  variety  the  angleof  ihf  gut  is  fixed  atahiKher  iwoal 
within  the  abdomen,  and  the  ffc&s  find  their  way  out  tfantogh  a  dtuatl 
bounded  by  n^lutinated  onlis  of  intestine  aud  layers  of  lymph,     Id  hotkaf 
thi«e  l<jrm»,  there  Un  cottsiderabtc  digtance  Iwiu'i-un  Uii*  eslernsl  >-■  .:---■' 
th*  aiHTHirc  hi  the  gut.     Thus,  then,  ihert*  are  ihn-e  f'»rni»"f  ai' 
dtfl^ril)^  frnni  >>ne  auother  acconliu};  to  the  BittiatioD  id  tbt*  OD^Ie  iJ  \t"  ^y- 
io  rflalion  U*  the  external  o|H-nini;aud  to  itfl  conuectiona. 

When  a  Fefol  Fittufn  ha»  furrrie<l,  ti)«  eoudiliuu  i>f  llie  part*  i»  MAieiilut 
diflerenl.  Th»  aperture  in  tlu<  iuteetiue  cuuai»t5  of  nierely  a  ama'l  pcrfimtixD 
in  itq  coala,  una(t«ud<^d  by  any  cuusidvrable  lum  of  vulwtancw.  thrtnigh  a-bidk 
a  'luaolity  uf  ihin  fei-uleut  mattvr  exudw,  giving  rise  lu  a  giMKl  dcml  of  trrita- 
ttou  (if  ueigbboriu^  ntruclurnk  lu  sooie  caaea,  there  are  wvcnU  anertiun 
cuniniunicattng  with  the  gut,  and  extending  tfannigh  the  akio.  FiAoloa 
o{>eQiDg9  nf  this  kind  nut  unfrequeotly  uudergu  spuotaueuitf  cura  aftef 
exiHting  for  a  few  weeks  ur  mouths. 

TreaiuienU — If  the  auerlure  he  merely  a  aiuall  one,  with  a  iuutoh  &uW 
leading  into  the  gut,  ine  chief  infonveniunce  pufltired  by  the  yn---—  '>■[« 
arises  from  the  irrilatjim  of  the  5k in  arouud  theoprniu;;  by  il  r<j 

moisluro  of  the  fe^inleut  ninller.  In  such  <^^im«  the  ekin  ahimld  ix  nr-t'YuJ 
hy  ncMis  of  xlnc  itlnlmeul  or  eucalyptus  oil  and  viueliue  upread  mi  list ;  tJti 
the  potient  sh'tuld  wear  a  jwid  tn  reBlmiu  the  dieehurptt.  By  tli«  pre«an«f 
this  pjul  (ho  tt|ienure  may  eiometime^i  be  tiiado  Xn  chwe.     Id  '>ih^r  eaam,  tlw 


'  ri»tiMt 

wck 

<-rv*iT'«Ul. 


occB^iouul  applit-atioD  of  the  fralvniiie  cautery  or  uf  a  rril  h><' 
'ennlraeti>>n  of  it^  edges;  and  in  oilier  instanoes,  a^in,  n  pi 
some  kind  may  be  required.  But  1  coofi!-^  I  linve  n 
advaiitagD  result  from  such  o^>cration8.  which  are  oltrn  I 
Aa  theexistencc  nf  an  ariiticiitl  anus,  by  iiiterffrini;  with  uutriti' 
givta  rise  lo  cohaiderable  emaciation,  it  l>«comes  nec<-*>:irv  \, 
nalieut's  ktrengtb  by  a  sufficrcnt  quantity  of  gfxkd  aud 
ts  uf  iircater  consequeuce  the  higher  the  Ibtula  ia,  n»  iht  ...;. ... . 
Mrlicr  stage*  of  the  digestive  pruces^,  and  the  luas  of  iiutritivt-  bai 
the  discharge  of  the  chytne,  is  proporliMnately  great.  8pontao«<>us 
occasionally  Lake  place,  even  though  a  perfect  arlilicifll  anus  exiaL  loaiaw 
under  my  cure  at  the  Hospital,  a  whole  knuckle  of  iutestioawu  gmognMMi^ 
and  sloughed  away,  leaving  an  arliticial  nuus,  which  dtackamd  the  i^iwlar 
part  of  the  intestinal  contents,  but  gradually  cxotractcd  aoaeleaail  witboit 
unv  loeat  application  or  treatment  beyond  attention  lo  cIcidIuio*. 

tf  the  u[wrtuir  become  a  permanent  arliticial  anus,  surgical  meaai  BWlbi 
adupti-d  iu  order,  if  puasible.  to  •.-tfcLt  a  cure.  Many  plana  bars  bics  sa^ 
gHleiJ  fur  cfrei-ting  tnis  nbjeet.  the  two  moat  iraporiant  beiDf;  Dapvjim^ 
opcratiuu  and  euiure  of  the  gut,  with  ar  without  icnwval  of  *  pofftiaii. 


I  nv^^SF 


ARTIFICIAL    ASUS — TREATMENT. 


777 


In  Do puy trcn'fl  npt^ralion  two  imp'irtant  imlicHtionfi  have  to  be  fulfilled  : 
the  firAt  ij)  tu  liimiiuBh  ar  ilcstroy  the  projc-tMing  vflU-filar  or  spur-like  process, 
and  tliiiR  lo  rcortiiblLth  the  rontinuity  of  (he  cannl :  and,  after  thii  has  been 
doae,  the  externnl  w»iind  may  be  cluacd,  by  paring  its  edges,  and  bringing 
them  together  nilli  harelip  pinn. 

The  finit  ohjfct  19  hi^t  Hccomplifibed  by  Dupuytreu'H  enterotome  (Vig-  792) ; 
this  ooiistiils  of  a"  instrument  something  like  a  painif  nciiuorii,  with  blunt  but 
scrnLted  bladc«,  wbicli  may  be  brought  l<^tber  by  acting  upon  a  screw  lliat 


tig.  TV3.— DupnjIrM)'* 
RnlervtooM. 


Pig  Tt3.^Knt«rotomo  Appiiod. 


traTeraesils  bnndle.  One  blade  of  the  instrument  (a)  is  pasted  intrt  the  npp«r, 
the  other  (b )  intn  the  lower  portion  of  the  intestine ;  tbey  are  then  approxi- 
niHted  slowly,  and  fixed  by  nienna  itf  the  screw  insiicb  a  way  as  to  comprwaon 
each  aide  thespnr-like  process  '  Fij;.  TU.S).  VcrT  gradually,  day  by  day,  this 
Bcrew  is  lightened  s>>  ns  to  induce  sloughing  of  iKis  jtrojeclion,  and  odiesiiin  i>f 
its  serous  surfnces.  A^  ibis  process  goes  on,  the  irritation  caused  by  the 
iDStrtinneut  will  orcfutiuo  inflnnimftlory  exudation  in  the  angle  formed  hy  the 
intestine,  so  that  the  peritoneum  anil  meHeniery  1>eeomc  consolidated,  and  all 
opening  into  the  peritoneal  cuvily  ii  iLvuided.  Should  the  spnr  like  process 
he  accidentally  cut  through  before  the  lymph  is  thrown  out  in  sufficient 
qnantiiy.  tlie  peritoneum  would  be  opened,  and  death  would  probably  ensue; 
benc«  the  neceiisity  for  cautino  in  this  prK^dure.  So  soon  m  the  blades  of  th« 
inHlrtimeut  have  come  into  contact,  and  the  spur-like  procet^  haaconserpiently 
alougheil  away,  the  great  obstacle  to  the  closure  of  the  artificial  anuB  will  be 
remnv«<l ;  and  the  continuity  of  lhe  canal  being  thus  recvtablisbed,  the 
lips  of  the  eilernal  opening  may  lie  pared  and  bruught  l^gelher  by  harelip 
pins  and  sutures.  In  sonie  casv».  from  the  length  of  lime  that  haa  elapsed — 
many  years,  |inssihly — the  fistula  continues  permanently  patent,  and  nr> 
treatment  i^avaihihle  for  its  closure,  lla  existence  is  not  incompatible  with 
gi>nd  general  heahh.  I  have  had  two  cases  under  my  constant  observation, 
in  one  of  which,  that  of  a  woman  about  fiAy  years  of  age,  the  whole  of  the 
iBleatiDal  contents  have  been  discharged  for  four  years  through  no  aperture 
uf  the  umbilicus,  in  consequence  of  tlie  BJoughing  awiiy  of  a  large  coil  of 
inieftinc  in  an  umbilical  hernia;  the  other  being  ihnt  of  a  lady  more  than 
eighty,  who  has  fur  upwards  of  thirty  years  haiia  fecal  fistula  in  tbo  right 
groin,  enneoquent  ou  an  operation  for  femoral  hernia. 

In  the  second  nielhod  of  operating  adupted  by  Dittel,  Billroth,  Czerny, 
and  many  ulJier  continental  Surgeons,  the  gut  ia  freely  cxpueod  and  dtsscclcd 


778 


nsBXiA. 


away  frum  iU  adheaioDs  to  tlie  abdomtaal  wall.  Tbi»  raoBt  bttel^ 
antiwpliu  prccautiniiii,  Ttie  buwcls  mtiat  havn  bc«ii  ihuniugUj  f/U 
lwfi>re  Lhv  <i|K*nilii>ti  in  niiminL-iicecJ.     Tlii>k>xtrrual  nj>.  i.    .  -i  |«  rmnntli 

cleoni^il  witli  flutiio  ftficieal  unliimptif?,  anil  unhr-althi  ^  u-tam  bhm 

b«  SLTBiK^]  nuny  with  »  Hharp  Hp-tun.  The  oriliri.>  ui  lIu^  ^ul  i»«ilaljob 
oleans<Ml,  ntid  n  Hiiiall  pieLV  uf  »ivmge,  whjrb  bas  Iki'd  pr«perlj  dklnfaanl 
bv  carlKtllc  hiliitu,  mar  lie  piuilieil  iuio  tbu  upjipr  orilu-e  lo  pivvefll  Uw«>a|i 
ut"  any  fecal  maUcr.  Tb»  npeiiiti^  throii>;li  whicb  the  iril  piMCruila  mM 
then  be  fiilar^'crl  by  an  incision  tarried  in  Itic  nu»l  ciovt-^ient  dlRBtM, 
anil  tbc  gut  <liftMrcl«<l  away  and  drawn  out.  If  tb«;  nitening  i>  no  eniil 
only,  and  very  small,  it  may  be  chwed  bysuturM;  if  larg<^,  thi- whnlMftari 

fmrtion  of  the  gut  is  cut  away.  The  detaiJB  of  lliis  outrratton  arr  daeriM 
Bter  on,  a»  they  are  iilentical  with  Lbitse  pructtsetl  in  tfic  rrmoral  <if  ^t^tiiM 
of  intcsLioo  for  other  causm.  As  Ix-fore  stateil,  the  il^mh  rate  aowaf  lU 
publtshed  CAMS  in  which  tbi^  operation  ha«  been  piTf»rmr<l  is  nttt  la  Mr; 
so  it  mu«t  not  lie  lightly  underiaken.  If  the  patient  »utft-n  nwrttyCnat 
feral  li^iula,  which  can  be  easily  coD(roIlo<)  by  a  niul,  it  wouM  •»! Jally  h 
aiijii»tili»bk  to  submit  him  tn  the  risk  of  such  tion.     If,  hovvnt. 

the  patient  is  otherwise  in  g<x><l  health,  but  sn  ."-at  incoova' 

from  the  artificial  anus.  an<t  other  njeane  hnv?  I>iil«ij.  Um  oparatiw 
out  a  fair  prospect  of  relief  nml  may  be  unficrtaken. 

OpKRAiioy  wiTHOL'T  OriiMs<;  Tiii:  Sac— Tbc  pcwibUtly  of  !<■■ 
the  stricture  in  atrangulaled  hernia  wilhout  laying  tbe  aac  opoi.  aatviUy 
auggwled  it«elf  when  it  was  kaown  that  in  tDany  cncM  tb*  itridan  aM 
0eat«d  in  the  teodinuoa  and  areolar  tiaguei  oulstda  tbe  oack  uf  thaac;*' 
that,  when  thcae  were  divide^l,  the  protrmion  waa  readily  radaead.  IW 
operation  was  porformeit  by  Petit  as  long  ago  as  1719.  bnt  waa  adidiHi  pv- 
tised  until  it  was  revived  of  late  yoara  by  Aatoo  fCey  and  Luke.  Tb*  fNal 
advantajjo  nought  to  Ito  gained  by  this  operation  ia  that,  aa  ihc  penum^ 
li  not  interfered  nitb,  nor  its  cavity  opeiieil,  the  risk  fruin  patiuoilii  vO^ 
pmportiunatciT  lewcned.  The  wound  made  by  the  operaiiuD  baiDgalMfal' 
Boperfioial,  au<)  the  sac  not  opened,  ita  risk  has  been  oompafed  la  tkn  li9» 
taxta,  with  the  additinn  of  that  which  would  result  froiu  a  auperflfial  nai 
This  argument  would  be  eonelusive  iu  favor  of  the  apemtliiu  wilkoM  ■f*' 
iujIC  (be  <iae.  if  it  could  be  shown  that,  in  all  ca^a  of  atraogulaltil  iMfMi 
:;ricouitiii  is  oLvasionixl  by  inEerferin^^  with  the  peritoneal  cavity;  bw^ 
>ver,  be  KdniitU--d,  even  by  the  keeneat  adrneau-a  of  Peiii's  oywad* 
lat  thLi  is  not  the  ease.  It  iim  before  been  pnlnteitl  out  that,  in  a  oauikf 
able  prnporiiiiD  of  uoaes.  the  intlamniaiiou  of  the  {«ritoneuui  »tarta  fKi*!^ 
injured  portion  of  gut,  and  is  not  tbe  conaequriiceof  arptJu  pr-i  --<--  -■■n^ 
ing  from  the  wound,  or  of  septic  matter  iutnidurvtl  by  tW  '^ 

Surgeon.  Tbe  former  cause*  will  conic  into  piny  whetbt- r  thr  nm-  it  "^"'^ 
or  Ditt,  and  the  latter  are  to  for  cuutrullt-il  by  tti«  lumli-rD  iiitpnm«HtallB 
tbc  treatment  of  wounds,  that  a  wuuud  of  tbe  peritoneum  ■  now  nUmA^ 
niiKil  of  ita  dangers. 

There  can  be  no  ilouht,  fmni  the  experience  of  forn  •jrff 

ing  into  tbe  cavity  of  the  abdoaiea  made  without   i  jsii 

attended  by  some  danger  of  setting  up  fwrilnuitis  ■  i 
may  exist  at  the  time.  It  is  equally  certain  that,  '< 
may  occasionally  fail  in  prevuniiug  sepsis  in  u  wound  Mated  »»  afar 
genital  urgoM,  as  the  drvasing^  n>ay  acctdratally  be  soilial  with  unai 
dbplaoril  oy  the  niovcmeuta  of  the  iwtient.  Ttas  argiitsmta,  tliiiiiftw. 
favor  of  Pctit's  operation,  founded  on  il«  mluetng  IM  rkik  uf 
cannot  l>t>  said  lo  be  couiplctclv  lnvaliilate«l  by  thci  mierai  Me  nf  ant 

Thure  are,  however,  two  objecttoua  that  may  be  Dfynd  agailwC 


nBRNlOTOHT    WITBOITT    OPENINO    SAC. 


779 


nptTitf'ir  with  more  jiwtico  ihao  that  it  (lo«a  oot  prrvetit  the  occurrence  of 
paitOMitiA.  The  6ret  U,  Lhnt.  if  the  iotestinc  be  nut  seta,  it  mnr  somctinim 
M  RCumed  ID  ■  gaQgrcnous  coDiiiiinu ;  and,  the  Kcond,  that  the  (ftit  mar 
poalblT  be  retarocd  uiti  straDijIeJ  by  baada  uf  adhesion,  or  by  inclusion  in 
■B  umeutal  aperture.  With  regard  to  the  first  objection,  it  niav  be  stated 
thaL  if  the  itiiitttiDe  be  to  a  j^angrcnoaa  ital«,  there  will  uduftlly  be  enmo 
erideoce  of  this,  either  ia  the  chaiij;^  that  han  mken  plaee  iu  the  i^Deral 
.....•, ,na  of  ibc  patient,  or  io  the  condition  of  the  mo  and  ita  caveringB, 
.f  ill  enable  the  8urgeoa  to  Ktiess  at  the  condition  of  the  eneKieed  pftftB, 
■i)[i  will,  iif  c<>ur»«>,  iuJu<.*e  him  to  expo»e  tiiem  fully  and  oxaniiae  them 
tktnMigbly.  ThU  ubjectioii,  however,  cnniiut  opply  to  tluMe  triweA  in  which 
ttttf  •InDt^utntinn  has  exitte'l  only  for  a  tini«  that  would  be  iiiHutficieilt  to 
■ll»«  (hr  ■Kvurmu'tj  "if  j!aiii;rvne,  and  does  not,  therefore,  "ppi»e  the  pej- 
I  Pflit'f  I'pf'rBttnu  iu  rweulawe*  of  ^tnto^uUti'm.  Wilh  r«nf'ifd 
irtfHce  of  iuternal  ttlrAii^ulatioti,  it  t»  excessively  mre  ;  uud  when 
ifcijflia  i>ccur,  it  mlill  ni'ire  rarely  happens,  whether  the  ^tniuiruluiinn  bft 
•ftotod  by  baud*  uf  adhe«iou  or  by  an  aperture  in  the  omentum, 'thai  the 
p»rta  can  be  returue*!  wiiliout  <>|>e(iiu^'  the  sac,  adhwions  usually  existing 
a.7v,  liftweeu  thia  structure  uud  its  oouteiit«.  But  tbu  Iwat  answer  f>  the 
<n«  against  ihu  operuliuu  without  opening  the  sac.  aru  the  results  that 
:_;^k  r>(llimetl  thia  prartico.  l<uke.  who  naa  had  ^rettt  ex|)orieuee  un  this 
IJrtiJMt.  alatrK  that  he  has  operate*!  in  84  vases  of  hernia.  In  2o  of  theae  the 
ItaB  mu  o|>enerl ;  in  f>V  ihc  eiie  runiuined  unopened.  Of  the  '2o  iu  which  it 
w«a  npeord,  H  dieil :  tthilat,  of  the  .t}l  in  whieh  Felit's  operation  via*  |>er- 
fimova.  only  7  dird.  If  to  Luke  casea  we  add  those  re[M)rted  by  X.  Ward, 
««  ahsll  find  it'>  deatliH  in  15;t  eaaee  uf  Petit'a  operation.  That  the  nnlinarr 
■pcnuino.  indeed,  of  o[>cntn^  the  ear  in  an  exree<lin^ly  fatal  one.  w  well 
known  to  all  biupilnl  .>^urgpi>n9.  nud  in  fully  )iroved  hv  surgii-nl  AtnlinticB. 
Of  77  opefrntinos  for  hernia.  n-porU'd  by  8ir  A.  Camper.  ^W  proved  fatal ;  and 
«f  545  OMCi  recorde^l  in  the  journalg.  Hnd  colleolinj  by  Turner.  2fiO  arc  r«- 
anrtcd  tn  have  died.  The  nttult.  thi-refort-.  of  LoUe's  operatiotM  is  very 
nvurahle,  when  eoulnuled  with  tlxMO  in  whirh  thr  sac  was  opened:  hut  it 
butt  Dot  hfl  aaaumed  thut  the  entire  dillereocc  i;*  due  tn  the  Mir  not  bcin^ 
tt^atni.  for  every  aeriouti  coniplicalion  of  hernU,  Huch  as  jraugrene  of  the 
gut,  pr(>]on);ei.iflrangiilation,  reduction  in  man,  etc,  uece«silated  the  openinj^ 
.  f  .k..  .... 

:tli(fn  without  opening  the  mc  may  be  practised  in  all  fr>mia  of 
nrniin,  mil  i»  tnurh  more  readily  done  in  souk-  varielie*  of  lbedi»eH»e  than  in 
ntlHtra.  It  ifl  ei|MS:in|]y  applicable  tu  cases  of  femoral  hernia,  in  whinh  the 
■tricturv  w  Mimnntuly  outeidu  ihi;  sae,  as  wilt  l;e  menlioned  when  KjK'akiug  of 
iJbst  fiirm  of  the  <ltw)aw.  Of  'tl  cases  uf  fenioml  heniin,  o|)enittn)  on  by 
L<!  -DO  n-<)uiref)  ojieuing  in  7  niijv.     In  inguinal  hernia  it  k  not  M 

■i-  :    rni  IVt>t'ao[iernti<>ii  ;  indeed,  in  the  majority 'if  caaea  the  •Sur^)n 

will  fail  !<■  rrmiivi<  the  striLiure  in  this  way.  This  is  owing  Vi  the  cotietrie- 
limi  being  uaually  tfeale>l  in  the  neck  of  the  sac,  aa  is  eapevially  otwcrvnblu  in 
.mogrnital  h«rtiiii.  Of  'JO  inguinal  berniie  operated  on  by  Lake,  the  sac 
rMuiretl  opening  to  lit  instance*. 

Ft>r  tliernriouBntasonsthHt  have  he«o  mentioned,  1  am  decidedly  uf  opinion 
that  tbi#  of>ctutioti  should  always  be  attempted,  in  preference  to  the  oniinary 
MM  (kf  opening  the  pac,  io  those  caaea  in  which  the  hernia,  not  having  been 
kag  iUranguUled,  presents  no  aign  of  the  occurrence  of  gangrene  iu  it, 
ianaian  npecially  when  it  is  femoral  or  umbilical.  Kven  if  thu  Surgeon 
'fliil  in  eompleling  J'elitV  operation,  in  conaeoucnoe  of  the  oxistence  of  a 
rtricRire  in  the  nrok-  of  the  sack,  or  the  eonitnction  of  this  pan,  nn  harm 
ou  haw  rcautted ;  for  the  >ac,  after  beJog  exposed,  maf  u  any  time  be 


780 


BKEBilA. 


opened  io  the  orJinary  way,  anJ  tba  operatioe  comptetMl  bj  divUbf  lb 
airifiure  fnim  within. 

Whpii  tbe  hcruia  is  of  large  site  ami  irrp<lurible.  it  h  of  evfwritl  )b(v«. 
taiicc  to  avoid  o|tciiitig  the  sac  If  it  be  opuiKtl.  tlie  coDl*rulJi  will  tdb^. 
and  fatal  periu^nitid  cutiinMnly  ensues.  In  tbear  eaiBe»,  a#  Luke  bw  potald 
out,  it  rurt-ly  hanpona  iKut  tbt>  old  iahcrent  parts  are  !rn  ui*!r  lUmnivhlej, 
but  the  wtinle  mischief  tsdciiH  to  beoeeuioncd  and  ch-  ^  >  btrNnnil 

by  the  new  protrusion  tbut  has  Uiken  place,  am)   r  -  H*n  b>  tW 

tenHi>m;  nnd  if  this  can  b«  liberated  and  reduced,  the  -  '<a«4iM 

all  that  need  be  accomplikbed.  The  eridem-e  of  the  rcdiu.^  .  ..u'  rvoil 
protrution,  allh»U)'h  the  old  adherent  and  irre<luciblr  hernia  bv  left,  • 
uiimlly  sufficiently  obvious;  the  [tortion  of  gut  returning  with  -<  •<"  -~4t 
gttri;U-,  with  considerable  diminution  iu  the  f^aernl  t(>n*i<>n  •'(  i 

Operation. — Wilb  rt-giird  to  the  niixlit  of  performing  IVin  ■  ••i>i>tfa 
littl«  iic>e<l  be  itaid  here,  aa  it  \»  precinely  identical  with  the  Mepa  of  iMolW 
operati'iii  up  tn  die  gteriiKl  nf  the  expn^ure  of  the  mc;  except  that,  wbi*  M 
b  Dot  iutvD'lctl  t<>  open  tl)i»,  the  inviiiinD  abould  be  placed  mtxv  dirwilr 
over  iu  neck.  The  alrirturc,  if  situated  outside  the  sac.  will  Ibeti  bs  fum 
either  in  some  of  the  tendinous  structures  Burrouoding  it,  or  obs  talk* 
Bub«ertius  aroluv  i'msuh  lyin^  up-'n  it.  Afu'r  the  divistuo  of  Um  oaotfill- 
in^  bamli!  in  thi«  situation,  by  int-ausof  »  probe-poiule*!  koifc  carriid  oato 
neatb  tbem,  or  by  diMCtiiiug  duwii  upon  iheni,  an  attempt  at  taxis  iM^bf 
made  by  cumprea^iug  the  tumor  in  the  uhuhI  way.  at  the  same  time  that  Ht 
otick  is  eu-atlied  by  the  flngere  td'  the  left  hand.  If  Uiv  owtcots  oaa  bs 
reduced,  ibe  inciitiou  in  the  superfirial  structures  is  bmo^it  togvilicr  aaJ 
dre»^»l  u*  alri'ady  di^cribed  (p.  767).  Hhnuld  {H-riuinitis  cumc  «o.  m  lis 
result  of  till!  fitrauKutatiou,  it  niusi  be  treatei)  in  the  u4ual  war.  If.  sillir 
the  Surjieon  bus  fitirly  divided  all  ifac  Klrurtun>e  nul«iile  the  tac,  ks  Had 
still  thiit  the  return  of  the  huruta  id  prevenlvil  by  some  eoiislricti*ai  intV 
ueck,  il  will  be  neec^ary  to  lay  tbts  open  and  divide  tba  oonalrirtioo  io  ikl 
nniml  wny. 

Kedaotion  in  Maas. — The  reduction  of  the  hernia  In  raoas  rr>n*t<>!*  (s  tk 
Feluni  I  if  the  s>ar  and  H»  contenu  int<i  the  iibdoincu  ktill  in  txnl.f  -V 

lutiiin.     When  it  is  xaid  that  the  iuir(.<  nre  retiiritcol  intti  ihr  al»<i  ^^1 

Uiil  it!  iiihb'nttouil  l-hat  they  are  pushed  bark  intu  its  cavily.  Iiut  iii»l  lb 
extenuil  pr(itrii*ioii  is  causeil  !'»  diwappwir  by  liiiiiL'  ni-tH  1  liit  i  I'n  -ak- 
serouniif-'olur  ti^ue  bt-hiti<l  nnd  undernfjilh  ihi-  y.i  « 

it  and  the  ulNldininnl  uius4^lc«.     This  remurknbi.    ..       .  "4 

describfil  by   the  French  Sur((c<)iw  of  the  l»wt  cenlury,  r  ■' 

ootiue  froni  practitiouere  iu  thit>  cmotry  until  attvntiou  *it-  m.  .•.!.  i>J 

I^uko.  by  wbuni  iu>  pntholofry  hM  been  curefuUy  studied.  Ittrkett.  «>»'  k* 
aUo  invctttiKiileal  this  coiidili'iu  with  much  c»ro.  Is  of  opinion  that  tb^atf^ 
not  t»ru  fn>iu  its  connections  in  the  scMtum  or  canal,  nnd  ixipbeH  tadk.  ^ 
that  it  i»  ruptured,  ueually  at  it*' iKwU-rior  port  at  its  ti' '  ■  ■  "^ 

contents  of  Ibe  sac  are  furced  ibnuiih  this  rt'ut  iiU"  tli  * 

liwiic:  «bil»t  the  rn»uth  of  the  sac,  ■till  c  .u4  ik* 

kecpin;;  it  in  a  slate  of t<tmnt;ulntii»n,  i^  pm-lr-  ijal  riiC 

It  nppi-itnt  to  nil'  tbnt  both  eipluuatiuiin  are  curtt  4  adoMI 

two  forma  of  D'duriion  in  niasH;  the  sac  b«-ini:  ihj-  m  aMlC 

of  8tnin)^ulal)»n.  in  one  fonn.  at*  dc^^rribetl  by  Luke  ;  whihu  ia  the  oiktr,  f* 
obserreil  by  IlirkFli.  thesao  is  rupltireil,  and  the  herofa,  atrmguUilMl  byd* 
displaced  nv-uih  of  the  aac  is  fomnl  out  tbniu^h  the  t«Dl. 

'('."aHten. — Hie  reiturtion  in  niaiu  has  betuj  far  morr  ff— •■—"•i*-  -J^-- ^-f  h 
enw«  of  inguinal  tlian  En  thoite  nf  any  nf  the  other  ':  U 

haa  been  met  with  in  fomoral  herala},  uut  very  raraly,  aii<i.»>  mr  a.*  i  bi»Hr. 


REDUCTION    IN   MASS — TBBATMKXT. 


781 


Dot  in  any  olhor  form  of  I  be  (liMMee.  Tiiid  comparative  fr^quenoj  of  its 
occurr«uce  in  ioguin»l  hertthv  in  iluubtlvsa  due  l<>  lleir  lurge  eizv,  ami  lv»te 
ar*«i|Brc«.)nnectiui«i.  The  accidtnt  httBinoreoftcn  occurred  Jromllie  patient's 
owD  trlTvrts  at  reducing  »tratiKulMtc(l  livruia,  thnii  Ironi  ihoic  vt'  the  Surgeon. 
U  IB  a  roniarkable  fact  that,  in  ni<«tol  IheJiiEilances  in  nliicli  it  lias  occurred, 
uuly  a  very  alight  degree  of  force  appears  to  have  been  ei»pli))'ed  in  ihe  re- 
duction of  the  tumor  ;  auil  the  accident  would  seem  to  have  resulted  trom 
the  adhesions  between  the  sac  and  tlie  neighboring  parts  being  much  weaker 
ihan  natural,  so  tliai  n  moderate  det^ree  of  I'urce  caused  tlic  wliolc  to  slip 
through  the  cannl.  It  tn^ty,  however,  occur  from  the  Surgeon's  eflbrts,  If 
these  be  too  t<ircil>lc  or  long-continued, 

Symjitovu. — The  aymptonig  iudieative  of  this  accident  arc  con^tilutiimai 
and  locfd.  The  C'OU«tituii><nfll  symptoms  cousiai  in  a  cnulinuouce  uf  iIkuec 
that  arc  indicative  of  tlie  existence  of  atningululiou,  notwithstanding  the 
disu.pricAraQt.'e  of  the  tumor.  The  romilin^  aud  ctiustinulion  puniiating.  the 
jifllieut  8|>ecdily  bccnmea  much  deprc«s[-d  in  sirt-ngtb,  being  seiwd  with 
hiccup  and  proiitration  of  all  vital  power;  eigus  of  gangrene  then  evince 
tbcmgelvcB  within  the  sac:  and  death  ensuex. 

An  examination  nf  the  purt.t  in  hernia  will  iiaualty  enable  the  Surgenn  to 
reoigniw  the  nature  of  the  aecident;  he  will  uncertain  ihat  a  tumor  had  pre- 
viously existed,  and  will  Icarn  from  a  description  of  its  general  characters, 
and  the  symptomn  occasinnt'd  by  it,  tiiat  it  wax  in  all  probability  a  utrnngn* 
lateil  rupture.  He  will  then  IJnd,  un  examining  the  part,  that  there  in  a 
total  absence  of  all  tbiit  fulness  which  is  occasioned  by  the  presence  of  the 
sac,  even  after  its  contents  only  have  bfpn  reduced ;  the  aac,  in  such  caws, 
always  giving  ri.«e  to  a  feeling  of  fulness  and  roundnesa  in  the  part.  lie  will, 
on  the  contrary,  find  that  the  abdotninnl  ring  is  peculiarly  and  verydiMiiictly 
upen;  it  n  uiuch  Itirgvr  iIihii  uauul,  and  eomewbat  rounded.  On  pushing 
lh«  linger  inl^i  the  cuual,  thi»  will  be  fliund  t^uite  em|]ty  ;  but  in  aumc  casei;, 
ou  deep  prtrture  with  llie  fingrr,  egjHrcially  when  the  imlieiit  ittands  up  or 
coughs,  a  runndc-U  tunmr  nia)-  be  iudistiuctly  felt  beliiud  th«  ordinary  seat 
of  toe  hernia.  lu  muuy  cugvb,  houever,  the  most  careful  uianual  e:[amiua- 
tion  will  fail  to  detect  uny  prominence  of  this  kind. 

Trt'tlmettl — If,  after  careful  exuu)iuutiuu  yf  aucb  a  case  as  tliin,  in  wbirh 
the  symptoms  of  etrangulation  continue,  the  Hurgeuu  learn  by  the  previous 
hiMory  that  a  tumor  haa  exicLed,  but  that  it  has  suddenly  gone  up ;  and 
further,  if  he  lind  that  ihe  Bent  of  the  fiiippused  hernia  preeeuls  the  negative 
evidence  that  bes  just  been  described,  it  will  then  be  necessary  for  bim  to 
push  hi.^  impiirii'ji  a  dtep  further  by  an  exploratory  incision.  Such  au  in- 
cision as  this  may  lir:it  be  iitied  as  a  »im]ile  mesus  of  diagnosis,  and,  as  it  dnre 
not  penetrate  the  peritoneitl  cavity,  there  in  no  danger  attending  it;  and  if 
the  nernia  be  fmiii<l,  it  will  serve  the  imrpoee  of  the  ordinary  inciiiion  re- 
quired in  the  operation,  and  may  he  upciI  for  the  relief  (if  the  atrangulation. 
The  firet  incision  ahonld  be  made  bo  aa  to  expose  the  abiiominal  ring  ;  if  thie 
lie  found  peculiarly  round  and  open,  it  would  increase  the  prt.bnhility  of  the 
existence  of  the  condition  i^ouglil  for.  The  inguinal  canal  must  next  be 
laid  open,  aud  the  parts  contained  wllhiu  it  tarelnlly  examined.  If  no  aii- 
pearance  of  hernial  sac  be  found,  hut  the  cord  be  dislinrtly  and  clearly 
seen,  still  further  presumptive  evidence  will  be  aiforded  of  the  reduction 
having  been  etfected  in  mass;  for,  if  the  hernia  have  been  put  back  in  the 
usual  way.  the  eao  will  ncceasnrily  be  left  in  the  canal,  and  will  pre-serve  its 
uauat  relations  to  the  cord.  This  supposition  will  be  strengthened  almost  b^i 
a  certainty  if  it  be  found  that  the  "  condensed  cellular  capsule  immediately 
investing  the  sac,"  as  it  is  ttrracd  bv  Luke — iu  other  worda,  the  condensetl 
and  laminated  aubecroua  areolar  tissue — has  been  left  in  the  caual.     An 


782 


BERVIA. 


openiDg  made  itiio  this  will,  m  that  ^urgmn  nbwrvfs^  allow 
bniiigtil.  int4i  (Niittnct  with  ibe  heroial  tumor  itfelf.     Bhtwlrl,  llsMR.tt 
condensed   nro4)lAr  tissue  not  be  found,  it  touHl  not  be  tonrlutbd  tka; 
hcrQiA  id  nrescDl,  iuaiinuch  u  this  inTCfltmcnt  ntftjr  hnvc  lM«n  acriAi 
ab«ent.     Thp  finger  should  then  be  puMwd  xnU>  the  intrmiil  rin-j   -l.' 
pnilwbly  b«  fouod  open,  and  shotilil  be  carriiKj  trnm  sidr  U>  »i' 
if  jireseiit,  nil!  t»e  detected  lying  exIvrDiilly  lo  the  p«rilnnruu>   ■' 
abdutuinal  wall.     When  fuand,  it  must  be  brou((bt  down  tnt')  thi' 
enlarging  the  ring;  it  must  Ih«ti  be  opened,  its  conlenU  enmiood,  at"!  ^r' 
•tricUire  in  its  Deck  divided.     The  intestine  that  has  beco  m>  ttnngM  not 
be  dealt  with  in  accordance  with  the  rules  alresdr  laid  down.     If  tb*  luour 
cannot  be  reailily  brought  down  so  as  lo  admit  of  an  esniniuation  uf  uu4 
Ita  contents,  the  iwlieal  should  be  desired  lo  make  tome  pnjpalihre  iImI^ 
aoas  to  cau^e  it  to  protrude.     If  it  siill  do  not  comcdifwn.  it  oioM  beofrail, 
nod  the  stricture  cautiouely  divided  within  the  abdonKO  witb  a  ibcalW 
bist-mry. 

Treatment  of  Straagitlated  Hernia  by  AipiratiotL — This  opcnlitn,  • 
which  it  is  attempted  to  render  a  strangulated  lieriiia  reducible  t^  vitUia^' 
lug  its  gaseous  and  fluid  cunieota  by  means  of  the  pneurnalic  afpinU«r,ti> 
tniroduced  into  practice  by  Dieulnt'uy.  and  is  thuB  iM^fi^rmed:  An  aipintv 
of  the  form  repreBcntcd  iu  Fig.  93,  page  254,  vol.  L.  i^  to  be  prcfttTvil.aM 
the  needle  mu^t  not  exceed  ^  inch  iu  diameter.  The  aspirator  baviaf  ka 
proved  to  he  in  working  order,  and  the  needle  clear,  a  vaeuura  b  nmjr  bj 
withdrawing  the  pintun.  A  few  drojiaof  water  may  be  leA  in  iJte  bdOna 
of  the  ryltndcr,  mi  that  gits  may  be  realized  oa  soon  oi  it  enlen.  TW 
neeille  is  now  iutroa]nc:e<l  inlti  that  part  of  the  luiuor.  whert>,  frun  rsMwa 
or  pert:ii»!tiiin,  or  elastic  feel,  the  gut  u  iiupix»eil  to  lie,  and  *^  t<^B  as  idlTt 
is  covered  the  vacuum  is  turned  on.     Tite  ntt^ilu  must  tt-  ■  fall^sH 

steadily  jiuithed  onwards.     If  there  be  tluid  in  the  mic  lli  -  ■•  uiwik> 

syringe,  and  as  so«)n  as  it  ceases  to  flow,  the  needle  muat  h«  a|[ats  oariMN 
pushed  onwards,  until,  fnmi  the  appearance  of  fios  or  frcal  taaltM  ■!■ 
syringe,  it  is  known  thot  the  gut  is  reached.  Th«  nvedio  niusC  fc*  Ml 
steR<lily  and  pushed  in  one  direcliou  only,  as  any  lateral  Diuvcfiwtttavltf 
tend  tu  ecrntcD  or  tear  ibe  gut.  The  gas  may  be  sultidpnt  in  <iittaiil7* 
Gil  thf  vacuum,  au'i  if  this  occur,  the  ci>ck  must  h»:  in--'  •"-  •■-'<* 
emjilieij,  and  a  fresh  vacuum  made.     If  ona  punctun*  f:>  ^ 

bulk  of  the  tumor,  the  needlo  must  be  withitrawn  and  niMi-rin  >i  ^^f^ 
split,  and  this  may  be  re]>valcd  two  or  three  times.  If  the  atnlle  We^ 
plugged,  it  is  belter  tu  ahatidou  the  operation  at  onet\  as  furtber  alli*f* 
wuuld  probably  meet  with  nu  better  auccesa.  AAcr  th"  ••|>frntioo  usitOQ 
b«  immediHti'ly  employed,  aiMl  if  it  fail  ihu  ord"  n  mot  ^t^ 

formed.     A^plratioo  baa  been   iter/ormtil  suffici  m  •buvlWif 

needles  of  thn  proper  site  be  use^l  cnrerully,  it  ts  alni(»t,  if  iu«t  abaii**'?* 
innocuous.  Dieulafoy  records  27  cases.  :J0  of  which  were  aucnwiil.  i»^ 
tinn  of  the  gut  by  tnxis  fdi«wing  the  uperation.  [o  the  retBatniog  *  it  ^ 
harmlnts.  and  nf  these  3  died  and  4  recovered,  after  the  offlioary  nfKH** 
for  hernia.  Olher  .Siirgenns  have  not  succeedeil  in  obtatniog  sorb  laia^^ 
tory  reaiilta.  At  Uuivenily  College  Hospital  a^jiiralion  hiu  htro  (<*'* 
ttniea.  In  1  ease  only  was  It  t'dlowed  hy  reduction  ;  in  1  the  Bmd  tba  >* 
aac  ivnly  was  withdrawn. yet  the  impulse  relumed  ai.rl  ''  '    «a»»«^ 

though  the  hernia  remained   unredui'e'l :  in   4  it  ':  .  aa4  <** 

onlinary  openilinu  wn«  |»»'rrormed  in  M     -  niiv.      in  tin  i«lsl  ^ 

two  days  after  the  o^KTHtinn  the  puiM  ;  l  br  found  at  tlw  f^ 

toortrtn  exiunination.  In  the  rvmiiini^,:  •  .■■  -  {'.••  |<wtirnt  was  ttMrlliaM^ 
Lbv  time,  and  died  a  fqw  niiiiulea  alter  iIk   "ji* ntiion.     At  tb«  potf-A''** 


lyonVAI.   HEBKtl. 

no  gas  or  Quid  couUl  to  squeczorl  from  the  punctures  in  the  gut.  It  6^eem», 
therelore,  that  the  <IaDger  of  tecul  cxtruvaaatinn  in  very  small,  although  it 
U  aaid  to  hnve  nccurreiit.  The  operatinn  may  fairly  be  triet)  in  Hiiitubte  ra^^cs, 
Especially  when  the  hernia  is  very  large  anrl  resrinanc  on  percussion,  ami 
only  recently  atrangulated.  It  would  be  untviae  to  atl«>rnpt  it  when  from 
the  duratiuD  of  the  etrangiilatiun  inflanimatiun  ur  gaogreue  of  llie  gut  might 
b«  Mupected. 


CHAPTER   LXn. 

SPECIAL  HERXT^« 


By  Ittfpiiiial  Hernia  is  meant  that  pnitrueion  which  occupies  the  whole 

or  a  purliuu  (>('  the  inguiuul  vaunl,  aud  whou  fully  f'jrmed,  passes  out  of  the 
extcraat  ubdomiual  ring  into  tlic  scnjluin.  Muiiy  varieties  of  this  licrnift 
arc  rccoguizi'il  by  .Surgvous.  Tliu«  it  k  stiid  Ut  bu  Comjtlde,  vtlic-n  it  iMueea 
out  of  tiiu  vxii-riiul  ring;  Jneo}»p!ete,  or  Jntertiitial, mt  long  as  il  u  ctintaiued 
within  the  canal ;  Obli'jue,  when  il  oceupJCA  the  wlu>Ie  courvc  of  llic  canal ; 
IHreti.  when  it  pHSat'S  lorwards  through  a  limited  exltiiU  of  it;  Cotujcuital, 
when  it  deacemln  through  an  unnblilerateil  procrsBiis  vaginalia  and  ties  in 
the  »ac  of  the  tunica  vaginalis ;  and  Kneyxted,  ur  Jnj<inli!c,  when  it  lies  be- 
hind tbiB.  Inguinal  hcrniiu  cnnstituie  the  cummnnettt  epecies  nf  ninlure, 
and  would  be  much  more  frequent  thnn  they  arc,  were  it  ntitfor  theobliigutty 
of  the  canal,  and  the  manner  in  which  its  aides  are  applied  to  one  anuther, 
and  cioaely  overlap  the  spermatic  conl.  They  occur  with  irKvel  readincea  in 
those  cvea  in  which  the  catinl  is  ehort  and  the  apertures  wide.  Althmigh 
these  herniie  are  commonly  incomplete  in  their  early  Btflges.  it  is  seldom  that 
they  come  under  the  observation  of  the  t^urgcon  until  the  protruaiun  has 
^paned  bejood  the  abdominal  ring. 

OttLlt}UE  iNi^rtNAL  Uekxia,  oIVd  cnlted  £x'€mal,  on  account  of  its  re]a> 
tioD  Ui  the  (;]>igiit>lnc  artery,  passei*  thruugl)  the  «bole  Icnglh  of  the  innal, 
from  one  ring  iiy  the  other ;  niul  u^uully  pnHrudes  ibrougb  the  external  oue, 
constituting  oue  nf  the  forn)»  of  Scrotal  Hernia. 

Coverings. — As  it  p&eets  along  the  caual,  it  ncceeearily  receives  the  same 
investments  that  the  sjtermattc  cord  doea;  althoufjh  these  are  often  gre«tly 
niixlified  by  being  elougHleil.  bypertrophied,  and  otherwiBe  altered  in  appear* 
auce.  If  we  regard  the  inguinal  canul  as  cousisting  of  a  series  of  protru- 
sioDB  of  the  different  layers  uf  the  Khdomiual  puiieles,  the  outermoel  being 
the  skin,  and  the  innermost  the  fssctii  trans  versa]  i»,  with  Ihe  periluneum 
applied  to  this,  it  is  cas)*  to  understand  how  the  hernia  in  its  dercetit  has 
these  prolongations  drawn  over  it,  thus  becoming  succcfrsively  invested  with 
the  same  coverings  as  the  spermatlu  cord.  Tbu»  it  tirst  pushes  belure  it  that 
portion  of  the  peritoneum  which  lies  in  a  fo»a  just  external  to  the  epiga»trio 
vnsela;  it  next  receives  an  inveatment  from  the  subperitoneal  fat.  wbieb, 
uniting  ftith  the  fascia  transversa  I  is,  constituies  \\ie  Jaaeia  pit^pria  oi  the  sac; 
aa  it  paeeca  under  the  internal  oblique,  it  receives  aume  of  the  fibres  of  this 


781 


SPB01A1 


muecle,  in  the  stiBiw  of  Ihe  creniiwtcrii'  fnscin  ;  ninl,  IjwiIv,  ««hra  it  fOrt— 
cIju  fxturuul  abduaiiuul  riug,  wliiuli  il  gn-allr  dii'tvii'lB  and  mi<i«T*  r«al 
anil  opoD,  il  boouoKK  ctiverml  by  ttie  iuterculumimr  Cavcla,  rcrriTiDB  ak* » 
puriiul  ioveeluiuut  around  its  ueck  fnim  Bume  of  ttie  exraioiiKd  aw  tHA- 
cqihI  Qbruufl  bands  tliai  Ub  near  the  ring,  aud  vhich  art<  alirajne  nuA  aaiU 
upuu  its  iHiter  eide. 

Eelatioiu.— The  relalktoB  of  the  spermaiic  cord  aod  itatea,  sad  tf  ihi 
epi|;aalriv  anvry,  Ui  aa  in^uiaal  lipriiia.  are  uf  gnM  iraportanoe.    Tbtf*- 
iKOlienmi  will  ainiiiel  iiiviirialitv  tw  fuuml  U>  be  a)lual«d  behiad  urnttit 
undtTutMilli  the  ubiH)ue  iuguiiwl  h^rniiL;  and  lUe  teMia  will  b«  faued  la  lb 
at  its  lower  and  back  part,  where  it  iitar  alwnytt  bv  diotiru-tly  &lt.     la 
caotM  the  elem«iils  of  llie  itjwrmHtic  c«>rd  beconit-  twparaird.  the  rai  dcftmi 
lying  on  one  side,  and  the  it|>eriiiutic  ti»k1h  on  tht  other.     In  uiktf  nn 
caae^,  aa  iDstaocc  ul'  n'hioh  there   'm  in  a  preparallun  in  the  UttiTrnilt  Ci^ 
lege  Museum,  the  hernia  lie^  behiml  the  cord  and  ban  the  tmu  in  inoA.   U 
oilwr  ca^ea,  agaia,  it  ni»y  hnppea  that  the  eti-menu  of  the  curd  are  all  wfa- 
rat«ly  vprexd  out  uu  tlio  lureimrL  ol'  the  hertijnl  tuiiiur.    Thr  rpiir-titrit  ^-'.■n 
baa  tb«  same  relnttonB  to  the  i>bli<{ue  tii{;uioal  lieraia  that  it  In 
malic  curd,  lyiug  to  the  tnuvr  side  of  and  l>ehind  il«  neck.     'I  i 
large  and  old  inguinal  herriiie  has,  bowerer,  a  tendency  to  mi-: 
tbe  relations  of  this  vetsael.     Uy  distending  the  ring?,  and  dn^t^ni;. 
terior  wall  dovrnwardfl  and  iuxrards,  they  shorten  th>-  <-niial,  nod  *.•»»>- 
detlection  of  the  artery  from  il«  natural  oour»e,  whifli  la  changed  it^p  v 
oblitiiic  direcliuu  to  uae  curved  downwarda  oud   innanU,  uoilfir  tW  <Nlff 
edtfe  »t'  the  rectus  muc>cle. 

I)iu»rr  Inoi  iXAi.  IIkk:(ia. — This  dinrB  not  yam  out  like  ti>«  abHfV* 
through  ilio  internal  utMli^minnl  ring,  but  pufehcs  forwards  thraugbatnuh 
gular  fipace,  which  ia  tojuude^l  by  the  epigastric  art£fy  on  the  outvr  B<i*.  l^ 
et^lge  of  the  rectus  uu  the  iuoer,  and  the  crural  arch  at  ita  baas;  ilin^ 
thi«  the  beruial  tumor  pnilrudea,  pusbiag  boforo  it  or  rupluring  tile  pqMnx 
wall  of  the  inguinal  canal. 

Coveringi. —  Iheae  vary  according  to  the  leoglb  of  the  euial  tliil  ik 
berniu  iraverses,  and  ihu  portion  of  tbe  pusierior  wall  ihruugh  which  r.  pr- 
trudea.  In  fact-,  there  are  at  leant  two  (lifitiui!t  fumia  uf  direct  ioptluf 
hernia,  whieh  differ  according  oa  they  are  aituaied  iutfrnal  iir  extmilf 
the  iibliteraled  hy]togastrie  artery.  One,  ihe  roiM  enmnma  varieiT 
ated  internal  tu  the  cord -like  remainit  ufthU  vcMel.bet»L-rn  it  and  :' 
e«ige  i>f  llic  rrciu.t.     The  olhcr,  whiL-h  is  ol"  '  ■i.-nt  oecutreuce,  i!«i'^ 

atul  oulHde  lhi«  vnukfl,  between  iL  und  tht:  '  j  urtrrr 

In  lliut  form  of  direct  iD^tiiiiul  hernia,  wliiuIi  lust  ix 
artery,  tlie  pnurueiuii  lakt-s  plnee  thri>u|;h  Ihat  part  "■  • 
the  iiiguinal  uniiat  wbii.'h  im  situated  almoxt  behind  and 
ternnl  ring.  Tu  (his  Dituntiuu,  the  inveftiuen(«  siKOf**! v*- 
heroia  are,  Unt,  the  perittmeum,  the  sub|)eril'jiK-al  Hii,  am 
versali*;  it  then  cjrow  into  coiiliict  with  tlw  rooj'jin<^i  •-■ 
Icrntil  oblique  tiiid  IrauarcrMilis  niuocleo.  which  it  mtiy  either  rupturv of  7^ 
before  It,  thinned  out  and  cx)innded,  M  -''  *'-- 'jucnLlr  th«sa  arv  rupU'*'- 
cuuflti Luting  a  partial  inveatment  to  the  n,  which  is  ntoal  fvtJcol'> 

the  iDnormuet  part  of  the  anc.  that  whit-u  ii>  ixMrest  the  niceutl  lioa.  A»^ 
hernia  tmiaw  Uinmgh  the  external  ubdomiiml  r^ng,  ii  nH-etre*  firom  tl«* 
iutercufumiiar  fascia  and  fibres,  and  lastly  hi  innsted  by  tlw  cansM  ft^ 
aud  iiitegumeuta. 

Id  ihe  rare  lltrni  ordin-ol  ingninal  hernia  which  Ilea  <•  ■  ■.ytfa^ 

mrtrry.  the  prittninioii  may  yoM  under  the  lower  ledgL'  <  ..  <i«l%* 

tnuvcle,  and  then  receivia  a  partial  iDveatinent  of  creouMtenc  ^aaria,  ■ip 


■rrit-f  «i-!  ■* 


TARIBTIBS   OP   INQUINAL    HERNIA. 


785 


siallj'  DD  its  iliac  side,  ns  it  comes  into  relstiun  vith  the  inlern&l  oljlique. 
'1h'\a  furio  uf  direct  iuguinal  berniti,  therefore,  receives  ver^  iienrly  th>e  same 

vovuriog  thai  ihe  oblic)uc  di^es.  though  its  iovestiucnt  by  the  cretnaster  is  not 

ai  pcrltta.    It  does  nut  come  into  rolatiun  with  the  coojoioed  tendoas. 
Relationi. — lu  tliu  itircct  iuji^uiiial  lieruia,  the  apermatie  cord  lies  to  the 

outer  side  ut'  tlic  aac  ;  ami  ilA  cUnucnt^  arc  never  separated  from  one  iinother. 

as  oot'tu  ion  ally  liafipitiM  in  tliu  ulilique.     The  ejtignttrie  artery  also  is  on  the 

Dutpr  side,  but  iismilly  arclitfs  very  ilisiiricily  ovi;r  tlic  neck  of  llie  enc,  sorae- 
ptiaK«,  indeed,  i;om]ii(!loly  enrirciiug  tbi>  upjHir  n«  wl-11  as  tlic  ouicr  margin 

(Fig.  794). 

I.v(X>Hpr.F.TB  or  Intriwtittai.  Hernia  i«  ui^ually  of  tlio  oblique  kind; 
febut  Lawrence  haa  observed  that  it  may  l)i>  of  the.  direct  variety.  It  uficn 
^(•capes  notice,  hut  may  not  luifrequtintly  be  observed  on  the  oppoeilc  aide  to 

in  ririlinnrv  in!:;iiinal  htTiiia. 

Double  Inguinal  Uerats,  on  opptwite  Bide«,  are  of  very  oommon  occur- 
innce,  and  they  may  be  of  the  name,  nr  aiiHiamc  diflurent  forms.     In  some 

ioBtances,  the  two  tonus  may  be  observed  on  the  same  side  (Fig.  "flo). 


>^     ^ 


k\ 


V 


r 


F%.  ;H.— Du«bl*  iJlrMt  IngalDKl  tl«>ttU.  Neafc  of 
8m  «rMMd  b;  Bpigutrtc  Arttry. 


on  thfl  Mm*  Bide;  Oblique  ftbore. 
Direct  btlowi  *»f>*rat*d  b;  B|U- 
fulrie  VmmI*. 


In  females,  inguinal  herniw  nre  miicii  le»s  frequent  than  in  malea.  They 
nay  occur  at  all  ajjes,  buL  selilum  come  under  tlie  notice  of  ihe  $urgeou 
except  at  advancetl  jwrioti;!  of  life.  Tbey  have  the  same  relations  as  iu  the 
Ui;ile,  except  that  the  round  ligament  is  aubsliiutuil  fic  the  spcrmaliu  cord. 

Signs, — Th«  «igD9  of  inguinal  hernin  vary  soiucwhut  according  tu  its 
character,  whether  intentitiat,  complete  or  scrotal,  oblique  or  direct.  In 
the  mterttiUai  hernia,  a  degree  of  fulness  will  be  |M;rceived  iu  the  canal  when 
the  patient  stands  or  cougba ;  and,  on  pressing  the  tlnger  on  the  internal 
riu);.  or  pa&«ing  it  up  into  the  external  ring,  nnd  directing  the  patient  to 
cough,  a  diittiuct  impulse,  together  ivitli  tumor,  nmy  be  felt.  In  the  onlinury 
obitfjue  inyuiniil  kemia,  a  tumor  of  nn  oblong  or  ovat  shape,  oltLiqne  in  iitt 
direc-tion,  uiking  thu  course  of  the  canal  downnanls  and  iorn'ttriln,  wilt  be 
fi^tt  prutrudiiig  through  the  external  abdoinintil  ring,  and  prot^ennng  all  the 
utual.digns  of  a  hernia.     So  long  as  it  is  confined  to  the  neigbborhoiHl  of  the 

VOL.  II. — 6U 


788 


SPECIAL   HXBNIJt. 


pubes.  it  i«  nf  moderate  nize;  but,  when  once  it  eaten  the  scrolan,  nUttii 
mei;U  with  tree  ret<i?tHncp,  it  may  gruduallir  enlarge  nntil  Jt  stutnt  u 
eoormuua  bulk.  The  tenlicle,  however,  mar  alwayt)  W  fell  inUnUr  timta 
at  its  poeterior  interior  part.  In  women,  tnia  form  uf  hemtn  ilnoHMbiila 
the  laViun,  but  never  atlJiins  the  sarne  magnituile  oi  id  maiL  WIkb^ 
IsTjE^  Bite,  these  nrptures  usually  contiiin  bulb  ioti^tine  ao<l  ixuratBRi. »» 
frequently  a  portion  of  the  ileum,  though  the  vsrioue  irihrr  Ti*<vra.  laAu 
the  ciccun),  b]a<]der,  ttc„  have  bei-n  found  in  iheni.  In  thr  titmt  impiad 
fumxa,  the  ayniptoms  chxcly  tewmhle  tb<Mff  i^f  the  obbqur,  citerp4  tmtlk* 
tumor  in  more  rounded,  huiI  niitiBlly  not  m>  Inr^ ;  \\\f.  noric  it  wiier,«ii 
situated  near  the  root  of  the  p^nia,  with  the  conl  on  !»•  <>«it»T  •idr. 

Ru»er  directs  attention  to  the  tniiM>rtan(  tact  thai  t  v  ix  ovnil 

in^uiutil  heinia  is  mo^t  romnii'n  in  young  nin)e»,   -  <•*  iatciMl  « 

direct  in({uinal  hernia  is  iilnioat  confiued  tm  eldcrty  men.  ibi«  apeaall 
be  owing  to  the  imperfect  closure  of  the  fanc-iciilar  pmrtM  of  tbe  fanlaMi 
being  the  commoD  cauae  of  the  firtt,  and  abiorpcioD  of  fiit  of  tb»  mobI 
form. 

The  different  fornig  of  ioguioal  hernia  are  not  unfrc^jueDllr  tamjfialfA 
with  varioua  other  iSectiuDs;  eiiher  with  different  kind*  of  ruptyrv.  oraUk 
diaeuM  of  the  cord  ur  testis,  euch  «£  hydrocele  uf  the  mnl  or  nf  tl»  uam 
raginalit,  or  varicocele.  The»c  various  ctimplicatiouanceaaarilf  nakftbt 
diagDwis  w^mevitiat  more  utjecurc,  hut  with  rare  uuil  practice  h  maj  paa 
allv  t>n^ily  be  made  out. 

Diagnosis. — Tlie  diajrnosis  of  inguinal  hernia  is  osually  nuHlj  lA^ 
the  chnraeters  and  p^Miiion  of  the  tumor  i-nHliliug  the  Surgmo  tii  intrmm 
its  true  nature.  In  moHt  caiH-H  it  i.<t  iisrleivt  to  i-ndrnv<ir  to  avn-rtain  «bttlMr 
the  hernia  is  oblique  or  direct ;  all  nid  oli]i(}ue  bernim  liaving  a  imAtMj  I* 
drag  the  inner  riufc  donriwurdft  iind  inKHnln,  approxiniutinn^  it  and  Inif 
tng  it  neiirlTojinDflite  to  the  outer  one,  shortening  and  de^trivio^lbeubfiritin 
of  the  canal.  Hence  the  direction  of  the  nerk  and  of  the  ax»  ufUielivM' 
in  these  caaes  bo  nearly  renemblcf  M-hnt  is  met  with  in  the  ditMlbrntf 
hernia,  that  the  Hurgeon  should  not  atlempt  tn  undertake  an  u^mliM. 
niorc  particularly  the  division  of  the  ttrieiurc,  on  any  imajiiumrf  Ois^^ 
Some  forms  of  Ycviaral  hernia  (nay  occnsi^wially  be  contouwlrd  iiiik  U* 
inguinal ;  the  di»|ii)giii»i|)itig  |>oint»  betwt^en  tbe»o  iw«  form*  of  ihediiw 
will  be  coiMidered  in  the  Kctii<n  on  femoral  heniiiu 

The  diflgtiM^i^  of  inguinal  hernia  fri>m  otl)er  ilJneaK*  io  ibif  vidaiif  iM 
to  be  r'iiiHiili>rcd  under  the  two  cunditioos  ill  which  the  rupturv  i>  &)«ail'>> 
in  (Ac  C'lntti,  and,  'J,  in  Mr  tm>liim. 

1.  Wliilst  still  lyirrg  IH  (Ac  canal,  inguinal  her-  :ia(Oi«" 

fhjm  the  follow  ing  cuuditiuns:    o, -Ji»rr«i,  des'.-  ■  mitini^ 

the  abdomen  or  mdvis  Ihrougli  the  canal,  and  ptia»iug  out  tfaroa|^  1^  ^ 
domiuai  ring.  The  diagn'Mis  niav  herv  be  effected  by  recngnisiaf  ik^ 
flucluiLting  feel  of  the  abm.-eaB,  which,  though  reducible  on  jvrcvarr,  ** 
dcsuending  on  coughing  with  a  distinct  IropulM:,  dt>ce  not  proant  Utt  *"* 
solid  rharncterB  and  the  gurgling  wnnalion  of  a  heroin.  6.  Kmpki  * 
Di^uarri  UtjdrattU  of  tli«  i'ord.  In  the  eneytied  h/drvcrft  ibeje  it  •  !■■" 
oval  ■welling  aitunteil  iin  the  c»nl,  which  can  he  apparvutly  reduoeil,  hi*S 
pnahed  np  into  the  canal,  and  deacends  again  on  coughia|t  or  straiBtBf;  U* 
It  may  be  didlinguiyhed  from  hernia  by  l>eing  alwayi  of  tbr  aaCM  iffi 
by  not  betnir  reilucilile  into  the  cavity  rd'  the  abduoten.  by  the  abaroe*  od'dl 
giirgle.  and  l»r  its  verv  delined  outline.  If  the  testicle  tn-  drawn  H**** 
UM  cnoy«te<l  nydroc4>le  hecomei  flxe>l  and  in  on  longer  fvdui- 
ttM  canal.  In  the  diffoMtl  hydronelt  of  the  (Mnt,  the  ahaeo 
impulM  on  coughing,  the  imp(«sibility  of  ri'tuming  ibe  ainillittg  c« 


DTAQNOSIS   OP   INOTTINATi   HEUXTA. 


vitliln  the  alKlnmiiin]  cHvily.  and  nf  foeling  the  con]  in  u  free  uml  imlurul 

.  etaui  in  bcmin,  will  prevent  the  Hist-R^pi?  from  Iwiii^  confounded  witli  each 

Kotiior.     e.  HiKmatocfle  nf  the  Cord.     Here  the  soil  and  Hiu'tnatin)^  iiLture  of 

Ithe  awdling.  the  eccliynioeis,  the  impoesiljilil)-  of  enninlete  rediictimi.  and  the 

iBfaeeiiee  uf  gurpliiig.  will  indicate  its  true  nature,     n.  Fatly  or  olhtr  Twmore 

oprasiiinally  ftirm  on  the  c»rd  ;  but  tlie  circumscribed  chHrucier  and  limited 

aixe  of  these  swellinpi,  the  absence  of  impulse  on  coughing,  and  of  rcdiiribility 

into  the  ciiri'.y  of  the  abdomen,  and  their  becoming  fixed  when  the  teslielc  w 

drawn  down  so  iib  to  put  the  cord  nn  the  strelch,  will  point  out  ihat  they  are 

not  hi-rni:e.    f..  /jotigement  oftkt  TVrfiJ  m  iHe  Inguinal  Cnnal  will  give  rise  lo 

a  iimior,  which  closely  resemble*  iocomploie  inguinal    hernia:    and  if  it 

ithould   happen   Lo  broime  inOanied  in   this  situotioD,  the  difficutiy  nf  the 

diagnoi^iH  from  strangulated  hernia  may  be  very  considernble.     In  the  ordi- 

rnary  undescended  testis,  the  ahaence  of  that  organ  in  the  scrotum  on  the 

aAected  side,  the  peculiar  sickening  pain  occasioned  by  the  pre^iire  of  the 

tumnr,  the  absence  of  gurgling,  and  ot  all  possibility  of"  reduction,  will  enable 

the  diagnosis  to  be  eH'evted.   /,  lufiamed  VmUitaided  Testis.    From  this  it  is 

not  ftlwaya  at  once  easy  to  effect  the  dlatrnoeis  of  incnmplete  iunutuR)  hernia 

in  a  state  of  etrangtdation,  with  which,  indeed,  it  may  be  complicHted.    This 

point  in  dingnucis  will  b«  more  hilly  treated  of  in  pjieakiiig  uf  congenital 

hernia.    lu  the  meanwhile,  it  may  be  statetl  that  th«  altw-ncaof/jpT'iV'-M/and 

coniinnout  vomiting  and   coUHtipaliou,  the  feel  ti  the   tumor,  hani   below, 

elastic  above,  and   the  peculiar  pain  when  it  ik  cnmpreMed,  will    enable 

'  the  burgeon  to  recognize  the  true  nature  of  the  tumor  rh  being  a  retained  and 

ioflanted  testia. 

2.  When  the  hernia  ha8  descended  into  the  wrofum,  it  may  be  ccnfonndcd 
with  :  o.  Hiidrocelt  of  the  Tunirn  Vo^inaiif.  In  ihls  disease  lher«  JB  an  oval 
or  pyriforni  tumor,  usually  transliicuul,  nnrhnngcehic  in  aize  or  shape  by 
pressure,  and  having  the  curd  cleaj*  and  ilii^tinot  above  it,  with  an  absence  of 
impulse  on  coughing,  or  of  gurgling  in  aiicaipig  at  reduction.  The  palicot 
wilt  usually  have  noiictrd  in  hydroei-le  that  the  Bweiling  Kr^l  appeared  at  the 
bottnoi  of  the  scrotum,  while  tu  hernia  it  des<*uded  from  above.  Id  ca»L'»  uf 
Ciiogeuital  hydrocele  in  chihlren,  in  which  llicre  i«  still  an  opening  comniu- 
ntcniing  with  the  peritoneal  wiviiy,  the  tuinitr  may  be  diminished  in  size  by 
[steady  pressure,  lint  gnulually  rt-tuni«,  fliietunieji,  aiul  \»  ininsluccuu  lu  theee 
fouea  its  traiislucency,  and  the  gradual  manner  in  n-hicli  the  ^ac  lis  emptied 
id  is  refilled,  very  dltlLrent  from  th<':  »iuddi'n  «li|i  up  and  prutrut^tou  <>f  a 
hernia,  enable  the  Surgeiui  l<i  eniablish  the  diaguoein.  In  inliinte.  however, 
it  must  be  rcmcmhrred  thnt  a  hernia  \s  oft4?n  translurenr,  as  it  seldom 
coptaias  omentum,  and  the  contents  of  the  gnt  may  he  chiefly  gufi.  It  not 
nnfrequeiitlv  happens  that  hernia  it  complif^alcd  with  hjdrocfJe  of  thf.  Utniea 
vatfinalln.  In  ihe«e  ousfs  the  two  acfwirate  tumors  can  nsnnlly  he  diatin- 
guished,  there  bring  some  degree  of  (.•onstriclion,  or  of  consolidation,  between 
them.  The  hydro(«le  will  present  ilx  ordinary  characters  of  tranalucency, 
irreducibtlity.  and  circumscribed  uutline,  and  in  commonly  placed  anterior  to 
the  hernia,  which  lie?  towards  the  hack  of  the  acrottim,  and  may  be  dislin- 
^ishc-d  hy  \X»  redncibility  and  i[i)|>utse  on  coughing.  It  ftometimca  hap|>ens, 
as  in  a  case  which  once  fell  under  my  oKiervation,  that  a  hydroccU  nf  ifu 
cord  u  nMotiatf.d  with  one  of  Ihe  tunina  vaginnlit  find  a  hernia;  in  snch  eir* 
cumMancen,  the  diagnosis  reijuires  a  lillle  care.  Init  niny  be  eflecied  readily 
enough  by  separately  determiniug  the  cliarncters  of  the  diJfereol  swelling*. 
6.  Varitwde.  Here  the  diagnopii*  may  be  effected  in  the  way  pointe*l  out  uy 
Sir  A.  (Vioper.  The  palienl  should  Ik;  pla<^wl  in  the  reeumheut  ptisition,  und 
the  swelling  reduced  ;  the  Surgeon  then  oreNfes  ii|>un  the  exu-rnal  ring  with 
hu  tingers,  tnking  care  ti>  cover  the  wuule  uf  it,  and  desires  the  patiejit 


788 


6PBCIAI.    UERNIX. 


in  »taiid  up.  If  it  b«  u  liemiti,  the  liimor  canuot  deac«iid:  botifH^htt 
vtu-icoceU.  it  will  si>oe<lily  r^jtpesr  irhUit  the  prr*ntre  is  6r»»f  htfi^^ 
bloofl  being  cuiivt<)-c<l  iiiui  it  ihmugh  the  Bpernmlic  nrierirs.  c  Tv>mi/ 
the  'fcstu.  Tlirot-  miiy  be  distinguished  rrum  bvmia  by  ibadr  aal«l  Ipv 
rounded  eliam-.  by  the  itliwDee  of  all  impulse  on  ooagbia({,  wkI,  wptdtlTi 
hy  the  cnni  heinjr  fell  free  atid  clear  alMive  tlifin,  and  the  inifuiskl  oial 
unoccupied,  d.  iliBtitaioetfe  uf  the  7W»roa  Vagirtniu.  Here  the  c«uati>ftk( 
swelling,  ilaoval  Blmpu.opnvil^.tKjIid  feel,  ihe  ab«eac«of  impqUennoMoiUaft 
Hiiil  llie  tiffiued  eliaraclera  of  the  curd,  will  enable  tha  Surgeva  to  ■uini 
diaenoeis. 
TreKtment — When  in^iinal  hernia  is  mlucible.  the  nipmre  awt  U  bfi 


up  by  H  well-made  truts.  the  pad  of  which,  of  an  oval  shape, ilMMkl  |«mMl 
only  upon  the  extcniitl  ring,  nut  upon  the  whide  Ir-ngth  of  the 


thid  form  of  hernia  that  (he  various  ofteratioos  f>>r  thu  radit^  enn  m  MM 
applicable.  When  it  h  irredacible,  and  of  large  ti7.e,  nothing  can  k*4(M 
Iteyoiid  aupporting  it  in  n  bfl)>^truas. 

Operation.— When  the  heniia  ia  etraugulatvd,  If  ibe  Uxii  ^nfmij 
employed  in  Lbe  <)irectioii  of  (he  canal  hare  fiiiled,  the  opvnUm  mm 
be  performed  in  the  following  way:  The  blailder  hnrinj*  ' — •'  '•••'-•— ^  %oA 
the  pubes  Khnverlilhe  palitiiit  should  be  brought  Ut  the  e*!.  ^ 

the  .Surgeon  standi ng  between  his  le|j^  and  having  thf*  *kiii  i-ivi-tiM^  ^v  *i- 
lernal  ring  well  pinvhe<l  up.  divides  the  fold  in  the  nnual  war.  br  mnbdsLN 
two  incbea  in  leii{!th,  commeneing  about  half  no  inch  sbure  tb>  tinml 
abdaminal  ring.  Should  upy  spuuting  veeael,  ii  the  •xtcntftl  pviBtt  ^ 
divided  in  this  Juoiaion,  it  had  beiier  be  ligntored.     The  Svrgvoa  ihf* 

firoeaeda  with  the  seeliun  througti  the  auhculaoeous  atmclsm;   Iw  mil, 
n  many  owes,  tind  the  su|>erlicial  fnaoia  considerably  ibickconl,  partioid^^ 
if  the  patient  have  lung  worn  a  truss.     He  diviiles  tbia  strnrtur*  in  tibial 
uf  ihe  external  incieiou,  and  iheu  expoaea  the  interoolamnBr  fiiia  irtH 
will  alw)  generally  be  found  thJekeDcd.  and  inciirpo rated  mish  UwnpMieist 
foBuia.     In  many  cnscs,  the  intereoiuninar  fibres  will  lie  found  cnndtwrf 
inti)  a  thick  nnd  broad  fillet,  which  limiu  the  further  exteation  uf  tlMMf. 
and  pnkducos  an  evident  conitriction  upon  the  neck  of  a  larp*  InjiiH' 
hernia.     An  opening  should  be  carefully  made  into  ihia  faacsa.  a  giwn' 
director  jMk««ed  under  the  odge  of  the  Hug,  and  thi«  slil  up.     In  anaa  flHn> 
though  but  very  rarely,  it  will  now  be  fuuod  ihnt  the  hemta  timf  be  n^itd> 
it«   strangulalixn    depending  on    the   coiiHiriciion    of  the  iBvpH  uf  i^ 
ai>erture  ;  must  commimtv,  however,  the  Mricliiro  is  sitiintcd  deeper  ihMlU^ 
The  cremaaterio  fascia,  wKioh  is  generally  condderably  ibiefcHied.  is  nu*  ■■■ 
p<jsed,  when  itA  fibres  will  be  found  to  form  a  kind  ij[  -tlniiiffW 

the  herniiil  tumor.    Thisstrnclure  must  be  rarefullv   I  ...mniipMW 

when  tlie  tranaversalia  fascia  and  subserouD  -buc.  or  jtuei*  F'W"*' 

will  be  laid  bare.     This  structure  la  usually  f  >'  )  anil  voMtilar.aM** 

unfm|tieiitJy  the  »Lrlctuni  appear*  to  be  attuaieil  in  it,  or  In  ■  kind  uf  Me- 
deosed  riu^  fonnod  by  the  inotrporaUou  uf  ii  nith  the  m(«bt*  of  the  tah 
roaster.  If  il  he  found,  after  the  diviiiou  uf  these  fwc-iK.  that  the  bm" 
can  be  r«iuce<l,  it  would  of  ouurve  be  uuneoemiry  l»i  lay  ojten  ■'■•■  -—  *■* 
the  patient's  chance  of  rvenvery  will  be  con^idcntbly  cuhono  ^f* 

tlouiarly  if  tlie  ttpemtiou  be  iwrforuieil  for  pn  old  scroti]  farmm  ot  itfP 
size,  by  not  duiug  en.  If,  huwever,  us  will  hapiten  in  the  ni^f*icil7  el  ■>■ 
•lAocee  in  inguinal  hemm,  it  be  found  that  the  etricturv  i»  in  iheMefcW 
the  ano  itself,  ticcusioned  by  n  unndemuioa,  ooaatrieii-in,  and  podtariafW 
It.  the  aac  ntuttt  tie  carefully  opened  at  itv  nnterior  pnn,  the  inter  Wtrr 
dticwl,  and  the  stricture  dirideil  from  within,  by  prrMtiag  the  wiget  wJ 
under  il,  and  cautiously  nlitltng  the  hernia-knife  aJoog  tbia.    It  is  «a  oMS^ 


STBAKOVtATED   IITOtTIKAL    HBRKIA — OPSRATIOK. 


lished  rule  is  surgery,  that  this  (Uvision  ehould  be  efll'tjU-d  in  a  directinn 
imroediatcly  upwards,  bo  timi  it  may  lie  pamllel  ivitli  the  cpi^ni^iric  vc^eele, 
wbelher  it  be  situated  upon  the  inner  ur  outer  eide  of  these.  It  is  true  thni, 
if  the  6urge»n  eould  be  sure  that  he  hud  to  do  with  an  obliciuo  inguinal 
hernia,  he  iiiij;ht  safety  divide  the  slriclure  outwartis ;  or,  if  he  were  vertaiu 
that  the  protruaion  wiis  of  the  ilirent  kind,  he  iiiighl  make  the  Miction  in- 
ward»;  but.  as  it  uoitiiiKinly  happ<-ufl  that  hv  raruKit  di^icriniiie  with  uliKDiiilo 
ceriaiiily  U|)')n  whirh  varicLy  nf  hrniia  he  ii>  nixratiti^,  liu  Hdo|iL«  the  safer 
phin  reeoriiiiifiKieii  liv  r^ir  A.  (Viojht  and  Hir  \V,  Lawrence,  uf  oiittin);  iip- 
wardg  frail)  Lh('  iniddlu  of  tlu^  r'tug  parallel  to  the  epif^ieiric  vcismIs.  Af\er 
tiie  tiiTiiia  huH  hi>(>u  r<^]ti[,-eil  the  ring  iiiiiy  he  clnHHl  in  proper  «u>cs,  as 
already  <!i.scril)rd  fp,  7.^0). 

The  Seat  of  Stricture  in  inguinal  hemln  will  lHiih  he  seen  to  differ  in  dif- 
t'ereni  rasfs;  ami  in  m>tnc.  ini^iiuiccs  it  exint^  in  two  situationH.  I  think  it 
lUiKt  oiinmonly  iMViirt  in  the  neck  of  the  eac.  owing  lo  contraction  and  elonga- 
tion of  it,  with  condrMHtttion  of  the  iinhsrroiis  areolar  tisKue  lyin^  immedi- 
ately upon  it.  Ill  ottier  cases,  thowgli  much  nnnv  rnrety,  it  seems  Ut  be 
formed  liy  a  thickening  of  the  transvcrsalie  fHseia  in  the  inner  ring,  but  aU 
tof^ther  outride  the  oae.  OceiiHinDally  it  is  nift  with  in  soine  part  of  the 
canal,  at  the  htwer  edge  of  t)t«  inlerunl  ubiiqne,  but  much  more  frequently 
at  the  external  abdoniiuul  ring.  In  luiiuy  am^  there  id  very  tight  constric- 
tion in  this  situation.  &»  well  as  in  Ihv  dei>|KT  pcrrli'>ns  of  the  c^nal,  ur  at 
the  inner  ring;  lieuce.  after  the  division  uf  any  strietore  at  the  external 
ahdoniiiml  rinjr,  the<k<u{>er  portion*  of  the  canal  should  always  be  carefully 
examineil  bclore  iiiiy  nltoiipt  is  mndi'  to  put  the  heriiiu  back. 

The  o|kcratiiin  for  an  IncomphtK  Inguinal  Hernia  reijuire*  to  be  conducted 
in  thi;  ^nnie  way  a»  ihitt  which  litis  jirnt  l)«-^u  lit^aci'th^rl,  except  that  the  in- 
cision need  not  bo  t|uitB  so  Idhj,'.  and  should  not  extend  beyond  the  external 
ring.  Aftvr  thiit  haa  been  laid  open,  and  the  tendon  of  the  external  oblique 
slit  up,  a  tlat  director  roust  be  p&-«ed  under  the  lower  edge  of  the  ialeroal 
oblique,  which  must  be  carefully  divi<led  ;  ehould  the  stricture  not  be  relieved 
in  this  war.  and  the  sac  reqnire<l  to  be  laid  o]ten,  the  deep  section  must  be 
made  in  the  surne  way  and  iu  the  same  direction  as  has  already  been  de- 
scribed. 

In  loguinal  Hernis,  oontalniog  either  the  Csecunt.  the  Sigmoid  Flexure 
of  the  Colon,  or  the  Urinary  Bladder,  the  |>n>truded  viscera  are  only  par- 
tially covered  by  peritoneum;  hviiee,  in  operating  upon  such  herniie,  when 
straogulated,  cnre  must  he  taken  tliat  Ihtt  contents  be  not  wounded,  which 
is  a|>t  to  occur  if  the  Surgeon  divide  the  ]>arts  without  due  caution,  not  !«us- 
pecting  himself  to  have  reached  the  neighborhood  of  the  visens,  but  believ- 
ing that  he  has  met  with  a  sac  which  iloc-s  not  exi^t-  As  the  protruded  parts 
are  generally  adhcreut  in  thtise  cases,  the  Surgeon  must  content  hinii>c!f  with 
leaving  tbem  unreduced  after  the  divi-don  of  the  stricture;  in  such  circtim- 
BlAQces,  it  bos  happened  that  the  protruHi'>ii  is  ultimately  drawn  back  Into 
the  abdomen  by  some  tiatural  action  of  the  puru. 

Operations  for  strangulaied  inguinal  hernia  are  requirefl  during  a  greater 
range  of  ages  than  ihowc  for  any  other  kind  of  prolruition.  I  have  operated 
succea*fullr  for  congenital  hernia  in  infanta  leas  than  iiix  weeks  old,  and  for 
ordinary  oblique  in(z:nimtl  ht-rnia  at  seven  weeks  and  nt  f-iur  mouths  of  age : 
and  the  operation  hna  hf^en  douo  im  ceiitenariauH.  When  fmiall  aiid  recent, 
the  protrusion  u:«UHl)y  c>>n!>ist#  <if  intestine  only;  when  large,  it  mnirnonly 
contains  omentum  as  well.  The  treatment  of  ihene  contents,  and  the  after- 
management  of  the  cas«,  must  be  conducted  in  accordance  with  the  rule* 
laid  down  at  p.  7G7  «1  sefj.,  vol.  ii. 


790 


SPSCIAL    HERN14. 


IIkhxia  iv  tre  TrNTCA  VAtirifAi.w:  Cosofwttal  !' 
cann  die  bcruia  •JeiK'^Q'U  by  ihe  un'ibhterati.-d  prtiw**!. 
periloneum  iDside  the  tunics  va^iunlis,  which  i-uitntuucr*  u»  mc    U»i>' 
ways  oblique,  aud  tukra  the  coui'K  of  tb«  egwrniKLic  oir«l,  tuart  ww*lj 
descrading  iolu  tb«  scrutuni,  but  BDiueiimc*  lv>"P  viiitiin  (Jweuial,oM« 
which  pcrTiafn  the  t««tu  hu  imperfectly  pRncn).    This  bemiadiflcnifnMiia 
onliitan-  oh)i<jue  hcTuia  io  the  ah«cnce  of  a  (H.Titonfnl  mo  of  o«w  fnraatiaft, 
the  {in>triid(Kl  parts  lying  in  the  ttiiiivn  vagiualix  m  ciiuiiil>i  with  tbetotiM 
(Fi);.  T!)(r).     Th«  pruat  poculiiirity,  inileerl,  ul'  thl«  hrmtti.  c<i4ui»u  i>  itt 
deBt*cnilin^'  nliHip  the  caiiul  left  0|ieti  by  iriv  dtMN'tit  of  ihr  ir»iis.    Ii  ib 
fiT>tU6  Ihi;  [OHlifl  iirit^nally  lies  below  thi-  kiilafty,  and,  as  it  >lr*readi  is  iW 
lutvr  tnoiiihH  of   intrauterine  life  iai^  the  bniatl 
cnuul  ami  e^^rotum,  it  pnllft  down  a  pn*lt«icanM  4 
the  [>enUinet)ni,  rx»rtiy  rrseinhlii));  a  bmuu  mc  U 
addiliuti  to  thin  ttrfiH-livc  clMeiiiT  of  ibe  tmfj^ml  wv 
oe«  of  the  peritiineuin,  ihvrt  is  another  ■iiilwAif 
condition  which  tniid*  u>  the  formaii  .n  of  inpyiiul 
inguinal  hernia — vix.,  an  abnortun  ..milwy. 

Thtj,  unlike  the  oprn  pf^rtionral  i':--  -  ^.  .-  an  mi* 
sary  irt  the  fnrmnUoii  of  the  htToia,  but  wbM  ts* 
mg  it  i*  a  material  fact^ir  in  tU  j  -  '  -^  -  -^i  m 
attended  by  thin  •rrioua  inoiinvrn  ■  m 

obatAcle  Uf  Ui«  rulieal  nirf  of  tiu-  nrrpta  ny  tkt 
cloaure  of  tiie  ojieti  funicular  jtrncoM  uf  y>U>idM 
by  the  pn^rvure  <if  a  IruM. 

Tlmt  |)ruli>uf!ati<>ti  of  the  peritmieuin  «b>rti  i•<•^ 
rieil  <tunu  around  the  (t-Htts  in   ita  dix<cet.  mt*  ki 
dividud  inU»  two  i>urtiuu»,  the  fuiiicuUr  und  liw  !«*► 
cular.     Tlje/iiHt'"w/'ir  is  that  which  corrvtcuniia  lo  tb*-  c;  ii»a  &•• 

the  tnl«rual  rin^  tu  thv  wrulnm  ;  the  ffWicWar  U  thut  mi  "•am  llw 

tunica  va^inali^.  A  cou^'uilal  heruin  oecunt  in  cH>nBei)orDC*  of  tht  faaio 
lar  |inilongati<)ii  D(»t  beeouiing,  a»  in  ihe  norraal  ednditiun,  ooBwrttd  irtO 
Hlanientoua  tibro-ocllular  titwiio,  but  remaining  (wrviuuii,  and  tboa  Mftiaiw 
a  nietlium  uf  ciiminunicutiiin  heLwtMUi  the  general  cavity  of  lb«  jmiUmki* 
and  the  tunica  va^inalie;  and  along  the  open  channel  thua  left  tWcDBfNii' 
hernia  deseendi). 

Hernia  in  tlie  lunica  vugioalifl.  though  ucually  oalled  "  c— jwlwl,'  ** 
rarely  eo  in  reality :  the  ten<lrncy  is  congenita],  but  the  ilinHS  u  ML  ^ 
not  unfrequrntly  [iBp)><<nH,  it  \a  true,  that  theao  heroin'  ahow  Um— Iwi <*^ 
in  life,  in  infuntH  a  low  weeks  or  months  old ;  tbongh  uvea  at  Umm  iff**^ 
fanicular  prolongation  of  the  peritoneum  may  be  m  oomplctelT  MniM 
thnt  the  hemin  which  occurs  is  of  an  ordinanr  oblique  cfaaraeter.  Nlti^ 
fretiueutly,  however,  the  hernia  doc«  not  take  place  until  «  rooodldhh 
later  period  of  life  than  thi«,  and  may  suddenly  nappe*  hi  Ch«  admh:  A* 
Velpenu  relates  instances  in  which  it  occurred  'f<»r  iJia  firat  time  bfCwcMl^ 
ages  uf  eighteen  and  twonty-6ve.  I  have  operatcil  In  a  caae  ao  •  inaa  ikifi; 
five  vearB  of  Hge.  in  whom  this  kind  of  heniia  occurred  6>r  '*-  ♦■"■t  "^ 
wbi-n  he  was  twelve  yean  old  ;  and  some  year*  ago  in  ■  ca-' 
pilal,  on  »  man  about  lifly,  in  vrliuni,  on  tlie  W'mi  careful  ini^ijuji .  r.  i 
appi'ar  that  the  pnitruniun  bad  not  sboitn  itself  until  be  waa  abcmt  thit! 
yv&r*  of  age,     'I  be  i-xplanntiou  of  these  CKKStis  that  tK<  'ptr  pxrtM 

is  only  partially  clostfil  or  conlracled,  and  I  hat,  under  it  .>furt,lkf' 

Mptum  is  brukeo  through,  aud  thus  a  knuckle  uf  gut  falb  mw  ibe 
vagioalia. 


m 


DK»NfA    IN    TUI    TUNICA    VAGINALIS.  791 

Siynt  tnul  Pia^nonf. — Tbo  eigos  of  heniiu  iti  the  tiinR'a  vugiimliH  cli>«ely 
ble  Uiow  of  the  rinlinary  >>l)lii|iie  ;  nnwt  cuninnmly,  howcvur.  it'itiTuLal, 
ibt  ItUBor  ii  much  rtmtiil^l.  and  the  nerk  feviU  iiarntw  and  votiatrii'lcd. 
TIm  UMia,  aim.  mnttot  lie  felt  ilbtinct  Hnil  separate  fnim  the  lutii'ir,  but  in 
Mrmuaiied  by,  Mud,  ȣ  it  were,  luiried  io  the  sulwtiince  of  the  heniin, 
tbroagh  which  it  may  Bomelini«s  he  felt  at  the  lower  rdiI  hack  part  of  thu 
seroCara.  Id  an  oraiDury  in;;uinal  hernia^  the  tenser  the  rac  the  more 
diBrly  m  tbe  tMticIo  eeen  and  fett  outside  It.  In  a  Lxingenital  hernia,  if  the 
He  ia  teur  the  tostiols  eaoDot  bo  felt  at  all.  On  luc^uiry,  aleo,  it  will  usually 
be  foand  either  that  the  hernia  hiu  cxisbcd  in  childhuoil,  or  that  the  tc«tt9  is 
■till  in  the  caasl,or  hu  dcdCfiiided  later  than  usunl.  A  hcrniaof  the  tunica 
v^pnUu  DMT  tw  aasociaied  with  a  congenital  hydrocele.  In  theM>  ciiMs, 
rnlUr  Um  fluid  bai  been  returned  into  the  periii>ncal  caviiy  by  >lir«ctin(?  the 
paiieot  lo  lift  od  hid  back,  and  raiting  tbe  serotntD,  tba  portion  of  protrudod 

SI  may  be  ftli  aud  r«eof(Dited  byitigut^e  and  upward  slip  wh<i-n  reduced. 
ic  hernia  may  be  aatodAt«d  with  tbe  testia,  either  uodeacended  or  lying  at 
lb*  estemsl  abdomioal  rinx-  In  the  firat  caM,  tbe  beruia  is.  of  oiurae.  io- 
•onplele:  in  the  aecond,  it  ig  scrotiil.  Whtfti  incninpk-tv.  the  ilia^nous  may 
be  mmdc  bv  fwling  a  tofi  swelling  with  the  ordinary  hernial  signs  abu\'e  the 
tmal  I  and  liarden^  testis. 

Wb<iJi  sympttKns  o(  strangulated  hernia  occur  in  a  person  io  whAro  the 
IbsCss  Aace  not  deieettded  into  tbe  scrutum,  very  izreat  difficulty  may  be  ex- 
periooevd  in  eflnstiui;  an  exact  diaguusin.  In  such  casta  as  these,  an  ohloofr 
^  rounded  tuujor,  teuse  and  painful,  hIU  be  found  tu  uccnpy  the  inguiual 
eaBal.  out  pa»iu|;  beyimd  llic  citcrnal  rine.  withsome  abdominal  tendenMBe 
aod  posiibiy  oau;»ea  and  const i[»ation.  The  qut-stinu  here  arises  as  Io  the 
aaturv  uf  this  tumor.  Is  it  simply  un  inflamed  unde^^endetl  tcetii^ ;  or  Is  it 
,  aa  uailcacvnded  testis.  ioJlaiiu-J  ur  not,  a#  tlie  case  luuy  bo,  having  a  knuckle 
^Br  Inop  af  strmogulated  intesliite  Iriuf;  behind  it  f 

^H^  Wbvn  tbe  tumor  coDMsts  simply  of  aii  inllameil  uudeeccndcd  testis,  the 
^BbIb  will  be  of  that  peculiar  chnnii^cer  which  la  indicative  of  orclittts,  and 
^Bw  oooatttuiionul  symptoms  of  Htntngulation,  however  simulator)  for  a  time. 
^Hlll  nnC  be  persiHtenlly  present.  The  following  case  is  a  gund  illuHmtion 
PVF  this  enndition.  A'  man  aged  about  forty,  said  Ui  Iw  laboring  under 
•tr»D;^latcd  hernia,  wns  sent  up  from  the  country  for  operauon.  On  being 
eaJbad  t^  him,  I  found  tbe  house-surgeon  attempting  the  rciluction  of  the 
tanor  in  the  hot  bath  ;  but  as  soon  as  I  felt  the  swelling,  I  was  convinced, 
hard,  solid,  and  irregular  feel,  that  it  was  not  a  hernia.  On  in- 
into  the  history  of  the  case,  it  appeared  that  the  patient  hiul  lor  tbe 
II  days  MtTered  from  KCcssiona)  vomiting.  And  had  iKeit  cntittipated  : 
Um  tumor  in  tbe  Kruiu  bad  not  appejire<l  suddenly,  though  it  had  en- 
I  with  [treat  rapidity;  that  it  was  ezcvedinKly  pnlufid ;  snd  that  he 
always  w»ru  a  truss  for  a  supptwed  rupture  on  that  §id<-,  until  th*-  last 
lu,  wb<-ii,  ill  cotiM->|Ut)ni^  of  the  iiiHtrtintent  breaking  he  bad  discoa- 
il.  <  >ii  eianiitiiii^  the  Kr<>in.  cartrfully.  m  tumor  hIhiuI  as  large  as  the 
was  found  in  tbe  right  iu^uinal  canal ;  it  was  teuder  to  tbe  Uiucb,  hard, 

irregular  at  the  upper  and  outer  port,  but  somewhat  lofl  and  fluctuat- 

ia§  bdow;  wheu  the  Quger  was  pftwed  iuto  tbe  exlerual  ring,  the  outline  of 
the  tumor  could  be  very  dtstioctly  felt  iu  tbe  caool.  There  was  oo  impulse 
ia  ii  no  niughing,  Inil  some  ab>Ii>miual  Leodemess  oo  that  side.  The  right 
leatis  was  not  iu  the  8«'rotum.  I  orlered  the  mao  to  be  bled,  tbe  tumor  to 
be  Icechnl,  ami  saliiin  adminiitcrrd:  under  this  treatjaeDt  the  case  did 
well.  When  a  knuckle  of  sLraugulatvd  intuetine  Hea  behind  and  ah4>ve  the 
|aa[is.  still  rrlained  above  tbe  cxtenial  ring,  tbe  aympConis  of  strangulatioa 
will  be  violcot  aud  persistent;  and  this,  even  though  the  tumur  prcstml  but 


792 


SI-KCIAl.    UBBNX^. 


.fati.i.'ij- 


little  the  feel  or  llie  ordinsry  rhararter  of  a  hrniiB.  In  far:,  in  *u-l'  ■  ■at^ 
lh«  HiifBrnn  is  giiirlnl  I15  the  rhiinirter  of  the  pnirrnl  lympi'  iii»,  and  r>  ■!  h 
thflMof  the  local  tumor.  In  a  c»iii*of  thia  kind  tn  which  I  ms  calltd. 
there  onld  he  felt  behind  nnd  nhove  an  intlameft  nn't  ■waUm  MtM. 
which  lay  nt  ihe  external  Hbdominal  Hdj^,  a  Kninll,  nt)  tumr^  ii 

the  npper  fxirlion  of  the  caual.     A«  symplunrt  of  »tr.i  ■  n  wcrfHrpm 

this  vras  cut  Aowa  upon,  tlt«  antcri«r  maII  of  thr  rannt  was  iiiriwl.  aod  cb 
tunica  vacinalU,  much  ili-temled  with  UniH,  wnt  laid  open.  mS-h  4  •ui" 
knuckle  of  Intealine  waa  fiHind   lyiri);  at  iUi  upper  fnart.  vrr^ 
alricled  by  the  inner  ring.     Hut  in  itther  cnw-s  the  diagooMt*'  1- 
th^  whole  tumor  lying  In  the  canal  ftels  »m<M'th,flafllir,  and  un 
no    nmiiuul    exmniiiution   can  eoalile  thv   Burgeim    lo  tay  *«)•»  - 
whether  the  (iimor  in  ati  inllnnted  lenl'd  »urn>un<ivd  hy  (laid  in  a  <i 
tituicu  vagiualis,  or  whether  tliero  is  a  liK>p  of  iutivtiae  l\'  -     ' 
do8CL*u<Ji.d  IvsliB.      Ill  Buch  ctUKi  as  ihew.',  however,  the  Sir  1    -' 

the  course  he  ehould  adopt  by  ihv  symjitoniD.  If  tbrH*  inr 
liuu  of  ititti>liue,  »ud  [K.>r?i^r,  utter  a  n-utuniMblc  time  baa  l>tt  m 
the  appltcatiou  of  leeches  and  hot  ftiniHiiUilionH.  ho  ehould.  aiihiiul  fiulbif 
delBV,  cut  ilowo  on  the  tumor  and  examine  its  natun>.  If  it  br  btmtil  ii 
[lart,  the  intertmt  ring  will  require  division,  the  iaii'sttne  nurt  Ui  wduial 
and  the  tf-BtiH  put  back  in  the  cnoal. 

'I^mfmml. — The  treatment  of  congenital  haniia  oonsiiiU  in  the  redaitiai 
of  the  tumor,  nod  the  applicalioa  of  s  proper  trites,  the  padiif  vhich  ibtAU 
cnmpreee  the  vrbole  leugtb  of  the  itiguinat  raool.  In  childroo,  •  ndial 
cure  may  be  effected  In  this  way ;  hut,  in  order  to  nccomplich  tliv  draraUa 
reauk,  (he  truss  must  be  worn  for  several  yeoiv.  The  upplirati>iD  of  a  tnui 
with  an  air-pud  will  in  maoy  iDstanoea  be  found  eeptvially  aaHiil.  ai  il 
applies  itself  with  ^renter  exnctnon  than  ao  ordioiuy  inooiopnii^Ut  uok 
lo  applying  the  tru^,  cnre  must  be  tnkeu  not  to  compma  tha  uatittf  «• 
deflMnded.  In  order  to  avoid  this,  the  tower  end  of  the  pad  may  t»  ni 
out  80  aa  to  bo  coucavc,  aud  ihua  press  down  the  testis  while  it  lupfMirulii 
hernia. 

\Vht;n  strangulated,  congenital  hernia  di-os  not  c\>mmoiiJy  admit  iif  twiw^ 
tion,  and  tliun  necefoarily  reuderv  an  0|>erHtiuu  impiralive.  The  prom^ 
is  more  cnninionly  required  for  this  kind  of  hernia  in  intuitu  than  in  tnfuit* 
The  operation  ia  the  Mime  ob  thai  f<>r  obliijue  inguinal  henita,  but  llie  |art» 
concerped  are  usually  thinner,  the  tunica  vagioalia  a»'rving  for  aiae:  k*^ 

more  caution  than  uBual  is  required  in  Ihew  eaaea.     Thf  sue  c ■■''  '■** 

taiuB  a  large  quantity  of  fluid,  usually  eUar,  but  ofteti  dark  ti  * 

being,  in  fact,  a  hydrocele  coiijotued  with  the  hernia.  The  M>i<>uir  '-l' 
lUnraya  be  found  in  the  neck  of  the  sac,  at  which  point  It  is  oAeo  eoaalntl*' 
by  a  sharp  narrow  ring;  hence  it  is  useless  in  these  cases  to  eodc«.v«w  (n  (** 
lieve  the  strangulalion.  without  laying  open  the  aae  and  dividltif  lUnK^ 
from  within.      The  f^lricIurc,  in  fact,  ap{>ear8  to  !>'  '\  by  tiw  InperltA 

coRtmction  of  that  {xirtion  of  the  funirular  prol>.^  f  ibv  piiiluaii^ 

which  normally  becomes  oblitemieit  before  birth,  Mid  t^uikliabe*  the  mytt* 
tion  iH'twci-n  the  tnn  serous  sacs  of  the  tunica  raetaalia  and  of  th«  pt«i>^ 
neom.  As  the  nmgoiiital  hernia  ia  always  rxterttaT  to  the  epi«wric  voaiib 
the  section  of  the  stricture  may  be  done  with  perfect  aafely  m  a  iUi«cti« 
upwanU  nnil  outwards,  though,  if  the  Burgeon  ahnuld  bare  any  doabt  as  I* 
Uic  exact  nature  of  the  nsf,  it  will  be  belter  to  divide  the  atridnr*.  .i;n--tlT 
upwanlx.    The  reduction  <ii'  the  contents  of  the  brmia  may  in  bt 

prevenn-d  by  adhesiona  in  the  neck  of  the  sac,  or  Iw-f-. —  ■  rbi 

IMtU.    I  have  found  t>oth  the  gut  and  nmentora  oh"  -i^ 

thia  organ,  and  requiring  tome  nice  diasMAiuo  toaajmnii^'  tnmi,     411  vfwr- 


^Hta 


lUOBAL   HERNIA. 


793 


tinjt  tinoninfnnls  ofd  verj'  tender  nge,  much  eaiilion  will  nerepparily  be  <Ie- 
snniJMl,  on  iiceouiil  af  the  U-iMutv  of  llie  (V'vcringfl,  llioir  tension,  rikI  llie 
-mall  eize  of  ihe  aperture*,  Th*-  n«rrrtw  rinp  foniiinp  tlie  slri'-liire  inny 
k'lU'ii  in  thtMP  CI18W  be  rupturc<I  by  pnwing  a  Hirectur  under  it  am!  stretch- 
ing it,  and  the  use  of  the  knife  i»  thus  avoided.  The  twtis,  as  well  lu  ihe 
epertnatic  cord,  the  veins  oi  which  are  excessively 
Cargid,  come  into  view,  uud  will  ueiially  W  f<)und 
Diuch  cnugeifted.  and  of  u  blaok  or  bluiisli-hlack  v<dor. 
A  species  of  coDjieiiitat  hernia  hus  Won  met  with  in 
ihe/ema/c,  evpecially  in  children,  in  which  the  i>rutrti- 
aioti  takes  place  into  theciinul  of  Nuck,  which  iuvcvt* 
the  miiDd  liparaent.  In  ime  instance,  I  have  eeen  a 
double  inguinal  hernia  in  a  girJ  five  years  old.  It 
IB  of  extremely  rare  occurreiici;.  and  rstjuires  llie  same  ■ 
tKtiiment  a»  the  corret<pondin(;  dt«eaf>e  in  the  timle.  ^ 

Encysted  IIkknia  oftul  Tinka  Vai;inali«.  or 
IsFANTlLE  HEitsiA.Hsit  has  been  sninewhat  absurdly  -'  / 

termed,  occurs  in  tbuee  cases  in  which  tlie  fiiiiiculRf 
portion  of  the  tunica  vaginnlu  is  partly  ubatrueled  by         f;g_  ,,.,.    iiumtilo 
a  septum,  or  by  bfing  converted  into  filnnieiitoiis  tie-  llvmb. 

aue.  but  la  such  a  vray  as  Ui  leave  n  pouch  above,  which 

)3  protnirled  down  iM-hind  or  into  the  innira  vaginalis,  so  that  it  Ilea  behind 
this  cavity  iFij;.  797).  TIktc  are  no  characters  by  which  ihc  encyi*led  can 
bedislinguishipd  from  the  nrdinary  cf>ngfuiln]  heruia.  If  it  »hould  lieoome 
•trangulated.  it  must  be  Ivirne  in  mind  ihat  dnring  tho  operation  the  tunica 
vaginalta  will  first  he  opened;  no  hernia  will  be  seen  h#rc,  hut  the  tnnu^r 
lies  behind  this  sac,  and  re«|uire*  to  he  diii(<ected  into  it  ihnmph  ihe  double 
wrout  layer  of  which  it  ii^  cQm|M#ed.  The  f>trictiire  will  jirobably  be  in  the 
n«ck,  and  re<|uiree  to  be  divided  in  the  uhueI  way. 

TEMORAL  HERlflA. 

By  Femoral  Hernia  is  meant  a  protrusion  that  escapes  under  Pouparl'a 
li^rament,  and  cnteirs  tlie  sheath  of  the  ve^els  internally  to  the  femoral  vein. 
Thia  hernia  pH»>es  down  lo  the  innermoet  compartment  of  the  sbcnth,  whicli 
is  occupied  by  fat  and  lymphatics,  and  usually  contains  a  gland  or  two.  It 
pinnm  first  of  all  through  the  crural  ring,  where  it  hns  Gimbernai's  liga- 
ntent  to  in  inner  side;  ttio  septum  which  )M?|)«rates  the  femoral  vein  from  Oie 
inner  compartment  of  the  ahe&ih  of  the  ve^^sels.  to  its  outer  a8|>ect;  Foupart'i 
ligament  in  fr>nt ;  and  the  bune  l>ehind  rFig.  798).  Aft*r  passing  through 
the  crural  ring,  it  enters  the  crural  caual,  which  extendB  for  about  half  an 
inch  dnvrn  the  thigh  in  front  of  the  pcctiiieus  muscle,  and  is  envered  by  the 
iliac  prolongation  of  the  fa«cia  lata.  As  it  approaches  the  lower  corner  i>f 
the  BOphunous  opening  where  tho  canal  terniinates,  it  passes  under  the  talci- 
form  proccRd  of  the  fuAcia  lata,  and  out  u|>on  the  thigh  through  the  naphe- 
nouB  aperture;  here  it  expands),  heeomes  rounded,  and  has  a  tendency  to 

I  turn  upwards  over  Ponpnrl's  ligament  (Fig.  7991,  lying  in  this  way  upon 
the  iliac  region,  and  sometimes  even  asivnding  to  some  distance  upon  the 
anterior  abdominal  wall.  In  the  descent  of  the  hernia  through  this  course, 
it  fint  of  all  pimlie'i  he-forc  it  the  peritoneal  mc,  and  then  reeeiven  an  invetit- 
nteot  of  the  stibDeroiis  areolar  tixyue — the  septtm  cniTtle,  a  mHi^s  nf  dei)«« 
areolar  tiwue,  coiitniniug  fnl  and  lymphatii-^.  ocx^upving  the  crural  ring. 
This  septum  ut^eii  heciime:*  incorjtorated  and  limited  Milh  the  coiitiguong 
portion  of  the  dieatli,  thus  coiMlituliu);  the  fascia  propria  of  this  lieruia, 

I     which  is  commonly  thickened,  laminated,  aod  of  an  opacjue  fatty  structure. 


794 


SFBCIJLt    HRBNI£. 


like  omentum.  As  tlio  Itcruia  cuatiaaw  to  deicead,  it  maa  tut  nUiH 
wiib  the  crlbrif'Tm  fiu^oia.  which  uocupie*  ih»  Mpbcnoui  vpeoiBj;  M. 
tuetly,  it  {)ii8b«ft  befure  it  the  inlvguuieoLal  ulructurm. 

A^  lUc  tumur  dwceoiU  through  this  vuurw,  it  nectMirtly  ODoawiilfrtt- 


Pl(.  m.— r«B*r*1  BctvU,  untti 

Pig.  TBS.— I.  Panoral  Ariary;  2,  FcumitbI  V»Id  )  i.  InnOTaKMl  OHvpMftwwi  aT  ttafkiiAW 
lb*  TMMt*,  iaUi  whlfifc  ■  •man  llwmla  U  pMl«>4li>gi  4.  B«)ib«aa  Vau. 

ttou  with  very  iniporUint  fwr[«  (I'*ig.  800).  Thus  il  18  iCfKnl^d  frnalki 
fenioral  vein  solely  by  the  wptuiu  of  the  «heath  of  th«  Trifili  It  bt  i^ 
cpinBtrio  artery  above  and  to  ita  out«r  tide ;  and  iho  iprriuatie  ^iA  b  Ai 
male,  or  the  round  ligameat  in  the  fcnialft,  almute  iuiziedialclj  akm  it 


is 


rt(.  S9II — I.  FMiM>t»l  llifnU;  1.  r»moml  Vaint  S.  r<Mor«l  ArUry.  |1*la(  AL* 
Truak  of  BplgMtHo  mi4  UbiuHtor  ArtwiM,  aa-l  i,  Siilfutrk  ArMrf  i  k  4 

Th«  Dbluralor  artery,  wbvn  arising  iu  the  nortnal  maoitcr  fm«  tim  laV* 
iliau,  line*  ii<rt  come  into  rt*lati<<a  with  the  uevk  uf  the  h'ic;  but  whm  iltlHi 
its  uriKiD,  IU  it  not  uafrviiticiitly  tlutat,  from  thv  exterual  iliac,  tbr 
or  the  i-uniiimii  femoml,  it  may  have  iiupurLaiit  relatiuiu  to  tiiu 
beriiia.     M'«l  couumuly,  iu  theae  ctrcuniuauoca,  it  pa— 'j  to 


m 

K 


I" 

■cl 

■  ll 

ft 

fi 

bt 

■ir 


nuter  side  of  tlie  neck,  hut  occanionaUy  it  winds  munrl  jls  itinor  cm  ) 
Mr)e,  c^miiij;  into  clme  rotattDU  nitli  It ;  iimi  tlir'ii,  a^  will  iiniiicdintely  be 
mentinned,  it  nmy  be  in  considerable  ilunjr^r  during;  lUu  ivfuratiuu.  Tliv  com- 
bination, however,  of  this  particular  variety  of  tiiu  ubiuratur  Hrlorr  and 
mural  hernia,  \i  a  very  uueoinmim  orciirreiicv;  becauise.  iu  tbu  finit  plnc«, 
;hi»  internal  diitlribuLiuu  uf  tbv  »rterr  ie  rtire;  and  wheu  it  duee  uccur,  us 
it  uanally  jiaNses  directly  uver  Cbal  jiortioM  of  ibc  (jruntl  riug  through  which 
th»  aac  would  protrude,  it  aeveasarily  streugthena  tbie,  and  si)  diminishes  Ibu 
(4iancc  of  rupture. 

ContAIltJ. — The  Cdiiteiits  of  a  femorul  heruiu  are  usually  iDtraitinal,  and 
tni^et  citiriiuunly  cuusist  of'u  p<>rti<in  nf  tlit.-  ilium.  UevatiioDatly  uiut;tKum  is 
CJOluiued  uithiu  the  sac,  but  lielduin  in  large  quantity.  I  have,  however, 
HvvL-nil  times  had  occasion  ti>  operate  in  cases  of  old  feniorul  hernia,  in  which 
it  became  uecessury  U)  remove  larpe  portions  of  adherent  omentum;  in  one, 
ten  and  a  half  ounces,  aud  in  another  about  neven.  In  eticb  ca.«e  there  wm 
m  Eiiiall  knuckle  of  intestine  strangulated  behind  the  omentum.  The  ovaries, 
yallopiati  tubes,  etc,  have  been  known  to  be  strangulated  iu  this  variety  of 
hernia. 

Bi^s. — The  ai^s  of  femoral  berntn  are  usuHlty  well  marked.  They  oon- 
eist  of  H  tolerably  tirm,  tense,  and  unyielding  tumor,  of  a  rounded  ehn)>e, 
situated  in  the  ^oin,  to  the  inner  side  of  the  fenioml  vessels,  and  tu  the 
outer  fide  of  the  spine  of  the  pubes,  having  its  oeok  under  Poupart's  ligs- 
meni,  though,  as  it  increases  in  size,  its  base  is  turned  above  (hut  structure; 
Bomctlnicfl,  though  rarely,  it  pai^es  ditwuwur^ts  upon  the  thigh.  Ii^  size 
.Tories  onsiderably ;  most  commonly  it  is  not  larger  than  a  walnut  or  n 
^t>igeon's  egg,  and  then  is  deeply  seated  in  ibe  angle  between  the  body  of  the 
pubea  and  the  femnrnl  vc«9els:  but  oecfisionally  it  may  nliitin  acousidembic 
bulk,  na  large  as  the  fiat  or  a  French  roll.  When  large,  thiei  hernia  rioca  up 
abiive  Poupart'ii  ligament,  and  exlendu  outwards  in  a  dirci-liim  pamllel  t^i  it. 
Bo  that  it  asHumett  an  ebmgaced  shape;  it  is  then  UNuaily  soiiiewiiat  doughy 
and  sntl,  evf^ii  when  strangulated  ;  very  diflerent  from  the  exceasively  tenae 
feel  that  it  has  when  small. 

In  some  nire  ca-ies  the  femoral  hernia  has  been  found  lying  external  to  the 
veasets,  the  mouth  of  the  sac  being  between  them  nnd  th(>  iliac  spine.  In 
these  circumNlances  Strang  id  atioii  cannot  w«ll  occur,  inai^nitich  as  the  mouth 
will  be  the  widei<t  part  of  the  i^ar;  but,  as  Ilesseibaeh  has  ob^ervcil,  if  the 
fascia  iliftcM  he  t'irn  by  the  pressure  of  the  ttimor,  the  ruptiir*^  may  be 
strangled  in  the  aperture  thus  formed.  Should  an  operation  e.ver  be  reijuirfd 
in  such  circumstances,  it  must  be  boroe  iu  mind  that  lite  circumdex  itti 
rtery  may  be  iu  some  danger. 

As  a  temural  heruiti  pasties  out  through  the  crural  xing,  it  comes  into  very 
close  relntiuD  t'l  the  Icniural  veiu.  being  separated  from  the  vessel  inerelv  by 
the  septum,  which  divides  the  inner  from  the  middle  conipartnieuL  oj  the 
femoral  sheath.  Wtre  it  uol  for  this  i*ptuni,  as  Ivoaer  has  observed,  the 
femoral  vein  would  l>c  compre**.'d  by  the  tcusc  hernial  tumor  prftru<led 
between  it  and  GiiuIktuuI's  ligumeut.  and  the  inevitable  cousei^uence  wuuUl 
,.be  ftMlenia  of  the  whole  lower  extremity.  As  the  hernia  pushes  down  iu  the 
'  ack  of  the  crural  cana),  it  can  make  no  impression  <m  the  inner  or  ou  tbo 
}Tostcrior  wall  of  thu  canal — ^hotb  of  which  are  uDvieliliug;  but,  jmshiug 
the  anterior  wall  upwanle,  it  dnigs  upon  the  Beptum  on  the  other  side  uf  tliu 
neck  of  the  sac,  renders  this  lentsu,  and  thus  savea  the  femoral  vein  from 
comnreiision. 

DiagnoiU. — The  diagnosis  of  fenioral  hernia  is  iir>t  alnavB  easy.  When 
llii;  ht-rnia  is  Inrge.  and  more  particularly  when  it  ri«es  up  above  Foupurt's 
ligament,  which  snme  hernia,  even  uf  very  moderate  mze,  are  apt  to  du,  It 


1 


796 


SPECIAL    HSBNI^. 


might  At  first  1>c  mlDtnlceD  for  kq  lofriiinftl  niptiirp.  Thfl  diagnniM,  htmvm 
may  usuhIIv  be  ofTvctod  hyiwc«rUiainc:  tl<^  r«litlion  lliAl  tho  dmA  oftloM 
has  to  P'lUfMirt'H  li|iiiment.  llie  injiuinHl  liernin  lM.Mnir  nituatwl  •&*«,  ^ 
femurml  helnw  tliis  conl.  When,  Imwever,  »  BmnM  fvnT<m\  hr-m'n  btfie 
mitii  me«  itpwiirfla,  sn  a*  U)  lie  over  PiMipart'*  '■ 
ohiaelr  Hii  ■n(-i>tD|)1ete  inguinal  hemia  ;  but  iL«  chi. 

hy  the  puua^  of  the  finger  up  the  iripuinal  cnn*!,  which  mli  lir  ttKiti.1  b-ta 
free.  AQ't  the  hernia  can  be  felt  odIv  tbrou^^h  itit  itxsterinr  nnd  mfiriir  •*" 
In  the  femiile,  the  finger  cannot  l»e  pa«etl  up  the  canal,  but 
hernia  will  dcvoend  into  the  labium,  ami  may  tbua  be  rwMgDi.-    ■ 
femiirnl,  which  li»9  in  the  upiwr  and  inner  part  uf  the  thigh.     Ii;  ^ 
the  relation!  of  the  neck  of  the  sac  to  the  epioous  prucvw  nf  thn  )>u)>-> 
can  always  he  felt  in  the  fattest  gubiect.s  are  lurjgt  important  in  a  ili*;''  ■•  < 
point  of  view.    In  femoral  hernia  the  spine  'i»  to  the  inner,  in  in^um. 
tn  the  oiitt'f  «iile  of  the  protruaioD  ;  aoH.  ehould  a  patient  hspi"-)  ' 
mibjectof  both  iu^uiunl  and  fcnurrRl  hernia  on  the  miiie  ^ide.  thr«p<&i- iuii: 
be  fi'lt  between  the  two.     Afler  reducing  a  fomoral  hfrnia^tbit  Gapr  (sa 
enniotiiuot>  l>c  pushe<t  into  tlit^  inferior  a|H?rture  of  Ihc  crural  ixaal,  what  ibt 
situatiuu  nud^hnrp  outline  of  the  fali-ifirm  proci«B  will  doteraiiwitlMnalBR 
of  tho  opoDiog  through  which  the  prutruaiou  has  itCL-Drre't. 

The  (llBoafleB  ocourrini;  in  the  eroiu.  with  which  feniurnl  hrrnia  mayaMI 
rrwiily  be  oinfonnded,  arty — ^1.  B'tlarged  Lymphatie  dtatnts  id  this  nluatii*. 
Frnm  these  it  may  bo  di»tin);uiehod  by  the  atuenee  of  impulse  in  tJic  eba^ 
ular  tumor,  and  by  the  siruultaiicous  enlargi>ment  uf  Kveral  k'*"^  ^ 
smail  stniDgulatMl  hernia  may.  however,  coexist  with  thew  :  beinj*  m^facM 
lu,  and  covered  in  by  iheat.  When  thU  ia  the  case,  and  tlte  lo^  ■>pi**f 
bcroift  areobararc.  whihit  thoBymptomaof  Uniusulatiou  tsnicinae.  boumm 
should  bo  miuk-  into  the  part,  auH  th«  diMcrtion  (.-arefuHy  carried  timo)^ 
and  uoderneaih  tbt-  gltiniU.  with  the  view  nf  detenitininu  whether  ibe  bMBii 
6xi«t  or  not.  2.  A  tmutl  Fally  (imwth  hua  be«a  m^L  m  itb  in  i  h*«  i^raril  saaL 
cI'Mely  fiiiDutatin^f  a  herniiL     The  want  of  iinpulitt>  ou  <'  -  '"^^"^ 

with  the  liroitwl  and  doughy  character  of  the  tumor,  will  vi  -irr^a 

t*!  di)ilin^ui*'h  it  fn>m  hernia.     3.  I^on»  Abttxtt  (ti;ix  [>>int  r. 
tion  i>f  fenionii  hernia;  but  geiierallv  it  lenves  tht-  nlwIonK  i 
veMcU,  while  a  hernia  is  iotcrnnl.    It  rntiy  l>e  further  dittiagowbtd  tn  <** 
Hiirlnating  fuel,  by  it«  soft  yet  Kmielasliu  charnoler,  and  by  (Kr  uxu'Til 
hiHtory  of  the  case.     The  impulw  on  cujching,  whii-b  ia  rerv  •!  ' 

ab^eesa,  is  conifDunly  more  forcible  and  direct  than  ihatufa  • -''' 

although  the  purulent  collectiim  may  in  many  onaea  he  aaiueexed  faacki^ 
tho  iibditirieu  whoti  the  palinnt  Vivr  down,  yet  ft  rrturne  without  a  rar^*."^ 
without  thiit  dininet  alip  which  areimpauifM  tbr  mluciioa  of  a  Iwrtfa-  ^ 
FtrLC  nf  the  Sififuifi  Vein  i*  in  tionic  rlnn;;rr  of  being  oonbuwlad  ^ 
hernia.  It  may,  him-evcr,  be  di^itingnixbrd  tram  tbia  by  ih«  ioiMilaa  W  ^ 
belne  leaa  dii^tini't  than  tn  hcniiii,  and  bv  the  enlargement  of  tha  Invtf^ 
of  tho  rein  hvina  niarkeit  in  the  varix,  but  nnt  exiatini;  in  tli«  rapiunu 

Fmoral  heruia  in'Ktt  cfmummU-  n<TrtiK  lo  Women,  and  very  tddoM  wilt* 
tho  affc  of  twenty  ;  diHi-riuc  in  Uuth  theiM  rciperta  from  the  iatpiiftd  rtf 
Ittrc.  Sir  A.  (.'-xtpcr  atalM  thai  he  had  aecn  rmly  three  caaea  andettlMaliMi 
aff».  It  rery  aeldiim  bacomea  atrangulaml  «i  an  early  period  of  Ufr.  •■■ 
when  existing.  I  hnvn  had  a  girl  of  ninetM'n  under  my  care  with  fenviril 
hernia  in  whom  Btrnngutatiou  had  already  orcurred  na  four  oceaatottt; 
ti*m.  h'lwrver,  having  been  happily  elTected  Mch  time. 

Treatmeot — The  treatment  of  fom<»ral  hernia.  wh*o  It  K  — ' — -^'- 
b*  cinducted  io  the  ordinary  way  bv  the  appliration  of  n 
cure,  however,  is  a«ver,  I  believe,  «f)uct«d  by  lbs  proHura  mi  n  j-n  i. » 


FRUORAL  HEBXIA— TRSATMKNT. 


m 


timn  bappeos  ia  inguinnl  herDia  ;  oniog  probably  to  the  rigiility  an^i  iii- 
(MmprcHibility  of  tlic  U*ti<iLUOiiH  nml  ap'^imuivtic  utruclures  Ihn/ugli  uliJcli 
this  rupiure  prolrudtw.  It  w  oi'tcD  dilhuuli  to  keep  this  I'oroi  l>I  lieiniii  up 
hy  memis  of  a  trues.  The  beat  iuatrunieui  fur  lliis  purpinw  ia  tlie  Mucinaiii 
Irusa,  wiiivii  I  huvo  fiiutid  to  Btivcecd  nbvu  all  uihei-ri  biive  liiiled.  Wheu  tbu 
hurnia  ia  irreducible,  it  ^huuUt  be  sujipurivd  by  tueaue  of  a  trun  wiib  a  uun- 
oive  pad. 

\Vdi*d  a  femoral  rupture  is  atratigulaletl,  reductiuD  ehunhl  be  effected 
eitbcr  by  taxiii  or  hy  opuintinu  as»puedily  as  piNseiible,  giiiigrcuii  cusuiiig  more 
rapiilly  tu  ihia  (huii  in  any  other  l\-vta  of  biTtiia.  Iti  atu-mpting  luxiii,  tbo 
etruclurvs  in  the  groin  abuultl  bu  well  rulnxvd  liy  flt-'xiu^  ihu  thi^b  upou  iho 
abdomi-D.  and  mliiucliu;;  it,  \thtcb  reliixt's  the  margin  of  thu  mij'Iiciioub 
optfiiin); ;  if  it  ilo  not  ttuccetd  wiLh  the  aa»i»tancu  uf  ibe  nieuiia  rcconiiiK-inJcd 
at  p.  7t>0,  vol.  ii.,  the  o|Hjralii)ii  shuuUI  be  pmceeiieil  with  at  oncv.  Tim 
ii]K:rntiiin  for  ulratiiiulati'il  femoral  hernia  may  be  unclerlaken  earlier  and 
with  a  tH'ller  proe|iect  uf  mu'cetja  than  that  for  any  other  form  of  rupture  ; 
thin  i.i  owiii);  to  the.  stricture  being  »o  coinnionly  seated  uuti«idc  the  sac,  that 
ibe  opemtiun  luually  nHniit.1  of  being  conj|iU'te(l  without  iniplicalinf(  the 
peritctteum.  The  Rfivanlnge  of  lliia  mode  of  prucedure  in  femoral  hernia 
hat  becQ  lully  pointed  out  by  A.  Key,  Luke,  and  Gny,  and  ia  now  -.ery 
generally  recoguixed  in  prartiL-c  Gay,  more  partivuinrly,  liaa  p>iinle<l  out 
that  the  alrictnre-  may  euninionty  be  divideil  vrithout  opening  the  »hv,  by 
making  a  very  limited  iticitlon  o»  the  inner  aurt'aoe  uf  the  neck  uf  the 
tumor;  and  h«  ubserves  that  the  operation  undvrlaken  in  thi«  manner  ia 
little  more  than  the  tjixi:*  with  the  nd<lilii>o  uf  a  siijierhcial  iiicisiuu.  There 
in,  hunever,  thit*  ini|H)rtant  dilierence  between  a  berntu  reduced  by  the  urdi* 

tary  )>iniple  taxi«  and  otvc  returned  by  Pelit'e  operation,  that  the  striingnla* 
111  in  ihtf  latter  vase  baa  beeu  far  lighter,  or  the  o{>eraiioo  would  nut  have 
:a  neeeaaary,  am)  tbe  cunoe^jueut  injury  tu  the  protruded  parts  is  much 
more  severe. 

The  stricture  in  femoral  hernia  is  oileo  found  to  be  occasioned  by  the  pres- 
sure of  the  sharp  edge  of  Uiuibernat'a  ligament.  Must  Surgeons  recommend 
that  this  should  be  divided,  but  some  advise  that  the  division  should  be  made 
at  ibe  junction  uf  Gimbernat's  aud  Puupart's  ligaments,  dividing  at  the 
sRine  time  tbe  fibres  of  tbe  superior  corou  of  tbe  falcifurni  border  of  the 
Hiphenous  opening  which  are  attached  to  Oimberiiat's  ligament,  and  were 
fin-i  described  by  lley,  under  the  name  of  "tbe  femoral  ligament"  (]S03\ 
Uey,  gubaequently  1 1814).  drupped  this  designation,  but  these  fibres  are  still 
Homelimea  cilled  "Ucy'o  ligament." 

It  id  in  this  siiuati'm  that  both  I^awrence  nud  Hey  recommended  the 
incition  to  be  made.    In  operating  for  femoral  hernia.  I  have  certainly  most 
fr*-t|Ufnily  found  the  stricture  Btill  to  continue  after  the  division  of  these  liga- 
meutoua  sUucturt-s,  aud  to  be  oi-cnsioncd  hy  the  deep  crural  arch  which 
forms  in  many  ca^es  a  very  dUiinct  narrow  and  ^lifliening  bund  lying  ncn>nB 
the  oeek  of  thcauc  in  the  I'uscia  propria  of  the  hernia;  and  I  a;^rce  wilfi  ihe 
opinion  expre*tcd  by  Sir  A.  Cooper,  that  the  neek  of  the  ;(healh  is  Ihe  com- 
mon aeut  lit'  fltrangiilatinn  in  fetttoral  hernia.     The  banda  forming  the  deep 
crural  arch  are  probably  thickened  in  old  hernia  from  the  pressure  of  llie 
^— truM  and  the  contents  nf  the  sac.     In  onler  to  expose  them,  it  ia  commonly 
^Beee«iutry  to  draw  the  neck  uf  the  sac  well  down,  when  they  will  be  seen 
^^■e^ly  to  in<ii?iit  ait<l  cocivtrict  it. 

^B  The  operation  without  opening  the  lae  may  most  conveniently  be  ner- 

^^oriued  when  the  loiiior  is  small,  by  mukltig  an  ineiston  by  tran»Hxiun  nU>n^ 

ibe  inner  nide  >^(  its  ne<-k,  and  then  dis^ei'iiug  ibruugh  tbe  aunerticial  slmc- 

ires  until  the  liucia  propria  is  bruugbt  into  view  and  carefuHy  opened,  aud 


■on 
beet 


798 


Bl'EClAL    UKRXI^. 


the  HU!  expowd.    Th«  point  nf  the  ftocor  BbouM  tfaea  be  camel  to 

Hide  nf  tlnx,  wril  iimlcr  ihv  liucin  [irii|>riii.     The  lia^er-tuul  nr  In 

may  then  lie  inttiuiintoil  umler  Llie  sharp  edge  u(  (tiinlti-rnat'v  UnoMal, 

at  ttif  piiiiit  oi'juD  I'll  I'll  vril-h  l*nu|iart'B.  may  be  divi'It'tt  ii|i«nif>liSDdi[ 

I'l  tlif  i'xu-tit  CI?  a  liiii<  or  two  by  mpaoa  ul'a  tK-rnin-Litifc.     By  ihii  iaoia, 

not  milv  U  the  v*l^v-  nf'Giiubcnial'B  aod  iV>u|mri'(t  lif.'anifiitdirHlei.balilB 

the  c-ondfiiMil  mxT  ntrnprCBseil  IWcin  prupriii  Irinf;  lit;tvtf£u  tbe  Mcawlli* 

inner  Bide  ur  the  crural  arch.     The  rwlu<-ti'>u  may  now  be  Blt(Mplei.ut 

often  eflected  ;  nhotiM  nay  uUitacle  eiist,  the  neck  of  th«  me  aitut  Is  «d 

drawn  down  and  expiieed,  and  any  tranBreree  bamU  Ik.-I.tnm'm''  tr,  iVx.  V- 

crural  arch  vhich  may  be  situated  iipoa  itdiasectetl  tli- 

aud  I'arccps.  Of  divide4l  on  a  director.    ThcK  bnnd^  n.- 

the  fttBcia  nr^ipria;  and  wrhon  they  are  found,  it  is  uiually 

geitu  not  liaving  exposed  the  neck  of  the  tac  aiiffick-ullr  Ih-|'>> 

uail  or  director  under  the   stricture.      It  a  owing  to  tlir>  ■> 

confliicd  tu  the  constriction  occasi(ine<i  by  the  tu|  < 

not  incltuliug,  as  it  ought  lo  do,  the  subjacent  • . 

point  of  very  great  practical  importance.     '~ 

constricting  portion  ut  the  fascia  propria  is  >- 

neck  of  the  nc,  that  it  cannot  be  divide<l  wilh--ul  <•[•■  i 

opcmlion  perf'trmed  in  thio  way,  without  yp^ning  the  - 

pimple  pnjcedore;  and  ndd»  Hltle,  if  anything— otrthi 

a  *iiuple  incision  through  ouperficiiil  Btructurei — lotbe :    _:_._,_ 

If  it  be  thought  deeirahle  to  Open  the  sae,  or  if  it  be  oeceaHry  i«d*>«uu) 
coQSequeucD  of  its  incorporation  with  the  fascia  propiia,  the  optnlitm  tmj 
be  pertbrmed  by  a  similar  incision  to  that  aboTe qtacrifawl. alii^tly  xUnM 
in  foigth,  hut  it  the  tumor  bo  of  considerable  am  lonie  SamoM  pnta* 
expose  it  more  freely  bv  an  '^  ibapc^i  incijion.  the  vertical  limb  '\t  vk>A 
puses  along  the  inner  side  of  the  sac  and  hnritontat  limb  panUUI  laPi^ 
pBTt's  ligament  and  iuimcdiniely  below  iL  Id  whtL-hL-TiT  way  tbt  M 
incision  he  inaile.  the  diiiaectioD  mu»t  next  be  carried  li  -^rtrnfntdd 

fitscia,  and  tht-  criltrifurni  (iascia,  nhen  the  fa«cia  pro|<i  .1  Ahealhui 

aeptum  cruralo  fuecd  ingeihor  i  will  be  cxp<iMd  ;  lu  »ou»f  .  iiDf  tf 

the  hernia  be  a  large  uutf,  this  h  thin,  and  rc<|uirr9  t'>  Ik  .  Aktt 

nn  a  director.     lu  many  instanccf.  however,  it  15  «•  ntutei,  iH 

changed  in  Btruciure,  as  scarcely  to  bo  reongnixeit  for  v.  Ti  mi  tB- 

frequently  happenn  tltut,  after  ibc  ffunerticiat  fnsi-ia  ha»  kil,u 

oval,  amooth,  and  firm  bcwly  in  exposed,  whiidi  at  lint  hnik.'    .^ intukl 

■ac.  or  a  tump  of  omentum ;  ihU  iit  in  reality  the  (ucia  propria,  IhiciiV^ 
by  the  long-continued  pretwure  of  the  truMi,  iind  oiiit,"*!!"!,  perbapt,  kfftb* 
atteiiipl«  at  re^liirtiun  ;  niid  in  the  midst  of  it,  the  lac  will  at  last  b*  Mb'' 
tiftcr  the  diweuliou  has  tieen  rarried  through  trrrnil  lavvn  of  tblB  litf* 
Cv»t8  conluining  bUxxlv  ti^ruiri  may  occasionn i ly  be  found  in  tt,  ao*!  tbtot^ 
ditbculty  in  the  re^-o^tiitiuii  of  [lie  slructtirea  is  gn-utly  incrvaoed.  TbMi(^ 
tlte  mobility  of  this  iiiiit>j<,  tht;  faeiiity  of  traving  it»  nri'k,  and  the  riMUnLoM 
of  iL«   gi'iterul   niiiliiie.  olXcu   cauw  it  In  be  niictak<n  '       ■  '  >>n>«'OUtt.* 

may  he  <Iifiiiigiii>ilu*d  from  the  lir»t  by  the  ab^cncK  *il  idcrWticT* 

M>U  u|H>ii  iu  Burfucc.  nud  fnim  the  secmd  by  iln  m-  '  '1.  aultd  ini, 

ittiil  otiifnriii  apiH-anince.     When  the  sac  Imii  betn  rt  .  -i.uH  bi  fiTf 

carefully  ojietied.  then'  being  Ufually  very  little  if  ati  ii  it  a4 

its  coiileni*  :  ihetliigFr  iiuil  niuet  then  be  passed  unilt  r  ^ 

Btricture,  which  ehuuhl  be  divided  in  adirectioo  u|iward5  and  iowm^ 
reufton  why  thbi  line  of  incision  is  univertially  rhiie«'n  '••  ■^"f 
conritry  nt  the  prtwnt  day,  is,  that  it  in  the  nnly  il 
flirietiire  mn  Ite  divided  without  risk  of  inflicting  serioon  mjutj  u^iii 


Fa^opkration. 

bnring  parU.  If  the  action  b«  mitilc  nuivrnntin,  lK«  fVitifirfll  vein  will  be  in 
ftangCr  ;  if  tipwarils  anil  outwanis,  ibe  epipiatric  artery  ;  if  directly  U|)wartl8, 
the  Bptfrm«lic  cwrd  ;  lie[ic«  tlw  only  cJirection  is  either  inwanls,  or  upwards 
and  intranlif.  It*  (be  cut  Ite  miide  inwurds,  the  sharp  edge  ol'  Ginihernal'a 
JigamcDt  alone  tviil  be  dii'ided,  aod  the  crural  arch  uul  BuHicieutly  liberated. 
But  if  tlie  iliviiiioQ  be  nmdc  upwards  and  inwards,  the  tension  oi  the  whtde 
of  the  arch  leseeued ;  the  only  danger  that  can  occur  from  the  divisiui]  of 
the  siriclure  in  this  direction  is  the  very  remote  one  of  the  wuund  of  tlie 
obturator  artery,  when  it  takes  the  nnomalous  ci^urse  round  the  inside  of  the 
ueck  of  the  sac.  Uuthrie  iitattB  thm  he  tia?  known  s»me  of  the  best  Sui-- 
getins  In  LoudoD  to  lose  pntients  by  hemorrhnge  after  (he  nperatiou  for 
femoral  hernia.  This  accident,  however,  is  nf  extremely  rare  occurrcuce, 
and  might  in  a  great  measure  \k  guarded  agninsl  by  5li)^htly  blunting  (he 
edge  of  the  hcrniaknil'c  bcf'jre  dividing  the  stricture,  so  that  the  leuso 
fibrous  bands  constituting  the  constriction  would  rield,  while  the  artery 
would  probably  escape,  being  pushed  before  the  tlunted  edge.  1  have, 
however,  more  than  once  seen  blood  well  up  rather  freely  on  the  division  of 
the  stricture  ;  but  it  has  ceased  spontftneouely,  and  I  have  never  known  it  to 
give  any  trouble.  If  the  division  of  the  etricturc  bo  limited  to  aline  or  two, 
there  will  he  but  little  danger  of  wounding  the  vessel,  even  when  it  takes 
the  abnormal  course. 

The  best  means  of  arrcBtinj*  the  bleeding  from  a  wound  of  nn  abnormal 
obturator  can  hardly  be  said  to  be  certainly  determined.  A.  E.  Barker,  to 
whom  this  arrident  hanpcned  In  npcrating  on  u  |wtient  in  Utiiversity  ('ol- 
lege  Hospital,  flnece-ssfully  arroatcd  the  heniorrhBgc  by  prfiture.  ihe  patient 
dying  frum  gangrene  nf  the  gut  four  days  afttr.  In  a  ciise  recorded  by 
A.  H.  C'orley,  of  the  Jcrvis  Street  Ilnspilal,  in  Dublin,  the  hlerding  via 
very  free,  but  wbb  easily  controlled  by  pa^tiing  the  forefinger  into  (his  »*ouud 
ana  grasping  the  abdominnl  wall  lietueecL  it  and  (lie  thumb,  A  curveil 
needle  was  accordingly  patwed  in  tbr\>ngh  llie  ring  and  out  iiunierlintely 
above  Poupart*s  liguiutnt,  aud  a  twisted  suture  apptitd  around  iL  The 
hemorrhage  ceased,  and  did  not  recur.  The  natient  died  from  <^!hcr  cuusev, 
and  the  ])adt-iuortera  exnnnnation  showed  llie  obturator  arising  from  the 
epigastric  and  cut  opposite  the  ueck  of  the  sac.  The  two  ends  had  retracted 
one  inch  apart,  the  distal  having  gone  so  far  in  the  direction  of  tli«  obturator 
foramen  that  any  attempt  to  reach  it  would  have  been  out  of  the  question. 
The  needle  was  Juuud  to  have  [lasevd  i(nuK'diBti,'ly  in  front  of  the  proximal 
eod.  crosaiog  the  track  nf  tbe  artery,  but  not  actually  Jiiciudiug  it;  yet  the 
traction  so  exerted  seems  to  have  been  cuuugh  to  close  the  vei^si;!,  ae  it  was 
obliterated  by  a  clot.  The  distal  end  contained  no  clot.  Hartley,  iit  the 
Annah  nf  Anatomy  nnd  tyur^t-ri/,  1881,  recunls  a  case  in  whirh  he  success- 
fuDy  ligatured  (he  vessel  alter  eiiEurging  the  wound  eufEcieudy  (o  bring  it 
int«i  view.  The  patient  recovpred.  Barker,wbo  collected  the  records  uJ  16 
cues  of  this  accident,  stales  that  iu  6  a  ligature  was  a|)]ilieil.  Probably  the 
best  means  would  alwavB  lie  to  enliiree  the  wound  up  to  Pouparla  ligament, 
and  attempt  torpinn  or  ligature.  The  artery  might  alpo  he  exnoeed  by  an 
JDcision  above  Poupart's  ligiimi^nl.  like  that  for  ligature  of  the  external 
ilimo  by  Cooper's  method,  if  simple  enlargement  of  the  wound  did  not  bring 
it  into  view.    If  these  means  fniI,acuprPMure  or  pressure  mav  be  resorted  to. 

It  will  g«nernMy  be  found,  that  the  intestine  contained  lo  the  sac  of  a 
femoral  hernia  i?  "dnrk-colored  and  tightly  nipped  ;  it  requires  to  be  treated 
in  aecordancc  with  the  general  principles  that  guide  us  in  the  mauagemeut 
of  hernia. 


800 


SPECIAL    BEBNIJC. 


My  umbilicat  hernia  or  exomphaliu  i«  meaot  b  protrurion  tkmigb  tbi  w 
bilic-nl  nperture.     It  occurs  either  Id  ctiildreo  nr  in  adalU. 

Umbilical  Hemia  u  Children  is  Bomeiimea  congenitai  At  ta  «>rijj 
of  f<ctal  iile,  a  great  part  of  the  iute^tiual  c«oal  iiei  without  lb* 
and  ie  gr»iluall,v  ilntwo  in  as  dcvel>.>pm«ui  advaooca.  Coagoiilal  mbiliait 
hernia  ur  true  exonipbalua  i>  the  rceult  of  no  imporreoUoa  ia  thii|irDaA 
Id  other  cawe  a  diverticulum  frooi  the  tlcuui,  due  to  an  iniprrfteCcuamrf 
thu  ductus  viteIlo-iiit<.-Bt!nalis,  may  extend  ftome  dUtaoce  up  the  ouH  (am 
the  iiavet.  In  eirhur  of  these  condiiinuB  it  may  happen  that  iIm  |)iiitnii« 
ie  iududed  in  the  ligature  applied  to  the  uruliilical  eurd.  Ifa  hup  pnrM 
of  iiitet^tine  be  attaiigulutei)  in  thia  way,  a  fatal  malt  muallr  iMam: 
but  if  it  be  merely  a  di vert icu turn,  ibo  stump  of  the  mrtl  may  KpuM 
eafely,  the  n[>eiiiiig  in  the  gut  being  ublittirated.  Id  otber  cmai  a  kal 
fistiila  may  form  at  the  uinbilirua. 

Umbilical  hernia  occura  more  frequently  ahnrtly  aflrr  birtb  in  eaomfoam 
of  the  child  straining  and  crying,  torming  the  etmditiiin  termed  hi  bvob 
"stArtiug  of  the  navel.''  In  this  form  the  umbilical  cicatrix  rtel4i,  lii 
natural  denreMion  beioe  completely  replaced  by  the  prfljpctioo  i.f  the  tMiia 
It  is  readily  recognizi^  by  a  aniootli,  roundeil.  and  l^nae  lutnor,  tutaif 
furwards  at  the  umbilicus,  readily  reducible  nn  prt.'iwtirfL  The  (Kiaatf 
ahould  consist  in  the  application  of  a  flmall  pad,  mnHf  of  a  slitv  uf  oft, 
wrapped  iu  a  soil  piece  vf  lint  aud  powdereu  nilb  •tnrrb  Tbis  aait  ht 
secured  in  posiliuu  by  a  circular  pi«ce  of  «i»ap-pl.i«ter  sfT.  imtioa 

of  the  American  rubl^rpliutvr,    Au  elastic  Wit  with  nn  m:  i  -.tattiam 

recommended,  and  may  Iw  applied  lu  older  children,  but  io  iufant*  it  t«  '(ulH 
u»elc»,  a«  the  variatiou  in  size  of  the  abdumen,  vccordiuK  t*'  iIk-  n'u:-.nlvt 
flatus  in  the  iuleslinee  ia  such  that  do  bandage  can  hv  rcalh  f' 

moet  cummunly  happena  that,  after  preaaure  baa  lU  thii  «ny  bt-  '  ' 

some  months,  a  radical  cure  resulta.     Tbi-sc  anuill  beniiai  are  i 
lated,  iind  cnn»equently  never  cause  death  ;  yet  it  is  vrrv  rare  i '  f<-  "<•  t^* 
child  of  ten  years  nf  age,  (hough  in  lufants  we  meet  wiln  ihpra  by  ll^  v^ 

Umbilical' Hemia  in  Adaitt  mui^t  lm]u<-iitly  uccure  in 
those  who  have  borue  many  cbililren.  ur  whu  are  bmdeil 
It  ia  by  no  mrana  unlikely  thai  a  leodettry  to  this  disease  ia  utluii  otaLluA"' 
in  cbildhood,  but  dues  oot  become  ilevelo|>e<I  until  the  abdocuinal  Btfds 
have  Iwen  relaxed  by  the  preaeure  u(  (be  gravid  uterus,  T^e  bcftl*' 
adults  duea  not,  as  a  rule,  stretch  the  umbilical  cicatrix  in  the  akia.  Tl*f* 
usually  clearly  reogniziible  at  the  lower  fiart  nf  the  tumor,  the  he«nit>^ 
oommonlv  escaping  through  ihe  upper  part  of  tbe  umbiliral  aprrUK. 

Umbilical  rupture  generally  attains  a  considerable  bulk,  and  oAtvaoVDm 
an  euorinoassiEe;  when  large,  it  is  commonly  irregular  or  M-ni]toDariDin|*> 
aonietimes  appearing  to  be  compoeed  of  teeeral  distinct  lumon.  It  b  oaM^f 
partly  d'lugby  and  partly  tympo-nitic  to  the  fi-el,  has  a  distinct  lei|wli'* 
wugfiing,  anil  h  readily  reoucible;  not  onfrt^Mienily  tt  happew,  bw"*** 
that  ft  jxirliou  of  the  rupture  cnolinues  irredurible,  i«wing  In  tlMi  «><«»'' 
odbcn-til  onicutiiii).  The  coverings  of  an  undutical  rupturr  are  ^B"! 
extremely  thin,  consisting  merely  of  tbe  peritoneum,  a  ii- 
fascia  n-hich  is  oAen  iHTforuted  at  weveral  pointu  by 
tbroutib  which  tbe  hernia  pn>trudes,  and  tbeintcgum''ntf  whitb  arv«t(w>^' 
over  the  part,  and  in  which  the  umKilical  ticairix  is  usually  clcuiy  |>f*<*r 
tibte.  Tne  sac  ffenerally  contains  both  intestine  and  ooMatUB.  M  ^ 
Btomacb  and  otovr  vtanra  hava  baao  iocludnl  ia  it;  and  Unmy  ^ 


3 


UMBILICAL    HEKlfIA OPBRATIOV. 


801 


iteriin,  at  the  eighth  month  of 


case  in  whirh  tl»'  gra' 
liirriied  the  oouLeriU  ol'  Hri  iiiiihilit'ail  liernui. 

T^reaimenl.—'Vhc  itvatment  cuDcifltSj  if  the  hernia  be  reducible,  in  wearing 
■  properly  constriicieil  iniss;  if  irreducilile,  in  appljiug  a  hollow  cuu- 
aliaped  ))od  mipporled  by  a  bandage  over  the  part.  It  nut  uDfrequeutljir 
happens  that,  in  consequence  of  an  indigestible  or  flatulent  meal,  an  irre- 
ducible umbilical  rupture  in  old  persons  hecomea  obstructed,  the  symptoms 
eoaeifltiog  of  tt-nsiun  of  the  protrusion,  with  nauBea  and  constipation.  la 
these  caaes,  much  discrimination  will  be  required  to  aruid  cont(Jun<)ing  this 
peasive  condition  of  the  tumor  with  acute  strangulation  of  it.  Thia  may  be 
done  br  attention  to  the  rules  laid  down  (p.  758,  vol.  ii.).  By  leeching, 
funientatious,  and  enemalfl,  relief  may  usually  he  nflurded.  Should,  bow- 
ever,  the  bowels  not  speedily  act,  nnd  slerooraccous  voiiiiiing  ccinie  on,  the 
tumor  continuing  irreduoible,  it  uMl  be  better  to  cut  down  upou  it,  and  treat 
it  as  a  strangulated  hernia,  dividing  adhe^iuiiii,  iinil  reducing  the  ^welling; 
for.  if  it  be  left  obstructed  and  unreduced,  the  whivle  tumor  mny  run  into  a 
state  of  gaugrenuus  intlammation,  and  then  operative  interference  will  be  of 
little  use.  In  such  circuinatunces  di^ath  usually  recults;  but  I  have  known 
the  patient  Ui  survive  the  gangrene,  the  whole  of  a  coil  of  intestine,  the  sac. 
and  much  mesentery  and  omeulum  sloughing  away,  and  au  incurable  artifi- 
cial  anus  resulting. 

When  an  umbilical  hernia  becocnes  strangulated,  as  ot^eo  happens  in  old 
irreducible  tunidrs  of  this  description,  the  symptoms  are  not  usually  very 
acute  at  first ;  but  no  time  should  be  loet  in  eliecling  reduction,  it  possible,  by 
taxis,  as  they  speedily  assume  an  active  and  urgent  character.  If  ta\is  fail, 
a  large  umbilical  hernia  may  sometimes  be  reduced  by  the  application  of  the 
elastic  bandage.  This  must  be  carefully  applied  n^und  and  over  the  tumor. 
Tbe  gentle  and  uniform  pressure  exertetl  by  it  may  di«plnce  s^iiiie  llatuH,  and 
thus  the  ct)nteuts  of  ihe  iicruiu  ruay  gradually  be  eui{tttc'<i  and  th*-  pruLrut<iou 
reduced.  If  this  lail  and  tlif  synipLoniM  are  not  acute,  xmall  duMt^  uf  itpium 
may  b«  given,  and  un  icchluddtr  applied,  and  kept  on  for  a  few  hours. 
TaxU  may  then  bo  agaiu  emploved,  when  reilucliou  of  some  portion  of  the 
swelling  will  usually  follow.  Hhould  this  not  succ-eed,  ihn  opcratiou  muat  be 
proccoiied  with  without  further  delay,  lest  gungrene  set  in.  If  thettympumis 
are  from  the  &rvl  acute,  the  ^me  rulf»  appty  to  umbilicut  as  to  other  hemitc, 
not  to  waste  lime  with  ineflieicnt  means,  but  to  try  taxis  under  an  anuathetic, 
and  (iiiling  to  reduce  to  npurate  immediatel}'. 

Operation. — The  parts  covering  an  umbilical  hernia  arc  utmally  very  thin 
in  places,  so  that  much  caution  is  required  in  making  ihe  <-nrly  incisions. 
The  stricture  should,  if  possible,  he  divided  without  opening  the  sac  This 
tnay  usually  be  ac(-om)ili!«ticd  by  drawing  the  tumoi*  well  down,  nud  then 
making  an  incision  in  it  ahmit  two  int^be^  in  length  over  the  net'k  at  its  upper 
part  in  the  mesial  line.  If  the  luttior  overlap  here,  it  may  be  more  conve- 
nient to  make  tbe  incision  ljy  the  siile  of  ilic  umbilical  cicatrix;  but,&B  a 
general  rule,  the  upper  part  is  the  be«t.  A Uer  tbe  division  of  tbe  integu- 
meotal  structures,  and  often  of  a  deep  layer  of  t»l,  the  end  ol  the  null  may  be 
•lipped  under  the  edge  of  the  sharp  circularaperlure  through  which  the  pro- 
trusion has  occurred,  and,  the  stricture  living  divided  away  from  the  sac^  and, 
if  possible,  in  the  niesial  line,  reduction  may  be  rvudily  and  safely  ucoom- 
pliabod.  Should  the  strangulation  not  be  thus  relieved,  tbe  sac  must  be 
opened,  aud  any  stricture  divided  from  within. 

Tbe  openition  f^^r  umbilical  hernia  was  formerly  extremely  fatal  if  the  sac 
was  opened.  e«|)eciutty  when  the  protrusion  was  of  great  size.  Death  usually 
took  place  from  septic  peritonitis,  The  wel'-knuwu  danger  of  the  operation 
formerly  produced  considerable  hesitatiuu  on  the  part  of  tbe  i;urgeou,  and 
VOL.  11. — 51 


802 


SPECIAL    llERHIiK. 


perhaps  tempteil  liim  to  lose  time  OT«r  ineffirirat  mniD«.  BDd  tlui  msj  htm 
been  anotlipr  oru»c  of  the  «xc«mivc  murtNlily.  The  risk  is  mv  fmitf 
dimiriUhi^l  liy  the  um  of  aotiMptics,  anti  jl  thi-  ofteriiti'ia  be  p«rlonMdaf}f 
the  <)enth-nit(!  ix  not  greater  in  utnhiltcal  (Imu  in  utber  ioram  of  kmt, 
Bonietintes,  after  Lbe  external  division  uf  th«  Bthctur*.  it  will  be  foami  IM 
there  18  an  ioternal  straa^iilatiuD  ia  the  hernia,  the  pnl  hariitx  tUffii 
through  au  aperture  in  the  omvtituni :  if  ao,  the  «iigv  ^r  this  wttmryij  lUfM 
opening  iimy  rei|uire  division.  Sir  A.  C<K>|)er  nientitiua  an  uiobiJinl  btcni 
forniiug  two  tuuiort,  having  a  coiuinuutcaUoa  between  ibriu :  and  S«A 
relatee  a  case  in  which  the  luuiur  reaeiublitl  a  6gure  of  H,  a  deoM  anolu 
band  binding  down  ibo  luiddle  uf  Ihe  mic.  Iu  such  caaea  ■■  tbac,  •ivid 
are  by  uo  iiit'ana  uncumiuou,  wutral  cunelrictiou  amy  nn)uin  to  ht&vid 
as  well  as  the  slrtcture  at  the  neck  of  the  one.  Adherent  nt»«»iutu  kni.  1 
think.  heUer  Iw  leA  in  the  sac  in  caeen  of  umbilical  hernia  ;  aiwl  gangrcaua 
intcFliae  ur  uitientuni  must  be  treated  u|Kin  geufral  princjidra.  It  «  »a 
otleii  thill  BtrangulatioD  of  an  umbilical  heruiu  occur*  duriJig  pnfoaftn. 
but,  should  it  ilo  BO,  the  operation  mu8l  tw  pcrfurninl  aA  tuaal ;  thit  nw- 
tioD  Aoea  not.  eomplicnte  the  case  tnurh,  and  instantva  are  rtcorded  fc*  Sr 
A.  Cooper,  Sir  W.  Lawrence,  and  ulbcr«,  of  iu  succeHful  peHivinaDn  i: 
this  period.  After  dirbiun  of  tbestriciurt!  and  redactioD  of  thtpart*.^ 
wound  must  be  closed  hy  sutures,  a  drainugc-Liibe  being  introdaoed  aadu 
aoitseptic  dreauog  put  on,  over  which  u  broad  6anncl  roller  mmyhtinij 
apniiod. 

When  the  patieot  ia  not  too  fat.  the  operation  m^y  ba  ooBi|tkwd  k 
removal  of  the  sac  after  ligaturing  iu  nct'k,  nod  an  atlrtiipt  niay  h*  am 
to  close  the  riog  by  eoturec.  In  very  fat  »ul>jcct*  th«  Atraiii  upoo  lb*  nflf 
would  l>e  so  great  that  thin  wuuld  very  pndinbly  tail.  U  ftboold  Dot  !■ 
aitempt^l  in  uie  abeeuce  of  the  mean*  of  ciirrring  out  efficient  aatiB^ 
(rvMlmenL 

VENTBAL  ni:aKtA. 

By  Ventral  Hemie  are  mmut  tboee  protrunions  nf  the  inteatiDe  lluln<v 
through  any  j^rt  of  the  abdominal  wall,  cxofjit  the  inguinal,  the  k»itiL 
or  the  umbilical  apertures;  they  mmi  conilDunly  iK-ciir  ta  the  infal-fiD*  te 
twei^u  the  recti  mtucies.  tb<*  linea  alba  appearltig  In  have  girai  way  is  tt> 
ritimiion  during  pariurilion;  and  here  (hey  niay  ntlaio  an  imBcaet^  ^ 
case  was  ourc  »eoL  to  lue  from  the  country,  in  whii-h  tbfro  waa  •  !«•;  B^ 
gular  gap  ihruugli  the  upper  part  uf  the  alxlomioal  null.  esteoiHlf  ft* 
the  amhilifU8  to  the  ensifurni  enniUgv,  tlimii^h  whi';h  a  Tuiitm^  t*' 
taken  piarr  that  was  nearly  us  targe  i«  an  adult's  brad.  That  nftM* 
have  alpo  Uiu  met  with  in  the  lint-a*  semilunara,  and  iu  the  hypoAtti^ 
and  iliac  regions;  and  ChKjuet  deNril^Ps  a  raee  oreurriog  in  the  koi^ 
region.  When  these  benii:e  form  in  thf  virauity  of  the  atomach,  tlir*!'* 
apt  to  ocraAinn  dyspeptic  avmptonut  and  murh  gastric  irriiatinn  ;  hot  lA*' 
renre  is  diiubttefin  riglit  in  thinking  that  thene  pymiMomeUio  tuA  an»k^ 
the  inipliraliun  of  the  stomach,  but  Dimply  from  irritation  of  tL  IV*^ 
lerent  protrusions  hiive  i-rcasionally  heeti  met  with  as  ilif  re*'  '"  '  '""f* 
by  which  iho  anterior  abdominni  wall  haa  been  laeer»tcl  ;  m  '^ 

dull),  if  evrr,  uke  place  below  the  iimhllicuii,  unlen  arising  tnmi  a  CiT*^ 
traumatir  raune. 

TrnahncnL—The  trralmeni  of  v^-nlral  hernia  m"-  -upMr^ 

the  tumor  hy  nioan*  of  a  broad  tiell  and  pmpt'rlr  r-M  HhoaU 

it  become  Hrnnguiali'd,  which  I  believr  very  r  '■*ing  fr'  f" 

width  of  Ihe  neck  uf  the  Hie,  ihe  operation  niuri  '1  in  t^  «■■ 

way  as  for  umbilical  rupture,  nire  being  taken  to  divide  oantiattilj  the  )•• 


OBTDBATOR   HBRNfA — TBBATMEXT. 

lineote.  iiuy  apoocurotic  iavestmcnts,  aod  the  peritoueal  lao  if  accessarj' ; 
etriuturv  nhuuld  always  be  divided  upwards. 
A  mre  kind  of  viMitral  rupture  lias  been  described  by  Ciutlirie.  in  which, 
afWr  a  blow,  the  abdouiiiiul  wall  tia«  bcco  nbeurbcd  or  yielded  to  a  (xioeider- 
able  extent,  foniiiit;;  a  bniad  mid  cx[iande<l  tumor,  without  any  distinct 
neck  or  petlicle.  Kmni'tirm^  this  tumor  may  attaiu  an  immense e^ixe,  slrclch- 
ing  perhafM  dnwn  to  the  kuf^v,  and  Rurituiniiig  even  the  gravid  utenis. 


PELriC  HERXI-K. 

Obtubator  Heuijia. — This  rare  form  of  hernia,  in  whieh  the  protrofion 
of  inbesiine  takes  place  through  the  thywid  fi>rftnien,  was  first  noti(M.>d  by 
fiareogeot,  in  llie  early  part  of  ibe  eighteenth  century ;  and,  since  that  lime, 
abfiut  ei^hty  caaes  have  been  recorded.  Its  oxiittence  hna  rarely  been  aacer- 
taiued  lill  after  death;  in  fact,  Lawrence  seems  to  doubt  the  poasibUitr  of 
the  recf^oiiirm  of  the  complaint  during  life,  in  cnnse-^uence  of  tbc  small 
■ixe  which  the  tumor  attaiuB,  and  it»  being  covereil  in  and  contpresHed  uniler 
the  pecttneu5  niUBcle.  But  wveral  casea  are  on  record  in  which  it  was  recog- 
niiMHl  during  lite.  It  generally  oocurs  in  ponuion  abov«  the  age  of  BUy;  in 
ci>DK<iuence,  according  to  Gurlt.  of  the  partioipaliun  by  the  muscular  struc- 
tures paaiing  through  the  thyroid  fonmien  in  the  general  wasting  vf  tissue 
whiuh  ocGurv  at  that  time  of  life.  I'lmbet,  who  hao  cnllected  the  records  of 
all  the  published  eases  up  to  18B2,  states  that  in  7^],  in  which  the  sex  waa 
meutiuned,  6>^  were  vronten  and  8  men. 

Syinptomg. — ill  obturator  hernia,  the  intestine  descendn  through  the  thyroid 
Ibranieo;  the  neck  of  the  sac  thiii«  lieH  behind  tlie  ht^rizontal  ramu?  of  the 
pubo.  Thesyniptums  have  in  some  casej  MifRcJently  resembled  th"ae  nf 
Hrungulated  leinnrni  hernia  to  lead  able  .Surgeons  to  suppose  llicy  had  to 
deal  with  the  tatter  aUcctinu.  lu  addition,  however,  to  the  ordinary  aymp- 
toiuH  uf  dtratigulatidii.  there  are  two  sjiecial  signs  which  may  load  to  the 
BuepicioD  of  the  exixtcuce  nf  Ehi«  hernia,  if  not  to  it^  putitivc  diagnosis.  The 
flrel  of  theie  is  a  slight  fulneit^  and  hardiie^  to  the  upper  part  of  the  thigh 
to  the  inner  aide  of  the  femoral  veiiscle,  often  very  iudiatinct,  yet  giving  to 
tile  surface  of  the  limh  a  rlitlerL-nt  outline  from  that  whii'h  i»  oh«crv<rd  on 
tlie  other  side.  The  oth<T  is.  pain  extending  down  the  inner  n'nie  nf  the 
thigh  lj>wanla  the  knee;  or  even,  aa  in  a  ca»u  referred  M  by  Birketl,  lut  far 
as  the  great  toe.  This  pain  has  been  noticed  iu  a  largt;  number  of  the  re- 
oordeil  caaea,  and  ia  due  to  the  preuuro  of  the  hernia  on  the  obtiirator 
nerve;  it  may  hIbo  be  increased  by  prcsaure  with  the  hand  over  the  thy- 
roid foramen,  and,  acpurding  to  Pimb€«t,  by  forced  external  rotation  of  the 
limb.  It  doe<i  not  extend  to  the  tesliji ;  hut  it  may,  an  happened  in  a  case 
which  I  have  seen,  nirect  the  thigh  to  such  an  extent  that  the  pnlient,  to 
relieve  i I,  flexes  the  limh  on  the  abdomen.  Uaier  ho.-^  recommended,  as  a 
ineanii  of  diagiytsis,  nn  examination  of  the  interior  of  the  pelvis,  per  return 
in  the  male,  and  fier  i\i//inftm  in  the  female.  M«)st  reliance,  however,  U  to 
be  placed  on  the  eyinptoms  which  i  have  de^icribed. 

Trfattnmt. — Taxis  has  been  emphiyed  in  a  few  casea.  In  one  inslaoee, 
Roser  reduce<l  an  obturator  hernia  in  thi.s  way,  the  patient  surviving;  hut, 
in  another  cane  under  my  care,  death  took  place,  a  portion  of  the  walls  of 
the  intestine  reiuniniiig  stran^iiilated.  Werner  wai>  succes^t'td  in  an  iuEtauce 
in  which,  in  ndditioo  to  applying  ]>re8sure  externally,  he  introduced  bin 
haiHl  into  the  VA>;iiia,  aiiil  employed  traction  hackwanU  aud  upwartls. 
Welach,  of  Ilerrenb^rrg.  reduced  an  obtiirstor  heruia  by  exiernal  pressure; 
the  paltetit  was  apparently  doing  well,  when,  in  a  few  days,  an  abscess 
appenrwl  at  the  site  of  the  hernia,  aud  he  died  b  aeveu  we«k8.    At  the 


801 


SPECIAL    HERNIJ:. 


pott'iHorirm  examinatioti,  the  end  of  llie  rcrinifonn  apprnrfil  wi»  feiB»l 
prnjec(it)^  tliruugh  llie  lliyroid  funimeii,  with  ii»  lip  Inid  upeD  \>j  ili«tui^«iv 
CJVti  |>ru<:e««. 

In  thirtteii  caws  of  whirli  I  can  find  fworda  an  opcratiod  wai  prrfimr.! 
folluMvd  in  four  case*  by  recovery  and  io  oiD«  Uy  dritli.     Th*-  r. 
uccurred  iu  the  pracliwof  Obr<^,  Brnnvby  Cwoper.  an')  I. >•!•.."•'  -.» 
and  thedeatbdin  ca»e«  opertittrd  ou  by  lIcalh.ot'Nt'Wi 
of  Ij«icv»t(>r.  Heilberg  and  JCuhrtninuD.Arntz,  of  llii>^M<»»«^ 
Wilms,  of  Berlin  (twucaBee),aiid  8tiginondi,  of  Vivaoa.    Ju  0>  < 
patitrnt  H'uH  seized  witb  vvniptonia  ol  filraugulatiun,  but  ao  Lui: 
detectt-d  in  any  of  tiie  ordioary  »uale  uf  lieruin.     "  Od  uncot^fti: 
pan  uf  bulb  tbighs  at  the  same  time,  the  eye  detected  a  sit;. 
hiinpn  in  i^carpu'i*  triangle  un  ihe  ri^bt  side;  tliiB  triiingle  t>i 
limb  vaa  well  tuarketl  with  a  holluM,  ur  depresBJifu  pawiog  dotv 
but  itiis  WAH  lost  OH  tbt>  alR-cteil  aide,  and  tbe  wbole  cuntuur  u! 
the  limb  was  Tuibly  fuller  ibnit  that  of  Ibo  citrrfBimndiDg  uor.     1  ^ ' 
DO  tumor  or  circumscribed  itweiliii^;  but.  ou  stiiuduif;  over  the  mm 
using  firm  prcasure  with  tbe  ends  i>f  the  fingera  over  the  oetghV 
fctnurBl  artery,  and  a  Utile  l>e!ow  ihe  BHphenodi!  opening,  a  di«i 
could  be  felt  (sligbi  in  its  exteoi),  giving  an  tmpr«i«ioD  aa  if  t 
the   reaeels  were    being  preised   on."     Taking  the  dangpfou- 
patienl  intit  couBideratiun,  Obr^  ncled  in  acconlnncv  with  the 
surgery  ;  and,  thinking  (hut  there  might  be  a  btrnia  deeply  slnii;^' 
the  femoral  CBnnI,  he  mnde  an  inciaion  downwards  in  thi«  #ituati«n. 
dtMippointed  un  finding,  when  the  saphenoufl  opening  u 
there  was  no  intestine  confined  there.     Ai,  however,  a  nar' 
be  felt  deeply  at  th*  inner  border  of  ibe  opening,  tlirfnsrin  U:.- 
nnd  the  pecttneua  muftele  divided  lo  the  extent  of  fibotit  twn  <: 
hernial  sac  of  ab<mt  the  eiu-  of  a  pigeon's  egg,  and  oc>ii' 
canK*  into  view.     In  this  operation  the  saphi'Da  vein  an. 
lying  in  Uie  course  of  the  incision.     The  t&c  having  been   h 
Btriciure  was  diTitie<l  upwards,  during  which  part  of  too  proccc! 
was  nccideutallv  cut,  and  reijuired  lignlure ;  nu  other  vr»el  wu  tie«i-    Ix 
operatiou,  whicn  redects  the  greatest  credit  on  Obri'a  diagDovtic  skiU  "^ 
dexterity,  wa*  perfectly  succcsslul.  the  pati«Dt  makiDg  aa  axetUtol  nrtMf 
In  Brnniby  Cooper's  awe.  the  patient,  a  woman  ag«d  fbrtr-nine,  rr«w^ 
frum  tbe  operation,  but  died  of  broDcbitif  before  leaving  lb«  bwpittt    i> 
Ijoriu0cr'«  case,  Ibeexittteuce  of  tbo  hernia  wai  dctectdl  by  vaginal  ow* 
uutioii.     Ou  cutting  dowu  on  the  herniation  the  elcvenlh  day  of  lbep*f 
CODIB)  the  iutesiine  was  found  gangrenous.    A  fecat  fiBtuta  nnJtd  ^ 
Bubsrquently  cloeed  ;  and  the  patient  survived  eleven  montha.drlagtfli' 
of  lul>ercul(«ts.     In  Szigraondi'i  raeo  ihr  patient  died  from  dwrniiMf  i** 
cinu'  aAlt  the  or>cnitiou.     In  another  ca»e  oucrated  on  by  tirOnbcif.  |^ 
patieui  died  on  tlie  twentieth  day  of  perfontuun  of  ibe  iniMtinc    Is  l^ 
K,  J.  iimllee  opi-rnted  on  a  eaae  iu  Unireraity  Cullega  Uoapteal  by  tt  i** 
oteiun  in  the  middle  line  of  tbe  abdomen.    The  homia  waa  ralticMt  mA^ 
ditBculiy,  but  th«  |)atient  who  was  exlretnely  cotlapied  at  the  iIbm,  t^ 
aliout  twenty-four  hours  uiler  the  o[>erution. 

OmMdrrtng  the  results  which  have  followed  the  openit- f  '--•  '^twiur 
bcrnia.  t  think,  that  when,  in  addition  to  the  ordinary  •  .raapb- 

tion.  there  are  ai^>  prt-nent  (he  altered  contour  of  tbe  lim^i  i  [imiiipa  tfs 
distinct  local  swelling  I  and  ihc  pain  which  liAve  bt-ru  above  dracribM,  tbai 
sytiiptoni*  not  only  justify,  but  d<>riinn<l,  that  nu  tv    '  .*  hidlki*  bt 

madv  throiiiffa  the  tlructum  overljing  the  obtumttir  sq  ■•  la  tt* 

amine  it.    If  a  bcmia  be  found  there,  it  muat  b«  dealt  wiUi  by  Um 


3 


DIAPBRAOMATIC    BERyiA — COJf OBMITAL. 


Hilei  already  laid  down,  acrordin^  to  the  8tat«  of  che  inteatinp.  Tlic  etric- 
tare  mtut  be  divided  directly  dowownrds  a»  tti«  nrterj  is  mmt  comnmnlj- 
ftliave  the  sac. 

Bfaid'v  ihci  ohtiiratAr,  Vflrioufl  otiier  p«lv1r  h«mit«  may  take  place,  as  into 
th^  p(>riortim,  the  vagina,  or  through  thtf  sciHlic  unto)].  Thf^ie  varinun  forms 
t>r  rupturv  nre  of  <!xtrem«  rarity,  and  preeeot  roaoy  difficulties  in  their 
d(*i:«i<i«i«. 

Ff.rixeai,  Hr.iiXiA  pcimmonly  occurs  in  the  middle  line,  between  the 
rectum  nnd  thu  bladder  in  men,  or  the  rectum  and  vagina  in  women ;  but 
•uiDvtimr^  the  itP'trusioQ  haa  been  known  tn  take  place  by  th?  f>ide  of  ihu 
aaos.  Of  these  variou!  furms  uf  rupture,  many  in^tanceii  have  beeu  enllectcd, 
by  lAwrwice  from  ditferenl  writers.  The  TVeahnerU  of  such  a  hernia  would 
aoDSttt  ID  supporting  the  prolruiiion  by  means  of  a  pad  and  banilage:  as  the 
aouUi  of  the  sac  is  very  larn^,  »traDguiHtioa  is  not  probable. 

Vaujnal  iIi:KMA  has  occasionnlly  been  met  with  ;  the  lunior  pmtrudiDf; 
thiouf^h  the  pisterior  or  upper  wall  of  the  vagiaa,  and  presenting  iho  ordl- 
nary  otui'vcters  of  tills  diaease.  eueh  as  impulse  on  cuugliing and  reducibility. 
biwnt  be  kept  up  by  means  of  a  peeearr. 

Pvi>Kvt>AL  HcKNiA  hoB  beeti  deHrril>ed  by  8ir  A.  Cooper  as  T«rT  closely 

respoiblinir  vafitDal  rupture.     The  situation  of  the  tumor  may  cause  it  to  be 

misbaken  r>.>ran  inguinal  hernia;  but  from  thn  it  may  be  reeo]2nized  by  the 

uppor  part  of  the  labium  and  the  rin;.'  being  oomplctely  free.  whIUt  u  tumor 

itinf;  the  onlinary  charaet^L-rs  of  a  rupture  ia  situated  in  the  lower  part 

.Um  labium,  and  fi>rms  a  protntncnce  along  the  tide  of  the  vagina. 

~    LvTic  tlcitvtA. — This  rare  form  of  hernia  hfl«  been  doaerit>ed  by  Sir 

tperas  passing  through  the  aciatic  notch,  where  it  lies  between  the 

bortier  of  the  pyriform  muscle  and  the  iipine  of  the  Uohioni.     It  lin 

eliMft  ralation  with  the  sciatic  nerve,  ami  with  the  internal  iliac  vetnehi. 

In  the  caw  related  by  Cooper,  the  obturator  artery  passsetl  above,  and  che 

ran  below  ibe  neck  of  the  aac.     From  the  depth  'at  which  such  a  hernia 

VMild  be  seated,  and  ita  small  vize.  it  would  probably  escape  obeervation 

-^■'-'"T  life:    but.  ifdetected.il   might  readily  \>e  retained  by  meaus  of 

'  bandages  and  a  pad.     Should  operation  ever  be  required,  the  deep 

incwoni  must  be  carefully  conducted,  on  account  of  the  great  im|>orlauce 

,  of  tfae  parts  surrk>undiRg  the  sac. 


Vcoag«x 


niAPHHAnMATIC   BEBXtA. 


tnital  defect  of  the  Diapbragnt  is  occnsioiinlly  met  with.'  It  baa  con- 
sitad.  In  moet  of  iho  recorde<l  oases,  of  an  aperture  in  thb  membrane,  vary- 
iag  in  diameter  from  on  inch  upwards ;  and  amounliag,  in  aume  rare  in- 
rtaaeaa^VTen  to  an  eatire  absence  of  one  or  both  winn  of  the  diapbrngm. 
Tbnmgh  these  openings,  the  coulents  of  the  abdomen  have  been  protruded  ; 
tlwMatiuicb  and  small  intestines  lieing  moat  frtnguently  displaced,  and  the 
nlMn  and  liver  having  liecn  found  in  the  cheat  in  a  tolerably  large  propor- 
UM  of  the  cases.  The  hernia  hwi  bit^n  m<istly  obAorveil  in  children  nt  or 
Mon  after  birth  ;  but  to  several  instancea  the  suhjecu  hh\f.  tive<l  to  ndutt 
■«,  the  hernia  at  last  taking  place  apparently  ai-oidentally.  In  i*(>me  of 
tMse  latter  osaes,  however,  ft  may  be  a  ononiion  whether  the  opi>ning  in  the 
dtanhra^  waa  not  tfae  result  of  un  acciaenl,  perlmps  some  time  nnUTetlent 
tn  iJie  oecurrenue  of  the  horniu.  The  n^wning  has  grneralty  be«D  found  in 
iba  leftside;  sumelimrt,  however,  on  the  right. 

*  A  fBTHl  sifDpUte  and  InXfi^lirig  account  of  Con^imlul  I>Unbrm;tD«tlc  ITftrnla  vu 
p«Miali«d  hy  Mr.  IImibm  Balf.Mr  In  iIm   iS>tiu*4iryA  Mafkal  Journat,  fmr  April,  IROV. 


80G 


BPSOIAL    HERMIT. 


Diaphntgtnatjc  heroin  ia  sometimes  obvioi»)v  of  traumttic  <ing(ft,Wii| 
the  result  of  a  wound  ur  taofcratioD  of  the  dinphrBf^m.  It  luuallyiaiiBft 
large  ?izc,  and  cuiiimonty  cmitainii  tbe  eLumacti  or  tbc  iruMvene  eoldvik 
a  pnrtiirD  ai'  the  omentxim,  vrhioh  forms  a  tumor  in  tbe  ihoraeie  cmfiiy.* 
oroachiug  upuu  the  luag&,aDd  puskiog  tbc  Uuun  to  one  aM«^  TbfebHM 
is  Dot  endoeed  id  r  periioneal  sac,  but  bae  bei-u  fuuiul  narltalljr  tafiriiipd 
by  ibe  pleura.  It  oei-uni  generally  'lU  tbo  left  aide  nf  the  t-bnl.  Inil  am 
have  been  recorded  by  Percy  and  others  where  the  injury  if  the  dtkfibnfa 
woe  on  the  n^hl  aide.  The  following  OM  ia  a  very  good  Stulanoci^  t^ 
rare  uSeciioa. 

A  miui,  »eveuly-fiiur  year*  of  age,  waa  admitted  into  UotT«f*iiy  Cdlip 
Hiwpital.  AUiut  twelve  luuuthM  Iicfoff,  be  bnd  fallrii  iiifi  na  nrraalwatM 
f«et  iltvp;  he  l*«-tievet]  thai  htt  Imd  iiijurnl  bi.>>  cbrst  and  he-ad,  m»  f^•m  iW 
time-  III!  had  xullcreil  much  rrota  Hbiirlii(^»  of  breath  nud  m- 
of  liulliK'Hiiciii,  liHct  a  hackin]]r  oiu^h,  aiid  could  uul  he  d4>i> 
some  <litl)culty  in  breiithiiig.  At  llie  liuie  "f  the  ncridvul,  b«  iiiiafhaj  m 
abouL  tbret-  epooufule  of  bloml.  Kver  since  the  xTJdfDt,  he  coAnJ  am 
from  dyspeptic  sytuptoma  and  couatipatiuu.  tbou|^b  U'tiire  b«  BMt  vitii  lb 
injury  he  bad  experienced  uo  ioeonveuience  iu  tbis  rnpi'ct.  Abont  a  OMriik 
tiefure  nduii»itiu,  tbe  diUiculty  in  bnaitbiu^  iiu-reaaei) ;  and  four  danbrfn 
he  cniiiu  to  tbe  hoepital.  violent  |«aiu  iu  the  abdomen  cami*  ou.  and  biilwai^ 
ceased  to  act,  altbuugh  he  took  a  variety  uf  ajierient  imilitisca,  attd  W 
enetiiata  cuutainiiig  crutou  oil.  On  ndmiEeiou,  the  nbdomra  mu  nacfc  dl^ 
tended,  tenue,  and  lympatiitic,  with  pnin  nroiind  the  umtiiliaia;  tlw  Impi 
waaortnted  witb  wbiti»h-lmmn,  moist  fur:  the  pulse  «rw  amall, qdck.Mi' 
somewbal  re«ating  :  there  ytaa  nauwa,  but  no  vainiting.  Tbe  aklo  sirmI. 
and  the  cuuiiteoanoe  anxioua :  tbe  biwels  bad  not  aeted  for  aeveo  ikj%  Iw 


ijf 


?ig.  KOI.— DUplir*traitii«  II«ralB  «(  Calaa. 

he  had  IVeiiuent  dcairc  to  gu  to  stool.  Be  irta  ordered  tm  aperioil 
evt-ry  (bin)  hour.  An  thi«  had  no  eriV-et  he  was  direirK-^l  u*  iaite  calon^ 
elat«rium  pills,  and  to  have  turpentine  enenutta,  whitih  affimleil  Ub  " 
relief,  ihouffh  tliL-y  hrnughl  away  no  fece*.  The  patient  becarae  ■oK'* 
leas,  the  skin  cold  and  flabby,  the  couulenanco  more  anninu*,  the  '■•^"f 
shorter,  and  the  abdomen  mure  tympuDiUc-,  and  ho  dii-d  two  dap  aiUt*^ 
miaaion,  and  nine  from  the  ooiumeDccmenl  of  tbe  t^iaUuctkitt. 


CATTSKS   or    ACUTE    INTESTINAL   0B8TRDCT10N. 

Examination  of  the  Body  UcenX^-Jour  hovra  after  death. — The  tibclomeD  was 
distended  and  tYmpaaitic.  and  tlic  peritoneal  sac  contnine<l  about  six  oudccs 
□f  fluid,  with  licro  aud  there  palchea  of  roocotlv  ctTused  lymph.  The  email 
iDl«8tin»  were  nut  diatended  :  the  large  wore  prrwitly  di^leoded  with  flatua, 
the  CKCuro  exleodiog  into  the  cavity  of  the  pelvic ;  the  asccndinj^  aud  the 
tranaverae  cuIoq  were  much  dial£Qdt>d,  ond  it  waa  found  that  o  larfio  loop  of 
the  trantvene  and  of  tbe  descending  colno  Imd  pawed  through  an  opening 
in  lh«  (Ktrdifiirm  temion  nf  the  diaphragm  int<'i  the  pleural  sac,  and  was  there 
Mran)it)Iated  (Fig.  801 ).  The  colon  below  the  strieturo  va*  oimtmctt^,  and 
entirely  empty.  Oo  opening  the  thorax,  the  loop  of  iulcntine,  fourteen 
inches  in  length,  of  a  pale  fllate-c<dor,  and  diiilended  with  ga«,  wan  found  in 
the  tefl  pleural  flac.  It  reached  as  high  as  the  Hfth  rib,  toiicht^<l  the  pericar- 
dium, and  wa«  overlapped  by  the  free  njargiii  of  the  leA.  lung.  Where  gtran- 
gulaleii,  it  van  of  a  darker  color  than  eWwhere.  The  opeiilug  in  the  dia- 
phragm, through  which  it  had  jutsfted,  a<]mitted  little  more  than  the  point  of 
the  forefiuj^er.  aud  bad  a  thin  t«ndiuoua  luargiu.  The  teoth  aud  eleventh 
ribe,  no  the  left  aide,  were  fimud  to  have  been  fractured  ;  the  ]att«r  wa» 
united  bv  bone,  but  the  tcuth  rib.  at  the  seat  of  fracture,  had  formed  a  false 
joint.  Oouocvted  with  thU  aud  with  the  ioterciHtnl  i>pacc  below  it,  woe  a 
firm  adhcaiim  about  an  inch  bruad  aud  uu  inch  aud  a  half  lou^r,  united  by 
ita  other  extremity  to  the  protruded  rneso-olou  aud  the  diaphragm.  The 
pnrtruded  mcso-wdtm  waa  firmly  udhcroul  to  the  upper  surface  ut  the  dia- 
phragm. cluGC  to  the  opeuiii^  in  it.  The  iuuga  were  tolcrabSy  healthy.  Tba 
right  pleura  cuuLaiued  three  oiiucta,  uad  tliu  lefl  eight  ouuuca  uf  isurum. 


CIIAPTKR     LXIII. 


INTESTINAL  OBSTRUCTION. 

IntflBtinal  Obstraettoni  may  be  of  two  distinct  kioda,  Acufe  nud  C^nwi. 
Xheee  must  nut  b«  cjuPjunded  with  oue  another,  us  thyy  are  usually  de- 
pendent uot  only  upon  very  diHurciil  t^uuditioudt  but  require  ditfL-rcnt  linea 
of  trcttliueul  for  llicir  rvlief. 

Acate  lutestiQ&l  Obstractioa  may  ariau  from  the  follnwing  pathcilogtcal 

jditioiiii : 

Inffnuii  SUitni/utalinn. — ^Tiils  may  iiridc  from  a  portion  of  gut  alipping 
through  au  apurtun-  in  the  ujt«eutery  or  omentum,  forming  the  B')-cnlleci 
intemal  hernia.  Or  u  nortion  of  the  int<»tiue  may  be  constricted  Uy  liecom- 
iDg  entangled  r<iuud  a  Itaud  j)»»ilng  from  oue  part  of  the  abdominal  cavity 
to  another.  Thee<^  hiiiids  may  be  entirety  of  new  formation  rettulting  from 
local  peritonitis  with  the  formation  nf  adhesinnd  which  have  becuine  grad- 
ually Hlretched  :  whilst  in  other  cs^eii  the  Btran;:ulating  baud  i.^  cr>mp<Kipd  of 
the  vermiform  appendix,  or  of  a  diverticulum  from  the  ileum,  the  free  end 
of  which  hail  l>ecome  attached  to  wime  jiart  of  the  abdominal  wall,  2.  A 
porlion  of  )fut  may  hecunie  twiiited  tm  Jt-Hplf.  tluia  forming  a  volvulus,  owing 
to  the  meao-c/iliin  nr  th«  mesentery  lieing  tinusiially  long  and  allowing  a  half 
Lwiat  to  take  plac«,  in  ronseipience  of  which  complete  nbslruotion  lakes  place. 
This  occurs  moet  commonly — in  fact,  almost  exclusively — \n  tbe  ugmoid 


808 


INTESTINAL    OBSTRUCTION, 


fi^xuFC  and  tlie  dMcending  colon.  3.  In  otiier  iiwtancw,  th*  symptotiwi 
scute  wbstruotion  nifty  ari*  io  (.•<>nBec|m>iici>  <tf  a  Htricture  gnuIuaUy  cl>wii 
ati<]  tlicii  nt-  U»t  iM'Cimiiog  8ud4ieuly  Wfluiled.  4.  ForeiKn  bodiM  obBtruct- 
ing  tliv  Biiiall  intestine  may  caiisv  the  Bitcns  of  auute  obetructJoD.  Aoiongat 
the  iiKwt  c<nmn(m  of  tliew,  are  large  gall-ntonen  which  have  fniind  ih«>ir  nij" 
ioto  the  iuU-irtioe  by  ulceration  fmm  the  j^all-bladtler.  0.  Severe  aail  evea 
fttal  intesLiual  ubstructiuu  may  orcur  aa  the  result  of  iDflanimutory  affectiotu 
of  the  iulvBtiuee  without  the  exJetence  of  any  mechanlt-al  leuiott.  It  was 
formerly  eiippcecd  that  Ihe  samecoDdiLion  might  arise  eiuiply  rntmapHsmoclic 
con  tract  iuu.  but  thte  is  not  supported  by  any  Euffieieiit  evidence:.  6.  Acute 
obBtructiou  fr^queutly  ariaeei  from  invagioatioD  or  iotussusceptioD,  a  part  of 


Fig.  302.— IntMtlnal  Obrttuctloa  from  loUraikl  llsmlft. 

the  intenlinc  slipping  into  that  below  and  being  conotricted  by  it ;  but,  as 
this  affertion  may  m^giimc  either  rq  acute  or  chronic  form,  and  pre«c»ta 
many  peculiar  features,  it  is  best  considered  apart  from  otber  causca  of 
obstruction. 

The  relative  rrecjULJicy  of  those  forms  of  obstruction  Is  well  illustratml  by 
the  fltalii*ti(»  publiaiied  by  Bryant,  derived  from  the  records  of  Guy's  Ilint- 
■lital,  and  collected  oblcny  by  the  late  Hilton  Vagae.  Of  124  caxea  of 
lutestiiial  obtptruction,  33  were  acute.  Id  chronic,  and  l<5  nere  due  to  intu*- 
SUDCepUon.  Of  the  •V-i  acme  caaea,  1  wm  due  Ii>  internal  hernia,  7  to  twiiils, 
and  25  Io  l>Hnd»  causing  internal  atrangulatiuu.  Of  the  'J.>  bandu,  14  were 
<^d  adheaious,  b  were  cottnectcd  with  diverticula  from  tbe  ileum,  2  with  th« 
Teriuiforiu  appendix, 2  with  Ibe  neck  of  aheroial  sac, audi  with  the  pedicle 
of  OD  ovuriau  tumor. 

Syr^om*. — The  symptoms  of  acute  tnteetinal  obetroctioD,  more  especially 
when  ansiug  from  a  mechatiical  cause,  such  m  the  formation  of  an  interaal 
beruia,  or  volvulus,  are  always  characterized  by  very  marked  vital  depres- 
siun.  There  is  con«tipalioii  fnjui  the  very  first ;  but  this  symptom  is  not  the 
most  protuiuenl  rme,  and  those  that  result  are  cvideuily,  as  in  SD  urdtnarjr 
caw  of  stran^'ulated  hernia,  as  much  the  consei^ueuee  of  the  injury  iD6ictea 
U|Hin  the  iulc«tiue,  as  of  the  mere  niecbnuical  obstacle  to  the  omvard  {uifsuge 
of  the  feces.  At  the  moment  of  the  ■jccurn-nee  of  the  eiraugulatmu,  tbo 
petieuL  id  usually  seized  with  a  sudden  feeling  of  somolhmg  wrong  having 
taken  place  in  the  ubtlonieu  ;  or,  he  iw  struck  with  intense  pain  at  one  |K>iiiu 
Thiit  pain  ]l«^)^i»ta  more  or  Icsi*  ihnmghoul  the  c»E>e,  and  Is  somciimex  vmlt-ut 
and  panixyamal.  There  may  be  sudden  ^yucojie,  though  nniet  usually  the 
depremtou  uf  vital  jHiwcr  does  not  amouut  to  this.  Vomiting  apeedily 
occurs^  at  tir»t  td'  ihu  contents  uf  the  sLomnch,  but  after  a  lime  uf  sturcora- 


CHROWIC   IITTESTINAL   OBSTRUCTION. 


ccoua  matter;  sonitliraps  it  nssutnca  this  fonn  alraow  from  the  very  first. 
The  abdcinicn  iKoonica  swollen  and  tender,  the  iiitestinca  being  hkjwn  out 
vitb  flatus,  giving  riso  to  immense  irmpaiiitie  dintention,  riiHinj;  nvcr  one 
another,  and  ocouioning  loud  nimbiing  and  gurgling  noiae«.  If  the  ab- 
dominal walls  be  thin,  the  rolling  of  the  inteatinen  may  be  distinctly  felt, 
and  in  many  ctinen  at^ea,  thniiij^h  them ;  and  may  Bometimes  he  observed  to 
be  ennlinued  up  t»  one  HpM,  where  it  renf^x.  At  this  point,  an  intnmea- 
cence  mar  sometimes  be  indinlinctly  felt  rorrpspondine  to  the  seat  of  iitmngu- 
laliua.  If  relief  be  not  afforded,  the  siiHerincfs  of  the  patient  become  very 
ievere,  and  bi.'<  nif-ntat  dintreiw  atroiiir.la^.  The  vomiting,  perhapfl,  liecom^v 
leM  fretjueni,  but  the  vital  (lepreeaion  increase)',  and  at  laitt  death  resiiltl>, 
DAually  about  the  sixth  to  the  tenth  i3ay,  thoi)[rh  sometiniex  sooner,  from 
eichau»lion,  peritooitin,  or  gangrene.  The  miud  remains  clear  to  the  last,  the 
juitient's  attention  being  iutentlyanil  di^tressiogly  riveted  upon  the  possi- 
bility of  getting  relief  from  the  boweU. 

Cbroxic  Intestinal  Obsteuctioh. — This  usually  arises  from  nue  of 
five  causes;  vii.,  1.  The  gradual  oblit«ralicm  uf  some  portion  of  the  eolrto  in 
coDsequcQcc  of  a  muliguaot  growth  from  ils  wall :  2.  The  couiprcasiou  of  the 
gut  by  a  tiiraor  growing  near  it :  3.  l.'hronic  pt'ritonitis,  uaualiy  tubercular, 
hut  Some  times  ctmiii-cLed  with  OilliiKcd  iiiulignaiil  growths  in  the  peritoneum  ; 
4.  The  obstruction  u(  the  large  iiilsBliDC  by  the  aeuumulation  of  turge  masses 
of  bardcDe<]  feculent  mutter;  5.  lotuseueucplioii  mayasaumc  a  ehrunie  form, 
HspedaJly  in  the  udult. 

The  relative  freijuency  of  theec  varii>U8  causes  Is  cle&rlr  shown  in  IlryaDt'a 
sttttielies.  Of  V2.\)  aasen  nf  obstruction,  including  intuii«tisei^pti<m.  70  were 
chronic;  of  Iheae,  H  reunited  from  feral  inipaclion,  ■'(  from  pressure  of  tumors, 
47  fmm  stricture,  and  2'i  from  malting  to^lher  of  the  intestinal  coils  fri>m 
chronic  peritonitia  or  cancer.  Of  the  41  slrictures,  2  occurred  in  the  small 
gut,  and  4-''>  in  the  large.  To  thcM  45  coses  may  be  added  6!)  collected  by 
Morris  and  Coupland.  Of  these  10-1  strictures  of  the  great  inlestine, 
78  occurred  in  the  rectum  and  Mgmnid  flexure,  19  in  the  transverse  colon  or 
at  one  of  the  flexures,  and  7  in  the  cjecum  or  ileo-colic  valve. 

The  S^jitom/',  in  the  earlier  stages  of  these  cases,  are  commonly  Ihoee  that 
will  Ite  describeij  as  indicating  stricture  of  the  large  intestine ;  but,  when  onee 
complete  obstruction  has  come  on,  the  constipation  becoincs  the  mont  promi- 
nent symptom.     In  some  instances,  this  will  occur  without  any  antecedent 
leading  to  the  supprisitinn  of  the  existence  of  stricture.     There  may  he  com- 
paratively little  ciinstitHtirmal  diiiLurbanee  at  first,  but  the  bowels  cannot  be 
niade  tn  net,  iiud  any  attempt  al  furciiiic  tlieirop^^rulinD  by  thti  admiiiistraliim 
of  purgativtif  gives  ri^e  to  Micktitsu  and  much  distrejws.     During  the  progress 
of  the  attack,  cructationH,   retchiu^s,  and   even   vomiting,  are   of   frequent 
occurrence,  but  it  fteld'ini  hapjjeu!)  thnt  this  iAstercomceous  till  the  very  la«t; 
there  may  lie  much  trmpHuiten,  wilh  rumbLing  bqiI  gurgling  of  the  inteKtines, 
pfcut  tnnst  freijuently  the  abdomen   hlle  slowly   and    gradually,  and    these 
''Sympt«}ma  do  not  occur  till  alter  some  days  have  elapsed.    The  dixtresaof  the 
jatient  doea  not  depend  so  much  on  the  length  of  time  that  the  olMtruction 
exi«led,  as  nn  the  amount  of  tympanitic  distention  of  the  alxlnmen.    The 
iter  this  is,  the  more  urgent  will  be  the  symptcmis.     In  many  inslauces, 
lile  is  prolonged  for  several    weeks,  for  five  or  six.  even  after  complete 
ruction  has  set  in  ;    anil    in    «ome   cases  a  recovery  may  take    place, 
even  though  a  vcrv  considerable  time  have  elaped  from  the  occurrence  of 
the  obstruction.     In  the  cbec  of  a  lady  whom  I  attended  many  years  ago 
Mr.  Powell,  recovery  took  [dace,  although  there  had  been  complete 
Btruction  for  upwards  ol*  five  weeks;  and  1  have  seen  other  cases  recover 


810 


'IKAL    OBSTRUCTIOH. 


in  which  from  forty  to  fi>rty-6v«  dayi  bjid  elftpaetl  be&ra  the  otatraetMavi 
reliered. 

IxTli58i'!<(*ErTJDN,  or  the  iDvagiiintiou  of  nu  up|>vr  iuto  a  lowrr  pottM^ 
the  iDtiMtine  is  a  ciimmoa  cause  uf  iiitutiiml  abatructioo,  esfieciaUf  la  du^ 
dreu.  It  may  occur  id  three  vituatiuns — in  the  ileum,  at  the  ikocMie  fain. 
or  in  the  large  inUBtiiio.  Iia  most  conimuu  Mat  ia  at  ths  U«t»'«uUe  nin.  Of 
the  1 24 cases  ufob«trucli(m  tabulated  hy  Bryaol.  lo  were  iDtaMUM«f*laa>;i< 
theee,  2  were  rectal,?  ileo-cwcal,  ami  (I  in  lliu  email  iutcatinct.  An  fattHW- 
ception,  wlieu  exAminm)  atler  ileatli,  is  fuunit  to  Im  oiapnavd  f^  thnalaha 
of  int«titinp.  nne  within  the  other.  The  ooter  lube  or  efaeatk  ti  mnwrni  d 
the  lower  part  of  the  inu-atine.  It  ib  throrD  into  nuneraia  foMi.  vUAai 
readily  iie  titraif^ht^ned  out  by  slight  irarltiio.  ihits  ifi^nK  *^  1*  *!¥"'*' 
poj-lial  re^liictton  of  the  iDva^itiHtion,  The  ini'Idlf.  or  reAectad  Ukt, » 
Uiniecl  inside  out,  bo  that  its  iiniooiiH  tnftiittratic  is  in  ruotftcl  whfc  ihatttTlb 
sheath.  On  making  an  incision  thrmi^h  Lliiit.  tbr  inner,  or  CAterfaiie  liAtii 
brought  into  view,  the  serous  Burfaoe  «f  whirli  it  in  otntact  wUh  tlkU  >4  iW 
reflected  tulM*.  In  th*  epAv^  h«tw(*ii  tlitw!  will  be  founJ  lln>  mttttWJ 
betnti^in^  lo  lilt'  «iit«riri{r  mid  refliSTti^l  Iu1n«.      If  thfr  iov  :  i  hMO*- 

mcncM  at  the  ilei»-colic  valve,  the  vermiform  apftetidix  ai»"  -...  .*  fcoa^i* 
this  spHtv.  An  intiiSfluiK'vptiun  ioereawn  enlirvly  at  tb«  expMHt  wf  lt> 
sheath,  the  line  of  reflection  Iwtween  the  entering  und  reHected  l«ih»  timiim 
ing  unchaniftd.  The  leoirth  of  the  part  inva^nnated  vnh<^  yrrmlly.  WL» 
limiled  to  the  smntl  inttatine  it  is  utfuallr  vhort,  not  muri'  than  t«i^  or  line 
inches  in  lentrth ;  in  the  large  gut  aa  many  feet  may  Ik  iot'uir^'L  TV 
inner  and  middle  tubes  show,  as  a  rule,  marked  evidence  nf  atrmoiptUd^H 
They  nre  intenwiy  injected  with  bloinl  and  eivollrn,  and  tbw  it****!! 
included  iu  the  spRce  between  i&  in  a  simtlur  omditiou.  It  u  tJiU  mSi^ 
that  offtrs  the  great  barrier  to  redueiion.  The  strangulation  »  nauaHl  tiTiW 
closely  (woked  folds  nf  the  sheath  ai  the  point  of  nAnlion  hi-tw<vn  it  M* 
the  reflectetl  tube.  The  fate  of  an  unrelieved  inluiMUoeptiiin  rants  snmi 
ing  to  circumstances.  If  iheetmnfrulatinn  is  very  slight,  nut  being  vuftn*! 
tu  caufte  gangrene  of  the  inner  and  middle  tube,  while  at  tba  ■uarliB'i 
seriously  or  oumpletely  obstructs  the  panage  of  feces,  daUh  MtNt  fawribMr 
oocur  sooner  or  lal«r.  If  the  oonstrictmn  is  siiffieietit  to  cans*  i^apw^ 
adhesions  mav  form  between  the  up[>c-r  part  oT  the  enterinj^  tabs  sail  *W 
reflection  heiweco  the  nheath  and  the  refleetpd  tube,  the  gsaipa^ 
|»i>rlion  may  thL^n  bo  cost  off  into  the  bowel,  and  enmpl«t«  ntamnti^ 
place.  lTnr»rLuuutc1y  the  patieni  often  perishes  frum  exnaiisdaa  bclint^ 
n  MComplinhed. 

The  causes  of  intiiHaii4i«ptiiiu  are  ofl£n  uncerlain.  In  chilHm  ikiyi'* 
•ometinies  due  to  the  irriuiii>u  of  womit  or  tu  ibe  uraiuioit;  tttomfiKjVf 
dyaeDterlodiarrb'pa.  InudultsUieiovagiQaliun  onLunlfcqoeiitly  coiiiui** 
mt  the  seat  of  a  tumor. 

The  «yin/>ronuof  inttimuMeptioii  muv  be  adate  or  cbr>ntc,  abeortGs|tM*"' 
wore  or  lew  tightty  stranenlate*].  Iu  all  oue*  the  iarut^Hi  iswsw**** 
patient  feelinic  that  soraethintf  has  ^ine  wniuij  iolejiiallr.  If  lJ»  s^,^' 
acute,  the  signs  uf  urgent  int«tiiial  strangulation  are  wrll  r-'-rV-)  iMBbi' 
aoGoiDimni'-d  by  teuesuius  with  the  paeaage  oTn  bloody  ni> 
charge.  V'oniitiug  S'hiq  tets  iu.  but  does  uot  ttrcome  fecuK-iM  in  vi^j-  — 
In  such  esse«  ibii  pativni,  mpeciHllv  if  a  young  child,  will  die  io  Uic(** 
of  five  days  or  a  week  from  culfapse.  K  <«ldrr,  he  may  rroiwr  •** 
gangrene  ami  eriMimtion  of  the  tndtided  iwrc  of  the  tatntinr.  OiiMoieM* 
oecur  more  frc(|ue»tty  in  adults,  but  may  be  met  with  in  ■ '  '"'^ 

the  ityniptomn  are  more  ulHcure.     Thsnt  is  a  nddm  ln\.>  ''"'^J? 

psroxyeinni  juln,  with  some  vomiting.    1^  bowels  may  m*  bs  iMisfMf 


MBi 


INTUSSrsCKPTIOX — DTAOXOSIS. 


811 


* 


_,_^_  cted,  fiK^al  malter  Mcaping  in  small  quantities,  oOeii  mixed  willi  blutxi, 
ikkid  tlm  couditiuQ  may  Itut  for  some  wevks,  at  lost  vudiug  iu  cumplete 
obtftructitm.  The  abd(imtn»l  iliatcutJon  Js  usually  uut  greaL  The  avule 
iiituwwception  iii  usuatty  oituated  in  the  ileum  or  at  the  ileo-cotic  valve  in 
children;  the  chniDic  is  cutnmoiily  at  the  ileo-uuHc  valve  ur  in  the  colun 
in  adults. 

In  all  oues  nf  intueeuecepttcD  there  is  a  tumor  at  the  seat  of  diwase  wlitch 
can  usually  \w  felt  ihrmigh  the  nlMltmiiiial  ^atla.  Ic  is  sausa^like  in  lorm, 
doughy  t(i  the  feel,  and  l)iicunif«  tense  under  nmiiipiilaiion  from  tlic  peri^lnllic 
contraction  of  the  gut  compi^iuf;  it.  It  is  tender,  and  the  hardening  during 
manipulntioD  ie  aceonipRuied  hy  eonie  griping  pain.  If  (lie  vatv  be  walehed 
from  the  beginning,  the  cnnit>r  will  be  found  tu  ohaiige  iu  puailion  as  the 
iovagiuBtion  progrei<ijes;  thus,  when  begiuniuj^  at  the  ileo-ooliti  val%'c,  it  will 
be  first  fell  in  llic  ri(;ht  iliac  fu^a,  0ubi<equ«nily  in  the  umbilii'sl  regiun,  and 
orieu  at  luitt  in  the  iefl  iliac  fowa.  If  tlie  intuseut^ce])liuD  he  iieu-cieca]  or  of 
the  great  intestine,  it  often  deecends  low  enough  to  be  felt  by  paaaiuf;  the 
finger  up  the  rectum.  In  one  caiac,  related  by  Hutchin*on,  the  intuaguseep- 
lion  wa«  of  such  length  that  the  inverted  iletveoUc  valve  wua  extruded  lor 
some  inches  beyond  the  cliild'n  anus,  and  had  bctn  miitUikcn  fur  and  treatcil 
OS  a  prolapfUB.  Such  a  condition  la  eiwity  re<-<>gnized  hy  puaaing  tlie  finger 
hettide  the  protruding  gut  into  the  rectum,  which  it  ii  of  counM;  impofteiole 
to  do  in  a  cajte  of  proUpaUB. 

DrAtiNo^ia^The  diagniisifl  of  the  catiM  of  the  obetrucUon  iii  of  great  im- 
portance ;  attention  a»  to  whether  it  aHUtnes  the  acute  or  the  chronic  form, 
will  throw  aomc  light  upon  the  eonditions  that  occasion  it.  It  h  often  diffi- 
cult to  determine  whether  the  nhjitructioii  in  mechanical,  or  whether  it  dc- 
peDda  upon  some  inflainmatory  aflcction  of  the  intestine.  The  practice  to 
be  adopted  in  any  particular  ease  luust  at  last  be  determined  hy  a  history  of 
the  syinptome.  by  a  careful  exploration  of  the  abdomen  and  rectum,  and  by 
the  Itglit  that  cau  be  thus  thrown  U[>on  the  question,  as  (o  whether  the  ob< 
_  eiruclion  be  dependent  on  causeu  that  are  removable  or  ni>L  by  medical 
means.  Iu  many  iu»tancv«,  th«  hmtury  of  the  case,  the  awemblage  of 
■trougty  marked  syiiiptome,  Hud  the  result  of  abduininal  and  rectal  explora- 
tion, enable  the  tr^ui^eou  to  determine,  without  much  difficulty,  that  tiie  ob> 
ttructiou  is  depcuiieut  on  cauM-s  that  are  nut  removable  liy  any  uieuus  short 
of  aperativH  in terliTvuce.  But,  iu  otlier  cuEce,  uu  means  that  we  poweaa 
enable  us  to  arrive  at  a  correct  or  even  au  approximate  diagnosis.  Gaaea 
are  recorded  Ihut  have  ended  tiitnlly  from  ubBlruc-tiou  in  forty-eight  huure, 
without  eirknesf),  lixed  pain  iu  thi^  ul)dt»meu,  or  tympauiteB.  TheRe,  how- 
ever, are  certainly  exceptintial,  and  do  not  hear  upon  the  quivtion  a»  to  the 
proprietv  iif  perfbniiJng  gUBtnitomy  in  thniw  instunceH  in  which  it  can  heitat- 
itifartoriiy  deteriiiiiicd  that  a  meclianicul  oliKlucle,  not  removahie  hy  medical 
means,  exiala.  That  the  diagniwiH  may  so  far  he  cilected  with  tolerable  cer- 
tainty ia  evident,  from  the  fact  thai,  in  all  those  eafiea  of  gastrntomy  which 
have  I)e«o  of  late  years  practii't^l  in  this  country,  tnechanicJil  obstructiuu 
irremovable  hy  any  but  operative  intBrferenre  had  been  diagnobed  and  waa 
funnd. 

In  all  cases  of  intestinal  ob8lrnci.ion,  certain  c»n<lttii>ne  should  Brvt  be  ex- 
cluded, whicli,  though  nut  generally  included  untier  the  name,  give  rise  to 
aymptoms  r.f  a  Bimilar  nalnre.  Thme  are  lend  colic,  lyphliiis.  nnd  general 
acute  peritonitis.  Lead  colic  may  be  in  mnet  caaes  recngnijed  by  the  history, 
by  the  occurrence  of  previows  attacks,  and  by  the  blue  line  on  the  giima. 
Tvphlilis  and  perityphlitis  may  be  rec^'gnixed  by  the  history  of  conBlipalion, 
with  gradually  increasing  pain  in  the  right  iliac  fowa,  followed  hy  a  some- 
what sudden  exacerbation  when  the  peritoneum  over  the  gut  become  impli- 


812 


fTKSTINAL   0B8TB00TIOX. 


caU**).  The  ubslructioD  is  aelilom  coni)ilt>t(?,  and  vomitinK  doot  iM  fcva  I 
niarkctJ  s/mpUtin.  Ttiere  U  fulnoan  with  aouw  teii'lcrnew  vnr  iW  vna. 
In  acute  attacks  there  U  unuallya  <lifliiiict  elvvatff'D  nf  tevppraum.  It 
tnauy  cases  there  is  a  history  of  jirevious  attacks.  Acnl<>  perituaUi  iii» 
(^niuHl  by  the  inlenso  ^neral  lenilt^rnPM.  with  ilbtetitinti  n(  ihraMf 
anit  the  peculiar  vomitinc  without  Mminiritr.  The  isutisi  vhieh  BMri  imiI* 
ri'semblf  some  form  nf  acute  inu>stiniil  olwiructioa  are  thme  afinag  ftm 
))erf>mlion  of  the  vermiform  a)ipenclix. 

The  firvt  ttfp  in  th«  Hiaftni^tii^  of  any  iiae  nf  acote  obmlruclitin  raaX  ilvtn 
be  a  careful  examination  of  iht  vnriotis  nhd.iminnl  noil  (■■ ' 
tome  of  the  mor*  ohsciire  turma  of  cxU'mal  hcmin  ;  for  m^ 
iotcrnal  Ktrantiuiaiton.  tt  hna  oo(.'aAionnlly  tiirneil  out,  at'i' 

()ati^nt    haa)    iieen   lalKjring  under  a  uniall   fmwtra],  olnn: 
ternia. 

The  poiDtfl  that  will  chiefly  en((af(e  the  Rurft«on'«aU«nlH>n  1 1>  ' 
t Ha  nature  of  the  obstruction  are:  1.  The  previous  hi«t'>rr  of  tb#  patirw. 
2.  The  mode  of  iavaeinn.  3.  The  iceneral  con>litioD  of  th«  p«ti«DL  4  TW 
characlpr  of  the  pain.  5.  The  charncter  of  th«  vomiting.  0.  Tbf  ilorttii« 
and  degree  of  onostipatioa.  7.  The  nhynical  examinatinn  of  Um  Mf- 
8.  Examioatioo  of  the  rectum.  9.  The  character  and  cptaatitr  nf  ijtt 
urine. 

I.  The  FreWous  Hiitorj  of\en  tlirowi  much  liffht  upou  the  uatanof  lU 
dtsoflse.     In  mrt*  of  iutcnml  hernia  or  nbstruoliim  by  baoda  or  tmiitM.  vl 
In  iuUi)vtit)t('eption,  the  giutient  hna  ut^ualty  nujuyed  good  health  o|t  ta  tkl 
time  of  the  oht<tnirtion.  althouich  in  eiimo  caaei  there  is  a  hlabirr  ti  %p^ 
vioun  atlark  of  the  oame  kiml.     If  the  other  Mrmptntm  Men  la  piat  I* 
Btnin^ulatinn  by  a  band.  iliiieaHeE  iikely  to  oau^e  !<>ciil  adhcBinnt  ia  thapav 
toneum  Ruch  ah  typhoid  fever.  typhliliK.  or  ovariliH  in  the  AuBaJe  my  \m'tt 
quired  for.     In  rhnmic  obfltrurtinn  arii^in^  fmm  trradunl  ehtmn  of  *  ttM- 
tan  there  is  n   history  nf  (jmitnnltn  inrr^uin^  diljiruttif  in    nhtaininf  r^ 
from  the  howcls,  with  uneaiincM  and  dyepetMin.     Mn«t  rommnnlr  then  knv. 
been  periods  n(  prolontlEed  mntHpalion  fnUntcrd  Ay  diarrhim,     Th*—  •l'" 
nittinir  perii«lB  of  constipation    and   diarrb'ra  are  very  rb.inu-trn- 
shrHiId  always  raise  a  «u«ptcioti  of  srriciure.  mo«t  probably  in  rh. 
teal-tne.     In  caaea  of  obatruolion  of  the  •mall  inuwline  from  in.i.n  ■.    '  '  ' 
)Fail-«M>np.  there  will  be  a  huilory  of  prolongfit  pni»  nnd  di»totn{.:--  , 
ijuin  of  1^  tj'iff'i'Mrlrr 'hiring  ihc  time  that  the  «tine  wa*   maV  i..-  i- "' 
by  ub-eralioii  into  (he  interline. 

'2.  Mode  of  lovaiion.— When  the  attack  oomnwncpj  with  irrrrr  fmm  it^ 
on  w  wld-'niy  that  the  pali'jiit  can  Mate  the  exnct  raorurnt  at  which  it  ^■" 
him,  or  when  this  in  ifuickly  followol  by  the  other  eiijof  of  ncul<*nh«trurtiM> 
aad  when  up  to  the  time  of  attiick  he  was  in  (;o"d  henltb  iherv  f  **f 
reaaoD  tu  believe  that  it  is  due  t»  nn  ioteniAl  hernt*.  a  twi^t.  or  an  aca*^ 
tUMUBception.  When  the  attack  betfiw  with  uiiftMine^t,  I'tirr^wwyW'Jii^" 
a  few  ftouTM  until  it  becomea  actual  pain,  followed  at  «o<iie  interval  VrtW 
■ifma  of  obttlruction  it  may  Iw  due  to  irnpnctinn  of  a  fornfin  boHr.  l*^* 
fcall'Stcine.  to  intlammnliou  nf  the  sruall  intestinca.  or  to  fud'len  obatrvttHa 
nf  an  old  stricture.  When  the  sympUm*  begin  yrodmnlly.  with  uneatiiM*» 
oonatitMition.  ihi'T  may  )>i'  due  to  nnv  one  of  the  chronic  forma  ofohHUit^ 
H.  The  Oeoeral  Condition  of  the  Patieot. — ivtrly  rMajme  b  a  alp  d^ 
of  the  acme  forms  of  obatrucli-n.  internal  hernia,  twtau  or  aeota  b*^* 
oeplion.  The  pnlne  in  eonslderaldy  (juickeneil  in  all  theae.  The  teaijWiW' 
ia  variable,  tinually  cli^htly  eleratad  at  firat.  but  aoon  beoualaji  taba**^ 
In  the  chronic  forma  ftMnptf  eamea  an  aiattly.     In  both  acota  and  ^V^ 


.SUM 


HA< 


►SIS  oTti 


OAPBl 


►  r    OBSTHUCTIOl 


318 


ubstnictioD  the  tongue  goon  becomes  furred  aotl  dry,  >nd  ibirst  a  oflen  a 
[troiuiiieiU  i^vrdjtloiti. 

4.  The  Cilaracter  of  the  Fain. — Acute  ftbdommn!  pain  fij-ed  in  vne  ifmt 
with  |ian>x}-eii>iil  vxttcerbiUiuiM  io  met  tvilh  iu  twists,  or  julvriml  etraugtilft- 
liuaii.  Jd  Hcute  iuluwuscvptioii  ttic  paiu  it  ot  the  tamv  cliurac-ler,  but  coat- 
luouly  iws  ut-ute.  la  vbruuic  iuLuHtuscvptiuu  tbu  puiu  is  parorysmat,  but 
Uffially  dintinHiif  iocatiieti,  la  cbmnic  ubelruc-tiijn  ot  the  gnat  iiitestlnu  it  ia 
diffv»eti,  and  there  may  be  {iroitJjigeil  iutervals  ut'  ease. 

o.  The  Character  of  the  Vomiiing. — iJtrly  iwvere  wmitiui/  wjieoiily  becom- 
ing aicrforatxuui,  a  (.'haraclerietic  nl  acute  ulatruutiuu  ol' the  etiiall  inttiDliDes. 
jLuHy  vomiting,  not  «/«rcorart'Dt»  fur  Irutu  twu  to  three  ilaye,  U  observed  \a 
twistfi  uf  the  fireal  iutesliue,  acute  rjbBtructioii  of  an  uU\  etnciure,  in  acute  ia- 
tii»U6ce|)lion  uf  the  ilio'culic  valve  or  colnu,  atid  id  iDHamoiatiTvatleeiioUB  uf 
the  small  iute&tine.  VomiUnij,  9li</ht  atjirt^,  and  not  nlercornceovn for  a  ueei: 
ffT  lux>,  is  characteristic  of  clirouic  uiisi  ruction  of  the  great  iuteaiiuo  Irom 
ubrouic  iulU!<8ueceplion,  Biricture,  etc.  la  chrunic  peritoailis,  vomitiDg  may 
be  delayed  for  uiauy  weeks. 

Vomitiog,  however,  even  wbeo  feciiIoDt,  is  uot  sufficietit  to  deternnne  the 
prEwDce  of  complete  tnccbanical  uhetructioii  of  the  bonreU.  for  it  may  occur 
in  cajFe«np]janDily  of  iDdommatory  origin  iu  which  the  ohgtructioQ  ieretoov* 
able  by  medical  rtieaDs.  Of  this  1  have  *een  acveral  instaiicts — the  feculent 
vomiting  being  very  ]^raieieut,and  the  patient  prescuting  all  the  iiiher  gymp- 
toma  that  arc  usually  cousidorcd  to  be  depeodeut  on  interna]  strnngulation; 
but  eventually  reeovering  under  the  use  ot'  opium,  and  other  medical  meaiia 
without  the  uecc»*ily  of  operative  interference.  It  ia,  therefore,  as  nc-cetsary 
to  bear  in  mind  the  occa^onal  dopeudinc*.'  of  feculent  vomiting  on  conditiona 
that  are  removable  by  medieal  aid  alone,  us  thai  it  may  be  nbgeni  in  caaea  iu 
wbieb  the  obstruction,  whether  neatcd  in  the  iniall  or  iu  the  large  intestine, 
can  be  relit'Vdl  only  Uy  hurj-ii-al  a.-si>tAii('e. 

li.  The  DuratioD'and  Degree  of  Constipation. —The  duration  of  the  con- 
stipation doe^  not  nece^narily  throw  much  light  upon  the  cauxe.  Indeed,  if 
patients  be  naturally  Cfistive,  constipation  may  last  for  a  considerable  num- 
ber of  <layit,  or  even  weeks,  without  pnxLueing  any  very  aerioua  coiisecjuencea. 
Most  practitioners  nui^t  have  seen  ea«ea  iu  wUicb  conelipation  baa  continued 
tor  tbi-ee  or  (our  weeks,  without  detitroyiug  the  patient.  Jobiigou  mentions  a 
caK,  in  which  it  laitted  doriug  forty-tive  iJaye.  In  these  cases,  however,  con- 
stipation has  ueually  v)iuv  uu  ^raduuUy,  beiug,  as  it  were,  an  aggravation  of 
the  patient's  uaturnl  coudiLion.  U  i»  the  character  ratber  thnn  the  mere 
duration  of  the  cou&tipaliou  ihul  ia  imjKjrtatit.  The  suddeu  oucurrence  of 
trreninvablc  <ib»trucliuu,  both  vl  tlatus  and  fei'ttt.  in  {K^rvous  othcrwtac  regular 
in  their  bowete,  uiid  the  seusc  of  ils  dc)>eudence  on  u  lixeil  cause,  are  points 
of  io)[H)rliU)ce,  as  teudiug  to  shoiv  that  it  uriseii  Irom  uu  acute  mecbauical 
coudiliou.  Ill  uculc  inlenial  slraugulatioii,  the  constipation  is  alwaya  sud- 
den, and  is  accompanied  ur  speedily  follontd  by  other  syiu[)ti>m8  indicating 
ubstruction.  Jn  cbruuic  olMtruclions  the  com]>let<!  couDtipalioD  is  usually 
merely  an  aggravation  of  a  previitus  wndtlion.  When  the  olwtruction  is  io 
the  small  iule»tine,  the  |)alient  feels  no  ^ense  of  riesire  m  defecate.  In  nbniruo- 
tion  low  down  thia  may  be  present,  esjiecially  if  it  ia  due  to  leral  aceuniula- 
liuD.  In  iniiiBsuiTCeptioii  when  the  iuvaginaied  portion  ie  in  the  vtdon,  there 
18  usually  frt({nent  straining  and  tenefimua.  If  the  Htrangulation  be  complete 
and  acute,  nothing  but  a  little  blootl-staincd  mucus  will  paas;  if  it  lie  chronic, 
both  flatus  and  feces  may  pass  in  small  quonlities  with  much  straining. 

".  The  Physical  Examination  of  the  Belly,  (a)  InfpeHion, — The  chief 
poinls  to  be  observed  arc  the  disceution  of  the  abdomen,  the  form  it  hoi 


814 


IXTESTIHAL    0BSTKUCTI05. 


UBamed,  the  sppevance  of  dtsteaded  cotla  of  intestiac>  nnd  perkultie  wmf 
mentB. 

DUfeutioH  of  the  Abdomen. — In  nouun  obstruction  HiibpntkAi|iikU]rMiii 
and  ueunliy  beooiiien  very  marked  in  a  fevdajB,  ufi«n  so  grestai  laioMfftn 
with  reapJratioD  and  to  forin  tbe  meat  dibtrcasiDg  Hrmpwim  fnuB  vkicklb 
pmicni  euffcra.  Id  olironic  ub«tniclion  i'nm  strioture  of  tba  gnmt  tMoiiM, 
IE  eoiuea  on  gradually,  aud  may  at  last  bccume  very  grraL  la  latOHOMiftn 
it  ia  uot  very  marlfed.  capccially  in  the  chruoic  caaw.  la  chrmiic  pfriMdOk 
or  disease  ut'  the  inicstiDrs,  there  ia  alwa}-B  acme  diaiainina,  bia  h  aMm 
forms  a  rtrumiiieiit  ayttiptum. 

The  harm  of  the  Abdomnn. — When  th«  uliatrucUon  ia  in  lb*  bbaII  imadM 
anil  acute,  the  <lLiteiittiiu  is  usually  most  marked  in  (he  (^pi^aKric,  Diabilial, 
an<l  h) -poj^udlric  rp(.>iiiiii<,  tlie  fljtnks  being  1«M  dUtendcd.  In  uhMniOHaittt 
duuu  iu  the  ^tv&\.  gut  the  distended  colon  on  each  aide  filU  oni  the  ivklk 
giving  the  nhdiuiifn  a  barrel-Hba|)f!.  In  aome  i^UM  of  atrftBguladH  bf  t 
bond  ur  iitternat  hernia,  the  abdomen  may  be  irrettulurly  diaUttded, OH odi 
ur  rvgiou  being  more  proniiueut  than  tbe  r«vt.  Tuu  iiiucb  itnpuMtuMtwM 
not  be  attavbeil,  huwever,  to  the  form  of  tbe  abdomea,  at  it  ia  oAca  daM^ 
live.  In  women  who  bave  burnv  cbildren,  there  is  alwB,^*a  great  prvaJaMc* 
in  tbe  umbilical  ajid  hypogasLric  region,  whatever  the  cauae-  of  th«  diiuaUca 
may  be. 

VoiU  0/  intedine  visible  'krovgh  O10  abdominai  walU  ubt  b«  ofaaomd  w^ 
tbe  putteut  in  tbiu.  in  all  forma  of  obalructioo  iu  which  there  i>  BtDck  diM^ 
tiiHi.  Tbe  visibility  is  eaid  to  bo  most  markeil  iu  ubstructioa  Ihu  dmtk 
peritonius.  Tim  didteuded  ooila  of  small  intcetinea  can  bu  arcD  twtilii(  Btf 
oooger  eels,  aud  are  uiXun  so  large  that  ihcy  may  b«  mistakea  fbr  iiaamM 
colon  or  ai^'iuoid  tlexiire,  und  thufl  lead  to  ■□  errur  in  diognaaia. 

J*eriMjiit>i*  ia  olU'ii  vibiblf!  iu  the  dlatended  roila.  This  ta  aatd  to  be  mat 
mnrketl  when  tbe  idwiruetioti  is  in  the  f^rrat  ttitrstine.  Whra  vtaiUtiiaiy 
betaken  aa  o%*idence  ihut  lliu  distention  in  nia  due  lo  ponjysb  uf  tba^Uv 
to  acute  periUiniliH ;  but  beyond  this  it,  ia  nm  of  roiicn  valur. 

/VnouioiArt, — Ry  perrunion  we  try  to  aaoertiiin  the  condition  at  Uwcot*. 
In  the  normal  eiinditiou  the  diderent  notea  given  by  the  f tomftch,  caIiA  ud 
anmll  inteatine,  usually  enable  us  to  determine  their  [trMiiions,  but  ia  tba  ^ 
I«ndeil  abdomen  the  evidence  thua  obtained  ia  often  tallacioua.  Tha  lUawi 
is  al«BV»  omccaled  by  the  distended  iutestinea.  it  tbe  small  intertttwia 
much  distended,  thoir  uot«  become*  indiatioguuhablc  fnm  that  of  tbi«cl>a 
Kxtreme  »upfrhcial  tympanitic  resonanoe.  uniform  in  not«  and  commJiH 
Uio  liver-«luh)e««, with  n  very  pointed  abdoiuen,  indicates  tree  itaa  ta  HufKi' 
tooeal  cHvily  either  from  actual  or  itii|)eiiiliug  (^^rfonitioa.  Hyprr-fivaaBa 
in  each  flunk  in  tuually  a  aiga  of  difteudeil  roluii.  I>uint»i  ID  the  Aieb 
disMpjieunni;  du  turnint;  (he  patient  ou  va«  »ide  u  u^uaUy  evidetia  u^  ^^ 
and  may  iridtcnte  that  (Hirilooicia  i>  LHimmeitciog.  In  a  t-a«f  in  I  ninnBT 
0>lli*g«  Hi»9piliil  a  few  ye«r»  u\^>.  tliii*  sign  was,  bnwever.  ■  "'''P* 

dent  >m  a  biaded  culou  wilh  a  long  iiirsi»- colon,  which  niuv<  1.  .  iMUt* 

whi'D  the  |>nticnt  waa  turuetl  to  the  uppuvile  aidr- 

J/ani/ju/a/tori. — Ity  ruunipulatiou  ibu  degrve  of  teonoci  is  limatM  v 
is  of  tuuch  dtagnuelin  value  in  tubercular  peritotiitia,as  the  peculiar  "J**!*? 
setMation  nay  serve  to  abuw  the  nature  of  the  diaeoae.  io  taiiiHuK«I^ 
the  tamor  already  described  may  be  felt,  and  io  maligaant  diotsp  « '* 
colon  the  iFTowth  may  be  perceptible  aa  n  hard  lump,  u  other  ctao,^**' 
tioo  usually  conceals  any  tumor  that  mar  be  pnsent.  Sometii— s  >"** 
spot  may  Iw  recognized  as  the  noiDt  at  wtiiob  pals  ia  ohtrfly  fUt,  af^  "* 
may  be  of  value  in  indicatiog  the  seat  of  obttraetum. 


DIAOHOSIS   OF  THE   0AU8B   OF   CBSTBITCTION. 


8.  Ezftmination  of  Sectum  Bhould  DPV«r  be  rmiitt^d  ;  by  it  Vi'^  ascertain 
the  pr^iBenee  of  stricturea  within  reach  of  the  fioger,  or  tuniun  presniu^  on 
the  rectum,  atid  nt'  fecal  accumulations.  Id  inluwueception,  we  nmy  tc«J  the 
end  of  the  invaginsted  intestine.  Those  whose  haods  are  snisll  enough  to 
pass  into  the  rectum,  an  uncommon  condilioo  in  dicd,  might  possibly  detect 
■  malignant  structure  in  the  aigmoid  Hesitre. 

If  the  stricture  be  seated  low  doun  in  the  sigmoid  6exi]re  or  at  the  upper 
part  of  the  rectum,  it  iiiny  be  recognised  in  some  cases  by  a  careful  cxaujin- 
Btiun  of  the  bowel  with  bougies. 

Another  method  of  t-xamiiialiim  often  employed  is  the  administrution  of 
the  largest  poeaiblc  tuema,  with  the  view  nf  asecrtuiiiinK  whelbcr  the  ob- 
struction is  low  down  in  the  great  gut.  Thia  is  very  tiillacious.  as  the  ab* 
dominal  dieu-nlion  is  often  an  great  (but  even  when  the  whole  colon  is  free 
the  pBiicut  cniiinx,  bear  the  iiijeclicm  of  mure  thtin  n  lew  ouni?e»  of  fluid. 

U.  The  ftuantity  of  Urine.— It  is  rrcqiHiitly  biaied  ibai  in  obstrii(.-tion 
high  up  the  quantity  of  urine  ser-crcicd  is  diininib>hc<l.  owing  to  the  lci«eni-d 
extent  itf  inlr<ilinal  surface  capable  of  absorbing  liquids.  That  acunty 
urine  is  commonly  met  with  in  these  cases  is  undoubted,  hut  it  is  probably 
due  t»  the  tiact  that  the  patient  vomits  all  ihe  liquid  he  takes. 

By  attention  1o  the  fore^^oing  points,  there  may  be  no  great  difficulty  in 
coming  to  an  accurate  opinion  as  to  whether  the  <fbAtructiou  is  in  the  large 
or  small  inlentine.  It  may  alsri  he  borne  in  mind  that  with  the  exception  of 
twists  of  the  colon  and  acute  intii!<.<)u»re|iiinn,  all  acute  nbslruntiona  are 
seated  in  the  small  inlestine,  while  the  great  ninjoriir  of  chronic  are.  in  the 
large.  The  rarlicr  occurrence  of  fecuknt  vomiting  when  the  obalruction  is 
in  the  small  intestine,  the  greater  tympanitic  diBtcntion  and  bulj^ing  in  the 
course  of  (he  caecum  and  ci>|i>n  when  it  is  sealed  in  the  large  intestine,  and 
the  r«8ull  vi'  careful  exploration  uf  the  rectum,  uill  most  cuuimi^uly  enable 
tbe  Hurgtfou  to  decide  this  (^ueation  with  sufficient  prvcisiuu  Oj  guide  him  in 
tbe  choice  of  an  uperution.  Vet  caeca  du  occur  in  which,  though  ibe  ob- 
struvlioii  be  Hrnled  in  the  large  inteslijie,  the  symptoms  are  acute  and  evi' 
dently  not  dependent  on  chronic  olwtructive  iii»ea»e,  vomiting  is  of  early 
occurrence,  the  distention  of  the  abdomen  slighl.  ami  exploration  by  the 
rectum  yields  nu  result;  and  it  is  in  CHsea  of  this  description,  presenting  a 
train  of  armpcoma  of  mixed  and  uucertaiu  character,  that  tlic  iliugnosis  of 
the  precise  seal  of  the  obstruction  cannot  be  made  with  sufficient  precision 
to  justify  operation. 

X'he  must  important  point  to  determine  in  reference  to  the  operative  treat- 
ment of  iiite8tinal  itbetructions,  ii^  whether  tbe  s^nt  of  occlusion  is  so  situated 
that  relief  cjin  be  given  by  "AmuMal's  operailon."  in  which  the  colon  Is 
opene<l  behind,  and  not  through,  the  peritoneinii.  This  can  be  done  when- 
ever the  obstruction  is  below  the  lower  end  of  the  descending  colon,  by  the 
ordinary  n|>erati(>n  on  the  left  side,  and  in  iht^e  rare  cases  in  which  it  is 
seated  in  the  trnnsveree  or  ascending  colon,  by  the  same  operation  on  the 
right  side.  If  tlie  obstruction  is  above  this,  it  will  be  ueceraary  to  do  iim- 
trolomy,  or,  as  it  is  more  correctly  termed,  La|)arutcniy,  an  operation  bv 
which  the  peritoneal  cavity  u  opened,  and  the  peril  to  the  j)atient  tlius 
greatly  increased. 

In  nil  doubtful  coses  it  is  better  nnl  to  rush  hastily  to  a  cnnclnaion.  The 
patient  should  bt  ctircfully  oianiined,  all  the  p'liols  mentioned  in  the  pre- 
ceding pages  being  cnrefuily  considered.  A  list  of  all  the  causta  of  olwtruc- 
tion  should  then  be  marie,  Bnd  c-acb  considered  in  order,  fiy  thus  eliriiinat- 
ing  tbe  various  causes  one  by  one,  a  correct  opinion  will  in  moat  casi-a  be 
arrived  aL 


816 


INTESTINAL   0U8TRD0TI0.N . 


TKf'.ATMKNT.    Treatment  of  Acute  Obstraotion.— Thb  raint  mcHid, 
be  in  a  great  nietutuic  ilctormincd  by  cbc  il)ut:ii>idi!4  titAt  i*  tOMdv  u  In  h 
caane.     The  treatment  ot  iiitu«iiftt*o|ttinii  preacola  au  nunv  «)ir<-iii 
thnl  it  will  be  bclKir  to  coDftiiler  it  M-parately.     If  tbo  getienu  •>!»- 
the  syni|ilunis  in  tbese  caa»  renden  un  exact  diajfouu*  ia  ibe  earli  Mifs 
atoKwt  iiiip««)»iblf>,  it  is  };eueratly  cx|iedient  to  try  the  effvvt  uf  p^•{■"  *"•'' 
ca)  treatment,  whicb  will  fMnnetiincs,  even  in  apparently  h<i|ielrMi  nt.^ 
relief.     In  t'urnier  tirnes  it  wax  the  cn»l»ni  Ui  ailminUirr  purxativ**  u.  .»> 
casee,  but  it  haa  loojf  been  recufjnized  thiit  they  dn  iiotbinp;  but  harm :  tW 
ioereMe  the  pain  and  vomiting,  vxluiu»t  the  patient,  and  can  hair  m  a* 
Huence  uver  uoy  real  iutet^tiital  ubstruvtion.     Ihv  uuly  |>lan  thai  ap|iranl«i 
me  uf  any  value  \»  th«  cuutinned  ndmiuistratiun  uf  upimi'. 
but  fuiufutatiuuM  u»  thv  abiJumen.     It  irae  lunncrly  ibv 
siuull  qiiHulity  uf  calumel  Lu  tbe  opium,  but  further  eKpuriv4ice  i*a»  tintti 
tbul  thw  is  nut  uwestary,  and  aa  it  itiigbt  pueeibly  cauae  aoiue  initatMi*' 
cbe  iutestintf  it  is  belter  avuided.     Tbe  upium  may  hv  (pven  in  t(M>  t"!*! 
tiinn ;  but  in  acute  ubatructiun,  it  there  ia  much  vumtling  thb  would  l<r  >■*■ 
leafl,  and  hypudermic  injeclioiis  uf  murphia  ibeu  be  admiuiMemi,    h  wind 
iw  given  in  such  quanliiiea  as  tii  relieve  pain;  ueualW  about  uat  gnwd 
opium,  ur  a  ijuarter  of  a  (^rain  of  morphia  hyiMtdermiiiilly  evet7  ms  to  c^ 
hours  will  be  found  euUicienu     Tbia  truatment  will  in  all  cbm*  be  >/ d»- 
siderable  wrvive,  uud  in  eoine,  even  the  muet  ho[wl«B  and  euaifdicaisd,  «d 
aHurd  satisfactory  results.    In  a  very  complicHted  cose  of  ioteaunal  slaow- 
Uua  which  1  attended  with  (turriMi.  this  plan  waa  cniinpnlly  oueetaBfal    A 
pAtient  was  admitted  into  ihti  Huapiinl.  having  .tymplotua  uf  iolcniai  cnt* 
gtilatioii ;  he  had  at  the  aame  time  double  itijfuiual  tieniia,  and  a  antall  tm- 
bilical  rupture,  as  well  aa  the  nmiHius  nr'a  tiitty  tumor,  wbirb  had  brt-a  pw- 
tially  removed  from  the  abdmninal  wall   many  year*  prrvtuualy.    liitn 
vere   perilouitis  with   tympnuiles,  siereoraeeotiB  vomiliiit;,  awl  mo<k  nd 
depres«iun  ;  but,  as  there  nag  no  »tmngulatioa  existing  in  any  ot  tkeeiue- 
nal  ht-miie,  and  aa  there  was  no  evidence  aa  to  the  priviae  locatUy  af  ika^ 
ternal   ratsrbief,  it  waa  not  thought  adviimble  U>  have  mx>uree  to  nyaiBlJM 
Tbe  patient  was  accordingly  tn-ul«?d    with   'tpium,  whiro,  on  tbe  trfitiiili;. 
tbe  obatruclion  gave  way  and  the  bowela  acted,  tbe  {aUieat  ultimately  ra*^ 
ering. 

H.  O.  Thomae,  ol  Liverpool,  who  faaa  paid  coiwiderablo  aUratioa  lottt 
aubjeet  ul  inteetinal  ubetnivtioo,  and  advocatea  the  excloaivv  iwa  of  ofM> 
in  all  Ibrms  ut*  tbe  afleetion,  givee  aome  valuable  prnctii-al  <lirectiiju*  ^''^ 
maDagemeot  of  tbeM  cnsBB.    He  inaists  that  the  drug  mutt  alw*,^- 
iuiui»tered  hypodermically.  and  in  aufficicDt  quantity  to  rvitar*  aii  i*"^ 
Tbe  pnLicut  muftt  uf  uourae  be  contiaed  to  tbe  reeuml»-ut  pvaitioB.    U»<1M 
muBt  be  limited  to  the  emalleet  fHiaiible  amouut.  and  ntuH  be  csd«K*pj 
liquid.     Arrowroot  or  ground  rice  and  cooked  with  water,  with  tite  atlilili* 
ut  a  little  bmudy  or  nine,  is  the  fuod  be  diiufl/  rceoDUmuida ;  mOai  ' 
cbidicu  broib  bein^  oecaeionally  allowed  aa  a  ehange.    Milk  be  IniBMalt; 
found  to  aggravate  the  symploma.     On  amall  quauiilici  o)  tbi*foo4,p** 
■t  inlervnla  uf  two  hours,  a  [wtieut  kept  warm  in  bed  and  under  Uw  iiifcM* 
of  opium  may  niaiiauiu  life  lor  many  weeks  without  cerioiu  loa  a^iuiaflL 
Hhuuld  natural  telief  take  plnce.  liie  rcMrioted  did  and  rat  aboaU  bt  r*' 
uoue<i  till  ull  pain  baa  puteul  uway  and  the  bowela  hare  beooae  wyil* 
In  Ltutva  of  acute  obalructioo  with  Mvcre  vomilJDg.  Thomaa  Maiei  IM  itt 
patient  expcrienccft  much  relief  from  having  tbe  luut  of  thi^  bed  raiaedab^ 
ten  inches  on  blnclu,  by  wbicb  the  act  ot  vornitiu^;  ta  tmnlitated.     Hi  i^ 
x'tM;%  that  the  aUliiuieu  abuuld  bo  kept  cool.     If  a^mploiu*  uf  c«Uaf«  af 
pear,  he  recommeudu  tlie  hypodermic  injection  ul'  amall  doara  of  atrufiwa 


•  KEaATK 


STRUCTIOX.     817 


Inversion  of  the  Patient  \»  an  ompiric-Al  method  of  treatmi>nt  thnt  hns 
oc^Hiiionnlty  j>n)ve<l  siiece^t'iil  in  llie  relief  Kt'cjtsed  of  internal  nlrAniriilatirin 
of  an  ob«cure  c)ianict«r.  It  \»  applicniile  only  1o  Lhnse  on»eA  in  whicli  the 
sadilen  invneion  t>f  tlie  (li«eii(«  tind  ihe  acuteness  of  the  symptoms  lead  to  a 
eirong  prewinptiou  of  the  presence  of  a  Lwisl  or  interuikl  hernia.  It  is  uw- 
l««s  Uj  nltempl  il  if  there  10  gruat  abduniiual  dlHtention.  The  opernlion  is 
diti>e  a»  folluwB.  The  patit^tit  id  unit-alhutizfd  to  cu'ji[>iKe  muscular  rvlaxa* 
lion.  Hv  i«  titvu  euspeudif)!  by  the  flexed  knees  over  the  «hoiil<Ier«  of  a 
stron);  man.  The  email  iuteslines  will  then  be  seeu  to  };ravitate  towariU  tli« 
epignelriuii),  the  pubie  and  iliac  regione  bccuming  liullow.  The  nhiJoriit^^n 
limy  uow  lie  gently  manipulated,  and  the  mun  wbn  supports  the  patient  m»y 
rtiiee  himself  on  his  toes  and  come  down  sharply  on  bts  heels  so  lis  to  give  a 
alight  eoiicuseiuu.  In  a  case  at  University  College  Hospital,  of  extremely 
aeote  ul>struetion  with  riolent  stereo raceous  vomiting,  this  trealnieot  was 
iuiuK^liutely  successful.  As  the  pniieut  was  inverted  tberewasu  loud  gurgle 
and  a  fouling  like  the  rednetion  of  a  large  hernia  waa  perceived  by  the  buud 
iin  the  abdomen.  I  have  seen  a  case  of  fatal  obturator  hernia — nnrecog- 
iiized  during  life — to  which  ui  the  po^lmorlfm  examination  it  seemed  prob- 
able that  iuversiuQ  and  shaking  would  have  effected  reduction  and  so  saved 
the  patienL 

£n8mata  are  uncles?  and  usunllv  injurious  in  oii9«8  of  arute  nbstruction. 

The  eztflrnai  application  of  belladonna  hita  been  recommended  with  the 
view  of  t^timnlating  the  poristuttic  action  of  the  intestine,  but  it  duee  not 
eeem  u>  have  been  of  any  wrvice, 

Fnuotare  of  the  Intestine  by  means  of  a  trocar  or  the  Bepimtor  for  the 
purpose  of  withdrawing  tlalus  tu  ca^^cB  of  ercnt  distention  has  been  fre- 
quently performed,  BomeiimcTt  with  gn!at  relief  to  the  patient.  It  inny  be 
Satcly  d)iuc  with  a  trocar,  about  a  tenth  or  twelfth  <>('  an  inch  in  fliana-ter. 
Tliia  mu*t  be  iutrodnceil  at  the  ninsl  prominent  re^iitnant  point,  Tii«^  trocar 
i^  then  withdrawn  Krid  [becaniik  letl  in  fur  fmm  live  to  ten  ininnEai,  the 
gM  being  allnwed  to  btiiw  otT  It  must  not  he  moved  about  neeiilessly  while 
it  IB  in  the  got.  When  no  more  ga«  eifcapes,  the  vaeuumof  the  Aspirntor  may 
be  applieil  to  it  as  it  b  withdrawn,  to  present  any  fecal  matter  falling  into 
the  periton4«l  cavity.  If  the  canula  becomes  choked  with  feoal  matter,  it 
should  be  wilbilrawn.  The  puncture  is  rarely  followed  by  any  escape  of 
feces  inli>  the  cavity  of  the  aodomeo.  In  some  apparently  hopeless  cases 
relief  of  the  obstruction  liu»  been  kuuwu  to  tullinv  the  paracentesis  of  the 
intestine. 

Operation  for  Acute  Intestinal  Obstrnetion. — When  a  patient  is  sutTeriag 
frotn  the  symptoms  of  iuterual  )>LranguIatiou  which  resist  medical  treatment, 
and  have  not  yielddi  u>  inversiim — if  it  have  Ll-ch  thought  oxiwdieni  to  cm- 
pl'iy  it — ho  will  to  a  certaiuty  die,  unless  relief  can  bu  attimled  by  opera- 
tion ;  and  lw>f  ga-ut  4m-suon»  will  at  last  pres  themselves  upon  theSurgcon'B 
Attention:  1,  whether  it  is  advianble  tn  have  rectiurae  to  oiH-rutive  intor- 
ferenee;  and,  2,  when  it  is  proper  t»  iiudertaku  it.  The  solution  of  these 
queettotis  is  fraught  with  ditTiculty,  anil  must  always  be  a  rotticer  of  the 
inoBl  anxious  considcraliou  lo  the  Hiirj^eon.  It  is  mtt  only  that  he  knows 
that,  if  the  patient  be  left  unrelieved,  he  must  necet^sarily  <iie;  but  that  he 
it  aware  that  the  only  nic«ns  nf  relief,  gaelroCumv,  is  probably  nearly  as 
btal  as  the  diseat^  for  which  it  is  undertaken,  nut  the  difficuUips  that 
ent  themselvert  in  the  Sfdutinn  of  the  question  are  much  inrreased  liy  the 
U  obscurity  in  diajrnoaing  the  cause  of  the  ohslrnction,  for  in  many  cases 

is  abeolutely  impoiiible  to  determine  with  certainly  whether  it  arise  from 
sedianica]  causes  or  not ;  and  by  the  fact  that  apparently  desperate  cases 
occaaionally  recover  without  operation.     If,  however,  by  attention  to  any  of 
VOL.  ir.— &2 


818 


TNTKSTIITAIi   0B8TRDCTI0N. 


the  poiuU  that  have  b«eD  pretty  fully  adverteil  to.  it  can  be  sHtisfftctorily 
made  out  ihnt  there  is  an  inlenial  ^tninguiAUon,  und  muro  especially  if  thu 
iotUBNSceiice  occn»iuDed  by  it  can  be  liell,  it  will  evideDtlv  be  the  duty  of  the 
Surgeon  to  give  the  patient  bis  only  chance  by  the  diTision  of  the  atricture. 
With  regard  to  the  lime  at  which  this  should  be  done,  the  only  gpuernl  rule 
that  can  be  laid  clown  i^  probnblr  ih<*  conclunlou  arrived  at  by  B.  I*hilli[is; 
that  opemlioQ  ie  justifiable  when  three  or  four  days  have  passed  withont  any 
relief  from  ordinary  meane.  constipation  being  complete,  and  voniilioj^  of 
fecal  niotierg  continuing.  Tlio  dctaiU  of  ihu  operation  will  be  deecribM  on 
a  auht<it|uonl  pn^e. 

Treatmetit  of  Intuseasception. — There  can  ho  little  doubt  that  gi>i>ntarieoui 
di8Ci>liiU(;l'-nieru  oecore  in  nmny  of  the  aliyhtL-r  caees  of  iiituseueeepljoo. 
In  others  Inflation  of  the  Obstructed  Intestine  by  the  injection  of  air  into 
the  rMTtuin  haa  been  roconmK-nded.aod  hm«  oc(<u<>ionully  been  practiced  with 
sucoess.  In  two  instances  I  liaveHiccewJully  bad  m-cotiree  to  it.  Oue  was 
the  oaae  (il  nn  infant,  a  f{'\v  nnnitliH  old,  sciiced  with  KViitptoni!!  of  intustiua- 
ceptirm,  whom  I  attended  with  ('-uuiiins.  The  other  patient  wns  a  young 
lady  about  ten  years  of  agfi,  to  whom  I  was  called  into  consullatioa  with  Sir 
T.  Watson,  I>r.  Murphy,  and  Dr.  West ;  intlalion  whs  performed  on  the  fifth 
day  after  the  setting  in  of  Kymptoma  of  acute  int^tinnl  obatruction,  ap- 
parently  dependent  on  intussuiieeption.  The  pn>peeding  was  followed  by 
perfect  success:  the  child  felt  "as  if  a  hone  broke"  in  the  abdomen,  the 
obstruction  was  removed,  and  motions  followed  in  three  hours,  thoOKh  all 
the  previous  treatment  had  been  unavailing.  For  ihe  <:<invenient  perform- 
ance of  this  opemtion,  I  have  had  an  apparalus  i^imst ruotcd,  consisting  o|  « 
circnliir  double-action  betlown,  with  a  Inn^^  vulcaiiir-cd  India-robbrr  tube, 
furnished  with  a  <ilop-rock  and  rcctum-tolH-s  of  different  sizes  for  children 
and  adullx.  Should  ihis  not  be  at  hnud,  ■  well-tilted  etomarb-punip  will 
answiT  the  purpos«,  lu  purfonniug  this  o])vration  too  much  force  must  ooL 
be  umhI,  as  verioos  injory  Co  tbv  iutceliue  has  beeu  kuowu  to  mult.  This 
Ireatiucul  cannot  b«  exjwcted  to  succeed  in  any  case  of  iutussuBCvptioa  ex- 
cept tbat  of  the  large  Jntei>tiow;  even  U'  it  Iw  at  the  ileo-cucal  valve  JiUle 
goml  usunlly  re«ulls  from  it. 

Operation  for  Intasstiiception. — If  this  tri^atment  has  failed,  the  only 
(!haui'<e  of  recovery  without  operation  lies  in  the  sloughing  awny  of  the 
invaginated  portion  of  gut.  And  what  is  this  chance  by  natural  cure?  Tbe 
answer  given  by  stiiliatics  is  us  follows  :  J.  L.  Kmith,  vi  New  York,  collected 
the  detaiU  of  50  caaes;  nt  these  7  recovered.  Ilaveu,  of  Bt*ton.  found 
that  of  !td  oaem,  there  were  10;  and  Oucbaussoy,  that  out  of  i:^.'>  cases, 
there  were  2!t  recoveries.  The  chance  of  life  by  natural  means,  therefore,  U 
about  l.S  per  cent.,  or  rather  ranrp  than  one  in  five— not  a  very  ho|>efuI  one, 
truly.  In  these  circumstances,  Surgpouc  liave  nHlurally  looked  to  gwtrotoaiji 
aud  the  manual  disentaglement  ot  the  invagitinted  gut.  as  otfenng  ■  better 
prospect  of  life.  And  this  operation  has  undoubtetlly  in  many  cases  been 
followed  by  recovery,  eioce.  under  the  directions  of  Nuck.  the  firet  well- 
authenticHleil  successlitl  ofierstion  of  this  kind  was  performed.  AsbbursC 
hss  collectd  the  particulars  of  13  cases  in  which  abdominal  section  was  per- 
formed for  intussnscf  ption.  Of  these,  five  succeeded  ;  and  more  recently  the 
operation  has  been  successfully  practised  by  Hutchinson,  Howard  Mar«)i. 
OtNllee,  and  others.  But  tbe  prospect  of  success  wilt  greatly  depend  oa  the 
nature  and  seat  of  the  intussusception.  If  the  strangulation  b«  very  acnU, 
and  if  (he  disease  be  scaled  in  the  ileum,  the  chances  arc  not  «•)  favorable  by 
any  means  as  in  the  more  cbrnnic  form  of  the  aflection,  when  the  large  iotw- 
tine  is  the  seat  of  the  invaifinalion.  In  these  coses  the  gut  is  incarcerated 
rather  than  strangulated.    There  is.  as  Hutchinson  has  well  pointed  out,  dv 


n 


TRKATUKKT    OF    CHBOXtC   IWTBSTISAL    ORSTRUCTIOS.     819 


hope  of  niitunil  cure  by  gangrene  of  the  included  portion,  and  the  patient 
will  die.  woru  out  by  irritation  and  pain,  uule<«  relieved  by  operalion. 

If  the  invMgination  be  attendnl  by  acute  symptoms  uf  strsiiguialion  the 
opem(ii>n  ia  m>t  adviaable,  as  in  these  cases  it  would  probably  be  inipij«iible 
ti)  dii««.>H tangle  the  swollen  gut.  and  moreover,  it  ia  iu  these  ttiat  there  ia  the 
b«<t  hope  of  a  Qatiirul  cure  by  separation  (>t'  the  Btruaguluted  portion.  In 
infautJt  under  one  year  recovery  very  rarely  takes  jdace  by  Beparatiun  of  ihp 
iuvagiiinteil  (rul,  ho  rarely  thai  imt  liitjre  than  one  or  two  uaaea  uf  spontaneous 
re^.'overy  are  on  record.  In  lh«*e  caaea  the  operation  «eeriia  t'>  hold  out  almost 
the  only  hope  of  cure  if  inflation  fails.  As  to  the  time  at  which  the  opera- 
tion should  be  performed,  no  rietitiite  rule  can  be  laid  dnvvu.  In  acute  cases, 
the  earlier  it  is  done  after  other  means  have  failed  the  bt'tter,  if  the  caae  be 
one  iu  which  it  ie  justifiable.  If  the  invnginatiou  be  chronic,  and  colic  occur 
iu  au  adult,  the  urgency  for  enrly  operattim  a  not  eo  great,  though  the  oeccs' 
sity  will  eventually  be  greater. 

^reatmeat  of  Chronic  Intestinal  ObBtruction.— As  before  stated,  this  iinacs 
[JDost  mtnmouly  fnim  iidc  of  the  followiug  causes:  feciil  impaction, comprcft- 
pioa  of  the  great  intt'Stiiie  by  a  tumor,  stricture  of  the  large  iiitcsliDc,  chronic 
InlussuBception,  and  chrmic  [tubercular)  peritonitis. 

t'eeal  itnpnciian  is  most  common  in  elderly  woinen.  When  it  is  suspected, 
the  rectum  should  be  explored,  and  if  it  be  litund  to  be  blocked  up  bv  a 
rounded  mafs  of  induratPfJ  and  impacted  feces,  the  Ktirgeou  must  condesfThd 
to  undertake  the  dutipd  of  the  nightman,  and  empty  the  human  eloacii  of  its 
fetid  accumuliitinna.  This  ia  best  done  by  unaiilheiizing  the  patient,  then 
dilating  the  itphiticter  ani  with  the  hand,  breaking  dowti  the  indurated  niai'.i 
with  a  sputiu  or  lithotomy  scoop,  and  Wfwhing  it  awny  by  c^ipjous  enemnta. 

If  the  obstruction  arises  from  the  gradual  compression  of  the  rectum  by  an 
intmpffvic  tumor,  or  fron  the  slow  ciiHtrictuiD  ol  it  or  the  col(»a  by  mniiyuatit 
*ii^iu^  of  Oitwnlh,  purgatives  will  he  wor»e  thuii  useleM;  they  will  irritate, 
will  otten  induce  vomiting,  and  will  always  otjosiderably  iocrease  tlie  patient's 
dialreas,  and  should  not  be  repeated.  The  patient  should  be  kept  quiet  in  bed 
and  have  a  lindted  supply  of  fowl;  sneli  as  leaves  little  residue  being  |»re- 
Arrred,  the  best  being  bctrflea,  meat  with  nrrowniot  and  h  small  cjuatllity  of 
brandy.  Milk  and  wxta- water  ie  soiuetimes  litken  easily.but  very  often  milk 
in  aoy  form  aud  eggs  are  iii>l  easily  digested,  Kuemata  niiiy  be  fairly  tried, 
>ul  if  they  do  not  soon  overcome  the  obBtruclioxi  uothiug  ii*  (•aint-d  by  |K-r- 
_)dsteutly  annoying  the  patient  with  them.  Iu  some  cases  the  iutruduc-tiou  of 
'ihc  tube  of  a  stotuach-pumii  as  fur  as  possible,  aud  the  HdiiiiuiatrHtiun  of  au 
i^^Ulioii  in  this  way  may  l)riiig  about  reliid*.  if  the  stricture  is  within  rejitdt, 
a  catheter  can  somelimea  l>e  introduced  through  it,  by  meamt  of  which  a  large 
olive-oil  enema  may  he  admini»tered,  and  in  this  wuy  the  niffilruction  nmy 
be  iivercome.  If  these  means  do  not  sucrecti,  oj)Ium  may  be  udminiHtereit, 
and  very  often,  anmetimeit  alter  some  weeks,  the  olistruction  may  give  way. 
Thoraa.s  stales  thia  has  freiiuently  occurred  iu  hia  prarlice,  and  that  be  has 
been  aide  to  prevent  the  early  return  »f  the  ohslructiun  hy  keeping  the 
patient  on  the  restricted  diet  already  mentioned. 

Whi^n  other  meaiii>  have  failed  and  the  patient  is  becoming  ex haiiBted, 
operative  interference  becomes  necewary.  When,R.s  is  the  coee  iu  ihe  great 
maiorily  of  cases,  the  diseaee  is  seated  in  or  below  the  Eigmutd  flexure,  the 
descen'ling  colon  may  be  opened ;  hut  should  there  be  any  reason  to  believe 
that  the  obstruction  is  situated  at  a  higher  point,  the  operation  must  be 
performoil  on  the  right  side. 

Id  fJtronie  iiituA»itJicefttioH  inflation  of  the  gut  may  bo  attempted,  and  if  that 
filib,  the  only  chdnce  lor  the  patient  lies  in  gaslrofimy. 

Jn  Tubereiiuar and  older j'urmg of  ehroatc pentomtlinoopcntivtiDt^rfRTtnct 


820 


OBaTBUOTIftwT 


Is  JQstifiablc.     It  is  ill  thr^o  cows  tlial  relii'f  hiu  twrnvtinm  httn  obtUH^li^ 
kneadinj^  the  altilmncii  'nuutMgK'i,  ur  by  electririly. 

Odirationm  for  Isr»>TiNAi.  <Jii.'<TRi'cn'l<»,N.— Outrot4B]r>  *'f'  ■  il  * 
more  correctly  termeiJ.  Lapuotomy,  nmy  be  rt'^jiiirwl  for  acol*  i*tfliiit) 
obstructina.frum:  1.  Intcrnnl  BtrnD>;uli»iiin,  h'iw<^ver  pmduwi ;  i  F-r  r4- 
vuluA,  or*  wmi-twitit  of  the  large  inieBlini- ft]  ilM-ll':  :t.  For  intiMHucvflM, 
i>ccflAional ly  when  acute,  anrl  nmre  nf^ea  whrn  chronic. 

In  performing  the  operaiian  of  gastrotomy,  all  thv  rulfl*  almdy  hid  Imi 
lor  abilnniiiml  operations  in  f;eDcral  must  be  aileniled  1o  ip.  737.i.    TW 
patient  must  be  laid  on  a  liigb  table,  the  le^  beinf;  allowed  to  InK  wvclih* 
end  of  it.aoaa  to  ntford  a  full  vi«vr  of  theaUlomen.     ThoaBaMtlwUeWiiif 
b«vn  adminiitlen'd,  and  ihe  bla<lder  eni^tiMl,  ibe  inciniuu  thnold  '■ 
^b«l<>w  the  uiubilicUR  in  Ib^  middle  line.     If  tht*  fKitietit  be  7«rf  fr.: 
be  neoeit^ry  to  enlnrKe  the  wound  iipWHrtln.     Kven  in  caaei,  Midi  a#  tw* 
auBceplinriH,  in  wbich  the  tumor  ia  iiitiiate<l  -ai  one  Nide  ol  tb«  mithllv  liar.lfe 
median  incision  will  alwaye  be  lound  the  l>eBL     It  i#  Hi-coiitpaniol  hf  lea 
betuurrliajje,  and  leaves  leufi  tendency  to  ilie  occurrvncv  uf  a  f  tiitral 
The  lineanlba  then  having  been  expoaed.the  incixiou  muat  b*  etrritd  tin 
the  ahdumiual  wall  until  the  (lerituneum  is  reached  :  ibia  muai  tli«a  ht 
bv  means  of  a  probe- planted  biHtuurv  guided  by  the  furetiuger  uf  tlic  lift  hmi- 
Ibc  incision  ahonltl  ui  lint  be  unly  just  Uir|^  enuugb  to  adaail  Ui*  Ibi4. 
which  may  be  inirtMluced,  williout  uJluuin);  the  iotcstiDf*  lofM^M.    kit 
Itomible  tbut  in  this  way  the  cnnaLrioting  tmnd  might  be  fell  aod  npCan^M 
the  intestine  rulieveil  from  tU    It'  ihittciiouut  be  dtiui:^  tbe  baud  nua  btnlV 
drawn,  when  mme  of  the  cuils  of  the  emaJI  inleetine  will  |>n<n)dc  Ui*m^ 
the  wnnnd,  mrlin);  over  its  edjres.     Thewe  mUEt  be  cjirclully  wipporu^bf 
asatxliint,  who  titionld  presfl  upon  thetn  viih  a  »otl  linen  tovel  uoiamri 
H  warm  Ntluiion  of  carbolic  acid  >'  I  in  /tO).     Ily  I'ollowinf;  tb«  intnliM 
n'diicin^  nni3  part  as  the  next  in  with<lrawn,  the  olwinirLion  may  al  IM 
reached.     It  19  nsunlly  recommended  to  find  the  col  bipeed  part  of  the  iowttf* 
and  10  follow  this  upwanU,  but  thie  tfi  more  ra«ily  Mia  tha&  diMw,alW 
dbti^nded  coilnof  the  intestine  above  usually  obscure  tbe  empty  part  beUv-  k 
will  ueually  be  found  that,  however  careful  the  Surgeon  may  b».  iftkifta 
much  distention,  n  large  part  of  the  intm-ine  will  be  expfw-'  '- '■  "  ■'••  * 
Btniciion  h  found.     If  there  be  a  hernial  coottriction   1 
advcntitioua  fihroid  baud,  he  may  divide  Ihe  band  that  cim^utnT.--  mr  ■^■r 
ture  on  a  director  by  nieana  of  a  probe-p»-inled  biBtodry  uf  hernia  kaift.t' 
break  it  through  with  the  finger :  or  he  may  withdra>>  ' '  .-ifirt«d  nd* 

intt-siiue  from  an  a|)erture  in  the  omentuot  or  meeci  '  wbirk  it  M 

ilipped.    If  it  be  a  case  of  volvulua.  the  otdon  may  b«  uutvualed.  aatt**** 
on  which  I  o]>erated  lu  IH49. 

If  the  case  be  one  of  intutiitUBception.  it  •«  usually  <i»clea»  to  atttaj"* 
reduce  the  invaginaltuo  without  bringing  the  wbole  tumor  o«t  ut»«  i** 
abdwninal  wall.     Tbia  can  uaually  be  dune  without  difficulty,  aiMl  a*  >^ 

Btcotiou  in  theae  caaea  ii  seldom  greal,  it  may  be  Rccoiut>lL>ti")  «>tft^ 
UowtDg  tbesmail  inlnttines  tu  escape.    Reduction  must  - 

proceas  of  kneading  and  drawing  down  tlicaheiilb,  rathi. .  -  - 

attempting  In  drag  out  the  entering  tube.  If  rtductioo  tt  JnpanWr.f 
Surgeon  baa  three  courses  open  to  him.  He  may  return  the  imwl  aaJ^"" 
the  patient  to  hia  chance  of  a  natural  cure;  he  may  bring  uut  th«  f^f^ 
inif-fttine  and  maki;  on  ortilicial  nnue  in  the  wound;  (-r  he  may  ™' ''Jr 
whole  invBginaied  part  and  sew  the  two  endanf  the  gut  to  eaekalbcr.  »■' 
ODune  b>  be  adopted  will  ilep<^nd  on  circunMiancrR.  Aa  it  u  pnaaMHl|||| 
the  opcratirm  ha^  been  undertaken  becauar  there  waa  no  bnn*  i4 » 
oeoua  cure,  tlia  flrsC  oourae  la  Dot  likely  lu  be  ■iiiiumHiI.  itiiugfc  kl 


AMUfiSAT'S   OPBBATIOK. 


821 


■Cues  it  is  the  ouly  ooe  that  can  be  nuopted,  owing  to  the  ezbaugted  etate  of 
the  patieot.  The  eecond  will  lenve  tbe  patient  uq  artificial  aous  ia  the  luoet 
incmvenient  poeition.  The  third  plap  would,  therefitre,  be  the  beet  lo  adopt 
irthe  condition  of  the  patient  is  such  bk  to  allow  the  necessary  time  for  it« 
performance.  The  chauuea  uf  rewivery  are,  however,  not  great,  whtehtvcr 
plan  be  adopted. 

Aftor  ihe  obstruction,  whatever  may  ha  its  nature,  is  remiived,  the  intes- 
tiue-*  mu»t  be  rcrtiirnod  and  tho  wound  chiaed  and  drwwed  as  dcBrrthwl  on 
p.  T:t8.  The  abdoiiii^ii  mui-l  he  well  Kiiftporled  by  ii  batida^'e.  and  iht'  knei-e 
muat  be  bom  over  a  pitiow.  Opium  mtisl  l>c  continuously  adminiiiterfd,  and 
Oothio}^  bm  i«i  and  lmrl<>y-watt>r  Hni>w<!d  for  from  iwonty-tinir  to  furty-eij,'ht 
hour#.  Tlit>  mortalitv  tnlhiwinp  jja^lrotomy  for  lh«  rnlipf  of  iiitfPtina)  ob- 
struction iit.HK  miffhl  bf  cxperU'd,  very  lii^^h,  Hnionnling  to  aliiHit  80  per  cent. 
ThiiH,  Ashhuril  fmdn  that,  in  fiT  caspa  in  which  the  operation  was  done,  there 
wer«  II  r^roverico  only. 

Colotomy. — The  operation  required  tn  j;ive  exit  to  the  iti(»4ttnal  <-<inlent« 
ifl  of  two  kinds,  tn  nne  the  intf^Mine  \»  ofM'ned  in  the  left  iliac  foMa,  by 
cuttin;;  through  the  p«>ritonenm  cov^rin);  it.  Tn  the  other  it  ia opened  in  the 
loin  hy  cnltin^'  between  the  layers  of  the  mesu-colon.  being  thn^  exposed 
where  it  is  uncovered  hr  peritoneum. 

Colotomy  may  be  re<joired  for  the  followinj!;  conditions: 

1.  InteAtinal  ohstnirtion  l>elow  the  descending  colon. 

2.  Intense  pain  in  defecation,  in  itlccrated  cancer  of  the  lar^  intestine  or 
reetum. 

3.  Crtocetrtust  fistula  between  the  rectum  and  bladder. 

4.  Oin^renilnl  absence  of  the  rectum. 

Ltttre's  Operation.  Inspiinal  Colotomy,— The  first  operation,  or  Litlre's, 
s«  it  hiiM  bfeti  c-KlJed,  was  prnpuseil  In' u  Surgeon  of  that  name,  in  1710,  who 
advised  that  in  these  cnaes  the  sigmoid  flexure  nf  the  colon  should  be  openetl 
from  Ihe  left  iliac  region  ;  but  it  wuh  n'>t  until  the  year  177l>  that  any  opera- 
tion of  the  kind  was  performed,  when  I'illore,  a  Surgeon  of  Kouen,  was  the 
linst  to  makean  artificial  anu.s  on  the  adult,  for  the  relief  of  retention  of  feces; 
this  be  diii,  uot  according  to  Littro's  method,  but  by  opening  the  cwcum 
from  the  right  iliac  region.  Fine,  of  Cieueva,  in  1797.  opened  the  traiiBverse 
culoo  from  the  umbilical  region,  in  a  case  of  retention  of  feces  produced  by 
"scirrhus"  of  the  upper  part  of  the  rectum. 

Littre'ti  operation  is  thus  performed:  An  inciaioD  is  commenced  al  the 
level  of  the  left  ttuIeri<T  fuperlnr  iliac  spine,  and  carried  downwanis  and 
iuwarda.  nearly  paralldl  to  PnupRrt*?  ligament  for  fnim  two  and  a  half  to 
tbroe  inchee.  The  muscles  niHi  fiiscia  traiisversAliB  fascia  arc  then  divided 
in  the  »ime  way  ng  in  the  operation  for  ligature  of  the  dEternal  iliac  nrlery. 
The  peritoneum  ia  (hen  iipened  nml  the  distended  sigmoid  ttoxure  UBtially  at 
once  preAcnu  in  the  wound.  It  is  then  drawn  into  the  wMund  mid  secured 
by  B  sufficient  number  of  stitches.  These  ahnnid  be  made  lo  include  the 
peritoneum  and  ivkin  in  the  abdominal  wall,  but  should  miss  the  muBcles, 
If  the  case  is  not  urgent,  the  stitches  may  be  made  to  pcnt^nite  the  muscular 
and  serous  cont  only,  and  the  gut  IcIV  unopened  till  the  third  or  fourth  ilny. 
If  it  is  necessary  to  open  the  gnt  ai  rince,  the  siiturea  may  penetrate  the 
whole  thickness  of  the  gut.  On  opening  the  perit*>ncum  a  piece  of  small 
Intestine  may  present  instead  of  the  colim  ;  this  is  recognized  by  the  ab»encc 
of  bnnrls  and  appendicea  epiploic^:,  and  by  the  fact  that  if  its  mesentery  be 
gently  pnlled  it  will  he  f^lt  to  he  fixed  tnwards  the  right,  while  the  colon  is 
fixed'tii  the  U-fl  *ide. 

Amassafs  Operation,  or  Lnmbax  Colotomy,— In  nnler  to  avoid  the  com- 
plication of  wounding  the  peritoneum,  Cultiaen,  of  Copenhagen,  in  1796, 


822 


IWTKSTINAL   OBSTRUCTION. 


proposed  opening  the  colon  from  behind,  in  the  lefl  lumbnr  rrgion,  where  IL ' 
10  nut  iiiivered  by  pcriloneum.  He  rtnc4>  attenijiled  thi^  operation  mi  tin;  dead 
Ixidy  (if  a  ciiild  ;  but,  tailing  in  hi^  ciiileuvor  ui  rench  tlic  intestine  witlmut 
wouiidiug  the  serous  mciubmiic,  he  tk-«in8  tu  liavc  rttlin^uished  nil  further 
iden  of  it;  nnd  it  was  aub^ucotly  mjccted  aft  iniprBcti cable  by  all  writer* 
on  Surgery  who  treated  of  this  subject. 

The  operation  of  eulutomy  propr«cd  by  C'Alluon,  was  lir^t  practised  ant) 
perfected  by  AmuMftt.  It  i»ouei»Tlbe  iu.<st  iro|>urlnnt  addilinn*  to  operative 
JSurgcry.  and  affurda  an  udniirabic  illufiinition  of  the  impurlant  pinclicnl 
spplication  of  an  apparently  trivial  anatomical  fact,  vm^  the  relation  of  i-be 
layers  of  the  mean-colon  to  the  de«eendiug  colon. 

AtuUBsat,  at  the  time  whi>u  he  was  utteudinj^  the  celebrated  BrouMaU  for' 
that  "scirrhous''  n^eotion  of  llie  rectum,  of  which  lie  ultimately  died,  naa 
led  to  reflect  on  the  reatniro-ti  that  Burj^ery  offers  in  similar  cssoa ;  and  after ' 
making  some  expertmeiita  mi  the  dexd  bmly,  willi  the  view  of  eoutniBting 
the  merit  of  the  dilterent  opernlimiH  that  have  Iim'u  pi-ufxiHi'd  for  the  forma- 1 
lion  uf  artificial  auus  in  cases  of  obetrtiction  «( the  lar^'e  intestines,  he  iK^caaie  | 
Convinced  that  tlie  operation  prupo^d  by  Caljiaeu,  if  somewhat  iiimlified, 
wa»  ni>t  t.<nly  prBctico.ble,  but  cal'e.     lie  »uuu  had  an  opportuuity  vrputlii))j; 
thi»  opinion  to  ihe  tost  of  actual  prnclice,  in  1^39,  in  a  private  case,  at  w  hich 
he  kindly  iuvited  me.  then  a  etudeot  in  Furie.  (o  be  present ;  and  eiuce  this 
time  the  operalion  has  takeu  u  recognized  piwiliou  io  Surcery. 

The  folluu'iug  u  the  best  uietboil  of  |)erlbrniiug  Lumoar  Colotoroy:  If' 
the  operutiou  ia  to  be  performed  in  the  urdiuary  situaticm,  the  patient  murt 
be  placed  on  his  right  side,  with  a  lirm,  foldeil  pillow  beueath  the  Haok.  9o 
that  the  body  may  be  slightly  curved  to  the  right  side,  and  the  space  belweea 
.Uie  last  rib  and  the  crrac  uf  the  ilium  oii  thf:  left  sidv  made  us  wide  a»  jko- 
fliblo.  The  8ugeon  tlien  meaaureii  fntm  the  anterior  superior  to  the  ptisterior 
superior  spine  of  the  ilium,  carrying  the  tapf^  Mrnight  from  mie  to  the  other, 
and  mx  aloi)^  th^  crest  of  the  ilium.  Krom  the  mitl-fHiiiit  betwf>eu  the  two 
spinis  i,IIeath\  or  half  an  ineb  behind  it  (Allingbam).  a  vertical  line  ll 
drawn  ujiwanla.  an  in  Kig.  «03.    This  correspoDda  Utlerably  a<-cur&tely  to 


I'eictndlng  C'lloa. 

the  line  of  the  colon.  In  this  line  a  noioc  is  takeu  exaclljr  raid- way  betweeo 
the  last  rib  and  the  crest  uf  the  iimm.  An  iiiciaion,  either  tmngverso  or 
iucliiieil  slightly  downwanls  and  forwards  (Kig.  MK{<,  is  tht-u  made,  pautug 
tbraugh  thi:^  point.  It  must  be  from  three  Ui  four  inches  lu  length,  half  on' 
each  side  of  the  vertical  tine.  If  the  meaHuremcniH  havu  Iwen  correctly 
taken,  the  posterior  extremitvof  the  incision  will  lie  at  the  edge  uf  tba 
erector  spina;.     In  fact,  the  edge  of  this  muscle  iu  practically  a  bettor  guU« 


.UMBAR   COLOTOHV. 


828 


tttiQ  the  vertical  lioe  jui^t  mentiotit^l,  Tlio  incUion  is  itt«At1>ly  deepened 
thntugh  till-  skill  aod  siipertic-ial  fascia  W  lij^ht  strokes  of  ihe  knife.  After 
these  are  divided,  the  «xteniHl  nblique  cornea  into  view  in  (lie  anterior  two- 
tbinl»  of  the  wotiod,  aud  the  latiissiniUH  dorsi  in  the  poeterior  ibirH ;  theso 
are  divided  by  druwiiig  the  knife  lightly  alung  the  wound,  and  the  internal 
obliijiie  is  then  expuved  and  cut  thn>ugh  in  the  same  way.  The  faiK-ifi  lum- 
borum  now  cuoiee  iotu  view.  This  is  the  timt  important  rallying  point.  It 
muBt  be  picked  up  carefullv  with  the  dissecting  IV>rue|)s,  and  opened  with  the 
kuife  held  horizntitally;  tlie  linger,  guiding  a  pr)b»-pi>iuted  bistoury,  may 
then  be  introduced  through  the  opening,  and  the  fascia  lumborum  divided 
freely  to  the  whole  length  of  the  wound.  At  this  stage,  the  last  dorsal  nerve 
and  the  artery  accompanying  it  are  ummlly  divided,  and  the  vecsel  must  be 
twisted  or  lied.  The  iacisloD  through  the  faecia  lumborum  alwaya  opens 
the  sheath  of  the  quadrutus  lumburiim,  the  extcrniil  border  of  which  must 
be  freely  notched  if  it  obstruct  the  wound.  In  tlividing  the  muscles,  two 
points  must  be  attended  to:  tirel,  llint  the«e  strncture^  arc  divided  to  the 
aame  extent  sa  the  skin,  othcrwieo  the  .Surgeon  will  continue  to  dig  in  a  deep 
aod  conical  pit.  and  will  certainly  fuil  to  recognize  Ht  the  botlom  of  it  the 
gut  of  which  be  ig  In  Bearch;  and,  accondly.  to  ovoid  drifting  dttwnwarils 
towards  the  crest  of  the  ilium,  as  the  incision  is  deepened  from  drawing  the 
wound  to  one  side  with  the  W-fi  hand. 

At  this  dln^e  of  the  operation  two  copper  spatulie  must  be  put  into  the 
wound,  by  which  it  in  drawn  widely  open.  >S<imc  loose  fat  then  comes  itito 
view,  which  muet  be  earcfullv  ti>rii  thrmigh  with  the  lingers,  no  forceps  or 
other  instnimoat  being  used.  In  thin  jiatientB  this  fat  is  wanting.  The 
fascia  iranttvcrealit  next  appenm.  Tliis  is  a  very  variable  atructure  ;  in  fat 
females  it  i«  scarcely  rccognij:ahIe,  while  in  a  thiiJ  male  it  ia  often  &o  atrong 
tu  to  Ike  mistaken  for  the  peiitoneiiin  or  the  gut.  It  must  be  ciin-fully  torn 
through  at  the  posterior  jmrt  of  the  wound.  The  i>uh|>eriloneiil  fnt  h  then 
exjK^aed,  varying  in  amount  with  the  fAtne^s  of  the  patient,  and  mii.il  be  torn 
through  carefullv  witli  the  fingers.  The  iiut  is  now  readied.  If  the  opera- 
tion iM  beinj;  perforttieil  for  obstruction,  the  colon  ii*  tensely  distended,  of  a 
greeninh  color,  Hod  usually  ri^ei^  up  into  the  wound.  In  cases  in  which  thifl 
operation  is  being  undertaken  for  relief  of  pain  in  cancer  of  the  rectnni,  th« 
gut  may  be  colla)ise<l.  lu  thl)*  state,  not  only  ii>  it  dilticuil  to  Unil,  hut  the 
part  uncovered  by  peritoueiiui  i»  so  small  that  it  is  ditftcnit  to  make  an  open- 
ing without  wfjtiuding  that  membrane.  AH  these  difficulties  are  at  once 
overcome  by  distending  llio  gut  with  air.  Liin<l  has  invented  an  iuiienioug 
Bpittratus  for  this  purjiose,  hut  the  gut  cuu  eu<iily  he  iliiitendotl  by  means  of 
an  ordiuary  eaQiua-Byriage,  the  anun  being  eloited  urouud  the  tulie  by  a.  man 
of  wet  ur  oiled  wool  pretiBed  against  it  hy  the  baud  of  an  aiMisiani.  A.»  the 
air  enters  the  gut  will  be  seen  and  lelt  rieing  up  in  the  wouml  <  Vi^.  SOi) ; 
end  in  most  cases,  if  the  tranitvcrHaliu  lii^icia  have  been  fnitlicii-ntly  lorn 
through,  it  will  rise  up  to  the  level  of  the  skin.  If  from  any  reueon  this 
taila,  the  gut  may  lie  found  hy  initiliing  the  forefinger  into  the  woun<t  till 
the  lower  end  uf  the  kidney  ie  felt,  inimediaiely  in  front  id  which  the  colon 
lies.  Pressure  cm  the  abdomen  will  mimetitucji  make  it  appear.  In  other 
CBtwfi  it  may  E>e  found  by  turning  the  patii^nt  im  hi(i  back,  pHAfiing  the  fore- 
linger  into  the  pue<tenor  part  of  the  wound,  and  then  seizing  between  it  and 
the  thumb  the  [xirta  in  nontact  with  it.  Th^*  patient,  in  then  rollcid  Uiick  on 
to  hid  Hide  and  the  gut  rlrawn  up  into  thn  wound.  In  whatever  wav  rlie  gitl 
is  seiiUNl,  it  must  he  drawn  widl  up  to  the  level  of  thp.tkin.  Twooilk  ihrt^ads, 
each  about  two  feet  long,  are  then  pa-**ed  thron;^h  the  gut  and  the  akin  and 
tat  on  each  side  of  the  wound  in  the  following  w.iy.  A  curved  needle  is 
threailed  on  the  suture;  it  is  firM  passed  through  the  skin  and  fat  on  one 


824 


FKSTIKAL 


LUCTIOK. 


side  of  the  woiind,  then  longituHinnlly  tlinniKh  (he  nuterior  part  of  tlie, 
exjwwL-d,  including  iibfiHt  one  inch  uf  ir ;  finsMy  Hie  iie«dle  is  paf»ed  fr 
the  wduiid  opp<i8ilo  to  the  point  at  vh'ich  it  enlerwl  on  the  oilier  Hiie.  A 
similar  thrvtid  is  then  p^flHcd  in  (he  ftiiino  vtay,  including  the  poeterior  part 
of  lh<^  gut  cxpnaed.  t^re  must  be  taken  not  to  puncture  the  peritoneum 
with  the  anterior  thread.  An  incision  is  then  made  into  the  gut  betwern  the 
two  Muliires,  the  finger  introduced,  the  Iwipa  pulle<l  out  and  divided  and  tied. 
Thus  the  gut  h  rapidly  secured  by  four  suluree  immediately  after  b*iiig 
openwl,  nnd  fecal  nialter  i*  jirevenlwi  (rom  running  into  the"  wound  (Fi;(. 
fiflS).  More  Buturcn  may  he  put  in  afterwords  if  ne<€*eary.  iriDueh  escape 
of  feces  is  expected,  the  wound  may  be  touched  wiih  i-liloride  of  aino  (er. 
40  to  .si ),  mild  the  posterior  part  over  which  freool  matlc-rwill  flow  rnaylw 
smeared  witli  iodi>- vaseline  ointment  or  carbolic  oil  before  the  j,'Ut  u  o|M?ne<d. 


ar 


pig.  804.— Inouiun  in  LoU  Lumbar  Bejion 


Ftg.  SOS. — Colon  e|>«D«tl  ^04  Stitcbod  to 


The  gut  should  be  brought  as  fnr  back  in  the  wound  as  can  conveniently  he 
done.  After  ihe  operation  the  anlerior  part  of  the  wound  may  be  closed  with 
AUtureii,  but  the  p<K<teri^ir  should  be  tetl  partly  open,  and,  if  neceflsaryi 
a  dniiniige-lube  iutroduccl  \<t  prevent  any  burrowiiiK  of  pus  in  tiie  loutesub- 
fwriloneal  nretjliir  li»ue.  A  |)nd  of  cariled  <hiIciiiii.  or  some  other  alworltent 
anliiH>ptic  nmleriul,  i«  then  applied  and  chnuj^ed  fre<|i)eutly.  A  piece  of  lint 
svnked  iu  curbolic  oil  (1  tu  lU)  uiny  be  ttpplieU  next  the  skin,  a  bole  being 
cut  through  it  oppociile  th^  gut. 

After  colotoniy,  the  iMitieut  will  derive  muoli  cvimforl  from  taking  i>owiier«t 
charcoal.  It  not  only  deodorizes,  but  hIm*  leuds  tu  harden  lh«  feces.  Wheu 
recovery  haa  taken  place,  the  aperture  iu  l)ie  lunibur  region  may  be  kept 
BUpiKirted  and  vIoBed  by  tueaus  of  a  irutss  with  u  large  pad. 

[t'ounJ  nf  ihe  i^erUoneum  \»  the  most  serious  accident  during  the  operation, 
aa  it  may  be  followed  by  peri  ton  it  ie,  but  is  by  no  meune  neceesarilv  so.  It 
mny  occur  in  three  i^tH^es  of  Lhi;  operation:  1,  while  dividing  the  fasria 
lunibitrum,  fmm  too  frei>  U!^  of  the  knife;  2.  the  poeleriur  relleotiuu  may  be 
torn  with  the  6iiger  by  usin>;  it  s»  a  honk  to  ilrag  the  gut  up  into  the  wound  ; 
3,  it  luay  be  punctured  by  the  rieetlli^n,  or  woundeit  hy  the  knife  in  o|K>niii^ 
the  gut.  In  rare  cases  free  ga^  is  met  with  in  tlie  [•erituneal  oivily,  and  this 
may  lead  U^  Ihe  peritoneum  being  mistaken  for  the  gut.  In  Binue  canea  there 
is  a  complete  me80-Cf>lon  met  with,  ^o  thiit  it  t»  imjioRiible  to  own  the  gut 
without  wounding  the  Berous  membrane.  In  fat  Bubjecls  theilepih  ipf  the 
wMiDd  increases  the  ilitKuulty  of  the  operation,  in  eonie  cawv  neoewitating  a 
crucial  incision  to  give  more  space.  DiHerfUt  SurgcouB  have  vaHouely 
modiftod  the  operBtiun  by  making  the  tnci^^ion  vbrlioaT-or  eemthtnar  inetvad 
of  traoBverse,  but  the  method  above  ileecnbeil  is  that  usually  preferred. 

Afl«r  colotnmy  two  com pticnt ions  are  not  un<>ommonly  met  with,  contnic- 
tiun  of  the  wound  and  prolapsus  of  the  gut.  The  firet  must  be  treated  by 
introducing  a  cooicnl  vulcanite  plug,  which  must  be  cousinntly  worn;  th*« 
•econd  bv  a  properly  constructed  pad,  secured  by  an  elastic  belt. 

The  OLUSM  of  deimh  after  colotoniy  are  usually  exhaustion,  seplicflunii. 


INGUINAL    AND   LUMBAR    COLOTOMT   COUPABEU.     825 

peribmitis  from  wound  of  the  membraDe,  and  occaBionally  secondary  peri- 
tODitis  fnim  burrowhifr  of  pus  in  tlie  subperitoDeul  fat  towarda  the  iliac  fossa. 
Comparison  of  Littre'i  and  Amniiat's  Operations. — AVIien  we  compare 
IIm  di^rent  operatiniis  that  have  beeo  pn>|M>sed  fur  the  formation  of  an 
ntifictal  anus,  it  wilt  be  seen  that  Cnllinen's.  as  modifi(;d  by  Aniussat, 
pRNOts  the  great  advantage  of  not  Implicating  the  pcritODeum,  aad  the  risk 
of  peritonitis  is  thus  avoided.  The  danger  of  death  from  this  cause  in 
Littre'a  operation  does  not  seem,  however,  to  l>e  so  great  ait  might  have  been 
■oppaeed,  and  its  advocates  claim  for  it  the  advantages  of  l)eing  a  less  severe 
opention  and  of  placing  the  new  anus  in  a  more  convenient  eitnation,  as  the 
Mtieot  is  able  to  cleanse  it  himself  Also,  when  the  o|>eration  is  performed 
fiirciin;.'cnital  absence  of  the  rectum,  Littre's  is  said  to  be  pri'feriible,  as  being 
mnch  leee  difficult  and  more  certain  to  reach  the  gut,  which  ia  often  in 
infiotB  attached  by  a  long  meso-colon  in  the  left  tuin.  It  is  said  also  that 
tlierisk  nf  peritonitis  in  Littre's  method  is  less  than  when  the  peritoneum  is 
•cdrjentally  wounded  in  Amussat's  operation,  aa  the  uniform  pressure  of  the 
nierior  abdominHl  wall  tends  to  prevent  the  entrance  uf  feral  matter  into 
u  tfceravity.  The  fact  that  the  sigmoid  Hexure  ia  so  often  the  seat  of  the  dis- 
cue  Id  mali>;nant  stricture  is.  on  the  other  hand,  a  very  strung  argument  in 
&Tiirof  AmuFsat's  0[>eratiou  in  all  such  cases. 

0»ar  Hawkins  has  collected  and  analyzed  44  cases,  in  which  an  artificial 
■nnvRs  formed  by  opening  the  intestine;  in  17  nf  these  tlie  artificial  anus 
«i>msde  through  the  peritoneum,  and  in  27  behind  that  membrane;  but 
fiif  various  reas4jus,  which  are  stated  at  length  in  the  i)aper,  Hawkins 
eidades  5  of  the  oase.i  of  peritoneal  section,  leaving  only  12  to  compare  with 
26  cases  of  o{>eratioD  behind  this  membrane.  Of  the  former  he  finds  that  7 
Jitd  and  ')  recovered  ;  the  recoverii*  amounting,  therefore,  to  only  forty-one 
pTcent.  in  the  cases  of  this  category;  wliilst  of  the  2(i  cases  where  the  peri- 
tooetim  was  uninjured,  10  died  and  10  rectivered  ;  the  proportion  of  recov- 
«iff  in  the  cases  <if  this  category  amounting  to  sixty-one  per  cent.  Though 
tlK  targe  intestine  was  opened  in  all  these  ciises,  (he  o)>eration  whs  {>erformed 
Mthen^/i^  side  in  10  iniitances;  in  4  cases  the  right  colon  and  cecum  were 
^tif\  thmuch  the  peritoneum,  and  of  tliese  all  died  ;  whititt  of  the  remain- 
•■ftB.  in  which  the  right  colon  was  opencfl  behind  the  peritimeum,  4  re<'OV- 
•f*!-  The  prefereuce,  therefore,  as  Hawkins  ohservet",  cm  the  right  side,  is 
wtaiiily  due  to  the  lumbar  operation.  It  is  remarkiilite,  however,  that  in  the 
pi*Mli"ii  un  the  fcfi  colon,  the  resulta  are  sotiiewhat  different ;  for,  of  8  caaes 
IB  vhich  this  intestine  was  opene<l  through  the  perit<mi'um,  5  reitu'ered  and 
^ffied;  whilst  of  'Hi  can**?  in  whivh  the  lumbar  <i|>eratiun  was  porformed,  11 
••wvercd  and  !i  died.  Hawkins  observes,  that  thf  ine<)ualities  of  the 
■"inbrre  ajipf^ar,  however,  to  leave  the  i|uestion  as  to  the  nm<le  <if  tuierating 
*1  tiie  descending  colon  still  unilecided ;  and  that  an  o|»onu<ir  is  jiitiiitii'd  in 
"'^ting  whichever  situation  he  thinks  best  for  the  t'orniation  of  an  artiRcial 
•"'isitn  the  Itft  side  of  the  body. 

Van  Krckclfus,  who  hac  rolli'i-ted  2))2  cases  of  cnlottmiy,  confirms  the 
^PiDiim  exprewed  by  Hawkins*.  ( >t' the  2fi2  casps,  Iti.j  were  jH-rformed  by 
^nuitaatV  iiieth'xl,  and  of  these  )!:{  died,  about  .'W  ]>it  cent.;  K4  were  [ter- 
■^•Tned  by  Littre's  niethinl,  and  of  these  '•'.*  died,  or  about  4(i  per  cent.  In 
■**  remaining  ciises  the  method  of  operating  w:m  nut  reronled,  (  H'  the  2)>2 
^•ea,  110  were  fur  cancer,  4!»  fur  striciurc,  44  fur  impcrfurate  an»«,  4.'1  for 
'**t»linal  o1).-itnirtiun,  an<l  Hi  lor  tistulmis  upcinngs  t'runi  the  rectum  into 
J^iphiwiring  puwages.  The  ililliTfiirf  in  liio  niurtality  ic.  therefure,  nut  great, 
^*lt  yet  U  dirtincllv  in  f'nvur  nf  .Vmui'MitV  upi-nitiun.  i  )f  thiw  cascf  in  which 
^'^th  has  resulted  from  Aniux-iit's  u])friiti<>n,  a  large  propurtiui)  Hp])CHr 
^  have  Utn  due,  not  direi'tly  to  the  upcratiun,  but  to  the  influence  of  the 


826 


OPKRATtONS   OK   THE    ABDOKIXaL    VISOSSA. 


frrcvtouB  diaeue,  the  uporntion  liaviog  oecASumftlly  boi- 
ut  extraniity.    We  shoiiUi.  thprHore,  have  Ims  hwdi" 
»xLra|>«ritt>nenl  uiiumtK^ii  iu  ttii  mrlv  B(Hyeuf  th>>-- 
fur,  DiHii  u'u  hIuiuIiI  if  lliv  veotiun  itot^Jt' were  aUf^'  i- 
tbft  pMtiviiL's  life. 


CHAPTER     LXIV. 

TAPPING  TDK  AllDOMKN— OPERATION'S  ON  THE  A8DOMi3l»t. 
VI80KRA -TUMORS  OF  THB  OROIN. 


TAPriNC  TUB  ADDl>UE!i.      fARAORSnTDilB  ABIKUIIKtl. 


ijiai.         I 


i'ui:  aMomen   often   nsiuim  Tftpping,  either  for  (rvoerml  mt 

ites.  This  uper&ti<«,  which  is  one  of  the  simplMt  iu  tui^rr,  miT  bs  )K^ 
formed  as  follt>ws.  The  bladder  having  bwD  empLied,  the  psitJeol  inttid 
OD  the  edge  of  the  bod  or  of  a  Inrce  chair,  or  if  very  wesk  lia  oa  llit  *i^. 
and  has  a  broad  ttanncl  roller,  splii  st  each  eod  to  wiihio  eii  iDcbs4f  lh* 
middle,  paaeed  round  ilie  Ixxiy  in  Mich  a  way  thai  ibe  iiDtum  ptrl  f**** 
the  fruot  of  the  abtluiuen,  whiUt  the  eudu,  which  arc  eruMcd  Dibii»(l,*>* 
given  to  an  a^sistuut  on  oaeh  aide,  who  luiut  draw  tightly  utKin  then  n  tb 
water  flows.  The  .Surgeon  then,  seutiu^  hiiuaclf  Mure  the  padsM.  tail 
haviog  aacertaioed  thai  there  ia  abaoluiH  dnlnen  at  thi.-  (Mtiut  at  abicbht 
iateoJa  to  operate,  makei  a  amall  iucisiuu  with  a  Hcaluel  intu  the  ntfisJ  iw 
abtiui  two  iaobes  below  the  umhilieu^,  unJ  LbmuKh  itiL-  »|M-ntaf(  ^oi  wt^ 
he  tbrusu  the  t/ocar ;  ai  thv  ttuid  u*cfi|M7(,  tht-  |ittiit-iit  ofiej)  h«ci>nM  U^ 
bul  this  may  commonly  be  guar<)ed  Axntiisl  by  coiitiiminfi  ti<  draw  Bynatll* 
baudA(>;o  so  as  to  keep  up  ^ikhI  pretuure  iu  ihf  aliddrticti.  Aflmlflh^ 
duid  huM  escaped,  the  aperture  tnuat  i>e  elooed  with  u  otriii  nr  <  '-^ 

atipporiMl  by  a  pad  and  banduKe.  or  a  pnul  of  iodoform  or  -  i  *>^ 

CDVcrt^l  with  collodion. 

The  inciuud  through  which  the  trocar  ia  thrust  miul  oi>t  i-xtr-r  ili.' 
neuru.     The  trocar  itself  must  be  uf  full  aise,  with  n  *■  jU< 

Sometiuies  it  is  c*)uveiiie»t  to  hairv  >me  Ktted  willi  a  s(oi>i  1 

which  a  vulcanixeil  ludia-ruUber  tube,  a«  repn-wnted  i<  >'tt, 

may  be  ndnpteil,  hy  whtcb   ihi*   lluiil  is  rarritv)  quiellr  uno  nitO'iii  «i<i: 
iug  into  the  fMiil  ilf«litie<l  Iu  receive  it.     •Should  the  parlitular  -Miwlttrii 
the  apcutuiilnlioii  of  lluid  iu  encysted  sscilttv  nut  allow  it*  wttbdmwal  liy 
aperture  ImIow  tlie  umbilicus,  the  abdomro  may  hv  Lnppttd  iu  any  other  flMl 
veuti-tit  fii(unli»»,  exci'pl  in  the  oHirw  of  lh«  vpiiruLric  veaaela. 

Aseitiu  duid  uiny  w  remuvt-d  also  hy  the  arpintt'ir  b'.tt  in  tlie  a' 
tbii'  iriMtrumenl  preseottt  no  advantuiivs  o%*er  ii-lrrirar. 

li.  SduiIu-v.  believiijg  that  a  gradual  win  id  1»  mmm. 

TantHgf'oua.  avoiding  the  risk  of  synctoiM)  and  theoeLvwity  of  haodafiac 
patient,  haa  devi«eil  a  staall  "  drainagulrucar,"  which  uii  b»  MV  i« 
the  ilistflntiuti  is  relievvl,     The  Quid   fl»ws  sieadlly  from  it  ai  lb*  ru»i 
from  ten  to  twenty  ounces  ]ter  boiir.  through  a  fine  India-ruhUir  tuV,     TK 
rnethud  of  relieving  aAciisa  has  been  found  very  eHica«rii>aA.     It  ha«  Dv  t« 
denoy  to  set.  up  peritonitis,  and  is  almixst  paioleas. 


PORT20X8  OF 


rTRSTlNK. 


8-27 


itfutiovAt.  OP  i>oRTroirs  op  toe  ixtibtinb. 

The  operntiou  of  removal  of  a  portioa  of  the  iatcetiue  for  diwue,  or.  as 

it  is  UrntiL-d.  Enterectomy,  or,  if  [fcrlVirmod  un  Lhu  oolon.  Colectomy,  wus  first 
atlompUvl  iu  I'fiiii  liy  KL-yliiird.  Thr<^«  iiichfx  of  ihe  noUm  were  rpiiiiived. 
iht'  ilivt^Ifl  t'tiilH  iiiiilMl  by  tiutiirc,  uihI  tliu  putiL-nt  reuavvrfd.  In  l>S'i6 
Di<-tleiiliu<'h  removifil  a  gnn^renoUH  purtiot)  nf  the  iiitCHtiiio,  ami  sutured  the 
enils  of  lh<>  }{Ut  Aiiroi^tisfiiUy  in  a  cuao  of  Htr»nj;iilHtR<l  heriitii.  Kxcielou  iif  a 
pEirtton  nf  the  intJMttne  remBined  on«  of  the  ciirxmiii'me  of  surgery  till  within 
the  laat  f«*w  years,  Hurinj?  which  ic  hiis  hern  freqiienlly  performwl  liy  Gue- 
scDlinuer,  Cxerny,  Billrulh,  Madflhing,  Juillaril,  ami  mnny  other  contineutal 
SurffeniiH;  and  by  Rryant.  Marshall,  Trevea.  and  others  in  this  cmintry.  In 
1882  JIadelung  collected  8S  cosc-4  in  which  (he  inltstine  had  been  iiniled  hy 
auture  lifter  complete  division.  witK  or  wilhoul  removal  nf  a  digeaaed  portion. 
Seren  of  these  were  accidental  wonnda,  and  of  these  three  died,  and  in  one 
the  mull  was  mu  n>corded.  In  41  it  v/fnt  undertaken  for  ^aiij^r«ne  of  the 
;rut  ID  ^tran^iilaled  hernia,  and  of  theoe  2:1  died  ;  in  three  for  internal  stran* 
jEulalion.  and  all  these  died;  in  22  fur  thf  cure  of  artificial  anus,  with  8 
death)! ;  and  in  ■)  fur  tuinon*  of  the  |rut,  with  3  deaths.  The»c  iitatiaticft 
well  illustrate  llie  natort*  of  thv  casea  in  which  Ihia  operation  ha*  bwn  un- 
dertaken, and  the  dejiri^;  of  succeea  that  haa  att»'nd*?d  i(.  The  caaea  of 
tumor  m<wt  adapted  for  removal  are  annular  papiiluinatu  or  columnar  epi- 
tbelioniaia  of  the  great  inlveline,  betlire  they  have  forrned  counecliona  with 
Mirruumliu};  parla,  Huch  tumurM  may  oft«u  be  rec<jgni«»l  by  the  (tytiiptonia 
of  stricture  and  by  feeling  the  growth  tbnmgh  the  abdominal  wall.  Tumors 
of  the  email  iutcsline  are  extremely  rare,  and  oould  acarcely  be  diagntwetl 
by  external  examination. 

The  syrugitcniB  of  the  various  conditioDs  railing  for  entereetotny  bnve 
already  been  sufficiently  described,  and  it  retuaioe  here  only  lo  {rive  a  brief 
description  of  the  operation.  If  enlercctomy  is  U>  be  perfiirmed  for  arliti- 
cial  anu)>,  the  pniienl  must  be  prepare*!  l>y  a  few  dayt*'  Vimilcd  diet  and  nn 
aperient,  followed  by  an  eneinn  to  enipiy  L}ie  bowel  iinmediaiLdy  hcforc  the 
operation.  In  other  cases  this  is  impoasilile.  The  jiciieral  dinclionH  jfiveo 
on  II.  737  ni»Bt  be  carefully  attended  to.  Tlie  patient  imist  ho  thoroughly 
imaer  the  itiflueure  of  the  aDa«Lbetie ;  complete  relaxation  of  the  ahdomt- 
nal  walls  iK-ing  a  great  a^Histanco  to  the  Surgeon.  Tht:  incisimi  must  bo 
made  according  to  cireumBiaucua.  In  coBea  of  tumor  it  is  most  conveniently 
p!ace*l  over  the  growth. 

The  abdnmco  having  liecn  opened  with  all  antiseptic  precautions,  the  part 
of  the  intestine  to  be  removed  must  be  drawn  well  out  so  that  not  only  the 
diseased  part  but  two  or  three  inches  of  the  healthy  bowel  on  each  side  may 
be  clearly  in  view.  A  flat  carlKilizcd  sponge  may  then  be  placed  in  the 
abdominal  opening  to  prevent  the  pnntrusion  of  any  more  nf  the  intefitine. 
The  part  of  the  gut  that  has  been  drawn  out  should  then  be  laid  on  a  clean 
linen  rag  moistened  with  some  warm  anili^eptir  solutinti.  A  sfdutiDii  of  car- 
bolic acid  {\  in  40;  will  be  found  the  mimt  effictont,  and  will  not  caus^  any 
irritation  of  the  gut.  If  these  precautionn  are  carefully  taken,  should  any 
fecal  matter  escape  on  dividing  the  gut  there  is  no  danger  of  iid  entering  the 
peritoneal  cavity,  an  acciflent  wldch  uould  very  probably  be  fatal.  The 
next  step  is  to  apply  a  clamp  about  two  ioi'lies  distant  on  each  side  of  the 
piece  of  gut  txi  be  removed,  partly  to  restrain  hemorrhage  and  partly  to  pre- 
vent a  copious  escape  of  fvcti,  A  |»air  of  )K)]ypU6-forcepe.  sheulhed  with 
pieces  of  drainage-tube,  will,  in  the  al>sence  of  a  special  instrument,  unawer 
the  purpose  very  well.     An  India-rubber  ring  may  be  put  ruuud  tbe  huudles 


828  OPBRATIONS   OS    THE    AUDOUI>'AL    TiaCKRA. 

to  beep  tbem  elided.  The  pioa  (tP  gut  U  chirn  cut  awajt  knCWMD  tW  i 
Id  tbe  cum  of  email  intrattne,  a  V-«hape>l  piecv  of  iha  nvMoWrr  U  m 
with  it.  Ajiy  fece«  that  wcape  muBl  m>w  be  woiliod  awar 
Ihnrouglily  cleaned.  Lintli  inside  bikI  out.  vilh  an  nattavptic  - 
bleeflins  i*  tb«u  iirre^teil.  nniJ  the  sutures  introilijo^l  in  th<MDaoD«r  <U»rrW 
at  p.  432,  vol.  i.  It  iti  now  geoemllf  agreed  tbnt  tiav  silk,  iolroJondvitl 
tll«  fioe'Bl  poaaible  oeolle.  U  the  best  form  nf  aularo.  It  tliwiliJ  hav*  Wi 
previtiuslj-  reoJered  tbomughly  asoptic  Ctfray  reoommeDiIi  bnilifli  it'« 
•onie  timeiQ  a  6  per  c«ut.  aolutloa  of  carbolic  acid,  but  linply  snakiii;  a 
the  ft»luli(iD  for  tweaty-fuur  hour?  is  pracucully  ijufficicnt  It  U  twDnb 
introduce  all  the  sutures  before  tighleuing  auy.  T«  ovcrcomo  ibr  difoiltt 
of  picking  up  the  ««roiis  nod  muaculnr  contit  odIv  in  the  oilUpsNl  UilMiii, 
Treves  has  invented  nti  TodiA-rubber  canifMiQ,  which  can  b«  intrndtMid  oto 
the  two  cridsaud  diaiendcd  with  air.  After  all  ihr  stiiclioi  hare  ban*' 
trotluccd,  but  bAfore  they  nro  tightened,  it  can  hi?  ulbiwed  to  enllapie-  airl ii 
then  easily  withdrawn.  Thesiitchra  having  been  tijrhwned.alinr 'tfwnw" 
bcflrrifNl  alimg  thr  V  !<ha|N:d  alit  in  the  raeaentcry.  if  it  be  entail  tfllnaa 
that  is  hfing  removal,  lest  an  ajterture  be  left  which  ini;;bt  n'wr  rtv  B 
internal  bernin  frnm  a  coil  of  j;ut  slipping  thrimgb  it.  The  r-lamiM  Am  lin 
reniiivcd.  The  gut  may  then  be  kept  out  uf  the  ahdoineu  fnr  a  niuiH  i 
two;  and  ahutild  any  feces  pam  inlii  It,  it  must  be  ejtrefally  cxi 
any  leak.  If  it  be  perfectly  light,  it  is  carefullv  rlraned  and  pal 
the  ahltmen.  In  cates  of  operation  for  artiSnal  anus  nr  ifanfi 
In  hernia,  tbe  external  wound  niay  have  a  drain  age- tu  hi*  inwrl'^^  ;  lai 
it  may  bfl  com[)letely  closed.  In  any  ea»e,  an  nniift«ptic  drvMiii);  i>a|i 
In  aomc  cases  of  tumor  of  th«  bowel  the  patient's  (nmdtlion  w  ludi  I 
ia  imiiOMtble  lu  submit  him  to  an  otiemtion  lasting  aftrn  an  h'>tit  uit 
half  to  Iw-i  hours.  The  tumor  miiy  thvn  lx>  remitvttd,  and  ih«*  trut  hr»«p( 
out  111  the  wound  su  n.*  to  firm  an  arlificinl  niiiii*.     Tliin  ■>  ^m  b*a 

performed  by  jJryani  an'I  Marshall.     Bryant  6  patient  sm  -  -ij  wii 

good  bcalLb  a  year  ailur. 

EXCiaiOir  OF  TUH  rTi^OBt^. 

Tlie  pfMsibility  of  reaorin;^:  the  pyloni.''  ftr  canr^er  wu  Irat 
Billroth  in  1877.     Gimenhnuer  and   V.   Winiwarter  eubwrnwt 
mentally  d4!mon<«lnLfed  the  piHsibility  of  reiuiiring  pirtiom  of  lltr  itim* 
from  aui'uals.     The  tlrtt  operalinn  on  the  human  snbjwH  was  p-*'' 
P(:an.  who  removed  the  pylorus  in  1H79 ;  the  patient  h  iwenr  - 
Ave  days.     In  1880.  Rvtyi^ier  rep.'ated  the  oporatitin,  but  i)i"  j  i 
in  a  few  hotiri.     In  188 ),  nillrolh  p'^rformf'd  tbe  firat  auc<'-->>>ui 
The  patient  w.n  a  wo;nin  ai^e  1  4:1 ;  lihe  mide  an  iinlntfrnipu- 1  ri-.Mll 
eat  a  iiiiitton  cutlet  with  the  beat  appetite  on  ih*-  (wcntirih  d<ir  i 
operation.     The  patient,  however,  did  f  lur  tn-nr' 
cancer  of  the  peritoneum  ani  retroperiloin''al  lyn', 
linn  hiw  «in<v  been  repPiitcd  io  a  coniidernble  numbor  uf  caM«  by 
V.  Winiwarter,  and  othiira,  with  n  fair  aomunt  of  succaH;  bat  tbf 
■talisHcs  have  not  yet  been  onll©cte«!, 

Thi?  opprntion  is  practicable  only  in  oawa  in  which  tho  nrtr.nu  his** 
formed  such  adhesions  to  the  surrounding  part*  m  to  prev*  ■  ■  ;  ^**^ 

completely  fnim  the  wound.     Biffore  tht  opcmlion  th"  ••  ' 
fineil  Vi  liquid  food  for  iome  days,     (mn^liatelf  1' 
iComach  most  h«  thoroughly  cleaned  by  mmns  nf  tb<:  ri'xiia.-n  j 
tepid  water.    The  incliinn  through  the  abdomioal  wall  mail  bt 
or  nenrlj  ao.  In  direction,  placed  over  tbe  tumor,  ■nil  Aw  MMgh 


ABSCESS   OF   TITB   MTBR. 

tlie  parts  tlioroughly.  lu  Billroth 'b  {'asrit,  the  txtrniul  wound  km  four  to 
five  iuohee  iu  kuglli,  rrtwbiug  lht<  iiiidclle  litie  atmvB  the  umbilicus.  The 
grvat  aiifl  (-iiinll  itnivntuiii  iiiu»t  be.  carflutl)'  iieiiuniUd  Ironi  ihe  |>frrtB  to  b« 
Kiuuved,  all  ))leeiliu^  vn^stln  lieing  tieil  as  divided.  The  i)yluric  part  of  the 
Mumacli  IB  ihtn  drawn  Irniii  the  wound  and  laid  i»n  a  carboliz^^  cloth  or  a 
flat  ti|M)iigf,  the  fliitiDequent  steps  of  the  operation  being  conducted  outt>id« 
the  abdomen.  The  Btoniiich  and  duorifiiiim  are  theu  cut  thruugh  with 
soisBors.  Alter  enrh  stnike  of  the  Bci.°sors  any  bleeding  point  is  Mt-ured. 
Before  dividing  ihe  dnorlennin,  n  lew  threado  tnu.^t  tie  parsed  through  its 
seruuB  and  miiitnilar  conis,  li'&t  it  slip  )>ack  into  the  cavity  uf  the  Hlidomeu. 
The  stomach  in  then  filled  to  the  diiodenuni,  by  the  reiiiovnl  of  a  V-^baped 
piece  of  its  walU,  either  in  the  greater  and  leeeer  curvature,  or  at  oue  aide 
ooly.  Finolly.  the  duodonum  and  the  atomach  arc  united  by  euturca  iii- 
sened  as  nlreadT  desrribed.  the  eloniach  returned  to  tlie  abdomen,  and  the 
wound  closed.  The  operation  takes  from  one  tu  two  hours,  and  liliy  to  sixty 
sutures  may  be  required.  .Success  depends  upon  attention  to  autiseplic 
details,  and  pr*v«utiun  of  tliK  eiicaiM!  of  any  of  the  intestiuat  contents  into 
the  abdomen.  In  the  alter-treattiitnt  uo  food  ia  allowfd  by  the  mouth  for 
two  or  three  days,  the  patient  being  sujtported  by  DU(rittv«  eoeniata.  Bill- 
roth sllowe'l  his  caee  w'^ur  milk  ou  the  third  day. 

In  a  caoo  in  vrhich  the  opemtiou  was  attempted,  but  fbuud  to  be  imprac- 
ticable, V.  Winiwarter  ingeni'iusly  perfornitd  rii  operation  to  which  he  has 
given  the  name  of  yaa(ro-enfrT<j*tomtf,  It  cnnsieta  in  drawing  up  tlie  third 
part  of  the  duodenum  and  establiehing  a  helulnus  opening  belweea  it  uuii 
the  great  curvature  of  the  etomach.  lu  the  tint  case  it  was  auccecslul, 
and  gave  great  relief, 

OPRBATIOKH  OS  THE  I.IVER. 

BufKical  proceduret  on  the  liver  are  required  for  Ihe  relief  of  abeceeses,  for 
the  cure  of  hydatid  cysts,  and  lor  eotne  aS'ectiona  of  the  gall-bladder. 

Abscess  of  the  Liver. — At>acesses  uf  ihe  liver  may  be  multiple  or  eingle. 
Multiple  ttbeceiweK  are  usually  the  rexultof  pyiemia,  and  admit  of  uo  eurgical 
treatment.  Thv  aingli^  abscciw  generally  uccuniiii  jiaiietits  who  have  lived  in 
tropical  regions,  and  h  cuueetjueutly  uHeii  leruied  the  "  tropical  abaceM." 
The  diagiioeisof  the  diseaisv  belongs  rutber  lu  the  phytiiciuu  than  to  the 
eurgeon.  It  will  be  sutCcient  to  meiittuii  here  that  the  chief  symptoma  are 
lever,  rigors,  lose  of  appetite  aud  bt-allb,  occasiounl  jaundice,  witb  paiu  in  the 
region  of  the  liver,  and  wmurtiniet  in  the  right  shoulder.  There  ia  ini-reased 
liver  dulnevH,  and  in  the  later  stages  bulging  at  some  point  i-:orr(.-e]!oiidiiig  to 
the  stirlace  of  tlic  liver,  (jiiher  in  front  or  beneath  the  lower  ribti  bitiiud. 
The  sliereHi,  if  unrelieved,  may  hurst  into  the  pleura,  lung,  inlesline,  or 
perit<inenm,  but  in  many  caeeti  it  points  towards  the  Rurface,  either  in  the 
right  hyntK'h<^ndriat;  region,  or  through  the  lower  ribs  behind.  ThediHgooBiB 
ul  the  ahat-ei-i«  is  iiiadi^  ceriatn  by  the  um  of  the  onpirator.  It  may  be  emp- 
tied in  lliis  way  ;  hut  ihii*  rarely  gives  more  than  temporary  relief.  In  order 
to  eftect  a  cure,  it  it<  in  mofit  ctieei?  nei-ewary  to  evacuate  the  pus  and  draiu 
the  cavity.  Tl)e  mode  of  doing  this  will  vary  with  the  depth  and  the  situ- 
Blion  of  the  absceta.  In  all  cases  il  abuuld  be  dune  with  the  strictest  onti* 
aeptic  precautions. 

^^-  According  to  Sir  Joaeph  Fayrer  it  ia  always  better  to  open  in  front  if 
^^p  nwnble.  If  the  absccas  ii  distinctly  puiiiiing  below  the  ribs,  tliia  maybe 
^~^  done  by  o  free  incision,  as  adhe^siona  will  certainly  be  present  between  the 
I  opposed  peritoneal  surluix-B.  A^  the  liver  substance  is  cut,  there  ia  a  moat 
I         alarming  gush  of  blood,  but  this  toon  tiope  if  pressure  be  applied  by  meant 


830 


OPERATIONS   OK    THK    ABDOMINAL    VISOERA, 


of  B  sponge.  A  Itirge  drain  age- tub«  mnst  tti«u  b«  inwrted,  iBd  tb«  a* 
irealeil  mttiseiiticully  iti  the  sBiiie  way  u»  any  other  abtco^  W  Hie§ium 
p(iiiit  hchitid,  iiniler  the  luwer  ritiA,  it  mar  be  orr^FMirT  ti>  itrkiTc  a  fanm 
of  ot)i;  of  Lhc.  rilu  lo  admit  a  (Inttnagc-tuue  of  BulHricnt  siic.  Iflte  afaaa 
be  d<>Pp,  and  indicated  mt?iv)y  Ity  hulginf^,  without  evidrnt  pniaii>p,aft» 
incidion  cnnuut  l>c  HBt'ely  made.  A  largo  tnxmr  mmy  ihen  bo  uunrflfli 
■nd  lell  in  lor  a  tew  days,  being  replavtii  by  a  drmiDag«>iabp  ■■  sMialta 
track  is  eufficiently  fstahlinhetl.  If  the  punctnrp  ia  mnrte  in  frunt,  iui 
peritunitia  ni»y  ensue  it'  no  adliesiuna  are  pmrnt:  to  avoid  ifaii  dacw. 
Vuiknuinn  reci'mracnds  thiit  the  aurlhoe  of  the  liv«r  ihould  ht  cxpflMthf 
an  iiicisioD  throii};h  the  abdominal  waW  with  antiecptie  prwaatioofc  IW 
wound  may  then  be  kept  open  by  the  inaertinn  of  a  piece  of  evfaaitc^H 
between  iti  edg««  till  ndhesinna  hnve  farmed,  when  the  ahiMa  may  be«Mr 
opened  as  above  described.  Injeoiion  of  the  abtocH  ta  Dot  iKBMiry  if  a» 
Mpdc  treatment  ti  carried  out.  but  should  this  fail,  and  the  disckaiga  hull 
foul,  the  cavity  must  be  IVequently  washed  oui  through  flie  tube  viikNM 
antiwptic  oututioa. 

Hyaatids  of  the  Liver. — A  hydatid  cyst  ia  'ry  a  fnM 

pro^rvTogive  eulargemvnt  uf  the  Itver,  reuular  or  i      i  <ini,MM«(hN 

the  BurtHv«  and  rounded  at  the  edg«.  The  genenti  health  wtfen  bat  liuAt 
there  ii  nu  fever  aad  u»  pain  until  the  turaor  reaches  u  (.'uaiHl«r«ble  tim  mi 
Caosea  Igcttl  peritonitis  with  the  furmatiun  of  adfaeniuns.  Wbw  the  laaif 
it  very  lar^ge,  BUppuratiuD  may  take  place.  Fur  a  niurv  detailed  tlewrifUa 
uf  thu  ilisease  1  must  refer  the  reader  to  works  on  metliciue. 

Surgical  interference  should  never  be  undertaken  until  the  tuaiur  nacW 
sueh  a  size  ait  to  become  n  mureu  of  ineonveDienue  tu  tht>  pati«aL  U  Mt 
doubt  uxiMx  as  tu  itK  uatnre  litis  may  be  at  once  cleared  up  by  the  iv>  Utii* 
aspirator,  thu  fluid  of  a  hydatid  cyet  resembling  uothirii^  n>  ihr  b-"ljr  rwtfi- 
cerebri>spinul  lUiid  i  vol.  i.  p.  y4i>).  The  ftdlowiug  art)  thu  rhief  mitatf 
trcuimcut  which  huve  bceu  Hdi)|)teu  in  this  dij>ea8e. 

Aruiiuncture.—HAtiy  cysw  have  been  cured  after  sinijik'  -r  rmf 

of  ncupuucturt!  needles  rcpiiitwl  at  sliori  intervals.    It»p[  ■  ilwi*^ 

e8ca[K'8  through  the  punctures  and  is  nb^orbed.     This  sin  ;  I'll  i», 

however,  very  frequently  been  followcii  by  supparntian,  !.■         :)g«2i» 

opening  of  the  cyst  to  save  the  patient.     It  is  «iid  nl*o  that  it  tuAXlttl  (* 


the  dittuhinn  of  the  parasite  through  the  peritoneal  cavity  with  ib»  i 
tion  (if  new  cysts. 

/v/rc/rWv'M  has  been  tried  In  asreral  oasM,  bat  presents  noadvantagnf*" 
simple  puncture. 

A»iiirti(ton  Iretptently  repeated  has  also  cureil  many  cai«g,  and  itfKibf* 
the  l>vt4i  iiii'suB  to  ))«  adopted  as  the  flniC  effurt  at  cure.  It  is  nnl  uan*- 
nionly  followed  by  iQltamniation  and  iinppumtiou  of  the  itpU 

InjrHivHuJ  ioaint  after  withdrawini;  some  uf  ll!*-  fltiitf  hr  tb*  aiplnl* 
doex  not  M^rm  t<>  present  any  H<U*snlA|.f«  ovrr  sir  t;. 

/'rxfinoyr  i^  ihv  cy«(  hv  nieann  of  a  cabula  itiri-  '^r  sail  W"' 

bus  bci'u  Biicccwl'ul  ill  itoiiie  ca>vs.     It  in  alwaye  followvd  by  supparstHe, ■*■ 
is  iitlrndcd  by  considerable  risk  of  |iertitiuitis. 

Oftrnini^  Om  n/ft  li\/  rutuh'oi  aa  reeommeudcil  by  K&Ainier  was  hrt*^ 
fre^picntly  adupteil,  the  oliject  being  to  form  ailhcsioiis  betwms  ibesf^^ 
surhitis*  of  iho  peritoneum  before  the  cavity  was  reached.  It  it  tc^MH*** 
jMiinliil,  and  is  now  oetdoni  adopted. 

(Jft^nintf  Uiti  rarity  aith  rrmoval  of  the  aarjthaloeotii  was  first  perli<m^  *! 
Lindeniann,  of  Hnnover.  He  divided  the  abdominal  wall  by  a  xtroai  ■- 
cision  under  antiseptic  ttrccautiona,  and  exposed  the  mrface  of  il*  1'*^ 
Tbo  wound  was  then  helu  open  and  a  number  of  fin«  salares  pavsd  ari*'*' 


3 


'ATIOH 


(B   SPLEStrT 


831 


mg  ihc  ppriloneum  tf>  tlip  akin.  Two  strong  threads  were  then  pasBod 
tliruiigh  the  crst-wall  |mrallel  to  the  edge  of  the  wdund,  by  mentis  of  which 
it  wna  drawn  well  out  of  the  ahdimien.  It  wns  then  opened  freely  hetweeii 
the  ihrcads  and  i-leaned  out  as  far  b.<>  pniijtihie.  Finally  the  cyst-wall  was 
cluKljr  spwn  (o  the  skin,  a  large  dratnage-tube  inserted  and  an  antiKptic 
drfMtng  applied.  This  operation  \v»»  recently  periormed  in  I'niversily 
0>llcge  Hijjpitfll  by  R.  J.  Giwllt*.  The  patient  went  on  well  for  three 
weeks,  when  she  died  apporently  Irnni  sepliceemia.  Vulkmann  advisee  that 
the  t>peratiuii  nhoiiM  be  jierti>niie'l  in  two  igtag^a,  the  surface  of  the  liver 
hcitig  first  expfiMKl,  llie  «t.nind  phigtitil  witli  carbolic  gauze  for  five  or  six 
dnyH  till  firm  adliesit^'nin  havtr  furn]e<l  bF-lncvii  Lhe  liver  and  (he  partetiil  peri- 
toneum, and  the  cy»t  is  then  opeuecl  nud  treated  as  nbove  det^cribed.  Fiir> 
iher  experience  is  yet  wanietl  to  prove  the  eafety  of  Uiie  uperation,  but  it 
wutild  seem  hardly  wiui  tu  adopt  Huch  aeriouii  pruceedingis  tilt  oiupler  lueaus 
have  failed. 

A  Hiippiirating  hydatid  cyst  niu»t  be  treated  in  the  entne  ^my  at  a  lirer 
abscesa, 

DibEA^Es  OF  niF.  <>ai.i^ri.adi)I:r. —  Diltiiutionu  of  tlic  gttll-bludder,8unie- 
timea  of  very  great  aize,  aro  ot-oBBionuIly  met  with  as  lhe  re«itlt  of  impaction 
of  a  gall*8toiic  in  the  cyhtic  duct.  Ah  the  iuipartioii  lakes  place  befnrv  the 
juncLiou  of  the  uvBtic  duct  with  the  hepalic,  there  ia  no  jaundice,  and  the 
fluid  dUlending  the  cvBt  lannt  colored  with  bile.  Inipaciiun  in  the  vi^minoii 
bile-duct  if  unreliovt^d  ia  fatal  before  any  great  dilatnlimi  lakes  place.  Jn 
some  ca«%  the  distended  ^ill-blactder  hag  been  known  to  inilamc, nuppumte, 
■nd  diachargo  exlprnaily.  leaving  n  fistulous  opening  ihrini^^b  uhii'h  gall- 
■toDCa  have  been  discharged.  Nclatun  advii^ed  ihiil  this  should  he  anttci- 
paloi  hy  (i|>eiiiiig  the  gaM-hlndder  by  means  of  caustics,  and  slaleH  ihat  he 
jxrrtornied  the  operation.  Handfit-ld  Jriucs  suggested  that  the  gall-hladder 
might  be  opened  and  ihe  obstructing  calculus  removed  from  within  it,  and 
Marion  i^ims  was  the  first  tn  perform  this  operation,  but  without  euccesa ;  in 
IKTfl,  however,  I^wson  Tail  «ticcc*afully  accomplished  the  removal  of  the 
impacted  gall-stone,  aud  tlm  patient  made  n  rapid  und  complete  recovery. 
The  diiignosiB  of  distended  gull-bladder  is  not  always  possible.  It  is  ueuaUy 
freely  movable  except  at  iu  upper  attachment,  and  may  resemble  a  renal 
lumcir.  The  operation  'n  jterformed  on  the  same  plan  as  that  already  de* 
ecribed  for  the  removal  of  a  hydatid  cyat. 


EXTIRPATION  OF  THE  SPLEEV. 

B.  Cred^,  of  Dresden,  has  collected  30  cases  iu  which  this  operation  has 
l>ecn  perfbrnied.  In  16  the  operatiuQ  was  undertaken  fur  the  enlarged  spleeu 
of  Iveucocylhirmia,  and  iu  every  cate  it  was  fntal ;  in  9  canes  lor  aimple 
hyperlropliy,  aud  of  these  4  recovered  aud  5  died ;  in  2  for  cvsts,  both  re- 
covering; in  i  tor  a  movable  or  fluatiog  spleen,  both  succeaaliil,  and  in  1  fur 
"tbc  spleeu  lying  in  a  peritoneal  abscess,'  also  succcaeful.  Tbew  elutistics 
show  that  exciMoa  of  the  apleeu  is  nut  justifiable  in  leucocythiemia,  and  that 
in  otlivr  caaes  one-third  of  tlie  patiems  die.  The  operation  presenis  nothing 
special.  The  tuioor  is  cxpoHcd  hy  a  free  incisiou,  abd  isolated  from  sur- 
rounding puru,  its  pedicle  bciui;  Bt:cured  by  ligature.  If  adbeeions  exist, 
the  splenic  eiilLitance  Is  very  liHcly  lo  ho  turn,  un  accident  which  is  accom- 
panlixl  by  fearful  hemorrhage,  which  hue  in  several  caaea  been  the  immediate 
cauae  of  death. 


832 


DISEASES    OF    THE    CKBILICV*. 


DISEASES  OF  THF.  UMBIMCTS. 

UlceratioD  of  the  H&taI  is  occasioually  moi  witli  aAer  ibe  si:|HnUi« ^^ 
the  conl  ID  at:w-b(»rn  cliildr«n.     Il  muiit  bv  trvaled  by  deaulinw 
applii-aliou  of  wime  ciniple  oinlnienl.     la  adulu,  raiMrciBlly  mtuv 
an<l  tiiicle4iDly  in  iheir  hnbila,  ecZi'iiiK  fulloued  by  iileeruiiitu  if  n»t  lun.--^- 
moD  in  vlie  ouvel.     It  must  be  tri-uUMl  by  syriu^^iug  nitfa  bfiradr  meni  Lam, 
and  the  nitplicatiuu  of  boravJu    acid  aiuiiiteiiu      !»uni(>tiriut  a  pnmmm 
futi^liiig  mass  ol'  granulatiotis  may  funii,  «h!rii  requim  dt»lruni<'i'  «i^ 
nitraic  ut  silver.     8<)ft  and  hard  chaQcrv*  liuve  be«u  met  witb  at  iti- 
aud  a  puriiletit  diaebarge,  rtsuttitig  fruu  guaorrbiual  uilcctiun«  ii  s^.  - 
have  Wcu  obrii-rved. 

A  W&rty  Orowth  U  occuloaally  oirt  with  in  childi«n  »|iria|pog  buaik 
hollow  ot  ilie  umbilicus,     ti  is  best  removed  by  li){flturc. 

Epithelioma  of  the  Navel  ia  a  rare  diMawi.  HtiouM  it  occnr,  the  ts«« 
must  ba  rviintved  frf«ly.  il'  tiec«wary  opeuing  tlic  abcltwioal  oatiiy  lai 
cIooIdk  (lie  aperture  by  lutum. 

Umoilical  yutvlm.—J-'ecatfietuia  at  the  umbiliciw  may  ari»r  from  ttnn^ 
latioii  »ud  sloughing  of  an  umbilical  hernia.     They  an 
con){euititl,  resiiliinK  cither  from  a  |>rotruBiun  ut'adivcn 
ileum  or  of  a  portion  of  the  smnll  ititcatioo  into  the  cord  bimI  ita  awakiMi 
ioclusioD  in  the  ligature  at  biitb.    In  othtr  cases  tbey  artve  from  prrt-niia 
of  tbe  small  ioteatiae  by  chronic  ulceratiun,  usually  tubvrcvlar, 
forniatiuo  of  a  circumacribe<l  Bb«ccss  aaiuugsi  the  coila  of  tbc  int'~>  " 
disuhargiug  at  the  navel.     The  creadneDt  of  tbcM  fistals  b  ' 
BaListkctory.     Tbe  application  of  Ibc  cautery  to  the  urifin  ia  'li  < 
aod  pla&liv  op«mtiou«  almost  invariably  fail.     If  tbc  dijiiaae  «iut»  r 
much  trouble,  it  ia  better  treated  by  the  applicailuu  of  a  |i«d  asd  hmo-.^ 
to  cleauliucM.    If  there  is  a  complete  artiiicml  anus  after  giu)j{r«MMib«n> 
a  cure  must  be  auempicd  by  the  means  already  dcaoribed  ia  ihi  lAaftir* 
Hernia. 

Urinary  FietuUe  arc  very  rare,  and  result  frmi  iaiperfcrt  tJ^tsoK  rftk» 
uraehus.  They  udmit  of  nu  trealmenL  BUinry  FiMuta  aUu  ban;  ben  m( 
with  1  tlicir  DiodL-  of  origin  ia  uuct-rluin,  and  they  alw  do  md  admbofta^ 
ment.  Paruleitl  FUtultr  aho  are  (U-ncri lied  by  ».itiie  wntera;  ihaeifcw'? 
collections  of  pus  usually  iu  the  abdomiuul  wall,  whivh  tuiri:  dkdtsrfJif 
the  MBvet.  They  arc  best  treated  by  enlarging  the  opening  aud  inMitioi* 
dniiuuge>tube. 

I  cannot  close  this  chapter  without  an  expreiaioD  of  n-i""?-;'-*  alA* 
great  advance  that  has  of  late  years  been  eHected  tu  all  i  tV^ 

tretLtaenl  ofdiseaMs  of  the  abdoiuinut  and  i^elvic  vitcrm  im  >u(  -i.^  ofvn- 
tioDt  and  a  recognition  of  the  merjls  of  tht«e  Surgeons  >*  ho  l^tlttT1'  a&i  i^ 
fully  have  led  th«  advance  in  thi>!  department  of  our  m'  '  '       ' 

importance  of  the  rtrsults  thus  acliieved  by  them.     iJui 
recording  my  iidmiraliou  for  the  sm-cwj*)!  tliat  hare  b*  ,  i  i-'* 

aiM  a  few  wurds  of  cnuttou  to  aapitanlit  for  distin-^tion  in  '  ^^  '^ 

practice.     I  would  venture  to  remiixl  Ilium  that  an  operatic  .  *' 

aarily  justifiable  because    it  is  pniciicabli — that  every  an  * 

audacity  is  nut  a  triumph  uf  sound  and  legitimate  »ti rgvry— 'BDd  (^  ' 
patieoi's  life  may  ponibly  be  prolotiged  ou  cuuduloni  le«  i  '  "  ' 
death. 


BKMOVAL  OF  TUMOBS  FROM  OROIN. 


833 


TUUOBS  OF  THE  GKOIIT. 

Tumors  of  vtiri<m»  kinds  may  dcvcloji  primarily  in  ihe  groin,  or  (lL>eceQd 
into  it  from  t!ic  nbdnmiMi.  They  arc  at'  the  fulluwlug  tiiii(lB;  1.  Knliirge- 
nient  of  the  Lymphatic  Glnndfi.  2.  Abswe*  hi  i>r  nroumi  tluiac  plflnila.  3. 
AbaccM  descending  into  llie  (troin  from  the  ahdoruPii^Paons,  IHhc,  Peri- 
eoec&l,  Peri  nephritic,  etc.  4.  Varix  of  the  Saplioua  Vein  at  its  euirance 
into  the  femoral,  h.  Aneurisms  of  all  kio'ts.  G.  Osteo-aneurisme.  7. 
Cystic  Tumcre,  bursal,  and  ileveli>[»ing  in  the  muscular  Mruelurcs.  8.  Simple 
•  tlid  Tumors,  as  fatty,  tilirouA,  «arooniAtrju)i,  or  lymphndea<>malous.  0. 
luligDOUt   Tumom,  primarily  ilevetoping    in  the    aolt   structures  in   this 

pna,  extending  Into  it  from  the  bones,  ur  secondarily  from  conlaniinalioii 
-of  the  glanda.  10.  Ilernife  of  ditfureot  kindt — inguiual,  fcuiora],  nud 
obturator. 

DiAfiNOsiR.— In  effectinR  tbe  diaRnoaia  of  these  various  tumors,  wc  must 
finjt  distinguish  the  pulsating  from  tliiwc  tliiit  do  uot  pulsate.  The  FulBating^ 
Tumors  must  either  be  nncuriHin^,  oetcu-aiicuri^me,  or  fAX  enrcomata  nr  nb- 
aceases  with  coiiiniunicatcii  puleatiou.  Tliu  diognoeis  nf  tfaeee  ditli;reut  t'unn'i 
of  disease  has  already  been  no  fully  given  at  pages  136  and  331,  vol.  ii.,  that 
I  Deed  not  enter  ufiou  ii  here. 

The  SToQ  pulsatmg  Tumori  nro  to  be  divided  into  two  great  clancs,  viz., 
Ihe  Hedu^il^e  iiud  tin.'  Imdticiltle. 

The  Jiedueitfe  Tumors  id'  iIil'  groin  are  either  hernia,  varix  of  the  ^nphcna 
,TeiD,  or  alxloniinal  alm-i'tw  pretjvnting  tindur  Pouparl's  lignnicnl.  The  diag- 
iQsif  of  these  ditfereuc  c'lndiliims  in  givi'n  at  pp.  13(1,  331,  vol.  li.  These  ail 
bave  ao  impulse  conitnunicated  fi  them  in  ctrngbing. 

The  Irrrdwiblc  Tumor*  of  the  grnin  have  further  to  be  divided  into  tlioae 
that  ooutuin  Fluid  and  those  that  arc  Snlid. 

The  irrtilucible  tumors  containing  Fluid  are  either  ahscpwce  in  or  aniund 
the  lyniphatir  ginnda,  or  cyatio  growths  of  vnriuun  kindrt.  The  diagn<>!<Is 
here  ia  fajty ;  the  irre^^nhir,  hardened  outline  of  glnndtiliir  aK><ceti»,  its  ra|iid 
^davelopmeut,  and  eolteniiig  from  a  previously  indurated  tilale,  uill  di«tin- 

lish  it  from  the  tense,  cleflrly  defined  outline,  sm<Hilh  ami  elastic  fw;!  (vf  the 
"slowly  developing  and  very  chronic  cystic  growth.  In  irrctliicible  Keniia, 
the  impulse  on  coughing,  the  gurgling,  and  other  peculiar  signs  chanicter- 
istir  »r  that  di-'case.  will  preveni  the  possibilitT  of  error  in  diagnnsia. 

The  tiolid  tumor*  in  the  groin  may  either  t>e  simple  or  malignant.  The 
history  of  ihe  case,  the  feel  of  the  tumor,  the  rapidity  of  its  progrew,  the 
extent  of  conlainiiiation  of  ueighboriug  part«,  ami  the  other  sigtts  that  f^rve 
as  dtniriioetic  dilferences  bftnevn  simple  and  mHlignant  growths,  will  enable 
the  fturgenu  to  efli-ct  Ibe  diagnosis  with  sullitient  accuraty. 

The  Tr&Oment  of  many  cf  tlnrse  tunions,  such  as  absce*»  of  various  kinds, 
aneurism,  vnrix,  and  hernia,  has  already  been  an  fully  considcrefi  in  the 
rarious  cliaplers  devoted  to  these  diwtwes.  that  I  need  not  enter  up<jn  it 
here.  But  the  qtiestiou  of  operating  for  the  rrmovnl  of  cy»tic  or  mtid  Utmorw 
of  the  gniin,  is  one  that  presents  several  speeial  imiiite  for  eonsiderution. 
These  are.  the  relalious  of  the  morbid  mass,  Ut,  to  the  I'eiuoral  vein  ;  2d,  to 
the  femoral  artery;  and,  :id,  to  the  abdominal  cuviiy.  If  the  tumor  lie 
up(»D  or  compress  the  femoral  vein,  '.edema  of  the  fo«vt  and  leg  will  be  the 
result:  and,  shttuld  tEie  compression  have  been  prolonged  and  very  chronic, 
tliia  (udenia  may  ntisumc  a  f>emi'8ulid  character,  so  a»  to  occasion  a  eouiiitioo 
of  the  limb  closely  resembling  elephaniiasia.  Although  an  intimate  relu- 
tioD  such  as  this  between  the  tumor  and  vein  would  obvjiuisly  inculcate  the 
neccBSit}'  fur  extreme  caution,  it  need  nut  necessarily  preclude  the  idea  of 
VOL.  II.— &3 


834      1>1SXA8B9    07    TBS    LaXGE    IHTKSTIKS    AKD   AVl'ft. 

operating  for  the  remoral  nf  the  tonmr,  «1itch  majr  jHwn)i)|-  W  itfwrtor 
aboTe  nnd  nnnlUche')  to  th<?  sheatb  'if  the  tc«mU.     1  outx  iiii— lint)  » 
Rir>v«>^I  n  tNi-voitI  and   ltp>>nial>iiit  Uininr  of  mnnT  venn*  itaiMliag.  io  i  (■• 
wliert-  thr  limli  wm  tn  ii9tai(.-<irspuri"ua(rlepl)Bnttaii»  from  onapnKi«  i(  tW 
fcmiTal  vt-in,  hut  ihi*  Tn**-)  was  oot  tDVfilveil  id  tbo  gniwth.     If  tbf  fofni 
Srtprr  l>e  crmipn-vH^l  U>  rurh  ad  extent  aa  tv  iotcrfcra  with  tiw  drwihl»* 
tlip'tigh  the  lower  part  nf  (htf  limti,  it  wt)!  ninft  probably  b«  ftwad  (1*1  tli 
ttintnr  (Itjm  iioder  i^r  Burrtmoila  the  vet««l,  wo  oa  to  render  nniwal  l^H^ 
tioMe.     Tbe   nier«  uverlaring  uf  iha  artery  bj  ■  frvely  OKinbla  ^^H 
without  aoy  TOmpnrntoD  »f  the  vt>«5«l,  oerd  not   preclade  "pnirn   4V 
growth  ti>:urvd  ou  p.  4S6,  vol.  ii.,  was  of  tbt>  kioo.     Tbi-  ouBsaetiM  tf  III 
tamnr  with  tbv  abtloniiaal  ur  pelvic  nvitira  oodcr   Potipail'i  ]iip»(il,« 
thmugh  the  ublurator  foraiueo,  muit  be  moat  earvfullj  namiaraT  Smdt 
this  exbt,  or  even  be  BtruDgly  eufpceted,  upermtion  it  oconKiil;  i|viti  imi- 
muHible. 


CHAPTER    LXV. 


DtSKASKS  OF  THE  LARGE  INTESTINE  ASH)  ANUS, 


ta 


rOSGENITAL  UALPORMATTOXa. 

CosgenlUl  HalfonnatioDs  of  the  sdw  and  r«ctum  an  b^  ba 
frc'iucut,  nuil  ftn-  of  c<<ii-tiJfnit>]v  importune*.  Tbinr  mar  exnA 
degrees,  which  Diaj  moat  coovcuieoUj  be  arraogva  ander  ilia 

Xarrowing  end  Partial  Cloatire  of  tbe  Adqb. — The  cattal  cmtiniwi  f^* 
^oua,  hut  Di't  autficti-nltv  f>  v>  allow  ol  I  lie  Im>wpN  iM-iogroRiplrtotjrMUfMA 
the  RiiitractiiiD  usually  merely  admitting  a  full-Eiied  (irobe.  loaMMff^ 
thp  olietru<-ti<in  appears  in  depend  upon  mnelriclion  uf  iba  anal  afiln* 
others  upon  an  ini|>errec-t  eeptuni  etreli-hin];  acruaa  iu 

Treatment. — Thia  conciuts  in  nou-hing  the  coulracted  aatw  wkh  •  '■•'■'■ 

Jointed  hiHloury,  and  then  iiUrndtiHiig  a  i)[Minge- <>r  Inminarta  tei 
ilnte  it  to  the  proper  at£e,  to  which  it  must  be  kept  by  the  ocrwiom-  •  - 
ducli'-ii  iif  a  hi'iigif. 

Complete  Closore  of  Antu. — The  anus  mar  be  <        '     *r  dwel  ^' 
ttienthrntintis  senium  hlreichinf;  arrow  it.  Uttaallv  hn  - :ijjht  tittt^ 

et-ntml  line,  and  n  slight  depreabion,  thfu^h  whirli  llx  ^utk  nwcuabo** 
be  ntcu,  itnd  on  uhji-h  an  irnpulae  can  W  Ml.  Thin  eonttitulo  |>cik^  1^ 
mi)»t  nmuiion  form  of  ninlfirtuation  that  i»  mH  with, 

Trratmcnt. — In  thiti  vimety  an  incision  must  l>r  ttuidv  ihruogb  tbl 
along  the  middle  line,  and  ncnxs  im  enrh  eidi*.  when   |h«  nwi**^ 
frerly  racape.     The   foor  ungulnr  fl«(w  that  arr  Irft  raitst  oirm  ht 
and  the  aperture  kept  iip»n  iiy  thv  intnHltictt'>n  of  n  wflliiited  plBJ-      ^. 

OoolniioB  of  fieetnm  above  the  Aotu  by  a  Hembrasou  ft*it»a-TV 
anus  may  remain  o|>en  ;  hut,  nt  it  dbtanee  of  aboqt  half  ao  '  '■^ 

from   i(»  ni>ert»re,  the  rertnm  will   be  found  on*ludr«l   by  •  * 

bmnoun  ofptum  ntrvtchinc  ncroH  iL    Thii*  in  a  nin<  and  Km.i  ^ 

kind  of  nialformstion,  as  in  it  the  infant  will  ba  ftmnd  to  bbur  arM<r 


ABSENCK    OF    AKUS    ANU    HBCTUH. 


885 


Unal  obetruction,  ant]  yet,  an  examiiiuliun,  tlie  aiml  orifice  wiU  lie  fnuriil  per- 


il 


^l»d 


tu  lh( 


it  of  the 


fecily  furiiieil,  ami  ttitis  the  ^ur^vmi  may 
obfltaclp.  Hi;  will,  however,  detect  it  by  iiKrnduciiii:  ii  prube  ur  tiie  end  oi* 
bis  little  lin^r  into  the  atiua.  It  cati  rmdily  litj  brou^lit  intu  view  by  iu- 
aertiiig  the  ame  epeculum  (Fig.  Gfill),  aoil  throwing  tight  up  tlie  buwel  by 
meaQB  of  a  laryngeal  mirror. 

TVwtfiftffnt — The  itperation,  of  which  the  following  are  the  details,  will  be 
Ibund  lo  hesnccessful. 

1.  The  child  is  put  in  the  Itthoiomy  position.  2.  A  trocar-canula  is  then 
1  down  tr>  and  pres-'ieil  against  the  septum.  3.  Then  the  imcar  is 
I  liown  the  onniilft  and  through  the  scutum.  4.  The  Irocar  U  with- 
rawn.  and  the  cannlti  left  in.  A.  A  probe  is  pa.'tsed  thruiigk  the  catiiilii. 
which  is  then  slipjied  diit  over  it  and  along  the  prol>e,  or  a  director 
which  may  be  substituted  lor  it,  a  narrow-bUded  pair  of  (Ireflging  fc»r<!ep8  is 
pushe<l  up  und  opcDcd  out  so  as  to  ftil&te  the  opening  to  the  septum.  During 
this  process,  the  retained  feces  will  have  cscnped.  The  aperture  inuiti 
be  kept  free  by  the  nceaeioual  iiitroductiou  nnd  expAusiou  uf  the  force|»  or 
of  a  lamiuaria  tube. 

It  is  important  lo  iib»i>rve  that,  although  the  anus  may  be  iierfectly 
formed  Miid  pateut,  with  a  canal  above  it  about  bulf  au  inch  long,  the 
rectum  may  be  entirely  absent,  the  sigmoid  flexure  terminating  in  a  dilated 
pouch  opposite  the  sticral  prominence.  lu  such  cases  it  is,  of  course,  ini|>o8- 
aible  U}  reach  the  gut  through  the  anuH.  Id  &  case  i>f  this  kind,  in  an  Jntnut 
four  dayv  old,  in  which  E  was  unable  to  reach  tbe  gut  through  the  anal 
aperture,  I  performed  hiinbar  coIoLomy, 

Complete  Absence  of  Antia. — The  auus  may  be  completely  absent,  betug 
blocked  up  by  a  dense  nniss  of  libro-cellular  structure,  from  half  an  inch 
to  an  inch  in  thicknc-^^,  above  which  ibo  rectum  terminates  in  n  kind  of 

Closure  of  Anus  with  Absence  of  Eeotum. — It  has  already  been  stated 
that  in  some  ca^.«  uf  perli.'et  tbrrimtiou  and  patency  of  tbe  auus  tbe  rectum 
b  absent,  but  more  eomuioDJy  the  anus  is  closed  when  the  whole  of  the 
rectum  i»  wanting;  the  inteetiue  (colon)  terminating  in  a  large  and  expanded 
pouch,  silualed  high  up  at  the  bnra  of  the  pelvis,  opposite  the  sacral  prumi- 
'Deoce.  A  ca«e  of  ibis  kind  ditTera  from  the  luit  only  in  tbe  extent  of  tbe 
nccluaion,  nnd  cannot,  indeed,  be  diittinguiahtd  from  it  until  iho  Surgooo  has 
made  an  incieion  in  liie  siio  of  the  nous,  and  ba^  failed  lo  reach  the  gut  at 
the  usual  dlHtanoe. 

IVeatutent. — lu  ihese  coses  the  Surgeon  must  first  make  an  attempt  to 
reach  ihe  bowel  from  tlie  perineum,  failing  which,  two  cuursca  ore  o|ien 
to  htm.  He  may  open  the  colon  in  the  lef^  iliac  l<tssa,  or  ho  may  open  it  in 
the  left  lumbar  region  hy  AmuMat'a  operation, 

1.  Perhiail  mcmioH. — The  perineal  incision  has  the  advantage  of  being  in 
the  natural  situalidn  of  the  anus,  and  of  being  easily  practised  and  usually 
succciwfut  in  all  ihnae  cmtes  in  which  the  anus  only  i»  imperfurale,  tbe  ri^ctuiii 
being  present.  In  those  cases  iu  which  therr  is  cnngcnical  ahiience  of  tbe 
rectum  this  operatiun  munt  neceitsarily  fail.  The  operation  is  thus  per- 
formed :  An  incision  abnnt  an  inch  in  length  should  he  carefully  made  from 
the  point  of  the  ciwcyx  forwanU.  The  dissection  requires  to  he  carried  with 
caution  to  a  crto^iderable  deplb  along  the  mesial  line;  and  the  Surgeon 
taking  the  curve  of  tbe  sacrum  ami  coccyx  lor  bis  guide,  ami  bearing  in 
Diiud  tbe  relations  <>f  tbe  blndder  and  large  vessels  in  the  nt^i^rhborbood, 
carefully  pruofcU  in  itt.'arcb  of  tbegul,  which  may  be  found  nt  a  conniilerable 
depth  from  the  fturfuce.  A  probe  may  be  pa^^^ed  into  tlie  urethra  of  a  male 
child,  or  the  vagina  of  a  female,  to  serve  as  a  guide  to  the  position  of  th««e 


836       DISEASES    OF    THE    LARGE    INTESTINE    A!(D    AXC9. 

cnnalx.  The  dnnf^r  of  wounding  Uie  liladtirr  mu6t  nlso  ht  camMn^ai 
may  t>e  iimtciiallv  lc8»cuc(l  hy  I'Ujjityiiig  IhiB  vtscua  by  prantng  «fmt  Ik 
puUcD  h«fitre  cuiumcDcing  itie  openitian.  I u  four  timtancvfiirf*  tkbknl« 
whicli  I  have  oper&t«<l,  it  woe  DCCCiBanr  Lu  [iri>cYe<l  to  «  dcptb  at  at  laK  «• 
aod  a  liall'  ur  tun  inclice  befurc  iho  biiwcl  wmi  rmrhfi) ;  which,  <m  toemi 
of  the  uarniwDtiisol'  ttic  nouiiil  ami  the  eiiiiill  »\ze  aoil  ttnpimBU  uliiiirf 
tiie  [xirtn,  ia  not  an  easy  mutter.  \Vh«ii  the  gut  is  iraebed,  it  niM  b  pn» 
turctl  aud  the  [iifconiutii  aUowfil  to  racajio. 

There  in  line  poitit  in  coiincctiou  with  the  i>pnnfia]  'ipormtioo  to  vbichfti 
of  much  im|Kirtaiire  fepevinlly  t<i  uticnd,  not  only  an  mprcts  the  iuMdiyi 
reeolt  of  the  <)|>rralinii,  hut  is  rp|ran]ii  the  ultimate  succvm  of  the  pmrnlait: 
I  Rifati  thp  briiiglii^  iliiwii  of  the  murniiH  nipnibrane  of  ibe  gat,  aH  fiiw il 
to  the  lipa  of  tht^  f  xtemal  woitiid.  tliilrsB  this  be  don«,  tbe  Iim  of  'aemk 
between  the  U'miinntinti  of  the  ^ut  and  ihe  Bpertnrfi  in  th«  itiiefilMUvfl 
degencrnte  into  u  tisliilounraiml ;  which,  ]ik<>all  fiKtuIir,  will  hm'teitmkatf 
to  cnDlmct,  Htiil  will  bt)  ii  snurre  of  endlpM  rmbarraflBiitctit  to  liM  fanw 
und  Uf  t)io  [tnlifot.  If  the  inucons  mcmhrniie  can  b«  brouEfat  dq*vt*a»d 
IixinI  i>»  the  opening  in  the  inie)jiimfnt.  |hii«  »ntirct;  of  inconTcniefic*  *ill  h* 
r«movixI,  and  the  patient  will  l>e  saved  all  that  danger  which  renillt  fr<a 
the  pawag?  of  iho  niecrtiiiuiii  over  n  surface  of  rocently  inciswl  arruUrliMM. 
Tliift,  ti<)wev«r,  can  l>e  done  only  «  hen  the  iDte»tiD«  lertniuat«i  at  a  sbbrt  <t»- 
t*uc«  from  the  surfuce.  If  the  perineal  iucivion  b«  tuo  or  three  incW* 
in  depth,  there  will  be  little  probability  of  the  i^urgcoD  bvio^'  able  b>  bnac 
the  intt^eline  douo  to  sMch  an  extcnL  In  ooe  cnm  in  which  1  altefitpifi  tn 
du  so,  I  found  that  tbv  gut  was  too  finuly  Gicd  to  be  reniuvcd  by  asylM^ 
UuD  that  it  would  have  htxa  aafo  to  omptoy. 

For  aoniu  considerable  time  afler  (he  uperaliuo,  the  nperturv  ahoold  Wllft 
dilated  by  nteeiie  of  bougies;  oragunj-LOaatic  or  pewter  tube,tiirDa|fcviKfc 
the  feces  art>  allowed  li>  escape,  may  be  fixed  in  llit;  [mrL 

I  have  fwveral  times o(>eraled  in  thia  nay  on  iuipvrfurale  childm:  Nlli> 
all  iustaucvs  uusucwevfully.     lu  onv  case,  liiere  «a»  an  anal  aprr     ' 
with  complete  iK!cIu»ioD  ol  the  rfvium.     I  operated  on  the  foarth  <  ;. 
Rticinptiug  to  reach  the  ^ut  through  the  anus;  but,  failing  in  Ihia,  pmurv^ 
the  luinltar  uperulJon  on  tlii>  left  aidv. 

If  it  could  be  asoertaiiKHl  before  pruceeding  to  operate,  that  lb*  nctni* 
abacut,  it  might  Iw  wiwr  to  Bcan:ii  lur  the  buwu  in  the  lumbar  or  i&a' 
region.  But,  as  the  Surgeon  has  no  bjeans  or  aacertaiaiog,  bdbra  mka( 
his  incision,  whether  the  rectum  be  one  inch  or  ihra;  iorhn  fh>m  ibeairl|n 
he  muHt  cut  into  the  perineum  iu  order  to  obtaio  the  tK<craairy  tBfiatMMi 
and  if  ouce  he  have  piuetrnled  to  such  a  depth  as  to  piM  beyoad  ihelmM' 
ani  muevie,  or  into  the  dei^p  fa^cice  in  this  situation,  &  great  p>irtiaatllW 
inimediaie  danger  of  the  o|>eratiou  will  hare  beco  incurred,  aod  (tw^mU 
think  it  ndviiuible  to  leave  the  perineal  operation  un6ui»bed,  and  rxpMvda 
child  to  the  additional  risk  of  opening  the  o^^ton  in  the  lumbar  rrgka.  ^* 
if  be  have  gone  on  deeply  us  he  dare  venture,  nnd  have  not  cnoowrttni  f* 
Uiwel,  there  is  no  allerualive  but  tu  open  the  intestine  through  fJiafththflta'' 
wall,  or  to  leave  the  child  to  ile  fate.  In  this  nltvmntive,  uwSofpM^ 
utlher  open  the  cdon  in  the  leH  iliac  region  or  in  the  Mi  loin. 

Biao  laoision. —  The  advantages  claimed  for  the  itiac  incittaa,  iir  Ub*^ 
operation,  are,  that  it  is  easy  of  perlbrmance,  and  that  wheliier  lIm  £*^ 
reach  the  colon  or  not,  he  m  certain  to  bit  upon  aoOM  part  of  the  ibl**'* 
lube,  which  may  be  drawn  forwards  and  opened.  Thm oifttHantt^mi*"^ 
that  tlie  artificial  anus  is  in  au  iDconveDicDt  ntuali'm,  that  there  u  dv^^ 
pcrilouilLs,  as  the  peritoneum  is  neceasurilv  wounded,  and  that  tht  ■if*'' 
flexure  may  not  prcseut  in  the  wound,  aud  a  portiun  uf  imall  ^a.umhm*^ 


STRICTURE— SIMPLE,  SYPHILITIC,  AND    UALI6KAXT.       887 

be  npPDed  in»tfnd.  These  olijections  ar*  not,  however,  quite  m  grcjit  ns  thev 
ftt  first  ap|>enr.  The  nrtilicial  anus  buint;  situatod  iu  front  has  thentlvRrilage, 
that  the  patient  'Min  i^nsily  pn*»  his  nioiioiis  into  a  properly  shaped  cnrv^Ml  |kiiu 
held  io  Ltie  groin,  and  cam  atlerwurtid  cIcHn  the  pxrts  htinaeir.  ^[oreover, 
dirTuse  ]>eritouilis  by  no  menno  ueco*s«rily  t'dhiwa.  The  mortality  is  no 
doubt  s;reat.  Aimnwat  Kiwteil.  that  uf  '2\  childreD  tims  oper«teii  on.  only  4 
ultimately  recovered;  but  Richiiril,  uf  Urirst.  writiug  iu  l^oy,  gives  ruuch 
jbptter  re;<u]t«;  I'ur  Iw  rvcirds  12  fuaes  m  having  i)ccurr«d  in  the  jiructice  of 
'biniM-tr  and  other  .Sur^cwna  in  that  town,  7  of  which  rtcovi^red. 

Lnmbar  IncUioiL — The  lunjbiir  iuLi^ioii,  or  Amussal's  op^raliou,  bait  been 
oflvii  9in;ix-«ruliy  practised  «u  inipertorate  cliildreu.     The  ailvaiilageji  ut"  this 
rineth<jd  coiisiiit  in  th«  piwsibility  of  opening  the  colon  iu  this  vilualiou  with- 
out wounding  the  (writoneuiu.     The  at>Jectiont  lie  in  the  frequent  malpusi- 
tioD  of  the  colon  and  iu  the  still  more  ireijueiit  nresence  iu  the  infant  of  a 
Imig  nieso-cfddu.     Moreover,  the  space,  esjtecially  In  a  fat  infant.  18  very 
liiuited.     It  thus  frequently  happeiix  tlial  the  peritoneum   is  unavoidably 
wounded.     Curling,  for  these  reas'iim,  prefers  Linre's  operation  to  Amu&sal'a 
In  these  raBea.     In  fact.  theHrgnmenis  for  and  agalnet  the  twonperaltimH  are 
Iw  evenly  balanced  that  il  is  diflicult  to  express  any  i>lr«ii)g  preference  for 
^oo©  over  the  other.     I  have  myself  preferred  Ainussat'e.  and  have  perfuriiied 
it  in  more  than  one  case.     In  pcrfurmin^;  the  ujieratioii  it  niiiBt  be  borne  la 
mind  that  ihe  kidney  i5  virry  inr^,  exicnds  far  outwards,  may  be  envelojied 
in  very  little  fat,  and  may  thus  be  easily  wounded.     If  the  operation  sue- 
cetnls,  the  result  is  very  sat  is  la  dory.     I  saw.  some  years  ago,  a  young  gentle- 
man, eight  years  of  nge,  who  had  thus  beeu  opc'ratcd  upon  in  Mexico  for 
eiuigeiiilal  abseneeof  the  anus  and  rectum.     An  iiH-i;<i(>u  had  Hrst  been  made 
ilii  the  perineum,  but,  no  ialcstino  being  met  with,  the  colon  was  opened  in 
Ltbc  left  lumliar  regioD.     The  boy  was  in  good  health,  well-nouriahcd.had  uo 
great  tmuble  with  the  artificial  anus,  which  waa  covered  with  a  truu-pad, 
tnd  Miflcred  only  occaaional   inconvenience  from  prolapse  of  the  mu<^iUA 
embraiie.     Th^re  watt  a  kind  of  sphincter-like  action  iu  the  muscles  about 
'ibe  orifice,  hy  which  the  finger  was  nrip[wd. 

Absence  of  Annst   Opening  of  Rectum  into  other  Canals.—The  anal 

orilice  may  be  absent,  »ih1  the  gut  may  ii|>fn  inCn  one  of  the  neighboring 
mucous  canals,  ns  the  vagina,  the  urethra,  or  the  bladder.  In  AUch  anr>ma- 
lous  cases  there  ts  usually,  I  believe,  hut  little  to  bn  done,  except  to  restore 
be  anal  orifice  if  pos-'^iMe;  but,  if  this  be  impracticable,  to  make  a  lumlvar 
opening,  and  then  to  take  Ibe  chants  i>f  the  other  preternatural  communi- 
cation closing.  This  it  will  sometimes  do  ;  and  eases  have  occurred  in  which. 
&lthinigh  the  whole  of  the  nkecuniijiu  with  flatus  had  escaped  par  tirethram, 
yet,  on  opening  the  rectum,  the  abnurmal  commuoicatiou  aeoiued  gradually 
to  cl'jse.  the  fecc?  being  directed  into  their  proper  channel.  In  a  case  in 
which  I  wns  ouce  consulted,  tliere  were  imperforate  auua  and  rectum,  and  ibe 
bowel  protruded  ae  a  red  fleshy  lube,  discharging  meconium,  and  about  four 
incbee  in  length,  from  the  anterior  abdominal  wall,  just  below  the  umbilicus, 
and  immediately  above  nu  cxtruvertcd  bladder.  Iu  suuh  a  complicated  nial- 
Ibrmation,  Surgery  could  evidently  do  uotbiug. 


STRICTURE — SIMPLE,  SYPHILITIC,  AND  MAUGKAXT. 

fitrictnre  may  occur  in  any  part  of  the  large  intestine,  but  with  very 
varying  degrees  of  frequency  in  different  iM^rlions  of  that  gut.  Excessively 
rarely  met  with  in  the  aBcendiDg  or  transverse,  of  uufrcquent  occurrence  in 
the  descending  colon,  it  becomes  more  common  in  the  sigmoid  flexure,  and 
verjr  frequently  occurs  at  about  the  junction  of  this  portion  of  the  colon  with 


DISMA8BS  or   TBB   LABGE    INTKBTtXE    AND   AVCf. 


the  reetmu.  Is  the  rectam  itself  it  is  mtjoi  oomiiioal<r  ftrnwl  tflbvr  it  in 
■pfwr  part,  from  ftjur  la  eiz  iocbea  abuve  the  aous,  or  elae  «  UlUeabDTtlhil 
■pertorv. 

Tli«  fmiuait  ptamre  of  nnall  quantititw  ttf  liquid  feceft,  wUb  MoriMl 
ca>k#ti(«tk<o,  tbuuld  always  Iniil  Lo  n  iiu^pii-iim  of  siricture. 

It  U  of  tbr»e  kiods:  I.  ihc  nmple,  i)e|»eiid(;iit  oti  simple  tUektaii^ */ tt( 
iiit»tioal  (WOU  :  2,  the  ty}iMlitic ;  and,  'i,  ibe  ma/i^oni,  eunriniag  4f  >  a^ 
ccfDUs  eruwth  of  itie  walld  of  the  );ut. 

1.  Simple  or  Fibrous  Stricture,  thuugli  ooca«ooally  nmirriaf  n  A* 
transvi^rae  or  di-Mecdini;  colou,  a  m<i«i  frci)iieiitlv  met  with  in  ibe  dfwil 
flexure  or  iit  it*  junction  with  the  ptolum.  '>r  at  l)ie  iippffr  p«rt  «if  thkt*. 
fnitii  fi>ur  ti>  six  inchwi  from  the  anus.  This  f  ■nii  of  «tri  ■ 
iuU^tiotf  commonly  occurs  in  elderly  pooplf,  titid  with  !»i-  ■ 
iromei).  It  ii  u»ually  the  result  uf  loiig-coutiniicd  iW.'H  '  .  -  i  tkiM 
dytenl«rT.  In  «orn«  cane*  the  narrtiving  u  rrally  miK'-t  iv-  irr^jmaMiry 
tbickvDipg  ouUide  llie  (;ut,  npe-cially  in  women  who  have  MfflsnJ  Am 
petrtc  cellulitis  after  lubur.  Tliiafbrtsof  rtrictureiiKated  juat  witkitM'A 
of  the  finger. 

!^mptom». — The  irmptomsof  Simple  atrtcture  of  the  m^tam  vwalMltliM 
nf  »i)me  difficulty  in  defecation,  the  patient  being  oblij^  to  rtimhi  KMi 
The  fece«  trill  also  appear  to  be  QatlcDt-d,  uarrowed,  ur  furnnrtil,ai>(  il 
many  ciuee,  more  e«))ccially  as  the  slricture  advoncvi.  are  paaaed  to  tlw&n 
of  small  scybala,  with  uccasioDully  h  kind  ul  apurioun  diarrbn*.  o^vaiHf 
of  the  jiaMBge  of  the  more  fluid  iutt^tinnl  contents,  wbiist  the  solid  HiM 
are  left  behind.  At  the  same  time  there  are  very  Dommouly  |.«ib  t>  *tt^ 
cation,  and  the  oreasional  paBm|»e  of  Mime  mucus  or  blifot ;  and  dTiftf'*' 
BTmptoma,  with  flaiiik-nt  dislemiiMi  of  the  at>d<tmen.  are  apt  tu  aamw.  U 
tLe  stricture  be  nilhio  four  »r  live  iuchtv  of  the  anus,  it  nmj  W  wtW 
with  the  fin^r.  nnd  iu  pivrii^*  MtuatJon  und  'linmeter  oseertainM.  If  it>*i 
this  poinl.it  mun  Ik;  oxaminetl  liy  the  inirtHluL-tion  of  a  «ell-^n«rd  \*<i'. 
Rtteution  being  paid  to  tin-  curve  which  thi;  n-vlum  ninki-s  fn>m  Ini'  i 
well  ns  from  bofuru  Imckwtirdi*,  In  iulmijuciitj;  a  hi»u;;if  in  rtrder  :..  ^ 
tain  the  nr«encc  of  a  stricture  above  the  np[ifr  end  ol'  the  reciuni.  bat  IlUl* 
infurmstiuu  eon  be  trained  in  many  caMcs.  as  tbr  (Hilnt  >J  the  itmramnlb 
apt  to  hitcli  in  folds  of  the  miirou*  membranr,  or  op|MHiilib  the  prmiOMiy 
of  the  Mcrum  ;  and  tlun^,  il!i  onward  pamia^e  ht-iu^  prFventrd,  thm  wtij 
seem  to  be  a  consiriciion.  which  in  n^nlitv  dm-A  not  nut,  and  util««i  lanki 
taken  the  muooutt  tiicndtriin<>  may  ncliinlly  he  lacrrainJ,  and  the  iutnMM 
forced  through  it  into  the  {leriloDt-iil  cnvily.  In  oilier  ca»rs,  the  bMi|[irnl 
apjM-Br  (o  |HUi.<,  when  irt  renltly  its  i>oint,  uieettu);  with  au  ub»UucciaU,CBnM 
downwHrdii  into  the  rectum. 

Tlie  jimrjrrAn  nnd  IrrminalioH  of  n  sinipte  ntlricturi'  vary  in  diB^-wnl  O* 
Many  prnuii))*  will  live  on  in  very  (p>o«l  Rfiu'rwl  limlth  (}iruii)>b  a  li«i«** 
of  years,  who  prevent  all  the  tymptoms  of  thi»  simjil"  9lrict«»  '^  ^ 
rectum,  In  others  the  contraction  may  jjo  on  iocrrasinB,  ontil  •*  ^ 
complete  occlnsioii  takn  place,  with  relmlion  uf  Ircm  and  all  the  >yia|rtM* 
of  olistructcil  btmcls.  Tliia  condlii^n  usually  c me*  on  alow'-  "•■'  '^ 
the  ubstruoiiun  te  complete,  life   may  continue  for  ecvcral  *■  ' 

some  inslnncve  the  obstruction  aeema  to  lake   place  mtber  i-i.  i  -^ 

with  all  tlK'KvmptnniH  of  acute  in  iwtiual  stninjiulnlioD,  death  i^  i-"  .:  'i' 
few  days.     AI)«H>e»  occasionally  forma  in  the  nei   '  '      '  '  the  i"*"^*^ 

and,  (uiminK  do»n  into  the  pi-lvtii,  may  burnt  i  .  <-  bcfci»***^ 

apace,  or  into  the  vagina,  or  mar  preseni  u|Min  ihi'  i;ilu>.  Th«  diKfttfft* 
pile  from  this  nonrce,  as  well  ns  from  the  mn<Mus  niemtrraue  lidlfl  "* 
iitriciure,  which  falls  into  an  ulcerated  olale,  tnay  induce  eitrcme ' 


TEEATMBNT   OF   SIMPLE   STRTCTURB. 


889 


ttod  hpctir,  to  whirh  the  impnirnipnt  of  nutritinn  conaequcDt  upon  the  dis- 
turbanoo  itf  i]i)!f^tion  n<iA»  mal«rinlly. 

Trfntmeitt. — Tlie  bnwels  should  he  kept  modprately  "pen,  but  pur^tion 

carefully  avoided,  ii«  it  i»  a  source  of  much  irritation.     Qutor  oil.  CWUbad 

1 4>lt«,  or  Miltiie  aperient  niinoml  waters  in  Rmall  doni^ii  suit  bcMt.     The  diet 

should  Iw  careAiily  reyulnted,  and  ihe  strength  kept  up.     An  fM-'CAsional 

enema  will  often  (tive  cjnsidentble  relief. 

The  ruryiati  trealmcsntof  8irii|ile  elrii'liir©  of  the  rectum  conoists  in  dilating 
the  cHnnI  Rt  it«  coustrieled  puint.  If  this  be  within  reach  of  the  finger,  the 
dilatation  cau  he  readily  carritil  out.  If  it  he  above  the  upper  part  of  the 
rectum,  nud  the  Blrictunj  be  li^'ht,  it  ie  extremely  diiiicult  to  introduce  the 
proper  inetruiDenl*  with  certiiiuty.  Whfn  thv  stricture  ia  low  down,  m  that 
the  end  of  the  flw^vr  cau  be  introduced  intu  it,  it  may  readily  be  r.ilatiKl  by 
tDlruduciug  u  rectum  bauuit;  every  second  day,  and  gradually  increasing  the 
iix«  ot  the  iuHlrument.  If  the  stricture  yield  hut  sluwly, 
•nd  be  very  light  and  indurate*!,  1  have  fotiiid  it  a  urmve- 
nieut  plan  t^)  introduce  a  sheathed  probe-poinled  bistoury 
into  it  and  Ut  notch  it  uiwunis  its  posterior  aspect,  where 
this  may  h«  doine  without  danger  to  the  peritoneom,  A 
teot  of  conipressffl  ajinnpe  or  nf  laminHrln  dipitaia  should 
then  Iw  introduced,  and  left  in  for  twelve  hoiiri.  On  ite 
wilhdmnal,  bougies  mav  ninre  readily  be  jiaseed :  or  the 
dilatation  may  be  c&rriet)  on  bv  rnennsof  tents.  When  the 
Btricture  is  above  the  reach  of  I^ie  finger,  a  giioJ  deal  of  man- 
igement  will  be  required  to  mnkc  ihc  bougie  enter  it.  This 
18  beat  done  by  laying  the  pniieut  ou  his  left  tilde,  and  using 
a  moderate-silled  eluatic  bougie,  aoilcncd  in  warm  water  and 
well  grcfued,  which  rauat  be  pamed  without  the  employiuent 
of  any  lorce.  When  once  the  Surgeon  bas  inlnKiuced  one, 
others  can  readily  be  made  to  futlow  in  the  name  track.  The 
great  danger  in  introducing  a  hmigie  high  up,  itt  that  of  mi)i- 
taking  the  oh«truction  offered  by  itn  pnint  coming  into  contact 
with  one  of  the  valvular  fohli*  of  mucous  menibraue  occur- 
ring in  thin  situation,  for  that  of  the  stricture,  and.  by  push- 
ing on  the  iiinirument,  [lerforaling  the  bowel — an  accident 
that  wi'uld  probably  oecasion  fatal  peri|nnitii#.  Durin!*  the 
tntrodnctioii  of  bougie»,  llie  bowels  uiunt  be  kept  regular  by 
means  of  a  lenitive  electuary,  and  the  occasional  use  of 
emollient  cueniftta.    If  (imch  pain  or  irritation  should  he  oc- 

caeioned  by  their  presence,  opiutii  shoulil  be  adrniuistered      ri|{.  B(io H«> 

internally  or  in  the  form  uf  suppositories.     Though  a  niniple        turn  miAtor. 
■tricture  of  the  rectum  may  be  much  relieved  by  the  »ne  of 
bougiot.  it  is  seldom.  I  think,  cured  by  this  means  ;  tht?re  being  a  great  ten- 
dency in  it  to  coutmct  so  ooon  as  the  treatment  in  iliHcontinued. 

Pitatation  mav  dometinica  lie  vetr  conveiiienlly  effected  by  the  use  of 
Todd'*  dilator  (Fig.  8()fi).  This  is  intrfvdufjed  chfled,  covered"  with  a  thin 
vulcnni/ed  India  rubber  sheath,  mi  as  to  avoid  nipping  the  raucous  mem- 
brane. It  U  iheu  expanded  to  the  required  extent  by  preasing  on  a  tri^^er 
iu  the  handle. 

If  complete  olwimclicm  m-cur,  purgatives  miiat  on  no  account  be  given. 
An  endeavor  should  be  made  to  relieve  the  pnttent  bv  the  use  of  enemata  of 
olive  oil,  and  the  strength  should  be  supported  by  n  diet  that  is  nouri.'fhintr, 
at  the  same  time  thai  it  leaves  little  or  no  solid  residue.  Opium  in  small 
doses  frecjuently  given  will  relieve  the  pain  and  prevent  sicknew  ;  under  ibis 
treatment  the  bowels  may  eventually  act  after  a  considerabie  lapse  of  time. 


M''>"^rn.:^  \>t  \. 


W*B 


tel». 


^tlm\ 


1W 


bi*«U 


ri4 


(fU.  i.  Ik  IMO.    The  kt  t;hM 
neb  ma^M  I^Mto  tk  ifca  4 
af  ihebgprfwW    iiiBif  I  rf^— 
kfVBr  u  Mffi  tfcii  «K«.    b  «  alwi 

r-"    r "  — 


Ikan  h  B«  nihpui  u  aippws  ttb  view.    Ix  «  >lMii  s  tcrtiarr 
■ad  a  widaa  aMKiBtBd  mfc  vtn  tmeaat  W  ifcc  ^^gwi      It 

^  f    ' r —  -^  r-rr'-"   r "  —  — ^^-  -^    ,  -  ' 

■WJngrlii    ii»iHii»dig  bMd  kfafeMififen  «Mt 

tlrtlirt  to  Ibe  li*««  pwt  «r  tke  ^mmA,  bat  liii|i«ily 
mdi  of  the  fagcr.    TW  i  ■■■l—ilw  wmi  ifce  pidci 
pai«,M  iHfl  itiMMch  aOn  aHMiMBd  vilb  all i mill  ■ 

MfW    Biwniwu  Bttfcr  pwyr  tff  iwf nt  iW  ■!«»  ■ 

aad  tkrn  tfir  'Irnw  irftptW  caBBtrici^  tMnb  abfi*  vtO 

UlcCfil.. .   ;,  ._  .,  .   -UtO  t'""   v*^na     ^)    aa   1.5   rs'ftti'rah    i 

Iff  ow  owe  amUr  tny  en: 

of  tlw  nctorn  iot*i  Uw  ;  ..^-  »...  ■  ' 

modi  f<«ii).  an*!  Are  niii<  The  ir 

tint  KnnrI,  tml  grmdukJIy  gi^c*  war  uDQn-  tn<!  jnin  aa>il  ItMi   nr-aniLk.*  >i» 

tow  iif  hlwid  and  di^dwi^ 

T'i'-  Trf/'oKfif.— Tbc  mtieDt  bmI  be  pat  BsdiT  th«  OMnl  ooMdOCia* 
IrratTivtit  f-T  ffj'pbilML  If  aksermlM  bftitl  pnpcat,tb«  bert  tnalMiil'*' 
•Itii  in  pwMJBg  boBgiM  of  eoeo«-Dut  bqtter.mcheiioUipi^«b^t  fearlaM 

SrauM  nf  iodaforiD,  into  tbt  rcidbi  oocc  k  da/.     If  tbi*  dov  ik<i  «mm> 
milar  bitu|^,  conbiiDin^  ■  mil  qnaotitj  of  tncblorid*  of  atfar?.** 

Mods  PI  liroK  M  Um  diMMBd  Miriur  if  irritated  bjr  Uw  pMwgr  of  fen*.'^ 
Uwo  ooliiUimjr  ntiM  be  performed  u  th«  ooljr  mnui*  of  fttriof  rvlirC  I3'*" 
Uw  ulcers  bml  without  oeccwtatins  ciloLomj',  tb«>  cintridal  cmUiw*>* 
maltinff  from  tlicm  tnny  be  irvnted  in  ihc  Mine  wajr  ac  a  nmplt  Mf**"*- 
The  i^xicnt  mK  ih«  diwasi!  usually,  boacvor,  mafc«a  tbit  Ibrai  uf  •mrt*'* 
•JltrrmHy  inlrnclnblc. 

Oaneer  of  the  Ractnm— Xalf^naiit  Strietura. — Tbe  form  of  aaor  <^ 
Willi  ill  till?  rvcturii  if  aliinAt  iovarinbly  ihc  C4)luiiinar  Kpiib«liiMH,af'*  * 
it  ofien  callad  Adenoid  t'lincer.  Irn  •triictur«  bai  l*eca  fully  d«criW" 
ilia  ohapt«r  on  Turoon  (vol.  L  p.  9tfo>.    Id  ibe  ractma  it  raris  ■om'"* 


ia  gtrufture  io  different  cases.  In  some  tlic  epithelial  structure  U  very 
abitndaDt,  tlie  growth  resembling  a  closely  packed  mt^ss  of  lubes  resembling 
enlarged  crrpts  of  X^berkilhn,  between  whivh  lie  ihe  vefcitels,  iitipportcd  by  a 
delicate  connective  ti)>«ue  closely  infiltrated  withsnmll  rouud  uclle.  In  others 
the  glnndutnr  element  is  much  Ic^  developct),  the  tihrnuK  struma  hciiii;  m<>ro 
fully  developed,  and  uhowin;.'  in  some  ca«'8  a  ti-Mdeucy  lo  cuniract  liku  that 
of  a  scirrhuB.  All  dej^rees  luiiy  bemclwiih  beiwucn  tliwe  two  extrciiiLW.  The 
diliienl  lenlnrcft  vary  with  llio  Btruclure.  Tlie  boIIlt  variulit-H  pnm  more 
rapidly,  implicate  surnmudiii^'  Mnieturic^  tiKiri:  widi.'ty,  and  ttml  to  iiiiVct  iho 
Ivniphatic  itIuihU  mid  imoniul  or^'iinx.  tmi  lead  ton  loim  cnniplctc  alrictiireof 
toe  gui.  The  firriKT  varieties  j(riiw  hIuwIv.  anil  olYrn  oxlat  a  hinj;  time  with- 
out yivin;:  m«  to  t^tannhiry  ^rowihn,  whihi  (rum  ihcir  tendency  lc»  cimlriicL 
they  cauci'  (;reat  niirm^finj;  of  ihe  j^iit.  The  sitfter  i^inuH  usually  uppt-ur  n» 
flat'caulilliuer  jrniwtha  Hpriiiging  fniin  the  inner  Hurliirn  of  llu;  g\H,  and 
tending  in  most  nisra  in  )>pmid  rirrularly  rDuiid  il.  Tliey  an-  uHually  ex- 
tremely pain  Tut,  and  blet^l  rpadity  vrhen  fxaminpd.  Thc^y  tiliHi^h  tfiirly,  and 
cause  extensive  destruction  of  the  bnwAl.  The  firmer  varieties  form  harti, 
nodulated  growrhs  jirojeicliiif;  into  the  nut,  narrowing  iu  calibre  greatly. 
They  ulcerate  slowly  and  bleed  Ipss  readily. 

True  Acirrhufi,  that  is  to  my,  glandular  epithelial  cancer  with  firm  Rbrous 
rtmmfl,  is  said  to  have  been  met  with  in  the  rectum.  If  sucli  be  the  ca«c,  it 
hi  certainly  very  rare. 

Culloitl  riucrr  alwi,  nri*fiTif»  Hp]mrently  from  coUoici  def;enerntion  of  a 
coliinmar  epillielinnm,  Imit  iN-m  met  wilh,  hot  is  exceedintily  nire. 

The  titmiirs  (lei>crilied  ns  Eniyjfhriloid  have  probably  liecu  nod  nialij^nant 
aarcomnln  coriiiiienciiii:  near  the  giiL  or  in  its  coati*.  but  these  cn^es  are  »n 
rare  that  it  is  imjKJssible,  at  present,  to  apeak  with  certainty  as  to  their 
■cm  dure. 

Most  UKualty  cancen>us  dijscuBe  is  seated  frum  three  to  live  inches  above 
the  anuH,  and  may  implicate  a  considerable  portion  of  the  bowel,  exteu>Jiiig 
upwards  rather  than  do»uward>>,  giving  n»e  to  considerable  iudunitii>n  nuu 
contraction,  an<l  attended,  at  least  in  soue  cases,  by  complirlu  occlusion  of 
the  interior  uf  the  gut. 

■Sytnptovifi. — <";incer  of  the  rectum  is  met  with  chiefly  in  middle  life,  but 
sometimes  'loes  not  occur  until  advanced  age.  Uoth  sexea  are  e<iUA]ly  liable 
to  it;  if  anythin*^,  it  is  more  rret|ueiil  in  women  than  in  meu. 

It  is  very  insiiliou!*  in  most  cases  in  itt?  early  manilVstBlinns.  A  sense  of 
uoeasine8.%  a  [endeney  to  diarrbtea,  a  slight  dibchnrge  of  blmid  or  mucus,  a 
feeling  aa  if  the  patient  had  [)ile3.  are  usunlly  the  only  early  evidences  of 
the  development  of  this  dialresi^ing  disease,  Afier  a  lime,  ihe  reelal  pain 
becomes  very  severe.  There  is  now  n  constant  feeling  of  pain  and  wei|:lit  in 
the  gtil,  widi  a  sen^ntinn  as  if  the  bowelK  liiid  not  been  eomfdetely  relieved, 
together  with  the  discharge  of  niueu?,  blourl,  or  piia.  and  some  flattening  of 
the  feces.  On  exploring  the  parts  with  tlie  flnger,  the  lower  portion  of  the 
rectum  will  usunlly  he  tonnd  iinallerE'd,  whilst  the  tip  of  the  Biiger  will  cimie 
into  contact  with  the  contracted,  hardened,  ulcerated,  and  merged  mass ;  at 
one  part  of  which  an  opening  will  be  found  tending  into  an  irregular  cavity 
that  paascs  up  through  the  cancerous  ma^  to  the  healthy  gut  above.  The 
patient  experiences  most  intense  sutTering  during  defecation,  to  ctniisetjuence 
of  tbfi  pasi'Sge  of  foc(»  over  the  raw  and  ulcerated  surface.  Thii«  pain  is  not 
confined  mei-ely  to  the  diseased  pari,  where  the  sensation  is  of  a  hot  and 
burning  character,  hut  usually  radiates  round  the  loins  and  down  the  thighn, 
and  is  »a  Kcvtre  that  the  patient  looks  forward  to  each  action  of  ihe  bowels 
wilh  the  greatest  dread,  and  restrains  it  aa  long  as  possible.  The  whole 
nervous  system  at  last  participates  lu  this  coDlinually  recurring  suflering; 


19^       DISEASES   OF   TBE    LARGE    INTESTINE    AND    ANUS. 

the  oiuiitfiinnce  becomes  niixious;  tlie  a|iirit8  are  (]epn<SHGi) ;  flle«p  uid 
digndon  nrc  destroyed^  The  patient's  crtnilition  is,  iridecd,  truly  iiitwrable, 
betweeD  the  dread  of  cxccaaivc  siiSoring  when  the  iKiwelit  uct,  ua  ihu  oo« 
baod.and  the  fear  of  impending  obstruction  on  the  other.  In  many  instances 
he  ia  «nm  nnt  bv  this  ^ufTeriDg.  occasionully  combined  with  the  coniitim- 
lion&l  cachexy  induced  by  ihc  contamination  of  the  system  and  the  develnp- 
raent  of  sccoiidarv  viicoral  prowlha.  Not  unfrequently  the  misery  is  much 
increased  by  the  formatioQ  of  fi^iuh^iia  openings  in  the  neighborhood  of  the 
bowel,  and  communications  bct»'eca  it  and  neighboring  pnrtJ,  uich  as  the 


Fl|.  MT.— CtBNT  of  tTppvr  Part  of  Reeltiin.    Ai  X  porrontloo  IwidlMf  W  f«Ul  P«rlt«aiU« 
l«uk  plbM,  during  adiainbinktton  of  mi  EnDUi*. 

TOfiiia,  bladder,  or  urethra,  with  rnnceroun  implication  i>f  thcra.     Fli 
well  aft  feces  thus  got  entrance  into  the  bladder  and  vajj^ina;  the  flatiu  _ 
ing  out  with  a  rush,  the  feccH  «'imcliiiioB  ubxtructin^  the  urethra,  and  often 
vcrv  gcriouily  irritating  the  bladder,  priwlueing  strangury  and  great  pain. 

Death  mny  put  an  end  to  the  patient's  autfcnngs  in  aeveral  ways;  by 
exhauAtiun  from  paiu  and  continuous  dischnrge,  together  with  cii:>U)ititutioiial 
cachexy ;  by  jjerloratioD  of  the  cjincorous  mam,  which,  ulceriiting  through  at 
some  point,  opens  into  the  peritoneal  cavity,  and.  by  hemorrhage,  internal 
or  into  the  gut.  inducing  fatal  co)la|we,  rapidly  destroys  life;  and  in  other 
instances,  though  more  rarelr,  by  fecal  obstruct ioti,  as  in  the  case  of  simple 
stricture.  The  reason  why  inlcstinal  obstru<:tion  is  not  more  coninion  than 
it  tft  in  cancer  of  the  rectum  is,  that  in  many  cases  the  diseased  raaiis  ulcer- 
ates and  nei^ruses  more  rapidly  thnn  it  growa  into  the  bowd,  and  thus  an 
irregular  chasm  in  l?fV  in  its  centre,  through  wliieh  the  feces  panes. 

Tyeatjttfnt. — This  must  necessarily  in  n  large  pniportioo  of  oases  be  merely 
palliative.  The  bowels  must  l>e  relieved  by  occasional  doses  of  castor  oil  or 
fly  erui-llient  eiiemata.  The  patient's  suffering?  may  in  many  cases  be  mocb 
relieved  by  limiling  him  to  a  diet  composed  s'dely  of  material  not  likely  to 
leave  any  solid  residue,  such  m  carefully  prepared  and  slraiued  arrovrroot 
and  inuut-bntths  of  various  kinds,  to  which  n  little  brandy  or  wine  may  be 
added.  If  the  patient  at  the  same  time  be  kept  warm  in  Sed  in  the  recum- 
bent position  so  as  to  economize  force  as  much  as  possible,  he  may  maiulain 
his  strength  fairly  well  on  a  comparatively  small  quantity  of  food.  .Small 
diWes  of  opium  may  he  given  to  relieve  pain.  On  this  diet  one  action  of  the 
bowels  about  every  three  weeks  will  be  quite  autficienl.  It  will  usually  occur 
spoutaueously  withitut  the  uecftssity  of  administering  a  purgative.  If  there 
n  much  pain,  hypodermic  injections  of  morphia,  often  Ui  a  large  amount, 
are  rc'iuired  to  lessen  the  patient's  distress. 

As  further  pallialiTe  treatment  Cototami/  may  be  required.     This  opera- 


CANCEB  OF  THg  BBCTUM — TBKA.TMENT. 


843 


tioD  U  performed  for  ooe  of  three  reasons  :  I.  To  relieve  tbe  loteose  aenaf 
rccultinK  fruni  the  pafss^e  of  feces  over  the  ulcerated  cnDceroue  dibbs;  2.  To 
relieve  llic  BufTerin^  and  great  iti^comfnrt  occBsioued  by  tlic  feces  parsing 
into  tlie  blndtler  or  vngiua  ;  3.  For  llie  relief  of  more  or  less  complelc  ub- 
fttruclioD,  giving  ri«c  to  dlsteolioa  of  tbe  nbdontcu,  with  rctaiui-tl  fvi:va. 
CololoRiv  Of  a  palliative  has  pruvc-il  most  enrceisgriil  id  affording  ttic  dii^ircd 
relief;  by  itit  lut-nua  lifu  iiiuy  be  iirobin;ii!d  m  well  as  rendered  mure  endur- 
able. Atieniptcd  dilatntitin  bv  nioatia  of  boufrii^,  tbe  upnlicatittn  of  c&n»lics, 
or  crushiDg  the  luuior  by  meuiia  «if  tliu  finger- for L'ej*.,  a«  reconiiiieiidei!  by 
Arouaeat,  ar«  wone  thnn  UHilfm.  They  caii«G  great  pain  and  irritation, 
basteo  ulcenttion,  and  aggravtile  tbe  diieosc. 

Erctfirm  oji/tr  Tiimor.  Partial  Krcisiun  of  ih^.  Rcriutn  or  Procioiomy  is  aD 
0|>crution  nhich  haii  lately  W-xi\  revived  with  considerable  Kue(>eH!i.  K^ca- 
Diier,  Yi<)a),  and  otberM  attempted  the  remnval  of  the  Mimnr»  when  riitnated 
near  the  anna  by  ligaturing  ita  biiiie  and  allowing  it  tn  nlotigh  nnar.  The 
only  advantage  in  snch  a  proceeding  \»  ibe  absence  of  hemorrhage,  but  this 
u  more  than  counterbalanced  by  tbe  dangers  arining  frnm  the  prpflence  of 
the  ftloughing  muss,  by  the  uncertainty  of  perfect  removal,  and  by  the  pain 
it  give*  rise  to. 

Removal  of  the  diseafie  by  PKcinion  of  a  portion  of  the  rectum  was  first 
performed.  ncc<)rding  to  Wlpean,  by  Faget.in  1730.  He  took  away  an  inch 
and  a  half  of  the  circumference  of  the  gnt  and  cnred  liis  patient-  Tlie 
operatitin  wa*  revived  in  1826,  by  Liwfranc,  who  removed  portiong  of  tbe 
rrctuni  in  nine  case*,  with  five  recuverie*.  The  operation,  however,  fell 
again  into  discredit.  In  18o4,  Chaisaignac  introduced  the  ^craxenr,  and 
applied  it  to  removal  of  rectal  growths.  Since  llieu  NuMba«m  and  Volk* 
naDQ  io  Germany,  Jordan,  Alllngbnm,  Holmes,  nnd  vthere  iu  tlii?  cnunlry, 
Imve  done  much  to  revive  the  operutiou  ;  atid  Jn  lt<80,  Hurriimti  Cripps  [)iib- 
liehe^l  au  intBre-ling  work  which  tme  added  much  to  our  knowledge  ni  the 
aubject.  The  cu^es  adapted  to  removal  are  not  iiumeroua,  according  to 
Crippe,  forming  about  one  in  five  tyf  ihoee  that  ct>nie  unrter  obflcrvation. 
Tbe  conditions  which  render  the  operutiun  juetifiubic  are  the  following  :  The 
patient  mui^t  not  be  too  old,  and  muet  be  in  fair  health  ;  the  growth  must  be 
to  sinmted  that  tbe  finger  can  be  passed  fairly  beyond  it,  and  it  n>ust  be 
freely  movalde,  not  having  implicated  surrmmding  part?.  The  most  favor- 
able cases  are  those  limited  to  one  side,  especially  the  pjisterior.  It  is  an 
important  question  how  far  the  dissection  can  be  carried  upwards  withont 
nroimtfing  the  peritoneum.  Oipps,  who  has  carefully  investigated  this  point, 
itatea  that  in  the  male  the  diwlance  from  the  rccto-vesical  pouch  to  tbe  anus 

[Si  two  and  a  half  inches  when  the  bladder  is  emply,  and  tin  nddilionnl  inch 
rfaen  it  m  dietendwi.     In  the  female  the  distance  from  the  reoto-uterinc 

[pouch  to  the  anufl  is  aomewhat  greater. 

The  removal  of  a  malignnnl  growth  from  the  reetum  is  aecomplished  ae 
followa:  If  it  be  very  small,  and  situated  very  low  down,  it  may  be  possi- 
ble to  bring  it  into  view  by  forcible  dilatation  of  the  anus.  This  is  done  by 
inwrting  the  first  two  fingers  of  cnch  hunr)  into  the  anus  nnd  forcibly  drng^ing 
it  open.  At'ter  this  the  anus  will  usually  he  sufficiently  relaxed  to  allow  of 
the  affected  portion  of  the  gut  being  seized  and  drawn  out  to  such  an  extent 

.w  to  allow  of  the  free  removal  of  the  growth  by  the  fecraseur,  aciseors,  or 

'Puqueliu's  cautery.     Cases  in  which  this  is  practicable  ore,  however,  very 
rare. 

The  removal  of  a  portion  of  the  bowel,  including  tbe  whole  circumference 
or  a  considerable  part  of  nnc  aide,  can  bo  safely  pcrforniGii  onlv  when  the 
anua  has  been  enlarged  by  incision,  aa  suggested  by  Deuonviiliers.  The 
operation  \»  thus  performed.    The  rectum  having  been  thoroughly  cleanted 


644      DISBASSS   OF    THK   LAKGE    INTISTiyE    AXD   AVVt^ 


Willi  an  eni?ma  immf^diately  hefnrp  the  nprratiDn,  the  pntirtit  if  plantlialit 
lilhittiimv  p'D^ili'iri,  niiii  a  ciirveil  sliurfi-piiinli'rl  hittliiunr,  };*JtirlMl  brlWU 
forp.(iii[fer,  U  pa^iterl  m  »l  ttic  aiiiis,  llie  liitrnllr  »  iht-ii  rnwK)  m  Am  tb 
pnint  14  iimHe  li>  piorce  llie  ^tt  »iul  M|iite«r  i^ti|>crliciiilly  cI<m-  !•<  tin  tip  t^ 
the  coccyx  exactly  in  t)i<^  midtllc  line;  the  |inrle  Iwtwpvn  tin  iJ 

anus  arc  thoo  divi<lod  by  h  ain^rle  cut.  If  n>i>r«  room  be  rt*j-i-.<.:  -_'^ 
this  opi'ratitm,  it  may  be  obtaiued  by  removiog  thv  cocirjn.  TbcUHdaif 
must  li'»w  be  arwwleri,  and  a  stout  ligature  may  bf  pastw)  ''  -  -  -'■  -o  «tl^ 
side,  by  tvliicK  tbe  two  ed|;v«  of  the  wtruiid  ruay  b«  favid  '  .rt   JU 

iuvUiiin  \»  iheo  carried  from  the  margin  uf  t)ic  wuunil  -irt  xQ'.'  mdi  n  a 
curved  directinn  round  the  anus  to  a  ornspundini;  point  no  tlie  atkriilt 
If  the  aniu  tlKlf  in  healthy,  this  may  he  nrndu  ut  the  Jud'."*  '  '^  9mmm 
memhrane  and  skin.     The  f^ul  can  now  be  B«pamted   j  «il^«l 

any  difUi-uky  by  meanft  of  the  tink'tir.  aided  by  tin;  sclMon,  m  ii>«  ntUf^mca 
of  l)ie  levator  aui.  When  the  sides  are  neparuU-d  the  j[Ul  iBuat  bf  iin«i 
backwards  and  separated  by  careful  <lt!<»ection  fnini  the  raciu  m  te 
ftirualc,  (tr  urethra  and  pnii^tale  in  the  male.  To  avoid  atiT  risk  af  ma*^ 
ing  thf>  urelhra  a  Inrge  ailver  cathcU'r  nbmild  be  paned  at  tbU  Mace  »/  lb 
opprntiim,  which  will  lip  clearly  felt  fnm  the  wound.  The  gut  havii|  bai 
ninv  sepHratoil  it  mav  he  cut  nway  by  nipnn»>  of  the  Acruear,  wtman,m 
Paquelin'a  cautery.  The  t^cnucur  ba»  the  advnntnga  of  prrmtdat  WflW 
rliH;."'.  n-hich  in  no  deep  a  wonn<l  mt;rht  he  difficult  La  artML  Vt^mlkft 
cnntorv  has  the  diaadvantaj^  of  hnnlenine  the  clges  of  the  intaMl.Bitb( 
it.  U  ditlfrult  to  ascertain  if  they  are  frvii  IVum  dw'We.  Duriof  liei^m' 
tlon  hemorrhnt^  niii«L  lie  arrested,  partly  by  the  nrr«Mirp  of  cpnogn  iti 
partly  hy  the  use  nf  forciproMiire  forccpi.  The  nt>ranrrhag«  caa  h  tt 
way  l>e  eaitily  kept  under  control,  and  wpMoni  f^uio  any  prcal  twakifc 
After  the  o[>erflti<^n,  it  in  utelcM  tn  try  to  brini;  t)i<-  niiii--iit«  ntrmhriBt iLiwl 
In  lhi>  aims.     A«  Crip|w  p'tinta  nut,  the  Btil^hr*  ;i  '  vtkm 

ii  gnme<\.     The  wound  nh'^itld  be  ihimm^jhly  >■■,'  ■  .tmt  tm- 

Mptic  solution,  chloride  nf  icinc,  'gr.  40  to  X}),  IxiU;^  tar  tbe  nKNt<iA(>>L 
It  may  then  he  sprinkled  with  i(x|i>fnrni.  lu  mn-t  c^*-  -  i'  i*  Iv?tt*T  la  !«■» 
the  whole  iociHun  tn  clow  by  granulalion,  as  free  -i  >  thro  r«ttM 

to  be  obtained.  Volkinrinn  recommeads  cluaiog  i,.-,  «.,.-_iior  p*"  "' 
insortini;  a  liirge  drainngetube  bebinit,  but  thor*  Mvms  little  adr.v 

§o  d'liui;.     The  after-lreatnicnt  ennsi*!*  in  well  fyriDc^-'  ■  "' ■ 

twice  a  day  with  iiime  antiseptio  solution,  and  the 
iodof<rni.  The  bowels  must  bo  prevented  from  aciiii^  lur  'a-ci  'ijiy  ■' 
forlni^^hl  by  proper  did  and  the  adminislnitioa  of  opiutiu  HmlrnKUk'* 
place  flowly.  and  tlie  mucous  membrane  beeomea  drawn  down  MaMi(n'>'f 
towar<I-t  the  skio.  A  slrtetured  anus  almoic  negfi—rily  remlla  if  lW«^ 
cireiimrcn?nce  of  the  bowel  have  been  reoiuved.  but  tliii  may  OHaUf  ^ 
kept  BirfBcieiitty  patent  by  tlio  constant  OMi  of  bouuiea.  Iiu»cuiiiM#  <■ 
fccea  li  more  rare.  (.Vipps  alatea  lliat  it  oocurrvd  In  aevca  cMos  i** 
IbirtysiK,  and  in  vix  more  it  occurred  slighlty  when  the  nxniooamtM^ 

Removal  of  a  part  of  tbe  circumt'erenee  is  a  much  more  su«naAl  •^ 
tJoo.  it  is  performed  in  the  same  nay  as  that  jiiat  d«Mrth^I  ^<'>i  ih^bwl^ 
rauonaa  membmne  and  the  ourreapondin^  part  of  theaoun  iW*J 

uninjured,  a  longitudinal  incision  with  «ettatni  beini;  oari,.-.,  .,,.  (J)#W<d 
on  each  i^of  tbo  morbid  growth.  It  ti  seldom  fullownd  ritbrr  by  mi^ 
nen'v  nr  serious  slriciure  of  the  bowel. 

Wound  of  the  |teritoncum  ii  a  miMt  aeriomi  but  not  neor«arilr  '*^''T 
fteni.     If  tho  o|H4iin);  Imi- stnall  and  within  rea>'l.  :  loaylie^' 

lootowlt  bysuiurti.    If  ibis  coauut  be  done,  ft< .  nUflhnitfl'' 


OANOBR   OP   THK    ANUS. 


845 


piticDt  u  given  the  best  cIiudco  of  lifu  by  the  iiitrorfucttoD  of  a  Aill-sizeil 
dninage-tohc  into  the  jivrituuval  [>uuch  Irum  ihv  recluiu. 

Ttie  ojoriulit^  fniTu  \[w  ojitralioti  i»  ronuidcrnblv,  as  judged  by  statistics. 
C.  Kulkry,  4ii'  y,evi  Vurk,  ctillijc-ltii  140  i-aste,  and  Hlatee  lUut  in  ^'J  i>i*  ihtse 
rapiil  {iviHb  followed  ;  in  10  from  peritonilin,  in  4  from  pelvic  celltilitiv,  and 
Jn  'i  from  licmnrrlinge.  In  ijnly  I!  had  a  permnnent  cure  reeultecl.  There 
»ecniB  no  cJonbt,  hiiwtvtr,  lliat  in  well-eelecied  cases,  taken  early,  the  ojiera- 
tijin  holds  mil  a  fiiir  jtroetpei-t  of  pnjionged  relitf,  or  even  cnre. 

Cancer  of  the  Ahqb. — The  annn  may  he  aflectetl  by  extensinn  of  ranremus 
gruwtba  from  the  rectum.  When  the  disefls*.'  ia  primary,  it  is  always 
vquamouB  epithelioma  (  Kig.  AM,  p.  993,  vol.  i.),  neciirring  at  the  annsj'iiat 
ad  it  doee  at  otlier  miico-ctitaneoiiH  eiirfncee.  It  forms  a  nodular  projection, 
ufteu  resembling  a  swollen  external  pile,  for  which  I  have  more  than  once 
eeen  it  mistaken.  It  ulcerates  later  than  the  ranie  disease  in  other  siltintions, 
the  innes  often  renehing  the  .>^ize  of  a  pigeon's  egg  before  the  surfaob  give* 
way.  [f  limited  in  extent  and  detcelcd  in  good  time,  it  may  be  advantage* 
ouifly  excifted  by  tin  op«.TAtion  ^tiiiibir  to  linit  for  removal  of  the  lowL-r  pHrt 
of  the  rectum.  At  u  ruort'  udvtiiice<t  period  such  a  practice-  can  scnrutrly  b« 
adojilc)  with  any  [iri»|K'ct  of  success,  in  coneeiqiieuce  of  the  impu»ibility  of 
rcnioviuf;  the  whole  of  the  tttruuturei  implicateij. 

Sarcomata  of  the  Rectum  are  very  rarely  met  with.  Kokilanelcy  faa« 
described  a  nu<Jular  torm  of  spin  die- eel  led  sarcoma.  I  have  eeen  Buch 
growths  forming  large  and  somewhat  pate  tnberous  ma»e8  projecting  into 
the  interior  of  the  gut,  and  even  protruding  through  the  anus,  giving  rise  tv 
the  same  train  of  local  ifyuiptom«  as  characterize  cancer  of  the  gut,  but  with 
lera  p.iin.  In  such  cases  an  the^e,  the  iliKase  mav,  If  limited  or  peduncu- 
lated, be  removed  by  the  icraaeur.  By  means  ol'  this  iDMruraeul,  I  have 
removed  from  the  iuaide  of  the  gut  n  tumor  of  this  tied  ncarlv  as  large  aa 
the  list.  Uccurrence  may  of  course  be  exiiected,  but  the  patient  will  gel 
relief  for  a  lime. 

Faptllomata. — ^ Large  papillonima,  ihe  papjllic  of  which  branch  repeatedly 
and  are  covered  by  eolunmnr  cpiihelium,  arc  occaaiouiilly  met  wJlU  iu  the 
reclura.  Tlicy  ch'Sely  ri»L-mb!o  cancer,  but  are  recognized  by  their  alow 
growth  and  by  their  b'elug  pi^^iluneulaied.  They  cau^e  liemorrliage  aud  soma 
obBiructioQ  of  the  bnwcl.  Thi-y  can  be  readily  rcmoveil  by  ihe  ^craecur  ur 
by  ligature,  aud  si'ldom  rcMirii. 

Polypi  arc  by  no  meuua  uncommon  in  children,  and  should  always  be 


PiK.  808.— Poljpu*  of  lh«  Reirttiin  with 
P*d)*l«)  r*D)0*atl  fruiD  aUilil  7  jiean 


Fif .  80U.— Puljpn*  or  tho  Rrctum 
cul  Dfian,  fbaalitg  CftU  lln«d 
bj  CnluntiMr  B|iUbcliuni. 


looked  for  when  a  child  posses  blood  from  the  bowe],  and  BufTers  from  pro- 
longed irritation,  jierlmpa  associalcd  with  prijlapBc  of  tho  rectum.  They  ar« 
tometimea  fIbruuB  in  structure,  smooth  on  the  surface,  nod  covered  with 


846      VISBA989  OF  THB   LABOB  INTBSTiyB    AKD  A9Cf. 

columnar   Fpitfaelium.      In  oilier  caB«  iJiey  are  l/tbulatr-!    'V-'   *■-    - 
pB|>illnry,  ami  mny  conLaiti  cvaId  lined  with  ivilumuar  epit. 
They  are  niuily  removed  by  the  npplicatioD  of  a  ligature,  it  dt  iwLtu^^-  Lii; 
Decli  if  it  \te  Ion?. 

In  A<1iiUs,  similar  growlh<i  are  leaa  commoaty  mnt  with.  Tbev  tn  ana 
common  near  the  aouf,  nn>]  in  »(>tDe  cnM«  are  fnum)  iiM<M<iatn)  ■iib  a  mmSl 
intracuihle  ulc«r  at  the  p>>iiit  et  which  the  free-  ptnl  ;  'i.^  fUL    TWf 

are  best  reniuveil  by  li^tiire  of  the  neck,  ttlct  vtWt -'.f  fHa;  Iksi 

away. 

RECTAL  rrarDLJC. 

Fittnloaa  opening  occa«i<)ually  occur  belwe«Qthftr«cCum  aad  lb* bluldir 

io  UK'ii,  ^)r  liettvcfii  ih«  gut  ami  Lb«  vag-ioa  io  wumeo. 

lUcto-TOical  FiatalSB  urt;  not  of  cumiuou  occurr«DC«,  anJ  ilfUaJlj  nmk 
eiUi«r  t'ruiti  iirgauic  divuase  ol'  a  cauoeroud  chamctvr,  oilablialiias  a  ci>awa> 
DicalioQ  bfiwci*u  the  rectum  uud  the  blad<liT :  or  frum  a  wouDiluf  tWfn 
duriug  Lhi)  upvraiinn  of  liihottimy.  lu  rant  cnseii  llicy  may  arm  Aia 
tubercular  abaoemis  in  tht^  vwiculic  wmiualua  nr  pMelmlr,  i»labtiiUB|  ■ 
optuiiui;  into  ibc  rectum  und  bladder  eimultauenudly.  In  thtM*  cavn ibt  ariai 
«Bcapcfl  per  anum  in  greater  or  \vm  quantity,  oocaiiiiaiog  cofutaat  imulM 
ur  uxi-oristion,  with  a  sort  of  liquid  diarrhtsa;  aod  Lbo  wet  »taU-  ui  vUcilhi 
patient  is  kepi  by  the  dribbling  nf  urine  ^vea  rise  tij  an  ntTenaive  »mim^am! 
odor  abrtut  bitn.  It  ihe  oommunicatiun  between  the  rectum  aad  bUthkiW 
cancenma,  feculent  matter  and  flatus  pass  through  the  np'-i'"'.*  sad 
from  lime  to  time  by  the  urethra  ;  perhaps  even  mapo  b1<  I' 

urine  doet*  ^JT  (inuia.  There  is  litis  difference  then  brttttti)  wir  iraaMW 
and  cancer-iUH  futulsc,  vU.,  that  when  Imumatic  the  chief  eacmpa  b  6^*lki 
bladder  into  the  rectum  ;  when  cani'erous,  of  the  oontcnta  of  ibr  rretaa  aW 
the  bladder.  It  is  remarkable  how  little  irritation  ij  often  ait  ap  bf  tti 
ndniixture  of  feces  vtith  urine  in  the  bladder.  The  fiatolofia  inrtBri  latk 
rtctum,  if  tniuitiutic,  can  readily  ^m  detected  by  inasiag  tba  DB|{Vr  iabtlb 
gut,  or  exttutining  ila  inlerior  with  tbeapeculamani;  wheaca&eaoaaititM* 
high  up  fur  this. 

Trctidnfiit, —  If  the  tistula  be  cancerous,  u-thin^'  can  be  done  ia  ifcaaay*' 
Irt-atmt'iit  boyoud  keeping  the  imrt«  clean,  or  diverting  the  ftKn  \-i  c  It'JUl'. 
but  if  it  be  traumatic  in  iCa  origin,  of  aniall  Mxe,  and  more  *»;■■  ** 

recent,  itfl  closure  may  not  untrei^ueiuly  be  accnmplinhed  by  t'  '  tt 

Ditrate  of  silver,  or  th«  tbernio- cautery  thrtiugh  a  aiteculutn  ** 

over,  the  fistula  be  nf  old  sumding,  and  the  at>erture  large,  cauid.3>— '^^ 
not  succeed ;  and  the  ontv  moiic  of  treatment  that  can  be  adctptcid  tnll  kl » 
l' 'iMn  tlic  bladder,  and  cut  -'  .        '.  tke  •phiw*' 


idMBH 

ihaalte 


introduce  a  gmoved  Btad 

ujMiQ  thi».  thna  laying  tlic  parts  intx  one,  aud  cooi. 
perim^al  fit>Lula.     ny  draining  ilie  bladder,  granuluti'.u- 
dcvp  uni'ju  bi;  acct]m[ilifhed.     In  caniYntus  rectv  vr^ieal 


anal  ifV* 


chtUTK-ter,  coldiomy  may  be  lind  rrc<>ur»e  tii  with  every  diuimkii  ui  autifX*! 
the  pittieiilV  ^iitlenng«  (vol.  ii.  ii.  821),  und  of  thus  pmlunpng  IHK 

Eatoro  vaginal  Fistula. — It  nru  happened  that  a  cimn  ^^ 

set  up  iM'twueti  the  iinintl    inti'Stine  and  the  vagina,  an  aan  i* 

fact,  |i)rming  in  this  cnvily.  These  cases,  hnwcvcr,  are  very  rar«,  aaJ  *f* 
indeed,  h*^  loirk<-<l  upon  a«  incnmble.  Hon x  and  <_?a«amKv,.r  •>(Mti4rui«ll^ 
etilablieh,  by  a  deep  nn<t  dittlcult  diaaection,  a  contnmni'  ***'^ 

small  and  largo  inteatino;  but  the  operation,  aa  might  h<...  i.-,.  tAfa!**' 
provird  fatal. 


^dAb 


BECTO-VAOINAL    FISTULA. 


847 


bill 


I 


Iteoto*TR^iuI  Fittnln  may  orlec  from  two  causei :  lit,  iloughing  of  the 
^poBCcriur  viuU  of  the  vu^'iiiu,  in  conee(|uc*uce  uf  undue  pretture  ozerci^  uuuu 
it  iluriiij,'  |}anuriLiou;  uod,  2(j,  iu  pcrforalioD  by  BypliiliiJc  ulfcraljoii. 
They  luuy  b«  raug«d  iu  ivro  clueeeii:  tmuc  cousieliug  ul  h  biiituuholt;  oji«ii- 
ing  (and  iIivik;  uru  otlcu  syphilitic),  aud  lliuec  cuniplicuttd  nilli  uioru  or  Ii-bb 
ext«ii«iv«  lu(-«nili(tii  (if  the  perint^uni.  The  size  ot  thtet  G(>luhiua  opt  ningn, 
fihvn  unc(>tnpti<'ulvd  »ith  ruptun>  tyf  th«  (wriu£uni,  varii-M  {greatly  ;  in  UDiiie 
raeeB  there  iit  mertdy  n  isnmil  |tert(irmiiiu,  in  others  (here  niiiy  be  Icmv  of  the 
greater  pnrtion  of  tli«  pteterior  wall  of  the  vagiua.  Whatever  their  size, 
they  are  neceifearily  soiircea  nf  very  great  iliscoiufort  and  Hnnttyaiice,  both 
physical  and  nietital,  to  the  patient.  The  recognition  of  the  disease  is,  of 
coarse,  at  once  made  ;  the  escape  of  the  fecen  und  Haius  into  the  vagina  being 
obvious,  and  digilnl  or  ocular  examination  hy  means  of  the  duck-liiliepeculum 
St  once  detecting  the  »e«t  and  extent  of  the  apennre.  Aa  there  is  jusl  possi- 
bility of  a  ooniniunication  exietiog  between  tlie  vagina  and  the  aninll  intes- 
tine, it  may  be  useful  to  beer  in  mind  that,  in  thin  case,  the  mtitler  that 

apes  ha«  been  found  to  be  yelhjwer  and  less  stercoraceous  than  when  the 
rectum  i^  openeil. 

The  Trtntmtnt  o(  the  noD-syphilitic  fistula  will  rary  according  aa  the 
fiatula  is  aimple,  or  contpHoated  with  lacerated  perineum. 

Simptis  untxmiplicaied  Jiecto-vof/iiiai  Fistula,  it*  it  be  smnll  and  recent,  may 
oocasionally  h<t  vloaeil  by  atleuti'm  to  c]eiinlioe.««,  at  the  same  time  that  its 
«dg«a  are  touched  with  the  nitrate  of  silver,  a  hot  irou  Hire,  or  thv  platinum 
loop.  If  it  be  very  large,  the  greater  part  of  the  posterior  part  of  the  vagiua 
having  b<>«n  destroyed,  it  will  probably  be  iucurablo;  but  even  here  the 
patient  Hbuoid  not  be  left  to  her  fate,  »ud  some  operation  should  be  attempted 
which  may  leaeen  its  size,  even  if  it  Jo  not  completely  close  it.  The  kind  of 
fistula  wlii'.-li  ill  ht^re  met  with  usuuUy  consists  of  a  circular  aperture,  that 
Rsdtly  admits  the  ptdnt  of  the  finger,  situated  just  above  the  sphincter  uiii. 
The  operation  lor  the  ci(j«ure  of  a  recto-vagitial  tistula  of  this  kind  contiatf, 
after  eniplyiii^  the  patient's  bowels  by  purgatives  and  au  enema,  and  the 
bladder  by  tlie  catheter,  in  iiitroduLing  u  duik-billtd  s]H:culuni  into  the 
vagina,  and  freely  paring  the  edgee  of  the  aperture.  As  the  fistula  is  always 
Low  down,  this  is  readily  done  by  placing  the  patient  on  her  back,  and  tying 
the  bands  and  feet  together,  as  in  Hthotoiuy.  The  vaginal  mucous  membrane 
should  be  dtsB&eled  oil'  towards  the  liiftula.  Tlie  next  point  is  lo  bring  its 
edges  into  appogition,  in  a  direction  transverse  to  the  uxia  of  the  vagiua;  and 
in  doing  this,  the  recommendation  made  by  CopeEand  and  Brown,  of  dividing 
the  ephincler  ojii,  should  always  he  acted  on,  as  it  is  a  most  important 
auxiliary  to  the  succew  of  the  operative  iirocedures  that  arc  requirwi ;  for,  as 
thereisalwuys  toss  of  substance  in  tht^si-nslulu',  thereisuecc^arily  a  lendetiey 
Co  tension  on  their  sides  when  any  attempt  is  mode  to  draw  them  together  ; 
and  it  is  also  of  impurtnncc  thitt  any  muscular  movement  about  the  parts  in 
the  ncighharhood  of  the  Hstuhc  should  be  arrested,  as  this  might  otherwise 
break  down  union  after  it  had  taken  place  between  the  edges.  The  aides  of 
the  fistula  must  then  be  drawn  into  uppoeition  by  silver  sutures  introduced 
bj  means  of  the  hollow  needle.     I  have  always  lotind  that  these  sutures  arc 

,Mt  easily  introduced  if  passed  from  above  doniiwarda — the  mucous  mem- 
'brane  being  then  drawn  upon  bv  the  neo<llc,  which  more  rea<lilr  transfixes  it 
than  if  it  he  introduced  from  below  upwards,  when  it  is  left  to  push  the  mem- 
brane before  it.  The  wirefl  are  thus  posted  across  the  fistula  and  out  through 
the  vaginal  mucous  membrane,  half  an  inch  beyond  the  freshened  surfaces, 
care  being  taken  not  to  incloile  the  rectal  mucous  membrane.  They  may 
then  be  twisted,  or  brought  through  a  leaden  plate  and  clamjied  by  shot. 
Th«  success  of  the  procedure  depetids  not  only  on  the  proper  completion  of 


848      DISEASSS  Oy  the  LAROK   INTK9TI2fl    JIXD  AVCI. 


the  tiepB  of  th«  o[>erati»o,  but  greatljr  on  the  nflertrMUMOL  TUi  AmU 
cocuist  ID  th«  itlniinUiniiJoD  of  o|iiuni,  to  prrvcnt  ll>e  bowrb  from*eti»fUi 
Ivi)  or  Lueive  dnys;  in(l«e<l,  utitU  lirin  uuiud  has  tnken  plaoe  Iwtvws  tk 
«mI},-4^.  Ttivr  limy  theu  be  niovvd  by  means  of  iaxatiret  aiMj  lAta^atntt 
euvmata  cnrcfullv  giwu.  iKiring  the  trvatowDl,  tli«  fmtu  abvold  U^ 
turbed  aa  lillle  tia  jiowible,  tlie  paticut  lyini;  'jO  ht^r  !iW1<*.  The  wttri^Nli 
bu  "irawo  uffbr  li  cathtrler  lwio«  a  day.     Tl  *j 

twice  a  (lay  »ith  Uiractc  ncJd   luliuii  or  a  e-  ir-or 

vliitrr  siiitfilc  niiri»p]>lic.  The  palJoul  uiu»t  l>t^  krpt  upon  ■  rvrj  nAriK 
dU-t,  ami  lIh>  etilclies  niuy  be  MX  in  for  eigbl  ilays.  when  tbcjr  aiHl  b»  Ol 
out  ami  i-arelully  iviiinveO.  EsbuuM  auy  puiat  uf  tlw  fljtula  ooi  WefcanA 
the  apiilk-aiiuii  ul  Lb«  nilrate  uf  eilvvr  iimy  tn<lu(.-«  pruper  uni"0  of  H. 

If,  as  verv  commonly  bapiwus.  the  Jtrtlo-vaginai  FtMuIa  heemmfdieattim^ 
a  LuefrateJ  I'wineuni,  tbe  ii|H.'rBlK>Q  fur  tliat  c<iti<lilluu,  •Irvcribcd  ■!  p.Mt 
vol.  i.,  must  be  perf-.rrme>l,  and  ibe  edgrs  of  tbe  fittuta,  laaeg  it»f|>lr  |«ii 
braiigbt  log«llier  at  ibe  Mime  time.  .Sometimrs  io  tbcve  mtn  i%  hHM 
ihaL  ibe  (teriiicum  uuilt-e,  leaving  an  anerliire  above  ifaia  Id  ibe  mli>-VMpiil 
eeptuni;  if  iIiIh  a|>erture  be  but  small,  it  may  be  doMftI  br  Its  algohilf 
touched  fruiu  Lime  to  time  with  the  netunl  tnutery;  if  It  be  Ur;^,  Hiilt 
allow  tl)c  iutniduetiiiu  of  the  fin|;er,  I  believe  that  it  b  gMiermllf  MdvM 
ntt^-nipt  to  chi(>«  thin  aperture  by  itself;  but  the  prriDenm  abualil  igaiaW 
diviilcd,  and  ihe  whole  operation  repeniMl. 

When  the  recto- vaginal  fistula  is  of  a  syphililtc  origin,  ibera  b  ■■% 
Bome  degree  uf  stricture  of  the  rt^rturo  asenciMl^il  with  it,  and  ■•  eilroanh 
exciirittted  aad  diaea«ed  state  of  the  vaginal  mucou*  titeinbrUML  la 
caaes  the  sutTeringa  of  tht;  [«tieiit  are  ntWn  very  grrat,  and  the  oatj 
of  relief  oppti  In  the  Sur((coD  i*  the  perfurmance  of  rulutnaiy. 

Ei)tero*Tesieal  Fistttlae.— A  lUtutuu*  coriiniuniatiion  may  t«  amfcl^fcal 
between  tin-  iole«liue  st  some  point  above  the  rectum  and  (be  bIwJdtr.  TW 
Hftula  usually  forma  between  the  eigmnid  iteiurr  of  tbe  mtb«i  aod  tbe  aHtf 
nnd  tfIL  lKt<:ral  part  of  tbe  bladder,  ll  it  \-Wib\e  ibat  th«  la&atl  istnlW 
tuny  be  tbe  teat  uf  thla  tiiftula,  but  moat  certuiiilv  eucb  aji  ocoirrvaoK  il  nn- 

I'u  these  cQlero-veatcal  HmuIo.*  there  is  usually  m  ]ou)f  uiltvrdeDI  hkt^ 
pointing  to  cancer  of  the  inteniiiiul  wall.     8<>nie  obteurv  bardntH,  vil^ 
deruae  or  occasional  shoutiiig  |Kiin».  is  then  uiet  with,  and  toJdcalf 
patient  ulwcrves  in  bis  urine  bouie  dark  odencivc  depm-it,  whicb.  on 
lion,  pruvcs  to  be  fecuk-iil  matter,  with  or  without  tlic  racape  of  Aaiua 
uri;lhru.     lu  other  enees,  aner  more  tliau  Ufciial  pain,  with  ngon  and  ll 
atituliiiiiui  iFVmptouia  indicative  of  suppumlioii,  tbe  urine  will  ba  6<eBdto^ 
ItKidrd  will)  pus  of  a  stinking  chnraeter.     In  a  few  days  feces  will  »|^w  (■ 
it,  und  flalu!!  pUMi  through  the  urethra.     In  either  ruse:,  adba.'siuo  hatftra^ 
Itetween  the  intestine  and  the  bladder.     Perforation  takea  plat**,  aad 
intpT'tinal  omlenls  eaeape  either  directly  into  the  bladilrr  or  thnna^k 
cavity  uf  an  intervening  ahtce»».     The  bladder- irritation  it  tMsallr  si 
Inil  trilling  ;  hut  aftrr  u  lime  eyslitia  in  devrlnprd  and  pbapphai"  'H""**'?' 

The  trratmrnt  in  the  early  stngfB  ehtrtild  ennnt^t  in  elenr'  ".e  W""* 

with  rastor  oil,  and  il»:ii  h-fkinn  t.h«-m  op  for  in  or  14  -i  wtB,*" 

as  to  give  the  linluln  n  tbnnce  nf  closing.     ^  -ftt^^ 

be  wiwihi-d  out  twice  dnily,  ntid  if  the  palt'  -  ■»#• 

render  life  «  hunlen.colutomy — a  palliative  tiie»pur<*— nut*  bt  rvw»M«i!*^* 
cvstotoniy  may  Ive  done,  nnd  thus  n  wider  outlet  for  fecea,  urioc,  tftd  1"^ 
afforded  through  the  |>eriueuDt  iban  the  urethrm  perttila. 


■„he   ■ 

irtB 

«ad 

ll 


ULCER    AND    FISSURE   OF    TBS    AXUS. 


84S 


CLCEK  AND  FISSVBE  OP  THE  ASUS. 

Thi«  dtsense,  (hough  trivial  tn  pDiut  of  Sim  aud  ia  its  p«tholnj;ical  rela- 
tions, i»  itl' grefit  praclical  imptirtance,  oii  acciunl  of  tin?  txcwsive  lr>ca]  pain 
ati<l  great  ciniitiuitionnl  irrilutioa  to  which  a  pnticnt  labnring  uoiler  it  i»  often 
fiubjvct.  Uk*er  an«t  fissure  cunitnnrily  «xint  togethtr  Jti  tliia  situation,  though 
it  by  D"  means  mifre/iiienlty  hiippetnf  that  the  twi»  comlilions  occur  separtttely. 
The  ulcer  IB  usually  nf  ttmall  eiize,  Bcldom  larger  Ihaun  silver  three-pt^Dce,  of  a 
circular  or  longituoiaal  shape,  siiuitted  between  the  Ibhtsofthe  nnicous  luera- 
brnne  in  the  upper  part  nt'  ihe  uuus,  or  rather  the  lower  part  of  the  rectum, 
ju8t  abtn'fl  the  riug  or  ledge  formed  by  the  ephtacter,  and  i»  usually  met  with 
towardfl  the  posterior  pan  of  the  gut  on  one  ilde  of,  or  oppoeile  U\  the  point 
of  the  coccyx.  Occasionally  more  than  one  ulcer  exists  m  this  situation.  If 
a  figure  Hcoonipany  the  uteer.  it  commoDly  leads  from  this  across  the  fatie  of 
the  sphincter  to  the  ver^c  of  the  anus;  but  in  many  ca-aes  one  or  two  figures, 
someuoie^  c-vcn  three  ur  four,  eii^t  without  any  ulcer.  The  fi;?«urt«  ere 
usually  slightly  indurated  and  cord-like,  eitending  merely  through  the 
mucoud  nitudirane,  scarcely,  if  at  all,  impliciitin);  the  deeper  etrucluros ;  nnd 
not  uiitreqiienily  their  external  tcrminattDn  is  concealed  hy  a  siunll  red  pile 
or  flap  of  intfg-uraoiit. 

Tlie  cxlitence  of  the  ulcer  may  usually  be  determined  by  explnring  thft 
rectum  with  the  finger,  which,  if  praolisoii  in  these  cxaiuinalionH,  will  delect 
a  small,  mift.  and  velvety  p*tch  at  the  diseased  spot;  on  Louchinj^  thin,  the 
patient  wilt  usually  cimpEitin  of  acute  oud  burning  pnin.  In  some  raxpjitiie 
ulcer  may  be  brought  into  view  by  examining  the  rcctuni  with  the  apecnium 
ani,  here  delineat^  C^'E^-  '^^^  ^^'^  811).     The  fissure  may  always  readily 


rig.  »i«,— AmI  Oilitor. 


Ftg.  8li,— dfitMilnia  Aai. 


be  detecleil  by  everting  the  mucous  meiiibrane  nf  the  anuii,  and  by  lifting  up 
Qr  turning  nsidt!  the  pile  thai  cuvers  the  lower  end  of  the  crack.  During 
tbu  esHndiiatirtti,  it  will  iiiually  be  found  that  the  sphincter  ani  is  in  a  more 
or  leaa  etKismodiuHlly  contracted  slate,  Hdriiittiug  the  linger  and  lUHtruraenc 
with  fiifficulty. 

Symplmnif. — The  pymptoms  of  ulcer  or  fissure  in  the  boub  are  very  character- 
istic. The  [Miiient  complains  of  pain,  usually  of  a  severe  burning  charnclcr, 
on  the  paatuge  of  u  niotiun,  especially  if  u  hurd  one:  it  commonly  occurs  at 
the  time  of  deJecation,  but  occa&iouaijy  commences  a  few  minutes  ailerwards, 
TOI~  u. — M 


850       DTBBA3CS   OF   THE    LARGE    1NTE3TIXK    AKD    AMU9. 


anrt  cnntinupA  from  Imlf  an  hour  to  several  hounit.  This  pain  ir  very  Mvero, 
and  ]ieculiarlv  wfuriii^  niul  burniii);;  it  is  gcnf^rally  rhwI  fiiU  (>|ii»(«ite  the 
aacro-iliBrHnu'ulatiuii.  but  not  oiitrt'<|tiei)tly  nitliatpiirnunil  I hn  pelvic  mf  <loirD 
thetliif^hs.  In  mnny  cuuee  it  proiinrets  ii  gotxl  tleal  uf  cutiliiiufil  irritalioQ 
about  the  geiiiln-uriiinry  nr^'ans,  giving  rise  to  aymptomB  of  spaemiKjii-  etrio- 
ture  ;  a  fwijiicnt  rfwire  to  urinatK,  tennerness  atioiit  the  prrwtace,  and  f>«niiual 
eini»i(»ni».  Tht-  pain  \a  ennietiines  so  sevf re  that  the  patient  avuidu  Heferalioo 
M  long  as  pfwilile.  an<l  even  flbfltainn  from  fowl  with  the  view  of  Iei>wning 
the  ntfcessity  for  the  fpei|uency  of  this  act.  Very  commonly  in  witrnen,  the 
naina  prrKiiiceii  by  ilie  rectal  Hiscnpe  simolale  those  occaflioned  by  uterine 
irritatiiin  ;  ami  in  lii>ih  sexps  ihey  may  after  a  time  become  continumii.  and 
be  Httetided  by  n  guiMl  deal  rtf  constant  iinen-iineso  in  sitting,  so  that  the 
pntienl  is  til>Iige(l  in  rflisethe  hipof  the  affected  side.  There  i<t  often  a  streak 
uf  pus  or  hlofkd  on  the  feces,  and  commnnly  a  good  deal  nf  mucous  exudation, 
with  Some  tenesmus  on  iletecntion  ;  but  in  some  instances  these  Kvmptotns  are 
aluigether  absent,  and  the  patient  never  stiffei-s  any  local  inconveDieDce  except 
from  the  [tain. 

Tilt-  conKtitutioiint  irrilaE)<in  is  often  very  great,  the  nervous  syslem  jjoiht- 
ally  uympatliiiting  with  (be  local  mi?chi«f.  The  couulenance  Wcomea  pnle, 
anxious,  careworo,  and  the  patieut's  exjtrewion  is  indicative  of  cotmiaot 
su  flu  ring. 

Oiruex. — Tliif  aflecli'm  most  conimonly  occurs  in  women,  especially  in 
thusu  of  a  hysterical  temjjenimeul  and  weakly  constitution.  In  »<ime  caMS 
it  acems  to  have  arisen  from  injury  during  ialwr,  When  met  with  in  mva, 
it  is  most  frciiueutly  seen  in  debililated  Buhjects,  and  appenrv  to  ht  the 
resirlt  of  a  bruketi  slttt«  of  bvalth.  In  persons  who  have  been  the  snbjvcts 
of  the  chronic  dysentery  of  hot  cliniales,  I  have  several  limes  notice"!  a 
peculiar  form  of  pntcliy  ulceration  within  the  rectum^  of  an  extremely  irri- 
table Bud  verv  inirnctable  character.  I  have  in  several  iuslances  oI)scrved  It 
ill  women  to  be  of  asypbiUlic  nature,  and  in  f uch  cases  it  is  situated  generally 
tonanl!)  the  side  or  the  anterior  part  of  the  nnus. 

The  rectum  may  be  injured  by  blows  or  falls  upon  the  sficnim  or  coccyx. 
Fissure,  Incerniinn  of  the  mucous  membrane,  rupture  of  the  inuseulitr  fibres, 
or  even  detachmeut  of  the  nholeof  the  rectum  from  ita  couaectiuns  with  the 
EAcruni  and  coccyx,  may  ensue  from  these  injuries. 

TrealmtnL — The  treatment  of  fissure  or  ulcer  of  theanus,  vben  tho  dtKoae 
ia  met  with  in  the  early  stages,  may  sometimes  be  successfully  conducted  by 
the  application  of  nitrate  of  silver  to  the  fissure,  and  the  use  of  an  anodyne 
or  astriDgcutsuppiisitory.  I  have  found  a  very  excellent  and  u^ful  sop[H«^- 
Utry  in  ibis  and  many  other  ptdnfut  aHectious  of  the  anus  to  be  eooi[Ki«ed  of 
2  grains  of  exlraot  of  bellad<inna,  2  grains  nf  the  acetate  of  lead,  und  4  of 
tauuiu,  made  up  to  a  proper  couBistencc  with  a  Uttle  cocoa-butler.  Thia  may 
be  inlrodured  intfi  ibc  rt-clum  every  nip ht  and  allowed  to  dissolve  ihcre; 
the  buwi-U  should  at  the  same  lime  be  kept  gently  open  with  caalor-uil,  or 
the  lenitive  electuary.  In  those  cases  in  which  the  disease  has  been  of  some 
atauding  these  means  will  not  suffice,  and  it  becomes  iiecesiary  to  have  re- 
course III  a  very  simple  operation  to  effect  a  cure.  This  eonsisis  in  dividing 
the  sflceted  niuenus  memliranc  through  the  ulcer  or  fissure,  with  possiblv 
some  uf  the  suhjauent  ^brcs  of  the  snhinoler  inuncle,  Uv  nhich  tlie  part  iit 
•et  at  rent,  and  eiralrizutton  speedily  lakes  plftc«.  The  relief  after  ihe 
operaiion  is  usually  immediate  ;  indcfd,  after  lis  performance,  a  patiient  who 
baa  bein  suReritig  severely  for  niontha  or  year:t.  will  often  (lei  ccnipli-ie  and 
alnir«t  inaiantaneoui  relief.  The  merit  of  inlmdueiug  this  plauof  1re»t- 
meiit  for  ibe  core  of  ulcer  and  Gsaure  of  ihe  :imis  inlo  ^iir^iral  practice  is 
duelo6ir  B,  Brudie.     Boyer  had  previoualy  recotuitieoded  that  the  B])hiDcter 


I 


I 


i 


ACDTE   ISCBIO-SECTAL   ABSCKSS, 

lift  be  Mil  complctrly  aoroa*.  in  order  that  its  action  might  be  pnnilv£«1  ; 
~tro>lip  tutiiid  iliHt  the  ulv«r  could  be  nmclu  to  btral  b»  readily  by  the 
iDcifi>.>n  iibv've  njeotii^Ded.  The  n|)erutiaD  t»  resdily  dgne  by  iiitro- 
»g  Ibo  left  furetiDger  iatu  the  rectum,  guiHing  sIttDg  it  a  jirobe-pointeil 
ITT,  and  theo  cutting  donruwapl*  and  uutwanls,  carrytag  the  knife 
tin?  eighth  of  bd  iaeb  in  depth.  No  dreHiog  is  requirtnT  after  thii 
itvio :  bat,  if  the  incision  du  not  readily  beat,  it  sliould  be  touched 
Uw  bottoro  with  the  nitr.tie  of  silver.  Tbe  patieot's  bowels  ahoald 
%•  w«ll  opeil«d  befjrc  the  operatiou,  nnd  a  dose  of  caintoroil  may  b«  gnea 
oa  tb?  wcond  or  ihinl  dhy  ailer  it,  Duriog  the  proocaK  of  cicatrizatnm  il 
will  '.'U**a  tie  advauLa^eotu  to  f;ive  iroD,  auii  to  jHit  Uio  patient  oo  a  uourUh- 

qitniwlio  Cootraction  of  tlie  Sphincter  Aui  is  usually  a^oeiated  with 
ftaure  ur  uJccr  of  ihe  anue,  or  iiidtiMimutorT  irritation  of  some  ueigbboriog 
Hgan ;  but  uceuiuoally  ii  oo;ur«  without  tliis  coiuplicalioD,  auJ  in  all  cawa 
k  mmj  bs  eoDoec-iotl  wiili  a  uuumlgiu  ci>aditioD  of  the  part.  Iii  by>stA'ri(uil 
Dwnea.  this  neuralgia  and  «paBin  are  especially  upt  lo  occur ;  though  it  is  not 
faquulMble  that,  in  many  of  the  so-called  caws  of  neuralgia  of  the  nuus, 
•ane  poailive  diwttM.  such  aa  asmiill  ulcer  ur  6asure,  may  be  delocted  on 
iIms  examinttion.  tu  I  have  had  several  ocoasiuna  to  verify. 
Mffhe  T^'ilmeiU  of  contmclinn  of  the  flphiucter,  wht-ther  associated  with 
^pnUpa  or  not,cuitfii.tii>  in  the  fruploymont  of  W-al  st-ylattru,  especially  the 
cnran  of  bcllatlonna,  gr.  j  to  gr.  Ij  lu  u  aupp^tory  ;  tho  bowcU  being  kept 
Ffllrvr^l  by  etiemala  and  confectina  of  «:nua.  Slii^uld  tht-ne  means  latl,  the 
'  iiiuaL  be  anii'vthvti^ed,  and  the  tphincter  forcibly  dilated  with  the 
u'r  lingern. 
P' Atony  of  the  Beetnm  is  c^>mmnn  in  middle  age,  in  those  who  lead  «^)en- 
nhrr  liv*-*,  and  vj'ptJciaMy  io  wnin.-ii.  Thtd  on  litiou  i*  the  consequence  of 
ko>l  N-«tl*  to  tmlMtual  c-juxttpation,  the  wall*  of  the  rectum  benmitng  ex* 
psnilnl  nnl  |K>uvhdike.  It  may  occfl«ii)o  the  retention  and  iinp.tctiun  of 
Lsr\lrnvil  feces.  A  mut*  of  t-lnvey  cousidtence.  and  ae  large  as  the  fuitat 
head,  rormtng  in  the  rvi'tum  and  inlerferiug  seriously  with  deleeatiuu,  bc- 
Mmes  a  source  not  only  of  great  di^^omfurt  but  of  serious  ill-boalth-  Like 
aU  ntaioed  excreta,  it  sluwly  p^ii^Kiux  the  systvm,  giving  rise  to  fuul  brenih, 
dir^  grayish  ciunplexion,  and  mental  doprmioD. 

ifht  TVertfaww/of  aiony  (d'thcret^-tutu  crnaistB  in  scrupulous  oare  in  emptj- 
ing  Uii*  bctwele  by  the  ad'miui^ttralionof  coUcoeioata.  If  impaotim  'pf  feoat 
have  orcnrrer).  thi!)  is  tu  be  reniedivd  only  by  putting  the  {mticnl  under 
cbloritlonB,  forcibly  dilating  l\ia  spliioflrr  with  the  hood,  and  breaking 
duwo  ibe  hardeneil  mat«  with  a  liihoiumy  tiroop  or  iron  spoon,  washing  it 
rilb  eneinaiu,  and  thi>4  clearing  out  llie  bnwel. 


^BUlLb 
VUIBCOS 


ARtiCRHB  AND  PtSTXTLA. 


not  uafrc<{iieoily  occurs  in  the  vicinity  of  Ihe  rectum  and  nnin. 
It  may  either  be  aujwrGuial,  being  coidiii>;d  to  the  muco^utaneous»lruc(urca, 

mn*.  r'-ing  Uie  ordinary  chariicterd  of  auiite  8ubcutiinet>u8  abttcess:  or  it 

m:  i>ly  seattHl,  forming  in  tho  Ischio-rvctal  fiMSO.     It  i«  thesu  ischio- 

r«c-.tti  aiMcesan  that  arc  of  the  niuat  praclicsl  inijMrtiince.     Tbcy  may  be  of 
two  kinds— AtfBte  and  Cbrooic. 

Aevta  Iithlo  rectal  Abtceis. — This  forms  dcoply  in  the  f  issa,  with  tbrob- 

bfn!>,*h->-><iii{;.and  .Hiiililiiit^  [istius,  through  the  ann^,  rectum,  and  jx-rineum  : 

ii'in,  n  hani  branny  aubetance  may  be  felt  in  the  art.-olHr  Iteaue 

of  the  gut,  eillier  by  exuniinaiion  from  without,  or  by  explora- 

twiD  tiiniugb  tKe  rectum.    |i  speedily  soften*,  and  will,  unless  an  ouiloi  be 


862       DISEASES   or    TBK   bABOK   IKTItSTlKE    AJTD  AVCI. 

made  fur  it,  bunt  t-ttiier  ejcivrnallj,  or  iolo  tiie  cnvitf  «f  th»  pt.  or 
W1T8.     '  Vide  p.  895.  vol.  i.) 

Cbronio  IacoIo  recta]  AtMC«ea  occurs  iii»iiliuu«l;r  in  penow  uf 
bnikco.  or  nlithi^ica)  cotwtituiiona.  WUliitut  Diuvb  uda  or  heal  iiww 
oiMK-v,  n  ouIlrcliuH  nf  jjue  rurnm,  n-hi<.-li  in  mtually  linitlMl  lo  vh  m)e«f  Ai 
iiicliio-rtfctBl  fueca,  but  in  other  r«i:v«  ac()uirM  cmuiderabl*  oh_ 
nudiog  llic  gut  to  A  cotihii  If  table  extcDi;  in  fact,  alntuat  ranaBnifiH  ti 
rL-ctuni,  nnd  l)i«.'n  »prc-ndiiig  wi(l<Uy  on  tbe  Datr«  i>r  liip,  pmnuiag  all  te 
onlianry  tliHrttcUni  of  a  chronic  ahipcevft.  Tkw  kind  ul  puraWat  «4lMliB 
may  foitu  iu  ihi^  as  io  uiiy  other  mtualion  in  llic  l**  '  '■•■  rmUW <■»■ 

iftHttun  or  of  Some  local  irrilation.    I  hare  M*vrrul  ti  it  Ml**  Uc^ 

hIdWB,  or  bruii>(A  of  the  lower  part  of  the  Ivmly,  or  i>-  >  .t^imkc 
lowcriji;;  ol  the  vitality  of  the  man  of  arcolMaili]hr-,  u  ■  •-  >ta  tiM 
rectal  Ivmsu  by  weakly  [wnsorut  sitting  ou  a  cold  M.itir.or 
time  on  the  icc  or  enow.  In  i>lher  cftuc*  the  initK-hief  i., ,  ■ 
arouud  tht  proMate,  and  an  abaci'M  forming  in  tbie  »iiunt»ua  aiay 
way  dowu  by  the  side  of  the  r«clum.  tiir  B.  Bnxtie  attribuli^  Unait 
acenea,  and  tbe  cooaequcnt  6atulK.  to  pcrluraliotw  of  thtf  mumot  tmmhM 
oftfa«gut;  and,  although  llhiuk  he  exKpwmiwI  ihc  frcqocBcy  ol '*■-•"■ 
uf  producliou  of  Ibe  abn-v»,  yet  there  catiCe  uo  doubt  that,  in  mmt* 
at  least,  it  occura  a?  the  result  of  perfontttoo  ol  tbe  bwwol ;  tilba  tn  m-r^ 
tiuo  from  within,  hy  the  formaiioD  of  a  6aaure,  or  by  aooe  fiinifB  U«lt,a 
a  tisb-bi'De,  trani-fixinK  it.  and  ihua  iodiiciag  inflanimatiati  ia  tW  anihl 
ti><iiuc  outside  the  rcctuni. 

Tbn«  Bl»ceta(8  are  mwt  comtnoti  in  yoDnt;  adalti — not  unfn<|onri  i* 
middle  age.  but  ran?  at  cither  of  the  extremv-v  ot  life.  I  Lave.  howcifr.iMl 
several  caan  in  children,  two  or  three  yeura  of  a^.  fttld  tbo^  mar  BanKlrf 
require  operation  in  Bepiuagenariaaa.  • 

IVeatmmL — In  ihe  treatment  of  these  absccnn,  the  priiiripal 
prevent  exteiiuve  dcnudntioD  of  the  gau  In  onier  tu  do  th>-.  i 
mutt  be  opened,  so  tuiin  aa  the  formatioa  of  pita  mo  be  aaren 
mVta  plae«,  by  making  a  free,  and,  if  necewarr,  a  d<vp  Iulj^..^  .^^^ 
itfchi'V rectal  apace  by  tbc  6idc  uf  the  bowel,  t'nlert  thU  be  dour,  itaaf 
ciihiT  burst  int<i  the  interior  af  the  gut.  or  apread  wi'1  ''-  -i:  ;t  tbe  aatatfl 
then  eivc  way.     Ttie  pus  that  i«  lei  out  ui  tbeae  •  -  ia  almyso- 

tremely  oflcjuive,  cvcu  though  ont  miitsj  with  au_\  ikuiul  mattor;  lb 
near  neighborlioiid  of  ihc  bowel  apitearing  to  deltrtuiuc^  Mitue  efcaapiall 
that  rrnilcnt  its  aniell  (iceuliariy  stt  rcorui-toius,     After  tli-  riarflii 

ulwoer-s,  ihu   psltent   i\reU  ea»y,  ami  thtuka   tlinl  all   i>  >>  JiMutV* 

icriuliiitlly  liviiciiiiit;  imd  the  cavity  coutractiug ;  but  It  tt. 
listidu  Hill  Iw  l*^ll,  which  couliiiors  1»  rxude  a  ihiu,  m:i     .  . 
leculeut  iiiull(-r,  |it;rhn|i»,  iitcumulnle*  fn^iui  time  tu  tlutf,  ipviug  ttm  ivifUft 
outbri'itki>  iiud  exlciiMittin  id  tlit^  disease. 

Anal  AbsceiB. — nt-Kid'b   the  tmi  loritU  of  alwcCM  ju>l  '■  ^Ot^f 

TlUff  ill   ihe  i«cl]i<>-rectul  I'>.>i<mi.  ariollier  ia  rontmottly  tw  iliAut 

trrtii  anal  ubaceiis  may  b«  applied.     Itcommrttcca  in  tbv  >•  i<  U«a»w 

the  gut  immt'dialely  nliove  tbe  anus.     Itti  cause  ia  uoi  it.... ..^  ..xkat.  » 

may  H rise  frotu  i>u]»piirHli»n  taking  place  brumtli  an  tndatncd  pUr<'i* 
wound  of  the  muci>u«  menibraiic  by  some  S"liil  b-wly.  m- '  '^-b-kaili 

the  lecta,  or  from  the  furiiiiilion  of  a  cascating  tutwrcglm  u  IW"^ 

nufXHM  tieauc.  The  pua  thua  formed  burruvra  dowowartu  tKi"«ra  tb 
Buooua  sad  muscular  cunis  of  the  bowel  till  it  raaeb«a  thr  ttw*:  tfUt^ 
liBNrs  out   licneBth  the  Fkiii   nnd   forma  a  auiaJI.  r-'  '^ 

marftin  of  the  aiiua.     If  uurelirvp<i.  it  may  burrow  r  .  '* 

outaii«i»u8  tiwue.     The  pua  in  tbia  case  lies  superficial  lu  tb*  tpli*"** 


A 


m^ 


riaTtJLA  ly  ako. 


Thosp  oliso«Mp»  may  he  nciite  or  fhronir  ;  when  clironic.  ihcy  flpc  frei^ucntJy 
tuhtrnulnr,  arlvniicin;;  slowly  ani\  ciMiUinint;  thick,  niirdy  pus.  They  burst 
Udunlly  b«)lh  internally  nnd  exlernnllT,  and  are,  perhaps,  the  most  commou 
cause  of  ihe  itnltnary  fistula  in  ano.  Rv  early  npenin^.  and  iJrcMinii;  with 
wet  bnracic  aoiH  lint,  and  frequent  bathing  wiib  a  onncentratod  nnlutiaa  of 
bnracic  acul,  th«y  can  eonietJjntf^  lie  n-'l  to  lieal  uilhnul  leaving  a  ti.«iu)a.  If 
they  are  tijhcrcnlur,  tliis  »«l<lom  hniipeux,  and  iKp  hf«l  (rwilnient  i«  to  lay 
them  thomughly  «peo  iuto  the  huwel,  lu  i^crape  the  surface  well  witit  a  sharp 
•jMinn,  Kod  Utdrese  them  with  ioiloform  ointment. 

Fi;*TUl>A  IS  Ano. — The  isiuu*  left  by  the  contmclion  of  the  cavity  of  an 
incliio-rectjil  or  anal  ahscww  constitntes  a  (ielufa  in  uno  ;  at>  flUi-cti'm  that  haM 
Bllracte'i  n  u'wjil  deal  of  atleuLi'iD  from  llie  fretjiieiicy  of  ita  occurrence,  and 
frwm  the  diOiouIty  of  curing  it  without  huviug  recourse  to  operatiou. 

Krtrfti, — Wlien  followinji  ao  annl  abscwe,  the  fistula  is  very  liruited.  being 
ruerety  the  sinus  left  iu  the  subroucoua  areolar  tissue  uf  the  anue  after  the 
bunitin];  of  the  superficial  collertion  tif  pus  in  thin  situation,  extending  to  a 
short  dislaoiw  up  the  gut  inside  the  Bpbincler.  This  form  of  futtuta  cousti- 
tutes  a  kind  of  spiiriouR  variety  of  tlio  dinpaae ;  for  the  true  iiatula  in  ano  is 
outside  the  tphincler  in  tliE^  ttnrroiiiuiini;  areolar  ti»iup,  t^xtendin^  always  as 
high  BH  the  upper  niar^iti  of  that  nuiKcle,  and  frcipifntly  Ktrt^tching  to  a  cou- 
siderable  dlHtanre  tip  the  F<ide  of  the  gut.  Mi>nt  frp()uently  the  lower  aad 
external  aperlnre  of  the  lintula  ie  ainglr,  and  is  Hitiiat^d  by  the  Bide  of  the 
BDUB  in  the  isohio-rpctal  fowa,  just  beyond  the  sphincter;  but  not  uiifre- 
quenlly  the  apcrtiire  in  in  the  peritieum,  or  pusifriorly  in  the  coi-cygeal 
region.  Occasionally  there  ia  a  (i:*tiiloii.i  oi)eninp  on  each  side  of  the  gut ; 
or  ^svernl  openinge  may  exist,  and  then  siiiuseR  extend  from  iheac  upwards 
and  outwards  to  a  considerable  dlscaiice,  un<lerniining  the  integnnienlM  of 
the  perineum  about  the  biutockfl,  even  glretcbing  away  towards  the  tro- 
chanters, and  opening  at  a  groat  distance  from  the  bowc).  These  cxteasiTO 
fiitulx  and  siouxc*  are  frefiueotlv  cftaneclad  with  stricture  of  the  gut:  bat 
theY  mar  occur  without  thin  in  «fd  and  neglected  cases  of  the  simple  disease. 

The  fiBtula-  are  usually  ohlifpic,  but  straight  in  their  direction  from  a 
fkotnt  half  an  inch  or  an  tneb  from  the  anaf  aperture,  running  upwards  to 
above  the  sphincter.  In  some  cases  they  are  torluoiis;  and,  occasional  Iv, 
'when  opening  at  a  dintance  from  the  gut,  and  extcnsivelv  undermining  the 
integnmentfl,  they  are  niij^ular,  having,  as  it  were,  an  elbow  at  that  jioint 
where  the  nupertirial  Bi'nus  raefta  the  deep  listulu.  This  peculiarity  will 
prevent  the  paMage  of  a  pntbe  thrmigb  their  wbo)e  length  until  the  external 
•inus  has  been  slit  up,  and  the  commencement  of  the  deep  fissure  reached. 
aud  may  lead  tu  the  euppositioa  of  the  fistula  being  more  superficial  than  it 
in  reality  is. 

Varieties. — Fistula  in  ano  is  said  to  be  Complete  wh^u  it  communicwtes  by 
one  end  «ilh  the  interior  of  the  rectum,  and  opens  by  the  other  upon  the 
external  surface.  It  is  said  to  be  Incouplttft  when  it  has  only  one  aperture, 
whether  that  be  external  or  internal. 

Complete  Fistula  \e  the  most  common  form.  It  probably  arises  in  Ihe  ma- 
jority ofca«j8  from  tonicsourceof  irrttntton  seated  within  the  bowel,  by  which 
the  lunnous  membrane  of  the  rectum  has  been  perforated,  and  an  abscess 
baa  formed  in  the  areolar  tissue  outside  the  gut.  The  external  opening  in 
tbie  rnrm  of  fistula  is  usually  from  half  nu  inch  to  an  inch  from  the  mar^iio 
of  the  anus;  though  it  may  be  ideated  at  a  greater 'listimee  than  this,  as  upon 
(be  hip.  It  is  commonly  small,  and  hntK  a  viiaeulnr  granulntion  projecting 
from  or  occluding  it;  nixl  u  thin  purulent  discharge  usuitlly  drains  away 
from  it  in  amall  ipiantiliefi.  moistening  the  surrounding  intcgumcnis.  The 
internal  ojiening  is  usually  situated  just  above  the  aphitieier,  where  the 


«  anally  mmimi;.    It  ii  i 

~    fmk^k,  bv  Minulaliaf  JU  iMliv 
i  «ift  •  Hobe  ilibpBJ  lA  MBk  aai 

«M  nnonri  in  tli»  ni .  bK  k 
•K  ••rirtT  of  ti<'  ■*■—•'     '•» 
Ala  [ot  6tiv. 

■  far  jnn  withovl  ;»■(■■> 
*iliifai>t  t^  pamlkakk 
.  a^  ia  banoK  iW  AiaU  * 

^    diwa  hT  tW  •{)»»<«; 

of  tbt  mam,m*h 

ft<M  ife  kiouB.  wdt  to  kal  tf 

Ibr  ik>  divyMu')^ 

in  BUnBj4>  to  AiMff 

^   *•    -__         l/tW  fiHnU  h.  itftt*^ 
if  Uk  W  (4'  •  M%<^ 

U*  U  « ■wbR<i' 

<r  1^1  ■>  fcac.  Ar^kmmd 

5  bed  n*dil  V  nc»tfi»    '  * 
a  HNMr<lL>t   cJiMftic  ^B  > 

rftWafchmr:  iftiMbtiiuMwlji&x 


ArrCR-TREATUBNT    OP    PJ8T17LA    11 


85S 


burMiiii;  of  lUv  nUscess.  or  Ht  aay  time  ir  there  be  mucb  iiiflaRimtitioD 

••II,  lliv  wuuiiil  iu  Hpt  t'>  a&iunu!  a  sorneuhat  filuu^liy  conilitit)0,  nuJ  Ui 

vith  groat  ililUoulty.     The  must  importnut  quratiuo  usuaUy  couueuted 

oiieraLiuu  ut'  dolula.  \i  the  propripty  of  perftirtniiig  it  iu  pblbisical 

ll  is  a  well-kiKiwn  fdct  that  fistula  in  bdo  is  eeprcially  apt  Ut  occur 

iniptivt!  io^Jividualii.  aud  it  is  iil\rn  a  aioe  poiut  lu  (Ivierniiue  wbmber 

itiuD  should  <ir  bIiuuM  out  be  performed  in  them  ;  tii>w  far  the  drain 

fistula  may  keep  up  or  even  generate  iha  teailency  Ui  phtbiais,  ut 

&r  it  may  lie  »alutiirv  iu  acting  ta  a  counter-irritant,  and  in  prevvntiag 

the  morhia  condition  of  the  lung  from  ■levt'btpiiig.     Theo- 

pbilu«  TbnmpMon  baa  stated  thai  the  ooexistr-urt;!  of  6dtula 

will)  pbllii^U  ap|»ear«  to  retard  tlie  progress  of  (be  latter  dia- 

eaae.  acting  ua  a  derivative;  aud  in  sixitt;  instances  ihia  majr 

be  ft)i.     I  imve,  bowovtrr,  in  «cvoral  cases  found  coiuiderable 

advatita^ie  result  from  uperatiug  for  lialula  in  the  early  stages 

of  pbtliiatii,  or  in  8UK|)Ccted  casea  of  that  disease,  the  patient's 

heallh  having  cootiderably  improveil  after  tli«  hvaling  of  the 

listuin.     But  in  cooBrmed,  aua  atill  letia  iu  advaiR-ed  plilbisis, 

no  operation  sboutd  ever  be  practised  ;  as  the  wound  will  doI 

hral,  and  the  patient  must   De  weakened  by  the  additiooal 

diceharge. 

The  operation  for  cvmpUie  fistula  should  lie  perfornied  in 
the  following  way.  The  bowels  bav- 
ing  been  wvll  cleared  out  the  day 
before  with  a  dma  of  catilor-oil.  and 
an  c-u<t?ma  aduiiiiisiered  on  Lbc  murn- 
lug  of  the  operation,  the  patient 
bbuuld  be  laid  on  i^u  left  eide,  niih 
the  uaiea  projcoiiDg  over  tbc  edge  of 
the  bc«i :  u  pmlie  muni  then  be  piuiKil 
through  tlie  tietuloua  truck  into  ibe 
rectum,  ami  the  Burton,  iuiroduo- 
ing  tbc  forefinger  into  the  gut,  feels 
for  the  eud  uf  the  iDslrument;  be 
then  poises  a  sburt  slnuig-bladtd 
proVte-poinled  hititiiury  of  about  the 

tiee  and  9ha{>o  of  that  represented  in  Fig.  8l2throtjgh  the  6»- 
luln,  uiung  tb«  probe lU  a  guide,  tbixi^b  in  M>tiii^  ra^eM  tbU  may 
|««titeptly  be  iii*|n*iiH'd  wild.  When  be  feeU  the  end  of  tin;  knile  pr.ijwt- 
ioto  the  rvctiitn  throu^^b  the  iiit^Tnal  a|>ertiire  of  the  fi^tuld,  b«  buoks  bia 
tfingrr  over  it  i  Fig.  •NU!),  after  withdrawing  the  probe,  and  by  a  <weep- 
and  pr(win[f  mf,  rabiiig  the  Imiidle  of  the  in«tru(iieut  at  the  same  time 
be  pUBbri»  down  itx  i>i>iut.  bring*  both  finger  aud  blade  out  at  the  aual 
tare,  cutting  through  tlie  whole  tbickue>«  uf  tiie  parts  between  this  and 
^-•■■U.  »i.  118  to  lay  the  two  caviliet  iuto  one.  Oirv  almuld  be  taken  to 
-pbinclrr  in  a  diroet  and  not  an  ubliquc  manner,  lest  u  flap  or  fold 
li,  •'•.Itch  will  interlcrD  with  the  pru|ier  beuling  of  the  wound.  Iu  [kt- 
ling  ibis  iiperatioii,  the  Surgeon  should  cut  with  hie  left  hand  if  the 
be  u|H)n  the  leii :  uu<l  In  either  cafte  should  be  careful  not  to  wound 
biaowa  linger,  at  aurh  cuta  often  prove  truubleeonio  iu  healing.  WluTe  the 
«>trmal  aperture  uf  a|ieriunr3  of  tlu'  tistuln  are  at  »trne  distance  fmm  the  gut. 
lb*  iotc^menia  being  underniintMl  to  a  c«iusiderable  extent,  )>erba|H  thinned, 
■>ft.  and  Idiiixh.  all  the  RU|KTticial  siousea  sbnuld  be  alit  up  :  and.  i»  lhf«e 
is  which  the  coumeol  the  fistula  runs  mure  or  le«s  at  a  right  angltwith 


.«1S 


M    nt>. 
fcr  rii- 


¥ig.  S13.— OpviaUoa  for 
Ft«lul*  !■  Aa«. 


tola 


^hifci^  HIT  ^r*** 

,  WhftWltaii^^*' 

iiiBtiBUfy  rfiM^r*.  ,-f  •  IhUr  aCMMl  ■  i  !■  i.  ud  mm  te*  tW 

*'  •■■  ''- r'^rianw.  nrf  «)Hf«  !■ I    il  ■  i  id  (tmmL 

^^  no  lacMTraim  or  rfMprni  BaMat  f^ 

,1  >i  r .":  lint*.  Mf  ihi  operation.  tW  w«BM  dMoU  ba  plugr^ ' 


fOsiXG  caI 


ILES. 


857 


Milirylif  ftr  ifidofnrin  wi>a!.  hikI  a  firm  [md  sj>plre(I  hx  menna  of  a  X-^'indnge. 
Should  pnifii^e  hlff«liiifj,  ill  conBiHiufntv  <•("  Iho  flK'Uinn  of  simie  of  the  hem- 
orrhotHa)  venMiIti,  come  on  ii  fow  l«>un«  nfler  lli*  oiifralinii,  nil  ffinguln  should 
be  clc«rwl  away,  the  gut  wnsbi^d  out  with  it-e-coul  water,  anH  then  spcurcly 
plupywi  eillicr  with  a  piet-e  of  compreMcd  »[)(mge,  or  with  a  lithnlomy  or 
ii^n(>hHsti»  lube,  eurnmnded  by  lint  eoiiked  iu  a  wiliitioii  of  perchloride  of 
iron,  Mini  j>iisbed  intu  Lbe  bottuni  of  thu  eioueetf  that  have  been  laid  opeD. 


nEUORRnoTr)s  ob  rii.tcs. 

Bv  Eemorrboids  or  Plies  ]^  mcniu  a  morbid  condition  of  the  blnodvesselfl 
nf  the  nntis  mid  lower  fifirl  nf  llic  rfcinni.  cgiierlnDy  of  the  vi'ine  of  Ihe^iib- 
mucijiignr  subeiilaiH'otii^  artroliir  tit^^iic,  (.'ivin;;  ri^  to  more  or  lees  iiilumes* 
cence  of  the  pari,  which  may  or  may  riof  bo  nlK-niifil  with  a  dli»eliarge  of 
blood.  Hurgoniie  are  r'unioiunlv  in  llu'  habit  uf  rhiMifviit^  pile*,  arcordingaa 
they  bleed  or  not,  into  Opea  or  Blind  ;  or.  uccurdinirafi  thi-y  fiiriii^'friim  nbnso 
or  below  the  verge  of  the  anus,  into  Internal  nr  Externnl ;  the  interual  heine 
always  within  the  gut,  the  exlenial  habitually  pnttnidinp  out  of  or  around 
thfj  anal  aperttire.  The  first  may  either  bleed  or  rot ;  the  latter  ore  always 
blind.  To  thiji  diviftton  into  external  and  intemnl,  B.  Oooper  has  added  an 
intermediate  Tariety.  l.he  Intero^xternal,  which  is  partly  within  and  partly 
without  the  anuH.  These  divisions  are  of  much  praelieal  niament,  U9  the 
treatment  is  rery  malerinlly  modified  according  as  the  hemorrhoid  is  situated 
above  or  below  the  anal  verj.'e. 

pRKDi-it'OsiNM  CAr^ors. — We  numt  look  to  the  peeuliar  arranffmifint  of  itut 
1WIW  of  ik^.  rrcltivi  as  Hirerlly  predi«pii»itnp  to  the  occurrence  of  piles.  The 
lower  part  of  the  rectum  nnd  ihe  vrrj^  of  the  anus  are  composed  of  a  plane 
of  muM'tilar  fihrw  and  n  mugo-culatieoua  surface,  with  an  iulerveninp 
MrHtiini  of  loose  areolar  tinaue.  iu  which  «  close  inlt'rlacenioiit,  ur  network, 
of  tortnouB  veins  is  Rituuted.  The  blond,  fmni  this  plexus  of  hemorrhoidal 
vem»,  finds  iiei  uay  into  the  ^^eneral  uyetera  through  two  distincl  c-htitinela. 
By  far  the  greatest  portion  of  it  ia  carried  iuto  the  inferior  mesenteric  vein, 
and  thence  into  the  vena  porbe,  through  the  medium  of  Che  superior  hemor> 
rhuidiil  vein,  which  may  be  lonkc<l  upon  a»  the  extreme  radicle  of  Ihe  portal 
ey^tent ;  and  some  passes  into  the  iiilernal  iliac  vein  through  branches  that 
aecompnny  the  middle  and  inferior  hemorrhoiilal  arteries.  We  mav,  there* 
fure,  look  upou  the  hemorrboidiil  picxnit  as  being^  placed  midway  between 
the  portal  :im]  general  venous  systems,  being  the  point  indee^l  at  which  they 
toouh  ;  iiul  n.s  hehmgiiig  nithcr  to  the  jiortal  than  to  the  pyntemic  veins.  Id 
ihi-'w  arrangements  we  cee  nil  the  elementt*  ilmt  wouhl  prettispnse  to  cungw- 
tion.  and  conevpient  dilnintion  of  the  vew^elBid'a  pnri.  There  is  a  large 
and  intricate  plexus  of  veins  in  which,  b.^  in  all  ."imilar  networks,  there  ia  a 
tendency  lor  the  blood  to  cironlate  slowly  at  lime?;  the  iiaiiiral  tendency  to 
stafis  of  thf;  hiood  being  much  iiicmHscd  by  the  dependent  position  of  the 
part,  and  by  th«  analopnicnl  fact  thai,  in  .conBe()uence  of  the  absence  of 
valveH  in  tl'ie  superior  henporrhntdal  vein  nnd  in  the  vessels  into  which  it 
jxHira  itc  cnnlentg,  the  whole  prcjsurc  of  the  column  nf  blood  jn  the  portal 
BTBlem  may  be  brought  to  bewr  upon  the  hemorrbnidnl  plexus.  The  circu- 
lation through  the  portal  sy'tcm  i*  likewise  subject  to  much  interference  in 
conBpqitencc  of  hepatic  and  intctttinml  obstruction,  and  in  theftc  changes  the 
Wood  in  the  hemorrhoidal  idexua  also  participate*;  and,  were  it  not  for  the 
prnviainn  ihnt  exiat.'^  by  which  this  plexus  may  frft  itaelf  t^>  a  certain  extent 
from  ovrr-distention  by  its  commnniciiilioM  with  tlie  internal  iliac  through 
the  medium  of  the  middle  hemorrhoidal  vein,  piles  would  be  much  more 
frvfjucuC  than  they  even  now  are,  an  a  consequence  of  obstructed  portal 


jkI  cireaUtkia,  ud  hecibligtl  tol«d  »wowt»JMiUryHfclhM» 

l>romr  M  that  Hge.    After  Um  pmi>l,  tbc  liability  to  Iba  4^^ 

I  notil  middle  a«  is  nadwd,  when  lb*  beadtDcr  to  iMmnTfatiU 


AMCber  gtmi  cmv  «<'  haMnfaaUBl  lalarfwl  It  » 
ivadia  A*  «aac  of  ■mnn  Uwi  iIm  wiwaf  ■&»  pltxaa  wiywiBwi  m 
ihtat  mmtaim  mpret  ihnac  JaSttaAam.  SmmtaA  m  ^mf  «f»  ia  anJir 
IMM*,  b<t««eB  a  fklase  of  aaaieslar  Jhf  ca  ama  iUe^  b»4  ^ieUia^  ■awi 
■wttbnac  oa  tbc  ocltn-.  wbtft  (fiaMdMt  bv  tka  oaiorirtioa  vliMb  ihy 
awlrrso  darioK  uwt  aArr  iba  axpnlaiM  <d  Um  wiwifc  o^  tbt  ncCbb,  ikf 
MamBrilr  gi*c  «ar  un  tbat  aid*  aa  abiek  tbaf  ba«a  Um  imm.  tffm, 
bein^  lurmd  duwa  mad  rtooescad,  Ifyibff  mtb  tb«  BMMaa  laaMbcMil  Mir 
vbtrb  (h«T  nmifj,  um)  whicb  bu  a  natani  Madrocr  to  bc«oaH  ifi^df 
evencH  dariag  lb«  act  uf  ddvcaUuo.  It  will  '-  i^-r,.!  fl,.i  t:!  tV,*  aHM 
naaie'tiate  ur  excitioi;  caus^  uf  piia  act  br  ui 

of  tbiMC  aatnral  teadcsaei  tbat  exiat  ia  tit*  «_^i. •-'>..  »;  >>.<.'>i»^  u<.  •u« 
cweraCion  or  detersiaatian  of  blogd,  at  tbe  taov  tiaM  tbat  lb«y  pndaMa 
lax  alate  of  fibre. 

Aye  exeraiRa  eooMlaraUe  laflaaaaa  in  pfaJSapojag  U>  fOm.  Tbb  imm 
H  D»t  unrrvqaaotly  iiMrt  witb  io  juaag  men  of  ngblMB  t>r  t««tilj  tmhW 
a^  :  more  eapeciaJly  if  tbejr  be  tu  a  raaxed  ajad  phlagiaalic  tamptnMM 
witb  laofpiid 
aalural  ur 

diambbM  aotii  middle  aga  la  naalwd,  wkca  um  teaatDcr  is 
aflbctioiw  is  again  iacnated,  aod  beeaoHa  man  laarkad  taaa  at  aaj  Cma 
pariod  of  life,  nwinj^  to  the  mare  active  oparatiaa  of  tboae  came*  ibat  Icarf  M 
UBpede  tlio  return  uf  the  portal  bUnd. 

aex  a|ipean  to  exerctM  man  in6aeaoe  oa  tba  acmrrvnca  of  hcnMffiWk 
at  particular  periodi  of  life,  tban  oa  ibe  geaeral  Itabtlilj  Io  tba  dJHma  b 
cerlainlj  appean  to  he  m<ira  frequently  nuA  witb  aawaiffM  dmb  at  aa  Mfif 
»^.  than  io  jouDg  w<imeo  ;  but  at  a  later  pcrtt^  af  life,  ao  &r  »  ar  iiar 
vatioii  (()«•,  tlte  diieaM  occurs  with  nearly  equal  frequency  in  biaa  ^na 
The  eomparatJve  exemption  of  young  wow^n  b  icadily  awMted  &r.  by  A* 
periodic  diieharitea  from  liiu  uieru*  preraotlas  Ibe  fliMawliuae  tlkst  adrii 
othortfiM  4icetir  io  the  pari*  in  Jin  vitfiittty.  The  greater  mufutaej  m  ftMia 
at  a  latur  [wriiMl  of  lifu  is  nitril>uublc  tiui  only  to  tbe  pfemara  «f  lb«  fn*A 
utf>ruH  on  tilt*  vrins,  but  alei>,  after  tbe  cenalion  of  the  mwiea,  Io  iha  Amt 
miiiation  that  iit  npc  to  be  »ct  up  in  certain  oricmtit  of  tbe  feiaale  nuamy, 
and  t"  the  rrtMnluiiou  of  the  p^irtal  cir(»l«iii>u  liy  tlie  acvuoiulalMia  ti* 
and  bv  otlivr  vauwa;  tbeac  conditiona  occur  cbiefly  in  women  oF  a  |4i4«b 
bahit  of  b«Hly. 

A  teHeuUirp  Hfe  witb  indoleat  babita  cotnUtute*,  nerbapa.  i'-  ■"  -'  '••^ 
fill  pretlU|»niiij;  mUMoflho  diauaee;  rnQreaBpreially  if  bain;  '* 

be  LiinJDiiinl  with  waul  of  proper  and  auffietent  exerciac.  lium-i.  .m  ant 
flt-MNi  and  liiicuriouB  hahiu  <\t  tbe  more  opnlant  cluaea.  by  Jiminabtn^u* 
at  tba  earoo  tiiue  that  they  hcmmod  plethora  and  a  tendenqr  tAabl>«>" 
engnrgement,  axerciM  a  couHideniltli'  iufloesoe  on  tba  oucumnre  •/ <>* 
diMnHP,  whii-h  ia  mocb  more  frequent  auougsi  thrai  tbao  {a  penont  i*  i** 
humltlnr  wiiikit  of  life. 

Ateohoiic  ezrtM  w  aintin^^t  tbe  mnet  rnmni'in  i^una  of  pilai  oaring  M 
hcpntic  ct>ngL-»iii>n  it  commonly  gives  rijto  lo.  if  it  be  carried  to  ^^'^ 
of  canning  cirrhniis  of  tba  Itwr  tbe  condition  becomee  aggravaicl.  l>"f 
tbeae  oiroumsinneca  btoedlng  pilca  may  sr-rve  a«  a  aort  of  aafiHyrAln  i*  ^ 
avcrloadrxl  piirtal  ciroutntinn,  aud  ahoutd  im  n>)  arcnunt  b«  intrrficrW*^ 
8<i  iuiporianl  i«  thin  thai  id  all  caaea  of  pilca  Iwforv  undcrtabiti"  »"  iiBriC 
tbr  kv 111 Pt< trim  of  cirrhnaiM — morning  vomiting,  failure  nf  "''*' 

mitteiit  iliiirrlnna  and  cict'ajional  cligfal  jauQdi(.t>— ebould  be  ••••c '' 

Tlittra  are  a  numlwr  of  minor  (vniditionH  wbii-h  are  commonly  la^ktil  >1* 
»)(  cauw*  of  thU  divQaae,  tbou|[b  il  ie  axtramafy  dl&ali  ** 


I 


STBVCTURK   07    PILES. 


869 


rminr  the  precUo  shnrc  (hat  cuch  hna  in  its  prodaction,     Amniifrst  three 
(J   Im   mfnliouvd   inlvriijKTtitR'e   lii  fooj ;  mii<l«nci'   m   WNrn),   luoixl,  aiiil 
Iwiiniit  climate*;  th*'  use  of  imiR  hikI  warm  Ix-riB,  or  the  opfuwite  c>R(litian 
•it;iiiv'  iiu  K  col<[  Btuue  ur  damp  otuliioQ.     Orer-«xcilen]eul  of  the  gcuera- 
-  sbo  will  occ»ffii)u  it. 
.  i-Mi  Caiviis. — Atiiou)j:«t  tlie  excittoK  cnuw*  may  b«  meiitirmed  tocal 
of  any  kimi.     TIiuh.  in  Bonie  people  hanl  ridiui*  will  bring  oq  an 
:k  of  piles.     The  Ao^tfiwi/  w«  o/  dnvtit:  ptirgutht-*.  more  *af>ei'inlly  of 
I,  rbub»rb.  etc-,  ii  well  known  tn  occasioti  the  (li.itase;  though  il  must 
lobKrvefl  Uiut  individuals,  who  make  habitual  twe  of  tlieec  reiueilies,  o^Xtm 
UQtiiT  sdijie  '}f  (hiiw  obalruetions  of  the  abdominal  viscera  that  have 
\y  htfn  Do'.iced  «.*  cfinditi'in;;  u>  piles.     The  existence  of  other  ili»tau» 
the  rtrtum  and  au\u,  ixikiix  aa  ii^Uila,  ulcer,  or  ftricture,  by  iufiueing 
I coOKeelioD  and  irritation,  may  excite  the  di^ciiw;  eu  al^ii.  uterine  affec- 
I  MXMT&riuat  diseaert  of  the  gaiiio-urinary  ortftins  may  give  rise  to  this 
idbcUoa. 

The  miiet  direct  exciting  cnuxc  of  ptiee  is  certainly  a  retardation  to  Ihe  rdura 
llkepcrlat  blood.  Aoy  irape«liment  l<i  the  onwani  current  of  the  blmKi 
>gh  the  hemorrhoidal  or  nie«entcric  veins,  the  trunk  or  nimificaiii)n8  of 
vena  porltc,  excrcides  a  marked  iniluenec  nn  the  tcodeney  u>  ci<n|rEi<tiim 
tKe  hemorrhoidal  plexus.  Habitual  c<>n»lipfttiiin;  the  nceumulation  of 
irnol  fi-ciilrnt  msMea  in  the  large  intestine;  the  want  nf  ilue  secretion 
the  mucDds  surface ;  obAtructiuii  to  the  proper  action  of  the  liver,  and 
COttHquent  connestiktii  of  that  organ;  the  pressure  of  abdonnoal  tumor*,  or 
nfthc  gruvid  iitcriid,  are  »ll  itctivt:  excitiiigcauKs.  interfering  as  (hoy  do  uith 
lb»pct'perrvluruot'tlte  p.irlal  b|i*o.l.  hi  some  cases,  even  tbeexi-iteur*  of  an 
oWtacIi-  to  the  rirculalioii  iu  the  cysteriiic  veins  nisv  occasion  ibid  diiu-iise; 
il  Ndl  sriM-  from  the  pre^eure  of  au  aoeurisroai  tumor  on  some  of  the 
tVenouf  trunks  witliin  the  rhe«t. 

L'KJL — A  I'ile.  whetiier  external  or  internnl,  cuii»it>li«  e«i?ntially  in 
IkfttiMK-f  of  u  vnriciiV'ti  condition  of  a  ]>orliou  of  the  hemorrhoiiln) 
rather,  of  the  smsU  veins  of  the  eubmucour  tiwiie  that  pour  their 
euatents  iulo  this ;  this  varicnse  couditiuo,  becoiuini^  prominently  devetopcd 
oertaUi  points,  giveo  rise  to  small  knots  or  tumon.  A  pile  in  this  state  is 
lite  toit  and  comorewible,  and  run  reatlily  be  emptied  by  pressure ;  and 
rhirii  vut  into,  it  will  be  fouutl  to  be  couipoeeil  of  unc  or  more  cy»ts  tilled 
vitb  btuwl.  and  surrounded  by  um)lar  tissue.  The  ap|>eanuice  of  cysts  is, 
bttwvv^T.divcptive.  being  occa»t(iiiefl  by  ascttion  of  tlicsut-Tuluted  and  dilated 
Wim  that  rnler  intn  the  comixisittou  of  the  tumiir.  A  fler  the  pilifS  have  existed 
fpT  sotnr  little  lime,  or  after  they  have  onre  litTome  inilami'i),  the  tiiimes  ihni 
mw  iutii  their  compatitiim  umlergo  mixliliralions  that  induce  C4>rri^|>4<niling 
IS  in  the  clinnicter  of  tUe  liimor.  The  coats  nf  the  wins  become 
cd ;  their  cell-like  dilaiaiions  nn-  tilleil  with  coagulated  bl<MMl ;  ilio 
liog  arviilar  tiimie  U  hyperirophied  or  thickened  ;  and.  r>ii  I>riug  cut  into. 
|iilB  is  H«o  to  be  comfiT^cd  of  a  spongy  kiml  of  ti>«ue  lilltH)  with  blood. 
Eternal  piles,  when  eKamineil  nfter  removal,  often  rfsemble  in  structure  a 
of  hyperirophied  eutnneotis  and  «ubeiilane<>ufl  tiiiaiie,  in  which  a  number 
■mall  vessels  of  uDiform  rbarscter  rantify,  but  without  any  ap|>enniuee  of 
rt-like  spaces,  lolerual  pili^s,  on  I  hi?  contrsry,  contain  more  of  the  venous. 
id  IcM  of  the  areolar  eleuifOt.  They  are  aU>  ■.^>mmouly  lunti>hed  with  a 
ill  cvninil  artery,  whiuli  i*  npt  to  bli-vtl  fn-ely.  or  even  dangerously,  if  the 
mr  Ik  cut  ucro*s ;  hviicf,  pr'iviile<l  they  arc  not  clo^g^d  with  L-i>»golale<l 
K1>mm),  thfv  may  nru'lity  bt?  injected  from  Ihu  inferior  niesenleric  arterv. 

In  itud)  iuK  the  *iructur«  of  henturrhnids,  it  is  uf  importance  to  niuicrve 
Ihai  tbey  uoeur  under  twu  differeot  furois;  one  lo  whicli  there  arc  dbtincl 


I 


DISEASES    or   THE    LAKOK   IKTHSTISB    AND    ASCS. 


tanion,  withio  or  external  to  the  anuK,  and  anntlier  in  whicb  tben  b  i 
■  varicofe  oondition  of  the  veins  of  this  region,  witht.Hit   diMiaM  ifll» 
mpswnce. 

Iti  thi>8P  cau«  in  which  there  in  mprcly  a  ^neml  rnricmpr  itmip  (/tba i 
of  tho  guhniuciids  areotnr  ik^ue  of  the  nnuF,  wilboai  nnr  rfirtiMi 
Bprineing  above  the  level  of  the  membraoe.  it  will  be  found  that  tb*  i 
bmnuicB  of  the  hemorrhoidal  plexue,  and  the  small  iwiga  ihalfolirikoi 
from  the  Rubniucoua  amtlar  ti^ue,  have  undergone  TmricoM  dilaiukn,  iMfaf 
apparently  ^reatlj  iDerea«e<l  in  number,  as  well  as  in  aiH.  Tba  ■■■«« 
lueiithrune  i«  of  a  deep  niulborry  or  port-wioc  color,  ftnd  baeowM  vmtd 
after  eiich  ruotiim.  Thcr^  is  usually  aonte  mudoui  Keretinti  AbfkiU  likaaHL 
rendering  the  juirt  moiat ;  and  the  pAiieut  cctniplaiiu  at  ttroea  of  WMfbtnJ 
of  beariof;  dimu,  wiili  pains  either  in  the  part  iiMlf,  In  tlM  aacnvtuUv 
region,  or  in  the  thighs.  The  motion*,  more  eMtMM-ially  If  hard, are  MffaW 
with  hliMtd,  and  more  or  leia  of  thi^  fluid  dro|«  in  a  rtt)Md  tnanuer  aArriW 
paasnge  nf  Ihe  fecen.  There  ia  seldom  mucli  bl-Mid  Iiwl ;  but  al  tim^  tbf> 
n  &Q  exiicerhaiion  of  all  th<.>9«  8ytn[»t>in]!i,  and  the  huii>«rrh »((••,  u  «ill  »-<t 
purlicularly  be  mentioned  hereaAer,  tnajr  bccotMVery  abun<1anL  Tk»e<^ 
diti<m  of  tfie  mucous  membrane  may  precede,  and  is  frv<iu<':itN-  f  ■ 
■cc^impany  tbe  true  pile,  whether  external  or  iutcrnnl.  auu 
apoD  OM  couittitutiug  the  Hrst  atu^e  of  this  disease.  If  (hi»  K'- 
alhmed  to  eontiuue  unrelieved,  the  tendency  to  cuDgetti'm  i 
and  more  of  the  mucous  membrunc  is  everted  and  prutrutled>iL-r  < 
tlie  submuctjus  areiplar  tii^uc  beoomes  stretched  and  lax,  and  tfaa  !■■**( 
to  iKT'iiMf  one  of  priiliifwufe  nni. 

Extsnial  Hemorrhoids  htc  tliovte  that  arc  Miunted  below  ih»  jvp*(\ 
anun.  anil  that  nre  iiivei<t4Hl  by  ruUinrinis,  or,  at  most,  by  iDoa*-c«t 
Uasue.     I{i<fiirfl  apjiearin^  an  duAnrd  lumnrB,  they  o"imlly  mn*titutr 
tudiual  foldd  that  Hiirnmnd  thn  nnat  iipr-rture,  or  t 
centre;  and.tbpjrtegiimentary  ^'overing  nnn»i8t)ng<il  fl 

tht-y  rr-Hemh|i>  fi^lda  of  thif  tissue  mther  ihnn  of  mu<*iitu  mvmi 
col>ir,  they  varv  from  that  nf  the  nainral  H[ruclur<«  to  a  ptok  or 
hue.     Their  site  vnrieit,  nrrording  to  tho  otate  of  t-ongmion  ;  ami  bfietl 
same  tumor  may  at  unit  time  be  soft,  Hocfrid.  and  h«»e,  Bppar»ntlT  •Mi 
more  rhnn  u  tuld  of  iDtegtimeiit,  and  at  smotlier  raar  beciima  lease,  tani 
and  ready  to  burst. 

Sffmpt'tttv, — When  of  small  sia»  and  rcwnt  formafinu,  fxli^rnal  pik*  4« 
not  in  geneml  give  rise  to  much  distress,  but  merely  sotiM-  local  beat,i»iek* 
ing,  and  itchio}^,  with  a  sen^e  of  fulnees  alter  defey^ti-m :  but  wbrvi/taf 
Mtf,  nrnl  inttanietl  or  irritated,  tbey  may  oceiu>i<in  vit. 
is  Di»t  only  deeply  sealed,  dull,  ai'hiiii;  and  ihntbbii. 
but  this  shoots  up  the  sitli'  nf  the  recliMii,  through  iLi  |i>:ri(itu:4i, 
tbo  nates, and  is  much  iucrenfiiyJ  nheii  the  imlii-iic  vtamts  nr  walk*, 
few  dnyi«  tluiw  symptoms  sulwidf;  stippurntKui  rithi*r  taking  plareio  ' 
or  the  hliMxl  CDUlaine*!  in  it  cwgulatiuc-  The  nxrts  nrr-.  h'twwvrr.  I 
thii<k'-iK-d  nnd  indurated  sLule.  and  d<>  not  rrally  n»«ume  their: 
and  llaccid  condition,  inHammatDry  clliixiou  taking  plocr  intn  tba 
tisfluo.  and  the  omuined  bloiHl  perhaps  ciingulating,  so  that  Ihe 
nu  longer  be  emptied  by  prasore,  but  osdumes  the  farm  ufa  brood,! 
or  ludurAtmt  mas^. 

Iiit«rnal  Fil»s.— When  the  pile  is  aitaated  altogrtber  within  the  tfp^  | 
the  auUK.  ii  in  nilletl  internal ;  of  these  there  are  two  prineipai  TorietM*' 
Jjoiif/Hu'tiwil  and  the  (JhbtUar. 

Tlio  Loogitadinol,  or.  as  It  is  aometimce  called,  the  Fleahf  pile,  it  pm'i'^ 
met  with  abjut  an  inch  or  two  up  the  rootom.    It  ia  spongy,  elMllc,ir*<' 


1«C', 


,  aiiilj 


* 

»" 

^ 

W^i 


IK. 

i 


eiufl 


High,  of  a  dark  rcildish  or  dusky  brown  tint,  U paring  upwards  from  a  hriMid 
c.  It  seldom  bleeds  or  varic-i  much  in  eiw* ;  between  the  pilos  are  Imttid 
amflll  riiriaiiis,  valves,  or  foliU  of  mucous  inembr»»e,  forming  twcculi  or 
uuucbrs,  nich  their  concavities  looking  iii»K»rds.  These  eacculi  are  ajil  tu 
become  distended  nod  pre>»ed  downwards  hy  the  feces,  evpecialty  if  ih« 
motions  be  hard  and  liie  buwela  ]mve  been  coiialipated,  thus  giving  ritte  to  a 
tendency  to  prulaphus. 

When  the  hemurrlioid  aaeiimee  a  Olobolar  form,  il  cooaliLtiles  the  ordinary 
b]tHrJiii)f  pile.  It  iniiy  be  ttttuBtud  uu  ti  broad  \ituv;  ur,  tie  not  unfrv[|Ut'atly 
hapjKUs,  ilii  point  of  attuchnK'Ut  tu  the  mucous  luvmbruuc  bccorntu)!  ehiQ- 
gxleil,  it  ueouiiies  a  pi.>duucniut(;d  »ba[ie,  Imugiug  d>>\vuirRn.le  into  tlie  cavity 
uf  the  rc-ttum.  Il  in  uf  a  d^rk  bluieli  color,  uud  uumeruus  euiiUI  vetiielB  of 
a  brighter  but:  ihtiu  tht-  body  ol  the  pile  may  be  cuen  ramifyltig  on  the  mucous 
;Aivmbniue  iiivc&tiug  it.  Ite  surface  is  at  lir&L  emouih  and  sliiuiug,  uud  may 
vouliuub  to  ihn'Ugliout,  being  covered  uith  a  thin  and  deiiculc  prolongation 
of  llie  lining  membrane  of  ibe  gut.  Nut  unlntjuvntly,  however,  BUpi-rBcinl 
ulceraituu  takes  place,  and  then  it  bua  a  granulated  straw  berry- liJie  ap- 
pearance. 
S^pfomfi. — Internal  piles  are  usually  attended  by  arenFntiiniof  bent^itch- 
'gr  pricking,  or  smaniiiK  about  the  atiue,  and  a  feeling  as  if  there  were  a 
foreign  boily  withio  llie  gut.  After  defecation  these  sensatiuitdure  increased, 
and  are  often  accompanied  by  a  hearing  down,  as  if  the  buwel  were  not 
eoiptieit  of  ii8  contemn,  that  lit  [>eculiiirJy  di»ireetiiug  and  Bickeoiug.  Tliit*  U 
Dccasiouetl  by  the  piles,  iir  the  elonguteil  anil  condensed  mucous  membrauc 
to  which  they  are  attached,  being  protruded  during  the  expuUion  of  tlie 
feces,  and  not  returning  euAiclently  quickly,  being  grasped  by  the  epliincter 
ani  and  constricted  by  il.  This  tceliug  ol  discomfort  and  bearing  down  ig 
Qtuch  increased,  if  the  patient  .tlsnd  ur  walk  much  aAer  having  had  a  st<H)l, 
or  if  hv  have  a  cdufined  state  of  the  bowels.  If  thin  state  of  tilings  be  not 
projKfrly  attended  to,  tlio  syiiiploms  become  increased  iii  severity  ;  the  bear- 
ing down  sL'iiiialiiin  amonnlit  lo  true  tenesmus,  and  the  act  of  detecatiun 
becomes  so  painful  that  the  patient  deters  it  as  hiog  us  possible,  anil  then 
when  it  dues  lake  place,  in  ci>n9ei{uencc  iif  the  accumulation  uf  the  excreta 
and  tbeir  indurated  character,  the  suflering  is  much  increased.  Externa] 
piles  now  usually  make  llieir  appearance,  if  they  have  uoi  existed  before; 
the  muciius  membrane  of  the  rec^tum  l»ecomes  prolapsed,  and  an  increased 
secretion  at'  thin  niocu^  takts  place  from  the  utitice  of  the  gtlt,  moistening 
e  jmrt  and  soiling  the  patient's  linen.  IrrilatiDii  in  the  neighboring  organs 
fre^lucQllr  set  up  ;  occaaiouully  to  to  great  an  extent  as  to  mask  the  urig- 
&1  cuniphiiiit,  tlie  puLicot  reterriug  bis  principal  pain  and  discomfort  to 
eee  fympaihelic  diKtuibauces.  Tiiere  is  often  a  dull  acbiog  fixed  pain  at 
the  lower  part,  of  the  lutnbar  spiuc,  and  more  frequeatly  opposite  the  eucrum 
or  the  sacro-iliac  aniculutiuu  on  either  side;  this  m  sumetiaies  very  severe, 
pcrbajiti  ruus  down  tlic  lliigb,  or  rouud  Lbu  gruio ;  irritnbiltty  of  iLe  tcxLicU-a 
may  come  on,  or  irritation  about  the  ucck  of  the  bladder,  causing  frcijucut 
dcetrc  to  luicturato,  uud  iucreasiug  ibe  patient's  sutli-riu^s  by  the  straining 
that  takes  place.  The  general  healih  now  suiters,  the  patient  may  bccxiuu 
emaciated,  tind  tbc  couutcuaucc  oftcu  prcstuis  a  peculiarly  auxioue,  drawn, 
id  careworn  took. 

Thcaymplora,  however,  that  fin>'t  of  all  and  roost  proDiinctitty  fixes  the 
tient'a  aitetitiim,  is  Hcmorrbage.     Tbia  varies  greatly  iu  quantity ;  at 
irsl  there  may  m«r«;ly  he  a  few  dmiM  falling  alU-r  tbe  paiu<age  of  a  motion, 
or  tbe  cytiuder  of  tcces  may  be  stained  mi  one  »ide  liy  a  streak  or  sputa  nf 
blood,  or  the  bleeding  may  amount  lo  several  ounces  or  even  pints. 
Tbe  hemorrhoidal  flux  ia  coouecterl  with,  and  in  the  great  majority  of 


there  isgfiiernl  tiinimeKn.'ii(.-e  and  cnn^mtiun  of  ih^  whole  of  tba  bmmi 
merDliraue  of  the  lower  piirt  of  the  rvctiim,  frtm  which  th«  Uond  cnteti 
drops,  or  it  may  even  epirt  in  a  (li»(inct  jet  ('Mm  ihv  open  moatii  of  • 
vcsiel.  It  is  I'requently  ushertyl  io  by  an  exuiTrhntinn  of  tboM  tTBfUw 
that  oommuuly  awompaoy  piled,  such  as  n  sensntiim  uf  fulooi»  wnfbt,  tU 
tensioD  abtiui  the  pnrt».  But  the  srmptoms  that  precofls  ila  ncoimwain 
bftoD  much  more  imperfectly  marlted  than  ii  uiually  iuic4,  aad  >■*  ft^ 
qucnily  uhcti^ut  nltogeiber. 

The  ili«<L-hargc  uf  blo'id  may  be  periodieal,  Mpeoially  in  womn.  oeaHita| 
evtMV  m»Dth,  or  nt  iDtorvuls  of  two,  three,  or  lix  nuiBtiw ;  and  ii  my  ha  » 
Dtitti>nt  or  iutcrmittoiu.  Whtn  onc«  it  ha*  B«t  id,  it  usually  ormtiBanfrM 
thr<«  U)  dix  davii,  ioi^rtnuiug  in  quAnlily  up  to  the  third  or  fcarth  iKj.nt 
tliCfl  luaettiog. 

When  iiiiMlerate  in  ((uantiiy  anil  abort  ia  daraiion,  it  ta  nfkcn  •  anatwaf 
re)tt:f  to  the  patient ;  l>iil  if  »  wry  largo  quaiility  Iw  lo»t  at  <hi«  tin«,f  if 
it  e.>atii]ue  for  tiHi  lung  a  period,  it  hecomes  a  »ourt.-«  of  great  drhililf  ;»■* 
barm  is  uaunlly  done  to  the  pntienl  by  its  long  c»iilinnatice,  than  by  tei 
oe»ive  quantity  at  any  ooe  time.    The  patient  may  twc»noe  n.i"  ^  l-Ii "" 
aod  anwuiiv;  uervout  headaches,  pallor,  palpitatitms,  apd  r^ 
suit.     Ill  tome  caaes  thia  distilinrge  is  of  aerviee,  aetiD);  a*  a  'i-  • 
preventing  diaeaiw  from  fallin;;  ou  more  impurtual  parlii;  it  has 
be«u  |uoke<I  u|M)n  as,  unci  duuhtleas  is  in  niaiiy  uaiws,  u  r-' ''  : 
plexy  uad  visceral  congestions  aud  oh«tructi>>ua,  iiarlicu 
H»  a  eouseiiiience  of  cirrhosin  of  the  liver,  or  la  pletbuni 
perenii8  who  liabiuially  live  too  highly,     la  other  ca^rc  ii  urn  . 
as  critical ;  especially  when  it  occurs  about  the  c-  i   lat  ontoHtiM 

period.-    Itul  a^  a  rule,  the  continued  Ities  of  bh^d  :i  -  ia  aoi 

iiijunous  to  the  |>atioiit't>  constitution. 

Hemorrhage  irom  \n\ea  is  <<'>mclimc«  viearioua  vrith,  and  at  other 
arreciB,  lh«  menstrual  flow.     In  a  cna*".  «hirh   [  alirnilwl  »ltb  fiarrwd.lii 
patient  had  auHcrod  Itoiu  tlie  liemorrhnid&l  tin x  and  piln  fn>«B  ttnULs: 
ptlbrriy.     fthe  nwnatruatcd  fi)r  the  fiwi  time  whrn  thirty  •**vcn  i 
lip  to  that  period  the  bemorrhnidal  dlachArgr  bad  nccurrrd  abuo 
monthly  inlervala.     Alter  the  late  eatahlinbmcnt  of  the  m«nstrual  haMMi 

the  pil>>it  continued  tu  bleed,  but  lew  regulartv,  and  abe  h^ *-' 

emaciat^^l,  and  deSilitatol  Co  the  last  degree.    When  ahe  wa^  <»" 

uf  age,  I  wiw  ber  for  tliH  Hr«t  lime;  the  pll^ft,  uhii-b  went  ^^ry  y 
vaactjlar,  were  ligatured,  tiiid  ahe  made  a  uitwt  perftTc-t  reeovtry  te 
health. 

Th«*  color  of  the  blcM)d  ia  moat  generally  flnrid.  M  if  U  mtsf  fr*  >■* 
•raall  arljfriee  or  capillarica  uf  the  part  ml  her  I  linn  from  -  ■     U**** 

appear  that,  iu  coiiKciiUt'nce  of  thr  ovr^1liIll>•lldr^l  and    >    i  >  mO^.* 

the  %'viiu>  id' the  part,  the  onward  Hdw  through  the  arten^aod 

leailiDg  Ifj  tliem  la  ob«iructed  ;  and  tbaf,  in  euasequaocn  of  thm  B ^,   , 

pnHure  on  thoae  vencla.  their  paricita  give  way,  altowing  the  toai  t^ 
In  eacafw  from  the  arteries. 

Very  cimniouly  the  internal   piln',  when  brought  down,  praaaM  > 
what  gnumlar  aurfuee.  in  oinswjuence  ofulceratiou  havinic  in*---'  "'"*  ■" 
the  whole  surfaoe  will  he  aecn  tu  exude  bhwxj  in  ilmfw.     Io  '^ 

the  bloni]  appears  Ut  rome  from  a  t^vtty  in  imi*  side  of  the  briikrrvr^" 
if  ru|tlufe  had  occurrtHl  from  over-difiiention  at  thni  part- 

The  hemorrhowlal  Hux  may  be  acoompaawd  by.  or  atiertuUa  wiiK  ■  ■" 


I 


< 


TERMINATION    AND   DIAONOSIB   OF   P1LS8. 


668 


ii7  BNCom  dwrharge  from  the  rectum  and  difieaner)  MrQcKircs;  this  would 

to  be  nothing  more  lHad  t-xcc^ive  secretitvii  from  the  menihriine,  in 

lucnop  of  the  irritation  9et  up  hy  ihe  prp(>4?nop  of  itie  piU-s  ;  it  i&  H^ldom 

Iciont  qiiintiiy  to  produce  iiuicii  nunoyance,  or  to  bo  uf'miich  uiuoicnt 

Fthe  pnlirDi. 

"TonrucATioss. — Piles  are  Doi  uDcominonly  complicated  with  other  difr 
n  of  the  rectum,  eui-h  u  finuret,  feiula,  or  prolapsua.  W'hto  connected 
whh  figure,  the  bemorrhoid  often,  as  8ynic  hu  remarked,  aesuntei  a  jircu- 
Bar  form  mid  oppenraoce.  preei-niing  itself  n5  a  small  rvd-ciilurt-il  boily,  like 
a  p«a  in  size,  tirni,  and  seated  at  the  hnse  of  the  Hiwure,  which  it  often  con- 
e**li:  ti)  a  prnctbed  eve,  huwf^vt-r,  the  pre^euce  i>f  a  pile  uf  ibU  peculiar 
eol*ir  and  •linpu  n  lufiicieiiL  lu  itidicnte  the  existetioe  of  a  (iMure. 

In  that  U'tui  iif  tittula  in  which  the  aperture  i»  near  the  anus,  one  or  more 
extcnutl  pilcK  itf  giniall  size  are  tilten  ftjuiid  Htuatfd  at  the  orifice  of  the  fit- 
UtlM- ;  AIM  prr)lu{i«UH  rnrrly,  if  ever,  is  met  with  in  ndulic,  wJthuut  the  KimuU 
j^lKous  nrrurreme  uf  pjte^. 

^^kWMiNATiON^. — Hemorrhoidal  lumon  may  termioate  by  Subiideoce, 
^■Bgttlatii'i),  Suppumtiun,  or  Sphacelus. 

^wBb«idence. —  Complete  eutisiJeiice  of  a  pile  can  take  place  only  when  tlie 
diaraee  a  uf  rrcetit  occurrence.  When  of  lung  standing,  and  aflur  it  has 
brra  rxpfwed  to  euccteeive  attacks  of  iuflamnialit^u  and  tur){C«ceuce.  an  ex- 
ternal pile  never  subsides  complvii'ly  ;  and  ihe  areolar  tifruL-  ami  the  inucv- 
eutani'out  Mruclurvtt,  htcomiug  hyperlruphied,  furm  eluugatcd  jwuduloua 
Abiw  aniMfKi  tliu  margin  of  the  anus. 

Coa^lation  of  the  cnntentBofthe  pile  is  the  rcfnltof  Inilnmraaiion  having 
takrn  pliii-c  in  it.  When  it  taken  place,  the  tumnr,  alter  mure  »r  lees  active 
tndaniniation,  iM-rnmcs  hard,  incompretnible,  and  indolent,  pf-rmaneut  in  eize, 
and  if  n  purplish  or  plum  color.  The  e<>nf;uluni  thus  formni  may  excite 
■a|i|iorali<>n.or  may  be  alisorbed,  the  hrpertrophied  tinuea  forming  one  of 
JmWimiI  anal  folds  if  the  pile  be  external.  In  bo&m)  rare  invtaneea,  the 
M^^Bi  may  be  calcified  and  form  phleholithea. 

^^B^ulatton  iflkeii  place  more  frei^umtly  in  external  than  in  internal  piles, 

•t«ini;  t4  the  great  impediment  to  the  reiorn  of  the  bliK-d  frum  them,  aod  to 

th,'\r  .T.-Atff  liability  to  inflammation,  their  exposed  »ituation  leading  them 

•\  or  otherwiao  injured.    When  it  occurs  in  ioiertial  itiles,  it  mosi 

^» ..-^  !irre<i»  thoae  that  are  of  a  columnar  or  lonf^itudiiiAl  sliape,  and 

^Bit  lrr->|iii  tillr  the  gluhular  variety. 

^'ttnitpiiratioB  Li*  not  an  unconimon  termination,  if  acute  ioflammation  have 
been  ••t  up  in  inlcnial  pile^  more  e«{>«cially  iu  thiwe  that  have  previnusly 
Int-o  iMngoUteil.  When  the  a)«ceM  is  di«ehar)ieil,  small  coa^ula  eH<-ape  nith 
ill  DMitrnts,  the  cavity  grannlatcs,  and  becumea  obliterated,  and  the  pile  ia 
corc'l. 

8phao«lQt. — In  some  casee,  when  there  ie  much  elongation  nf  the  mucoaa 

lOBMbrBiK  fnim  which  the  pile  spring,  prolapfus  of  that  membmne  nnd  of 

Ibc  pile*  may  taki>  plar>> ;  aurl,  this  being  gravjied  alttr  it  has  deacendefJ  by 

tba  eonlractitin  rif  theBphinctvr,  the  same  cHi-ct  mav  be  produced  us  if  align* 

buv  v«re  applied.    The  tumor  becomes  much  utrnlfen,  hard,  livid,  and  tenw; 

tiwra  BIT  much  ci^.^titutional  disturbance  and  mtlcffiuesB ;  bai  after  a  few 

dan  thfl  part  that  is  constricted  alougbs  and  drop*  off.  aod  all  tbo  symploou 

•re  relieved. 

DiA(i!(tw>t8. — ^The  diajroMis  most  be  regarded  in  tiro  pdnta  of  view:  ],  aa 
OnBcerm  the  BemarrhMdat  Tumon;  and,  %  with  reference  to  the  Honor- 
Ht^idai  fluT. 

1,  Bamoirholdal  Tomors  must  be  diagnosed  from  prolapsus  ani.  polypoa 
of  Um  rectom,  epithelioma  of  the  aoua,  and  condyloniala  abuut  the  anus. 


DI8BASB8   OF   THK    LAROK   IllTBSTIKK   ASD  A5Ci. 

From  prolapnu  Ihe  diagnout  u  not  always  easy;  iBdctd,  Uw  ra»< 

are  HO  gcuernlly  ti»i^o(.-iaU4i.  tliul  it  Is  of  little  luoDNnl  to  aMMifl  iL 
truP  proinp^iit^,  uctilur  exaniiniiLinii  will  suffire  t/>  dUtinguUh  Um 
wall  of  Uic  iutestine.  t'oniiiag  n  iiniwttii,  rouu(le>l,  aud  C(>i»c«hai  IvtaUurt 
Boouiar  piMlubi'rancc,  fruiii  thu  isDluled  liimnni  «•('  pilem.  lo  pclypw  iW 
hiamry  «f'  the  case,  tlie  pe<liin<.'ulHtril  ao<]  »ulttary  (?h«niclcr  ol  iW  l**^. 
it*  lar^  siu--.  an')  coiiipnrativc-ly  mlight  tendmcy  m  nrn-*Uc*\  htmwiia^ 
will  enable  the  Murgvim  ui  make  the  dinsauclc.  Epitneliooa  ir  rtit'Ar  na^ 
oized  by  \u  h&niataa  aad  by  its  diK-p  iiibltratioo  t,f  aurroui^  -     in 

any  cue  uf  doubt,  a  (liKital  psaniinutiiio  of  ilie  rrctuni  will  .  ii-in 

evident.     From  condylomata  th«  diagiinkis  i«  eajiy:  the  »■  ^  ^tva^ 

an<l  narltiko  chanictvr  ot  tliMe  growths,  their  hulory,  ami  ti>ir.<  ■■«.<umA>x 
at  other  points,  as  tlie  {>erinfun),  ecrotum,  vulva,  an<l  buttocks.  «il{  vnhk 
the  Surgcnn  to  di><tiii;;'iii!th  them  without  any  dit&cuUy. 

'i.  The  Hemorrhoidal  Flax  must  be  (]iflt'iit(;ui»hr<l  frtMa  oibM  iitntM 
hemorrhages.  Thia  may  be  daoe  by  atteutii>n  to  the  clianii-i<  -  '  i'><ul, 
uhich  \«ill  eiial.tit!  us  in  iiiuuy  cftse*  to  d«t«rruiD«  iu  source.  .  -•joa 

i'roni  piles  it  ie  liquid,  of  ■  more  or  lea  fit>rid  color;  not  uoJ 
(juiie  briuhL,  staining  or  coating  the  feces  rather  thoa  being  mixed 
theoi.  When,  on  the  c><Dtrary,  the  blood  in  pirurcd  out  ol  oohm!  htgbw  { 
in  the  intcvtinal  cauul  Ihati  the  usual  seat  uf  hcmorrhuids,  it  ta  uf  ai 
sooty  character,  mixed  up  with  lit^uid  feces  either  in  a  ditftunl  fvra  •«■ 
small  black  cua^ula,  and  do  j'resb  or  bright  hlouil  will  be  Ti^tblc.  DipMl 
exploratiou  of  the  rectum  in  cases  of  pilua,  and  tb«  pmeon:  of  srnpMK 
indicating  the  existence  of  oiischief  at  a  higher  jion  uf  the  intntint  tim 
the  aiiue  in  e««ea  of  meloiDB,  wilt  alsu  serve  to  }»>iut  tu  the  scat  of  tl»r  la 

Treatment. — In  coudueliup  the  trealnieot  of  a  case  of  pilas,  th*]' 
geou  will  succeed  best  who  looks  upon  the  diseasi!  not  as  ■  laal 
merely  re<juiring  manual  interference,  hut  as  a  eympuim,  or  rmthsr  i 
of  remoie  vuceral  olistructiou  und  iliscntfe,  the  remoml  of  which 
bcsiifticieiittoucromplibh  the  cure,  utihoul  the  neiMV'-  ^vlonl  iauHll^ 

enee ;  or,  ithotild  it  he  Lhouj^ht  nccciMury  lo  huvc  tr  .  c^ratin  f«» 

cedurc,  thin  must  l>e  made  M-condary  Ui  the  n-nioval  <ii'  lli'tc  ctMxntxAs  ikM 
have  pririiai'ily  occusiotied  the  cont;efttii>n  and  dilmuLiua  of  the  beoMfrlMiU 
Trinnf  If  The  trt-atiiient  of  pile5.  thorcfore,  uiual  l>r  corisidvreil,  I,  ••  ft^lii 
the  Retuovfil  of  these  Constitutlonul  Oindilionsor  ViKfrnt  lt!i.trunio<i»lta 
oocation  the  diseaM,  together  with  any  Topical  Appli<  it  v**^ 

considered  necessary;  and,  2.  with  reference  U^  th«  0,^ v   i'nmdani 

that  may  be  r^-<^uire<]  for  the  removal  of  ibv  affsctiiHi. 

U.  The  Conititational  Masagement  of  piles  necescarity  raries  ranUtf- 
ably  according  to  the  condition  of  the  pntivut  in  whom  tbey  on-ur.  aani  U' 
visceral  obatrucliou  to  which  they  inay  be  referahlv.  Thus,  wbeo  thryitffV 
lu  debilitated  uenotu,  apimrently  fnitu  relaxation  of  Ibr  TiiTls,iaM  hffr 
will  be  derived  from  u  mild  Ionic  nud  nutritious  plan,  at  the  sane  ttaal^ 
the  bowels  ure  kept  regular  by  Sotiio  of  the  apcrieuts  ibat  wilJ  xtammlhU^ 
bti  lueutloned.  lu  ihette  cumts,  uI»o,  much  advaulage  is  ofleu  ubtaioerf  ^'^ 
administration  of  the  coiiJVction  of  hlHck  pepper,  whirh  acts  as  s  iwAf 
Ic»rnl  Htiiiiulunt  to  the  vcesele  uf  the  rectum.  A  ould  w«t/r  iuJAdiissAv 
each  motion  is  very  useful  in  thne  cases.  In  the  gftsi  amjnnty  i^  iiaas''^ 
however,  more  particularly  when  occurring  ahaui  the  middle  periaJ  rf  ^ 
pilMare  counctrted  with  a  plethoric  stale  of  system,  and  ubitrvete*''^ 
abdominal  viwrera.  In  theae  oireums lancet,  our  rtfliris  ahoold  he  dls*^ 
lA  the  retliiclion  of  the  plethoric  c*mdition.  by  puni—'  •'■••  — 'i*« 
proper  regimen,  iiruhibiLing  the  uite  nf  fetimuliiats,  &■■ 
of  animal  food  tlinl  he  is  in  the  habit  uf  taking.    \\  um  [nx:*  nine 


tlMrla 
■ar  «!««&■ 


TREATXBirT  OF   PII.B8 — LOCAL. 


805 


pretssiire  <:)f  a  enirid  uterus  or  other  ab<!riri]iusl  lumnr.  little  CKD  be  doDc; 
except  br  IqchT  pullialives  aod  mild  aperieuls,  to  moderate  the  iacooveuienoe 
attending  them. 

la  all  cases  of  piles,  but  more  particularly  in  tho<e  ariaiog  from  hopnlio 
ob«tructioD,  niild  aperients  are  ut'  essential  service;  br  remuving  feculent 
ttccuniulatiiiDe,  and  eKlablieliiDg  a  free  ^crrction  from  tne  iiiteatJiial  aurfnce, 
tbej  teod  materially  to  prevent  coDeeslion  of  the  portal  syateni.  At  the 
eanie  time,  drab<tic  purgatives  of  all  kinds  should  carefully  be  avoided.  The 
lQo«t  useful  nperieitis  are  the  eleclusry  of  eennn,  sulphur,  and  castor  oil; 
one  or  other  of  which  elioiilJ  be  taken  regularly  tvicc  or  thrice  a  week  at 
bedtime,  la  as  small  a  quantity  as  will  be  sutficient  to  keep  the  bowels  free. 
la  nmoy  cases,  the  conl'eeliiiu  of  senna  niav  Hdvautageously  bo  given  in 
conibiaaticu  with  prc'ci)j tinted  sulphur  aod  tlie  biiartratc  of  potash,  equal 
fiarte  of  each  uf  these  being  made  into  a  mu^  with  twice  their  qiianiity  of 
the  confection  and  u  little  syrup ;  of  tliiu  tlcctuary,  a  desserttipoonftd  tuay  be 
taken  every  nigtit  or  every  seuoud  uight.  If  there  bo  a  rulaxed  conditinti 
of  the  rt-ctun)  and  anua  conjoined  with  the  piles,  oa  not  unfrecjucntly  happens 
in  old  ail  well  &s  in  young  pcitplo,  tho  adminitttratton  of  an  electuary  oom- 
pueed  of  c<iubI  parts  of  the  confectinnn  nf  senna  and  of  black  pepper,  or  of 
cubeba,  vill  be  found  very  useful.  In  fhcl,  in  alt  ciue3  in  which  the  black 
pepper  is  adminintered,  an  aperient  should  be  given  from  time  to  time,  to 
prevent  its  accumulatiun  in  the  large  intestine.  When  the  liver  is  nmch 
obstructed,  the  treatment  should  he  specially  directed  to  the  relief  of  this 
oif  an ;  with  this  view,  a  eourse  nf  Phimnier'a  pill,  fnllowed  hy  taraxaciim, 
and,  in  relaxed  cumititniiDns,  the  niineral  acids,  will  ha  found  especially 
serviceable,  at  the  same  time  that  the  bnwela  are  kept  free  hy  gentle 
aperients. 

Tbe  habitual  use  uf  lavem«n(«,  consiiitiug  either  of  soap  and  wat«r  or  tbim 
gruel,  will  be  fuuud  advHulugviius  iu  many  coses  of  piles,  though  in  some 
they  apfwar  to  irritate,  and  rather  to  increase  the  disease.  H'licu  the  piles 
occur  iu  relaxed  coustitulioiia,  the  lavement  should  be  used  cold ;  but  when 
the  patient  is  uf  full  habit  of  body.u  tepid  one  will  usually  be  fuuud  to  agree 
best.  In  the  general  niHuugemeut  uf  pilee,  it  need  scarcely  be  observed  that 
any  hnhils  which  favur  the  disease  shnuld  be  sedulously  avoided. 

The  Local  Treatment  uf  piles  is  of  cousid(;ruble  impurtauce.  The  parts 
should  be  regulitrly  s|><>nged  >silh  colil  water,  morning  and  evening.  If  there 
be  much  relaxation,  and  the  pik-s  be  iulenial,  bcnctlt  may  result  from  the 
employment  uf  some  uHlriiigent  ii]jecliuii,such  us  a  very  weak  solution  of  the 
sulphate  ofiroti,  kt  of  the  linciurp  of  the  WBtpii chloride — n  grain  of  the  firat 
or  ten  drt)])^  of  the  second,  to  an  ounce  of  water;  of  this,  aliuut  twu  ounces 
may  Iw  injected  every  night  and  left  in  the  rectum.  The  application  of  an 
astringent  ointment,  such  as  the  unguentum  galliv  co.,  extract  of  witchhn7.el, 
or  the  employment  of  the  anodyne  and  astringent  supp<tsitory  already  recom- 
mended for  lissure  of  ihc  anus,  will  be  nllcnded  witli  much  henelit. 

If  exlernnl  piles  become  inflamed,  the  patient  should  keep  his  beil,  ami 
leeches  should  be  freely  applied  around  but  not  upon  the  tumors.  Tepid 
lotions,  poultices,  and  poppy  fomentations,  must  be  sasiduously  used,  a  very 
qmre  diet  enjoined,  and  the  bowels  opened  by  mild  saline  aperients.  If  u 
cooguluni  form  in  an  estcnial  pile,  as  the  rciiultof  inflammation,  the  tumor 
should  be  laiil  open  with  n  lancet,  and  Its  contents  cither  squeezed,  or  turned 
out  with  the  flat  end  of  a  director.  If  abscess  form,  it  must  be  punctured  in 
the  unual  way,  anil  the  part  afterwards  fomented  or  dressed  with  borneic  lint 
Boakcil  in  warm  horacic  lotion.  Should  atriingulation  of  the  piles  take  place, 
the  prolnided  swelling  must  be  returned  by  gentle,  i^teady  pressure,  and  the 
port  aAerwards  well  poulticed. 


DIStASEB    OP   THK    LABOS    IXTKSTIITK    AKD    AllVS. 


'2.  OpcntiM.— The 


wnw  wAcstcd 


of  piln ;  bat  iF  (be  divwe  i 


I  tBcmTeBlctrt 


II7  wSciaM  in  «A> 


•  Itr   Lltuif  < 


rdU 


la  genenl  irriiAiiuo  utJ  local  uoeatiana,  or  if  cW  abuorUti 
Atge  be  wch  as  tenomij  to  inicHere  siifc  iW  bealtii  of  ilii.  ,^..  «..  a  (-1 
WoMe  aeoBMuy  at  Um  10  have  reeoarae  10  MMnuive  iaiemreDoe.  viikt 
TIM  of  kootIi^  the  rlJMnil  amctnRiiL  Xo  openikRi  draoM  mr  It 
ttwItTimfceD  «hiM  the  [die  ia  in  aa  i«fla«wd  Mate,  leM  nohnliliT  iaftuiH^ 
tioa  be  aet  Bp  io  the  part ;  U  ii  alao  well  i»  get  ibe  patit^i't  tiraitk  «>• 
gped  itate,  aa  nTvipelas  amj  olberwiae  fiJIeir  the  oprrattoo;  asrf  Mi» 
prtrre^iBg  to  perform  U,  care  abeald  be  lakes  U»ai  1 '  '  '*  ban  !■■ 
veil  <rpes^.     If  the  patient  b  aaScyiBS  from  cirriHM*  <>.  r,oo<ifn- 

t&oo  tvjoiiifiable. 

Hiere  are  fire  plRU  of  treatacai  toamimlj  adopled  for  th«  naannl  rf 
pites.  Tir.  {'tc-hinn  of  tb«  tDfDor,  tti  atnuipilatiQa  bj  ligatitrr.  tu  deAnriM 
by  the  clamp  and  caalery.  br  eroibilig.  and  br  tb«  um  o(  mustica  Thm 
mathwdi  of  iYcatBi«sK  almald  oot  be  caplorcJ  iodiKrifninnU'tv.  Tl*  Im 
it  alove  applicable  to  exlental  piles ;  tbe  vwn  to  tbe  ioUrmaJ  furai  of  6a 
dneaav. 

BxeukO. — ^Tbe  mDoval  vf  external  ptlta  is  naHily  efl^cd.  Tb*  tamm 
•boat*!  b«  seized  with  a  Tuleellum  or  bwfc.  drawa  f(>rwnrdif,  aod  iaijifvd  tt 
with  a  pair  of  knife-edged  wamnn,  nirred  upon  ibe  0aL  At  |J»  1 
wbeo  toe  external  pile*  are  rcmored  in  tbi»  war,  »iiy  pTOdahK«lla|ai 
ID  tbcir  viciniiT  ifaould  be  exciwd,  leot  tber  bcooaie  iirttated*  uhI 
Um  faaaii  of  a  fresb  pile.  AAer  tbe  exciBoa  of  utaraal  pilca,  tbcK  ■  _ 
but  triflio};  hemorrhage,  which  anj  readilT  be  antstM  br  the  appHMrt*" 
of  coM  liDt,  or  a  pad  ami  T'baadagfc  Should  aor  Hmalf  ann7UMl.it 
najr  ba  piothed. and  the  bemorrh^e  ibaa  sto|^ied. '  Tba  heniuRiufr altar 
dant  OD  this  little  operatiuQ  ■  aomMtniea  raUier  pcnfW. 

Ligatvn. — Inieruul  pilee  are  mual It  removed  by  the  li^talan;  iafai 
it  may  be  laid  dunn  as  a  rule  ia  aur^rr.  thai  no  interaal  pile  ■bouMvifr 
be  truted  b^  ciciaiuD.  Tbe  reaaoo  of 'this  diflbrcMiB  in  the  pnruot  raW 
adopfted,  at^cordinj;  05  the  pile  U  situated  above  or  below  the  niaritio  td  il* 
anu.  b  the  liabiliiy  t<>  iiciunrrfaagv  io  tbe  one  ease,  but  nm  ia  ibe<«W. 
The  bleedinif  that  full'iwa  the  exctflioo  of  an  external  pile  1*  tuii  onlrMdl 
io  qunntity,  hut  may  rea>1ity  be  armied  by  culd  ur  preaMirc-.  WiA  iairrBii 
pile*,  however,  it  io  dilfi-rt^til :  thrmt  taoion  are  out  oul*  toore  raetakr. 
being  often  fed  by  a  lar^  (-f^ntral  arterial  twig,  but  are  rWfUv  aeaud,  ttJ 
d<i  not  reatlity  lulitiil.  of  thf  ■'■■n  of  twuis  f.ir  i'  -    :TlWi* 

ofUliiutl  frtiiii  lliHiii.      Kti  di:  ■'.  in  sfiti  tbv  hlrvdii.  .i«  imnil 

pile  iu  PHiruL-  com-si,  tbnt  patifiit>  Imvi-  ai'lunllr  l>>*t  tltrir  livo  rj-t>ial^oM 
at^r  it*  i-x<>i>i>m,  wm  in  tbf  bnU'li'  of  Miuie  u(  (liv  tinMt  dtHiltp*i*bld "* 
gitun.  The  i!Xct«iun  i>f  iulerual  piles  ha*,  euiiMrtjuvoUy.  l)«ea  rcry  prapnT 
abnrtdoiifrl. 

The  Ojtrnttion  Jvr  the  lAyiliirr  of  In/fnuti  f^l^t  inny  m'»t  orwi«»i*dl  m 
coiHluclttd  ill  the  lollijwing  riianuer.  The  puiimi  lnnln/  tin, I  hu  brt^ 
cleartjd  out  by  a  d'»e  of  ciutor  oil  on  the  day  |ir  '  i*' 

o'pemtiun,  ahould  have  au  nbiindaut  laveiueutof  » -.,■  "^ 

abtnit  nn  li-iur  iH-forr  (lio  Sur^'eon  arrives;  and  he  »h»uli]  >  -^ 

to  eil  for  half  an  hour  on  a  bidet,  or  over  a  pun  c«>niaititD}:  b--i  wai"^.  'i^' 
iug  down  at  tbe  s»mc  time,  bo  m  Ut  cause  tse  |>ilra  li>  pn>lrude.  Wbtai" 
ia  readv,  he  Bhoutit  be  laid  on  tlie  beil  on  hie  left  eide.  with  the  aal'»f<*' 
prujoeuna;  tbe  Hurgemi  then  aeisea  the  tn'»t  prominent  pile  with  »  Hif 
foraein  iPi^.  HUi,  dmws  it  «i<ll  ftirwardfl,  and  tin  it«  bue  aa  tighllf  ■ 
iBVl^le  with  a  thin  whipt'ord  ligHlure.  The  ri nj:- force jm  taay  be  t^M*** 
olip  or  by  a  »tn>ng  Iiidin-rubber  ring  i»o  tbeabaok*.  whidhdivntk*'' 


m 


d 


OFBRATIONS   FOB    PILES  — LIQATtTBE. 


867 


Tig.      •)1S.  —   UailMri 
Ligatai*  iv  Pll«f . 


drawn  down  to  the  haiidEes.     He  does  the  tnrae  to  one  pile  after  the  other, 

DQtU  all  thnt  CAD  he  met  with  have  been  stritngulated  io  this  way.     la  some 

eatm  the  pile  ia  so  broad  nt  the  bnse,  thut  the  ligature  will  Dot  ioclude  it. 

lu  such  cases  some  Surgeons  employ 

lr».Dsli](ii>n  ;  this  may  usually  be  uoiic 
,  readily  cnougli  by  ruenus  or  a  aicvue- 
'  needle,  or  by  ihe  iustru  dicdl  repreacntcd 

in    the   antiexed    drawiiijr  (Fig.  815), 

Biwheg Needle,  which  cmiflista  iif  aitlw;] 

ehttok  fixed  iu  au  ivory  liuudlc,  and 

haviug  ItJi  free  cud  ptrforiucd  tor  th« 
,  reccpiioD  of  a  needle-eyu  near  it«  poini. 

In   chie   infltrumcnt,  iioi  only   itt  the         IF  'J 

,  angle  formal  by  the  ucedio  and  the 

shank  a  very  coiivenieDt  one  for  pa»$in^ 

a  ligature   through    a   pile  JDNide   the 

BiiuA,  but    Tnore    particularly,   as   the 

n*^le  can  be  rletacherl,  it  may,  aa  soon 

a*  it  ifl  onrried  acrocs  the  hfme  of  the 

turner,  he  ^eparoted  and  so  withdrfltrn 

more  readily  than  it  otherwise  could. 

Transfixion  of  the  pile  and  it*  lignture 

in  two  halves  ia,  however,  a  very  dan-     Ftg.  8u Rlig- 

ferous  procedure,  and  should  never  be  rorotjx. 

•d  recour-te  to  if  it  can  possibly  be 
avoided.  The  danger  of  this  operation 
coiuidt«  in  the  possibility  of  a  hemorrhoidal  vein  being  traogfixed,  and  the 
two  halves  thuu  tied  iwparately.  In  this  way,  tbe  vessel  ie  left  upeu  and 
cannot  collapse,  and  the  risk  of  direct  septic  absorptJuu  b«cijuie«  very  great. 
Trauefixioa  may  ueually  he  avoided  when  the  pile  a  large  nud  round,  by 
snipping  through  the  cutaneous  portion  by  meuus  of  curved  svissuns,  Ihua 
leaving  a  deep  groove  fur  the  reception  of  the  ligature,  which  Chen  couetricU 
only  the  subetunce  and  mucous  surface  of  the  neoiurrhoid.  If  the  pile  he 
longitudinal,  it  may  be  deeply  notched  with  Kcitssura  in  a  direction  upwards 
firom  itB  lower  attachment,  at  the  line  of  juncture  between  the  skin  and 
nmo<HiB  raembraap,  and  the  ligature  tied  in  the  gnwve  thus  formed.  In 
whatever  way  the  ligatures  are  a[>plied,  care  should  be  taken  that  they  are 
tied  as  tightly  ns  possible,  so  that  the  piles  may  be  eHectually  straugled  at 
once;  as  in  this  way  they  separate  much  more  reiidily,  and  with  far  leas 
pain  to  the  patient  than  if  loosely  tied.  When  all  the  tumors  requiring 
ligature  have  been  tied,  the  ends  of  the  threads  must  be  cut  off  cloeie,  and 
the  strangulated  mass  pushed  back  into  the  bowel.  If  there  be  any  exter- 
nal piles,  tbe^  must  now  be  cut  off;  for,  unless  this  be  done,  they  become 
irritated,  swollen,  and  inflamed  by  the  presence  of  the  ligatures,  ami  consti- 
tute a  source  of  much  distress.  A  morphia  suppository  is  admini8.tered  and 
the  patient  must  now  return  t*^i  bed,  and  should  keep  the  recumbent  posture 
ontil  the  ligatures  separate,  whieh  ufiually  happens  from  the  sixth  Io  tho 
eighth  dftv,  when  an  ulcerated  surface  will  be  Icfl.  which,  however,  speedily 
closea  and  eontrauta.  In  sunic  cases  this  |)roeos8  may  be  faeililntod  by  (ho 
application  of  the  nitrate  of  silver  through  a  a|ie<iulum  ani.  On  the  third 
or  fourth  day  after  the  operation,  the  bowels  may  be  opened  with  a  dose  of 
cantor  oil. 

In  the  afin-treatfMiit  of  the  cnite, care  nuist  he  taken  lo  prevent  the  recur- 
rence of  th^ne  causes  that  gave  rise  to  the  atTection  in  the  firat  iaslauce. 


8       P19KASB9    OP    THE    LARQE    INTESTIJCK    A^TD   AlVt. 

After  pilfs  bsve  beea  drd,  more  puiimUrlr  if  tkvy  W  iealad  imiAik 
BHierior  pAit  of  the  raddiD,  tWre  h  frcqoMttlT  grc»t  irriutioa  «t  Hf  tUi 
the  aeck  of  the  bbdiier,  to  that  the  (wtiect  rxprrwofan  dHBniltf  u  pMf 


rig.  »U.— SnUfa't  CUMf. 

hti  arinr,  and  sometimes  suflets  from  com  n  ;  a  whb  Up  1^ 

an^  a  full  doM  of  hjraacjramns  and  niir  >  oMwIh  lAwH 

and  cnablo  the  urine  lu  pajs :  if  H  fiub,  a  olkM 

niavt  be  pawrd.     In  wuoe  OMC*.  whan  lk>  altm 


pilra  are  Terr  Urg<*  ami  vnwular.  and  lie  f*** 
i,  tiw  yniiniiry   r-  '•     -r  ••attias  U«  ' 


(a.aad  I  a» 


debilitated 

mar  advaatageocuty  be  il 

knoatioD  of  the  tnnitinriit  i>; 

be  adopted.     In  aucb  cases  so 

tbrouKn  the  iDlcgunienla  mevalv,  ;iii<i  ir.i'n  uk-j 

tied  ID  the  course  of  tbe  groorc  thu*  T'lroed. 

IbcM  meaoa  iho  pain  and  cuB»r  '  VulaA 

ooDsrqQCDt  on  tae  inclusion  ci  .mS^ 

tvgumrnt  id   th«  llnture  air  av->i>lr<i,  at  tkr** 

time  thai  liie  risk  of  bcmoirhacc  »  not  iDcam'' 

The  treatmeot  of  pilis  bv  rigatar*  b  aoi  tl» 
getber  devoid  of  daogi^r  in  {wnom  of  brokaB  e*- 
fititutinn.  1  baTt3  mure  iban  oove  kDovn  AtM 
from  pviffmia  r»u1t  in  LhoBc  caan. 

Smith's  Operation.— Pilra  may  be  rmaoftd  «)i* 
but  litile  feur  of  bL<iuorrhage  by  tbe  tactboi' 
iluced  by  II.  nmitli,  nbich  is  ai  mitms.    T) 
bruiiiflit  down  and  ftciecd  in  a  damp  (Ki 
6xv<l  hya  feu  turnsitf  lbL'A<!r«w.andfaanit 
t!aut«ry.     Tbt  clniup  is  i'  ..'y  rtb 

alio*iI>)  ntiv  blru'fliri^  lakt*  |  hamiDM 

iHh  ifdiidaawB^ 

Th'  .■«{«tal)Ha» 

lijfniiiri;',  aud  it  luilnwcd   I  •  ialilfcrt*f* 

tulla    beniorrbiKe  !»  iiruvi-tili-*),  and  dcalnuitiott  ii  t. 

The  fiemoral  of  Pue»  b;  the  Oalranie  Ecraieor  may  re»ily  ba  lAriali 
llie  [lilt'  ln-iiit;  ilrtiMii  iluwn  with  nnp-f'iivt)"',  au'l  «'•  -i^"-  i-itwlrielrf  kfi** 
plaUnuiii>v<ire  uf  the  £crHM'iir,  wtiicli,  tning  liglitfn  ir  tbep^fl"*"* 

mais  wry  readily.     Tliie  irf-alnifrit  is,  howi'vcr.  ni'  -  ■ne.aMf**' 

•eota  nt>  advantages  oxer  the  nielbt)d  by  tbe  rlainj'  ^. 

Cnubin;. — The  plan  of  tt-ntoviop  piiw  by  cmibiuih^  i.a.-  i"b  taw^*'^ 
by  Polliirk.     By  thia  metltud  ilie  tiemorrb<4d.  aftrr  Laving  bmsi  rfOf^ 


rig.  SIT.— AiringiisBi'i 

CUop. 


fn-ed  by  snippiuK  with  ■ciaaorB,  ia  sf iet^  in  a  {aur 
li^hli'ned  m>  n«  to  rtxiipreM  ibe  pile  inU>  a  liflrmw 
lliv  pri)j(>('ti[i^  {Hirliun  IH  lli''n  cut  utf  and  tbe  :    - 
hnin  liHri  invented  aclanipi  I'ig.  817)  for  tbiB  pi<>  ^    - 
ibau  till!  forre|M  and  ?ery  easy  of  managemeoL 


rwp^aUci*' 
V  partwii*' 

:.mnd.    All»r 
la  mor«j><*f^ 


m 


DANGERS    ATTENDING   OPERATIONS   FOB    PILKS. 


869 


CauBtics.^Iti  certain  kinds  of  internal  pilnt,  the  npplicntioa  of  nitric  acid 

|liia  been  rccommeiicicfl  hy  Hoitnton,  of  Duhlin,  anrl   11.  I/co,  and  may  oer* 

linty  be  adoptee)  with  a(lTantne:e.     It  musx  tint,  however,  be  applied  lf>  the 

eternal  or  to  the  intero-extenial  pile,  as  it  will  prndiiee  extreme  irritntinn; 

inr  can  it  he  looked  upitn  a»  a  oiibiitittite  (or  the  U^nture  or  the  eniilery  in 

>temal  pile<i  ^nerally.     It  is  especially  in  the  grnnuhir  pili-,  hiivin);  nn 

llcerated  surface,  that  this  mode  of  treatment  i»  uaeful ;  »s  in  these  ea»c«  it 

>pears,bj  destroying  ft  portion  of  the  mucous  membrane,  not  only  to  cure  the 

lie  to  which  it  is  Applied,  but,  by  pi-oducin^;  au  ulcer,  to  ^ve  rise  tu  a  cicH- 

riz,  wliicli,  by  contracting.coiisolidatee  the  partii  iu  ite  viciiiily,  and  no  lueevue 

W  n?Iaxed  gUtle  of  the  rectum,  which  fuvurs  the  heraorrhoiiluj  lenileucy. 

le  acid  may  couvenicutly  be  upplieil  Ihrotigh  ti  gl»M  8|>eculum,  buviuf;  au 

ap[>vrtiirc  on  oue  eidv  (Fig.  81H),     This  sbuuld  be  iutroduced  well  uiltd, 

until  the  pilt)  projvcU  through  the  opeutug  iu  it,  when  it  iuu«t  be  frv4;ly 

ibbed  with  a  piece  of  stick,  or  ii  glara  rud,  or  bruith,  dipped  in  the  acid  ;  the 


7if.  BIS.— K|tecu]iiai  Anl. 


Fl(.  810.— OItt  Clip, 


p' 

th 
th 


then  immediately  wiped  with  n  pinfe  ni"  lint  satumted  with  pre- 
ftlk  and  water,  nnd  the  in.Htrument  removed.     Or  ihc  gilt  clip  (Fig. 
19)  may  he  nseil,  no  as  efleetimlly  to  protert  the  netghboring  [mrla  from  tbe 
action  of  the  anrl.     A  thin  i^lou^h  (leparate^.  leaving  n  raw  surface,  wbioh 

i^ndnally  cic«(nxeH  and  contmct.t.  The  applirntion  of  the  acid  oocasioua 
>ut  little  pain  when  fairly  mnde  within  the  rectiitn;  hut  if  a  drnp  of  it  ncci- 
dcntally  come  into  contact  with  the  niiicn-riitnneouK  niirlare,  a  viu«t  deal  of 
irritation  nnd  inftnmmaiion  isexciutd.  This  plan  of  treatment,  though  UBcful 
in  particular  forme  of  pile,  m  wheo  the  tumor  U  jfraniilar  and  Hat,  so  aa  not 
tn  allow  of  ready  removal  by  the  ligfltiire,  »honld  not  be  prnciiacd  when 
other  means  eiin  be  employed,  a*  it  i»  by  no  means  so  certain  a  mode  of 
trentriiPiil,  It  cannot  be  considered  altogether  devoid  of  risk;  for  I  have 
known  one  instance  in  which  fatal  ery^ipeln^  followed  the  cauterization  of 
le*  with  nitric  acid. 

Dntujert  aitemUny  Of  if  ratio/is  for  ,PiV«#. — ^The  operation  for  the  removal  of 
pile«  may  be  attended  by  three  sources  of  danger.  After  etcisinn,  and  even 
the  apidication  of  the  ligature  or  of  nitric  acid,  erysipelas  may  develop.  If 
tbe  obiecli'iniilde  practice  of  Iransfixinu  tbe  pile  by  tbe  needle  l»e  followed, 
sod  it  he  tie<l  in  two  separate  parla,  a  hemorrhoidal  vein  may  thus  he  opened, 
,nd  ita  sides  held  apart  by  the  action  of  the  ligatures,  and  thus  n  lendency 
direct  pywmic  infection  he  induced;  and  lastly,  I  have  seen  a  kind  of 
erysipelatous  coiitie  follow  the  operatii'D,  leading  to  profuse  niuco*|Mirulent 
discharge  and  high  fever.    I  have  nlao  in  uue  case  aeen  pelvic  cellulitis  set 


870       DI8ZA8S8   07    TirX    LASOK   IVTUTI^ffC    A3fD   A] 


op.     BDt  all  these  varwoB  mtooiarj  »ftctit«i — crTiJ(»dai 
and  cellaliliii — Br«  Imppily  of  rare  ouxiijwub. 

A  permaDtnjtly  moiit  condiUoa  of  tbe  ikfai  txoukd  thi  uu  i»  Mt  «&» 
qu«ot.  as  lb«  Keult  of  pfirta)  rtkogottkto  or  a  bciuorrbuwiAt  UmJcsr*.  h  • 
beat  n*moT«d  by  tb«  habitual  um-  of  aprrieal  mIums,  or  of  aperMiDOHnl 
vaten.  as  thnr«  of  I'fllloa  or  Fri^tJncbsball. 

Frnritss  Au  is  ofUo  uo  «xtr«awlT  troublveome  uBIeeHoa,  th* 
seoerBl  irriutioo  about  th«  auu»  beiDg  alninvt  unbcmnibir.  Id  tnmx 
u  due  to  the  prcwoce  of  exlerual  fiilw  or  wonns.  lo  utbcn  it 
tbe  irritAtioD  of  tbe  Bkin  from  the  touooaa  diMbuvr  jun  ncstioMdl 
oiJMn  apiio  it  »  due  to  eczenia.  Excen  is  >IeiibiiQe  ninn^astit  imVM 
ooBBtipauoD,  and  other  coodttiutui  msv  give  rht  to  it;  bat  &e<)«em)Tlki 
a»Mt  careful  ioresttgatioti  faili  to  detect  an;  c«iii*.  Tb«  TVaHtaeit '■■ft 
have  reference  to  tfae  cause  if  one  cao  be  found.  If  there  be  an  cxunal 
pile,  the  removal  of  it;  if  vomts,  their  espubioo  viU  prohablf  am  da 
cnodition.  If  it  is  due  to  ecxenia,  boracic  arid  oiotntcot  with  ■  dmtetf 
extract  nf  bpllaitDnoa  added  to  each  ount-e  will  freqtuntlj  brine  abMt  ■ 
•pwdy  cure.  If  there  is  a  niucotts  diecharge,  the  fm)aeiit  anpUoUiM  4 
borac'ic  Acid  IntioD  mar  give  relief.  In  sacmi  easct  it  term*  atft»in%  « 
goat,  and  thetr^iment  for  that  disease  removes  tfae  pnirilo*.  InotlMfeMa 
arwnical  nrcpamtioDa  will  be  found  UM-fitl,  together  with  the  local  «^fl)<» 
lion  of  chlorinated  lotion*  nr  those  cootoinini^  hydrocyanic  acid.  fiooMinn 
tar  apfilierl  by  mean*  of  a  piece  of  oakum  gives  oa«a]>leU  retief.  bat  in  mmj 
ctMD  uwtbiu);  succeeds. 


l^OLAFBCS  AKI. 


m 


Prolnpnis  Ani  oonei^tB  in  a  protrunon  of  the  maonu  BMonbcsne  at  At 
rertuin  thniuj^b  the  anal  ongce ;  the  areolar  titsue  thni  lias  nodiracalli  ii 
beini;  also,  in  the  majority  of  inMances,  much  thtdcened  and  fdongilsl   I* 

thr  onliiinry  i>n)la|n<ui),  the  muscular  strueturea  of  tbe  gut  ai«  not  pniinM; 
vet  occaainnitlly  the  muscular  eont  descends  with  the  uiuooot  owmbnaKss 
invaginatinn  of  the  h'twel  tdlcin;*  place,  which  eonsttlutiM  a  &r  ours  mAm 
oonditioi).  The  formt^rc<>iiditioti  alone  is  oorreetly  tormc-l  Tir.ilirmnsail,  lis 
Utt4'r  U  more  t^rrectly  spoken  of  as  prolap«i4  or  pr-  'ti.    P)*- 

lapuii  r«cti  is  rarely  m<<t  with  in  adults,  and  is  in  thnm  (..  .  '■•-<''   '' 

children  it  i>  the  commoo  conHition,  trtia  prolnp^ni  ani  h- 
The  pri>lapiu*  ofchildrenis,  tborefore,  better  cooMdenod  sopsrairir  nuwu- 
of  sdulut. 

Caiues  of  Prolapioa  Ani.— Tu  weakly  perswi  gent-ratty  there  is  s  utitai 
teudcDcy  U)  i>ni)»j>-ui< ;  th^  xliL'tit  prolrution  of  the  ninniu-  nwanlitaiw  eloA 
takes  nluci'Mtiniik:  d(•^^1iti<■ll  Ix-in^' itirr«>ftMd  by  ar>  ilaaadilte 

that  giwvB  riw  to  atony  "f  llie  inu'<ciilHr  Hyatem,«s(-  \tian«flk* 

inteeiinul  mucouB  njenilii-Nni'  iw  *>>iijoiiU'il  with  thi-.  -y,  tknslf 

dinrrh'i'ii.flc.     S»,  iiKMiii,  iht-  hnl>ituai  rolwtijfation.  .-  ia|*iW 

of  n  rvlnxfd  biibit  nf  bmiy.  nj>|wirfiitly  pr(ic**ili  .wfia** 

rvctitm  tu  expel  ils  iH>utent«,  and  rvuuiring  en  —     i  Hs»l,y* 

dunoees  Ui  thid  afTiKtion.  It  is  cspectaliy  commun  in  tbnse  «bn  IsbamMH 
fltncture.  stone,  or  any  other  diwaee  about  the  urinary  organs  thai  iw(*^' 
considerable  efibrt  to  be  made  in  expi'lliu^  the  ntnicntj  uf  the  blsdifaf-  7 
penoDs  wbon  coostitutioo  hiu;  brea  reluxnl  by  a  louu  residesior  in  IbAb>*' 
atwase  also  frequonitv  occurs.    lo  uthor  casee,  and.  indeed,  most  usoallT.^ 

SrolapBuiisaaKwiateil  with  piliti,  the  weight  aud  dragging «>f  the  fassMia*"' 
rawing  down  the  mucous  membrnne.     Tliis  u  ospectally  apt  le  Wf^ 
whnn  tn^ro  is  genernl  hemorrhoidal  tendcacy  about  the  aatOL    la  tut*''* 


I 


d 


rAPSUS    AHl — blAOHOAlS — TBBATMBNT. 


871 


cftuSM  of  prolapsus  niay  be  Riimmfil  up  undfr  three  hpa<la :  1.  Siniplo  rcInxA* 
tion  of  tissue,  audi  as  is  met  with  in  weakly  persons;  2,  SympftllieticirritniioD, 
as  ill  clinmio  iene.'rmis,  Atotvi-  in  tin*  lilafMer,  etc.;  'A.  A  liemorrhoiijal  or 
polypoid  cotif)iLii>n  of  llie  nuicoutt  ii)bnibraQ>e  of  tli«  rectum. 

DiAGVObia — Prolapsus  is  readily  recoguited.  Il  cuBgi»l»  in  die  jirolriuiiuu 
of  a  ring  of  tiiiicuija  uieiTibratie  of  h  red  or  purplieb  color,  ami  hiiving  a 
suiiiewliAl  turgid  litak,  rulht^r  lubuluted  iti  ehupe,  trnd  vurying  in  niiv  {mm 
half  n  waJiiut  to  a  Hnmll  oraDge  (Fig.  ii20).    The  muL-uua  luenibraiie  cuveriug 


iC^ 


this  rinf;  will  he  found  tn  he  continuous  with  that  investing  the  fiphtncler, 
And  this  constitutes  tbe  mark  nf  diMinction  between  ordinary  prolapsus, 
a  projeclitifT  intussusception  i>r  a  protrudin)^  polypoid  growth.  In  prolapgiia 
tiiere  is,  when  the  protrusion  is  down,  n  dragj^ing  and  smarting  sensation, 
often  alleuded  with  a  good  d«al  of  epasm  about  the  neck  of  the  hiaddur,  and 
uot  iiufret|UL-utly  willi  eyiuptoins  of  stricture.  lu  cliruuic  cuet's,  ihv  uuul 
Apurture  tippeun  to  be  pernmiiently  relaxtrd  ;  &t>d,  on  iutrodu>c:iug  (hv  linger 
into  it,  it  is  fouu<i  to  W  widened  uud  weiikeuvd.  Tlie  folds  of  skiu  in  its 
neighborh'jud  arv  relaxed  and  eIougat<.M),  rudiuliug  froiu  it  us  from  a  centre; 
they  niv  couiuiunly  bluieli,  eull,  soniiiwhut  ewollen,  and  pendulous,  and  oflen 
the  si-at  of  a  good  deuL  of  irritation.  The  prolrueiuu  ut  tirst  uecurs  uuly  afler 
defecation,  and  then  readily  gots  buck  of  itself,  or  is  reduced  by  steady  prrs- 
aare  upon  it ;  aflvr  u  time,  however,  it  tvill  come  down  at  other  periods ;  thus 
it  may  protrude  during  riding,  walking,  nr  even  standing,  and  is  returned 
with  much  difficulty. 

Btrangulatiou  of  the  prnliipHus  may  occasinnalJy  occur,  ifit  be  allowed  to 
protruile  (or  a  consitierulile  length  of  time  withmit  a  jiroper  ailernpt  being 
made  to  push  it  back.  Et  then  beconiet«  swollen  and  livid,  with  great  pain 
And  tenesmus,  discharges  a  fetid  ill-pouditioned  pii?,  and  nmy  eventually  fall 
into  A  aloughy  state,  and.  thus  gepamtiiig.  undergo  a  spontaneous  euro. 

There  is  a  form  of  prolapsus  that  h  rises  f'roni  complete  atony  of  the  levator 
and  sphincter  ani  muscles.  For  this  noLliing  chu  advantageously  be  done  by 
operation.     Pnllialiou  by  simple  support  is  the  sole  trentment. 

Tkkatmlst.— The  treiitnienl  of  prolapsus  nmy  be  said  to  be  palliative  and 
curative.  The  Falliative  Treatment  c^jnsists,  in  the  first  place,  in  reducing 
the  tumor  when  protruded.  This,  in  onliuary  circumstances,  the  patient  dues 
for  himself;  but,  ifit  become  congested,  it  require*  the  help  of  the  Surgeon  to 
put  it  hack.  This  may  occosioDAlly  be  rendilv  done  by  laying  the  patient  on 
[laa  side,  or  making  him  lean  over  the  hack  of  a  chair;  and  then  greasing  the 
BtASB  with  some  oil,  seizing  iiwiih  a  sofl  towel,  and  gradually  compre^iug  it. 
Working  it  back.  It  tuay  lie  kept  up  by  wenringabelt  with  a  pad  and  elastic 
■upport.    Olive-shaped  pewter  pessaries  arc  occasionally  employed,  with  the 


872    DISEASES  or  TH^Tin[^ 


rvs. 


view  of  preventing  tlie  prrdniBicin  ;  hut  T  Iiavenevpr9<*n  lliern  of  any  wrviee, 
the  ephiDcter  hvitig  UHiiuily  t«o  relaxed  U>  keep  them  up,  And  tlieir  pressure 
apijiearing  to  oxcil«  irrilalitm. 

Tlie  regulation  of  the  bowels  is  a*  itnporUnl  in  prol«p«ne  ns  in  piles.  It 
is  usually  hest  dnoe  bv  the  atlmiDislratinii  of  ifaiiee  luxntives  tbat  have  been 
reootninemleil  for  the  mtter  <liBeit3e.  It  is  a  gooil  pIno  tu  pntlnpoiK  Ut  gel  the 
pBtieut  to  have  his  duily  inotJoD  at  l>e<ltime  iusteHil  of  at  the  usual  hour  io 
tbemaroing;  the  recumheat  pnHitina  aod  the  imirorai  tempenilurr  of  the 
bed  preveiiliiig  the  irritation  of  the  Bphiocter  ami  epUBni  of  the  una)  muBclu* 
that  coniDionly  coatiuue  for  potue  time  after  the  reduction  nf  the  pnilapsus, 
and  which  are  a  source  of  great  discomfort  when  occurring  io  the  eorlj  part 
of  the  dar. 

Curative  Treatment, — The  relaxation  of  the  mucous  loembraiie  nf  the 
rectum  tluit  e^cntially  constitutes  prolapsus,  may  oAen  be  obviated  by 
astriugeul  injections  or  ^iipp>i@itorie8.  The  best  injection  ia  that  of  the  sul- 
phate of  irou,  in  the  elrength  of  from  one  to  thn?e  grains  in  an  ounce  of 
water,  thrown  up  in  small  ouantities  sufficient  for  the  bowel  to  retain.  In 
Dilld  cases  of  prolapsus,  conjoined  with  a  relaxed  Btalc  of  the  mucoua  mem- 
brane of  ilie  rectum  and  relaxation  of  the  sphincter,  the  use  of  the  iron 
injection  will  be  found  particularly  beneficial,  at  the  same  time  that  the 
action  iif  the  bowels  is  regulated  &y  means  of  an  electuary  taken  in  the 
morning  or  at  night.  By  thus  giving  tunc  u>  the  bowel,  at  the  same  time 
that  constipation  is  pr^vonlt^H,  the  disease  will  occasionally  undergo  a  cure, 
provided  it  be  not  nMocinlcd  with  any  offectitin  in  other  urganB. 

In  those  cflsu  in  which  the  prolapsus  is  hemorrhoidal  or  polypoid,  the  pro- 
trusion being  dragged  down  by  the  wpight  and  strain  of  the  pile  or  polvpus, 
the  same  treatment  mnst  be  adopted  as  has  been  recomracudcd  for  the  laller 
disease;  and  usually,  after  the  lifjature  ami  removal  of  tlie  pile  or  |»"lypu», 
the  prolapsus  will  be  cured.  lu  slight  ca«e«  of  prihiji^us,  in  which  the  die- 
ease  appears  rather  to  lx<  owing  to  the  relaxation  of  the  sjiliincter  and  of  the 
tissue  external  tu  it,  the  miico-culaneous  inti^umenl  hanging  in  lotce  fohls 
around  the  unus.  considerable  benefit  will  cummouly  result  fnuii  snipping  off 
thc«e  jHrndulouH  Hups  of  vkin ;  the  cut  surface  that  is  leA  ci(«tntini*,  and  by 
itscoutracliun  bracinyup  ihepnrt.aud  thus  nrevcnting  its  further  protrueioo. 
These  pcudulous  ii\\]vs  arc  best  removed  io  a  direction  radiating  from  th«  anal 
oriiicc,  with  curved  knife-edged  sciieora. 

When  the  prohiiitui'  is  considerable,  and  the  onliuary  palliative  treatmeot 
after  a  pnt|}«r  trial  fails  iu  effecting  a  cure,  it  will  be  neceKtary  to  remove 
the  protruded  tiiucouA  mendiranc  by  operatiou.  This  should  lie  iloue  by  tho 
appiicatiou  td'  the  ligature,  or  by  the  clninp  and  cautery;  cxnision,  though 
eany,  being  objeclioniible  in  this  as  in  the  cuee  of  pilee,  on  account  of  the 
danger  ihiin  hemorrhage. 

ApplicatioD  of  Li^ture. — The  patient  having  had  the  IkpwcIs  freely 
npene<l  on  (he  preceding  day.  and  an  enpnm  of  tepid  water  on  the  morning 
of  operation,  should  lie  directed  to  nit  over  a  ]mn  of  hut  water,  in  onler  to 
make  the  prolafieus  descend  ;  a  pnrthm  of  it  tn»y  then  be  seized  «i(h  a  pair 
of  broad-ended  forceps,  such  as  are  represented  in  Fig.  814,  ilrawu  well 
forwards  and  firmly  tied  with  a  strong  piece  of  whip-ronl.  A  similar  pro- 
ceas  is  then  repeated  on  the  opposite  side  of  the  anus.  Should  there  be  any 
difficulty  on  account  of  the  shape  of  the  protrusion  in  ligaturing  the  bus 
firmly,  this  may  be  obviated  by  transfixing  it  with  a  hemurrhoidal  needle; 
and  tying  it  on  each  side.  I  think,  however,  that  it  is  !>etter.  if  jwiflaihlp.  to 
avoid  doing  this.  If  the  protrusion  be  very  large  the  ligatures  should  nM 
be  made  to  include  too  much,  lest  the  muscular  coat,  or  perhaps  even  the 
8«rou9,  have  also  descended,  and  should  be  accidentally  included,  or  leat  • 


PSOLAPSITB   OV  THE    SSCTUU — TRKATHKVT. 


873 


luro  of  the  bowel  Ktiuulil  MUiw  the  ci|K-ratit;u.  Ttic  eads  of  llie  Mature 
Iheri  Ue  cut  ebort,  lite  wliuk-  ]ircilnifiii)ii  reuirnt'd  into  tlie  bond,  the 
oxteruul  llapB  of  skin  i:ut  lAV,  aii<l  n  riioriihiu  euiiumhory  intruiluced  iuto  the 
b(>wcl.  HtiittU  rlosesiif  ()|iium  ur  nmrphia  may  8ui)K(;<)ueulIy  bu  aitiumielcreil, 
HI  »s  lo  arrKBt  all  iterititiiltic  action  lor  ii  few  ilayit.  Hh<iitl<I  tlio  uioerated 
flurfiifs  Bbi>w  any  ilitiicnltv  in  hpalin^,  i(  mtitti  1h>  l^xii^bfiil  wtLh  the  nitrate  of 
Isilvcr.     This  operation  iihvnyfi  Ifjivf^  n  pi-rmnncnt  cure. 

The  li^^atiiff!  iif  prolnpsus,  like  ihat  of  intemnl  piipfi,  it  not  very  painful, 
anil  for  it  chlorotorm  need  not  l>e  administered  ;  indfed,  in  some  macH  it  ia, 
perlm|»,  hetttr  thnt  n  shniild  not  he  given,  ns  the  protrusion  is  apt  to  kHj)  up 
under  its  influence,  the  pulient  not  being  able  to  exercise  the  proper  cxpuUive 
efFort5.  Bin,  tis  the  excision  of  the  cxternnl  flaps  and  piles  is  attended  by 
Tery  sharp  siiffcriDg,  it  is  iiflvcllto  adminlMer  the  anieathetic  at  the  time 
when  they  are  being  removed. 

If  the  elamp  aud  cnutcry  he  uwd.lbcy  are  applied  in  the  same  way  as  for 
pile*. 

Should  a  prolapsus  become  fltrangulated,  it  would  be  necessary  to  try  to 
reduce  it  through  the  sphincter  by  the  employment  of  the  taxi«;  if  this  cnn- 
Dut  readily  be  accompliahed,  free  inc-iaionn  may  be  made  iuto  it;  if  it  be  not 
re^luced,  it  will  ali>U(:h  away,  and  thus  undergo  permanent  cure. 

ProlapiDS  of  th«  Bectom. — Aa  before  stated,  this  iji  rare  in  adultji  and  ia 
seldom  extensive.  It  can  only  be  suspected  wheb  the  amount  extruded  from 
the  anus  if  very  large.  In  children,  OD  the  other  hand,  a  pro]a|)tiui!i  almottt 
invariably  iockides  the  wholeof  the  coats  of  the  bowel.  It  presents  a  sniooth 
red  surface  ami  projects  usually  for  some  distance  from  the  anus.  As  muvh 
as  six  or  aeven  inches  have  been  known  to  be  extruded.  It  has  before  been 
pointed  out  that  intussusception  commencing  at  the  illo-ciecal  valve  may 
reach  the  nuDii  and  actually  prrtjcc^  fnmi  it.  In  ihie  condition  the  valve 
itself  forms  the  apex  of  the  protrusion.  If  the  intussusception  occur  in  the 
rectum,  It  may  still  mon*  readily  pnucct  from  the  auue.  These  condiiious 
arc  e-asily  diutinguished  from  true  prolapeua  of  the  rectum,  for  in  the  latter 
condition  tlie  mucous  membrane  covering;  the  protruded  jriit  ii  continuous 
TTtth  the  skin  at  the  mar^n  of  the  anu!4,  while  in  an  intiisBitaceplion  the  fln^^r 
can  be  jiassrd  inti)  the  howcJ  by  the  Hide  of  the  priije<Tting  invaj^ination.  I'ro- 
Ia[>dus  of  the  rectum  is  seldom  inucli  Kwolten  an<i  very  rarely  becomes  olntngii- 
lated. 

The  Chti^fm  of  pro1a|>9US  of  the  rectum  in  children  are  various.  It  is  com- 
mon in  contiectloD  with  dysenteric  titnrrhtra,  especially  in  weakly  chit<lren. 
The  irritation  of  worms  is  one  of  the  moet  frefjuent  cause!*.  Polypus  of  the 
rectum  is  an  occjisional  cause,  and  is  easily  recognized  by  the  protrusion  of 
the  tumor  with  the  bowel.  Stone  in  the  l»ladder  is  most  frei^juently  accom- 
panied in  children  by  some  prolrucioo  of  the  bowel  during  tlie  straining  to 
pAM  water.  On  the  other  hand,  »n  extensive  proLap-us  may  cause  irritatioo 
of  the  bladder  in  a  mate  child  anil  thus  siinulale  stone. 

T^eislmeiil. — Aa  tbi;  protrusion  consists  of  ihe  whule  bowel,  it  tS  evident 
that  nuy  0)>eralive  iut4?rfereuce  would  be  accompanied  by  dHii^;er  of  wound* 
ing  the  |)eritoneutn,  and  is  couitequeutly  unjustifiable.  Superficial  cnulerica* 
tiun  and  removal  of  pieces  of  initcuiis  inenibmne  have  l>een  recommended, 
but  thvy  fire  never  necewury.  In  the  vust  majorily  of  cases  the  tendency  to 
prolH|)«u8  speedily  disappears  it'  the  cause  be  removed.  Tonic  medicines, 
eK{K;cially  iron,  regulation  of  the  bowels  by  mild  aperients,  and  the  admiuis- 
tnitiou  of  a  moderate  quantity  of  uustiiuulutiug  food  will  soon  relieve  it  if 
due  merely  to  weakness.  If  worms  are  present,  salt  and  water  or  ijuassia 
injections  will  soon  get  rid  of  them.  It  there  is  any  urinary  dlsturbauuc 
the  child  should  be  sounded  for  stone,  the  removal  of  which  will  at  once 


874       DISEASES    OF    THE    LABQE    INTESTINE    AND    ANUS. 

cure  the  prolapsus.  The  prolapsed  bowel  should  in  all  cases  be  bathed  with 
cold  water,  and  then  reduced  by  gentle  pressure  with  some  oiled  rag. 
Should  it  become  straofrulatcd,  a  condition  of  extreme  rarity,  an  attempt 
must  be  made  to  reduce  it  by  pressure,  but  if  this  fails  it  must  be  allowed  to 
slough  off,  while  opium  is  administered  to  relieve  pain  and  arrest  any  actioo 
of  the  bowels.  In  this  way  it  may  safely  separate  without  the  occurrence  of 
peritonitis. 

FrotniBion  of  an  Ovarian  Cyat  from  the  Antii  occurred  in  a  unique 
case  recorded  by  Stocks,  of  Salford.  The  cyst,  which  was  the  size  of  a  cocoa- 
nut  was  removed  by  incision  through  the  coats  of  the  bowel,  which  were 
forced  out  before  the  tumor ;  and  after  the  wound  had  healed,  the  gut  was 
returned. 


DISEASES  OF  THE  GENITO-URINARY  ORGANS. 


CHArTEK    LXVI. 


SECONDARY  DISKASRS  OF  TIIR  URINAIIY  ()R(JANS  ARISING  FROM 
SUimiCAL  CAUSKS— i'Y.KMIA  AXD  rtE?TIC.EMlA  IN  UlUNAHY 
DISEASKS. 

The  i^rciil  mujority  ui'  cuim»  iif  »ltme  in  Ihe  blaiUJer,  stricture  of  the 
urethra,  cystitis  sectnidary  tu  jtiiralysiB,  retention  from  eiilargwi  prostAte, 
tumora  of  the  bhiiidfr,  nm\,  in  short,  of  every  liisenae  tending;  t(i  hinder  the 

iCscape  of  uriue  from  the  blmlder,  or  to  JDduL'e  (.'hrotiitr  inHammtitioii  "f  that 
orgKD,  tcritiiu&le,  if  nut  relicverF,  by  f^i^'ing  rise  to  fatnl  <li>^K«e  'T  the  kiil- 
neys.  This  fact  nlcnte  i^i  Buflicient  to  ninke  the  »tu<iy  of  the  sen-ri'lsry  aH'ec- 
tlODB  of  Iht!  kitliiey  of  the  greatti'itl  importance  to  tlie  pnidioal  Surpeou ; 
and  the  obscurity  which  furrounds  their  diagmwid,  auil   the  fp't'eral  impo- 

^teDC«  of  Ireatment  intended  for  their  relief,  render  the  Buhject  well  worthy 
the  fullpst  invPHtiyatioii. 

Xorbid  Cocditioni  of  the  Bladder, — If  we  exaoiiue  a  cajie  in  whicli  d^ath 
lias  occurred  frojii  one  of  ilio  abuvc-uanied  discasea,  we  find  Uiut  llie  mucous 
membrane  of  the  bliuldcr  ehou'it  signs  of  both  rcoont  and  old  inflrtmrnaii/in. 
The  recent  U  indicated  by  the  awnllen  aud  softened  condkiuu  of  the  mucous 
membrane,  and  the  iulonso  purple  of  the  Bunimits  of  the  nigje.  and  pot-aihly 
by  patches  of  ulceration,  the  ult-LTulod  surfaces  heiuj;  olleu  raivered  by  a 
thick  Bluu)*h  closely  re^emhlinj;  diphtheritic  meiidirane.  The  old  inflaramu- 
tion  ia  indiiyitcd  by  the  dark  alule-gmy  pigtin-ntation  which  itfrtcta  thp  greater 
part  of  the  mucous  membrane,  and  which  hatt  resulted  from  repealed  attacks 
of  intense,  congeittion,  in  which  reil  bliiiKl-ciiritucelcH  have  h<"eiimc  cslravaii-*> 
ated,  and,  aller  breakiiijr  up  and  b<>coming  al>sorlK^d.  have  left  their  pif;ment 
behind  them.  The  inu»cular  wiilhif  the  bludder  ia  funtid  lo  be  hjpcrtroptiUd, 
or  not,  according  to  circumstances.     If,  in  ordt  r  in  expel  the  urine,  it  have 

['been  called  upon  to  make  a  grpatly  increased  presunre  on  ita  cnntenia,  the 
hypertrophy  will  be  vpry  marked.  If  the  nbstruelion  to  the  flfiw  of  urine 
have  been  of  a  valvular  niitnre,  as  is  often  the  rase  in  enlari^ed  prostate,  then 
dilatatian  of  the  bladder  will  greatly  exceed  the  hyperrropiiy  of  the  muscu- 
lar walla.  It  may.  therefore,  always  be  .'*npp(H»ed,  when  Rreat  hypertrophy 
with  contraction  nf  the  hlmlder  is  found,  that  increased  difficulty  exialed  in 
expelling  the  urine,  but  the  increased  power  of  the  bladder  proved  equal  in 
the  occasion.  When  dilatation  ia  fmind  combineil  with  hypertrophy,  wo 
must  conclude  that  increased  pf»wer  was  required  to  expel  the  urine,  but  the 
Increase  of  muswular  tissue  wns  not  fjiiitti  sufRcieut,  and  that  the  bliidder 
luffered  frefpiently  frum  over-d intention.  Wtieii  ditalatiuu  aloue  is  found 
with  acarcely  any  hyperlrupliy.  we  know  either  that  the  bladder  hae  been 
paralyzed,  or  that  theobcttructiun  to  the  exit  of  urine  was  valvular  in  nature, 
■0  that  increased  force  applied  to  the  couteuta  of  the  bladder  coulil  unly 
ibut  the  valve  more  closely;  and  uver-diiileutiou,  with  eucli  uu  amount  uf 


S78     SBCONDABV    DI8SASBS  Of   THE    I'SIKAKT   OB&A^* 


altetchiog  of  tho  neck  as  to  ivnder  ib«  Tslve  iKVOBipcwat.  ww  Urn 
meaiu  by  vhich  uriup  ojuld  be  pnned  vilhoat  BrtlfiooU  aid.  Tka  iatt 
diliDD  u  [•cculiiir  to  pmttatic  diwnsc.  BDd  finme  i  iww  of  Ubmit  of  lh»  UlA 
der.  Jd  a)l  caa^  of  ^rcnt  hypertrophy  of  the  tnoaniUr  walb  of  A*  bbite, 
ihfl  bundlea  of  Who*  form  ri*1gefi  ud  t'ho  aurfiuw*  0viog  rae  lo  tfa*  aaS6m 
known  as  JaaeiaUation.  Id  [ubdv  cases  in  which  grt*t  fvtmmn  kai  !•■ 
quc-uUy  oKibtert  in  ibc  blatldcr,  cltlier  frutn  the  forcible  aaane^aa^' 
bypenrophitd  walla  on  the  conuiDcd  urine,  or  from  Mmpl«  awTHfiawM*' 
from  rcuniioo  artalngfrom  aTsUularobftUuclioniQ  ih«prutut»,  tiktmeai 
niMnbrane  booonm  tbriut  b«lwoen  the  bundle*  of  naoacuUr  fibra.Mfif» 
)»(•  puuohes  c&Wvti  iiuieuli.  Thete  laeciili  arc  looat  frvqueot  in  Utf  fwig 
port  of  iht!  bladder,  and,  in  otott  caaea.  th^ir  walli  at«  compoaed  HMvl/if 
uiuouuA  tiifQibraDC  and  peritoneum.  Sofi!ieUm(«,boweT»r,  alajfrof  ■■«■* 
libru  u  iil«o  found.  Thevc  Mcctili  form  |ioui--bui  iu  whiiib  putrid  ww  ■» 
cumulAU«,  and  frequently  }[!«■«  rise  Iu  iudniuni^ti'tii  of  tbe  louecw  Hi* 
brane,  aumetimoi  endinf;    in    ulcvratioii,  nii'l  rfuratiaB  tf  lb 

bladder.    Much  more  oflen  it  {jives  rise  lu  lu  li  periiMiit>,ia^^ 

purtiaoa  of  ioteetiue  may  so  become  adiiereut  I')  tliu  iiiaddttr. 

Tbe  cauM*  whicb  i^ive  rise  to  nn  incrc-a»i)  ilvmaiid  f-ir  T^h^t  in  tii-4'-« 
of  tbe  uriue.  and  coosequently  to  hypertrophy  of  ihf 
The  njo»t  cunimon  a  [lerhajia  obstruction  iu  tuc  urethr:i 
some  caM»  it  may  arise  from  uu  irrvgular  enlargenri;: 
which  the  ubslruciion  is  not  valvular  iu  character.      \  « 
ulher  tumors  uf  the  iiliutilet  mar  call  for  incmuetl  force,  fr 
strucUDg  (bo  orifice  of  the  urt^Itra.    Chronic  cyatitla.  fr>.>m  ui> 
produces  in  the  character  nf  tbi-  urine,  always  cauMV  mnrr  or 
trophy.     Stone  iu  the  hluddrr  auiw*  olwiructi'm  of  the  fluw  of  orice, 
nicehuuioally  and  partly  hy  (he  chrunir  ryHlitis  to  which  it  BMia 
riite.      The  tliifk  ropy  mucus  of  chronic  cy«tliis  undouMiJty  dllm 
cuu^idcrahle  oUtruction  to  the  (low  of  thr  urint^     All  ihcar  ctuna,  tJM» 
fon%  may  pve  rtM  to  more  or  Iras  by | h' r trophy.     Tlirrc  ta  n<i  vridiacf  Iktf 
mere  fre']uciicy  of  action   plays  any  iniportnnt  part  iu  the  ficadadMa  ■ 
hypertrophy.     In  the  few  recorded  case*  in  which  thore  waa  ifteat  Avqaaif 
of  micturition  with  henlthy  urine  in  caact  of  catculuna  pyelitis,  ut  bAB^ 
is  inndc  of  any  mnrltod  hyperirophy. 

There  is  every  i-enson  to  lielievc  that  hypertrophy  of  tbc  bladder  pkf»« 
very  important  part  in  thfl  pn-duclinn  of  kidney  di«eaaft.     lo  do 
result  of  olvstructioi)  to  lh*>  exit  of  urine  fM)w  ihe  bladdfr,  do  » 
valves  of  the  nreterH  incom|>ftcat.     In  the  simple  dilauiiitu  fr 
Dbstructioii  in  Ihe  pnNttate,  Ihey  nre  c[>«rd  <; 
reign rxilati on  talcea  [ilnc«,  but  of  courae  th<-  jt 
ueya  Mill  lie  incre»)iit-<l.  while  the  bladder  i«  m 
of  the  walli',  wi*  liml  nUo  a  certttiii  anmuiit  ol 
urine  into  the  bladder,  as  the  ureter  hiu  to  ihum  nl' 
ened  wall,  and  u  ilouhtlew  olWit   nrvaiwd   on   by  ih 

The  swelling  of  the  muooila  nieniliraiin  nl  the  oritire  ot   thr  un-Srf  ifl  u** 
Hnmed  bladder   itrobably  adds  tu  thu  ohwtruoiion.     ][<r.<  th«B.  b>^*^ 

*  '  ■■ '   K^^O* 


rcEJM 


then  may  be  uu  over  ■distention  of  Uie  bladder, 

in  tile  un^len  and  kidneys,  the  force  uf  secretinu  r 

nlMlructtou  tu  the  onward  Dow  ts  offcn^d  by  ibi*  p: 

of  thu   urvters.      The  degree  uf  obslniclion  nn<i<i> 

bladder  varii-a  much,  as  it  is  nnt  uneumraon  to  ilnd  rtm 

of  the  wall  «f  the  bladder  without  auy  marked  maw   oi  yrr^ 

orders  xr  kidnet-s.     In  cases  of  villous  tumor  of  tha  bUuwer, 


0B« 


mod  kidney  only  may  bo  found  to  bo  adbcted.  and  it  will  th«D  he  i^  i^ 


dM 


J 


KFFBCTS   OK    ACUTK    INTBK8TITIAL    Mil 


ns. 


881 


Mccnf  which  to  say  tin;  hast  whs  improbohlo.  Lntcr  olwcrvalioiiBby  Koch, 
vith  improved  mcthoila  ot'  atniiiin^,  have  ciparly  deinunstrated  the  fact  thut, 
in  every  cb«c  of  disscmiiint^il  ^ii|ipiiriititiD  fullowiug  on  eoplio  ohaugi's  of  the 
nrinc  in  the  ptlvia.colitnics  of  niiorooocci  arc  foumi  scnttercd  thrnughi)iit  the 
kidney,  dijuttuding  (ind  obstrueting  the  urinary  tubules.  Thrsc  micrococci 
are  uimilar  tn  those  found  in  putricTuriuc,  and  are  believed  to  be  the  ft- rnient 
to  which  the  change  is  due.  The  alkscegncs  o(  the  kidney  thus  arising  in  acute 
wppurative  nephritis  mii«t  not  be  confounded  with  thofte  seen  in  pywmia. 
These  are  uHii»lly  Inrger,  are  more  dislinL-tly  wedgt^-shapcil,  and  sometimes 


.-  'l^t%^^ 


fig.  832.— AeoM  Intcrttlilal  Mspbhilai  Con- 
dittoo  of  Epllbalimii' 


Flf .  S23. — A-  9roap  ot  AbHf«««i  uo  Surfan 
otKXdnty.    h.  VvrtienlSMtionoftbeMinia. 


Burrouuded  by  ft  x^itue  uf  hemorrhai^e.  They  are  always  in  the  cortex,  and 
the  pyramids  show  no  sigua  of  disi-a^e.  Pyelitis  i»  Hhsetil,  but,  as  belbre 
,  Btat^.  it  may  be  wanting,  or  feebly  murked  in  ca^es  of  genuine  mteretitiai 
Depbritis,  secnnUary  to  atft-ctious  of  l)t«  bladrler.  Kuch  bas,  moreover, 
pointed  out  an  imporlanl  niicmftcupii:  distiucttoti.  Micrococci  arc  found  in 
the  pywmic  kidney  as  well  aa  in  pyelo-uephritic  kidney;  but  in  the  former 
tliey  are  \a  the  vpi)selR,  e»|)eciHUy  in  (he  Mulpighian  loops,  while  in  the  latter 
they  are  in  the  lubulei*.  Microecopiu  exatniuHtion  of  a  py;eniie  kidney 
further  shows  an  ahseni-e  nf  ihe  general  difiused  iuiliiinmation  chnracteristio 
of  the  ordinary  septic  kidney. 

3.  f-'J'frlH  of  Form  IT  AUnrki  jTom  which  the  PaHent  A(w  Hecovered. — It  is 
poeaihie  chat  the  kidney  may  undt-r^'n  extensive  inlertnbulnr  change,  and 
yet,  if  the  cause  he  removeil,  the  iiifkmmatcry  gr<)wth  may  be  completely 
Bbporbed.  and  the  nrRan  repain  its  normal  condition.  More  cnnimonlv,  bow- 
ever,  the  new  growth  unflergoes  a  ilfvelopnii-nt  into  librniis  tissue,  a  change 
corresponding  exactly  to  that  which  ocrurs  in  the  cicntrixntion  of  a  granu- 
lating  eore,  and  accnmpanieiil  by  b  Birnilar  procese  of  contraction.  Thus  we 
get  an  iurrcasc  in  the  intertnbular  connective  tif»ue,  and  at  the  same  time  a 
contraption  and  induration  of  the  whole  organ,  bi  much  so  that  it  is  ^onio- 
times  reduced  to  less  than  a  quarter  of  its  normal  bulk.  If  the  pvramidBl 
portion  have  undergone  tthsorplion,  this  ia  never  re|)nired,  but,  as  ita'function 
teems  merely  that  of  a  duct,  its  log?  is  of  no  great  moment.  In  a  kidney  of 
thi«  kind,  wc  6nd  the  fat  adhei-ent  to  the  capfule,  and  the  capsule  t^  the 
glend-tiMue.  It  strips  off  with  difficultv,  and  is  thick  and  o|>a(^jue.  The 
surface  of  the  kidney  is  irregular,  granular,  or  perhaps  even  puckered  by 
cicatrice.  Scattered  over  the  surface,  in  moat  eases,  arc  numerous  email 
cyat*.    These  are  euppoaed  to  be  due  to  the  strangulation  of  the  tubulee  by 

VOL,  ti  — S3 


878     SBCONDARY    DISKA8SS   OF   tUK    CKINABV    uito! 


cytttilifl,  aixl  n»  instrumi-iit  hiul  Uocn  pnwcd  Hurin^'  life,  la  ikb  a* 
tir«l<^ni  vi-pre  grvatly  iHIaUhI,  aiitl  the  pelvu  on  cii<-n  9'nic  wu  exfVMMi 
tn  roiituin  mnny  ntniceA  of  lliiid.  The  kitlncTK  wcrr  .■iimr<«'hat  incneMntb 
fixe,  aiitl  before  bein;^  npenei)  felt  like  gretit  (htck-walle'l  bajp  •^ftul 
giving  nil  over  a  HUtiiict  son^  nf  floctuatioii.  On  being  cut  oMa,i 
preseoled  tlie  followinfr  appenriincM.  Tbt<  cnfwule  wa»  Umjf^  asd  oft 
RBd  sepnrnted  with  dirticiilly  frtirii  the  Icitliivf-dubvUncv.  Blijjhlly  Icansf  1 
in  m  Hoing,  nod  leaving  tlie  fturfuce  coar»e  ami  irre^lar.  Tbe  wrfc'v  ni 
uniformly  pnlc,  and  whiti^li  iu  color.  No  lrac«  of  the  pynknjda  mta  ■.  i- 
MWD,  but  wUere  eacli  tfhuuld  have  twen  waa  u  <lv«p  hoII<m  liaai  «u  1 
emooth  muiiibranu  voutiauout  willi  dial  liDiuj;  the  pelvis  of  Lbc  kkkmj. 
Thu  cortex  wae  of  about  uurmal  tbickucM,  but  in  vitne  parU  Ihiiipir 
Datural;  it  was  Koiuvwhat  tougb  iu  coueiBti'UL^,  aud  preaeoUid 
upacjue  wbtliali  tiut.  The  whole  kidney  wtu  thua  iMarerted  iab<  a  grm 
8acculat«d  bag,  cuiu|>mKl  oil  one  sidt-  of  tb«  dilute*!  uid  UtiekeanJ  jidtk, 
and  on  the  other  of  the  expuudf<l  oorux  of  the  kidney.  Then  ««i  ■ 
sinu  uf  past  or  present  arut*-  influniuiaiJoii.  On  miiTiiaeopk 
or  a  section  of  the  cortex,  tlit>  chief  chancre  noliceablr  wu  an  il 
email  roond-relled  iuNltralioa  of  the  intcrtitbtilar  tiMua  itf  Uip  kMar, 
Every  tubule  was  separated  frnm  its  neighhiini  by  mptdlr  m«tof  pmi 
oooDOctive  timue,  crowded  with  small  round  (N^Uit,  and  thia.  ny  prca^  « 
tlifi  veaeeU,  hadf^iven  ri»  to  the  pale  oolnr  ab>tve  notMl.  Tb«  bo«  fTMd 
mu  maet  abun<Iant  mtind  the  Malpig:hian  bodies,  tbo  capnilM  uf  rtick 
were  KKAIIv  thickened:  so  much  so,  tlint  in  many  the  vc«ade  kii  \m 
alraDRl^il  aud  ohlit«ra(ed.  The  amonnt  nf  change  wiu  not  ttoifliriD.  tfa«  H* 
gr«)wth  hoins  more  abundant  in  some  paru  than  In  otbrrt.  Tbf>  laMs 
themselves  showed  no  frrent  signs  of  change.  They  were  •lightly  difaMl  k 
some  parts,  and  the  epithelium  looked  u  if  ltiiitetiP4l  by  prwani.lwl  il 
other  re*pcots  it  wa»  perfeetlv  beftlihy.  This  case  show*  that  ottwpll(lls< 
t«aiii4>n  from  partial  o^iist ruction  of  the  ur«t«r  gives  ni«  to  a  uradotJ  ahm 
tion  of  the  pynuiiid^,  and  to  a  condition  of  intnrstilini  inflammatioaef  W 
kidney,  probably  varying  in  eeverity  with  tbe  degree  acd  acuUM»«fth 
obetruclioD,  In  more  extreme  casetf  than  that  above  dc«i*ribeij.  tlwaUof'^ 
of  the  cortex  beC4:imee  much  more  advanced,  till  uotltiag  mar  be  Wi  ws 
layer  of  kidney-eubfltaDce  not  thicker  than  a  chilling.  TIm  Mkwif 
shows  also  more  dilnlnlion  of  tbe  tubules  and  flattening  of  the  aoitlidis^ 
It  is  AD  intcreetJDg  fact  to  be  notod.  that  in  the  case  above  deacribeaikllRn- 
tiou  of  urine  was  ubundant.  its  f}wcific  urnvity  was  1009.  and  it  mnhftv^ 
albumeu  and  casts.  It  is  aUo  evident  {lint,  if  ftuch  n  kidaer  as  tUt  n" 
expieed  tonnv  additional  source  of  Irritation,  more  acute  inflaaiBaliM i^ 
oompalibto  with  life  would  reiidilv  be  set  up. 

2.  Aade  Diffiue  Inttntiliai  In^amfmUian. — Itt  ttus  euoditiua  tW  )tUmf* 
soft  and  swollen.  The  capsule  isupaque. and  small  VfMels  an 
in  iL  It  separates  eoeily,  hut  teur^  ihe  bidoey-tiubtftancv  in : 
surface  of  the  kidney  is  eoar»e  aud  irn>};ular.  The  eolor  of  die 
mntiled,  the  (greater  part  beinj;  usually  of  a  pale  y<llovi*h  lint 
«itb  [-urptc  patches.  Sometime  the  mottJing  Is  very  anr,  almot  ffn^- 
Tlie  venouB  Man  always  seen  ou  thir  surface  of  tht  kidney  are  wj^tAi^ 
show  out  pmminentlr.  On  acctiou,  the  cortex  is  found'  tii  br  absdiaal'* 
soft,  and  to  preMui  tlie  same  mottled  odor  u  (lie  surfac*.  SoowliBa'^ 
part  of  the  cortex  corresponding  to  one  pvmmid  raav  pn9»Dt  a  adft  1 
liirmly  pale  apiHiimnce  tliaii  that  l«clongin>r  lo  anoifirr.  .Small  rril**^J 
SjioUi,  Ittukiu);  like  inioulc  collection*  [>|  pun,  may  Ih>  pmeat,  o^il 
however,  «m  wetioM  found  t4i  he  «did.  fb'jii;;li  wry  wift.  Tbe 
UMially  ititeoAely  iaJ4-cted,  aud  contrml  strongly  wiLli  the  palcf  aJirtsx. 


m^tk 


d 


CAUBSB   OP  IKTEBSTITlAb   NBPHBITI8. 


888 


by  BUppuration,  after  the  n|>eratiou  of  litholrity.  Gasea  of  thin  kiui.!  have 
occurreil  in  which  ihc  cyatilis  wus  Dot  iucrea&e'.l  by  the  operation,  Iq  nhich 
the  decompwitioD  ol'  urine  remainctl  uochanged,  and  no  altered  circum- 
BtADce  existed,  except  the  mechanical  iujury  of  the  paesuge  of  the  inetrU' 
meat,  to  flccriunt  for  the  stidJen  Hupervi'iUion  of  acute  De|ihritis.  In  these 
ouses  »igua  of  chronic  disease,  which  liiu  been  rendered  acute  by  the  ndcli* 
tional  irritation,  aru  iilwuya  present.  Lastly,  a  few  cas««  have  been  observed 
at  University  t'ulleyc  Huf^pimt  afier^ppcrntiuus  for  stricture,  witli  the  view  of 
aeoertuiDiug  if  ajiy  chan^-  imviUI  be  fituud  in  (he  urine  110  the  direct  result 
of  the  operation,  in  Ihreo  eumr^  nf  HutlV  dilutatiun,  ilie  urine  was  I'nund 
to  be  free  from  bhxid,  or  to  eoutuiu  rii>  nuin-  than  cimld  be  ncrtmnied  for  by 
the  uiJemiiiin,  during  tin;  tirt>L  hour  or  hour  mid  a  halt'  after  the  ojitTation, 
and  iheu  to  bee<inie  griidnatly  mure  anil  nion.!  Iiloixjy  for  unniher  hour  or 
hour  und  u  Imll,  and  ulter  that  to  heciimu  ynidu:il!y  fret;  from  blood.  ]n 
ouu  (!iuH>  there  huh  almotit.  total  Huppret^lon  tor  liu-.  tir^t  hour  rikI  a  half,  fol- 
lowed by  very  bloody  urine.  In  one  i.^iHe  of  iuteriml  nrpiiinitoiiiy,  diiritig 
the  Qriit  hour  tho  urine  Hxwed  away  in  greiit  qnantiti^i,  and  was  almost  free 
from  blood.  Fur  llie  next  xix  Kour»  it  was  pn».4i-il  in  moderate  qiiHnt)ly,anfl 
Wfl9  very  darkly  tin;;e4l  with  bltrnd.  In  all  lour  caites,  there  wa*  some  rensun 
to  believe  ihiit  the  bJ.Hjd  came  from  the  kidney.  It  oocurre<l  arter  tlio  hem- 
orrhs^e  from  the  uoimd  windd  have  ceased  ;  it  wa*  unifurmly  mixed  with 
the  urine,  and  free  from  cloi«,  Tliuse  c»»es  arc  of  ci>iir»o  iusirlficienl  in 
numiier  to  draw  any  concluiicuts  from  them  ;  but,  as  far  a»  they  ^o.  th«y 
tend  to  show  that,  in  all  ca«(--»  of  njK'rHtiun  on  the  urelhni,  tiiere  is  a  minia- 
ture repros4-ntHtiun  of  tliiit  intense  cni^esliou  of  the  kidney  whieli  Is  found 
in  CJUW4  of  death  from  su[)preMion  of  urine  nfler  simple  catheteiisrn.  i'oa- 
sihly  in  some  ciwe*  the  ddalutioii  of  the  vessels  is  preceiled  by  a  cmtraction 
of  longer  or  shorter  diinitiou,  giving  rise  to  the  suppre&?iou  noted  above. 
La  a  healthy  kidney  such  an  attack  of  acute  hypern^miH  soon  pahses  off  and 
does  no  }iurin  ;  lijt,ijup|)<K4inj>  the  kidney  to  be  already  diseased,  thesuhnciite 
eoodition  may  readily  become  acuic  and  terminate  fiitally.  Repeated  attacks 
of  »ui:h  hypenecnia,  which  probably  result  from  the  irritation  nf  a  stone,  or 
paasiug  urine  throuj^h  n  bad  stricture,  would  in  all  probabiltLy  be  alone  suf- 
ficient to  lead  lo  a  ubroiiic  interstitial  change  in  the  kidney.  U  is  a  matter 
of  observation,  that  fatal  afti^'ctions  of  the  kidney  scurcely  ever  result  from 
operations  performfd  oti  the  ptiiilij  portion  of  the  urethni. 

3.  l^fif  prt-«eHee  iij  .Sf/ttic  Mailer  in  tfie  PchU  of  the  Kidnef}. — TSIe  plnyi 
the  n)ut<i  iiiipiirtanlpart  in  pnMlucing  i Ik;  final  acDte  condition  which  mi  olten 
kills  llie  patient.  In  the  first  place,  tbo  mere  preaenr*  of  «uch  an  irritating 
subdUiaee  it«  ammoniucal  uriuo  in  llie  pelvis  of  a  kidncv  already  diseased, 
would  certainly  intenttify  the  exi»tin);  inflaminatiun.  It  Deems  probable, 
however,  that  in  many  casei!  the  septic  matter  thus  pent  up  at  sfime  degree 
of  pressure  (for  the  thick  mixture  of  mucun,  pu<«,  and  urine  cannot  paa!)  the 
valves  of  the  ureter,  already  somewhat  obfttructed  by  the  swollen  muC'Ona 
membrane  anil  perhap.'^  by  a  hypertrophied  or  distended  blnddf  r,  so  readily 
as  healthy  urine)  beoome^  ahHorhed  by  the  lymphaties  of  the  kidney,  and 
thufl  gives  ruie  t^  a  diffujie  intertubular  inflammation  rapidly  ninninfj  on  lo 
■uppuratioD.  Thin  would  account  for  the  pale  streakn  tteen  running  in  many 
caaea  parallel  to  the  straight  tubules  in  the  pyramids,  and  expandin;;  in  the 
cortex.  The  presence  ol  the  inicnKocci  in  the  tubulen  may  ajpo  hv  taken  ae 
evidence  that  the  decomjurieition  of  tht;  urine  may  extend  far  into  the  kidney 
•ubitance  from  the  pelvi;^.  Probably  this  condition  ulone  is  sullicieut  to  ac- 
coliDt  for  many  ca><^)^  of  acute  sn]ij)orHUve  nephritis,  but  rt  innet  be  remem- 
bered that  suppuration  of  the  kidney  iloes  occur,  occaaioually,  in  cases  iu 
which  the  urine  in  the  pelvis  is  fre«  from  detium|XMtliuu.     George  Juhnsuu 


880     SECONDARY    DISEA.SSS   Of    THr    rBIXABT    ORQ&XI. 

Uie  pn[)lllii,  or,  if  thnt  have  heea  partly  destniyed  br  presMfv.  a*  &r  « ik« 
pijini  :il  which  thr  Luhiilcs  opt^D  into  the  pelTii.  Hiti  <oa<ilU>4i »  »4  an- 
riabte,  aa  Bomt-tiiu^'fl  the  ab«ceM««  tre  [tcrMctly  EaaUtr^l.  aod  tiiaw  bo  aaaw 
U<>a  whatever  with  the  pjraDiidal  pontoo  of  thf  kidnrr  »  V-«»4mi*!Ii  <«i 
or  more  of  the  absceMea  may  buret  beneath  t): 
tb«  kiilney,  and,  giriog  rise  tu  further  tuiifiii- 

organ  in  a  lar^e  colteotion  of  j^uh.    Thiii  t\>rm  or  kt<iner,  «b«'^  •«,  p«laf« 
that  mi«t  fr»|Uenlly  met  with  in  the  pi«t-mort«iu  rtxtta,  ta  fnffumUfft*- 
jiiinwl  with  the  nj^ni  of  preMUrtf,  ahMrption  of  th«  pyrBniiiia,  mwl  ililaiatka 
uf  the  pelvis.     The  injcruecope  itbuws  Lhal  in  thu  form  uf  ktdDty  th*  97?'*''' 
anotw  are  ee»eulially  tha  aaoHi  ««  io  the  last;  the  chief  cbaagt  Uiui 
accumulation  of  cruw^U  of  snuill  niuoil  cell*  in  the  ialcrtabalar  wU 
th«i  ili>gn.*e  of  c«ll-iuttltratiou  varrin);  in  almost  ervry  fitM  of  Jm  r 
acopc.     At  thtt  point  ut  which  an  sbdccos  a  forming,  ur  at  Uw  nanfio  <^  c 
already  formL-^l.  the  t-rowda  of  email  ruuQil  celli  are  mbb  to  |«<h  aptaa* 
tubuica,  KparatiQg  them  widely,  and  aqueesiog  ttwir  walls  UmUka  'Fc 
821).    Then  the  wall  beocHDaa  iodiatioct;  than  only  a  few  apowJiuB  ■» 


i^j^r 


m 


MM  .^ 

rtf.  ftSI— Aeiilv  Inivntltlat  >*|>l>rlllai  g«BtlH«>J  AIsh-i"***.     Mii<4»  tj  •>r-vuulhf 

iaOltrailm.  lo  ih«  laft.  " 

can  I>c  rvcojrni 7.eil  in  the  crowd  of  I^urorrtcs;  lastly,  uothia|f  bal la 
can  W  f)eeii,and  a  lltllu  nt^rcr  the  centre  the  iaicruel I u Inr  lubalaafltl 
fluir!,  and  the  celU  Hmit  frer,  and  \m»  is  thus  ftirmetL  The  rvd  arula  ii  ^ 
fuund  to  he  due  to  extruvtisation,  iilthuiif^h  htiiiorrhaK>^  "'^*  ■'iI«tMiUVM 
tliruugh  such  a  kidney.     The  yellow  Mtn^aks  in  die  pyr^i  :  juad  tnht 

due  ly  aeimilar  coudiliou  of  in(«rtul>iilar  cell*iufiltniU'/..  •;~^*(U« 

may  bo  seen  in  the  vowels  of  the  pynunldfc     Thwte  are  pr  '■  -hT 

to  tlic  tutlHRiiuatiou  uf  the  part*  aurrouudiun  thi;  vesaela.  A*  m  \"-~-  ■''■■' 
variety,  uniiilt  round  ccIIh  may  be  found  iu  the  tubula  aa  wvU  •«  trt^ 
them.  Thee|>itli<^liuHi  is  usually  much  »wijlleu,iuid  n'metitaadw^aini*'*! 
the  chukint:  the  tuhulu!!  1  Fig.  S'i'I),  but  this  i«  oalr  in  thijcc  anatiaiki* 
the  iutcnititial  intlauimulicii  is  moat  advanced,  lu  otban  it  say  Aff* 
almoet  hfallhy.  In  the  pyruniiilnl  portion  uf  the  kidtMjr  imuiy  of'iWI*'!' 
lub(«  lire  fonnd  lo  have  lutit  tlu'ir  c  pilhflium  by  deaqtiamalfon.  Tbk  ft** 
of  kiihiry  merges  iiitu  thu  dilfiisi*  variety,  the  a'lltd  yellowiab  ^mU  M" 
mentiotxH]  reprsaencioft  points  wlii<'h.  had  thi-  imtirnt  lived  loupr.  h^ 
have  Hoflened  into  abacewea.  KIiiIk.  many  yeiirn  uet>,  deacrihed  taapfV 
of  micnmcopio  or^ni^nw  in  the  »ti|ipu rating'  kiiltiey.  iiui  thu  nxaaauf  vtaff^ 
lion  Were  at  thai  lime  m  imjierfoct  thnt  eonwdijralile  den'-'  -'•■"f^aiw*" 
correclnena  of  the  observation,  mnre  psfwcially  aa  hp  d*"-  liwKrt** 

luhaeiiuently  dcvelopluga  branching myoeliutu — a  form  m  ^r.-^ik,iiinB^ 


;CTE  INtI 


tPURITia 


IS8SS.    879 


i«treakfl  ran  often  he  seeo  running  parnllel  to  the  strniglit  lubiiles.  These 
are  moAt  freijiient  in  thoM cases  in  wliirli  tlic  pC'lvis  is  filled  with  jxitrid  tiriiie. 
The  |>elvis  is  fmind  in  eimie  cn^ea  free  from  nny  ^igiia  offtciiU;  iiiDuninmliou, 
though  more  frei^iiently  it  is  n^ucti  affvcl^d  and  tilled  nich  J'oul  urine  uiid 
maciis.  The  appearant-cs  h«re  i]c0cnb«ii  are  uficii  cuujoined  wilti  the  aigns 
<f  pressure  mentioned  iibove,  vHr^iug  from  incrv  fluttvaiug  tu  complelu  de- 
BtrucUoii  of  the  iiymniidi!.  The  uiicroecupe  «buwi>  that  this  cuudttiou  la  a 
mere  exaggemliou  uJ'  that  fuuud  as  tbe  result  of  simple  pressure.  The 
nbuige  ie  chietiy  and  pricnarily  iaterslitial,  but  the  small  cell-gronth  is  so 
abundant  as  in  iimtiy  pnrU  lu  press  upuu  and  even  lieotruy  the  tubules,  areas 
hc'iuji  fuuud  in  which  nothing  but  cruwds  of  small  n>uud  ctills  can  be  seen. 
Tbwe,  nheu  large,  form  the  small  yelluwish  spots  risible  to  the  naked  eye. 
It  requires  ouly  an  increased  intensity  of  the  inBaninialinu  and  a  softening 
of  these  sfwls  to  convert  thern  into  minute  absceases.  As  iti  the  form  of  inier- 
atitial  uejihriUs  first  meDtioned,  the  eel  I -infl  It  ration  is  most  marked  round 
the  Mulpighiau  Ixidies.  The  cimnge  is  rarely  uniform  throujfliout  the  kid- 
ney. It  varies  in  degree  usually  in  every  field  of  the  microec-ipe,  and  parts 
may  be  found  appareutly  ainiitst  healthy.  The  epithelium  throughout  the 
kidoey  let  usually  swolleu  and  granular,  and  readily  washes  out  in  preparing 
the  specimen,  but  it  does  oot  choke  the  tubules  as  in  acute  catarrhal  Dcphrilis. 
lu  very  acute  cases,  small  round  eclls,  similar  to  thoae  outside  the  tubules, 
are  seen  in  the  lumen  of  the  tube  surrounded  by  epithelium.  These  have 
probably  found  their  way  in  from  the  outside,  and,  if  washed  on  by  the  a«cre- 
^  lion  from  above,  would  appear  as  pua-oells  iu  the  urine.  The  veascU  are 
^^LotVen  seen  to  be  gorged  with  blood,  and  occasionally  mintito  hemorrbages  are 
^^Kpresent.  It  is  not  luwayit  easy  to  distinguish  this  form  of  die4'a&e  by  the  un- 
^^Midcd  eye,  ns,  from  the  pallor  caused  by  the  pressure  on  the  v^&qtU  from  the 
^^Blmail  cell-infiltration,  it  closely  re.<ieinblefl  the  fatty  kidney  or  »nme  ca«es  of 
^^Kcatarrhnl  nephritii«.  The  niicrui^co|>e  alone  can  ileeide  the  rpit^tiuu  uith 
^^r  oertaintv.  Kveii  in  snich  a  kidney  the  secretion  of  urine  may  be  mtKlerately 
abundHnU  In  a  case  at  Univeraily  College  Hwpilal,  the  patient  excreted 
orer  300  grains  of  urea  on  Ibe  last  day  uf  his  life. 

8>.  ActUe  InttrrniUini  2k\phrUi-»  ivitfi.  Scaltertd  Ahsc€t4e«. — CSuppuratiou  uf 
the  kidney — euppurntive  uephritts;  when  accom(wnied  by  pyelitis — pyelo- 
nephritis (Rayer).J  This  is  usuhIIv  fouud  in  conjuuclion  with  that  form  of 
acute  pyelitis  in  which  the  [telvis  of  the  kidney  is  filled  with  putrid  uriue, 
pus.  and  mucus,  but  is  by  uo  means  cousiantly  so.  In  oue  ease  which  was 
observe*!  at  University  College  iloepilul,  both  kidney*  were  ei|ually  riddled 
with  abscc»ti'i«,  but  in  one  the  pelvis  was  acutely  inllaiueil  nud  tilled  with  Imil 
urine,  while  in  the  iiiIilt  it  wiu*  frei^  from  disease,  and  the  urluu  it  cuutained 
acid,  and  without  u ii [ileiif^aD I  ttmell.  The:  kidney  is  ^eaenilty  swollen  mid 
enlarged.  The  fiit  Hurroiinding  it  is  ueuHlty  abiionually  adherent  to  the  I'ap- 
eule.  ThecapHule  i»  thick  and  opii<|ue,and  marked  by  rauiiform  veKseI.H,!-how- 
ingrleariyoii  the  surface.  It  HennraTes  easily,  Imt  iu  ku  doing  teure  tliQ  kidney- 
subeianw.  The  surface  of  the  liidiiey  presenia  a  more  or  Icta  mollted  appear- 
ance. The  chief  lint  i»  the  Mment«  in  the  diffiise  form  just  described,  antl  is, 
in  fact,  due  to  the  existence  of  the  ^ame  cnndition;  but  scattered  here  and 
there,  usually  in  group,*,  are  bright  vellow  apots,  surruuiidwl  by  a  dark  red 
areola,  and  varying  iu  size  from  a  pin's  bead  Lo  a  split  |H!a  (Fig.  &i'.i).  On 
cutting  into  these  yellow  spois,  each  is  (bund  to  contain  ii  drop  of  pus.  These 
minute  abscesses  are  usually  grouped  in  areas  correitpondiiig  lo  that  pari  of 
the  cortex  which  belongs  to  a  single  pymmid.  [f  now  a  Aection  be  made  of 
the  kidney,  the  point*  of  suppuration  will  not  Iw  found  to  be  limited  to  the 
surface.  Ollen  they  are  continued  down  towards  a  pyramid,  and  are  con- 
nected with  a  yellow  streak  running  parallel  in  the  straight  tubules  as  far  as 


882     SECONDARY    UI.SEASUS    OP    T]IIE    USINABV   OKOAJis. 


the  fibrous  growth.  The  color  U  ueuatly  dnrk  ami  •onunhst  ivi.  «lik 
DUfucruuB  diuhII,  i)iiuLc<l  v&ias  showing  ou  the  eurruce,  Oa  Moao.  te 
curiux  will  be  litutiil  t<i  hti  grtmtly  iliintKtl.  iictiififiiitnuttmrs  a<n  IlikibT* 
a  fihilliii}:.  The  pyrmiiiilK,  unless  abi«i>rl>(^  fnim  previuu*  prMran,anl 
liult!  allvn^l.  Die  wIkiU;  ar^^aii  iii  i>(  a  lealhcrr  toit^liocH  wkkb  h^A 
peculiar,  Tliu  ptilvts  muy  he  pi^iucnteil  from  prrvi<tu«  inftammatna.  lb 
inicriiBc<i|)e  nhon-ii  a  great  increasci  of  the  iniortubtilar  ti«Mi«»  vhlek  aWi 
deiwe  fibriiiil  ctmraiTter.  The  tubules  vary  iosizr;  »ome  arv  Hnapimi 
and  cimipressed,  Miliera  are  dilatnl  above  the  ■trangiilntiiin.  Uaajriftb 
Malpighian  c>>rpiiscles  are  oblii«nite<l,  leaving  merely  caMolea  oaatuMi 
the  reiuatna  of  the  oblitemLcd  veesels.  The  capuiloi  fifultbe  MiIjm^hb 
bodie«  are  greatly  thickened.  The  epithelium  may  be  flaUHwd  bjryvM^ 
or  normnl.  The  small  nrieries  asiially  show  soiDe  bjrpertnplijr  tf  Am 
miiwulur  conta.  .Such  a  kidnoy  a«  thi's  iiiny  uiiHerj^i  a  aMMul  itMkll 
acute  iuHiimmnLion,  and  we  then  fiud  a  ctmbiDatioD  of  the  torn  of  that* 
traded  kidnev  wi)h  the  color  aud  mdaeaa.  and.  poaublj'.  Ibe  ■iiWiiJ 
ab«c«sMf«.  uf  lIiv  acut«  variety.  It  will  be  eeen  from  the  nSuva  dtacnMo^ 
that  Ibis  form  of  kidney  dilfera  in  no  uav  lo  the  iiakt  :t  tlworMIT 

grauuhir,  i-outnictW)l,  or  gouty  kidney.    We  do  nut,  )i'  ^d  tti«  pMlM 

changes  amt'iciiited  with  that  diseaM-.     In  a  caM<  Mliicti  jmd  ■ 

Uuiversily  C'lllege  Il'ispilul,  in  which  this  cundilion  wiu  v.  -■   ••'-d  tf  >W 

result  uf  Dlriutiira  of  the  urethra,  there  was  nu  hyjiertruidty  of  tbv  bemrt,Mri 
uo  vfaaage  could  be  recognized  in  Ibe  walla  of  iIh:  ciuall  voadt  bi  i4kif 
parto. 

Caii8«s  of  iDterctitial  InflammatioiL— The  folloirliig  ma^r  be  stakdatt* 
cauees  which,  in  vurvin^  decree,  take  part  in  the  pniduvtiiia  of  brtcnutf 
inflammation  of  the  kidney  :  1.  Tcii^iuu  ;  'i.  It«llt'x  irriiatloa  of  lb*  kHmji 
3.  Tlie  [ire^ence  of  tie|Hic  matter  in  ibe  pelvis  of  the  bidiiry,  Eaeb  iif  Aaa 
acliiij'  singly  may  induce  serious  disease,  or  perlia|>s  even  rmmm  (kBtb.titf 
wu  iteldiiiii  see  ^iich  cases.     More  ufleu,  two  at  len^t  are  in  artVMi. 

1.  Tension. — It  lias  been  ehuwii  befure  how  ihi«  is  induced  bjr  asT  wbuw 
tiun  to  the  free  euiruncc  ul'  urine  into  the  bladder.  Every  practicaJ  ^rp* 
u  acquainted  with  the  fact  thai  tcuaion  is  one  of  the  most  powerful  iiriwiM 
to  which  the  living  tiMues  can  be  rxnoAoil.  Id  the  liver,  Wirkhaa  1^ 
and  olhern  have  shown  that  ligature  of  the  hllc-duct  cau»r«  inlrratitial  kef** 
titifl.  In  the  kidney,  no  recorded  case  bi  to  be  found  of  ■■■'-'■■■^•ino  \teat 
ring  as  the  result  of  simple  tension  ;  but  in  all  case*  in  ^  >  t«aci  tf 
tension  exists,  that  is  t<i  say,  dibkted  nreter  or  pelvis  of  lli  urMM 
source  of  suditen  obstruction  as  a  mure  or  leai  im(MLct«<)  ■  «itMtf 
interstitial  inflainnrntiim  will  be  found.  It  Mems  almost  a-  ii  ni^  ortc^ 
growth  were  a  conservative  clisuge  intended  tn  strengtheo  tbe  loboki  t* 
rei^int  the  incresM-d  pr<>«ure.  However  this  may  lie.  n  kidney  ioChistfB'^ 
tiiin  is  in  a  »lal«  in  wliicli  it  little  further  irritation  from  any  nause  mtji^ff 
it  on  to  tstal  and  acute  iiill:iitittiHtiiin. 

2.  Jt^jUj:  [rrit-ition  of  ihi-  KitlHry. — Meohanical  injuries  to  tbe  aitkit^ 
bladder  or  |t<MtiTt<ir  part  td'thu  uivLlini,  ntid  jinibably  disenMa  ikf  tba»l>>l* 
iu  which  eouilunily  recurring  irritation  is  prv*rnt,  react  upon  tbs  LiMf 
tbrougb  the  iuttuenoe  of  tbe  uervous  syAem.  It  (s  neadltM  hen  UiaW^ 
any  exjilHualiou  of  tbe  exni't  manner  in  which  this  takos  plaos,  ssit*^ 
be  merely  a  matter  of  spccututiou  ;  but  a  few  GuOs  may  be  glvM  as  f^.'f 
tbe  aascTtiun.  it  is  welt  known  that  srveral  msr«  am  un  rvwird,  b  *■" 
death  has  ucuurmd  from  suppmaition  of  urine  fullnwing  the  simpU  intrv^ 
tioa  of  a  catheter,  the  poMlmortem,  esamlnatioa  showing  a  (noattiiai  Jj^ 
tense  congi-^ion  of  the  kidney.     Agua,  patieau  witb  atoas  in  the  bl>** 

vionally  die  from  acnie  inAammatioo  of  tha  kidacy,  oftan  aisjuai*** 


ZVTECT9    OP    ACUTK    I  NTBHSTITI A  Ij    NKPHRITIS. 


881 


encc 'if  which  to  say  llii!  Ifwl  wati  ini|irfibahli>.  J^ter  nliservatiaiiR  by  Kocii, 
vilh  im|>ri)ved  itiethixla  of  t^taiiiiit^,  Iiuvh  clearly  ileiiiDnEtnilpd  ihe  fact  that, 
in  every  ca»e  of  ilinvE^niinatt!!!  HtippiirHtmii  fdllowing  on  F«|)tic  chatigpe'  of  the 
urine  in  the  iielvi5,rnlonie!*  of  micnjcocci  are  fomul  ncattered  ihroughmit  the 
kidney,  distending  and  olietructing  the  urinary  tubules.  Theae  tnicr4)vucci 
are  similar  tn  thoee  found  in  put  rid  urine,  and  are  believed  lo  be  the  ferment 
to  which  the  change  is  due.  The  al«ces8es  of  the  kidner  thus  arising  In  acute 
auppuraiive  Dephritts  must  nnt  he  confounded  with  t^oae  seen  in  pyicmia. 
ThcM  Arc  usunlly  Inrger,  are  more  distinctly  \rcdgc-shepcd,  and  somelimea 


^i:<® 


<> 


FIk- 822.— Ami*  InuriUtiul   NipbrilU;  Con- 
dlclon  oC  Epitb«Ilum. 


Ptg.  3S3. — 4.  QfOup  of  Abtceriw  od  SurhM 
of  Kldnaj.    D.  Vcrilna]  SaptionafLhc  wun»> 


furroimded  by  a  zone  of  hemorrhage.  They  are  always  in  (he  cortti,  and 
the  pyramids  chow  no  sigiw  of  dineflitr.  Pyelitia  i»  absent,  h\U,  at  before 
Stated,  il  may  b«  wanting,  or  feebly  markod  in  ca»ea  of  genuine  mtvrstitial 
nephritis,  wcoudary  to  aflpclinnfl  of  ihp  bladder.  Koch  hat*,  moreover, 
poiDte<l  out  au  imt>orl«nt  micnwoopic  distinction.  Micrococci  are  found  in 
the  pywmic  kidney  m  well  as  in  pyelo-nephritic  kidney;  but  in  thie  former 
they  are  iu  the  veewle.  especially  in  the  Malpiybian  loops,  while  in  the  latter 
they  ai-e  iu  the  lubok's.  Microscopiir  examinatimi  i>f  a  pyiemic  kidney 
further  nli»we  an  absence  of  the  general  diHuHed  inflammation  cliHracteristlc 
of  the  ordinary  Ptptic  Kidney. 

3.  Effect*  of  Former  Attiirh*  from  tvhith  the  Patient  ha*  Hecovered, — It  ia 
pofsible  that  the  kidney  may  undergo  ezteneive  intertubular  i!liange,  and 
yet,  if  the  cause  \w  nmovi-il,  the  inflammatory  growth  may  bu  completely 
■beorbe*!,  and  ihp  organ  regain  its  normal  eondilion.  More  commonly,  how- 
ever, the  new  growth  undiTgoes  a  dt-vehiprueul  into  fibr'jua  1ii«ue,  a  change 
oorrppponding  exactly  lo  timl  wbic-b  occurs  in  the  cicatrization  of  a  granu- 
lating aore,  and  arcnm)iatiie<]  by  a  similar  proceM  of  conlraoUon.  Thus  we 
get  nn  iucreaee  in  Ibe  inlertubulur  connective  tissue,  and  at  the  eamo  time  a 
ooDtraction  and  induration  of  (he-  whole  organ,  so  much  do  that  il  is  some- 
times  reduced  to  lei^s  thun  a  <|uarter  of  its  oormal  bulk.  If  the  pymmidal 
portion  have  undergone  alw>r[>tiou,  this  is  never  repaired,  but,  as  its  function 
seema  merely  thai  of  a  iiiict,  itu  hiau  is  of  uo  great  moment.  In  a  kidney  of 
thia  kind,  we  tind  ihr  lat  adherent  t<i  the  capsule,  and  the  capsule  to  the 
gland-tiwue.  It  fitripn  r.fl' with  diflicultr.  and  is  thick  and  opaque.  The 
turface  of  the  kidney  is  irrPKiilar,  granular,  or  perhaps  even  puckercfl  by 
dcatriccD.  Scattered  over  thp  surfaCM^,  in  moat  caaes,  are  numerous  dmall 
eyita.    These  arc  supposed  to  he  due  to  the  strangulation  of  the  tubulea  by 

VOL.  II  — '»» 


^ 


882      SeCONDAHY     DISEASES    OF    TUB    URINARY    ORGAVS. 


tliti  fibrous  gnnvtli.  The  eolnr  k  tii^iially  dark  nod  sumcwhal  red,  wilh 
uumuroua  uiiiuU,  ililuLed  VfiiiN  DliDwiii^  uti  the  BUrt'uoc.  Ou  evi'liun,  the 
Oonex  will  be  fuiind  t>}  be  ;:rMit]y  lliiuiietl,  iM^iiigfitriiutiiiU'8  u<jl  ihii-kur  than 
a  shillii)};.  The  nyraiiiidH.  utilt.>^  al}.4(iri)i;i(l  t'ntiu  pruvjitub  |iri.-s^iir(.>.  an*  but 
iiuLe  ahurtHi.  Ihe  whol^  organ  iii  of  a  leathery  Li>ughit<%i)  which  i&  quite 
peculiar.  Th«  pelvin  may  1)^  pignientet]  fnim  prL-viuiii  inBamiiiRtinu.  The 
itiicni!«rnpe  showd  a  great  increase  of  the  tiiterhihular  liwue,  which  is  of  a 
denae  filir-iid  characlt-r.  The  liihules  vary  in  siste;  S'tme  are  stranjfulatcd 
iind  com  pressed,  others  are  dilateil  above  the  strangtilatiim.  Many  uf  ibe 
Malpighian  corpiiacles  are  iibliter«t«?d,  leaving  merely  ca|>Biitpfl  c«ntaining 
the  remains  of  the  obliterated  vessela.  The  capsules  of  all  the  Malpighian 
btidicft  are  greatly  thickened.  The  epithelium  may  he  flattened  liy  pressure, 
or  norrual.  The  small  nrierles  usnallv  show  some  hypertrophy  of  their 
muscular  coata.  8uch  a  kidney  as  this  mar  undergo  a  sectmd  attack  of 
acute  iiiflan)matton,  and  we  then  find  a  combmati'in  uf  the  forni  of  the  con- 
trtoled  kidney  with  the  color  nnd  sitftneas,  and,  p<je9tb!y,  (he  st'sltered 
abieesaes,  of  the  acute  variety.  It  will  be  seen  fnita  lliw  nbuve  de«criplioo, 
thai  thin  form  of  kidney  ditlent  in  iiu  way  to  the  naked  eye  rrom  the  unliuary 
grauular,  iMUtrac(ed,()r  ){<>uCy  kidney.  We  do  nut,  Imnever,  ^ud  the  general 
^xhangeK  ajv^neinted  with  that  distfase.  In  a  case  wliieh  Ulely  occurred  at 
TJuiversity  College  H<>»|)ila),in  which  IhtB  cundilion  wa«  well  marked  ag  the 
result  of  Btrictu  re  of  (he  urethra,  there  w:ib  no  hypertrophy  of  the  heart,  and 
no  change  could  be  recognised  id  the  walla  of  the  ainall  veavela  tti  other 
parts. 

Caaiei  of  Intentitlal  Inflammation. — The  fnllotving  may  be  staleil  as  the 
causes  ivhicli,  in  varying  d<.';;;ree,  take  part  in  ihe  priHluctluu  of  interstitial 
iQltammiiition  <if  the  kidney  :  1.  Ten»iou  ;  2.  Ue'Hex  irritation  of  Ihe  kidney; 
3.  The  presence  nf  eeplii'  mutter  lu  the  pelvis  of  the  kidney.  Each  nf  iheae 
Rctin;;  singly  may  iuducc  ecrioua  disease,  or  perhaps  even  cau«ie  death,  but 
wc  eeiihim  t-ee  such  cases.     M'ire  ofteu,  two  at  lea^t  are  iu  aetion. 

1.  Tsimion. — It  has  been  &howu  before  bow  thi^i  is  induix'd  by  any  obeiruc- 
tluu  tu  the  free  entrance  of  urine  inut  the  bladder.  Every  praciical  Surgooo 
is  acquainted  with  the  fact  that  tension  ib  one  of  the  moftt  powerful  irritantB 
tu  which  the  living  tissues  can  be  cxiMise^L  In  the  liver,  Wickhaui  L*^ 
and  otliers  have  ithowu  that  ligature  of  tlie  bile-duct  causes  ialeretitial  hepa- 
tititt.  In  the  kidney,  no  rceui^od  case  is  U)  be  found  of  suppuration  occur- 
ring as  the  result  of  simple  lousion  ;  but  in  all  casra  in  ubich  evidence  of 
tensiitn  exists,  that  U  to  say,  dilated  ureter  or  jietvis  of  the  kiduey,  ur  anmt 
source  uf  auilik-n  obstructicm  as  a  mnre  i>r  le^  impacted  calculus,  mibacule 
tntenititiHt  inflainmatinn  will  be  found.  It  Beemn  almost  as  if  ibe  new  cell- 
growth  wt-rc  a  conserrative  change  inlendcfl  to  strengthen  the  lubulea  to 
reHiBl  the  increased  precsure.  However  ibis  may  he,  a  kidney  in  this  condi- 
tion \»  in  a  state  in  which  a  little  furLh(<r  irritatiun  from  any  cause  may  hurry 
it  on  to  fatal  and  artite  inflammation. 

2.  lirficT  Irritntion  of  tin:  A"(rfri^»/- — Mechanical  injuries  to  the  neck  of  the 
bladiler  or  p(Mteri<jr  part  nf  the  urethra,  and  jirobably  diseases  of  those  )>urta 
in  which  condlantly  recurring  irrilatitiii  i*  pre-tenl,  react  upon  the  kiduey 
through  the  influence  of  the  nervous  system.  It  'u  needles  here  to  attcmiit 
any  explanation  of  the  exact  manner  in  which  this  takes  place,  as  it  would 
be  merely  a  matter  of  speculatiou  ;  but  a  few  fact»  may  be  given  as  proof  of 
the  assertion.  It  i^  well  known  ttutt  several  cases  are  on  record,  in  which 
death  has  occurred  from  i*up[ires.Tiiou  of  urine  folkiwiug  the  simple  intri^duc- 
tion  of  a  catheter,  the  pMt-mnrtem  oxamiuattoti  showing  a  conditiim  itf  in- 
tense couKe-intion  of  the  kidney.  A;j^iiu,  patients  with  aloue  in  the  blad<J«r 
occasionally  die  from  acute  ixi6«iuuiaULin  of  Ibe  kiduey,  ufl«n  acoompaoied 


SYMPTOMS   OV   lyTHHSTITIAL   KEPHttlTIS. 


686.. 


I  noBtlw,  the  patient  crailuiLllv  bocorain<*  veaker  and  weaker,  until  h«  IB 
fltrrieil  off  br  nomc  intercurrent  <iis4>a»e.  or  Hies  of  pure  exhatittt!<in.  MorA 
axnmnalT,  how«Ter.  an  nculo  attack  supervene*  on  the  subncuie,  t-ilher  flpunt*- 
Brously  nr  u  the  rwiuli  of  some  surpienl  interference,  and,  rapi-lly  ending  in 
BUppurKtixo  of  the  kidnrr,  tcrminatott  fatally.  On  the  other  liiiud,  the  symp- 
toms i>Acn  gradually  t(ul)»jde,  the  temperature  becomex  onrmal.  and  thepatient 
gtitt*  ^tren^h.  The  impntvement  usually  c>)ineidcs  with  some  dimiaulion 
of  (he  local  irritati'D  at  the  primary  M^nC  of  diwraw,  ouch  lu  re«ult8  from 
mt  in  h«>i|  in  a  ciote  of  ttone,  tir  from  the  cleaiuinf;  <if  a  f<Mit  bladder.  A» 
tha  aymptumut  are  somewhat  iudfliiiite,  tt  i»  often  dilSoult  to  anv  how  much 
Ik  due  to  rtiml  intMchief  ani)  how  much  to  the  primary  utt'eetiim ;  but 
wherever  we  find  »  dry  toti;;ue,  a  persUtenl  oix-turtia.]  elevation  of  t«mpcra- 
intr,  low  of  RpiM-titf.  yeueral  iv<rnknrw;#  and  emsicialion,  we  ought  to  make 
•vvry  a.tteiii|>l  to  jjet  rid  of  the»e  syiiipdiiiiji  before  undertaking  any  serinua 
nrjpcal  pHK-eiliire.  such  tm  th«  lr«atiiieut  of  stricture,  lilhotoniy,  or  lilho* 
llUr.  (he  irritaliou  of  which  might  »t«rt  the  ginouideriog  inHammatiou  into 
activity. 

Jrw/r  inttntUiiU  and  mppuralipe  nepSritU  ^tvct  rise  to  much  more  mani* 

tan  ttyniptotiie.  oAcn  eupervenin^  on  tli<)»e  juBt  deeirribed.     The  attack,  which 

;bafteu  inducL-d  by  some  »ur^nral  pnicedure  although  it  may  eommencespoo* 

taaocmaiy.  beginv  with  a  iHn-en>  ripor,  rollowcid  by  profute  sweating.     Xbe 

•■■prrature  may  rim  tn  lori'  t\  or  lOli'^    F.     Alter  tba  rigor  it  falU.  bat 

maaitts  Mimen-hat  ab<)ve-  normal.     The  riirorn  and  i>irealiu>;  may  be  repeated 

nntre  than  on<T.     The  tongue  becomes  rH|>idly  ilry,  rtui,  auil  tiMiured.  InokiDf 

like  a  pii-re  <>f  broiled  ham,  and  RordpH  arrumidute  on  the  t^th.     Tbera  are 

mmplrte  !<«»  of  appetite,  flnd  mpid  riiaciation  ;  nnuttea  ts  almost  a  conitant 

•ymplom,  and   ncliiiil  vomitini;  is  common.      DlnrrhoMi  may  occur.     The 

paient  soikn  sink*  into  n  heavy  dn>w,iy  stale,  otlen  with  noniraclo*!  pupiU, 

m  tbmt  the  condition  may  ctoaely  resemble  that  of  opium  poisoning.     Ha 

tka  be  rmivd  and  answera  rationallv  if  spoken  to,  and  in  mmt  ause*  com- 

]Aain»  of  litile  pain  or  discomfort.    'The  leinperaiure  now  uttnally  falls,  enme- 

lime»  l«elow  nanoal,  and  the  skin  feeU  cold  and  clammy.     In  this  form, 

Ibere  i*  UMially  some  tenderneas  on  pr«*«in>t  firmly  in  the  rejrion  of  the  kiil- 

^M*.     A*  tbe'  caw  prugrewee,  mutterini;  delirium  »ct»  in,  followed  by  more 

Hbiplelc  inaeniibility.  but  it  rarelv  reache<9  a  condition  of  nbsidutc  comn, 

Hu.  i>'  are  extremely  rare.     There  ia  no  cedeiaa  at  any  time.     Tbe 

K-i  *  much.     It  iinually  becomes  more  or  leM  blo<>dy,nnd  in  rare 

K.>  'i>re«9ed  ;  nmcb  m4>r«  fretiuenlly  a  couBiderable  ({iianlity  i»  pa«Md 

||i  ime  of  deiilli.     It  i«  utiunlly  in  »uch  a  state  from  deo>mfKwitioa 

•Dd  lilt:  prtwrnce  of  puf,  ttlixid,  and   mucutf.  aa  l<>  render  accurate  ciicmi<.itl 

«nfl  mici"»c(>piitu!  inve^tiu'tuion  iiiipomihle.    Pus-celli  an*  eonetantly  prLvcnt, 

bat  wbetbfr  they  (ume  i'roni  the  kidney  or  the  bladder  in  any  ]>articular 

CMe  cannut  Iw  n«tf^ruitnrd,  uuImc  they  are  louud,  as  to  rnru  cuaea  they  arc, 

la  tbe  form  of  pu«  cat(t«.     In  «omc  ammmloua  ttis».  diarrhn^a  forms  a  very 

prmnlDenl  aym^Hom.     In  onn  mse  that  tm-urred  in  University  Odlege  Uue- 

pitsl,  the  Rlixils  nxBdlv   rraeiuhled  thiue  of  typhoid  fever,  and  the  voalr 

■mcfUm  examinniion,  in  addition  to  eupfmralion  of  the  kidney, ahowed  uloer- 

Ukm  of  tho  lower  pan  of  the  amalt  inic«tin«. 

'^   ISerho,  who  hiia  written  an  admirable  troatiee  on  unemlc  fert-r,  de- : 
-  a  form  of  thta  dbenM  in  which  fteonndary  abauMOB  appear  in  variouft 
jpaxt^  the  eimf^oN  of  which  have  an  urinaus  odor.     It  it  doubtful  if  this  u 
[hi  id  r^lity  h  fi)riii  of  pynimia. 

Tbe  duration  of  an  ft<-ute  attack  aa  abovo  daurlbed.  when  termtnatlog. 
fiitally,  varies  fntm  a  few  davM  to  a  couple  of  weeks.  In  favorable  caMd^ 
•««D  after  very  marked  syiuptoms.  »ucn  aa  rigon,  dry  tongue,  vomiling, 


884     SBUONDAtlY    DISEASES   OF   TUE    UKIXAP 


luggcels  that  iho  ecottervd  Bb«c«we»  may 
Uie  tubulcit  and  Ine&l  extravuuti>>D»  vi 
Biiftc'iicd  l)y  ncute  ititprftitijtl  ue|tbritu.  It 
occur.     I>i(kin3*'n  jhtihiuu  liir  liie  aUcof-" 
in  the  vciit^  a  &ort  t^f  local  pyaeuiift:  but  l)iv 
and  the  fort  thai  every  otngv  u  fuuoii  bt>' 
tial  itiflatnniation  and  the  fully  loriin;«' 
view.     Giwilbartf  of  Out's  Uuepiial.  ' 
bvlwe«-a  crj-aipelaB  aod  pup|iiirati<iu 
v«ry  mliTMling  aviilcnce  iii  tHVur 
tbfir  tiiveiitigaUoD.  nlth»uf!h,  ar  '  .    ii 

purd'in  iif  ilio  deaths  t'n>m  Lh» 
It  will  he  Bttn  from  (fan  ah' 
nc|'liriti»  a  Dumbc-r  of  i' 
eitijflv,  niid  tiu  excli»iv. 
(KUli'iii  'if  Ihr  flifvi. 

Symptoms  of  Kidtic 
Organs. — imitfjl'  </ ' 
daii|fi'riug  iliL'  nu<  I 

reniarkalilr  l<  ■■  ■ 


„■  m^ 
i.r  m^kdUt 

rttf'niti*  icnliilA ' 

■  tol  •!    I  OH 

l'      til      W.  1  'ill-iili  •     <i><^M 

.  ui)d  ll»'  fact  ihftt  the  IMflt- 

Ti   -    .  '      TIm'  vntdAtK^  tal 

I  i  !■  ftir  lu  uf  [iCTiBViiB 

•  I,  l>ul  !l  '  tii)[  hu  a«  da 

ntid   t)i»  >if  iMbfanUW 


ture  (d  thekiili 
fiMm  tlm^-ausp 
hi-altli.     U  gi 
the  hincimu 
iuereaae  ii 
In  a  ami' 

of  liriiiv 

it   i?   ■  n   - 


atiB) 
ftll'- 


<•■  e|Kili*,  mill   (.ill-   .  ill  ■Hilf 

:  till'  rattf  Bho^'e  lit' 'I  i-iaw»Wt 

-l.fr  iH'fiire  iK'fltli-     From  niftiK.  tti*<)MW*i* 

Ll:C  t'iini|ik>tv  intiTtniwiitii  nfirr  ike  tmmint 

..-t  rrm«iiil>prcd  thai  pBticuiR  «liu  litf*  mAim 

^^  ..hie  tu  attack*  of  fever  aftvr  auy  opanuiMitai 

rsBie  F«T«r. — Thia  term  has  beea  aowmhat 
.-  fiiltiiwfil  hy  Hwcalin^.  and  ninre  or  lea 
'  <|iifnl  on  Biinie  np('rnli[>n  cm  tht 
nilH-iintily.      1(  will  he  .tn  II  at  nom  llal  In 
i>'  .:.    i;iU  rriitial  ii<-|>hr>lie.  aa  nhiivf-  iltv^TiiMHl.  sadi^ 

-i<  111  Ims  hfTii  Htirl  til  havf  dit>ij  itf  *'  urethral  iira," 
iMii4  hus  lit-trn  tiivtirialtly  foiind,  althiiii|;)t  bm  Hur|M> 
II  hi>l<-  Itvirtitia   unili-r  urflhriil   fiVi  r      It  w  |iiiiml> 
'I  ;hc  iilfi-clirin  is,  at.  Iftifti  in  t)i  '  '■n 

.. irL'iilntinti  in  tin*  kiilncv,  nr  »  liW 

rvdcK  irritnlinn  friitn  thr  iia«wi|:«  «il'  th«  intfrai 
^-.w,.  .11  fifakinjidf  th*"  sourrra  (ifirrimtinn  Ui  lb»  ki«la«y. 
'^^m  abgnff'li'jn  of  urine  frtun  a  wound  in  ih*-  urinary 

:'  '  fact  that  rigor*  are  rar*  atl«*r  lilh>i(i>nir.  and  arr 
I  ^•f  «xlravasntiun  uf  Qrlnc,  nod  that  aouDdo  nf  thv  a 
I'jlum  Bcarcoly  ever  give  ri»<'  t"  Ihrm.     T' 
called  urv'thnil  fever  is  Bapportrd  hy  M 
^  Itinaie  /'icrr.  a%  be  wnuld  enll  it.     It  i- 
,;  f^irthiT  Imtiwlrdpe  niij-lu  he  gnlni^  by  r 
'  (ity  auil  ((imliiy  of  itie  urii'    - 
:i,  tin<l  Mt  the-  Mime  time  aot  u. 
'.',  HVt-n  whi'n  the  rlpir  doea  not  uccur.     ilallt«ba  ttoia*'' 
;  ire  ri;-!*!  In  ulmiwt  every  ca«;  and  in  om-  "f  the  fmriti^'^u 
iiinned  lM>tori',  the  lempemlure  ruc«  l"   <'  '^^"^S^^^l 

!,.  oiK-mtion.  when  iht  urine  became  bIo«»dy.  .  loBjB^^ 

id  i!i»aii|M*nred  ;  but,  ihrte  hnura  after«ard*.a  lilU«iM«W" 
I  ii^-  M.  nnd  ihr  tt-nipf ratlin?  Bjtiiin  r«w  to  ]IX>:!'  K. 
raosia. — The  prucnixtx  in  ncuii'  iifTectiooi  i>f  tha  kid»T.  immitil^ 
r  ili^fa-*,  is  al««v»  (!™ve;  but  <*v«-n  thr  most  unprou  '  ■■  -  ~— f  *T 
r.     Voniiiiitjj,  di-liniiti).  pitritul  iiiM<n«ibllily,  ami  a\  ''*" 

«lt  ><nd  -i^'iM.     A  riDirK'.l  diminution  of  the  qiuuitilT,  anu  mors 
(^  arc  iiulavMrnl'U'  ByiupUinw. 


SYMPTOUS   OF    INTBRSTITIAL   KBPHBITIB. 

eveo  months,  the  patient  frrailuaDy  liccuniiuj;  woaker  ftod  weaker,  uolil  li«  is 
corned  oil  by  euiiiv  inlurcurivut  d'iiuws^,  nr  <lice  of  puru  iixlinuvtion.  Mere 
ooiuiuoaly,  bowcvt-r,  nn  luuite  uttuvk  Aup<->rveiiCM  uti  tlie  (<ubaciU(.-.  «ilber  spuuta- 
neously  ur  m  the  rueull  »{  Btujm  sur^iciil  iiil(!rruroDi;e.  and,  rupidly  ending  in 
nippuratiuD  of  thekiilney,  tt^nninntps  iMtally.  On  ihcothur  linud.  tbesynip* 
ton]sufVengru(hiullYnuh»<iile,  thet«mperHttirH  lHH:iiniL>»ntirinnl.!indliie patient 
gahia  Htrcngth,  The  iniprovem<-nt  iHiially  coiiu-idi!!!  with  Mtrui*  diuiinution 
of  lliu  lonil  irritJiti'ui  at  the  prinmry  sent  of  di.4(Mise,  ^iicb  lu  results  from 
tvbC  ill  IhsI  in  a  m^p.  <if  stone,  or  from  the  cleanRiii^  of  n  foul  bladder.  At 
the  liympMmii  are  fiomewhat  indefinite,  it  is  nften  diffiniU  to  eay  huw  much 
is  due  ti)  renal  miAohief  and  how  much  in  the  prtniury  alffeii'in  ;  but 
wherever  we  find  a  dry  tongue,  a  per«»tent  nortiinial  eltivatinii  of  wiu|iera- 
tnrp,  Inas  of  nppeiit*,  funeral  wenknesa  and  emm-iation.  we  ouj-bt  lu  luako 
ever)'  attempt  to  get  rid  of  these  aymptoins  before  underlJikinp  any  sL-ri'ina 
surgical  procedure,  Buch  a^  the  treatment  of  stricture,  lilhor-iimy,  or  litho- 
trity,  the  irritntioD  of  which  might  start  the  sinnuldering  intl  am  motion  into 
activity. 

AaUe  ititeretitiai  anH  suppiuyitlve  nephritu  give*  ri«e  to  much  more  mani- 
fest itympti)ri)»,  nlWn  supervening  uti  th<u»e  juMtdwcribcd.  The  attack,  which 
i«  often  iuduoed  by  some  Hurgieal  pn>i;edur^  attbouKb  it  nifty  comments  spon- 
tuneonttly,  begins  with  a  severe  rignr,  fullimeil  by  profu^  sweating.  The 
temiK'iKture  may  rinB  to  105"  F.  or  IO*i^  F.  AIUt  the  rigor  It  fidls.  but 
rentaiiiif  »omewhal  above  normal.  The  rigors  ami  sweating  oiay  be  repented 
niiire  than  unce.  The  tongue  becomes  rapiilly  dry,  red.aud  ti^nre«l,  liHiking 
like  ft  piece  of  broiled  liaiii,  and  sonlea  aceunmhite  on  the  let^tb.  There  are 
cumplete  loas  of  ap|>etite.  anil  rajiid  eoiacialion  ;  natinea  ia  almutit  a  constant 
symptum,  and  actual  vomiting  is  common.  Diarrliu-ti  luay  occur.  The 
patient  soon  sinks  into  n  heavy  drowsy  stale,  oAcn  with  contracted  pupils, 
so  that  the  coudiliim  may  ehisely  reseml>lo  tliai  of  opium  pui^oning.  He 
can  be  rtmstd  and  answers  ratinnallv  if  sjmkcn  to,  and  in  most  cases  com- 
plains of  little  pain  or  diflooniforu  'The  tumpernturc  now  usually  falls,  anme- 
iimee  below  normal,  and  the  itkin  feels  cold  and  clammy.  Id  this  form, 
there  U  usually  some  temierneiw  on  ppe?i*iing  firmly  in  the  region  uf  the  kid- 
neys. As  Uic  taiae  progresaeg,  ninttering  delirium  sets  in,  followed  by  more 
eompletti  inscnMibility.  but  It  rarrdtv  reachex  a  ctrndllinn  nf  ah^oluie  coma. 
C'mviiItfiiinH  are  extremely  rare.  There  is  no  dsdema  at  any  lime.  The 
urine  varies  much.  It  nmtnlly  hecomm  muro  nr  ten  bloody,  and  in  rare 
cases  U)  )3up)>rej»t:il  ;  much  mure  frequently  a  conatderable  iptuinily  is  passed 
up  to  the  time  of  denth.  Tt  ia  iiAuallv  in  Aueb  a  Mate  from  decoiupoiiilioa 
and  the  presence  of  pus,  liloml,  and  mucus,  aa  tn  render  aceurnte  chemical 
and  micriMcopical  invei4lit;Htirin  impnHsihle.  PuA-celia  are  con^^iantly  prettcnt, 
hut  whether  they  cxime  from  the  kiflneyor  the  bladder  in  any  particular 
case  cannot  lie  ftscertaiiiMl,  unless  they  nre  fmind,  tm  in  rare  caaca  they  arc, 
in  the  form  of  pus-cwals.  In  some  ftnomalifu.*  cajiea.  diarrhir-a  forms  a  very 
prominent  symptom,  hi  one  case  that  occurred  in  Univer*ilj  College  Hos- 
pital, the  stools  exactly  resembled  those  nf  typhoid  fever,  and  the  rxut- 
morfitm  examination,  in  addition  to  suppuration  of  the  kidney,showed  ulcer- 
ation of  the  I(>wi>r  part  uf  the  small  inl«sline. 

MalherVH-,  who  ban  written  an  admirable  treatise  on  iiriemic  fever,  de- 
scribes a  form  of  this  ilisease  in  which  secondary  alMC«s»es  apfiear  in  various 
pnrts,  the  contents  of  which  have  an  urinous  udor.  It  is  doubtful  if  this  is 
Dot  in  renlity  a  fi)rm  of  pyemia. 

The  duration  of  nu  acute  attack  as  above  described,  when  lerminatini; 
fatally,  varies  from  a  few  days  to  a  cnuple  of  wevks.  In  favorable  cases, 
even  afler  very  marked  symptoms,  such  as  rigors,  dry  tuugue,  vomiting, 


88€     SKCOHDARY    DI8BASB3   OK   THE    URIWART    OKn-tA-^. 


It' 


and  HinrrbfTa.  the  pattcat  mnr  slowly  recover.     TIm  imifrfbf  cai 
dentil  ill   iimoy  casfi  sMtiis  to  be  |>uidi>»iiig  rnmi  absorptiaii  uf  iW  t 
niniliT  fri'iti  till'  kiilnoy  nilhL-r  ilitiit  ur»-iiiia.     (Yrlainly  tite  OMdeAfi 
(lifTera  ii^rtntly  fruiu  thnt  of  ui'Ulf  Drijtlit'a  JUcnM!,  the  pruftMiBd 
couvulsiiini  Ijciiij^  very  r*pely  pnin'iil. 

Thf!  J)ia>;na»A  has  to  bu  nmile  from  pywioEa,  p^rilKni't-   ■v(.K.4il 
and  a^ue.     From  pyii-nitn  Lhc  iliBftnimU  i*  iMMtiewbal  il<i  '  aaati* 

portAtit  jwimlA  bein^  the  vontlliiif;.  the  nh*f.m-e  oi*  m-ciii>,.„(  .  u.«.-vwr«,(ltt 
droTTfly  mute  into  wliich  the  palienl  iUH>n  full*,  opd  th«  fnt-l  ihul  ihr  Urmfoir 
ture  »»IWn  remains  fur  dnys  iK'fore  ilmtb.  U'hiM  nnrmal.  Tbt*  Tumiliiic  uA 
«xlrenie  illnew  niay  reM-mble  the  low,  ditliivi!,  iminlrw  Irirro  nf  fwrilxtldi 
0oDif ti iiifp  even  in  iifli-cliou»  of  the  blfiiUler.  but  tiic  vn.'. 
uiiipiua  charncter  ol"  thai  in  p*rit"iiilis,  ami  the  rlrv.it 
x>r  iht-  tirat  tew  dava  is  uiilik*'  thnt  IWnii  •*(  i»crit«nii!  '«• 

turi?  18  [wnsistfUtly  low.    Huppiirttliti^  kidney  cati  rv** ;  ,  «lf 

ill  rarv  uaei^v,  aud  Ihv  nlweiioc  uf  spola,  aud  tlw  lt!iii|vniiurc  wiiJ  Dtuall^ 
Bdrvi'  to  ilii^tiiigiiisli  thfiit.  In  (lie  ra^e  above  iiit-iitionrd,  the  Iroij 
was  (m-Uiw  n'iniial  r<<r  three  weeks  before  death.  Kriioi  Hfcue,  tbv  < 
diagtitjsetl  by  the  abs4-nn>  of  the  rumph'te  iMlprmifaiiti)  alivr  tb« 
stage;  liut  it  miiat  \>p.  nlnnys  rfiuenibered  tlial  palieule  who  baT»  kiI 
friiiii  ni;iio  lire  itiii^ularly  liable  tu  attacks  of  fever  aftvr  mujr  openliuacalk 
urioury  ort^Hii?. 

Urethral  Fever  or  Uramic  Few.— This  term  hta  been  snmewhst  bodf 
Ufted  to  «)f;riify  a  ri»nr  followed  by  sweating,  and  nmrr  or  Irm  pnilMq{i4 
elevation  of  Leniperaiiire,  (vjnftei)iient  on  H'ini'  opt'ruiion  tio  itw  erioM^ 
or^au-*,  or,  possibly,  nri:4in^  iipontaneriii^ly.  It  will  In*  tetn  at  noce  tlatM 
d^nition  iitcluden  iioute  iiitcridilial  nephritis,  a:t  ahnve  ilcfc-rtb«^I.  wdj 

py»tnia.     When  n  patient  has  bee^n  said  to  have  died  of  "  imlbral       

one  uf  tbne  two  conditions  has  b«'en  invariably  roiiitd,  Hltbuu^  oafilllplB 
would  intentionaDy  inoludc  prvniia  under  urclhrnl  fwi-r.  1r  i*  iinmUt 
that  the  real  nature  of  the  uHWiinn  Ik,  at  least  in  the  un  i  »«*i 

a  disturbance  of  the  circiilutii>n  in  the  kidney,  or  enme  in  'nio 

function,  due  to  reflex  irritation  from  the  nnsaage  of  Ih"  in*tnit 
before  deacribed  in  ipcaking  nf  the  sources  of  irritattoti  to  tbe  kidnejr. 
il  IB  Dot  due  to  abeorptioD  of  urine  from  a  wound  in  the  urinary  fiw^w. 
evident  from  the  fact  that  ri^fori  are  rare  aRcr  litbntt  r- 
marked  eyniiitom  of  extraraealioD  of  urine,  and  that  wm< 
anterior  to  the  acrotuni  scarcely  ever  ^ix1l  riac  to  ihcm.      t  ■ 
renal  orijiin  of  so-called  urelhrul  fever  i»  »upport«l  by  M 
treatiBO  im  IJrtrmie  Ffttr,  as  he  would  call  ii.     It  \»  Hifti'-uli  t 

Iiroof,  but  fori  her  kiiowleilge  niij;hi  be  gnine^l  by  far»*fiilly  •-■■ 
)y  b<iur.  llui  *|iiiinliiy  and  i(uality  of  the  urine  Becrvier 
or  vi^ii-ul  niH-niiioii,  and  itt  the  f-ume  time  aocuralely  ob-  ■ 
in  lvni|icTnturi',  even  when  the  rfgor  duea  uol  i>ceur.     Alalbcrbci 
the  leni|HTiUiire  riit-M  in  atinoM  every  cue;  and  in  one  uf  lb«  flMti 
stricture  nientionei)  before,  the  tenitH-niturt'  rj»e  to  lOO.A"  F.  aboiltl 
houm  Bft4-r  the  oiN>^ratJon,  wlu-n  the  urine  becnine  bloody.     It  fell  u> 
whfn  the  blood  ilinftppearrd  ;  bul,  lbre«  boiira  aftt-rwardca  little  BMrft  I 
ahonrd  iliu-lf,  ntid  the  lempemture  attain  niDv  to  100.t{^  F. 

Prognotis. — Thr  nni^noiiis  in  acute  alfrcliona  of  tbt?  ktdncT,  aecoadAfy 
bladder  dirirRM-,  ifl  alnnvA  (frave  ;  hut  evm  the  most  unpromE^ik|F  nan 
receiver.  Vimdlinp,  delirinnt.  jdirtial  inMo^ihilSiy,  and  a  eery  iiry  toni 
are  all  bad  oi^iiii.  A  nmrkt'd  diminution  of  the  iitiantity,  9»\  nodi-i' 
in  the  urine,  are  unfavorable  cyiuptums. 


urbthra: 


r — TBSAi'MKNT. 


887 


Trefttment. — Pr*\'eiiti(in  is*,  of"  coiiret.  fitBt  to  be  tiimed  at.  Nt»  pslient 
Bhoiiirt,  tliorfruii*,  be  aiibmilU'il  tn  ftii  DpurHtioii  on  tin*  uriiiiiry  orgAiii!,  irxt-t'pt 

'  in  CSMS  of  ueci'Kttity,  wilhuiit  u  curelul  L-xuiniiiHtioi]  of  the  wIioIl-  dny'^  iiriD6 
U  to  Bp^ifiu  ^nvity,  the  ]>reHi?iicv  hikI  quuiitit}'  of  Hlbuiiivn,  uti<i  iho  micro* 
soopiu  apueiiraticee.  It'  i>iie«ible,  thu  temperature  should  be  ubaerveil  uight 
aau  inoriJiug  fur  two  or  three  dnyx.  If  utiy  HUBpicino  arise  as  to  the  coiidi- 
UoD  of  tbti  kidneys,  tbut  operation  should  be  eelected,  when  pructirable, 
which  gives  rise  Lo  leust  irritatino,  Hull  iaetrumetils  i^hould  be  employed 
iDBleud  of  metal,  and  a  sufficieut  interval  allowed  between  their  use.  Above 
all,  any  treatment  caJcuhited  to  cnuue  cyslitie.  nr  tu  give  rise  to  decompoBi- 
tion  of  the  urine,  should  be  avoided.  Ah  there  cnu  be  no  douhi  that  the 
causee  of  dvcomiiosiiiou  are  olWii  introduced  into  the  bladder  by  catheters  or 
other  iuiitniuieiils.  these  should  be  kept  ficrupiilously  cleaD.  For  this  pur- 
pose the  tiiatrunient^  may  be  grenfed  with  caru>rj]iL'  neid  and  'ill  ( 1  to  10).  If 
aeconip'H»ilii>n  alreAilv  exist  in  the  urioe,  it  ghouM,  if  pfis^ihle.  be  arretted 
by  wni>hin;^  out  the  bladder  uitb  sonic  anti^'ptic,  fur  which  purport:  <|uiuino 
aud  diluted  sulphuric  neid,  in  the  prtipi>rtiii[i  of  ;^r.  ij  and  %[}  to  nn  ounce 
of  water,  will  be  found  very  etHcueiouB  ;  or,  better  still,  10  grains  of  iodulbrm 
to  4  ounces  of  water,  and  .^88  of  niucilagp.  If  the  cause  of  the  reiml  luiechief 
be  airieiure  of  the  urethra  or  atone,  aonio  opcratioti  niuat,  of  courw,  be 
UDdertaken;  but  if  the  temperature  be  elevated,  or  there  bo  other  signs  of 
renal  disease,  it  sbuuld  be  delayed  until  an  attempt  has  beeo  made  by  rest 
aod  other  rciuc<tie«  to  bring  the  kidneys  into  a  healthy  state.  If.  alter  a 
few  days,  no  improvement  be  seen,  and  it  seom  probable  that  the  disease  ia 
kept  up  by  the  presence  of  the  stime  or  stricture,  further  delay  is  UBe]>cas; 
U)(l,  ebooaing  the  least  severe  and  irritating  procedure,  the  Surgeon  inuBt 
operate  at  once. 

The  ireniment  of  welbiimrked  interstitial  uephntiu  is  extremely  uu»uti** 
(ncUiTv,  If  there  be  any  t«^nderoe'<s  iu  the  loins,  dry  cuppiug  may  be  of 
service.  The  howeU  should  be  well  acted  ou  by  purgatives,  and  the  skiu 
by  hut-air  batha,  to  relieve  the  kidneys  »»  much  as  possible.  Heroic  opera- 
tion«  undertukvu  during  acute  uepliriti«,  iu  the  hope  of  reuioviiig  the  cause, 

^are  almottl  always,  if  uot  invariably,  fatal,  (^uininu  and  upium  have  becQ 
recommended  for  the  prevention  of  the  rigors  that  frequently  follow  catbe- 
lerism  or  ulher  operations  ou  the  urinary  organs.  Opium  is  probably  of 
servieu,  but  must  be  giveu  with  great  ntutJun  if  any  syniploms  of  urwmio 
poisouiug  exist:  hut  i|uinine  has  not,  ticcordiug  to  most  mIiu  have  tried  it, 

r'prove'l  uf  auy  u»-.     A  pure  milk  diet  will  usually  be  found  the  hext  lit  all 

^eaitefl  if  the  patient  can  take  it :  stiniulalion  mij»l  he  regulated  ou  general 
principle. 

Sir  Amirew  Clark  has  recently  nuggesled  the  miaiiit  name  of  "cathoter- 
fever"  i'ar  those  p-iiB<y  in  which,  phortly  after  the  ci>mmpnrenient  of  the 
habitual  uw  of  a  cotlieter.  nliHcure  fehrili*  tiymptnms  .'^et  in  gradually,  lenni- 
nating  in  death  in  a  large  propnrtii>n  of  the  cases  atfecletl.  The  ^vm[>toms 
BoEt  commonly  develop  about  a  week  after  habitual  cntheterism  hna  been 
commeuecxl,  and  almost  iiivariiibly  iti  those  cases  in  which  it  is  rendered 
neceseary  by  enlargement  of  the  jinistate  or  atony  of  the  bladder  with  par- 
tial retention  of  urine.  With  the  ordinary  :4yniptom8  of  febrile  disturbance, 
there  is  a  diminution  of  the  specilic  gravity  of  the  uriuc  and  in  the  amount 
of  solids  excreted  by  the  kidney.  There  are  at  the  same  time  but  nicidcrate 
Bymptonis  of  oystiti*.  The  syniplnnu  may  gradually  pnjs  off,  or  the  palient 
may  die  exhausted  nt  the  end  of  three  or  four  weclis.  At  the  poHt-morleni 
examination  it  is  ^aid  that  the  kidneys  arc  f-iuntl  perfectly  heailhy,  and  no 
definite  organic  cliangc  is  present  to  account  for  death,  .^ir  Andrew  Clark 
is  inclined  lo  attribute  the  fever  to  repeated  disturbance  of  the  nervous 


888     8KC0NDABY   PISKA8KS   OF   THE    DRIKAET  OaOAll. 


^Btem  b^  tbe  puBOffe  of  the  iasLrument.    The  aU«iitit)D  dnw _. 

JectbfHir  Anarev  Clark  caosot  tnil  tubojiroiluL'tirc  of  turcli>-r  iflfot^vte 
and  increoHMl  knowIe<]ge  C4)iit?eriiin<>  it ;  but  it  rL'tiiniu*  to  bo  flcen  knraMf 
cases  will  be  lefl  to  be  int'liick-il  uinkT  tlie  immc  i>f  "  «ith«ur-frTtr"iAv 
the  eliminatioD  of  chnjiiic  !<>e|iliL';>'niia  and  pvn'cnia,  nnd  of  iboMCiMii 
which  the  kiduey  shall  have  btt'ii  proved  by  iiiicnMi^opti!  rxaminatiaitoW 
aSl'cted  hy  chruiiic  or  subacute  iut4.>n«tl(ial  in  flam  mat  loo  aggraraiadkytb 
rcilcx  irritaitiuti  ot'  the  paaaaee  of  iostriiraf-ntA.  The  trMUmcol  of  ihtmam 
must  consist  of  ro^t  in  bed,  mand  diet,  especially  mtlk,  and  the  oat  of  ofiia 
in  mnderAtc  diis^s. 

PTaemia  and  Sopticsomia  in  Diseajcs  of  the  TTriiiary  Or^aAf .  — TImm  na- 
ditionii  are  Dot  UDcummunly  Ibe  atuoe  of  death  atWr  o[>eratioai  oa  tt* 
uriuary  pa««ag««.  Their  general  nv ntptunis  and  i>atholo((y  b»v«  bctt atnai^ 
fully  described:  but  a  few  words  ou  lh«  peculiarities  they  fr«qacsUy  u^ 
l««l  ivjien  aecoodary  lu  affectioiui  of  the  urinary  orgaoa  i»ay  kM  U  «M 
of  place  here. 

Fyuiuia  may  assumti  tbe  ordiuary  rapid  oouiM  of  embulic  piraniii.«iA 
Mcoudary  absccMCB  in  the  viscera ;  but  this  is  not  of  veir  fnqucnc  oiiimwM 
Should  it  iHx;ur,  Bollcaiag  thrunibi  uill  usually  b«  iuund  la  Ih*  praWfe 
plexuH  iir  ill  the  vesical  hrunchiv  of  iho  iutenial  iliaa  vein.  Man  eammmkl 
vittcuml  iibiiCGaws  are  wanting,  the  secondary  seats  of  suppiumtaan  bdBBWtt 
fretiucnlly  the  jiunts  and  tiubriitauuuiiB  liwue.  In  sucli  i.>aan  Uie  pNCMB^ 
though  Imd,  is  not  h(i[»pl(»).  The  dioeaw!  not  unrommunly  aMancsaobnBB 
form,  and  the  lutlicnt  may  roouver  atier  lung  sufferinf^,  ptMsiblf ,  wltk  mt*r 
more  juintu  ati^rn^^I. 

SeptJCKroia  may  appear  under  tbe  forms  of  fleptic  poisoninj;  ud  ttptio 
infection.  Poiaoniog  fnim  the  absorption  of  the  ohemhvl  prndort*  ttf  psii^ 
faction  is  prohnbty  the  immediate  cause  of  death  in  nmoy  nf  ihnw  oub  n 
which  the  bladder,  ureteiw.  and  pelves  of  tbe  kidneys  are  fillM  «iiL  kci 
decomposing  urine  nnd  mucus.  It^  symptoms  presnt  nothing  )m<v1v 
Septic  iufeclion  may  be  n^umed  to  be  the  raaw  of  death  io  tbtm  ov 
in  which  then?  is  i'tbrile  diflturbnuti-  of  varviiig  itererily,  prMvtled  ar  anltT 
a  rigor,  and  ending  in  death   fnjm  exhaustion  in  n  :  f  ttvahlf 

days  to  a  fortnight  or  three  we«'k»,  and  in  which  nl  ll-  i-sa  nwaii^ 

tioa  a  definite  source  ofintectiuu  can  be  found,  without  the  |iRMO0t4w* 
an  acciimtilalioD  of  putri<l  matter  iu  the  urinary  tract  m  to  rm4cr  Ml* 
septic  poisoning  probable,  and  without  evident  fatal  disease  of  ths 
£;uch  cases  are  not  iincomntouly  met  with,  ee|>ecially  after  opersti 
urethra,  and  less  fre<iuently  aAcr  those  afilvtiug  the  bladder,    lu 
Univeraily  College  Ili*pital  the  source  of  infection  was  a  •liyhl  in 
the  pt>int  of  n  catheter  to  n  prominent  ridge  of  a  fasciculateO  Mailil«f 
tb«>«  cases  the  wound  la  found  to  be  covered  with  an  aiUicrcnt  ip*j  ^Hf^ 
closely  reseiiibliug  the  false  niumhmne  of  diphtheria.     A   m 
thntugh  this,  and  the  |)arls  l>eneatb,  Bbixtn  that  the  mvmhrBBPOS  ttytf^] 
couipoMd  of  a  coagulated  fibrinous  exudntion,  everywlirrw  crowfao  «*^ 
mierocoix-i.     The  8Uomuc4)us  llM^ue  and  the  puir  '  -how  tiM  aniin^^ 

appearancei*  of  inflammnliou.  anrl  in  many  caii»>  .  •eood  eaa  b* 

oguized  invatling  the  nHecto^l  tusues.     In  some  casm  lurlliHr  la 
shows  the  nearest  lyniplinlic  glands  In  be  swolteD.  and  mirmeofld 
foutKl  forming  <!^lonic«  in  their  substance.     I'tidrr  ihnwctreui 
is  ilmng  rea84in  to  believe  that  the  diseased  spot  has  hem  tli«  M>unf> 
nischicli  and  thai  some  intmive  material  baa  foiiod  iidrntMuoii 
hy  infecting  the  whole  sysleni  has  been  iho  cause  nf  death.     Ti 
these  cai)cs  Io  the  chronic  form  of  pyiemU  fl  V*nr  rlosr;  prw- 
cooditioDs  arc  identical,  the  prneoc*  or  absmo*  «f  aevocMUry  « 


-*-- 


•  nfi^ 


STONK    IK   THB  KIDKKT. 


889 


merely  an  accifleiital  variation.  The  vhief  pt'coliarily  of  the  eondilion 
ii  lt)Ht,  nttbough  thtre  etrcms  good  evidence  of  a  geiKTal  infective  prftcws,  it 
t*n<h  to  run  a  somewhat  chronic  courw.  BottieUines  lavtin^  for  weeks  before 
rmioating  fatally,  and.  proWbiy,  in  inimy  casfs  ending  iu  recovery. 


CHAPTER     LXVIl. 

SUKOICAL  OPEKATIONS  ON  TUE  KIDNEY. 

Until  wilbio  the  Inst  iifWn  years,  although  minic  doubtful  cases  of 
removal  of  renal  Ltulmiii  by  ()p<>rnLiiin  had  Ikh^u  reronicd,  hut  few  atTectiona 
of  lite  kidney  uert;  coiixideretj  within  the  reach  of  eurgicul  iuterfercDce. 
Kcnul  abbccBHee,  when  diKtiiicLly  pointing  in  thci  loin  wereojieucd,  and  calculi 
bad  been  in  tixceplional  cmei  di»chHr^eil  fmni  the  o[>ening  then  luade;  but 
uulil  Hiniiiti,  of  H«iil«lbi>rg.  in  l<S<lfl,  succesxliilly  removed  the  kidney. 
Do  definire  operalioni^  were  fv^tettinliciilly  itiHlenuken  on  that  organ. 

At  the  pre«>eni  time  the  following  diHtinct  operntions  are  performed  od  the 
kidney:  \.  Exploration  by  aciipnnctiii-e.  2.  Ai-piration.  'A.  Mephrtilomy, 
(ir  incision  of  ibe  kidney.  4.  Nephro-lithotomy,  or  removal  of  n  »lonc  from 
an  otherwise  healthy  kidney.  5.  Nephrectomy,  or  complete  removal  of  tlia 
kidney.     6.  Xephroraphy,  or  fixing  a  movable  kidney  in  the  loi:). 

The  vnrioua  morbid  conditions  for  wbicli  theeo  operntirtna  arc  required  are 
fully  described  in  works  on  medicine;  and  it  is  iuijiossiblc  to  give  here  more 
than  the  briefest  powible  summary  of  the  chief  syniptonia  of  each,  indicating 
at  the  ftarne  time  the  operalion  rcfjuired  for  its  relief. 

Stone  in  the  Kidney. — Depiwiis  of  uric  acid  nod  oxalate  of  lime  freouently 
take  place  iu  the  kidney.  In  the  great  majority  of  cases  the  calculous 
matter  paaaes  down  into  the  bhidder,  cither  in  fine  )>art)cles.  whc-u  it  is  com- 
monly apokcn  rif  an  gravd,  or  in  larger  muase*,  when  il  i*  termed  a  renal 
caieultu.  The  pasMVgo  of  any  niasa  of  nuffieienl  »ize  lo  offer  rcsi*itance  on  its 
way  down  is  accompanied  by  the  fiynipt»iisti  of  renal  colic.  There  ia  inlenso 
agonizing  pain  siiooliiiit  from  the  li*in  downwards  to  t!ie  groin,  atid  uwialiy 
inio  the  iipernintic  cord  and  testicle  of  tlici>amceide.  In  many  eases  it  radiates 
into  the  inner  t^ide  of  llie  upper  pari  of  the  thigh  of  the  same  side.  There  ia 
retraction  of  ibe  testicle,  and  stoiiiciimc^  much  nausea  or  acltial  vomitiogaiid 
faiotoesa.  As  the  stone  cuicn«  the  bladder  the  patient  experiences  sudden 
relief.  Tlie  stoue  may  be  pti^ed  by  tlic  urethra,  often  with  considerable  pain 
and  irritation,  or  may  lodge  and  iorm  n  vesical  calculus.  Iu  many  caae«, 
perhapa.  after  matiy  stoucs  have  been  passed  at  different  times,  one  lodges 
pcrmiincutly  in  the  kiduey.  and  then  gives  rise  to  the  symptoms  "f  stone  in 
the  kidney.  A  reual  calculus  may  form  tu  one  calyx,  ami  be  permanently 
fixed  there,  or  il  may  b^  siluateil  in  the  pelvis  and  send  branching  jtrocesaea 
into  the  i>urrounding  calyces.  The  svmpLoins  of  renal  catcnlunaru  the  follow- 
ing:  There  '\a  puin  usually  referrei)  to  the  loin,  hut  oreu^ionally  rndialiug 
downwards  in  llm  line  of  t  tic  order  or  to  I  ho  tcflticle.  The  pain  !(« sickening 
in  character  and  varinlile  iu  inteUHity.  It  \s  in  most  cafiH  dit^tinctly  aggrn.- 
vatfld  by  movement.  In  Kome  caseH  walking  giveti  mont  uiicai^liirt^,  apparently 
from  the  movement  of  the  niusclcfi  npon  whicii  the  kidney  lies.    In  other  cases 


J 


STTRr.tCAL    OFBBATION'S    ON    THR    KIPVIT. 


wmlktn;:  rauM'a  but  tiilc  puin.  nhilu  jokiDi,'  of  any  kin<l  mun-s  iattaMmMU* 
mg-  iu  other  vubch  uuv  kiml  dI'  ninVfiiiL'iiL  U  ulimui:  uiili*-ArsUf.  TWw 
OWT  be  acute  tcnileriii-«i  un  [irr-»urc  lU'rr  ibe  utTct-U-d  ki'lttrv;  bat  tit  tW 
«taK^  of  the  dLseA^e  iio  I'lilar^jOMiriit  w  lit  be  rern^-iiiwil.  KrMiiinifi  •  f  n-' 
turitioii  tuny  or  iiiajr  uot  )>e  pi\-;tfUt.     Iti  flotnc  <-a«e»  it  fum 

primitiuut  symplimi^,  ft  much  »>i  tliaL  ibc  iMS«  iimy  Itc   nii:.~.^ _   . 

clUeaxe  of  llic  blmlder.  Th«  urine  sluuKit  nIhiiy*  cunlain*  «  tnK«  uf  UmI 
to  b<.^  r¥Cu};nixe«l  by  the  RiH'ruM'0[>e.  Rml  (KX^4i"Uiil  attacks  of  pruAw 
bicmiituriu  nre  coninioit.  twj«^t  fre'(uei)tly  bruti^lit  uo  by  violrat  ibotobU. 
In  Lbe  i-«rly  »t»gi-8  pus  Is  nliK-til,  ur  i>uly  h  tew  curpiwcla  mi  ba  (uobi 
Cubicitt  ci-lls  urv  Btiid  to  uocur  einiiliir  to  tb'm;  formiaj;  the  superftml  bjm 
ofthvopithvlium  iitiiiig  ihe  pelvis  of  t)iv  kidaer.biit  tbc»c  ar*  not  MlBivaril 
deiioiie  to  draw  auy  euucliidion  from  tboiu,  ub  aitulUr  celli  ntajT  Wdvircl 
frum  other  pHrts  of  the  urinury  tract. 

Treatment. —  Danots  the  de»(:ent  of  a  reiial  calculus,  whtcb  alwanoecqia 
many  houm.  uud  {M>rha|)i^  g>inie  day?,  the  patietit  bIiuuM  have  full  iJaa«i/ 
fipiurn  ai[iiiii)iii>t<^rei).  drink  hlniid  dilueiiliH  freely,  Ik*  put  lutx  a  war*  ti^ 
bath,  and  hnve  hot  fomciilntion?  ur  muslArd  wtukit-t^  applU-d  to  tbe  Ub; 
the  bon-els  should  bI»u  be  thoMti^ltlr  fni|aie<l  l>y  t- tieniau.  It  um^l  in  bar 
in  mind,  that  a  somewhat  similar  trsiu  of  BVinptoma  to  tbat  ioduoej  bttlw 
desoeiit  of  the  cnlculus.  may  he  excited  bj  some  fomui  of  irrilalina  or  Ma- 
Wnt  ditttcntion  of  the  cfocum  and  deeeeadin^  oolao,  which  will  iKpin 
approprifite  frratincni. 

Should  the  ^lone  fail  to  descend  and  fi;\ve  rim  to  the  traia  nf  tjmftK^ 
just  dcscrihod,  mthlical  treatment  mar  be  of  much  \ae.  Ad  atlenntnTbt 
made  bt  dissolve  thestonc  by  the  adniiniMration  nf  d<iM4  *>f  pnUm  ar  laMft 
sufticient  to  keep  the  urine  persistently  alkaline.     .\t  the  -   '   '  tb«M 

roust  be  siriclly  altendod  tit  on  the  principles  laid  down   >  >  jA*  M 

Urinnrr  Calculi.     The  patient   muM   uite  dittilletl  water  ■  riakiif 

Surposes.      Bv  this  treatment  the  atone  nppeari  in  some  ca-  .iv  bva 

i«dolvcd  sufficieutly  to  allow  of  ila  paaaa((e  br  the  urrtcr.  If  ih#  ftlMt 
circnmHtancra  allow  uf  it,  several  m>.)nlh«'  iwt  in  the  rrcambiBl  pwiti* 
may  be  tried,  ns  under  this  trenlment  tbe  calcuiu*  liromet  enryiM  mi 
fixe>J  io  one  cnlyx.  and  may  cease  to  cnum  trouble.  If  tb«w  iMaasiaL 
the  quet>tioa  nrisca  of  performing  tbe  operation  Io  which  lbe  t«na  nf^fcf*- 
lithotomy  has  been  applied  by  Morris,  who  was  the  firrt  to  aii4eftaK'  ^ 
This  opifrntioD  dilTers  so  eesenlially  from  that  performed  in  ihv  later «t«!K 
that  it  well  merits  a  distinctive  name.  It  miut  not  be  awgi—J. bi>*»W. 
that  every  case  of  renal  calculus  is  one  fnr  openituio.  Tha  fuwdJuwi*- 
tifyim;  BiiiRiciil  inti'rfercneo  are  th»?  following:  1.  The  diaoMw  ■■!*••• 
lasteit  fiilbciently  l»ni;  to  make  it  rtriain  that  there  is  do  hoptiiwlMri 
cure  by  epontaneonn  fxpul^iun.  "i.  Th*-  incinvenience  cauied  nul  lw«4 
that  it  »eriou»tly  inlfrfereK  with  iho  patimtV  enjoyment  of  lifr.  8.  M^** 
treatment  must  hare  bi-cii  tiiirly  irit-d  and  have  failcfl.  J.  The  paliwf* 
uot  he  passing  gravel  hnhitimily.  ne  it  h  I'vidi-iii  that  under  ibcM  eafilt* 
a  fruh  atone  would  pmbably  form  in  the  injumi  kidner  and  lodir  It** 
afler  the  ofteration.  iS.  The  symptoms  must  be  di>linelly  uaiUur^  ^ 
Tbe  (uitldnt  mual  benthenviM-  in  (^iid  brjtlih,  o<»ttoi>old,  and  f^pcnilK*'', 
too  hit.  7.  Laally,  If  in  snite  of  treatment  the  ayjTi-'— -  ■■'  ■•-♦alka" 
the  petvis  (Htme  on,  e«|M>eially  a  steadily  inermaln);  >•  ia  V* 

Urtnc,  the  openitloit  may  \m:  undeMnken  in  tbe  hii|M-»  i-t  •--imfi);  mp  a^ 
and  of  pr<-vrtilin);  the  oceurri'nee  of  prone phr>i«i>,  pr»vide«l  tkal  «Cbiri^ 
dlliiinit  an-  fnvunible. 

Calcutooa  Pyelitis   forms  iho  sci^md  vtafre  uf  »tnw  io  iW  kidiwT. 
the  aaine  Bym|Konis  a»  above  desmbetl  perBist.  but  lbe  peia  i»  man  < 


^B 


TUBERCULAR   OR   SCROFULOCTS   KIDIfEY. 


891 


thnugli  often  lew  acut«.  Th«re  may  be  great  frequency  of  micturition. 
The  uriDe,  whicii  remains  Hci<l,  cnutaitie  n  gra()iiatly  iocrcofiiDg  amuuut  uf 
pus,  reaching  »i:>n»^times  bi  tunny  ouuces  daily.  If  the  several  *]UBDtities  of 
urtQe  pHssed  duriog  the  day  be  collected,  it  may  be  fouuii  timt  ihe  pus  is 
variable  in  fjuuntily,  and  may  even  i.Li(-Appear  for  a  fen  liours,  or  cveu  day», 
ite  nrappeurnnco  being  nccumpaoied  by  some  relief  of  die  paius  in  llie  loin. 
Inicrniittoni  pu»  in  aoid  uriiie  may  be  regarded,  aa  Knyer  pointed  out,  08 
undoiibu-d  cvidt-ncfl  of  pyelitis  nt)v(-t.iafr  one  kidney  only.  Hofurc  lon^,  llie 
ureter  and  petvie.  (Mirtly  obBtructed  by  Ihe  Blone,  bi'cotne  insuffictifiir,  to 
drain  the  piia  uwnv,  and  dinlinc-t  mid  often  very  grenl  pnlargciDtnt  of  Ihe 
kidney  w-re  In.  Tlie  swelling  Braiiiiit«  (ho  ordinary  fnnn  nC  a  ri-iuil  tiimcir, 
to  bu  I'ulwiiiuiiitly  <k«eribfd.  The  pelvic  becuiiiejt  dihiti'd,  lh«  ntlyceu  en- 
larjred,  tlu!  pyrainida  dcatniyeiii,  and  at  last  Ihc  kidney  niay  be  rt-iiiicrd  tu  n 
muitilocolar  sar,  the  vvallM  of  whicli  iin-  «(iin|K»SL-d  of  tbe  thinnrd  rortex 
surrountlt'd  by  th«- tbii-krnt.it  cuptiiile  and  ihe  indurati'd  perinc^ihrilir  fat. 
FliH^tnaliim  in  often  ilitiiinctiy  peroi-iitibie.  Tlu«  <"oinlttior  is  termed  Pyone- 
phrosis. If  the  disease  be  allowed  to  proj^rcss  imrrstralncd  hy  troniment, 
tbe  dilated  pelvic  or  ihe  thickened  eortex  may  f^ire  way,  and  a  p^rinephrittc 
absceA!!  form.  The  pus  then  gradnally  points  t>jwardf)  the  giirfnce  in  the  loin, 
but  before  doing  so  it  may  extend  wiilely,  from  the  iliac  fo»«n  to  helnw  the 
ribs.     In  other  cases  rupture  into  the  c^lon  may  lake  place. 

In  these  eases  iiKilieiil  treatnient  is  nBele«.i,  nud  early  surgical  interference 
gives  the  only  chance  <)f  cure.  Three  oppratinn-i  iiiny  be  performed;  aspira* 
tiou,  nephrotomy,  and  Me|»Kreetoiiiy.  Aspiration  tu  »ieldom  of  any  umj  in 
catctiloiis  pyonephrosis,  except  as  a  means  of  dia;fimsb.  thu  nec^lle  sometimes 
grating  Ngitin»i  the  sloiie  «»  the  piiricluro  is  niatle.  It  may.  however,  be  ad- 
vantageous to  Htteiiipt  to  retluce  tbe  hulk  of  the  lunior  hy  aspiration,  re* 
neateil  at  shurt  intervale,  threw  or  lour  limes  before  proceeding  to  nephrotomy. 
Kephrutoniy  islheoiieratiim  .ipeeially  indicated  in  these  cas(».  Nephrectomy 
has  been  frequently  perfiTjned  for  calculia  pyonepbrii.Mi?,  but  the  general 
opinion  at  present  entertained  is  that  much  better  reiiults  are  obtained  by 
nepbrutoniy  with  antiseptic  drainage,  followed  at  some  months' interval  by 
DcphrGctomy  if  recovery  does  not  follow  the  pimpler  operation.  The  cal- 
culus which  has  been  the  cause  of  the  mischief  Is  removed  at  the  lime  tho 
Dcpbrotomy  is  performed.  The  removal  of  a  iitone  from  what  must  be 
recanted  as  the  cavity  of  a  large  abbess  k.  as  Morris  points  oui,  a  very 
ditfercnt  operation  fn>m  □ephro-lithotomy,  and  should  certainty  be  disliu- 
guiehod  by  another  Qaine,  otherwise  great  confusion  niuBt  arise  in  our  staUa- 
tical  records. 

Tnbercalar  or  Scrofulous  Kidney. — The  polholotry  and  svmptnmfl  of  this 
diKi''a»c  are  fully  dt-icribeil  in  ui>rks  im  nu'diciiiL'.  It  will  be  Biitficiciit  to 
alliulrr  here  mtTcly  to  tho«e  points  ihnt  have  a  beariu!;  on  surffery. 

Tubercular  distase  of  the  kidney  is  indewl  of  considerable  intercBt  to  tho 
Surgeon,  not  only  twcause  ho  may  be  called  upon  to  perform  nephrotnmy  or 
nephrectomy  fur  this  cause,  hut  beeauBc  in  a  cimsidcrable  pr()portion  of  cases 
the  early  symptoms  arc  referred  hy  the  patient  to  the  tr.wer  urinary  tract, 
and  may  clojielyainmlatp  stone  and  varioug  other  vesical  affections.  Tubercle 
of  the  kidney  may  form  merely  a  part  of  general  tuberculosis,  but  in  these 
tttst-a  the  infection  occurs  late  in  the  disease  and  gives  rise  to  no  ftymplnms. 
Primary  tubercuhisis  of  the  kidney  may  eomineuce  in  that  org-tn,  and  be 
limited  to  it  fir  some  time,  or  it  may  be  merely  a  part  of  general  tubercular 
diMMie  of  the  geitito-uiiuary  tract.  When  the  disease  l>e^iiis  in  the  kidney, 
it  commencea  by  the  formation  of  a  case-iting  centre  in  the  cortex.  This 
soflens  and  i^rudually  extends  till,  by  the  <lestructif>n  of  the  pyramid  orre- 
Bponding  t'l  the  atlect«d  jart,  it  reaches  the  pelvis,  and  the  pn>«lucC8  of  the 


L. 


892 


StTRQIOAL   0FERATT0K9   O.V   TUK    KlUXST. 


proosHi  mixed  vrith  pua  nro  ttieohar^f^  witli  tlir  urine.    ivTml  aotkflan 
in  Tarioug  Staf^M  v>t'  «<>ri«iiin^  nii>l  <liHiiitc;;rati'<ii  nn-  ububIIv  mH  «iU  iltk 
MJiie  kkliiey.     Ttw  muc>iti4  mcnibrKDu  of  the  |i«lvu  (ben  bveooM*  •Atfii', 
and  llie  (lisi'uM*  txtcixl^  to  lli«  Ulndder.     In  mmn!  caurs  ihti  diwM-Ulm 
thprevente  courve,  cumiinsncing  iu  (b<!  |>r»elul«  or  blailtlrr,  RDd  mxut£tf 
Upwardft  t'j  iho  kidnc^r.    ll  IreqiientlT  tiapp»n«  in  llw  liit*"-  -"■  ■—  'l-*'  i»- 
ur«t«r  bocijnieB  ubiiu- rated.    The  <liet;a"«  iben  fulli^wv  oi 
either  (b«  chronic  Biip[>urati>Mi  coutiiiue^  iiud  tlt«  retimtnt  ol   ■' 
coui«  tliitteuded  iutu  a  huge  HbAcess  wfat<:h  inny  finaliv  r>utQt 
burst  iulo  (be  j;ut,  or  tbv  tiuid  parts  ul'  the  \>ub  uiuy  U;  ab*- v 
resi'lue  I'urm  u  tliU-k   |>utly'like   muw,  wbrcli  luny  rtniaiu  uu  '  "".-'  ' 
mootlis  or  your*.     The  lormer  cimditiftii  miial  uecwasrily  occur  u  jh'  -  ■ 
iDg  aubetauee  rematim  uudt»tri>ywl  in  tli«  kidney.     Tin*  ptt^-^nrt. .,  ,:  -rr- 
aucea  uf  a  kidney  in  the  udvanirctl  .-^taget*  iirr  ibe  r>ill' - 
kiduuy  is  ^n^atly  piiliirged,  otien  tii  tive  tir  ux  iiiuta  iti  i 
fwriueiihiitic  lilt    is  deu^elr  induraied  by  elmmii*  tiiiK^.!,. 
liniately  blended  with  the  eafMule;  the-  ca|>AuN-  i«  ibii  i^   > 
with  niodemte  cnae  from  the  cnrlex ;  the  cortex  if  any  r^ 
tough;  the  pyramiiU  have  didappenred,  the  p«'lvis  aod  c 
and  the  whole  ruvity  i«  tilted  with  a  thirk  cruamy  or  puti ;■ 
a  sour  offeaaivo  amell.     In  1«m  idvancetl  cases  tmlr  ouc  •■i  .-..  , 
with  the  oorre^ponding  jairt  of  the  e«mcx  may  be  niTcctod.     Twi.  !■ 
facts  with  rcennl  tn  ihU  nfTcction  iir<-,  Hrst,  that  in  tbf  great  ttaj.Kn; -^ 
caw»  both  kidneya  nre  implioatpd,  thniigh  the  disnuo  i*  alvan  aMni^ 
vantx'd  in  i>iie  tbAi)  in  the  iiiher ;  nnd.iieeandly,  ibat  if  it  U  at  all  aJfanati 
the  luorbid  con'lition  extiMidM  a  greater  or  le««  liixtAnn*  down  iba  umcr.  TW 
$ymf>tom*  may  io  the  tTirly  »lage  be  reft'ired  rhietiy  to  llin  bladdrt :  ili»»» 
may  l>e  jireat  irrit«liim  and  an  alunKit  amtitatit  dwitv-  tn  [«•  wiuw,  »ai 
waidiiip,'  paiu  during'  the  «cl.     Thfn- i»  nl  the  warn-  ;v  !•«- 

luually  dull  aud  a^-tiin]^,  and  not  mdiatiut;  to  the  t<->  .1  1>  m' 

be  iiHTHafed  by  uiovenient,  fH)Hrdnlly  of  the  nei^hboniijf  luuMba.    W^ 
both  kidneys  are  evriouely  ulleeied,  u<>ii»laut  vutuitinic  may  fortn  a  laaiiaJ 
feature  uf  the  case.    The  urine  eontBina  pue.  ufteD  in  ooondefable  tm^^ 
Bod  iaiermiltent,  and  the  bacillus  uf  tubercle  haa  bc«o  raooffiiiaad  is  it,  vi 
the  dia)!t)>i«iH  thua  I'lttjiblii'hud.     Blum]  may  wvur.  but  ii  audam  abMi*^ 
aud  ullcu  ciiuiplutuly  wanting;.     If  bitlh  kii^iiesii  iire  utrcete^t,  tfaa  avMlf)? 
of  urioe  gnulnully  dimiiii^lii«,  iiiid  the  nmouiit  of  Bolidi  i-iicr«inl  M^a* 
laaa.     Aa  iIil-  ditttnu'e  iidvanorfi.  the  cnlHrgeil  kidney  berutnsa  o)cKrl>    -  "" 
tible,  pn-ju-ntiu):;  the  onliii:iry  nigiiH  of  u  renal  tumor.     A  oftirtifti'. 
gmdually  form!!  in  the  loin  in   mitny  cancv:  j^-ni-ml   labcrroUr  uii><''* 
t>ki«  placf-,  nnd  the  patient  difs  of  cxhauBLioa.     The  d)a)^r»ta  of  1^  a*^ 
eofle  is  ttl^cn  extremely  ililBciiIt  until  the  piilar^l  kitlnry  can  bcdiariy^ 
Repented  vomiting;,  pro^rewlre  enineiation,  ihe  peniatenl  ihill  AmnOP^ 
xhp  ptiin,  the  roiii|)»riitiTe  nhience  of  blofhl  in  the  urine,  and  thwiiiila'" 
tubercle  clflewhcre,  na  iu  the  proatate  or  luufip.  are  lh«  ebi.*r  r-.Tnli  !■•***" 
leodnil  cn;  but  in  Kpitc  of  erery  care  thcM  caan  caoonl 
etiiflhrd   from  ttuoe.    The   TrFnlmmt  w  a  matter  "T  ' 
Whwii  nli)t«:c«  forin*.  early  nephrotomy  pve*  grwl  r 
loti|r«  life;  but  shtMild  nephrcctoriiy  be  ever  pt>rfiirn)>^>i  t^n 
the  «arly  »tat,'>-'9.  before  the  kiiluev  i«  much  nilaritetl,  tfar 
certain,  oven  after  extKnination    by  an  explorntorv  i 
•carocly  ever  be  jiuliliabU  Ui  remove  the  oricitn.     In 
both    kiilni'VA   are   airet:t«<l,  as   la   nlu)-i»t    liivarii    ' 
would  evid'-utly  be  um*leiii,  aud  probably  fatal. 
atiou  ore  also  very  great,  t»  the  klducy  b  usually  liriul^  a>ib«nBt  u  1^' 


(KOfllS   OF    BKSAL   TUMORS. 


rtB.    On  ihc  wboltr,  it  aeems  advisable  not  to  interfere  with  tbive 
exwpt  br  nepbrotomr. 
Pjoaepbroiu  hum  otb^r  causes  ibitQ  siooe  or  tubercle  is  rar«.    It  is  occa- 

Elly  met  wiib  as  a  Btquel  to  guporrliwa.  lu  a  caw  of  ibia  kind  iQ  Uni- 
.y  C»ll«ge  llospilal  tb«  patient  was  cutiipletely  cured  by  two  aspimtjoiui, 
J  a  pint  of  ma  being  rvuiuv«d  on  each  occastou.  H«  died  some  yean 
after,  and  the  kiuaey  was  found  to  be  reduced  to  a  mere  siirivvlled  umus  of 
Sbn'Us  I'ufifuo. 

HydconephroslB  may  be  congeoital,  arising  from  a  malfurmalian  uf  the 
■retar,  or  tuay  iK-cur  as  Lhc  result  of  partial  or  complete  obstruction  of  ibe 
■ntcr  by  an  iinjmctCHl  calculus,  or  by  tlie  pressure  of  a  tumor.  Tbe  early 
MAges  bare  iilruidy  becu  Jewribcd  aa  the  result  of  increased  urinary  ten- 
akw  ;  ID  exccptii'Dal  ca^es  ooty  does  the  dilatation  continue  to  iucrcasu  till  a 
\mTfr  tumor  ie  lormcd.  The  »ympi<>m»  are  tboi>e  of  a  renal  tumor,  fluclu* 
Blio^  di)>tiuctly  au<l  aceompaiitcd  by  little  pain  and  no  bieinaturia.  TIm 
dtagtwKM  may  be  coutirmt-d  by  aapiraliuii  and  czamiuatioo  of  tbe  tiuid  witli- 
ilrasn.  which  will  be  Inuad  u>  contain  urea  and  uric  acid. 

7'ifatmenL — Aflpiratino  can  t-vidcDtly  be  only  of  temporary  M-'rvice  ;  ncph- 
rolM»r  and  drainage  Would  probably^  followed  by  an  incurable  urimu7 
fiMoIa.  Ncpbrectomy  by  the  abdnminal  incision  lia«  l>een  practised  succes- 
iy,  but  probnbly  the  befit  trefltment  would  be  aQtiac|Hic  draioagc  aod  sub- 
it  luiittmr  Hf^ihrerlomy. 

of  the  Kidney. — ^ngle  cysta  are  not  nocommoQ  in  tbe  kidney, 
bat  tliey  teldoni  reacb  vach  a  «ize  as  to  call  for  surgical  intorlcrcnce.  Uy* 
datid  cy»l*  arc  tK-cHKionally  met  witb  and  may  be  recognized  by  tbe  cbai^ 
artvr  u(  tbe  lluiil  drawu  olf  by  tbe  aspirator.  The  diseiiM.-  known  a*  eiutic 
kitimts  t«,  huwever,  an  excepli»ii  to  ibi«  rule,  lu  ibu  di«eaM  the  whole 
ttKati  niay  \tv  i»iiverte<l  iutu  little  more  than  a  maM  of  cysia,  varying  in 
•I.'  ■  iitn  to  an   omn^'C.     Tbe  kidney  may  thufi  tnrra  an  enormous 

tiii  '   »  <>  jjreat  |>Hrl  of  thv'  aMomen  and  exiendiug  down  Ui  the  pelvis. 

ll  ia  Do<  umvmmonly  double,  but  one  side  m  utually  more  atTecteil  than  the 
Mbrr.  Tbvvc  tumors  scciii  to  uuum!  but  little  trouble  beyond  that  arising 
frora  tbrir  fiir^*,  and  ure  ol\en  dincovercd  only  on  the  post-mortem  table. 

Caniuoma  and  Sarcoma  of  the  kidney  are  of  moderatclv  frequent  occnr- 
tmem.  Tbu eansomnta  are  frftguently  ntet  witJi  in  infautsana  young  chUdren. 
Th^  are  usually  spindle-celled,  but  striati'd  muscular  fibre  baa  been  met  with 
is  many  of  the  congenital  ^picinienR.  diririnonia  is  usually  aoft  and  rapidly 
znnring,  and  itccum  after  middle  life.  Thrife  tumors  increase  quickly, aoine* 
tUDfla  witb  little  pain,  in  otbere  with  conHtsnt  aching  and  uucasiueH.  The 
iDijflt  imfHirunt  eympiom  is  free  hteraaturia,  nnd  in  the  ahaeuoeof  this  wears 
aever  ju!itifi<d  in  nmking  a  diagnosis  of  renal  cancer. 

Tbf  Diagnosis  of  Renal  Tumors  is  UHually  not  nccompanied  by  any  great 
difficuliv.  In  manipulativo  examination  of  a  kidnev,  whether  healthy  or 
>tia<  %wni_  tbe  patient  munt  be  placed  oo  hiii  hack,  witd  the  knees  drawn  up 
ikfid  tbe  shouldcnt  supported.  The  Surgeon  then  places  one  hand  in  the  flank 
"^ih  the  lip«  «d'  tike  liogtrs  immediately  outside  tbe  maM  of  the  cre<ii»r  epimo 
just  b«low  the  last  Hb,  and  pushes  (irmly  rurwante,  while  with  the  other 
band  pUce^l  flat  uimju  Ibe  abdomen,  uuteidv  iho  edge  i't  the  rectus,  be  preasea 
Iwckttardjt.  The  kidney  in  tbu»  grH«peil  bvlween  the  two  hands,  ami  m  this 
way  a  bealthy  kidney  can  uaunlly  Ik;  iltolinctlv  felt,  and  in  a  di«ea«ed  organ 
it»  vit*-  and  form  (3iu  be  readily  judged  nf.  It  is  more  difficult  to  estimate 
tiir  Jf^ree  of  mobility  in  thin  way.  im  tbe  parts  to  which  the  kidney  lolberea 
U  tbia  region  are  ihenipelves  movable.  A  tulierciilar  or  imlcid'ius  kidory 
vbitb  a  really  adherent  to  a  maia  of  indurutetl  fal  ctin  often  Iw  moved  for* 
ward*  and  hack  wards  for  some  UtiJMa.     If  tbe  Uimur  l»e  large,  the  band  nost 


894 


SURGICAL   OFKRATlONS    ON    THK    KIUSKY. 


next  be  pawed  bolow  its  border  to  asccrUiin  by  the  abKnoe  of  a  pedicle  pH 
iDg  iato  tlic  pelviit  that  it  is  nut  ovtiriau.  Wheu  tbe  tumor  is  of  eiicb  size 
thut  this  cflUQot  be  done  crron^  arc  ver;i'  likely  to  occur,  and  numeroua  cases 
arc  ou  reoorii  in  vfbirh  the  inual  BeeomplUhed  ovnriotomista  have  boeo 
deceived,  the  nature  af  the  cMe  bt-ing  ttse«ruiiiie<i  only  after  opening  the 
abtl»iiii--M.  The  anlcrior  burdtr  of  iht-  tumor  must  next  b«  examined  ;  all 
renal  tumors  are  ruunderl  in  liurm,  and  Inbulaliou  'u  coiumoD.  The  move- 
nieut  durlug  re^tuirulinii  iiiunt  uot  bu  too  much  relied  upon;  renal  tumors 
more  lepa  lliau  tbone  of  the  liver,  but  are  nut,  us  a  rule,  Sxed.  Tbe  outline 
of  tlii^  tumor  niuiiL  next  be  ati(*ertained  by  percuwion;  it  will  bc  fuund  that 
alt  reus)  tumors  t'oriii  an  angle  with  the  coAljd  margin,  wbieb  U  Iws  than  a 
ri^lit  angle.  The  revprite  is  the  case  with  splenic  tumoiii  and  Si*rnft  of  those 
01  tbe  liver.  The  Hank  will  lie  found  to  be  perju»tently  dull  in  any  jKieilioo 
ill  which   tlie  patient  may  be  placed.     The  most  characterLitie  ftigu  is  lh£ 

Er&ieuce  of  tbe  cohiii  crossing  thtf  tunior.  This  may  itometinieti  be  recoj^lz^d 
y  manipulation,  ami  after  watchin^j  tbe  ciW''  f^'r  a  few  dayi*  and  exaiuttiing 
ntpealedly,  no  ta  Lu  hit  upou  n  limu  wheu  the  vulun  c<muiu»  Ihitus  a  line  of 
Ksouauce  will  oAen  bc  t'ouuil  paiwing  aeriie»  the  dull  mwsa  of  tbe  Luiuor.  A 
retroiwritoucal  sareoma  cb»e  u>  the  kidney  may  not  only  elusely  rtwiiiible  a 
renal  tumor,  but  luny  be  iudii^liii^uishublu  from  it.  lu  tbe»e  ea!«a  the  prv»- 
eoee  of  a  rapidly  growing  t'ut't  tumor  in  the  reual  regtun  without  bsuniaturia 
would  lend  tu  a  ttuapieioii  Lbai  it  did  not  implicate  tbe  kidney. 

The  presence  of  a  renal  tumor  baviu)^  bet'u  made  out,  it  reinaim  to  deter* 
mine  its  nature.  When  tluctuatiou  is  distinctly  preeenl,  it  ia  probably  eilhet 
bydnmephrusis,  pyunephr<isi»,  or  a  cyclic  kidney.  A  very  eofl  earcoma  may, 
however,  yield  a  mum  of  ela-sliolty,  or  even  of  fluotuatinn.  The  diugiioBts  ia 
beul  edected  by  mpiralion,  <liiriu^  which  the  tliagn<)sia  may  be  still  furtbor 
cleared  tip  by  the  neeille  impingiag  on  a  enlculu». 

If  it  be  pyonepbnisis,  the  pus  hati  uBUally  a  peculinr  sickly  smell,  esfie- 
cially  if  it  be  tubercnlnr.  In  calculous  pyelitis  it  is  sometimes  offensive  fntn 
deconipositioD  which  bus  spread  up  from  tiic  bladder.  This  h  far  less  com- 
mon in  tnbercutar  nyelitia.  All  renal  abscesses  may  acquire  a  fecal  amell 
wheu  they  npproadj  very  near  to  the  colon. 

Tbe  lobubiied  form  and  great  size  of  the  cystic  kidney  and  the  abaence  of 
hematuria  would  probiibly  serve  to  indicate  its  nature.  Profuae  biefflaturia 
following  the  examination  Ih  Kugaiealive  of  malignant  iliscaae.  In  some  cni^es 
of  large  ai-cumulationa  of  calculi  grating  ha^  lieen  felt  during  manipulaliun. 
Tbe  above  taken  iu  connection  with  tbe  symptoms  already  dcacrihcd  will 
usually  enable  tbe  Surgeon  to  deiormine  the  uature  of  a  renal  tumor  with 
mifficient  accuracy. 

The  Treatment  of  Carcinoma  or  Sarcoma  \»  necessarilv  limited  to  nephrect- 
omy. This  ban  been  done  b^th  through  the  loin  and  by  the  abdomen.  If 
the  tumor  exceed  a  moderate  size,  the  latter  is  the  only  poRiible  method.  In 
small  tumors  the  lumbar  operation  is  practicnble  and  ha.s  so  fur  yielded  the 
best  results.  The  operatiou  is  uot  to  be  lightly  UDderlaken.  The  disease  ia 
nut  usually  a  very  painful  one,  and  for  that  reason  tbe  caae«  of  it  are  »oldi?ia 
•een  till  the  tumor  is  of  considerable  si/.e.  The  immediate  mortality  is  great 
and  ihe  prottjwct  of  fferiuanent  cure  very  small.  If  the  disease  be  detected 
Bul£cienlly  early,  the  operation  might,  however,  give  the  patient  a  chanoe  of 
prolongation  of  lift-  if  not  of  cure. 

Fistuloos  Commuoioationi  between  the  ureter  and  the  nterua  or  vagitm 
are  oecaaionalty  met  with  as  the  reiiutt  of  injury  during  labor  or  dunog 
ovariotomy.  In  these  eases  tlic  kiiluey  being  healthy  may  be  very  safety 
excised  bv  the  lumttar  incision. 


A5P1BATION   OK   KIDNST  —  NKPHRO-LITHOTOM Y.        895 


Awting  Kidney.— Thppe  deprcp?  of  abnormnl  mnbililv  of  the  kiilney  arp 

iwiih.     Ill  itit.-  !>li^li(i-st  furiii  thi:  urgnn  rnu  bo  moved  iipuanltt  iiud  ilown- 

jf  for  abuut  All  iiicli  boucAili  (li«j  |)«riliiiicuDi;  ibis  is  verv  L'uiiimuu.     A 

l«r  dtgnw  of  niDVL-iia-nt  in  tlit'  Boniu  direction  boueatli  tho  perilout-uni  is 

liih  ID  rare  rnsi-'ii,  and  siitl  uiutx'  mrely  tlie  pcritoueum  cuiiipletely  sur- 

id*  th«  glsDil,  fortoiog  a  u)t«4i-ucphruo.    The  first  ia  reooj^iiiKL-d  only  by 

fill  «xaniinatioD ;  the  Li*n  more  fXLrcnie  degn.-t-«  may  givf  rise  to  (wn- 

kt  umI  wvitc  paia  of  a  lickening  character,  uconsloDally  accompanist)  by 

Uuria,  which  c-an  xonietimes  be  induced  by  haniUin^.     Thme  cutnlitloDfl 

'  furnirrly  lrejite<t  by  th«appli<'atiiiii  of  a|uidded  elsNlicbpttiHlHl  allboujfb 

i»»el<liini  t^ltiL-ieul,  ittibuuld  nItvavH  be  Iri^tl  b<-fiiri>  DUg^jei^l ingot lifrni«uits, 

it  fwi)\*  mill  (be  |>Hlii-iil'«  life  i»  »i-arc«ty  eiiilunil>l4>  fntin  (be  {laln  in  tbt;di»< 

plnvTil  ki'lti«y,op<frnliv«  iiiterfereni-e  beoitniw*  jiislifiable,     Nepbr*ct<nuy  haa 

ort-u  R'lHiitcilIr  pcrfuniitrd  fi.ir  Lbi«  coudilioti,  btit  it  is  a  feverr  nieu»ur«  ill  a 

dtavsM-  Hut  Htteudvd  by  nny  ijuutiur  to  life;  lately,  however,  ilnbii,  of  Ik-r- 

liu.  ha*  BUggeatvd  Bsiniiilvr  proi-vnling:.  whioli  bni<  bevu  »uc<.T»futlv  carried 

^at  10  aeverel  eaaes,  and  to  whii'ii  ht>  has  uiwu  the  tititui!  of  iirjmrvrojthf. 

oomisla  merely  in  ex{M)tin}r  thu  kidney  oy  the  mt-thud  to  b«  preseiiUy 

rilied.  and  seniiif;  the  periiieidiritic  un-oliir  ttesue  tu  the  tuargiu  of  the 

■aud,  leaving  it  HubBe<]iieiilly  to  heal  by  gmiiulatioii.     The  o|>eratiou  is 

luat  frtw  fruro  danger,  and  Khould  be  i-ertainly  preferred,  if  auy  eucb  pro- 

ling'  Is  DecseesarT,  lo  one  so  dangerous  as  uepbrecturay. 

OPEHJITIOXS  OS  THE  KIDNKT. 

Exploration  of  the  Kidney. — If  the  syiupUinis  uf  renal  calculus  are  well 

^■arkcil.  betbre  proceeding;  lo  anv  more  severe  measure  the  kiilney  mnr  lie 

^^plorvd.asBumeetcd  by  A.  K.  J^arker,  by  nieuus  of  the  aspirator,  u  long  line 

^•cefllebcinpuBied.    This  i»  preferable  t<'  niakin^runeof  an  Hcupunelure  ne<Nlle, 

m  the  f«nip4f  of  urine  «how»  that  the  iuatrutneiil  has  n ached  ibi'  |ivlvi».    The 

I    iiimt  of  iliL-  kidney  if,  nituated  about  iviu  iochen  from  Ihu  middle  Hiip  and 

I    tppoailc  the  first  lumbar  spine.     If  the  needle  be  imroduced  immrdiAlety 

txteraal   lo  the  erector  spin.T  at  thid   level,  nud   passed   almost  directly 

Ajrwant^i  it  will  proliably  enter  the  pelvis.     Kxpc-ri«rDC«,  however,  ha&fibown 

Ikat  owing  to  the  thicknev  of  the  solt  parts  eovcriug  the  kidney,  the  ex  plora- 

meo  carried  out  by  this  method  mnut  necmarily  be  very  imperfect,  and 

^■DDot  b«  consiilened   conclunive   if  yielding    negative  restilts.     Thn  only 

^Kbrnugb  metbod  of  explomtion  ta  fully  Kt  expo*e  the  kidney  before  uiung  tb« 

Kdle. 

Aspiratlan  of  the  Kidney. — This  o)>eraiion  is  performed  io  the  same  way 
aa  ill  Ntbcr  })arlfi.      A  ^)«»ii-ni2e<l  neexlle  *hoiild   l>e  uneil  if  pus  is  exiiected  to 

tprrwrnt,  ue  Jt  10  oUen  too  thick  to  pan*  tlin>ii>;h  a  tine  tul»e.  The  h|hiC 
ctol  must  vary  wilb  lb«  caM*.  but  care  should  lie  tftkru  to  avoid  niiy  rink 
kplcturiug  vither  the  eoloi)  or  jieritoneum.  In  all  eitlHr^^uieiiljt  of  the 
Brtbcwr  are  (-arrinl  forwanls.  If,  therefore,  the  uoruinl  line  uf  lIic  ctilon, 
^P  U^  s«y,  a  line  drawn  vertieally  opwanlx  froiii  midwiiy  )>et«eeo  tbe 
Bar  and  [Hwlurior  nupcrior  iliun  Kpiiiei',  be  taken,  the  uei-dlc  ia  ccrtxitn 
to  paaa  behind  tlie  gut  if  there  be  auy  diettuct  enlargemeut  of  tbe  kidney, 
any  part  of  the  tumor  be  particularly  prouiinenl  this  may  be  iiunctured, 
'  il  it  lie  in  front  of  tbe  line  just  nieutioi».<d  a  careful  examiuuttoa  for  tbe 
by  polpfltion  and  percuiwion  nhould  be  mmle.  Aspiratioa,  if  catv 
rrfurnied  with  a  clean  iuttlrument,  is  iH-rtecLlv  i'rw  fnim  ilimgrr. 
lination  of  the  Kidney  through  an  Open  Wound,  and  Hephro-litho- 
tomy. — 'fhrfe  inriii>>nK  liAVe  been  ret'ominendii)!  for  ixiMeinj;  ihr  kidney  in 
the  loin:  a  rertjcal  incision  immediately  oxtemal  tu  the  edge  uf  the  quad- 


■ 


SITftGICXX.   orSKATlOV*  OS   TBS   KIOVKT, 


or 


tbc 


ikefrM 


IB  Ifae 


iftW 


ifcankbKifliM? 


ipuied  In  iMb^- 


Ai 


■  rrtmth  below 


AMBlJMfilSK 


'ill  Ihmi  uBiiMii  rf  Ml  liiili  Thit 
irj,  art  bcia^  ufccn  u>  vtmA  <■ 
rma  be  lectured  fiir  &nj  par} 


lowibeU 


j»J!iii-  Ai 


1 4o«a«BH>  biwaraa  li.* 


itwai,  paralkJ  Cow  aoier  hetierai  tbr  qjuadeum  luatboram.    1 
Ika  of  ibe  padcM  •ad  tatif  wngta  of  tbe  openi>«a  mf  tlw  •■aar  k*  »••»«  ■= 
v^otmmr,  tuetpt  tbfti  tW  mciaw  it  placed  Ughcr  op,  um)  ibr  t^e  utstoBf 
•f(bri*  i^rm^ibcmderiiKfemdio  tfaed«Mrip6p«of  ibU'fi' 

aiM    .  TlMMmbeot  the  kkboybibg  Racked.  UitvnviKlBuiW 

held  SuFoUy  Qfea  bj-eoppcr^ataUe^  while  aa  MiieUnt  pobvibekiteiy 
tovardi  Uw  womid  bf  iiiiiiiE  go  Uk  abdooMo.  Tbe  fiU  ■  tbia  m 
Ifcrnigh  with  foni  or  fiMi7ef%  fcaapac  to  Um  back  pan  of  ibe  VMradetv 
tha  quadimf.  If  tfaa  bt  ie  Hacib  laaantad  bj  duwo  fiiriaMhrififc  <» 
■dmbta  difical^  laaj  bt  levad  in  axprajay  Um  oapml*  of  tbe  ufawy.  b* 
m  a  can  tAnjUmJ  to  aephip-HthatoaiT,  ia  whieb  tbi  kxda^  n  bwkfcr. 
BO  fUfficolty  ii  fguBd  in  ao  doiag.  tfea  wmm  of  WMtaBoe  (And  bjr  w 
aulid  BMH  of  tb*  iaiatij  vill  vm  ae  a  gnide  lo  iba  dirMikie  io  wUck  ft  a 
tohsaBiighi.  Tbia  nutcf  tha  optgadao  ia  aaeoaipaiiwd  bf  aeanaiy  mtj  0 
BO  bhndug.  The  kidney,  baiag  upsaad  hlly,  aboaU  aov  bo  iBetlwdiially 
poBcund  irUh  a  imootb  rooDd  aeeuh.  A  cowbm—  daraiag-Bendle  hM  to 
a  pair  of  toraion-iaraepi  aanran  ibe  porpoaa  adaurably,  A  pjeot  of  at- 
buUiad  lUk  majr  be  jmmtd  tbrougb  ibe  ijt  aad  tied  nMiad  tbt  Cireqa  to 
preveai  lbs  needle  worn  aoeidfatallT  stipynDp  oaL  If,  aAer  a  laMbitotot 
agaminalkiM  carried  oat  urer  ibo  wboJe  kuatr.  Bf>thiii|^  k  felt,  tbe  farrfMOi 
may  b«  paited  before  end  bebioJ  it,  aitd  tK'  pnMMd  betaeea  IM 

anti  the  pelvis  examined.     Kveo  ftfter  all  1.  i-nrv  hea  tbowa  Ikil  • 

stooe  two-lhinls  ol'  an  inch  in  diameUr  nay  eKBf>  u.    If  tbe  petiw> 

aulfericig  have  btcn  very  fireat.  aoti  mure  tstiea-Iii  :  f  !>  *ii  tacf^aaf 

dittcliargct  ul'  piu,  it  may  be  jii-  ^  and  etfiaa 

the  ndvtii  with  the  fioKer, a«  cvi  „   1.    .-.:.. ■  , lau  fneeitlH 

has  oeen  knuwn  in  several  oues  tv  kit*  ^n*l  nlivt, 

K  a  atuiie  be  folt,  a  Hcal|wl  nwy   be  paawd  don  to  ;'    ■_— ■  i-t  by  de 
D««ill«.     An  tlie  iical{wi  i*  wiilidniwti,  •  pruruav  guab  of  >  •  foliMh 

wbich  ii  at  fimt  very  aUrmiuj,'.  but  llic  prweurc  nf  n  n>-ng^-  i<t  •  •* 
miiiula»  armu  iu  A  pairof  p-'lv)>un-furc9{«  mar  llico  br  poHeuia,Uil>^ 
wound  eiilar)t<:<l  liy  uiieiiiai^  tliv  Liladoe.  Tlits  \t  acr"iu|iaaHnd  by  Karaetjaq 
bleeding.  Tiit^  liii|j;vt  may  thvu  Ix- iiucriol,  ao<l  tbo  clijoc  perbafebM* 
uul  by  It;  butif  thieciLDUut  bedone, a  |Murof  rorG<L'paii)uHbeappliM,(MW 
by  tlif  tiiii^T.  It  in  better  iu  nil  casta  to  cut  tbnnigb  tbe  wswx,  aed  M  ■ 
try  tu  ojM-ii  i\w  jwlvia.  Wuuoda  of  ibu  Itiilovy-BUbMUMe  bcaJ  nwdilf^ 
lliuwot  ihcpirlviv  lira  apt  to  ItrnvaaBatula.  'fbe  st4)M  fcavioK  ben  natf^ 
and  lUl  blwidiii^'  iirrvHtnl  by  teni}>onuv  pcMUra  ou  the  kidney  witb  kip^ 
tbe  exlcruol  nuuiid  may  be  cluaeil  by  Mituree,  leavioK  ao  (wcnuig>>* 
middle  fur  a  largv  draina^tube.  The  uriud  will  probably  uiiw  6f*~* 
wound  fijr  eome  wcidcB,  hut  in  Mwrnl  of  tbe  rbc«ri-i  '■"--  p«-.;.i  ^«IiWW 
taken  placi*.     Tliu  tm»t  vxtronrilinnry  in  ibal  r>  >  ^ 

So  removed  aftbinc  weighing  titin  ounce,  au<i  m   r^ucmni  w.^-*^ 


NEt'liREOTOUY. 


897 


completely  healing  in  five  vreeks.  The  tlreraiug  should  be 
strititlfftJUR^ic,  and  wliile  the  urine  i»  e»cupliig  it  mui^t  he  chiingvil  twice 
&  fiay.  Morris  recumrnendd  Knely  powdered  German  mnsa-fwat  H5  the  I>e6t 
sli«urbet)t  material  to  plac«  beneath  the  patient  out«ide  the  <ire«ing.  The 
operatiou  of  removal  v(  a  stone  froiu  a  healthy  kitiney  has  not  been  very  fre- 
queullv  performe-l.  but  &u  far  hae  been  uniformly  itucceaet'iit. 

Nephrotomy.^Tliis  coiiUBte  merely  in  making  nn  incision  Into  a  kidney 
disceiideil  with  pus.  The  incision  must  be  in  the  si^me  position  aa  tliut  juet 
desicribed,  but  need  Dot  be  so  exteoflive,  as  do  expluratioii  of  the  surface  of 
tbe  kidney  is  re({uireil.  T)ie  euHuce  of  ibc  enlurgcd  kidney  being  exposed, 
it  tnusC  be  punctured  by  a  brond-bludetl  so»l|;{;],  and  the  linger  lOserLed  at  tho 
puncture  before  the  pus  ftscapea.  lu  thi«  way  the  dilated  culycea  are  eawly 
examined,  and  sh<iu]<l  a  «toue  ho  present  it  may  be  removed.  AlW  the  ope- 
ration a  lar^!  drainage-tube  is  ini^eru-d,  rcai-biug  well  tuto  the  pelvis  of  tho 
kidney;  thirt  tiiu»t  be  gradually  shortened  a»  the  cavity  clogca.  The  drcfi!- 
iugfl  should  bo  autl»cptic  thn>ughout.  Ncphrot^imy  fur  culi-uloua  pyelitis  is 
ullcn  succeanrul ;  for  tubercular  pyelitis  scarcely  ever  so,  allhoiigii  it  gives 
relief  and  prolnngn  life,  [f  aftinuit  remain?,  ihe  drain  from  which  la  exhaust- 
tDg  to  the  patient,  the  iincAtion  of  lumhar  nephrcctnniy  must  bo  comudered. 
The  operation,  far  from  being  increased  in  difficulty,  Ls  actually  facilitated 
by  tho  previous  drainage. 

Nephrectomy. — By  nephrectomy  is  mennt  the  complete  extirpation  of  the 
kidney,  an  operation  thfii  a  few  yeftre  since  would  have  been  considered  as 
unsound  in  physiological  principle  an  impracticable  to  aurgicat  art. 

Before  proceeding  U)  the  removal  of  the  kidney,  it  becomes  neoewary  for 
the  Burgeon  to  a«cerlain  that  a  j»cr«on  conid  not  only  Hve,  but  that  the  health 
might  be  nminlHined  after  the  reniuval  of  90  very  important  an  eliminatory 
orguu,  That  Lhie  can  be  hua  been  provecl  by  the  result  uf  injury,  by  patho- 
logictil  research,  and  by  physiulogiwil  experiment. 

There  are  cases  uu  recurd  in  which,  in  coneeqiience  of  a  deep  stab  or 
slashing  cut  iu  the  loin,  one  kidney  has  been  wuunded  and  forced  out  of  the 
wound,  whence  it  bus  beeu  removed  after  ligature  of  iU)  pedicle,  the  patients 
making  a  good  recovery.  Then,  again,  it  has  long  beeu  known  to  patholo- 
giets  that  a  person  may  live  with  one  kidney  practically  useless,  either 
blocked  by  ailculus,  destroyed  by  eupiiuration,  ur  converted  into  a  mere 
aoc  in  hydronephrobis.  Simon,  ot  Heidelberg,  proved  by  numerous  experi- 
ments on  dog9  that  one  kidney  might  be  extirpated  without  danger  of 
uncmia,  and  that  the  animal  not  only  recovered,  but  enjoyed  perfect  health 
afterwards. 

The  ground  having  thus  been  cleared,  and  the  fact  having  been  proved 
by  the  combined  cvidcnee  uf  (^bflt.■rvlLtioQ  aa  to  the  result  of  injury,  of  tho 
eOect  of  pathological  changes,  and  bv  experimental  inveetlgiition^,  GuBtav 
Simon  WBB  encouraged  to  undertake  tho  opcraiion  for  the  exiirpation  of  one 
kidney.  This  ho  did  in  I.BB9,  in  the  oaae  of  n  woman  who,  having  had  the 
ureter  cut  ocross  in  the  uperatiim  of  ovariotomy,  was  loft  with  a  urinary 
fistula  otherwise  incurable.  The  kidney,  which  waa  healthy,  was  removed 
by  a  lumbar  iucisiim.  The  patient  nmde  a  good  recovery,  the  fisluta  being 
eared.  Seven  yeara  after  the  operation  she  was  iu  perfect  health.  Since  this 
lime  the  operation  ha<i  become  an  established  one  in  surgery,  and  has  fre- 
quently been  performed. 

The  eonditioTui  under  whicli  nephrectomy  is  undertaken  hare  been  already 
dciicribed.  Il  tiui^l  nlwayei  be  burue  in  mind  that  tlie  gravity  of  the  opera- 
tion is  guch  that  it  shxiiUI  never  be  ()erfoniietl  except  for  vomlitionH  threaten- 
ing life.  In  all  cai^cs.  before  uudertukini;  this  opemlion,  the  condition  of 
the  other  kidney  must  be  ascertained  it'  possible.  Various  means  have 
VOL.  II. — 57 


898 


StrXOICAt.   OPEBATI0N8    ON    THE    Klt'NEr. 


be«n  9iigge«l€il  for  duitifr  iIiIr  Cathutpnimi  nf  thr>  nrrtcr,  vraa  ■  A« 
fomnle,  ranimC  he  carried  out  with  «itl>cit-til  c-rrliiiiiir  Ui  bv  of  An  ac 
R.  T)avy  has  propostd  prewiire  on  the  tinrliT  leading  ftita  lbs  nuttk 
kidney  hy  meaim  of  the  same  lever  thnt  h«  eniphtyit  in  cutapnmum  li  li» 
ilinc.  It  remains  to  be  Ken  whetlir-r  this  i»  |ira«(tcnbl«.  At  pnaral  m 
ineiinA  of  cuttinfi;  off  the  flow  of  urine  from  ou«  |ti-''--<^-  "'tile  nisMw 
that  from  the  other  can  he  Hid  to  be  |>rani(-«ll>  Tbr  am 

kidney  must  be  exnmined  hy  manipulation  for  enliti);- xi' ui  or  tmliiwm 
Severe  Toniltiog  ehould  alw«y«  lend  u>  a  grave  suapicioo  uf  d(4ililcibaK 
A  marked  deticienc-y  io  the  iiuaulily  ul'  uriuo  cxcreteil,  or  ia  the  mbit 
elimiuatvd  by  the  kidneys,  ut  nliK>  a  ^rave  oign.  Id  operatioK  bjr  tkri^ 
doininal  iucitinit,  the  other  kidney  iu»v  be  fell  for  from  withto  tlMaUDa& 
In  spite  of  nil  precautious,  houevvr,  the  uuly  working  kidney  baa  hmti  » 
moved  more  tlinu  once. 

The  operation  may  be  performed  by  ibe  itanbar  or  the  oMtfuunaf  ineiaA 
If  the  lumbar  method  he  a<iopt«d  the  traoevunie  incisioo,  wilk  Ike  vvtiol 
extension  enrrieil  from  it  to  (he  crcnt  of  the  ilium  is  th«  hot,  w  |ti*iiC  ■■* 
room.  The  earlv  steps  of  the  ojHTatioo  are  the  •anw  aa  io  nepliro-lilWMifk 
Whui  the  capsule  h  reached  this  must  be  openeil  in  auia  of  pydhk i> 
otiwr  onwB  it  shnnld  be  preserved  uninjured  if  punible.  Tbe  kidary  ii  tW 
cerefully  enucleated  with  the  fineem  uf  one  linud  till  it  rnnaiaa  altaiial 
merely  by  its  pellicle.  In  doiuethis  rare  niui>t  be  tak<-n  tnkeep  doK  t»tki 
gland  lc«t  the  poriioneum  or  colon  be  torn.  The  tumor  may  do*  be  drm 
forwards  in  the  wound,  and  if  the  ureter  can  be  iMilated.  this  s^iaM  heitai 
and  n  double  ligature  paased  round  it.     It  mur  llieD  '<  'V  d  brtwattlte 

ligatures,  its  end  being  tonched  as  it  is  cut  witb  a  ■•(  eUaiiiiif 

zinc  leAt  jieptic  matter  pass  from  it  into  the  mound.  In  ■nsw  tf  fwm 
phro«i»  it  is  usually  impOMiblc  to  separate  the  urrier  from  the  rratot  ikt 
pellicle.  A  strong  citrholixed  silk  ligature  is  n>i«  pnsM^]  ibntu^h  tb»  (xibk 
and  it  is  tied  in  two  piecex.  If  this  be  done  carvfiilly  with  a  blunt  aartfin- 
needle  there  it*  uo  fear  of  panel tirin)|i;  the  reiinl  vein.  Tbe  p«nltd«  si  tte 
stage  must  not  be  dragged  on  too  forcibly,  first,  for  fe«r  of  tvanti.-  r  -  u4, 
leoundly.  lest  on  the  right  side  the  ligature  bo  applied  too  d"'  ^ 

cava.  Tbe  pedicle  having  been  securely  lied,  the  kidavy  ia  •.)-.  ■-■■  --'-  ■ 
pair  of  sciaaors,  not  too  cloee  to  the  ligature.  All  blecdlnji  barb^  ^t 
arrealed.  tbe  ligatun^  are  cut  short  and  tbe  wound  is  doaid.  a  tarp  '"  '■ 
age-tube  being  iuserted,  and  the  case  treated  as  an  ordinary  we«B<: 
other  part  ol  the  body  by  aotne  form  of  antiMptio  drannf.  1'b'  •^■^ 
datigen-  during  the  opcratioa  are  hemorrhage  firom  the  — brtaw  MOt 
kidney  in  the  case  of  a  tumor,  wound  of  the  perituneura,  and  fmrndsf  *^ 
oohm  in  cases  of  pyonephroeis.  TbcM  ore  avoided  br  keeping  •ouil*'^ 
ca[wu  If  iu  the  former  case,  and  ioside  in  the  latter.  The  fabock  ol  ibe  tf*- 
tion  is  great  and  often  directly  faul. 

Abdominal  Ifephreotomy  ia  performed  with  all  the  praeaatkiaa  alr^ 
laid  down  iih  biiug  nece^iary  iu  abilomlnal  operatlaoa  (p.  737).  Tbt**** 
sinn  now  adople<l  in  all  raaes  is  that  reoommendctl  by  l.*ngiaibeck  i>^ 
linea  ncmilunaritk.  It  has  the  great  advantage  ovtr  llie  tneillaa  ■tliv'J 
more  directly  exposing  the  pedicle,  and  of  enabling  (be  intusCinfalo  ht^ 
more  readily  on  one  side  during  the  uperation.  When  the  mir^etti^ 
tumor  is  expoaed,  the  peritoneum  external  to  lli«  cmI»»d  mus«  be  LBlri4 
divided,  nil  bleeding  heiug  immediatelv  nrrrstc*!  hy  furciprfwuw  4*5^ 
The  i>cdicle  if  then  carefully  expo^A  uitd  lh«  v<»«-U  tiifmium!,  ••■• 
sppwmtely  or  in  the  same  way  m  in  the  lui,  unlffa 

thcu  divided  between  two  ligatures,  care  h  -•  J^ 

nooe  of  ita  cunteota  pasa  into  the  abdominal  c»vity.      Ibv  diraieJ  ** 


dH 


2 


be  immodiaU'ly  dieinlVctetl  wilti  chlurule  nf  xiuc  (40  gr.  to  ^j^     The 

[eaiiiiti  of  llii;  tiitiior  caii  ttif^ii  bu  (^oinplelt^il.     Harwell  liaa  recummeniJer] 

thul  un  aperture  for  the  itraiiiagi^-tiibe  should  now  lie  maile  in  the  loin,  ntid 

capRs  ill  which  the  raw  mirfacH  left,  ailer  the  removal  of  the  tumor  la 

ry  large  it  would  uiHloubiedly  \m  a  wise  precaution.    The  wound  is  closed 

the  onlinnry  way.  The  operation  ehoiiiu  be  |>erforme(l  with  all  antiftfjptie 
precautioD9. 

In  the  nftcr-t refitment  of  nephrectonij  the  patient  must  be  covered  up  as 
warmly  as  possible  to  prorante  the  action  of  the  skin.  Vomiting  is  almost 
always  a  troublesome  symptom,  and  muat  be  relieved  by  ice.  Opium  muflt 
be  u»cd  fiparingly,  as  the  opposite  kiduoy  often  become:*  congoatcd  and  some- 
what disturbed  in  its  functions  for  a  few  days. 

The  resultit  of  ITephrectomy  were  at  first  very  discouraging,  for  out  of  th« 
first  12  casM  in  which  the  operatiun  WHS  done  but  2  recovered.  BDlincreaMd 
experience  in  the  operation,  a  more  just  appreciation  of  its  difficultiea,  and, 
above  all,  the  great  advances  in  abdominal  jturgcry  geDcratly,  have  during 
the  last  ten  years  turoed  the  baJauce  in  favor  ol'  the  operation,  so  that  the 
recoveries  dow  exceed  the  deaths.  For  irora  the  statistics  of  100  oases  of 
nenhrectoroT  collected  by  I>r.  Harris,  of  Philadelphia,  all  that  have  been 
published  up  to  May,  ld82.  there  were  4^1  recoveries  against  45  deaths,  the 
remaining  6  being  still  under  trcHtment. 

Dr.  Uarria  t>iate:<  that  Uj  tlo»ting  kidneys  have  been  removed  by  nephreo 
tomv  with  10  recoveries.  Two  were  by  the  lumbar  method,  14  by  abdominal 
section.  The  2  lurubar  cases  recovered  ;  of  the  14  iibdoininal,  0  dic<l.  Of 
18  cases  of  m^liguant  disease  !>  died.  The  remaining  cases  were  as  follows: 
Lsj'ge  cysts,  4  died,  1  recovered.  Ilydro nephrosis,  4  died,  4  recovered. 
Calculous  hydroueplipisis,  2  died,  2  recovered.  UyilroxiephrosiB,  with 
sarcoma,  1  died,  ryonephrouifl.  '>i  died,  (i  recovererl.  (lalwilouo  p_\one- 
phn<pis,  2  riieii.  {Jalculous  pyelitis,  H  diwi,  1  recovered.  Urethral  fisiuin,  1 
jclie«l,  8  rewivered.  TuberrubmiH,  2  died,  2  recoverud.  Of  %  niseH  in  which 
te  of  incision  is  nieniiorufi,  4fi  were  abdominal  operations,  with  2il  deaths 
"  23  recoveries,    Liimhar,  19  dejitlis,  27  reooveries,  with  4  under  treatment. 


CEAPTEU    LXVni. 


UBINARY  CALCULUS  AND  LITHOTOMY. 


URINARY   DEPOSITS  AND  CALCULI. 


TuE  urine  is  liable  to  deposit  various  solid  matters,  which,  when  impalpable, 
src  termed  SfrdilBsnts;  when  in  tine  gritty  particles,  Gravel;  and  when  forra> 
ing  a  large  concrete  mass,  Calculas  or  Stond.  These  depusits  may  be  the  result 
of  constitutional  ahnorninlitv,  and  the  conditions  giving  rise  to  them  arc  then 
sometimes  termed  a  DiathesiB.  Much  importance  was  formerly  ascribed  to 
these  so-called  diitthcsos,  as  it  was  believed  that  there  was  some  det>nite  c<iu- 
iititulional  condition  corrt^puuding  to  each  form  uf  urinary  depuisit;  but  this 
view  c-an  no  longer  ba  mainlaiued. 


DUIKART   0AL0ULU8   AVD   LITUOTOMT. 


TTrto  or  Lithic  Acid  DepoiiU.  - -Tlifw  nccur  in  two  rornu,at  6^  - 
an<i  n»  uraroH.     l'r*'<^  uric  uiiil.  in  the  ('■rin  of  cryilaU,  U  ncrrf  a»  t 
healtby  urin^.    Whi^ii  it  fornisi  n  (le[M)ML  it  appears  ft*  hiuaII  mj  i;raai*!icA 
m«y  be  conijMired  iti  yentrtil  npneftranoe  to  cayenne  peppiT.     I'air  -i- 
micru»C(>[>e  it  is  fouod  to  be  crystallioe.    The  form  of  ihi-  crrnlal*  \> 
siderably  ;  most  conimonlv  tliey  m|>[>ear  m  siumtth,  trAn»f>-<r"<'   '•< 
plat«s,  mixed  with  which  ntiLy    h«  diamond -fthaped   (trt~ 
shaped   cryaUiU,     Ooca»iou»lly   Ibcj-  are  Wrcl-ihapc^l  \.' ■!;.  ■■-■»      .i- • 


r 


f 


-?\  • 


■■1. 


rig.  834.— UrkAfld. 


tv 


rig.  «2&.~rnt«  vt  A«»N 

AmurpkaM  ITntet. 


rule,  they  are  dnrkly  gtaioed  with  urinary  pigment  and  proKOt  •  r*AU 
color,  but  Ihe  tinl  varien  Ktvatly  iu  dif!«^rviit  ca»c».  The  vrjUait  in  rwflf 
soluble  iu  dilul«  aolutiuus  uf  |>i>[ueh  nod  Mxla. 

Urates  funu  1b«  UMtiimuu  {-nlu  yellow  or  reddish  rellow  de(w«it  vhitiii* 
fn.H)Uvutly  obtrrvol  tii  furui  &»  urine  cuola  ailer  h>''ntc  mmeli.  ThisiIcfMl^ 
often  termed  laUritiutu,  is  )iui«ir)diiiu&,  and  has  no  very  <Ic£aile  dwmoiff*' 
poeiliun.  cuiieiKtiiig  td*  urio  ncid,  (Mnibined  uilh  wxla.  potuh.  ukI  aMMt'i 
vnrj'iii^  propiirtioue,  with  tnicvs  of  lime  and  magueeuu  The  depUiATM^ 
is  pmiHtrlioual  to  the  amount  of  pigment  in  the  urioe. 

Urate  of  amiuouia  (Hj;.  S'ioi,  in  the  form  of  Bpikvd  glohuUr  BMB^i* 
uocaaiuoally  nwt  with  atune  or  mimd  witii  nmorphoua  mt-'-^  TtwM^ 
phous  urateB  are  readily  recuenizul  clinically  by  their  ou:  Vm/t^H 

when  the  urine  ia  vrarmetl.  Free  aric  acid  and  urates  nxv  o'.i  gm-uavA'T 
found  (ogether. 

Uric  Hcid  n  one  of  the  {mxltiots  formed  in  tlie  eliru!  .f  ntm^U^ 

genoos  material  from  the  body.     Ufld«r  normal  r!r<  i  -<  by  a  fX** 

of  oxidnlir<n  it  Wconitv  coiivert4.<4l  into  urea  ami  <-arU>ut(:  afid,  the  h*' 
being  eliminated  with  the  urine  and  the  latter  by  thr  Itinjr*.  Socb  oMH" 
aa  remaiuB  unoxidiwd  is  excreted  in  the  form  of  uraln  in  vadiqwaMV* 
is,  under  normal  conditions,  readily  wduble  in  the  uriov.  TW  f**^? 
an  excess  uf  uric  acid  is  thereforv  du*;  to  iinpti-rfcct  oxidation.  TU*^ 
ciency  of  oxyg«>u  miiy  be  iibsolute,  ns  when  the  (latioiit  is  ooafisMl  ItBtf 
ill-venlilntv<l  rooms,  and  takes  insuliicient  exvroisa  in  the  ofMO  air,  <*r  *"* 
he  sulTvr}  from  some  disease  interfering  with  respiratioo,  M  phthani "  *f' 
pbysema,  or  when,  from  the  deficiency  of  nd  oorpuaolos,  tbe  Uoed  ■  ^^  * 
a  Btnto  to  take  up  the  oeoeasary  (]unntity.  In  all  tbca*  eocuUtiaaa  ''f'^ 
depotils  of  lithates  are  habitually  met  with.    In  otbor  risia  tho  aappF* 


15  iinrmal  iq  amouut,  but  the  refuse  producU  to  be  oxidizoil  are  ex- 
Thia  luar  aruw  froiu  uu  (ixeeeaivo  lupplr  ul'  uitrogcuou^  iooti,  or, 
in  fact,  of  food  of  any  kind,  for  there  seems  reMuu  to  believe  that  the  carbo- 
hydrates, starch,  au^r,  etc.,  auii  alcohol,  oxen  a  sort  of  jirofertnce  claim  oa 
tbe  oxygeii,  aod  if  supplied  in  exccseive  iiuaniitica  Jenvc  au  insiitfieieDt 
amoUDt  ior  tbo  jwrftel  oxidation  of  tbe  refuse  uiiri»K«»»t«  suhslanees  ari^iag 
from  the  natural  waste  of  tin.-  body.  Thesis  dcpnuiiiiarc  tburyforc  wiuiuionly 
met  with  in  individuals  of  a  robust  habit  of  body  and  Itorid  upnimritiK-e  who 
have  lived  too  well,  (.'opiou^  depoallfl  of  iiratt's  nrt^iir  alwi  in  all  febrile  con- 
ditions which  iirtt  itivariubly  8»'oriiil«>)l  with  ati  i iicroa!<4M]  watite  of  the  ttatues 
of  the  lnwiy.  Viidcnt  and  |)n>lHiig<rd  iiuii>(.Mi)ar  exertion  may  pnidiice  the 
same  eifL-i-t. 

Exvcsfi  of  ur!r  acid  in  the  blond,  aa  \raa  clearly  demon»trate(l  hy  Oarmd, 
ie  au  tHe«ntial  featiirf  of  gout.  In  thiK  di^nu^e  depoHitit  of  nrir  arid,  either 
as  litlmlcs,  nr  an  purr  uric  arid,  are  always  met  with  in  tht^  uritie  ;  and  thf! 
gouty  depnsits  in  joints  and  nther  Btriictures  are  composed  of  tirnCe  of  sojin. 

Uric  acid  is  fr^^qiicnily  nii'l  with  in  nnhealthy  children  of  the  poor  and 
lew  commonly  amonfj  the  children  of  the  rich,  who  are  allowed  more  animal 
food  than  they  can  readily  digest. 

The  mere  deprmit  of  the  normal  quantity  of  lithntea  on  the  cooling  of  the 
tirine.  concentrated  by  excessive  swentiu^;,  may  be  regarded  a»  a  natural 
condition. 

Caicuii. — The  calculi  containing  uric  acid  are  of  two  kinds ;  tbe  pure  uric 
acid  and  the  ur»te  of  ammonia.  Uric  acid  iu  the  furm  of  minute  cnncre- 
tioDs  fnrnifl  the  mo»t  common  variety  of  jfravel.  When  a  distinct  calculus  itt 
lbnne<l  it  i»  uoually  >>f  regular  form,  oval,  winivwhat  cnnipressed  and  flftt- 
teil«d,  smooth,  or  slightly  nodulnr  on  the  aurface,  and  of  a  fawn  color.  On 
section  it  is  seen  to  be  la/niuated,  and  to  present  viirinuB  ehadcH  of  light 
brown  or  fawn  tinU  Fiwures  are  occasioinj-ily  met  with  id  it«  Htructure,  the 
origin  of  which  it  h  ilifficult  to  explain,  and  in  rare  cases  the  whole  stuae 
has  been  Icuowo  to  break  up  spontaneously  into  omail 
fragments.  The  urate  nf  aniinonia  calculus  is  of  very 
rare  occurrence;  it  occurs  chiefly  in  children,  Js  com- 
posed  of  concentric  rings,  has  a  hue  earthy  appearance, 
and  is  claV'CoIored.  The  uric  acid  calculus  may  be  dis- 
tinguisheil  from  the  urate  of  ammonia  by  heating  a  frag- 
ment in  solution  of  caustic  potash;  both  dissolve,  but 
tbe  urate  of  ammonia  evolves  ammonia  in  the  proceaa  of 
BoUition. 

TrfotmenL — -The  treatment  of  urtc  aeid  deposits  muf^t 
be  directed  to  the  removal  of  tbo  prime  causeii  of  this 
condition,  viz.,  mul-a^similation,  dei'ectivf^  oxygenation, 
and  tJic  ingestion  of  too  large  a  quantity  of  niiri>geiiou3 
fbod.  All  these  may  be  remedied  by  attention  to  ordi- 
nary hygienic  measures;  the  patient  tnuAt  live  sparely,  should  avoid  fer- 
mented liquors,  especially  red  and  cflervcAcent  wines,  and  abntain  from 
sweets,  pastf)*,  etc.  He  snould  take  plenty  of  out-door  exercise,  and  keep 
the  skin  in  healthy  action  by  warm  dry  air  or  vapor  bathing,  and  the  use  of 
horsehair  gloves.  The  bowels  also  munt  be  carefully  regulated  by  mean?  of 
•aline  and  other  tiperients,  with  occajtional  alterative  doH««  of  blue  pill ;  to 
which,  if  the  constitution  b^  peculiarly  rheumatic  or  gouty,  some  colchicutii 
may  advantageously  be  adderl.  Preferable  to  all  mediciiiei",  |»f  rliaps,  are  the 
natural  aptrient  !«aLine  waters  of  riillna.  Frieiirichahall,  ur  Carlsbad,  taken 
jfcstiug.     The  patient  may  aUo  be  directed  to  drink  iwme  uf  tbe  natural 


Pig.  9!e.— Cric  Aeiil 
Cuiculiit. 


^2 


URINARY    CALCULUS    AMD    LITOOTOMY. 


■Ikaline  waters,  u  thoBc  of  Vichy,  Vnl»,  or  Fm-liingon.  TJw  V\Ay  nut*, 
cuDUining  a  lorj^  <|Uftnlity  of  carUiDale  of  foih,  nirli  frtv  catUdiK  tmL 
are  nn^D  extrenivly  aervic«abte.  If  they  cannot  hv  prfcurvd,  a  rm  p«i 
alkaline  drink  pmisiBtn  of  a  «cruplp  of  bicarboDale  «f  poUtb  oDdinpim 
of  nitre  (lifBolvecl  in  a  tumbler  of  cold  or  lL-|ii*J  uulor.  tc>  wbiek  ab4  tn 
grains  oT  citric  arid  i.>r  a  tablcapoonful  of  Icitiuu-juicc  luny  !■•  addid;  doi 
should  be  tnkeii  early  Id  the  morning  or  in  tlic  middle  uf  t^«  day.  TVi  y» 
paratioDs  of  lithia  are  of  euential  Krvice  Ju  reiuoviuK  aric  acid  fnni  «r  ■ 
clearing  ibo  urine  of  urates.  Ttiey  may  be  given  afooe,  or  ia  ooniaMM 
wttb  the  citrate  or  cnrbonale  of  polafih. 

Oepoiits  of  Oxalate  of  Lime.— Oxalate  of  lime  appnus  in  two  ibraiha 
otilahediu  iFig.  t^'iT),  and  as  dumb-bells.  Tha  eryaials  ar*  mtociis  « 
nearlr  so.  The  dumb-bells  soiDetlmea  beooo*  agpI'>m>-rBtMl  'mta  Hnll 
ronutled  otasses,  forming  the  so-called  htMi)|>-i*v^  calculi.  Tlw  aiifim  d 
oxalate  of  lime  io  the  urine  is  a  eomcwlial  tloubtful  \\aitiU  (><alv  am  ii 
not  [m«t-ul  uornmlly  iu  the  urini.%  and  \&  ••ii|i|Hwd  to  bv 
acid  by  imperfect  uxiduttoo.  It  has  been  AAcrilt^^il  &!■<>  t 
datioD  of  the  carbohvdratea  taken  as  f<mtl.  Certniu  :n 
•orre]  And  rhubarb,  which  conliuu  oxalates  in  cun^id^r: 
cauw  their  prc«<<ncc  in  the  urine.  Tt  was  fornirrly  9-\. 
with  marked  syntptonis  indicating  the  tO'called  oxnlii  -.  :.  -u,  thn  patlaa 
being  pale,  hypochondriacal,  dyspeptic,  and  sufTeriug  from  antUty  nfite 


tnan  wot 
SUL,  m 


be 


Fig.  ^i;;.— Crfitab  at  Oulits  or  Lin*. 

ilomacb,  dbturbed  sleep,  aud  loss  uf  iiexuat  powar  W.  IUb«fi,lll«M 
stittv«  ibat  oxaluria  accompituica  nu  txiti^tant  tniin  of  firmptf>n»,  «D«t  i«^ 
tbal  the  prv»cui.i!  of  oxniutca  fumi»hf«  no  ildiriitT  imlimtion  Tit  trest^A 
Urine  ci>utaining  oxiilntca  ih  usually  [>ale,  abundaDt,  and  ackl,  ^  bu 
cause  it4>iuu  tvimsiitiiiD  of  beat  and  p»iD  iu  its  paSMit^  along  thi-  — '"''  ^ 
fonii8  nu  di-Rnilc  deposit,  but  Is  usually  awociattHt  with  a  •!  * 

mucus.  The  crrslals  adhere  (o  the  eidt»  of  tbi*  gliw  in  lio»»  c"tn»j— ';*# 
to  any  irregularity  in  the  glaHi,  ur  to  murks  left  liy  the  elutb  n*^  i>*lf^ 
It  out.  Then?  i»  plmoj;  reason  to  believe  that  in  timnv  mnei  the  auJk^ 
is  produced  during  the  early  stagcb  of  dccoiiijmHiLiiiu  afler  lbs  uriw  l" 
been  naased. 

OahnUuM. — The  a^calate  of  limo  or  mulberry  calculus  is  osaallTof  sM 
brown  or  even  black  color,  rough,  tuhrrculntcil,  aod  soactuaas  alwl  ^* 
lated  on  the  surfuco  (Tig.  828).  It  is  very  hearr and  hanl.  I>  iw** 
rcaehrs  a  great  sl&e,  aa  the  irrilatiou  it  caasM  rails  attentioa  to  it"?- 
Oxalic  miculi  of  «mall   sizo  arc  not  unfreqaeotlj  paaed  aafnrri. 


rnoSPBATIO   DEVOSITS-^l 


908 


Fig.  SSv.-'Cr^itAlt  of  AmmoBlb- 


7Teatment.—Vf\ien  t\tv  [mtient.  [ijibilimlly  puaea  oxalates,  and  especially 
if  they  appear  as  gnivel,  hv  must  lie  put  apoa  a  light  ami  nuiiritJiiug  diet, 
npeciitliy  lish,  an  reconimvatled  by  Bird, 
caulioniog  hitu  to  avuid  Bn-Mt«  and  nl]  r<er- 
meoted  liquore,  with  lh«  exception  uf  a 
moderate  qimutity  of  weak  Bpiritii  and 
water.  Toaics,  particularly  tbe  luiiiurnt 
acida,  iron,  zinc.and  cjuinine.  mny  be  given 
and  the  residence  Bhould,  if  p>i<s«ib!c,  be 
ehaaged  I'lir  a  time  U>  a  wnnu  climate. 
Diaiilled  water  only  mui»l  be  used  lor 
drioking  purptmc^.  Whco  enlculus  ta 
formed,  tliorc  is,  uwiu^  to  its  roughuesB, 
aad  Iho  irritable  sLiitc  of  the  patieuc's  nor- 
voua  gysteii),  ui^ualLy  a  gtiod  deal  of  jwiu 
in  tbe  region  uf  iho  bladder,  requiring  the 
free  administration  ot'  »ptatM. 

FhoBphatio  DeposiU. — The  scdimenu 
and  calculi  containing  phosphates  occur  in 
three  distinct  forms  :  i.  Triple  or  An]mon{o<magtieeiaD  Ptiosphate;  2.  Phos- 
phate of  Lime:  aui],  :x  ^lixed  PhmphatN,  consisting  of  a  mixture  of  the 
preoedinp  rarictiei*. 

1.  The  Triple  or  AitutMnio-maffuPMau  phosphate  is  met  with  in  all  spieci- 
mens  of  iirlne  tbnt  are  decomposing.  It  has  no  pathological  idgnilicance, 
and  t!i  not  aiwrtciateil  with  any  npecial  ^institutional  condition.  It  forms  tbe 
chief  part  of  the  vthite  cnial  which  ie  depuaited  oit  all  instrunieDts  tie<l  into 
the  bladder  for  nny  length  of  time,  and  od  all  stones  which  have  given  riaa 
to  severe  cystitis. 

'2.  The  Amorphcnu  i'honphaie  of  Lime  is  deposited  whenever  the  urine  be- 
ootues  alkaline,  whether  from  tbe  aduiinisLration  of  alkaline  drugs,  fn'm  tbe 
presence  \>{  alkaline  mucus  in  large  Quantities  secreted  trom  an  intlumed 
bladder,  or  from  tbe  furmatiou  of  carbonate  of  ammonia  from  decomposi* 
tioa.  It  very  rarely  forms  a  conrretiou  alone.  Exi^e^  of  phosphates  U  met 
with  in  some  forms  of  disease  of  the  nervous  system,  but  unle^  the  urine  be 
at  the  same  time  alkaline  it  does  not  form  adc|H)«it.  Amorphous  phttsphatea 
are  very  frequently  |m:<Bed  a  few  hours  after  a  meal,  during  the  sn-colled 
"alkaline  title"  in  the  urine,  especially  about  eleven  <ir  tweU'e  o'clock  after 
a  heavy  late  breakfast.  This  occurs  more  readily  if  tbe  actual  amount  of 
pboephales  be  in  excese.  Tlic  causes  of  thLi  coniiicion  arc  not  verv  clear, 
but  the  alkalinity  can  i-asily  be  shown  in  manv  ca-oes  to  he  due  to  trie  prea- 
cnco  of  alkaline  carbonatei<,  the  urine  ertervefiMng  vignrouslv  on  the  nddi- 
tioD  of  any  acid.  It  is  freijnetitly  associated  with  late  hours  and  overwork. 
Tbe  patient  is  often  much  alarmed  by  the  appearance  of  the  phosphates,  as 
they  usually  come  at  the  end  of  micturition,  (brining  a  white  cloud  in  the 
stream  which  he  may  take  for  seminal  fluid.  If  the  phosphate*  arc  very 
abundant  they  nftc-a  hang  about  in  theurt^thra.and  may  cause  severe  smart- 
ing  or  burning  pnin  after  micturition.  The  condition  is  easily  detected  by- 
examining  tbe  urine.  The  white  heavy  depaiit  looking  almost  like  pus  dis- 
appears immediately  on  the  adrlitlnn  of  a  little  acid. 

it.  Mirfl  I'Sotjifiiitff  siTc  UHually  met  with  in  all  cases  of  disease  of  the 
bladder  with  animnnincal  urine,  as  in  the  cystitis  following  an  injury  to  (be 
spine,  or  in  advanced  case**  "f  prostate  disease. 

Gxlculi. — Pure  phosphattc  calculi  are  very  rare,  if  we  exclude  those  soft 
concretions  that  form  in  a  fuul  bladder.  Tbev  are  commonly  computed  of 
mixed  pboaphatee  in  varying  proportions.     If  the  proportion   is  about  two 


I      mixed  pboapl 


904 


UKINARV    CALCULUS 


COTOMY 


parts  of  the  amnion io-tuagoMian  (o  one  pari  of  the  phoajdialB  if  Ua^k 
lUMi  readily  ioto  r  hdnj  before  t4i«  lilowinjio,  ntirl  hn*  bflOM  baoD  alMiH 
lusible  calculus.  This  calculus  la  friMblr,  luiuiimte<l,  aud  haa  adaAy* 
earthv  look.  The  amoioQiomAgn««mti  calcnlu*  U  \e»  eotamou.  Il  aaf  W 
beoutifully  crystalline  in  structure.  The  plitviphate  uf  lini«  ralrulu*  y«3l 
more  rare,  a»  the  aaiorphous  pli>»iphatC8  seem  to  »liuw  but  lictl'  leo^oiCTti 
agglomerate  into  a  concretion,  Ine  few  that  have  be«Q  met  wttfa  are  tw- 
uuled  and  harder  thnu  the  other  phosphatic  Mnncn. 

TVeaiment. — The  tr€ttiiiicnt  uf  the  depusit  of  phueplintea  i»  in  BMt<MM 
piir<-ty  local,  dccompci^iutin  of  tht>  urine  bfini;  iircvi-olMl,  Kod  Um  liMifer 
kept  (^Icao  hy  thoee  iiK-ana  that  uill  be  deerribra  in  thm  riiapiw  «■  CliAik 
The  pawage  of  amorplumii  phoephaic«  miiy  Iw  trratrd  htr  avtv'daix»ai«>*«^ 
vork  and^atc  Iioure.  am)  by  exercise  in  the  oprn  air,  a  frw  dajt  r>f  wiiA 
trratment  will  iihually  cause  a  nmiplctp  (liMpftcaranrv  nf  ih»  trmfum^ 
Tunira,  eeppcliilly  nitric  arid  or  uitro-hydrD^hhiric  ari<l  and  tiflCWnw  MS 
TOmi(rn,  are  aflrn  of  use. 

CyBtiiie  ie  one  of  the  rarer  formii  of  morbid  product  orcanooally  bM  vilk 
in  the  bladder.  It  differs  from  all  other  infrrcdienu  in  roDiainUif  a  lam 
quantity — about  26  per  cent — of  sulphur.  It  in  verr  rarriy  awn  m  a  ■•- 
ment  iu  the  urine;  but  when  it  nooiirt  in  this  form  It  pmcAta  ths  laii 
acopic  charaeters  seen  in  Fig.  ^30.  beinj;  cunipttfcd  of  bexsi|p)*al  laaJMa 
The  cauDea  which  lead  to  its  rirmation  are  uncertain,  but  tb«  miumtj  lalt 
19  o(Wu  lierefiilarv.     I~'ul<-uli  containing  cvi»tin«>  h«\i'  "    t>**»  a* 

with.     Goldidg  Bird  otatca  that  in  Guy's  Jl't*i>itfll  .M  :*  #Wni 

coiuiMi0n)  uf  this  [N-i'u!inr  »ulniaii<.v;  aa^  <i 

,-'^,  ,  the  MuKHim  of  (."uircnsilv  •'■■11^?' •♦!'•'' 

jr--  '  aome  good  spcciinrup.     *'■  ■  <»i«l» 

V^,j  ..'  has  a  peciilinr  ycllowtei  ^tcxmiat 

tS^^'C;/'   rjjj  V^i^lw'^  grwn  after  i'Xp*>*unT  t"  thr  Bir,as4ft*>f 

look,  tbuE  dilKring  much  fran  anr  Mk* 
inffredieot  met  with  iu  nrinary  caaatbaa 
Friction  applietl  to  'tin  cut  paHmn  (■»! 
to  emit  a  iimpll  likR  i  hnt  of  irarlir. 

O  o-^^H  Zantbioe,  or  Xantlue  Oiid*,  mm  M 

^5'j^\^^^    /""^  noticed  by  Slarcei,  and  has  siacs  b«i  4- 

_    '^  ' '  serrod  by  l^tif^icr.  Langenbeck.awlvtka 

It  u  of  extrrmoir  rare  nemmnre.  a»<l  k« 
been  found  only  In  f>»ur  reourrisd  ilMM* 
intbe  form  nf  ealculiiusconerelkMa  Ttat 
f\f,  exo,— ctyauk  of  c^Miim.        bftvc  generally  been  of  aaall  dac,  aiik  tt* 

extK'piioD  of  the  ooe  reruMTii  by  Ub^ 
beck,  which  weighed  'SB&  grains.  For  a  deuiM  accMiDl  nf  tfa*  ctaaO' 
characters  and  oonatituenta  of  this  «ub«tsno«,  aa  well  m  nf  the  f*^'^ 
rials  of  which  calcnii  are  formed,  I  must  refer  to  tbe  weriti  tif  CI.  ffii 
Bcati\  *tc- 

Oarbonate  of  Lime  has  occaaionally  been   met  with  as  aa  aatfykM 
[Hiwdvr  in  alkaliui!  or  very  faintly  nciil  urine.     D*rl  ••-•—  'i  —  '  ^^  ««**' 
carbonatt^  of  lime  a»  formin]^  a  dlttincl  straluni  ta  •-' 
andThudichum  hascxaminM  priwtntic  conorplionK  C'l  •' 

of  this  aubstauoe — the  urinary  origiii  of  which.  h'»"  '-*   ^' 

urinary  vniciil  calculi  vumpuf4.'<)  of  varbuoale  of  liitiv  arr  i.'^ntuiif'? 
rarely  nti't  with. 

Clwmirai  EsaminatioH, — For  a  couiptelr  accnaot  of  the  rfcariiw 
naii'in  of  urinary  calculi,  I   niusi  rcft-r  the  nmdef  ta  work*  •■  ■■ 
chemtstry  by  C  U.  Rulfe  and  utbcrs.    Tbo  ibtlowing  rough  tai4»  wkj. 


^ 


mm 


STRUCTURE    OF   CALCtTLT. 


905 


I 


ever,  hf  employerl  for  the  three  cliief  vnrietie*,  the  ntlier  fcirms  beiiif  so  rare 
that  they  nmy  be  ))mcticnlly  exclmWI  from  conniHeratinn.  Place  a  emali 
frnfftiient  on  a  piece  of  plalinuiu  foil,  and  hold  it  in  the  flame  of  a  npirit 
lamp.  If  it  burni)  complelclyawsy.or  at  mnst  leaces  a  scarcely  appreciable 
r«i(iue,  it  is  probably  iiHc  ncid  or  urate  of  aoimonin.  If  it  htackens  aod 
llteu  leave*  a  white  rwidue  of  the  Bniu©  size  as  tbt-  original  fragment,  it  U 
either  oiHlatoa  or  |)hw|>hateiJ.  Then  place  thrcm  very  small  fragmrnts  on 
three  glatw  slides,  ami  add,  by  mwine  of  a  piw»  n-«J,  «  drop  of  dilute  liquor 
potassie  tu  one,  of  awtic  uiid  to  another,  and  uf  dilutu  hydrochloric  acid  to 
the  third.  If  it  dieeulves  in  the  liquor  polmww  it  ia  either  uric  acid  or  urate 
ofamniunta;  if  it  dieeulves  in  acetic  acid  untl  hydrochloric  Jl  is  phosphateii; 
if  it  dissolves  in  hydrochloric  acid  and  not  iu  acetic,  it  14  uxalnte  of  lime. 
If  it  divsolvee  iu  liijuor  potHiiaEe,  put  a  gins."  i^uver  clip  over  it,  uud  then  nin 
in  beneath  u  drop  of  acetic  or  bvdroidilortc  acid;  as  the  acid  uieetfl  the 
alkaline  fluid  a  while  ci<'ud  will  appear  ;  examine  this  under  the  niicr'>- 
ecojie,  and  it  will  be  fi>nnd  to  be  compowil  of  diamoiid-tdiaiwd  cryslaU  uf 
uric  acid.  As  a  confirmatory  test  for  osnlate  of  lime,  the  white  residue  left 
after  beating  on  the  platinum  foil  nmy  be  placed  on  a  glass  slide,  and  a 
drop  (if  acid  added,  when  it  will  be  ?cen  to  diesnlve  with  etTcrvcBccnce, 
oxalic  acid  having  been  broken  up  by  Ibe  beat,  and  cBrbtiualc  of  lime 
maioing. 


8TONB  IN  THE  BLADDER. 


SrRfcroiiE  OF  Calcitli. — Calculi,  though  iwmetimes  composed  through- 
out of  the  same  dcjKjsit,  iire  not  unfrequently  made  up  of  layers  or  .ttrala, 
differing  in  clicmicnl  com  posit  ion  fn»m  one  another,  Rnd  the^e  nnufllly  go  by 
the  name  of  altfmatinff  calculi  (Fig.  8'i]  ).  Moet  fretiueutly,  the  nucleus 
coiisista  of  uric  acid;  next  in  the  order  of  frequency  comes  the  oxalate  of 
lime;  and  theu  the  concretiou  of  a  phosphatic  character  throughout.    It  ia 


PIf.  631. — SMtion  «l  AD  AUvrDfttlBS 

Oaleului. 


n$.  iS2, — E«liaD  of  OxhUIc  nt  Lim* 
Ckloalni  Inorutlad  with  PboapbctM- 


very  seldom  that  the  nucleus  is  absent;  bat  concretions  have  orcK^^ionnDy 
been  met  with  in  which  none  could  be  detected,  or  iu  which  it  was  even 
replaced  by  a  cavity.  The  nucleus  is  ubuhHv  as  nearly  as  possible  in  the 
centre  of  the  cnlculus,  and  is  generally  nearly  regular  in  sha|>e;  occaeioually, 
however,  it  is  branched  or  curiously  radiated,  and  then  the  concretion  gener- 
ally affects  a  corr4>i<poDdiQg  outline.  Calculi  containing  two  or  three  nuclei 
have  someLinicJ  bc^cn  found,  coufiisLing,  probably,  of  an  equal  number  of  con- 
cretions agglomerated  together.  A  foreign  body  occasionally  cakes  the  place 
of  a  nucleus. 
The  body  of  a  calculus  having  the  uric  acid  uucloua  is  usuatly  compiled 


906 


CRINABY   CALCULUS   ANI>   LITnOTOMT. 


of  the  Mmc  sulwcancc,  pottibly  niixcH  with  acinic  uraim;  bat  am 
Queotly  tb«s«  are  inorusted  by  b  di^piMit;  of  [>h>itf|>liat<'M     In  iitk«r  bttuii^ 
llw  bodj  nia;r  be  wholly  c<>nipij«)t>*l  vf  aomv  of  ttiv  '  ^pkatotiM 

more  rarely  alteniRl«  with  the  nxaUic  <*(  limv  or  ri  {•l»cvpfait*>_ 

Ad  oxalate  of  lime  Daclen  uvually  has  a  body  of  ihu  mmn  omnb 
bat  iu  lonie  oihm  it  is  incnutcd  by  puoephato  or  uruics  (Hg.  9SS}. 
the  iDtcrior  is  phoephatic,  the  coocretioa  ia  aJiiarR  'if  thv  eamt 

The  nUoratioait  in  the  ooDipoaittOD  of  a  calculni  an  dua 
oooditioiw  of  the  geDcral  bcallb,  and  ooaferjueotJy  of  llw  ekuumcba  a»d  o*- 
Btitueut^  ur  the  urme,  oad  of  the  eiati*  of  the  liubg  oMimbnun  of  Uh  hmui 
The  uric  acid  and  oxalate  of  time  nuclei  aud  layerv  aro  uadooliladlT  dw  to 
caiiftitutioiiHl  ciiuew.  Tht!  ph(i6photic  lamioic,  whether  iBterpowd  Wvmi 
the  uric  ncid  or  iDcrtistiiit;  the  cali^ulus,  are  depeudeul  uu  veAcal  iiriiaiM 
and  dceoiupueitiou  uf  ihe  urine,  efinaequeut  on  ihe  nrvscnee  in  iha  bhMv 
of  the  uric  ucid  or  oxalate  of  iinie  uuclcua  which  baa  mtaa  praTtoualj  i€mi 

Origin. — Calculi  may  1k'  lonui-d  eillicr  in  Iho  hidui-y*  or  in  the  UadiW. 
ThddK  that  contain  nuclei  of  the  urates  or  oxalates  arr  pn>bahtr  khIb 
their  origin  ;  whil.>«t  thiute  that  have  a  phii^phalic  nucleuii  arc  uiuaUv  (Wal 
from  the  first,  renal  nurlei  of  thii)  ci>tnpi\4itii>n  bciiift  rarely  iiiel  with. 

All  renftl  caIcoII,  ull  those  vesical  calculi  ihat  hsvf  ■  rcoal  nnpa.Bi 
some  of  thdae  even  that  appear  to  he  primarily  forun-il  in  (he  hladder,itn» 
constitutiotial  source ;  they  arise  from  a  morliid  Mate  of  the  urine,  whidk  ia 
ita  turn  probably  dependg  upon  mal-a»iinilttlitin,  the  peculiar  form  of  aiacA 
determine*  the  chemical  compoeiiioo  of  the  «t«ne.  Thoiw  calcol:  thoim 
foniivHl  by  depo«it  from  the  urine  upoQ  and  nroiind  aonw  fbn^  bodf.  ■•  > 
pia  or  straw  avoideutally  iutpxtuct-d  into  the  bladder,  aod  aoiD*  ttA  fh* 
phatic  coucrvtiuus  that  appear  to  be  the  rvauU  of  an  unbe»lthy  ttalm  tOlt 
nacouB  iiR-iubntuv.  may  be  looked  upon  as  bein);  local  io  Ibnr  oripa. 

The  symptoms  urieiu^  from  u  »touv  in  the  kidney.  an<l  durini;  if  pM"P 
to  the  blndder  have  beeu  alreadv  described  (  p.  '<^f^  |.     Though  a  <nawod(» 
cuius  often  owes  its  origin  to  the  desceot  uf  a  stone  from  the  ki< 
frt'iiueiitly  there  is  no  evtdeuce  of  ita  eotmn^  fn'iii  such  a  eooroe,  bat| 
ap{iearan(«  of  its  being  defxwited  in  the  bladder:  a  nucleiia  beiBgunp~ 
formed  in  this  viscufl  by  Ihu  a^gregatioo  of  some  aabulmu  aaUan,' 
tod  npuu  which  fresh  depotiilB  take  place,  until  a  true  calealiu  h  bmai  }* 
mtae  in^tanoee,  vesical  calculi  have  been  found  deiHuiled  upoo  and  iauaair" 
foreign  bmlics,  accidentally  intrxluoed  intxi  t]u>  bladder,  aaeb  aa  a  faM* 
straw,  a  pin,  a  hit  of  bouj^ic,  frn^incut  of  heme,  etc. 

NuHURlt. —  The  number  of  calculi  in  the  Idudder  Tariea  ouMadwM* j 
noBt  commonly  rmly  one  ia  encountered  ;  hut  in  ab«>at  oae-fiftfa  or  i«**i^ 
of  the  cttMi  operated  upon.  »evcral  will  be  fonnd  :  fnmi  lwi<  t>t  «x  ur<i<^ 
arc  by  o<>  ineanji  uDoommonly  met  with.     Occa^i"'    "  -ral  do«*»ta»« 

been  detected ;  and  there  are  lostaoce^  on  reconi  i;na  MMk»' 

dred«  of  distinct  tod  sepiirate  ealcull  have  Imm-u  fouii>I  iu  *^at>  blaiis.  tW 
moat  remarkable  caae  ol  thi«  kind  w  one  in  whieh  [*hv^i.'k  rrtrnvrrd  INi • 
judge  ill   the  United  Statca  upwnrd*  of  a  thousai  '  ** 

from  u  purtridge-«hot  toabeao.  and  each  runrkM  n  ^  -  »^ 

oalruli  may  become  matted  toeether  in  one  large  concretion,  aa  ia  th»  u^f' 
repreiwotalion  of  a  calcalus  <  I'ie.  H:t;t  t  that  I  rentorvd  from  a  cbiM  fyatj^ 
old;  it  waa  formed  of  eleven  distioot  uric  acid  tnlculi  Mhtmd  tWgtWf » 
thia  way;  bciidva  which,  three  othera  wen  loooe  in  the  bladdac  WImiM" 
or  more  calculi  occur,  it  a  remarkable  how  uniiorm  they  oiUn  «e  la  Aif^ 
aa*.  and  weight,  one  bein^  the  exact  counterpart  of  tin  athmt.  thm^MM 
matry  u  remarkable  when  the  calculi  are  very  anoMriMU,  duaaoi  M^^f 
atooea  of  exactly  the  aame  aixe,  shape,  and  waiglU,  bsiag  laM  mm^v^M 


tAOTKRS. 


907 


Cftlcnliu  ii  rery  rarely,  if  ever,  inund  awociaied  with  aumerouit  smAll 

Eihva  tbrre  are  Bcvenil  calculi  in  the  blaiidcr.  lliv  aUritinu  of  one  agftiost 
mlier  UHially  cauKs  the  opptwiog  surfaecK  to  bec-imie  HDKHitli,  llius  cou- 
•Ulittitig  "  facets"  {  Fi(?.  ^S4).  ThU  is  jiroUibly  owiny  i<i  the  lilail'lfr  being 
■toQiu,  alvravs  coDtainiD^  urtoe,  and  lliu«  not  r<>iupiT««io)r  aiid  grio'ling  llie 
eaU'iiU  agBiDst  oue  aiintber.  lo  boiuc  rast».  Iiuwi'ver.  wbeu  the  i-alcufi  ure 
numrrHt*.  ihere  are  ui»  »\ftoa  of  uttritiuti.  In  a  |iatieiit  uf  niinu  wbo  bad 
fiftceu  calculi  in  lii»  blndiivr,  alt  tti«  stmira  wt-re  ri)iinc(,  aboul  the  f^ize  and 
•b^H)  of  marbltT^,  tviihtoit  any  Imxu.  In  otlier  rasea,  again,  ihirp  may  be 
Guxts  im  ooi!  calculuu  tlian  coin panian -calculi  in  the  bladdtT.    A 


r>i 


.ttl— rrta  AoM  Csleull  ntXUi 


Fl|.  »34.— Cdnll  Niib  Fmvo. 


Veood  Btooc  may  occaaioD  two  or  even  three  fiiceis  on  the  first,  having  rolled 
tnt  I"  ntitf  ami  ijivu  to  the  other  «dc  of  ll. 
Spontaneous  Fracture  uf  a  calculud  will  s<:imetinie«  occur  within  the  blad- 
Tbi*  curi-iiia  pbtfuoiiienun,  which  has  b*en  met  with  only  in  itrir  acid 
ili,  iitay  ti]i|>peu  tu  a  stoue  thai  isi^iugU',  ur  tuont*  amuug  several.  Wbca 
.  (■  .-real  irritiibility  yf  tliu  blaililcr  is  evl  uji.     There  arv  stjveral  waya 

_  ii;^  lliia  traL'tun-.  or  rallier  ilisiiiU'crstiou,  uf  A  culcului^     Civialo 

•npiiufttA  \i  tu  occur  by  tht-  o^niraclion  of  ihv  liypertrophied  cjaie  vf  the 
butader  upon  llie  M'me.  Il  \»  |Mv«lhle  that,  when  tlit<ro  are  aeve^al  calculi  in 
Kbe  bladder,  the  uuncuseion  of  one  aeainet  imoltwr  may  ^i\e  rise  tit  it:  and 
tor  tlie  breiikin^  uji  of  a  calculus  t4i  tiap|>en.  it  vrouM  by  no  means  Ih>  neoe»< 
mmry  thai  tJits  pressure  of  the  bladder  or  concunion  enuald  be  sufficiently 
■truog  tu  molvc  the  stone  at  once  into  fingmentB.  If  a  cmck  or  (isi>ure 
aM9<ely  be  formed  in  it,  the  infiltration  of  the  urine  into  this  tnay  so  »<>flen 
wmA  looaeo  it»  cohesion,  that  it  beoomefl  reftulved.Trithout  further  violence, 
tDtu  a  numhrr  of  piece*.  In  8<»oie  Instances  lliese  become  agglotueruted 
■■prtber,  by  the  deposit  of  ii  <)Unotity  of  pbonphatic  matter  upon  and  around 
HKm.  In  t>lher  case^,  ibr  ditl'^rent  fragnientd  may  each  lorni  the  nucleus  of 
•  r  '<  iitui,  so  that  the  bladder  may  afterwards  contain  numerous  con- 

»l«  \\.  riiAKA<TKlw«.— Thv  Bin  of  calculi  varies  from  that  of  a  hcni[>- 

'(Mn'R  lipad  tu  a  concretion  of  iuimenae  nia^niturte.     One  of  the  litrj;nit 

with  whioh  I  »m  acqiiitinted,  waa  a  calculus  remove*!  by  the  hieh  o|terallon 
by  Uyttcrhoeren,  of  Unissels.  which  I  saw  some  time  a^o  in  ht»  pononion, 
■sd  of  whJeh  be  has  been  ubliginj;  enuu);h  lo  ftivc  me  a  cast ;  it  )i>  pyrifurni, 
■ad  measures  1!)|  inches  in  its  longest  eiruumference,  and  12)  inches  n>und 
at  ita  broade«l  pari,  being  04  inches  lun>c,  and  about  4  wide,  lu  the  cele- 
blBtad  case  of  Hir  W.  (Vilvie,  Cline  attempted,  but  faileil,  to  extract  a  (Tnlculua 
riofr  IG  iocbes  round  one  axis  and  1-1  round  the  other.  It  weighed  44 
and  must  have  bei-n  ali<iut  ihf  sizo  id'  fyttcrhoevcu's.  Thi-w  enor- 
I  ooncrrttiins  are  happily  rarely  met  with  at  the  pn-aent  day;  the  usual 


908 


URINARY    CALCULUS    AKD    LlTMOTcm V. 


Bue  of  ttoDGt  romovml  by  npcnitinn  bring  from  iibnut  on*  to  two  arv»  u 
tbo  loDfftst  duimet«r.  eomowlint  narrnw.  nn<i  t>rrhMpR  (UUcomL 

Tlio  Weight  of  cnlculi  varies  fri>m  n  few  crnint  to  flVTCral  mam;  thi 
cdfiiniiiiH'?!  WL'i).'ht  ia  from  throe  <lrnciim&  tn  nlHiiit  no  oaaon^  rtMw  tHA- 
sionallv  from  ihrpc  to  six  ouDco«:  from  th'w  tb«}r  iDAjr  nac*  npwar*  Mi 
severaf  {hiunda  aro  reached.  Thus,  in  C'lioc's  cue  the  Mont  <ni(^  44 
ouu(_>cs.  DfsehonipA  saw  uoeof  51  ouDc(M,(iQd  Monod  one  w«tpbiii£  <  Ok: 
none  of  thL-«e  u<lmiit«d  of  removal.  The  UrfreM  calculi  arr  imbJIt  <n» 
posed  of  phMphntM,  in  ^rpnitu-  part  if  not  in  urb-ite.  Larp  &»!  bary 
calculi  are  ocrtainty  leM  fre(|Uoi«ly  mot  with  daw  than  f—-  -'-  nmioftt 
o{>eratiimH  fur  utoiiu  being  MmpK-r  nud  lew  dreaiM  tiacv  \  laeikaff 

anwi'<t!ifli[-it.  nin)  lunurt*  nmt-ti^cd  Ja  ftu  earltAr  itAi^e  of  the  iliifMM. 

Tin-  Hardneia  nf  calculi  vurit-n  Lvioniderahly;  ib«  oxalate  af  Haa  ti  ikt 
hardest;    tlip  lilhiiKs  i.'om«  next    lo  roDUiitoticc',  an  i  ''"a  very  hoi, 

thou^rh  hrittle;    the  phi»phutic  islcuti  ar«  always  iivriyaaAad 

frinlilf. 

The  81iape  of  calculi  present*  great  variety :  miMt  commooly.  bowem.lh^ 
have  au  uvoid  Qgiirc,     Omcri'li-iui  uf  urate  of  ammunia  anil  urioKldM 
geueriilly  pretty  re^iularly  ovoidiil.aiuot.'th.au'l  tJwk-like.    Tii.f-r  <\i' 
oxalate  uf  limcfireusuallyBjmvwhat  globular  or  a>tunrf- 1 
rou^h.  undulated,  or  spiculuteil  upuu  the  nurfare.     Thv  ;■..  ^,  ..-uc 
preaoul  usually  the  mu«t  irregular  uuiltue;  m-tst  uimmimly,  it  b 
are  oviiid  or  globular,  but  are  uat  unfrequoully  braiiche<l    --   '■'   -hi. 
the  interior  of  li  sntTulaie*]  bladiler,  cimittricUK],  nr  iif  m  -•■m  tblfc- 

Thi-  rvfiline  ralruli  aro  generally  toturahly  ovnl  nod  rceoinr  m    uinaa. 

FositioB. — Most  freonently  calculi  lie  lnrMM*  in  tbo  bTaddcr  ;  but  wcaMh 
ally  they  may  ho  fix«ii.  t^ilhor  by  beinz  enryti'd.  ami  tbra  lyiag  ta  HStW 
the  aarnili  that  havo  alreatty  been  describdl  vitbin  the  wntU  itT  UMtbUMv 
(Fij{s.  8^1  and  83(i;;  nr  by  being  Oxed  in  and  embrmceH  bv  oa*  ul  A* 


•a  Kncj-dviJ  (U«u)h  tt  n, 


Flf.  Sta.— iMvnM  ftf  tU  (UM 1 
lti$  mall  Oriaw  kWlag  lafti  <>«•<■   '^ 
Urator. 


urHcfs :  Dr,  in  other  caaea.  by  beiig  dapoibed  opon,  and  partly  iaeWi'  ^ 
villuuB  or  nmliL'Uimt  growtha. 

C'AffitJf. — Wht'nevor  a  foreign  body  of  any  kind,  u  a  pjaiaafl*™ 
catheter,  etc..  ta  iiiirixluccil  into  the  bladder,  it  will   f'^tm  fh*nw<*Ba«' 

oalrulugi,  8|K!fdilY  iKt^owin;?  incnistf-d  by  calcu'i  ^ 

the  cnuiMitt  of  cnlouli  occurring  8|iiintanei>tiiilr  i>' 

be  little  doubt,  It  is  true,  that  the  dilTerent  forou  of  cuncrvtUNi  ar* 


OAUSSft   OP    POKHATION    OP    CALCULI.  909 

the  Torious   geoernl    and    lucul    ooutlitiouB    tliiit    have  alrendr    been 

rribcti;   and  ire  ninv  look  upi)ii  the  t'i)ritinli<iii  ^f  n  caiciilua  a»  an  indica- 

of  the  exinlencp.  in  a  greater  degree  of  iiitrn^ily  than  uaunl  of  the 

ei  wbirli  nrdinarilv  give  rige  to  eedinieDts  or  gravel ;   but  why,  io  par- 

}mr  caaot  sggr^^iiou  iD^]  a  calculous  masa  takes  jilaee,  it  is  impocaibto 

If*  exertdMaooDridtrablc  influence  upon  the  prodiiciion  of  oalculi.  Stone 
f  occur  in  the  bladder  nl  nil  pertode  of  lite,  and  even,  occordiair  to  Stah), 
W  eaDgcnilBl.  The  gr«ateet  nunib«rof  cases  afiparentlf  occur  durttit;  iho 
fvst  two  dfcuiDial  periods;  ihnt,  in  the  ilatistics  collected  by  Sir  Hcnrr 
ThoinptuD  from  the  chief  hoepitals  of  this  country,  he  shows  that  oue-ihinl  ilf 
tbc  entire  nombor  u(  cstea  occurred  before  seven  years  of  axe,  and  one-half 
hilBfB  the  ihirief^ntli  ycarta  completed.  Coutaon  has  collected  TJ12  recorded 
CHH  of  lithoiuiuy  from  various  sources;  of  the«e,  UGtJ  occurred  under  the 
ife  o€  ten,  7;ll  from  rleven  to  twenty,  SOS  from  iwenty-on«<  to  thirty,  204 
mm  thiny>«me  to  fifty,  and  '.iOG  from  tifly-une  upwards.  These  xlaii^tica 
nfer  CDlirvly  to  Inwpilal  practiee.  The  later  BtatiifUcs  published  by  Thomp- 
•on,  derivi-il  fnim  his  own  praclic«,  public  and  private,  show  »ouewhat  dif- 
ferent n-euIU-  Thtu,  uf  812  patieuta  upon  whom  he  has  i<|K'rated,  5^o  were 
above  Si\f.  Tbi»  apparent  uiecrepancy  aric«s  from  two  cauws.  First.  tJie 
nore  extetiaive  alati»ti»  are  derived  front  cskk  operated  on  chiedy  before  ibe 
days  t>f  ■iiii-»lhetic«.  when  nunteroiu  adulla  died  unrelieved  rather  than  face 
ifae  b(jrr(.>r8  of  lithotomy  ;  whereas  children  bud  little  choice  in  the  ojatter. 
Dis^osi^  also  was  not  so  perfect  at  that  time,  and  many  siiiall  slunes  in  old 

aiie  escaiied  deleciiou.  Sccundly,  Thutupon'e  own  statieiics  are  chiefly 
T«d  fh>iu  priviut.-  pninlice,  and  it  is  well  known  that  the  children  of  tlie 
ifeh  Tcry  raruly  «ufiVr  from  stime ;  whereas  thai  disease  i»  very  <'i>itimon 
UDoaj;  the  (Hfor.  The  cituiu-  of  lim  u  not  very  certain,  but  M)tue  attribute  it 
ta  ineuflicieuc-y  i>f  milk  in  the  diut. 

St*  influence:)  malcrially  the  occurrence  of  stone,  which  ta  farmnre  fr&> 

qaem  in  tlie  male  tbun  in  the  female,  in  the  proportion  of  about  twenty  to  »ne 

(if  owes  rcfjuirinj*  operation.     This,  however,  doe*  not  rcprement  the  exact 

ratio  ;  a»,  owin)(  to  the  fthorttiOKi  and  liirge  aiia  of  the  urethra  in  femalM, 

maoy  Mnall  calculi  iire  voided  by  them  thttt  wouhl  be  retained  in  the  male. 

It  woulil  appear  that  i'k  jumtfimrln  ojiht  world  calculus  is  a  far  more  common 

<)iiiraae  than  in  otben.    It  Is  ({enerally  more  frequently  met  with  to  cold  than 

■Q  warm  eHmateg.    The  negro  race  in  remarkably  exempt  from  this  alfeetion. 

Il  ta  a  iiin|tular  fact  that  in  tome  parta  of  the  same  countrj*  ealeulnu»  diminlrta 

an  of  far  more  fre<iiient  occurrence  than  in  other*.     ThUfi,  it  is  well  known 

tbmt  tb«  inbabiUkiit*  "f  the  east  coast  of  Knj^land  and  Scotland  are  pemtlinrly 

Uahltt  to  lh««c'  dinonlem;  and  that  in  Nurlvlk  «toD6  occurs  with  esffecia)  frv 

1 .  the  niortAlity  from  cnlt-uliis  t>«inK  muth  bibber  her«  iu  pro|Hirti>>D  to 

.Ailaliiiu  than  in  any  Klher  euuiit^  of  Kngland  (C'ndf^  t.     In  Ani«ni-a 

«l^t.  It  Mi>uld  up|iear  that  tliu  iubabiiantM  nl'  certain  Stales  are  itvculiarly 

nfaaoxiuuii  til  this  nOr^'tiun;   nnil  1  iinder>lauii    that  iu   »)nie  districts   of 

Oemmny  the  dimase  may  be  said  t<>  Iw  alni<«t  unknown,  whiint  in  <'lherB  it 

it  of  common  oucurmice.     The  relative  fret^ueucy  of  the  kinds  of  calculus 

alko  varicn  iu  dilii>rent  ctmntrin.      U.  V.  Carter,  who  has  aualyzeil  and 

dweribed  upwards  of  a  hundred  aperjmeua  cuniained  in  tha  Museum  of  the 

Grant  Medical  College,  at  Hommy,  shows  that  the  pcrcentajfc  of  calculi 

with  an  uric  nriil  or  urate  of  ammonia  niicleu)>  is,  in  India,  ^().30,  in  Ku);land, 

iI.Tl.' ;  while  tliat  iif  calculi  with  n  nuclrux  of  oxalate  of  lime  is,  in  India, 

^Aj&b,  in  England,  lft.87.     The  oalcali  oomnosed  purely  of  oxalate  of  lime 

•!■»  frratly  exceed  in  number  tboae  whien  cundtst  entirely  of  uric  acid 

bt  unie  of  atDmonia.    To  what  these  diflcrencce  ore  owing  it  is  impoasible  to 


I'BINABY    CALCULUS   AKD   LITnOTOMT. 


MT.  Peculiarity  of  race,  of  constitution,  and  of  diu,  irilk  nram  to 
prevnli-'iit  Mvt«rlv  wind?.  hav«  all  been  aseiguwl  m  reaantu  ferlMa:  kd 
probality  nnton  very  HUtticient  grouods. 

HvMi'ruMhi. — The  syiuptoius  <if  Blooe  in  the  bUtldtT  tsft  aenofdinf  H  tW 
calculiH  \ie»  loose  Id  the  cavity  of  the  TiBOiia  or  ia  t-i    '    '  Tbcir  iHMiky 

will  (lujwnd  OD  the  i>ize  nnd  :^hspt'  of  tht>  Ktooc,  tht  .  i  of  tlM  UiMM, 

and  the  cunstituuim  of  (he  patirnl.  Miwt  rnmmitnly,  tbr  MVcrlQ'  of  Aa 
aymptoDiB  is  la  propurtion  to  the  ma^itudp  of  thr  calrulm.  ThK  iMattw, 
ia  not  ulway8  the  ca»6.  In  a  patient  whom  1  oiion  cut,  tti»  tnut  \atnm 
«ufl«riug  nuJ  repeated  attacks  of  oy«titifi  had  bwu  occafioiied  by  a 
sharp-priiu((-d  calculus,  uot  weighing  mure  thaii  a  dracbni;  ainl  aooiail 
ago  Imw  a  patit^nt  in  wbi»e  ltla<lderflv«  calculi  wet?  ff*iit''  -'•■  ■ 
a«  lar^  an  ohcfltDutii,  though  their  pr«*eoce  had  nevf-r  I' 
life  by  thd  different  Burgeonn  under  whoae  car«  he  ha<l  <>'  ' 
little  dietreMba^l  they  •rKrcasione'l,  In  some  cane*,  tlif  Nvn.::'  '.- 
»ll(ldellly  declare  themgelv«;  and  then  the  SorHi-.ui  lin-i- 
tliv  patient  baA  a  calculuD  of  Bouit-  iitx,  which  muat  h;i-  .  ^ 

furmiuif  withi.>ut  attracting  attention.  Kough  and  angular  i:At(.-uli 
give  rjae  to  tnorv  ecvere  i>yinptuiiiii  ihau  tioootb  onca,  owiox  to  Ibcfa*  iote- 
iiijr  a  chronic  form  of  cy«titit^;  ait  ph'wphatic  calculi  are  drptsitvd  alaMtflt- 
variably  as  the  oonsrcfuuncc  uf  cyi^iitU  with  fuul  urine,  thryarv  aiaaai^aaM 
by  much  IiHml  euHvriug  and  conslitutiouiil  diolurbaooe. 

The  Hyriiptoiiis  iinhiceil  by  Ptouo  arc  the  result  uf  the  Dwc^aiual  inii*' 
tion  pnKhii%d  by  the  prenuicc  of  a  foreign  body  in  the  blatldrr ;  tbryoiMia 
of  Fain,  IncreaMMi  Frequency  in  Micturition,  iMi^astanal  Slofipo^  »4  Ik 
Urine,  nn<l  VariouM  Morbid  4*ouditions  of  that  Fluid. 

The  I'ain  in  ralculuH  is  ot\en  the  first  i^ymptoni  that  attracts  attrathi;  k 
Taries  greatlv  in  character  and  decree.  It  may  not  only  he  fTornmodk 
the  region  ot'  the  hiailder  and  the  perineum,  but  may  raiiiate  WMUyil  Ik 
courw  of  the  uervea  of  the  lumbar  and  aacral  pli^xiiaM,  iImi  patiatmafUt- 
ing  of  n  heavv  and  dragging  seDi<ntion  in   tin  'xtiaj;  don  ik 

«dinikipi» 


out«idv  or  back  of  the  tnigbs,  ami  not  uucomn, 


iiplsiaikj 


I  amr-«  - 


of  the  fet-u     The  ]>onis  ib  the  seat  of  a  good  deul  --i  uumuii 

of  a  sharp  and  cutting  jKiin  at  the  end  of  the  ylan*.     Thi* 

noticed  iu  children,  in  wb«iu  at(</iUion  is  oflen  nttr^i 

their  C4ju»tantlv  iMiueeiing  and  pulling  the  organ  i"  < 

KuOisr  iu  it.    The  pain  in  much  increaMd  by  any  muveim  i 

atone  it  jolted  about  tn  the  bladder,  aa  in  driviug,  riding,  •■< 

a  e8))ecially  severe  in  those  caaet  in  which  cystiUit  oi-cura.     1 

aevere  towards  the  termination  of,  or    inuneiliatelY  aftxr,  tun 

there  la  then  a  teodeucy  for  the  calculua  to  roll  forward*  loa-anb  ibe  w^ 

of  the  bladder,  where  it  cuaiex  into  contact  with  and  U  gnupe«]  by  tJic  *>* 

sensitive  iiart  of  that  organ.     Hence  it  i»  not  uufre<|Uent,  in  oum  ftf  ttk** 

liitu  in  children,  to  find  that  the  little  patient  iupttincuvclv  Ilea  upnn  iti  \mA 

or  »ide  whilnt  paMJug  urine,  and  thus  »('H)m  much  or  tb«>  acmy  i^  ^ 

would  otherwiae  ituHer.     In  adult*  in  whom  lh<'  prttnale  liappana* w  Wis- 

birged,  the  calculus  it^natly  Ilea  in  a  depreiviun  hehind  thla  |^nd;«a' 

benoe,  being  prwentt-il  from  bdng  sqnwK-^l  hy  ihi-  nrck  of  ibe  bbMvii 

consequence  of  iini>erfect  coniraotion,  oonutiina  Icm  •uAerinjf  tbui  la 

casM. 

In  oonMi]uenQe  uf  the  irritation  aet  up  in  tha  bladder  ocr«i«^irtin<* 
inflammation  of  the  raucou*  rocmbrane,  thrrv  i§  an  Imtm- 
MieturilioH.  niitre  by  day  than  ai  night.     Th<'  □rln'-  b  paa»> 
Rmall  i)Ua»tltii«  ni  a  tiine,  unually  containii  tiini«  mucut  or  < 
•iooatly  ting<-4l  with  bhwMl,  or  loadol  with  thick  rontsal  nmcti*. 


SYUPTOMB    OP    STONE    IN    THE    DI.ADDKR. 


911 


nanr  cmm  the  urino  roinnius  reraarkalily  clear,  traospurcnt,  and  True  fruin 
DtarKMl  adfaiztores  tbrougliout.  Albuiuuii  I'nim  blocxl  or  pus  is  (v>mriionly 
pnMDt,  uiid  iu  llie  tutor  aUuree  when  Uie  kiiiuuy  Ix'C'iincs  titU'(:le<l,  it  may 
coDMfrom  tlint  tunjr<;(<  also.  The  jinsence  of  bloui)  in  the  tiriui^  is  oJleu  one 
c^  tbo  earliest  signM  ul'  stone  in  the  blHildur,  and  in  cliililn^u  eajierially  Hbould 
lead  to  the  mispirinn  of  calciilnti.  It  may  be  in  large  tjuantities,  »tid  may 
couiinue  ior  many  wcekfi,  eHpecially  in  the  earliest  stages.  The  urine  may 
ihen  clear  aethe  bladder  becomes  accustomed  to  the  presence  of  the  sione, 
and  the  blond  may  reappear  only  under  the  influence  of  active  movement, 
or  of  any  can^e  ot'  increased  irritation  of  the.organ.  But  it  Is  important  to 
(ibservp  that  the  quantity  of  nlbunien,  ns  shown  by  boiling  the  urine,  will 
continue  to  Ke  very  ^'rent.  It  verj*  rarely  happens  that  a  etone  has  existed 
for  any  time,  without  the  urine  becoming  occasionally  streaked  or  tinned  by 
bloud. 

An  occjisioniil  Sloppagfl  in  tJtefiovi  nf  Urine  before  the  bladder  is  emptied 
owing  to  the  stone  being  impellcti  against  it5  neck,  and  thus  blocking  up  the 
urethra  is  a  common  symptom  iu  children,  but  vtiry  rare  iu  adults.  On  the 
patient  Iviiig  un  liis  back  or  on  his  aide,  the  stream  flows  again,  the  situutiou 
of  the  cali'iiIuH  bviug  cliitoged. 

As  n  ri'BuIl  of  the  etruining  and  general  irritiitiou  about  the  gcnito-iiriuary 
organs,  }*rolcrpeu$  of  (he  Anua,  uc-ciinpanied  by  Tcnmntu,  is  by  no  meant!  un- 
coiumon,  ti'Kpvuially  in  children;  and  in  some  cosei*  there  is  very  trouble- 
some^ }\iiipifm. 

Stone  ill  Elderly  Men  often  gives  rise  to  but  feebly  marked  symptoms. 
This  fact  has  been  specialty  calletl  atteution  to  byBir  Henry  Tbompton.  lie 
states.  Its  the  result  of  hie  unrivatted  experience,  that  possibly  from  dimin- 
ished seDsihility  of  the  bladder  in  elderly  men,  partly  from  the  frequency 
wilb  nbich  only  a  moderately  enlarged  prositatc  may  mask  the  sympLums, 
many  a  man  may  and  does  carry  a  uric  acid  calculus  for  three  or  tour  yeum 
with  little  or  no  incouveuieDce.  so  (hat  the  preseuce  of  the  stone  may  (:at^ily 
be  orerlookod  till  it  attains  such  a  size  &»  to  malic  its  removal  a  seriouo  iirifl 
poasibly  a  dangerous  operation.  In  these  cases  the  symptoms  he  ngards  as 
moet  characteristic,  are  slight  pricking  or  smarting  at  and  nejtr  the  cud  of  the 
penis,  often  but  not  iuvariably  fell  duriug  and  after  the  close  of  micturition  ; 
increased  frequency  of  micturition,  less  lelt  ut  night,  and  more  manifnil  in 
the  day,  especially  during  exercise ;  but  if  the  paticut  lead  a  very  quiet  life 
this  symptom  may  l>i:i  wanting.  Florid  blood  in  small  quautilie«  may  appciar 
after  mure  violent  exercise,  iir  Jolting  from  any  cause.  Tlio  urine  is  acid 
and  clt-ar,  and  often  dcposit-i  lithates.  By  Bounding  the  patient  when  these 
slight  symptoms  are  present,  a  small  stone  may  olten  be  detected  and  re- 
moved withmit  appreciable  risk. 

Stone  in.  Children. — The  symptoms  in  children  present  few  pcouliaritiM, 
except  that  the  piitJent  is  often  tninhle  clearly  to  describe  what  he  feels. 
Pain  on  movenieut  is  indicated  by  the  child's  disinclination  to  play  or  run 
about.  Screiiming  or  crying  after  mioUirition  is  common  ;  the  irritation  of 
the  atone  often  leads  to  inconltnence  at  night,  and  frequent  wotting  of  the 
clothes  during  the  day.  C>>nstant  handling  nf  the  peniA  and  pulling  of  the 
foreskin  till  it  seems  in  sntue  caiicis  to  be  nettially  lengthened,  are  also  im- 
portant signs.  With  these,  straining,  ivith  prolapsus  nf  the  rectum  during 
micturition,  is  usually  pre^^ent,  and  )>udden  stoppage  of  the  stream  duriug 
micturilioo  is  uot  uncommon.  Whenever  a  child  prc.'tents  thr»e  symptoms, 
he  should  bo  ut  once  sounded.  If  no  stoue  be  found,  the  child  must  be  ex- 
amiDed  for  worms,  the  irritation  of  which  may  give  rise  to  symptoms  closely 
nsembliug  tho»e  of  st<;ue.  A  light  iihimosts  will  aUo  cause  symptoms  dis- 
tiuguishuljle  from  slone  only  by  sounding. 


tJRIXARV    CA.LO0LUS   ±SD   LITBOTOHT. 


Eacyited  Calonltis.— When  a  stonv  U  mey4**i.  tbom  wvmpum^  tkn  h- 
[M-ud  upon  ita  Liciug:  Iihmc  iloiI  ruUiup  aliuui  id  tbo  bladtlcr.  w  iNe^Bn^ 
abeent ;  thus  there  u  no  stuppogv  ut'  iho  uriue,  ihb  fluid  k  mXdam  UmA*, 
and  the  pain  u  uut  matcnaUy  iticnnH.'d  lir  ji<1u  aoil  roncb  aMVHtf;    , 
thiiU);!)  L)it>re  are  «(.-i|;bl  unti  paiu  in  tbc  UHua]  F^iluaUDoa.  aaaiDBtiMlfit-  M 
qui-ncy  (if  niictuTiliou  Irum  tttv  prvasuru  and  irrltaUDa  uT  Lbe  oalcaba.  \ 

FiiY^K'M.  I)ia<:ni\-i.-  or  SroNti — The  exieteooe  of  atone  ii  flaaU; 4a«- 
miiK^l  l)v  Sounding  the  Bladder. 

A  Sound  i'4  a  solid  steel  iiuiniinent  elmiifd  like  a  calbeler,  bat  Aorterh 
the  curve  i  Fie.  KM),m  that  jt  may  i^x|tlore  Iburou^bly  all  pan*  «f  d» 
bladder,  especially  thow  behind  the  prast&te.    It  ibuuld  have  a  vi^  tai 


^ 


Pl«.  »T.— 8011114  fvr  aiuiiiilat  ai»M«r. 

smooth  «tecl  handle,  and  be  ilightlj  bulboiu.  Sir  H.  ThompAn  prdhil 
hollow  «ound  nilli  a  round  handle.  The  operation  of  toundin^  ■•  r-induricJ 
Be  Ibllows,  The  pntienl  lies  uptiu  hia  hack  on  a  han]  nrnttrv**  with  hia  batuvb 
well  raised  onapillotv;  a  full-tixed  sound,  uell-oitrd  auil  mrmMl,  ta  tkM 
paased  into  the  hloitder  which  should, it' the  niitjirnt  <  '  W 

to  contain  three  or  four  ounc«  of  urine.     The  trtir^  ■  Uft 

hand,  or  croeeinK  over  to  the  pAtieiit's  right  >^iilf>,  MlitcUe^k-r  ha:  fibu^aM 
convenient,  carefuily  i)irect«  the  bvak  of  tlir  iitatruoK-nl  towanb  the  \mk  4 
the  bladder,  turning  it  frotu  right  to  led  over  the  whole  uf  that  RgMi  ^ 


|V.*il».Mi|f 


A 


r/ 


f\t.  &U — SowMtlns  iot  JioB*  iNbtoi  PtmUM. 


aa  tfaa  Bade.  lAffiofrKbl 


JiOSt  draws  it  forward  on  one  «idc  as  far 

MDtly  with  it«  beak  ;  he  repeals  the  same  maoivuvr* 

uUtIv,  directs  the  end  of  the  instrument  by  raiaing  its  hatuila  tola  tiM  t)** 

fundus,  which  be  carefully-  explore*.     Uiunllv  the  iU^e  u  tiadilT 

by  tliew  msmeuvres,  and  its  pinition  in  tbo  bladder  will  uftm  be'd 

upon,  an>l  mny  to  a  oertain  ext<>nt  be  taken  u  an  appro xlmattra  k_ . 

of,  \\»  <nm.     Thus,  when  moderately  larga,  it  will  aauallr  he  fiMiad  lyiM[^ 

one  Kide,  mn«t  generally  the  right,  of  the  Dock,  of  ^hm  bladil«r ;  «bea  maIL 

it  will   be    placed  towards   the  fundus,  near  the   ortAw  of  tmm    nr  olW 

areter.    Tbcae  then  are  the  diualiona  iu  which  the  Sofgco*  dbodd  Cm  hA 


BOUNDING    FOK    STONE. 


913 


fat  a  stone,  aud  in  which  he  will  gt'ner.ii]y  fiiul  it  when  prraent  Should  it 
AOfc  ht  met  with  her*;,  the  i-h&iices  »rv,  nioro  especially  if  the  patient  be 
(dderly,  lliHt  it  will  Im  i<>uuil  itt  »  pouch  behind  the  proHtnl^,  where  it  majr 
^^)%  det^cteJ  by  depreseiug  the  hand!»?  aud  tsn  turuini;  the  beak  of  the  soiiad 
dowuwHpjB  (Fig.  8:18).  Hhwuld  the  Surgeuu  nol  detect  the  calculus  in  aiiy 
of  thuee  ftUuutLuns,  lie  deprcBties  the  buudle  betnteu  the  thighs,  aud  tilts  up 
the  beak  so  aa  to  exatuiae  the  pubic  portiou  uf  (be  urgtiD  (Fig.  83U).  in 
the  event  of  bis  oot  meeting  witb  &  sLune,  he  may  explurv  the  bladder,  first 
oa  one  side,  then  oo  the  other.  Should  the  mtiuual  syuiptoius  of  stoue  be 
well  mai'ke<l,  though  uo  calculus  be  struck,  the  Surguou  must  not  give  a  de- 
cided opinion  in  the  negative  after  the  first  exploraUou,  but  aliould  examine 
the  patient  again  a  few  daye  later,  with  the  bladder  in  different  state  as  to  its 

\ 

^^M  contents.  In  making  this  eecond  exuminatioD,  I  have  found  it  of  great  ser- 
yioe  to  use  a  hofluw  Hwl  sound,  by  which  the  organ  can  be  injected  or  emptied 
at  pleasure  (Fig.  840).  The  patieut  ehituld  on  this  occasion  have  his  bladder 
injected  thmugii  such  an  instrument  as  this,  with  foar  or  e'lx  ounces  of  tepid 
water,  so  m  to  <liBlend  the  organ  eligbtly,  and  prevent  the  folds  of  mucouii 
niembrauc  from  overlajipiug  auy  mucretion  that  may  exist  in  it.  Its  inte- 
rior is  then  carafully  explored  in  the  way  already  described ;  and.  if  tlie stone 
cannot  then  be  detected,  the  contents  of  the  bladder  arc  gradually  allowed 
to  escapti  through  the  sound,  and  the.  patient  Js  desired  to  stand  up  whilet 


i^mmmmi) 


'4,-;-*--J 


Fig.  iHi. — SoundiDg  Tor  SUia*  ftbnv*  PubM. 


Fig.  840.—I!ono<r  Bound. 

the  exph)ration  is  being  prncecded  with.  In  this  wot.  hy  examining  a  patient 
in  diSerent  posltione  and  in  different  conditions  of  the  bladder  as  to  capacity, 
a  calculus  is  sure  to  he  ilclocU'd  if  one  exiftt.  A  llthotrile  may  occnsionally 
be  advantageously  used  as  a  sound  for  the  detection  of  small  cak'uli  lying 
behind  the  prostate,  a  situntinn  more  readily  reached  by  ita  short  beak  than 
by  an  instrumeiit  of  larger  curve.  These  examiDntiona  must  not,  however,  be 
too  protracted ;  the  time  occupied  should  not  exceed  6vc  minutM,  le«t  cystitis 
be  induced.  When  a  stone  is  struck  by  the  sound,  thcr«  is  not  only  a  char- 
TOL.  II.— 5H 


URINAHY   CALCCLU8   AXD    LITHOTOHT. 


tit.  bulk  tcdcrtU; 
N  and  fttyiwly 


acterifliic  anil  dUtinct  shock  commtinlcatnl  u*  th<  ' ' 
1ou<l  click  is  given,  which  ran  be  heanl  by  the 
by  the  p«tit*ti(,  as  well  m  by  rhe  Rurueoo. 

Koii^h  ftiitiiidinK  18  thxibly  iiijiiri<>ii».  [t  injurf-«  fh^  Mft'M^r  andUlfl 
find  I  ho  8ton«>.    The  atiine  U  ollon  iiiita<4>il  in  fiiiiit>  I  y  whn  muil, 

by  Ixfin^citrrted  to  nnd  fro  as  the  tiritii?  nmi  I  he  liln'.  im1  l«ckni4 

anil  forwnnli>  by  miigh  iimiiipulatioii.  It  uiil  tw  ti'un<l,  if  tbe  fMti  kA 
alluwed  (ii  bL-coiiie  'jnii^ccut,  that  the  et^xiv  liilU  to  th*T  Ixittnm  bvbiait  tk> 
pm»t«t«,  wh«ru  it  will  be  fuond  by  a  gentle  lapof  th«  s»imrl  flr»t  uaoMMdl 
then  ijD  the  uLbcr. 

By  (Mnrlucliug  the  ButioJiDg  pn)per)r,  Ibe  Surveoa  may  uMially  aKTrtiis 
nut  uulv  the  extsttiuce  v[  a  atone,  but  it»  size  aon  hnnlpn*  ;  nhrtbrr  it  k$ 
single,  if  it  be  encyoled,  and  the  general  etutu  <if  ibi-  blmlijrr;  wit^  all  4 
which  it  U  of  iiiip<irtuuee  that  he  ehonld  be  acc|iininli<<l  brforr  underlaUll 
any  operation.  A  g<wd  deal  of  this  iafunimtion  iiiiiy  he  i-licitcd  by  tbtantt- 
nary  sound,  but  twiiie  uf  the  pviuls  can  be  accurately  dttmnumiA  «ly  if 
soanding  with  the  lithntrite. 

Tbe  hardnejig  of  the  stone  moy  usually  be  judged  of  by  the  noraor  !■ 
clear  ringini^  chnracter  of  the  click  ;  n  uric  arid  or  oxal»te  fif  Uim  nkatal 
^ving  a  sharper  sound  than  n  phoephalir  c>^ncreti'in. 

A  ealculuit  niuy  generally  bo  kuovPn  to  be  eitrjftted  if  the  loiiBd  Mrikt  ilil 
times,  but  not  at  otbon  (Fig.  S41) ;  if  theBtoneKlwaya  appear  lo  beindii 


Flf.  Ml.— Swindii^  rat  E»«/>l«l  OakNlva. 


one  iiitiiation  ;  and  if  the  benk  of  the  iustruroeDt  cannat  be  mad*  to 
round  iL,  kj  as  t<>  iftolate  it,  hut  a  kind  of  tumor  pri'jrcling  thrnueb  tbi 
of  the  bladder  i*  felt,  around  or  on  one  sidtf  uf  the  point  where  tba 
is  Ktruck.  -^^ 

The  fiutcieulalpcl,  rotitfheno').  and  tuorulated  tnndUion  e>f  fftf  lllartifrr  mtif  ■ 
generally  Iw  detected  hy  the  way  in  >^hieh  the  beuk  nf  the  loamiOMni, 
and  run  over  the  oivan. 

The  aJM  of  tlie  ck^uIuh  is  best  determined  by  a  llthotrit^.    It  Is  tme^H 
a  .Surgeon  mar  tHimi'tinK's  come  to  a  deriition  ns  bi  tbe  bnllE  of  a  cal<^lM.li^ 
ufaierving  the  extent  ofnurt'ace  aloitj*  which  the  sound  is  in  >s.iit«..-<  >:(h  th*, 
■tone,  as  the  inntninient  ia  lieinir  wiihdntwn.    But  a  verv  nlr 

can  bo  made  io  this  way;  and  [  hare  frequently  sivn  •-"'  -sT' 

gauna  deceifed  in  their  estimate  of  the  size  of  a  caico  ifs 

serenU  email  ones  lying  together  for  one  lar^ge  ooo.    li;  '■.  »  iiik»> 


KATHOLOOIOA^OHANSB^ITD^BU    BY    OALODLUS.     915 

Crii0  lAd  seixiu^*  tlie  calculus  geiitlj'  between  its  bUd«8,  a  correct  estimiit«  of 
iti  nice  may  aluavti  be  arrivril  at. 

In  order  U)  di'lrrminv  llmt  serial  mlnUt  exist  Jii  the  blmliler,  it  is  wioie- 
CinMB  saSii'leut  for  tlie  Hurgwiii  t>j  fuvl  that  the  beak  uf  the  »iiiind  cornea  !alo 
ooDtact  with  a  Btuiieoo  each  tide  uf  the  organ,  or  that  il  cna  be  dietiuctly 
iwiBaaled  b«lwt«ii  two  concretious.  In  sunte  cases,  huwever.  thwe  jHiints 
«HBOot  ekarly  he  made  out ;  and  then  the  ^urgetin,  inlroduciDg  a  lithutriie 
and  aeiziBg  the  first  eiik-ulus  with  which  hf  iiicel.«,  ehouhl  hold  itits  between 
the  hfaules  of  the  instrument.  Rnd  whilst  It  h  nn  fixed  move  it  and  the  titho- 
triie  frum  side  lo  side ;  when,  if  a  click  be  heard  and  felt,  he  raay  be  mire 
of  the  rxisl«9)oeof  another  stone. 

Souadiugubjno  mean^  destitute  of  danger,  more  especially  if  mughir 
done,  or  in  patieoU  who  have  chronic  kidney  disease.  In  the  first  cose  it 
wtmy  give  rise  to  cTsiitis  or  profuse  and  continuona  hemorrhage;  in  the 
weana,  to  ri|,'on  and  ttuppn^s^ion  of  uririo. 

Srrors  in  Soanding  i>coA»)onAlly  occur.  The  Surgeon  may  mistake  a 
bardenc-*)  und  tW>ctciilatc-<l  bladder,  having  ito  ri<lgi»  ptsrhajifl  eiicniett-d  wilh 
pbosphstic  roatt«;r  for  a  calculus;  this  in  enpecialty  apt  to  ha]>{>eii  in  chihln-n. 
In  toeve  ^-asn,  however,  the  mistake  may  usually  lie  guardvd  against  by  the 
■bnooe  of  a  distinct  click,  thmich  a  rough  grating  sensaiion  he  experience*!, 
mad  by  the  Surgeon  being  unable  to  isolate  a  stone.  Yet  the  difficulty  in 
•Dsnecaaea  is  great;  Velpeau  stated  that  he  was  acquainted  with  four  in* 
flaDOCS.  and  8.  Cooper  with  seven,  id  which  patients  have  been  cut  and  no 
cmlculos  found  :  and  when  we  reflect  that  these  accidents  have  happened  to 
■tefa  mm  as  rheseldcn,  who  oa  three  occasions  cut  a  patient  and  found  no 
atone,  to  Crodee.  to  Houx,  and  to  Dupuytren,  it  h  easv  to  underetiind  ttint  in 
■DOW  cases  the  diffiouhy  of  ('<.>tiiiii;:  to  ii  i-orni'ot  dc-ci^ion  must  be  very  grcnt. 
KmunatioD  of  the  Bladder  by  Manipulation  ran  be  easily  carried  uut 
in  children.  The  patient  is  fully  aniesthotiM'd  ;  the  Hurgeou  then  passes  one 
iager  into  the  r»^ium  and  preMes  firmly  with  the  oihcr  band  above  the 
pOBCa.  If  a  stone  be  prwent,  it  can  lie  clearly  felt  by  the  finger  in  the  rectum 
and  ilB  flK  ascertained.  In  adults  th»  ronde  of  examination  iit  of  courae 
impoarible  if  there  be  murJi  abdominni  fat  or  any  enlargement  of  the  proe- 
tale,  and  even  in  the  absence  of  these  conditions  it  is  very  uncertain,  as  the 
incer  dues  not  reacb  far  enough  up  to  gmsp  the  stone. 
Rane  in  WomeiL~tii  women  the  symptoms  of  mono  cloeely  reaemble 
,  llioie  nkct  with  in  m«>'n,  and  the  deteclirtu  of  the  <'ftlcuhiA  is  usually  very 
ring  to  the  ahortncsu  of  the  cAnnl  and  the  facilitv  with  which  the 
lay  be  tilted  up  by  introducing  the  Sngen  of  the  leH  band  into  the 
The  itound  usett  in  th«>e  cases  shunld  be  shorter  and  less  curved 
tltat  «n|.l.iyeiJ  for  the  detection  of  calculus  in  the  male  bladder 

iiOLoiK-Ai.  CuAN'tij*  i>fi>ioEi»  uv  C.\ix:i:ll'9. — After  a  stone  has  ex- 

lor  some  time  in  the  bladder,  it  induces  »eri>^uB  pathological  changes  lO 

Ihc  whole  of  the  urinary  npparalUB.     The  iiMAro  usually  becuraee  slightly 

dilated  ;  and  thf  protiaie  not  unfrvquently  somewhat  enlarged  and  irritable, 

io  conrojuence  oi  which  a  kind  of  {Kiuch  ia  formed  Wbind  it,  in  which  the 

^■Iculof  is  apt  to  lod^.    The  moat  important  changes,  however,  take  place 

^B  the  bladder  and  kidneys.    The  bladder  becomes  extremely  sensitive,  espe- 

^Bhlly  almut  its  neck,  ana  ia  oonae(|uently  unable  Ui  enntuiu  as  much  unoe 

Bfc  usual :  hence  it  beoomes  ooatraoteil.     Ia  some  rare  instances,  however,  as 

^wiU  bo  more  (specially  noticed  when  we  coroB  to  apenk  of  liihotrity,  it  falls 

into  an  atonic  condition,  and  then  is  apt  to  become  rather  largely  dilated. 

The  mWKMii  membrane  13  commonly  a  pHvl  deal  iuflamisl  and  irritated  by 

the  psneaoe  of  the  calculus  ;  and  the  muscular  coat  becomes  thickfuod  and 

hypertraphled,  so  as  to  give  It  a  very  fasciculated  up|)earaooe.    Saccull 


016 


[TBiNABY    CALCULL'S  ANU   LITHOTOMY. 


eocuiouolly  form,  contiiiuto^  sabulouB  matter  uid  fetid  pus  or  urine,  aod  in 
■OfiW  casca  IiMlging  a  concreliou,  uliicli  theo  cc)Qi>titute8  ao  enc^'sted  caiculut 
lying  aitoj^ilier  uuuidi!  tlie  fuvity  of  the  bladder,  with  wUicb  it  mereiT  cora- 
mutiii-uti*  by  a  vcrv  imrrow  aperture,  as  in  Fige.  835  aud  i*'M,  represtDting 
a  c-ttHe  Ltiat  wa»  uadvr  uiv  can?,  and  wliicb  is  fully  described  id  tbe  JouraaU 
for  Miinh,  185;-{.  The  \iitnetfs  are  oficu  eongi-sutl,  frequently  io  a  state  of 
chronic  or  t^uhacute  hiLcretitial  intlnmmaiiiiii,  aud  tiltimately  be<?ome  the  scat 
of  Kiu-h  Btnifaiirul  clmiigtn  a«  an;  iiif-ouipatiblo  with  life.  When  death 
occurs  an  the  luiiitwqut-iu'v  iif  Hloue,  the  patient  usually  sinke,  worn  out  by 
protracted  HiitTeriug  aud  kidney  diauaae. 


UTHOrrOMY. 

It  is  not  my  intention  to  enter  into  the  general  history  of  lithotomy,  an 
operation  that  has  been  practised  from  the  earliest  ages  ;  nor  to  give  a  SKetch 
of  the  gradual  modifications  that  have  at  various  times  been  introduced, 
from  the  rude  attempts  of  the  Greek  and  Roman  Sur^e^JiM  to  the  barbarous 
and  unscientific  procedurw  adwpt«l  by  the  itint-raut  operaUirs  after  the  re- 
vival of  letter*.  For  all  this,  I  would  refer  tbe  reader  to  the  classical 
workH  of  Desehanipis  and  of  Juhu  Ifell.  The  o|teratiou,  as  now  generally 
practised  iu  this  country,  is  esaeiiLially  that  iutruduce<l  by  Cheseldeu.  aud 
modified  more  or  less  accoriiiug  to  the  views  of  ]>articular  bur^^ns. 
Though  Burgeons  generally  are  agreed  upon  the  great  principles  involved 
in  it.  they  diifer  iu  their  modes  of  carrying  these  out ;  thus  tbe  direction 
and  extent  of  the  incisions  and  the  instruments  employed  have  beejj  much 
varied  to  suit  tbe  tastes  and  views  of  particular  operators.  But,  although  I 
look  upon  Cheaelden's  operation,  as  modified  aud  practised  bj  Lt&ton,  at 
being  on  the  whole  tbe  simplest  and  Bafcst  mwic  of  cutting  fur  stono  m  yet 
introduced,  there  can  be  no  doubt  fbat  reeourac  may  occttsioually  bo  bad 
with  advantage  lo  other  methods  iuetead  <)f  it.  Indewl.  there  is  oo  opera- 
tion that  reouires  to  be  considered  from  m  many  and  «uch  different  poinia 
of  view  ats  lithotoniy.  The  size,  sba]M;,  aud  piwitiou  uf  the  stone,  the  age 
and  eoustiluliou  of  the  |>Htieut,  all  render  it  desirable  and  indeed  UDceasary, 
to  modify  the  method  uf  operating.  Hence,  a  Surgeon  ithonld  not  be  too 
exclusively  wedded  to  one  plan,  but^ihould  adopt  one  or  other  of  the  methods 
about  to  iic  described,  according  to  the  exigencies  of  tbe  particular  case 
before  him. 

lostraiQentt,  etc. — The  table  for  operating  must  be  firm  and  of  a  cou- 
venient  height,  m  that  ulicn  the  Kui^emi  Bitu  on  a  rather  Km-  al^Kd  the 
patient's  nates  will  be  nn  a  level  with  hia  brea.*tt;  a  few  blankets  doubled 
shonid  be  laid  upnn  tbe  table,  and  covered  by  a  piece  of  mackintoah  cloth 
hanging  aver  the  end  ;  and  a  tray  of  aawdust  placed  under  it  on  the  Soor. 
The  instruments  necessary  are  the  following:  a  pair  of  lilholomy-lapea,  a 
•harp  and  probe-pointed  scalpel,  a  staff,  forceps,  and  scoopi  of  varioua 
sizes,  and  a  tube.  To  these  may  be  added  a  searcher,  and  a  brass  injecling 
syringe. 

The  tape*  should  be  of  coarse  flannel,  about  three  yards  long,  by  tbree 
inches  broad. 

An  infinite  amount  of  ingenuity  has  been  expended  in  giving  variety  to 
the  shape  of  the  knives  usetlfor  opening  the  d««per  portions  of  the  uretbrs 
aud  neck  (if  the  bladder  in  lithotomy.  lustrument*  of  this  kind,  slraigbt- 
edgfd  and  shouldered,  beaked  and  probe-euded  in  every  possible  way,  have 
btvu  devised  ;  and  each  has  bad  its  special  advocate,  but  has  seldom  been 
adopted  in  practice  by  any  except  its  Inventor.  All  tbeae  modifications  of 
tbe  ordituiry  scalpel  are,  to  say  the  least,  usuleoB;  some,  perbape  actually 


LITHOTOHT — INSTRUMENTS,  BTC. 


917 


dangerous.  They  simply  seek  to  supply  by  mechanical  means  that  safety 
in  the  deeper  iDcisioDS  which  may  oa  readily  be  secured  by  a  broad-bladed, 
■t^ugh^backed  scalpel,  if  properly  guidecl  by  a  hand*  that  is  ordioarily 
skilful. 

The  cutting  gurget,  formerly  much  ia  vngue,  is  all  but  univerBally  discarded 
as  m  must  dangerous  tool  bv  toe  modern  lithotomist. 

The  aeafpel  for  the  adult  may  be  of  the  size  and  the  shape  represented 


X 


Fig.  812.— LUbotomjr  SoftIp«1. 

(Fig.  842)  ;  for  children  it  may  be  made  a  little  smaller,  A  probe-pointed 
litkotomy  knife  o(  the  size  and  shape  here  represented  should  also  be  at  hand 
(Fig.  843). 


Fig.  SiX — Prab«-potnt«<l  LUhotomj  knire. 

The  ttaffBhoulA  have  a  deep  groove  on  its  \eft  side,  occupying  nearly  one- 
third  of  the  instrument ;  it  should  be  well  curved,  of  as  large  a  size  as  the 
urethra  will  admit,  and  have  a  roughened  hautile  (Fig.  849). 

The/ortsept  must  not  be  too  heavy,  but  should  be  of  a  good  length  in  the 
handles,  and  have  the  joint  well  set  back  ;  tlie  inside  of  the  blades,  as  recom- 
mended by  ListoD,  should  be  lined  with  liuen  to  prevent  the  stone  from 


Pig.  SU. — Opcn-blsdeil  I. ith 01010; -force p.  lined  witb  linen. 

slipping  '^Fig.  845).  Coxeter  has  made  them  with  o|ien  blades,  but  lined 
with  linen  as  heretofore  (Fifi-  844  i;  in  this  way,  as*  there  ia  less  metal,  the 
weight  is  diminished,  and  the  diariietor  of  the  iii'^trumont  with  a  »tnne  in  its 
grasp  is  materially  lemoned.  The  ordinary  f>)rco[)s  arostraiirht,  but  it  is  ad- 
vantageous to  be  provided  with  funo  that  nro  curved  'Fifr.  84)>).  The 
handles  should  be  miide  with  a  loop  <in  mw  sidt-  iiiul  a  rin^  mi  the  other  ;  the 
ring  fur  the  reception  of  the  thumb  sliuiild  be  placed  SDmowbat  iibli<|Ucly. 
the  »eoopf  of  (lifli'rcnt  sizes,  ami  eiirved.PiUi  most  cDiivfuiently  be  upcd  when 
fixed  innmghened  handles  i  Fip<.  817  and  >^A>^).  The  fi/6c  should  Iw  of  silver 
or  gum-elastic,  well  niunded  at  the  end.  juid  providorl  with  silver  riu^,  and 
may  be  petticnatpd.  The  ^rnreher  is  a  slightly  curved  siniiid,  haviiijr  a  bulb- 
ous extremity  (Fij^.  8r>0  i.  The  mjrinrjf  should  Iio  provided  with  tJr<).«9's  l)all 
nozzle,  which  projH'ls  a  rcvcrscil  current. 

Id  describinfT  the  operation  of  lithotomy,  wc  shall  tirst  of  all  examine 
teriatim  the  different  steps  of  an  operaliiui  that  |)rcsents  no  unusual  compli- 


918 


URINARY    CALCULUS    AND    LITHOTOMY. 


c&lion  or  difBculty ;  wc  shall  theu  couttider  the  difficulties  that  laav  be  met 
with,  Lhe  accideuls  thut  may  ou(!Ur  during  tlie  operation,  suil  lUv  |iriDcipal 
sourtiea  iif  daD^^er  and  tlio  ca.usQ8  uf  death  ailer  its  p«rfortnaaoe. 


I 


¥ie.  MS.— 

Fif.  Jtfl.— 

Kie-  SIT.— 

Flj.  HS.-~ 

Fig.  8(0.— 

Fig.  8M,— 

Vorovps, 

Curved 
ft>Tet\>t, 

Handlo. 

^eoop. 

Suff. 

8«*r«b«r. 

FrAparatiOD  of  the  Patient. — I)«f<irc  subjectiug  a  potient  to  operation,  liT 
gontral  licalih  iiiucl  l>e  iiniptrly  ailciidcd  tii ;  ami,  iiHJrod,  if  wc  find  the 
coti«iimiiuii  mucU  hniki-u  by  [irolmijii-Hl  sulToriuj;^.  thi*  bladder  or  kitlnuy» 
acriau^ly  diitoaeed.  &»  iiulientL-d  by  tlm  cxiiiLi-iu-f  of  pita  or  atbiiuu-u  io  lurge 
quaiiiily  ill  liiA  urine,  and  by  ttit-  pr(wni»!  of  the  ttyiiipt<imt<  of  intcnutitial 
nrphriliB  (p|i.  ^!l(t~H!>4),  it  will  bv  wiHt.'  Id  poigliHtiie  the  ii|HTiitioii  for  a  lime, 
»r  pcrhuiM  i-'v(!Ti  In  nbftiidoD  it  altxigether.  Tht^re  are  few  coiidttiotiH  in  which 
a.  Surf^uoii  \»  pliiRod,  that  tu«t  bin  moral  courage  more  severely  than  lhe 
refiisul  t'l  o|M>rate  nn  a  patient  for  nttine,  and  thus  allnwing  him  to  die  unre- 
lieved. For  a  Stirgeou  to  di)  tliitt,  unmoved  by  the  entreaties  of  the  pBtient 
and  iif  hia  friends,  reijuireH  no  little  Etelt-reiiiLncc.  Yet-,  when  the  palieot  ia 
greatly  eniacialed,  Kin  coiiDlitiition  broken  duvrn,  and  htH  kidneys  evidently 
miK-li  d i.«f iiM'd,  lithotomy  n*oulH  he  attended  hy  nn  inevitahly  and  mptdly 
fatal  resitlt,  mid  the  prrmrnianne  of  an  ofieration  wotild  be  a  nseletw  act  of 
cruelly.  SupjKistnp;,  hoivever,  thai  Ibe  atone  is  of  mixlerate  »izp,  that  evi- 
dence of  rpnnl  disease  is  absent  or  slight,  tlint  lltore  'm  vo  vii^rerul  cumplicfl' 
lion  111  prevent  the  ix*rforiiiftncc  of  tlie  onenition,  and  that  the  palieot'l 
heallli  is  in  a  tolcrftldy  yo^id  slate,  it  will  be  necessary  to  subject  him  only 
to  proper  prfiiarnlivc  treatment  for  a  short  tinif,  sn  »»  to  allay  or  reroorc 
irrilability  of  Ibe  urinarj*  organs  befijpc  procerdinjf  with  i(.  With  this  view, 
he  should  l>e  ki-iit  ta  <:|tiiet  a»  |His8ible  for  about  a  week  or  ten  days  preceding 
the  operation ;  his  dtol  sliould  be  nropterly  regulated,  hut  not  too  low ;  the 
pain  idiould  be  leii^eneil  by  the  naininititration  of  opiates  or  b^iibane,  and 
the  bowels  properly  relieved.  Ou  the  day  preceding  the  operation,  u  dose 
of  cuBtor  oil  or  eunie  other  apeneul  elioutu  be  iidmiuiBtcred ;  and,  on  the 
uioruing  of  tiie  operation,  thv  rectum  must  be  emptied  by  meuna  of  an 
enema. 

Latekal  Oi'UKATiov. — All  the  urine  contained  in  the  bladder  baring 
been  drawn  oH',  thai  organ  should  be  filled  by  the  injection  of  about  six  or 


* 


eight  ouucis  of  tepid  water,  in  order  to  steady  il  and  tu  fucilitate  ihp  seizure 
and  cxtracLiuu  of  llw  &Umu.  ACler  ciilnnituriii  hau  bti^ii  adrciiuiHtcrn],  the 
SurgooD  should  iulruduLt,'  a  Jut]-i(iz«d  ulnff,  whicli  he  uttes  oh  a  boiiiiiI,  in  order 
to  feel  (vr  ibo  calciitus.  If  hu  detvciuj  il,  he  jintccttdo  with  ttie  op(>ni(iim  ;  if 
he  caiiiittt,  d(!tect,  it,  il  in  ui'ualty  m'otiinieiided  that  he  ehnultl  withdraw  the 
Ktuff  and  iii1rtidu(-e  ii  nniind,  with  which  he  exarnineo  the  hlndder;  and,  in 
the  event  «)'  hw  j'till  tailinp  to  dificnver  the  preeeiioe  of  the  Btone,  the  opera- 
tion niiii-l  hi!  defrrr*-*!,  fur  it  is  an  imperative  nile  in  Burgery  thnt  lithotomy 
should  never  he  pert'trnied  iinlegs  the  etone  can  be  felt  at  the  time  when  the 
pntient  in  actually  nii  the  table.  It  in.  howevet,  snf'er  not  to  proceed  with 
the  (ifveration  nnlesa  the  atone  eon  be  felt  with  the  staff;  lest  the  point  of 
this,  ihonph  apparently  in  the  bladder,  be  nciunlly  engagefl  in  a  fnlae  pa»- 
sa^.  The  Mone.  then,  havinj^  been  felt,  the  patient  ia  to  be  firmly  tifd  up. 
This  is  done  by  making  a  clove-hitch  on  the  tape,  and  passing  it  riiund  ttie 
wrist,  afler  which  the  ends  of  the  tape  arc  pa^ea  round  the  instep  and  hand 
in  a  figur&-of-8,  as  in  Fig.'Sol.    Some  Surgeons  prefer  leatlier  anklela,  which 


Tif.  fiS1.— Paailien  of  l^tlentimd  Line  ot  Iii«iti<>B  In  LftUmI  Iiilb&lMnf. 

are  attnched  to  eollars  round  the  wrists  by  hooks ;  but  these  take  lons.'er  to 
apply,  and  po^ess  no  purtieular  advaiituge  over  the  tapes.  The  paiieiit  is 
now  brought  to  the  end  of  the  table,  so  that  big  nates  projeet  beyond  it, 
where  he  ia  to  be  securely  held  on  each  side  by  an  assistant,  who  gruap-t  the 
foot  in  his  hand,  places  the  patient's  kuec  under  his  arm,  and  dmwe  the 
limb  well  aside,  so  that  the  perineum  may  be  fairly  exposed.  It  is  desirable 
that  the  perineum  be  thus  fullv  expcaed  to  the  Surgeon.  In  a  patient,  how- 
evi-r,  on  whom  I  once  operated,  this  could  not  bo  done,  owing  to  the  left  hip 
being  stiffened  hy  chronic  rheumatic  arthritia  ;  hut  I  did  not  experience  any 
particular  difficulty  in  the  operation,  ihouah  somewhat  i  neon  von  ic  need  by 
the  p(»flition  of  the  limb.  The  Surgeon  Mien,  acating  himself  liefore  the 
patient,  shaves  the  perineum — if  this  have  not  already  been  done— and 
introduces  his  finger  into  (he  rectum.  This  is  done  with  three  ohjc<'lfl:  first, 
to  ascertain  the  depth  of  the  perineum  hy  feeling  for  the  apex  of  the  prostate; 
MCnndly,  to  make  »ure  that  Ihe  rectum  is  empty ;  and.  thirdly,  to  cause  a 
contraction  of  the  put,  which  will  kpep  It  out  of  the  way  during  the  first 
incision.  He  then  [^ives  the  t^tiiff  into  lh(v  char);e  of  a  *.ruHLy  assistiint,  who 
stnud))  on  thf<  patient's  letl,  and  who  raises  hihI  draws  aside  the  scmtnm  with 
,ibe  lefl  hand  whilst  be  ho1d»  the  staH'  in  the  right  (Fig.  SfA). 

The  Surgeon  then  sees  that  the  staff  is  held  in  the  way  in  which  he  prefers 


oso 


UBINART   CALOULUS    AND   LITHOTOMT. 


il.  Tlicro  are  two  ways  id  which  it  nmy  be  held ;  it  may  either  be  dmwn 
Wfll  up  iuto  ttie  (irch  uf  the  pultes,  or  it  may  be  pushed  somewhat  doiTo.  aud 
8lif;htly  turned  towanls  the  left  of  the  perineiiui.  Listou  always  employed 
the  lirbt  rut'thuJ,  which  1  certainly  think  ie  the  best,  as  it  tvud«  to  in<-n-a^«  tbe 
8|>acebvlwvc-u  the  urethra  and  the  rectum,  and  conscqueulty  lascnn  tbe  danger 
of  wuundiug  the  gut,  vvbicb  more  tbao  couutitrhulauc^d  Uie  B4lTiui(agc  of  tbe 
other  method — that  of  ajipmaehing  tho  membranoua  |K)rUaD  of  tlie  ureihim 
to  the  surfacic. 

The  exlvrual  inpijiion  ia  made  by  entering  the  knife  in  tbe  mnhe  of  tbe 
penneuni,  (inc  iocb  and  a  half  above  the  tinue,  and  ntrrying  it  rlnwawards 
and  nulwiirds,  until  it  rcflelK')!  a  pidut  that  is  jui>t  ti^tnn-  the  anus,  but  about 
ooe-third  nearer  to  the  itibertisily  oi'  the  itirhiuni  than  t(»  the  marjrin  of  tbe 
anal  apertnri?  <  Fij^.  H5]J,  It  'a  uw\vh6  u>  prohmg  the  inciniim  beyond  this, 
as  any  freer  division  of  tbe  atruclurca  of  the  scrotum  and  on  the  natee  cannot 


Vv 


FIf.  SAX.— lAt*nl  Lllhaiom;  ;  f  EBg«rD»il  Ut  anon  of  th«  SuJL 

faeilitate  iheextraclionof  thextDnc  ;  but  it  ninet  occupy  tho  extent  tudical«d, 
oLberwii<v  couaidurabli:  ditlirulty  may  l>e  experii^iirvd  in  the  lulor  Ete|)e  uf  tlw 
operntinii.  Tbt;  di'plli  tu  which  this  intusinn  .should  be  rarriinl  niiib<l  vary  ac* 
c»)rdiii^  tu  the  olnvity  of  the  subject:  usually  from  about  thnfM)uarttiraof  aa 
inub  to  an  incrli,  bni  not  so  deeply  above  as  IihIow.  ily  ihitt  inciHinn  tbeskia, 
sufKirlieial  riiBciH,  tfiihaitaneoits  fat,  and  inferior  hemorrhoidal  vemels.  ara 
divided.  Ader  it  is  oornpleted,,  the  knife  \s  apiin  inlnidueetl  a  tittle  below 
the  np|ier  part  of  the  vvouiid.  and  the  blade  \a  run  lightly  downwards  n\'er 
any  naisling  Btrufturcp  ;  the  left  liirelinger  being  placed  at  the  middle  id' the 
wound,  »o  as  to  (miteet  tbe  rectum.  In  this  way  tlie  triangular  ftpace  b 
opened  Iwlween  the  nccelenttor  urinic,  the  erector  penis,  and  the  tranareraatia 
perinset  muscles;  and  as  the  knife  is  carried  downwanU,  tbe  laat-naitied 
muscle,  the  transversnlis  porinfei  artery  and  ftome  areolar  timue  arc  cut 
through.  Tho  lower  border  of  the  triangular  ligament  also  is  notched  so  as 
to  open  up  the  apace  between  ihc  two  lavors  of  the  ligament,  in  which  the 
raembraaoUB  part  of  the  urolhra  licit.  The  knife  \i  then  withdrawn,  and 
the  left  index-6nger  is  puahcd  deoply  into  this  apace  until  the  edge  of  tbe  nail 


LATBRAI.   LITHOTOMY. 


921 


•<_ 


is  lodgt'il  in  the  ffroove  of  the  staff  (Fife-  852'),whicli  cnu  be  felt  just  anterior 

lo  the  jmwtnte,  thinly  covered  by  the  tnerabranoiia  portion  of  tlic  ureLlira,  the 

«>ij»trictor  iiretiine,  and  the  deep  transveree  muscle.    The  point  of  ihc  kuife 

18  Iheu  nuHhed  through  the  urethra  at 

its  menibraDoUB  t^art  into  the  groove  of 

tb«  Blaff,  above  ttie  index-linger,  which 

prutects  and  preeses  to  the   right  the 

rectum  lyiog  beueatb  iC  (FJga.  863  and 

6o4). 

When  the  knife  is  felt  to  be  well 
lixiged  in  the  groove,  i\g  handle  U 
elightly  'fepreaatxl,  ao  thnt  the  point 
may  be  raided ;  at  the  same  time  Lhe 
b!ad«  should  be  rainewliat  latvmlixed 
6o  that  its  e\dt  lies  piirtitlel  lo  the 
nuDUS  of  the  ischium.  If  the  eilge  hu 
turned  too  directly  downwani<t  towardii 

the  mesial  line,  the  reciuni  may  be  wounded ;  and  if  it  be  directed  too  tnuch 
outwards  the  intbrnal  pudJt?  artery  will  be  eudangcred  (Fig.  855) ;  hence  the 
mid  course  ia  the  proper  «nc. 

The  Surgeon,  keeping  the  knife  steadily  in  this  poeitton,  and  pressing  the 
point  firmly  against  the  side  of  the  groove  of  the  etafC,  whi(^h  ho  must  never 


fig.  SM.— Knth  In  Oroav*  of  Staff. 


A 


Vt- 


moment  low,  pnsh<«  it  forwarde,  dividing  the  membranous  part  of  the 
urethra,  the  :int(-ri<ir  part  of  the  proKlatc  gland  and  the  i^heatli  eiichieitig  it, 
and  a  few  fibn^ofthii  levator  aui  i  k-valop  pn»8taln!\  ami  ibim  malii*  un  eulrr 
intn  the  bladder  (Fig.  854);  ho  then  wiilidraws  the  knifu,  kfi-ping  iia  ImcK 
against  the  iM&ff,  act  as  nut  to  enlarge  the  extent  of  the  excision  in  tJic  proeiutA. 


URINAKT    CALCULUS    AND    LITHOTOMT. 


Tbmugii  tlii».  &it<l  ulitu}^  tlio  :iUiif.  bi<  ihcn  pwAac*  hiB  left  lailax-Aivv  uciliL 
rraehm  tltn  bliuMtT,  wlit^ti  lie  enrlcRvon  Co  ffv\  tii«  mIoiIu  mib  i»in. 
Should  his  liiigcr  be  ahori,  the  perineum  dr^p,  or  tho  proiUta  «ahig«i,M 
tntiy  be  unnblc  to  rencb  the  hliuldor  in  ihia  wav;  ukI  tawat  AftmiUnttn 

A  blunt  gorgf^u  a«  rccoHUMoMt^ 
Chcaelden  luid  MarttiM«u.ia«f4vi> 
dilate  tbe  apenarr  io  tlM  prwttBk  V 
be  uae  lib  laay^r  Ttir  lliw  fofrin, 
he  f^ivt*  it  a  twist  or  two  a(W  yi* 
ill);  it  thnjugli  tb»  pn-f-T<-   ->  m  w 

fiiUrgti  lliv  ai)«rtun)  t  •'^  < 

J/'      ;  •  ^^S— ,^BIfci\^fe^^  '*  ♦"'lerwl,     Haviiiji   i^  •  tUi 

/        latfff^jT^^^^^t  ^^^^         ''    '*   '"    *'"'   bUitdw,    .11   1    :i4.;c^  rf 

^^  ^^  ^ctt        jMiBBible.  fvll  the  fivor,  b»  ttiTwti  tbi 

ttwistant  to  wtlbdrav  lb*  itiff  fe« 
tbe  ur«tbra. 

Ilmi   Ivt   us  pauae,  aad   i  umm 
lb<*  principal  piitDta  id  tiMac.  ife  fa> 
^^ri  JJBfS'^B^VI"'  '^''  ''^'*''>'*^  Magu  itf  tbt  opcffStiMk.  Il 

V^i^killlBl^^lv  *'"  ^  obaervad  Uiat,  ia  aaaa^— 

¥V^%\CB^By  *■■'*  ^*)  '^""^  autbnritica  ap«  te 

1      >^Hm^^^  subject,  aad  witli  niT  o«b  nperiiaEl 

^^^^r  I  linvo  reuonimcndra  tba  tfitmal  » 

ci?ion   to  be  frw,  ihp  ravton  tu  bi 
protected  by  the  lefl  jiulac-flBffir,  tk 
KiiifetobrMmevtbat  laientJlHihRilf 
and  nflor  tbo  oprninj;  of  the  urethra,  nnd  ihe  d«>p  incisiuu  to  be  limiipd. 

1.  The  Position  of  tbe  Knif^  rnuet  be  oanfully  aTleoil^  to,  wpm>>Dt 
during  the  deep  or  secoud  incision,  At  tbw  itaffc  uf  tbe  upetmtioft  u*  i^P 
should  be  UittraUteAi  that  ia,  dirc-ct«l  abuut  midway  betw««i)  Um  liailaaBl 
and  ]K-r|x-iidii;ular  positioos,  so  that  the  atirtkc*  of  tbe  bbuk  Um  attHj 
parallel  tu  ibe  ramus  of  the  ischium.    Tbv  oiiiitn«r  uf  holding  the  knifB^ 


Fie  8&3/ 


-Art»rf«*  vf  P^tiiMnni  anil 
D*ap  Fautla. 


FIk.  SM.— Pwiiton  %X  ItkRd  ftiiil  Knifi 


Fi(.  SiT.-I'Mtthi  of  Nm4  a^  I 
{Lt*u»k 


bwD  much  dlscuHed,  and  xwceasarily  and  iiatumllv  raH«»  with  di 

SormoDS.     I  believe  it  Bitruifivs  tittl*  bow  the  baotfle  of  ibo  inifniltf 
hold  between  the  SurKean's  fingers,  proTidcl  the  mIjco  bv  turrar  tunMila^ 
wards,  but  b«  atwnvs  kept  weiriaCeralizw],  with  the  poiot  st^ulilr  pi^nA 
into  the  groove  of  tbe  stnfll 

If  a  Surgeon  know  wbnt  be  is  about,  he  innv  safely  hold  hb  knif*  as  hat 
suits  hia  own  cunvenieiiee.     In  the  firat  iociiion.  mr«t  "prrat'TT*.  T  *   " 
bold  the  knil'c  under  the  baud,  as  reprvtentad  in  V 
that  exeollent  litboioniist  aod  aocompllsbed  Surgi      .        „        .. ,  , : 
throughout  tho  o^Tflitoa.     Liaton,  tn  the  eariy  part  oi'  bia  oarwr^ : 


UOVE   or    HOLDIKO    THE   CKIFC. 


923 


FIf.  n}<l._pMmaa  •(  IUd<I  mJ  Kttih  (Anlttn-). 


to  lutvc  bdd  tbc  koife,  iu  the  «ec>mi)  stage  orUie  upemtioo,  a6«««  the  hand ; 
•od  ill  nil  th«  reprv(>«nLnli'.<ii«,  |iiilili!>lu-il  »k  wril  ati  uiipubllitlieil,  ihat  he  has 
IcA  of  bis  vi>vrHti«D,  hv  htm  •■W-i>'u\.tn\  (he  knife  am)  liantU  iu  the  pMJtioD 
thtrwn  in  Fig.  HoJ ;  which,  in  tliu  Ihx(  tililion  ut  lii>'  i'rtttlieal  Surgery,  he 
describee  as  a  correct  ekutoh  of"  llic  |»L«tti*>ii  ut  the  hamie  uud  kiiitv"  at  tiie 
coii.Tiienn-nipnl  uf  ihe  eec<iti<l  ttagu  of  the  u|>cra[ioQ,  There  can  be  uo  doubt, 
buttuver.  aa  l'er)^usBi>a  baa  jKiiaLeil  nui,  that  Ju  actual  jtructlce,  at  least  aRer 
U>  fir»l  lew  yean  as  on  opcratur.  he  held  itio  kuitc  uuilt-T  the  band,  witli  the 
tadc'x-Qnger  uiwn  the  side  or  the  b»ck  of  tlic  blade. 

Kiir  my  nwii  |>art,  I  believe  that  i:very  Surgeuu  will  bold  the  kaiic  in  the 

war  which  be  titidd  ntiiet  t'on%'e[iieut,  aiul.as  it  ntrv,  nuturul  to  bini.     It' any 

mies  cno  he  Inid  duuii  un  this  |hjIiii.  1  iib>iulil  t-ay  lliat,  in  uperatiog  on  a 

child,  or  OD  BO  adult  with  a  shallow  ])eriiieutii,  the  ktiile  is  uiiist  convenietitly 

Kelt!  as  reprcacnit-d  in   Fiy.  W.'iG. 

But  if  th<-  pniicnL  be  tat,  luid  tbc 

perineum  di-vp,  then  I  think  that 

It    r«  a  <iurstiiin  wlicther  greater 

•lifaitiDf^a  may  not  sninctimes  be 

•rruretl  by  holding  the  ktiile  some- 

whnt  ID  the  mnnner  of  a  gorget, 

with    tbe   index-fiager  pcrhapt  a 

liitiv    tnnre  upon  the  side  of  tbe 

haii<lte  (Figs.  808  and   954);  la 

tliia  WBT  the  poiDt  is  brinly  pressed 

ioio  the  groove  of  the  stall',  out  of  ubich  it  eauuut  slip,  as  it  is  secured  and 

■upported  bv  the  iodex-Uuger  being  mmiewbat  iimlfr  it.     The  »ecti'>n  nf 

the  pnulote  tn  thus  made  liy  a  steady  piitih  i»r  Ibniml  of  the  koife  forn-antii, 

asd  Bat  by  aiiy  euttiug  iiiovemeiit  dowiiwHrdx.     Nu  danger  i-an  result  la  the 

deep  incision  6*1110  put^hing  iIil-  |N>int  of  the  knife  up  into  tbe  groove  of  the 

•Uff;  but  lheri>  is  great  danger  of  miming  the  bladder,  aii<l  entering  Ihe 

ncUHveniral  8pan>,  if  it  he  ut  all  rlepreaen)  and  the  han<tle  mi^ed.  though 

thi?  ranuni  always  Ik>  avoided  if  the  HtalTbe  pushed  det-ply  into  the  bladder. 

may  happen  tliat  th<-  kctile  will  not  run  readily  along  the  groove,  if  its 

de  form  u>o  small  an  angle  with  the  part  nf  the  AlaH'nitli  uhich  it  is  id 

:tact.     The  hand  inuNt  ihen  l>e  slightly  raise*l  and  depressed  again  as  the 

nife  glides  along  the  curve  of  the  slnlT  into  the  bladder,  so  that  the  jjoint 

IT  he:  kept  well  In  the  grxove;  nnd  nil  rivk  of  slipping  nut  avoided. 

%  Tbe  iDCtsion  into  the  Prostate  tnu^t  he  at  least  of  sufficient  size  to 

Riit  the  tin  of  the  litrrtiiigcr  resdilv.     The  extent  lo  which  it  should  be 

'ye*\  has  Wen  ibe  Bulijt-<rl  i.f  niuefi  iliwuMtou,  and  of  wide  divcfintT  of 

n;  Juhn  Bell  advising  that  the  iiieinion  should  roach  barkwardis  to 

ddrf,  nud  Scarps,  that  it  should  not  cuceed  five  lines  in  adulla  and 

in  children.     The  danger,  however,  it  hiubI  be  Itortie  in  mind,  d(»eii  not 

luist  in  the  section  of  tbc  proelule  itself — which  is  in  reality  a  struclnre  of 

but  little  imporUncc— but  iu  cutting  bvyon-l  it  t<>  such  au  extent  hs  lo  open 

up  Ibe  lo<«K!  areolar  tissue  surrouuding  tbe  bladder,  which  woiihl  vxpow  the 

patient  to  the  daugcr  of  urinarj'  vxtravaaaliou  and  diflu^e  inflsninintion. 

It  was  formerly  suppowed  by  some  Surgeuos  that  a  sttiue  of  moderate  mm 
oruld  be  extracu'tl  through  ttie  pnistntf)  utthoul  tenriiig  the  fibrous  ca|i«ule 
of  the  gland  derivwl  fntm  the  recfh vesical  fascia,  nbieh  was  aaecrlcd  to  ro- 
main  uninjunil,  and  lo  prevent  inntlraiion  of  urine  into  the  surruuiKliiig 
pans.  KxiterimeDl  on  ihc  dead  Itorly,  ititd  the  |>c)<iii -morti-ni  examination  of 
tfaoM  who  died  after  litlnilomy.  eleiirly  deriii>u9irale<]  (he  falliiey  of  ibtro 
vttwa.  \n  stone  of  one  inch  in  dtaniet«'r  can  be  removl^l  ibnmgb  a  healthy 
ithuut  dividing  the  gland  and  its  cafMule  for  a  considerable  part 


924 


URINAKY   CALCULUS   AND   LITUOTOHT. 


•ufb 


I  111    Ht    U I  it  111    tl»e   KXlMMl 

K.'l  liwuc ;  nad  lb>t  dfali» 


of  their  leiipth.  aaA  if  the  calcaliis  be  of  con- 
found  to  cxteiifl  Ixinkvanls  in  tbo  fliM^r  >if  t: 
the  Jert  uiTter.  The  danger  of  urinnrv  i;  t"'i 
parts  of  the  wound,  but  in  ihc  Iniuio  ftubir*-!  ::< 
gimheJ  nniitomi^t,  Ellis,  taught  Tiimiy  years  a^  that  thr  evmnlian  hw 
the  cnvit}'  of  the  pelvia  und  lh(>  eslc'mni  pnrui  In  which  a  ptbotoa;  ^mi 
cnn  be  eafotj  mitde  u  not  ihe  shcAth  of  tho  pro«tntp  bur  ihr  Utrral  and  ul» 
rior  true  ligamcnte  of  the  blaii<1er.  or.  in  ot^er  wonU.  the  recto-Tc^eal  &■>. 
Hcntw  the  iuciBion  may  he  safely  carried  thmuf^h  the  wbola  Icnetli  ^f  tk 
lower  and  outer  eide  o'f  the  pri^tate  up  to  the  Tcrr  orrk  nf  the  hhAto. 
provi-lod  ii  d<t  not  pou  bcvomi  iho  aitavhment  of  the  lau-ral  lipim>Bl«flki 
bladder,  and  bo  ojien  up  ilie  Uu^ie  Bubperitoneal  tlwie  aniDod  tim  riMm 

There  are,  howc-vc-r,  otht-r  danifi-r*  beside  cstraVAiBtioD  of  arijM  lk«  Mf 
arise  from  too  free  uae  of  the  kuife  iu  ibe  deeper  part«  nf  the  waaui.mf^ 
cially  hemorrhage  fmiu  the  vetioun  jilexus  fturriiuodini^  tbe  pn^sla  M 
wound  itf  the  rectum.  Tor  thc^e  reiuims  t  prefer  Vi  iactM  the  M«atat«lDI 
moderate  extent,  eularjftD);  the  ajverture  by  siretchin;;  with  the  fordhpf- 


Kf.  4M.— IselilaB  Id  Pniaui*. 

Id  the  Motion  of  the  pn>stiite,  then,  two  point*  hare  *p(¥ctallT  in  W  i^ 
tended  to:  one  ia,  that  the  knife  in  entering-  itv  not  pu^hnl  r>>rwanU*i  >• 
creut  nn  an^^le  with  the  staff,  »o  as  to  cut  wiilely  ;  nod  the  ttih*^  it,  thil* 
it»  withiJrnwul  the  blade  be  kept  stearlily  ia  conUiet  with  thr  rtaJt  {ttim^ 
1  believe  that  there  it  njore  danger  of  doing  mi«chirf  in  tbe  wijWfWil 
thnn  in  the  entry  of  the  knife ;  for,  if  it  h-a^'e  thr  naif  for  a  mamMt^ 
guide  \s  Inst,  and  the  edge  raav  aweep  diwnwnrds  thnmgb  tbe  ham^  ^ 
pnisUitetind  the  Uix'k  nf  ttie  bindder.  A«  (hr  ktiife  i*  witlwlfwo.  A>  H^ 
uidex'ling<>r  is  pushed  f-irwardi  into  the  apcrtun*  in  the  proatato, ''^"* 
Ihen  dilnted  hy  its  pressure  to  u  BuSteieot  extent  for  the  faitnvlii«& 
furceps,  which  are  Hiippod  io  as  the  fin|{or  is  withdrawn,  and  Ibrtfai 
tion  of  the  Btooe:.  Thin  part  of  the  operatiim  may  very  r-.nrf-n' 
twrrtrmed,  as  waa  iisonlly  done  by  LUion.  at  the  raomnit  * 
u  Btoopin};  down,  enjnge'd  in  auleetinjr  his  forcepi.     Tl"- 

Erostiite  is  rendlly  dl^Med;  for  ihiii  nrueture,  thoogh 
renks  down  eaiiily  under  louiewhat  forrible  prcsiore  bv  lii 
vay,  by  a  mi^re  notchinfr  of  the  printate,— by  a  nodara' 
apex,  Pjllowwl  by  Mtuple  dilatation  with  the  finger. — tu^ 
oDtained  for  tbe  exiraotluu  of  all  miKlerate-fified  eal 
ployiQcnt  of  any  violence,  or  ibe  inOicUou  of  any  braiautg  upuy  tlw  ; 


friable,  wl 
laiUi 

.  td  'm 

J 


EXTRACTION   OF   THE   STOKK. 


925 


Bnl  another  ohstBclp  pxisU  which  will  prevent  the  dilatation  of  the  Deck 
nf  the  bladiior  to  any  very  matfrittl  extoot,  withmil  jin  amount  of  hniifting, 
or  Ucerftliim,  tir  even  rii]>t.iire  that  woiilti  pmhubly  prove  fatal  to  the  pattcul. 
ThU  ulisUicle  consists  of  a  firm  trsi^tin^  ti!*j«iie,  which  liiu  bwn  dt-scribed  by 
1  Tyrrell  as  "a»  olaj>li<-  ring,"  surnniiKiin);  the  neck  of  the  bladder;  by  Liatoo 
KW  "»  fibmus  or  lijjaioenl'jwa  band  snrryuuding  the  uriticc  of  the  bladder, 
[into  which  the  muscular  fibres  of  the  or^u  are  inserted."     If  thi»  ring  or 
Imnii  be  ruptured,  either  ly  the  fiuger  or  by  the  expansion  of  the  forceps, 
fatal  consequences  will  ensue;  but  if  it  be  dividetl,  the  other  tissues,  as 
XibtvD  observes,  will  yield  to  ao  iucouceivable  extent)  without  injury  to  the 
recto-vesicul  fascia.     The  division  of  this  ritig  must  be  practised  only  to  a 
very  limited  extent.     I  believe  that  it  is  always  etfecled  in  the  act  of  push- 
ing the  Ecal(iel  inwards  iulij  the  bludder;  a  mere  iiolchiug  of  the  tibres  of 
.the  ring,  iudeed,  is  sufficient  to  allow  the  requisite  expansion  to  take  place 
iirben  pressure  is  applied. 

I  In  thus  describing  the  mode  of  incising  the  prostate  and  neck  of  the 
■■tladder,  1  have,  generally,  ueed  the  term  "  dilatation  ;"  and  I  believe  that, 
by  a  t^imple  prm-esa  of  dilatatioa  ur  expanaion  of  tlieee  jtarts,  and  without 
any  violence  whatever,  email  oatcull  under  an  inch  in  diameter  may  be  ex- 
tracted. In  fact,  f.ir  the  removal  of  such  Ptonce.  no  force  whatever  is  re- 
miired,  either  in  u|)eniii;r  up  the  prostate  or  In  withdrawing  the  calculus. 
But,  ia  removing  stones  tif  greater  magnitude  than  this,  I  believe  that  the 
jtrocen  of  expHUsion  of  the  proetate  and  neck  of  the  bladder,  whether 
|flflbcted  by  the  finger,  by  a  blunt  gorget,  or  by  the  ripening  up  of  the  blades 
'  the  forceps,  is  a  pnieese  of  laceration  rather  tliai)  of  dilatation,  a?  I  have 
]Uently  had  occasion  to  observe  in  experiment;^  on  tbi-t  jioint  made  on  the 
dcau  subject.  If  this  laceration  bo,  however,  confined  to  the  substance  of 
the  proatatc,  and  do  not  extend  tlirough  the  lateral  ligament  of  the  bladder, 
and  into  the  jHubperitooeal  tissue,  no  Imrni  ri.-sults.  It  ia  difficult,  with  ordi- 
nary farce,  to  lacerate  the  dense  ligament.  This  slructure,  therefore,  re- 
baains  ax  a  firm  unbrnken  barrier  between  the  pelvic  areolar  tifwue  and  the 
Tvctenial  wound,  j>reveuting  the  pfx^-iibility  r>f  the  infillratidn  of  urine  into 
the  internal  iiuhperitiioeal  arcrdar  ti^oiie,  and  tii'xening  materially  the  chance 
of  diffuse  intlanmiatitm.  Itut  if,  in  the  withdrawal  of  the  stone,  nr  by  an 
undue  expaniiion  of  the  htndea  of  the  force|)s,  the  Surgeon  feel  a  iudden 

fiving  way  of  a  ten^e  annular  struclnre,  he  may  I>e  sure  that  the  lateral 
iganieitt  has  been  corn,  and  fatal  mischief  will  probably  ensue. 
Extraction  of  thfi  Stone. — A  forceps  of  sufKcient  length,  of  a  »tte  propor> 
lioncd  to  that  of  thi;  calculus,  and  previously  wanned  by  imoiersioQ  io  tepid 
water,  oiust  be  slid  along  the  index-finger,  which  is  kept  to  the  wound,  nnd 
by  which  llic  neck  of  the  bladder  should  be  drawn  somewhat  down  co  ue  to 
meet  the  inslrunieut.     In  thiJt  way,  also,  the  stone  may  often  be  fixed  hy  the 
point  of  the  finger,  and  its  jiusition  thus  accurately  detcriiiined.    The  forcepe 
iliaviug  bcL'i)  introduced  clok>ed.  the  finger  is  willidruwn,  when  a  gush  of  urine 
rill  tisually  take  jtluce  through  ihu  wound,  if  thut  lluirl  liuve  not  already 
iped  at  the  time  when  the  incisi^in  is  made  thr'>ugh  the  pnwlale.    Hy  this 
ish  the  calculuM  may.  as  Fergiiraon  observes,  »Muetitiii»  be  carried  into  the 
rrasp  of  the  instrument;  mottl  c^mmionly.  however,  the  aUntu  re(|uin's  to  be 
alt  for  with  the  doped  forceps.     When  its  p(i»itir«i  hiu  been  a«cerUiined, 
Lvsually  at  the  inferior  fundna.  liie  blades  of  the  instrument  arc  opened  ;  anil, 
by  pushing  one  against  the  watt  of  the  blndder.aml  giving  it  a  slight  shake, 
the  calculus  generally  drops  hetween  them;  though  ocaislouatly  it  is  some- 
vrbat  troublesome  to  seliie,  and  this,  indeed,  otlen  conatitutci^  the  most  ledioue 
and  annoying  part  of  the  operation.     Fergusaon  adrbed  holding  the  forcepe 


926 


UB1.SAKV    CALCULUS    ANn    I.ITOOTOHT. 


traaBrcTMly,  opraing  them  us  widetj-  ns  powibtv.  (hcD  /     '  :aHt«ltn~ 

»ii  UB  U)  make  the  lover  hliulc  srixip  aloug  the  Huor  i)f   i .  itt,  mkm  « 

clicitif;  th<!  Tttrceps  the  stone  will  u.^iiallr  be  caught.    Tht  bUti«,liafifl(lk 
eluue  in  their  grasip^  are  then   cliK>e<l,  and  the  atone  is  dmira  rfewawjl 


\fli=^ 


PIk-  Mit.—iy\tmHiom  uf  Fora^i  U  lslrmtttl«ti  of  StoM*. 


wound. 


extracted 


IDC= 


Tif.  Ml .— r>««ttUB  of  Tingtr  ud  8«(Mp 


ilrodaird 

the  btuJ«8,  ia  order  tu  feel  whether  it  u  iu  a  pr>>por  |HHtiti(m  for  eUfictaa. 

If  ita  lonfc  axU  lie  acriMt  the  wntmillii 
muit  1h-  chnn^ ;  aoil  It  miHt  tlm  b 
withilniwn  h_v  a  kind  of  t<HUw)-fm  Wftt 
Difnt  in  th<-  dirt-rtion  of  tb«  ant  rfAr 
pelvU  Fii;.  Ht>U^  8h<jttM  tW  tloM  » 
furtuuitleir  be  brokcD,  or  •bouM  t^tft  k> 
several  Hiiiall  calculi,  the  ftayiitwrt* "tf*^ 
eiiiiilt  calculi  may  kqdmsII?-  *-  '"*  ?»- 
moved  by  raeaof  of  the  »«»[■ 
In  the  event  of  fracture  occurring,  it  will  be  noceanuy  to  wMb  out  iir- •>'■-' 
freely  and  rct>eat(Mllr  with  t4!pid  water,  injected  by  ucMMof  ft  bnmfji^ 
thrtm^h  a  tulie  iutroduucd  by  the  wuuud. 

If  thi?  pt'riiietiin  Im*  vt'ry  deep,  and  the  prwtate  enlargKl.  U  OMy  htf^ 
that  the  neck  of  iht;  hhidder  \s  mt  far  n>rooved  from  the  aurftn  Uut  ^ 
flo^r  canntH  reach  ibi  interior.  In  these  cireu mitauoet.  the  Oui pw  Wt 
be  can^fiil  in  luuMiu);  the  I'lirfrfiM.  that  the  iuslniim-ni  do  D<-t  atlp  lothsii* 
of  the  incii^toii,  ihe  ^lide  iind  ft(ip|M>rt  t>f  the  indtrx  tinp'r  brtU);  liaL  !■  t* 
ur  three  cnacft  of  thix  kind  thai  hare  ocriirrr<l  fi  m<-,  in  wbirh,  iiiiia|[t«ll* 
aaautiuieal  reaannH above  Htiited.  I  ould  n<il  renoh  the  't!a,M- r  wiihtltttif 
of  my  forelin^r,  I  have  directed  the  nsiifitnn(  wh<)  ht'l<!  iamb' 

draw  it,  but,  u-iing  it  lu  a  goide,  hi»ve  slipiH-"!  the  fur.;.,  _ 
and  over  iti  concavity,  in   thii  way  making  it  enter  ihc   ; 
rreat«st  ease  and  certainly.     TbU  manceuvr«  I  would  ctrob,;.. 
the  caacA  alluded  to. 

It  Uof  the  firtit  importance  to  extract  the  atone  whole  wittiovt 
it,  or  even  chipping  frsji^ents  fmni  it  with  the  blndra  of  iJte  fiBnafs. 
elflirt  consistent  with  the  tutfrty  uf  the  fwtient  shiiu'  ^Ibimc 

thi«  desirable  reeull :  not  fur  the  sake  uf  any  ruii.  ^alttJC 

but  from  a  regard  to  the  weJI-beiog  uf  the  petieul.     U  Ibe  M*«ia 


iamb 

hnJm 

ma.    l(o 


MTHOTOHK    FOR    LATKEAL   LlTUOTOliy. 


927 


broken  by  ih«  aUeni|il  al  cxtrartinti,  wlial  hapjH'iwl'  The  c^ir^con  is 
oblijj^J  to  iiiir«4]ti(<u  rc[K-uu-iliy  ilu-  fnrtcpe  aiid  ihe  nc*>np  in  hi?  Htlempu  u> 
elcAr  Lho  IiIiuIiIlt;  tlti^  niuniiis  mi^iulirune  nf  which,  fnllitifr  uj^m  nnrl  c-n- 
liog  the  fragnienlfi,  w  liubli!  tt)  be  [>rirkeil,  hriiii^eH,  iind  cxpnrinted  in 
uideATor  to  dHko  fhcni.  The  Itlnrld^r  rt^rguirra  to  he  fretiiicutlv  uMheJ 
with  pi^piflut)  injectioriR  of  topid  wnter.  nnd  the  operntiou  thus  beconm 
tlv  and  danpermiflly  ptohmfjed.  Kven  after  much  lime  «nd  labor  l)ave 
«peot  in  thfite  elf  >rt»,  fnijfmeiilg  are  npl  ir>  be  left  behind  nhich  may 
iftn  frreni  present  irritatiun,  unil,  if  retaioed,  will  form  the  nuclei  of 
futurv  calculi- 

In  children,  and  indeed  in  mi«t  cades  in  which  the  pcrloeum  ia  not  very 
deep,  »<>  that  after  the  JDlroducliou  vf  tlic  finger  the  stone  can  be  felt  ana 
bixiKril  fwrwariiu,  ihe  *<X'up  is  a  muet  cutiveuivut  iuetruiueut  fur  its  estmctioQ  ; 
«uil  ill  Ihrte  CTiws  1  have  uft«u  wiiplyvf.-d  it  in  prefrreurc  lo  the  rorce|>R. 

A-tter  the  caIcuIus  hue  been  reoxived,  il  niuot  be  examined  tor  facets,  and 
tbe  BogCT  mtut  be  p«Med  into  thu  bladder  and  its  cavity  uxploreil  while  firm 
vnaBare  Is  made  above  the  pubee.  In  this  way  the  whole  interior  nf  the 
bladder  is  easily  explored  excejit  in  ihoM.'  c«b«b  in  which  the  jierineum  is 
nooMially  deep.  The  inlcriur  of  the  bladder  may  be  turther  explored  bv 
■Msna  of  a  wareJurt  and  if  other  rtonf«  Im-  fotiuu,  they  must  be  dealt  witii 
■B  Uie  same  way  as  the  first. 

If  the  urine  han  been  fuul  before  the  operatioD,  it  u  well  toBponee  tlie 
■urfare  uf  the  wound  over  with  chloride  nf  ziuc  (,gr.  40  tu  ^),  and  to  insert 
s  Htile  io<Iiif(irtn. 

Tti>*  ^an-rlaMic.  lube  tnar  then  be  JnlnKlticed,  and  secured  with  tapes  to  a 
i«tid  round  the  |>atient's  aSdotnen.  Tbl?  tube  mutit  be  kept  free  from  coaeula 
by  the  inirodiietion  itito  it,  fnmi  lime  to  time,  uf  the  fcatner  of  a  pen.  The 
nbe  is  of  great  service  in  nreveniin^  the  wound  from  becoming  blocked  up 
hf  coagala,  by  which  the  free  escapn  of  the  urine  would  be  interfered  with. 
nr  mcttitsnf  this  tubes  ready  outlet  is  given  to  the  urine,  the  chiiucc  of 
infiltntlion  i?  lef^ened,  and  if  there  be  hemorrhage  the  wound  may  readily 
be  plugged  rniiud  ii. 

LitbcMme  for  Latent]  LithotoiDy. — .Surgeons  hare,  at  rarious  times,  ex- 
IKtttitfl  miiL-h  ingenuity  on  the  construction  of  instruments  calculated  to 
CKilitnte  the  owralion  nf  lithotomy,  and  to  enable  the  operator  to  make  hn 
incition  with  absolute  precision.  Most  Surgeons  prefer  to  rely  on  their  own 
•kill  to  accomplisb  this,  aad  mechanical  coDtrivaoces  have  very  geacfKlly 
lad  perhaps  somewhat  unjustly  been  discarded.  Of  all  the  iustrumenls  of 
the  kind  referred  to.  that  which  is  the  invention  of  N.  K.  Smith,  of  Balli< 
■nir,  is  tbe  mwt  ingenious  and  practically  usefuL 

The  inslninieQl  consists  of  a  ittaffwith  anpliances,  and  ■  peculiarlTibaped 
bnt  rotting  gorget,  It  whs  first  describon  and  fignred  by  Smith*  in  1831. 
It  IwB  andergone  many  modifications  at  the  hands  of  its  inventor,  and  is 
iMnr  oirea  to  the  profession  with  all  ii»  improvements,  as  seen  io  Figs.  862 

The  BtAff  coDsistB  of  three  parts.  1.  A  rectangular  tubular  staiT,  with  a 
vide  slit  m&king  a  quarter  inm,  so  as  to  fit  it  fur  tulernl  lithotomy.  2. 
Attaelied  to  the  stalT  by  u  hinge  close  under  the  handle,  is  an  "  arm-piece," 
or  "  cunducttir."  This  endii  in  a  knife- blu'te,  met  at  right  angles  to  tbe  shaft 
and  deeply  groore<t  at  its  under  part.  :t.  An  "  indimtur  '  consists  uf  a 
sieoder  ru^  traversing  the  handle  of  thf^  staff  and  terminating  in  a  cup  sliding 
in  Ibe  tubular  sta.ir. 

tWt  mode  of  action  of  the  insitriiment  is  as  follows:  The  omduclor  being 
drawu  hack  on  iu  hinge,  the  rectangular  slafl*  ts  passed  in  the  usual  way 
into  tbe  bladiler,  the  ntigle  being  brought  just  in  front  of  the  prostate  and 


UBINABY    ClALCULUS    AND   L17UOTOJ1T. 


928 


resting  oa  the  membranovu  part  of  ibe  urclbnu  Wbco  tbc 
wtiiried  hinisflf  that  tli»  BtafT  in  iu  |ir(«[irr  iimUon,  be  drawvdiiva 
ductor,  aud,  pro^iD^^  u[i(>ti  i(,  |>usbefi  iu  termm&l  knife  Uiraoi^  iIm 
of  the  ncrtncum  uutil  it  rnlere  tiie  slit  in  tbe staff  Tbe  j^rticrra  iatW"!*- 
ductor  nuuide  llie  pt'riQeiim  is  now  rualiDumin  nilli  that  id  llwfUF«W 
u  iu  the   urethra.     The  "  iDtllcatur"  is  uow  ilrawa  u(i  au  ll>al  itsofBri 

irimiedial«lv  uoder  tbe  groove  of  tW~ a* 
ilucuir."  The  super&ciml  uiriiMa  bann) 
been  matle  ia  tbe  UHial  »«j,  ih»  unAn 
in  opeoeil  on  the  gronve  ia  tJw  "onadww;' 
the  beak  of  the  knife  U  then  emfiJa 
the  cup  of  the"  iodirai"-  "  '"■f  uUwkaS 
advances  tbe  rod  ut'  t)>'  ■  Juo»i| 

but  CCBM8  to  move  if  Uu-  uiiujr  iic|«n  km 
the  prijper  route  byflipptag  nutoftbtfi 
to  tiie  ttaff  and  »Uips  m  ben  tbo  <wj  «f  tkl 
groove  la  r«ncheil.  Tbe  koife,  or  ie«iy< 
*.  Fig.  8ti3  J,  ends  iu  a  bluBt  beak,  avd  &i 
fauulle  is  «et  at  an  angtt  X*t  tha  blwk,Ma 
to  enable  IheSnrgvon  to  watch 
rately  iu  attitude  and  poattioai. 

Prvfevor  Jvhamou,  of   Balliawra.  ha 
aaed   tfaii    ioatrunieDt    loanjr 
fpenks  highljr  of  its  utility. 

Altar-treataent  of  LtUDta«f, 
the  npeniLioa,  the  patinil  »IM  fa* 
to  a  bed,  ffhich  tbould  ba 
ranged  by  having  a  iaf)(a  *4i»ra 
tatnah  cloth  put  acmaa  it.  On  tbia  *  fuUd 
sheet  should  be  laid,  ahicb  mtut  be  rtOd 
upon  the  further  »idc,suiluu.a>ii 
wetted  by  tbe  eacape  of  uriiie,  il  nvN 
drawn  aomn  fnnn  uader  tlie  paikeL  nil 
must  be  chon^^  freauenlly,  ia  titiK  to 
kce|>  him  dean  and  dry.  A  tall  ^m  W 
tinf?iure  iif  optum  in  Wrley-waur 
then  be  given  ;  a  warm  flannel  hU 
tbu  abdiimen  ;  plentv  of  harlcT* ««  f^ 
water  allowed  f<>r  drink,  and  nothing  hut  rice-uiilk  or  liji^ht  |>uddia(brdH 
during  the  fiffll  ibrtp  or  fiiur  day*.  After  ihtt,  mw '■•"■''■  '•■■-•  ?«  alfcmt 
and  tlic  (jualily  of  the  fttod  gradunlly  iui|»rurt!d.     1 1  :  i«iRffir,il 

may  1*  iipcfwary  to  depart  fnitii  tbt»  n>utiue  vyrtein  n  miiinj;  th*  part* 
afler  lithol'imy  ;  and  I  have,  with  great  mWanlage,  allowed  wuMtaaa*** 
brandy,  a  day  or  two  after  the  o|)eration. 

At  thi.-  euit  of  thirly-«ix  or  forty-eight  houn  tlte  tubeoaar  be  lawufwl,^ 
•idea  of  tlie  incisiou  by  that  time  bnving  hcvooK'  glaxed  over,  and  Bflk 
danger  of  iotiltratioa  existing.  Tire  {mticiil,  who  up  tu  tbia  ut»  laa  kl* 
Iving  on  his  buck,  should  then  t>c  drri%te«l  to  ehangv  his  puatim,  ftnll«V 
sulu  aii<l  thi'U  lo  ihe  other.  Ilio  buttocks  and  hi|H  ahoaltl  be  wcOlM* 
Htncsred  with  vosvliue.  00  aa  to  prevrat  Uie  irriiatiu^c  p6ia<a  uf  tba  ariMV 
dminage.  The  urine  eoalinuea  to  flow  entirely  thnMigh  lite  wouad  fati* 
firat  four  or  fivr  days.  About  this  tiniit  it  fre<iuently  auddcoly  ooMa**^ 
BO.  eacapirig  by  the  urethra.  Tfaia  is  owing  to  the  pruaU!-  1^-^  "! 
(torn  inflanimatary  Bwcliing,  and  thus  blocking  up  ibe  . 
as  tbb  swelling  goee  down,  in  the  nourse  of  a  day  or  two,  «>»■  ut 


Pic.  t>1l3.— Soiltk'*  Utbtt»mj  «US  anU 

Cen4iK((ir. 
Flc.  U3  (to  ftgkt).— Siatlli'*  QiirttU 


LATBRAX   LITHOTOHy    IS    BOVa. 


escappi)  by  the  wound  agnio,  and  continues  lo  do  so  in  graduallv  decreiising 
quantitii^  until  the  aperture  is  finally  closed,  which  bappens  usually  at 
abuut  lliL'  end  of  lourtcon  or  cigbtcen  days;  though  in  paticnla  who  nave 
suffered  from  phmphatie  cuIcuIuh  it  entnelimea  takes  a  longer  period,  owing 
to  the  broken  state  of  the  general  health.  Should  the  wound  fall  into  a 
sloughy  state,  the  |>atient  luumt  be  put  on  a  very  geaeroua  diet,  even  n  free 
allowaoee  of  alimiilanU;  iind  the  tincture  of  bvnzii'iD  may  be  daily  applied. 
When  slow  id  healing,  it  may  he  iiliniulatetl  with  nitnit«  of  silver  applied  to 
the  botUim  ;  an*!,  should  a  fii«tiih>UH  ujierture  be  left,  that  may  be  touched 
with  the  electric  cautery.  After  the  operation,  appropnuLe  ennHlitutiounl 
tri-atiiienl  should  be  continued  for  some  time,  in  order  to  prevent  a  recurrence 
of  iht^  di.'*e«.'*e. 

Lateral  Lithotomy  in  Boys  under  the  age  of  puberty  is,  perhaps,  the  most 
succestifut  of  all  tlie  grtat  o|>eratione  in  Surgery.  It  is  performed  niiich  in 
the  same  way  rh  in  the  male  adult ;  tiiere  are,  hnwever,  some  points  of  modi- 
ficatiou  or  of  dittereuee  in  the  operation  nlieu  pruoliged  oo  young  subjectj. 
The  lullowiiig  arc  worthy  of  note,  aud  should  b«  remembered  by  the  Surgeou 
in  proceeding  to  o|>erate  on  children. 

1.  The  urethra  iu  buys  will  cuiumouly  be  found  larger  than  would,  jwr- 
hap6,  at  first  be  expected  from  their  a^,  readily  admittioe  u  No.  S  or  9  stall. 

2.  The  perineum  k  uaually  pro|jortioualely  more  vaacoTar  iu  boyg,  iu  con- 
Be<iucuce  of  the  (itraiiiiug  produced  by  the  irrilatiou  of  the  caleului. 

A.  Then  is  often  front  the  same  cause  a  tendency  tu  prolapsus  of  the 
rectum. 

4.  As  the  prostate  is  a  rudimentary  organ  in  the  buv,  the  deep  iucision 
Decpemrity  pai«e!^  Wyond  iu  limila  Into  the  neck  of  the  uladder. 

6.  In  buys  the  ttesues  are  more  yielding,  and  more  readily  lacerable  under 
tbe  finder. 

6.  The  most  important  point,  however,  is,  that  in  the  boy  the  bladder  lies 
bigfa,  being  rather  in  the  abdomen  than  in  the  pelvis;  hence,  it  is  of  ini- 
porlancc  to  raise  the  jjoint  of  the  knife  somewhat  more  than  in  the  adult  in 
roakiog  the  deep  incision,  and  to  be  carefiit  that  it  do  not  slip  into  the 
tissues  uet ween  tbe  rectum  and  the  bladder,  which  may  happen  unless  this 
precnulion  be  taken.  I  have  known  this  to  occur  in  several  instances  to 
Ilosjiilal  Surgeons  of  skill  and  experience,  the  forceps  being  passed  into  this 
space  under  the  Buj([>oaition  of  its  being  the  bladder;  and  iu  every  ease  the 
jinrient  diet!  unrelieved.  This  accident  is  the  more  likely  to  happen,  Wcause 
in  boy»  the  parts  arc  very  yielding,  and  readily  admit  of  being  pushed  before 
tbe  knife  or  finger;  and  the  fiiieer  may  thus  paw  between  the  neck  of  the 
bladder  and  the  pub«5,  or  into  tne  Ioom  areolar  tiseue  between  the  rectum 
and  tbe  bladder.  The  urethra  beiug  opened,  urine  esoapes  ;  and  the  Surgeon 
introduces  his  linger  into  a  distinct  cavity,  which  he  believes  to  be  the  interior 
of  the  bladder,  but  which  is  out  so,  but  the  recto-vesicul  space.  The  liability 
to  the  occilrreoce  of  this  distreeeing  and  fatal  accident  is  materially  lessened 
by  injecting  the  bladder  fully  with  tepid  water,  by  which  it  is  steadied  and 
brought  lower  down.  But  in  young  boys  lithotomy  is  from  this  cause  always 
au  anxious  operation.  It  falls  to  the  lot  of  but  few  Surgeons  of  experieuco 
in  lilholumy  to  pass  through  on  active  professional  life  without  meeting  with 
difficulty  aud  anxiety  iu  operating  on  boys;  and  when  such  an  untoward 
accident  occurs,  those  will  be  the  most  cliartlnblu  in  their  judgment  of  olhera, 
who  have  themselves  had  the  mi»it  ex{K>rioiiec  in  the  operation,  aud  have  bad 
moat  freipjbntly  to  tnnounter  its  iiiLrlnsie  ditliculticii. 

In  order,  then,  lo  obviate  the  speria!  dangers  that  have  just  been  men- 
tioned as  likely  to  occur  in  the  lateral  lithotomy  of  boys,  the  following  p<.dntB 
should  lie  attended  to. 
voi_  It.— 59 


DBINABY   CAtiCOtiUa    AWO   LITHOTOMT. 


1.  The  bluddcr  slioulil  bt;  injected  with  two  or  thr«o  ouocee  af  tepid 
If&ter. 

2.  The  knift!  shimld  mil  be  too  narrow,  ru  it  lioa  to  uiako  an  opeaiog  of 
sufticleiit  s\»a  tii  mliiiil  tim  foruliiiger  of  l1i«  opvnilor  in  tliu  cbild  ae  iu  tlie 
adult.  It»  point,  niwn  it  ]iiu<  enlerud  llm  griHtvt^  iif  thu  KtulT,  should  ba  kept 
ver^'  Rrmly  prctuied  against  itu  aide,  and  curried  aomewhat  upwards  instead 
of  straight  forwards. 

3.  WWn  the  knife  ia  laid  anide  and  the  Surgeon  pmoeedn  to  pass  his  finger 
into  the  bluddcr,  he  will  find  the  following  tnaiumvre  bi  facilitate  this  slep 
of  the  n|ierntinTi  very  greally,  and  le»»eii  muterially  ihe  dan;r«T  of  pushing 
the  neck  of  the  bhulder  before  hiro.  I'lnciug  the  nail  of  ihe  left  index  in 
the  groove  of  the  staff,  he  should  not  carry  it  along  the  convexity  of  this 
iostrunient,  but,  nliding  it  over  to  the  conciwe  side,  gently  hut  atea<lily  work 
his  nay  along  this  into  the  bladder.  In  doing  so,  hepassee  the  finger  between 
the  roof  of  the  urethra,  which  \s  a  fixed  part  of  the  canni,  and  the  staff, 
iostead  of  between  thiis  anrl  the  flnor  of  the  urethra,  which  ia  mobile  and 
yielding.  There  is  the  additiimal  advantage  that,  by  pressing  down  tbe  staff 
as  tbe  hng«r  goes  above  it,  the  urethra  nud  neck  of  ihe  bladder  are  somewhat 
dilsU^l. 

C'  Henlh  recommends  the  following  plan,  which  will  be  found  mo»t  ^- 
cient:  »»  moo  »»  the  kuife  i«  witbdniwn  b«  iiiserla  a  strong  director  with  a 
handle  like  (h»t  uf  a  tituff  i>et  at  a  convenient  angle.  This  ts  paMed  aloDfi 
the  gruove  of  the  stalV  like  the  comluutor  in  me<liaa  lithotomy.  The  staff  U 
then  withdrawn  and  the  finger  putwed  above  the  director,  which  is  at  ths 
aaine  time  preseed  dowuwanls. 

4.  Ha  soon  IIS  the  finger  enters  the  bladder  and  the  staff  is  withdrawn,  the 
calciiluH  should  lie  6xed  Hith  ito  point  against  tbe  floor  of  the  bladder,  where 
it  may  then  be  seized  easily  by  the  forceps. 

Djr-i''HULTii'H  DL'uiNu  LiTHoTOMV. — The  difficulties  before  and  during 
the  oiKtraiiim  are  threefold:  ],  In  Finding  the  Stone;  '2,  in  Kolering  the 
Bladder;  and,  3.  in  Seizing  aiul  ICxtrat'tiug  the  Calculus. 

1.  Difficulty  in  Finding  ths  Stone,  cither  by  the  etofT  or  the  sound,  may 
exist  before  commeneing  the  operation ;  and  soinelimes  it  is  itopoasible  to  tied 
the  stone,  although  its  presence  may  have  liecn  distinctly  and  inooatcstably 
aaoerlaiDcd  a  few  diiye  previously.  In  those  (.'ircums lances,  the  Sui^fjeoD  niMt 
OD  DO  account  be  tempted  to  proL^ivd  with  the  uperaiiun;  but,  after  a  care- 
ftilly  conducted  cxplornlion  Iuls  failed  to  elicit  ihc  actual  pre^nce  uf  the 
stone,  all  further  proceedings  mu^l  be  ileforred  to  another  opportuntiy.  The 
stone  may  escape  detection  in  three  ways.  1.  It  may  have  bt-eu  paased  by 
the  urethra,  hctwepn  the  first  examination  and  the  time  fixed  for  tbt-  opera- 
tion. A  small  calculus,  especially  if  clongatcrl  and  spindltt-shaned,  may  give 
a  very  ill^tinct  click  against  the  sound,  and  ret  be  not  too  large  to  pas 
through  the  urethra.  2.  The  stone  may  have Ticcome  encysted.  3,  It  may 
have  Bccnme  enveloped  in  folds  of  the  mucous  membrane  of  tiio  collapaed 
bladder,  and  m  may  esra]>c  contact  with  the  Round.  All  these  events,  except 
the  presence  of  an  encysted  calculus,  nre  more  likely  to  happen  in  children 
than  in  the  adult,  and  it  is  in  them  that,  for  want  of  attention  to  these  pre- 
cautions, the  unforlimate  accident  of  cutting  into  the  btmlder  and  finding  do 
atone  has  moRl  freijiifntly  oomirrfd. 

2.  Difficulty  in  Entering  the  Bladder. — Thin  is  rarely  experienced  in 
•dults.  It  may.  however,  arise  in  cou8e<iiieoce  of  the  Burgeon  neglecting  to 
keep  the  point  of  the  knife  well  lodged  in  tbe  groove  of  the  i^tal)',  and  thus 
letting  it  slip  between  the  rectum  and  the  bladder;  the  tisnue  of  which,  treiiig 
brokeu  up,  lea%'es  a  kind  uf  cavity  that  h«  nmlakes  for  the  iuLerior  of  the 


1 


;ULTiss  ii 


9S1 


Pig.  SA4. — TatDor'uf  Protlnl*,  nntu- 
ral>li»,t*uiov«l  during  Lilhotnmj* 
from  n  mftn  a|{*d  St. 


\deT.    If  the  pennfttim  he  very  'toep  anfl  the  prostate  «ijl«rg«J,  he  raay 
experience  soino  ditficuUy  in  reaching  the  blachler;  but  he  can  scarcely 
fait  to  do  an  if  he  pueh  ihe  knife  well  uu  Iti  the  grcoveof  the  atafl',  and  dilate 
ihe  incUion   in    tlie  ]>rmtAUs  with  a  hluut 
eorgel,  if  his  f)ng«r  fail  to  reach  the  c-avity 
bevund  it. 

rcrhape  the  must  serious  ubstacle  U>  eoter- 
ID)^  the  bladder  euusiiits  in  the  presence  of 
large  tuiuurs  iu  the  pn>stule.  The  coiubiaa- 
Liou  uf  It  deepperiueuoi,  ati  enlarged  prostate, 
and  a  tumur,  certainly  cilDt^titute«  a  ftjrcuid' 
able  series  uf  obstacles.  In  these  caBee,  the 
finger  when  sliiiped  along  the  etaH'  does  not 
enter  the  bladilcr.  but  becomes  involved  in 
the  smooth  and  irregularsiouosltiee  that  wind 
between  the  pi-oetatic  tumors  (Pig.  804).  In 
such  cashes  it  is  well  to  practise  the  mnnaMivre 
that  has  already  been  aescribcd,  viz.,  uf  using 
the  stair  as  a  guide  into  the  bladder,  slipping 
the  forceps  along  the  aide  and  concavity  of 
this  instruracot  before  it  ta  withdrawn. 

In  botfs,  great  and  Bomciimwi  insuperable  difficulty  has  been  experienced 
ia  reaching  the  bladder.  Thii  difKculty  ariaca  in  consequence  of  the  small 
sise  of  the  urethra,  the  mobility  of  the  bladder,  and  tbc  ready  lacerability 
of  iho  tiasuea.  If,  after  the  gronre  in  the  statf  has  been  exposed,  care  be  not 
taken  to  inainiiate,  as  it  were,  the  nail  into  the  oponing  in  the  urctlim  thus 
made,  the  memhratimifi  portion  may  he  torn  acrosa ;  and  the  iieck  of  the 
bladder,  receding  belore  the  finger,  may  easily  he  pushed  away  from  the  sur- 
face, so  timt  the  8uri;eon  may  fail  iu  reaching  the  cavity  of  the  argan. 
When  the  road  is  once  lu»t  in  this  way,  there  is  the  very  greatest  difficiilty 
ill  Gudiug  it  aguiu.  The  counte  that  ahuuld  be  pursued  is,  I  think,  as 
lullowa.  If  the  sIjiU"  have  not  been  withdrawn,  the  Surgeon  must  agaiu 
place  the  knite  in  its  groove,  aud  carefully  push  it  on  towards  the  neck  of 
the  bladder,  uotchiiig  that  structure  aud  pMsviut;  the  ttuger  cautiously  along 
the  groove,  aud  huokiug  down  the  part^  with  hiit  uail  uutil  he  reach  the  in* 
side  of  the  bladder.  Should  the  Blaff  hiive  bten  withdrawn  the  Surgeon 
must  endeavor  to  pass  it  ugaiu  ;  if  he  sucu-eed  iu  this,  he  may  act  as  just 
stated :  but  if  he  ciuinot  succeed  in  iairoduciug  the  stalf  fairly  into  the 
blad{ler,  lie  muBt  on  ito  acrount  whatever  endeavor  to  open  that  vlmcus,  or 
continue  his  attemjita  at  tht>  extraction  uf  the  ralcuhiB,  but  must  at  once 
abandon  the  operation  until  the  partn  have  h»ale<l,  when  he  eau  rejieat  it. 
The  great  danger  in  these  caaes  ariew  from  the  f-urgeou  losing  hin  pre8ence 
of  mind,  and  endeavoring  to  enter  the  bladder  without  a  guide — a  pro- 
cedure which  must  be  unauccessful,  and  can  end  only  in  the  destruction  of 
the  patient. 

In  adulta.  the  difHcuIty  is  to  get  out  the  atone;  in  childreu,  to  get  into  the 
bladder. 

3,  Difficulty  in  Seizing  and  Extracting  the  Stone  is  far  more  frequently 
met  with  than  in  reaching  the  bladder.  This  may  be  owing  to  a  variety  of 
causes.  It  is  likely  to  happen  in  all  those  cases  in  which,  either  from  the 
depth  at  whieh  the  bladder  lies  from  the  surface,  or  from  the  peculiar  posi- 
tion of  the  calculus,  the  stone  cannot  be  felt  with  the  finger  after  the  laci- 
tiona  have  been  made  into  the  neck  of  the  bladder. 

Difficulty  from  (he  Poaidon  oflhf  Sfon*-. — The  calculus  may  be  lodccd  m  the 
lower  fundm.    This  h  esiiccially  apt  to  happen  if  the  patient  be  ola  and  fat, 


rKI5ART    CALCULUS    AUt)    LITHOTOMY. 


tad  haim  *  deep  periDaeni,  fwrhapi  with  enlftrg«d  proMaio^  MomI  ^ 
Ift* itaM  nsy  be  lodged.    Thu  co[uftitut«e  the  greateec  difBcaltf.    B«nl 
^Mt  ftaa  a  to  bm*  a  mucli<;urire«i  pair  of  fiirceps,  aod  to  tilt  tJbe  bladilir^ 
bf  iatraduciog  the  finger  iDto  tbe  rectum,  «o  k»  to  briog  Clw  MoMviikB 

When  tbe  stone  it  ntuate^l  in  Uke  ujtper  Jund\u  of  Ibe  bUdder  alPMW  tte 

Eubes,  it  is  altogether  out  of  Ibe  axi«  of  the  iDcision,  and  ta  audi  a 
B  extracted  ooTy  with  great  difficulty.  A»t<iii  Key  recomioeada  that  i 
cases  tbe  abdomen  ehuuld  be  ooniproMtd,  nod  Uie  cftlcului  Hiiup— hw 
iato  reach.  Tlti^  suggc^tiuu  is  a  very  useful  one ;  uid  it  wb>  ottir  hj  f^il^- 
H»  this  m&nutUTre  aixi  using  a  very  curved  scoop,  that  1  euufd  nrn^n  • 
csTculus  lodged  above  the  puhes,  in  the  first  pitieot  whoa  I  eat  at  tbe  H» 
pital  many  years  ago. 

DifieuUv  m  eottsequenoe  0/  th§  SUme  hmnn  Firrd  to  or  rdaimtd  im  Ifct  JMfc 
— A  small  calculus  mny  ht  envdaped  by  tht  jM/>  a/Ae  wusaam  wismSiWMi, sal 
in  this  way  cliido  tbe  gras|)  of  the-,  forcope.  In  these  circuBwlapass  tbenii 
nothing  f'^T  the  Surgc^iu  to  do,  but  paticDtly  tn  try  Ut  disentnngt*  and  r«BB<f 
the  calculus  by  means  of  the  finger  and  «ronp,  if  it  can  be  sn  reached ;  If  w% 
by  expanding  the  forcepe  in  the  bladder,  t£i  try  to  ptub  uid*  lbs  ■soa 
membrane  that  surrounds  the  stone. 

In  consequence  of  «pasm  0/  iXe  biaddtr.  It  Is  said  to  bAve  oecssiossB; 
bainiencd  that  a  cnlcului  has  been  m  llrmly  fixed  as  not  u*  admit  of  lb 
at>p!ication  of  the  forcepa,  the  blades  of  which  conid  not  be  iMndsod 
between  the  vratls  of  the  vuvrus  without  tMiD|;  an  imiiroper  d4|rnt«f  fi*K 
nnd  giving  ri»e  to  the  danger  <>f  rupturing  the  m-cKotthe  MmMv,  1  W 
dispoee«l  to  think  that  thix  "sptumof  tbu  bladdt^r"  i»  purely  ilM^aafy,  ftsi 
that  the  real  dilfictilty  ha>(  arisen  from  some  other  cauto,  as  ptnisfn  s  nn- 
traoted  and  rickety  pelvis.  But,  wliatever  mav  be  th«  nral  oanse  rf  i 
difficulty  that  h»t  undoubtedly  bwu  tiiwiaitered.  I  think  it  would  be  iiftr 
for  Ihv  iurye^jn  to  desist  fruui  the  upemtion,  and  iu  the  couneof  a  Urn  i»n 
or  weeks  endeavor  to  complvie  the  extraction,  and  thus  perforn  tbe  efos- 
Uou  "  a  deux  tetiipa  "  of  Dcschampe. 

The  at4)ne  may  be  m  fixed  beheeen  hypertrophied  /curiniyi  in  tbs  iHanw  d 
the  bladder,  as  to  he  detached  with  coueiderabledimcuUr.     Innieh< 


■coop  will  be  fouud  tn  be  the  moet  uselul  inatrunu>nt  fnr  its  r«movsL 

When  thif  calculua  is  eneystod,  its  extraotioa  will  pfobablr  be  nspniA- 
cable,  or  Mturml«<l  with  mnet  dangerous  oonsootieooen.  Hsoee.  it  bexpaiii' 
nut  to  operate  iu  caSBe  of  encysted  calculua  titat  an  known  tn  be  euck.  U 
bi^wever,  tbe  Hurgeon  have  been  unfortunate  enough  to  out  into  a  hUM 
oootoining  an  eiiin'Mtrd  calculus,  he  mu^t  be  guidM  in  the  eoaim  hsilwsM 
gtdopt  by  the  condition  in  which  be  finds  the  stone.  If  the  aperttm  Im^ 
into  the  cy-tt  be  very  small,  tis  in  Fig.  836,  the  lietter  plan  will  be  to  p*t»> 
uo  further  with  the  operation,  as  it  will  b«  olcftrly  impcmdbis  tn  fcnore  Ar 
etoDO.  If,  on  the  other  bund,  the  aperture  into  the  cvst  be  large,  bemigbtli^ 
di9>i»:4od  to  make  an  eflitrt  to  extract  the  calculus.  With  tbitin  vi«wbamigtt 
adopt  the  plnn  pur^ueil  by  Hir  B.  Brodie  Id  such  a  auv,  and  endmenr  W 
rulnrge  the  orifice  of  the  cyst  by  means  of  a  probe- poiote«l  bi*lnar<'  ■— "■'■»'«^, 
applieiJ,  and  then  finish  the  extracttoo  by  tnuia*  of  ■  seoop. 
ect-diug.  however,  is  in  the  highest  degr«e  ha£ar<](>Uf,  00  boc<'ui>i 
rc«<lineaa  with  which  the  section  mav  extend  into  tlie  perituoeal  cmrily ; 
writ  OS  diliicult  in  executiui),  from  the  depth  at  which  the  parts  are  liii 

I  Iwlivve  ibat  a  calruluH  may  occasioDally  become  encvwtcd,  or 
oa)i«u1eii,  iu  aniKhur  way, — by  beJog  eoveretl  inby  akina  of  fiib« 
wbilft  lying  00  tlie  floor  of  the  bladder.    This  condition  I  Ibandia  nbof  •• 
«!••      '     -ftrau-^l  tor  stone  some  yean  ago.    AAw  ramoving  a  eaknlB  d 


DirPIOULTIB»   IN    LATBRAli   LITHOTOMY. 


983 


about  Lbe  iiw  of  a  pea,  I  felt,  with  the  end  of  the  Qii^r,  a  bant  irregular 
botlr,  covered  apparentJy  by  iuucoub  mcmhrnti^,  IvId;^  at  the  intbrinr  fundtii 
of  the  blii<lder.  On  ttcraping  through  the  mcmbmnc  covering  this  with  the 
point  of  nijr  nftil  and  a  curved  acoop,  I  exposed  the  calculus  [^Pig.  833.i,  and 
VBBoTrd  it,  with  a  cm  attached  to  it.  On  examining  the  Atructnre  of  thii 
eysl,  which  wttA  of  snout  the  tbickneasof  ordinary  writing  paper,  ofareddiflh 
color,  and  resembling  a  piece  of  mucous  memhrane,  it  was  found  to  be  a  false 
mcmbntae,  compiwed  of  organiiced  librocellular  tiasue.  The  patient  tnadea 
'  rMMver^.withtlie  exception  of  a  slight  attack  ot'g«oondary  hemorrhage, 
lick  occurmJ  ou  the  eighth  dajr  nftfr  the-  ofK-ration. 

JTibraid  7\tmitr»  in  Itit  I'tiMt-ilr  o^netitul«  iMjnietiinea  rather  a  eerious  diffi- 
llty  iu  litbotoiuy.  They  may  Ju  this  in  Iwu  ways:  firet,  by  elongating  the 
iiMatic  part  of  thv  iiivthra  to  eo  great  an  exleot  aa  to  carrj'  lh«  ucck  of  the 
ladder  far  from  the  eurtaw  ;  and,  aecondly,  by  being  iu  the  way  during  ex- 
traction of  the  «loi)e.  A  tumor  of  this  kind,  an  inch  ur  more  in  diaiuvtur, 
otcosaarily  tills  tip  tu  a  very  seriuue  extent  the  8{>uco  in  the  wound  throueb 
whiob  the  atonu  has  tu  pan  ;  it  jamtf  up  the  oritice  and  prevents  the  fre«  plsy 
of  the  fiirce|«.  These  tunioiv,  however,  when  caught  between  the  blades  or 
iks  of  tbe  forcetw,  swti  shell  nut.  and,  rolling  out  of  the  wound,  allow  the 
exit  of  the  calculus  after  them  CFJg.  864). 

'  e/the  J'ihio  Bonen  may  cotutitvite  a  fterioiw  or  even  an  insuperable 
lele  to  the  extraction  of  a  calculus.  This  condition  mny  act  in  two  ways. 
ly  uarrow  the  brim  of  ihe  pelvis  in  its  antert>-poetenor  diameter,  to  so 
mat  an  extent  n9  to  prevent  ihc  passage  of  the  atone  downwards  after  it  has 
Deeo  Kizeft  bv  tbe  forceps.  This  coodiliOD  ia  more  to  t>e  feared  in  children, 
m  whom  the  bladder,  being  an  abdominal  organ  and  lying  high,  is  altogether 
■bora  tbe  brim  of  (he  pelvu  in  these  chmr.  Or  there  may  be  ditiiculty  in  the 
•Ktnicdon  of  the  stone  through  tbe  inferior  outlet,  owing  to  the  approxima- 
tion of  the  rami  on  eacb  aide.  The  first  cause  of  difficulty  onoo  oceurred  to 
m»,  in  operating  on  ■  very  rickety  boy,  four  years  and  a  )talf  old.  Of  the 
ncond  I  have  bad  no  ox|>crionoe.  Tbe  rickety  condition  of  the  pclvid  may 
be  «a«pfct«d  in  vkmm  in  which  tbe  lower  lirabg  are  much  dtftlort«d.  Its  exlst- 
fDoe  may  be  aMertained  by  digital  exploration  of  the  rectum,  and  by 
bfual  nieasurcmenu.  If  it  be  found  tu  exi«t  to  an  extreme  degree,  it 
lid  pr<jb»bly  b«  safer  to  perform  th«  suprapubic  otteration. 
1  old  men  the  outlet  of  tbe  pelvis  may  be  greatly  narrowed  as  a  00i»Sfr 
1C«  of  M-uile  osteomalacia.  This  is  recognised  by  the  approximation  of 
ischial  tuben.isitie«. 
JM^ieuUy  depmdiny  upon  tht  Shape  and  Site  of  the  Stone. — If  the  sl^Toe  be 
r>und.  it  lit  uiiualty  more  difficult  to  seir.e  than  nhcn  flat  or  elongated. 
,  (iitk-»liape<l  t-alriili,  however,  oucasioually  latt  iut4i  the  fuudu«  of  the 
btadder  brbiu'l  the  pnwtaie,  and  then  cannot  he  rcfldily  reached  by  the 
broepa.  which  poiu  over  theiii.  In  ihc»o  circumittanucs  they  arc  best 
titraetcd  by  the  curvf^t  ocoop.  Very  flat  broad  ralruli,  and  imee  that  an 
lod,  ftgg-sha|ier],  ur  branrbeil,  are  iho  most  difHcuk  tn  remove,  emn 
j};b  their  Btxe  lie  not  very  great.  As  a  general  rule,  however,  it  mav  be 
that,  lbe  larger  tbe  calculus,  tbe  mure  difficult  is  its  extraction.  This 
■  not  so  much  from  I  he  out  let  of  the  pelvis  being  too  narrow,  as  from  the 
of  making  the  intirnnl  inrinjoni  through  the  [iriMtatc  very  limited. 
vUl  always  be  contttderable  iliHiculiy  in  extracting  calculi  weighing 
or  eight  ounce*  and  iiiiwnidH;  though  r&fon  arc  reroniei)  hy  t'heseldeo, 
io,  iind  otheni,  in  which  calculi  fnrun  twelve  to  tiOeen  ouitceo  in  weight 
kTi>  Iwen  extract'^  bv  the  hitcral  npcmti'iii.  Any  cnlrulii*  above  ooe  inch 
asd  a  half  in  itsohorkr  •liaiueter  Mill  be  bani  to  extract  tbmugh  an  inciaiua 
af  tbe  ordinary  length  (nut  tpxceedtng  eiight  lines)  in  U>«  prostate,  even 


iMt 


9S4 


URIKAAY   CALCULI 


LITHOTOMV. 


though  thJB  he  cansidorahly  dilnted  by  the  pirseiire  nf  tlir  fingers :  anil  I 
think  it  may  Kc  nafcly  rsu),  ibat  a  i-atciilun  two  inchcn  am)  npwariU  ia 
dianicler  can  fLcarccIylw  removed  by  (he  ordinary  Inlernl  operation  with  any 
degree  of  force  which  it  is  nafc  to  enijiloy.  The  practice  adopted  in  such  a 
caw,  more  tiian  a  century  ajfo,  by  GuocL,  of  Kurwich,  i»  iirolwbJy  the  bett 
that  can  bt:*  pursued.  It  consisU  in  drawing  the  slune  ne}l  d<»wii  with  the 
forwfpe,  and  then  letting  an  ai«intanl  rurerully  di%'ide  the  li*fiii«  that  re«i«t. 
In  this  way,  by  a  prucees  of  traction,  twisting,  and  ilivieiun,  the  ulone  may  be 
bruughl  out  with  safety.  In  ttie  fucilily  wltli  which  the  calculus  i8«xtractetl, 
however,  much  will  ilejwnd  u|Rm  the  make  uf  iho  forLt-pB.  A»  Ltstuu  nioel 
truly  olwervw,  "There  ean  be  no  tuurc  fatal  error  ibun  tnnUempl  the  extnic- 
tioD  of  u  large  atotie  with  ebburl.  ami  sliabby  forcupis."  lu  thcie  ci)m>»  the  ojien- 
bladed  forceps  (I'lg.  844)  will  Uv  found  useful,  the  uhsence  of  metul  in  the 
jDust  convex  part  of  the  blade  leEceniug  materially  the  bulk  uf  the  instrument 
when  grasping  a  si»ne. 

In  the  event  of  the  calculus  being  too  large  for  extraction  In-  the  ordinary 
lateral  uperaliou,  what  course  should  the  tjiirgeon  puretie?    Three  are  oj^ien 

to  him  :  1.  Division  of  the  Right  Hide  nftlie 
Prostate  from  the  interior  of  the  notind :  2. 
Cnituhing  the  Oilculus  in  the  Bladder,  and 
then  removing  it;  and.  .I.  The  perforninnce 
of  the  Recto-vcsicftl  Operation. 

Tbc  Incision  of  the  Right  Sideofthe  Pros- 
tate gives  ojiieiderable  adiliiional  ^pai-e,  and 
is  sufficient  for  mn^t  ordinary  purposes; 
very  large  calculi  being  fortunnlely  seldom 
met  with.  This  section  may  be  made  by 
intrcKlucing  into  the  wnuud  a  pntbc-pninled 
aralpel  t  Fig.  842),  guidtd  by  tlio  index- 
litiger,  and  very  cautiously  dividing  the 
right  »idc  of  the  prostate  dounwarda  and 
outwanla,  in  the  name  direction  that  the  flec- 
tion of  the  lelt  has  been  made.  Tbia  proce- 
duie  mut<t  be  canlinoiily  done.  The  parts, 
lieing  put  ivell  oil  the  nlretcb  as  the  atone  la 
dr.iwn  forwards,  are  carefully  notche<J,  and 
thus  yield  lo  the  traction.  In  two  canes  I 
have  lateen  Liston  do  this.  In  one  tlip  patient 
recovered,  in  the  other  he  died  of  diffuse 
inQammatiou  of  the  areolar  tissue  of  ihe 
pelvii^.  I  have  practised  it  once  on  a  {Miticot 
at  the  Ilospital,  who  made  ao  excelleuL 
recovery. 

The  set'iiud  plan,  that  uf  Crushing  the 
Caloolai  in  the  Bladder  thnmgh  the  wund 
in  the  jK.'riiieuin,  would  certainly  be  a  hajtnrd- 
uus  proct'dure.  The  irritation  that  wuiild 
uetHx«arily  be  set  up  by  the  l8rg;o  lithocrite 
or  crueber  (Fig.  805)  that  has  been  invL>>aced 
for  this  purpose,  by  the  preeence  of  the  fragraenta  of  stone,  and  by  Iho  neees- 
mry  dimculty  and  delay  of  clearing  them  out  of  the  viaciuf,  would  be  a  sennas 
and  possibly  falal  complication  of  the  operation.  In  the  event  of  its  being 
impoasibic  to  extract  ifie  calculus  througli  the  {terinnum,  1  think  it  would  he 
■afcr  to  adopt  the  third  couree,  and  to  perform  the  rwJo-iwiwj/  op/Tiitien^ 
which  will  presently  be  described.    Should,  huwever,  the  unusually  large 


fig.  M6. — Lttbol»iD7  Cnither  kdiI 
Drill  for  Lmrg«  Cklanll. 


I 
I 


I 


ACCIDENTS   UUBINO   LITHOTOStT. 


93d 


BiS( 


ynv 


'  of  the  8tODc  bftvc  boco  recogniwd  before  the  comDieDConicnl  of  the  opo- 
1,  it  mifHit  be  thongbt  more  wfe  lo  praciisv  nt  oqcc  the  bigh  thnn  ihe 

Unity  from  Fracture  of  the  Caloului. — The  difficulty  of  extractian  is 
Illy  incroued  if  ihe  etuoe  be  bnik^u.  Frncluro  of  a  catcului  is  of  two 
idA.  Iq  the  ouc  caM*  th«  ^tonc  is  Hioiplv  broken  into  several  fraj^roeota,  or 
liotera,  so  lo  speak,  ure  detacbi-d  fniin  it.  This  n(.-cidei)t  may  bappen  lo 
d  aa  well  as  lo  sufl  oalouli,  autl  is  ^t^noraUjr  owiufr  lo  tbe  Surceou  employ* 
loo  much  prenurr  on  tbe  blades  oi'  the  forcejw.  fcarinir  tbnt  tne  stune  may 
ipe  from  betwMb  thvoi;  or  tt  may  arise  fnim  tbe  liirge  siiw  nf  tbe  calcu- 
requintig  ttinie  force  to  hu  t!xem»e<l  in  it^  extraction,  when  tbe  Surgeon 
Tcry  apt  to  c»m|ir*>«!i  tbe  forcepfl  as  be  draws  tbe  ittnne  down.  Whi^n  tbis 
jWcitivot  a  found  Ut  have  ncciirrt^d,  tbe  Surj^eim  mnst  remove  witb  itinall 
or  the  •OHiji  the  frn){nients  tbnt  have  been  tletaebed.  He  iilir>uld 
_^Vaiib  ont  tbe  bimlder  by  ojpiou^  injectioits  of  te|ii<l  water,  hixI  very 
tfully  exariiiiie  ilK  tnteriitr  ftir  any  lonve  piet^ett.  It  n>  m^bloni  that  auy 
euui>e(iueuc«  results  fruiu  tbb  occurrence,  ihuQ  delay  iu  tbe  cuuiple* 
tloo  of  tlie  uueration. 

Tbe  secotM  mode  of  fracture  eousists  io  tbo  crumbling  dnno  of  tbe  calcu- 
.  so  suuu  us  it  ia  seized  by  tbe  t^jrceps,  into  u  soA  murtary  muss ;  the  stuue 
broken  iuto  lai^  piuces,  but,  baviug  oaiurallv  litUu  eubceiuu,  ilisiute* 
itcs  into  a  man  of  snfVish  frsi^ents,  none  uf  wliieh  prubably  cxveed  a 
livrry'Stnnc  in  size,  and  which  iurleed  resemble  a  wet  sabulous  a^'gregation, 
rather  ihaa  dietinet  pieces  id  ealciilus.  This  cninibliii^  donri  eaii  occur 
ly  in  phnephatie  i-nleuli.  It  is  in  no  way  tbe  fuiilt  of  the  AurjfeDU,  but 
I  from  want  of  roht-i^ion  iu  ihe  etilculiiH.so  tbnt  the  bladea  of  the  I'irreps 
lie.  aa  it  were.  tlin>ht;h  it.  It  is  an  unpleasiint  arc-i<lent  to  occur,  aa  it  be- 
>me«  extremely  itilfieult,  if  not  impfissible.  U>  clear  away  the  whole  of  the 
mnrtarv  dilriius  fn^m  the  interior  of  the  blailder,  ti)  the  lininp  mem- 
itie  of  wKifh  it  lenaciously  adheres,  small  massen  lying  under  tbe  ftilds 
whirh  the  cohlnicted  organ  is  thronrn.  An  much  as  poauble  »bonld  be 
pd  br  ibe  iKTMip,  mid  (he  rtfriiainder  wiutbed  iiwAy.ns  far  AS  prartit-able, 
oipioun  tnjectioDti ;  with  all  care,  however,  sumo  will  b«  left,  and  may  be 
rbnr;:rd  throocb  tbe  wound  some  days,  or  even  two  or  three  weeks,  atler 
nftorHtioo.  When  this  happens,  th«  bluddt-r  should  l>e  thoroughly  wsAhed 
It  every  day.  or  every  iwcond  day,  by  warm  water  injei*tioD8  tbrown  in 
Irnugh  a  catheter  passed  down  the  urethra,  and  ullutted  to  re){ur;;itHte 
krotigh  tbe  wound;  and  tbia  plan  muat  be  perse%vred  in  so  Ion);  ns  any 
eign  body  escapes.  Should  the  wouml  have  healed,  the  detritus  inu»t  b« 
ited  as  in  litbotrity ;  and  the  blnii>ler  must  be  waebed  out  every  second 
cbirH  day  by  a  large  eyc<t  catheter,  until  all  is  removetl. 
ArnnrMv  PiKisri  Litihttomy. — The  principal  accidenia  that  may  occur 
iring  tbe  prrr-irmiimt'  of  the  lateral  operation  of  litboUimy  are  Henmr- 
bage;  Cuttin);  the  Bulb;  Missing  the  Membmnou.a  Portion  ol  the  Urethra; 
Tnuod  of  the  Ueclum ;  or  Wound  of  the  Pijotorior  Tart  of  the  Bladder. 
HaBorrhagfl  during  litlntlomy  may  occur  from  three  siiurces:  1.  The 
Fr6eial  Arteries  .if  the  Perineum  ;  '2.  The  Deep  Arteries  of  this  repion ; 
3.  The  Fmetalic  and  ittber  Veins.  When  cxceasive,  from  whatever 
■ourFC  it  proeeedii.  It  is  alwavs  a  very  serioui^  complication;  for,  even  if  it 
de  not  prove  fatal  by  the  in({uctiou  of  syncope,  etc,  which  I  believe  to  be 
rery  rarely  the  cji.>«e,  it  la  apt  to  lend  to  a  fatal  termination  ioilirectly  ut  a 
biu-r  period,  by  pr«^liii|Ki«ing  to  the  occurrence  of  infective  procewcs  either 
local  or  geni^ml.  I  lielieve  that  patients  who  lose  a  large  quantity  of  blood 
wl  till!  i>{><-mti(iii  »c]doti)  recover. 

1.  Hemorrhage  from  the  Dimnon  of  the  Safer jieialarOte  Tnennene  ArUry 


936 


OBINABY    CALCULUS    AND    LITHOTOKY. 


1 


of  the  Perineum  is  Kldom  very  dsngeroiia,  though  ococuioTintlT,  if  tI]«M 
vessels  be  larger  thno  usual,  they  may  furQieh  u  M^rioue  i^uimltlr  ot*  blood; 
io  Bucli  circumstauceB  their  ligatun;  would  be  required,  antl  mi^ht  hv  prac- 
tised either  before  or  after  Ihe  extracticjii  of  the  calculus.  It  i»  betttrr,  if 
possible,  to  wait  until  the  completion  of  the  opcratioD,  levt  the  ligature  be 
pulled  off  duriug  the  extmccton  of  the  ntoiie. 

2.  The  i>(m/(«i  of  the  Deep  Arteries  of  the  perineum,  that  of  the  bulb 
and  the  iuterual  pudic,  would  be  attended  by  far  more  berious,  perhaps  even 
fay  fatal  oouDequences ;  as,  from  the  depth  at  which  the  veflttvls  are  seated,  it 
would  be  almost  impoasible  to  apply  a  ligature  to  them,  iiulest-  the  patient  ^ 
were  very  thin,  and  the  perineum  proportionately  shallow.  The  facility  ofH 
ligaturing  any  of  t1ie«e  arteries,  especially  that  of  tbo  bulb,  when  wounded.  ^ 
IB  greatly  increased  by  enlarging  the  iDcisioD  upwards.  Id  the  event  of  a 
ligature  not  being  applicHblc,  the  Surgeon  would  have  to  trust  to  plugging 
tbo  wound  round  the  tube,  as  described  further  on.  or  to  the  pressure  of  ui 
as^stant's  fingers  continued  for  a  cousidcrablc  time,  or  to  ihc  application  of 
forciproasuro  forceps.  The  pressure  of  the  fingers  of  relays  ot  awiiitants, 
kept  u|)  for  a  conaiilornhle  length  of  time,  although  it  seems  to  hiivo  been  an 
efficient  mode  of  treatment,  i«  painful  to  the  patient,  and  \a  difficult  to  carry 
out.  The  prei^urc  must  be  kept  up  for  many  hours;  ihua  South  relates  & 
cnae  in  which  It  was  niaintaincd  (or  fourteen  hours;  and  Brodie  one  in 
which,  after  twenlyfoLir  hours,  it  fiucoeeded.  The  aBsistanta  should  not  be 
changcil  rm>rc  frequently  than  ncoewiary,  each  keeping  up  prcsaure  for  two 
or  three  hours,  and  removing  hi«  fingprs  an  cuutiounty  as  poMtble.  It  is, 
doubtless,  very  rare  for  these  arteries  to  be  wounded  when  they  follow  their 
usual  course;  though  such  accidents  hax'c  hap|>ened  in  the  handx  of  some  of 
the  roost  skilful  lithotomtsts,  such  as  Home,  Bell,  Roux,  and  Desault.  It 
was  tlie  opinion  of  Aston  Key  that  the  artery  of  the  bulb  was  generally  cut 
duriuL'  litlii>t»riiv ;  but  in  t\m  he  waj»  mistaken,  so  fHr  as  it«  trunk  is  con- 
cerued,  though  iloubtWss  in  luxuy  caeee  the  bulb  itself  may  be  wounded,  and 
the  mesh  of  tuigs,  in  which  tlic  veeevl  terwiuales,  divided ;  this,  however, 
would  nut  yield  au  alnnuiug  hemorrhage.  The  trituk  of  the  orterv  of  the 
bulb  would,  houever,  be  enuaugered  by  openiug  the  urethra  too  high  up, 
and  latvnitiziug  the  knife  too  early,  and  if  wounded  bleeds  very  freely. 

It  may  hapfwu  that  on  pulling  the  wound  widely  open  the  bleeding  point 
may  be  seen,  but  at  such  u  depth  that  it  in  iiiipoesible  to  apply  a  ligature. 
It  may  then  be  seized  iu  tonuon  or  forcipressure  furcepa  aud  immediately 
twisted.  t;r  if  this  does  uot  succeed  the  pjrce[«j  may  he  left  hanging  on  the 
vessel  for  a  few  hyura.  l-'iir  this  purpose  the  forcipressure  forceps  are  the 
beat,  us  Ihey  more  efficiently  crush  and  obliterate  the  vessel. 

The  internal  pudic  artery,  bound  down  by  aetrong  fascia,  and  under  cover 
of  the  ramus  of  the  ischium,  runs  but  little  riiik  unlees  the  knife  be  latcral- 
ized  too  much,  and  the  incision  be  carried  loo  far  outwards.  In  children  in 
whom  the  ramus  or  the  ischium  is  to  a  great  extent  cartila^nou?,  this  acci- 
dent could  more  easily  happi'n.  It  \b  In  aome  of  the  nnomaluus  diT>Lributtoo9 
of  thcHt'  vessels  that  the  greatest  danger  would  lie  occasioned.  The  artery 
of  the  bull),  the  inferior  hemorrhoidal,  the  dorsal  artery  of  the  iieiiis,  or  the 
intfirnnl  jtudic,  may  take  such  an  BnomBh>us  course  that  thi-ir  di%'isi<in  is  ia- 
eviuble ;  and,  aa  the  ■'burgeon  has  no  posihle  means  of  knowing  beforehand 
whether  the  dietrihuttnn  of  ihc  arteries  is  regular  or  not, and  as  his  incii^iooB 
are  all  planned  on  the  supposition  that  they  arc,  he  is  uot  to  blame  in  the 
event  of  a  vessel  being  accidentally  divided,  when  it  take*  an  abnormal 
direction,  with  which  it  is  impossible  U)  be  acquainted  until  oiler  the  acci- 
dent has  occurred. 

If  the  incision  he  commenced  too  high  up,  and  especially  if  the  upper  (lart 


I 


ACGIOENTa    DURINQ    LATERAL    LITQOTOUT. 


9S7 


Inl  inciBton  W  niude  by  pushing:  the  knife  in  too  deeply,  the  corpus 
8p«>u^;itieiim  and  it!i  veiutels  may  be  wnuiulcd. 

It  nmy  be  slAterl  a»  a  general  rule,  that  serioii(<  hemnrrhitge  is  usually  be»t 
avoideil  by  m.ikinfi  tlie  iocisi'Jtis  low;  nnd,  indeed,  I  Ijelieve  itiat  the  great 
secret  of  suecese  in  tlie  laleral  u|)eration  of  llthotmny  constsU  in  niakinu  alt 
the  deep  tnciiilons  as  low  as  practicable  ;  the  knife  entering  the  groove  of  tiie 
stafTfroni  below  upwards,  rather  than  fntin  abuve  downwards. 

3.  Venovs  Hemorrhage  may  occur  fruui  two  sourceg — the  ^perficial  or  the 
proetatic  veltis.  It  ia  very  seldom  that  any  tniiible  ariscti  from  superficial 
veins;  but,  in  one  ea.Be,  I  have  seen  very  ctiu^iderablc  loss  of  blood  occur 
from  a  large  vein,  ruDuing  irnnsver^ty  near  the  up|>er  angle  of  the  wnniid, 
lying  almoal  immediately  uQ<1er  the  i^kiu,  which  had  been  incompletely 
divided.  From  the  ]irmiu[ic  jiIcxub,  hemurrbage  is  moet  likely  to  occur  in 
old  people,  in  whom  the  veins  iu  this  nituattuu  aro  ollen  enlarged — almost 
hemorrlioidal. 

Whether  the  vcunua  bleeding  take  placo  from  a  superficial  or  from  a  deep 
source,  it  is  very  apt  to  find  itn  way  back  intn  the  bladder,  to  mix  with  the 
urine,  and  thtin  to  e-icape  through  the  tulie  rather  than  fnim  the  w.tnnd 
itaelf ;  or  the  blood  may  probably  coagulate  in  the  interior  of  the  bladder, 
distendiog  that  organ  and  producing  a  feeling  of  dyouria.  Should  it  proceed 
tnua  a  superficial  source,  il  may  be  nece^ary,  aa  wan  done  in  the  case  just 
alluded  to,  to  pasH  a  ligature  under  the  vejwil,  and  thua  arrest  it  If  it  occur 
from  the  pro.4tatic  vein!),  the  better  plan  will  be  tn  plug  the  wound.  Thia  la 
done  hy  jiassing  long  strips  of  lint,  either  dry  or  soaked  in  a  solution  of  per- 
chloride  nf  iron  or  of  alum,  along  the  i*ide  ofthe  lube,  which  muRt  be  leu  in 
the  wound  and  kept  pervious;  or  the  lithotomy-tube  may  have  a  "petticoat" 
of  thick  muslin  ti<'d  around  it.  into  wliitii  llie  slips  of  lint  are  stiified.  Tha 
advantage  of  thie  arrangement  is,  tliuc  the  whole  apparaluD  may  wry  easily 
b«  removed  toguther  at  the  end  of  lorty-eigbt  hours. 

A  far  more  efficient  means  of  applying  pressure  ie  by  menus  of  the  "Air 
Tampon,''  invented  by  IJuckston  Browne.  It  consists  of  au  ordinary  guiu* 
elastic  litliolomy-tube,  surrounded  by  an  India-rubber  bag,  which  cau  be 
distended  with  air  from  a  Bynnge  by  means  of  a  tube  iitted  with  a  stop-cock. 
This  te  inserted  into  the  wound,  eo  that  the  India-rubber  bag  fills  its  whole 
length.  On  distending  the  bag,  lirm  uniform  pressure  of  auy  desired  force 
cau  be  applied.  Afler  from  twelve  to  twenty-iour  hours,  a  little  air  cau  be 
let  out  so  as  to  reduce  the  presaure,  and  this  is  repeated  at  intervals  till  the 
tube  can  he  removed. 

Hemorrhage  from  aoy  of  the  above-named  sources,  but  more  eepeoiallj 
fn>m  the  deep  arteries  and  veins,  may  lake  place  into  the  bladder.  When 
this  occurs,  the  uriue  that  cdcapea  will  be  ^ccn  Ui  be  deeply  mixed  with 
bluwl ;  and  coagiila  will  form  in  the  interior  of  the  viscus,  which  becomes 
difitende<l  ami  rise)  abuve  the  pubcs,  with  dulncas  on  percussion  in  the  hypo- 
gastric region.  The-  patient  will  become  pale,  faint,  and  (vild.  In  such 
circumstances,  the  conguln  must  bo  wa^^heil  out  of  the  bladder  with  cold 
water,  the  source  of  hemorrhage  ascertained  by  au  examination  of  iho 
wound,  the  further  flow  of  blood  arnslcd  hr  plugging  or  ligature,  r(«tora- 
tjvre  adrninisU'red,  the  pelvis  placed  high,  and  the  palicut  kept  cool. 

Woond  of  the  Bulb  is  not  of  very  uncommon  occurrence  in  lithotomy ; 
anil,  I  believe,  is  of  no  coiwequcnco  beyond  funiUhing  a  smalt  additional 
riuaoticy  of  blood.  Indeed,  the  bulb  in  so  situated,  in  many  cases  ovt-rlap* 
ping  that  membranous  portion  of  the  urethra,  that  tliis  can  scarcely  ba 
opencfi  without  wnuoding  it. 

His&ing^  the  TTrethra  altogether,  and  opening  up  the  bladder  through  or 
even  altogether  beyond  the  prostate,  in  an  accident  that  may  hapimn  if  the 


038 


URINAHY   CALUUIjUS    AND    LlTltOTUMV. 


Sur^m  mtecntculato  the  dopth  of  Ihe  perineum,  aod,  keeping  the  intrtsK'ns 
too  low,  tlirii.>a  tliH  kuifu  too  tleeply.  It  its.  I  b«<lievc,  an  incritubly  fnUl 
itocident,  as  In  it  the  base  uf  the  tiliulder  uuil  the  reciu-vfsieu)  faecia  are 
upeiio<t.  anil  the  patient  ifi  ihiis  ex\yise*\  Id  the  (i<*currvnce  of  rlifiuM  iofliim- 
niation  uf.  nn<l  lutillxatlon  iuLo,  the  pelvic  areolar  Ltmic  I  was  prowot, 
many  yi^Hn*  a;^i,  at  the  [»ii3t-ii)orlfni  exauiioalion  of  a  fatal  caac  tit'  lithohiRir, 
in  wiik'h,  |)prliap»,  the  m<uiL  skilful  o]KT»ttir  of  that  day  had  oni-nfil  the 
Miiiliicr  Itevund  the  prtietale.  Ifa^'inj;  the  urethra  unlouchel ;  tln^  p3itii.'nt 
die>I  from  th^  r.iii.i^'  just  ntateil. 

Voand  of  the  Rcctnni  occurs  more  frentienlty  than  is  generntly  siip[tiipe<l. 
It  nuiy  happen  eilher  in  (■(niapi]uence  of  the  BtafF  heing  tito  much  depreeeeil, 
of  the  edpe  «if  the  knife  tnrned  ton  rlirectly  downwanU,  or  of  the  recUim 
being  dist^nde^l  an<l  overlapping  the  !<idv5  of  the  pnistale.  I  have  also 
known  the  lower  part  of  the  rectum  perforated  by  the  .Sur^oo's  fineor. 
whilst  depressing  the  gut  w  m  to  keep  it  out  of  the  way  or  the  knife.  jT« 
Treatmrnt  of  thia  accident  will  vary  according  to  the  size  and  ttiluiition  of  the 
aperture.  If  it  lie  uf  but  moilerate  extent  and  low  down,  Ju^t  above  the  anuSf 
it  will  ]>rol)iiblv  clow  as  the  wound  granulates  and  the  urine  reftumee  ita 
pa»wi[re  throuj;))  the  urethra.  If  the  inctjiion  be  more  extensive  anil  higher 
up,  thi'  parient  will  incur  the  ri»k  of  the  niiiterHble  infirmity  of  rect't-re^iral 
fitirulii  tx-iuf;  induced.  In  such  circumstances,  the  pro[>er  Irentment  is  to 
diviile  the  vphiticttT  ani  from  the  opening  downwards,  and  thus  lii  lay  the 
gut  and  wound  into  one  euvity,  which  wdl  pnibiihlv  till  by  granulation,  and 
ihu"  lIiw-  lilt'  iiriniiry  paxsntres. 

Wound  of  the  Posterior  "Bnxt  of  the  Bladder  ii<  very  rare;  yet  it  bas  hajK 
peiierl  in  eousequence  of  the  knife  being  thniat  too  deeply  along  the  gnwjvi' 
of  the  Btair.  mure  [mrticularly  in  operations  on  children,  and  would  li-' 
specially  apt  to  happen  in  such  case:*  if  the  bladder  did  not  contain  etifficieot 
urine  at  the  time.  This  is  an  additional  reaaon  for  injecting  the  bladder 
betbro  operating. 

In  children,  the  lateral  operation  of  lithotoniy  presenta  certain  spedal 
diHicultics  which  have  already  been  adverted  to.  Tnese  are :  1,  the  Surgeon 
mining  the  bladder  and  opening  up  the  rectn-vcsicai  space  (p.  929  <:  2,  not 
opening  the  urethia  and  neek  of  the  bladder  aufficienlly  with  the  knife,  but 
pushing  these  parts  before  the  fln^er,  and  so  tearing  ncroae  the  uretbrn.  and 
thus  nc'Cfiisarify  being  unable  to  complete  Ihe  operation  u>.  fl>{l);  and,  3, 
running;  the  knife  too  fur  along  the  groove  uf  the  etatf  into  lue  bladder,  and 
thu»  \v.)unding  the  posterior  pari  of  that  organ. 

Soi:RrE3  OF  DANtinn  AND  Cauhes  or  Death  after  I.iTnorojrv.— 
Lithotomy,  even  in  healtbv  subjects,  is  always  a  dangenius  ofk'raliou  ;  and, 
though  the  rate  uf  mortality  doubtlei<s  depends  greatly  njvon  the  dexierily 
and  fckill  of  the  operator,  more  is.  I  believe,  due  to  the  cnnirtituiion  and  ago 
of  the  patient,  and  especially  to  the  state  of  bin  kidneys.  Sir  B.  Broilie  mntf 
justly  says:  ''.Success  in  lithotomy  mnst  undoubtcflly  depends  in  a  great 
decree  on  the  manual  skill  of  the  Surgeon,  and  on  the  mode  in  which  tlie 
operation  is  performed ;  but  it  denemls  still  more  on  the  condition  of  the 
patient  with  respet^t  to  his  general  health,  especially  on  tlie  existence  or  nnn- 
existence  of  orjmnie  disease."  That  tlie  mere  rutting  into  Ihe  bladder  i*  not 
a  very  dangerous  proceeding,  prnvidw!  that  viwus  and  (he  kidneys  be  healthy, 
is  evident  I'mm  the  fact  that,  in  those  oiu*c-«  in  which  Surgeons  have  hud  to 
extract  bullctc,  bits  of  catheter,  etc.,  from  this  nririin,  had  consenoenc*^  have 
rarely  iicctinvd,  though  ihe  o [Mirations  have  often  been  tedious.  In  lithntnmjr 
the  eaiie  ia  dilferent;  for  here  the  bladder  i*  not  only  usuallv  in  a  state  of 
chronic  irritiitinn,  hut  the  kidneys  are  iVe'ioenlly  dii<eai>e<l,  and  these  cmdi- 
tinns  influence  the  result  of  the  o[>eratiou  more  materiatly  Ihau  any  other 


I  in 


1**1 


MORTALITY    AFTER   LATERAL   LITHOTOMY.  939 

ircaiDBtances.  Hence  an  operator  may  have  a  run  of  unsuccessful  cnseB ; 
IT,  by  a  fortunate  concurrence  of  favorable  cni^es,  more  particularly  in  chti- 
Irm,  it  had  occasionally  happened  that  a  Surgeon  has  cut  20  or  30  patients 
D  HiocefleioD  without  losing  a  single  one;  but  several  deaths  then  occurring, 
bough  the  opeeatioQ  was  |>erformed  in  the  same  way  and  with  the  same  care 
IS  before,  his  avera>^  has  fallen  to  about  the  usual  level.  Green,  at  St. 
naomaaV,  cut  40  patients  in  pucce^sion,  and  l«st  only  one.  Lynn  cut  25 
Mttents  for  stone  without  losing  one,  and  he  said  that  he  thought  he  had 
A  last  discovered  the  secret  of  ])crforniiDg  lithotomy  with  success ;  hut,  he 
iddrd,  the  Almighty  punished  him  for  his  preeumption,  for  he  tost  the  next 
I  cases  that  he  cut.  Branaby  Cooper,  of  Guy's,  cut  30  patients  in  succession 
■itfaout  a  death,  but  then  lost  several,  thus  reducing  the  rate  of  mortality  to 
the  usual  standard.  Liston,  during  a  period  of  six  years,  in  which  he  oper- 
ited  24  times,  lost  no  patient  from  lithotiimy  at  University  College  Hospital ; 
but  out  of  the  whole  •}?  cases  which  he  cut  during  the  ]>criod  of  his  connec- 
tion with  that  institution,  there  were  5  deaths ;  reducing  the  average  to  1  in 
7.2.  This  success  was,  however,  very  great  when  it  is  taken  into  considera- 
lioD  that  most  of  these  cases  occurred  in  adults,  and  that  many  of  them  were 
of  ft  very  serious  character.  I  find  on  reference  to  the  Hospital  records, 
that  onlv  seven  of  the  patients  were  under  10  years  of  age,  whilst  14  were 
above  56;  of  these  two  were  80  years  of  age,  of  whom  1  died  and  the  other 
Kcovered.  I  believe  that  Liston  lost  only  one  patient  under  60  years  of 
we,  and  that  was  a  lad  of  18,  in  whom  he  found  it  necessary  to  divide  the 
iwht  side  of  the  prostate  as  well  as  the  left,  an<l  who  died  of  infiltration  of 
nnne.  Thirty-eigot  patients  successively  operated  (m  at  the  Norwich  Hospital, 
reoovered,  but  the  average  rate  of  mortality  in  that  Institution,  calculated 
fkom  871  cases,  has  been  1  in  7.50. 

The  accompanying  Table  gives  much  valuable  information  on  the  rate  of 
Dioitality  after  lateral  lithotomy  at  diflL-rent  ages.  It  may  be  taken  as  a  fair 
ezaaiple  of  successful  English  practice  in  this  operation. 

OF  PATIEXTH  ON  WHOM  L.VTEEtAl.  LITHOTOMY  WAS  PKItFOltMKn  AT  THE  NORFOLK 
ID  NORWK.'lt  HO:^ITrAI.S  FItOM  JANI'AEtY,  1772,  TO  DKCEMItKK,  18U9.  IIY  CIlARLEa 
OXIAMA,  F.B-C.S..  ASSISTANT  SCKIJKON  TO  THK  IHIfl'ITAf.. 


»  j; 


t:      M 


a.*-        X     s.     s: 


«    I    M       (l.rt-,       44     7.V'7      II      2H:l     I"      l.l  I      •                                     .„  .,  I   ■■     4  94 

«     12i)|5:i.Mi     US    ti.:      :;i;     i-.:;      i  ■■    ...i:.     ,  ''^     -'■'*    "-    ■■■ '    ■ '  -'    '        *■'** 

»       W      -.114      1.-.    7ii.s(       7     -..i.i     I"    :;.!-     .  "-     "■-■"    ' '■■'••     ■■'^     -'■'•'     '        •'■" 


I,    ii»Tl|  r.io    •*fi.<'.'<     III!    \:\M-2     1  in    T..."        >:!  7..;.    >!. 'N    M<',     i:;.:;i!     l  in    7.50 

Cheselden  hwt  only  1  in  every  101;  and,  according  to  South,  at  St. 
Ihomas's  the  mortality  has  not  amounted  to  more  than  1  in  Oi ;  but  a  goo<l 
nanj  of  these  patients  were  probably  children.     Kir  B.  Brodic  states,  that 


940 


CRIKABy    CALCULUS    AKD   LITHOTOMY. 


of  Uie  59  casGfl  operat«il  on  iu  alt  tlio  LodiIod  HoepitabiD  the  ycsr  ISHii,  10 
died  ;  mnkiD^  llie  mortality  as  nearly  as  poaaible  1  m  6.  But  the  more  recent 
and  cxt«niled  stati^liL's  cjiioutcil  by  Thompson,  i^hitw  tliat  the  avt^raL^c  mor* 
tality  in  the  l^nndoii  Hi»i)ituld  U  I  in  7i.  According  l<j  Couloon  the  uveragic 
mortalilv  iu  Hugluiid,  dtiducud  fntiu  1743  caaed  uf  the  lul^nil  operatinDr  is 
1  in  6-93  cMfd ;  whilst  in  France  it  i«  1  in  5.7  ;  and  for  Europe  gcnemlljr 
1  in  6.14.  The  more  recent  atatistica  of  Sir  H.  Thonip«o«  show  a  more 
favorable  result  for  latcml  lithotomy  in  England.  He  finds  that  out  of  1S27 
recorded  co^^  there  were  2'29  deaths,  or  nearly  at  poanble  1  in  &  Klein 
states  that,  of  4486  caws  of  lateraJ  lithotomy,  in  Moscow,  thera  were  552 
deaths;  the  mortality  thui  bcinj;  nearly  the  same  as  in  England. 

The  peroentage  of  di?ath»  atlcr  lithotomy  iu  the  adult  will  doubtless  be 
found  gradually  to  inereaiie  with  the  iiioreaitiug  me  of  Htliutrity.  Thid  must 
not  be  referred  U>  any  delect  in  the  meth(Ml,  or  to  want  uf  skUl  in  the  pet- 
Ibrmance  uf  lithotomy,  but  to  the  fact  that,  inAteaul  uf,  aji  heretofore,  being 
the  general  meth<Hl  of  reniciviiig  cnlculuH,  it  han  now  become  the  exi-epliutuU 
one.  Almoat  all  cases  of  small  and  moderute-sized  cilculi  in  men  with  other- 
wise healthy  uriuary  organs  are  now  subjected  to  litbotrity,  whilst  those  case* 
iu  wbieb  the  sLone  is  too  large,  or  the  kidneys,  bladder,  prostate,  or  urethrm 
too  diiettsvd.  tu  udoiit  of  this  mode  of  ojK-rating,  are  reserved  fur  lithotomy; 
mod  OS  the  mortality  after  this  openUiou  increases  iu  thu  exact  proportion  to 
the  size  uf  thu  stuuc  and  the  dis(>aite  iu  the  urinary  organs,  wc  must  exj>ect 
that,  when  iu  jKirl'urmuQce  is  couSucd  to  persons  with  iarec  calculi,  irritable 
bladders,  eular^'cd  prostates,  disi»ucd  kidaeys,  or  «lrictured  urctbne,  a  higher 
percentile  of  deaths  will  fidlow  it  thuu  was  the  case  whcu  aU  Ikvorable 
cases,  and  nut  the  unfavurablc  ones  ouly,  were  subjected  to  iL 

Age  exercises  a  mure  marked  iullucnco  on  tbo  result  of  lithotomy  than 
any  other  condition.  Lithotomy  may  be  looked  upon  as  one  of  the  moat 
SHCcefHful  operations  irv  surgery  at  early  periods  nf  life,  a  hazardous  one  in 
middl«  age.  and  an  extremely  dangerous  one  in  advanced  age.  At  the  Nor- 
wich Hi>,^pit«I,  lithotomy  has  been  found  to  be  four  tiraea  ob  fatal  in  men  as 
in  hoys.  Coulaon  finds,  nn  nnalyting  2'.i72  cases  of  lithotomy,  that  the  mnr- 
talily  at  each  succosaive  decennial  period  ia  as  fullows.  Kelow  10  yearA  it  is 
1  in  13,  and  thence  gradually  augmentsfrom  10  to  80 years  tol  in  0,  1  in  6, 
1  in  5,  1  in  4,  1  in  o.G5.  1  in  3.'2'i,  and  I  in  2.71. 

The  reason  of  the  small  mortality  after  lithotomy  in  boys,  as  compared 
with  adults,  is  most  probably  that  the  urinary  organs,  more  especially  the 
kidneys,  are  healthier  than  in  the  adult.  Hence  when  boy;*  die  afiec  lith- 
otomy, they  do  not  usually  perish  from  the  ^ame  eausM  that  provo  fatal 
ID  the  adult,  viz.,  kidney  disi^Hse  and  dilfuHU  pelvic  iollammatiou  and  iu6)* 
tration  ;  Uut  the  fatal  result  is  generally  the  cuuseqiieneo  uf  aoinw  acxident 
having  occurrwd  or  violence  been  inflicted  during  the  oneratiuii,  such  as  by 
mistaking  the  recto-vmcal  space  for  the  interiur  of  the  bladder,  the  tearing 
across  of  the  urethra  and  nun-extraction  id' the  stone,  wuuudingof  tiie  recto- 
vesical fjtd  of  peritoneum,  or  [lerfomtion  nf  the  back  of  the  bladiler  by  the 
Eoint  of  the  fical|>el.  It  is  by  these  accidents  usually  that  liealh  happens  in 
oys  that  arc  cui  for  9t<ine,  and  not  from  unavoidable  circumstaucta  that 
may  fitlhiw  ihe  in»jL  skilfully  performed  operation. 

The  Shock  of  the  Operatioo  occaeioiially  proves  fatal,  though  probably 
much  less  frequently  since  the  introduction  ot  chloroform  than  waa  formerly 
the  cnseL  Yet,  even  now,  patients  occasionally  die  from  this  cause,  induced 
either  hy  a  very  much  prolonged  o|>8mtion,  or  by  the  system  being  weak- 
ened, and  having  lost  its  nsistiuf;  power  in  consequence  of  diaeosc  of  the 
kidneys,  perhai»  of  a  latent  character. 


Tbe  SUte  of  the  Kidneys  intlut^nces  the  rc«ult  of  lithotoniT  id  lh«  adult 
BMrv  dir«>.-tly  tban  any  <jther  coDdJtioD.  If  Chew  orgaDi  be  aouod,  tbe  patieat 
■rill  usunllr  recn%'pr;  henc«  in  cbildreD,  in  wbom  ibe  coiupItcsUcm  of  rcnftl 
iiseaae  rHrely  exists,  lilhoLomy  i§  very  EUccc»ful,  even  though  the  operation 
k  prQportioURtely  far  more  severe  in  tJieni  than  id  aduiu.  If,  oo  toe  ulber 
und,  the  kidneys  be  extentiively  diseased,  the  jMitieol  will  coqidiodIv  die, 
pren  though  he  hare  been  operated  upon  with  the  utmost  (»re  and  skill. 
rhe  condition  nf  the  kidneVB  that  is  especially  fatal  has  been  fully  described 
ia  Chapter  LXVII. 

A  Frolong^d  Operation,  even  under  QDn?sthotic«,  is  dHii^-niue ;  and^ 
■hboogb  it  i8  cerlaiiily  ixn  welt  to  operate  a^uinut  liiiif.  yet  il  is  und<>u))teilly 
■dvantageous  to  fiiiiitli  tbe  operation  with  aa  litllo  dc-luy  an  U  consiAtent  with 
liw  «afety  of  the  patient,  even  thuuj^h  he  he  aiiiJi:$thet)zed. 

Bemorrbage  does  nut  ho  otlen  |m)ve  ftitAl,  either  nburtly  after  the  opera- 
tion, or  at  a  later  jwriiK),  an  might  he  exfH'cied  from  iht*  great  vui^cularilv  of 
tiM  parts  incised.  8oroiidary  hemorrhage,  uf  u  dangerous  or  even  fatal  char' 
Acter,  mavi  however,  come  on  six,  eight,  or  ten  days  sfler  the  operation.  I 
hftve  known  it  as  late  ta  the  ftxirleenth  day.  It  must  be  borne  in  mind  that, 
wbcD  hemorrhage  takes  ptac«  after  the  operation,  the  blood  may  find  it«  war 
into  the  bladder  rather  tlian  e«cApe  exK>rnnlly,  dUtending  the  vi^cus  yiiln 
Boagnla,  but  not  giving  any  external  evidence  of  the  mischief  that  has 
tfcearred.  Svcftndary  hemorrhage  will  iwiially  cente  on  plugging  the  wound 
with  Hponge  or  lint  Risked  in  alum  «olntion.  Should  it  prove  serious,  how- 
C!«*r,  the  arlnai  cautery  may  Iw  ndv«utage«'usly  employed.  In  a  case  that 
occurred  to  me,  thi-  htti-ding  on  the  ninth  day  Hnit  ^l(jp)ted  by  wiping  out 
the  wuimd  with  ihe  actual  cautery,  a  practiw  which.  I  have  been  infonned 
by  A.  Dnlrymple,  was  oecasiouaiJy  Buccessrully  practised  by  that  excellent 
lilh.i|rtrni*i,  bis  father. 

Cjstitii  i»,  in  my  ex{>erience,  a  rare  sequence  of  lithotomy.  I  have,  bow- 
wer,  seen  it  occur,  attended  by  the  secretion  of  large  quantities  of  viscid, 
ropy  mucus  from  the  bladder,  coming  away  two  or  three  days  after  the 
opt-niliiin.  with  tendernees  in  the  suprapubic  region.  It  mav  exist  belore  the 
operalifin,  or  may  l>e  produceil  by  long-con tinuetl  or  ruugh  manipulations 
with  liie  fbrcepB  in  senrching  for  tlie  stone,  or  by  the  irritation  of  the  tube. 
Tbe  symptoma  are  apt  to  simulate  thoee  uf  pplvic  iterilooitts.  Tbe  JVeat- 
aienf  eonsi^lB  of  fomentnliuns  above  the  pubca.  almit<lant  diluenls,  aod  waab- 
iog  ont  the  bladder  with  tepi<l  water  injected  thr>i)^'h  the  wound. 

DUniM  Infiammation  of  Uie  Areolar  Tisiue  of  tbe  Pelvis,  ei«]HH-ially  of  the 
UyerB  around  the  net-k  •){  tlio  hla<lder.  belwi-en  it  ami  the  re^'tum^  which 
extend  thence  under  the  tieritoDcura,  is  the  mont  frequent  cause  of  death 
aAcr  lithotomy.  Thi^  intJnmmaiioD,  which  is  always  diffuse,  followed  by 
lapid  sloughing  of  the  texturt-«  that  it  invades,  may  arl^  from  two  causes  : 
1.  Frtmi  tbe  urine  being  infiflrafett  into  (tic  armlar  tuiguf,  id  cottsequence  of 
ihc  inrision  extending  b^ond  the  limits  uf  the  prustnle,  into  the  looae  layers 
of  ttnue  that  lie  behimf  the  reoto-vesical  fascia  and  around  thebtad4ler; 
i.  In  ci-nivjuenceof  the  bmi^inyrnd  laceration  to  which  the  neck  of  th« 
bladder,  the  nrostate.  and  the  textures  between  it  and  the  rectum,  are  sub- 
jected, in  proloogvd  attempts  to  extract  a  large  cnlculus  through  too  small 
Hjocwitm. 

Ml.  Tbs  danger  of  Catting  beyond  the  lAtttml  lAgtimgnl  nf  the  Bladder  ia  the 
Mult  ha*  al ready  been  ad rer Led  to.  In  the  extraction  of  calculi  of  ordinary 
•iie,  then  ean  b«  do  necessity  to  extend  the  internal  incision;  bat  when  the 
calcalua  ia  of  oonsiderable  mugDitude.  the  Surgeon,  wishing  to  get  as  mncb 

yioe  aa  pflaslbW,  may  inwivenenily  carry  bis  uif«  beyond  the  proitate;  or, 
ba  make  a  cut  Into  tbe  right  side  of  this  gland,  bo  may,  ptrbapa.  prulong 


J 


942 


URINARY   OALCULUS   AN!)   LITQOTOMT. 


it  a  little  too  far,  und  tliu«  open  the  lo^jee  arvolur  ttisauc  or  fascia  which, 
beyond  it,  noil  w'hi;;fi  is  cuiitiuuouB  with  lliu  Kubjieriloucal  {ilanc  uf 
lur  tifsii'e.      llv  <liliiliii^  llm  iiifi«i<iD  iu  the  proetato  downwanU  aail  ou 
wiiriJs,  ehhur  with  tlii^  i'ln^vr  ur  with  a  blunl  t^>rgct,  iujury  to  thia  tiaBUO 
prevetiteJ. 

If  the  incision  extend  heyoDd  the  prostate,  the  urine,  as  iimcapvs  thmugh 
tlie  wound,  sunks  into  the  meshes  of  the  looee  areolar  liaaue  over  whirh  it 
AovtB,  and  thus  gives  risr  tn  inRitrattnn,  followed  by  rapidly  exteuding  ioflatn- 
matiou  nod  eloiighing,  whit-h  speedily  involve  the  whole  of  ihe  neighlwring 
texturea.  This  mischief  generally  occura  within  the  first  forty-eight  hoars; 
indeed,  I  have  never  seen  it  come  on  after  the  third  day.  It  h  inilicateii  by 
the  paiieiic  being  8eix,ed  with  rigors,  followed  by  dry  heat  of  skin,  a  quick 
pulse,  which,  after  a  lime,  may  become  iDtermitt'tnl,  and  a  dry  and  bmwn 
tongue.  At  the  same  unte,  he  will  complftio  of  snme  lenderneea  about  the 
lower  part  of  the  ahilonteit  and  in  the  groioa ;  the  belly  becomes  tympaoilic^ 
the  body  covereti  with  a  profuse  eweat;  hic-eup  comes  on,  the  pnUe  becoinefl 
more  weak  and  tUitiering,  and  death  usually  occurs  abinit  (he  fourth  or  Sflh 
day  afler  the  o|K*riiti<>ii.  Iu  souit;  eastii,  there  nrv  mure  decidtnl  ttigns  of 
peritunoat  inllamomlion ;  but,  hh  Brodie  very  truly  remarks,  this  is  otit  the 
primary  disease,  hut  is  only  induced  evcoudarily  by  the  inBammatiuo  and 
sloughing  of  the  areolar  tissue  uf  the  pelvis  spreading  to  the  contiguous  serous 
membrane. 

The  Treatment  of  such  cases  must  be  conducted  on  the  ordinary  principle? 
that  guide  us  in  the  mnniigement  of  difl'ueeinfiammalion.  It  is  only  by  admin- 
isteriug  ainruotna,  with  such  a  quantity  of  wine  or  brandy  hh  the  state  of  thi^ 
ayetem  may  iridicate,  together  with  such  nourishment  as  the  jwtientcnu  take, 
that  life  can  be  preserved.  The  disease  is  a  depressiag  one,  and  requires  a 
«tiimilatii)<^  plan  of  irenlmeiit.  Brodie  has  rceorameaded  that  in  these  cskb 
a  free  incision  should  be  made  thmugh  llie  sloughy  ti^ues  about  the  wound 
into  the  rectum,  in  accordance  with  the  gcnonU  principles  that  guide  ua  in 
the  managenieut  of  similar  adectione  elsewhere.  In  one  case  oi  that  kind 
that  occurred  under  \m  cure,  lie  saved  ihu  patient  by  parsing  a  curved  probe- 
piiintcd  biBCoury  into  the  wound  to  its  furthest  extremity,  U>  the  left,  aide  of 
the  neck  uf  the  bladder;  he  then  pushud  it  through  the  tunics  of  the  rectum, 
and,  drawing  it  downn-ardH,  divided  ihe  lower  jHirt  of  the  gut  together  with 
the  sphincter;  thui«  laying  the  wound  and  the  rectum  into  one.  The  relief 
was  immediati!,  and  the  patient  recovered.  This  plan  uf  treatment  ooruioly 
seems  nitionul,  and  Wfirthy  of  trial  in  idmilar  cssfs. 

2.  Dlft'uKe  intfiimmation  of  the  areokr  li<Hue  anmnd  the  neck  of  the  bladder 
and  prostate  arising  from  Uruinng  mid  (herdiMrntton  of  the  parts  during 
the  extraction  nf  a  large  calculus  is,  t  believe,  a  more  frequent  occurrence 
than  inhltrntion  of  urine,  and  fully  as  fatal.  This  M-qucncc  of  lithotomy  is 
especially  apt  to  occur  in  those  casta  in  which,  in  conacquence  of  diseiwed 
kidneys,  or  the  existence  of  i^her  organic  miochief.  the  patient  is  more  than 
usually  liable  to  the  supervention  of  dilbiBP  intlammalion. 

In  the  extraction  of  large  calculi,  considerable  iraoLiou  is  require*?,  a 
force  must  be  exerted  ;  hence  undue  hruiaiug  and  laceration  are  very  ajd 
be  inflicted  upon  the  parts  that  constitute  the  line  of  incision.     It  is  in 
way  that  the  danger  of  lithotomy  increnst's  almost  in  exact  proportion 
the  size  of  the  calculus:  for  here  the  Surgeon  is  often  placed  between  the 
horns  uf  a  dilemma.     He  must  either  cut  beyoud  the  limits  of  the  pr 
and  thus  iucur  the  risk  of  inducing  urinary  inliltratiuu  into,  aud  diffuse  i 
Uammatiun  of  tiie  |>elvie  fasciu.' :  or  cIm.',  by  limiting  his  iuvinion  lo  llie  glau 
and  thus,  having  an  aperture  >jf  iuiiLdHcient  size,  he  niny  inlltcl  sevt-re  inju 
by  the  bruising  aud  laceration  of  pu-rts  during  forcible  and  poastbly  p 


I 


HKOIAN   LITHOTUMT. 


« 


ms 


loDg«d  eObrlfl  at  extraction.  It  must,  however,  be  borae  id  miud  thnt,  the 
larger  tbe  stoae,  the  mnre  pn-babillty  ia  tbere  of  the  exUtence  gf  old-elaod- 
iixg  diaeftse  of  the  bladder  or  Jtidueve,  aod  of  an  uiitavornble  reeult  from 
tiuM  cauK.  Cro8»e  lioe  drawn  up  a  table  thai  ahows  very  strikingly  the  Jo- 
flueoce  of  the  weight  or.  in  other  worcia,  of  the  size  ol  a  cttlculus  tm  the 
results  of  litholoniy.  He  found  that  when  the  etone  wh^  otie  ounce  and 
under  in  weight,  the  deaths  won:  in  the  pniportioii  of  1  in  11. 2y  coses. 
When  it  was  from  1  lo  2  ounces  Iti  wei^Iil.  tliere  was  I  death  in  G.til  cans : 
when  from  2  to  3  ounces,  1  dcaih  in  2.18  cjista :  when  from  3  to  4  ounces, 
1  death  in  1.57  cages:  Mheii  fmni  4  to  5  ounee».  1  di'Htli  in  1.G6  cs^es. 
This  table,  which  has  been  conBtnirtcnl  on  thii  n-sults  uf  70S  cases,  illua- 
(traies  very  clearly  thuse  fads,  that  ihc  opt-nitimi  for  the  rf/moval  of  a  large 
^fialcutuB  in  far  more  daugurous  titan  that  fur  the  exlrartiun  of  a  small  one, 
&nil  thai  the  duii^tT  iiUTi'iiHcH  in  llui  direct  rutin  of  llie  »\7m  uf  the  »tono. 

The  MyuiptoiiiH  of  dillufte  iiiHuminution  of  the  aretilar  tJHKuc  arising  from 
thitf  cuu»e  very  clotty  resemble  thiicw  from  intiltmtion  tif  urine,  and  the  treat- 
ment must  be  cuiiduoted  on  preciiv^ly  nimilar  principles. 

Feritonitis  muy  occur  after  tithittomr,  R.t  a  consequence  of  the  cxtonBion 
of  indaramation  from  the  Kladrler  or  the  pelvic  areolar  tifumc  to  tho  HerauB 
membrane,  fmm  wound  of  the  pniJteri<ir  jtart  of  the  bladder,  nr  from  cxtcn- 
fliou  of  inflammation  from  a  !taccnlui«  of  the  bladder  to  it«  immediate  invest- 
ment of  peritoneum.  To  i>ne  or  other  of  these  condilionn,  more  fflpecially 
ioflaramation  of  the  pelvic  fasciae,  it  will  always  be  fonnd  to  be  secondary. 

Blonghing. — In  leeble  and  cachectic  persons,  cstiecially  in  thoee  who  are 
the  stibjwts  of  pboisnhiitic  calculi,  the  woumi  will  often  wsume  a  Blouj^hy 
condiliun,  and  heal  slowly,  and  il«  surface  may  become  coaie«1  by  phosphates. 
In  Aiich  ca-se."*  a  liberal  allowance  of  slimul»iitj«  will  be  required,  together 
with  the  lucal  appLicatiuri  of  compound  tincture  of  benzoin  ;  and,  in  order 
to  taciittatv  healing  at  a  more  remote  period,  a  dolutiuu  of  uitrnte  of  silver 
may  Ik-  applied  to  the  wound.  The  pbusphatcs  may  be  removed  by  injectioo 
of  the  dilute  nitric  acid  lotion. 

Fyteinia  and  Septio»mia  are  not  unoommoo  causes  of  death  after  litho- 
tomy. Acute  i^eptica'miu  it  umuhHv  the  immediate  cause  of  death  in  diiruse 
pelvic  cellulitis,  the  patteut  perishing  from  general  bloud-poisoulug  rather 
than  from  the  local  condition.  Pyaemia,  when  it  occurs,  UHually  sets  in  after 
the  first  week.  The  Bccondary  absceBSeB  are  not  UDCommonly  couiined  to  the 
joints  and  subciitancou!^  areolar  ti.s»ue,  and  the  diseaae  oiay  assume  u  chronic 
form.     The  treatment  presents  pntlilng  special. 

Qthkb  MhTi'HoixH  Of  Pkri-okminu  Lithutdmy. — Having  fiuifihcd  the 

naideratiou  of  the  ordinary  lateral  operation,  we  Bhall  n»w  proceed  tutbat 
if  other  methods  for  extracting  the  stone  by  cutting  procetlures.  These  ore 
the  Mectmii,  the  liUnferal,  llie  Mediolaleral.  the  Redo-vesicai,  and  the  Suora- 
pubic  operations;  each  of  which  hss  its  advocates,  to  the  exclusion  ot  the 
others,  and  each  of  which  undoubtedly  possesses  certain  special  advantages, 
lo  addition  l-o  these,  there  are  various  modifications  of  these  different 
operations  which  the  in^uuity  of  Surgeons  has  devised,  but  which  have 
ueunlly  little  to  recommend  them  in  the  opinions  of  Any  except  their  origi- 
oators. 

Meui.4S  LirnoTOMT. — ^The  median  operation  of  lithotomy  is  that  pro- 
cedure by  which  a  stone  is  extracted  through  an  incision  in  the  rapht^  of  the 
perineum  extending;  into  the  urethra  behind  the  bulb. 

HiMory. — The  hisLorv  of  the  median  o]wm[ion  alfords  an  illustration  of  the 
lability  of  profe«gional  practice,  and  makes  it  appear  as  if  there  were  a 
_  cle  of  opinion  in  aurgcry,  as  iu  fashion,  politics,  and  philosophy.  The 
median  operation  was  introduced  three  or  four  hundred  years  ago.  and  coa- 


944 


URINARY   CAtOUtUB   AND   LITHOTOMT. 


tinueil  to  be  practised  up  to  the  middle  of  the  laat  century,  trheo  its  t«tlious- 
uess,  its  paiRnil  character,  and  the  excemive  tDortaltty  folIowiDg  it,  caU8«tl 
it  to  fnll  iuto  disuse  as  soon  as  the  safer  aad  rimpler  methud  of  Cheseldco  wa« 
introduced.  Of  late  years,  however,  it  has  beea  revived  trnder  a  suiufwhat 
modified  form;  and  it  is  this  modern  median  operation,  aad  its  suppi)«4.il  ad- 
vantages over  the  lateral,  that  we  must  here  consider. 

The  oht  mcrlian  upnration — called  aitut  the  "  Marian,"  from  SanctuB  Ms- 
riaous,  who  wrote  oa  it  t!ioiij,di  it  did  uot  originate  with  hiin,  and  the 
"  operation  of  the  apparfitiw  major,"  from  the  number  of  iastrumtnU  used 
in  It — was  jierfiirmeil  in  ihe  ildhiwiiif;  maiitiL-r,  acn>rdiug  l/<  John  Bell.  A 
grooved  sulf  Visa  iuLrodtii-cd  iiitu  the  blndder,  and  the  tiaueot  titM]  up  in  the 
usual  way;  the  lithotomiHt  then,  ktieeling  or  ititiiu^  Vfore  him,  made  an 
incisiuu  in  the  pcrluijum,  nut  exactly  in  tho  raphe,  which  wae  thought  to  be 
dangeroue,  but  very  sli^rhtly  to  the  IcIY  side,  and  terminating  juet  abiive  ihe 
anus.  The  kuifc  wa»  then  carried  on  to  the  mcmbrnnouii  ]>ort  of  the  urethra, 
which  wan  opened  on  the  gnuive  of  the  staff;  anil.  The  Ituife  being  k^pt  Hrmly 
pressed  against  the?  »taff,  a  long  probe  waa  intrndnRctl  into  the  bladder  by  it» 
side.  The  kniffi  and  the  staff  were  now  withdrawn,  nothing  bnt  the  probe 
being  left  in  the  bladder,  to  sfrve  as  a  guide  into  this  cavity.  Ah>n|;  tbi» 
probe,  two  iron  rods,  called  "  conductora."  were  now  pajued,  and  with  the* 
the  operator  dilated  the  prootate  and  neck  nf  the  bladder,  by  separating 
the  handles ;  at  least,  it  wa*»  said  that  he  dilated  them,  but,  as  John  B<>ll 
pithily  observes,  "he  dilated,  or  in  plain  language,  tore  open,  the  pnwute 
gland."  These  conductors  being  held  aside,  "dilators"  were  introduced  so 
aft  to  enlarge  the  oj^enlng,  the  forceps  was  then  pushed  into  the  bladd«r,  and 
the  stone  extractdl  a*  It  best  could  be. 

The  principles  of  this  opcratiou  were — a  limited  incision  io  the  mctubranouft 
part  uf  Uii'  urethra,  above  the  anuK  ;  dilatuliou,  and  not  iucieiou,  of  the  prce- 
tut«  and  ueck  uf  thv  bladder;  or,  to  use  the  nurds  of  Le  Cut,  "small  iuciston; 
much  dilatation." 

Its  rcDulta  were,  however,  so  unsuccessful,  that  U  foil  iuto  tmtire  dii^use  here, 
aud  al moot  BO  oii  the  coutiuent,  merely  appeariug  from  tiuio  to  time  under 
various  moditicatium)  at  one  or  other  of  the  cotitiueuial  schocds.  Thia  condi- 
tion of  things  prevailed  until  a  new  form  of  mediau  o[»eratiou  was  deviled  by 
Allartun,  wbo  with  great  perseverance  and  e^^ual  ability  urged  it  U]K>n  the 
attention  of  Surgeons  in  this  country,  by  whom  it  has  now  JiKeu  extensively 
practised. 

Operation. — This  operation,  for  the  introduction  of  which  into  modern 
eurgery  the  greatest  ci-eilit  is  due  to  AMarton.  is  performed  as  follnwa:  A 
Btail,  grooved  along  its  convesity,  having  been  inserted  into  the  bladder,  the 
patient  is  tied  up  m  the  usual  manner;  the  Hurgcon  then,  sitting  in  front, 
introduces  his  left  index  finger  Into  the  rectum,  and  feels  fur  the  apex  of  tho 
prostate-,  against  which  he  keeps  it  lodged,  in  order  to  judge  of  the  dislanee 
of  the  pri'jslatc  from  the  surface,  to  net  a^  a  guide  to  the  knife,  and  prevcot 
the  rectum  from  being  wounded.  A  straight- backed  bistoury  is  now  enU'red 
balf  an  inch  above  tlic  anal  aperture,  and  pushed  straight  forwards,  lo  a 
depth  of  about  an  inch  and  a  half  in  the  mesial  line,  so  as  to  cDler.  if  pos- 
sible, the  groove  of  the  staff  ot  the  apei  of  the  proBlat«.  A  aroail  ineisioD 
npwArds  is  then  made  in  the  groove  of  the  stall,  and,  as  the  kuife  is  wnth- 
drawD,  the  incision  in  the  skin  i«  also  extended  upwards ;  the  knife  is  then 
laid  a§ide,  and  a  long  ball-pointed  probe  is  introduced  into  the  bladder  alnng 
the  groove  of  the  stalT.  which  it  then  wilhdrown.  The  probe  is  mm  the  only 
guide  to  the  bladder;  and  up  lo  thid  piint,  therefore,  there  is  but  liitlr,  if 
any,  difference  between  the  modern  median  and  the  old  Marian  ojieratiom^ 
except  that  the  inctaion  is  exactly  in.  instead  of  a.  Httle  to  one  side  of,  tba 


I 


I 


I 


I 


d 


MEDIAN    LITUOTOHT. 


946 


middle  line.  The  furefinger  is  now  intruduced  along  the  probe,  and  hj 
vorkiog  it  forwards  the  prostate  U  dilated,  and  the  finger  enters  the  bladder, 
wheo,  the  probe  being  removed,  the  forceps  is  introduced,  and  the  stone 
extracted.  Thus,  it  will  be  seen  that  the  only  real  point  of  difference 
between  this  and  the  old  Maiian  operation,  is  that  in  the  modern  median  the 
finger  is  used  as  the  dilator,  whilst  in  the  Marian  the  prostate  and  neck  of 
the  bladder  were  forcibly  expanded  ur  torn  open  by  the  use  of  instruments; 
e  diflerence,  however,  of  do  slight  moment. 

I  have  found  it  advantageous  to  modify  this  operation  in  one  or  two  pointB. 
Tbe  fint,  which  I  think  of  some  utility,  is  to  use,  instead  of  the  ordinary 


Fig.  6G6.— Medi»D  Operatioo  with  RectAnguUr  SUff. 

eorred  btaflT,  a  rectangular  one  grooved  from  about  one  inch  above  the  elbow 
Bearly  to  the  point,  reBcmbling  the  staff  introduced  by  Buchanan,  of  Glasgow 
(Fig.  866).  Its  use  and  advantages  are  that,  when  iu  the  bladder,  the  angle 
rests  against  the  apex  of  the  prostate,  and  can  be  felt  in  the  perineum,  and 
ibe  Surgeon  can  judge  of  the  exact  point  where  to  enter  the  kuite  (directing 
it  lo  as  tt>  open  the  groove  just  Iwlpw  the  angle),  which  he  cannot  do  with 
the  curved  staff;  the  iticit>iou  upwards  also  is  limited,  and  there  is,  besides, 
less  danger  of  wounding  the  rectum,  the  urethra  being  drawn  upwanls  away 
{rom  it,  and  not  pushed  down  against  it,  us  with  the  ordinary  staff.  The 
knife  should  be  straight- bucked,  having  the  back  not  more  than  two  inches 
long;  so  that  the  Surgeon  can  tell  to  what  depth  he  has  entered  it.  I  have 
Ibund  it  advantageous  in  practice  to  curry  a  beaked  director,  bhajted  like  a 
large  horuia-di rector,  along  the  groove,  afler  the  incision  has  been  made  in 
the  urethra,  so  as  to  ojten  up  the  canal  and  thus  to  clear  the  passage  for  the 
Soger.  And  having  oi>en('<l  the  urethra,  I  think  it  better  to  dilute  the  pros- 
tate before  withdrawing  the  stafl";  by  pushing  the  finger  slowly,  with  a 
rotatory  movement,  along  its  nuh,  the  blaiidur  is  entered  with  more  case  and 
certainty;  whereas,  if  only  the  prolie  be  used,  it  may  not  be  stiff  enough,  and 
the  Siirge<jn  is  apt  to  pusli  the  bladder  before  him.  It  has  been  pro]M>scd  to 
employ  niei'hanicul  means  of  dilatation,  instead  of  the  finger,  to  open  up  the 
prustate  nnd  neck  of  the  hladdtT ;  and  I  had  some  dilators  for  this  purpose 
eoDStructed  by  C'oxeter  on  the  principle  of  the  two-bladed  dilator  of  the 
female  urethra.  I  tried  them  on  tlii.'  dond  itubjcct;  iiut  1  have  not  ventured 
to  use  them  on  the  living,  Ie»t,  by  the  eruployuient  of  screw-power,  the  same 
deep  lacerutionx  of  the  neck  of  the  Madder  should  rottult  that  were  so  tatal 
in  the  old  Mnriun  ofn-ration.  Indeed,  I  helieve  that  their  use  would  be 
fraught  with  danger  from  their  liuhility  to  occasion  rupture  of  the  neck  of 
the  bladiler;  and,  if  |H'niisti<<l  in,  1  cannot  hut  fear  that  they  will  bring  dis- 
credit on  the  o|)eralion,  reducing  it  to  the  condition  of  an  old  Marian,  and 
.    TOL.  II. — (10 


OM 


VniNAKV    CALCULU9    AKU    I.ITUOTOllT. 


repeating  ttio  daugcrs  nl'  thut  procedure.     Xn  safe  dilulatioo  can  b«  efie 
exci'pt  Ity  tliB  liugur,  witli  which  iin  harm  i^iu  be  duuu,  wliilsl  it  appeare  to 
me  timt  tlie  gr^at^st  iJiueilile  iiiiEK^liief  may  bu  Aoan  uith  8crew>dilaton. 

COMI'AKIl^n.V  Kfl'WKKN  TIIK  MkIHAN  ANH  TIIK  LaTEIIAL  OpEBATIOJtB. 

The  two  upvrHtiiiue,  the  lateral  and  the  tiiediaD,  caiinot  with  prv>pri«t7  be 
compared  at)  a  whole,  oa  we  havo  aa  yet  no  siifiioieiiL  utatiiilJca  to  enable  us  to 
dctermiDe  whether  the  nmrtality  atier  the  median  has  licen  less  tbaii  that 
which  h«9  followed  the  lateral.  We  may,  however,  compare  the  nnnlem 
median  operation  with  the  lateral,  and  endeavor  U)  rieterminw  iu  what  r^pects 
the  rDcdifto  %s  superior,  in  what  ioreriur.  to  the  lateral,  and  in  what  c&ms  it 
might  be  employed  inslead  of  the  latter.  For  in  this,  a*  in  lithoirity,  the 
Surgeon  »hmiM  not  be  too  exolueive  ;  it  ia  his  duty  tti  learn  aud  to  practise 
diflferent  methoda  of  attninin;;  the  same  end,  and  tii  make  use  of  one  or  the 
other  according  to  the  requirements  of  the  actual  raitc  buliire  him,  and 
to  endeavor  to  select  what  is  good  and  to  reject  what  is  duubtrul  in  every 
method  brought  before  him.  It  would  be  in  the  highest  degree  uuKurgical 
to  cru^h  only,  or  to  cut  only,  every  patient  with  ittone  coming  under  rare  ; 
aud  I  believe  that  there  i«  a  choice  as  l<i  thi-  culling  operation  to  be  per- 
forniod.  In  fact,  there  are  no  operaliuuit  tn  (surgery  that  re<)uire  to  be  so 
frequently  moditled,  according  to  the  ueceiwities  of  the  pArlicular  case,  aa 
those  for  Btouo;  the  ago  of  ihu  patient,  the  eixe  and  number  of  the  calculi, 
and  the  coodiliuu  of  the  nriniiry  organs,  all  exercise  very  important  modi^- 
lag  intlueiicee,  and  prevent  the  burgeon  from  coufiuiug  himself  to  one  uethod 
exelueively. 

Id  order  lo  make  a  proper  compHriDOD  between  these  two  operatioiw — th# 
median  and  tlie  lateral — we  must  take  them  ttrtafim.  The  dilliculties  and 
dangens  of  the  lateral  operation  are:  1,  the  difGculty  in  some  c»ee«  of  entvr- 
ing  the  bladder;  2,  hemorrhage;  3.  the  rUk  of  wounding  the  hulb;  4,  of 
wounding  the  rectum;  f),  too  extensive  au  incjeiou  in  the  prnetnte.  and 
opening  \ip  the  pelvic  fascia;  0,  the  difficulty  in  extracting  the  stooe. 

1.  Qeoeral  Ease  aad  Simplicity  of  the  Operation. — There  is  no  doubt  that 
the  Surgeon  will  be  mure  skilful  in  that  oijenitiou  which  he  has  more  often 

Serformed  ;  but,  so  far  as  ease  and  eimpKeity  are  coucerned,  there  is  no  great 
iflerenco  between  ihcm,  In  the  lateral  operation  there  is  very  seldom  any 
difficulty  in  entering  the  bladder,  though  SurL^Kina  have  sometimes  been 
foiled  iu  this;  but  Surgeons  of  the  greatest  skill  have  also  had  great  diffi- 
culty in  entering  the  liladder  iu  the  median  o)feraliou.  The  bladder  tends 
lt>  be  pushed  upwards  and  backwards  before  the  finger,  especially  in  bora, 
in  whom  the  pnistate  ia  uot  developed  ;  and,  unlcM  the  neck  of  the  bladder 
bo  well  open&l,  there  appears  to  he  great  danger  of  tearing  aeroaa  the  mera- 
branouB  part  of  the  urethru,  and  of  pu!«hing  hnckwardA  the  separated  bladder. 
In  boys,  the  perls  are  tto  very  nmall  and  undeveloped,  aud  toe  space  to  work 
tn  IB  so  very  narrow,  thai  au  ordinary  finger  can  only  with  great  ditticultv 
be  got  through  the  neck  of  the  bladder  unless  tliLi  have  been  iVecly  incised. 
But,  by  doing  this,  we  depart  entirely  from  the  guiding  principle  laid  dowD 
by  the  advocutea  of  the  mc^dian  operation,  vh.,  dilatation  aim  not  iooi«iuu. 
8o  far  OS  facility  of  entering  the  bladder  is  concerned,  the  two  opcratioos  are 
probably  on  a  par  in  the  adult;  but,  in  the  boy,  the  result  of  recent  expe- 
rience wonld  show  that  ihe  difficulties  in  this  respect  are  far  greater  in  the 
median  than  in  the  lateral ;  so  great,  iu  fact,  that  the  operation  should  never 
be  performed. 

2.  Hemorrhage. — Iu  t.hie  respect,  the  median  operation  has  decidedly  tti* 
advautnge.  If  the  inL-ision  be  mude  in  the  middle  line,  without  wounding 
tlie  bulb,  although  there  may  be  tolerably  free  bleeding  at  the  time,  yet  Ihere 
is  no  veoel  that  can  furnish  dangerous  consecutive  hemorrhage;  whiUt  ia 


I 


I 


« 


TltHATMENT   OF  TBB   PROSTATB. 


to  ( 


the  lateral  operation  there  are  the  dnngcrs  of  arterial  and  of  profuse  venous 
hemnrrhage,  the  knife  coniinf,-  iiilo  clusc  relation  with  the  artery  of  the  btilb 
antl  others  of  some  size.  If  the  object  were,  thcrcfnre,  Bimply  to  save  blood, 
the  meilinn  is  so  far  better  tlian  the  lulornt.  But,  afler  ail,  it  must  in  fair- 
nesB  be  eaiii  that  the  danger  of  exceasive  hemorrhage  in  the  lateral  operation 
bamatl.  With  care,  it  will  rarely  happen  that  the  patient  loses  a  dangeruiu 
amount  of  bliiorl. 

3.  Wotind  of  the  Bulb. — This  may  occur  in  both,  hiit  i»  more  difficult  to 
avoid,  ami.  iudeed,  !-■*  very  litoly  to  happen,  in  tho  niedian.  a«  (he  hiilb  (fjtiie- 
time*  »u  <.iv«rla]«  tlie  rneiobranuiis  part  of  the  urethra,  that  it  Is  diHicult  not 
to  cut  it;  wliiUt  in  ihf^  Intera!  operation,  by  cutting  low  duwu,  aud  enleriog 

groove  of  the  etatf  well  bjick,  and  fri>ra  helo»'  upwardu,  tliia  luiiy  usually 
avuid«d.  Il  is  true  that  ilivision  of  the  I^ulb  in  thf  mesial  line  seldom 
give*  rise  to  much  liemorrhnye ;  but  cases  have  occurred  to  niy  knowledge, 
though  not  Iq  tuy  praetice,  in  which  patients  have  died  from  this  cause 
&n«r  fwrineal  section,  the  bloud  reguri^itatiug  into  the  bladder,  and  filling 
that  vidouH. 

4.  WoTiQd  of  the  Bectum. — This  gut  in  not  in  much  danger  in  the  lateral 
operation,  unlee^  it  he  diatcudcd.     lu  the  luudian,  ou  die  other  hand,  the 

turn  K  in  connidcrabh;  danger.    If  this  operation  be  performed  on  the  dead 
ly,  it  will  be  found  that  the  back  of  the  bistoury  conies  very^-I  niiiy  wiy 
Dcomfortably — eloite  to  the  linger  in  tht;  rectum ;  and,  if  another  Hnger  he 
laced  in  the  wound,  they  will  iraiiie  into  wi^ry  t-Ioce  appoeilion  juet  anicrior 
to  the  prostate.     In  the  old  Marinu  optralion,  the  reetutu  used  to  be  very 
frequently  cut.  gas  and  iWea  ist-uiiig  Iron]  the  wound. 

0.  Treatment  of  the  Prostate. — Ak  to  the  diHVreiice  in  this  reepect— i.  «., 
dilatation  in  the  meilinn,  sei'tinn  in  the  lateral  operational  believe  iL  to  be 
more  imaginary  than  rtal.  I  think  that  it  is  very  nearly  the  same  in  both 
operations  when  pro|>erly  pcrfurtned.  All  are  agreed  that  in  the  lateral 
operation  but  a  limittd  incision  should  be  made  in  the  prostate  and  neck  of 
the  bladder,  the  openingbeing  dilated  with  the  finger,  so  aa  to  avoid  opening 
the  |>elvie  fascia.  The  difference  between  an  incision  that  opens  the 
psuleof  the  prmtatc,  and  dilating  this  structure  by  the  finger,  is  very  grtiiL 
great  object  in  lateral  lithotomy  is  not  to  open  up  the  pelvic  fascia  with 
the  knife ;  and  it  is  diffiL-nlt,  if  not  impossible,  to  tear  this  with  the  finger. 
If  we  take  an  aponeurosis  out  of  the  body,  it  will  be  found  to  be  vt-ry  diffi- 
cult to  t«ir;  but.  if  touched  ever  so  lightly  with  th*'  knife,  it  separates  at 
once.  So,  in  the  meiiisn  operation,  the  prostate  may  he  dilated  to  a  cou- 
aidcrable  extent  without  opening  it*  capeule.  I  hav«  used  the  woid  "dilate," 
but  dilatation  appears  to  me  to  he  an  errooe"UB  term.  I  believe  thiit  the 
prueiiLte  is  not  eimply  dilated,  but  lacerated  ;  that  there  is  an  actual  lacera- 
tion of  the  substance  of  the  prmtate,  but  not  extending  into  or  through  it« 
capsule.  I  have  ofleu  examined  the  prostate  in  the  dead  subject,  after  it 
has  been  auhjected  to  thi:)  proceas  of  "  'lilatation,"  aad  have  alwavs  found  it« 
Bubeianec  more  or  less  torn.  A  laceration  of  the  substance  of  the  pruelate, 
however,  is  of  no  con9e([ueuce,  and  become^  dangerous  only  when  it  extends 
far  backwards  aa  to  tear  the  lateral  ligament  of  the  bladder,  when  it 
:poee8  tho  patient  to  the  fatal  accident  of  extravasation  of  urine  and  ditrutiu 
inflammation  of  the  pelvic  fascia.  JJnw,  iu  the  lateral  operation,  in  running 
the  knife  down  the  groove  of  the  stnCT.  the  Surgeon  mav  readily,  unle^^  ciire 
he  taken,  and  very  olicn,  I  believe,  does  actually  and  sliaoec  unavoidably  go 
beyond  the  limilj*  of  the  proatate,  and  thus  exposes  the  patient  to  all  these 
dangers.  In  the  median  this  cannot  be  done,  if  tho  knife  l»e  not  mtwl  after 
the  ureliira  is  o|M'[ied,  the  prostate  beiu"  dilated  solely  with  the  fiiigrr.  So 
far  Bs  this  p<tint,  then,  h  concerned,  the  median  may  he  regarded  as  safer 


The 


948 


[NAHT   CALCULiri 


fTUOTOM' 


Ibfin  the  lalerftl  operation,  it  being  impnmhle  to  open  op  tlie  rect^yvpftical 
fascia-  with  the  linger  in  the  tufrdinu,  wliilsl  it  may  be  openfTtl  by  the  koile  in 
the  Internl. 

Ill  tiicl,  tJie  neclc  of  the  bludder  and  the  proetatic  portion  of  the  ureihr& 
are,  iu  the  uKHJiuu  operaliuu,  phiced  \ki\  much  in  the  poMtloa  uf  the  ticniAle 
urethra  wheu  that  w  dilated  tur  the  extrucLiuii  of  a  citiuulus;  btiog  diiatcd 
to  a  great  extent,  uod  somewhat  lau«raiud,  but  uut  Uirii  through  bo  aa  to 
admit  uritiu  into  Ibe  subperitoaeul  eellular  lisaue  uf  the  pulvia;  nud  io  this 
1  believe  the  great  aud  vEacutiul  EUperioril)'  of  the  median  over  tb«  lateral 
openilii'ii  to  eoiiBLHt. 

0.  MaaipulattoD  of  the  Forceps  and  Extraction  of  the  Stoce. — Id  the 

adult,  the  maiu  dilliculty  of  lithotomy  di>ee  not  tie  lu  euteritig  the  bladder, 
but  ID  tlie  eompletitJii  of  the  operation — the  removal  of  the  Gloue.  And  tbe 
difiieulty  aud  danger  increaee  in  proportion  to  the  size  of  the  calcutub;  the 
tisBueH  bet«seen  the  neck  uf  ihe  bla<lder  aud  the  perineal  imegutueute  muU 
either  be  widely  cut  or  extensively  loru  and  bruised  to  allow  the  ^mmaga  of 
a  Inrgi^  glone.  Xd  Hiiiuiint  uf  simple  dilaution  of  nhteh  these  tiaaun  are 
Biuceptible  can  make  a  ptuenge  through  them  that  nill  allow  the  oKirnctioii 
of  a  stone  \h  inch  in  diameter;  such  a  stone  must  either  he  cut  or  torn  uuL 
Now,  vbat  space  have  we  id  the  median  operation  for  the  iutroductloo  of 
the  forceps  and  the  eiLmction  of  a  large  stone?  Here,  I  think, is  the  weak 
point  of  the  median  operation.  In  it  the  incision  ie  made  and  nil  tbe  manipu- 
lation is  practi^d,  towards  tbo  apex  of  the  narrow  triangle  formed  by  ibo 
rami  of  tbe  pubic  buDc».  The  base  of  Lbia  triangle  la  repreecoted  by  a 
horizontal  line  corrvefionding  to  the  level  of  the  membranous  portion  of  tbe 
urethra,  and  consequently  does  not  occupy  the  widest  part  of  the  peri- 
neum ;  it  is  formed  oy  the  lower  portion  ol  the  deep  perinail  fa«cia  nr  tri- 
angular liganieut,  the  apace  behind  it  being  tilled  up  by  tbe  rectum  and  ita 
rnu»ctM,  and  the  iachio-rcetal  faL  Tlie  ligament  forms  a  barrier  stretching 
across  the  perineum,  which  cannot  Im  <tepresse<t,  and  requires  to  t>e  dividen 
laterally  into  the  iaehio-reclal  foesa  before  a  »tone  of  any  considerable  mag- 
nilude  can  be  removed.  It  wa»  in  c<>n)ter|itence  of  the  extensive  bruising  and 
laceration  of  theae  sIructureH,  and  the  difficulty  experienced  iu  bringing  the 
Stoue  through  them  that  the  old  Marian  operation  fell  inXo  disuae. 

In  performing  the  median  operation  there  are  three  points,  or  rather 
planes,  nf  obstruction,  between  the  Hur face  and  the  interior  of  the  bladder. 
The  firat  \»  occasione<l  by  the  muecles  uf  the  jierineum,  and,  perhape,  aleo  by 
tbe  under  portion  of  the  deep  perineal  fa^ia.  In  the  lateral  opvrntion  we 
cut  ncrosti  this  plaue,  aud  lay  open  the  isehio-recLal  fiwa,  giving  nbuudaace 
of  room  for  the  manipulation  of  the  furceiK  and  the  extraction  uf  the  slooc^ 
alou^  the  base  of  the  triauglc  formed  by  the  rami  of  the  t»cbium  and  pubea. 
But  in  the  median  wc  have  to  extract  tonarda  tbe  summit  uf  this  space,  at 
the  apex  of  a  narrow  triangle,  bavitig  tbo  muscular  structures  foraUag  a 
Cense  oar  along  its  buee,  and  offering  a  material  obstacle  to  Uie  introducuun 
of  tbe  forceps  and  the  extraetiuu  of  the  stone. 

Tbe  secoud  obstacle  lies  iu  tbe  [irusiatu ;  but,  as  it  is  easily  removable  by 
dilalotion,  it  cannot  be  eousidcred  a  serioua  one. 

The  Uiifd.  tbe  deepest  and  uio&t  iiu|Kiriant,  ut  situaietl  at  the  neck  of  tbe 
bladder.  We  &ud  here  a  narrow  tense  ring  lieyond  the  pruetate:  and  tbts 
bar  remains  intact  in  spite  of  the  dilatntiim  and  laceration  to  which  the 
prostate  has  been  subjected.  On  introiiuriug  the  finger,  we  ijiall  feel  it 
grasped  Lightly  by  ihiK  ring.  1  have  found,  by  experiments  on  the  dead 
subject,  that  this  inner  ring  of  the  neck  of  the  bladder  cannot  be  exuaoded 
to  a  size  more  than  suUicient  for  the  extraction  of  a  calculus  of  one  lueb  in 
diameter  without  laceration  or  incision  :  and  its  laoeratioa  or  rupture  ts  well 


I 


« 


I 


INDICATIONS    FOB    THE    MEDIAN    OPERATION.  949 

known  to  be  one  of  the  tnngt  dangerous  and  fatal  accidents  in  lithotomy.  It 
M  ID  consequence  of  the  obstacle  offered  by  ihia,  that  the  median  operation 
is  not  available  for  the  extraction  of  large  calculi.  A  calculus  over  one 
■nd  a  half  inch  in  diameter  cannot  be  extracted  by  the  median  operation 
without  the  employment  of  great  violence.  But,  though  much  force  is 
BBually  required  in  onler  to  extract  a  calculus  of  even  moderate  size  through 
this  tenae  rin^  at  the  neck  of  the  bladder,  it  is  an  undeniable  fact  that 
■erioua  consequences  seldom  follow  the  violence  so  used,  and  that  a  degree 
ei  force,  which  would  be  fntnl  in  lateral  lithotomy,  may  be  employed  without 
danger  in  the  extraction  of  a  calculus  by  the  median  operation.  In  this 
respect  the  extraction  of  a  calculus  by  the  median  npemtion  reecmbles  the 
mnoval  of  one  through  the  diluted  urethra  of  the  female ;  the  great  junnt  in 
fiiTor  of  the  median  over  the  lateral  pri>cedure,  and  the  cause  of  its  conipara- 
Uve  safety,  being  that  the  lateral  true  ligament  of  the  bladder  is  not  incised, 
nor  otherwise  opened.  But,  it  may  be  said,  what  is  easier,  when  the  tinger 
b  in  the  bladder,  than  to  push  a  probe-pointed  bistoury  along  it,  and  cut 
downwards  and  outwards  through  these  structures  into  the  ischio-rectal  fossa, 
if  the  atone  be  large,  and  thus  get  plenty  of  space?  Nothing  could  be  easier 
or  more  simple;  but  what  would  be  the  consequence?  AVe  at  once  reduce 
the  median  to  the  conditions  uf  the  lateral  operation.  A  free  incision  in  the 
neck  of  the  bladder  and  prostate  increases  the  tendency  to  hemorrhage, 
opeoB  up  the  fascia,  and  exposes  the  patient,  in  (act,  to  all  the  dangers  of  an 
lA-contrived  lateral  operation,  destroying  at  once  and  altogether  the  principle 
of  the  median  operation,  viz.,  dilatation,  and  not  incision  ;  and,  if  we  do  not 

J  KID  apace  by  incision,  but  attempt  to  extract  a  moderately  large  stone  by 
ilatation  of  the  parts,  we  shall  certainly  not  succeed  ;  but  our  dilatation 
will  end  in  a  laceration,  not  only  of  the  substance  of  the  pnwtate,  which  is 
mte,  but  of  the  neck,  ant)  perhaps  of  the  base  of  the  bladder,  which  will  be 
btml.  Urinary  fistula  was  common  atler  the  old  Marian  operation.  It 
lemains  to  be  seen  whether  it  will  be  so  atler  the  modern  median. 

In  conclusion,  then,  it  npnears  to  me,  that  the  median  o{>eration,  when 
performed  in  suitable  cases,  has  the  advantages  over  the  lateral  of  being 
attended  by  less  risk  of  arterial  hemorrhage,  and  less  danger  of  injury  to  the 
lateral  ligament  of  the  bladder;  but  that,  in  con:sequence  of  the  very  small 
■iie  of  the  opening  that  can  be  made  in  the  bladder  by  \t,  provided  these 
advantage*  are  maintained,  it  is  applicable  only  to  eitonos  of  at  most  a  medium 
sixe,  and  that  it  cannot  in  all  ciixes  be  substituted  for  lateral  lithotomy,  as 
the  geneml  operntinn  fi>r  stone,  where  lithotrity  is  not  admissible. 

Indications  for  the  Median  Operation. — The  me<lian  operation  may,  with 

Siropriety,  Iw  performed  in  the  fnllowing  claoj't*^  of  cases  :  1.  In  cases  where 
brei^n  h'Kliet*.  such  us  pieces  of  bnufrie,  of  tobacco- i)ipe,  etc.,  are  ItHlirod  in 
the  blaildur,  the  median  is  preferable,  the  body  hv'ut't  siiiali,  elougatecl,  and 
easily  extracted.  2.  It  iduv  be  employed  to  remove  stmu'S  not  exeeedinjj:  one 
inch  in  their  smallest  dinnieler.  But  then,  it  uiav  be  said,  calculi  of  tins  size 
can  genrnilly  lie  t>afely  subjeelcd  to  lithotrity.  That  is  true  ;  but,  in  certain 
of  these  cases,  lith'>tri(y  is  nut  udiiii!»^ihlc  ;  ?•>  that  tlie  mediiiii  oiKration  is 
indicated  in  cases  of  small  calculi  in  which  tithulrity  <'annot  be  [irnctised  in 
conseijuence  of  inlhinirtiatiou  of  tlie  bladder,  or  i<-mw  other  complication.  If 
a  small  calculus  be  loil^cd  just  behind  the  pri<<:tate.  in  a  pouch  which  occa- 
•iooally  forms  at  a  lower  fundus  of  the  blndder,  we  may  come  down  on  it  at 
once  by  the  niedliin  incision.  :',.  When  iliere  are  iiunierous  small  raleuli, 
lithotrity  is  not  desirubh-,  and  then  the  median  iijicnitiou  apjH'ars  to  be 
preferable.  4.  In  t'tm-n  in  whuli  lithotrity  \iaa  been  performt^l,  and  the 
patient  is  unable  tu  expel  tiie  Ira^iriUMilH,  we  in;iy  perllinn  the  median  ojiera- 
tioD,  and  readily  extract  the   detritus   by   the  siMop,  :is   it    lies   behind  the 


960 


URINAKY    CALCULUS   AXD    LITHOTOIIT. 


pn>6taie.  5.  Iti  the  case,  also,  of  calculi  which  aro  too  lai^e  to  be  saci 
fully  suliJLTltii  to  liiliuirity,  but  which,  if  leiuoveri  by  the  lateral  operaii«_. 
ar«  jiiuinlwl  by  a  frighllUI  rate  of  mortality,  it  seems  to  me  that  the  ravtliaD 
oppraiiiiii  might  i^ifi^thly  hb  advRUtageously  eombiDett  tvilli  liihulritr.  The 
etotiii  haviti)^  hwu  iirukou  up  at  uue  aiiiiii}:,  Ltio  fragments  jni^-^bt  at  uuce  be 
exlrartn]  throiigli  u  liiiiitrd  inc-ieion  tn  the  medial  Imc  of  tlie  pcriocuui.  6. 
In  v&H-if  ill  whirl)  the  iHtticnt  m  so  aiia-mic  that  the  lo^  nf  uu  aiMiiioual 
ounce  or  two  of  hhitxt  luij^'lit  turn  (he  scale  against  him,  meiliaD  is  |)r«--KTahlc 
to  lateral  lithotomy.  For,  althim^h  it  is  by  uii  iiieuuit  a  bliKxlle^  opfraiiun, 
as  i»  su|)[iriHeci  by  aomc,  yet  there  la  k«8  hemDrrliaL'C  during  the  j)i>rri>rumuce, 
or  rnther,  [H'rha|)«i,  lesa  coaliiiuiiua  ooxiiig  after  ila  com)ilction,  than  iii  ibe 
lateral,  atid  thera  is  certainly  uot  t})>(^  danecr  of  the  jinifuw  bleetliuj;  that  ta 
sotnetimefi  seen  in  the  latter  oimratiun.  Whtre  we  have  tn  ilo  with  a  etuoe 
of  largo  Hixe,  the  nu'ilinn  in  uol,  in  my  opiiiioi),  safe;  anch  an  amount  of 
traction  miiHt  be  ntted  ua  will  iiifullibly  bruitte  and  lacerate  the  uerk  anil  haae 
of  the  bladder,  and  uxpom!  tlio  |iatieiii  to  infiltration  of  urine  aud  deep  pelvic 
inflanaoiati<in — to  nil  the  danfrers,  in  fact,  of  the  old  Marian  operalion ; 
dangers  which  were  ko  great,  that  more  than  half  the  patienta  subjected  to  it 
periiihed,  and  which  caused  it  tn  he  abandoned  for  the  lalenil. 

The  median  operation  is  not  lulnplcd  to  children.  The  »|uice  in  them  b«- 
twci-u  the  r<'ctum  and  the  piihe**  is  tivo  .'>niall,  and,  moreover,  "  Hilatnti'in"  of 
the  pruKtalo  would  ho.  inipossihle,  as  it  is  not  lar(;e  enough  to  allow  ihc  finger 
to  pass  thr«u>;h,and  any  attenipt  la  do  »n  without  free  indMon  would  prulia- 
bly  be  attended  by  tranarerse  laceration  of  the  urethra.  Moreover,  the 
laieral  operation  in  boys  ia  »o  eucc««8ful  that  there  is  do  rcasoo  for  a<I<iptiog 
any  other. 

Bii-ATERAL  LtmoTOMV. — The  bilateral  operation  introduced  by  Dtipuy* 
trcD  is  a  inodiGeatiou  of  the  old  median.     lu  it  u  curved  iratutverse  iocision 


Hg.  acr.— 'Line  <■[   InciiiuB  in  llitatHiail  l.iihut-iinjr  ^ llupu/UVD)- 


ia  made  across  the  {Mrineum  half  an  inch  above  the  anua,  towards  which  iU 
concavity  looks,  the  horns  of  the  incitiiou  extending  to  two-lhirds  of  thti  dis- 
tance between  the  nnns  aud  the  tuber  ischii  on  each  side  (Fig.  8t>7).  The 
diseectioD  is  carefully  carried  down  to  the  central  point  of  the  perineum,  and 
the  membranoue  portion  of  ihe  urethra  is  opened  nn  a  groiivcd  ni«?ian  staff 
previouely  introduced;  along  Ibis  the  double  tithntmiie  eaefi^  (Fig.  fAiS)  ig 
passed  with  its  concavity  turned  upwanla.  The  Surgton,  having  well  nasurvd 
nimself  that  the  instrument  is  fairly  in  the  bladder,  turns  it  so  ihut  ita  con* 
cavity  looks  down  towards  the  rectum;  the  aprlng  in  the  haudU-  ii>  then 
preased,  and  the  blades  expanded  to  a  pmjier  ilistance  previously  regulated, 
tnd  both  lateral  lobes  of  the  proatate  divided  to  a  corresponding  extent 


BILATERAL    LITHOTOMY. 


951 


downvards  aod  outwards  in  withdrawing  the  instrument  (F^.  869).  The 
extraction  of  the  etone  ia  tlien  effected  in  the  usual  way.  Ttiis  operation 
^ipears  to  me  not  to  have  received  the  attention  that  it  deserves  from  Sur^ 
gBons  in  this  country.  By  being  careful  to  introduce  the  iithutome  into  the 
■eoibranoua  portion  of  the  caual,  the  arteries  of  the  bulb  are  not  endan- 
gered, and  indeed  the  transverse  and  superficial  arteries  of  the  perineum  are 
alao  above  and  beyond  the  line  of  iDciaion.     The  prostate  is  divided  equally 


Fig.  868. — Dupuytren'a  Litbotoma  C«cbf ,  Opeoed, 

oo  both  aides  in  its  greatest  diameter ;  if  the  expansion  of  the  lithotome  be 
oarefully  guarded,  there  is  no  danger  of  going  beyond  the  limits  of  that 
oi^D,  or  of  wounding  the  internal  pudic  arteries  (Fig.  870j;  and  the  inte- 
rior of  the  bladder  is  reacheil  by  the  most  direct  and  readiest  passage.  la 
withdrawing  the  lithotome,  the  handle  must  be  well  depressed,  and  great 
must  be  taken  that  the  instrument  be  kept  securely  in  the  mesial  line, 
that  the  section  may  not  be  made  more  feeely  in  one  side  than  the  other. 


Fig.    SSQ.— Bilnrcrftl    Sec- 
UoB  of  ProiUta. 


Fij*.  S70. — I.ine  of  Inciiion  to  tbe 
I'rostiile  In  Bilateral  Litbotomj, 
fhowing  it«  relation  to  tba  Bulb  and 
the  Internal  Pudic  ArtflTj. 

The  operation  has  not  been  performcil  with  sufficient  fre()uency  in  this 
oouDtry  for  any  reliable  statistics  as  to  the  results  ;  but  Eve,  of  Nashville, 
has  done  it  in  78  cases  i>f  all  ugos,  with  only  (f  ileiithi). 

Medio-oii.aterai,  Opkration. — Civiak'  hiis  recomniencled  a  combina- 
tion of  the  median  and  the  btlntonil  n|KTations  of  lithotomy,  by  whicli  the 
chief  objections  to  both  ure  got  riil  of.  Tiii:*  operation  is  easy  of  execution, 
■od  has  been  performed  for  the  extraction  of  large  stones  from  the  bladder; 
ibr  those  calculi,  in  fact,  which  cannot  be  removeii  by  the  ordinary  median 
operation  without  too  great  an  amount  of  force,  and  consequent  bruising  or 
laceration  of  the  parts. 

The  otMsration  may  be  performed  in  the  following  manner.  Tbe  patient 
having  been  tied  up,  and  a  deeply  grooveil  rectangular  staff  pn«:<ed  into  the 
bladder,  the  urethra  is  opened  at  the  menibranous  [lart  with  the  crige  of  the 
koife  turned  upwards,  as  (k^cribcd  in   the  n)e<tian  operation  (p.  044) ;  the 


952 


URISART    CALCULUS    AND    LITHOTOMY. 


double  Ittbot^tnic  iH  then  mlitl  along  the  BtnfT  inlii  the  blaililer,  itii  ooncn\'li; 
turu»l  fliiwiMvunlH,  tlu;  lilaHcs  expamifd  lo  btit  n  limited  extent,  unci  the 
nnwtate.  nr  llm  iiilaUTiil  pirRet.  (Fig.  S71),  invented  hy  J,  Wfiod,  of  New 
Viirk,  may  lie  pu?hK(!  alnng  the  staff,  niul  the  eoll  etructtires  between  it  and 
the  BurfarB  iiirised  «h  it  is  withdrawn.  .  If  the  etone  be  not  very  lnrp:e,  ihe 
inr-i-iiin  niav  be  confined  to  one  side  only,  and  mndo  with  n  probe- pointed 
bifltoiiry.  It  will  be  found  tbnt  sufficient  space  is  obtnioed  by  the  perpeo* 
diculsr  iiicinnn  of  the  iikin ;  whilst  the  lirailcd  internal  traTisrerso  cut  re- 
moves that  tension  and  resi^tnucc  of  the  deeper  siructnres,  wbioh  io  the 
ordinary  medion  opemlioti  interfere  seriously  wilb  the  mnnip- 
ulation  of  the  forceps  nnd  ihe  extraction  of  the  stone;  and,  by 
the  division  of  both  sides  of  the  prostfilo  l^  a  limited  extent, 
Rbundance  of  space  is  obtained.  Experiene*  has  shown,  how- 
ever, that  the  advantafp*  arc  rather  theoretical  than  prac- 
tical, and  that  its  performance  in  this  country  has  been  at- 
tended by  iiusatiBfactory  results  ;  two  of  the  principal  danger* 
being  wjuml  i>f  the  n^ctimi,  and  tearing  through  the  sphincter. 
Many  other  tiiiKliKcationB  of  the  metlian  and  the  bilateral 
operations  have  been  pracliseil  by  vjiryiiiK  the  dirw^tion  of 
the  external  incision,  and  by  making  the  internal  one  on  one 
or  bt>th  Bidefl  of  the  prwtate,  gr  by  uotchiug  this  structure  in 
various  directions. 

ItixTO-vEsiCAL  LrrHOTOMY. — This  operation  was  sug- 
gested by  iMinson  in  1847,  as  a  itieaas  of  removiDg  large 
etoQes  and  avoiding  the  dangers  of  hetDorrhage,  bjt  tbe  re- 
sults have  not  been  such  as  to  justifr  its  performaoce  in  pre- 
ference to  other  methods.  It  ii  thus  performed.  A  staff 
crfiovcd  on  its  convexity  ia  pas»e<l  into  the  bladder,  the6aew 
IS  then  parsed  into  the  rcciiiin,  and  the  pun  of  the  slafT  lying 
in  the  nifmbranout!  portion  uf  Uic  urethra  felt  for;  a  knElb^ 
with  it*  «lg«  din-etcd  forwurdfl,  in  then  ptL-wcd  along  the  6a- 
Pi*. flTl'-^oiidV  t^^^  •"**'  ^'"^  gniove  of  the  Ht«il  and  withdrawn,  dividing  the 
BiUunit  (inrgn.  inlemal  find  external  Kphinricrs  and  the  »kin  at  the  margin 
of  the  anus;  it  is  then  reiritnidiired  with  ila  etige  din>ctrd 
downwards,  and  run  along  the  groove  rif  the  atafT,  dividing  the  pmstalc  and 
notching  the  neck  of  the  bladder,  and  the  stone  is  ihcu  extracted  in  tbfl 
Dsiial  way. 

Hn.n'oR  Suprapubic  Operation. — Although  the  median  and  lateral 
operations  for  lithotomy  are,  perhaps,  the  snfpgt  for  the  extraction  of  stones 
of  small  or  moderate  size,  yet  there  can  be  no  doubt  that  their  reauIlJi  are 
extremely  unfavorable  when  the  calculus  exceeds  a  certain  niAgniiude  :  and 
iu  these  circumstances  it  may  be  deemed  expedient  to  perform  "  high  opera- 
tion" in  preference  to  ibem.  It  is  fortunate,  however,  that  large  calculi  are 
comparatively  rarely  met  with,  and  will  dotibllcsa  hccnme  more  rare,  as  the 
diagorwis  of  Blone  can  now  be  made  at  a  very  enrly  period  of  the  existence  of 
the  calcuhw.  and  aa  the  treatment  is  now  generally  preventive.  Thus,  of  the 
703  N'nrwirh  cases,  t lint  form  (he  hacis  of  Crosse's  taMes.  and,  inde<«d,  of  inir 
chief  iiifornmtioii  on  these  points.  b'iO  were  under  1  ounce  in  weight;  119 
weighed  fmm  1  to  2  otnices;  S5  from  2  to  3;  11  from  S  to  4;  6  from  4  to  S; 
and  only  4  were  above  this  sixe.  Ht-iicc,  if  we  confine  tlic  hich  oiK-rati-m  to 
those  instance;)  in  which  the  ciilculus  is  abtiw  such  ii  si»e  q«  will  readily  admit 
of  extraction  thn»ugh  the  periueum,  we  ebnll  seldom  Uavv  occasion  to  pertorin 
it:  yet  ioslaaces  occasioDuIly  occur  in  which  no  other  method  of  extracting 
the  calculus  presents  itself.  Thus,  by  this  method,  UyLlerboeveo  succeedc-d 
in  extracting  a  calculus,  of  which  lie  ba^  kindly  given  me  a  cast,  which 


I 


I 


Jk 


leaniirwl  IfiV  inrlics  in  one  circuinrerenoe.and  12i  in  theothtr.  It  wae  per- 
"  rtly  moiiltiwi  to  thfi  aliape  nf  the  ineiile  of  the  bladder,  and  clearly  cuiild 
nnt  have  Ijeen  rpmoveit  bv  8iiy  incisioDB  thruugh  the  pcrlnpuni,  as  the  ogtlet 
would  lm%-e  been  itisutticient  lor  ite  extractiun.  The  patient  nurvived  the 
operation  eight  davH. 

Bnt  not  on!  J  may  the  high  operation  Iw  required  on  account  of  the  size  of 
the  calculus  ;  it  may  be  rendered  rccfasnry  by  other  conditions,  auch  aa  the 
existence  of  bo  much  rigidity  nbDul  the  bipa  in  consequence  of  rheiimatic 
disease,  as  wonld  prevent  the  proj>er  exposure  of  the  perineum;  or  by  that 
reeion  being  the  seat  of  disuse  wbirli  would  interfere  with  any  operntinn 
being  practised  throuxh  it;  or  the  pelvic  outlets  nmv  be  ao  ciiDlracte<l  by 
rickets  as  to  prevent  the  possibility  of  tbo  exlracticm  of  ft  stone  through  them 
by  any  of  the  perineal  operations. 

Operatiojt. — The  high  operadon  conaiala  iu  making  an  incision  thr&uph  the 
abdominal  wall,  above  the  pubw,  and  opening  tlit  anterior  part  of  the  bladder 
below  the  rodection  of  the  peritoneum  that  pu^KA  upwardd  frum  itd  fiummit. 
In  i)erforming  this  operation,  it  is  nvceesary  that  means  Bhould  be  taken 
to  raise  up  the  Bummit  of  the  bladder,  so  that  il  may  project  welt  above  the 
pube»,  and  thus  admit  of  being  safely  opened.  To  do  this  it  must  be  dis- 
tended with  fluid  as  the  first  step  Iu  the  operation.  The  fluid  used  should  be 
some  unirritating  antiseptic  snluti'ju ;  perhap  the  best  is  a  conceiilrate^l  cold 
solution  of  bunicic  acid,  warmed  to  the  proper  temperature  before  being 
ased.  Thymol,  snlicylic  acid,  and  jierinnngnijate  of  potai^h  have  also  been 
recommended.  Whatever  solution  be  used,  [he  bladder  should  be  thoroughly 
WMhed  out  with  it  two  or  three  time«  if  Itie  urine  be  foul.  If  il  be  actd 
and  healthy,  this  may  be  diB|>eused  'nilb.  About  twelve  to  sixteen  ounces  are 
then  injected,  and  an  India-rubber  ring  put  round  the  penis  to  prevent  the 
fluid  I'rom  escaping.  Thiii  part  of  the  operutinn  may  ho  performed  thn>ugh 
a  raetal  cntbeiur.  which  can  l)e  aecurelv  plugiii^d  iitid  left  in  to  serve  aubfto- 

3uenlly  ait  a  guide  to  the  bladder.  Msmy  fiurgwins.  howt'vfr,  prefer  witJi- 
rawing  it.  Too  much  force  must  not  be  used  in  injecting  the  hlad<Ier,  as 
aeveral  caaea  have  been  ntconled  in  which  rupture  hnu  resulted  from  so  doing. 
The  bladder  having  been  distonded,  Petersen,  of  Kiel,  recommendtt  that  an 
IndiariibbHr  hag  of  a  pyrirorinHliHpe,<»LnaSleofb<)1ding  about  sixteen  ounces, 
and  stiff  enough  tn  retain  ils  form,  sthoiild  \w  introduced  into  the  rectum  and 
distended  with  water  thri)iigh  a  tulip  fixed  lo  itA  aytex,  and  provided  with  a 
stopcock.  In  thifl  way  the  bladder  w  steii<lied  and  pitched  forwards,  m>  thai 
it  can  be  felt  clenrlv  through  the  iibdominal  walls. 

The  incision  is  then  made  Accur«lely  in  the  middle  line.  It  ahonld  be 
about  two  lo  three  inches  in  length,  nnd  slmiild  extend  slightly  over  the 
pubes  at  it«  lower  end.  The  r>yranitdnle«  being  drawn  on  one  side,  and 
slightly  notched  if  ne«-esisftry.  I.nc  linea  alba  is  expowd.  cautiously  opened 
near  the  piibes,  and  divided  upwards  for  ahotil  two  ini^hes.  The  fat  above 
the  pubes  it>  then  pushed  upwards,  and  the  distended  bladder  felt  for  with 
the  linger.  If  an  instrument  havi?  been  retained,  its  handle  must  be  depressed, 
BO  as  to  make  its  point  pn'tject,  pushing  the  bladder  before  it.  The  part  of  the 
bladder  uncovered  by  [leritoueum  may  be  recognized  in  adults  by  its  muscular 
fibres;  in  children,  Dulles  stales  that  its  hluish-gray  color  is  rharacleristic 
Tbe  bla<lder  having  been  fully  exposed,  must  now  lie  secureil  by  a  tenitcutum 
pnaKd  completely  through  its  cuul«.  Suiue  Surgeons  prefer  two  teuacula, 
Detweea  which  the  opening  may  be  ruude.  The  object  of  thus  securing  tlie 
bladder  ia  to  prevent  it»  being  tost  behind  the  pubes  as  soon  as  its  contents 
are  let  nut.  The  incision  into  it  must  Ite  made  with  the  edge  of  the  knife 
directed  towards  the  pubes.  The  Guger  is  then  introduced,  followed  by  the 
forceps,  and  the  stone  withdrawn.     In  doing  this  no  force  must  be  used,  lest 


9Si 


UKINART    CALCULUS    AND   LITHOTOMY. 


IhawntBhouId  extentl  to  tho  perilaneal  surface.  Should  tlie  nrigmnl  ojicii^ 
ing  be  too  »mall,  it  muttl  l}(>^iilar);t>«l  UiwiinU  tlic  piilii>s  wilti  a  priil>e-poiDUd 
btstourr  till  th(?  riilciiluH  cko  be  ttrawii  out  without  violeace. 

Tbv  8toiiu  Mag  r^titiivcd,  tlircc  cuur»i:-ii  nrc  o|»vii  to  the  Surfjetm:  be  may 
cloite  tiie  blH(Mt;r  un<l  the  extennvl  wiiun«)  with  Mittircs ;  be  Diiiy  sew  up  the 
bladder  atid  leave  the  exterual  wouud  upeu  ;  ur  hu  may  leare  bulb  open  and 
iusert  a  largu  draiDage-lub«.  Fiirthvr  vxjwrieu^w  U  vet  requireil  befure  it 
OttD  be  detiuitely  elated  which  ul'  these  is  the  btrsl.  It  vriu  hoi>ed  that  by 
aduptiDg  the  firet  uiethud.  nud  at  ihe  Btiiiiu  liiue  periurniing  toe  i>iieratiun 
with  atitiDeplic  precautions,  that  cooipleie  uuiuu  by  the  iirst  iDteiitiuti  might 
be  obtaioed,  but  at  pn^seut  the  resulU  of  this  mode  of  treatment  have  out 
beeu  very  satisfactory,  and  it  is  bow  generally  agreed  that  if  sutures  are 
applimi  at  all,  it  is  better  in  all  cases  to  leave  the  uxterual  wound  open,  as  it 
is  a  great  safeguard  against  inQltrntion  of  urine,  and  the  delay  uf  a  few  days 
vehile  it  heals  by  granulation  h  n  ruatter  of  little  cousetjueuce.  If  suture* 
are  applied,  they  ehuuld  l>e  of  oat^ut,  and  should  include  the  muscular  coat 
only,  missing  the  nuicnns  membrane.  If  the  i)|>ening  he  very  lar^,  the 
lower  part  (if  it,  when  the  hlaildor  is  ooltaptied.  will  be  bo  far  behind  the 

fubes  that  ^reat  (Iif5(.'ultv  would  be  found  in  inserting  stitches  airuratcly. 
f  the  wound  in  the  bladder  be  bcwd  up.  a  catheter  must  be  pssKtl  every 
few  hmiiv  to  draw  olT  the  urine,  or  it  may  be  tied  in  and  the  bladder  draineil 
by  an  [ndin-riihl>er  tube  attached  to  the  end  of  the  iostrumenL  MoBt  bur- 
geons prefer  leaving  both  the  wound  in  the  bladder  and  that  in  the  external 
parts  open.  If  thi^  tie  dune,  a  drainage-tube  of  good  bIzq  ebould  be  paased 
to  the  funiluB  of  the  bladder,  and  retained  for  n  week  or  ten  dny5.  A  gura- 
elastic  catheter  may  at  the  «ame  time  be  tied  into  the  urethra,  but  this  h  not 
aeoeoaary  if  the  drainage  from  the  wound  be  efficient.  The  beet  dreasing  is 
to  Bmear  the  external  parln  with  iodo-vaseline  ointment,  aud  tn  apply  n  large 
fpongfi  squeezed  aa  dry  tut  ponsihle  out  of  a  1  in  40  Aolutioo  of  citrbulic  acid. 
Tbia  muBt  be  changed  every  hour. 

In  order  tn  prevent  the  riak  of  urinary  inftllratioQ,  the  older  Surgeons 
kept  the  bla<lder  empty  by  making  inciHionA  through  the  perineum  into  the 
membranous  portiim  of  the  urethra  or  neck  of  the  bladder,  thus  acriouBly 
and  needte«9]y  complicating  the  oi>eralinn.  Viilal  recommended  that  the 
bladder  should  be  exp<u)«d,  and  the  wound  left  opt^n  for  a  few  days  to  grana- 
late  before  making  the  inci^iim  for  the  removal  of  tlie  ett>ne,  but  thii>  would 
fail  in  its  object,  as  all  the  adhesions  would  be  broken  down  during  the  ex- 
traction of  the  calciduB. 

Another  caiise  of  danger  in  the  operation  is  wounding  the  periiooeuiD. 
This  may  occur  when  the  bladder  is  so  contracted  aud  byperlrophied  that  it 
cannot  be  sufficiently  distended  to  make  it  riw  above  the  pubes.  If  the  stone 
be  very  large,  the  wound  may  extend  back  during  extraction  of  the  stune.  and 
thus  iriinlicale  the  peritoneum.  If  the  peritoneum  be  accidentally  wounded 
before  tne  blndder  la  upcued,  the  operation  niuet  be,  for  the  tiuie  at  laart, 
abandoned. 

Dulles  linde  that  the  suprapubic  is  far  lees  favorable  than  the  lateral  in 
its  results  lor  I'aleuli  below  .^  in  weight.  Fur  those  between  ^  and  ^ij, 
tbere  is  little  diUureucc,  whilst  for  caluuli  above  .^ij.  it  is  far  more  favonible. 
He  states  that,  of  u  grtws  tuuil  of  Hio  cases  of  the  suprapubic  operution,  in 
both  sexes  there  had  been  \'.i<>  ileatlis,  or  u  ninrtality  uf  1  in  3.44  ;  the  mor* 
tality  being  ubout  1  in  'd  in  maica,  against  1  in  K'2  in  females.  This  high 
rate  of  mortality  mav  U)  a  certain  extent  be  ureoimteil  for  by  the  fact  that 
the  patieulK  eubjecUHl  tn  Huprapuhic  lithotomy  were  on  an  average  one-third 
older,  and  the  stones  four  and  a  half  timca  heavier,  than  in  the  cases  subjected 
to  the  lateral  operation.     Dulles  gives  a  table  nf  43  cases  operated  on  by 


I 
I 


I 


I 


« 


HISTORY    or    LITHOTRITY.  dSG 

AmericaD  Surgeona,  of  which  1-1  died,  or  aa  nearly  as  possible  1  in  3.  This 
^treea  with  the  statistica  previounl}'  published  by  Humphry,  who  collected 
104  caaes  in  which  this  operation  had  l>een  performed ;  of  these  31  proved 
fttal,  chiefly  fnim  pcritoottia  and  urinary  infiltration  —  the  mortality 
amouDted  ctmsequently  to  1  in  3.^;  and  Souberbicllc,  one  of  the  greatest 
moderD  otlvocatea  of  this  operation,  lost  1  patient  in  3.  The  general  result, 
therefore,  is  Dot  very  satidtactory  ;  though,  aa  in  many  instAocea  the  opera< 
tiun  was  performed  in  caaes  in  which  the  lateral  method  was  not  applicable 
on  account  of  the  size  of  the  stone,  we  cannot  with  justice  compare  the  two 
procedures  in  regard  to  the  mortality  attending  them. 


CIIAPTEK    LXl.X. 

I'KIXAKY  CAH-ULLTS  [co,i I !,„.<'./). 

l.ITItDTlUTY. 

The  operation  of  Lithotrity,  by  wbirh  the  stone  ta  cTushe<l  in  the  bladder 
kud  the  pulverized  frugnienta  are  ex|>elled  or  extracted  through  the  urethra, 
ia  of  mocfern,  and,  indeed,  of  very  n.'(-ent  invention ;  for,  uotwith^tunding  that 
Various  rude  and  incomplete  attempts  may  at  ditliTent  times  have  boon  made 
with  this  view,  it  was  not  until  about  the  year  IKIX  or  1820  that  the  subject 
begao  to  attract  serious  attentiim  :  and  to  the  French  ^rurgeona  ia  undoubt- 
edly due  the  great  merit  of  huvinj;  Dr>t  only  iiitrtHluced  but  perfected  this 
operation.  About  this  time  Civiule,  followe<l  by  Aniussnt,  I^roy,  and  others, 
began  constructing  instruments,  wliieh,  though  very  imperfect,  yet  were  suf- 
ficient to  break  down  a  eiilculus  in  the  hladiiir.  This  was  publicly  done  by 
Civiale  in  182'2.  From  this  periinl  the  system  made  rapid  prugrcsa;  and  the 
■uccestive  impn>vcments  made  l)y  the  Surgeona  wliusc  names  have  jiiat  been 
mentioDeil,  together  with  the  ingenious  mechiuiifal  adaptation:^  introduced 
by  Ch:irritire  and  Weiss,  enabled  Surgeona  tn  attat.'k  the  stone  with  certainly 
and  effect. 

The  importance  of  lithotrity  was  urged  upon  the  pnifesfion  by  the  writings, 
and  its  applicability  demonst rated  by  the  pnu-ticf  nf  (.'ivialc,  Ainugsat,  and 
Heurteloup,  in  France,  and  of  lirodic  and  tlnstclln  in  tliis  couiHry.  The 
practice  thus  coninu'ni'ed  and  ('ftahlirihed  by  these  Surgeona  has  from  time  to 
time  been  improved  by  the  ingiiitiity  and  e'kill  <if  others,  amongKt  whom  Sir 
William  Fergut>8<m,  William  (.'Mul.'<iin,  and  Sir  Henry  Thompson,  were  c<in- 
ipicuouH.  To  Tlionipatin  er'[)i'eially,  the  pmlt'ssinii  is  indebted  fur  Iniving  laid 
aown  with  precision  those  rules  Iry  wliit-li  the  o{)erntii>n  may  be  port'orioeil 
with  B8  much  simplicity  ns  ^iatety.  I'p  tit  the  year  1S7<^,  llie  openilinn  of 
lithotrity  continually  improved  by  llie  coruliincd  Liburs  ut'  these  di>tingtiislie<l 
8ureeoDS,  aide«l  materially  \>y  the  skill  and  inL'-miity  ..f  the  surgical 
mecfianieian,  had  W>en  practised  km  the  lines  originally  laid  down  by  Civiale 
and  IJrixlie.  In  tiint  year,  bonever,  a  new  {uiiicipti.-  in  the  operation  was 
iolnwlui-ed  by  Uigelow.  of  Boston,  by  wliich  its  practic<>  waa  materially 
modified,  if  not  completely  rt*voliitioni/.cd,  old  rules  were  discarded,  new 
methods  intriKluced,  and  in^truiiieuls  of  novel  and  ingenious  coni<truction 


DRiKABT   CALGlTLtTS    ArfJ>  IITHOTRITT. 


devised.  lu  treating  of  the  eubject  of  Litlintrity,  therefore,  the  op*rfltioii 
willbedcscribetl.lirecaa  practitedaQteced^anllyaud  uptn  l>t7S;Hud,M-ci>n<1W, 
88  duue  uiacQ  Bigclow's  opcrnliou.  lo  which  he  hns  given  the  M>inewhat 
t^uniiit  nnino  of  "Litholnpaxy,"  ha?  bocn  generally  ndopted  by  Surgwuift. 

Lithotrity  as  practised  Wore  1B78. — The  iDveatioa  nf  iithoirity  wu 
BuraitHintei)  by  iliHttnilUfS  of  nil  kinds — nnntomicul,  pathnto^Mcal,  and 
mechaiiieal — ami  lo>i)  much  <-rodit  cannot  be  given  to  thnee  !^irgenD»  and 
Mechanicians  by  wh<me  untnuisinir  labor*,  praciitnl  Bkill,  and  inventive 
genius,  ihfue  grave  diffinullicR  have  been  8U(>ces8fulty  overcomo.  But  nnw 
that  they  have  been  fliirnmuiitetl,  the  inpre  practice  of  lithntrity  ta  extremely 
fliniiilo,  mid  tho  opuratiim  is  vany  of  execution. 

For  iht  mi'a  ami  [»rii[H'r  [MTfonimimG  then  of  the  optration.  the  Siirgenn 
musi  not  only  in*  anpjainUtd  willi  thi-  j.'oni'rai  principlf-a  on  which  it  i»  under- 
taken, hut  he  muHt  be  ihormi'^hly  coiiversani  with  iht'  more  minute  details  in 
ihe  contiLriK-Lion  and  tlip  mMni|iuliition  of  the  itittrumcnta  employed,  as  well 
aa  with  (he  ntate  nf  nvcry  part  of  (he  urinary  orgaux.  It  id  iinpnaeible  fur 
nuy  "Surgeon  who  wishes  to  practise  lithotrity  RucocssfiiUy,  to  devote  too 
much  time  and  attention  to  point*  of  detail,  which  nay  oftui  at  first  appear 
trivial. 

Instrumksts. — The  instrnment*  required  for  lithotrity  are  the  following: 

An  ordinary  eound  wit)t  a  short  hcait  in  rf-qnired  to  examine  the  coDdition 
of  (he  bladder.  The  !it<>el  »i>iind  tiboulil  be  hollow,  so  that  the  bladder  may, 
if  necessary,  be  injected  through  it  after  or  dnring  .nounding,  without  the 


I 


T 


n^. S7S.^LIUMiiHUt  Sound  for  &I«aiur{nt;  :L<t.<:.     U  i: 


■■o  ik«t  tbm  bladder  oaa  lu 


neoMntjr  of  changing  the  inBtrunient  (Fig.  872).  This  will  be  found  of  mach 
aerrice  in  the  later  stages  of  the  operation  for  detecting  small  fragment*. 

A  broM  fringe,  with  rings,  having  a  large  piston  rod  so  that  it  may  work 
easily,  and  admitting  of  adaptation  to  the  hollow  sound,  should  be  at  hood. 

The  Surgeon  should  be  pruvided  aUu  with  «Viw  calhetfr*  of  three  different 
kinds:  one  with  large  lateral  eyes,  another  with  a  large  eye  in  the  convexity, 


<^^- 


Fig.  STS.— Wiim'*  Old  Tkumb-Mrvw  Lilltalrite  for  lirmtkioi  lbs  Stan*. 

and  a  tliird  with  a  large  eye  in  the  concavity  near  the  pnlnl  (FIks-  883.  flS7. 
ASS);  all  having  an  elatilic  gum  bougie  fitted  to  the  interior,  instead  uf  a 
Btylet.  to  clear  out  the  fragments  (Fig.  $81lj.  These  also  ahontd  tit  tu  the 
syringe. 

The  insti-umcnt  for  breaking  the  atone  ia  enlle<I  a  Hthotrite.  This  innira- 
ment  has  undergone  various  modificntiona  and  improvemenlH  at  the  hnntts  of 
Mechanicians  and  Surgeons.    To  Weiss,  in  (Ids  country,  and  to  Cbarrim, 


i 


A 


CONSTKUCTIOK    A.ND    FOKHS   OF   LTTHOTBITES.  957 

in  Fraoce,  we  are  especially  indebted  for  haviog  brought  it  to  its  preseot 
state  of  iMirft-ction.  lu  the  earlier  days  of  lithotrity  thu  thumb-screw  litho- 
Uite  was  geuerally  used.  Sir  W,  F^rgussou  invented  a  rack  and  pinion 
iiutrunicnt,  which,  however,  found  little  favor  with  Surgeons.  Civiale'a 
Terv  ingenious  and  beautiful  inslrutneutB,  having  the  double  action  of  screw 
•na  hand  preesure,  were  those  t<i  which  many  gave  the  preference  until  the 
iurention  of  the  cylindrical  liaudle  by  Thuinpiiun.  This  instrument,  having 
the  same  double  action  aa  Civiaie's,  is  that  which  is  now  commonly  used. 

The  lithotrite  must  be  made  of  well-tempered  steel ;  and  should  be  tested 
hj  being  made  to  crush  a  piece  of  sandstone  grit,  of  about  the  size  of  a 
walouL  It  should  be  of  as  full  a  size  as  the  urethra  will  readily  admit ;  it 
must  have  the  male  blade  well  serrated,  and  the  female  or  under  blade 
pierced  at  the  beak  by  an  oval  aperture,  through  which  the  detritus  of  the 
crushed  stone  is  forced,  and  thus  any  entanglement  of  it  between  the  blades 
i»  prevented  (Fig.  873). 

The  object  of  this  open-bladed  lithotrite  is  to  l>reak  the  larger  and  harder 
itooea  into  pieces;  but  it  is  not  intended  to  pulverize  smaller  calculi  and 
fragments. 

The  lithotrite  should  be  cut  out  of  a  bar  of  solid  steel,  and  not,  as  is  the 
cue  vith  sonic  instruments,  made  of  a  plate  of  this  metal,  turned  up  at 
the  edges ;  as  such  a  one  possesses  too  little  strength  to  be  used  with  safety 
OQ  large  and  hard  calculi.  Those  cut  out  of  a  bar  of  metal  have  an  exter- 
nal blade,  having  a  grooved  shai>e,  as  in  Fig.  87o.  In  this,  the  male  or  in- 
ternal branch,  cut  to  fit  accurately  (Fig.  877).  slides  smoothly,  the  whole 


t*ij 


Fig.  »7i  FiK.  sr5.  Fig.  PTO.  Fig.  877. 

fvutiiiii^  uf   I.ithiilrite#. 

instrument  possessing  an  amount  of  strength  and  power  that  no  calculus  can 
mist.  The  lient-up  iiistrunioiit  i^  ci>mpr)Sf<l  of  an  outer  tube  of  metal,  as 
repreeenteii  in  its  trHnsven<e  scctinu  iFi;.'.  874),  in  which  Ihu  internal  blade 
fil4  ie«j  accurately  <  Fig.  87(i),  and  wliicli  poy.«eii!k'8  less  strength,  especially 
at  the  elbow,  than  tlie  lithotrite  cut  out  of  solid  steel.  The  scoop,  however, 
may  without  danger  be  cnn:-triicli'd  of  bout  iiictal. 

Civiaie's  lithotrite,  such  as  is  reprc^entctl  in  Fig.  878.  has  a  most  ingeni- 


^^ 


Fij{,  >>7s.  -Civiiili-'-  Lillnitrile  fur  I'lui'luii;;  Fra;;iDciiti'. 

ous  double  action,  fnablin<^  tin;  Sur;:i-iin  to  wm-k  it  eillicr  by  the  presitiire'of 
the  hand  or  by  a  screw.  In  this  iiiritruimiit.  tlicro  ia  no  fenestra  in  the 
female  blade.  It  is  of  two  kind;:.  In  niie,  tlic  uiali'  blade  in  nuich  narrower 
than  the  female;  in  the  otlicr.  it  is  ncmly  an  brom).  The  fin>t  kind  is  use- 
ful in  cru.Bhing  thruugli  iiiiitltratc-sizt'd  Fitoiit':^;  and  the  seconil  kind,  with 
the  broad  male  bladi.-,  i.-'   u.^ud  in  cijitiiik'ttly  cruiihing  and  removing  the 


958 


UniXA&r    DALCDLU8    AyV   LITBOTRITT. 


ili-lrittiB  iif  nmall   calculi,  anil  the  large   fragnieola  ioln  irhiah  a  MaM  I 
b«*n  broken  by  the  opcn-hladi-d  lilliotriw*. 

Thompson 'alilhotrke  (Fig.  8701  eotiiewbat  rraenibiM  drtalc"*  &b  ilt  aid 
but  is  more  lianHy.     It  is  maite  u  itii  a  ft'iieaimled  ftnotUe  blade  tat  ltttltiif\ 
the  stoDe,  or  with  a  scoop  for  crtuhltig  fragnienu. 


PIX>  Ort.— ThompMB't  Iii>pr«r*il  UtbntHU. 

Preparation  op  toe  Patibst.— IJeforp  proceediag  to  ibc  afrnda  i 

lithotritT,  it  ia  ti«ees»arr  that  (he  patieiit'ti  citiibtituiion  ah'Mild  be  cwffc" 
attcndw  tu  ;  the  Ituwcis  Hhoiil'l   Ik;  freely  ojiened,  ami   the  a.ttdttMrn  ufl 
digestive  urgans  regulated,  anil,  nwn  tttp«^<ittlly,  all  looit  irntabilllT 
the  urinHnf  urgatiB  ehuiild  be  siibiluerl  by  onliiinry  nmliail  tn->>iiu-a:     Tklj 
t«  eveo  of  much  ^renter  imt^jruiicw  in  lilbotrily  than  in  lithi'i 
rily,  we  muat  aluayti  exjwct  tliat  any  exbtttng  irrilati'Ui  ur  liti.o..-.. 
the  bladder  will  hv  iiicrv-iuH-d  by  the  nwutNiry  intnxluctioo   vt  imt/itwiaS,  I 
aud  by  the  presence  nf  sbarp  frug^nivnlB  of  nilculus  in  the  bladder,  asd  lh«ir 
paaiage  ulotig  the  urethm ;  but  in  lithotomy  all   source  uf  irritalHin  »  *1 
vDce  reiuoveU  by  the  extniclion  of  the  Hlone.     The  ci>oditioo  of  tin  arnwrJ 
organs  must  be  very  carvlully  exatiiineil:  and,  if  theae  h«  diMMid, il M I 
pr«)bably  be  requisite  to  abuud'-'U  the  operation.  f 

In  a  sub^eijuent  part  of  (hiH  chapter,  when  we  oonw  to  tb*  eovparini/ 
litliotoniy  and  lilhothty,  we  shall  examiue  the  c<ioditi<iiii  which  nitliir  is^ 
catc  or  negative  the  performance  of  tlie  latter  operatioD.  Al  pmBl,** 
will  MppcaeacBM  id  which  the  Supcre^'a  tnny  have  ret^iunt  to  lilfaotrA 
with  every  prospect  of  readily  and  iK-rmnnenily  freeing  the  patiaot  4  m 
calculus;  one  in  which  the  calculus  is  of  niodiTuic  size,  «iDgU>,  and  hUm 
bard;  the  urinary  organs  healthy:  and  the  palicul  an  adult,  btu  Builo 
aged.  Id  performing  the  opcrnuoo  in  such  a  catc,  but  llule  ptmriMT 
trektmeDt  i^  requin^d ;  though  it  is  well  lo  keep  the  paiieot  quiM  nrafe* 
days,  and  to  n^gulate  bis  bowols  before  anything  is  done.  ShuaMlhs|MMt 
b«  nervuuB  about  the  use  of  itutrumenis.  or  sboulil  the  ar«<lu«  be  tiuttUh 
u  large  Kound  may  be  pawed  every  second  day.  so  as  to  accuatam  iliefMial 
and  the  parts  to  the  u^  and  pootact  of  instrument. 

L'sK  OK  AN.*»Tni-Tics. — Much  difference  of  oninioa  eruled  )hraari|fl* 
to  thfi  advisability  of  employing  ancatbetiea  in  liihotrily.  It  bis  hm^^ 
Je<^ttrd  to  ihi-ir  usi!  that  the  aeasations  of  the  patii-nl  am  a  UM-fn)  tnUt  ^ 
the  Sur>;i'»n   in  bin  ruaiii]iulatiuQa  ;  and   that,  if  iboe   be  '  ^ 

aiiitdt holies,  iujury  mny  he  tii.<at  by  lb«  litliotriie  nipping  or  '  '  '-'**' 

iu;{  tbe  mucous  memhraui*.  Hut  this  objecliuu  ia  nut  ti'uablc.  It  ivih*^ 
iMtlioit!!  of  Uto  Sui^':<iu,  Olid  not  those  uf  Utc  jtalicut.  that  ootittitote  a  v*^ 
able  guide.     Although  in  the  iiiaj<jri(y  of  cosiv  lithotrity,  wbea  ff^V"^^ 

pcrfornie»l,  !9  aliu'«t  a  pninltw  proitnlurc,  yet  <•?- —   -''- .i.  .wwf 

in  which  the  patient  can  witb  didJculty  support  '^ 

aud  in  which,  either  from  nervouiueas  or  tn^ru  iniuinniiy  "i  n.t  t>'a»'i't.  ■* 
cjecU  bis  urine  on  the  introductiua  uf  the  litfaotrilc.  or  cvea  does  tntt^ 
his  bladder  to  be  duly  distcnJe<l  by  injection.  lo  such  cases  aaaalkdi*''* 
uf  inestimable  service;  und  tiintiv  i>atira(t  when  aaisBtb«Uacd  can  W •**.' 
aubjoctcd  til  Utbotnty,  wlio  cuulil  nut  aufler  tli«  openitioB  aadcr  otkr"^ 

Bg  as  lithotrity  was  done  by  tbe  uld  meUiod  of  short  liaiafi,^ 


OPBRATIOff    OF   rilTHOTHTTY-. 

ailiuiuif  Lration  nf  ana-eihotiit!  rciiiuiucd  to  etiino  extent  an  ii)ien  <(ii(«tion ;  bttt 
iu  uiuderii  lilhotritj,  lui  |)racliiH>il  &iuce  ItiiH,  bv  C()iii[>l«lc  evuciistion  of  the 
fragmeuts  at  tmc  proiiiiigeil  »tUii)g,  aiKCBlhelics  are  itidbpetiHalile,  and  are 
now  invarialily  used. 

Opekation. — The  0|ipmtii)ii  of  liihotrit y  may  Iw  ilivided  into  three  stages : 
1.  Thi!  Intn)ductini]  of  the  liietninirnt.  2,  The  Search  for  and  Seizure  of 
the  Swine.     3,  The  Crushing  of  the  Htone. 

1.  IntrodactioD  of  the  Lithotrite.— I.ithr.tnty  mny  moet  ronveniently  be 
performed  with  ihi'  palipiit  lying  on  his  hack,  fither  upon  a  hard  mattress 
or  nn  n  conch  or  table.  The  pelvis  miist  be  raisefl  hy  a  hard  pillow,  so  na  to 
allow  ihe  stone  to  roll  up  on  the  poelerior  surface  of  "ihe  bladiier.  The  Sui^ 
eeon,  ainnding  on  the  right  side  of  the  pnlient,  carefully  introdiic«  the 
Eollow  Bound,  or  catheter,  and  dravs  oti'  the  urine ;  he  then  slowly  and  very 


l.r 


■tv 


Fig.  880. — Intractuaiion  of  U>«  LIlbDlriU. 

cautiously  injects  the  bladder,  by  lueau*  of  the  bra«e  syringe,  with  from  four 
to  six  ouDcea  of  tepid  water ;  or  some  auttHbjitLC  eolutiuu,  such  as  boracic  acid 
lotion,  or  C^iudy'e  fluid  and  water.  C'arliulic  acid  (I  in  50)  baB  been  U8«d, 
but  it  is  tiK)  irritating.  Tht>  use  id'  drawing  idf  the  urine  i«  to  make  sure  of 
thebladderhiddLuglliu  proper  quantity  of  lluid  wlion  it  is  aflerwards  injected; 
and  the  object  in  tnjeetitig  it,  i5  to  di.steud  it  to  Bucb  an  extent  as  to  prevent 
the  muiH)ii9  membrane  frum  being  Feixed  in  the  grasp  of  the  lithotrite,  or 
injured  by  the  epiintenng  of  the  stime.  The  iualniment  is  then  withdrawn, 
allcr  the  nitiiatioa  of  the  stime  bafi  been  detecLed  by  it,  aud  tbo  lithotrite  is 
iutroduoed.  Hhould  the  piUient  be  abl«  to  hold  euouL'b  urine,  viz.,  frnoi 
three  to  four  ounces,  to  pri>tecL  hiH  Madder  fnini  the  acliun  of  the  lithotrite 
ur  the  fragments,  the  injection  mav  be  disppiiHitd  with,  and  the  lithotrite  may 
at  once  be  used.  As  this  ia  strnigJit,  with  a  sharp  elbow  ut-ar  the  beak,  some 
little  akill  is  re-quired  io  parsing  it  In  doing  ihu),  the  Surgeon  must  keep 
his  eye  upon  the  short  curved  beak  of  the  instrtiment,  the  direction  and 
iwsition  of  which  must  be  constantly  observed,  or.  rather,  judged  of;  and 
especial  care  must  be  taken,  in  carrying  it  under  the  pnliwi,  not  to  injure  the 
urethra  by  pushing  the  h(^ak  of  the  lithotrite  forwards  too  Hiiddcnly,  iDstcad 


960 


CHINARY    CALCULi;&    XHV   LlTOOTBtTT. 


of  wiudiag  it-,  ad  it  were,  under  tb«  arch  of  (hftt  bnnc  TIm  ia»tn«al 
Bhinild  tireL  bo  iatrtfiuctMl  Dearly  parallel  to  thr  aUI'iruvn.  tbt  prfin  >>»( 
h(!lil  l>etwt:vti  tliu  iurc  aod  middle  bu{;t<ra,  and  Jrswa  oTrr  il  A>  tiw  Uk- 
trite  \m&vii  down,  it  niiut  be  gradually  ruised  lu  tho  ncrp<fij<tirvlsi  [•>«.<-4. 
and  as  ila  ciirvu  pueas  uuder  the  pubea,  tba  haadla  tbould  b«  immti 
between  tbu  tliit;lis  (Fig.  SSO).  The  direotion  of  tbo  currc  k  t^  tLifta 
bear  in  luiml;  aud  the  iHtsitiuQ  of  the  haoUle  must  be  raiivd  in  acevnUar* 
frith  the  <^)unto  wliich  tiiis  lakes.  The  lithoLrile  »h'Jold  b«  well  ywpd  wu> 
rarbolizetl  oil,  m  that  the  bl&dee  aod  ifcrew  may  wurk  inooUilj.  latim] 
ointment  ahnulil  not  he  u«ed  for  thid  |)ur}K«e,  as  it  la  aptUiolo^Mli 
eotangli'  gritty  bits  of  calculus. 

2.  Seisiire  of  the  Stone. — The  iii^it  point  ui  to  aein  thaalaac,  wUdivS^ 
MDerslly  be  found  in  iho  situutiun  where  iu  prmMOoe  ma  dOfscMil  im^ 
uw  sounding  of  the  hliidiler.  If  large,  the  stone  will  pmbalily  lie  l^ra,  oav 
the  neck  of  the  blaihler ;  if  tinmll,  it  ih  imiKt  fr«Mf  ut-iitly  met  willi  at  ikt  nylc 
aide,  or  at  ihe  inferior  fnndti^t.  Should  it  be  tfiiuatrd  iu  a  dcprrauuBiaUii 
region,  it  may  most  readily  be  »(^ize<l  by  inlriMluoing  a  finger  inlii  ika  i 


Pif.  Sai.— Bro41«'«  UvUiod  of  Katrine  ika  £Imm. 


and  raifiin];  up  the  lower  part  of  the  bladder.     Brodte  itruagly  ail 
the  litbolritc  ehnuld  never  be  used  aa  a  aouod  to  aiccrtaio  the  punboo 
Bl<iuc ;  if  ihiB  be  done,  the  patient  aull^ra  niln,  Ui«  liliuldcrr  i*  irri' 
urine  expelt<^<i),  and  the  iione  not  readily  aeize<1.    T)  nbjerttai, 

erer,  t^)  d»ing  »»  while  the  patient  ia  under  the  inll  :  an  awrtHi^ 

In  seiung  the  calculus,  a  goo<l  deal  of  tact  Is  rH^uirrd.     iU*  r  ■«}* 

of  aeiBing  the  stone.     BnMlie  recommend*  that  it  i^hfiuM  Imi  a  '-^ 

the  feniale  blade  of  the  Hthotritc  againH  the  ttif>-nor  fundua  u(  tii*  UaP"* 
prvsMiiig  gt-iilly  down  with  it  eo  as  to  make  a  conical  ili  |iii«iiiiii  in  tin 41^ 
tion,  and  then  inciintni;  the  beak  towards  the  stone,  drawing  faftek  tW*** 
blade  with  the  thumb  rFig.  881):  with  anligbt  shake  or  jerk,  t^baSBi^ 
then  trios  to  |rut  the  calcufiis  between  Ihe  blades,  at  the  same  tutw  llisl  >^ 
male  branch  is  being  pushed  forwards  to  seize  iL  In  tliia  mamnTrr. 
female  blade  should  b«  moved  as  little  as  pmibte.  but  tin  aluoe  nut 
leized  by  pressing  the  thumb  upon  the  half-circle  of  steel  flxei  oa  iIm  a 
braacb.  In  this  way,  the  atono  mar  ofieu  be  Mised  at  the  fine  aUc»|4,M 
in  other  cacei  it  ii  not  gruped  until  afUr  several  attempu  have  beaa     '*" 


11^ 

a 


BBKAKINO   THE   STONE.  961 

to  fix  it;  tbe  calculus,  especially  if  round,  slippiag  away  from  between  the 
Uadea  of  the  iostrument,  and  being  merely  ecraped  by  them.  GWiale 
adopted  another  procedure  (Fig.  892).    In  paasing  the  lithotrite,  be  felt 


Fig.  tiS2.— CivUle'i  Method  of  Eeliing  the  :>toue  bahiDd  tbe  Proitate. 

rhere  the  Btone  lay ;  he  then  very  gently  turned  the  beak  of  the  instrument 
owarda  the  opposite  side  of  the  bladder,  opened  the  blades,  and  then,  tum- 
Dg  them  over  towards  the  stone,  seized  it  between  the  open  blades.  In  these 
Danceuvres,  all  rough  handling  must  be  most  carefully  avoided,  and  tbe 
mtrument  should  be  turned  about  as  little  as  possible.  It  is  far  safer  to 
leaitt  from  the  operation,  if  there  be  any  difficulty  in  seizing  the  stoue,  than 
o  persevere  in  repeated  and  fruitless  attempts,  by  which  the  bladder  mar 
te  Kverely  injured.  leather  than  do  this,  tbe  patient  shuuld  be  allowed, 
f  not  under  the  influence  of  an  anaesthetic,  to  get  up  aud  move  about  for  a 
isw  minutes,  when  the  position  of  the  stone  may  be  so  far  altered  that  ijt  will 
idmit  of  being  seized. 

3.  Breakillg  the  Stone. — When  the  stone  has  been  seized,  it  is  gently  raised 
D  tbe  grasp  of  the  lithotrite,  so  as  to  be  placeil  about  the  middle  of  the 
iladder,  and  it  is  then  crushed.  This  important  stop  of  the  operation,  like 
ill  the  others,  requires  to  Iw  deliberately  ami  carefully  done  C^ig.  883).  If 
[Tivtale's  or  Thompson's  improved  lithotrite  be  used,  the  stone,  if  small,  may 
)llen  readily  be  crushed  liy  the  pressure  of  the  hand  alone  without  the 
iction  of  the  screw  (Fig.  884).  If  the  ordinary  lithiitrity  be  employed,  the 
breaking  should  not  be  cfiected  by  suddenly  and  forcibly  screwing  up  the 
initrument,  but  tbe  screw  shoultl  be  gradually  worked  by  a  scries  of  short 
ind  sharp  turns,  so  as  to  constitute  almost  percussive  movements  (Fig.  885). 
In  this  way  the  calculus  in  generally  made  to  crumble  down,  rather  than  to 
St  aaunder;  and,  as  it  yields,  tbe  screw  mu:>t  be  worked  tightly  home.  The 
blades  of  the  instrument  may  then  be  opened  again,afrugmcnt  of  the  broken 
calculuB  seized  and  crushed  in  the  same  way  n^  before;  and  thus  the  com- 
pete disintegration  of  the  stone  is  gradnally  elfticted. 

Before  withdrawing  the  lithotrite,  the  t?urgc(in  must  be  careful  to  see,  by 
tbe  scale  on  the  handle,  that  the  male  bhido  is  well  home.  If  this  be  not  the 
cue,  and  the  instrument  l>e  cnlar<rod  by  any  fragments  or  detritus  entangled 
between  the  blades,  laceratinn  of  the  neck  of  the  bladder  or  urethra  might 
occur  in  attempting  to  withdraw  it. 

It  was  formerly  considered  of  the  greatest  moment  that  too  much  time 
ihoold  not  be  consumed  at  one  sitting.    The  rule  enforced  before  1878  waa 

TOL.  tl. — 61 


962 


ITKINABY   CALCL'LUH    ANI 


tOTMlTV. 


tbat  the  8linrt«r  the  aiUiiigit.  the  more  likely  wa«  t)in  <-iim>  tn  do  will.  TW 
fir»t  fltuiu;:  wafl  uol  up  cxc<hmI  four  miDutcs,  ncxl  tho  iiiib«r>|u«ot  •iim«tRW 
be  u  sliort  lu  iKieeililv.  In  the  re)H!tili«)ti  of  the  ■itiiiijjv,  lb»  Barg«M>i* 
gutJoil  by  tlio  vlluct  [iruiluwd  mi  thu  8ti>n«  auil  (to  tb«  blktlder.  Tb«  aiaim 
wu  oileu  entirely  dcstruyetl  lu  one  silling,  but  nioeC  aimmouly  ffuBtkMlB 


Pig.  SSJ  —  pMltton  uf  IIhbiI  la  »M»g  Orlal*'*  Uihaum 


V\%.  fU3.— PmIIhhi  of 
Uttotnla  in  Cni«li. 
!»(  tkn  8t«ft*. 


Fig.  9U. — P<Mlt)a»  «r  IIumI*  (»  naiag  TlMak-Mr«*  UtiMnii. 


i 


five  or  tix  vrere  require<l ;  thwe  wore,  if  poHiiblo,  onotluctod  at  tntcrtkh  rf 
thfM  or  four  dftva,  tbougli  this  dcpendod  ufwu  the  amount  of  irritatioo  iail«aJ 
by  thorn. 

At  the  first  fiittiag,  it  was  coofidered  fuffideot  to  brank  up  Um  bImm):  ifc* 
OagmoQtA  b«iiig  loli  u>  bo  dealt  with  8absei}ucntly.  Thk  mtiajt  wmi  by  far 
the  most  iniportaot  of  all;  it  was  not  permititid  to  oocapy  OMira  ikaa  a  niy 
few  minutes.  AAer  the  stone  bnd  been  broken  up.  the  pftlieac  was  maik  I* 
lie  in  bed  on  hid  beck  forabuul  tweiiiy-foiir  huuri.  was  k«fH  warm, mod  phnu- 
Ailly  supplied  with  dilueaUL     He  wua  not  allowed  to  paai  waivT  !»  >•  uriDal, 

.;  or 

.-TlU 

.  tW 


nor  to  Htaod  up  or  leau  forward,  lt»t  the  fra|fnKDi«  should  i 
bboome  fixed  in  the  neck  »f  the  hladder,  where  iher  ml^-^ ' 
Irrildtlou  nud  dtdUtAi.     )(uch  uf  the  snectw*  of  lilbuirtir  : 
Up4iD  Out  gentleness  with  whtrh  IIik  pr<H-eeitin}r>  wen;  ron 
dnt  iiiltint;,  and  the  eare  with  which  the  {tatinii  na»  ma\ 
two  ■iili!it->|ucntly. 

After  tliu  stuue  had  been  broken,  little  delritns  usually  >^ 


iri«(th» 


THE   OPERATION   WITH    HAITT  SITTINGS. 


96S 


Lithiiloiy  C*thilen. 
Flj.  SSfi.— Ejoi  Ht  Kxtteiulty. 
Fig-  8S".— Bye  in  Cunumvily, 


first  twenty-four  boura  ;  but  afier  tliis  il  was  expelled,  in  aome  cnees  m  oon- 
eiderablequnutitv.t'acli  tinimbcuriuewaapasBe*!.  In  others,  it  did  not  escape 
6>j  rea-lily;  aud  tlicu  ibc  Surgeou  woa 
pfteQ  i'ulli?<i  up<iu  to  U8U  C'ivialu'e  in- 
JBtrunieiit  (Fik.  ^7M),  by  wbicb  lifcimbi 
Mixe  tli«  ainallcr  fVa]!ini'nltf,t>ruah  tbem, 
'and,  screwing  ibc;  iiiatrument  bnmt^, 
extrurt  the  lieak  fillnl  nitb  detrltua. 
Id  imng  this  inetrunii'tiE,  bnwcver,  it 
was  neoeatuiry  not  to  fivl  hnUl  of  too 
large  a  fraf^nient;  fur  in  brenkitig  this 
up,  ihR  beak  wan  fasily  c3ngg<'d  with 
detritus  in  piich  a  way  that  it  could  not 
c\me,  and  then  there  was  cunsiderable 
difficulty  in  withdrawing  it.  If  thi?ac> 
cidvnt  orcnrreil,  the  somp  was  enipiied 
by  passing  its  lienk  bnok  into  the  blad- 
der, tapping  Bliarply  ii)"jii  tby  iiixlni- 
ment,  and  moving  tlio  mule  branch 
tu  and  fro.  In  criii<hin)^  iViii^mviits 
behind  ihtf  proM^te,  Clviale  turned  the 
concave  purl  uf  the  beak  dimuwanis, 
and  seized  the  (Vajriiionlin  lliis  piisitioa 
(Fig.  yy'i).  In  doing  this,  however, 
great  rare  itinst  bu  lakcu  not  tti  nip  the 
imiC'His  meiitbnini-'  of  th«  bladtter. 

Before  1876  much  differeuce  exiGled  in  the  practice  of  Surgeons  witb 
respect  to  washing  out  the  bladder,  but  the  majority  abstained  from  hi  doing, 
especially  at  (he  lir»t  silting.  The  objectiim  lo  Chia  practice  arose  from  the 
fear  of  aetting  up  or  nggravnting  eyatilis,  as  it  was  not  then  fully  recognized 
that  the  niecnanieal  injury  is  a  Itse  powerful  cause  uf  uyatilis  than  the  accu- 
mulation of  a  quantity  of  fon]  and  decnni posing  mucus.  The  in^trumetita 
used  for  washing  out  tlie  bladiler  before  the  invention  of  thoHC  to  be  presently 
described  were  chie6y  eathetera  of  the  fonn  reprt-'xi-tited  in  Figs.  8^C-SS8. 

Clover,  however,  had  invenied  more  than  twmiLy  years  ago  an  ingenious 
and  simple  inetrLimeut  which  mav  liccousiilered  thin  parent  of  all  [ho"evacHa- 
tora"  now  in  use.  It  was  i»tt--n(ieil  not  only  to  watiti  out  mueua  nnd  detritus, 
but  to  remove  the  smaller  fruj,'menl«  nfter  each  nitting.  The  iustrumeat 
(Fie.  889).  however,  did  not  meet  with  the  amount  of  favor  it  deserved. 

Under  the  old  plan  the  interval  between  the  ailtinga  va,ricd  according  to 
the  effect  produced.  If  all  went  well,  the  second  silting  usuallv  took  pfaee 
alxiut  live  or  six  days  afber  the  fir.<it,  and  they  were  then  repeat«if  at  intervals 
of  fr«im  three  tn  fatir  days,  canh  fitting  not  exceeding  live  to  eight  minutes. 
AVhpu  the  Surgeon  believed  chat  the  bladder  had  been  emptied  of  all  frag- 
ments and  rk'lriluB,  a  final  ej-phiralimi  was  maile.  Tlib  la.st  act  of  the  opera- 
tion both  formerly  and  now  'n  neeesftarilv  one  of  the  greatest  importance,  aa 
on  the  prerifiiou  with  which  it  u  conducted  depends  iu  a  great  degree  the 
future  immnnity  of  the  patient  from  a  recurreuL-e  of  the  disease;  any  frag- 
ment, however  minute,  that  is  left  behind  necessarily  constituting  the  nucleus 
of  a  further  calculus- 

Tlie  exploration  is  be-st  ioniIueti;il  by  means  of  a  small  lilholrile,  the 
bladder  containiug  but  n  ni>Hlerate  quaiilily  of  urine.  The  whole  of  the 
interior,  but  ei«periallv  the  part  behind  the  pn^late,  should  be  c«r<;fidly 
explore<l ;  and  if  any  iVugment  he  found  it  must  b«  crushed,  and  the  detritus 
exlnieted.    Civiale  empfoyed  the  "  trtlobe,"  allowing  tb«  urtue  slowly  to 


964 


URlIfABY    CALOnLtTS    AJTD  LITHOTBITY. 


trickle  out  tbrouuh  tbc  ehail  of  the  bstrumont,  at  tbc  time  wb«u  b«  dnwl 
and  closed  tlie  bfiidcs  over  the  Uoor  of  the  bladder,  by  pushing  the  tubularj 
shank  ovtr  tbciu.  Aaa  mtasurcuf  additioual  safiity,  tbe  exploratioa  fthould] 
be  repeated  oiler  tbc  lapse  of  a  week  or  two,  aud  ibe  bladder  be  well  woAlied ' 
out  atler  each  pmoodure. 

Duriug  the  M'hole  of  the  treatment,  it  is  iicceeeory  to  adopt  means  1^  altayj 
Irritatidu.    With  this  view  the  pntit-ne  dhoiitd  be  kept  in  bed.nr  on  acoacb;] 
a  moderate  diet  ouly  xhould  be  alltiwod,  plenty  of  ueniulcent  drinks  given, 
such  as  barley-watcr,  »oda-waier,  or  milk;  and  opintea  or  beobane,  if  new -i 
sary,  Bhould  bo  administered. 


Pif.  889.— OloTw'*  LitbotrUjr  InJ«oli»n-n|>|>ikrnin*.     I.  Rlutlo  Stjiat  tor  Ulholrltj  C*tl>«t». 

i,  n,  4,  A.  LilhoUltjr  Cktbelon  itilli  Uig«  ej-w  kt  and  or  in  diffwieat  sid«^  to  ba  nmod  »itb  ^ 
Dt  witbcnt  lb«  Injrclion-npparatuf,  ^M 

The  amount  of  irritation  of  tbc  bladder  developed  after  litbotriiy  in 
wverai  eittinRS  varied  grejitly  in  didcrent  cases.  In  some,  iu  which  the 
stone,  when  unbrnken,  had  excil<Hi  much  jiain  and  irritability  of  the  orj,in, 
the  Bufferings  were  at  once  leaseniod  by  its  being  broken  up.  It  la  ditBewIt 
to  account  for  thi.t,  except  on  the  HUpiKmition  (hut  I  ho  fragmentfl,  l>cing  spread 
over  a  wider  surface  tlian  the  unlinikiMi  calculua,  prcuaed  Ic^  direelly  «o 
any  one  part,  and  bo  produced  less  hical  irritation.  Mure  fn-qneutly.  htur- 
aver,  the  crushed  sloue  pniduccd  much  greater  irritalton  than  ibe  unhmken 
one.  In  this  respect,  bowovor,  much  depended  upon  tbe  care  that  was  taken 
after  the  operation.    If  the  patient  was  kept  lying  on  Ua  back,  if  diluents 


i 


d 


THE    OPERATION    AT    ONB    aiTTlNO. 


I  froclr  f^iveri,  niitl  ojiiiUtffliLiKl  bellatluiina  rectal  iiijectiont^  uttt^i,  the  irri- 
Qn  J'n>m  tliU  Hource  was  niateriully  Itflneiied.  Itut  If  (liu  patu^iil  was 
allowed  tu  walk,  abmit,  ati<l  tn  pai^  iiriiiu  HUmiliii)^  up  ur  Ic^uing  furwarda, 
Slime  ut*  till!  fraf^nieiits  miglit  be  driven  iiiLo  the  ii^ck  ol*tIie  bladder,  ur  eveo 
the  deeper  part  of  the  urellira,  protliK-iiiK  the  miiat  inteusie  and  painful 
strangury.  When  this  unfortunate  accident  occurred,  the  patient  passed 
urine  every  half-hour  or  oftener,  Bfjiieezing  out  a  few  drorw.  writhing,  and 
perhaps  screaming  with  the  agony  he  sufternl,  a«  the  vesical  neick  contracted 
on  the  rugged  fragments :  \m  pulse  became  quick,  his  skin  hot  and  perspir- 
ing his  tongue  dry,  the  urine  scnntv,  high-colored,  and  perhaps  more  irritat- 
ing ;  and  unless  relief  were  speedily  given,  ncrvona  exhaustion  set  in,  and 
death  ensued.  Iti  euch  unfavorablo  circumstances  no  time  was  to  be  lost. 
The  patient  had  to  be  anresthetizcd,  the  bladder  injected  with  weak  bella- 
donna-solution, the  Itthotrity-acoop  introilufcd,  the  fragcncntd  broken  up  as 
completely  ns  po^ihle,  and  detritus  laktn  away  or  washed  out.  No  nioanfl 
other  than  tliis  or  lithoioiny,  would  iiiive  the  fntient. 

Lithotrity  lubsequently  to  1878. — Lithotrity,  a«  practised  by  the  beat 
marten)  of  the  art,  had  gradually  been  improved  in  simplicity  and  in  safety 
since  the  days  of  Civiale.  It  had  been  applieri  iu  various  conditions  of 
xliiDB,  of  pnjstate,  and  of  bladder,  to  which  it  had  not  previously  been 
thought  applicable;  and  thus  many  cases  had  Iweu  brought  under  the  in- 
fluence of  this  operation,  for  which  lithotomy  had  heretofore  been  the  only 
remedy. 

The  principlea  on  which  it  was  formerly  conducted,  and  to  which  It  owed 
its  Bucceas.  were  those  of  extreme  care  and  gentleuese  in  the  employment  of 
the  Ittbotrite,  brevity  in  the  sittings,  and  care  (but  the  bladder  and  urethra 
be  not  injured  by  the  iustruincDt^.  or  irritated  by  the  fragments  of  stone. 
The  grt'Bl  p^incipIl^  that  guidud  tithotritiwis  was  the  avoidance  of  tlio  pro- 
louged  use  of  in»lruHient»  iu  the  hluxlder.  Pn^longcd  iogtrumontatiua  was 
looked  upon  m  one  of  thn  chief  dungcm  in  the  opiTUtiou,  aa  nccaaioning 
cystitis  at  tho  time,  and  Iiwling  to  irritubility  and  atony  of  the  bladder  aub- 
eequently.  ThuBnrgeim  wan  cnpfrially  enjoined  not  to  allow  a  longer  tim4 
than  fr<nn  two  to  four  minutea  fur  eiicK  titling;  to  break  up  l\w.  BtonH  in 
the  first  instance;  to  pulvprine  itatHubi!B({ueutsitliugu:  to  allow  the  delritug 
to  cecaiie  during  ihe  act  of  micturition  ;  and  not  even  to  UBsiet  ilx  removal 
by  waiiniug  out  the  bladder,  or  at  leat!t  to  be  very  careful  in  doing  thie,  usins 
Clover'a  lutpirator  for  the  purpose.  It  is  tru(>  that  occaMionully  a  sinutl  ctil- 
culu^  wuH  broken  up,  pulverizcl.  and  rE>mitve<l  at  one  billing;  but  iu  thn  vast 
majority  of  cascfl  i*cveral  sittings  were  re^piired,  often  as  many  as  five  or  six. 
These  were  n^peated  at  intervalx  of  from  four  to  six  days. 

This  slate  of  thitip'.  'he  details  of  wliich  have  hec.n  described  in  the  pre- 
ceding page0,  continued  up  tn  the  year  187S,  when  a  complete  change  came 
over  the  prnclice  of  lithotrity.  For  iu  that  year  Bigelow,  of  Iloiston,  UAA., 
published  under  the  title  of  "  Litholapaxy,"  or  '*  Uapid  Lithotrity  with 
Kvacuation,"  a  method  of  operating,  by  which  calculi — of  larger  size  than 
bad  previously  been  subjected  to  this  operation — couM  he  broken  up  and 
safely  removed  at  one  sitting,  often  of  a  very  prolonged  character. 

The  esM^ntial  priuciplc  of  Rigelow's  operation  consists  iu  this,  that  danger 
does  not  arise  so  nuicb  from  the  prolonged  use  of  instruments,  as  from  the 
irritatioti  produced  by  fragmeuts  lefl  iu  the  bladder.  "  It  in  probable,"  he 
«ays,  "  that  injury  from  the  u^e  of  iustrumeuts  has  been  confuunded  with  that 
resultiug  from  the  preeence  of  fracTnents  in  the  bladder."  Bigeluw  uot  only 
entirely  discarded,  out  acted  iu  direct  oppoailiuu  to  the  principles  laid  dowu 
by  all  previi>us  lithotritists.  Hu  used  heavy  and  largo  iaslruiueute.  He 
broke  up  the  stone  sq  thoroughly — oommiuuted,  but  did  not  pulverize  it — by 


BIGKI.OW  5    OPEKATIOX    ANT)    IXSTItrMBNTS. 


!)«7 


For  the  [Hirposcs  of  his  niieratiun,  Bigtiow  has  iiKHlitietl  the  olJorlilhotrite 
ED*)  (hi;  vvHi-uatiti;^  cntiu-teiii.  Hrni  has  iuvt;iit<?il  aspirHtors  <•!'  variouM  kinJs. 

The  iHJCuliarities  uf  tiia  litholriU;  are  a»  f'lllowe.  It  is  larger,  lienvwr,  and 
altogether  more  powerful  than  any  jirevimiBly  in  Ufv.  The  liatKiles  are  large 
and  niMBive,  anil  oval  in  form  to  Ht  the  Iihik].  Tlie  blailes  are  souicnhat 
loDger,  and  the  female  blntle  has  u  Inn ^  bluiite<)  poiut,  curved  touartl»tbe 
floor  of  the  urethra,  sq  as  In  protect  tlie  meiiibranouB  part,  ngalnift  the  roof 
of  which  the  ptiiot  of  the  inRtnimeut  h  directetl  as  it  pssses  thruugh.  These 
inasive  instruments  are  ui-ed  only  for  breaking  up  a  large  etone.  The  fras- 
ineiitB  are  (.'riiehcd  by  smaller  iniitruniente.  more  lilie  tho«e  already  described. 
Before  climeing  the  iiielrunient.  whether  the  lithotrite  ur  the  evacnatiog 
cstheccr,  Bigelnw  ciirciully  niensum!  the  urethra.  The  bIzc  of  the  catheter 
he  generally  uBce  \»  ^0  Frent-h  (18  Knglith),  but  stnallcr  aizoa  arc  oUcn 
oecfMRiiry.  In  Hij^Oow'a  inctluKl  of  operating,  the  stone  is  seized  and  broken 
up  in  the  way  already  ilfgrrilK-ii.  \\  hen  from  ihe  size  of  the  fragmenta  it 
u  evident  thai  the  eione  in  fairly  broken  into  aevcral  pieces,  the  large  fene- 
8trate<l  iitstninK'nt  ia  withdrawn,  and  a  smaller  Instruiricnt  passed  in  ila 
place.  When  the  stone  is  thoroughly  broken  up,  the  evacuating  r-aiheter  m 
paised.  Th«ie  I'athrtera  are  nf  various  forms  and  sizes,  with  n  large  eye 
Mtuated  in  the  coneave  !)ide  of  the  instrunn-nt,  ch^e  to  iln  (^xlrt-mity.  In 
•ome  raiwD  Bigelow  employs  a  straight  instrument.  The  inetrumi-nt  should 
be  of  the  largest  Kize  that  the  urethra  will  safely  admit,  and  must  be  passed 


: 

■  Blgelnar'a  Cfttbalera,  full  <ti*. 

I  nc.SSfr.— BigcJai*'!  !!lraiKht  CitchtUr.  Pig.  8Wt.— ni|{«law'«  Curve<l  CmlivWr, 

^^L  carefully  with  sti'ady  pressure,  but  no  undue  force.  It  is  better  to  use  a 
^^fnBBllcr  sixe  than  to  run  t.he  rmk  of  injuring  the  urcthrn  by  aiccmpting  to 
force  in  a  larger  instrument  than  it  can  saiely  take.  If  the  ohtttruetion  is 
al  the  oriHce,  thi»  must  hi!  ilivided  with  a  probe-pointed  bistourj*  or  a  urethro- 
tome. The  catheter  having  been  |mr<»od,  and  the  bladder  ciuptied  through 
It,  the  "evacual'ir"  is  applied  to  it.  Nuniorous  furnisof  erocuator  have  been 
invent<'il  Hint-o  If*"?*,  but  they  arc  all  foundeil  on  the  same  principle  aa 
CloverV  apparatus — viz..  s  t^trong  India-rubber  bottle,  which  can  lie  eniptie4 
into  (be  bladder  by  Bipieezing.  and  which  is  of  sufficient  atrenglh  to  expand 
forcibly,  and  empty  the  bladder  again,  the  moment  the  prvs^ure  uf  the  hand 
is  removed.  Otis  has  lately  invrntnl  an  extif-mely  compact  and  handy 
evacuntor,  of  which  a  drawing  ib  given  in  Fig.  897.  Attached  to  the  evacu- 
atnr  in  situations  varying  in  difTcrent  imttrunicntt*  iii  a  glsuw  receiver,  into 
which  the  fragments  may  fall  bj-  gravitaltoD.     It  is  essential  that  the  India- 


968 


DEIXARV    CALCDLUS    AND   LITHOTRITT. 


r 


rubber  bulb  must  be  of  stifiitnent  strcDgtb.  Otborwiu  the  reguf^itHOt 
Btream  wit)  dol  be  guflidciitly  forcible  to  withdraw  anv  but  the  smallest 
iragmeulg  from  the  bladder.  The  Huitl  in  tba  bottle  nhoulcl  alway*)  cnaiaiD 
some  niuiseptic;  buracic  acid,  or  iML'nimn^aDnle  of  potash,  are  ncrhape  the 
heat.  The  evat'uat'jr,  prcviougly  filled,  haviDg  bfcn  attached  to  tne  catheter, 
bj  alterDAtely  compressing  and  relaxing  the  rutjltcr  bulb  i>f  the  inftrumeot 
llio  bladder  ia  filled  and  emptied.    At  each  injcctii>n  the  fr:\;;nieiiU  are  thrown 

up.  At  each  relaxalion  of  the  l)uth.»itine 
aresuclc*^!  nul  in  tlienifh  of  water.  Tb<«e 
drop  into  th«  gla«8  receiver,  where  tbejr 
can  l>e  t^reo  by  the  l?ur|>coD,  wbo  thus 
judges  of  the  progreaa  be  it  making.  This 
proccM  ia  continued  until  all  fmgniruts 
are  evacunied.  Should  Bome  l»ive  been 
led  behind,  too  large  to  paw  tlirough  the 
evacuating  callieter,  the  litiiolrite  wust 
again  he  iuLn>duccd,  and  these  bmken  up 
sulliuieutly  fur  cvacuuiioii.  wbii:h  mtiift 
then  be  resumed  and  iHinlinued  until  tlie 
bladder  ie  foiiptiitii  of  all  calculus.  The 
Surgeou  kiiouu  when  fragmenla  are  left 
behind  tiio  lar^^e  to  pant,  by  their  falling 
agaiuHl  the  eye  of  the  rslh«!ter,  hlw.king 
it,  and  lliu8|)n;venLing  the  return  of  water 
into  the  bulb  of  the  evacnalnr,  na  ehowo 
bv  ila  fulling  to  expanil.  This  may  nrue 
aiai)  from  the  eye  of  the  inalrument  hav- 
ing cotne  in  contact  with  the  wall  of  the 
bladder.or  from  the  catheter  having  been 
accidentally  withdrawn  till  its  end  lies  in  the  prostatic  urethra.  Before  con- 
cluding that  the  obstruction  ia  due  to  a  fraenient,  theiie  two  conditiuna  muat 
be  eicTuded,  by  puahing  ihc  catheter  a  little  further  in  and  rotating  it.  A 
more  certain  »ign  of  a  j'ragment  ia  a  loud  and  diadnct  click  every  Umo  the 
bulb  i«  allowed  to  expand. 

The  remo%-al  of  everv  fragment  ia  the  e«ence  of  the  operation.  Xo  ?tona 
muat  be  lefl  behind.  The  operation  must  be  concluded  at  one  aiuiDj;,  how- 
ever prolonged.  In  thii4  way  stones  of  large  size,  or  ma»eB  of  mullipla 
calculi,  may  be  broken  up  and  removed  without  reference  to  the  slate  of  the 
bladder  or  the  proelate;  for  it  ia  perfectly  nnplicAble  in  casu  of  aubacute 
cyatitia,  of  atony  of  the  bladder,  and  enlarged  prostate- 

That  this  operutioD  connlitutes  au  immense  and  moat  inii>ortant  advanoo 
ia  litbt'Lrity  is  undoubted,  and  its  universal  adoption  by  litbutritists  is  th« 
best  evidence  of  il£  utility.  It  makes  lithotrity  applicable  to  numerous  eases 
vhicb  under  the  older  and  more  slowly  comtuct«l  system  wen  not  adapted 
to  and  could  not  bo  aofuly  treated  bv  it. 

Sir  Henry  Th<impeiin.  who  lias  largely  and  imwt  successfully  practised 
"lithotrity  at  a  aiuglb  (fitting,"  has  loade  neveral  ini|>i>rtant  mcHliiications  in 
£igeIow's  meth<Kl  uf  procedure.  Ue  neither  usea  llie  large  and  heavy  lilho- 
trile  nor  evaeuntiug  catheters  of  so  large  a  xize  as  th<«e  r«<:M>mmeaded  bv  the 
American  Hurgeou.  The  Ittbotrite  be  uses  is  that  with  the  cyltD<iricaI 
handle  which  he  invented  many  years  ago,  and  hta  cBlbeters  are  not,  ma  A 
rule,  larger  timn  ^m.  15  to  16,  Knglieb  scale,  ilia  evacuator  also  is  of  ft 
Boaewhut  different  etinalructioij  (Fijpt.  8i)S,  899*. 

The  longest  time  that  Sir  Henry  Tlii>m{«on  hna  occupied  in  an  operation 
at  a  single  sitting  has  been  70  minutes.    This  wan  in  the  caeeuf  un  unusually 


FIf ■  SOT.— Otii'i  Hvwulor. 


I 


« 


4 

I 


AOCIDEHTS   IN    LITUOTKITY. 


968 


oric  aciti  calculus  wt-ighinff  21  ounces.    In  the  perfornmnceorpnjlouj.'ed 
fcUon  Ht  a  sincle  sininji.  he  onjoios  tbe  very  iiuporluut  tiiutiou  tbut  Uie 
tient'a  lowrr  exlreniities  should  be  eucased  in  loup  wmilloo  stDckiogs,  and 
apecial  care  b«  taken  to  preveat  his  getting  chilled  by  exposure. 


K»riy  Bvuaator. 


FIf.  8M. — Sir  H.  TbonpMn'i  lid|mr*d 
BvkciMUir. 


T.fm  13*  LrrnoTRiTT. — tn  coiiaiderini;  the  accident*  in  litholrity,  I 

oat  of  conniileralixn  tlK«e  that  may  ariw  I'mra  the  i^urfje^in  ■cttDj!  care» 

Ir.  or  with  impix>|wr  foro^,  ami  ihiwoccaMonioii!  Iaceniti*in  ofihv  urethra, 

injary  to  the  coate  uf  th«  blndJcr:  bo  also  accideot*  (K:curriug  Intm  thu 

~  *  Bg  or  brenkiug  uf  tbe  iuEtruiuciita  will  icarcely  hapjM-ti,  if  thotc  have 

feMB  properly  tested  on  a  piece  of  Baudetooe  grit  before  bciii);  ciiipluyed  io 

the  bladder. 

Impaction  of  Angular  Fragment!  of  Stone  in  the  Urethra. — ThiK  most 

daflge^)Ul)  and  jiaiuful  nccid-'iii  nu^  nut  uucuuiuiun  in  tin-  uM  ^.y^tum  of 

UthoCrity.     In  modern  iiilinlrity  it  cau  liap{fen  uulv  if  a  Inrvu  fnifrnieut  haa 

beao  acfideDtally,  li:lt  behind  or  if  fnmi  any  cau^  llie  i)|wraljun  has  to  be  left 

^^caniplet«.     If  there  in  any  n-a^on  lo  Iwliive  tlinl  fnig-ments  are  tefl  in  tbe 

^Badder  the  patient  must  he  kept  in  a  rrrtinilM'nt  ]M)utinn,aH  impaction  ntoeit 

^Vmrnonly  arisre  frnni  the  putirnt  nitiviiiL;  about  khi  mnrh  ur  straining  to 

pas  wafer  in  an  upriphi  p«usition.     'Thv-  hidjiimient  of  a  fnijrment  not  only 

occiu>ion>  great  local  irritation,  ending  perhaps  in  cj'Flititt  nr  absceaa,  but  may 

giro  ri»e  to  severe  ripim  and  nervoufl  pnvtration.      The   fragments  are 

Mpedally  apt  to  lodge  in  the  pnistntio  nrethra,  nr  ahmit  the  hnlh,  and  there 

'.T*  riae  to  a  very  grtal  decree  of  irritation,  and  even   i>f  fatal  n>i«ohiot'. 

urinp  print  c>-ii)>lit)tli>>iinl  disturlmoce  of  an  irrilntive  ami  a^ll-i 

CH  th"'  pic<N'*  an-  iinpacte"!  h'W  down  in  ihe  urrthrn,  it  is  :>  > 

ry  t/i  riiiiDve  tln^ni  frini  iho  canal  j\»  speedily  n*  jxiwihli',  U-*i  ii]«;  mn- 

ti'inal  dii>lurbani.x>  ucc«j*tot»d  by  them  prnve  fntal  >>>  the  [uilirnt.     Tlits 

ftiay  Ik'  dfinc  in  various  vays.    M'lst  fretpientlr.  Ihfv  may  l»  pushed  t>8tk 

iiitt>  the  blaiMer.  by  pantng  a  larije  catlietcr  carefully  down  lo  them.    The 

ikKMrt  cuDVeniint  JiiatrunieoL  fjr  Urn  purp<ise  isune  that  la  open  ended,  fto  that 

the  fiKgioeut  may  be  received  iu  the  aperture  at  the  cad  of  the  iottruracnt. 


h     XIB    (>»fJIUVU» 


CRiyxmr    CALCCLDS  AX»  LtTBOTUCT. 

shI  m  pwbcd  OS  bdbre  it    Throng  wtdk  a  c«dhi**r  w  Ckli  t  «M 
water  mjr  bt  iajected.  asd  tfac  fintncM  iJuw  fcrnd  fattdu    tTh«aU  { 
iMMiiiuiiij  flul.  It  faM  b«ca  pwpow  to  cnMb  t^  fiafiiii  in  ik»  vm^ 
vithaiHaUIiihDtnte<Fif.900);  bot  thk  [Hit  ■  ii»wh«  hatinlifn.  mi. 


& 


;nnnnc=*=* 


m  Tvrr  diScdU  to  aruid  pioclittift  ap  iW  cnucoof  mcoit 
tbebiu  oraUioe.     The  safMt  prwnic*  mcbm  to  li«,  x.- 
Uirougli  th«  anthral  iwiltLv,  or   lu  cat  tlwm  uul   tbfvu^  U»« 
Bxtiaetioo  tlir»(ieh  ibr  urtrtbral  orifiw  mav  b«  vflvctad  brdHtw   _ 
901, 902 1,  or  hy  CiTiale '«  toMntaMDt  1  Fig. '934,  toL  I).   8b>mkl  ikat 


Fl(,  Ml^I^nUtml  Ftwiffc 


Ail,  or  §houlil  the  fragment  be  very  deeply 

portidQ  of  llie  uretlira.  sod  ibv  liical  and  coottituiinnal 


Mated,  B8  ID  the  nai 

irrllBltfla 
by  JL  be  •■>  great  a>i  to  threaten  abtoMi  arn  fatAl  ixnaii  bru^r[>^ 

would  be  ID  make  an  inoiuon  dirMlljr  down  upuo  il,auu  ._  :--.jveiLl 


.■C  ^- 


Pif .  »S.— rmtiral  FoTMp*,  with  Allljrmtuf  i*m  A«liM.    Thi 
Jaw  dl  t^a  fAKc^H^Mt. 


•Dwtcvni 


ifae  porioeum  by  A  meilian  operation  of  Hlbotnmr.    If  Meh  an  ofPcnM* 

tbli  be  renuirctl.  the  SurfjeoD  mitfht  piAibly  kvI  diipoced  to  «xttn<)  t^ 
iDcuinti  o  liUle,  aod  cnapty  the  blmlder  i»f  any  rcniainiD>E  dctritoa  by  a^" 
of  a  UN  I" p. 

The  Chronic  Eolargement  of  tbe  Prostata  of  old  pe^ioU  w«.  r.,r!wrir^' 
of  iho  niiMt  serioua  coinpHcatioiu  of  ihc  opemtion  of  II  ■»* 

from  the  difficiiltr  it  cbumnI  iu  the  iiitruduction  uf  ioaa,^,..,  ..■^.  .t.-.  ■.i-v 
oWuiele  it  iitrL'reif  U)  the  expuUitiD  of  the  frftgmeDt*.     But  •■rm  Mtn'^ 
intfoiluriiou  of  the  more  pt-rfwl  evacmiuir*  Dow  In  uw  <  t  '  >       '  pria 
not  eoiHi<l<.T(.'d  by  iitiy  meaua  ou  iuguptrnblt.'  bar  to  lii  m. 

BUiDt  had  Ik-uI)  cru>ht--d,  the  hlud-lcr  <^>uld  be  ■ 
by  Clover's  Bppuratm,  or  by  Sir  P.  Cmmpl-v  ■i*' 

*  %UBtmg  the  air  frum  a  pri>|>«rly  ootuilrurtcil  boUlc,  &iir1  nitij  &^ 


DANaKRS   IN    MTHOTRITY. 


»71 


It!  ihen  attarhiiif:  thb  to  a  catltf^lpr  prcvionnly  inlroduccd,  and  o[»cniit((  the 

sCopctK'k,  when  the  prfwtire  «il"  the  ntmofiphi^ra  drore  the  contcnta  fit'  the 

biftililcr,  urine,  anrl  pnt.  inlo  the  exhausted  hotlle.    Wilh  ihe  iin-t^iil  eviifU- 

■U>r«  miMleratt?  fiilarcctiient  ot  the  prruiiiite  am  srarcely  he  lerni»<l  hd  iiicnn- 

Teoiftit'^.    A»  a  ^rnernt  rule  it  i»  nrilher  neccwary  nnr  dcsimbte  to  turn  the 

blail<>»  itf  (he  Itlhntrite  dnwnwardii,  lenl  the  tliMir  of  the  bladdt^r  be  iDJurcd  ; 

but  when  the  pri»tnlc  i»  ^nlarjietl,  the  «ton?,  if  «inall,  or  ttte  frajimeiilB  After 

the  fir*t  criiithtnK.  tall  into  a  poucli  behind  the  neck  of  the  binihler,  and  it  is 

tbeu  inijHi«»ibIe  to  ^eiie  them  except  by  this  ntantpuvre.     Whro  tbv  blades 

are  nrversed  the  bundle  of  the  lilhutrile  muitt  be  well  deprt^ted  belwt-*n  the 

pntieul'0  thighs,  the  bhid«r»  are  tlieu  gvntly  oiK-neil  and  cinsal  nvrr  the  b«M 

of  tht?  bladder.     U'heu  the  stuuu  is  fleiw<l  the  blades  must  be  carcfuUf 

turne<I  intu  the  ordinary  |M«ili>)n  before  it  is  crushed. 

DAS^.tR--  ix  LmtoTKiTY. — The  pnuciml  dangers  io  lithoirity  nrise  from 
the  etste  of  llie  blniider  and  kidneys.  ^^  faeu  death  folhius  the  o|>emlinn,  ic 
multa,  in  the  great  majority  ufcaees.  frnni  wptie  ituppiimtioQ  of  the  kidney, 
preceded  by  ryitlitis.  Atony  of  tlie  bladder  adds  cH^rtousty  to  the  daugere. 
PjTieniia  a  a  mre  eoiuplieatioii. 

CMitU. — The  iK%nirrenee  of  cystitis  was  formerly  atlribnled  snlcly  tu  the 
BecMtiical  irritatiim  tuwhich  the  blathler  in  eiibjecleil  during  iheuueratioii. 
The  BUircFOH  which  has  nttendwl  Iithotrity  Ht  a  Fiinirle  nitliug  hae,  however, 
detnonstratrd  beyond  a  doubt  that  the  bladiler  ii>  much  mure  tolentnt  of 
mrehauical  irritation  ihaii  wat<  at  one  time  believed.  The  etTect  pr<M)uced 
directly  l>v  the  (>)N-n)tion  h,  in  nixfit  fa<>es.  limited  to  idight  catarrhal  iiillam- 
matiott.  Willi  an  alinndant  aecretion  of  miiriiB  and  some  irritability  of  the 
bladder.  In  the  operation  by  niinieroiis  sitting  this  was  freqnenllr  n^'gni- 
vaied  by  the  presence  of  Inrj^  and  angular  fraRnicnt?.  The  ihictt  niiieua 
Kcreted  under  these  circnnistancos  'u  never  i>erfetily  expelleil.  hut  n  certuiu 
amount  remains  ntlherinff  to  the  nmconj)  incnibrane  of  ihe  htadiler  after 
nieturilion.  This  epeeiJily  iindcrgm's  deconijMipitiiin,  and  (he  ni<«t  potent 
etuse  of  er^itis  is  the  t-itntaet  of  thiit  fuul  mixture  of  nuieu9  amt  urino 
vitbin  the  interior  of  the  btiidder.  When  deeompanttion  Hcl*  in,  the  alka- 
line pTTuluctB  of  the  decom posing  urine  rvuder  the  mucus  thick  and  ropy, 
lad  tills  still  further  adds  to  the  difhculty  of  its  c«>mplete  «xpul»ioi).  Under 
iJieM  circumstances  the  patient  Itecomes  poiaoned  by  the  niMnrptton  of  the 
nttrid  contents  of  the  iutlamed  bladder,  the  teraperalnre  risen.  lh*i  tnnKne 
MComcB  brown,  and  if  not  relieved  the  condition  will  very  likely  terminate 
ia  doatfa,  the  imme<liate  cause  of  the  fatal  result  beinj;,  in  mm|  cnw^.  exten- 
■ioD  of  the  deeuni position  to  the  pelvis  of  the  kidney  and  setline  up  suppu- 
Mtivo  nephritis.  .Such  a  condition  necessarily  oH'ere  an  insuperable  nbsiacle 
to  any  funhor  crushing  oporatiim.  «upp(«ing  any  f tone  Ut  Ire  still  pn«ent, 
and  tlie  only  counso  that  jiives  a  chance  of  life  is  to  perform  median  lith* 
Dtfioir.  by  which  not  only  are  the  fragments  removed,  but  the  bladder  is  elti- 
cienilv  dmineil  of  its  decom|K'!^in;;  eontenta.  The  prevention  of  this  com- 
plication  is  best  accumnlished  hy  the  Uf>e  of  anii»eptio».  There  te  every 
TrmNDD  to  believe  thai  the  putrefaclinn  of  the  urine  is  due  to  the  inin»«luc- 
tj»u  of  an  ctrf^nizcd  ferment  from  without.  This  may  be  earriotl  in  by  the 
iDBirunieuts  or  by  the  water  u«eil  in  wnahinj;  out  the  bla'hier.  The  inHiru- 
mrota  should  therefore  be  oilnl  with  carbolixed  oil  and  washed  in  earlmlio 
lolioa  before  bein^  u»ed,  and  the  water  used  to  vftuth  out  the  blu>li1er  should 
contain  some  antuepite.  There  is,  however,  another  way  in  which  .ItTompn- 
ailion  may  reach  the  bladder.  As  before  atateil  the  nieehniiical  irritalion  of 
the  n|w-ration  setii  up  siome  culurrh  of  the  bladder  and  of  the  urethra  at»o. 
The  thick  mucujt  M-creliil  in  roUMnfuenrv!  of  this  adherer  to  the  mucous 
laeiDbnuM  of  tlie  urclhrn  s»  that  thU  cnual,  instt'fld  of  being  washed  clean 


978 


UUl.VART   CALCULUS    AKD  LITUOTRITT. 


br  Ibe  urioe  at  each  act  of  micturition,  alware  contaioi  a  staiiaaDt  or  par- 
tiallr  etaguuDt  layer  uf  mucus  down  which  decomposition  may  exti^nd  Ui 
the  bladder.  It  b  O'A  »iufficieut  ihereTure  luerel;'  to  cRrbcIize  the  iti^tni- 
nients  and  to  use  aQti^ptie  ti'>lutir>u-)  in  the  evacuator ;  the  ^id  of  the  peoifi 
should  l>6  constantly  covered  with  a  strip  of  lint  soaked  in  Lrlyceriiie  aud 
carbolic  acid.  In  ^pitout'all  precHUtioii^,  however,  (locomposjtioii  will  ot'Wu 
take  place,  aud  Ihcit  the  hludder  umti  ho  washed  out  twice  a  day  with  an 
antiseptic  sulutiun.  The  mcchanicnl  irritatiim  caused  by  so  doing  Ib  of  little 
UDporiaDco  when  coni|Mired  with  tho  danf^ersof  a  aoptic  accumutatiun  in  the 
bladder. 

Atony  of  the  Bladder  is  ona  of  lUc  umet  dan^^rous  c<inditiona  that  can 
occur  iu  litliulriiy.  Ttiis  i^tatc  of  thiii/ii  happeiu  ustiallv  in  old  people,  in 
whom  llic  urinary  or^mng  tuay  ap|)«ar  Ui  bo  lu  a  [HKiuliarly  (juiei  aad  favor- 
abli;  c«)ndition  before  thu  4>pf?rilitin,  the  patient,  buinj;  able  to  hold  bin  urine 
for  eix  or  i-i^ht  liour»,  and  tu  hoar  iho  iujertiou  of  ten  or  twelve  ouuoea  at 
fluid.  In  th<»o  circuniatdn(ri¥.  the  .Sui^on  tihoiild  be  upon  hiA  guurd  ;  for 
the  danjcer  of  thin  condition  ift,  that  the  blaclder  diten  not  possefs  nuHicient 
contrnctiU:  power  to  expel  ilii  contenls.  These  conspquentlr  acrumtilote  in 
the  lower  fundus,  and  irrilnte  the  rniir/)iis  membrane;  and  thus  the  fouoda- 
tiim  may  be  laid  tor  fatal  cyst)ti»,  which  in  these  cases  always  amumes  a  septic 
tytve. 

Tho  niony  of  the  bladder  appenro  to  arise  partly  from  that  natural  want 
of  expulMve  pnwer  which  in  not  nnfrequent  In  old  people,  and  partly  from  a 
kind  of  pHrnlynis  of  the  orjjan,  induced  by  the  contact  of  the  in»truioenl«. 
especially  alter  loii^  killings-  Such  patieuta  usually  die  of  suppurative  ia> 
flammatton  of  the  kidney. 

Atony  (if  the  bladder  ia  not  so  serious  a  complication  in  the  operation  at  a 
single  sitting,  although  it  ueceautatc*  the  cAreful  washing  out  of  the  btiulikr 
for  9»uine  time  ufterwardB  to  prevent  tho  risk  of  a  buptio  accumulation,  la 
the  operation  by  rvpeuted  eittiuge  atony  was  much  moro  eeriuus,  aud  it  wtu) 
essential  ibal  th«  Surgeuu  tthuuid  rid  the  patient  of  the  fragments  ho  cuuld 
not  vxpel  by  woishiug  uut  the  hiaddur;  but  it  wma  usually  safvr  to  get  the 
pnti^■nt  iu  uts  good  a  cundition  aa  puesihle,  and  then  out  him  by  the  luediaQ 
ojwratiun. 

This  1  once  did  in  an  intvre»ting  cusu  under  my  care  at  the  Hospital ;  tho 
]>utieut,  an  old  man,  ha<l  bueu  litliotrized  by  a  ^urgcuD  out  of  doura  a  few 
wcuks  before  admisaion,  but  no  fragmuuta  bad  passed  ;  ou  eouuUiug  him,  I 
found  a  moderate-sized  calculus,  with  what  appeared  to  be  a  large  maea  of 
soil  cnnrretioD.  of  the  nature  of  which  i  wan  not  aware  until  aftvr  its  re- 
moval :  the  patient  having  uoaooaled  the  tact  of  his  having  been  lithotnKed. 
On  cutting  him  in  the  usual  way,  I  removed  a  litbic  acid  calculus  about  as 
large  as  a  pigeon's  egg.  and  a  handful  of  fragnieoid  of  another  calculus  of 
the  eanie  comp'jsition,  wliioh  had  been  crusted  over  and  matted  together  by 
phoitpltatic  dep<i8it.     The  patient  matle  a  very  good  recovery. 

Disease  of  the  Kidneys  is  in  Liihotrity,  as  in  all  other  o)>crations  on  the 
urinary  organs,  the  moei.  common  cau^e  of  danger  and  of  deal  h.     Tho  various 

forms  of  fntal  kidney  dteeaee  have  been  bo  fully  described  iu  Clmpt«.T  LXVIL 

^^L         that  I  mu5t  trei'ar  ihir  rc-iidi_'r  to  it. 

^V  Constitutional  Disturbance. — Very  conaiilembic  constitutional   disturb- 

W  nnce  occasionally  follows  litholriiy.     The  patient  is  seiEcd  with  severe  and 

I  long-continued  rignra,  followed  by  profuse  sweating,  lasting  for  many  hours^ 

I  These  eerioua  symptoma  are  most  apt  to  come  on  after  the  6rst  sitting ;  but 

I  the  experience  of  fiigclow's  method  aeems  to  show  that  they  are  not  much 

I  more  prone  to  occur  after  a  moderately  prolonged  operation  than  at\or  the 

I  short  sittings  formerly  adopted.    They  may  pass  off  quickly,  apparently 


• 


IIKKAL   LITHOTRITT. 


978 


iRtof?  annlngnns  t«>  thofte  nervniiR  phenonirnn  that  nrc  apt  to  follow  the  in- 
acli'in  <if  in!>lniment5  in  strictures,  etc.,  or  thry  mnv  persist  and  oasumo 
oharHcler  alrrnily  Hi'scnbefl  a*  indiCAting  septicicmia  r<r  rtoal  iDtlamuia- 
IMIL  These  •eriou*  c>nnse{|U«nc(?s  are  pepecialljapt  to  hflppen  when  there 
vioua  iliseaw  of  the  kiilti«-v8.  Tnilufd,  there  u  do  cuuilltioa  timt  is 
directly  anlJiponistit:  to  l^e  wicoea*  of  litholrily  than  iutenilitial 
rilis.  When  this  ie  preicnl  to  any  consiilerahlc  «xt«iit,  with  or  without 
I  nlhtimra  iu  thd  urtuc,  ciuttB  of  liih^s  and  hlood,  the  increased  irrita- 
D  iaduced  by  the  o|>eraliou  wilt  alnimt  to  a  certainty  prove  falaL  In 
tker  inatsDoes,  aj^iii,  (he  latal  re»utt  is  more  directly  depeadent  ud  the 
irritation  induced  by  the  oji«ni(i»D  leadiuf*  to  the  t'ormaUou  of  nbscen  id 
the  neighborhood  of  the  prostate,  or  around  the  ucck  of  the  bladtler ;  and 
in  other  iiisiannv.  again,  ou  the  Buperveation  of  unhealthy  snppuraliun  in 
•ome  of  the  BArculi  that  are  occaaiooally  met  with  in  ihiH  or^iin. 

The  TVrartfiF'ii/ of  this  atate  of  things  Bhouhi  consist  in  the  free  adnitni»- 
tion  of  siimulfluts — hmndy,  ammoata,  and  ether — followed  by  a  fwll  do§o 
cf  opium,  an<i  abundant  warm  diluenle.  If  the  bladdtir  contmos  foul  urine, 
this  must  Ik  rt^nx^ved  by  washing;  out  nith  antiseptic  eolutions.  Ke|H-cial 
eare  must  bo  taken  in  Lhwe  cnacs  in  which  any  sLone  rvmaiDS  Dot  Co  ro[H.-at 
tbe  silling  for  at  lendl.  n  week  or  ten  days  afier  the  rigors  have  poMcd  oft'. 

pHRiNKAi.  LiTiioTiiiTY. — After*  8toue  has  been  broken  up  but  not  c<'>m- 

'pletHy  removed  at  one  »ittin<r,  it  oecAsionally  happens  that  the  fVagments 

Mcnmc  a  source  of  so  much  irritation  that  the  enianiog  operation  has  to  be 

lban<ioned,  and  litholomv  is  required  in  order  to  relicTfl  the  patient     Again. 

during  ibe  operation  nf  lithotomy,  the  <ijM'ruior  may  meet  with  so  large  a 

Rtone,  that  he  ennont  extract  it  with  Mfely,  and  he  then  breaks  it  up  in  order 

lo  remove  it  in  a  fragmentrtry  manner,  or  the  stone  may  he  so  sotY  that  it 

erumblen  under  the  pressure  of  iIil-  riircegM.     The^c  circumst&DCca,  familiar 

to  all    lilhotoniinti'.  have  led  various  Surjteons  to  recommend,  aa  a  formal 

p^ratiMn.  the  hreakinj;  up  ut'  <nlcuji  before  extraction,  in  order  that  the 

ovfti  of  tile  limkcu  HtL>ne  might  be  tOccted  through  a  smaller  incision  than 

Id  tM>  r<'>(oired  f^r  its  extmction  if  entire.     Without  going  b»ck  to  the 

U  ot  ancient  or  even  me4li:cval  .nurgery  for  illicit  rations  of  this  ii|>enitiiin, 

iulBces  to  aay  that  in  modern  times  auch  a  procedure  has  be«n  advocated 

toaoy  dbtiuguiahed  f^urgeom!,  morb  especiaUy  by  Malgnigne,  under  the 

of '"  Lithotriptic  Lithotomy." 

Dulbeau  has  reduced  to  a  formal  operation,  which  he  baa  described  as 

Perineal  Lithotrittf."  iboec  procedures  which  wer«  formerly  uadertaken 

itiiout  any  very  deHnite  rules. 

The  operatiou  itself  is  tixtramely  simplo.  It  confiisti  of  four  stages:  1. 
Tbe  making  of  au  iucisioa  in  the  uie<liuu  line  into  the  membranous  [Mirtioo 
of  the  urethra  im  a  en>oved  ntutV;  1.  The  »hnr  mid  gradual  dilauuiuo  of  tJie 
■k  of  tilt  hiiiddcr  by  mi".ni!t  ol'a  ^ix-l^lrtde<l '"ililutor;"  S.  Theinlniduction 
rough  the  dilale<l  neck  of  ihc  bladder  t)r  the  "  lithoclasi,"  a  [xiwerful 
fi>r  iH'ixin^  and  breaking  up  the  ftone ;  und  thu  extraction  of  the 
ents  and  pulverized  slnne  by  meiinii  of  email  forct-|M  und  the  socMip. 
t.  Dot  beau  gives  very  minute  dirrctiond  for  the  proper  performance  of 
e  Ttirirms  stages  of  tbe  operation.  They  resolve  thi'iuaelvrs  into  the  simple 
rnlm  nf  a  modcmle  external  incision,  very  slow  and  methodical  dilatation  of 
I  pnntalic  urethra  and  vesical  neck,  and  cnmptcte  "  fragmentation  "  of  llie 
cuius. 

Fnini  oar  knowleidge  of  what  happens  when  a  atone  is  accidentally  broken 
the  cru*h  of  the  forceps  during  an  ordinary  lithotomy  operation,  we 
outd  not  entertain  verj'  Mngutue  views  of  the  results  of  the  same  procetlurc 
tuQ  purposely  performed.    The  delay  in  extracting  the  broken  fragments 


.th 


074 


URINARY   UALCULtJS   AND   blTHOTRITT. 


!■  great — Ihc  bla-lder  emptied  of  its  urine  coatracta  upon  and  is  irritated 
thorn,  imtl  Uie  uucertainty  ai]<i  difficulty  u(  clearing  away  all  frngmenta  1^ 
Doaau^  <if  lurvepti,  i^odi),  and  injei'tiuu^,  are  very  couardenilile;.  Ttie  mi'ddeot 
is  ouv  ibul  ia  justly  areaded  aud  gimixled  agaiusl  as  t'ur  ae  possible  by  the 
prutniml  litUotiimiat. 

JicBuUa. — Tlic  results  of  perineal  litbotnty  do  not  appear  hitherto  to  have 
been  either  very  brilliuut  or  cvtm  aatiflfnetorv.  In  thirty  ti]>cratiou8  there 
were  five  deaths,  which,  cjtnsideriiig  that  at  feast  four  nf  the  paiicou  nrere 
under  twentv  yeani  of  n^e,  ia  fully  om  high  at,  if  unt  higher,  than  what  occurs 
in  lateral  litliot<:)my,  aud  fur  excocde  that  remilting  from  lithotriiy. 


-rT' 


-/ 


7\g.  1103.— P«rtitHl  Mtbotriij.     Inlroiliictira  of  DIUtar  (Dolbwn). 

AppiicabitHif.- — Whpu  we  compare  perineal  Htliotritr  with  ordinary  Hthot* 
rity,  or  lithotomy,  wliether  lateral  or  median,  it  presento  poHitive  disadvao- 
tages  iu  many  cases,  uo  advantage  in  others,  and  appears  to  be  appUcabla 
ouir  to  a  fw  exceptional  juafanceB. 

Iu  cs*in  of  email  or  medium-aixed  calculi,  the  reeultn  of  onlinary  tithotrity 
are  intinitely  moreBatisfact'iry  ;  and  no  object  can  be  gained  by  complicating 
this  "fperalion  with  an  incision  into  (he  urethra.  For  opdioary  caieuli,  too 
large  f;)r  lithotrity,  the  lateral  and  aupra-pubic  operations  offer  fully  ad 
succwaful,  if  not  more  succesBful,  results,  than  tho»e  which  have  been  ob- 
tained by  perineal  lithotrity  ;  and  very  few  Surgeons  would,  when  once  ihey 
had  seized  the  atone,  trouble  Ihemaelvea  to  breeJc  it  tip  before  extraciioK  K 
or  subject  their  patient  to  the  delay  in  the  operation  that  always  occurs,  even 
when  the  eloue  is  accidentally  broken  after  scinure — a  delay  occasioned  by 
the  prolouged  manipulHtion!>  which  then  become  ueceesary,  and  which  an 
not  without  their  own  special  ilangera. 

The  only  cases,  indeed,  in  which  I  cnu  otmccivc  that  perineal  Lithotrity 


4 


J 


rmOTOMT   AND  I.ITHOTKITT  OOUPJIRKU — STATiaTICS. 

would  Im-  (hIujUchI  hy  n  Siirpcini.are  thoBc  in  wliioh  he  li«»  to  do  with  n  very 
r,  %(ifl,  pl)r«phntir  ralriiliiit.     As  such  a  Mone  almwt  ineritiibljr  crumbles 
rn  wht^n  wiKfd  hct'oiv  fxtrartion,  it  might  ]Hi««ibly  be  no  well  to  convert 
It  step  €if  &  n'gutar  operation  that  occurrence  which  would  ntberwiae 
ipni  tm  an  acridrnt  in  ordinnry  lilbntomy.     8hr>uid  it  become  necc»^ary, 
>r  ordinary  lUbolrity,  to  cut  A  patient  for  the  npeedy  extraction  nl'  the 
%cM»,  Dijlhean'n  method  of  dilating  the  neck  of  the  bladder,  and  his 
ill  fiircep*,  mif;ht  be  found  useAil. 


roarARisox  BHTWEES  LiTnoTosfY  AXD  i.rmomitrT. 

TJlhotoniT  and  lilfaotrity  differ  io  entirely  from  one  another  iu  priuciplfl 
sod  detail,  uiat  it  in  usck«ti  u>  attempt  to  cstiiblith  a  c<inif>arison  beLnecii  the 
diHcrt'nt  Hc\^  of  tbv^v  mo  i)i>eration^.  It  L",  liowever,  n  <juesiion  of  the  very 
fint  iuip-jrtau(v  autl  inturost  tu  ajR-erlain  by  which  o|»eraiion  a  patient  can 
nicnt  isfcly  have  a  calcului*  removed  from  hia  bladder.  In  determining  Lhia 
jjaaint,  it  is  neceiMary  not  only  to  make  a  comparison  between  the  general 
BiuIlB  of  CA6C*  that  have  been  Bubjoctcd  to  the  two  procedures,  but  more 
Vpecially  to  ajiccrtain  tboee  clrcumMancfs  that  influence  tlie  rcdutt  of  each 
operttlion  in  {•articular  cnftra — to  determine,  in  fact,  in  what  caacfi  lithotomy, 
mod  in  what  litbotritv.  holda  out  the  best  prospect  to  the  patient.  It  in.  I 
think,  in  the  highest  clegree  unpracticnl  to  i>ntcr  into  a  discuMion  ra  to  which 
■hould  bo  the  general  motbo^l  of  treatment  in  cak9  of  stone.  That  8urgeoa 
sfaowfi  hi«  practical  »kilt  the  bcDt,  who  choo«e«  which  operation  ia  nioet  appro- 
priate to  llie  particular  ca»e  lielore  biiii,  and  who  knows  be*t  huw  to  apply 
the  o[ieri)tion  I  hat  be  selects  ni<j»t  nittelj.  l^ith  operations  have  been  reduced 
In  l^rvat  ^implicily  and  certainty  ;  but,  neither  tihould  be  exclusively  prne- 
tieetl.  It  19  utuloubledly  the  duly  of  tlie  Surg«<in  to  make  liim^elf  familiar 
tlith  the  ]iracti<.'v  of  bulb,  Hud  to  adopt  ibnt  one  which  promtata  best  in  the 

erlicular  instance  with  nbicli  he  has  (<>  do.  In  all  cat<e8  iu  which  it  w 
Icticttble,  and  iu  all  cases,  even,  in  whicb  tlie  chantvs  of  the  two  uperatiooa 
)  evenly  Italanceil.  lilfaotrity  shuuld.  as  a  matter  uf  bumauily,  Iib  preferred 
U)  lithotomy.  Trobahly  about  four-lifUis  of  all  caeca  of  ttlone  o<M:urnDg  in 
the  adult  arc  proper  for  litbotriiy,  and  the  pro|>urtiuu  would  be  much 
grvtkter  if  the  paltenie  applied  earlier  fur  relief,  or  if,  instead  of  being  sub- 
jectc»i  to  mwlical  Ireatment.  they  were  at  once  put  under  proper  Kurgical 
core,  and  the  stone  detected. 

tyrATlBTH*.— The  PtiKistiLs  ninnot  represent  tlie  iruo  state  of  the  question 
ao  fiir  as  a  general  {yimjiarison  Iwiween  tlio  0[HT«liona  is  concerned.  For  it 
nmt  be  home  in  mind  that  tha^e  canv  thut  arc  litholriscd  have  invan'obly 
been  picked:  wliil^t  lithotomy  ban  been  |M>rfornH'tl  on  almoi^t  nil  patienti 
mdncriminalely  ni  ihoy  have  presented  themaelves.  Kor  litbotriiy  lo  ba 
sarcCMfully  dime,  it  \a  nfcca^ary  ibat  the  stone  be  of  moderate  size,  and  that 
tliB  urinary  organa  be  in  u  bcntlhy  fttnte  and  free  fnim  irritation  ;  and  this  U 
^e  stale  iu  which  mittft  of  the  caaca  have  l>ef'n,  in  which  cni^hin^  ha«  bMU 
^■l«.  In  lithotomy  caM't,  OD  the  other  hand,  the  Surgeon  boa  had  Co  con- 
Vflfl  with  all  the  difficuilin  of  large  or  multiple  cak-ult,  diseased  bladder*, 
and  Ind  constitutions.  Hence,  in  com]mrtng  the  »tnlwlic»  of  the  re»nlt«  of 
itthotrity  with  ibose  of  litholomy,  we  com|iarr  tlie  statislic*  of  tbu  nsulla  of 
operationa  (ivrliirmed  under  the  mml  fa%'ttrablo  circumstances  on  a  series  of 
•eleetetl  com-*,  uitli  those  of  ca»e*  taken  iDdiscrirainatelj  and  often  prewul- 
iug  niiwl  iiiifavornble  conditions, 

in  Sir  III  ury  Tbniiipiion  bn>  n-'-  ■■■  '     '    >ote<I  out  in  his  ft'lmimble  c^iirae 

;leclureji,  delivere<l  At  the  Uova.  <  I  ^urgeiin»,  the  only  rni'lhiKl  hy 

.  wa  uan  oaverlain  the  elTccl  uf  liiht>thty  ia  nxlucintf  Ui«  mortality  from 


976 


URISABY   CALCULCS   AKD    LITHOTRITT. 


atone  !□  the  bladder,  in  to  contract  the  resnlti;  obtnJned,  when  lithotomy  wa« 
tliK  «ile  operation  practispd,  with  those  of  thn  present  day,  wht-u  lithntrity 
h*»  become  the  rnip  ami  the  cnttinp;  operation  the  exi-eplioii.  For  tiii«  pur- 
pose he  contrasts  tU«  statistics  of  three  periods:  first,  when  lithotomy  ouly 
ifM  perfortned  ;  secondly,  the  transitional  perirxl  iVorn  18:io  to  U;twe«n  1860 
nud  laiO,  when  nhout  an  etjual  number  ol'  aufeit  wvrv  liubiuitted  (o  eaoh 
operatiou ;  and.  lastly,  the  uiudvru  period,  wbeu  lilhotumy  baij  \kvu  tbe 
exouptiou.  For  the  hrat  [Ksriixl  h«  eel«cl«  the  MatisUcs  of  tbv  Norwich  Hos- 
pit4il  I'rom  177U  U)  1830,  a«  published  by  Croue.  During  that  time  7(U 
patieute  of  nil  aK«8  were  uperatod  ou  tor  nloLe;  of  tbtw,  'So  were  fuuiales,  uf 
whom  2  dt«d  ;  i^-t:i  were  niale«  uudcr  20,  of  whom  i!7,  or  8  p«r  cent.,  died. 
The  remaiuiug  3^B  were  adult  malvt),  aud  of  thuH<  64  died,  or  20  [wr  cenL 
or  th«  adult  luales,  7o  w«re  over  tiO,  and  of  these  2'i,  or  2d.3  \iet  cvnU, 
died.  These  correspond  very  closely  to  the  larger  Btatistica  collectMl  by 
Thompson,  iucliidiD);  1827  lithotomies.  Of  these  1028  were  on  patient^ 
from  1  year  of  ago  to  l(j  luclui^ive  ;  of  thcso  68  died,  or  6.8  per  cent. ;  -b-S 
between  17  and  d8,  nich  86  deaths,  or  16  per  cent. ;  and  271  between  59  and 
81,  witli  75  deaths,  ur  27.7per  cent. 

For  the  seoond  period  Tliom|>H<)i]  gives  the  etatisticB  of  Keith,  of  Aber- 
deen, and  Sir  William  Ferf^uHson.  Keith  operated  upon  ^04  cases  nf  all 
ages ;  4  were  feniuleit,  none  of  whom  died  ;  23  were  children ;  19  were  sub- 
mitte<l  to  lithotomy,  and  4  to  lUhotrtty,  with  1  death.  The  remaining  277 
were  male  adulla;  uf  these  161  were  cut,  with  38  deaths,  or  24  per  cf'nt.; 
116  were  submitteil  to  llthntrity,  with  7  deaths,  or  6  per  cent.  The  total 
death-rate  amongst  male  adiilte  was.  therefore,  1  in  6),  or  15  per  cent.  F«r- 
gii»ton'3  caaea  amounted  to  271,  imduding  52  children,  all  cut,  with  2  dcatbf, 
or  4  per  cenL  The  remaining  219  were  male  odutta;  of  these  110  wen 
cut,  with  33  deaths,  or  iJO  per  cent. ;  atid  109  crushed,  with  12  deaths,  or 
11  Mr  cent- ;  the  combined  death-rate  for  the  210  caaea  being  2n  per  ceut. 

For  tlic  third  period  Sir  Ilcnrj-  Thompson  givca  his  own  ronulta,  althou^ 
possibly  the  earlier  ca^es  might  be  more  properly  included  in  the  int^riae- 
dinto  pcri'K).  The  proportion  of  lithotomies  iu  his  practice  haa  ateadily 
diminished.  Of  hia  first  2011  coaca,  48  were  cut;  white  since  1878.  of  211 
cad(«,  he  has  cut  only  15 ;  and,  of  the  last  125,  only  4  were  submitted  to 
lithotomy.  Sir  Ueury  Thompson's  caaes,  being  derived  chiefly  from  private 
practice,  show  but  a  amall  pmportion  of  children,  15  in  all,  of  whom  12 
were  cut,  with  1  death,  anJ  3  successfully  crushe<l ;  13  were  females,  of 
whom  10  were  cut,  with  1  death,  and  in  3  lithotrity  was  perfurmed.  £z> 
eluding  these,  there  remain  782  adult  males.  Of  these  UO  were  cut,  with 
39  deaths,  or  3^j  per  ceut. ;  672  were  treated  by  lithotrity.  with  43  deaths,  or 
6,5  per  cent.,  or  1  in  154  ;  making  a  total  of  782  cases,  with  82  deulh^K,  1  iu 
9J,  or  10*  per  cent.  No  le«  than  595  of  these  palienU  were  over  50  years 
of  age.  The  number  of  iudLviduaJH  upon  whom  these  operations  were  per- 
formed was  716 ;  61  oases  being  operated  on  a  eeoond  time,  9  a  ihirH,  3 
four  times,  and  2  five  times.  Cbms  of  small  secondary  phuephatic  aocumu- 
lalioos  were  not  included  as  operations.  During  the  last  five  Tftura  Sir 
Uoury  Thompson  ha«  uniformly  adopted  the  operation  by  the  single  sitting, 
and  the  reeuttii  have  been  most  satisfactory.  Of  121  cases  treatod  bj-  this 
method,  only  4  died,  1  in  30,  or  3.3  per  cent. 

The  general  rcatult  of  these  bgures  is  to  show  tliat  when  iitliotoiny  was  the 
sole  mode  of  treatment,  about  1  in  5  of  all  adult  males  o|>enit«d  on  died ; 
that  during  the  iraoeilion  period  the  death-rate  wait  about  1  in  6;  and  that 
since  lithotrity  has  been  more  extoaeively  adopted,  it  has  fallen  to  about  I  in 
91,  and  that  thbt  has  atill  further  been  reduced  by  the  adoption  of  the  opera- 
tion at  one  milling. 


I 

i 
I 


1 


aSLXCTION    or   operation    for   8TOHC. 


977 


ibioa^l 


mnrtality  fmm  liihotritr  in  hoepilal  praolice  has  ububIIv  beeu  higher 

in  privute.     Thus  Mal^'aij^^iie  many  Tears  agu,  before  lithotrky  vu 

'bt  lo  its  pre^'iit  [>erlecti<'i),  estiniateit  the  dfHth-rale  at  1  in  4  in  the 

^teraojui  hospitals,  wliile  lie  CHlcuInlod   thai  of  private  eases  to  be  1  id  8. 

'  Tbift  diflhranoe  betwoco  the  results  of  this  opcniuon  in  boepitnl  and  in  private 
prmctioe  nn  Msilr  be  accounted  for  by  the  difference  iu  tlii;  comtiluiioos  of 

'  the  pftlienta,  and  by  ihcir  applying  for  relief  in  private-  in  a  lew  advaaced 
Ihrni  of  the  disease  than  iu  hoApitai  practice.  We  find  that  the  same  holds 
cpod  with  regord  to  the  results  ot  liihotomy.  Thus,  Coult>cn  states  that 
Dodlcv  \ml  only  1  in  ;Kt  of  the pritaU  paticnU  that  he  cut;  )[«ttaucr,  1  in 
96)  ;  Martincau,  I  id  42 ;  and  Mott.  I  in  50.  These  results,  Mhich  ar«  fully 
■B  fiavorable  aa  the  best  8iati«ticft  of  lithotrity,  niiut,  however,  be  rc^fiinled 
■•  exc«pcional ;  but  ibcy  suffice  to  show  the  luflucnce  which  the  conHiituUun 
of  th<!  patwnt,  and  a  pn>|)er  euleeLioD  of  cases,  may  exerciae  upuu  the  resulta 
of  tliv  cutting  operation. 

Litlxjtrity,  aa  has  alremly  been  stated,  cannot  be  applied  to  all  cases  ot 
Moa«;  in  tiioot  thnt  are  unauited  tn  tins  op«r«tioii,  htliotomy  may  b«  dooe 
with  success.  Id  vome  catcs,  however,  no  uperalion  can  be  practised,  iu  con- 
•MiueDce  nf  eerious  diaease  of  the  genitals,  bladder,  or  kidneys,  or  of  aooM 
TOCenil  mischief  that  would  uecessnrily  Interfere  with  the  Mrformance  of 
any  capital  operadou.  The  necessity  of  teiwlintf  cases  of  fitbutrity  is  oa 
great  as  «ver.  although  the  tield  of  the  operation  baa  been  greatly  enlarged 

LJuftbe  mudero  iiuprnveDients  id  its  performance. 

!^pBEI.Et^los  OK  Oi'KaATioN :  Lithotomy  or  Lithotkity. — The  circum* 

^nncM  that  must  ehiedy  determine  the  Sur^reon  in  the  selecliuu  of  tfas 

6 articular  uperuiion  u>  hi-  performed  are :  1,  tbo  Age  of  the  Puiieut;  2,  the 
tie  *ud  Character  uf  the  Htooe;  and,  3,  the  C«idition  of  the  Urinary 
Organs. 

1.  Age. — The  ape  of  a  patient  isnii  important  element.     Asafii'iiera!  rul«», 

may  be  8tJite<l  that  at  the.  middle  utid  udvuneed  periods  of  lift:  lithotrity 

muel  sucoeMful ;  white,  in  early  ugve  liibotumy  'a  tlie  preferablit  operatiim. 

chiUlreD  under  the  ago  of  puberty,  the  geuito-urtnary  oi^ans  are  unde- 

>pc(l;  the  urethra  is  narrow,  and  the  bladder  small.     These  comlitiona 

onlv  aeeeasilalp  tlie  eniplnynient  of  instruments  sp4>cially  con.<itructed  of 

eed  site,  and  render  great  oare  in  their  manipulation  requisite,  but  the 

wneas  of  the  urethra  is  especially  opt  to  render  the  eipuUion  of  the 

frmfcioents  of  the  crumbed  stone  extremely  difficult,  and  to  favor  their  impac- 

tiua.     If,  in  addition  tn  this,  we  bear  in  mind  the  great  i^enailiveneM  of  the 

btailder  in  youtiK  rhildren.  and  tlieir  reetle«sneM  under  the  repeated  instru- 

BwutAl  iuterfereiK-e  which  may  be  Dec«ssary,  it  can  easily  be  undentood  that 

Ikhotrity  i«  neither  an  e»sy  nor  a  safe  operation  iu  them  unless  the  calcului 

b»  •»  Hiiiall — nut  tarter  than  a  cherry-stotie^that  It  can  l>e  crushed  and 

brought  aMay  by  n  aiugle  iutn»luction  of  the  litliotrite.     Lilhutuniy,  on  the 

Other  baii>l,  ii  m  auceeeaful  au  ij|ii-nitiou  in  cliildrt-n,  that  the  .Su^^l•»u  would 

Sain  uulhing  by  vubstituliug  liihotritv  for  it.     Tbui-,  >if  30  cliildrrri  under 

to.  I'ltrniled  uu  by  CheiK*lduu,  only  1  tlic<l;  of  >>H  children  cut  fur  aUme  at 

Ht.  Tbtiiuus's,  but  i  case  proveil  fatal ;  and  (hr  average  uiortulity  <if  lilhotomr 

nmat*  in  ehildrvn  is  not  more  than  about  I  in  14.     Guervant,  at  thu  Children  b 

JQospital  in  Paris,  performed  lithotrity  iu  children  40  times — 3ii  of  tlie  coses 

being  in  boys;  uf  theae,  7  died,  and  'i  at  leaeL  of  the  others  required  to  be 

iail«rwanl^  suhJecLeil  to  lithotomy.    Of  the  deaths,  4  were  caused  by  croap 

had  scarlatina,  and  'd  were  atlribiitahle  to  the  operation.     Tlwse  rc»alt«  am 

Anything  hut  unlbfiictory  when  comparc<l  with  tboee  of  lithotomy  in  children 

in  ihiit  amntrv,  or  even  in  Uuerssnt's  own  prHCitce;  for.  of  100  that  he  cut, 

J4  died.     I  think  that  the  beat  and  most  experiencfd  Surgeons  are  agraad 

Toi_  II. — 02 


U 


978 


URINAHY   CALCULUS  AND   LITHOTBITY. 


in  this,  that,  although  lithrttrity  is  praolicahle  on  Hats,  yet  lithotomy,  hfinff 
ranch  eafer  nnrl  far  i^jif^dier,  fhoiild  he  preferred  to  liiholrify  in  all  patients 
under  puberty. 

At  very  advanced  periods  of  life,  the  irritable  Btate  of  the  urinary  orKann, 
the  tendency  to  the  supervention  of  cystitis,  and  the  entitrijed  state  of  the 
prasUte,are  oflen  such  as  to  prevent  the  performnace  of  lithotrity  with  any 
proepect  of  success.  At  the  same  time,  the  Bucct!«s  of  lilhutrity  in  ohl  ti^e 
has  ueen  very  ^t^i'eat  in  the  hands  of  some  Bur;;Mn8.  Thus,  Segataa  slatn 
that,  of  14  octogenariana  whom  he  lilholrized.  he  did  not  luee  one;  and  of 
27  Bei>tuaf;^nnnaD8,  but  two.  LitlioLomy,  on  the  uther  hand,  is  very  fatal  in 
aged  person*. 

It  IS  at  the  middle  i>eriod  of  life,  or  in  jwreomt  who,  thoug-h  adviincwt  >n 
years,  |)re*erve  their  powers  uiiim|)aired,  that  litliutrily  is  luosl  geueruUy 
»pplic»ble  and  mcisl  aufceasful, 

±  Size  and  Character  of  the  Stose.— With  regiird  to  tbc  size  of  the  eVmc, 
there  is  no  doulit  that  a  Hjnnll  eluau  is  more  fuvnmble  l<i  Ittbotrity  Ihna  m 
targe  one.  All  cilIcuH  below  one  inch  in  ilinnieler  may  easily  be  crushed, 
provided  no  sjieeial  cirxninisttince  is  prt^cnt  rpn<tpring  the  operation  uiideHir> 
able.  In  rfgnnl  to  larger  fttonm,  it  iij  dJflicMll  at  the  pnseiit  day  to  lay  down 
any  hani  and  faKt  linp.  Until  recently,  it  wns  not  conwdereil  ailvirable  to 
attempt  to  crtish  a  xtnne  that  wat)  above  one  Inch  and  a  half  in  diaraetcr; 
but  flince  the  introduction  of  Bigelow's  method,  mnnv  einne?  considerably 
above  this  Rize  have  been  Huccessfully  removed.  Mucli  will  deiM-nd  on  the 
oompowtion  and  density  of  the  cjtlculiis.  The  chief  objection  to  lithotrity  In 
Inree  mtunee  was  not  bo  much  that  the  stone  could  not  be  broken,  because 
unics,"  it  \»  tito  large  to  get  into  the  blades  of  the  lilhotrile  this  could  usually 
be  done;  but  that  the  niase  of  fragments  to  come  away  by  the  nrethra,  ana 
the  repeated  operations  required  for  their  removal  would  produce  a  dan- 
gerous amount  of  irritation,  Tlie  use  of  cvacuators  has  to  a  great  extent 
overcome  these  objections  for  stones  of  two  inches  in  dianMter;  but  we  are 
not  in  a  position  as  yet  to  say  what  ia  the  maximum  size  that  can  be  safely 
attacked.  The  different  forma  of  stone  vary  in  the  ease  with  which  they  are 
broken  up.  TTric  acid  enlcuH,  giving  a  clear  ringing  sound,  do  not  disin- 
tefprate  readily,  hut  split  up  into  sharp  aud  angular  spicula  and  scales. 
Oxalnif  of  lime  calculi,  occurring  chiefly  in  young  people,  comparativetv 
rarely  admit  of  lithotrity,  but,  wlicn  crushed,  break  up  very  readily;  and, 
as  there  is  usually  a  coexisting  beiillby  state  of  (he  urinary  organs,  the  eaMt 
have  a  favorable  indue.  Pfionphntic  culmli,  which  are  soft  and  friable,  and 
do  not  yield  angular  fragments  reiulring  re[>eated  disintegration,  may,  even 
if  of  larger  ^mm  tliao  that  nieiitioned,  be  broken  up.     At  the  same  time,  tbe 

tiatient  may  oAen  derive  great  Iiene6t  from  the  thorough  wasbinc  out  of  the 
(ladder  wiili  the  evacuator,  as  these  concretions  are  cvimmonly  the  result  of 
chronic  cystitis,  with  alkaline  decomposition  of  the  urine.  But  the  shaltend 
stale  of  system,  and  the  irritable  condition  of  the  urinary  organs  areim>- 
panying  pbosphatic  calculi,  often  counter  balance  the  advantage  tbat  would 
otherwise  have  been  derived  from  the  character  of  the  stone. 

If  there  be  several  tloneii,  the  propriety  uf  performing  Htbotritv  will  depend 
io  a  great  degree  upon  the  size  of  the  calculi.  If  these  be  small — not  larger, 
perhaps,  than  small  uuts,  uud  not  very  numerous,  the  bladder  bting  healtliy 
— the  <i|H>raiion  may  be  [lerformcd  with  safety.  I  have  removed  sncoe.'wfullr 
in  a  few  sittings  live  or  six  calculi  about  half  an  inch  in  diameter.  But  tf 
the  calculi  be  larger  than  that,  lithotrity  is  not  a  very  suooeBafu)  proce^hire; 
for,  though  each  nilitiUis  may  not  lie  very  large,  yet  the  aggregal«  nf  the 
whole  tH  considerable;  and,  hcsidm  this,  the  calculi  will  each  require  a  Bejta- 
rate  operation,  as  it  were,  and  may  each  contain  a  hard  and  pnasibly  verj 


i 


< 


I 


8BLKCTI0N   OF   OPEBATION   TOR   STONB. 


979 


resisting  Ducleiu.  Occaaionallythe  bladtlercontainB  » large  oumberof  amall 
pea-shaped  caluQli.  These  amy  be  successfully  broken  up,  atid  washed  out 
through  a  large  eyed  catlieter;  fn>ni  50  to  100  sepHmte  ones  may  be  thus 
remuved,  Siriuetitnea  a  caleulus,  aller  baviog  l>een  broken  up  into  several 
fragiiicuts,  lia^  inii-n  left  iu  tlif  bladder,  eucli  trof^mont  l<>rmiug  the  nucleus 
for  a  uew  atouc.  Such  ca^es  are  iiimally  mu)>L  succcE^fiilly  rut ;  but  in  fuvur- 
able  circuuiitiHUCO)^  m  to  the  euiKlitioD  uf  the  urinary  urgaiis,  ihcy  may  be 
iubjecled  to  lithotrity. 

S.  The  CoDditioDs  of  the  Criaary  Organs  that  iniluence  the  propriety  of 
perfortuiiig  litlmtrity  or  ItiluiKniiy  liavt  rofereuco  lo  the  atalc  of  thfi  tctilneyt, 
thebiadJer,  the  unihrft,  and  the />roftate. 

As  a  gcnerut  nile,  it  may  be  elated  ihiit,  tb<>  greater  the  irrilabilily  of  the 
urioary  orgiini-,  the  less  aiicccsaful  will  litliutriiy  be.  The  rt-pcattd  intro- 
dnctinn  (d'iiiHlriin)^Til«,  however  {rarefnlly  and  «k'ilfu]ly  c-oiidueted  ;  tliu  pres- 
ence of  fragnipiiti^  uf  cfllrulus  should  any  be  left  bohiud,  and  their  tendency 
tn  impaction  or  entanglement  in  the  urethra,  ueeeiiKarily  dutpane  to  inHam- 
mation,  even  in  the  moat  favorable  eases,  and  very  ri^ndily  excite Jt.  if  there 
he  any  tendency  to  it  existing  in  the  parlR,  If,  however,  the  stone  be  small, 
or  of  moderate  size,  and  friable ;  the  bladder  healthy,  and  of  good  contrac- 
tile power;  the  iirethrn  rajkiLrioii.i ;  and  the  patient  nf  sound  constitutitm 
and  "luiel  temperfttnetit.  the  stone,  even  under  the  old  system  of  many 
sittings,  is  often  broken  up  and  the  fragments  expelled  with  comparatively 
little  sutferiMK-  I"  ^ft'^t.  in  such  a  ciombination  ot  favorable  circumslfLncea, 
lilholrity  ought  unrpiefttiunably  ti>  be  preferred. 

If,  however,  the  bladder  be  very  irritable,  or  if  the  patient's  constitution 
He  an  excitable  <ine.  »t)  tlial  he  doen  not  bear  well  the  introduction  of  instru- 
ments; more  particularly  if  it  be  found  that  thia  local  and  couatitutioual 
eeniiitiveuebjt,  instead  uf  being  bluulv<l  by  the  methodical  introduction  of 
»uuuds  or  buugiea,  ia  rather  iucreaei-d  thereby  ;  niid  especially  if  the  stone  be 
of  uousiderable  eize,  lithotomy  wa«  formerly  Lbe  only  safe  mode  of  treatment. 
At  the  present  lime,  however,  by  the  ue«  of  aaiesthetiL's  aud  the  tidoptioa  of 
the  operation  at  one  bitting,  eveu  these  difticultiee  may  he  safely  overcome. 

The  exiMeuce  of  urgatiic  dtseaae  about  the  urinary  organs,  e<mstituteii  the 
greatest  obstacle  to  lilhotrity ;  aud,  when  extensive,  must  furni  a  complete 
bar  to  the  performance  of  that  openilion.  It  is  not  easy,  however,  to  deter- 
niiue  the  amount  of  local  disiease  that  should  thus  be  held  to  cotitrnindicate 
lithotrity.  Ou  this  point  the  optnioua  of  Surgeons  diHer  much;  and  it  is 
particularly  in  the  manngemeut  of  thuK  oaseu  that  the  advantages  of  tact 
and  dexterity  in  the  use  of  the  crushing  inKlruments,  which  habit  alone  can 
give,  is  well  exemplified. 

The  coodiijou  of  the  khlneyt  merita  ejwcial  ntteoUoo.  If  theee  organs  be 
diseased,  aa  indicated  by  the  presence  of  casts  of  tubes,  or  of  a  cunsidcnible 
quantity  of  albumen  in  the  urine,  or  in  any  other  way,  the  performance  of  a 
prolonged  operation  in  the  bladder  would  be  likely  rnaterially  to  increase  the 
mischief  in  them,  and  consequently  ought  not  to  be  undertaken.  On^ic 
disease  of  the  kidneys  is  a  more  serious  obi<taole  to  lithotrity  than  to  lithot- 
omy, ou  account  of  the  prolonged  tiniure  of  the  operation,  and  the  greater 
liability  to  sympathetic  or  propagated  irritation  in  these  organs.  It  ia  not 
ooly  by  the  operation  incrcneing  the  renal  mischief  that  harm  might  result, 
but  also  in  conaev|uencc  of  the  tendency  to  diffuse  inflammation  of  the 
bladder,  prostate,  and  surrounding  areolar  places,  and  to  pymmia,  that 
alwiiys  coexists  with  kidney  disease. 

The  conditions  of  the  bladder  that  interfere  seriously  with  lithotrity  are 
partly  functional,  partlv  organic.  The  functional  dorangemenu  arc  of  two 
very  oppD«it«  kinds ;  viz.,  a  state  of  extreme  irritability  of  the  organ,  and  an 


980 


OBIITABY   CAICTTHTS   AKD    LITHOTRITT. 


1 


abnormal  vraot  of  aeDaibiiity  of  It — a  state  of  atoav.  Tbe  oreaaic  lesions 
conswt  of  bypertro[)liie(l,  fusviculatcd,  gacculatcd,  an<f  jK'nuuocQtTy  coDtracted 
states  of  the  viscus.  wbicb  h  tlica  ixKitl  cututuouly  irniabli-  as  well. 

A  chroniaiU^  injUimcd  ur  irriUibk  ilaie  of  the  blndtltr,  more  particolarly 
if  tbe  organ  be  thickeuci]  auil  fufiutculalvtl,  ho  tbat  it  will  not  bi-ar  the  iojec- 
tioo  of  afewouuoo8<>f  iL'pid  water,  atriimsly  iiiterffnw  wilb  ibc  success  of 
lilbotrily.  A  very  irritable  and  ftctiKiil%-c  bluddur  wilt  not  uiily  bo  ibo  seat 
of  severe  riulfirring  on  the  iiUrndiiijimi  of  iiiHtruintiits,  hut  may  not  be  able 
to  hold  HutGcieiil  unrie  Ld  iimkn  ibv  operaijon  a  safe  ooe,  and  may  readily 
become  duogiiniUHly  iufluiiied  in  roneequenoe  of  the  repeatct)  introdiiclioo  of 
{□strumeuts,  ami  ifie  [>n-Ht.'n(-e  of  angular  fragniontiK.  rlenee,  if  the  ordinary 
opcratiiin  of  soundiiij;  occasion  niurli  iliptreRa;  if  thE>  patient  cannnt  bold  hia 
urine  lon^.  but  pass  it  in  small  <|nantities;  if  it  be  blortily,  or  niucb  loaded 
with  viHi'iil  mucus,  be  will  scariTcly  be  able  to  bear  the  proceilnreai  ncceftiary 
for  the  operation.  In  »()me  instances,  however,  the  irritalnlity  of  tbe  bladder 
may  be  oven'ome,  and  in  all  it  may  be  mnteriully  leaoened,  by  keeping  xhv 
patient  in^bfd,  and,  ns  Tlrodie  recomnienda,  <laily  injectiof^  t<-pid  water.  If 
the  bladder  be  tarculated,  there  n-ill  be  a  still  greater  rif^k  of  an  unfavorable 
result:  the  sacculi  not  only  retaininji  fragment-t  of  calculus,  but  al«o  becom- 
ing filled  with  decimposing  mucus  and  ut-ine,  in  consetiuence  of  which 
unhenllhy  inflatnmation  of  a  very  serious  character,  followed  by  pya-mic 
syioplimiB  and  iuetn:^tatic  absccMes,  may  result,  or  in  some  cases  leadinjc  to 
perforation  of  the  peritoneum.  In  such  caaes  as  tbe«e,  early  lithotomy  oflera 
tbe  only  chance  to  the  patient.  The  existence  of  a  moclerate  amount  of 
vesical  catarrh,  if  the  bladder  be  otherwise  healthy,  is  no  ol^ection  to 
lithotrity. 

lu  cncyaUd  calcuhi$,  Jiibotrity  i»,  for  obvious  reaaoos,  inadmissible. 

Atony  of  the  bladder  is  not  only  a  serious  incouveuience,  but  a  great  source 
of  danger  iu  litbotrity.  It  cannot  in  all  caeee  be  pufiitiveJy  oBcertained 
beforehand ;  though  it  may  be  euspected  if  the  patient  can  hold  his  urine  for 
a  great  many  hours,  and  eau  bear  without  compiaiat  the  iujection  uf  a  large 
quantity — eight  or  ten  ouncee — of  fluid,  tbe  interior  of  the  bladder  fueling 
large  and  smooth  to  the  bound.  Thie  condition  oceunt  chiefly  in  old  meu  of 
feeble  habit  of  body.  Civiale  considered  this  condilioti  to  be  a  si>urce  of  great 
danger  after  lithotrity,  the  organ  not  possessing  sufficient  expulsive  power  to 
rid  itself  of  the  fragments  of  tbe  presence  of  which  it  seeme  to  be  iuseosible, 
so  far  as  the  feelings  of  the  patient  are  concerned ;  while  its  low  vitality 
renders  it  neculinrly  liable  to  subacute  cystlti)<,  excited  by  the  presence  of  the 
fragments  in  the  lower  fuudus.  By  the  use  of  the  modem  evacuntor,  a  stone 
of  moderate  size  may,  however,  be  safely  removed  at  one  ailtiug  fnnm  an 
atonic  bladder.  It  must  be  borne  in  mmd,  that  this  atony  of  the  bladder  ^ 
may.  especially  in  feeble  and  aged  iudividualfi,  be  induced  by  tbe  contact  of  fl 
the  instrument,  and  eapecially  by  prolonged  sittings.  ™ 

If  the  urfMra  be  the  seat  of  stricture,  or  be  very  irritable,  liihotrity — 
which  may  require  the  frequent  introduction  of  iastrumonts  of  larg«  sue 
— cannot  be  safely  performed.  Stricture  of  the  urethra  does  not,  bowover, 
obsoUitelv  prevent  trie  performance  of  lithotrity,  but  only  retards  the  opera- 
tion until  the  con^trietton  can  be  properly  dilated.  Should  ibis,  however,  be 
not  practicflblu  to  the  full  extent  of  tbe  urethra,  lithotomy  on  aamall  staS* 
must  be  practiited. 

Moderate  enlargement  of  the  prottaU.  such  an  in  often  met  with  in  eldfrly 
people,  does  not  prevent  tbe  porformunce  of  tilholrily;  ihuuph  it  slightly 
complicates  the  opt* rntiim.  The  intrcMluction  nf  the  iithotrite  will  be  alteoiled 
by  considerable  difliculty ;  and  tbe  fragments  have  a  tendency  to  become 
Lodged  in  a  pouch  of  the  lower  fundus  behind  tbe  enlarged  gland.    Tbil 


RKCUKBBXCB   OF   CALCULUS    AFT! 


981 


c«|M;dallj  happens  if  the  midillo  lobe  be  enlarfced ;  T«l  in  theM  drcuro- 
lem,  the  stone  iimv  be  crushed  without  great  difficulty,  and  tbe  fragments 
ivetl  by  the  evncuator.    Any  inflaiumatory  diwase  or  abec«wof  tfa«  prot> 
(at»  muel  iitceeearily  |ireveiiL  tbe  performance  of  lithotritjr. 

OiabetM  i»  out  coramooly  anoctated  wtib  calculus.  I  bare,  indeed,  but 
wry  rarely  seeu  the  two  cooditious  combined.  The  only  form  of  calculus 
Umt  1  bnvc  M-t-u  in  diabetic  patienla  baa  been  the  uric  acid.     It  i«  nccea* 

kily  very  baxarduua  to  <)[>i  rate  in  such  ca*c8,  at  least  by  lithotomy.     And 
ic  if  tithi>trity  be  deteriiiiued  on,  it  would  be  ncll  to  defer  the  o|}eratioii 
tal  tbe  glycneuria  has  beeu  checked  or  removed,  at  least  fur  a  time,  by 
proper  treaUnenL 

1  liavo  raid  onthin^;  in  ihix  roniparidrm  iK-tween  lithotrity  and  litb(rtoruy  of 
llie  pnmjinrative  painfuIm-A^  of  ilm  two  oiwriilioL's ;  for,  a»  anitsthetif*  may 
be  ->ml  wilb  equal  advantage  in  buth  ca.m:)',  there  in  litllc  dillrrc-ncc 

^  1 1  -,  ■  i-t,  ^xcej»t  tnat  perhaps  the  »lviuilagu  lie»  ou  tbe  e'lda  of  litb- 

|bniy.  as  Ix-ing  tbeabnrter  proceeding. 

^■Troni  all  that  prec«de«,  then,  it  irould  appear  that  although  lithotrity,  as 
^Bprpaent  performed,  is  adaptefl  to  by  &.r  tbe  larger  number  of  casea  of 
^W>ti£  in  the  adtill  male,  it  cannot  be  looked  upon  as  a  aniverBat  mode  of 
ireatnieul,  beioit  applicable  only  in  favorable  conditions  of  tbe  urinary 
oreaiis,  to  calculi  of  moderate  ■ixe,  and  after  puberty ;  and  that  a  consider- 
able number  of  ca^es  will  always  be  left  in  which  fithotomy  otfers  the  sole 
larftiiK  of  nliof. 

Choice  of  Operation  of  Lithotomy. — The  particular  operation  of  lithotomy 
tw  which  n.-coun!B  shouid  b*  had,  will  also  vary  acconliiij;  to  the  character 
of  the  etuue.  If  this  be  nmall,  nod  the  patient  an  adult,  the  median  opera- 
tion may  iulvaat8j,'f<m!!y  be  iierfonued.  If  it  I>e  of  moderate  or  tolerably 
large  »ize,  and  umre  jiartictilariy  if  (be  0|>eration  be  practiced  on  a  child, 
the  htrT'ii  up|H-ur8  tu  ine  to  be  (be  more  applicable.  If,  again,  the  catculug 
be  of  iiiordiuiite  niHgnitude,  the  mtprapuhic.  the  inftUubHaUml,  or  the  redo- 
mriciU  operation  should  be  the  method  selected.  In  fact,  tbe  Surgeon  should 
BOt  enniine  him^ilf  too  exclusively  tu  auy  one  uielbMl  of  0|>craiiQg,  but 
ahould  ailopt  that  procedure  which  appeara  to  be  beat  ada|itetl  tu  tlie  ajpeclal 
circnm^^lnnrcA  presented  by  tbe  jmrticular  onae  before  hini,  and  shuulfl  vary 
hb  mpth>x|  accftniing  to  the  atate  of  the  uriuary  organs,  tbe  age  of  the 

itirnl.  tind  tbi^  rir.t;  and  phnractor  of  theBtone. 
Tbe  Beiult  of  Operationi  for  Stone  will  depend  in  a  great  measure  upott 
B  condition  of  tht*  Idadder.  ami  the  character  of  the  stime.  If  tbe  blaifdor 
healthy,  all  symptoms  will  cca.'e  o»  tbe  removal  of  the  culctiiim.  and  the 
ticnt  will  be  restored  to  perfect  hrnlth.  This  naually  happens  wht-n  the 
leulus  i«  of  the  tilhic  acid  or  the  oxalate  of  lime  variety,  and  of  renal 
origin.  'If.  however,  tbe  bladder  be  unsound,  irritable,  ami  the  nrine  alka- 
Xittti  from  decom position,  and  dispfwed  to  the  deposit  of  phiMphatic  matten, 
tli«  calculus  being  pbosphutic.  nod  chiefly,  if  not  wholly,  vesical  in  iteorigiD, 
then  an  irritable  state  of  bladder  may  l>e  left,  or  may  speedily  reium  aiker 
tbo  operation,  which  will  cocueqaeotfy  have  been  prodactire  of  little,  or 
^■^  of  tempnrnry  beoetit. 

^pftnruaKKNci:  or  CALCt'LlTs  Arrm  Oi-eratiox. — This  may  take  place 

^^to  fiiur  <lii«tiuct  caosea:  1.  In  conM^ueucv  of  a  continuance  of  tbe  consti- 

lulional  enndition,  under  tbe  inBuence  of  which  the  calculus  was  oricinally 

i\  2,  from  the  dcM^'nt  ofn  renal  <.-alruUis.  which  ha»  existed  in  ihekidDer 

I  tbe  lint  o|ierution  ;  :E,  from  a  fragment  of  calculus  having  i>een  aoca* 

1y  Icfl  ill  the  bladder;  au<l,  4.  from  tbe  accumulation  ot  phivphatio 

dapuaU  u  tlio  fundus  of  the  bladder,  or  iu  tJie  line  of  imperrcctly  healed 

fawUoDB. 


983 


L'BIHABY    CAI.OULDS    AND   LITIIOTAITT. 


H: 


Bdapse  fromtbcfirelcauwispnfbaMjr  rmt  v«r'  >     WWsl 

the  Rcummt  calculus  is  41I'  ttiurw  nf  tbu  hutnc  <  >  d  m 

MM.  Tb«  oooumuil  •KwurrencL-  of  rclupec  ehuws  litt^  uirrr«ilT  oToDaiiii^ 
ooostitiiUooal  treatnienc  BfUplciI  lo  the  jiurtii-uliir  iluitbn>v,  mtur  iht  m^tm 
of  the  c»lculiii>  from  the  Muddur. 

Kociirrence  of  otlcutud  fruin  the  il(W(i>nt  nf  »  new  ntnae  fmm  l^  btef 
erenr  now  aod  then  occitrs,  ami  iij  eFprrinlly  liablr  to  br  met  with  in  tk* 
raso)  in  which  the  primary  ciUciiU  are  multiple  ami  »awll.  Id  tkim  m^ 
the  relapse  may  uke  place  very  ahurily  nfirr  Uin  Rm  oprratiua.  aad  viUli 
prpcMlcd  hy  the  usunl  symptoms  of  the  descent  of  a  modc  froiD  tW  Uiatf. 

R^Iapw  from  the  retcotinn  of  a  frngnicnc  which  wma  aa  tb»BaalaH  rf 
another  stone,  will  undoul]tedlvocca8ionnllyocrur,Blthoaf;h  lUooeaniMaa 
fairly  attrihuiable  to  want  of  due  care  on  the  pari  of  the  tHtrgvtu,  1(  ■  al 
to  hnnpcn  more  i'rc(|uentlr  after  lithotrity  iIiad  after   tilbolonr.  and  ili 

Einly  to  ihia  eflu<e  chiefly  that  uo  ntu^l  n'.'for  !h^  greater  liaaiUf 
after  the  cruihing  than  the  cnltiuc  -  '     -     !    mav 

litliolumy,  thut  »  rra^im-iit  ia  Ifft  U .  1  oe  ium 

brok«n  durini;  exLnicli<'ii,  and  the  bliidder  imt  iliunrti.  -  i«d  wot.    Sm 

cvei)  it)  lliici  case,  th«  liit  uf  stoat*  will  uetinlly  bv  oun  '.  "f  the 

by  thv  ll'iM  of  urinv  llirongh  it. 

K«currt;nc«  from  the  fnrmaliuti  of  a  phtwpbatic  calculwin  tb« 
th«  reaull  of  chronic  cyatitb  wiUi  deeompiniuim  of  th«  uriD«,  may 
■ionally  aflvr  lithottiniy.  but  is  nmuh  luurv  t.-«iiiiniiin  aficr  UOn 
tbtat  casee  a  lilhotrite  must  be  iiossed,  and  the  *u(V  uuu*  v 
WMbed  uut  with  a  catheter  and  vvacuut^ir.  The  iiulicut  luuM  br 
waah  his  own  bladder  out  regularly  every  day  witli  a  dilute  atid 
which  i>iime  quiniuo  may  be  added.  I  have  lali-1y  had  imilrr  wy 
patient  eif*hly  years  of  uge,  oQ  tvhom  I  perfurmt^l  liiliuirtty  f<ir  a  ofk  ttid 
cnlculuH  nlxiui  live  years  a"*),  nud  from  wh'tm  I  have  mii«ivt<d  lar^fAar 
phatic  cuiicrelioHH  more  than  a.  doaeo  iimf)>  since.  At  th«  pnanillMia 
year  has  elajised  aiuct:  the  toet  i))ieratinn,  nml  nu  urw  fiinoaUaa  ha*  Uh* 

5 lace.  On  some  occasionB  ttie  muM  in(^«8iire<l  iivtr  an  inch  and  a  Wf  it 
luneter,  ret  under  an:c8th(>tiM  it  wus  broken  up  and  wvhiHl  out  wiU  Bifr 
low's  apfuiratUH  without  tbc  «lif;hlcst  irritation,  the  patient  uaually  ntaninf 
to  the  e<»untry  on  the  scrond  day  after  the  oprratKm. 

Fhnsphutic  dejmstt  may  take  place  aUn  in  the  trai^k  of  a  partiallf  htM 
Hthotoray  wonnd,  forming  a  rrust  on  iu  )turtiic«.  I  hare  knon  toA  ■  ^ 
posit  to  form  in  the  perineum,  when  the  wound  had  dex*ocratiJ  iaU* 
iriiius. 

According  to  ('.  WilliamH,  the  rflapvm  in  the  XorwiL-ti  Tlmpital art 27 ii 
lUl>'t  operations,  or  1  in  HB,  t>r  in  ^i'>'>  lithotmnifD  1  m  Xi.  1  jthntowr  «ai 
performed  a  second  timt>  in  1^4  imlifutx ;  a  tttini  tinw  iti  *  Mftfc 

time  in  I.     Twenty-three  werp  cur^it,  .'►  ilie«l.     All  ih**  p'l  Bsiia 

The  recidlem  of  tin-  LouiitviHe   lliwpital  jjive  1  r^  .  .rf  ttk- 

otoiuy  :  an<l,  acoonliriy  tn  f  "ivinle,  ibf  n-iurn  of  < .  .  (»y  wsi 

in  Bavaria,  1  io  3'j!,  in  Bohemia  I  in  Mi,  la  l>AlmBtia,  I  in  -U,  and  m  Tn^^ 
1  in  74. 

After  litbutrilv,  relapse  i»  more  <<imimua  ;  altboai^  it  is  prohalily  kN  ^ 
qucDt  now  than  Vurmurly,  uud  wUl  beeume  leas  iVeqiieni  an  ths  ikuak'^r^ 
operation  cumc  lu  be  better  undersliMnl,  and  more  carefully  ptiariwJ  t 
the  practice  iif  CiviaU!  it  txTcurreil  abimt  nore  in  erenr  imth  case.  |htl>* 
osljniiite,  hijfh  as  it,  fiillx  below  what  liappnnnl  farmrriy  tn  •urpoal  w*"'* 
(.'ivialo  stated  that,  of  •!(>  private  patlrntK  on  whom  be  (ipfsmiKl  la  IP(^  ** 
had  previously  hf^n  op<'nitrd  on,  thr  stine  hnvio|;  mpprarrd.  Tba  ^ 
evidently  have  oriseo  from  same  fragxnenl  of  calimlos  hariof  «eapsd  i^"' 


dB£i 


CRKTHRAL   CALCULUS. 


083 


tixn  Rad  beiog  hfl  behind,  tttus  coDXtltutiug  a  uucleug  for  »  fre»h  forniulioD. 
The  frequency  of  the  occurrence  of  secondary  calculi  alter  lithotrily  has 
greatlj  uiiuimelicd  siuce  the  time  of  Civiule,  and  cun  do  longer  cuoslitute 
au  objcclioD  to  that  uperaiiop,  yet  it  still  ovcurs  ofteu  enough  to  show  the 
Deceesit^  of  the  Surgeon  aimi  carefully  exnmiiiiDj;  the  bladder  befuro  ho 
pronounces  the  pntieiit  cured  :  ami  evrn  then  watching  him  fur  eoiue  tcn^h 
of  time,  ill  order  Vi  meet  a  remirreut  falculiis  at  iti^  firat  titriiiutiofi.  and  to 
adopt  mcan«  for  its  early  removal.  I.iihdiriiy  cannot  therefore  be  said  to 
be  m  eom|ik'iiJ  it  cure  in  all  tMUfva  m  lilhotoniy.  Not  only  in  recurrence  of 
calcultiH  rnuru  i;i)niiiiiiu  ulcer  the  former  tliun  niter  the  latter  (i|H;ratiun,  but  it 
Dot  uiieiimmtmiy  Iiiipfiuiiti  that  patienUf  wht  havehtjun  licholrtxeil  »iii!e(!i^fulty, 
ami  in  whom  no  re(.'urn:rtt  calculuH  liu.^  furtiicd,  rontiiine  to  culler  for  a  ^reat 
length  lit'  time  uflcrwHrdri  fntm  very  flii'tri'HHin^  irritability  <>('  the  hludder, 
which  ri>«ii^t4  in  liiu  moct  olietinalci  manner  all  the  onlimiry  mrthodti  of  tre&t- 
ment.  Thi»  la  not  the  eu!)u  after  lilhotomy  ;  when  u  iiatient  onre  recoveru, 
hia  bladder  usually  regaina  its  tone  amiplelely,  and  no  trace  of  evil  conse- 
quences is  left, 

Tratliuent. — In  the  eveut  of  a  secondary  calculus  forming,  nlielher  aftpx 
lithnlomy  or  lithwtrity.  either  DiethoH  may  Aj^aiii  he  employed,  according  to 
the  mititre  of  the  case.  Most  yonerally,  the  bladder  may  be  cleared  of  the 
recurneiit  calculus  by  means  of  the  lilbfitritc.  If  lilhotomy  have  previously 
been  performeil.and  it  be  tliuui^ht  pro^jer  again  to  have  recnnrse  to  it,  this 
tDfly  liedone  again  Itk  the  usual  '\Tay,  through  the  eictttrix  left  by  the  ftirmer 
wound  ;  or  tlie  Hurguou,  if  ambidi.-xtnjus,  may  adopt  Liston 'a  advice  tu  cut 
through  the  right  side  of  the  perineum  on  a  stalf  with  a  groove  to  the  left  of 
its  convexity.  jVs  this  procedure,  huwever,  would  entail  the  use  of  the  left 
band  lor  cutting  and  extracling,  moat  burgeons  would  pri'fer  either  [ho  opera- 
tion tbrutigh  the  site  of  the  old  wound,  or.  better  still,  the  median  operation. 
Whatever  procedure,  however,  n^ay  be  adopted,  it  should  be  borne  in  miud 
that  the  rectum  may  have  become  rather  lirmty  adherent  to  the  membranoua 
porlion  of  the  urethra  and  the  apex  of  the  prostate,  iu  coiitietiuence  of  the 
contraction  uf  the  old  cicatrix,  and  may  thus  be  endangered. 


UKICrUKA],  CALCULUS. 

Calculi  are  not  unfrequently  found  impacted  in  the  urethra,  especially  in 
children.  These  are  raoiit  cumniunly  formed  in  the  kidney,  whence  they  pass 
into  the  bladder,  and  thence  into  the  urethra,  through  which  they  usually 
'  wcape ;  but  in  ts-nae  Instances  they  h>dge  in  the  latter  channel,  mure  espe- 
cially at  the  bulb  or  in  the  navicular  llMsa.  These  calculi  are  cimmiouly  of 
the  uric  acid  or  oxalate  of  lime  varieties;  they  are  geiieraliy  round,  but  not 
uncommonly  i^ixiigaiei]  orapiudleKhajied. 

Althuuch  tiHiBl  urethral  calculi  are  undoubtedly  renal  !□  their  origin, 
there  can  be  Utile  doubt  that  in  some  more  rare  cases  they  may  Im.>  primarily 
forme«l  in  the  caual.  They  will  then  be  found  (o  be  jihoe)ihHlie,  usually 
consequent  upon  stricture,  and  perhaps  of  large  size.  In  »jme  cases  these 
concreliuns  are  monldeii  iu  Ihe  pnistatic  and  bulb'-us  portloiiBurthe  urethra, 
being  elongated,  rounded  at  one  end,  and  ]iointed  at  the  other.  In  other  in- 
itaoces,  again,  they  a|)]>ear  to  be  furme<l  in  a  pouch  tliat  lies  to  the  outside  of 
the  urethra,  and  tliat  is  connected  with  it  only  by  a  small  aperture.  I  have 
removed  a  stone  of  thLs  kind  composed  of  triple  phosphate,  weighing  an 
ounce,  and  about  the  size  of  a  walnut,  smooih  and  rounded,  from  a  point 
lying  between  the  upper  wall  of  the  urethra  and  the  symphysis  pubis,  in  a 
dei^gyman  who  had  for  many  years  guSercd  from  very  iight  i-tncture.    One 


984 


rAtODLTJS   A»D   LITBOTEITT. 


of  the  moat  romnrkable  inetancea  of  this  kiicl  is  rpprffii-nted  in  the  ann^x^ 
cut  (Fie.  U04),  taken  from  n  drawing  in  8ir  K.  Cflrewell's  c<>llei-ti"»  i 
iliiivi-nnty  CoHego.    The  atooe  here  was  of  very  largesize — equal  in  bulk 
two  horse-chetitnuts. 

SymptomB. — In  tho  adult,  the  [>r€SeDccof  acniculus  to  the  urrthra  niarl 
iiu8|>ectc<I  by  the  difficultv  that  in  occa^ioocd  in  micturitioo,  aod  aftpertaint 
by  the  pnsaibilily  of  feeling  the  stone  through  the  walla  of  the  canal,  or  of 
detecting  it  by  introducing  a  sound  into  the  urethra.  To  boy»,  impactino  of 
calculufi  in  the  urvthra  18  almost  the  sole  cause  of  retention  of  urine.  Wh«i 
called,  therefore,  to  a  child  sulTcring  from  this  condition,  wc  shoaM  olway* 
at  once  tiiDijieot  calculus  as  being  the  eauiie,  and  examine  the  urethra  from 
the  perineum  or  r«;tum,  (ind  by  llif-  introduction  of  a  souod. 

Treatment — ^The  trenlment'of  urcihnil  calculus  will  vary  in  th*  adult 
and  in  the  child.  In  the  aduH,  urethral  calculi  may  W  reratived  by  extrac- 
tion, incision, or  Hthotrity.  When  situated  towards 
the  anterior  part  of  the  canal,  a  urethral  calculus 
may  tVerjuently  be  extracted  by  tjuietly  workiag 
the  stone  forwnrds  betneeo  the  finger  and  Ihutob, 
the  patient  being  under  chlorotbrm.  Should 
this  plan  not  succeed,  it  may  be  removed  by 
paming  a  long  and  very  narrow-bladed  pair  ot 
foroepa  down  to  it,  by  which  it  b  seized  and 
drawn  forwards ;  occaaioDally,  when  it  haa 
reached  the  navicular  fossa,  it  will  not  paa 
through  the  urethral  orifice  unless  this  be  CO* 
larged  by  incision  with  a  probe- jxiiu ted  bistoarr. 
If  the  calculus  be  Coo  large  to  be  extracted  lo 
thla  way,  and  appear  to  be  firmly  fixed,  an  in- 
cision may  be  iintdo  down  upon  it,  through  ihe 
urethra,  by  which  it  may  be  removed.  It  is  a 
gixid  rule  not  to  make  thitt  inriHion  in  any  part 
of  the  urethra  nnterior  to  the  scnitum ;  for,  in 
ciinsequence  of  the  «ivering«  of  the  penile  por- 
tion of  the  urethra  being  very  thin,  the  apertan 
will  pnibubly  not  close,  but  a  Katulous  openiog 
will  be  left  When  the  stouc  is  situated  in  the  serntul  portion  of  the  urethra, 
there  would  beaumo  rii>k  of  abscnu  and  of  urinary  iniilrnilinn  if  the  incision 
were  made  through  th<!  Inx  limues  of  the  Acrotum.  Hence  it  In  better,  if 
possible,  to  push  the  ptone  Itack  towards  the  membranoun  portion  of  the  canal, 
to  cut  down  upon  it.  and  extract  it  through  the  perineum  by  ao  inei»i<m  in 
the  mesial  line.  Thia  operation  ninv  readily  l>e  done  by  passing  n  M&S, 
grooved  along  lis  convexity,  or  an  ordinary  director,  as  far  a»  the  calculus, 
and  making  an  incision  upon  the  end  of  il,  ?o  as  lo  lay  open  the  urethra  ;  the 
Btaff  i.1  then  removed,  and  the  cftlculnsextraclcd  by  niean.<)  of  a  sleodwr  f»«ir 
of  foroepa.  A  catheter  should  next  be  passed  into  the  bladder,  and  retained 
there  for  a  few  days,  in  order  to  lessen  the  tendency  to  thefurdiation  of  urinary 
fistula.  Should  it  not  bo  thought  ndvifitble  to  cut  the  patient,  the  at 
mar  be  pushed  hack  into  the  bladder,  and  then  crushed  by  a  lithotrite. 

It  may  happen  that  the  caIcuIus,  impacted  in  the  urethra,  is  only  one  i 
Mveral;  others  being  lodged  in  the  bladder.  In  order  to  ascertain  this,  tl 
Surgeon  tibould,  after  renioviug  the  calculus  for  which  the  opvrstioa  hfl 
been  performed,  pass  a  sound  into  the  bladder,  so  as  to  ascertain  whether  any 
other  concretions  exist  io  that  organ ;  and,  if  so,  they  should  at  once  be 
removed  by  the  median  operatiou  <j{  tilhotouiy,  the  iacisiun  of  the  mem- 
brnnous  portion  of  the  urutbra  being  extended  backwards  to  the  prost&te. 


Pig.  SOI.— Ratm-uralhr*! 

Cakulaa. 


3 


PftOSTATrc   CAr.CDI-t75. 


985 


I  once  MLW  I/igtfjn  cxtnict  two  vp^ivnl  cAlctili,  tifter  tiavin;;  removed  one  that 
faati  blocked  up  the  urethra,  by  cunrerting  the  periueitl  iuctiuuQ  into  tliat  of 
Inlernl  lilholomy. 

Impaction  of  a  Calctdni  in  the  ITretlira  of  a  B07  may  lead  to  very  serious 
cODSvijueuceg.  In  the  uiajority  of  iustaDceit,  it  ocrusioiis  more  or  leiui  lytm- 
ptelc  retenliuu  ui~  uriue,  which  rt^nires  rvtiel'.  This  may  be  given  in  one  of 
two  ways :  1.  If  the  stone  be  near  the  urethra]  orifice,  it  may  be  extracted  ; 
and,  2,i(  situated  mure  <leep]y,  it  may  be  puehed  back  to  the  perineum, 
there  fixwi  by  the  finger,  ami  cut  down  upon  in  the  niesinl  line.  It  should 
never  be  pushed  bacli  iatu  the  bladder,  aa  euch  an  act  would  render  lithotomy 
necetsary. 

Jf  the  stone  is  allowed  to  continue  fixed  in  the  nrethra,  very  serious  ct>n- 
eequences  may  ensue.  If  il  completely  obstruct.'*  the  cannl,  the  membranous 
part  of  the  urethra  may  give  way  during  Ihe  violent  efforts  at  micturition, 
and  extra va.oatJnu  of  urine  will  take  place.  In  other  cases,  if  it  be  irregular 
in  shape,  a  small  qiinnlitv  of  water  may  pasa.  Under  these  ctrcumstnucos, 
there,  is  inteose  irritability  of  the  bladder,  the  urine  passing  with  much  pain 
every  few  minnleB.  or  ounstani  dribbling  may  set  in.  The  distended  bladder 
can  be  recognized  above  the  pubp«,  Kome  purulent  diacbarpe  will  be  ob- 
served about  the  meatus,  and  there  will  be  some  hard,  ill-defined  swelling  in 
the  perineum,  with  much  tcndcmcBS  in  thia  rocion.  The  presence  of  the 
etone  niav  at  last  cause  ulceration  of  the  urethra,  with  the  formation  of 
urinary  absoeiM  in  the  perineum,  ffjllowed,  perhaps,  by  extravasation  of  urine 
into  ihc  Bt-Totum  anrl  its  diffusion  beneath  iho  siiperfieial  fast-ia  in  the  usual 
direction,  with  the  ordinary  disantrous  rpnults  of  inflammation  and  nloughing. 
On  puling  a  sound,  no  st-me,  probahly,  will  be  fnund,  as  this  has  L«cupcd 
from  the  urethra,  and  is  lyinjit  in  a  pouch  in  some  part  of  the  perineum,  and 
in  the  midst  of  broken-down  areolar  tissue  and  pus;  into  this  cavity,  the 
sound  will  readily  pass. 

The  Treatmeiil  in  these  cases  is  simple.  It  consists  of  introducing  a  grooved 
staff,  placing  the  boy  in  the  lithotomy  ]K>sition,  and  then  freely  incising  the 
meflinl  line  of  the  perineum,  so  ns  to  open  up  the  urinary  abscess ;  in  (bis  the 
stone  may  be  tbuiid,  or  it  may  be  so  enveloped  in  thesiouj^liy  tt««ue8  as  to 
etcape  detection ;  pttrbajia  it  will  encaiK;  through  thi  wounti  in  a  few  days, 
and  be  found  lyiug  mi  the  bed.  >Should  there  be  inuclt  hemorrhage,  a 
catheter  may  be  tier!  iu  and  the  wound  plugged  with  salicyliu  or  iodoform- 
wool  secured  bv  a  T-bnudage.  If  uxtravHealiuu  of  urine  have  occurred,  free 
inctflious  must  W  made  iu  the  usual  way,  and  the  child  be  put  upon  a  stimu- 
lating diet. 


PBOeXATIC  CALCOLtra. 

Prostatic  calculus  differa  from  all  other  urinary  concretion?  in  situation 
and  composition,  being  formed  in  the  ducts  of  the  prostate  gland,  and  com- 
posed pnneipnlly  of  phosphnle  of  lime  and  some  animal  mailer;  usually 
about  85  per  cent,  of  the  [>bosphate,  to  l-*)  of  the  organic  ingre<lieni8.  The 
concretion  is  said  to  consist  sometimes  of  carbonate  of  lime  (p.  004^.  It 
generally  occurs  in  old  people,  though  it  may  soraelimea  be  met  with  in 
young  Bubjecla.  From  n  lad  of  nineteen,  whom  I  cut  for  vesical  calculus,  I 
extracted  two  prostatic  concretions. 

CnAEACTERs. — Prostatic  cnlculu*  it.  usually  of  a  gray  or  ashy  color,  some- 
what triangidar  in  nutline,  suKmlh  and  polished  (Pig.  90ft),  having  facets, 
being  very  bard,  and  seldnrn  much  larger  than  a  cherry  or  plu m stone ; 
though  it  may  occasionally  attain  a  confiiderabln  bulk,  having  been  met 
with  as  large  as  a  Itpn's  egg,  and  then  preaenting  a  branched  or  irregular 


986 


UBINARY    CAI.OUE.US    AND    LITHOTRITY. 


appenrHnre.  TIkmi^Ii  iiBiiulIy  btil  one  or  two  exi«t,  whiuli  arc  ftoiuvi'iEQl 
depo^iu^il  ill  :i  kiial  of  I'^'iit  in  tlie  or)n>Ji>  sn  mmiy  us  lliirLy  ur  forty  bafft 
been  met  with,  the  ducto  bdug  lill^l,  aiitt  iu  wliolu  liesue  beiag  stuililud  with 
them. 

Symiiximh. — OalcuUi.H  iit  the  primtHte  givas  risv  to  a  sense  of  nvight,  [Mia, 
nod  irritation  in  the  perineum,  »i)m('timt«  to  retiMilimi  of  tiriup,  Htid.  in  fiict, 
to  the  ordinary  sytnptonis  of  enlur^i^i  imd  irritutcd  nroHLate;  it  often  occa- 
sions a  tolera(>iy  free  rli^eharge  of  miicnn  in  the  urine.  Oq  intnidiiriiig  a 
sonnti,  this  paases  over  the  stone,  socnetimes  rumbling  or 
Birilcing  it  with  a  distinct  grate  or  click  before  its  beak 
enters  ihp  blH(i(ler.  This  is  increnscd  by  the  finger  io  the 
rectnti)  pu.'^hitig  the  organ  up,  and  thus  bringing  the  stone 
into  more  flirect  contact  with  the  sound.  In  eume  instancies 
Fif.  905.— Pnwuiio  tbe  calcuUis  is  deeply  imbedded  in  the  prostate,  and  can- 
o«lcaliii.  not  be  touchevl  by  tfie  sound.     In  these  «iM«,  the  atone 

mny  usnnlly  be  felt  through  the  rectum.  If  there  be  many 
small  calculi  in  a  mki^uIui*  in  the  |iroi»l»Li^,  they  may  hv  fell  by  intividticing 
the  Itn^jer  tnli>  llio  rectum,  when  a  pi^'culinr  crackiiug  or  t;ralin^  »4-n^Mtion 
m»y  be  cx|KTience<l  by  clic  rubbiug  togvtht;r  uf  the  talculi,  tiuiiiftbing  like 
that  prudured  by  bead^  in  a  ling. 

Tri:.4Tmknt. — The  ircatment  of  proatatic  calculus  will  de|>eod  upuD  the 
situation,  size,  am)  uumb«>r  uf  the  cuiicri^tiomt.  When  thvy  arc  large,  single, 
or  at  Diwl  two  or  three  iu  number,  readily  struck  with  the  souud,  »ud  situ- 
ated ou  the  urethral  surlMce  of  tbeurgun,  the  ordinary  median  opvrstiuu  ma^ 
advantageously  be  perfurme<l,  and  the  calculus  removed  with  a  scu-'>p  or 
forceps.  If  the  calculi  be  siuail  and  very  iiiimeruus,  not  to  be  fell  wilb  the 
aound,  but  ouly  through  the  rectum,  it  will  i>e  wiser  uot  to  liave  recourse  to 
optsralioo,  which  cuiilil  nut  remove  the  whole  uf  the  concretions.  In  such 
circumstances,  a  palliative  treatment  directed  to  the  aulKlual  of  the  irritalJoa 
of  the  proslate,  and  the  ii^  of  the  catheter  to  relieve  retention,  is  the  only 
Course  to  pursue.  Wlien  prostatic  and  vcitical  calculi  occur  together,  the 
same  uperaliim  will  rid  the  patient  of  both  forms  of  the  disease.  (Fur 
foreign  bodies  iu  bladder,  vide  vol.  L  p.  S37.) 


I 


CAtX;ULU8  IV  THE  FEMALE. 

Stoni;  is  of  rare  occurrence  in  women  ;  in  lyoniioii.  certainly,  it  is  not  alien 
met  with.  Thus,  Houih  slates  that,  during  a  |)eriufl  of  iwcnty-three  years, 
144  males  were  openite<l  on  for  »tonc  at  Ht.  Thomas's  H<>.<ipitnl,  and  only  2 
females.  In  aume  didtrictA,  however,  stone  would  appear  to  be  more  comtoon 
In  women  than  this.  Thus,  according  to  CroA-se,  at  tbe  Norwich  Ilotpical. 
the  proportion  has  been  about  1  woman  to  lit  men.  ('Iviale  states,  as  the 
mnlt  of  his  re-tearchej*.  that  in  the  North  of  Italy,  the  proportion  \»  t  to  18; 
and  in  Franre,  about  1  to  '22.  .\t  Unirentity  College  iTi^pital  we  hnd  not 
had  a  casp  of  stone  in  the  female  for  many  years  until  IsrtS,  wlien  three 
came  under  my  care  in  tbe  course  of  a  few  tuoutlis;  and  since  that  jiertod 
many  have  occurred. 

Voical  calculi  in  the  female  are  often  nothing  more  thnn  phosphatic  in- 
crustaliong  deposited  around  »<jme  foreign  body  that  has.  either  aocidenially 
or  from  depraved  tuoiive^,  been  paaaed  up  the  urethra  and  liaii  been  droppett 
into  the  bladder.  Iu  thi»  way  hiiir-pius,  pieces  uf  bougie,  uf  catheter,  or  uf 
pencil,  will  often  be  found  to  furnt  the  starting  jioint  and  the  nucleus  of  the 
Concretion. 

Symptoms. — The  symptoms  of  stone  iu  Lbe  female  closely  resemble  thoM 
that  occur  iu  the  wale,  and  its  preeence  may  usually  ho  easily  detected  by 


I 


KEMOVAl 


lALE. 


987 


fa  short  ami  nearly  stratpht  snniKl,  or  a  tVniftlp  cathrttr.  It.  is 
inilnted  very  clusply  M*  th«*  irrilalifoi  ncrnflioned  by  a  vflBcuIar 
urfthrnl  tumor,  or  by  an  irritable  bladiler;  but  exploralion  r.f  ilie  viscus 
will  always  delermine  the  rliaK""*''*'-  Tho  larger  calculi  can  he  Celt  from 
the  va^un  if  Urm  pressure  be  made  nc  the  same  time  above  ibe  piibee. 

I*arge  cwk'uii  may  be  met  wilLi  in  very  younR  lemale  ehildreu.  I  have 
removei)  &  uric  aciti  ealt-ulus  iiicrtisled  willi  |>)iLW[>batra,  meaetirioe  1 1  inch 
in  length  by  i  inch  \u  breaiilb.  frum  a  lillle  girl  four  yenre  tiUi.  The  etooe 
wa»  removed  uiit»rokcu,  by  gradual  dilaLatiuu  of  the  urethra. 

In  the  uduU  Ibey  may  attaiu  a  very  large  size.  I  have  exlraclKl  une 
from  a  youug  wumaii  mL-iisuriug  ^  iuches  lu  ha  )<mg,  aud  6  iiiuhes  iu  its 
.'Short  circumfL'reuce. 

Calculus  iu  the  female  bladder,  if  allowed  to  roiuaiu  unrelieved,  will  not 
only  ucouiuu  the  various  mnrbid  couUitiomi  tn  the  urinary  organs  that  have 
been  described  us  fullnwing  the  loMg-contitiued  pre&euce  td  stone  iu  tlie  liialo, 
hut  will  give  rise  U>  diseased  etnteis  peculiar  to  the  female.  Thus  the  sluuB 
may  be  spontHneoHsly  dischargeil  through  the  urethra;  if  nf  Hmnll  aize, 
without  Boy  bad  rci^ults  following;  hut  if  large,  by  n  pnicesH  of  ula^rat.iun, 
in  Consequence  of  which  [wrmanetit  incontinence  of  urine  will  remain;  iirit 
may  elotigh  through  into  the  vagina;  or  lastly,  il  may  oH'er  a  wriona  ob- 
stacle during  parturition  to  the  descent  of  the  fVptal  head,  when,  if  it  cannot 
be  pushed  aside  to  be  dealt  with  ailerivarda,  It  must  be  cut  out,  or  cmnt- 

■my  bo  performed. 

Removal.— A  atone  niav  be  extracted  from  the  female  bladder  by  one  of 
three  methods:  1,  by  Litliectasy.  through  a  ililntcd  virethra;  2,  hy  Litb- 
otoniy  ;  3.  by  Lithotrily.  These  different  operatioiia  cannot  be  employed  in- 
discriminately, hut  each  one  i«  more  especially  adapted  to  certain  kinds  of 
calonltii'. 

I.  Litheota«y  may  ho  [M^rfiirmed  in  two  way* — cither  by  simply  DHafing 
the  Uetihru,  nr  tdtte  by  Jncininif  the  Mucou*  Memfimne  at  the  fiiimc  time  that 
the  cannl  i»  bi-ini:  I'xjinnded. 

a.  Simple  Dilatation  of  the  urethra  may  bu  t- B'ecied  quickly  by  the  iotro- 
ductioii  (if  a  thret'-bladefl  dilator,  whi(^h  in  rapidly  screwed  up.  tn  thi«  way, 
in  a  few  mintiLen  the  cannl  may  be  eaitily  dilated  Huflieientiy  to  allow  the 
intradu<:tlon  of  a  pair  of  foreepti,  and  the  extraction  u(  n  calculuit  of  mode- 
rate itize.  ^)n:ie  Surgeons  prefer  a  t»low  pnicciM  of  ditalatinn,  e<intinued 
through  many  h<nin<,  by  nifaii!*  of  a  sp-mge-tent ;  but  this  appeani  to  me  to 
no  advantage  over  tlie  more  mpid  expHn-tion.  and  has  the  very  decided 
vantage  of  prolonging  the  jmlieut'a  ^iiHeriDgs.  In  the  sbseuee  of  a 
per  urethral  dilator,  it  is  always  euttv  to  dilate  the  canal  by  means  of  tbe 
With  tliia  view  a  director  is  Grst  pst^^e<],  and  along  this  the  8urgeoo 
gradually  iu^lnuntvs  tht  tip  of  his  finder,  and  then  soon  succeeds  in  expand- 
ing the  urethra  i»ul]ii*icutly  for  all  ordinary  piirpoee^. 

0.  Dilatation  may  he  enifdoycd  coujoimly  with  incision,  in  order  to  pre- 
veut  iiijuriuut!  stretehiug  of  the  urethra,  and  consequent  laceration  oi  its 
mucous  mcmhrauc.  The  incision  should  be  made  after  the  urethra  has  been 
dilated  to  some  extent,  a  probc-poiotcd  bistoury  being  introduced  by  the 
nde  of  the  canal,  and  the  mucous  mcmbraue  divided.  Brodic  made  an  in- 
ciaiou  directly  upwanls;  LibCon  dnwuwarde  and  outwards  on  each  side — ou 
the  whole,  I  think,  the  la-Jit  direction  for  tlic  incisiomf,  m  more  sjiaee  may 
thua  Im:  obtained. 

By  dilatation,  either  alone  or  with  incision  of  the  mucous  membrane,  small 
atones  tnay  readily  bo  extracted  ;  and  those  calculi  that  are  fornu-<l  hy  tbo 
phoephatic  incrustation  id'  foreign  hoilies,  may  hi;  removed  in  this  way.  I 
nave  Ihua  extracted,  by  dilatation,  a  full-Bized  gum-clastic  bougie  from  the 


986 


DUlNABr   OALODLUS    AND    LI1 


bladder  of  a  youn;?  woman.  In  ttic  removal  oj 
ever,  the  gnaii  objpciian  u>  thix  opi-ratioD  u  tbe  Hal 
urine  r<-'siiltiri^  from  it.  It  in  <lif])uult  t')  ttay  to  what 
be  ililatvH  wiilititil  iticoutinL^uou  riituUing  ;  tliie  roust 
fereol  iniliviilimls.  It  certainly  {-an  lu-  ex|>au<lud  I 
introduccinn  of  the  iniiex-linger,  anil  thn  extmcl.inn 
lines  in  diameter,  wilhtjiit  any  evil  reeullinjf.  liK 
that  may  be  ietl  afler  the  re.mitval  of  hirger  calculi  t 
any  ine^ns  complete ;  hut  a  weakened  state  nf  the  a 
reaulls,  an  that  the  patient  cannot  hold  her  urine  fa 
two  at  the  must. 

2.  Lithotomy  in   the  female  ni»y  be   perfnrmed 
Thero  are.  hnwever,  only  three  modes  of  praetiHins 
peiar  in  me  to  deserve  serious  attention ;  Ti£.tthe5i 
anil  the  Vayinal. 

The  Suprapuhio  or  high  rtpemtion  in  women  difl 
respect  (Witii  till-  Bjuiie  iinioedurc  iu  men  ;  except  ihj 
care  in  coni^e<]iience  of  the  difBculty  there  is  in  caut 
to  retain  enough  uriu«  or  ^ater  to  make  the  vtscua  ri 
pubes.  The  extravtion  of  the  elone  is  euny,  aa  it  can 
of  rho  fnreepa  hy  bein^r  pushed  up  frum  the  \-a(rina. 

Urethral  Lithotomy  U  a  very  simple  and  vHicieal 
in  plncinjj  llie  pxtiettt  in  the  lithotomy  innitioa,  i 
grooved  slaff  is  thi^n  introduced  into  the  bladder,  a 
toury,  jjuidfd  by  it,  ia  piished  Ihrmigh  the  tlwr  <A 
inch  and  n  half  from  the  meatus,  i\w  canal  heing^ 
wards.  The  forceps  may  then  he  readily  carried  ii 
calculus  uf  g-ood  size  removed.  After  the  bladder  \ 
sized  catheter  should  be  introduced,  and  lefl  in  th 
edges  of  the  urethra  brought  together  over  it  by  two 
auliire. 

Taginal  Lithotomy  i»  an  operation  casv  of  perforn 
tieed  by  passing  a  straight  ^rt^ovcd  stntl'  into  the  hla 
well  down  against  the  anterior  wall  of  the  vagina,  anii 
left  index  finger,  A  Bcal]H?l  is  then  pushed  through 
vagina  and  inferior  fundus  of  the  bladder  into  the  gt 
ia  made  to  enter  ju8t  behind  the  urethra,  and  is  then  n 
li  inch;  through  the  aperture  thus  made  the  forceps 
extracted.  The  iuclaion  into  the  bladder  through  ih 
should  be  brought  together  by  metallic  sutures,  as  io 
vesico-VDginal  G*tula,  and  may  thus  be  aucceasfully  o 
by  J.  Lane,  Avcling,  and  others. 

On  Comparison  of  these  three  operations,  urethral  i 
easiest,  the  least  severe  at  the  time  of  its  ]*erformanco 
be  attended  br  afler  evil  consequonees.  It  is  quite  s 
tion  of  all  ordinary  calculi.  The  only  possible  evil 
18  the  want  of  union  of  the  incision.  But  should  thi 
cedure  at  a  subsequent  period  can  easily  remedy  the 
bo  left. 

Both  the  high  and  the  vaginal  operations  are  easy  ( 
high  operation,  there  would,  with  care,  he  but  little  rl 
toneuni ;  and  the  chance  of  urinary  infiltration,  whic 
in  the  male,  may  be  prevente<)  in  the  fenmln  by  the  i 
catheter  into  the  urethra.  The  vuginnl  operRtii>u,  tin 
anoe,  is  open  to  the  objection  of  possibly  leaving  a  pel 


LITHOTHITT    IS   VOUBS. 


98& 


If,  however,  the  lips  of  ihe  inciaiou  bftvo  not  been  bruised  by  ilie  forceps,  or  in 
the  extraction  of  the  stone,  ami  be  immctliately  brou>tht  together  by  metallic 
sutures,  the  risk  of  a  fistula  is,  after  all,  not  great.  Vagiual  litiioloiuy  may, 
in  some  casc«,  be  the  only  alternalivR.  I  extracted,  by  this  operniion,  a  cnl- 
culua  measuring  eight  inches  by  t»ix  in  circumference,  from  the  bladder  of  a 
woman  twenty-thrte  years  of  age,  who  had  nutTered  from  nymptonis  cif  stone 
fnmi  rhildhood.  The  utoiie  by  itd  size  offered  ao  MriouK  nu  tjbiitacle  tii  the 
descent  of  llie  Iwlai  head  tltiring  fiaritirition,  tliat  cTAiiiotomy  had  been  ren- 
dered] neer-«8nry;  the  niiterior  vaginal  uhII  had  been  a  good  deal  brnined,  and 
I  fearetl  tliHt  Mtoiightug  of  it  might  Uke  place;  heac«,  I  extracted  the  stone 
by  the  vajjinal  mtihiKi. 

Lithotomy  la  not  i><j  dnngeroi])*  tin  operation  in  the  female  a»  in  (he  male ; 
yet  deulh  uecasi^juBllj-  iiccui»,e8i»eeiHlfy  iu  feeble  children,  from  cystitis  and 
l^eritunilie,  more  particularly  if  itie  extraction  uf  the  stone  buve  been  tedious 
and  ditijcuil,  the  bludder  being  much  manipulated. 

3.  LilhotlHty  iu  the  female  rekjuirea  to  be  pructiwd  on  iho  same  priucijiles 
att  in  thu  male.  The  details  of  thu  o|ieration  ditlt^r,  liowever,  iu  some  itn- 
IHirtaut  purtitiular:;.  The  chief  ululuclc 
in  the  perliinnuuce  ivf  the  o]H-rution  in 
tlio  feiMule,  conuibU:  iu  the  ililhuully  with 
which  the  bladder  ivtaim^  urine  or  water 
that  ia  injected  iiiLu  it.  In  couHeijuence 
uf  lhi»  there  ifi  not  only  great  ditticnlty 
in  Mtiziug  the  etoue.  the  bladder  collupe- 
ing  and  tailing  into  fnlds  around  it,  btit 
aUu  danger  of  injuring  the  njucoiii*  mem- 
brane with  the  liihotrite.  Iu  order  to 
cause  ihe  bladder  to  retain  the  necessary 
qusDiity  of  urine,  the  pelvis  must  be  well 
tilted  up,  and  the  urethra  compressed 
against  the  tithotriie.  It  ia  vrell  not  lo 
dilate  the  urelhrA  before  tt^eintriiductinn 
of  the  instrument,  «-■*  the  incontinence  i^ 
thereby  increased. 

The  ordinary  male  lithotrite  is  not  a 
verj-  ciiuveoicnt  iuittrumcnt  to  use  in  the 
female  bl«d<lor,  thc^  handle  being  awk- 
wardly long.  This  is  especially  the  ease 
in  female  children.  Heoce,  I  have  found 
it  ooQvenienC  to  hare  a  shorter  instru- 
ment constructed,  with  which  it  ia  far 
more  easy  to  manipulate  in  the  female 
bladder.  If  uriue  or  water  cannot  be 
retained,  the  calculus  may  more  safely 
be  seized  and  crushed  by  means  of  a 
email  and  strong- bladed  pair  of  lithot- 
omy-forceps ;  or.  if  the  stone  bo  largo, 
by  a  crushing  iuelrument,  made  of  tiie 
shape  of  that  4lepicled  in  Fig.  i)05.  In 
performing  lilhotrity  in  the  female  it  is 

uol  necessary  lo  pulverize  the  eah'iiluH,  but  merely  t«  break  it  up  intn  frag- 
ments of  such  n  size  as  to  admit  of  ea»y  extraction  through  the  urt^lhra. 

Aller  the  stone  has  hfen  broken  up,  the  urethra  ( nnlens  thitf  haK  [irevioUHly 
bvou  done)  niuy  be  diluted  by  meuns  of  the  thri^e-bladcd  iii»tnimenl  to  a 
mnderato  decree,  the  larger  fragnientH  removed  by  means  of  u  pair  of  slender 


Pig.  vol— Crutbar  Tot  1iirg«  C*loiilui  U 


990 


niSKASKS   OP  THSBLADOKR. 


furoept),  and  the  detrittitt  and  sniuller  rnign](<t)t8  cleared  out  of  the  l>U<1rler 
bjr  repeattMj  tnjvclionA  of  t«pi(I  w:il«r,  ur  by  an  t^vaciiator,  such  aa  is  useij  in 
tm  male.  The  whole  uf  the  fragmeatji  nuii  detntus  ehouiil  be  removi^d  at 
one  sitting.  The  sborlnew  and  wide  capacity  yt'  the  female  urethra  will 
rendily  allow  the  escape  nt*  any  detritus  that  may  unavoidably  be  left. 

For  all  calculi  ia  the  fenmle  bladder,  except  thnse  a(  the  very  largest  lavi, 
this  operatioQ  is  the  inoel  appUcuble.  I  nave  in  this  way  cruened  aatl 
extracted  at  one  sitting,  from  tlie  bladder  of  a  ladv  about  50  years  of  age,  a 
ph(»phiitic  calculus  fully  a»  larj^e  as  a  hen's  egg.  By  ihie  operation  the  stone 
may  be  rcmoveti  pieccmenl  and  at  once,  withuul  the  necessity  of  dilatlDg  the 
urethra  to  sucli  a  dcji^ree  ae  to  iucur  the  ri^lc  of  incjntinence  of  urine  reanlt- 
iag.  Litliotrity  may  be  had  reeoirrto  to  at  nil  ages,  in  the  very  ynoug  as 
well  08  the  old,  I  have  crushed  and  siiccc7«ftiEly  removed  n  lar<;e  calculus 
from  R  child  three  and  a  half  yoar^  of  age,  the  youiij^t  patient  on  whom 
I  have  ojieralcd  by  this  method.  Althuii»h  the  urethra  of  so  j^oung  a 
female  child  cannot,  wiihoul  danjier  of  iiicontincuce,  bo  ranch  dilated,  yd  it 
inay  ^cly  and  eaeity  be  enlarged  sufiicicDlly  to  admit  a  uodcraCe-«ized 
litholritc. 


I 
I 


CHAPTER     LXS. 


PISBASRS  OF  THK  BLADDER. 


COSOENITAL  MALPORMATIOK. 

Extroversion'  of  rnr.  lli.Ar>r>i-R.cooflitttii>R  in  an  absence  of  the  anttnor 
wall  of  the  orgau,  with  deficiency  in  the  c<ir responding  part  of  the  nbduininal 
parietM,  is  occasionally  met  with  as  a  congenital  malfurraatiou.  It  may 
occur  in  either  sex,  but  i»  must  common  in  males. 

This  condition  essentially  c^)i)sit4t#  in  an  »rre»t  of  development,  in  couiW' 
qaeuce  of  uhicli  the  anterior  part  of  the  ftelvic  girdle  is  dclicient,  the  bodies 
of  the  pubic  buuee  being  imperfectly  developed  and  the  eviuphyfitB  being 
absent-.  The  recti  niuscTcs  separate  at  their  lower  part,  auJ  ihusb  ubli^uelr 
oulnanle  to  be  iuwrtcd  into  the  lateral  ubuiiiionts  of  the  pubic  bonen.  A 
triangnlur  stmiv  le  ihuo  left,  which  i^  HUcd  up  by  the  posterior  wall  of  the 
bladJcr.  which  i^  (continuous  with  the  common  inieguiiiciits,  the antmor  wall 
being  abecut.  uud  the  interior  of  the  bladder  cxpu6«d.  The  clofl  coiumonly 
extends  up  to  the  spot  at  which  ihu  umbilical  cord  eiitera,  ko  that  the 
umbilicus  ID  wanting.  Tlia  pcni^  is  deil  along  its  dorsal  ue]>ect.  exposiag 
tliu  Ihior  of  the  urethra,  forming  the  coudition  known  as  ejiiH)>ttdiaa.  The 
poRtcrior  wall  of  the  bladder,  being  pushc^t  forwards  by  the  preflsnre  of  the 
abdomiual  viscera  behind,  forms  a  rounded  tumor  about  the  8ize  of  a  small 
orange  jiieC  above  the  pubt«.  The  surface  of  thiu  tumor  ih  reil,  vascuUr,  and 
papillated,  evidently  (:nnipoe>^l  of  inucouu  mumbrane ;  at  its  lower  pnrt  the 
oriRces  of  the  ureters  will  bo  i^&oa  diuoharging  urine  in  drops  or  in  a  strMUB. 
For  H  full  description  of  the  mechanism  of  the  pawnge  of  the  urine  in  this 
malformation.  I  wunhl  refer  to  a  cant;  which  fell  under  my  notice,  and 
in  which  I  made  a  number  of  experimcnt«  on  the  rapidity  of  the  paamge 


I 


of  foreign  iiiHtt«rs  through  the  kidncTS,  rci>orted  in  the  Medical  Oatette  nf 
1845. 

His  mnl formation  ib  of  the  raogt  distrcwiog  kind.  The  oJor  cnDsiantly 
exhaled  from  the  peticDt  by  the  dribbliuff  and  dccom position  of  the  urioc  is 
R  source  of  BDnovfluce  tu  hiniM-lf  and  of  disgust  to  others.  Id  order  to  render 
hifl  presenoc  at  all  tolcrahle  to  olher»,  tliia  dribbling  must  be  prevc^nted' 
by  8ome  rnechnnical  eitnirivanco.  With  this  view  the  palient  should  wear  a 
properly  eon*lriieted  inslriinient  to  reerive  nnd  collect  the  urine,  o(m«i»liug 
of  a  hollow  shield  strapped  over  the  i»art,  coniniunieating  by  means  of  a 
tube  with  fin  India-rubber  bottle,  which  oay  be  attached  along  the  inside  uf 
the  thigh. 

IViwr(nien(. — T7p  to  a  cnropflffltively  recent  periiwl  lliia  condition  km  ron- 
•idered  incurable.  Of  late  years,  however,  »|>erations  have  been  devi.scd  wnd 
practisetl  with  the  view  of  covering  in  the  expf«c<l  bladder,  forming  an 
anterior  wall  tu  the  vikcus,  and  restoring  the  urinary  canal ;  no  an  to  protect 
the  tender  extroverted  surface  of  the  bladder,  to  prevent  the  pain  and  irrita- 
tion nrising  from  contact  of  the  clothes  with  it,  and,  by  giving  a  proper  con- 
duit to  the  urine,  to  tvhich  an  apparatus  can  be  applied,  to  save  the  patient 
all  the  annoyance  of  constant  dribbling. 

The  first  operation  for  the  remedy  of  this  nialfririnatioa  that  was  buccmb- 
fuily  perlurnied  was  done,  in  ItfoD,  by  Ayres,  of  ?iew  York,  in  the  case  of  a 
vuung  woman,  '2H  years  of  age.  He,  coiisequentlvt  ha^  the  merit  of  huvijig 
0«eD  the  pioneer  in  this  braucti  of  Surgcrr.  He  wn?  followed  by  Fuucoost, 
of  Philauelphiu,  and  i^ubgcquently  by  Ilolmes  Hud  Wood,  of  Loudon. 

Ayrea's  Operation. — The  operation  praclised  by  Ayrt'g  comprised  twogtejis. 
TLe  Dm  coui^i^ied  in  dii^sccting  douu  a  long  Hap  of  integument  uud  of  i;u{}cr- 
ficiol  fuacia  from  tlie  unleriur  wall  of  [he  abdomen  iibuvi:  the  bladder,  uud 
turning  thin  down  eo  that  the  cnlicular  Burtiu-e  was  innc^rmotit  and  lay  over 
the  expOHed  bladder  m  far  as  ita  inferior  brirder.  I,uleral  union  wrb  then 
secured  in  thiit  ]MKtition,  but  the  lower  part  uf  the  Hap  was  Ich  open,  eo  ne  to 
allow  a  fr<;e  exit  for  the  urine.  In  thio  way  the  bladder  was  covered  in  eom- 
pletelv  by  a  akin  Hap,  having  ibj  cuticnlar  surface  underneath,  and  conse- 
quently next  to  the  exposed  venic-al  mucoua  membrane.  The  inlegnmenls  of 
the  abdomen  were  now  auHicientiy  separated  from  their  areolar  connections 
wilh  ihc  miiacEes  beneath,  on  each  nido  of  the  reversed  flap,  to  admit  of  their 
sliding  forwards,  and  JH'ing  united  hy  mituree  along  the  mesial  line,  soascum- 

Eletely  to  cover  in  the  exposed  raw  surface  of  the  flap.  In  this  way  the 
lndd<>r  was  overlaid  by  integnmenlal  Ptructures,  which  readily  united  along 
the  mesifti  line ;  and  were  the  patient  a  male,  little  more  wonlr)  require  to  be 
done  than  tn  diMect  np  the  integiinientAl  i>lructures  below  thin  flap,  and  so  to 
clo«e  in  the  epispadias  and  form  an  anterior  wall  lo  the  iiictlirn.  In  Ayre»'« 
^Casi-,  as  thi^  patient  was  a  female,  the  second  utep  of  the  o|)eraEion  (which  was 
practiwd  after  a  lap«e  of  three  weeks)  consisted  in  fashioning  a  covering  for 
the  vulva,  by  dissecting  up  the  iinegiimenla  covering  the  pelvic  bones  ou  «itch 
side,aiid  uniting  them  to  one  another  on  themetiial  line  and  tuthe  lower  purl 
f  tiie  ri-ver*ed  flap. 
The  principle  of  the  operation  adopted  bv  PnucoaM,  Holmes,  and  Wood, 
fSB«Dtially  the  same  na  that  practtite*!  E>y  Ayre« — viK.,  that  of  raising 
te^uiniMital  tia^is  from  the  abdominal  wall,  and  covering  in  the  blailder  by 
turuing  the  cutieular  surface  uf  tbv«e  flitjis  tu  wards  It.  ijut  the  details  uf 
the  operaliuus  ditier  chiefly  iu  this,  that  thu*  llujw  have  bi>en  taken  from  the 
groiuK  and  lateral  aspects  uf  the  abdominal  wall,  with  their  b&sce  downwards, 
so  that  they  might  be  nourished  by  the  su[wrlicia!  branches  of  the  common 
femoral  artery. 


tfa 

I 


to  BMt  in  tlie  median  line,  anil  to  rover  Tn  the  a 
ftoes  or  the  twn  cntin  tlnro  being  in  coQMct  wii 
revened  umlii)icai  flap,  The  flapa  are  thea  aeoij 
pins,  each  pin  passed  ao  as  t»  transfix  bmh  the  gi 
umbilical  flap  beocfltb,  holrlinfr  ihit  three  Jinalj 


Wood'*  0|>eraUoa  fajr  1>*| 

(AlUf  Wm4.) 

•uturea  are  required  in  the  fia|ie.  The  edgmQi\ , 
from  which  the  flaps  have  boeo  rmlsed  are  then  fai 
piiii  and  wire  sutures  .'Fiji*  90S),  and  brcMd  atrig 
■o  u  to  BUpport  the  \mrln  and  to  remuve,  as  far  I 
the  flaps.  The  patient  muat  be  kept  in  ^'^  '~ 
kneea  drawn  up. 


ACUTE    CYSTITIS. 


S9S 


If  the  operalmn  be  siiccessfnl.al!  tlie  pins  ftiut  stitiires  may  be  remoTed  by 
about  the  sixth  or  ei^'htli  <ley.  H»tl  civatriuitk>n  will  probably  be  complete 
before  tlie  end  df  a  itumth  ;  the  expftsd!  surface  of  the  bladder  beiuy  com- 
pletely covereii  in,  leaving  uuly  a  small  openinj;  about  the  root  of  th^fiBaured 
peots,  to  which  an  ajtimrAtii^  may  he  ri-adtly  oilaptal  to  catch  tbe  iiriue.  If 
the  umbilical  (i»\t  bv  uot  of  Butficleut  Icugth.  wry  truublesuiue  tiatula-  are 
apt  to  be  lefl  at  it«  uugle».nrquiriiig  rurlL^-r  plastic  opvruLiuue  fur  their  cure. 
llixperieuce  lias  shown  that,  if  the  operutiuu  bu  lell  at  this  stage,  the  benefit 
u  not  pcrtiiaueut.  The  contractiuu  uf  tbi;  cicutriees,  and  the  constant  ten- 
dency  to  protrusion  of  the  mucous  meiubraui;  of  the  bladder  trora  beneath 
the  new  ojveriug  at  the  oiieniug  left  at  the  root  of  the  penis  TFig.  908],  lead 
to  a  gradual  iuerease  in  iac  size  of  the  opL-itiiig  and  a  partial  return  of  tlie 
»yi»ptoiu8.  To  prevent  this,  the  tisflured  penis  may  be  covered  in  by  the 
following  luelhod.  The  wlioJe  front  of  the  bcrotutn,  incluiluig  the  darlos,  ig 
raiwd  »u  as  to  form  a  bridge  of  skiu  connected  with  the  groin  at  each  side. 
This  is  lifted  over  the  penis,  and  placed  upin  a  raw  surface  prepared  hy 
turning  down  a  ndlar  or  flap  fmm  the  lower  arched  border  of  the  new 
bladder-cove rin^f  and  from  the  allies  of  the  iiretliia  and  penis  as  far  forwards 
as  the  glaiiB,  A  continuoue  wire  euture  is  applied  to  keep  the  flaps  in  place; 
and  the  transplanted  scrouil  structures  arc  united  to  the  border  of  the  bladder- 
covering  by  a  line  of  interrupted  auiurRs,  The  scrotal  wound  ia  readily 
cUwed  by  c<oiiie  wire  suiuref.  By  this  means  a  sort  of  urethra  is  formed, 
containing  the  muscular  tissue  of' the  dartoe  In  its  roof,  which  may  oven  give 
it  a  slight  power  of  contraction,  so  as  to  enable  the  new  bladder  to  retain 
small  <]uantiLies  of  urine.  This  second  stnge  of  the  opcmtion  'a  oflea  some- 
what interfered  with  hy  crccliotia  of  the  peuiB.  These  are  beat  contrcdlcd  by 
ice-biigs.  Thb  ktiecs  shouhl  be  kept  drawn  up  so  as  to  relic\'e  tension, 
oapec'iully  Id  the  (irsl  stage  "f  the  operation.  After  the  cure  is  complete,  th© 
patient  is  often  tmubled  by  the  grnwth  of  hair  from  the  under  surface  of 
the  umbilical  llap,  and  the  accitmulatinn  of  nhojtphttteA  upon  the  hairs  and 
in  the  angles  of  tlie  new  bladder.  This  is  nent  relieved  by  extracting  the 
haira  with  a  pair  i>l  forceps,  and  by  oiling  weak  acid  injections  to  remove  the 
accumulation  of  phospbatea. 


CYSTITIS, 

Idiopathic  iullamiuatiou  of  the  bladder  is  of  rare  oucurrcuce.  When  it  ia 
met  with  it  is  usually  iu  gouty  subjects  from  exposure  to  cold.  Acute  cys- 
titis most  tii>tniiioiily  origiuaU^  fniiii  trauuiatic  uJin»eH,  as  from  the  parage  of 
iuBtruments.  the  irritation  of  broken  frugnieiils  of  calcul  \i»,  etc.  OccHsionally 
it  arises  from  the  extension  of  gimorriiii'a  to  the  interior  of  the  organ.  It 
may  bo  caui^ed,  aleo.  hy  certain  irritant  poimtuK,  of  which  luiulbarides  ia  the 
most  importjtnt.  Occabionaily  it  m  ilirectly  dejiendent  on  decorn position  of 
retained  urine,  but  more  commonly  this  aggravates  iuftamnmtion  originating 
fnim  other  cnuHed. 

ArcTi:  CvKriTif*. — The  Symptoms  of  cyatitiH  consist  nnt  only  in  local  paia 
and  weight  about  the  hypigiwtric  and  iliac  regions,  with  tenderness  on  pres- 
sure Ell  these  situations,  and  a  good  deal  of  coiLstitiitional  irritation,  but  in 
the  tsxistenoe  of  extreme  irritability  about  the  bladder.  Ho  soon  as  a  few 
dropa  of  urine  collect,  thev  excite  so  much  irritation  that  they  cannot  be 
retained,  and  are  expelled  by  a  kind  of  spasmodic  or  convulsive  effort,  con- 
Htitnting  ^rnni/Kn/,  often  accompanied  hy  a  good  deal  of  tenesmus  and  great 
BuHering.  The  urine  will  he  found  to  he  high  colored,  mixed  with  more  or 
leas  mucus  or  pus,  and  ofU^n  tinged  with  blood. 

Terminttiion. — An  acute  attack  of  cyslilis  usually  tcnninatM  in  the  chronic 

VllL.  II. — ('•3 


904 


DISEASES    OP   THE    BLADDER. 


form  of  the  <Iis«isp,  and  t  litis  ^niliiiillr  uiidcrgoM  rMiIuiion.  Owasionally, 
hoWRVtr,  it  iPrminaleH  fulally ;  aiul,  wlion  this  i-i  tlie  cax,  the  urioc  hi-comoB 
exoeaively  I'oiil,  niid  dpnth  Uikce  pkuc  from  iKptic-rmin,  nuppuratinK  kidney, 
or,  more  rarely,  fnttu  iieriUinitis.  The  t(^tnI)crnturc,  which  at  first  may  hara 
b«n  clrvnte<l,  graduafly  ginks,  the  tnrifruo  bccomwi  brown  and  dry,  the  pulM 
rapid  and  wcnk,  nnd  llic  patient  sinks  into  n  dniwHv.  eeiut-comatose  Btate 
bt'forc  death.  On  cxaniinatiun  afler  dt^th,  the  bladder  in  found  to  coolain 
foul  urine  mixed  with  mucutt;  the  mucous  mrmbritne  is  of  an  intoii»e  purple 
color,  and  rre^jucntly  covered  in  partM  by  an  adherent  membranous  layer 
almost  like  that  of  diphtheria.  In  other  cases,  the  inflammation  has  gone 
on  t*i  u:nngrene  of  the  nnicoun  merahrane,  coltectioni>  of  pus  may  lie  found  in 
the  suiii'liincp  of  thp  wall  of  the  bladder,  and  not  wntrtnjin'nlly  tlie  perilooeum 
is  iniplicaled  and  dilliifte  peritonitiH  Dret  up.  OLTai^ioniilly  the  Itlndiler  has 
been  [lerforated,  and  infiltration  of  urine  in  the  de«p  areolar  tissue  of  th« 
pelvis  may  lie  met  with.  Very  commonly  the  misehitf  baa  extended  to  the 
ur«t«rsRnd  kidneys. 

Treatment- — The  firat  step  in  the  trealiueiit  is,  if  poesihle.  to  render  the 
urine  lc#e  irritating  by  diluting  it  by  the  free  admiutitlmiion  of  l>arley-watcr 
or  mncilacinous  drinks,  and  by  giving  liuuor  |KitA>«iu  or  bicarbonate  of 

Eotafih  iu  doses  suBietent  to  neutralize  it.  The  patient  must  be  ooutiued  La 
(h1,  and  hot  foiiieutatiuus  or  poultices  appljeti  over  the  lower  part  uf  Ihs 
belly.  L(>U(^- continued  hot  hip-bntlis  usually  give  great  ruticf.  To  tbcst 
ineauH  niav  lie  added  the  admimstratirm  of  hcabaoe  in  full  d<«es  and  toorpbta 
auppiKitorus.  No  s;K.'elfie  niediciucti  are  of  any  me.  No  iuetnimcuts  should 
be  usimI  during  ueulc  cyetitis  if  they  can  {M<»4ibly  be  avoided ;  hut  should 
the  urine  bi-cotne  foul,  an  attempt  muy  be  mnde  to  waeh  out  the  bladder,  as 
the  nuK'hanicul  irritaLiou  of  the  catbt'tcr  is  a  lees  evil  (ban  au  H4-irutuulatioa 
of  putrid  mocoe  and  urine.  If  it  he  necesBary  to  do  thi.''.  gn'-at  gfiitleoen 
must  be  ut^ed,  tb?  qiiiintity  of  tinid  injected  being  limited  u>  about  an  ounoe. 
The  dit't  niupt  be  ciirpfnily  n-guhiled  ;  no  salt  or  spiced  fond  must  be  allowed. 
Ab  r  rule,  ft  pure  milk  diet  will  be  lound  the  beat. 

CnuoNic  <_h'STrri!<. — Chrmic  cystiti."  in  by  far  the  most  oonimon  morbid 
condition  of  the  bladder.  It  mity  follow  acute  inflnmmation,  the  intensity 
of  the  process  grndually  auhsiding,  or  it  may  from  the  first  be  chronic.  It  u 
met  with  in  all  cases  of  9tone  in  the  b]a<Ider  afier  the  disease  has  existed  for 
a  certain  time ;  in  atl  old  an  d  tight  stricturea ;  and  it  i»  the  inevitable  ooose- 

?uence  of  the  presence  of  decomposing  urine  tn  the  cavity  of  the  bladder, 
n  mime  c&^es  it  is  apparently  of  gouty  origin  ;  but  perhaps  the  most  per- 
sistent fortii  is  that  wbieh  <(oinetime8  follows  gouorrhtea,  which  may  be  acquired 
in  yoMlli.  and  lend  to  life-long  roiiiery. 

Pathological  Changes. — On  examining  the  bladder  of  a  patient  who  has 
aufieted  from  chronic  cystitis,  the  mucoua  membrane  will  usually  bv  found 
to  be  of  a  <lark  gray  or  slate  color,  A«  iu  moat  cases  there  ha*  Ijcen  »<>me 
exacerbation  of  the  condition  immediately  before  death,  dark  red  »tr  purple 
patches  are  usually  seen  in  varioua  parts,  eHjtecially  on  the  »ummit«  of  (he 
rugn.  Dilated  and  tortuous  veins  commonly  ramify  on  the  surface,  tb« 
blood  in  which  is  usually  blackened  by  the  contact  of  the  decoin|WMiiig 
urine  after  death.  The  mucuus  membrane  is  tougher  and  thicker  than 
natural,  and  not  UDconimonly  there  is  distinct  thickening  and  induration  of 
the  aubmucoue  tieeue.  Ulceration  of  the  mucous  membrane  is  occasionally 
met  with.  The  muscular  coat  of  the  bladder  is  seldom  unaltered,  as  tu  Iha 
great  majority  of  eases  chronic  cystitis  is  associated  with  conditiona  wbiob 
interfere  wilJi  free  micturition.  If  the  obetruction  has  been  of  such  a  kind 
that  no  amount  of  iucreai«d  force  could  have  emptied  the  bladder,  as  ia 
many  cases  of  enlarged  pr»>talc.  the  bladder  is  dilated,  and  ita  muscalar 
coot  may  bo  tliinned  and  atrophied  with  an  excew  ol  fibroid  Uatue  between 


i 


d 


CHRONIC   CYSTITIS — PATHOLOGICAL   CHANGES.         996 


Fig.  t>11.^5iiuciilui  in  tha 
WhII  of  the  lilidJor. 


the  muscular  elements.  In  cas(»  of  strit-ture  of  tlie  urettira,  and  other  ob- 
itnictioDa  wliieli  can  be  overcome  by  increased  force,  tlie  bladder  ia  nitiially 
eoatractetl,  and  its  muscular  wall  jifreatly  hy[)ertro|>hied  aud  thiokcnefi. 
The  hypenrophictl  fasciculi  of  iiiuacular  tissue  form  folds  or  ridges  beneath 
the  mucous  membrane,  havinj;  irregtilar  dejires-tiotiK  between  tliem,  so  as  to 
cause  tbe  interior  of  the  bladder  to  re:<emble  somewhat  tlie  inside  of  one  of 
the  cavities  of  tbe  heart,  with  its  projecting  cohimiue  carneie.  The  hyper- 
trophy is  usually  dop^^udellt  on  the  same  cause  that  has  given  riae  to  the 
dirunic  intlammatiou,  but  in  s^fuie  cases  cvi'titis  alone  may  cause  the  hyper- 
tnpkr.  It  wouhl,  then,  seem  to  be  due  to  the  obstruction  caused  by  the 
thick  ropy  mucus,  which  reijuires  greater  force  for  its  cxpulsiou  than  healthy 
arine,  and  it  is  consequently  only  an  indirect  otTect  of  the  iuflammalitm. 
SaccuU  are  commoulv  found  ])rojecting  at  the  (HMterior  and  lateral  parts. 
These  are  of  two  kimU,  both  of  which  are  formed  l)y 
projectious  between  the  lasficuli  of  the  wall  of  ihu 
oladder.  [n  the  lirst  and  Icaitt  commou  kind,  the 
muscular  as  well  as  the  muooutt  coat  is  puiihed  out- 
wards; in  the  fiecond  form,  the  mucous  coat  alone 
Jbrms  a  kind  of  hernial  prntriisiion  (Fig.  t)!!*.  In 
the  sacculi  thus  formed,  accumulations  of  various 
kinds  may  take  place;  mucus,  pus,  phosphatic  de- 
posits, aud  even  calculous  concretions,  not  un  frequently 
being  met  with  in-tbcse situations.  The  urine,  mixtti 
with  mucus  and  pus,  retained  in  these  pouches,  where 

It  undergoes  decomposition,  is  the  cause  of  the  great  fetor  of  the  urine  in 
Mich  cases,  and  of  tnedifticulty  in  cleaning  such  bladders  by  washing  them 
out.  Sometimes  ulceration  takes  place  as  a  contieipiencc  of  the  irritation  of 
the  fetid  accumulation,  and  jKtrtbratiim  may  oci-ur.  folKiweil  by  i»eritoniti8 
and  death.  Ul'-erution  of  the  mucous  membrane  and  abscesses  in  the  sub- 
mucous tissue  are  oec:b<ionally  met  with  in  bladders  which  have  suffered  from 
chronic  cystitis,  but  they  are  usually  the 
result  of  the  exacerlmtion  that  often  sets 
in  before  death.  The  ettect  of  chnmic 
cystitis  in  causing  dii>eaae  of  the  kidney 
Mi  alrea<Iy  lK>en  described. 

Symptoai*. — Chronic  cystitis  gives  rise 
to  symptoms  closely  resembling  those  of 
the  acute  form  but  differing  in  <legrcc. 
Tbe  diseased  and  tender  blaildcr  is  uu- 
able  to  bear  more  than  a  slight  degree 
of  distention  without  |tain,  consequently 
there  is  a  fretiuent  desire  to  pass  water, 
and  tbe  urgency  is  such  that  the  rili^htcst 
delay  gives  rise  to  consi<ierable  su tiering. 
This  pain  Ivfore  micturition  ir>  iilways 
one  of  the  m<Mt  prominent  ^ymplonis. 
The  fluid  is  generally  ejeelcfl  forcihy  or 
eren  B[>asmiKlicully,  and  in  small  quan- 
tities at  a  lime.  Its  pas.fuge  niuv  he 
attended  by  8<mie  [)ain,  hut  .xi'ldoin 
enough  to  he  termed  strangury.  It'  the 
«jBtitis  is  not  complicated  by  stune,  there 
Is  distinct  relief  aUer  micturition.  The 
arine  is  turbid,  always  contains  an  excess  of  mucus.  In  slight  cases  this  is 
■mail  in  amount,  but  more  commoulv  it  becomes  abumlant,  viscid,  and 


%Q^"^^ 


Kii!. 'JI2.  —  M ii' ro^ <?(>)> io»l  A |i;ieiiraiii*CK  in 
Miii'iiiiof  Venicnl  ('atiirrh.  1,  I.  Mucik. 
'1.  K|<itlie1iinii.  :'..  i'lan.  4  "  Or^^HDii- 
tituliule.'."  iiipt  with  in  tha  I'rinc. 


«rsfc«nw*w 


•ta&A&o  or  TBc  9hAtnnLit. 

I  «v  ytv«aft  it.tMuiw'  "-ai  nod  A«i>tn>'  A" 

tWh MWiliiiiufm  thick.  TJ- 

m^^mft*  ami  fmrair^'  vt'*^*'''^** 

the  MCaad  «Wb  )'  l  haaBD  I' 

n  ii  4ui^  tM  tnu  ifntwUaci  «tf  tmma^ 
tfc«  vm.    Tbn  rwap*  of  ibil  <Aa^  •  • 
MHKiw  iC  fRM  iMwtMOi^  aa  lit  irrit«lli»ii  ivowaibM 1  ww  • 

iW  UhUct  H«M»M  th»«aM  iBinituii  <MUh  iwnbuatt  of  fOiM 

cMmtL.  h  «  pferafly  "  i  gr^H  '  thai  It  ukc*  i»^«c«  bjr  «  piww  4 1^ 
■cUBiiia,  has  1^  taaataamrmatthafenaent  bas  iK-ra  a  mstinr  of  ^if^ 
All  «<■■  —Jriyiag  aaMMrital  ftt— auuioo  l»  fxtir  ■. -mol  m^- 

■pofic Btfi aiwa^ ■!!?■  rf Tariaa» kJada.    The  tniMt  conri   j  •bmUni^ 

mgaior  ■kiauMcai. fcat wiA  Ait rwt-«h«pM  ^r^niim*  «r  bmcM^aktkm- 
i»f  arthr«  ■nfiau^  ar»  alMoal  inirariably  pn>«^iil.  Tb««e  nnummmi 
^nrr  -roemilr  rrcaixM  m  thm  aetaal  fanmm,  aod  Uk-j  an>  tuMoad  k  to 
carried  tato  tk«  bkAlcr  la  tooat  <■•■(•  bv  iiMtnjiti*tut»  i»«<l  in  m  wan^ 
of  tbe  variaat  iwitititww  apoa  wbtdi  Lb*  c7»iiil>  b  depeoikaL  IV  «n 
J— PI  ia  &Tar  of  tUi  vitw  caanot  U  fiillv  tIbooaMd  ktftv,  bai  it  ■w'  to 
brMrilaicd  UMtaxpvfiawM*  hv  liMcraod  oclMnbava  klM)»n  ihai  toaton 
vriM<im««  fronik*  biatM«r«iUi  pfT)t»j'  .i»t  tbe»it»»* 

«r  orfaaiKH  fioai  lb*  air,  iato  nwra  wt<  <  bese  biaitJ  « 

axfoaaA  ta  ika  iana  of  a  qiinl^laaiii,  cbu«*  •  ntK^i^  if* 

laMtmi  deeoauMntiaa,  bs«1  amy  be  anaarv*'  in  cwoIbci  ^ 

fiUamt  air  wttboat  IwoDai^g  aammBoaL  U  a  out  amTunmia.  aiMMV, 
ia  praetM*,  lo  meet  with  mm  ia  wbich  tb«  patsmt  hat  bnm  aaaU*  («- 
pMcljr  to  ««iptr  his  bluklrr  for  manj  mootht  ia  nnw«|DVBea  of  |irtatil^A- 
«aae,  and  y9i  thv  nrioe  baa  reoiaiDcd  aciil  aiid  fnw  trma  il0n«ii 
tbroagfaoai;  at  bM  a  mtbftcr  it  jiniiil.  and  niikin  thrw  dao  tba  umt 
decoaipuuBg  mad  auooi^j  aauMMuaal. 

TbeK  Jiids  eeeai  to  «B|gwt  Mraos t  j  that  the  frrmmt  ■  nminl  tito  < 
bladder  from  withouL  Ckta  are,  bowerer,  not  uolmpifQtly  bmI  wA 
nhirb  the  urioe  is  fnol,  imd  jH  Do  iiutnimcnt  has  vTvr  faciB  vamai. 
tbew  the  ezplanatxm  HmMed  if  iIhU  the  nacoi  ncmcd  at  t»v  mil 
cjMiiiB  hangs  to  tbe  orauia.  wtu«h  b  aai  wttbed  dcui  tt  armj  tH^at^ 
tnriiioii,  and  rtniAinntlv  fonut  a  channel  of  Odtnnimlcataiia  fcalava  tto 
exlpmal  air  and  itit-  bluddt-r  hv  tataat  of  whidi  deoocipaiilitai  mafaOaa 
int'i  ihf  bladdrr.  Urin*  «hicii  a  inard  with  a  cotnidcrtble  prnfonitti' 
alkaliuL-  inucuji  dwompoaef  far  luutv  rrjidlly  ihao  tbt  beallhr  novtiut. 

The  oDnelitutmntl  impUnnt  u(  chrtioit-  rraticu  uri*  oliii-fiy  d(M>  t*  ikf  ^ 
tnrbancc  at  at};ht  anrt  waul  of  rc»t.  uiilr*>  Oii-  urito'  •>  ••tl<.i«t<d  to* 
foul,     ir  thin 

Diiially  manib-at  itieii]M.>ivw,  irrrjii 
toai  tnngue,  nod  |iri>^rv»tiv«  vtiifli.iati<>n. 

Chronic  rjMilis  i»  oM  uofrmjiiciitly  fatal,  d«th  nwiltinf  in  l»<*  •[• 
from  aeptiorniia,  ur  fn^m  ext(.-ii>u<n  of  dMnai]>i«i|i(«  in  the  arias  aot 
areten  ami  [m-Ivch  of  tin-  kidneys  with  lupiMnt:  t-.  -  — 

in  'ilii  paiiiiitc,  tli>'  ir^-iwiniit  dtMiirliancr  mar  cau»t>  di  -  i-wyd-* 


in  hapDcn,  (he  ordiuttry  •yiutii'ioM  <■;  i*  |Jta*C 

lifi-at  llieoiMjIvw,  irrrcular  fuorile  dtoii^..-^^-.  '■■«  ■a«ff<* 


Treatmeiit  of  Chronic  Cyititii.— The  tmumroi  of 


^iliiii 


4  haw  refenmw  lo  iu  cause.     If  it  Iw  dn*  to  atMtta  or  Mnctfi^'' 


TKEATHHNT    OT  ORBONIO    CT8T1TI8. 


1)97 


Kilt  inipri)vcnicol  enit  hv  obtained  lill  tb»e  c&ums  are  rcniovr<l,  bot 

urHli-rtflkhi^  th'a.  it'  tlit*  »yiu|>U>iiia  nrn  viT^iii^  uu  tlnMO  uf  llit>  acuta 

ioviD,  litit  hi[>-tia(li8,  foiurntaliiitiH.  iiiuciliif^iuuuB  driiiKs,  liPuliaoi?,  with  alkm- 

^*"    "xl  p»|HTiiillT  [xjUtstt,  nill  Ih}  found  ntiwt  U!)«fu[.     The  bowels  mu»l  be 

:.'iilar  b;  «nenMla  or  cAStor  oil.     If  liiert!  »liuuld  Iw  strun^ry.  uiar- 

b(.>|]ailimaa  mtppiiaittirim  will  pve  nioel  rvlivt'.     Uy  thew-  nieaua  the 

may  be  prtvenu-d  fruiii  iissiiming  tlie  form  of  chronic  veftotl  catarrh; 

UII-.   Ill  uriler  to  iitc^urt*  tliia  it  is  most  imp^irtant  tliat  dpTotiipwitiKU  of  the 

ttlitit*  flIiiHild  bt'  {in'venied,  or  if  it  have  already  commence<)  that  i(  should 

btMT«8l4*d.     Fur  llic  prevention  of  thcdecompositioD  all  instruments  ahi^uht 

be  vasbed  in  rarbolic  acid  lotiou  (1   in  40)  before  beirij;  used,  and  then 

wnmaeA  with  "  Lund's  nil,"  com|kwed  of  absolute  phenol,  1  jmrl ;  enatnr  oil, 

"4  porta,  and  olive  oil,  15  part«  ;  or  uith  the  lullowing,  which  has  the  ailvan- 

•■yrof  not  crystallijiin^'  in  witter;  ahBolutc  phenol,  I  pan;  castor  oil,  7  [Mirta; 

nd  almond  oil,  K  partn.     The  peuis  may  also  lie  washed  with  boracic  acid 

ftr  wu-bolic  acid  lotiou  after  micturition  buU  covered  with  liut  soaked  in 

glyc<'nnr  of  carbolic  ucitl,  or  a  piece  of  salicylic  wool.     If  the  urine  baa 

once  lM*coin«  foul,  it  becomes  necewary  to  adopt  locnl  means  to  correct  it. 

govd  can  be  expected  frtm  medicinea  bo  bnt;  as  the  bladder  it  full  of 

d  mucus  and  urine.     The  bladder  mu«t  therefore  be  waahe<l  out  with 

le  anlifepttc  9»|i]tioD,  once,  or  if  nuctsary.  twice  daily.     This  »  done  ai 

i>w>,  a  soft  cnthclcr  is  passed  and  the  urine  drawn  nff.  about  two  ouucw  of 

I  are  then  thntwu  in  from  an  ludin-rubber  bottle  fitted  with  a  br«M 

_,       e  and  atop-c^>ck.     The  Duid  is  then  allowetl  to  run  outagain.auil  thb  b 

refMiile^l  till  inat  which  eume»  back  is  quite  clean.     \othinf^  is  ^Ined  by 

iairctinf;  larger  quaDtiiieft,  which  only  cnuN?  needless  pain  and  irritatioo. 

iMfW  is  another  method  of  wiisliiii;;  out  the  bladder  which  will  often  b« 

ftnsd  useful.     It  couatsla  in  atlKchiii}:  uu  I  iidiii-rubl>er  tube,  nboul  three  llMt 

kn^,  to  the  catheu-'f.     At  the  other  eud  nf  the  Luhe  is  a  glan  ftinDcl.     By 

tmisiDf;  the  fuQDcl  about  two  tl-ct  above  the  imiient's  body  and  pourint;  the 

ioid  into  it,  luffideut  fiiriH!  will  be  obtained  to  fill  iho  bladder.     When  saf- 

ftdeoL  fluid  baa  eaienNl,  the  funnel  may  be  allowrd  to  haufr  fiver  the  nide  of 

the  bed  over  a  veuel,  when  the  Auid  will  be  withdrawn  from  th«  bladder, 

the  lubt>  actiii;^  an  a  siphon.     Amon^t  the  mmt  uAcfii)  of  all  unltAeplic  in- 

3e«.*tioii9  i.4  itcruiiuifrauAle  of  p^ito^h;  the  indiitiun  may  l»e  injected  re{>cati'dty 

till   it  iVimrii  liiuk  purple,      tw  eflect   i»,  however,  very  temporary,  and   it  iil 

well.afttfr  till'  MiiddtT  hail  I>een  denned  bv  ('kady'ii  Auid  and  water,  to  thmw 

in  a  small  (pintility  <>f  Aume  more  ptitvcrtul  aniiflrplic.     Perhapn  the  b»tl  of 

thcM!  i«  ipiiiiitic.  iu  tiic  atrciitfth  of  lw«»  In  throe  [rraioH  to  the  ooncr  of  water, 

with  a  uiiitiiii  of  dilute  sulphuric  iicid  Rilde*!  fitr  wu'li  i;rmn  ;  of  ihi^  ali^iut 

nn"   dnu'hiii   tuny  l»c  left  in  ult^-r  the  catheter  is  witliriniwii.     4>therHiiti- 

iiU't  are  Uieful,  as  borucic  and  «a  cnuwiitratcl  solution);  bichloride 

rcury  >  (jr.  i  to  .y  i,  a  ci|)c«iilnite«l  poluttou  of  thymol;  d!luu>  nilric 

ad<l  (  "i  ii  to  .^i  \  etc.     One  of  the  must  etfioteot  of  all  nntiscptin*  I  have 

^i  tie  itxluform.  in  the  proportiou  uf  from  two  to  four  finiius  tn  the 

lee  of  water,  with  a  litlte  iiiucila}^  to  sutpend  it.     The  only  dru^;  wliicb 

IIS  to  exert  any  influeiux*  over  the  deotm position  of  urine  in  the  bladder 

i»  beniEoir  acid.     This  l^'ountw  converte^l  into  hippuric  acid,  and    ia  dis- 

ehnrv'^i  in  that  Cirtn  with  the  urine.     It  may  be  K>ve»  in  leu-Kntin  dneee 

thrt-c  or  four  times  a  tiny,  either  tn  pUI  or  in  a  mixture  containing  mucilage 

t  .  -  i-fH-nd  il. 

\'.  I1--H  br  ihfwe  mean-  the  urluc  has  been  hrmijjhl  into  a  tolerably  huaUhy 
V  'ni-tion  in  ciinccnit^l.  (here  mill  may  continue  a  con- 

•i<i        ,      .  .  ,1^  which  renders  it  prone  to  decom^Mwe.  and  ualvaa 

«Dtwtaol  cara  is  vxerciw^d  the  |mUenL  may  «|>eedily  relapse.     To  check  thta 


996 


bISSASSS   OF   THt:   BLADDKR. 


Tuious  astringent  injections  nre  oomctinics  nf  use,  ftuch  as  Lanuia  (gr.  j  fo 
5i);  llcetftU"  <>t"  k-ad  •t^r.  i  I"  AJ'I  or  nitratfi  (if  silver  (gr.  i  tojj). 

Bimiil(!iuenu»ly  nitii  nntWiilir  nr  n^trinf^cnt  iDJi-cliuiitt,  medif-al  trtAUnent 
tony  at»»  be  carrie*)  «iijU  Tlie  grealest  Iwncfit  will  he'  ili'rive<l  from  warm, 
gtiniuUting  and  hnUaniic  diuretics.  Amongst  ihe  best  of  these  ort^  iiU'usioo 
of  buciiu,  uv«  ur»ii,  aud  Iriticum  re|>en8;  but  these  remiidirji  are  usfltsB,  uo- 
Ivts*  laki-u  iu  quautiltes  of  a  {lint  or  a  ]>inl  and  h  hulf  iu  tli«  day.  When 
the  diitvusv  i»  very  cliruuic  no  reniedy  ap|ieai-«  to  me  to  |x«««)>8  m>  mucb  in- 
fluuuc«  owr  the  iiii;r«  ropy  niucijid  dtKchar^e  a^  tlie  baltmni  i>f  ct»paiba. 
Turpenliuv,  cubeb*.  tvud  tincture  of  the  8ciK|uivhloride  of  iit>n,  will  be  fimnd 
ueeful.  It  is  ulWu  diUicull  tu  say  Wforehaud  which  diuretic  will  ctiit  btst, 
aud  I  can  lay  donu  uo  precise  rules  U)  guide  the  prucliti'mer  iu  tide  re»pecL 
But  tb«y  luuy  olteo  be-  tried  vt  atleruated  with  iidvauU},'e.  Iu  many  case* 
great  relief  i»  yblaiued  froni  each  uew  reiueily,  but  it  ta  uiit  niaiMtntMwI. 

The  diet  mu»t  l>e  very  curefully  atttuded  to  ;  no  hot  or  npieed  i\x)d  should 
be  allowed,  uud  little  or  iiu  salt.  Alwholie  »tiaiulaut>t  »re  better  wilirelj 
aviiiiled,  but  should  any  be  reiiuired  weak  ^u,  or  Hullandri  aud  water,  or 
whiskey  un<l  water  aru  the  beot.  C^flee  niuet  be  etrictly  forbiddeu.  but  weak 
l(;a  may  be  takeu  without  re»tnunl.  Much  beueJit  luav  ufleu  Ih;  derived 
from  H  pure  iitilk  diet  fur  some  weeks  if  the  patient  can  bear  tt;  if  it  prove 
too  ririi,  the  cn'aiii  nuiy  he  taken  otT.  A  course  uf  oue  uf  tlie  alkuliiie  min- 
eral waters  may  sunietimei)  prove  of  Fervice,  especially  in  gouty  aubjecte. 
Tbe  body  must  he  warmly  clothed  and  all  ex|>osure  t<i  cold  avoidetl. 

Ikuit.miility  OF  TiiK  Bi.ADiiEH.— Tbis  is  not  a  diseaee  ;  it  in  merely  a 
eym]ilon).  It  ie  of  ver^'  frequent  occurrence  and  is  met  with  at  all  ages, 
and  arises  from  a  great  variety  of  nauses.  It  consials  iu  a  rrequenl  desire 
to  paea  water,  not  depemleiit  on  an  increase  in  the  quantity  of  tlie  secretion. 
Tbe  desire  is  usually  i^o  urgent  as  to  amount  to  actual  pain,  nnd  in  extreme 
ca^es  it  is  impossible  to  delay  tbe  act  by  any  voluninry  cflWrt.  The  nriiie  £s 
generally  ejceted  forcibly,  or  even  spasmodically,  and  in  smnll  quantitit^  at 
a  time.  It  may  or  may  not  b^  attended  by  strangury  ncconling  ta  the 
cause,  and  tbe  pait  aflcclwl.  Siningury  is  most  marked  in  Uioae  cases  in 
wbkh  it  is  due  to  ilisease  of  the  prostate  or  neck  of  the  bladder. 

Causes. — Irntaliility  of  the  bladder  may  arise,  as  lioft  already  been  «tat«d, 
from  a  great  variety  of  cause's.  These  difler  somewhat  as  the  disease  ufcan 
in  men,  iu  women,  or  in  children.  The  enuiKs  uf  irrilability  of  the  bladder 
in  mm  may  l)e  arrangeil  under  the  following  heads. 

1.  Morin'd  Coiitlilioiiii  of  lite  Urine. — If  tni«  Becrction  he  pretcmaturally 
acid  and  loaded  with  lithatee,  or  uric  acid,  it  is  especially  apt  to  occastoa  on 
irritation  of  tbe  bladder,  attended  by  pain  aud  a  frequent  deeire  to  expel 
tbe  offending  Quid.  Uriue  containing  oxalates  in  Inrjie  quantity  i»  some- 
times, th*'Ugh  more  rarely,  a  source  of  irritability  of  the  bladder,  which  in 
these  cHseif  is  perba|>e  iDereaee<l  by  tbe  morbidly  sensitive  state  of  the  Derroiis 
system  sometimes  coexisting  with  these  conditions  of  tbe  urine.  Amorphous 
phosphates  passed  at  the  eud  of  micturitiou  may  cause  severe  pain,  with  a 
coualunt  desire  to  pass  water,  lasting  for  an  hour  or  less.  It  passes  off*  us 
soou  Hs  the  ulkaline-cide  in  tbe  urine  has  passed. 

Iu  (fotiMrritability  of  the  bladder  is  not  UDfrequently  met  with.  This 
may  iu  nome  cases  be  owing  to  the  acid  character  of  tbe  urine  ;  in  others,  to 
tbe  excitatioa  of  a  distinct  gouty  inflammation  of  tbe  bladder  and  proatatc, 
coexisting  or  altcroaung  with  the  articular  funii  of  the  disease. 

2.  lienai  Dueatt,  mom  pnrticuhiry  tlie  hNlgenient  of  a  stone  in  the  kidney, 
will  ollen  oocastDnsyoipnllietic  pains  iu  iho  bladder,  with  much  irritubility 
uf  tbat  organ,  so  og  cloacly  to  eiinulate  vmeul  discus,  or  even  to  lead  to  a 
Biupicion  of  tbo  existence  of  stone  in  the  bladder.    Tuberculous  pyaUtis  will 


I 
I 


TRBATHENT    OF   IRRITABILITY    OF   THE    BLADDER.      999 

pwt  rise  to  Bimilar  symptomB,  in  fact  in  some  cases  the  irequeucy  of  tnictu- 
litioD  may  be  greater  than  id  almost  any  other  affection  uf  the  urinary 
ornDB. 

3.  Dueate  of  the  Bladder  itself,  as  a  chronically  inflitmed  state  of  its 
■DGOUS  membrane,  will  give  rise  to  pain  ami  irritation  uii  the  accumulation 
of  a  small  quantity  of  uriuc,  with  freijuent  desire  fi)r  its  expulitiou.  So,  also, 
when  the  interior  uf  the  or^an  ia  fasciculated,  or  t-acculated,  and  more  eepe- 
Oftlty  if  there  be  a  tumor  in  a  state  of  ulceration,  a  decree  of  morbid  irrita- 
bility viti  be  induced,  ofleii  of  the  most  severe  and  intractable  kind. 

4.  The  Tjodgement  of  a  Stotie  !ti  Ute  Bladder  will  always,  by  its  mechanical 
action,  by  its  weight  and  |ire&$urc,  by  mlliug  about  when  the  body  is  in 
motion,  irritate  the  interior  of  the  organ  ;  and,  in  fact,  the  "rational  syrop- 
toma"  of  stone  in  the  bladder  arc  simply  those  of  irritability  of  that  organ. 

5.  Injlummatiim,  Cleerathn,  Abneesii,  Tubercle,  or  other  Di«e*tse«  of  the  Pro»- 
tale,  aau  inflammation,  goiiorrhu^al  or  simple,  and  alscess  or  stricture  uf  tbe 
deeper  portions  of  the  urethra,  also  not  uufrequently  occasiuu  irritability  of 
tbe  bladder. 

6.  Various  Disecues  in  Neighboring  Organs  will  occaBiou  this  conditiun. 
AtDODgBt  the  nioct  frequent  are  fissure  and  ulcer  of  the  rectum  ami  anus, 
^es,  pn>lapud,  intestinal  worni!>,  gall-atones,  and  varicocele. 

SiagnoBit. — The  diagnosis  of  irritability  of  the  bladder  is  made  liy  the 
patient  himself;  but  it  is  often  a  matter  nf  no  little  difficulty  to  the  Sur- 
ceon  to  ascertain  the  precipe  cause  of  that  irritability.  This  can  of  course 
be  done  only  l)y  a  careful  surgical  cx:pliiralion  of  the  whole  of  the  urinary 
organs,  and  oficn  of  the  ncighltoring  parts ;  no  mere  inciuiry  into  the  nature 
1^  the  symptoniit  can  do  more  than  establi^ih  tlic  fact  of  the  e.\it<tence  of 
"irritability  of  the  bladder,"  and  atfonl  some  evidcnc-e  of  a  negative  kind 
as  to  the  alMcnce  of  certain  cjiuses.  But  nothing  .short  of  a  careful  surgical 
•zpluration  by  means  of  the  catheter,  finger,  and  sound,  of  the  uretlira, 
priMtate,  and  bladder,  can  enable  the  practitioner  to  i^tate  with  absolute  cer^ 
bunty  ou  what  this  condition  of  irritability  depends.  I  have  re[>eatedly 
•een  casM  of  stune  in  the  bladder,  and  of  pnuttutiu  di:*o:ise,  vainly  treated 
by  metlical  means  for  months  a3  ca.<€S  of  simple  "irritability  of  the  bladder;" 
tbe  existence  uf  the  real  caut!C  of  the  symptoms  having  been  overlooked 
altogether,  until  a  pro])cr  surgical  examination  of  the  urinary  organs  waa 
inatituted.  Su  closely,  in  tact,  do  the  symptoms  of  ve:jieal  irritation,  arising 
from  gout,  or  sympathetic  with  kidney  <li:<ea^c,  ^iinnhile  those  that  are  (K*ca- 
iioue<i  by  stone  in  the  bladder,  that  it  is  impoijsiblc  for  (he  mo^t  ex]>erienced 
metlical  practitioner  to  refer  them  with  certainly  to  the  riglil  cautte  without 
exploring  this  cavity.  I  have  known  iieveral  patients  who  had  been  oiier- 
ated  on  for  stone,  an>]  who,  Home  yeai^  afterwards,  ^ulfered  from  gouty  irri- 
tability of  tlie  bludiier,  imagine,  htit  ernmeoiiiily,  that  they  were  laboring 
tinder  a  recurrence  of  the  ealeuluij,  so  elosely  do  the  two  elatues  of  symptoms 
coincide  in  character. 

A  few  cases,  however,  will  l>e  met  tviih  now  and  then,  in  which, in  spite  ot 
the  most  careful  exaniinalion  u»d  prolonged  <ib;^ervation,  no  tangible  cause 
will  lie  found  for  the  irriUiliility  of  the  liladder. 

Tretitmeni. — In  the  treatment  of  irritability  of  the  bladder  it  niutit  be  Iwirne 
in  mind  that  this  condition  ix  not  a  siihiilaiitive  di^'a-e,  hut  is  an  a^MMublage 
of  8ynij>tnmd  resulting  from  tlie  Inflmiiee  of  a  trn-at  nunil)er  of  very  various 
causes,  which  must  first  be  removed  before  tli*'  bladder  can  recover  it.-<  inirinal 
•eosibility  and  tone.  When  oiuf  the  oceasjoniug  caii^e  has  U-en  ri'inovcd. 
whether  that  he  a  calculus,  or  g>iiit,or  pro>l:itie  di.-ense,  or  a  )iile,f>uch  loeal 
Teiical  irritability  aM  may  n-inaiii  may  )>e  removed  by  alkaline  and  mueila- 
ginoiu  drinks.    SedativL-s  may  he  of  u^e ;  some  in  one  case,  others  in  another. 


I 


1000  DISEASES   OP   THE   BLADDER. 

Opium  ftocj  belladonna,  cither  by  nioulh  or  iu  suppoeitory,  are  amongst  ibe 
b^t  Hi7nbanc,  or  luHian  hemp,  HuiuwtiucpiLiicnU;  and  chloral  ianniODf^ 
the  tnotit  generallj-  useftil  rcmwiiw.  The  diet  should  be  cureftilly  r^ulateil, 
and  warm  hip-hiUhtt  used  frequently. 

Cystotomy. — In  cases  in  which  no  tangible  cuumj  can  He  found  and  ro- 
moved,  ami  which  prove  liopelt-naly  intractable  to  every  means  of  treatment 
local  and  cniidtitiitional,  rintning  can  be  more  mijierable  than  ihc  stale  of  the 
iiofortiinate  victim  of  an  "irritable  bladder."  In  ttueh  extreme  and  lone- 
contintied  rascti  in  which  the  patient's  lite  ha*  l>ecome  a  burden  Lo  faim,  tn 
which  every  constitutional  remedy  and  Incal  nedative  has  been  UDaraiHoglT 
trie<i,  the  i<lea  has  occurred  to  Surgeong  of  incising  (he  inflanied  and  dtaeMM 
parts  by  an  operation  as  for  lithotomy.  Guthrie,  who  in  1)^34  strongly  rec- 
ommended this  procedure,  states  tl»at  Sir  W.  Blixard  successfully  practi»ei) 
it  iti  several  caaen  ng  far  back  as  IftOH,  dividing  the  entartre<l  pmstste  and  M 
neck  of  the  bladder  with  a  double  Rorget.  Ol  late  year*  it  has  been  pro-  % 
poaed  to  make  an  incisioj]  m  for  median  or  metlloOnteral  lilbotomy.  into  the 
Deck  of  the  bladder,  and  by  InlrtKlucing  a  caoutchouc  lube,  allow  the  urine 
to  drain  away.  This  operation  liaa  proved  8uccii>sful  in  the  bandu  of  Ver- 
neuil.  and  is  certainty  u  proper  proecdurc  in  hopelessly  chronic  aud  olber- 
wiee  incurable  ca^vn. 

Irritability  of  the  Bladder  is  Boys  may,  as  in  adults,  ariee  from  a  variety 
of  cauiH.il.  Auioi)};  Hil-  lose  ciimmi>u  ie  stVuio.  but  this  should  always  be  ex- 
cluded tir«t  by  eurcful  Hoiiuiling  leitt  lime  be  Itiet  in  useless  trealment  ofsotne 
other  MUj)p(*cd  cuust.  A  long  forcHltiii,  i-Mpeciatly  with  aec-umulatioD  of  the 
pmputiaf  eccrctiou  bcueuth  it,  nr  a  phiraiKis,  may  f^ve  rise  to  couridcrable 
frc(]uency  of  micturition  aud  pain  in  a  young  b[iy.  If  neither  atone  nor 
phimoiiis  be  pri^4-UL  tliu  urine  sliould  be  cxamiunl,  aud  piusiblv  a  dcpuailof 
uric  acid  may  be  present,  which  is  not  uncnmmrm  in  younp  chifdrcn  who  are 
overfed  or  exposed  to  an  impure  atmosphere  in  a  crowded  city.  If  much 
mucus  be  present,  or  even  pus.  it  may  be  due  to  chronic  crstilis.  This  ntTec- 
tion  flppear>  to  be  nnalogt^vus  to  the  strumous  inflammation  of  the  mucous 
memhrnnea  of  the  eyes,  nose,  and  throat,  that  commonly  occur  in  scrofulous 
children.  In  this  condition  the  child  pafaea  water  with  great  frequency  aad 
with  much  pain ;  the  urine  is  offonMve,  and  usually  pnosphstic ;  there  is 
much  uncRsiuess  complained  of  about  the  groins  and  aloug  the  penis;  in 
fact,  many  of  the  ordinary  symptoms  of  stone  arc  present.  On  sounding 
the  bladder,  it  will  be  found  roug;bcncd.  fasoiculatea,  and  often  containtag 
ftabjIouB  matters  mixed  with  mucus.  OccJisionallv,  though  rarely,  tnbar> 
cular  disease  of  the  uriuary  tract  is  met  with  In  chihlreu.  It  presenla  tba 
same  appearaucwf  as  in  the  adult.  Irritable  bladder  in  children  is  very  ft»- 
quently  due  to  liiread-woniis  in  the  rectum,  which  ahould  alwsys  be  soujiht 
for  in  all  doubtful  caaes.  More  rarely  it  may  arise  from  the  presence  criT  a 
polypus. 

The  'iWatmciU  cousixtti  in  removal  of  the  cause  when  this  is  passible,  tn 
the  Btrumou«  aflection  of  the  mucous  membrane,  if  the  uriue  be  font,  the 
bladder  niual  if  {Mwaible  be  cleaned  out  an  in  the  adult,  should  the  child  be 
old  enough  for  thin  Lo  be  done.  The  bladder  may  also  be  washed  out  from 
time  to  time  with  a  weak  solution  of  nitrate  of  silver.  Beyond  tbi»  the 
treatment  consists  in  attention  to  tlie  general  improvement  of  the  health,  in 
the  removal  of  intestinal  iritation,  in  the  regulation  of  the  di;^tive  fune- 
tious,  and  in  the  administration  of  copaiba  in  small  doses,  either  aluneor 
coni'>ined  with  a  few  minims  of  liquor  potosic. 

Irritability  of  the  Bladder  in  Women  oflen  simulalca  slnne  eo  cliwely. 
that  it  is  i»nly  alier  very  careful  sounding  that  the  Surgeon  is  sallsBiNl  that 
no  calculus  exists.    This  condiuon  may  arise  from  a  variety  of  cauacB,  eliiu- 


L 


ATONY    OF   THE    BLADDER.  1001 

Iftr  tn  thoee  described  at  p.  988,  aa  occasioning  irritabilitr  of  the  male 
bladder.  There  are  some  conditions,  however,  \a  which  it  occurs,  that  are 
peculiar  to  women.  1,  It  may  be  a  trulr  neurotic  or  hysterical  affection.  2. 
It  is  often  sympathetic:  being  connected  with  some  local  disease  of  the 
geDito-urinary  organs,  with  a  vascular  tumor  at  the  meatus  of  the  urethra, 
DF  with  some  congestive  afTection  of  the  uterus,  which  will  require  to  be 
cured  before  the  bladder  can  be  brought  into  a  sound  state.  3.  Prolapsus 
[^  the  anterior  wall  of  the  vagina,  drawing  down  the  corresponding  portion 
of  the  bladder,  will  keep  up  this  condition  ;  if  so,  the  prolapsus  must  be 
eared  by  some  plastic  operative  procedure.  Id  all  circumstances,  however, 
irhen  this  state  has  once  been  set  up,  it  is  very  difficult  to  remove.  4.  In 
many  cases  it  is  undoubtedly  due  to  the  irritation  produced  by  a  morbid 
Mate  of  the  urine,  depeodent  on  mal-aseimilation,  and  usually  connected 
with  an  excess  of  lithates.  In  cases  of  this  kind,  careful  regulation  of  diet, 
and  the  administration  of  potash  with  henbane,  will  afford  much  relief;  but 
the  complaint  is  of  a  very  intractable  nature,  and  under  the  most  careful 
treatment  will  often  continue  for  years.  5.  In  strumous  girls  it  maybe  due 
to  a  congested,  thickened,  and  irritated  state  of  the  vesical  mucous  mem- 
brane, similar  to  that  which  is  met  with  in  other  parts  of  the  body,  as  the 
erelids,  nose,  and  throat.  It  is  commonly  associated  with  a  muco-purulent 
diBchai^  from  the  vulva.  In  cases  such  as  these,  the  patient  requires  to  be 
put  upon  a  general  anti-strumous  treatment,  and  the  bladder  should  be 
moppeil  out  with  a  very  strong  solution  of  the  nitrate  of  silver.  This  is  beat 
done  by  dilating  the  urethra,  passing  a  silver  tube  into  the  bladder,  and  then 
through  it  a  small  sponge-probaug  charged  with  the  solution. 

ATOSY  OF  THE  IILADDEEL 

By  Atony  of  the  Bladder  is  meant  such  a  degree  of  weakness  of  this  or^n 
that  its  power  of  emptying  itself  is  partially  or  wholly  lost.  It  is  in  the 
great  majority  of  cases  a  condition  of  old  age,  and  is  not  to  be  confounded 
with  paralysis  of  the  bladder,  such  as  occurs  in  cases  of  injury  or  disease  of 
the  spinal  cord.  In  atony,  the  nervous  supply  is  unimpaired!,  it  is  the  mus- 
cular tissue  that  is  at  fault.  The  muscular  tissue  of  the  bladder  may  be 
impaired  from  several  causes.  By  far  the  most  common  is  the  chronic  strain 
to  which  it  is  exposed  in  over-distention  of  the  bladtler  from  mechonical 
cbetructton  at  its  neck,  arrniug  from  enlargement  of  the  prostate.  In  this 
condition,  if  the  dilated  bladder  bo  examined  nncroBcnpically,  its  walls  will 
be  found  to  contain  a  ;;reat  excess  of  somewhat  dense  fibroid  tissue,  amongst 
which  lie  scattered  patches  of  niuscuhtr  tissue. 

In  some  rare  ca.-*Of*,  atony  of  the  bladder  may  result  from  a  ainple,  pro- 
longed, voluntary  or  involuntary  over-<li.«tention.  In  such  cases,  the 
itructural  changes  just  dewriticd  would,  of  course,  not  l>e  present. 

Besides  these,  there  in  another  variety  of  atony  of  tlie  bla<l<ler  commonly 
met  with  in  early  middle  life.  tliou;rh  it  may  occur  at  any  age.  In  all  the 
caaoB  in  which  I  have  won  this  form  i)f'  atony,  it  has  bei'u  the  cotisc<(UPPce 
either  of  gonorrho'al  cystitis  or  nf  cystiti-i  following  lithotrity.  It  may  lead 
to  partial  or  complete  retention.  It  is*  of'ren.  but  not  always,  aiisociated  with 
veeical  catarrh  and  fetid  urine.  This  condition,  when  once  it  has  become 
chronic,  is,  I  believe,  Incurahle.  In  it.  structural  clinn'jea  take  place  in  the 
bladder  con.4cquent  U[)im  tlie  extension  of  the  chronic  iiiflaiiiiiiatory  process 
from  the  mucou!^  nierabranc  to  the  submucous  tissue  and  niiiscular  coat.  Its 
walls  become  lhickpae<I.  rugged,  and  poucla-d.  The  lilndiler  is  able  neither 
to  retain  the  normal  amount  of  urine,  nor  completely  to  empty  ileetf.     The 


retaiaed  urine  usuitlly  uiiderf^f^ea  deconipowlion,  and  this  conditloD  i»  verr 

apt  to  end  iu  fatnl  disease  of  tiie  kiHneyH. 

ExcIudiDg  nil  theee  coudilinus,  tliere  is  yet  another  form  of  atony  of  the 
bladder  v,  liicli  niiiy  be  refjanled  att  tlie  most  typicji!  variety.  It  i*  easentially 
acoodilitiu  of  old  age.  and  appefus  U>  be  uKeiiile  degenerative  chniijice  analiv 
gous  to  thufte  of  the  lieurt  iiud  other  orgac!)  so  comoioaly  met  nilh  at  th 
time  of  life.  Such  a  change  ocrurriii;;  in  a  bloiJder  caoses  its  dibteutiua  from 
alight  causes  of  ohetmctioa,  wttiuh  cuuld  be  readily  overcame  by  the  healthy 
or^an  of  a  younger  mau.  Thus,  we  nut  uofretjuejitly  see  a  dilated  aluoic 
bladder  occurriuj;  as  itie  result  of  stricture  of  the  urethra  iu  an  old  mno, 
JD&tcad  of  the  contmeted  hyp(-rlro)ihied  or^u  comiuoDly  met  with  as  tho 
result  of  this  disease.  A  »ln>ug  bladder  may  overcome  a  moderate  ainouuL 
of  obstruction  Co  iho  escape  of  the  urine — an  atouio  Itladder  utterly  fails  to 
do  so.  Thus,  we  see  tlint  a  condition  of  atony  of  the  bladder  niay  occur  in 
on  otherwise  healthy  rnnu  from  the  ohgtruction  of  prostatic  disease,  while,  on 
the  other  hand,  a  degree  of  olwlruction  that  would  be  hurmleas  to  a  healthy 
mau  may  cause  serioun  sympt^mia  in  one  whiwc  hlnilder  is  atonic  to  be^in 
with.  It  K  difficult  t«i  determine  in  meM  cases  which  is  to  be  rei^nte^l  as 
the  primary  conilitian.  The  tiict  that  atony  of  the  bladder  is  rartly  met 
with  in  women  wouid  siif:jrc«t  that  in  the  great  majority  of  euttes  meehauical 
obetruclion  from  enlargement  of  the  prostate  is  to  he  re^rded  oa  tiie  primarr 
factor  iu  the  production  of  the  disea.<ie. 

Symplomn.—Whc^n  this  condition  comes  on  alowly  as  the  reaull  of  advanc- 
ing yeant,  tlic  patient  ummlly  findn  that  the  urine  escapes  in  a  dribbling 
mauuer;  that  there  i.i  some  difficulty,  and  at  last  an  impueuibility,  iu  empty- 
ing the  hlatider  completely  ;  that  there  is  not  that  fnreihlc  ejection  of  tfco 
last  drops  of  urine  that  in  characteristic  of  a  healthy  tone  in  the  organ  ;  ai 


the  aame  time,  there  is  not  unfrcquently  a  tendency  to  the  dribblinf;  away 

'pa  tuwimis  the  end  of  the  emi88i<, 
ceaeation.     The  putivut  leela  a  deaire  to  paw  water  nioi-e  fre(|uenliy  iban 


of  a  few  dropa  towtml^  the  end  of  theemissiuu  of  urine,  and  after  its  apparent 


uwjal.  He  cauuuL  retain  his  water  for  more  than  an  hour  or  tw.» — is  oitea 
disturbed  duriug  the  night,  aud  if  he  does  uot  ut  ouce  obey  the  irnpulw,  is 
aut  to  wet  hiv  ciutbe«.  Thin  freiiueut  desire  to  pa«s  water  iii  du*?  to  the 
bladder  never  viuplyiug  ibielf,  a  certain  quantity — several  ounce* — of  residual 
urine  being  left  behind;  by  the  addition  of  a  small  quantity,  tlie  bladder 
becomes  overloaded,  and  the  desire  to  mielurat*>  n  felU  Tempomrv  relief 
Is  afforde^J,  but  as  secretion  contiuues  the  bladder  suuu  tills  up  again,  aud  so 
the  proce»s  goes  on.  Wlieu  complete  retention  uccun,  whether  this  tak« 
pluiit  i;milually  or  suddenly,  the  blailder  nlowly  enlarges,  rising  out  of  the 
pelvis  into  the  ahdunien.  streli'hing  up  into  the  hvpogaslric  region,  reaching 
even  as  high  as  the  iimhilietie.  On  examining  tlie  lower  part  of  tlie  aUlii- 
men,  the  organ  will  b«  felt  hani,  elastic,  rounded,  and  iiyrifortu  in  abape, 
prr)Jccting  above  the  piibea,  and  feeling  much  liki>  an  enlarged  uterus.  Id 
this  situation,  also,  percuafion  will  elicit  a  dull  iM)un(l ;  and  on  exploring  the 
part  through  the  rectum,  the  bladder  will  be  found  to  project  in  thiB  direction 
altHi;  aud  on  tupping  with  the  lingei?  above  the  pubcs,  tluctuaUi>n  may  be 
felt  through  the  wall  of  the  gut. 

The  distention  of  the  blailder  is  enmetimes  so  very  gradual  aud  plow,  thai 
the  uver-d intended  organ  luis  been  mistaken  for  au  abdominal  tumor.  No 
pain  and  but  little  ineonvenieni^«  is  felt;  the  urine  drihhlis  away;  but  at 
the  end  of  two  or  three  months  the  over-distended  bladder  is  felt  m  a  large, 
firm,  elastic,  and  rounded  tumor,  stretching  up  lo,  and,  perhaps,  aliore  Uie 
umbilicua.    GCdema  of  the  legs  may  occur  from  its  preaeare  on  tbt»  Uiao 

Atony  of  the  bladder  is  a  sufficient  cattse  for  incomplete  ret«ntifia  of  nrioa 


DIAGNOSIS   AND   RESULTS   O?    ATONT.  1003 

But  it  does  not  appenr  to  be  adequate  to  explain  the  complete  rctenUon  with 
disteDllon  of  the  bladder,  that  ie  coiuiuonly  seen.  For  this  to  occur,  there 
must  be  some  mechanical  olwtacle,  however  slight,  to  the  outward  flow  of  the 
uiDe — contraction  of  the  neck,  or  a  congested  or  enlarged  prostate.  Couid 
eomplete  retention  occur  from  a  merely  atonic  bladder,  we  should  meet  with 
it  as  frequently  in  women  as  in  men.  It  m  the  mechanical  obstacle  at  the 
neck  of  the  male  bladder  wliich  intensifies  the  ejects  of  its  atony  and  leads 
to  the  complete  stoppage. 

Al^er  the  bladder  has  once  become  diatendod,  the  retention  may  be  com* 

Slete,  but  it  more  commonly  happens  that  u  quantity  of  urine  continues  to 
ribble  otit  of  it ;  in  fact,' the  amount  that  escapes  in  this  manner  may  be 
Terr  considerable,  thouj^h  the  retention  continue  unrelieved.  This  reteniion 
wUh  dribbling  ia  a  condition  of  much  ])ractical  importance,  as  the  continued 
escape  of  urine  may  lead  the  patient,  and  even  the  Surgeon,  to  overlook  the 
true  nature  of  the  disease ;  the  more  so,  as  in  elderly  ])eople  retenttcm  slowly 
indiicetl  otten  occasions  but  little  inconvenience,  f  have  drawn  off  nearly  a 
gallon  of  urine  from  a  patient  in  whom  it  had  not  been  Buspected  that  reteu- 
tioD  existed,  in  consequence  of  the  continuance  of  this  dribbling.  lu  women, 
retention  is  not  by  any  means  go  common  as  in  men,  but  the  bladder  will 
■ometimes  attain  an  cnormoud  hIzc,  rising  as  high  as  the  umbilicus;  and 
mch  tai^  bladtlers  have  been  tapped  under  the  supposition  of  the  tumor 
being  an  ovarian  cy.-it,  or  some  similar  growth.  I  once  witnessed  such  a  case 
in  which  the  Burgeon,  to  his  surprise,  on  tapping  the  tumor,  drew  off  a 
qoantity  of  clear  and  healthy  urine,  instead  of  ovarian  fluid ;  fortunately,  no 
Dad  etiects  followed.  This  retention  with  dribbling  occurs  in  consequence  of 
the  bladder,  as  it  rises  out  of  the  pelvis,  elongating  its  neck  ;  and  us  the  body 
becomes  bent  forward  over  the  pubes  a  sharp  curve  or  angle  is  formed  at  the 
junction  of  the  neck  and  body  of  the  viscus,  thn>ugh  which  a  small  stream 
of  urine  continues  to  dribble  away,  nnd  escapes  rather  by  its  own  gravity 
than  by  any  cxpuUive  effort  on  (he  part  of  the  patient. 

Diagnntis, — Retention  from  Atony  can  ea^^ily  hi*  diii<rn(ised  from  retention 
frum  ObKintfiioti.  In  the  former,  on  introducing  the  catheter  when  the 
patient  is  lying  on  his  back,  the  instrument  will  not  only  readily  enter,  but 
the  urine  will  t>iniply  flow  out  in  a  «low  uniform  i<tream,  not  being  projected 
in  a  jet  by  the  contraction  of  the  walls  of  the  organ,  hut  rising  an<l  falling  in 
obedience  to  the  rcj-piratory  movonients,  or  to  the  contmctions  of  the  abdtmii- 
Dal  muacles.  In  retention  from  obstruction  there  will  be  experience*!  some 
difficulty  in  {mssing  the  instrument  at  suiiie  one  point,  either  in  the  urethra 
or  prostate;  and  when  once  it  is  introduced  Into  the  blachler,  the  urine  wilt 
escape  in  a  free  and  liir  prujecteil  stream. 

Jiesulta. — The  habitual  retention  of  a  small  (pmntity  of  urine  in  an  atonic 
bladder  which  U  incii|iuhU'of  <iischarging  ('oni|>letely  the  whole  of  its  contents 
occurs  much  more  I'reijuently  than  Is  suspected.  Tlic  qtiantily  thus  retained 
will  vary  fnim  un  ounce  to  half  a  pint:  the  patient  believing  that  he  has 
emptietl  hin  bladder.  The  oxit^teiiee  of  this  residual  urine  is  roa<lily  deter- 
minnl  by  telling  the  patient  to  try  to  empty  his  l)lad<ler.  He  thinks  he  has 
done  so,  but  the  intrtHluction  of  h  catheter  will  jirove  the  exi.-'teiu'e  of 
retained  urine.  This  condition  will  be  a  source  of  ireriouf  inconvenience,  and 
eventually  of  disease,  to  the  patient.  In  eoii^etjuenee  <d'  the  bladder  never 
being  e«)iiipletely  emptied,  there  will  he  fnqueiit,  r:udden,  and  alnwK't  irre- 
sistible call)'  to  ]nwH  urine,  ko  iis  to  simulate  irrituliility  of  the  bladder.  The 
retaine<I  urine  becomes  otIeiiHive,  nnnnoniaetd  or  Hc^liy  in  odor,  mid  mixed 
with  mucus  or  muco-pux.  The  eoii!>iituentf<  of  the  urine  become  reahsoHieil 
or  are  not  excreted,  derange  the  health,  give  ri»>  to  impaired  nutrition,  and, 
being  eliminated  by  the  skin,  irritate  it  and  occasion  iutnictahle  forms  of 


1004 


DISEASES    OF    TUK    BLADDKR. 


8kiu-<li8e.at<e.     I  have  »eeu  clironic  ecyj?ma  of  the  most  iaretcrale  ohar«?fpr~ 
prodiicc'l  in  this  whv,  «ml   yield  to  trciilnituit  onlj"  on  cure  Wiuj;  Uik^ii 
U>  keep  itie  bliiddtT  clunr  tiini  free  t'rttm  residiiat  uriue. 

Tbfi  ('(foci*  uf  i-otnitio'l  uriiit'  ami  of  reteiittou  iire  not  identical.  In  fet*tnt«l 
urine  l)>e  ^I'livntl  health  suOvrs,  the  |>»tioi)t  becomM  slowly  ])oiwDeil  hy  the 
iuubiliU'  tu  £vl  rid  mf  au  vxcretiou.  lu  rct4.>utiou  tJie  daugcr  us  tiior«  immv- 
<liat«  aud  <lirectly  depviidcut  ou  the  iiahilily  Ui  eccuudiiry  diseaw?  •)(  tb« 
biuddvr  imd  kidueys.  Subacute  cystitis,  fallowed  by  iuw  fever,  will  come  oa 
a«  the  rcfiiiit  of  tho  continued  over-dittlcntioo  of  the  bladder.  Thv  syiiiptorm 
are  eucb  as  described  at  p.  885  us  being  indicative  of  urinary  fever.  The 
patient  vuSen  from  cbilU  and  small  rigors,  followed  by  dcpreesioa  Hnd  low 
Bpirittf.  Fever  of  a  typhoid  ly|>e  cornea  uo,  with  brown  tongue.  uccwMoual 
rcLchings,  mild  delirium,  and  great  prflstratiuu  of  strength.  Thie  condition 
occuning  in  an  uged  mito  loa^  suHerinf^  from  atuuy  of  the  bladder,  with  must 
probably  an  uiiaoiiud  stste  of  the  kiiliievB  aeoondary  to  this,  is  comiu'mly 
latal.  it  is  thus  that  chronic  retention  from  bladder-atony  dtvtroys  life,  not 
by  iiloeraiioH  of  the  organ  or  by  extnivasation  of  urine,  which  doee  not  otrur 
in  the«e  cases  ae  in  other  i'om\»  of  more  acute  retention. 

Treatjnent. — Atony  *)f  the  bladder,  except  in  a  few  cases  that  ariMt  from  a 
Binf^le  nver-ilistention.  is  an  incurable  atteetiou.  It  is  dependent  upon  senile 
changpt*  in  the  viacus  of  an  organic  chnracler  that  may  be  relieve<l  hut  cannot 
be  I'emeilied.  The  great  danger  in  this  state  arises  from  the  retained  uriu«, 
even  though  retention  be  by  no  menus  complete.  80  long  as  this  reaiilual 
urine  is  in  small  quantity  no  harm  reiiult^.  £ven  when  it  Hceumula(«s  hi  aa 
tn  amount  to  several  ounces,  it  nmy  give  rise  to  no  symptoms  beyond  frequearr 
of  micturition.  Sooner  or  later,  however,  the  over-distcution  causes  some  irn- 
talion  (if  the  bladder,  and  the  urine  becomes  cloudy  from  exceee  of  mucu^ 
Dcifimposition  nf  tlte  retained  urine  then  frequently  takes  pUoe,  either  from 
extension  of  docomp>M<ition  down  the  urethra  or  aOer  the  passage  of  in»tru* 
nienls,  lU)  alreiidy  deHcribed.  It  niuftt  not  be  suppoAetl  liial  mere  retention  of 
a  amall  quantity  of  urine  &Her  each  act  of  mirtiirition  in  auflicient  in  itself  to 
cauiie  decomposition.  Xothing  in  more  comnrou  than  to  find  patientj)  who 
have  not  em|>tled  their  bladders  for  niiiny  months,  and  yet  wboNc  iiriue  is 
perfectly  normal  in  e%'«ry  respect.  The  statement  >iometim«i<  made  that 
decomposition  never  takes  place  till  after  an  inntrument  has  been  iHiRiieil,  is, 
however,  not  accurate,  although  in  the  great  majorilv  of  case»  iht;  urine 
becomes  ammoniacal  only  after  surgical  interference.  When  this  lakex  pla« 
all  the  symptonif)  of  chronic  or  subacute  cystitis  set  in,  l-'ehrile  diMurbancs 
of  the  typ«  of  chronic  septic  poisoning  sut«  in,  aud  death  may  follow.  Thia 
ia  more  esiwcially  likely  to  happeu  when  the  kidneys  are  affected  by  chronic 
iuteratitial  nephritis,  which,  ax  ulreadv  pointeil  out  (p.  >HiA).  a  a  common 
result  of  prolonged  ovcr-diBtoutiuu  of  tlie  bladder. 

The  primary  object  of  all  treiuuieut  in  ordinary  uncomplicated  senile  atony 
of  the  bladder  is  to  free  the  putli'ut  from  the  rv«iduat  urine,  which  he  U  no 
longer  able  to  expel.  This  cau  be  done  ouly  by  the  use  of  the  iraiheter.  aud 
it'is  the  duty  of  the  Surgeon  to  teach  the  patient  bow  to  u»u  thiE  instrument 
for  himself,  so  chat  at  nil  tinu')<  he  may  bo  ttio  ni:uiter  of  his  own  tituatiou, 
and  relieve  himeelf  when  netft»nry. 

The  commencement  of  *'  catheter- life."  as  it  has  l)«cn  appropriataK'  lormed 
by  Sir  Andrew  Clark,  is  nn  important  [K>ri»d  in  a  man's  oxistenoe.  For  when 
once  the  use  of  the  instrument  has  been  begun,  it  can  rartily  be  di«rontinue>I. 
Hence  it  is  well  not  to  begin  it  unnecH.iuarily  early.  But  it  ia  of  at  least  cqaal 
importance  not  to  fall  into  the  upiKtsite  error  of  delaying  itii  uati  tt>o  long. 
lest  the  residual  urine  be  allowtrd  to  accutmihite  lo  «nrh  an  extent  ns  lu 


INCOXTINBKGE   OF   ITBINE.  1005 

.  IOttrc«  of  (li»comfort  to  the  patient,  of  injury  to  hia  general  hcaltb, 
kOf  daugar  by  iuilucing  iseptic  (n.stiti»  «nd  ull  its  coiiconiiiant  evils. 

The  um  of  Uie  catheter  in  cwiee  of  atony  of  the  bladder  for  the  removiil  of 
reeidual  uriue  is  h  very  simple  buBiaegs,  and,  if  the  kidoeTB  be  eouud  and  the 
moat  ordinary  precautions  taken,  iinuttfaded  by  any  unngcr.  The  safcet 
catheter  to  use  is  a  sull  one.  Metallic  inetruniculs  oeed  not  be  used  by  the 
Surgeim,  and  ehauld  never  be  employed  by  the  patient  himself.  The  ordinary 
elbowed  proBtatic  catheter,  or  the  conical  one  with  a  biilboiie  end  of  modium 
size,  will  be  found  the  most  conveoiout.  This  ^liuuld  be  |>a8sed  whilst  the 
patient  is  Bianding  up,  mth  every  pdasiblc  care  and  genlleoesa.  Tho  inetru- 
nieiit  should  be  lubricated  uilii  au  autiseplic  uil.  After  and  before  use  the 
imiruntent  must  be  washed  iu  culd  earUuliuHl  vater.  bo  that  all  ehanc-i*  may 
be  avoide<l  of  tcrmcnlative  material  beinf;  carried  iiiut  the  bladdt>r,  and  thus 
leading  lo  putrefaction  of  the  urine.  At  liret  it  may  be  quite  Mufiirient  if  the 
residual  urine  is  drawn  olfeverj-  third  tir  secnud  day.  After  a  lime  this  will 
be  nN|uirctt  ouee  or  ti>vi(?e  daily,  UutJl  tli«  (latient  beounics  arcuKlonied  to 
ihc  ufceof  the  ctttUctcr  eli  uuoectjtsarv  exertion,  fatigue,  and.abote  all.cbilU, 
abouki  he  must  carefully  avoided.  When  once  the  habit  has  bcon  ^'fitabUshed, 
these  precautions  tnny  be  rc\&xed,  provided  there  u  no  evidence  of  renal  dUease, 
and  the  urine  continues  clear  and  healthy. 

The  cathc-tor  muitt  not  be  retained  lest  it  nceasion  subacute  eyatilis.  Tf,  as 
ol^D  happens  in  senile  atony,  the  prnstate  in  someirhBt  enlarged,  care  must 
betaken  that  the  catheter  refllly  enters  the  bladder,  and  that  the  dilated 
prostatic  urethra  be  not  alone  emptied.  The  vreiprht  of  the  residual  urine 
cauBCa  the  fundnti  of  the  bladder  to  pnucb  behind  the  prostate.  This  ]>nucb 
must  he  thoroughly  emptied  by  slowly  withdrawing  tlie  catheter  when  llie 
bocly  of  the  bladder  has  been  drninod.  Should  subacute  cystitis  come  ou, 
with  de>.tuupuBitiou  of  urine,  during  thu  treuliucul,  the  bladder  must  be 
vasbed  out  after  umptyiug,  with  antiseptic  lotions  of  the  periuauguaate  of 
potash,  quiuioe,  or  iodotorm. 

Wb«u  ouee  a  bladder  haa  iK-eurue  atonic  iu  advaueed  age,  it  never  com- 
pletely r«vovere  its  i-outraetilitv.  The  regular  use  of  tb«  catheter  becomes 
uuperative,  and,  by  lakiug  uif  tlie  habit  of  retention  and  of  uverluading  of  the 
bladder,  it  may  do  much  to  restore  the  uormal  contractility,  in  some  degree 
at  leaet.  When  once  fairly  eatablished,  "cathoterdifu"  may  continue  ior 
many  years  without  diKCouilort  or  appreciable  danger. 

Ho  niediciues  are  of  any  special  service  in  these  cuaea ;  except,  perhaps, 
nux  vomica  ur  strychnine  iu  small  doses  long  coulJnued.  The  general  health 
must  be  attended  l.ii  on  onlinary  princinlea;  and  It  uiimi  not  be  tlir^roltea 
that  one  great  dilliculty  and  source  of  diMiasc  in  advancing  years  is  ior  the 
^lem  to  rid  iiaeif  of  its  excreta— to  clear  away  itaown  asheii — from  organa 
and  tissues,  and  that  the  residual  urine  found  in  an  atonic  bladder  is  but  one, 
though  possibly  the  tnoat  obvious  evidence  of  this  lai^rk  of  power. 

The  treatment  of  thai  form  of  atony  of  the  bladder  which  arisen  in 
younger  subjects,  as  the  effect  of  gouorrhci'al  cyslttia  or  stone  In  the  bladder, 
consists  In  the  daily  use  of  tiie  catheter  with  the  same  precautions  that  are 
to  be  adopted  In  cases  of  senile  atiiay.  Whenever  the  urine  becnttiee  turbid 
or  offensive,  antiseptic  injectioua  must  be  used  to  clear  the  bladder.  All  this 
the  patient  may,  in  most  ca^es,  be  readily  taught  to  do  for  himself,  Wheo 
once  be  has  acquired  die  artuf  auto-cathctcrism,  he  may  pursue  the  ordinary 
busineas  of  life  with  comfort  and  without  peril.  But  he  must  never  relax 
his  care  of  himself,  lestsubucute  cyatiti^  may  come  on,  or  phosphatic  de|Hwita 
form  in  the  bladder. 

Incontlnknce  of  Uiuke.— This  term  is  usually  applied  to  all  caa»  in 
vbich  the  urine  is  passed  involuntarily.    It  occurs  in  three  forms:  1.  Paasive 


1006 


DISEASES   OP    THE    BLAI>DSa. 


irM 


iDDoatiiMnea  in  which  the  arine  :    " '  '  _  f^a^  a*  It  ti 

bIsdH«r  rvmrnutiog  empty.     2.   1  '  I«<UkT  with 

:cifuiuieii(.v  Id  which  tiiQ  UaUtlttr  u  vufiUnl   inTwIsBtuilf 
1  .   -  br  iu  (jwu  cijDiractioD. 

i.  fsMiTe  InoontincaM  sriaei  mow),  cominooly  frgn  pumlfM  af 
oT  the  bla'lder,  inim  ^iwiH  ur  iojory  of  tlw  wputMl  oord.  h 
iDCt  with  to  childnm  from  cauja  that  arv  UfA  cJearlj  MowtanaL  Oii 
■tata  that  it  has  b«ea  knowD  u>  ariw  from  iiapaetioauf  a  calcalat  m  i 
Deck  of  Hm  bUtlder  tu  >uub  a  way  ■■  to  preveut  iu  chuJin,  aod  j«i  Ip  i» 
saSek&t  nMim  for  ihe  urine  tu  naaa.  Verr  rare  caiiia  hara 
orcurring  ia  later  life  in  whiiui  it  wfta  tfuo  tu  vBlai^eanml  of  ite 
KibM  of  tha  pruatate,  with  a  niiddlv  hibe  ntual«d  beiwvca  ihaai  *n 
wmf  as  tf>  keep  tlium  apart,  and  yet  ooc  to  block  lh«  obbdIbie  iua  ifct 
Intabtmilnr 'Itwaseof  lh«  prwtate.  with  extcnalTa  ummeiiaB  af  ihtgll 
coaiplM'!  inmatiaence  may  iKvur.  Paaflivi;  iaoootliMiaee  b  uemiiamm 
with  to  women,  as  the  result  of  dilatation  of  th«  urvthra  fi>r  iha  nmmm 
MMK. 

2.  DiitcnCian  of  the  Bladder  with  Orerflow,  lu  It  i^ !  .  'noaa 
nay  b«-  due  Ik  ati^ny  of  tht^   ItUdtit^r  (|i.  liHt^I),  or  i  <            .,<'i]ial4f  d 
middle  loW  of  the  pmstate.     The  tSecvt  M'  iiUmr  iu  caiuuif  orerf**^ 
urine  have  lw«n  niraufy  descrihed  ;  overflow  fmm  pru«t«tJc  d  '"" 
iltacriUH)  eubM')uently.     It  i»  of  the.  utmmt  importaoo*  thai  thu 
flhoultl  Im  di>'lin>,^iL'ilie>l  frtmi  true  inc^niiiM-nce. 

3.  ActiTe  iQCOStineace  U  invt  with  lu'jst  fny|i]eutly  io  children,  aad  k, 
a  rule,  out  i^JUtftaul,  occurring  twly  at  uight.  It  occurv  almust  vxciiHtn 
iu  boys.  It  Dtwms  t^j  arise  to  8*>nw  casta  fn^m  Um*  naticot  Inaafi 
ovvr  ibo  H|iliiuclvr  ilurinK  sle^p,  so  sooo  as  a  sniatl  quantily  of  arias  h 
BCcuiiiulutvd  iK-tiiud  it.  Phis  troubletome  coodili-m  may  laM  tuatWll 
aad  is  a  miutlh;  of  grval  tnisvry  and  disounifuri.  I"  ti  it  u  ia 
casus  Byiii))n(lH>tic,  hrin^  (lvj>eudcnt  ou  the  irrilaii  -^hl  foraka. 
worme  in  the  ret-tuiu,  or  uf  a  )>ulypus.  Iu  other  oims  it  may  bs  m»l0f 
flTmpUiiu  of  HtiHK-  iu  the  bladder.  In  slrumooa  chtldrvn,  Doetamal 
tinence  may  tx-  prmlueeil  by  the  irritutiou  of  iirioe  cuntalni^  am  • 
L-rytiLule.  All  iheK- oonditioos  must  bu  carefully  Bought  fbrinerery 
reniove<l  if  {toaaihle. 

TVeiitmmt. — In  true  iocuntincow  little  ran  bo  d<»»e  beytmd 
uutieul  with  a  prufwr  fuilia-rubt)er  iirtiml,  which  caa  be  vom 
rh«  Lrcatment  of  uverUun  cnutiiats  vulely  in  the  iwrimlical  use  uf  thr 
(p.  100i>).  In  Llie  noctunml  inttrntinence  uf  children,  if  it  tw  not 
with  some  evident  stturce  of  local  irrilatioo,  which  Hhould  tbsa  be 
the  adrniniaualion  of  Ionics  will  be  found  usw-ftil — either  cpil: 
tincture  of  jK-rchloritlf  iif  inin,  nlnne  or  eonj" 
rtde».  If  there  be  irntnliun  of  the  mucous  ^ 
nilRiiiiiiilrutioii  of  nlk»tie;»,  in  cmiuiiotion  wIlli  a  i-'-- 
of  iron,  -t  n  little  copailm  niixtit  with  huni-r,  will  i  ' 
Colli  »{N>ngiii|^'.  li;;lit  clotliiu);  nt  night,  and  means  ratcitlnml  Ut 
habit,  aneb  a»  nakiiij;  the  diild  nt  th"  tims  at  which  it  geiMfmlly  aoi 
chaiigin;;  lii»  jHisition  iu  b«<l,  etc.,  should  not  be  umittsd.  Of  all  ivs 
f^r  ini-Miitinetic-v  of  urine  in  children,  bclladoona  ia  th«  in«Mt  aaeaM 
Ittngc-r  luUivcs  it  to  b«  given  in  full  doses;  from  10  to  DO  moMUim  ti 
tin^'t^lr^  tlif-o  linK-s  n  finy. 

Hy«terical  Eetentioii  and  InooatiBsaM  of  TIriD«  oot  oofivqaaBlly  m 
in   nervoiiB  jbtirl*,  ami   re<piirt<   to    be  trcatad    by  aoti-hvstcrieaJ   nm 
which   )>repnmtionB  uf  ncrctilorida  uf  imn*  ettber  altM>  or 
"i  bo  found  nK«t  useful.    Coltl  duoehes  aiv  alao  of  gnai  si 


TUBERCLS — SACCDLI  OF  THE  BLADDER.        1007 

In  casefl  of  hjaterical  retention,  it  may  sometimes  be  necessary  to  use  the 
catheter;  but  in  such  circumstances  it  is  well  Di>t  to  employ  this  ioBtrunient 
too  frequently,  as  the  j>atient8  are  apt  to  get  into  the  habit  of  having  it  intro- 
duced, and  will,  with  that  morbid  propeusiity  that  characterizes  hyetoria,  con- 
tinue for  a  length  of  time  to  rc<iuire  its  introduction.  If  lell  to  themselves, 
though  the  bladder  may  become  much  dii^tenrled,  it  will  not  burst  but  will 
probably  empty  itself  without  further  trouble,  particularly  if  the  patient  be 
put  into  a  tub  and  well  douched  over  the  hips  and  loins  with  cold  water.  In 
some  cases,  these  morbid  conditions  in  women  appear  to  be  connected  with 
Bome  local  irritation  alniut  the  urethra  or  uterus;  and  then  proper  treatment 
most  be  directed  to  these  organs  before  the  disea-ne  can  be  removed. 

Painful  Cosditioss  of  thf.  Blaudei:. — The  bladder  may  be  the  seat 
of  severe  puiu,  either  continuous  or  remittent,  withtmt  any  iliseusc  being  tlis- 
oemibte  in  it  on  the  closest  examination;  the  pain  being  either  a  kiml  of 
neuralgic  condition,  especially  occurring  in  hy»>t«ricnl  or  hypochondriacal 
patients :  or  else  l>eing  sympathetic  with,  and  dependent  on,  discnt<e  at  a  dis- 
tance, as  in  the  kidneys,  uteruti,  rectum,  etc.  At  the  same  time,  it  must  be 
borne  in  mind  that  the  secretion  of  »cid  or  irritatitig  urine  will,  in  some 
individuals,  be  a  source  of  much  and  constant  Butferiug;  and  that  any  dis- 
seated  about,  or  coming  into  contact  with,  the  neck  of  the  bla<ider,  as 


tumor,  stone,  etc.,  is  especially  apt  to  give  rise  to  i^vere  suffering,  and  will, 
in  many  caiies,  be  accompanied  by  fretpient  desire  to  micturate,  with  much 
spasm  about  the  part. 

TUlIEltCLK  OF  THE  BI,AI>D15K. 

Tobercnlar  Disease  of  the  bladder  appears  to  be  very  rarely  primary.  It 
il  usually  an  extension  from  similar  disease  of  the  kidney  and  ureter,  or  of 
the  prostate.  The  blad<Ier  usually  presents  tlie  ordinary  appearances  of 
chronic  cystitis;  but,  in  addition  to  these,  ulcers  are  found  slightly  raised  at 
the  edge,  having  a  yellow  gninular  surface,  and  situate  exclusively  near  the 
trigone.  The  symptoms  are  merely  those  of  chronic  cystitis,  and  often 
cloeelr  resemble  those  arising  from  stone.  The  urine  contains  pus,  usually 
abundantly.  The  diagnosis  can  be  made  only  by  the  coexistence  of  tuber- 
cular disease  elsewhere,  more  especially  in  the  ki<lueys,  i)rustale,  and  testicles. 
Little  can  be  done  in  the  war  of  treatment  beyond  washing  out  the  bladder 
to  diminish  pain  and  the  irritation  as  far  as  possible.  Morphia  Injections 
may  give  great  relief. 

BAfCULl  OP  THE  l(I.AIHti:K. 

Sacculi  have  already  been  mentioned  at  pp.  87(i,  i)14,  and  iiQo,  as  arising 
in  connection  with  ovenlistentiuti  of  the  bhiddt-r  or  obstruction  to  the  esca]>e 
of  urine  from  it.  These  arc  of  small  size,  not  u.sually  exceeding  a  pigeim's 
tgg.  They  arise,  tm  already  dwcribed,  in  the  bladders  of  eliterly  men  who 
have  suflered  from  severe  mechanical  obstacles  to  the  p:iB.sa^e  of  the  urine, 
in  the  shape  of  stricture  or  enlarged  prostate,  an^  associated  with  a  generally 
tbiclceuetl  fasciculated  state  of  the  organ,  and  apjM'ar  to  be  the  rt^ult  of  pres- 
sure on  the  c(mtaincd  urine  during  etlorts  at  expiilHiim,  causing  extrusion  of 
the  mucous  and  serous  coats,  and  perha[)s  of  the  thinneil  muscular  coat  at 
some  points  of  leo-it  resistance. 

Sacs  connecte<!  with  the  bladder  are,  however,  occasionally  met  with,  the 
origin  of  wiiich  can  hardly  be  explained  in  this  way.  Thi'se  may  be  single 
or  multiple,  aod  may  attain  an  eiiormoii-t  magnitude.  The  largest  t  have 
Men  occurred  in  a  man  'i'*  years  of  age,  otherwise  [lertectly  healthy.     He  was 


1008 


DI8SASKS    OF    THE    BLADItXft. 


admitted  iuto  Unlrereitj  College  Uo0|Hu1,  and  iras  under  Um  jobi 
WiltioD  Fox  (uid  myself,     There  wm  a  tcnM  cJoetic  UiiDor, 
rounded,  ixNrupying  ttie  whole  itbdumvu  «ud  uxU-iidiug  iuto  lh«  peln^ 
to  b«  felt  tlirouuli  tliu  ivcliiiu.     Had  it  ocvurr-.'d  in  i  Muman.  Uk 
would  prubiiblylmvebeeu  |>ruiiuui>c«d  uvvnau-     Tbv  tumur  bad 
■ix  moatlig,  bad  gradually  inci-eaiMKl,  but  ocvaaioutil  n<>  un^a* 
ita  pmnire  eBecla.     There  vraa  and  liud  bwti  uo  <i  -.u 

or  m  dafceulioii.     The  tumor  wai  aapirat^^il  at  itJi  it>  m 

sevdD  piuta  of  clear  urine  were  drawn  uff.  Tlie  imtirut  Middenty 
ialnt,  aud  died  of  syncope.  Ou  exaiutuatUm  alter  dt-atb,  tau  amnbi^ai 
Trere  fnuod  cuiiuucled  with  the  bladder,  uoe  ua  each  side,  br  a  rnundad 
ing  that  wimld  admit  tlie  little  finger.  Tlitm  oriQcct  «fre  n|uii 
lliu  luivial  liuc,  aud  about  au  inuli  aod  u  half  abtiru  rarJi  tin4cr< 
were  tli  in- walled,  comyyieed  uliielly  of  mucoua  mi-mbrar;-  -t-' 
poasibty  baviog  scaucrnl  muscular  fibres  in  itii-ir  (»:- 
empueil  Lhruugn  tlit;  bladder  by  the  one  puncture.  Tbr  un-u^r  «u 
vna  adlifireni  tu  tbo  wall  of  the  eacculu«  and  caciaidtrablf  pwirf  opaB.H 
as  ihc  remit  of  tbi^  the  pulvca  of  the  kidni-yft  wore  dilalcd ;  llw  pjnnoA 
portion  of  the  kidney  waa  absorbed  and  the  Oirtex  (•realty  thiekeafll  ■ 
indurated  by  chnmic  inten>tiLial  inBumnintion.  The  bladder  wao  gn' 
dilated  and  bypertruphii^i,  itA  mucous  membrauc  wan  itpaj^ue  and  sbiu-, 
ahowetl  no  signa  of  old  or  rceent  rystitia.  The  pnittat«  ao>]  omhisi 
healthy,  and  no  source  of  mcehanica!  obAtrudion  waa  d^tectod.  Tbaoa 
of  t)ie  condition  is  extreme-ly  obscure.  There  ii  a  nmlUr  ip<yri— ,  h 
Bumewbat  leea  marked,  iu  the  museum  of  University  Otdtofv; 
Bprioga  from  the  same  Kput,  which,  iodeetl.  from  comiiartsuo  wilii 
niena,  seema  to  be  the  common  poiut  of  origin  of  all  sacoali  of 
which  reach  any  considerable  aixe. 

TCHOnS  or  TRK  BLA-t^nRE. 

Various  forma  of  tumor,  both  malignant  and  ainip]«,  mt*  met 
bladder.  The  moet  common  finipif  ^niwth  is  the  VlUoDa  Tsaar  BC  Ik| 
lomo.  It  cousiets  of  ilelie-ate  branched  prooesMB  which,  vben  thcfravlk 
imnuuved  in  water  Hoat  out,  sn  that  it  aoinewhat  nimwhlw  •  bbs  ammm 
Thae  may  springy  from  a  narrow  boeo  forminf;  «  pediuealaicd  warn,} 
spread  over  a  coasidenible  area  of  the  bladder  wall.  The  bwe  frga  wlii 
thev  ariae  may  be  aliuoat  level  with  the  surface  of  the  bladder,  or  Hajr 
a  tfe^hy  maae  of  some  thickneea.  Mieroaoopic  cxandnali-^  liwwa  thu 
papilla  i»  composed  of  a  fine  capillary  loop,  surrounded  by  an 
dolicalc  connective  tiasuo.  in  some  parts'  almost  homogeneooa,  with  niUMii 
founded  or  spindle^haped  colls  aoauefed  throagfa  IL  The  B(ufikeaiB« 
ared  with  epithelium  of  the  same  character  as  that  of  the  blathler.  t 
more  delicate.  The  celts  ara  often  ovml  ur  fiuiibnD.  and  are  anannad 
several  layers.  The  delicate  epithelium  separalea  alnkoai  immeiliataly 
the  growth  is  pat  in  waiAr,  ana  is  consefjueutly  kiRen  Itat  tu  oticroM' 
apeoimena.  The  haae  k  compuaed  of  louae  and  highly  raacular  eoftaM 
twoe.  Theae  tumors  almtwt  invariably  »priiig  Srom  aonv  part  of  tlw 
gone,  usually  Uf-ar  the  uriJiee  of  Due  ureter  or  Um  ncalus  iaicrauiu 
are  nsually  single,  hut  iioua»i<iiially  two  or  mon  an  fgand. 
Thompauu  atatee  Uiat  only  about  one  in  six  or  aenn  aiv  dlacinctl 
luteal,  the  gn-at  maj<irily  being  mure  or  les  bcbbU*.  When 
thu  pedicle  may,  iu  rare  cases,  b«  of  oousldecwble  Itngtb,  eucDe^na 
or  more. 

Other  simple  tumors  are  Docastonally  mot  with.    TIhb  in  child 


IS   or   THE   BLADDER. 


1009 


k 


I  polypi  have  l>een  oheerved.    Tfai-j  nre  smooth  or  nearlf  smooth  on 

the  Miruioe,  and  composed  chiefly  of  mvxoma  diwie,  ilmitor  to  that  seen  la 
Ihtf  simple  polrpos  of  the  no««*.  In  othen  the  eonnectire  timae  basis  of  the 
lumor  KOe  to  firm  and  the  papillation  nn  the  surface  »o  imperfect  llmt  the 
growth  hat  been  described  a«  a- Jihronut,  Probably  all  these  growths  are 
etoecly  related  to  each  other,  oonsistinf;  easentially  of  an  outgrowth  from  the 
■ubmucuHS  tiMue  of  tho  bladder.  .1/yonuila  also,  or  tamoni  ountainini^  non- 
Blrialed  muscular  fibre  bave  been  ntel  with  spriugiog  from  the  wall  of  ibe 
Usditer. 

Sarmma  of  the  bladder  has  been  met  with  in  a  few  case».  The  growth  is 
cviopoeed  uf  round  cifllv,  or  mixed  round  uud  spindle  c«lla,  and  U  papillarr 
oa  tbe  Burfact'.  The  dUlioctiuo  betwc-vu  Uiie  and  u  pHpilloiua  wiiu  a  thick 
base  which  bus  beeu  iuflanivd  is  uot  eu«y  tu  uiak«  ool,  aud  i'urllier  ioveati* 
gstioci  is  rei^uirt^d  U'f>jn>  li  clear  K'pnrntiou  aiu  b«  umde  bettnevti  these 
tuiDorB ;  niiirv  eepecially  at  all  ik>w  growths  in  the  bluddvr.  whether  aiuiple 
or  nuUitfiuuit,  tend  to  tuuumt-  a  papillary  form.  Sir  Ueory  Tbompaoii  de- 
Msribei  tumors  which,  in  his  opiuion.  ihtcupv  a  place  b«iweea  papilloma  and 
■UOOna,  aod  which  be  lernis  "  trauailioual." 

J^^mpfoRUL — Simple  tumors  of  the  blatlder  occur  usually  in  youth  or  early 
middle  aee.  Tbe  earliest  symptom  in  all  furni»  of  simple  tumor  Is  bemor- 
rhage.  At  Rrst  it  is  small  in  umouot  and  intermittent,  but  aa  the  diseaae 
progrcMes  it  becomes  raort;  abundant  and  almost  conftant.  The  charaoler* 
MIC  sign  of  hemorrhage  from  n  viUous  tumor  is  thai  the  bloott  is  not  uni- 
formly mixed  with  urine,  but  comes  chiefly  towards  the  end  of  micturition, 
•MDCtimM  dropping  away  almost  pure  after  the  urine  has  oeased  to  flow. 
Tbe  quantity  may  be  \'erv  largo,  and  clots  are  often  passed.  As  the  disease 
adnuHie*  frcqu«ocy  of  micturition  and  the  general  si^ns  of  irrildbilitr  of  the 
Uanlder  may  make  ihi^ir  appearance,  but  hR?maturia  may  form   the  ouly 

mptom  for  many  monih»  or  even  years.     I  have  known  abumtant  ho^ma- 

ria  to  continue  for  many  years — for  twelve  or  fourteen — probably  from  a 
papilloma,  wiihouc  dpranging  the  gencnki  bcnlth  to  so  great  an  exteui  as 
might  be  expected  from  so  continuous  and  copious  a  loss  of  blood.  Tha 
■gfi  importaot  sign,  and  one  which  should  always  be  peraistently  sought 
fbr.  is  Ine  passage  of  recognizable  fragments  of  the  growth  in  tbe  urine; 
But  little  iut'omiation  is  gained  by  sounding;  occasionally  some  irregularity 
nay  be  fell,  but  its  nature  and  outline  cannot  be  detemiioed.  A  hollow 
•DQod  may.  however,  returu  with  some  of  Ibe  growth  in  its  eye,  and  thus  de- 
ICfiaiDe  the  nature  of  the  case.  Profuse  hemorrhage,  af)er  souudiug,  com* 
mooly  occurs,  but  is  uut  suffioMDt  to  found  a  diagnosis  upon.  Kxammatioo 
of  the  trigone  from  Iho  reclum  never  givea  aoy  infurmatioo  nnloM  the  tumor 
bfl  vcrv  large,  when  it  might  p'jatibty  be  recognized  by  pressing  firmly  above 
the  pulies  at  the  hbiuo  time.  Oareful  examinatioD  of  the  bladder  by  means 
of  a  small  flat-btaded  lithotriie  may  deUiL-1  the  prosraoe  of  the  tumor,  as  in 
"'m  first  ease  reoorded  by  Tbomptoo. 

_  Tfaeae  tunon  ocoaaloiially  become  encrusted  with  s&oipAafse  mattar,  de- 
poalled  upon  thum  by  the  urine,  and  then  they  will  resemble  stitt   more 
wly  a  calculus  «bcn  the  bladder  is  sounded  ;  from  it.  however,  thev  may 
diatinguiahed  by  their  fixed  character,  and  by  the  Empooiibility  or  pass- 
a  ftiiunil  around  them. 

f  tlie  dtsMuie  be  left  unrellcvMl  it  termiaate«  &tally  Booner  or  later,  some- 
cs  bv  exlintaliim  fnim  ivinstani  loss  of  blood,  but  more  oflen  by  disease 
tbe  tt<)ii(tys  iii<lucfd  by  ilie  olietiruction  to  the  orifices  of  the  ureters  by 

le  gn>wth,  or  by  wptic  cystitis  extending  bi  the  pelvis  of  the  kidney. 

Till-  diognuois  can  usually  be  made  by  ntLt.-nli<m  to  the  above  points;  but 
should  this  not  be  poeBiblo.  tbe  blatlder  may  be  expliirad  in  the  following 
VOL.  II- — 04 


1008 


DI8IASS8  or  Tue  uladdbb. 


bdmiLtcil  into  Uoivenity  College  Uospiul.  and  wu  onder  lh«j«bi< 
Wiliion  Fijx  ami  inywii'.     Tlivrti  wiis  u  ivntv  oliuLiu  tumor,  aiwMk 
rounded,  ovcupying  the  whi)I»  alMluiiieu  aud  uxteuding  iam  tlu  peltii,  im^ 
to  be  felt  througli  itie  rectum,     lltui  it  ucourrvd  iu  a  woman,  the  dkos 
would  prulmhly  uavebei'n  tiruaouocvd  uvarian-     The  tuaior  hatlesMnlftr 
Btx  moDlbs,  had  gradually  iDcrea&eil,  l>uL  uccattiuuLil  w  tin'^wtaiaicHifa  hf 
Us  pressure  eOecta.     There  wa«  iiud  had  Imm.<u  im  ditii  '.itmiBft^m 

or  ID  dcfccalioD,     The  tuiuor  wHsaepiraied  at  it8  nui?:  ,  tit  mrvud 

Hveo  pioU  uf  clear  uriue  were  drawn  uff.  The  poiient 
&itit,  and  died  of  ^vDCopc.  Ou  eJEaminatiuO  aiUr  dcntb,  t ..  .  ^ 
were  found  cooDCCtcd  with  the  bladder,  one  uo  each  aide,  by  a  root 
iiig  that  would  admit  the  little  finger.  These  onficu  wcrs  rquidii 
tiie  medial  Hdc,  and  about  ao  inch  and  a  bali'  abm't;  nicfa  ur«ter.  Tb«w> 
were  thin-walled,  composed  chieflr  of  mucous  membr  ■  ■  -  ■  i  {xnfioiaa, 
poKiibly  having  scattered  couacular  fibres  tn  tbctr  C'  ■  i;  botli  am 

emptied  through  the  bladder  by  tlie  one  puncture.  The  urcUT  oa  aack  liif 
was  adherent  tu  the  wall  of  the  saoculua  and  contiderablr  pnaMd  Dpoa,u4 
as  the  reeult  of  tbia  the  pelvea  of  the  kidneys  were  dilated;  iht  oynrnM 
portion  of  the  kidney  was  absorbed  and  the  ourtex  gresUr  tluduttMi  wai 
indurated  bv  chronic  interstitial  iuliiuumatiou.  The  btamiw  wm  inatiT 
dilated  and  Lypertrophied.  ita  raucous  membrane  wu  opa(]0«  mod  ir|iit«,aM 
Bbowed  no  »igus  of  old  or  receut  cystitis.  The  proitaUi  tad  tuvtlua  nn 
healthy,  and  no  source  *}t'  Tnechnoical  obstructioo  wu  detectttL  TttcCMH 
of  the' condition  is  extremely  obscure.  Thor«  ia  a  iimilar  tpeanMa,bil 
somewhat  less  marked,  in  the  muacuiu  of  Untverdty  Callrge;  tbcflunt* 
springe  from  the  aaao  spot,  which,  indeed,  from  ooranariBLMi  with  uther  ffiM- 
mens,  aeems  to  bo  the  common  point  of  origin  of  all  wocoli  of  the  Uaodff 
which  reach  any  coasidcmbic  eize. 


TUMORS  OP  THE  BLADDER. 


Various  forma  of  tumor,  Ixnb  nialigoant  and  simpln,  ara  nwC  wtlh  bj 
bladder.     The  most  common  jiiru|ile  ^^rrowtb  is  thr  VtUotia  Til  ~ 


loma.  It  coniti^U  of  delicate  brancbcd  pructi^se*  wliich,  »li«n  the 
immeraed  in  water  float  out,  »u  ihul  it  Bouu'whnt  rcawmblea  a  aea  : 
Tbeee  may  spring  from  a  narrow  hnse  r'>rniiug  a  p«duiu-ulalcd 
spread  over  a  condiderabte  area  of  tlie  bladder  wall.  Th«  baM  Itoki 
they  ariae  may  be  almoot  level  with  the  auriace  of  the  bladder,  or  mar 
a  flmhy  man  of  some  ihickuesii.  Microecopic  ezamiuation  showa  th^ 
papilla  ii  composed  of  a  fine  capillary  loop,  surrounded  by  an  ext 
delicate  couueclive  tiwue,  iu  some  |>art«  almost  bomugeucouv,  with  aoBwr** 
rounded  or  spiudlv^baped  c«lle  scattered  through  iL  Tbe  sur&oe  Met- 
ered with  epithelium  of  the  aaiiiv  eharacter  as  that  of  the  bladder,  W 
more  delicate.  The  cells  are  oiXvn  oval  or  fusiform,  and  are  ai  mif  1  i* 
several  layers.  The  delicate  epithelium  separata  almoat  Jmiaedlatify  if 
the  growth  is  put  in  water,  and  is  consequently  often  lust  in  auersaafH 
Aiiecimeus.  The  base  is  oompoeed  of  louee  and  higlily  vascular  ifflir***— 
tissue.  These  tuniom  almost  invariably  spring  fhaii'»om«  put  af  ilayt- 
gone,  usually  near  the  orifice  of  tjnc  urctM-  or  the  meattta  iaiamat.  TW; 
are  usually  single,  hut  occasionally  two  or  more  are  ftmwL  Sir  H^vy 
ThomjiHou  »tate»  tliat  only  about  one  iu  six  or  aeven  ue  diatiaell) 
lated,  the  great  majority  being  more  or  leas  SMsile.  Whea 
the  pedicle  may,  in  nn  cases,  be  of  cooaiderable  ImgCh,  > 
or  more. 
Other  simple  Uiuors  are  occasionallj  met  with.    Thnt  id  diUdrw 


TUMORS   or    THE    BLADDKR. 


1O09 


_  M  pol!/pi  haT«  boen  observed.    Tbey  are  smooth  or  neartj  smooth  on 

mirnoe,  bdcI  cumpoied  cliieftr  uf  myxomft  tissue,  Buntlar  to  that  teea  In 

'  timple  polypus  of  tho  uo«o.     In  others  the  connective  ti«>ue  \>A»i»  uf  the 

■or  WM  so  Dnn  antl  the  pKpillnlion  on  th«  turfiice  «o  imiterfcct  thnt  the 

iwlh  bus  been  described  as  a  ^romo.     ProbiLbty  nil  ttieee  p-owtbs  are 

•ety  related  to  each  other,  ooosistiug  essentially  oi  an  outgrowth  fn>m  the 

>niucouB  tiaiue  of  the  bladder.    Myomata  also,  or  tumon  cuiiUinin^  noo- 

rtated  muscular  tibre  have  been  met  wiUi  apriogiDg  from  (be  wall  of  the 

ladder. 

\SaMwma  uf  the  bladder  baa  been  met  with  iu  h  few  cases.    The  growth  is 

■poeed  of  round  (tilla,  ur  iuixe<l  round  and  spindle  celia,  and  a  papillarr 

toe  surface.     The  di^tinctiou  between  tbts  and  a  |>apilltim»  wUn  u  thick 

which  has  been  iuilamed  is  uut  easy  io  niuke  out,  and  further  iuvesti- 

b  rei)uired  before  a  clear  scpuraituu  cau  bv  made  belweeo  these 

I ;  more  eapecially  as  all  new  (growths  in  the  bludder,  whether  simple 

or  mal^ant,  tend  to  assume  a  papdiary  furui.     Sir  Henry  Thompson  de- 

Mribcs  tumors  which,  in  his  opiouui.  occupy  a  place  between  papilloma  and 

nrcoma,  and  which  be  terms  "iran^ilional." 

I         Sympfonu. — Simple  tumors  of  the  bladder  occur  UMially  in  youth  or  early 

I    middle  age.     The  earliwt  eymptom  in  all  forms  of  simple  tumor  is  hemor- 

u|uh     At  first  it  \i  amall  in  amount  and   intermittent,  but  im  tlie  dJMase 

^^^HhMfl  it  becomes  more  abundant  and  almoiit  constnnL     The  character* 

^UPrign  of  hemorrhage  from  a  villous  tumor  is  that  the  blood  ia  not  unl- 

fiwnily  mixi'd  with  urini.-,  but  come*  chiefly  towards  the  end  uf  micturition, 

ecMnelimi,4  droppiuv  away  almost  pure  after  Uie  urine  has  (.'eased  lo  flow. 

The  quantity  may  be  very  large,  and  cloid  arc  often  possei.     As  the  diaease 

Wane**  fre4(uency  of  micturition  aud  the  ^'enc-ral  sigiu  of  Irritabiltty  of  the 

Jer  may  make  their  appearaocf,  hut  ho-muturia  may  form   the  only 

lorn  for  tuaoy  months  or  eveo  years.     I  have  known  abundant  hxma- 

ito  continue  I'nr  many  year* — fur  twi^lve  or  fuorteen — probably  from  a 

ptilomsi,  williriut  deranging  the  general   health  to  so  great  an  extent  aa 

[lit  be  expected  from  so  continuous  and  copious  a  loos  of  blood.    The 

■t  important  sign,  and  one  which  should  always  be  persistently  soiufbt 

fur.  is  the  passage  of  reco^niiable  frngoicnts  of  the  growth  in   the  unne. 

Bat  little  informatiou  is  gaiue<l  by  sounding:  occasionally  some  irregularity 

Biay  be  felt,  but  iu  oalurc  and  outline  cannot  be  determined.     A  botlow 

sound  may,  however,  return  with  some  of  the  grovplh  in  its  eye,  and  thus  de- 

icrmine  t^e  nature  of  the  ease.    Profuse  faeoiorrlia^,  slier  sounding,  oom- 

,    aonly  occurs,  but  in  not  sufldent  lo  found  a  diagnosis  upon.     Exauinalion 

WKf  the  trif;oo«  from  the  riH'tum  never  gives  any  information  QtUess  the  tumor 

^K  TtTV  large,  nbmi  it  might  piKuihly  be  recognised  by  pressing  firmly  above 

^Kn  puMS  at  the  aame  limiv     Carel'ul  cxatninntioD  of  the  blatlder  by  means 

^V  •  saUl  flal-bladed  JithoiriU!  may  detect  the  presence  of  the  tumor,  aa  in 

the  fini  case  recorded  by  Thumpnou. 

These  tumon  occanotially  bKnime  encrusted  with  pkapkaiie  matter,  de- 
posited upon   them  hy  tlie  urine,  and  thitu   ihuy  will  reaemblo  stJU   more 
'4Mrly  a  mlrulun  whrn  the  bladder  is  souudcd  ;  from  it,  however,  ther  may 
~  dt»tini;ii<»heil  br  tbtiir  6xed  character,  and  by  the  impoaaibillty  ot^  poas- 
•  a  N'lind  anHind  ihi'm. 

If  the  iliscaso  l)c  left  unretieve<l  it  terminates  fatally  sooner  or  later,  aotne* 

by  cxIinuAtiiin  (u<m  cotistant  Iom  of  bloMl,  but  more  oAi.-n   by  diMtase 

the  kiilnc))>  itidtRtxl  by  th»  obslructiim  tu  thu  i>riHces  of  the  ureters  by 

kegniwth,  or  by  »eptir  <'y»litis  <<xt4'tiding  to  thr  pnlvis  <if  the  kidney. 

Im  dia^usis  can  ustiully  be  imule  by  att(^nti«n  Ut  ihf  abuve  ixiints;  but 

•boold  this  not  be  ptusible,  Ibe  bladder  may  be  explored  in  the  following 

VOL.  lU—M 


1010 


UISBASBS   OP   THE   BUAUDER. 


nianoer  n&  prncti&ed  by  Sir  lleary  TIioiddsod,  the  exploration  btiiag  followed, 
if  possible,  by  removal  of  the  growth,  uiould  it  seem  suited  for  such  treat- 
meat. 

The  |)8ticDt  being  placed  in  tlie  litbotomy  position,  and  a  centrally  grooved 
staff  intniduced,  the  uie'liaa  poriuoal  scciiun  ia  made  upon  thi«,  the  mem- 
branou8  portion  of  the  urethra  opened,  and  the  flnjjer  passed  into  the  blad- 
der; the  interior  of  vrhieb  may  thus  be  rtnrheil  and  explored  In  all  its  parts 
by  prfajiinj;  down  the  anterior  abdominal  wall,  the  muscles  of  which  must 
hb  tiiDriiuglily  retasetl  by  full  nuasihefiis.  tih'ntld  the  papilloma  be  found, 
thii)  iuiiiBiim  will  servo  fur  ils  removal.  Should  there  be  no  papilloma,  the 
mtiihiid  of  exploration  will  dcteriuinc  the  condition  of  the  intenur  of  the 
MaddiT.  ilie  prcseucw  or  not  of  mali^'uani  disease,  or  of  encysted  caleulus. 

The  Trrutmmt  of  simple  lumoi-i!  of  the  bladder  was  up  to  ■  rewnt  [M-'riitd 
Af  iJio  most  uusatisfaetory  elinruct^-r.  Sup^'Couh  uijually  (vinii<ntini^'  thfoi- 
eelTCS  with  restraining  the  licimirrlmgi'  by  iiicuti^  of  gallic  acid  and  oimilur 
siiiringcniK.  Openilivc  mean-  were  Beldom  employwl.  It  ia  true  that  <*iviale 
removed  a  small  growth  of  thifl  kind  siiuntpri  noar  the  neck  nf  the  bliidder 
by  Aeizinff  and  twinting  it  off  with  a  liihotrite.  Warner  removed  a  tumor 
of  thifl  kind  the  size  of  an  egg  fi*om  the  blatlder  of  a  woman  after  dilatiog 
the  urethra. 

Billroth  removed  a  tumor  from  the  bladder  of  a  boy  which  proved  to  he 
in  part  a  myu-sarcoma  in  olheni  a  myo-cArcinonia.  It  wan  an  larf^e  a^  the 
fist,  and  had  a  pedicle  which  appeared  to  he  cnnnerled  with  the  niustrolar 
cont.  The  operation  consisted  nf  cyatotoniy  by  the  ordinary  laleml  upem- 
tiuii.  Itut  as  th«  tumor  was  tno  large  to  ho  ^mi  away  thrnugli  tlie  perineum, 
the  bladder  was  opened  above  the  piih*'!*  ny  a  free  iransvcrBC  cut.  The 
tumor  was  then  torn  away  by  the  finger,  and  the  pedicle  cui  acroM  with  a 
knife  guarded  by  the  finger.     The  patient  did  well. 

Uunipliry  in  1J^77  opi-rat'Cd  on  »  buy  who  had  a  tumor  in  the  bladder 
causing  dysuria  and  hcinurrhage.  He  upeued  the  bladder  by  lateral  cystot^ 
omy  ibruugh  the  periueum,  and  rvmuved  the  tumor  with  forceps  and  the 
finger-nail.  It  proved  to  bo  a  hbru-sarcuma.  The  patient  made  a  good 
recovery. 

Voikmann  and  Marcacci  have  buth  performed  aupra-pubic  cystotomy  llbr 
the  removal  of  vesical  myomalu,  but  with  fatal  nsulls.  in  It^fSl,  Jtansohoff, 
of  Ohio,  removed  a  tumor  as  large  as  a  small  peach  growing  from  the  puate- 
rior  wall  of  the  bladder.  Tho  operation  he  practised  was  lateral  cystotomy; 
the  tuninr  was  then  scraped  away  by  meous  of  one  of  Volkmann's  ^arp 
spoon?.     The  patient  recovered  arter  a  teilious  oonvaleecenoe. 

To  Hir  Henry  Thompson  ie  <hie  the  merit  of  having  simplified  the  nperation 
and  placed  it  on  a  moni  delinite  baeiit.  Hi9  opernlino  ponsiDts  in  opening  the 
urethra  by  the  onlinarj'  median  perineal  aection.iiilating  the  pmetstic  urethra 
and  neek  of  the  hltt<hier  with  the  finger,  feeling  for  the  tumor,  and  then  re- 
moving it  by  properly  constructcil  forceps,  bv  \rhich  it  is  seizeil  and  crushed 
or  torn  away  from  the  mucouh  membrane.  The  bladder  is  then  washed  oat 
and  drained  with  an  elastic  tube  till  all  hemorrhage  oeues,  when  the  peri* 
Deal  wound  ie  allowed  to  heal. 

Thus  it  will  be  seen  that  three  operations  have  been  adopted  for  the  re- 
moval of  intra vesicjil  tumors,  viz.,  cystotomy  by  the  suprapubic  method; 
cystotomy  by  the  laleiiil  perineal  incisions,  and  urethrotomy  by  the  median 
perineal  incisions.  The  operation  that  the  Surgeon  will  select  must  Deces- 
sarily  in  a  great  measure  ncpend  upon  the  size  and  consistence  of  the  tumor. 
AVhen  tliis  is  very  large  and  firm,  as  in  Billroth'^  and  Humphry's  cases, 
cystotomy  by  one  or  other  of  the  methods  adopted  by  these  Surgeons  will  be 
re«iuired ;  when  of  smaller  size  and  soil,  urethrotomy,  with  dilatation  of  the 


I 


( 


H^KATURIA. 

oeck  of  llio  bladder,  as  adopted  by  Tboiujuriu,  »uf&ccfl  for  the  exiractiou  uf 
the  gnwUi,  oud  bc-iog  the  oimpler  luid  less  daujjeroua  tneihud  should  be 
adopted. 

Id  papilloma  and  mvomu  of  tbc  female  bladder  the  urethrm  should  be 
dilated  so  as  to  adtnil.  ifie  furofinj^r ;  aloug  rbi:^  the*  sharp  spoon,  or  Thomp- 
son's fitrreps  may  b«  i^lipfHtd  and  the  trt'o^'tb  grrapi^d  away  or  crushed  ntf. 

Camtji  of  thk  Bi.Ai>ni:B. — The  bladder  ie  not  a  uoianmn  seat  of  primary 
cauec-r;  U  is  morv  niXeii  '\m\A\vatfil  ity  the  cxtcnaiun  (if  maligti»Dl  di'eeaae 
fnim  some  neighbririD);  [tart,  nit  tliii  rectum  or  uusrus.  Ai'ttordmg  to  Walsbe, 
It  lU'VLT  Bppt^rH  liefore  the  4t)Lh  ypar.  The  form  i)f  caric«r  i>ccurring  in  the 
blidliler  as  a  primHry  disea.'<R  h  squamous  opithelioraa.  Hcirrhua  is  daid  to 
have  l>oen  mei.  with,  but  tiinst  prribably  it  c'ommcnc«l  in  the  prostate  aud 
not  in  the  bladder  il^elf.  Kpithelitima  of  the  bladder  often  commenced  on 
the  poslerior  surface,  extending  aectindarily  to  ihe  trigone.  The  ulwrating 
surface  of  thetnraor  occaainiially  bect>mpfl  encrusted  with  phosphaticileixKiit, 
and  iiometitTiM  a  phosphatic  calculus  may  form  in  the  diseased  bladder,  Hud 
tl)ii9  .Tdd  greatly  to  the  inlfinse  pain  that  uKually  attends  this  aifeotion.  The 
Symnfotns  it  gives  rise  to  are  intense  dysuria,  with  discharge  of  blu'xl,  and 
viscid  mucus,  In  which  fragitn'iiLs  of  the  tumor  may  be  found.  No  c>id<;Iu- 
si'io  of  any  kind  cuu  be  drawn  from  ;^ingle  celUf  it  is  only  when  n  rliTttmct 
gniup  of  cells  is  found,  poiuibly  MttAoliet)  to  a  pL>rtion  of  sLn>[iia,  that  any 
opinion  can  be  formed  iia  to  tbeir  source.  In  a  ewe  under  the  care  of  Ber- 
keley Hill,  the  nest-like  arrangement  of  the  oj>itb»flial  cells  hhs  recoguized 
iu  Some  fragments  pasjsed  in  t!ie  urine.  Sir  H.  Thompson  states  that  the 
diagnosis  of  cancer  from  simple  Uiniurs  may  be  made  by  the  age  of  tbe 
{uitientv  and  by  the  fact  that  pain  aud  tVetpiency  of  micturitiou  apjiear  early, 
u^eu  before  the  blood.  The  rapid  pnigress  of  the  diaea.9e,  and  the  intensity 
of  the  patient's  sufferings,  difier  widely  from  the  alow  progress  aud  slight 
dticomfort  caused  by  simple  tumors  during  the  early  period  of  thoir  devel- 
opment. 

When  secondary  to  rectal  cancer,  a  commuoicatioD  will  usually  have  been 
established  between  the  two  oaTitics  through  which  flatus  and  feces  pass  into 
tbe  bladder,  and  thus  greatly  aggravate  the  patient's  suH'erings. 

The  Trfitttieiii  of  caueer  of  u»e  bladder  as  aeoeasarily  of  a  purely  pallia- 
tive character,  fur  iu  those  miserablo  cases  nothing  of  a  curative  chanu^ter 
can  be  attempted.  Morphia  hypodermically  administered,  the  fnKjucnt  use 
of  the  catheter,  willi  rlisinfectanl  injectious,  possibly  drainage  of  the  bladder 
through  a  median  [mrinoul  semioo,  and,  iu  tlioeo  cases  that  are  secondary  to 
rectal  eanecr,  (^lotomy,  constitute  the  main  olemeDta  of  the  treaLmen't  of 
this  incurable  malady. 


I 


H.KIILATrUIA. 

The  admixture  of  blood  with  tbe  urine  may  usually  be  recognized  by  the 
color  that  it  communicaces  to  this  lluid.  If  the  blood  he  in  large  rpiautity, 
the  urine  will  be  dark  brown,  chocolate,  or  m.troiif-colorwl,  aud  will  i*Uuii 
red  the  bottom  of  the  utensti  or  a  pieco  of  white  bl<)l ting- paper.  If  it  be  iu 
Rmaller  iiuautity.  the  urine  will  oc  brown  in  varying  shades — smoky,  or 
having  something  tbc  iuih'i-I  of  thin  beef-lea;  and  in  other  coses  it  will  be 
little  discolored,  but  will  dep<jsil  a  red  or  brown  i^etliment  on  standing. 
Under  the  mierosL-ope,  blood-disks  may  be  detected  iu  large  number*.  Kent 
coagulates  the  blood  into  a  brownish-gray  deposit,  leaviug  a  vloar  Muperna- 
tout  Uuid.  Micrusdopic  examination  should  never  be  neglected  iu  doubtful 
vases,  OS  by  that  meaus  ^mall  traces  of  blood  may  be  cerLuiuly  recognized; 
aud,  moreever,  it  must  be  rumeuihored  that  in  tbe  condition  kuowo  as  bwma- 


1012 


DISEASES   OF*  THK    BLAnUBB. 


tiDuria 


ith  blood- 


but 


irine  is  darkly  ntained 
puBcles.    The  paticDl's  word  that  he  lins  paasMl  blood  iboald  ■■ 
upon  too  iiuphcitljr,  as  hieh-colored  urine  daposiliDg  arid  BCtd  or  wntm  a 
oftfn  i^omiuly  auppf^ed  to  contain  blood. 

Hspmatuna  niny  ariae  from  n  confiUutianal  oondilion  or  frnm  a  loiadnK 
When  eonttUutumal,  U  ia  usually  the.  conHcqui^noe  of  pcnrvT.  In  ihae  tarn 
it  will  iie««8Baril]r  be  aseocialod  with  olhrr,  and  probably  iiiark(<l,  MidawB 
of  the  di»eaKP.  A  form  of  hirinatunn,  depending  on  the  pmuwe  of  ■  pn- 
Bite — the  Hilharsia  Iia:matohui — h  prevalent  in  Africai,  and  hat  baa  Mj 
invcatigatoii  hy  Leui^karl.  John  Harley,  Gobbold,  and  olbera. 

When  arinnp;  fnim  local  cauec^,  haimataria  is  a  aroiptftiu  nf  dbeaie  eat- 
ing  in  ai*me  part  of  the  urinnry  apparatiia,  and  it  <iftea  aiaaiuet  ^rcai » 
portance  from  the  Ioas  of  blood  induc4>d. 

&Niroe«. — Hteninturia  ma^  ariw  (Wtni,  1,  the  Kidocvi ;  2.  the  Blarfte;^ 
the  Proitate;  or,  4.  ibt  Urethra;  and  frftm  each  ?■'  -r—  — !-~t  datiiM 
cauiMM  will  produce  it.    The  recoffniiion  of  the  pii  aidiiMa 

that  }[ivcK  rise  to  lui^miituriR  h  of  the  Kr«t  ini|>tirtaDL-i-  m  ii»  in-aunrM. 

1.  Hemorrhage  from  the  Eidneyi.— Whvn  nccurrine  froiB  Iba  iUam, 
tlie  blt't^iiug  nmv  be  the  result  id'  cxjujjectiun,  orule  inllstsiBatJca^ar  aait 
nant  diwuseof  tji'jite  orgatw,  of  acute,  tubercular,  or  calroloua  praGliit 
passage  of  a  calculus  don-o  the  ureter.  Tbe  mi»t  orrlain  eridetia 
olood  comes  from  the  kidney  ie  tbe  preveoee  nf  blood-coirta  nf '  _ 
tubuletF.  The  renal  coogeitioD  tnny  be  ioAaniuatiiry  or  pawtvv;  Id 
ca£c  the  urine  vrill  present,  after  the  discharge  of  blood  ha^  rraard,  i 
of  rhronic  renal  dieeaee  in  the  form  of  albumen,  pu^,  or  caati>  <tf  tiAs 
When  the  hemorrhage  arifcs  from  renal  ralculus,  cither  Malioaary  tr  i*' 
aceudlng,  tbcaymptomsof  that  morbid  i-ondilion,  det^ribrd  at  p.  80,  til  a. 
will  be  well  marked.  Blnod  from  the  kidney  dow  not  often  appenrvdMi 
and  is  uniformly  mixed  with  the  urine.  Blood-eaata  of  tbe  nrrtrr  ban  baa 
Bcon  in  rapes  of  very  prfvfupe  renal  hemorrhaer  from  cancer  or  injan, 

2.  Hemorrhage  from  the  Bladder.~If  the  ulnod  proceed  tkom  ifw  UuU*. 
it  may  l»e  the  result  of  rongrsi.irin  of  the  nunMUH  mrnibran.  ■  ^  ''  inilaii* 
of  a  calculus,  of  a  papilloma  r.r  other  rillous  tumor,  or  .■  iswarf 
malignant  disease.  When  it  depends  on  Tf^i^-nl  eonpe*!:  nillW* 
Mnwiion  of  weight  in  the  reffion  of  the  bladder,  with  tH',  .  <  t/^f» 
urine;  when  on  calculus,  tne  sprcial  sympt<->mit  of  the  « .kUttr&cef/MiV 
will  be  present.  When  it  occurs  from  a  vittouA  tumor  at  tbe  Md[  of  li* 
bladder,  the  quantity  of  blood  lost  ia  uniinlty  very  great  and  tbii  h»> 
rhageperxistent.  If  il  arise  from  mali^iiHiit  diaeaae,  the  di»rbar|e  o/ |* 
and  or  tbe  tUbrtJi  of  the  ulcerating  lumor,  may  afli>nl  evidroot  of  <^ 
•oufceof  the  hemorrhage.  Blood  from  the  bladder  usually  b  iiKaCahante 
towards  tbe  end  of  micturition,  ««p«rially  in  casea  of  'itamor.  1W  Irt 
Tiriii©  ibal  pai*es,  or  that  is  drawn  otf  by  a  catheter,  hf-^-r  — '-  ""^  '*• 
bloody  than  the  last,  and  at  tlie  termination  nulbing  h^..- 

Id  stnne  and  cyrtitis  it  is  more  often  unif'Tmlr  uiixni  vmu  mr  »•''- 
IrreguliirmasseHof  clot  arc  often  paaaed  when  tbe  Ittniurrbag*  faasbMB**? 
abundant. 

3.  Hemorrhage  from  the  Prostate.— If  tbe  proataia  be  tbe  aoniv " 
hemorrhage,  the  dt«'barg(t  may  lie  ueeuioned  by  ooogaaUm  of  ibacw^ 
or  by  its  ulcvraiion,  simple  ur  lualigunnL  In  these  oaaw,gapl«ifrif  hy** 
rectum  and  urethra  will  indicate  the  true  cuuxe  uf  tbe  bkiiilnig.  TW^^ 
usually  finds  its  way  Imrli.  into  the  bladder  mlher  than  toamt^  tl*  F^ 
urethra,  and  thus  may  appear  timanln  the  end  of  i  o,  nr  bt BMMWf 
mixed  with  the  urine,  aa  in  faemorrbage  Irom  ih 


ACUTE    \K¥hAiiUkTloy   Of   THB    PROSTATE. 


4,  Hemorrhage  Irom  the  Urethra. — Tlic  iilBt^liii};  mny  arittc  fn)m  eimjile 
m>nf^ti<in  111' ihi;  imurnuH  timmbmuc,  I'min  iullaniiiiatory  irrtlutioo  of  it,  tir 
Riuy  follow  rupture  i>f  thu  wallu  of  the  cAiial,  cuuDfiqueat  on  injury  or  on  the 
introduction  of  iimlrutiKtiiU!. 

Bluutl  from  th«  urechriL  usuiilly  flows  indeiwiiiiently  of  micturition,  iis  iu 
recent  injiirieH,  or  |>hr9p»  witli  the  tirst  ibw  dmpH  of  urine.  It  may,  however, 
oooasionally  come  with  the  lust  drnpn  expellet).  This  va  by  no  m^ns  iin- 
tmoamon  in  gonorrlKra,  or  in  coseit  nf  gleet  dependent  upun  ii  granular  condi- 
tion of  the  mncmis  memhnine  of  the  biiibous  portion  of  tlie  urethra.  It 
8e«ms,  then,  to  l>e  due  to  the  contnurtion  of  the  ejaeulntor  urinic  squeezing  a 
drop  or  two  of  blood  from  the  iiiflnmed  9p(>t. 

TfefUmfitl.—'Yhe  treatment  of  htematiiritt  must  necessarily  have  reference 
to  its  raut<c.  When  it  depends  on  n  morbid  constitutional  state,  as  scurvy  or 
malarial  poisoning,  the  treatment  of  the  discnse,  of  which  the  hn^mntuna  is 
merely  a  symptom  or  an  et^ect,  must  be  conducted  on  ordinary  medical  prin* 
ciplefl.  If  it  arise  from  ioHamniatory  congestion  of  the  kidneya,  bladder,  or 
prostate,  cupping,  or  the  spplication  of  leeches  over  the  allL-ctwl  pMrt,  demul- 
ceuts,  and  Nifiuu  driuks,  will  bv  munil.  efficacious  ;  if  from  [tasHLve  coii^entiuQ, 
saline  purgatives,  fiillcwcd  hy  the  use  of  astringvnls,  will  speedily  induce  a 
cenaationof  the  beiiiurrbage.  The  astringent  that  exercises  the  most  marked 
iuHuetiCti  in  arreatiiig  hit^tniiLuria,  wbeu  that  couditiou  \»  pdrvly  paMive,  is  un- 
doubtedly gallic  acid.  This  may  be  given  io  live  or  ten  grain  doses,  frequently 
repeatt^d,  iu  infu»iun  nf  bucbu  or  uva  un't. 

Bonietimes  the  bladder  bect>mes  dititeudtitl  by  n  large  sofl  coaguUim,  lilliag 
Qp  it»  interior,  and  canning  it  to  reach  to  the  umbilicus,  forming  a  rounded 
solid  tumor,  like  a  gravid  utenin.  Iu  such  circumstances,  the  lurgetttcatbeter 
that  can  be  introduced  must  lie  pawed,  and  the  syringe  of  an  aspirator 
adapted  to  it.  By  ibis  nienn.s  the  blcrod,  even  when  coagulated  into  a  single 
large  clot  filling  the  whole  bladder,  may  be  ea^ly  removed,  and  thus  a  com- 
pltcatioo  furnierly  most  troublesome  to  the  Surgeon  sod  agonizing  to  the 
patient  is  uren»iiiie  without  the  siightest  dilBcuUy.  The  evacuator  usee)  in 
lithutrity  would  answer  the  pur}ioee  cquallr  well.  If  these  instrumeoti  be 
not  at  hand,  the  iluid  coutcnt^t  of  Uio  bludtfer  must  be  drawn  otf  by  a  large 
catheter,  and  the  more  solid  [lortioiis  bnpkeu  down  and  washed  away  hy  the 
iujectioa  of  one  of  the  antiseptic  lolutlons  rccnnimcndcil  for  cleaning  the 
bladder  iu  chronic  cystitis  (p.  997).  Should  decomp<n<itioa  occur,  the  blad- 
der uluat  be  frequently  washeil  out  with  autJseplic  llulds. 


CHAPTER    LXXI. 

DIBEASKS  OF  THK  rBOSTATE, 


Tub  pmatate  ia  suhjeot  to  Arute  and  Chronic  Inflammation,  to  Hyper- 
m^phy.  and  occasionally  to  Atrophy,  Maligiianl  DiHaise,  Tuliercle,  and  the 
formation  of  Calculi. 


PRCieTATITIS. 


AoQte  Inflammation  of  the  Prostate,  or  ProstatiEu,  very  rarely  occun  aa 
idiopathic  aflectiun.     When  met  with,  it  ia  usually  the  reault  of  gonor- 


1014 


IIB  BASKS 


rb(Ba,  or  of  the  use  of  etrictur&iDstrumenu,  more  cepcctolly  in  tni4idle-iged 
men. 

Symptmrui. — These  are — (Jeeply  seated  dull  pain,  with  heal  and  weight  in 
the  periiieiin],  a  frequent  <k«ire  tu  pnae  urine,  nud  very  gr^t  and  apajmodk 
pain  accompanying  the  act;  in  fact,  tlic  irritability  that  is  ect  up  kbout  tbc 
neck  of  the  bladder  is  perlmps  tbe  moat  marked  and  distrctting  f«iUuK  ia 
the  dieeaae.  These  symptoms  are,  however,  common  to  varioo*  inflammatory 
affections  of  tbe  urinary  organs,  and  they  can  be  distinctly  Kfenv^d  ta  the 
inflamed  prostate  only  by  rectal  eiplomtion.  Ou  introducing  tJie  finger 
into  the  gut,  the  prustate  will  be  found  much  enlarged  and  exquinitfly  tender 
tA  the  touch  ;  ana  the  patii>nt  ofWn  suflTeri  considerably  from  the  prenore  of 
the  iiiflnntcd  organ  uf>on  the  rectum  during  defecation. 

Trt^itnifnt. — Thin  Bhould  be  of  an  actively  niitiph logistic  eharacler,  ao  ai 
to  prevent,  if  poemble,  the  formation  of  aoaceM.  The  perineum  mu»t  bs 
capped  or  well  leeched  ;  warm  bip-bnthK  and  poppy  fMiiieiiCaliona  awiduou^ly 
employed;  and  aaliiies  with  Rntimony  administered.  In  Uiif>  way,  lh«  for- 
mation of  ubt>cess  within  or  around  the  pr(j<etatc  may,  in  many  caaea,  b« 
prevented.     Morphia  suppoeitoric^  may  be  used  to  relieve  pain. 

Prostatic  Abscets  qihv  form  either  ae  a  coam!<)UeDce  of  acute  inflnmniAiioo 
ronniug  on  to  the  suppui-alivc  stage,  and  in  this  way  it  i$  not  very  unAv- 
queutly  met  with  as  a  otmiplieadoD  of  gonorrbtea;  or  it  may  occur  wUb 
comparatively  little  untccedcnl  inflammation — aa  eomclirucs  bupneoa  iu 
pysmia,  or  if  tbo  orgau  be  accidentally  brui«cd  during  litholrity.  Id  tbtse 
cuce,  abscess  perhaps  aa  frequently  funoe  in  tlie  aroofar  cnvclopo  as  in  lbs 
organ  itMlfl  Idiopatbic  suppuration  of  the  prostate,  irrespective  of  any  of 
tbe  above  causes,  is  of  ran:  occurrence ;  but  it  may  occur  in  individuals  of 
broken  health,  the  nmtter  thtn  usually  accumulating  in  large  quantity,  and 
discharging  ilr^lf  into  the  bladder 

^mpfenta. — When  inflamnintion  of  the  prostate  tetTninates  in  abeccss, 
rigors,  with  strangury*,  ami  perhspe  retention  of  urine,  occur  In  many 
casen  the  |<erineum  becomefi  bniwny ;  in  others,  tenderness  of  tbe  glaod  and 
deep  fluctuation  may  he  felt  through  tbe  rectum.  When  left  to  itself,  the 
absoess  mcwt  usually  gives  way  into  the  urethra  or  neck  of  the  bladder;  bat 
it  ntav,  especially  when  occurring  in  the  prostatic  capsule,  open  externally 
into  t\\e  perineum,  or  even  into  the  Tectum.  In  many  cases,  the  absceM  on- 
scnting  on  the  urethral  surface  of  the  prostate  is  burst  during  tbe  introaoo- 
tion  of  the  catheter,  used  for  the  relief  of  retention  of  urine  induced  by  the 
pressure  of  the  tumefaction;  the  matter  escaping  along  the  side  of  and 
through  the  inatrunieiit. 

TrmtnietiL — It  not  unfrequenlly  hapi>fU8  that  the  first  certain  inditAtion 
aflbrdeil  to  the  Burgeon  of  the  forruatiou  uf  a  priwtlntic  alwcw*  is  the  escape 
of  pus  by  the  urethra,  or  mixed  with  the  uriue.Ko  an  t'>  give  this  fluid  a  thick 
milky  appeumnce.  In  such  circumatances,  lliu  only  available  (reatnient 
is  that  which  ts  directe*!  for  the  relief  of  strau^^tiry  and  local  vesical  irrita- 
tion on  ordinary  medica)  principles,  «uch  a«  have  already  been  described. 
But  if,  aa  sometimes  happens,  the  pua  come  forward  into  the  pertneinii,  then 
a  more  decided  line  of  treatment  is  required.  In  these  cases  a  hard  brawny 
mass  will  be  felt  lying  deeply  on  the  side  of  the  perineum ;  and  into  tha  a 
deep  incision  should  be  made.  The  8urgeon  must  not  wait  for  tluctuaUon, 
but  must  cut  deeiity  in  the  direction  of  the  matter,  keeping,  however,  aa 
nearly  as  nnniblo  in  the  mesial  line,  with  the  back  of  tbeknite  towards  tbe 
rectum.  Even  if  no  pus  escape  at  first,  it  may  do  so  if  the  part  be  well 
fomented  for  a  few  hours;  and  thus  cunimuuicatiou  with  the  urethra  or 
rectum  may  be  prevented.  When  the  ahscesa  points  tuwanla  the  rectum, 
and  fluctuation  can  clearly  be  felt  by  the  finger  in  the  bowel,  it  may  be 


lAirf&i 


I 
1 


CHROMIC  ABSCESS   BBTWfitN  BLADDER  AND  RECTUM.      1015 

^MDed  ID  this  situation.  To  <Io  thit>,  the  bowels  must  first  be  thoroughly 
>peDed,  and  the  rectum  cleaned  with  an  eneniH.  The  patient  is  then  aosee- 
loetized  and  tied  up  in  the  lithotomy  position,  the  pelvis  being  well  raised  on 
ft  pillow.  A  duck-bill  speculum  is  then  passed,  and  the  Huctuatin^  spot 
ucplored  with  n  good  sized  tispirator  nec<)le.  If  pu:i  is  found,  a  scalpel  may 
tw  pushed  in  ;  the  o{>ening  is  then  dilated  with  a  pair  of  poly  pus- forceps  and 
k  drmiDag«-tube  inserted.  The  tube  falls  out  in  a  tew  hours,  and  nee<t  not  be 
replaced  as  the  cavity  usually  closes  rapidly  as  siK>n  as  the  pus  is  let  out.  If 
the  incisiun  be  limited,  and  kept  as  nearly  as  possible  in  the  middle  line, 
there  is  no  hemorrhage  of  any  c<>nt<equence. 

Betention  of  Urine  from  iS'ostatitis. — In  prostatitis,  retention  may  occur 
from  the  swelling  of  the  organ,  from  the  infiltration  of  exudation -matter 
around  it,  or  from  the  formation  of  pus  in  it.  In  these  cases  the  neck  of  the 
bladder  will  be  carried  to  a  considerable  distance  from  the  surface,  and  may 
very  probably  not  be  reached  by  an  ordinary  catheter,  which  may  be  buried 
up  to  the  rings  and  yet  not  enter  the  cavity  of  that  organ.  In  these  circum- 
■tences  a  silver  pnistate-catbeter  should  be  employed ;  and  this  must  be 
ouefully  introduced,  lest,  by  entering  the  cavity  of  an  abscess  which  has 
klieady  burst  per  urethmm,  it  might  be  3U[>posed  to  have  enterctl  the  bladder 
itwlf.  In  introducing  the  instrument  in  theiH;  circumstances,  care  should  be 
taken  to  keep  its  point  constantly  in  ctmtact  with  the  upper  surface  of  the 
■rethra.  and  to  hook  it  round  the  pubes.  The  upper  surface  of  the  urethra 
■  e  sure  guide  to  the  bladder  ;  for  any  abscess,  false  |>assage,  or  irregularity 
of  direction  will  always  first  afiect  the  lower  usjiect  of  thiscanni,  being  sur- 
nMinded  by  yielding  structures ;  whilst  the  upper  part,  being  firmly  supported 
1^  bone  and'  ligament,  cannot  so  readily  alter  its  direction. 

Chronic  Inflammation  of  the  Prostate  may  ftilUiw  the  acute  afiection. 
■specially  when  it  is  gonorrhceal.  The  patient  is  troubleil  by  a  sense  of 
weight  and  fulness  in  the  perineum,  and  there  may  be  an  occasional  glairy 
diichai^  from  the  urethra,  fine  threads  of  mucus  may  often  be  seen  boating 
u  tbe  urine,  especially  in  that  first  passed,  and  in  the  last  few  drops  expelled 
bjr  straining  if  these  be  collected  separately.  Freqnencv  of  micturition  and 
■ome  pain  during  and  atler  the  act  may  be  pret^nt.  JExamiuation  by  the 
tectum  shows  that  the  prostate  is  slightly  tender,  hard,  and  entergeil  on 
one  side  than  the  other.  A  chronic  abscess  may  slowly  form  without  great 
ucrease  in  the  intensity  of  the  symptoms.  This  complication,  which  is  for- 
lODBtely  rare,  is  recognized  by  examination  fnun  the  rectum.  Should  the 
sbeceiM  burst  into  the  urethra,  the  cavity  in  tbe  indurated  gland- tissue  may 
be  very  slow  in  beuling.  I  have  known  a  v&se  in  which,  alter  many  years, 
tbe  pnetate  remaincil  hard  and  enititxed,  and  on  pn-s^ing  firmly  on  it  from 
the  rectum,  pus  could  be  made  t<i  How  from  the  urethra.  The  patient  was 
obliged  to  draw  off  his  water  with  a  catheter,  but  siiHered  very  little  in  his 
general  health. 

The  Diagnotis  of  this  con<lition  from  tubercular  diseiu-ie  of  tbe  pnutatc  is 
eft«i  extremely  difficult.  Its  extreiiii-ty  chronic  nature,  the  al>sence  of  any 
disease  of  the  testicles  or  vcsiciihe  M'niinaleii,  the  nmre  uniform  and  regular 
enlargement  of  the  gland,  und  the  history  of  the  case  will  usually  determine 
its  nature. 

The  Treatment  of  this  consiirts  in  rcjieatedly  bji.ilering  the  [Hrineum,  Bel- 
hdonnn  supiNisitorics  may  Himctimes  relieve  tlu-  uncondortable  fcnsatlons. 
Any  treatment  by  the  urethra,  such  a.-^  injections  of  nitrate  of  tiilvvr,  will 
only  aggravate  the  cniidition.  Tonics,  change  of  air,  and  sea-l»itliiug  are 
•ometiroes  of  use.  Iodide  of  ])otiiFt»iuin  may  lie  given,  or  tlie  i<H!i<Ie  of  inni 
if  tbe  patient  is  aniemic.  Slmuld  tin  ab»cet>:-  form  and  point  towards  tho 
NCtum  or  perineum,  it  must  be  o[K'ned. 


1016 


tSBASES   OP   THE    PROSTATS; 


Frostatorrheea  has  hcon  descnKp<l  by  Gtitm  aa  a  HMchar^  ftf  clear  (•laify 
nincus  from  the  prostate,  in  consetjiiencft  itf  irritalion  of  thai  orgsn.  The 
diseflw  in  characKrizpd  by  the  discliarp*  of  a  few  drop*  of  ropy,  viscid  inucu* 
itMii  the  urethra  after  micturition  or  defecation.  It  is  of  i[iiporiaDc«  chiefly 
from  ita  liability  to  be  confoun(le<^l  with  HpermaUirrbtoa,  aod  from  the  depreB»> 
inc  effect  consequently  produced  upou  the  pnttcol's  miud. 

The  Diagnosis  of  prietntorrhosa  frotu  rpennatorrliaxi  may  bo  eflwted  by 
microscopical  examination  of  the  characters  of  the  discburgi*. 

The  Trcjtmcnt  cuii»iat8  in  atteiiliuu  to  the  etalc-  of  the  gencnil  hualtb ;  the 
arl mi II iet ration  of  tunics,  iiiorewij'ecially  of  iron  ami  nux  vomica;  the  remcvRl 
of  auy  lix-al  «uurce  uf  irritation  in  the  urctbra,  rectum,  or  anue,  tia  slricture. 
pilee,  or  (immure;  and  thv  local  application  to  the  prostatic  portion  of  the 
urcthr»  of  I  In.-  nitrate  oftjilvcr.  The  application  of  a  blister  to  the  perineum 
is  hcuL'titia!  in  eome  ca^es. 

Deep-seated  and  T«ry  Chrosic  Abscees  will  Bometimes  slowly  form  in  tbe 
pelvis,  between  llie  bladder  uud  rectum,  behind  the  prostate,  giving  tiae  by 
itH  prcffiurK  to  a  long  tniin  of  olisruni  Bvinpiome.  indJoilive  of  irrilation 
about  these  organn.  Hiich  ai^  ilvouria,  Htrangitry,  and  occasional  ailmixtnre  of 
pUB  with  Ihii  urine.  On  careful  examitiHtinn  of  the  perineum  and  rectam, 
some  slight  hardnese  may  perhape  be  deeply  felt  Id  the  mesial  line,  ur  towards 
one  side  of  it.  'Vim  Hlowly  increases,  and  perineal  ab^oeaB  of  an  ill-defined 
character  develops.  When  this  has  become  sufficiently  evident,  a  free 
incision  should  be  made  into  it,  when  pus  in  greater  or  less  abundance  will 
escape.  Oi)  careful  exptoration  bv  a  probe  ot  the  cavity  thus  opened  up,  a 
deep  sinus  will  pn^ibably  be  found  leading  into  the  pelvic,  and  to  the  original 
scat  of  the  abscess.  This  rivjuires  to  be  opened  up  by  a  free  incision  on  out 
side  or  other  of  the  perineum,  as  if  for  Intt-rul  lithot'timy,  and  n  proper  and 
direct  exit  given  to  toe  matter.  The  cavity  must  then  be  allowed  (u  graoulat« 
from  the  bottom. 


I 


CnitOKIC  ENI^IiGRUrifT  OP  THE  PR08TJk.TB. 

Chronic  Enlargement  of  the  Prostate  may  be  looked  upou  as  a  ei'nile  di^ 
ease,  seldom  occurring  befom  the  »<^  of  tifly-tive,  but  commonly  met  with 
mflcrtliis.  At  that  peritxl  uf  life,  as  Brodiu  obi-erveM.  when  the  bair  Itecc^mw 
gray  and  scanty,  when  the  coats  of  the  arteries  bti;in  to  become  ulheroms.- 
louti,aud  when  the  urcus  senilis  fonuB  on  the  CN^rneu.tlie  pmslatoonen  becomes 
increased  in  siui;  but  unlcw  the  enlargetueut  of  the  prostate  interferes  with 
the  free  escape  of  the  urine,  no  dtueasc  ran  properly  lie  saiti  to  be  eetablislicd. 
Xf  we  took  upon  the  diseased  enlitr;xement  of  the  pr'istate  as  such  an  amount 
of  bTpertn>pliv  of  this  oriran  at*  interferes  seriously  with  the  dLacbarge  of 
ti)«  urine,  we  shall  |)rohulily  not  tind  il  m  freipient  even  in  old  nieo  as  is 
geoerslly  suppoe«d.  Uulhrie  slutcs  that  it  ih  not  commonly  found  in  the 
penaoiKrA  At  Greenwich  Mospital.  Thomjison  found  that  an  enlnrgemeal 
uBRciable  after  death  exixted  in  :i4  per  cent,  of  men  above  tlie  age  of  sixty; 
bat  that  such  a  degree  of  enlargement  as  to  give  t\^  Lo  syioptoms  during 
fife  was  met  with  onlv  in  15  or  Kl  per  cent,  of  the  cases  ne  examined. 
TWmheIi  *gv  must  he  looked  upon  as  the  primary  cause  of  this  particular 
Lj|-nM"|Sy  of  the  prostate,  there  can  be  little  doubt  that  it  may  W  pmlia- 
_g^^^  any  conliniiod  sixirce  of  irritation  of  the  urinary  organs,  such  M 
^I^mW*,  stricture,  f>r  hard  living. 

^ ^-^M fcfTEiBi.— KulargLine n t  of  the  prostate  m  due  to  hypertrophy  of  the 
11^ — niuicniar,  fibrous,  and  glandular — of  the  organ.     Mott 
if  All  excess  of  development  of  the  museular  and  fibroD* 
I,  ha««v«r,  the  size  of  the  gland  has  ht*n  rery  slowly  and 


,dL 


I 


SIMPLK    PROSTATIC   TCVQUS. 


1017 


not  gr«ftUy  culnr^'^1,  iht^re  is  uearl}'  equal  hypertrophy  of  all  the  tlflStlM. 
Id  rare  ii)etaucc»,  there  in  exc-««8ive  lievelopiuent  of  thv  glandular  element; 
nod  in  8oni«  cases  horuuloiious  tumors  ar«  develi^ptHl.  The  enlargeinvnt 
gCDerutly  occupies  lh(<  whole  of  the  orgnu,  and  may  cause  its  sixe  to  increase 
to  that  of  a  heuV  egg  or  a  small  orange.  In  must  oues,  all  the  lobes  are 
enlarged  equally  or  nearly  av,  but  sonielimeB  there  is  a  diBpropdrtionate 
development  of  one  of  the  laternt  Inbeii  or  of  the  mtd'lle  portion.  More 
rarely,  the  lateral  lobes  or  the  anterior  comniiseure  aloue  are  enlarged. 

The  enlarged  prostate,  la  the  earlier  stages,  presenla  m  the  naked  eye  an 
appearance  of  rotundity  and  incren5e<i  fulnetis ;  nt  a  more  advanced  stage,  there 
may  be  great  irregularity  of  outline,  There  ia  usually  no  change  of  color 
exceriially.  and  the  texture  of  the  gland  is  generally  indurated  ;  though  some- 
times, when  the  glandular  cleiuent  \e  chiefly  increased,  it  is  found  to  be  looser 
sud  softer  than  natural.  On  making  n  section,  the  cut  surface  bulges  above 
the  level :  and  the  ehadfs  of  color  are  more  strongly  marked  than  in  the 
healthy  prostate.  Not  uncommonly,  single  glnnd-lobules  are  found  hyper- 
trophied ;  and  in  eome  cases,  aphcruidal  prominences  arc  aeon,  which  are 
easily  enncleuted,  and  which  are  tnmora  ftirmM  io  the  substance  of  the 
gland.  Of  these  wc  shall  prcseutly  speak.  In  some  tniftHnccs,  an  abundance 
of  fluid  escapee  from  the  cut  surfan:  and  from  the  openings  of  the  prnslutic 
ducts;  while  in  other  caaiw  thi;*  is  entirely  wiinting.  Small  cavities,  dilata- 
tions uf  the  glaud-f')lltoIct«,  ar(>  orcafiionally  found ;  somotimca  empty,  some- 
times containing  a  yellow  tluirl  rescmhling  pua  in  appearance,  hut  consisting 
of  the  prostatic  secretion  in  u  thickened  state  The  prostate  may  attain  a 
Terv  larpe  size.  The  liirgest  that  I  have  seen  is  wrtainly  one  in  the  Xor- 
wicii  Hospital  Muiwuiii,  taken  from  a  man  of  eighty;  it  weighs  more  than 
twenty  ounces. 

Simple  Prostatic  Tumors. — ^The  nature  of  simple  tumors  of  the  prostate 
has  been  carefully  studieti  by  Sir  Henry  Thompson,  to  whose  elaborate  work 
on  the  diseases  of  this  organ  the  student  is  referred  for  further  information. 
According  to  Thompson,  tumors  uf  non-malignant  character  are  met  with  iu 
RKwt  cases  of  liypertrophied  prostate,  and  al^  occasionally  when  there  is  no 
enlargement  of  the  organ.     He  divides  them  into  two  classes: 

"  1.  Tumors  which  ar«  generally  imbedded  in  the  substances  of  the 
prostate,  hut  the  structures  of  which  are  isolated  fn^ni  tlioi*e  which  sur- 
round it. 

"  'L  Outgrowths  which  are  continuous  in  structure  with  the  F'^rLs  of  tba 
prn«t«te  whence  ihey  spring,  but  which  oiauifeet,  a  tendency  to  l>eL-ome  par- 
tially isolated,  by  assuming  u  more  or  lesH  polypoid  form,  and  maintuiuiug 
ftttacfament  lo  the  parent  organ  thniugh  the  niiHiiuni  of  a  pe<liclo  nuly." 

I.  The  isolated  tumors  in  the  Hulmtauce  of  the  profitaio  have  hwu  n^mg- 
Dizcd  bv  Sir.  £.  Home.  Oruveilhier,  KokitHnsky.  I'aget,  and  other  patholo- 
gists. Tbev  may  occupy  any  [Mtrtion  of  the  organ;  hut  are,  i>erha|)s,  more 
numerous  m  the  lateral  lobes  than  elsewhere.  They  aru  easily  enucleated, 
having  but  a  louse  connection  with  the  nulistance  of  the  gland.  In  diameter 
they  vary  frnm  ~^\\i  to  Uhs  of  »n  inch.  They  are  lirmer,  and  ninKLly  piUer 
iu  cidor,  than  the  pni[)er  prtvtatic  tissue,  and  are  \em  vnseular. 

"  The  buHts  of  the  tuiiioiv  appenra  Ijo  he  the  tihrous  basis  or  stroma  of  the 
prostate  itticlf.  an  admixture  of  uoBtriped,  sotl,  pain  muscular  (ibres,  and 
oonnective  with  a  little  oliwtic  lissue,  ci(»sr]y  interwoven.  InterBperfieH  with 
this,  ihrre  are  prcM^nt  in  most  cases  email  cavities  containing  H.'ittened 
[Mdygonai  or.tphemtdal  epithidium,  like  that  seen  in  a  pouch  at  the  extremity 
nf  a  prostatic  gland-duct,  and  sometimes,  also,  some  pri.smatic  epithelium. 
These  cavities  are  Bometimcs  solitary,  sometimes  slightly  hranche-d,  and 
sometimes  of  an  elongated  or  tubular  form.     In  a  few  inBtances  there  is  very 


1018 


DISEASES    07    TUE    PROSTATE. 


little,  or,  perhaps,  no  such  glanitular  tissue  to  be  fouod ;  ^enernllr.  howertr, 
a  onreful  Hcairli  will  discover  ii.  In  some  uf  tbc  outlying  tiiiuore,  iho 
glaiiiiular  Htrm-ture  is  more  iit^i  rrctly  dcvel<>|HHi — iii  some  it  h  nuite  »> — aai 
M  ilui-t  is  Ainiiehetl  wiiich  RviJeully  carric«  iK.-c*rtU0D  to  Ui«  a^ipaatud  deali- 
oatiuii." 

2.  The  part  of  the  prostate  whiuli  \»  mmi  itt\ial\y  the  seat  of  oulffrototh  is 
the  tnitidle  or  uretbrnl  portion,  wliich  may  bt-i.>otiie  greatly  enlargeu  in  sise, 
with  nr  without  hypertrophy  r)l'  the  ifttuml  lobi's.  The  growth  assama  a 
pyriform  shape, and  is  more  or  letm  jiedunciilat^d.  It  Ik  DtintiDuuiis  in  struc- 
ture with  the  pn^tatic  tifteiieA,  and  has  iut  own  duct,  which  opeus  into  the 
urethra  throujrii  the  pedirle.  ]*roBtatic  toncretions  are  commonly  found  in 
these  outgTowihs;  never  in  the  iiuilated  tumors. 

Though  most  common  in  the  nii<ldle  portion  of  ibe  prostate,  outgrowths 
may  occur  from  the  (lositerior  part  of  one  of  the  lateral  lolies,  or  fmrn  that 
p«)rtion  uf  the  gtan<I  which  lies  above  or  in  front  of  the  inner  orilice  of  th» 
urethra. 

Ill  rare  instances,  the  veruniontanum  alone  apiiears  to  be  affected,  forming 
a  tliickcoeil  polypiiiil  projccliun,  which  projects  in  a  valvular  manner,  and 
iiitvrferee  miit^riully  with  iho  flow  of  urine. 

Thuni{M<in  poiuta  out  tliul,  as  hn«i  btx;n  eug^Mted  by  V\*I[H-nti,  remarkable 
analogieo  exist  between  t)ie«e  primtatic  out^ruwtba  and  the  libroid  tumoro  of 
the  uterus.  This  view  ie  in  accordance  with  the  teaching  of  Leuckart. 
Simpson,  ami  othi^rij,  that  the  prostatic  utricle  in  the  male  is  the  analogue  of 
the  uterus  in  the  female. 

Mechanical  Effects  of  Enlarged  Prostate  on  the  Tfrinary  Organi. — 
Kniargemetito  of  thp  pniBtnle  are  productive  ol' inconvenience  with  regard  U> 
the  ili>w  of  urine,  giving  rise  either  to  retention  or  to  imxmtiueuce,  or  to  a 
kind  of  mixture  of  both  cooditi^ms.  When  the  lateral  lobes  are  ealarged, 
there  is  a  diminution  of  the  lateral  or  trani'ver^  diameter  nf  the  raosl,  st 
tbo  same  time  that  the  anlero-poeterior  iliaiueler  i«  increased,  so  that  the 
caoal  bocomes  a  chink-like  passage.      The  urethra    also  beoomee  greatly 

elongated  and  tortuous,  and  is  diverted  front 
the  nalura)  dircclioa — this  varying  with  the 
form  of  enlargc'menl.  When  the  median  poi^ 
tion  is  enlarged,  there  is  a  more  or  leas  angular 
curvature  of  the  eaooJatthe  prostatic  portion. 
When,  in  mldttion,  there  is  enlargement  of  a 
lateral  lohe.the  urethra  is  curved  also  laterally 
in  tbc  (iircciton  of  the  enlarged  lobo.  The 
lateral  deviation  may  occur  also  when  there  is 
enlurgcmcDt  of  the  middle  lobe;  but  it  then 
affects  both  sides. 

The  inner  orifice  of  the  urethra  also  under- 
goes ebanjrtfl,  Knlargement  uf  the  pusterior 
part  of  the  middle  portion  of  the  pr<<.«Late^VH 
itucrcsfcntic  form, with  the  convexity  directed 
upwards  ;  ami,  in  enlargement  of  either  lutera) 
lobe,  the  convexity  of  the  crescent  lies  towards 
the  tride  opposite  the  enlarged  lolie.  Some- 
times, when  there  are  two  or  more  irregularly 
enlarged  lobes,  the  orilice  is  very  much  dis- 
liirted,  elongated,  and  tortuous.  i^onwtiniM, 
in  cases  of  valvular  or  petluneulsled  projections  from  tlie  posteri<.>r  p>irtioos, 
the  orifice  appears  to  be  overlapped  altotrelher.  This  condition  exi»led  in 
the  casjc  from  wbicb  the  accompauyiog  drawing  (.Fig.  t)13;  was  taken:  the 


Pig.  f>l3.  -  Biftddcr  UM  npvB, 
■boniiis  EriUrgciavnt  of  Ura- 
thral  Pwrtkin  «f  Pro«raio. 


I 


! 
I 


« 


I 


"        ^ 


M 


MBCHAXICAt  EfFECTS  OF  ElVLARORD  PROSTATE.       1019 


M 


[ 


third,  OT  median  lobe  forraiiig  a  pedunculated  tumor  vrhieh  acted  like  & 
ralvo — obetructing  the  exit  oi  the  urine  from  the  bUdder,  though  It  did  not 
offer  any  obatacte  to  the  iotruduction  of  a  catheter. 

The  elongation  and  expansiim  of  the  proiitatic  portion  of  the  urethra  givEs 
nie  to  an  increase  in  iu  <!upactty,  so  ihal  it  i^ometinieA  holtin  two  or  three 
ounce*  of  urine;  nnd  the  eloDj^tion  will  carry  the  neck  of  the  bladder 
upwunlti  and  hfhind  the  pubev,  to  a  considerable  iliiitance  from  it«  normal 
pooilion. 

While  the  lateral  enlargements  cause  the  uretlira  to  aworoe  »  somewhat 
tortuuuN  course,  the  mi<t(lle  lobe,  if  hypertrophied,  may  readily  occaeioo 
retention  hy  projecting  a^rainet  the  en* 
trance  to  thi«  wiiidmg  channel,  and 
fikllinfr  over  it  like  a  \»\ve  whenever  the 
patient  att«mpt«  to  pniw  urine,  a»  in  Fij;. 
914.  Id  this  condition,  no  urine  iv 
pawed  until  by  accuuiuJatioa  nilhin  the 
bladder  tbc  neck  has  become  so  slrvtchcd 
that  tbo  valve-like  ubelrucliun  uu  longer 
dotts  the  oriSec.  Then  a  «matl  (juanlity 
of  urine  its  expelled  ;  the  ticck  of  the 
bladder  collaixtcs,  and  bet<>re  the  cavity 
tt  coniptetelv  emptied  the  imtico  is 
blocked  by  tli«  projecting  middle  lube, 
and  tbe  flow  ceases.  Thtm  a  certain 
amount  of  urine  is  alwavs  retained, 
which  is  comraouly  terme<l  tiie '"  reeidual 
urine,"  and  none  escapee  till  the  hlaiKler 
ifl  in  a  state  of  coDsirlerabIc  tension. 
As  the  middle  lobe  increases  in  size,  a 
grenter  degree  of  Btrelchiog  is  nece»arT 
before  urine  can  escape.  Under  this 
(wnstant  tension  the  bladder  «lowly 
yielHs  and  becomes  dilated,  ita  walls  are 
thickened  by  flbroiil  liskuc,  and  it  gradu- 
ally becomes  coniplelely  "  atonic,"  losing 
all  active  power  of  c<jntraction.  At  last 
a  condition  is  reached  iu  which  urine 
flows  only  when  the  bladder  is  greatly 
distendtil,  and  the  escape  of  a  few  drop* 
is  suHicieut  t<i  render'the  obstruction 
complete,  and  thus  a  condition  of  almost 
rou9tjint<lrihblingnl'uriTiei8e»tnbli»hed. 

This  forms  the  most  typical  variety  of  prostatic  obetructiuu.  Less  commonly, 
the  obstacle  to  the  paseage  of  urine  is  of  such  u  nature  that  it  eno  be  forced 
by  increased  pressure,  and  ne  then  hnd  the  muscular  coat  of  the  bladder 
hypertrophieo.  iia  in  stricture  of  the  urethra.  In  still  more  rare  cases,  the 
middle  lobe  lies  between  the  enlarged  lateral  lobes,  thus  propping  tbe  neck 
of  the  bladder  open,  and  then  true  iucontiueoce  mny  occur  with  cuiutaut 
dribbling  of  urine. 

The  effect  on  the  kidney  will  vary  according  to  rarcumstancea.  If  the 
bladder  is  in  a  constant  atatc  of  over-dlstentlon,  a  similar  increased  tension 
will  occur  in  the  ureleni,  as  it  is  evident  that  increased  force  will  lie  requiied 
to  drive  tbe  urine  ihmugh  their  orifices.  We  conseoueutly  find  alt  the  Bjgns 
of  increased  leusifm  already  degeribud  (p.  877);  dilated  ureters  and  i^Jvis, 
absorptioD  of  tbe  pyramids,  chronic  interstitial  nephritis,  elo.  (Fig.  [tl4). 


BUtltlci    eolarggil:      I'tnloti    dilat«it: 
Clirunio  Dit«Ma  uf  Ridoej*. 


1020 


DISEASES    OF   THE    PROSTATB'. 


FiDully,  »hr>n1(l  decomposition  ocrur  in  the  urine  reiaiued  in  the  bladrler,  it 
may  extend  tlu^tugh  ihc  oriticcs  »f  tLe  UKlcr  to  tlie  kidney;  auil  io  ibis 
way  a.  large  propiatiun  of  patieuts  saflering  froiD  pruetatic  tliseaae  die  of 
8opttc  fltippiiriitiro  ncphritix. 

Moral  Effects  of  Enlarged  Prostate. — The  irritation  of  u  cungveUsl  and 
calargt!il  priNitate  will  oxcit«  liliidiuouit  ideas  iti  the  Hgcd,  vbicb  may  le«3  to 
the  {>cr|ictratton  of  acta  of  indecency — such  a^  exposure  of  the  pertwiD,  iode- 
L-«nL  asiftultii  on  children,  or  to  a  general  impairmcut  of  the  moral  toQ«. 
But  not  only  dne«  the  diooaseil  state  of  thiA  li<Kly  thus  excite  a  depraved 
condition  of  the  mind  ;  the  c-nnver!ie  will  also  li»p|>eu.  And  if  the  inia 
history  of  many  cas^s  of  pruAtalic  cmi^^mtion  and  hcni(irrha|:e  were  tAld,tb« 
diMiucs  would  lie  found  tn  hi-j^in  in  undue  ur  irregular  rcxuuI  ur  erotic  ex- 
citement, by  whir^h  the  genitnl  organs  have  been  injurinuitty  ovi-r-dltmulalcd. 

SYMrroMs.- — The  nymptonis  of  enlarged  proiitate  arisu  primarily  from  the 
mechanical  nli^tacle  i^ttVi-^d  to  the  eNcape  of  the  urine,  'fhe  first  symptoms 
usually  ctnHiitl  in  the  Ividing  of  a  necemity  to  strain  slightly  before  tbv  urine 
will  flow  ;  and  iheu,  after  the  bladder  has  been  apparently  emptied,  in  the 
itivoliimary  escape  of  a  small  quantity  of  urine.  The  patient  alto  tiods 
that  be  U  much  louger  than  ueunl  in  emptying  the  bladder;  for.  iboujeh  the 
■tream  flom  freely  enough  »i>  soon  qm  it  liu  unco  begun  to  eecai>e,  yet  it  can- 
not be  properly  pn>Ji-fted,  thu  viseuti  having,  to  a  certain  exieol,  tott  its 
tonicity.  It  uoniuiouly  bapitemr  liini  the  mure  he  strains  the  lean  readily 
will  the  urine  coiiiu  away,  whereas  ^vbeu  be  remains  quiet,  it  wilt  usually 
How  with  iimro  freedom.  TIiIh  ist-Bpecially  the  case  iu  pedunculated  eniareie- 
juenta  (>f  thu  middle  lirlH,-.  About  iIuk  lime  frcqueiiev  of  niicturitiou  utually 
beounie;^  u  marke<l  feature,  tvin-eially  at  nl^^ht.  Io  fact,  the  great  majority 
uf  patit.-ut«  "Pi'ly  I"  Lhe  Hiir^'eon,  not  im  aeeouat  uf  difQcuiLy  io  paaaio; 
water,  bur  because  they  are  cnlled  upon  to  perform  the  Bt^t  of  micturiliaa 
ton  triHiiit-ntly.  This  c^indition  may  gradually  inrre:i.<<e  till  it  amnuuts  to 
actual  dribliling.  The  fre(]uent  dist^'burge  of  a  fimall  qnnniity  of  urine  may 
leud  the  incHUtious  Sur^on  to  sappoM^  that  the  patient  is  iitTected  with  true 
incontinence  of  urine  or  with  irritability  of  the  bladder.  This  error  may 
always  he  guarded  ngntiist  by  careful  examination  r>f  the  pubic  repoD  by 
perctiaaion  and  palpation.  Dulne^ie  will  often  be  found  extt^udint;  half-way 
ti)  the  umbilicus,  and  the  tense  distended  bladder  may  be  readily  Ink  above 
the  pubcis. 

The  svmptomB  mny  for  n  long  time  remain  limited  to  frequency  of  mirtu- 
rition  with  s^me  difficulty  in  the  act.  The  urine  remains  ncid  and  n'-niiol 
iu  «vcry  ri«|iect,  and  the  patient  sulTiTS  but  little,  if  nl  all,  in  bis  ^fetiTal 
health.  Tht?  condition  i»,  however,  always  one  of  con^ideralilc  daiii^r.  The 
over-distended  bladder  is  always  prone  to  slight  attni^ks  ofcystiti*  fp>m  M- 
ptjdure  t-i  wld  or  other  cnuswi.  The  urine  then  become*  cloudy  from  ♦•xceas  of 
mucu».aud  often  acquires  an  ofTen^ive  ti«hy  small,  while  »till  remaiuins  acid. 
The  mucus  »<.TumulaleH  in  the  fHiuch  Iwhind  tbeenlnr^i  )ir«i"tiite,  nod  i*  with 
di[Hculty  ex|>elled.  Under  thetfecoudilions  animouiacal  dccora|M»»iti<>D«  may 
readily  lake  place.  This  may  "ccur  without  the  passage  of  in»truruent«.  but 
in  a  coueiderabie  proportion  of  cases  is  not  noticed  before  the  ui*e  of  the 
catheter  has  been  commenced.  Should  it  happen,  the  cvKtitis  bec«Mnee  more 
acute,  and  the  symptoms  of  septic  p)i»oniu|; — febrile  dbtturbauee.  jjreat  d^ 
preivtiou,  brown  tongue,  nausea,  delirium,  etc. — may  set  in  and  terminate 
fatally,  when  tteptic  inflammation  of  the  kidneys,  by  cxteusion  up  the  uretar. 
will  usually  b^*  found  to  have  heeu  the  immetliale  aiuse  of  death. 

Complete  Beteution  of  Uriue  from  Enlarged  Prostate  is  a  commua  com* 
plicaliou  of  Llie  di.M-itse.  Ii  niity  arist-  in  the  |>iitieiit  vU.>  has  not  beva  able 
to  empty  his  bladder  for  flume  time,  and  u  little  more  tbuo  au  a^'grarattoB 


I 
I 


i 

^ 


DIAGNOSIS    OF    KNLAROSD    PROSTATK.  1021 

cf  bis  tuual  condittoD,'  or  it  may  occur  in  an  old  man  whose  proatate  is  cod- 
■derablj  enlarged,  but  who,  under  ordinary  circumstances,  gets  rid  of  his 
wine  without  difficulty.  lu  the  latter  case  it  is  due  to  congestion  and  swell- 
ing of  the  diseased  gland,  usually  induced  by  exposure  to  cold,  or  alcoholic 
or  venereal  excesses.  It  is  especially  apt  to  occur  after  drinking  the  sour, 
Wd  wines  usually  provided  at  public  diooen). 

Diagnosis. — ^Theexact  condition  of  theenlai^d  prostate  can  be  ascertained 
only  b^  examination  through  the  rectum  and  urethra.  By  rectal  explora- 
tion with  the  finger,  the  degree  of  enlargement  of  the  lateral  lobes  can  best 
be  ascertained ;  though,  as  in  many  cases  the  end  of  the  finger  cannot  reach 
the  further  extremity  of  the  }:laud,  it  will  be  impossible  to  say  to  what  extent 
tlie  bypertrnphy  has  exteixleil.  The  urethral  exploration  must  be  conducted 
bj  means  of  a  long  gum-elastic  or  a  silver  prostatic  catheter,  and  will  afibrd 
information  that  rectal  explomtiuu  cannot  give ;  by  it  are  ascertained  ap- 
proximately the  sizu  of  the  middle  lobe,  and  the  condition  of  the  urethra  as 
to  elongation  and  curve. 

The  diagnosis  of  obstruction  in  ctmsequence  of  enlarged  prostate  has  to  be 
made  from  that  pro<UK-pd  by,  1.  Stricture  of  the  Urethra  ;  2.  Calculus  of  the 
Bladder ;  3.  Vesical  Tumor ;  4.  Chronic  Cystitis  ;  5.  Atony  of  the  Bladder ; 
6.  Paralysis  of  the  Bladder. 

1.  In  ^richire  the  stream  of  urine  is  stnall,  but  the  jet  is  increased  by 
■training,  while  in  enlarged  proetate  the  stream  is  dribbling,  but  not  reduced 
in  volume,  and  straining  only  makes  matters  worse.  Stricture  most  cora- 
noolv  occure  before  middle  life,  prostatic  disease  always  afler.  In  stricture 
the  obstruction  is  within  six  inches  of  the  meatus;  in  prostatic  disease  it  is 
ftt  least  seven  from  the  orifice.  It  is  not  wise,  however,  to  trust  too  implicitely 
to  measurements  in  inches,  as  the  penis  varies  considerably  in  length.  If  the 
finger  be  passed  into  the  rectum,  it  can  at  once  be  determined  whether  the 
point  of  obstruction  is  in  front  of  the  apex  of  the  prostate. 

2.  Calculus  presents  many  symptoms  in  common  with  enlarged  prostate, 
and  its  more  special  symptoms  may  be  absent.  In  stone  the  frequencv  of 
nicturition  is  greater  by  day,  in  prostatic  disease  it  is  worse  at  night.  *The 
presence  of  a  snmll  quantity  of  florid  blood  in  the  urine  passed  after  exercise 
should  make  the  Surgeon  strongly  suspect  the  presence  of  a  stone;  but  the 
use  of  the  sound  will  alone  lead  to  an  exact  diagnosis. 

3.  Vaical  Tumor  gives  rise  to  more  jwiin  and  tenderness  on  the  introduc- 
tion of  instruments  than  prostntic  enlargement ;  and  the  urine  generally  con- 
tains bl<M>d  ant]  mucus,  often  with  sabulous  matter.  Microscopic  examination 
of  the  contents  of  the  urine  may  show  the  presence  of  the  cuuipcment  tissues 
of  the  tumor.  Tumor»,  rsjwciaily  of  the  malignant  kind,  may  be  felt 
through  the  rectum  ;  while  villous  tumors  give  rise  to  the  almost  constant 
presence  of  blood  in  the  urine. 

4.  In  Chronic  f'y^/iVij),  without  complication,  the  al^sence  of  the  physical 
Bgns  of  enlarged  prostate,  as  ascertained  by  examination  by  the  rectum  and 
nrethra,  will  estubii.-<h  the  <Iiagnosif!. 

5.  Atony  of  the  lilndder  is,  as  tK'fore  PtntCil,  verv  commonly  associated  with 
enlai^l  prostate.  Its  al»enoe  would  be  shown  by  the  urine  flowing  from 
the  catheter  in  a  .<!teady  stream,  not  influenocd  by  the  respiratory  movements, 
indicating  an  active  contraction  of  the  bladder. 

6.  True  Paralt/trin  of  the  bladder,  acci>m]Kinie4l  with  a  similar  aflection  of 
other  parts,  is  rcittgnizcd  by  its  concomitant  cmditiiin!',  and  by  the  absence 
of  physical  signs  of  enlarpeii  prostate,  and,  as  in  ntnny,  by  the  passive  nature 
of  the  flow  of  urine  throu^'h  the  catheter. 

Treatmext. —  In  the  tri'atment  of  enlarpeii  prostate,  little  can  he  done  by 
medical  means  ;  though  the  patient's  condition  may  be  somewhat  ameliorated 


1022 


mSBAaKS    OP    THE    PKOSTATii. 


hy  remfnha  calculntetl  to  lessen  IrrilaLmD  about  the  urinary  organs,  and  to 
iiiipnive  iii<^  tN)ii(liiii)U  of  ihe  uriuu.  If  il  be  very  acid,  alkulics  with  benbane 
should  be  given.  If  tliCfivrnputiiiB  oroiironic  cyslilu  uakc  ibuir  appearanoe 
tbe  various  renicdira  n-X-umnieiKlod  iu  tbi-  trunlmeut  of  that  diaciuc  may  be 
givcu.  If  lieniorrhage  ut>cur,  tincture  of  |)«ri^hUiride  of  iron,  iafueiun  of 
uva  urui,  or  gallic  aciil.will  be  useful.  CuuiiLor- irritation,  tbn  njipUcalion  of 
iodiue,  and  otber  nieasurex  calculated  to  protnole  alisorpUnn  nf  the  enlarged 
gland,  are  not  of  iliu  dlightesL  service. 

Various  operative  prncfdurea  hare  l>een  recommended  and  prturtiaril  by 
Mercierand  otheni  for  the  removal  of  the  meebantcAl  obstruutiiia  caua^  by 
the  enlarged  prntitaie.  hut  they  are  both  inefHcicnt  and  dangerona,  and  have 
been  almost  unnnimonsty  condemned. 

In  fact,  the  stde  trentment  of  enlarged  pnwlate  coDsiels  in  the  regular  ne 
of  the  catheter,  in  order  lo  draw  off  retniiied  urine;  and  when  once  tim 
ireatriirut  has  bi*en  (Mmiiieuced,  it  mudt  W.  i-onlinued  for  the  remainder  of 
life,  the  patient  being  taught  to  use  the  itiiilrument  for  himself.  Il  is  eane- 
cially  noceasary  to  empty  tht>  ]M)ucb  thnt  i\>riu»  in  the  ImtfonA  of  the  bladoer 
behind  the  prostate;  and  whk-li,  being  below  (he  level  of  the  urethra,  tendii 
to  collect  an  ftcouniidatixn  of  vim-id  mucti;^  and  tutid  urine  nhich  the  |i»t>eiil 
cannot  expel  without  aid,  {uirlly  from  their  grnvitating  into  this  pouoh,  and 
partly  from  the  muscular  power  of  the  organ  being  impaired.  The  re- 
moval of  these  matters  is  of  great  imitortaince  ;  ai!i  tbey  may,  by  undergoing 
putrefaction,  give  mo  to  ftepttc  infection.  The  bladder  should  be  ellectually 
emptied  at  least  twice  ewry  day.     By  far  tbe  must  convenient  instrument  in 


Plf.  I)  1».— Elbowed  CKtbster. 

Ihe  majority  of  cases  in  the  imft  French  "  elbowed  "  catheter — the  "  catheter 
a  coude,"  of  the  size  and  sbnpp  here  represeiited  (.Fig.  'JIo ).  Tbe  stent  b 
fAX  and  pliable,  but  the  angle  and  eyed  point  are  made  of  firm  gum-catbelw 
material,  liy  keeping  the  point  well  up  against  tbe  uretbra,  it  wiil  often 
slip  iu  very  easily  and  smoothly  in  case«  of  enlarged  prostate.  Tb»e 
catbvters  are  made  with  their  poiut«  bent  at  different  angles  or  with  duuble 
elbowD.  instead  uf  siugle,  and  very  ofleu  when  one  will  not  pon,  another  of 
a  slightly  dideront  form  will  slip  lu  readily.  The  size  of  the  instrument  ii 
of  some  importance.  As  a  rule,  No.  8  or  0  passes  mofit  readily.  There  is 
nothing  ^rained  by  using  a  smaller  iuetmmcDt.  as  tho  passage  through  the 
dtseaseil  prxfltatu,  altbuugb  it  obstructs  tbe  tlow  of  urine,  is  atwaya  larger  tiian 
that  through  a  healthy  gland. 

If  the  coud€  caUieler  dnee  not  pasa,  a  Qaxible  India-rubber  catheter  may 
often  be  of  utie.  tliitcbintum  ittatus  "  that  in  almost  all  caaes  of  proetatio 
cetentloD.B  flexible  Indiarubbur  i-atlieler  without  a  btylel  can  be  paae«l  into 
the  bladiler."  Its  use  is  so  perfectly  puink'»K  and  free  from  danger,  that  it 
may  always  be  tried  before  adopting  more  Bevere  measures.  If  from  any 
cause  it  be  neoeesary  to  retain  such  an  instrumeut,  Hutchinson  uses  a  nonde 
with  rings  paaaed  into  the  orilioe  of  the  India-rubber  catbeter,  nod  fitted  with 
a  "  styletled  plug."  The  nozzle  is  about  thr(^e-<]uarters  of  an  iuch  in  lengtli, 
and  is  fitted  accurately  by  the  plug.    The  stylet  reavbui  alMJUt  two  inebes 


down  the  catheter  so  as  to  ntitTen  it. 
patient  need  not  be  confined  to  bed. 


With  such  an  inatrumeot  in  use,  the 


I 


TRXATUKNT  OP  ENLARGED  PROSTATE. 


1028 


If  neither  of  tfaeee  InatrumeDtB  will  enter  the  bladder,  a  commoD  French 
ileal  inatrument  may  pass;  but  this  very  rarely  succeeds  when  the  coud6 
tBtheter  fails. 

A  commoo  gum-elastic  catheter  of  full  size,  which  may  be  bent  to  anj 
aagle  in  hot  water  and  fixed  by  immersiog  it  in  cold,  mav  pass  when  other 
iBBtraments  fail.  Sometimee,  if  it  be  bent  tu  a  curve  like  tliat  of  a  Hthotrite, 
li  may  slip  over  the  enlarged  middle  lobe.  It  must  be  remembered  that  the 
heat  uf  the  urethra  soon  causes  the  catheter  to  lose  the  furm  impressed  upon 
it,  and  consequently,  if  it  does  not  enter  at  once,  prolonged  attempts  to  pass 
it  are  oselees. 

Sir  B.  Brodie  recommended  that  a  gum-elastic  instrument,  long  and  of 
large  size,  on  a  well-curved  stylet,  so  that  it  might  preserve  its  curve  when 
tint  18  withdrawn,  should  be  kept  in  readiness  for  these  cases.  A  mana'uvre 
■Motioned  by  Sir  B.  Brodie  will  often  be  of  uee  in  surmounting  a  large 
Middle  lobe;  viz.,  after  passing  the  gum-elastic  catheter  as  far  as  it  will  go, 
to  withdraw  the  stylet  slightly,  so  as  to  tilt  up  the  point  of  the  catheter,  which 
then  passes  over  the  obstacle. 

If  none  of  the  foregoing  means  succeeds,  the  Surgeon  must  have  recourse 
to  ailver  instruments.    If  the  prostate  be  much  enlarged  it  may  be  necessary 


Fig.  910.— Kolkrgcd  Middle  Lobe  of  Proitmtv,  Arreilinf;  ProgrcM  of  Cfttbeter. 

in  order  to  reach  and  empty  the  bladder,  to  use  a  prostatic  catheter.  This 
imtniment  should  be  made  nf  silver,  and  be  of  lar^  size,  equal  to  about 
Nou  12.  In  order  proi>erly  to  enter  the  bladder,  which  is  carried  away  from 
tbe  surface  by  the  elongated  urethra,  the  prostatic  should  be  about  four 
iacbea  longer  than  an  ordinary  catheter;  and,  as  the  neck  nf  the  viscus  is 
waallv  pushed  up  high  behind  the  pubes  by  the  projection  upwards  of  the 
lateraf  lobee,  the  curve  nf  the  instrument  should  he  greater  and  longer  than 
vmal.  I  find  the  best-shaped  proiitatic  catheter  to  be  one.  the  curve  of  which 
il  exactly  the  thini  of  the  circumference  of  a  circle  live  and  a  half  inches  In 
diameter.  The  eyes  should  be  large  an<l  rounded;  and  I  have  found  it  of 
an  to  have  the  lower  end  of  the  stylet  provided  witli  a  piston-plate,  so  that, 
bj  withdrawing  this,  the  mucus  nmy  Iw  sucketl  in  through  the  eyes  of  the 
faMtniment.  In  intnxlucing  the  catheter,  cart;  must  be  taken  when  the  point 
4Bten  the  prostatic  portion  of  the  urethra,  to  depress  the  handle  well  between 


1024 


DI8EASKS   OP   THE   PROSTATE. 


tho  tl)igli»,  wliile  the  instrumeDt  is  drawD  ilightlj  towardi  tbepubfli^lfiatkbe 

euil  liUcb  agaiDst  the  enlarged  middle  lube  (Fig.  916).  If  it  be  nmplj 
depressed,  witLout  at  the  same  lime  beicg  held  bnck.  a  little,  it  will  probaoly 
tuunel  the  ob8tructii>D.  Iq  Bi>nie  cases  the  ordinary  catheter  passed  in  the 
eaiac  way  will  euter  mare  easily  thao  the  prostatic.  It  is  eometinies  possible 
to  lift  tlio  catheter  over  the  obstructiou  by  pressing  on  it  with  the  finger  dd 
the  rectum.  In  fact,  no  one  ctir^'e  or  one  tind  of  instrument  will  aaswer  ia 
all  Cfues.  If  it  is  necesisury  to  uea  a  rigid  io^trumeut.  I  certainly  think 
a  Bilvor  iastriimeut  ia  safer  uad  more  easily  maotged  ibaa  the  gum-elaDtie. 
It  might  be  suppiMcd  thai  a  Ims  chanue  of  miftcbiuf  would  result  from  the 
gucD-elastic  than  from  the  metaltie  catheter,  as  being  the  sufVer  and  moro 
yielding  instrumeut ;  but  thh  ia  orroncous,  if  iho  stylet  bo  allowed  to  remaiu 
la,  OS  it  in  then  oa  rigid  at  the  tioint,  as  hard,  and  as  likely  to  (it>uelraic  soft 
structures  as  a  silver  ouc  wimid  be^  Tlio  paiiuat  himself' should  use  a  m(t 
iujitjuuiout.  it'  piK^ihle,  but  it  ooua^ioiially  hapjWDs,  as  occurred  in  a  cose 
uudar  my  caro,  that  iiu  miX  L-alhntcr  of  any  shape  ooiild  he  made  ui  pass ;  in 
such  cases  the  pationt  can  maily  be  taught  to  use  a  metal  iniitruracnt. 

Ireatmeat  of  Complete  Rstention  fram  Prostatic  Ealargement— In  these 
oaaes  the  patient  iiHi-ti  Uo  ri>licvoil  by  an  instrument  m  noon  aa  poAiiblc,  as 
elderly  people  are  liable  to  sulfer  severely  if  there  ia  any  delay,  fever  aooD 
setting  in,  which  may  be  fatal. 

It  cannot  he.  too  forcibly  inni<tt«d  on  that  in  these  ca<i^  there  i.<t  no  actual 
narrowing  of  the  canal.  The  enlarged  pnistate  is,  no  doubt,  swollen,  but  there 
is  always  sufficient  space  left  for  the  passage  of  the  largest  catheter,  if  only 
the  proper  way  can  be  fttund.  Ni>thing  is  gained  by  using  small  instru- 
ments ;  anything  below  No.  H  or  9  ( English)  is  liable  to  wound  the  swolleo 
mucous  membrane,  and  cause  troublesome  hemorrhage-  In  complete  releo- 
tioD  the  various  modes  of  overcotuiag  the  obstacle  in  the  proetat«,  which 
have  just  been  deecribed,  uiuat  tiri^l  be  attempted,  beginning  with  suit  tn- 
atrumeat^,  and  using  silver  only  ufler  these  have  failed.  If  the  retentiuu  ia 
thus  relieved,  it  becomes  a  4uusliuu  whether  the  catbvterehould  be  left  in  tiie 
bladder  or  withdrawn  afWr  the  viscue  h  emptied.  A»  a  gvueral  rule,  it  is 
certuiuly  far  better  not  to  leave  the  catheter  in,  for  the  reaM>u»  given  at  pag« 
1005.  The  instrumeut uhould  bu  iulroiluced  twice  in  the  tweaty-i'our  hours; 
and  care  should  be  taken,  if  possible,  to  empty  the  pouch  behind  the  pruatate 
by  depreaaiug  it«  poiuL  Should  the  mucus  be  very  viscid  and  offensive,  the 
bladder  may  be  waiihet]  gut.  After  the  bladder  has  been  emptied  for  the  &nl 
time,  it  will'  be  fouod  to  refill  in  the  course  of  a  very  feir  buurs.  usually  in 
six  or  eight,  the  secretioo  of  the  kidneys  appearing  to  be  set  free  OD  the 
removal  of  the  pressure. 

Should  any  great  difficultv  be  experienced  in  inlrodudng  the  catheter,  it 
may  be  thought  desirable  to  leave  it  tn  the  bladder  for  two  or  (hreedaya;  and 
thoD  a  giini-elaalic  one  is  always  to  be  preferred,  as  in  tht-se  circuraatanoee  it 
presents  a  crent  advantage  over  the  silver  catheter,  beiNjming  aof^.  accfimmo- 
dating  itself  to  the  shape  of  the  part«,  and  not  being  no  liable  to  irritate  the 
mucous  mombrjinc  with  its  pDitit,  which,  dipping  dowu  into  the  pouch  behind 
the  prostate,  acta  as  a  siphon,  emptying  this  part  of  the  bladder  far  bettar 
than  a  silver  catheter  could  do. 

Should  the  Surgeon  Jaii  to  past  any  inMntn\ent  into  the  bladder,  it  heennm 
au  important  question  what  course  is  to  be  pursuinl.  In  these  coses,  whith 
however,  very  rarely  occur,  three  lines  of  praclice  may  be  atiopted :  puticiurt 
of  the  bladder  above  the  pubt$,  puncture  through  the  rtetum,  or  /ortible  catht- 
teritm. 

Pnuctore  above  the  Fubes  can  very  seldom  be  r«f(uired.  Since  Uni- 
versity College  Ilu^pital  was  opened,  only  three  cases  have  presented  them- 


^ 


8UFBAPUB1U    PUNCTURE   OF    THE    BLADDIB.  1026 

nlTea  in  which  it  was  thought  proper  to  adupt  such  a  procedure  for  retention 
from  enlarged  prostate ;  and  in  one  of  tlirae  canes,  which  was  under  my  can, 
tlie  enlargement  of  the  pnietatewa^  complicated  with  impermeable  stricture, 
vhich  vaa,  indeed,  the  main  cautic  of  the  rcteiition.  The  operation  consists 
•ther  in  pushing  the  trocar  at  once  through  the  abdominal  wall ;  or  else,  as 
bk  tappine  fur  ascites,  making  n  small  incision  about  half  an  inch  in  length 
through  tne  integuments,  exactly  in  the  mesial  line,  immediately  above  the 
pabee,  and  then  pushing  a  curveti  trttcar,  with  itn  concavity  downwards  and 
iMwkwards,  into  the  bladder  behind  that  bone,  and  consequently  underneath 
the  reflection  of  the  peritoneum  (Fig.  t>17).     After  the  bladder  has  been 


Ffg-  917. — Punctnr*  uf  Iha  BlmJdcr.     Tlia   u)>|icr  iD.>truiuc[it  if  in   tlie   fosItluD  ot  Punetur* 
ftboTfl  the  Pabe^i  tbe  lower  in  that  of  llie  Tuncture  lhruu|{h  tlia  Ilsirtum. 

emptied,  the  canula  or  uu  elu^lic  gum  tube  must  be  left  in  for  the  escape  of 
the  urine,  whiUt  the  continuity  of  tbc  iiatuml  passuge  is  being  restored. 
When  the  bladder  is  greatly  dirteudetl,  in  couscqucucc  of  retention  from 
enlargement  of  thti  pr<»>tnt(<  or  uuy  otlit;r  ciiu^o,  the  pi-ritonetil  reflection  is 
carried  up  with  it,  and  »  considcnible  iiortion  of  the  anterior  wall  of  the 
organ  uncovered  by  pcriloni'uui  is  left  aoovo  ttio  pubes.  In  a  case  of  unre- 
lieved retention  from  eiricturo,  in  which  the  piitirnt  died  su<I<lenly  during 
tbe  administration  of  cblonirorm,  uud  whioh  I  hiul  nn  opportunity  of  dis- 
secting, I  fouml  thiit  tlic  suiiiniit  of  the  bhuldtr  ruucht-d  to  five  incbis  above 
tbe  symphytfis  pubiii,  and  vant  only  two  iui-lio  l>el»w-  the  umbilicus ;  that  the 
line  of  reflection  of  the  )>i>ritonvum  was  :]'-  iuclu's  ubuve  the  bone ;  and  that 
the  space  uncovered  by  mthus  nienit)riine  wild  '2[  inclies  wide.  The  bladder 
cuDtainctl  nearly  forty  ounces  of  urine,  the  retention  having  lasted  forty- 
eight  hour«. 

Brandcr,  of  Jeraey,  and  ntliers  have  moditied  this  operation  bv  puncturing 
through  the  sympbysis  pubis,  by  nieunA  of  a  trocar  and  canula.  There  is 
Dot,  however,  sufficient  evidence  to  enable  »»  to  decide  o:*  to  the  merits  of 
this  procedure. 

Pimctnre  through  the  Secttini  m  not  generally  a  safe  procedure  in  reten- 
tion from  enlarged  pnwtnte,  in  coniiei|iience  of  this  tilructure  oncn>arhing  on 
that  part  of  the  inferior  fumhid  of  the  bladder  wliich  ii>  uncovered  by  peri- 
voL.  II. — '■>.'» 


1026 


liISEASBS   OF   THE    PROSTATE. 


toneiim.  When,  however,  the  retention  iirtsea  from  enlargement  of 
urethral  portion  rather  than  of  tlie  lateral  Inhes,  thi£  openuion  mar  be 
safely  ilnne;  and,  indeed,  I  have  known  it  put  in  praetJce  with  advantage 
in  mich  casea  (Fijr.  017;. 

A  procedure  that  was  formerly  recommended  by  Brodif,  Liscno,  and  moat 
6ur{!e<)nti  of  authority  in  the^e  matterfl,  wan  Forcible  Cftthet^rlsiD.  or  Tofl- 
nellin^  the  Prostate.  As  the  reUntion  i»t  generally  owing  to  an  enlargement 
of  the  ur«;tl)ml  |K)rliou  of  the  prostate,  relief  vm  afionled  by  puibiQg  the 
point  of  a  silver  catheter  through  thii  vbtitActe  into  the  bladder.  A  falw 
paeeagv  wta  thus  putixisely  funuedf  iu  which  the  iuslruiuenl  waa  left  for 
about  forty-eight  boura  whtjo  it  would  usually  enter  it  agaiu  with  sufficient 
readiuups  oo  heinif  reintruducud.  This  prwctiw  has,  however,  hee«  very 
geuerttlly  rcudenKf  uunecoBsary  by  the  uao  of  improved  iuHniment*,  aideii 
by  an;i»tbetic-s;  and  "  lunaelliug  ihv  pn^tnte  "  may  be  looked  upon  &»  t>e- 
loDciug  to  a  pa«t  age  of  Urinary  Surgt-ry,  ruder  than  tiie  praseut. 

Wh«u  the  bladder  lias  been  relieved,  the  patient  uiUBt  be  fretly  purged. 
Bellii'Ioiina  Hupixigitories  are  oflen  of  ui:e,  but  if  there  be  much  jxiin,  opiuiD 
or  morphia  ^till  be  pn-ferable.  In  a  tew  ilava  the  congestion  of  the  |)rii«tate 
paR&60  ofl',  and  the  patient  may  be  again  able  to  pasn  water  uuaidvtL  In 
many  cases,  however,  the  bladder  of  an  old  man  which  has,  perhaps,  not 
been  com|]IeLcly  emptied  for  some  time,  becomee  permanently  atunic  after  a 
single  attack  of  retention,  and  he  '\s  never  able  again  to  diepense  with  tha 
catiieier. 


OTHRB  DIRRASes   OP  THE   PROSTATE. 

Atrophy  of  the  Proitate  sometimefl  occurs.  It  may  be  the  tcboU  of  m- 
baunting  disease,  especially  plitbl»i«,  of  old  a^^e,  of  mecbaoical  preasure  from 
tumon  or  calculi,  or  of  local  dtaeaee  of  the  gland  itaetf  dtngenital  defici* 
eucy  of  the  proatate  may  also  occur. 

Cancer  of  the  Prostate. — ^The  jirmtate  is  verv  rarely  attacked  by  caucer, 
but  rare  &s  the  disease  im,  I  have  seen  at  least  three  instances  of  it,  and  can 
therefore  scarcely  agree  with  the  estimutti  of  Tanchou,  given  by  Walahe, 
that  it  ouly  occurred  live  times  iu  upwards  of  eight  thousand  fatal  Ctt»M  of 
cancer.  The  form  met  with  is  moat  commonly  scirrhue;  one  i-ase  of  colloid 
has  bt.H>n  recorded  by  Stanley  Boyd.  I  have  seen  true  scirrbus  in  a  maa 
about  70  years  old.  He  died  with  secondary  tumon  iu  the  lymphatic  glands, 
and  with  a  liver  studded  with  cancerous  uodulea. 

The  Sipnphma  are  obscure  [lain  and  irritability  about  the  neck  of  the 
bladder,  with  the  occasional  pu^Hii^e  of  blood.  Digital  examination  by  the 
rectum  will  prubublv  delect  a  hard,  ill-defined  moss,  occupying  the  situatioa 
of  the  pnistaLc,  nodular  on  the  surface,  and  often  jieculiurly  tixed.  It  is 
slightly  tender  on  pressure.  The  rapid  increase  in  tize,  with  oKstrnetion  to 
the  passage  of  urine,  and  fretjuetit  hiBmaturiit  and  increasing  jiain,  will  reveal 
the  true  nature  of  the  disease. 

The  only  Trt'ilmr.nt  that  can  1)6  adopted  ta  that  cJilciilat«Nl  to  relieve  the 
bladder  from  the  mechanical  obstacle  to  the  escape  of  urine,  and  to  palliate 
suffering  by  nrditiary  meana. 

Taberdfl  of  the  Prostate  is  not  uncommonly  met  with.  It  usuallr  fttnns 
a  part  of  extensive  tubercular  disease  of  the  genito-urinary  tract.  In  fact, 
it  n  mre  to  find  it  sufficiently  advanced  for  a  diagnosis  to  be  made  withont 
one  or  both  epididymnt  being  similarly  afior^ted,  and  it  is  ofleo  Terr  difficult 
to  tell  where  the  diw^n^e  originally  commenced.  The  vcsicniro  scminales  are 
usually  implicated,  and  the  tubercular  inSltration  freouently  extends  to  the 
floor  of  the  bladder.    Not  uucomnioniy  it  is  associatod  with'  tubercle  of  the 


I 


URETHRITIS.  1027 

kidney.  The pott-mortem  appearances  are  thuse  oftulwrcle  tlsewlii'iT.  rioften- 
ing  yellow  maaaca  are  found  usually  near  the  urethral  surface.  After  a  time 
the  mucoua  membrane  givca  way,  aod  a  raj^ged  cavity  with  yellow  walla  ia 
left  in  the  tloor  of  the  proetatic  urethra.  Sometimes  the  tubercular  abeceaa 
BUiT  open  into  the  rectum,  and  thus  a  fistula  may  be  left  between  the  urethra 
and  the  bowrl.  More  rarely  it  causes  an  abgcfss  [Minting  forwards  in  the 
perineum.  Tul>ercle  in  the  lungs  ia  usually  present  at  death.  The  Stftnp- 
tnu  vary  very  much,  according  to  the  situation  of  the  ulceration.  If  it  is 
limited  to  the  prostate,  it  may  cause  suprisingly  little  disturbance.  In  a 
ease  which  occurreil  iu  I'uivcreity  ('ollege  Hospital,  the  patient  died  of  tuber- 
cular meningitis,  some  months  atler  castration  for  tubercular  testicle.  At 
the  jNwf-mor/ein  exaiiHuation  two  cavities  were  found  in  the  prostate  large 
oiough  to  admit  the  top  of  the  thumb,  but  the  patient  had  made  no  com- 
plaint of  any  urinary  trouble.  If  the  ulcernticm  extend  towards  the  bladder, 
there  may  >>e  extreme  symptoms  of  irritable  bladder.  Digital  examination 
bj  the  rectum  shows  the  prostate  to  be  hanl,  nmiular.aod  irregularly  enlarged. 
Sometimes  a  softening  patch  may  be  detected  in  it.  The  vesicula;  seniinales, 
if  they  can  be  reached,  are  usually  found  to  be  enlarged.  There  may  be  a 
purulent  discharge  from  the  urethra,  and  pus  in  the  urine.  The  detection 
of  the  tubercle  bacillus  would  determine  the  nature  of  the  case.  The  Treat- 
metU  is  merely  palliative.  The  disease  is  tou  widely  diwomiuated  when  first 
recognized  to  make  it  possible  to  do  anythiug  by  exposing  the  gland  and 
■craping  it 

CTltl  or  Cavities  are  Bometimes  found  in  the  prostate;  they  may  be  dila- 
tations of  gland -follicles,  absceeses,  or  cavities  containing  concretions  or 
calculi. 

Prostatic  Calculi  hare  been  already  described  in  the  chapter  on  Urinary 
Calculus  (vol.  ii.  p.  985). 


CIIATTER     LXXII. 

1>ISEASKS  OF  THE  IRKTHK.V. 
1-RKTHEITI.S. 

Simple  Inflammation  of  the  Urethra  is  especially  apt  to  occur  in  strumous, 
rheumatic,  or  gouty  individual,  from  sliglit  sources  of  irritation,  either  direct 
or  avrnpathetio,  that  would  not  excite  it  in  more  healthv  constitutions.  In 
■trumous  children,  it  niav  arise  from  worms  iu  the  intestines,  or  from  gastric 
irritation;  and  in  goutv  or  rheumatic  subjects,  it  ap|M>ar3  often  to  occur  in 
connection  with  an  acid  state  of  the  urine.  Excessive  beer  drinking  may 
cause  a  slight  discharge  from  the  urethra — the  "biertripper"  of  the  German 
itudeuts.  In  other  cases,  the  irritation  of  a  stricturo,  the  pni>sage  of  instru- 
ments, or  ordinary  sexual  inlercounto,  may  occasion  the  4lisi>aiie,  without  there 
being  anything  of  a  s|>ecifie  character  about  it.  t'ontact  with  women  who 
are  out  of  health,  pregnant,  or  suflering  from  leiicorrlio'a,  may,  and  often 
does,  give  rise  to  local  irritation  of  this  kind.  Un-thritis,  especially  when 
arising  from  sexual  intercourse,  is  frequently  mistaken  for  gouorrhu-a.     From 


1028 


DISBASBS    OF    THB    URETURi,. 


thie  it  luiL}',  as  A  rule,  he  tlUtitiguii^hiMl  by  tho  tees  intense  degree  of  iitflaffi- 
maLton,  aiid  by  tike  ulMt^iiro  dT  tii<^  mrimtlury  con8e<)uenc9es  that  frequently 
follow  true  gitiiorrliu-a;  yel,  in  many  iiititanoea,  the  diagnosis  is  extremely 
dilficult,  esjiecially  Irtuii  the  subacute  fortiui  of  gonorrhcea  that  are  oominoa 
in  I^ndon. 

Symplomt. — Urethritis  !»  characterized  by  heat,  pricking,  and  t«naioii  about 
the  urethra  for  a  day  nr  twi>,  followed  by  mucopumleDt  discbarge,  ofUo 
rather  profuse,  and  accompanied  hv  sonie  ardor  urinie.  The  symptcma 
■Itoecther  are  not  severe,  nnd  the  diseaee  usually  sulwides  nt  the  end  of  « 
week  or  ton  days ;  but  somettmcfl  it  becomes  chronic,  especially  if  conjoined 
with  stricture,  and  then  conatitntea  an  extremely  troublcaome  affection,  more 
particularly  in  gputy  individuals. 

TVeaimetU. — The  treatment  of  urethritis  ia  mildly  aDtipblogistio.  The 
bowels  should  be  kept  open,  and  aalincs  frf.-elv  ad[nini&t«red ;  in  coaes  in 
which  there  ia  reason  to  BcUeve  that  the  afrectioa  is  of  ^uty  origin,  amall 
doses  of  colchicum.  in  combination  with  alkalies,  wilt  be  found  of  especial 
service  in  cutting  tlie  diseiive  short.  The  use  of  emottient  or  slightly  astrin- 
gent  iujectiono,  such  as  ogiiate  lolioas,  or  a  very  weak  solution  of  acetate  of 
lead,  with  beliudimna,  will  be  found  serviceable  as  the  disease  is  on  the 
decline,  but  not  until  then;  and  when  the  alTectioa  has  reached  a  chrunic 
stage,  small  doseii  of  copaiba  may  be  advantageously  administered.  The 
diet  in  all  cases  should  be  uf  the  blandest  character,  stimulanta  of  all  kinds 
being  interdicted). 

If  the  disease  be  conjoined  with  slight  stricture,  it  may  not  unfrequently 
give  rise  to  temporarr  retention  of  urlue.  This  may,  however,  most  commontv 
DC  readily  relieved  by  antipblugistic  treatoieot,  cupping  or  leeches  to  the 
perineum,  the  warm  hip-bath,  and  salines,  with,  herhajw.  opiate  suppoeito- 
ries,  and  plenty  of  demulcent  drinks.  The  catheter  should  not  bo  uaed  in 
these  cases,  if  it  bo  puesible  to  give  relief  without  it. 

QONOUBUi^:^. 

Oonorrhffia  is  a  specific  disease,  accompanied  by  inflammation  and  no 
abundant  nuico-purulent  discharge;  affecting  the  urethra  most  commonly, 
but  also  the  other  mucous  membranes  of  the  genital  organs,  as  of  the  pre- 
puce and  the  glans  in  the  male,  and  of  the  vulva  and  vagina  in  the  female. 

The  urethra  is  the  usual  scat  of  gonorrhoea  in  the  male;  and  the  dlMue 
may  be  looked  on  as  an  infectious  urethritis.  Its  seat  of  gTeatesi  inteotlcy 
is  usually  the  fos»a  nflvicularie;  but  it  may  extend  over  a  much  greater  snf- 
lace.  affecting  the  entire  length  of  the  canal,  and  the  whole  mucous  lioiog 
uf  Llie  blad<ler.  In  the  female  it  ounimonty  spreads  over  the  exteosive 
mucous  Hurtace  of  the  extenml  organs  of  geueration,  and  sometimes  invades 
the  uterus  and  Fallopian  tubes. 

Cauuk. — Ooiiorrhojo  has  its  origin  in  the  female,  and  is  poesibly  develi'j«^ 
dc  novo  in  pruotitutes,  thnt  is,  without  infection  from  the  male.  It  isa  hi^lily 
infecUve  inflammation  of  the  mucous  membrane  of  the  vagina  generated  by 
the  decomposition  of  retained  semeu  and  of  foul  dischargee,  the  result  of 
repeated  acts  of  indiscriminate  intercourse  without  proper  attention  to  clean- 
linese.  It  is  impoaeible  to  say  where  urethritis  or  vaginitis  ends,  and  infec- 
tive eooorrbtcil  begins.  In  the  male,  gonorrbiea  arises  in  all  cases  from  the 
appltcation  of  a  peculiar  animal  poison,  generated  in  the  female  by  impure  or 
inaiscrimiuBte  sexual  intercourse,  to  the  parts  which  it  attacks,  and  mutt  not 
be  confounded  with  the  various  non-specific  inflammatory  diseaties  that  may 
aflect  the  parte  commonly  the  seat  of  gonorrba?a,  aud  which  are  all  charac- 
terized by  mu co-purulent  diacharges. 


^  ■  ^-      *- 


OOIVORRHCEA — SYMPTOMa. 


The  poison  of  gonorrhoea  HifFera  cnlirely  from  thi»c  of  the  venereal  dis* 
caaes  described  in  Chapter  XXXVI.,  &b  ha*  been  fully  proved  by  the  unerr- 
ing test  of  inoculntiun;  these  diwases  not  being  cupame  of  reproducioKone 
another  id  nuy  cirenmatn^eca.  The  actual  nature  of  the  virus  has  not  lieen 
certaiDty  ag*'ertoined.  The  pu9  fnira  gonorrhtra  alwoys  contttiui  mierococci, 
and  il  haa  beeo  maintained  by  Nuiuer,  Bokai,  Bockbart,  and  others,  that 
this  organism  iit  the  aotuat  virus.  Br>kai  inwulal^d  fix  RtLidentH  with  tha 
ArgaDiam,  which  had  liecn  ctilcivated  \q  Huituble  fluids,  and  in  three  gonnr- 
Tbcea  fidlowed.  Uueklmrt  sIbo  mjcoessfully  inoculated  the  organiAm  in  the 
QKlhra  of  a  man  alter  it  had  been  rultivnted  to  four  generattong  in  pre- 
pared gelatine.  It  ^eeniH  prtibahle,  therefore,  that  the  "  gonococcug,"  aa  it 
Qaa  beui  termed,  ij  either  the  actual  virus  or  iu  eoine  way  connected  with  it* 
development. 

The  suppurative  iiillaminatinn  which  is  characteristic  of  gooorrhwa  has 
these  peculiarities :  1,  It  ba^  a  distinct  aud  leogLheneil  period  of  iucubatiou  ; 
2.  It  rapidly  propagates  itself  aloug  the  mucuus  tracts  that  it  aflects;  -i.  It 
il  coDtagioue  ID  tiie  nighest  degree  uul  only  when  (be  pus  is  applied  to,  and, 
aa  it  were,  rubbed  iutu  the  mucous  surfacte  of  the  generative  organs  during 
coitus,  bub  when  il  simply  touclicat  otlmr  iauc<ju«  surluoe^  :  and,  4.  It  is  some* 
times  nttcuded  by  remuto  coiutitutiouat  jtheuomeua  partaking  of  a  pyiemic 
character. 

Obabacter. — QouorrhiL-a  is  usually  lucked  upon  as  a  jiuroly  local  atiec- 
tioD  of  tbo  genital  urgaiis.  Sume  Surgeons,  however,  amungst  wltooi  may 
be  especially  mcutiuned  Travora,  seem  to  couaider  it  as  occaaioually  assum- 
iiiga  cou8titulii:inai  charucler:  in  thtH  opinion  I  entirely  agree.  AUhuugh 
gODorrhiim  iu  the  early  slagt.'^  ix  doubtleat)  a  strictly  local  alfecliun,  yet  it  is 
occasionally  fullowed  by  a  parlictdar  train  of  very  cliarncteristic  phenoinoca, 
that  can  scarcely  be  lookea  upon  in  any  other  light  than  as  the  result  of  con- 
stitutional infection  ;  the  more  so,  as  some  individuals  never  have  gonorrhoea 
without  the  disease  being  followed  by  these  sequences,  whilst  others  are  alto- 
gether exempt  from  tbem.  The  parts  that  are  secondarily  affected  are 
chiefly  the  flbrous  tissues,  the  mucous  and  the  cutaDCmis  surfaces.  The  affoo- 
tioDS  of  the^^roiM  tissues  give  rise  to  soeallcd  rheumatism  and  to  peculiar 
fbrma  of  innammntion  of  the  testicle  and  of  the  sclerotic.  The  aflectioD  of 
tbe  iRiusotM  membrams  displays  itself  in  speciflc  inflnmmation  of  the  eyes. 
The  occurrence  of  tbc^c  various  alfeclions,  assuming  aa  they  do  a  specific 
type  so  distinctly  marked  thai  they  cau  at  once  be  characterized  as  goaor- 
rno'sl,  certainly  tends  to  show  that  the  disease  impresses  iho  constitution  io 
aom«  peculiar  manoer,  somewhat  analogous  to  sypnilis  or  pywmia ;  though 
ID  a  fur  mior  d(>gree,  and  with  much  leas  certainty,  than  the»e  diseuMes. 

Symitomb. — Tiie  symptoms  of  gouorrh»ea  in  the  male  may  be  divided  into 
three  stages:  1.  The  Incubative  Stage,  or  the  period  of  Irritatioo ;  2.  The 
Acute  Inflammat'iry  Stage;  and,  3.  The  Chronic  Stage. 

1., Incubative  Stage. — The  first  stage,  that  of  irritation,  usually  comes  on 
horn  three  to  five  days  af\er  coonectiriu.  when  the  patient  begins  to  expe- 
rience some  degree  of  beat,  itching,  and  general  irritation  about  the  peuls. 
The  Jips  of  the  urethra  areBomewnat  red  and  swollen  ;  its  orific«  gapes;  and, 
CD  s<jueeziug  it,  some  mucus  exudes.  This  stage  UBually  ooDtinuee  for  three 
or  four  days,  but  sometimes  fitr  six  or  eight,  whea  it  termloates  in  the  second 
stage,  which  is  nnc  of  active  inilainmatioii. 

2.  Acute  or  Inflatnmatory  Stage. — The  discharge  now  becomes  abundant, 

E thick,  aud  of  u  green ii*li -ye Mow  color;  there  is  grent  paio  in  making  water, 
vitb  considerable  heat  and  smarting,  and  the  urine,  which  flows  iu  a  dimin- 
ished stream,  is  passed  with  iucren»ed  freoueucy.  Tlie  urethra  ie  swolleo, 
firm,  aud  cord-like  to  the  touch;  the  whole  penis,  indeed,  looks  generally 


1030 


DISEASES    or    THE    URKTURA. 


red  and  turgesceut.  At)  the  disease  advaoces,  aod  tbu  bulbous  porticm  of 
the  urethriL  becomes  afteoted,  weigbt  nud  tension  id  the  perineum  will  be 
complained  uf.  If  the  pri»etatic  portion  be  the  seat  of  dii^iiM,*,  there  will  be 
heat  Hod  weight  about  the  aniiit.  During  tbii  wholv  iif  this  pcriiKl  tbere  it 
geiieraHy  a  gOiMl  deal  of  conslitiitinnHl  liLiturbance,  nvtlexsneflB,  an»I  (tver. 

One  of  the  most  trnnblew>me  gymptoms  in  thifl  pWgc  i>f  the  roninlaint  is 
the  oocarrence  of  Chordeo,  which  ooosists  in  painful  >^n;<;tl<^n5  at  night,  nith 
a  twist  in  the  body  of  the  penis,  which  is  usually  curved  down  towards  tbe 
Bcrotnm. 

3.  Chronic  Stage. — The  acute  symptoms  usually  cunliniie  for  about  a  fort- 
night, when  the  third  stage,  that  of  subacute  or  chronic  inHainmalion.  tvlsin. 
During  this  period  of  the  atTection  the  indammalorr  symptoms  gradually  sub- 
side, but  a  thin  niu co-purulent  discharge  keep  up,  with  some  degree  of  beat 
and  irritation  about  the  urethra,  and  occasional  smartiog  in  passiDg  urioe. 
Under  proper  treatment,  this  usually  subside*  in  the  course  of  another  fort- 
night or  three  weeks;  but,  if  neglected,  or  in  certain  constitutions,  it  may  last 
fur  innuy  monlliif,  or  even  yeare,  then  degenerating  iiitu  a  Gtert.  la  propor- 
tion to  the  continuance  of  ibe  affeclion  the  intlanmiat'iry  syroplonis  subside, 
though  the  tfpecilic  and  contagious  character  does  not  disappear,  and  the 
aUeclion  may  conliuue  so  long  as  the  discharge  keeps  up.  Hunter  mviittons 
tbecaM  of  a  girl  who  bad  been  two  years  in  the  Magdalen  Hospital,  aod  who 
infected  a  person  with  whom  she  had  connection  immediately  after  she  left 
that  iiiHtitutiim.  The  persistence  of  the  contagion  of  gteet  ie,  it  is  true,  more 
marked  in  women  tbao  iu  men.  So  lone,  however,  as  any  purulent  dis- 
charge coulinues  from  the  male  urethra,  tliough  it  be  but  a  daily  drop,  tfa« 
patient  must  be  lookeil  upon  as  infectious. 

The  wverity  aod  the  continuance  of  gODorrbiBa  are  often  onpoeed  to  one 
another.  Thus  the  diseasQ  U  most  sovore  in  young  and  pletljoric  persons, 
and  in  first  attacks;  but  it  is  iiiaat  itifHfrull  of  cure  in  strumous  aoa  phle^ 
mntic  consiltutions,  mure  capecially  if  ibere  be  a  gimty  or  rhenmotic  tendency 
coexisting,  and  is  very  troublewime  to  remove  after  ru[>cat4>d  attacks.  I  have 
observed  repeatedly  that  it  k  very  apt  tu  degenerate  into  a  gleet  in  pdopls 
who  are  subject  to  chronic  eirzomu. 

There  is  a  form  of  c^hnmir  gleet  which  mniinues  very  itervintcnily  after  an 
attack  nf  gonorrhii'ul  cpididymittu.  In  theiwt  cbsfk  the  dtticbargo  is  noi  so 
niu<'h  urethral  ai>  testicubir.  It  appear?  to  prooeeil  from  thu  incn'ased 
exudation  fnim  the  mu(N)UR  membrane  of  the  oecretory  and  eOirunl  struc- 
tures of  the  testis,  during  the  pnicetu  of  rosoliuion  of  the  tnflamnmtiou. 

The  length  of  time  that  the  infecttou  of  gleet  will  continuir  in  btitb  sexeo, 
but  especially  in  the  female,  makes  it  somewhat  diflicult  to  say  whcthe-T  the 
poison  of  goiiorrlirea  can  lie  getierale<l  de.  noi'o,  as  it  is  not  impmhablc  that 
many  individuals  communicate  the  diseei^e,  believing  theniiielves  to  be  per- 
fectly cured,  though  still  suffering  from  slight  gleeU 

Gleet. — The  term  tjlcft  is  applies)  to  any  mucous  or  rouco-porulent  dis- 
charge, whinh  is  very  small  in  amount  and  persists  for  an  indefinite  time 
unaccompanied  by  any  other  obvious  symptomx.  This  cfmditioo  ia  one 
which  gives  rise  to  great  mental  uneasiness  in  many  patients,  and  some 
rarieiiea  are,  moreover,  liable  to  terminate  in  stricture  if  unrelieveil.  The 
correct  diagnosi^i  of  its  nature  and  source  is,  therefore,  of  extreme  imporlaoce. 
In  the  fintt  place,  it  i»  ut-ceseary  to  romcml«.T  that  iu  young  men  a  somewhat 
copious  flow  iif  mucus  is  apt  to  accompany  an  eruclion  of  ibe  penis.  When, 
as  i»  frequently  the  case,  an  erection  occura  just  before  waking  iu  the  morn- 
ing, the  nmcus  may  be  found  glueing  the  lips  of  the  urethni  together,  and 
may  be  mistaken  by  tbo  palieul  for  a  gleet.  Again,  true  gouurrbo-al  gleet 
must  not  be  confounded  with  prtRstatorrhwa  (see  p.  1016).    Deaormeaux  has 


I 


I 


i 


GLEKT — TRKATUEKT.  1031 

■howD  by  meaos  of  the  endoecope,  that  a  true  gonorrhu'al  gleet  is  due  to  the 
preseDcc  of  chronically  intlaiuca  patches  of  mucous  iiionibrane  tn  the  urethra. 
Xhese  patches  are  purplish  or  dark  red  in  color,  wlierean  the  uorraal  urethra 
■  a  pale  pink,  ^mictimca  the  ^urfitcc  <>(  the  inucoua  membrane  is  covered 
with  amall  granulations,  like  those  seen  on  the  conjunctiva  in  granular  lids. 
This  condition  Desctrmeaux  calls  "  granular  urtthritis."  The  patches  may 
be  multiple,  but  more  often  there  is  only  udc  situated  in  the  bulbous  jmrtion 
of  the  urethra.  The  ftftnptouut  of  such  a  condition  are  the  following:  A 
•light,  sometimes  almost  colorless,  somotinies  rellowish,  discharge  vill  be 
found  glueing  the  lips  of  the  urethra  to<;ether  in  the  morning.  This  dis- 
charge is  little  affected  by  diet  or  stimulants,  but  is  usually  greutjy  aggravated 
by  connection.  If  during  micturition  the  tirst  few  dnips  of  urine  he  passed 
into  a  separate  vessel,  flocculi  nf  mucui*  and  pui)  are  seen  Hoatiug  in  it.  There 
is  no  pain  or  discomfort  in  micturition,  but  the  slroani  may  be  slightly  nar- 
Towed,  and  a  few  drops  of  urine  may  be  retained  in  the  urethra,  aud  dribble 
•way  atlerwRfds,  us  in  a  slight  stricture.  These  inflamed  patches  may 
OBuallr  be  detected  without  difheulty  by  the  use  uf  the  olive-headed  bougie. 
Am  the  sound  passes  the  intlnnied  spot,  the  {latient  will  complain  of  pain, 
and  on  withdrawing  it  a  drop  of  blood  mar  be  tbund  upon  its  bulb.  A  slight 
feeling  of  n-sistnnce  to  the  instrument  is  also  telt. 

In  other  coses,  the  gleet  may  be  due  to  a  cbroiiic  inflammatory  discharge 
Irom  the  glandt*  and  follicles  of  the  urethra.  Hill  states  tliRt  it  occasionally 
ariaest  also,  from  small  vegetations  or  warts  situated  immediately  inside  the 
meatus. 

Treatment. — The  treatment  of  gonorrhu'a  must  be  conducted  with  refer- 
ence to  the  stage  to  which  the  disiMise  has  attained,  but  esperially  with 
Kgard  to  .the  amount  of  inflammatory  action  accompanying  it.  It  is  of  two 
kinds,  ratiowtl,  and  xpeeijir  or  empiriatl.  Both  plans  are  usel'ul,  and,  indeeti, 
naually  necessary  for  a  proper  cure,  but  they  cannot  l>e  adopted  indiscrimi- 
nately. Thus,  if  specific  means  be  employeit  during  the  acute  inflammatory 
■tage  of  the  complaint,  much  mischief  may  ensue  :  whilst,  if  antiphlogistic 
tRatment  be  persevered  in  for  loo  long  a  time,  the  disease  may  be  kept  up 
indefinitely. 

It  has  been  pn>pogcd  to  adopt  what  iios  been  termed  the  aborlire  or  rcntt^ 
mve  treatment,  during  tlie  earliest  ctages  i)f  giinorrhii'a;  indeed,  during  the 
meubaiive  pvriml.  This  method  coH^icts  either  in  the  injection  of  a  very 
■troag  solution  of  the  niirntc  of  isilvor  into  the  uretlira.  or  in  the  upplicatitin 
to  the  inflamed  mucous  membrane  of  a  strong  ointment  of  that  ^olt  hy  means 
of  a  bougie  smeared  with  it;  othrr  Surgeons,  again,  have  recommended  the 
administration  of  very  large  ihnfin  of  copaiba  at  thif  period.  These  various 
plans  have,  howevi-r,  'le::ervedly  liillcn  into  disrepute.  I  have  on  several 
occaaiuos  seen  most  intfuse  itillaiiimation  produml  by  this  mode  of  treat- 
ment, and  never,  in  any  vtx^f,  any  goo<)  ni^ult.  Independently  of  this,  it  is 
impiiesibic  t4)  know  whether  the  cum',  iti  the  t-arlie^t  stage,  will  prove  to  be 
one  of  simple  urethritis  or  a  K|>ecitic  goiiorrhu-a. 

In  the  aeule  injtummnhrtf  f/'iy.  attended  by  heat,  swelling  of  the  organ, 
great  ardor  urimv,  and  abundant  niueo-pnrulcnt  tliseharge,  the  treatment 
must  be  entirely  antiphlugititif,  the  activity  of  the  iiicasurex  licing  propor- 
tioned to  the  intensity  of  the  inflammation.  If  this  be  severe,  warm  hip- 
baths, [Mippv  fomentations,  or  the  euvt'lo]tiiktit  of  the  [tenis  in  warm  water- 
dmsing,  will  be  of  <-ss<-iitinl  service.  At  the  same  time,  the  urine  must  be 
diluted,  and  its  acidity  leis^encd,  by  the  patient  drinking  large  quantities  of 
alkaline  diluents — barley-water  or  linseed-ten  enntaining  carh<male  of  potash 
in  aolution  ;  anrl  the  r-kiii  iind  liowets  may  he  ke[it  in  action  by  the  adminig- 
timtiuD,  every  sccon<)  night,  of  a  dose  of  blue  j'ill,  aud  every  lourth  or  tixth 


1032 


tSEASKS   OP    THE    URETHRA. 


hour,  of  ajKtwder  cnn)po«eii  of  a  drnohm  of  sulphate  of  magncna,  fi  gniu  < 
nitre,  and  -^jlh  of  a  gniin  of  lartnr  eniclic,  dissolved  in  a  wine-glasB  of  waler. 
Alt  alcoholic  Ktim[ilaiil8,  itpii-fs,  salt  food,  nml  coffee  must  bo  nvoiiled,  the 
diet  bfing  restricted  to  light  8iot*,  nnd  perfect  rest  enjoined.  Br  such  raesna 
M  lhe«e,  the  activity  of  the  iDllftmm&tion  will  be  praduallv  lesBcoed,  tlie 
discharge  bt^coniing  thinner,  the  tjiimrtiiij,'  In  micturilioo  less  sevcK,  and  the 
erections  less  jmiiiful.  The  pntieul  should  ulitfi  be  desired  to  pass  his  arioc 
frequently,  so  a»  to  wash  the  urethm  clean. 

Dtiriii);  this  stage,  ur  earlier  if  the  nature  of  the  diaease  ii  recognittd, 
W.  W.  Cheyne  recommends  the  use  of  iodoform  and  eucalyptus  bousiea. 
These  are  com]K>»ed  of  ioUolbrm.  5  gr. ;  oil  of  eucalyptun.  10  th,  ;  ofl  of 
theohronia,  35  gr.  This  U  suilicient  to  make  one  bougie  four  in.-he*  long. 
It  ii  thug  used:  [h«  patient  fint  pusses  water  to  clean  (he  urethra,  be  then 
dif>0  the  bougie  in  carbolic  oil  (1  in  20)  and  puwoj  it  quickly  into  the  urcthrt 
before  it  becomee  sufWued  by  the  heat  of  bia  iiugeni.  It  must  be  pu*hed  io 
with  a  jteucil,  or  douie  convenient  intttrumcnt,  till  it  oomuleteiy  diaappeara. 
Ad  absorbent  pad  of  iiHloform  or  salicylic  wool  is  then  placed  over  the  end 
of  the  penifl,  and  covered  with  oiled-silk  nr  gutta-percha  linuc  secured  by  a 
atrip  of  plaster.  The  palient  Uico  refrains  from  making  water  for  aa  long 
as  piKwible.  One  bougie  may  be  used  daily  for  two  or  tbrea  days,  and  in  ihe 
interval  some  simple  injection,  mich  a»  chloride  uf  zinc  (gr.  i  to  3J>,  or 
eulpho-carbolate  of  zinc  (gr.  ij  to  ^)  may  be  used.  Cbeyne  states  thai  bf 
.'iheee  means  the  inflammation  is  often  cut  short  and  a  cure  efl'ucted  in  a  wme 
)r  ten  days  or  sooner.  If  it  fails  it  does  no  harm.  One- twentieth  of  %  grain 
of  perchloride  of  mercury  added  to  ciich  bougie  is  said  to  increase  the  e  a 
taiuty  of  their  action. 

During  the  second,  or,  in  fact,  in  atl  stages  of  gonorrho'a,  much  harm  if 
often  done  by  applying  lint  to  the  pt-nis.  This  doe«  not  absorb  the  discharge, 
but  rather  shuts  it  in.  It  \b  better  to  put  the  penis  in  a  Macint<»h  gonor- 
rhoea-bag, at  the  bottom  of  which  a  good  sized  piece  of  salicylic  troot  may  be 
placed  to  abs{)rb  the  discharge. 

When  the  third  atage  of  the  disease  has  been  reached,  speciSc  treatroeal 
may  be  employed  with  great  advantage;  while,  if  recourse  were  had  to  it  at 
an  earlier  period,  it  would  certainly  increase  the  inflammation  and  g:ive  the 
patient  much  distress.  Even  in  this  stage  the  specific  remedies,  soch  is 
eopaiba  and  cubebe,  mu-it  he  cautiously  given;  the  Surgeon  filing  his  waf 
with  them,  and  being  prepared  to  discontinue  tbem  nnd  to  return  to  strictly 
antiphlrqjifltic  measures,  if  he  find  that  ibey  increiue  the  irritation.  Shoola 
the  disease,  however,  from  the  coniniencement.  have  assumed  a  subooats 
character,  the  specific  treatment  may  with  safety  be  adopted  at  a  much 
earlier  peri'jd. 

Copaiba  and  cubebs  are  the  remedies  that  are  almost  univenatly  Dsed  io 
this  stage  of  gouurrbfca.  Of  these,  copaiba  is  the  least  irritating,  and  coo* 
•equently  most  generally  to  be  preferred.  It  may  be  administered  in  s  variety 
of  ways  ;  in  capsule,  pill,  draught,  or  extract  The  capsule  is  generally  to 
be  preferred,  on  accouuC  of  the  nauseous  taste  being  thus  more  completely 
disguised ;  but  in  many  casce  it  acts  with  more  certainty,  and  with  bctte 
effect,  if  given  in  either  of  the  other  forms.  When  the  capeulos  are  gifcn. 
the  patient  may  take  from  six  to  eight  or  ten  in  the  day,  and  should  at  the 
aarao  time  have  an  alkaline  mixture,  which  increases  materially  the  effect  ol 
the  drug.  A  vcrv  excellent  mode  of  administering  copaiba  is  to  rub  it  dumi 
into  a  mai«s  wilb  ^urut  magnesia,  and  ui  let  the  jwtifnt  takeabouc  a  draohm 
of  this  paste  three  times  a  day,  in  u.  buliis  wruppEHl  in  wafer-paper  :  or  if  the 
taste  be  not  much  objected  to,  he  may  take  it  moet  advantageoualy  in  nrnd- 
lage,  with  liquor  potatis:c  and  tincture  of  henbane. 


TREATMENT   OF   GONOKRHtKA.  1033 

Id  some  relaxed  constitution?,  and  more  particuturly  after  frequent  claps, 
cubebB  will  be  fnund  to  cure  the  patient  more  rciidily  tlmn  copaiba,  or  riithcr 
moat  fuccesst'iilly  if  given  in  comliinnti'tn  with  it.  An  excellent  plan  is  to 
ptit  about  half  an  omicu  of  iKtndered  cubel)s  into  a  mortar,  and  to  rub  it  up 
with  as  much  copuilm  an  will  form  n  Etift'  paste,  of  which  the  patient  shouin 
take  a  »irachni  as  a  bolus  ihrice  daily.  The  eftccts  of  tliis  electunry  are  often 
tniiet  Mrikinp;  but  it  can  be  uwd  only  in  the  r<  mot  it  lit  ions  indicated,  and 
aUer  the  nu>re  active  inflnmniatory  symptom<>  hiivc  sulisideil.  Copaiba  in 
mmDV  subjects  brin(i:s  out  n  red,  niised  rash,  most  marked  on  the  backs  of  the 
hands  and  feel,  but  sometime*)  exteo.ling  over  the  whole  b<Hlr.  It  is  acconi- 
paoied  by  eondiilerable  itching  and  oAen  by  f«i>me  ri.»e  of  temperature-  Hill 
•tates  thai  a  similar  criiptiiin,  but  more  papular  in  characlcr,  may  fidlow  the 
admin ist rat iim  of  eubebs.  Hn.>maturia  has  been  occa)>innaliy  observed  as  the 
result  of  large  doses  of  copaiba.  Oil  of  yelltiw  samlal  wood  may  Bometimea 
be  employed  with  advantage,  though  its  action  istsomeHliat  uncertain.  It 
may  be  given  in  cajwulcs  in  doses  not  excep<ling  twenty  rnintms  three  times 
a  day,  or  the  following  fonnuln  will  be  found  usi'ful ;  oil  of  vandal  wood,  .^ij, 
tragacanth  in  powder  sas,  water  to  .^viij,  oue  ounce  to  be  taken  three  times 
a  day. 

It  is  during  the  third  stage  of  gouorrha>a  that  Injections  may  advantage- 
ousir  be  used.  Much  ami  very  unfuunde<l  prejudice  exists  against  their  use 
in  tfie  minds  of  many  ;  but  furely  it  is  as  safe  to  apply  pro|>er  local  applica- 
tions to  an  inflamed  urcthm  as  it  is  to  an  inflamet]  conjunctiva  ;  and  the  bad 
consequences,  such  a^f  stricture  and  iDfiame<l  testielc,  which  have  sometimes 
been  referred  to  their  use,  have  either  been  due  rather  to  the  long  continu- 
ance and  to  the  severity  of  the  disease  itself  than  to  the  renictlics  emploved, 
or  to  their  application  at  t(»o  early  a  stage  or  of  ttw)  great  a  strength.  It  is 
in  long-standing  cases  of  gonorr*h<va,  in  which  the  discharge  continues  ^or 
months  or  years,  that  stricture  follows,  not  in  cascit  of  onlinary  duration; 
and  it  is  the  result  of  the  chronic  iuHammatorr  thickening  of  the  mucous 
membrane,  and  has  no  more  to  do  with  the  injections  than  with  the  copaiba 
or  salines  which  the  patient  may  liuve  taken.  As  the  ardor  urinn:  subsides, 
emollieut  and  slightly  astringent  injections  may  bi>  used.  The  beet  is  per- 
haps chloride  of  zinc  of  the  ttn'iigth  of  two  grains  to  twelve  ounces  of  water, 
tu  which  two  drachms  of  extract  at'  belladonna  may  be  added.  This  injec- 
tion mav  be  used  frequently  during  the  day.  Acetate  of  Icatl,  from  one  to 
two  grains  to  the  ounce  of  watt-r.  is  ot^cn  usK-fid.  If  this  inthice  irritation, 
a  few  grains  of  the  watery  extract  of  opium  may  iidvanlngeoiMlv  he  addeil. 
As  the  discaik^  sulfides,  a  stronger  astringent  if  requinHl,  and  then  one  or 
two  grains  of  the  acetate  "f  line  may  be  a'ldcd  t<i  each  ounce  of  the  injec- 
tion ;  or  a  weak  solution  of  sulphate  may  be  em]>ioyr-d.  gr.  ij  to  each  ounce 
of  water;  or  an  injeL'lion  «if  gr.  l  of  tht-  nitriitt-  of  iiilvir  to  the  ounce  may 
be  use<l.  During  the  whol»*  of  this  jsiage,  the  diet  and  habit.-*  of  life  must 
be  carefully  reguletctl,  and  all  cliniuhinls  iiiionlirtcd.  The  iiijei-tii>ns  should 
be  discontinued  us  soon  as  the  di.-i-liarLie  h:).<  iru^ed  :  uiih=:'<  this  be  done, 
they  may  n-indure  it. 

The  mixle  of  injectinn  is  of  importance.  A  glii^j  syringe  slimild  always 
be  usc<l,  with  a  smooth  rouiide<I  no/zlc.  The  palienl  .-•itting  on  the  edge  of 
the  chair  and  holding  up  thi>  pcois,  should  c:iri-lully  insert  the  cud  of  the 
syringe  Ivtwecn  the  li|w  of  the  urethra,  and  iIk'Ii  .-lowly  throw  in  the  injec- 
tion as  far  a:'  it  wilt  go.  Although  tli<-  iiilhitiiiiiiiti'in  is  usually  at  first 
confined  t»  iIk-  anterior  p-irtion  of  the  iirttlini.  vt-l  it  in  iiioft  ca-ts  exlen^ls 
to  the  bulb,  and  (he  iiij^i-tlmi  should  be  applied  to  tlie  wlioh-  hngth  of  the 
inflanii-d  nuirous  ni<-iiiliraiti-.  If  niir  i-nti-r  the  Idaddcr  it  ciiniMt  si;!nify,  as 
it  will  immediately  be  d<-i'iiiii|)iQ'i'd  liy  the  salts  and  mucus  >>f  the  urine. 


1084 


DISKASER    OF    TUB    DBBTIIRA. 


Imtcod  of  the  nrtJinary  gluae  eyrii))^-,  tliv  iujectur  (Fig.  91Sj  may  be 
TRntagpQUBly  ug«d.  Hy  it,  the  imt^cuou  i>i  tlirovrn  from  twbiud  forwardi,  so 
that  wbi^n  p(i»K-<l  bpyoiid  the  inflaiiititl  pari  it  washes  out  the  dwcbar^,  Iq- 
gtend  of  foroin^;  it  further  on. 

Treatment  of  Gleet — In  gleet,  intu-h  dilTiculty  will  oft^n  be  oxpcriencett 

in  (ruriii;:  tlio  patient  of  his  iliscliargt'.     Ilvn^  much  <Ii![)eii<l^  not  ouly  ua  the 

a<lmini^irati>>n  of  proper  remedies,  hitt  cm  care  l»'ing  tHkf>ii  uttcutivL'ly  lo 

regulate  bis  habits  of  life.     It  will  conHluntly  l>e  found  that,  uder  the  disease 

hns  ap]>nrenily  Ikvii  cured,  exoesaes  at  table,  and  more 

eepocialiy  the  drinking  of  beer,  or  of  ert'ervesfing  nr 

acid  wioes,  will  bring  back  the  diacharpp.     It  will  re- 

turu  also  all^er  coDDectinn,  though  it  have  previoiuly 

ceascfi  entirely.     Thta  is  especially  the  cju^e  in  fllrunious, 

gouty,  or  rbeumntic  const ituiions,  in  vrhich  all  urethral 

inflammations  arc  with  diliicuItT  removed.     lu   thrar 

cn&eo,    then,    ubslinencc    from    alcoholic    liquids    and 

iliiitctic  i4timu1nut»,  and  a  cuullacul  life  must  nc-  i^trictly 

eujuiiie*!;  but  the  local  treatment  requires  car«ful  atteo- 

liiiu. 

In  the  early  stajie*  uf  gleet  au  attempt  may  be  made 
to  cure  it  by  injvciiou*.  For  this  purpoee  soiucwbal 
strvjugffr  solutinuB  are  required  thao  in  the  more  acute 
period  of  the  diaeaeC'  Bulpbate  of  copper  will  oAen  be 
iuuud  uHefuJ,  commeDciug  with  half  a  grain  t(»  the 
ouuc«,  and  gradually  increasing  it  to  one  or  eves  Itro 
grainii.  Tanuic  acid  io  the  strength  of  from  two  to 
fuur  grains  to  the  ounce  will  wmettmes  check  the  di»- 
cfaar^.  Soluble  bougiee,  similar  tu  thoee  already  de- 
scribed, but  coutuining  lauuic  acid,  sulphate  of  zinc,  or 
acetate  of  lead,  art;  ulleu  of  great  service.  These,  cooi* 
bined  with  the  iutcmal  a4lminiittratiou  of  copaiba  and 
cubfbs,  or  the  |»erchloridc  of  iron,  may  effect  a  cure 
If  these  do  not  succied,  tlie  occasioual  passage  of  a 
full-eizcd  bougie  is  of  the  greatest  use.  The  orifice  of 
the  urethra  uiu^t  ul«>  Ik-  examined  for  warty  growth*, 
which  may  keep  up  tlie  discharge. 

When  the  dlseaao  hus  become  very  chrouic,  and  hu 

amumod  the  form  of  granular  urethritis,  it  is  ilitficuU 

of  cure;  for,  as  Dcsormeuux  hus  pointed  out,  no  inicctinn,  which  the  healthy 

portion  of  the  urethra  is  cnpahlc  of  bearing,  wilt  have  much  effect  upon 

the  iu6amwl   patch.     He  therefore  n-commends  the  applicntion  of  a  wmj 


1 


'Jl 


';n  In; 


Pi  J,  913.— T»«vMi'« 
Injoclor. 


-4 


Fig.  UV.— Uuyoo'*  lai-sUtr.    Thv  SmalWr  Flgur»  laitrMmu  tba  Npolt. 

stmof^Bolutioii  of  nitrate  of  silver  through  the  endoscope;  but  equallv  eatii> 
factory  resalts  mny  be  nbtnined  by  the  use  of  Guyoo's  injector  (Fig.  910). 
This  consists  of  a  hollow  bulbous  souud  perforated  in  the  bulb,  ood  fitted 
with  a  small  gjrringc    The  bulbous  souod  having  be«D  passed  6rat  up  and 


COHPLtCATIONS   OF    GOyORBHCEA.  1035 

down  the  uretbra  till  the  exact  situation  of  the  inflamed  apot  ia  fouDi)  b^ 
Um  tenderness  and  slight  cling  before  mentioned,  the  perforated  head  is  held 
Czed  at  the  diseased  spot,  am]  a  few  drops  of  a  solution  of  nitrate  of  silver 
(ton  to  twenty  grains  to  the  ounce  of  water)  are  injected.  The  patient 
ahould  pass  urine  immediately  before  the  injection,  and  not  again  fur  mxae 
hoora  if  possible.  Berkeley  Hill,  who  has  had  great  experience  of  this 
■ode  of  treatment,  states  that,  if  the  patient  keep  quiet  for  some  time  after, 
ao  complications  are  likely  to  follow  ;  but  neglect  of  these  precautions  may 
be  followed  by  BW*elled  testicle  or  even  perineal  abscess.  After  the  operation, 
a  weak  astringent  injection  must  be  used  for  a  few  days,  and  the  passage  of 
boagiea  for  a  short  time  aflcr  ia  usually  necessary  to  complete  the  cure. 
Otis,  of  New  York,  is  of  opinion  that  every  prolongini  gleet  is  the  result  of 
m  narrowing  of  the  canal,  and  he  recommends  internal  urethrotomy  as  a 
cure — cutting  the  urethra  up  to  its  normal  size  by  the  method  described 
Doder  the  treatment  of  stricture  of  the  urethra.  The  operation  is  somewhat 
■erere,  and  should  never  be  had  resort  to  till  all  other  means  have  failed. 

Tbe  treatment  of  gleet  may  therefore  be  summed  up  as  follows.  The 
patient  must  be  carefully  examined,  in  order  to  detect,  if  jKi<<sible,  some  con- 
•titutional  condition,  such  as  struma,  gout,  or  rheumatism,  which  may  serve 
■I  a  guide  to  general  treatment,  diet,  and  use  of  stimulants.  Change  of  air 
and  sea-bathing  are  often  of  essential  service.  The  orifice  of  the  urethra 
niut  be  examined  for  warty  gn>wthB  or  suppurating  follicles.  If  these  are 
fimnd,  they  may  be  touched  with  nitrate  of  silver.  If  they  are  not  found, 
tbe  electuary  of  cubebs  and  copaiba,  or  one  composed  of  cubebs  and  the  sea- 
quioxide  of  iron,  may  be  administered  with  advantage,  and  the  injectiona 
neommended  for  the  chronic  stage  of  gonnorhcea  may  be  persevered  with. 
Should  these  fail,  and  should  the  olive-headed  sound  give  distinct  evidence 
of  a  tender  spot,  and  perhaps  a  slight  narrowing  of  the  urethra,  the  passage 
of  a  full-sized  metallic  bougie  every  second  or  third  day  should  be  tried.  If, 
after  a  fair  trial,  this  fail  al8<i,  injection  of  nitrate  of  silver  by  Guyon's 
injector  must  next  be  had  recourse  to,  followed  by  mild  injections  and  the 
panage  of  bougies ;  and.  lastly,  if  everything  else  nave  failed,  and  a  distinct 
narrowing  of  the  canal  be  present,  internal  urethnitomy  may  be  tried  as  a 
laat  resource. 

Complications  uf  Gosorriufa. — Gonorrhwa,  when  acute  or  virulent, 
seldom  runs  its  course  without  local  complications  of  some  kind,  the  result 
of  the  pnt|>aga(iiin  of  the  inflammation  to  neighboring  parts,  otten  of  con- 
siderable severity,  and  occasiinially  even  hazardous  to  life, — such  as  chordee, 
fAimosis,  syiniutthetic  bubo,  periui-nl  ul>sceifs.  irritability  of  the  bladder,  re- 
tention of  urine,  hemorrhage  from  the  urethra,  etc.  Many  of  these  compli- 
cations present  no  special  features,  but  require  to  tie  treated  on  general  prin> 
ciplea,  without  reference  to  their  specific  cause.  Others  demand  more  s[>ecial 
management,  anti  thi'se  we  may  hrietly  consider  here. 

Iidammation  of  tiie  Lymphatics  of  the  Penis  may  occur,  stretching  along 
tbe  aides  and  dorsum  of  the  iH-uis  in  the  form  of  hard  thread-like  lines, 
with  much  miness  and  ii-denia  of  (he  integuments,  and  general  swelling  of 
the  organ,  the  glans  in  these  va^vF  often  Oi-.^uniing  a  turgid  as{>oct  and  a  dull 
brick-red  c^lor.  This  condition  is  a  very  serious  ouc,  as  it  may  Ifad  to  one 
of  two  consequences,  or  both  may  ensue,  viz.,  intlamiiiatiou  and  suppuration 
of  the  inguinal  glands,  or  blood-poisoning.  It  is  the  tatter  result  that  gives 
rise  to  the  most  serious  constitutional  ollects  in  gonorrho'a,  closely  resembling 
tbe  less  severe  forms  of  pvirmia. 

Cbordee,  or  painful  erection  of  the  pcni.-,  with  twist  of  the  organ,  coming 
on  at  night,  is  often  a  mnxt  di)>tre)>King  and  trotiblei^ome  symptom.  It  is 
Dually  iKSt  relieved  by  the  application  of  cold  to  the  part,  by  the  adminis- 


1036 


DISEASES    OY    TilS    URETHRA. 


Imtiiin  ut  beikime  of  a  pill  romptecJ  iil'i^r.jot'iipiuni  with  gr.  t  of  camplior. 
KkmhI  n:cunmieii<l»  a  »ti{i]H>i;itt)ry  tif  cnnjjdiur  and  npiuiti,  ^r.  x  of  camphor, 
luiil  gr.  j  (it*  tliQ  waterv  bxtni(;t<if'ii|)iuiii,  lo  be  itir.niiiuciNl  into  the  rcetuioio 
liiiiir  lK;ti)rc  hrttltriie,  hh  the  l>eHt  nic]iii»<]t' removing  the  teiiilvucy  Ui  cbordee. 
Full  (lii^(>c«  of  liriitniile  of  pDinwiiiiii  nrv.  &iiiiii!t.imeB  of  use. 

Acute  Prostatitis,  prcM'nting  all  the  sympiom!)  described  on  p.  1013,  and 
in  riiro  aaea  termlontini?  in  abaceas,  is  aii  ncvasiooal  complication.  It  miui 
be  treated  aa  lher*>  ileRiiribed. 

ChroDLC  Prostatitis  is  riithcr  a  sequel  of  gooorrhdm  than  a  complieatiao. 
Its  syinploma  nud  trefllnient  have  bwo  already  descrihwl  (p.  lOl."!). 

IimammaUoi)  of  the  Keck  of  the  Bladder  with  fitraDgniy  and  Dysnria  U 
not  nu  uncommon  complication.  It  iiriM^  from  cxi>oeure  to  cold  or  wel 
during  a  clap,  and  occaaioDnlly  from  the  UM  of  too  atronj;  injections.  The 
discharge  may  lessen  when  the  symptoms  of  th«  deeper  liiSainniatioii  wt  in. 
When  the  neck  of  the  bladder  only  is  inflamed,  the  urine  remnins  acid,  and 
contains  but  a  slight  cxcc-as  of  mucus.  Frequency  of  miciurition,  I'tiea 
exoestve,  and  accuoipaniiKl  by  the  most  severe  juiin,  forms  the  ni(»l  prumi- 
neul  symptom.  Pub  and  blood  may  escape  with  the  lasl  few  drop^  of  urine. 
It  is  distiuguiabed  from  acute  prcMlalJtis  by  rectal  exumioation.  when  abitence 
of  proslalic  swelling  and  tenderness  will  be  recognized.  The  iuflammatioo 
in  many  cases  is  less  acute,  esjN-cially  when  the  itidamiuation  comea  on  at 
three  or  four  weeks  after  tbe  commencement  of  the  clap.  In  tb#  acute  form 
leeches  to  the  perineum,  hut  baths  and  fomentations,  and  full  doses  of  Duv^r'i 
powder,  or  of  henbane  and  potash,  wilt  afllird  much  relief  If  tbe  paJD  b 
very  severe,  a  morphia  suppository  must  be  inserted  into  the  rectum.  In  more 
chronic  cases  the  ndminlstratioQ  of  tbe  perchlortde  of  iron,  with  belladonna 
Buppiifitories  will  be  beneficial. 

Cystitis,  of  nn  acute  character,  may  occur  bv  the  extension  of  tht  uretfanl 
iuflamiimtiuu.    The  urijtbml  discharge  dimini^licg  as  the  Bymptoms  of  cysdtia 
cotiic  ou,  or  ceases,  just  UH  in  ejiididyiuitis;  the  patient  is  ecized  with  intolera- 
bii:  and  t'rL'qiicnt  dysuriii,  tilraugury,  am)  general  febrile  dbturbauce.     Tbe 
urini-' ln'C4(mf«  htaded  with  muoctpus.  and  may  be  fetid  and  alkaline.     Tbe      , 
coiidiciiin  \»  |H>ril<)i)».     There  is  danger  to  life  if  the  cimsiilutiou  tie  broke^^H 
nn<l  there  jm  alwayn  danger  of  pruloiigod  or  ptwalbly  itilnii'lablc  gubacul^^fl 
cyt^titia.      Indeed,   1   lielieve  thai   many  of  tbe  cases  of  cbniiiic  subacute 
cyscitim,  with   muco-pus   in  tbe  urine,  and  perhaps  atony  of  the  bladder 
occurring  in  niiddleagetl  men,  may  lie  traced  back  to  the  iDflueneo  of  a 
gonnrrha'a  contracted  in  early  life, 

The  Tre/itmfnt  of  this  comlitinn  consiitts  in  the  employment  of  belladunna 
or  opiate  t^uppo^itories;  the  Ireqncnt  use  of  warm  blp-bath*i ;  the  application 
of  fomentations  to  the  perineum,  and  of  hot  poultices  to  the  pubic  region. 
Itrodie  makes  llie  im|)firlanl  practical  statement  that,  if  the  urine  continue 
Arid,  tbe  best,  trcatint'ut  con»i»lfl  in  the  administration  of  calomel  and  opium. 
This  ia  entirely  in  accordance  with  my  experience,  and  where  the  patient  b 
mtnlerately  young,  and  the  urinv  acid,  wilb  ptilfte  good,  calomel  with  opium, 
or  D'^ver's  powder,  will  give  elfectual  relief.  As  the  cystiUfi  subaidea,  tbe 
urethral  iliscliBrsrv  n-apptiirs. 

Pyelitis  and  Xephritls  arc  fortunately  very  rare  complioationa  of  gonor- 
rhifii.  MiircbisDti  bn<(  recorded  two  caS'^-H  in  which  death  rapidly  fuliowed 
extension  to  the  kidney,  with  coma  aud  dctirinui.  la  a  ca»«  lately  in 
Uoivtrrsity  College  UuBpital,  a  slight  urethral  dtschai^e  was  folluwed  by  pain 
in  the  Cftunte  of  the  ureter,  and  the  symptoms  of  pyelitis.  The  uisesM 
a»ume<l  a  chronic  form,  the  pUB  in  tbe  nriue  being  very  abundant.  Goour- 
rbieai  rheumatism  of  a  severe  form  Ret  in  at  tbe  same  time.  AAer  about 
two  yours  the  patient  partially  regaioed  health,  the  amount  of  pus  beconilog 


COMPLICATIONS    OF   GONORRH<EA.  1037 

TV17  small.  Id  uDother  case  in  the  eaiiiu  hospital,  a  large  renal  abeceea 
fcrmed  some  time  after  an  attack  of  gouorrhd-a,  to  which  it  eeemed  to 
be  directly  attributable.  The  abiicesa  was  uspimtetl  twic-e,  and  the  patient 
noovered,  but  at  his  death  some  years  after  the  kidney  was  found  to  be 
ihrivelled  tu  a  small  mass  of  (ibrous  tissue. 

Xetention  of  TTrine  from  Gonorrhoea  may  set  in  at  any  period  of  the  acute 
Kage.  The  obstruction  is  usually  deficDdent  on  congestion  and  inflammatiun 
of  the  mucous  membrane  of  the  urethra.  ]A>eches  to  the  perineuiu,  the 
warm  hip-bath,  and  opiate  suppositories,  will  probably  afford  relief.  It  is 
always  desirable  to  avoid  using  the  catheter,  as  it  is  apt  to  lacerate  the 
•wolleo  and  soAened  mucous  membrane,  and  thus  to  occasion  troublesome 
bleeding ;  and  will  always  produce  much  pain,  and  increased  irritation  of  the 
eanal.  Should,  however,  the  retention  have  coDtinue<l  twenty-four  hours,  or 
Imger,  it  will  probably  not  give  way  to  the  means  above  indicated,  and  then 
it  will  be  necessary  to  use  the  instrument,  when  a  full  sized  one  should 
be  very  carefully  introduced;  a  large  instrument  entering  the  bladder 
•■easily  as  a  smallt>r  one,  and  with  less  risk  of  injury  tu  the  tender  walls  of 
the  canal. 

When  the  catheter  has  been  introtluoed,  it  is  otlen  somewhat  difficult  to 
determine  whether  it  should  be  letl  in  or  taken  out.  If  it  be  lefl  in,  inflam- 
mation is  increased.  If  it  be  taken  out,  the  Surgeon  may  not  l>e  able  easily 
to  iDtroduce  it  again.  The  isolution  to  this  question  is  to  be  found  in  the 
ftcility  with  which  the  instrument  is  passed.  If  it  have  been  introduced 
witiiout  much  difficulty,  it  is  better  to  witiidrnw  it  after  the  bladder  has 
been  emptied,  and  to  continue  the  antiphlogistic  treatment,  when  a  second 
introduction  may  not  be  required.  If,  on  the  other  hand,  the  catheter  have 
been  paaeed  with  great  difficulty,  and  be  firndy  gmf>pe<l  by  spasm,  it  should 
be  left  in;  but  very  active  treatment  must  be  employed  to  prevent  it  from 
exciting  too  much  mflammation. 

It  must,  however,  be  remembered  that  the  retention  may  be  due  to  more 
■eriouft  conditions  ;  to  prostatitis,  to  abscess  in  the  prostate  or  the  perineum, 
or  to  inflammatory  exudation  in  the  tii^ues  about  the  neck  of  the  bladder. 
In  these  circumstances,  more  active  autiphlogi-itic  measures  will  be  required, 
with  the  use  of  the  catheter  twice  in  the  twenty-four  hours,  and  probably  free 
incisions  into  the  perineum,  if  tliere  be  pus  or  urine  extravasated  into  that 

IWOD. 

Id  many  cases  of  gonorrhn-til  retention,  an  old  siriciurt'  ci>m|ilicntes  the 
clap.  Here  the  emplnyiiK'nt  of  energetic  antiplilogistic  measures  and  the 
use  of  the  catlicter  an-  indicateii. 

Hemorrhage  from  the  TTrethra  may  occur  either  at*  the  rt't<ult  of  ctmrdee, 
and  coDseiiucnt  rupture  of  some  bloixlvi'iisels  of  the  corpu."  spongiaoum,  as 
the  consequence  of  attempts  at  p:i!<sing  the  catheter,  or  as  a  kind  of  i-xuda- 
tioD  from  the  muctais  niendtrano.  M>i^t  cnTDiiiniily  it  may  be  arrested  by 
the  application  of  ice,  and  the  eriiplnyment  of  uuidirAte  loL-al  antiphlogistic 
treatment.  Should  it  be  abundant,  the  iiitriKJurtiou  of  a  large  gum-elasttc 
catheter,  and  prcstsurc  by  nu-uns  of  a  bandage  to  tlic  pcni;'  or  pi-riueuni,  will 
arrest  it. 

Urethral  or  Peri-arethral  Abiceai  ucca^ionally  forms  in  gonorrhtra.  It 
IB  supposed  ti)  result  from  inflammation  i-ulniiiiating  in  i>uppuration,  taking 
I^ace  in  one  of  the  lacuna'  or  glands  of  tht-  inucon>  numbrane.  An  ali^cesi 
maj  form  at  any  part  of  the  urellirn,  I>iit  llii'  two  iiioiit  i-ninmon  situations 
are  near  the  end  of  the  ]H'iiis  and  in  the  region  of  the  bulb.  It  is  p<w!<i- 
ble  that  in  many  ca:>i>s  tlie  pui^  luay  be  dii^cliarged  into  the  urethra  without 
being  reeognizt-d ;  but  if  the  oil  lection  of  pu^  n.'a('hes  any  t-ize  it  |x>ints 
towards  the  surface.     In  the  neighborhood  of  tht-  glans  it  forms  a  rounded 


1088 


DISEASES   OP    TBS   UBKTHllA. 


swelling,  usually  projecting  undtr  or  to  ouo  side  of  Uie  Trsiiiuii).  It  a  um- 
tler  on  prcttsurc,  nud  the  jinrts  npiind  are  swullen  au<l  ailcmatuus.  In  ibis 
siluati'in  it  should  be  upoiied  hs  early  as  {Hiraible  Ivst  it  sliimtcl  bunt  inUi  the 
uretlim,  after  which,  Bi*  the  utwrture  i»  tisually  iueuflicient,  a  swicnd  i)])eD- 
mg  will  t'ortn  on  the  BurfUcf.  leaving  a  fietula,  which  is  very  truubleeome  tu 
Ileal. 

When  the  ab9««8  forms  in  the  regioD  of  the  bulb,  it  forniB  a  hard,  tender, 
eweUing  in  the  perineum,  constituting  one  of  the  varieties  of  peri»«ti  abtixm. 
In  this  situation,  also,  if  opened  early  by  a  free  incision  in  the  middle  line, 
it  will  bcfuuud  to  have  no  oommiinicatiun  with  the  urethra,  and  \^ill  ntiirkty 
heal  without  leaving  a  fistula.  If  it  be  not  npened  in  time,  it  may  tuirruw 
widely  benealb  the  acceleralor  u rime,  and  the  expansion  from  it  covering  the 
peaiB.  Under  these  cireumslances  it  may  be  tell  both  at  the  root  of  the 
penis  and  in  the  perineum,  and  there  may  be  considerable  swelling  of  the 
Mrotum.  The  incision  iu  such  a  case  should  be  made  behind  the  scrotum 
unly.  If  lelt  too  long,  a  communication  with  the  urethra  may  hare  taken 
place,  but  provide*!  the  incision  ta  made  io  the  perineum  only,  it  will  heal 
without  difficulty. 

SEiit'EScEe  OF  GoKORRH<KA. — The  sequence*,  or  more  remote  complies* 
tiousof  gouorrh<i-a,ure  partly  hx-ul  mid  partly  coustilnlional.  Amoug^t  tlie 
local  we  find  more  parliculMrly  Warts  iilK>ut  the  prepuce  and  glansnr  withiu 
th**  urethral  orifice,  which  require  to  hv  Ireuted  by  (^xcisiou  or  caustics;  and 
Stricture,  the  inanagemeat  of  ubich  is  fully  OeHcribed  eliiewbere.  In  some 
cnsen,  also,  in  couB«queuc-e  of  extravasation  of  blood,  or  inflammatory  exu- 
dation  into  the  c"rpu)t  epongiovum  or  the  corfHtrn  caveroova,  limited  and 
localized  IndoratloQ  and  Thickening  of  the  Penis  may  result,  attended  by 
chordee,  painful  eiectioDH,  and  a  pi^nuanent  twist  In  the  organ.  Id  gucL 
conditions  as  these,  an  attempt  may  \te  made  to  produce  absorpUou  of  tlie 
otTused  iimm,  by  tbe  admin isl ration  of  small  doees  of  bichloride  of  luercury, 
with  the  inunction  of  iodide  of  lead  ointment. 

Allcr  the  cure  of  a  clap  that  lina  been  of  long  continuwacc,  the  generative 
organs  aro  often  left  in  a  weak  and  irritable  date;  the  peni«.  t^crotum,  and 
a|wrmatic  cords  boin;r  lax  and  elongated,  witli  an  apparent  want  of  power, 
and  often  painful  and  drugging  sensatiuDs  about  the  conis  and  i^roins. 

Beudea  tbe  etrictly  loi'al  eniuplications  of  goaorrbu>a,  certain  sefpieocit, 
to  which  some  coualitutiona  are  eiipemlly  liable,  occaaiunally  occur  as  ttie 
rei^ult  nf  this  dii>eai!«;  vii.,  inflammation  of  the  lestes  and  of  the  eyes,  and 
rbiiumatism.  Some  of  t!i(>«u,  m  tbe  ufl'ecticuis  of  llie  eyee  and  teAet*,  mar  he 
either  local  or  e^uietitutioual ;  the  oilter»  nro  clearlv  coni>tiluttonal.  "Tht 
cunstittilion&t  effectA  of  gonorrhoea  oder  characters  tbat  have  »ome  annlogT 
to  those  presented  by  the  more  ehmnic  and  subacute  forms  of  pyiemia. 
This  ill  more  esppoially  the  pnee  in  monartbritic  inflammation  of  tbe  knee  or 
wrii4,  Ipflrling  to  disor}:(nnir.aiion  or  permanent  ankylosis  of  these  juinls. 

Oonorrhieal  Epididymitis  i<i  certainly  the  most  common  of  ibeae  seipietiots. 
It  ftlmoet  invariably  affects  only  one  testis,  and  commences  in  the  epididymis, 
whence  it  cxtetids  U>  the  bmly  of  tlie  organ.  It  usually  occurs  in  individuul* 
who  lisvo  n  lax  nnd  long  sterolum.  with  very  pendulous  teHtee.  It  beldciin 
sets  in  before  the  third  week  ofler  tlie  iK-currence  of  gonorriicea,  but  mav 
occur  at  any  jHrriod  during  the  contiinmnt-e  of  the  diM::bni^e,  tbough  it  u 
O)0re  frequent  between  the  ^(Ih  and  sixth  weeks  than  at  auy  otber  lime.  In 
caaee  of  gleet,  kIro.  it  not  uncommonly  occurs  at  a  later  [>eriod.  Iu  masT 
instaucca  it  it  referred  to  some  slight  injury — a  blow,  or  squeeze,  receivea 
during  the  continuance  of  tbe  gonorrhea ;  but  in  some  ca«»  it  would  ap|)eu' 
to  rise  from  exteueion  of  the  iui)»mmution  along  tbe  viaculatory  dueC  It 
was  formerly  believe<i  to  ari&e  iu  some  cases  from  so-culled  metastasis  of  ia* 


• 


TBBAmENr   OP    OOKORRHtBAL   GONJUKCTIVJTU.      1039 


itinn  from,  tlie  uretlira  to  the  tMtig.    That  the  diteftM  commeDoeai  Id 

■fiididTaiu,  mar  be  actranced  ia  sup|>ort  of  the  tint  opinioD ;  whilst  the 

tlutt  toe  (lischarge  usunllj-  ceases  when  the  iulIsmiDStioD  of  the  ttstivle 

nu,  and  ivturtu  as  it  subsides,  has  been  adduced  iu  tiupport  of  tli« 

n«  rif  itji  iiifUistatic  origiu.    Curling  is  of  opioiua  that  the  dimiuutiuD 

'  dlscliarKB  is  due  to  couDttir  irritation,  as  be  bas  seen  a  cose  iu  whiub  tbe 

rat  <liscbarge  ceased,  althnugb  the  orcbilis  bad  been  iKi:astouGd  by  a 

As  tbo  symptoms  and  ttvaimeut  uf  (p)DorHia>al  iiiUammatiifn  of  tbe 

:le  ]irr9ml  notmnK  peculiar,  I  xball  rvivrvc  iheir  f^ioBi'lcnuion  until  we 

f^  dbeaacft  of  inlsorgaii.     (lonnrrbnTil  t-pididytuitis  ia  apt  to  be  ful- 

bj  lonr-oaatioued  gleet,  ronfri^uunt  on  the  fxuduliou  fmra  the  tiatng 

branee  nf  the  vtut  flt^tVn-n^.  iind  tin-  M-<'n.-i<>ry  »[iparaius  of  the  teaUs, 

'  Ooaoirhttal  InflammatioD  of  the  Eyes  is  ftirtuuatrly  not  of  very  oominoD 

ocnirrrarr.     It  mav  ii(f<H-t  either  the  coiijunetiTa  or  tbe  sclerotica. 

OoDoirhsal  Co^fanetiTiUs  is  mii'  of  the  meet  destructive  forme  of  ophthal- 
mia, tciving  rise  not  nnfrvtiueiitly,  in  tbe  course  of  forty-eigbt  hours,  to  the 
mmt  intrniie  cbemo«is,  with  opacity  and  aoAeaiof;  of  the  onrnen,  followed 
by  st^phrloma  and  a  dtMbarfi^  of  the  humors.  In  the  raajoritr  of  in- 
oes  only  one  eye  is  affected ;  but,  in  sr>me,  both  arr  involved  to  an  r>qual 
t.  The  di»ea»e  commence*  with  the  ordinary  jtymptoma  of  tvinjunrti- 
inflammation ;  itching  and  swelling  cif  the  eyelids,  velvety  r(!<lue««  of 
tbe  conjunctiva,  muro-punilent  discharge,  with  ranch  tachrymation.  The 
:  <  wMsets  in  parly,  and  is  very  iiov^re ;  and,  unless  treatment  atford  speed/ 
:.  the  comie<]ueoce8  are  mo«t  di«a«truus  to  vision.  Lawrence  states  that, 
ol    i  i  vwew  that  fvll  umlvr  hid  obnervnliuu,  9  bad  only  one  eye  sHVctt-<l  and 

5  both.     Of  ihv  ^  ia  «-hora  nnc  eye  only  was  diseased,  the  organ  was  lust  in 

6  cases;  of  the  5  in  whom  both  eyes  were  alleoted,  both  organs  weredtetroyed 
in  one  case;  in  2  one  eye  only  vras  loot:  oue  patient  recovered  imperfectly: 
■od  in  only  one  did  complete  recovery  ensue. 

It  has  been  u  cjueetioD  with  Surgeons,  whether  gODurrhoeai  ophthnlmia  is 
tbe  mull  u(  the  direct  application  of  the  specific  pus  to  the  coujunctira,  or 
occurs  at  a  cnnotitiitioDnl  disorder.  There  is  no  doubt  that  tbe  application 
of  the  pus  to  the  surface  of  tbe  conjunottTa  will  occasion  the  iliseatte;  and 
Ibis  is  now  gvnemlly  Acknowledged  to  be  the  only  mode  of  origin. 

The  Treatment  of  this  duugcroua  ntlection  miiBt  be  nf  on  active  character. 
Tbe  violent  depicting  moasarci  formerly  recommentled  are  now  universally 
flpodemocd.  General  bloodletting  is  never  required  :  much  relief  may.  bow- 
■vcTt  be  given  by  the  exirnctioo  of  a  small  amount  of  blood  from  the  tempkt 
hj  leecbea.  The  patii-ut  must  be  confined  to  a  dark  room,  the  bowels  iMit 
be  kept  regular,  and  a  moderate  diet  allowed.  The  most  active  topical  agent 
thnt  wc  pnasesa  is  the  alirate  of  silver.  Tbe  use  of  this  astringent,  originally 
luced  by  Litth',  has  been  much  insisted  on  by  Oathrie,  Walker,  and 
[  •,  and  is';^!nt<railr  adopted  at  tbe  present  day.  beia^  oertainly  the  mon 
mmiSal  agent  that  Mt>  fxisseaa.  Sui^^Ob  diffi-r  Bomcwhal  in  opinion  as  to  tb« 
alrettgth  nf  th«  applimtlou;  snine,  tbe  Ciermani  especially,  advise  that  tbe 
•olid  titirk  should  Ik'  usc<I  ;  whiUi  others  employ  it  in  mdution.  of  tbe  streuifib 
nf  a  drachm  to  the  ounce  of  distilled  water.  Wharton  .Tones  employs  a 
wmker  SDlulioti,  nat  of  four  or  live  grains  to  the  "Uoce,  and  I  have  seen 
cmniv  very  vucci-«cfullr  Ircnled  by  this  plan;  so  much  m.  indeed,  that  I  am 
disfMiwd  to  prefer  it  lo  the  ittrouger  so|iitii>n.  A  few  drt>[«  must  be  intro- 
dttoed  ab(}ut  twice  in  the  twenty-four  hours, into  the  inner canthus  of  the  eye; 
tbe  lids  in  the  mfanliiiM-  bring  kept  covered  by  compresses  dip[>e«l  iu  weak 
■lum  )Miiiin,  ami  ilir  punilmt  discharge,  as  it  aceuuiolattM,  careliilly  washed 
away  by  tepid  ulutii  iuicctiou^.  Instrnd  of  alum,  boruoic  aci<l  may  be  used 
with  griwteflact,  and  lately,  a  very  weak  solutiua  of  bichloride  ut  mercury 


1040 


l>IS£A8Ea    OP    THE    ORBTHBA. 


(1  iu  5000)  ha«  b€uu  tried  uiLli  cousidomlilo  suocen.  In  du'uig  tbi8,gnit 
care  iuu£tbo  iiik<:ii  tUat  uuuuol'tlie  (ii^ctiargooomcaiiitoouolact  with  tlieejw 
of  tilt}  tiurgooii  or  uureus,  as  iL  u  hi^'lil}'  uuiiiagious,  uiil  will  almuet  tu  a  oer- 
tuiuty  prixlucu  tiiu  (JisGiuc ;  iiiBinouuH  aru  ruainlvd  in  which,  iu  this  wav.  liio 
aLteiiilaul'ti  vigiou  hus  bti:u  dentroyed.  If  Ltio  clieiDoeiii  be  (Xiii)!ide»&lc,  it 
mutil  Im  iiiciHud  ;  iiiiil,  an  tht>  iiiHaniiiiaiiou  atitttidea,  UoltadiiDDa  lutioas  may 
be  einpliiyi^d  with  ailvauUi^H,  and  the  uhh  of  the  Dilrate  of  silver  and  other 
lotiona  gnuttiaily  di8(!<>iiLiniie<l. 

Great  care  Tiiuut  be  taken  to  [irevfint  infection  of  the  other  ere  when  ooly 
one  is  nflected.  It  may  be  ouvered  with  a  compress,  or,  as  Dixon  recotn- 
mendK,  a  wiit«h-g1as9  may  be  placed  over  it  and  aecured  by  plaster. 

Qonorrhmal  Sclerotitu  ie  br  no  means  of  auch  frequent  occurrence  m  the 
ooDJiinctival  in  Hnm  milt  ion ;  when  it  happens,  it  will  be  found  to  be  Msoetated 
with  gtinorriKinaL  rheiimatism,  and  not  nti frequently  with  inflammatton  of  the 
testicle,  occurring  apparently  in  IndiTidual^  in  whom  there  is  a  tendency  to 
affection  of  the  Hbrous  tiesues.  This  disease  is  evidently  of  const itntional 
origin,  as  it  cannot  possibly  arise  from  local  contagion;  it  is  allcndtnl  by  the 
ordinary  8igu«  of  tictcrotic  iutlammation,  and  is  usually  accompanied  by  some 
degree  of  iritis. 

TbeouUHtilutioaal  Treatment  is  tliat  for goaorrboeal  rheumatism.  Locally 
the  eye  iiiu»t  be  prutecled  from  light,  and  a  few  dro|ia  of  atropine  soIutioD 
put  ia  occasionally.  If  tbere  is  much  pain,  blood  may  be  taken  frgta  the 
temple  by  cunping  or  Icechee. 

Inflammation  of  the  Nose,  attended  by  profuse  suppuration,  is  a  complic** 
tion  that  1  have  mun;  than  once  bad  occaaiou  to  observe  in  gonorrhiua.  The 
swelling  of  the  organ  is  considerable,  the  tendernees  great,  and  the  discharge 
abuDdant;  a  oonditiou,  indeed,  of  the  t?cbnvideriaD  membrane  thai  seems 
Aoaloguus  to  the  inflammation  uf  the  conjunctiva  just  described. 

The  Treatment  that  I  have  found  to  succeed  best,  consists  in  fomentations, 
followed  by  asiringcnL  lociun^  or  injectiooa. 

OoDorrhoea  of  the  Keotom  hoM  been  met  with  in  rare  cases.  Id  women 
it  may  he  the  result  of  infi^ciioii  from  vaginal  discharge,  but  in  men  it  is 
usually  the  result  of  unuatural  vicu.  The  ttyiiiptoms  are  pain  in  the  bowel, 
with  a  thick  muco-puruk-ut  discharge.  Thu  7'r'«a^Jnen/ consists  in  iujoctiuai 
of  acL-lJiti;  i>r  IlmiiI  ainl  iipium. 

GonorThtealSheumattsmjiriucipally  occurs  inyoung  and  otherwise  healthy 
persons.  The  exaut  nature  of  tlu:  disL-aso  is  very  uncertain.  It  is  euppoeea 
liT  many  tn  he  a  form  of  btood-poiMniiug  analogous  to  pynmta.  BorkeJey 
Hill  states  that  his  observattuns  lead  him  to  believe  timt  the  disease  ia  met 
with  chiefly  in  gouty  or  rheumatic  subjects.  If  the  patient  have  not  pny 
riously  sutfered  from  these  afl»ctinns,  a  family  history  indicating  a  tendency 
to  them  will  utiually  be  found.  In  patients  who  are  distinctly  rheumatic  or 
gouty,  Hnt^hinAon  states  that  any  urethral  diitcharge,  whether  apccilic  or  not, 
may  give  rise  to  symptoms  identical  with  thoAe  of  gonorrh<EAl  rheumatism. 
The  aflection  is  more  common  in  men  than  in  women,  and  seldom  sets  in  till 
the  third  week  after  the  commencement  of  the  discharge,  though  it  may 
occur  as  late  as  the  secon<l  month.  The  disease  may  a^nme  varioiui  forn& 
It  may  commence  insidiously  with  pain  in  the  joint.i.  quickly  tblUiwed  by 
considerable  effusion.  Several  joiols  may  be  atTecte^l,  but  ihe  knee  is  attackwi 
with  far  gi-ealer  frequency  than  any  other  arliculallon.  The  febrile  didlurb- 
anc«  may  be  slight.  The  paiu  and  sMclliug  last  usually  for  some  weeks,  and 
gradually  sulwide;  hut  rela|)S«s  ar«  cummuu.  In  other  cases  the  course  of 
the  affection  more  cluwly  resembles  that  of  acute  arthritis;  the  pain  ii- 
intense,  and  the  ligaments  are  early  affi;ct«d.  The  ewdUug  assninus  an  ovnl 
form,  elfusiou  into  the  articular  cavity  being  slight,  or  evcu  wanting.     Th* 


\ 


* 


[ONORRHt 


THE   PXKALI. 


1041 


dtotional  disUirlMiice  u  aCTere.     This  vnriety  most  commonly  endii  m 

kyloeiB.      Id  another  form  occaeiooally  met  wjth,  paiu   furms  the  chief 

>m,  without  »w«lliiig  or  iDterJerencv  with  moveiueat.     Other  atructora 

the  joiou  IDB)*  be  affected,  u  the  faAcite.  the  shealhs  of  teo<loa»,  burae, 

,  oooSHoDall}'  the  Dervei.     Oonorrhoeal  acleroUtu.  as  atreaiiy  meutiooed,  in 

ij*  coooected  with  rbeumatiam,  and  orchitu  may  arbe  from  the  aaiue 

Ml     Quoorrhceal  may  be  difltiaguisbed  Irom  umple  acute  rheumatuiu  by 

ikttack  being  ieta  eevere,  by  the  afTectiou  usually  being  limited  to  two  oV 

I  iointi!,  ana  often  to  the  knee  only,  and  by  the  absence  of  the  profuM 

~tng  and  the  creamy-whita  loogue.     The  progaoiiB  b,  a£  a  rulo,  good. 

tmuion  may  occaeiotially  take  plaoe,  and  the  disease  tben  lucrj^te  into 

t4>  ba  immediately  described,  gooorrbceal  pyiemia.     Aokylous  u,  hov- 

r,  very  comiuoii,  especially  in  the  arthritic  form.    This  arises  doC  ao 

:h  fmm  diKtructioD  of  the  cariilugoi,  but  from  shortening  and  contnic> 

of  the  intlampd  capsulu  of  thu  joiui  as  recovery  takes  place.    This  form 

'tjUmii  is  practically  incurable. 

cmL — Tho  6r»t  essential  point  of  treatment  is  to  check  the  urethral 

as  quickly  an  i>usflibte  by  the  means  already  dascribod.     Iodide  of 

inm,  with  alkaline  tonica,  arc  sometimes  of  use.    Cklontel  and  opium 

formerly  administered,  but  are  not  now  believed  lo  be  of  any  value. 

Icrlate  of  anda  in  large  doses  has  been  tried  with  varytng  effbcu    Quinine 

'  he  given  tf  tlie  temperature  is  elevated,  and  in  the  later  stages  perchlnride 

ran  t»  often  of  malorial  service.     The  IfK«l  joint-aHtction  must  he  tn-ftt«d 

;*bsolutd  r«sl  0Q8pliiit>>,  blistering, and  ntrapping  over  mercurial  uiutuient 

"ka  Islar  stages.     If  ankylosis  occura,  it  must  be  treated  as  described  on 

rhiml  Fyvmia. — It  is  not  easy  to  draw  a  cleitr  disUaotion  bvtwwn 
il  rlieumatiBti)  and  py»-mta.  Tha  t«rm  pymnia  is  appliwl  to  thoM 
iTat«d  cases,  fortunately  of  very  rare  ooourr«Dce.  in  whic-li  the  juint- 
tioD  terminates  in  suppuration,  with  OMoplHe  destructiuu  of  the  artiou- 
M.  In  tb«ee  cases  ab»o.«)!«s  ar«  not  nncommonly  met  with  iu  other  parti 
10  boily,  especially  in  the  uubcutaueoas  tissue.  Viaowal  abeceases  areofvery 
!  uTc.urrenoe.  Tliusyniptouiii  arc  thuao  of  chrooic  pyaiuiEl.vol.  i.  p.  U20). 
''Cataneooi  Emptions,  chiefly  cuusistiug  of  rosoola,  with  slight  pityriasis, 
and  pcrhapH  a  f«w  juitiOitM  of  psoriasis,  have  been  deacribed  as  occurring  occn- 
lally  iu  severe  cases  of  gunorrhiua.  The  description  given  by  Traven  of 
■B  eruntioDB  makea  them  correspond  &t)  cluscly  to  the  early  manifestations 
[aypbiiw  that  it  is  probable  that  they  raaily  rvsullad  from  an  inim-urpthral 
icn?.  mistaken  for  gonorrhtea.  If  tlKse  eases  and  thoae  in  nhioh  the 
ariaos  from  copaihn  and  cubebs  be  ezoluded,  it  is  doubtful  if  any  truly 
irvboAl  skin-eruptions  L'xiHt. 
flhwerrhan  in  the  Female  differa  from  the  same  afTertiim  in  the  male  in  out 
bmig  so  severe,  though  it  is  usually  more  fxtensivt,  and  nf  longer  duraliuu. 
Tba  severity  is  len,  on  accouDt  of  the  shortness  of  the  female  urethra  pre- 
TMiling  the  occorrenoe  of  the  retention  of  urine  as  In  the  male,  and  alio 
(Hmb  ibe  absence  of  such  parts  as  the  pntstiit^,  t^stce,  etc,  tho  implication  of 
'  ioh  constitutes  Uie  principal  source  of  difficulty  in  men.  Oooorrhusa  in 
female  may  alTect  the  ports  to  very  ditTcrtnt  dcgnva;  thus,  the  vulva 
may  be  inip)ic»lcd,  or,  as  m<j«t  comrouuly  li»pp«ns,  the  inflsmruation 
spread  to  ihv  irhole  of  the  mticouw  mt'mhrane  of  the  vagina.  The 
ira  is  leas  commonly  tlie  seat  of  dismsc,  though  occasionally  implioatcd 

e other  parts ;  and,  ustly,  the  interior  of  the  uterus  may  beoiMM  aflectad 
l|apecific  iuflniDmstiou.  In  some  casn  it  will  even  spread  along  the 
pitn.  tubes  tu  the  tivaries:  and  ovaritis  and  fatal  peritonitb  also  may  be 

vot.  It.— m 


1042 


DISKASKS   OF   THE    tTRKTHRA. 


The  SymptomJi  of  gonorrho-a  in  wnmrn  arc  aufficiPiitly  woll  marked  in  the 
early  fitagcs,  when  there  is  an  abiinrlant  rnuco-pumlcnt  Hiacharge  from  the 
parU  ftffpctcti,  with  a  good  deal  of  inflammntory  irritflUon,  aceotnpnnipd  with 
pain  in  niiciuritinn,  and  a  frpquent  dfsire  to  paa<>  urine.  Ab  the  diseiue 
becomes  chronic,  however,  it  is  more  difficult  to  actermine  it*  true  character ; 
it  being  »pt  to  l>e  confounded  with  some  of  thone  nccidentAl  and  leucurrhttAl 
discliarges  to  which  fema]««  of  &I)  ages  are  subject. 

Diiiyno*U.—ln  the  majority  of  ca^es,  gonorrbtea  may  be  distinguiahed 
from  ail  other  muco-j/urulfnl  dlgcharyet  of  toe  female  organs,  by  the  preaenne 
of  inflammation  about  the  externa)  partx,  »ud  the  muoous  membrane  of  the 
va{;iua  and  urethra,  tn  tht-M  case*  il  will  be  found,  on  introducing  a 
speculum  (which,  however,  occMeiuns  cijnsiderable  paiu,  and  is  firmly  graaped 
by  tlie  contracliou  of  the  vagina  i,  that  the  discharge  conies  from  the  vaginal 
wall,  and  that  (]i*>  uterine  orifice  i»  free  from  it,  or  nearly  »o;  wliereu  id 
Jeuairrh'i-a  the  discharge  procec-cU  in  a  great  measure  from  the  interior  of 
Uia  uterui^,  the  08  and  cervix  of  which  will  probably  also  prei>ent  t«igiu  of 
diseawd  aclion.    It  must,  however,  hv  boroe  in  mind  that  the  discharge  in 

f;onorrh<pa  may  occaaiouolly  bo  iu  n  great  degree  uterine;  and  that  ihal  of 
cucorrhu:-a  luay  be  an  cxudaiton  from  the  mucous  membraoc  of  the  vagina. 
Iu  such  circumatanceB,  whoii  tlie  iliseusc  is  chronic,  it  is  almoet  inipoeeible  to 
arrive  at  a  correct  conclusion  as  to  the  nature  of  the  case  from  simple 
iuBiwction ;  &ud  in  these  cauva  of  doubt  the  8urgeun  had  better  give  a  very 
gutirded  opiniou,  k«t  he  he  kd  into  the  error  of  incutpatiug  au  innocent 
wumuu.  The  diflieully  is  increa«iii,  and  a  go4Hl  drul  of  obfcunty  timiwn 
over  the  ca^,  by  the  fact  that  ]<?uc4irrha>al  di!!chargefi  will  ut^aaiouallv  giw 
riae  to  urethritis  iu  the  mate,  which  closely  eimulutei?  gonorrhu^.  Fctn&le 
Childrim  ii\m  arc  occnsionaily  mibjcct  to  an  acute  tnflitmmatton  of  the  vapua 
and  nymphs;  as  the  result  of  simple  irritation,  of  consiilutinnal  distnrlwince. 
or  of  teething;  thee*  cases  require  to  be  recognized,  as  they  have  frequently 
been  the  cause  of  unfounded  accusations. 

The  rrcnfmcni  of  gouorrhcea  in  the  female  must  vary,  according  as  the 
disctue  is  acute  or  chronic.  In  the  acatc  stage,  general  and  local  nnu- 
pblogistic  meanH — salines,  tow  diet,  rest  in  bed,  and  emollient  sedative  fomen- 
tations— must  be  Ufted.  As  the  disease  subsides  into  a  chronic  condition, 
astringent  injections  must  he  employed  ;  a  weak  solution  of  acetate  of  lc«d, 
or  the  liquor  aluminis  coinposiiua  largely  diluted  with  tepid  water,  being 
especially  useful.  In  other  cas«s,  a  weak'  solution  of  nitrate  of  silver  nity 
be  UM>d  with  much  advantage.  These  injections  should  be  employed  three 
or  four  limes  a  day  and  in  large  quantity.  After  they  have  been  thrown 
up,  a  piece  of  Itnt  well  soaked  in  th«  lotion  should  be  iutnxluced  between 
the  op|Mised  mucous  surfucea,  »o  a»  to  prevent  their  coming  iulo  ap^xwlion, 
the  ducharge  being  in  a  great  measure  kept  up  by  their  friction  against  one 
another.  In  order  that  the  injection  may  be  properly  given,  the  woman 
eliould  lie  flat  on  h<^r  baek,  and  pump  in  the  fluid  by  meauo  of  one  of 
Kennedy's  eljuttic  bottiea.  In  the  treatment  of  gonorrhwa  in  women,  epecilicfl 
are  of  no  use  unlessi  the  urethra,  be  affected,  when  copaiba  may  be  given,  as 
in  the  male.  The  dist^ase  ia  apt  to  degenerate  into  a  ctironic  gleely  condition, 
leaving  a  thin  muco-puriform  discharge,  which  will  continue  to  b«  infectious 
for  a  great  length  of  time. 


I 

^ 


RTBICTURE  OF  THU  UBEl'HIU. 


Much  discrepancy  of  opinion  for  a  long  time  existed  as  to  the  structure  of 
the  urclhra,  some  Surgeons  admitting,  others  denying  its  muscularity.  The 
presouce  of  muscular  fibres  in  the  urethra  had  &een  suspected  by  many  in 


TABIETIES   or   STBTCTUBK    OF  THB   TJBBTHBA.        1048 

ooOMqueace  of  the  ptienoitieDa  preventeil  by  some  forms  of  stricture  beiag 
solely  «xplical>le  iu  this  way,  their  pn»ence  was  Gnjt  actuaUy  deraonsl rated  by 
Kolliker  aud  Haucuck,  who  shuweil  that  the  tube  is  surrounded  thruugli  it^ 
entire  length  with  an  organic  musculur  coat.  Hancock  has  denioDstratcd  the 
oounie  of  theae  tibree.  He  has  pointed  out  that  the  Bbrcs  of  the  inner  layer 
of  the  muscular  coat  of  the  bladder  poas  forwanls  iiiiderneath  tlie  niucoua 
membraae  uf  the  prostatic  portion  of  the  urethra,  and  thoee  from  the  outer 
layer  of  the  mui^cular  coat  of  the  bladder  outside  the  pra'^tate.  Thc^c  two 
layen  joiu  at  the  menibranuns  portiou  of  the  urethra,  forming  the  muscular 
covering  of  this  portion  of  the  cannl.  At  the  bulb,  these  iwo  laycn  divide 
again  ;  the  inner  lying  underneath  the  mucou?  inembraoe,  scparaled  from  it 
merely  by  areolar  ti^i^ue;  the  externnl  lying  iiutitiiic  the  corpus  spoDgi(utum. 
between  it  and  it«  ttbrous  invostinenl.  At  ihe  auterior  extremity  of  the 
urethra  ihcy  unite  again  and  form  iu  lipa.  Thus  the  urethra  is  surrounded 
through  ita  whole  length  by  muacular  libres.  a  double  layer  of  which  inveala 
it  at  the  tucmhranouB  poriiou,  and -agiuin  at  the  oxtttrnal  meatus.     The 

?ro6tate  and  corpus  aponglcwum  are  included  between  plants  of  these  fibres. 
he  vericles  and  ducta  of  the  prostate  are  surrounded  by  layers  of  inToliin- 
tary  fibres  ;  those  of  the  ejaculatory  flucta  coming  from  the  oon-striated  layer 
of  the  vas  dftfcrt^ns.  Those  fihrra  are  totally  distinct  fnmi  the  common  mus- 
cular apparatus  of  the  perineum,  and  their  existence  proves  the  urethra  to 
be  a  miiBculo-membranoiis  ranal. 

I  By  Striotnre  of  the  Urethra  is  meant  a.  narrowing  of  the  canal  at  one  or 

more  points.  Th&ie  may  proceed  from  three  distinct  conditionn,  v'n...  1, 
Spasmodic  Artinn  of  the  layer  of  the  involuntary  Muscular  Kihres  Fitnated 
outj^ide  the  mucoun  membrane ;  2,  Congeslion  oi"  the  Mucous  Membrane  of 

,  the  canal;  en,  3,  Organic  Changes  in,  tne  Mucous  and  Submucous  Tisaues, 
consisting  of  thickening,  iuduratloo,  or  the  deposit  of  plastic  matter  within 
them.  According  as  the  disease  arises  from  one  or  other  of  these  causes,  it 
may  be  termed  a  fipaainodic,  ti  Qmffeitive,  or  an  Organic  stricture.     These 

j        diSereut  fonus  of  the  disease  having  the  one  eoodition — narrowing  of  the 

I  urethra — aud  its  consuquouces,  iu  copnmou,  and  in  practice  beiug  ulluu 
associated,  present  so  much  variety  in  their  syruptouis,  iu  the  treatment  they 
rei^uire,  and  the  coustitutious  iu  which  they  occur,  as  to  require  separate 
description. 

Spaimodio  Stricture. — The  existence  of  this  form  of  constriction  has  been 
mucli  cavilled  at.  Hurgeous,  disregarding  the  evidoHi-e  of  their  own  seusee, 
and  beiug  ted  away  by  an  imperfect  anatomical  exuminatiou  of  the  urethra, 
have  denied  the  poi^ibility  nf  t^parioi  of  tbi^  canal,  not  being  able  to  demon- 
strate the  exifltence  of  any  tnuhculHr  fihrea  in  Eiiifficimitly  nhwie  proximity  to 
the  mucous  membrane  to  inHomici^  it  by  their  action.  The  jKnuesrion  of 
muscular  contractility  by  the  urethra  is.  however,  obvious  fnim  the  fact* 
^at  a  bougie  may  ocf^onaliy  he  introduced  with  eufficieut  ease,  but  that 

I  the  Hurgeon.  on  attempting  to  withdraw  it,  will  find  it  tightly  grai^ped;  ao 
alao,  occasionally,  on  iutrodncing  the  instrument,  he  will  feel  tt  meet  with 
an  obetruotion,  which,  on  steady  pressure,  will  yield  with  that  epecies  of 
quivering  that  is  peculiar  to  epaam  of  muscular  fibre.  Again,  the  fact  that 
a  patient  will  at  one  time  paKi  his  nriue  with  the  most  perfect  freedom, 

,        whilst,  if  it  be  rendered  acrid  or  aciil  by  drinking  spirili*,  efTerreecent  wines, 

'  or  other  similar  beverages,  almost  complete  obstructinii  will  ensne,  tends  to 
prove  the  exifltcnce  of  an  occasional  spasmodic  con.'^iriction  of  the  canal. 
The  etiect  of  aiifcsthetioa  in  facilitating  the  passage  of  a  catheter  must  also 

L  be  attributed  to  relaxation  of  spasm.  These  facts,  though  sufliciuitly  cod* 
vioctng  to  many  Surgeons,  had  failed  to  carry  proof  of  the  existence  of 
apaainodic  stricture  to  others,  until  the  resenrches  of  Kolliker  and  Hancock, 

I J 


1044 


U1SSASC8    OF  TaS    UBKTHRA. 


inn— aodkHI 


which  have  been  referred  to,  Bet  the  question  of  the  muMotinty  «f  Al 
urethra  fiDRllv  Ht  rest. 

Caueeit. — The  cauwe  of  apaemodio  Btricture  are  geoerallj  rkIi  OMiAkii 
BB  oc^rasioo  an  irritable  state  of  B^'stem,  as  long  re«iilrtioe  id  bcA  tlbMlB. 
especially  if  coojoiueil  with  habitual  exceflKs  in  drinking,  bi);h  liriiif,  tad 
sexual  indulgenoee.  The  more  immedtale  caueea  are  itaually  an/  cmam> 
etanccs  that  occnaion  irntatiou  of  the  urethral  nuicoua  mcffibnae,  «bc^ 
being  prupngnUMl  to  the  smooth  muscular  fibres  bencaUi,  mlb  tbon  ■(• 
atrtivity,  nnd  thus  gives  riitc  to  the  spastuudic  aflbotion.  Tbc  meMaoiUf 
the:sc  arc  thoM  couditions  of  the  syitteni  io  which  the  lltbatM 
eliminated:  as  exposure  to  cold  and  wet,  by  which  th«  B<-tK>ci  of 
Buspcoded ;  ,or  um  free  an  indul^^nce  in  spirituuiu  am)  urid  litjQi 
red  or  eflTerTescenl  wines,  hecr,  or  punch — uhJch  ant  well  known  togrnoa 
to  au  attack  in  luauy  constitutious. 

Symptonu. — In  Bpnsmodic  stricture  we  find  erideDL*e  of  BarrDwbig  of  Ai 
urethra,  nnd  coDfiOtjueat  impediiaent  to  the  (rt^  flow  of  uritH',  r«t>4dlT 
Teniog  under  the  influence  of  certain  rauKv,  and  aa  ipefNlil;  lu'  '  *~ 
patient,  for  inBtance,  in  bis  ordinary  health  and  paasing  arine 
take  Buch  food  or  drink  as  will  give  riae  to  a  very  acid  condtl 
fluid,  if  he  be  exposed  to  cold,  or  get  out  of  health  in  noy  way, 
finds  bitnHelf  able  to  pass  his  urine  only  in  a  Bmall  strewn  by  dn»' 
much  ati-aining,  or  may  even  be  seized  with  compteto  ntOBttm.  UaAo' 
approprinte  trentoieDt  these  symptoms  rapidly  subside;  rtKurring,  bovcfV, 
on  the  application  of  any  exciting  cause.  At  the  time  of  tbc  uccumaot^ 
this  spasm  there  is  oAcn  a  sensation  of  weight  and  unauilMM  ill  ihrpvn* 
neum>wilh  evident  irritation  of  the  urethral  mucous  uctubruw, aa ibm h« 
reddening  of  ihc  lips  of  the  orifice  ;  in  fact,  a  tendency  to  A  cofafatliati'v  df 
the  congestive  with  tlio  epo^modic  form  of  Btriciurci.  Then  will  ufis  bt 
found  to  be  a  very  slight  organic  stricture  in  csau  of  the  y —atft  tam  ^ 
this  disease ;  so  that,  when  the  spasm  eubaideB,  the  ontlm  wilt  mt  be  qdto 
go  free  ae  natural. 

TVeatment. — If  the  patient  be  suficring  flrom  nMamodie  diflenlty  i>  PM- 
ing  urine,  an  injection,  consisting  of  hau'  a  dracbtn  of  laudaauB  ta  a  Bttli 
starch,  should  be  thrown  up  the  rectum,  a  morphia  supponiory  . 
fall  dose  of  Dover's  powder  adminiMcred,  and  the  worm  hip-baih 
tlie  opium  begins  to  take  effect,  the  urine  will  utuaJly  be  paaeJ 
much  difficulty.  The  bowcla  should  then  be  made  lu  at'l,  wbai  l^ 
will  usually  he  relieved.     If  the  spaam  eontinne,  m  it  <>ft'  Cir 

days  or  weekn  after  thi^,  a  full-«!z6d  soft  bougie  shuuld  br  .-d  «nfi 

Mcond  or  third  day,  in  onlvr  to  leMen  the  irritability  of  i  >  i..  Litra.  Il 
some  cascc,  tbia  i«  more  effiictually  done  by  Ihu  uw  iiT  »  p1.i:>  .  i  upt  vdl 
warmed  nnd  niled.     Whatever  instrument  is  u»et\  »)<■   ^  '  i-  -irffUit, 

from  'So.  $  to  10.     A  small  Iwiugie  will  ollen  be  ftrrt.-ir<i,  m..'.  ni|] 
much   irrilatinn,    when  a  large  one  will   pajw  readily.      If  the   u«* 
instrument  caui>e   irritation  and  iucreiue  of  «pM>m,  it   t«  b«lt«r  to 
entirely,  and  to  trust  to  coastitutiunal  tn-niuieot.     But  tbe  t^rgeoa 
not  be  discouraged,  if  tbe  first  few  iutroductiout  uf  the  bougie  appT 
inorcuso  tbe  irritation :  as  the  urelbn)  be(9>mvs  ncctntomed  to  tbe  oae  of  ^k 
instrument,  relaxation  uf  the  spasm  will  take  ptaor.     At  the  suae  ti»e.t^ 

ERtieut'ft  general  beallh  sliould  bo  carefully  atlciidc<)  to :  llie  bowdt  vert  ^ 
cpi  uiH'U,  aud  the  diet  reeuluted  ;  all  acids,  etimulante,  asd  nreiti  leiiC 
carefully  avoided.    During  the  time  wbi-u  the  bougie  it  being  v&ed,  ha  tkt^ 
take  the  citrate  uf  pota«h  well  diluted. 
As  a  prevmtvte  treatmatt  of  these  attacks,  a  careful  rrgnlatioa  of  tWAit 


I  CMMj 


elotfaiog  with  tlic  iiw  of  flanii«l,  aot)  k<M?]ilng  tlie  akin  i 
I  of  bonebair  j;Iot»i  snH  tcpi<l  hettui,  will  br  fouDri  wrvioeable. 
ragMtive  Strictnre.  -Mnny  Htiiyeons  look  Qpon  ^ttunodie  tbiuhtn  u 
itiall^  dependent  on  iv>nKestion  of  the  rauooos  tueminuie  of  the  aretbrs, 
ATerloiikinj;  allrtffcther  the  existence  nf  snaam,  or  ronaidorlog  it  u  th<^  mult 
of  irrtuiioa  of  tne  perineal  muAcles.  nna  m^t  of  t\\t^  true  organic  muscles  of 
the  canal.  That  the  two  conililii)nt>  of  cotij^Mtinn  and  anaAia  are  freciuently 
MBociated  in  the  urethra,  io  th«  rclntion  of  cause  ami  eJrert,  there  cau  bt*  no 
doubt ;  and  thin  is  the  mo«l  frequent  condition  in  which  ^patiinodic  stricturea 
fuund.  Indeed,  congestioo  plays  an  ioiporluiit  i>art  iu  all  fornu  nf  Htric- 
I! ;  it  may,  aa  we  bare  just  s««u,  be  connecleil  with  the  spasmndic  variety  ; 
.may  ot-x-ur  alone;  or  it  may  be  aiwociated  with  urgaoic  ttrictMre:.  8ome 
Iris  of  the  urethra  appear  to  be  more  subject  to  congestion  than  other* ; 
iu»,  for  imttanc-e,  thf  iiieiubmnoiiH  aud  proelatir  {Kirliuu^,  e*[>eciaUy  the  folds 
mucouB  menibniuc  i-ouetitutiug  the  veruniootanum,  are  peculiarly  liable 
haooiiw  ooDgeated. 

CbuMS. — Cbueestivest  picture  frequentlTOccuraas  the  result  of  chronic  and 
~  j-ooutinuMl  iiiHuniiiiuLiun  of  the  urethra,  or  of  tbe  passage  of  urine  that 
bean  rendered  irritalin};  by  being  too  couccntratcd.  or  by  au  adruixturc 
an  UDdue  proj>orti<>n  of  lithatea.  It  'm  especiAlly  in  gouty  or  rhrumalic 
bjecta  who  sumr  fVum  irritahility  of  the  akin  and  uuooua  membnutea  that 
lis  cuudition  urcura.  In  three  cases  there  is  no  true  or  permanetit  utiatruo- 
;  but  the  dieeaBe  is  txan»tory,  and  due  aolelv  to  a  swullen  state  of  tbe 
ibmne  of  the  |iart.  But  in  the  majority  of  casea  it  cum  plica  tea.  and 
eraTatm  Beriously,  spasmodic  and  slight  organic  firiolurea. 
Sp^Ueme. — In  awgeetive  striclure  we  not  only  6nd  the  c^nnmon  svmptoma 
ckccttnioned  by  an  impediment  to  the  free  passage  of  tbe  urine,  but  some 
awtliiug  of  the  lips  of  the  uretbm,  with  reddening  and  evenion  of  then. 
«lao  slight  gleety  exudation,  and  not  unfreipienlly  an  abundant 
dliicharge.  in  fact,  urethritis  of  a  marked  kind,  with  a  aettae  of 
U  or  fltlncm  in  the  perineum,  pain  in  micturition,  and  aoroettmet 
ittMA  in  defemlion.  I'liis  slate  ufthinp^crtatititiiteii  A  vf-ry  trouhlMOToe 
ion,  intimately  cunoectMl  with  the  ^-arinus  form»  of  urethritis,  and 
itltnglv  Apt  to  relapxe  fmm  apparvntly  very  trivisl  circuni))tAHCiii,  itligbt 
>ni  of  cfiel,  dy8|>eplic  derangemt-nla,  or  any  local  »ouro«  of  irritation, 
"be  TV^ntniml  \a  these  caiwa  should  c<>D9i!<t  in  careful  regulation  of  the 
and  habitM  of  life,  and  e»peciallT  in  ibe  ndmioitttmlinn  of  the  cilnitenf 
•h.  and  the  Mline  aperient  niineral  watert,  ss  thnw  of  Cnriabad  or 
drirhxhnll.  If  theri^  be  much  lenderoesB  or  weight  iitxiut  the  perineum, 
appliattioD  of  leeches  to  this  part,  together  with  the  use  of  tbe  warm  bip- 
li,  will  Ik- BiTvictaltli', 

Congestive  strii.'lure,  thoufib  mnro  iofineoced  by  constitutional  than  by 
'  mmns  in  many  cew^.  yet  ia  often  groatlr  relieve*l  by  the  ocrnsional  ia- 
trtxlnclion  nf  bougies.  In  e-ome  inotances  a  soft  inatnmenl,  in  nthera  a  siltrer, 
will  h<' found  Lo  answer  beift.  Whatever  is  used,  eare  should  be  taken  to 
|tro<)iice  it  bIdkIt  and  with  every  poMJblc  gcntlomn.  With  alt  care,  iqqm 
Kniorrhai;!'  usually  follows  the  pMMge  of  the  instrument;  not  from  dc«p 
laceratifin.  but  simply  as  the  result  ufcompreivion  of  the  mueoiu  membrane; 
and  the  tlischarge  of  blood  nppean  to  he  beneficial  rotber  than  otherwise. 

Organio  Btrictare.— Tliis.  the  true  form  of  stricture,  is  the  result  of  the 
fermation  of  dense  fibrous  tiwue  in  the  raucous  nmnbrane  and  submucous 
linoe  of  a  portion  of  the  urethra,  in  many  cases  extending  tu  the  neighboring 
spongy  tinue,  or  even  further.  This  is  iirodueed  as  Ibe  resnlt  of  chronic 
inflainmalion  or  of  the  hfatiiiK  of  uloera  or  wounds,  and  differs  In  no  reapeot 
from  tbe  eieatricial  fibroid  tiMiue  formed  tn  other  part*  under  similar  circum- 


1046 


DISEASES   or   THK   CRSTHRA. 


stanoee.    In  its  doveloptnent  it  showi  tbe  lendeDcj  lo  oootjitfiaii  tl 

forma  the  ctmracterifllio  fenturaof  r)I  fibruuE  tissue  produced  Msoai 
at' iiitUuiinaiitin,  and  tbue  leads  to  n  dbit<i«  Ing  :ii'  ihe  caitai  il  nrmiik 
Till-  eauset  of  stricture  are  :  1.  Chronic  intlnn)iniitioD  of  tfav  nanai  vm- 
brann,  resulting  from  gooorrbfca.  Re{>L>Bto>l  ^nnnrrlm-aj  uicl  loog-fMofenaal 
gleets  are  by  fnf  tlie  tuoet  fertite  causes  of  tbie  diBeuo.  Tbe  tine  OMBW' 
ance  of  tbe  iotlammaLiuu  ia  luoro  to  be  dmulod  than  its  iaMMiij  ia  ■»■ 
noning  ttiLi  mischief;  heitce  it  Is  of  great  iiufMrtaoce  ont  ta  albni  gWMili 
run  on  indefinitely,  aa  they  will  to  a  certainly  be  fnUntred  by  nHHinfliMK^ 
nimc  portion  of  thu  urethra.  2.  The  healing  of  an  iDtiBuretliral  diiMiv 
alwayn  given  rioe  lo  a  stricturo.  Thia  ia  met  with  within  an  iaeb  dTllM 
orifice,  flutl  w  &  comparatiroly  rare  funu  of  the  iliMraw.  3.  Tbe  BiA 
invelemte  form  of  stricture  arises  from  Lraosverw  lacermliuD  of  the  ar 
^m  hlovs  or  kicks  in  the  |)«rineum  healing  hy  a  iMUtrai-lnl  neat.  > 
oontitvionii  of  other  pnrU  of  the  canal  may  in  tiie  aAtne  t«tiy  cauae 
of  iU  calibre.  A  more  rare  cause  is  the  injury  done  to  tbe  urethra  >>ra< 
by  Uie  hidgemeot  of  a  cnlculuB,  or  in  tbe  t-fTurt  to  extract  it- 

A*}t. — Stricture  of  tbe  urethra  may  be  met  vritb  at  aoy  age  a04T 
The  causes  that  usually  give  rise  to  it  selUum  couie  into  opcratioe, ' 
before  tbe  adult  age ;  ocnrc  (Strictures  are  not  very  commoa  bcfm  2&f«a 
of  uge.  Between  that  |>criod  aud  the  age  vii  -10  ibey  ujuM  commoolj  anfi- 
nate,  and  luay  tbeu  omtinuu  for  an  iuuoliiiite  p«'ri<Hl.  Tbftearlieatifeat- 
which  I  have  eccn  trui>  organic  (Stricture  of  the  urethra  baa  been  is  a  t»7  ~ 
years  old,  when  it  bad  alrviidy  txiaed  for  more  than  12  moaiKt :  It 
situated  an  indi  and  a  half  from  the  meatus,  and  waa  so  light  af 
Co  admit  of  Kg.  I  <»tJieter.  It  was  complicated  niih  and  had  giveo  riw 
(tfitula  in  perinten,  through  which  the  greater  part  of  the  uriM  aeapaJ.  Ik 
boy  in  whom  it  occurred  could  give  no  ezplanati'in  of  iUs  occumwe.lvlil 
waa  probably  traumatic.  Hin  attention  waa  firBt  directfd  to  tl  by  a  ludifas 
attack  of  retention.  The  stricture  waa  hard  and  gristly,  about  half  aa  isii 
long,  and  required  urethrotomy  for  its  relief.    Tber«  was  no  calcidoa. 

iieat. — Tbe  Beat  of  organic  striotnre  varies  considerably :  Indeed,  laj 
portion  of  tbe  urethra  may  he  affected  by  it,  except  the  pnvtatic.  It  «w  tf 
one  time  belit'vt^l  that  the  membranous  portion  i>f  iht-  caiia!  -  i'-«M  fn- 

quently  affocletl  hy  this  disease.     This,  howevor,  then'  ran  '  -uU.  if 

an  crrtinifous  opinion.     11.  Smith  has  cxamini-d  !(K  -;  irVun 

coulnined  in  the  diflervut  Iximlon  inuM>unw;  nf  iXn-av  h-  -1  tUt/A 

in  iht'  mem  lira  nous  [>ortii>n  of  the  tin-tbrH,  wbili*t  77  w«-rv  aitirfinr 
angular  ligament;  the  majority  i>f  thise  being  either  in  llu*  bulhottfl 
of  the  urethra,  ur  a  little  in  advamt"  of  this.  Hir  H.  Thoniptoo, 
excellent  work  ou  Stricture,  states  that,  in  tin  examination  ut  !i*JO  ftf 
he  found  '215  at  the  junction  uf  thesiHiug^'  and  mvmbrunona  pDrtiooa  trf"  A* 
urethra;  51  iu  tbe  spongy  portion,  from  an  inch  in  fruat  uf  ila  eoouMBi*- 
ment  to  within  tivo  inches  and  a  half  of  the  external  mcattta;  and  Mat  the 
external  orifice,  or  within  two  incbea  and  a  half  of  it.  The  part  omA  far 
(juently  affected  b  the  Sret  inch  of  tbe  tpoogv  portton ;  in  tba  tarnWuMt 
portion,  stricture  ia  extremely  nire,  being  airnDsi  invariably  uf  tnuiontiD 
origin  when  oiiuulcd  in  this  parL  He  says  alio.  "I  may  o^Dfidrnlly 
that  there  is  not  a  singlo  cose  of  stricture  in  the  pruslatic 
urethra  to  be  found  in  any  one  of  the  [tublic  tuoaeaBM  of  _ 

burgh,  or  Paris."    Occasiounlly  mtricturcs  aro  multiple,  two  frvqoenily! 
ring,  and  somelimes  m  many  a»  four  or  five. 

Pathological  Appearances. — Inde^ribiD<;  the  apnei 
wilh  iu  ft  wetl-mnrkcil  ca^-'of  or^nic  stricture,  it  will  be  noit  doui 
suppose  that  ibo  whole  canal  boa  been  laid  open  along  Its  roof,  atn)  to 


OBOAKIC    STBIOTITRK    07    TUB    URETHRA. 


1047 


■der  the  parts  in  the  following  order.  1.  The  part  of  the  urethra  anterior 
to  the  Btricture.  2.  The  stricture.  3.  The  urethra  behind  the  stricture. 
4.  The  bladder.     5.  The  ureters  and  kidneys. 

1.  The  Urethra  anterior  to  the  Stricture  is  perfectly  healthy,  uoteas  it  has 
been  injured  bj  instruments.  If  the  cut  edge  of  the  mucous  membrane  be 
taken  in  a  pair  of  forceps,  it  will  be  found  to  show  a  considerable  degree  of 
dasticitj.  Its  color  is  pink,  and  it  is  semi-transpareDt.  The  spaces  of  the 
aponjn^tinue  beneath  are  empty  and  open,  or  filled  witli  blood. 

2.  The  StriHure. — At  the  narrowed  part  the  surface  of  the  mucous  mem- 
bnuoe  is  of  an  opaque  white  color,  marVed  by  longitudinal  ridges,  and  often 
parch  ment'like  in  appearance.  If  its  edge  be  seized  in  the  forceps  it  will  be 
moDd  to  possess  but  little,  if  any,  elasticity,  and  to  be  firmly  nzed  to  the 

S parts  beneath.  The  submucous  tissue,  instead  of  forming  a  delicate  areolar 
'er,  is  represented  by  tough  rieid  fibroid  tissue  firmly  adherent  on  one 
e  to  the  mucous  membrane,  and  blending  on  the  other  with  the  cavernous 


Fif.  930— .Striclura  from 
CoDiioliilfttiuii  or  Cor- 
pni  S|>oagioiun. 


Fig.  U2).— Bridle-ilricturr. 


Fijr.  922. — Strietarvkt 
tha  Ant«rinr  pftrt  of 
tha  Uralhrm. 


tissue  of  the  corpus  spongiosum.  Tlie  spsces  of  the  spongy  tissue  are,  in  all 
more  advanced  8[>ccimenB,  obliterated  for  a  greater  or  les^  extent  uear  the 
stricture,  so  that  the  corpus  8|>ongiosum  at  thisspot  is  converteil  into  a  dense 
solid  mass.  In  very  extreme  coses  tlie  chronic  intltimmatory  Induration  ex- 
tends even  to  the  areolar  ti^ue  beyond.  The  diameter  of  the  stricture 
Taries  greatly.  In  somtM  cases  it  ix  annular,  encircling  the  whole  canal 
equally  for  some  little  distauce.  When  it  is  elongnte<l,  there  is  usually 
marked  ctmsolidation  of  the  corpus  spongiosum,  as  in  Fig.  U20.  In  other 
eases,  again,  annular  strictures  may  be  narrow  and  sharp-edged,  and  are 
then  called  "pack-thread"  or  "bridle"  strictures;  consisting  of  bands 
•tretchiuf;  across  the  urethra  (Fig.  921 1.  Soinctimefl  there  are  several  of 
these  in  close  proximity  to  one  another,  leaving  merely  narrow  [lassages  l>e- 
tween  or  un<Icr  thorn.  These  bnnd:)  occufioiially  stretch  directly  across  the 
canal,  but  at  other  times  and  more  commonly  they  take  a  somewhat  oblique 
direction  (Fig.  922).    It  is  not  very  clear  how  these  bridles  or  frsena  stretch- 


1048 


UISKA8BS   or   TUK    UttETQBA. 


lag  acroBS  the  urelhra  are  formed.    It  can  scarcclr  bo  by  iuAmnwalarj  i 
datioo;  it  iit  mnre  prulmblc  that  Ibejr  are  twcaniKiied  bv  perferatka 
aDoaUr  Damiwing  of  the  inucuue  inuiubranp  by  the  pfiini  of  the 
Tfaese  varioii.a  kimis  of  organic  strtt-turc  are  hard  aiia  etaMie; 
when  otil,  nlmofl  rsrtilagitiuua  in  iheir  tieusity,  feeltoi;  griatljr  bmI 
the  instniiiiRnt  that  pasBca  over  tlieiu. 

The  Ammmt  of  Coiulrirtien  TuricR  greatly  in  urpinii*  Blrirtupe,  froa  dMi 
narrowing  of  the  channel  to  almuet  (HimplcUi  nhBtnictina  of  iL  A  ifamm 
has  Rfisei)  whether  (he  canal  of  the  ur«lhre  is  eviT  renilvm]  oomplew/  ia- 
permeable  by  a  Btrlcturc  In  noeworiog  this,  il  is  uect-vArr  Ui  b«  tipmt 
upon  the  meaning  of  the  term  "impermeuhle."  If  bj  II  be  ffleaal  iaipiM 
trable  to  the  paswage  of  a  catheter,  there  can  be  no  doubt  thn'  — -^  .••^^•••^ 
may  oocasioQally,  though  very  rarely,  occur;  the  ehannet 
oblique,  or  tortuous,  that  the  instrumenC  cannot  be  panrd  tiiniui;ii  o.  .-i»- 
turee,  however,  of  this  description  may  usually  be  iittimaicly  mam  penaBihlr 
to  instruments  by  proper  and  careful  treatnient.  If  by  "  inpenucabk"  b 
meant  generally  imporvious  te  the  paaaga  of  urine,  there  cao  b*  n»  dosk 
thateuch  a  condition  does  uot  exist.  It  would  clearly  be  inc<:>nipatJU«  vilk 
life,  unl«^  a.  fistulous  o[>eoing  existed  behiud  the  ptriclurr,  tbroaffa  *Uik 
the  uriue  might  pass  uut ;  and,  even  with  such  an  npertum  exIstiBCi  I  h>** 
never  heard  of  or  seen  a  ca«  io  which  no  nrine  whatever  noaped  hylfci 
meatus,  unlem,  in  conpequeace  of  injury  or  diseaK,  a  portiOD  of  tb*  vMt 
calibre  of  (he  urethra  bad  alougbed  away;  and  it  i«  clear  that, so  loof  ■ 
any  urine  pasaev  out  in  tbii  way,  a  itricture  cannot  be  looked  upoo  m  tntl; 
imperroeahte. 

3.  The  Urethra  behind  the  Strlotttre  a  dilated  nften,  m  aa  to  fisia  a  o«- 
eiderable  pouch,  in  which  in  rare  cases  phosphatie  concrrti^os  My  hnt. 
The  muoDUfl  membrane  is  more  opaque  than  natural,  and  its  loos  orcwiinir 
is  indicated  by  its  bcin^'  thrown  into  longitudinal  folds;  it  is  nwallyof  u 
ash-gray  color  indicating  that  il  has  suffbrf>d  from  chronic  HinnmlMill  v  io- 
Qamniation.  The  orifices  uf  the  lacuna:,  and  of  the  small  claadi  «paiai 
upon  it  arc  dilated  often  to  n  cuusiilerablc  aize.  This  is  alao  viery  laaiW 
ID  tbe  floor  of  ibo  proelatJc  urethra.  These  small  pits  and  bollowa  «A» 
cause  oonsiderabic  emharraasmcut  in  treatment,  the  ioslnnDcst  lod|ria{  li 
them  after  having  safely  passed  tho  «trictun>.  The  cause  of  these  ctim^m 
Is  the  extreme  tension  this  pan  of  iho  ureliira  is  exposed  to  dariiig  mkMri* 
tion.  owing  to  the  obetmction  in  front,  and  tbe  powerAil  bypertrofUiA 
bladder  behind. 

4.  The  Bladder  in  all  well-marked  cufles  of  stricture  shorn  erldoMt  «f 
chronic  cystili.".     Its  mucous  menibnuie  ii  ihic-kene^l,  rigid    i"-'    -f 
gray  color.     If  frura  any  cauM*  the  condition  has  been  At  -1] 
deatli.dark  red  and  purple  patches  will  be  found  upun  iu     .i 
cavity  of  the  bladder  is  dimiinHheil,  and  its  umwular  cuat  grrtUly  h] 
trophied,  giving  ri»<>  to  marked  tasciculatjon  of  ilit  inner  tuHacv.     In 
Uooal  cas^,  v«pecially  in  old  meu,  il  may  be  dilated  as  wvU  as  thk 
eacwuli  are  very  (,'omtiioa. 

5.  The  Ureters  are  often  more  or  less  diUted.  This  b  not,  as  was  fbrantf 
8uppoe4Ml,  due  to  regurgitation  of  urine,  but  to  obetnieUoa  tu  the  oriSoi  m 
the  ureter  by  this  chronic  iiiQaniuiuiion  of  tbe  mnoous  tDsmbraMt.  sad  tbs 
hypertrophy  of  the  muscular  coat  of  tlie  bladder;  the  f'-rro  that  dilat#s  tbt 
ureter  lieing  the  furcv  of  secretiim  from  the  kidney.  Ill e  further  chaii^ 
thiu  occur  in  the  pelvis  and  id  the  kidnovs  arc  fully  dcacribcd  la  CSkapor 
LXVII. 

Bymptams.— The  amount  of  constitutional  distorbance  t^t  np  by  a  sirir 
ture  will  vary  greatly  in  different  casea.     lu  oiany.  and  iodecd  id  bw«i  at 


[xamihation  or  patient  roi 


ECTVRK. 


1049 


.  it  ifl  Dot  very  great.   The  extent  to  which  the  contititiitiMn  i«  influenced 
generally  be  in  proportiuo  lu  the  tighlneM  and  duration  of  the  atric- 
''tore;  but  it  U  surpriiiiDg  how  macfa  coufltiluttuual  irritatioo  is  Kt  up  in 
■cHae  eyvtc-CDS  by  a  Btriclure,  even  though  it  bo  not  vcr^  tight.    The  inter- 
fervDct;  with  the  free  flow  of  urine  ultimatelj  causM  accondary  mischief  in 
tl>e  kidney,  the  nature  and  the  symptoms  of  which  have  been  Jully  de- 
>c^be<l  in  C'hapt4?r  LXIl.,  In  which  I  must  refer  the  reader.     In  w>me  cMea 
'  ooulitutionat  syniptomt)  are  rather  nf  a  nervous  character;  the  pntient 
not  only  great  pain  In  inicturitiDn.  hut  being  seiKcd  with  rigors. 
b/  Derroufl  pmetmtii>n,  each  lime  the  urine  flows  over  Uie  tender 
fcble  snrTace. 
'~2Joea/SL{rn«af  ntrirliire  are  always  well  markerl.  are  very  uneqalvo* 
are  dependent  sittiply  nn  the  mechantral  otuilacle  prewntCil  hy  the 
urt^thra  in  the  free  twajie  nf  the  urine.     The  disease  usually  com- 
iwlth  the  retention  in  the  urethra  of  afew  drofw  nf  urine  after  cvacu- 
'■tion  of  the  cnntentA  of  the  hlatlder ;  these  escape  and  wet  his  clothes.    The 
patient  finds  that  be  has  to  (tass  urine  more  frequently  than  tiBual,  both  by 
ttlght  and  day ;  there  U  some  straining,  perha[»  a  flight  glectr  'Ititcbarge, 
JBKJ  ft  feeling  of  weaVnees  about  the  genital  organs.     The  stream  of  urine 
mgf  changes  imprei^tsed  upon  it  during  its  ]iawnge  through  the  strictnre,  by 
nnilch   its  shafve  and  direction  arts  moflified;  thus,  il  may  bect»tne  forked, 
lcmt(ere<l,  twtsted,  fan-like,  or  tie  discharge*!  in  a  double  current^-ooe  pro- 
jected directiv  furwanlf",  the  other  dn>ppiug  perpendicularly  downward*. 
There  is  usually  but  little  pain  in  micturition,  and  such  as  there  is  occurs 
during  this  act,  and  cea^v  hs  snon  as  it  b  completed.     As  the  dii>eaev  ad- 
TBDCCS,  the»eHign!<  necessarily  become  more  marked,  until  they  may  terminate 
in  complete  retention  ;  they,  however,  often  come  on  in  a  very  insidious  man- 
ner, and  when  ihe  pntient  seeks  advice  be  li  found  to  be  already  the  subject 
of  a  very  tight  and  intractable  etricture:  indeed,  in  some  caaea,  the  first  oir- 
eanatance  that  dirccix  the  ntiention  *->(  the  patient  to  bta  complunt  is  th« 
anddm  occurrence  of  retention  of  urine. 

Bxaatination  of  the  Patient  for  Stricture. — In  all  cases  of  suspected  strio- 
tnre,  the  Surgeon  should,  if  powible.  ?ee  the  patient  pass  water  before  using 
an  instrument.  He  will  thus  he  able  to  judge  of  the  actual  amount  of  ob- 
stimelion.  It  sometimes  hap[>ens  that  the  cbdbI,  though  not  greatly  nor- 
ntwed.  is  tortuous  and  indurated,  m  that  an  io»tmmcnt  enters  with  greai 
dfSeulty,  altiiougfa  the  palienl  passes  a  fair  stream  of  urine.  Ruch  a  eaM 
nigfit  readily  be  misLakej)  far  a  very  tight  strirture  if  the  examination  k 
cMaraenoei)  by  attenipling  to  pass  an  instmmenL  The  exinti-ni^^  nf  a  stric- 
ture can,  hnwrver,  be  dcterniined  with  certainty  nnly  by  the  inlnxluetinn  of 
ttu  iwlnimrfil  la  pxplnring  the  canal  in  n  )iui{>ecte>l  case,  two  points  have 
i-nain«il,  ihe  cxiMlenev  nf  a  fttrirliire,  and  its  degree  of  tightu««s. 
Krirlrnrr  of  n  Slric/tirr  Is  bnit  determined  by  passinu  a  snA'  conical 
lich  Ixittgie  alHiut  Xn.  M  ( F.n^f linh  Hcale).  It  riiOHt  l>e  »lii,'htly  warmn] 
Well  filled.  Thin  will  paw  rejtilily,  unlrni  the  canul  b^j  distinctly  eon- 
lct«<l.  when  it  will  l»e  arrested  at  the  iinrruw  fwinU  In  tliin  exploralion, 
iamall  an  ioetrument  must  not  he  uscl,  lest  it  hitch  in  the  fnaw  of  the 
urethra  or  against  the  vrninKMitannro,  and  this  accUlental  arrest  be  mis- 
Uikao  Jbr  the  obstruction  produced  br  a  stricture;  or  it  may  pass  thn>ugli 
tha  atrictnre,  and  thus  mislead  the  Surgeon.  The  ciietence  of  a  strirture 
haruiff  beau  asoertatnc'l.  the  next  ivunl  is  to  determine  ita  decree  ^jf/i^AtAns. 
Thfa  ■  bart  done  bv  witlulmwing  (he  in^trtiincnt  previooalv  used,  and  then 
lalRldt»oin}r  a  amalter  one  nlMiut  the  niz4>  of  the  stream  of  urine  that  the 
patfmt  pa»ea.  If  this  fiiil  to  enter  the  strioture.  a  smaller  one  ntill  mual  be 
and,  DDtll  thai  aiie  is  reached  which  can  be  introduced  with  but  a  moderate 


1050 


DISKASES   or   TU£    URETHRA. 


degne  of  force    In  tlib  way  the  cxintonce,  the  seat,  and  degree  of  i\i 
nees  of  ihc  stricture,  arc  ascertained. 

A  soft,  in&tnimcut  should  always bfliiseii  hy  preferenw  fi»r  thia  preliniinary 
examination,  as  it  cuudM  less  pain,  and  with  the  mnesL  oniinary  skill  imii  cue 
it  is  iniposaiblr  to  do  tho  patient  any  injury  with  it.  There  i»  no  doubt  that 
infornmlioii  an  to  the  lenjjith,  <legree  of  induratiim,  and  farm  af  the  narroir- 
iiig,  may  be  gained  by  the  experienceii  Surgeon  by  means  of  a  metal  boo^e ; 
but  thf!  kuowt<*(Ige  tliUH  gained  in  not  sufficient  to  coimter-balanoe  the grealCf 
eaM!  and  safety  of  a  sod  instrument. 

The  slighter  naiTowioKs  "f  tlie  urethra  are  not  eaaily  recoguit*d  by  the 
meanjj  just  described,  Por  tliis  purpose  the  cuoical  or  oltve-faeaded  bougie 
(Fitfs-  "H'-i,  d'ii)  will  be  fuuod  nioftl  useful.     The  conical  shape  of  this  in- 

elrum'eut  enables  it  to  i>aM  readily  lowanli 
thtf  bladder,  but  on  withdrawuif^  it  th« 
ebuulder  bitches  ou  any  narrow  part.  The 
instrument  should  be  ^aduated  in  inefaet, 
so  that  the  exai^t  distance  of  the  etrictar« 
from  the  oriliee  can  be  readily  detenniaed. 
If  it  be  deairetl  tu  deterujine  more  acco* 
rately  th«  seat  of  thu  t^iricture,  the  dis- 
tance of  the  ririficti  of  the  bladder  from 
the  meatus  extemua  must  first  be  deter- 
mined by  carefully  passing  a  grmluated 
"catheters  ftoule,"  uu\\  uoliug  the  exact 
moment  at  which  the  uriue  comueuces  Ut 
flow.  The  graduated  olive-headed  sound 
is  then  paffied.  and  alowlv  withdrawn.  If 
the  hitch  or  cling  lie  felt  wtween  one  inch 
and  nuc  and  ibree-quarten!,  the  stricture 
is  in  the  membranous  part.  If  between 
one  and  three-quarters  anil  three  inchcB, 
it  is  in  the  bulbou.i  portion.  Knr  the  pur- 
pose of  meaBuriug  these  elii.'hl  siriL-tures,  Otis,  of  New  York,  haB  invented 
au  instrument  wbicb  he  calls  ibe  "  urcihromeicr"  (Fig.  025).  It  .-onstwisof 
a  straight  tube,  the  end  of  which  can  be  diUted  into  a  sort  of  fen<^trai«l 
sphere,  and  the  size  to  whith  it  ie  dilated  i»  registered  on  a  small  dial  on  the 
handle.      The  iuetruraent  can  be  readily  inlroduoed  into  the  bladder,  if 


RC'  M8.— Oon- 
loftl-hMdad 


Wis-  «!.— Oljve- 
fatitiloil  Sound. 


Fig.  I'SS.— OlU'a  rrttiir»B:etir.     *.  Opm  s.   Sad  t1«Hd. 

Deceesary,  but  there  is  no  adraotage  in  so  doing.  When  in  the  uretlira,  be- 
bind  the  stricture,  the  bulb  is  gradually  expnnded  till  it  is  just  held,  but  not 
tightly  grasped.  It  is  then  drawn  steadily  forward,  and  when  it  is  stopped 
the  bulb  is  gradually  diminished  till  it  panes  the  stricture.  The  cxaa  six* 
of  each  part  is  thus  regiiitereil  on  the  dial. 

The  employment  of  soft  wax  i)uugte»  has  been  recommended  with  tlie  view 
of  taking  a  mould  of  the  size,  shape,  and  direction  of  the  stricture,  by  pra^ 
ing  tbo  end  of  the  Instrument  iuto  it;  but  no  possible  advantage  can  bt 


ORAPnAI.    HECHANICAI*    DILATATION. 


1061 


iTcd  froin  tbis  proceediatc.  an  J  a  Surgeou  accaKtomwl  to  tbe  uiw  of  metallic 
iineDta  can  outsiti  nil  this  iiiformntioti  with  more  certainty  b^  the  finer 
,  Allbrdal  hv  iheni. 

it. — "fhe  treatment  of  nrganic  stricture  of  the  urethra  may  be  eson- 
by  tbo  fuliowiog  methixlH:  1.  Orn<lual  Mncbanical  Dilatation;  2, 
lUnuous  DiiatatioD;  3.  Cnustics:  4.  Forcible  Espnmnon  or  Kiipliin! :  5, 
real  Uretlirotomy ;  6,  Exterunl  Urethrotomy  or  Pcriuejit  Section.  WhaC- 
plon  of  treatment  bo  a(iopti.<d,  the  Hureeon  muet  bear  in  mind  that  his 
•tiana  have  to  bo  conducted  upon  a  tender  caoat  endowed  vith  exquixile 
ibility.  which  RTuipathiuw  cioralj  with  the  conditions  of  the  general  ays- 
1,  and  in  whieh  improper  violence  or  too  active  measures  may  set  up  a 
of  irritalifin  that  will  readily  extend  tii  neigfaboriog  itnictnres,  and 
J  jeopardlM  the  tifib  of  tJifi  patient.  But,  though  it  is  neccaearT  to  reeol- 
all  ttiis.  he  must  not  run  into  the  opposite  and  c<)uatlr  dangeroiu  extreme 
Mdiiptiri^  iiiffficii'nt  measures  for  the  removal  of  tbe  ohatraotion.  A  bad 
clutv  in  uufi  of  the  most  Kerioufl  diacasfs  to  nhirh  the  human  frame  iji 
>le.  and  will  almost  inevitably,  if  left  to  itaelf,  t«rmiualt*  fatally  bv  the 
luctioQ  of  reual  disesae,  or  of  kHous  local  com  plications.  We  must  tbere- 
not  hesitate  to  adopt  sufficiently  energetic  measures  fur  lie  removal ;  and 
TS  these  be  properly  coDiiucle<l,  there  ts  scarcely  auy  afleclioo  ia  which  the 
ar;geuQ  can  ai^^nl  liis  patient  greater  relief  than  in  thif.  At  the  muive  lime, 
}wcvvr,  that  lucal  means  are  beiug  used,  couetitutional  treatment  should  not 
neglected.  Organic  stricture  is  oAeo  more  or  le»  aasociated  with  a  spas- 
modic or  coogeetive  condition  of  the  urethra,  and  reiiuires  the  fatan  cunstitn- 
1  ireatnipnt,  modified  according  to  circumetnuoen,  that  ia  necesary  in 
atft-rtionn— proper  regulation  of  diet,  avuiiiauco  of  all  articles  uf  food 
It  generate  liilmte*.  anil  cnre  not  to  allow  the  urine  to  l>ecome  too  concen- 
Atlenliim  tn  the  maiutonance  of  tbe  healthy  action  uf  tbe  liver  and 
In  wilt  also  tend  much  to  )ncrcaM>  the  patient'a  comfurt,  and  to  ward  off 
'  more  serious  ronsc-ipjences  of  Blrielurc, 
[In  all  pxrcpl  the  Hli^hteot  raw*  of  airiiTture  it  is  ailvimible.  lH'f'>rc  begin- 
mrchauiral  treatment,  to  Huhjrct  the  jiatient  to  conslitiilitiDtil  remediea 
niniah  as  far  as  iMMHihle  the  congestion  and  iipA.am  which  mity  be  pitaenL 
'utTsenoua  difficulty  beRniiripateH.and  if  the  riroumetanccft  of  the  patlmi 
mlt  it,  ho  ahould  be  conBued  to  bed  for  a  day  or  more.  The  bowcla  should 
freely  opened,  and  be  nbould  Kit  for  some  time  in  a  hot  hip-hnth,  morning 
■ad  evening.  An  opium  or  morphia  supnoiitonr  may  he  adminiMored  at 
night,  and  if  the  Biijn"  of  congeation  b**  well  iiiarlted.  a  few  lect-hes  may  be 
)plit-<|  to  the  |ierineuni.  Occaitionatly  blixters  over  the  seat  of  stricture, 
'ten  it  can  hu  el<-arly  fett  from  without',  niny  lie  of  wrvice.  By  these  meiuu 
jne,  a  vtrirtun'  whirb  at  tint  ii>-eine<i  ahiiiwt  impermeable  may  be  so  for 
ImvM  hs  to  liiki-  n  No.  4  'ir  >'i  mlhcter. 
_  I.  Oradoal  Mechanical  Dilatation,  as  it  is  erronemmly  termetl.  is  the  uonal 
Mht  certainly  the  mi>st  sticerKMrol  uiihIl-  of  tniiling  orvlinarr  vtri^liin-o  ;  hut 
is  not  the  ninre  Btrplrhiiig  or  fftrcitde  rliluinlion  ')f  llie  ptrit-tun*  ihiit  iiire* 
Tbn  nieaus  employc^l  (<•  {inxlucr*  ililntnlion  tuiid  to  pronmli-  the  nliHorpliou 
Fobroaio  intlammator)*  producia  in  ami  undemeaLh  the  mucous  membrane, 
licb  •specially  constitute  the  stricture. 

ytkt  mstninients  that  are  umhI  for  dttalatloa  are  either  metallic,  such  aa 
r  catbetera,  steel  aonndi,  or  plainl  tmugica ;  or  made  of  some  sufi  and 
Iding  material,  as  gum-elostic  cvthrters,  catfut,  whalebone,  ur  elastic 
igtea.    Though  each  Surp4>n  will  mostly  prd&  one  kind  of  iustrumcnL 
„'  uwtber,  it  is  well  not  to  be  too  exclusive  in  the  uae  of  anr  one ;  fur  it  will 
1m  ftmnd  in  particular  ftrictora  and  certain  constitutioDS  that  it  is  advan- 
lo  depart  from  the  ordinary  practice,  and  that  the  Surgcan  may 


1060 


DISEASES   OF   TUI 


.degree  of  force    In  this  way  the  exit 
runs  of  the  stricture,  are  B^cerLaiucd. 
A  Bofl  iDsirumeuc  should  always  b<- 
cxamiimtion,  as  it  ciiu5i?8  leas  paiu.  nii 
it  is  impoaaiblc  to  do  the  patient  any  :< 
iDfurmnliuu  as  Id  the  Icagtb,  dogrco  tr 
JDg,  may  be  gained  by  the  expenoDcc'l  ' 
but  the  kDowledgo  tlius  gained  is  not : . 
«at)e  and  safety  of  &  soil  instrumenL 

The  Ktighter  narrowincs  of  the  urt'H 
means  ju»t  deocribcd.  For  tbiAput]< 
(Fijp.  923,  924^  will  be  found  m-' 


_    I  tltftl  be  adopt*. 

b{K  by  Boft  instni- 

^orintJaQ,  end  tb« 

^r  «i«fcute  is  (i^ht, 

^■BtJT  impotsible  to 

5^  jwel  bougie  or  a 

»  Iwen  carried  to  a 

~.  i-nlhctcr,  tbiio  wift 

a  this  stajro  of  the 

—  .maU.oniiical  steel 

••lit  but  ()ait«  M 

— i  «il)et«r8  with  fru/bow 
^^m  fcr  l»s  irritatioii  aod 
.  ^,t0tBBtKd  mnoouB  men- 


^p.  iDStramentB.  In 
«  ^  «(»t  &nd  mnet  agi««- 
.  ar"Oi:h  a  tight  irritabla 
^mUk  uDc«,  fail  to  pan* 


Tig.  »M.— Dm- 
ie*l  -  liwi4«d 
Soand. 


Fig.  «*.— ' 


pow  of  nieaauring  these  pli' 
an  intitrumeut  which  ho  eail 
a  straight  tub«,  the  eud  r.C  ■ 
sphere,  uod  the  size  to  vthii  i 
handle.     The  instrumeot  < 


■rcati^ut.  may  flometimM 

^,.«T other  instniroeot  fail* 

^^^ctrr  U  of  li'.lte  use  in  the 

^.jtfiKsl  iBatrunieiit.  the  rhiiiit ' 

^— BJ  tkc  etrirture,  can  eaaily  b« 

--— 1-'-  dilating  fore*  with  itfl 

'  -ill  gmii-olnalic  which  ii  the-, 

,-  Itiio  the  ptricture  at  ailj 

-    1  is  nnl  ftitf  enough 

,  u»  «liffen  it,  il  becom 

i  as  a  Btoel  bougie,  and  il 


Fig.  ei6.- 

necvwary,  but  there  if 
hind  the  stricture,  the 
tightly  grnaped.     It  i;- 
tibe  bulb  is  griiduaily 
of  each  part  la  thus  r 
The  employ  roout  cil 
of  takiuK  "■  n*oM  ot  . 
log  tlie  end   of  the  n 


irUfbt,  but  twisted,  the  pUa 
■  .1  ;v»nlagooHidy  employed 
■:!  li  .iigie,  mid  beuuing  it 
.  ■  .w  inch  from  the  pMiol,  « 
^^rutn  to'tro  clofioly.  In  ihl 
g^^  inipiMablo  may  be  rcadei 

*  ^j^lie  nuat  efficient  are  c«dk 

^ipj     1]ifi  bwt  curve  for  tb«-, 
f^lji^ciri'un)ft-ronci'  of  a  circle  41 
.  of  tiiroe  aiiea  iMJtwoea  Uw 


RKBULTB   OP    IHTRODCOTION    OF    AN    INSTBDMBNT.      105S 


poiiit  aod  tbc  liiickesl  (>nrt,  which  comipouJe  to  lli«  twoduf  the  iiulruiueut. 
Tb«  poiui  siiuuld  Ih;  well  ruuuiieil^  luiil  tne  iustruuieuipanee  mure  rt-atJily  if 
then  is  a  eWgln  cuustricdoD  iroiiietlia.i«ly  iKVOod  iu  The  inslrument  should 
b«  made  uf  uickvljilated  steel,  sod  tie  highly  poliehed.  It  ahmild  have 
ft  broiul  motallic  haudk,  which  uansiuits  anyKiualion  cx>mmuDicBted  to  the 
point  mure  rvadlljr  ihao  a  wimmIcd  oae.  That  this  instniineiil  will  paM 
Buch  mure  wuuly  liiaii  a  caiheter  is  self-evideut,  and  the  latter  sbuuld  he 
owd  ool;  wheu  it  in  iutt-nded  to  lie  it  in.  If  a  catheter  be  ueeO,  it  ^huuld 
be  nade  rery  «Kdi<l  and  aliff.  The  nugs  ahuuld  be  lane,  bo  as  to  wrve  for  a 
bandle,  and  the  eyt-»  vvrtl  nnindcd  off  and  somewhat  (^nreaaed,  bo  that  tbej 
■aj  nut  acrajK'  the  un-thra.  These  inittrumenis  should  h«  used  with  ererjr 
pDMlble  care  aud  geiitlcneaa;  hut.  thonj^h  no  oae  recoenizej  more  strnn^ly 
ihAn  I  do  the  ueoeasity  of  not  t^niployiiif;  uDoeoeMarj  violruce  in  ibi'ir  intro- 
dDccioii,  it  ia  uselc^  to  think  of  [mssing  a  catheter  through  a  tight  hard 
Mricturv  without  the  cmpluvmoni  of  «>me  degree  of  force.  The  catheter 
will  not "  t)ud»  iu  own  way^'  here  as  it  may  in  a  healthy  urethra,  but  it 
muKt  be  guided  aiid  directed  by  lh«  band  of  the  l^rgeoo :  aud  there  is 
KftTcely  an  opcratiuu  iu  surgery  that  requires  more  tact  and  delicacy  of 
maoipulatian  than  that  uf  pnesiiig  au  instniiiient  through  a  tight  stricture. 
Here  some  force  must  be  used,  but  the  skill  is  shown  in  proportioning  this 
Id  the  amount  of  rcHistuuce,  aud  in  using  it  in  a  proper  direction.  The 
abearance  of  force  is  inde«^  oft«u  greater  than  the  reality;  for,  though  the 
PMnt  of  the  catheter  have  passed  a  tight  Htricture,  il  may  still  require  cod* 
•iderable  pressure  to  push  the  rest  of  the  inatruineut  ihivugb  it.  With  a 
oouieal  steel  bougie  iusa  force  ia  requireil  than  with  the  catheter,  aa  the 
atretefaing  is  not  t^ue  with  the  point  which  usually  mums  easily  throaeb  the 
iliicturc.  but  with  the  expanded  part  beyond.  whi<ui  from  its  oonieaf  form 
puMS  without  much  difhculty. 

Jntmdueticn. — Catheten  and  sounds  are  best  ititroduoed  by  laying  ihc 
patient  flat  upon  hie  back,  with  the  pelvis  somewhat  raised,  and  the  head 
and  shoulders  low.  The  (Surgeon,  standing  on  the  lell  side,  inserts  the 
instrument,  well-warmed  and  oiled  with  "  LundV  oil  "  or  VHseline,  into  the 
orothra,  with  ItA  concavity  turned  luwarde  the  lefl  groin,  and  pa«Bca  it  down 
the  canal,  at  the  same  time  drawing  the  penis  upwards  with  his  Icfl  hand,  lo 
■a  to  put  the  mucous  membraofl  on  tho  stretch.  As  the  instrumcDt  ap- 
proaches the  triangular  ligament,  the  handle  is  carried  to  the  mesial  line, 
and  at  the  muic  time  rai^^l  per]>cudiculnrlv  ;  and,  as  its  point  pasaea  Doder 
the  pubes,  it  should  be  kept  well  against  the  upper  eurlaoe  of  the  urethra. 
and  made  to  enter  the  bladder  by  depressing  the  handle  towards  and  between 
the  ibigba.  The  sureai  guide  to  tne  bladder  is  the  upper  sur&ce  of  tihe 
aLfetfam.  which  is  more  fixed  than  the  lower,  and  lev  liable  to  tiw  existenos 
of  fisluloiu  iipeuiogs  or  false  passages,  ."^hould  dit!ieultT  be  experieooed, 
Ibe  lalroductiou  mov  bo  facilitated  by  iDJecling  and  slightly  distending  the 
uretlirawiih  olive  oil  bufure  paaring  the  loMrumenL 

If  dilliL:ulty  is  fiiuud  iu  intnMlueJng  thu  initrumeot,  and  if  any  doubt  exist 
■«  to  iu  being  iu  the  right  poaMgo,  the  tin^r  muat  he  introduced  iDi<k  the 
mHum  aud  its  position  felt  l»r.  If  the  point  uf  tbe  inslrument  has  left  the 
un.-thm,  this  may  be  recoguize^l  by  its  being  too  thinly  covered  aud  loo  near 
the  gut,  or  by  its  being  out  of  thv  middle  TinSL 

Cnlorjfuriu  or  ethvr  need  Im;  udiuiuiiiter«il  only  if  tbe  stricture  be  very 
t%bt  or  tbe  patient  irritable.  Under  the  uifluenoe  of  an  anaslhetio^  bow- 
WW,  many  strictures  may  ba  readily  paaed  with  metallic  instrnnenU  Uint 
are  not  i>fTvi"iif  any  other  w.iy. 

Aesnlls  of  Introduotionof  an  Instmment. — Tlie  introduction  of  an  iBslm* 
meal  usually  gives  rise  ui  a  smarting,  painful  sbnsatiun  in  tbe  arethns  ;  this 


1054 


i>]CBlASBS   or  THE  TTBBTHBA. 


Seoerally  moet  s«vpre  as  Lbe  point  upproachefl  the  neck  of  the  bladder, 
is  then  eometinies  attmidtKl  by  t)iiU9(>a  and  auddea  fiiiatiieH.  A«  t 
general  rule,  the  in»lrument  should  be  paewd  every  second  ortbird  daj.and 
whea  iutrgdueed  should  be  left  in  for  ahout  five  niitiiites,  or  until  the  spam 
of  the  urethra  induced  by  ltd  intriHluDtiun  has  lulwidetl.  If,  houuver,  the 
Btricture  be  extremely  tight,  a  very  Hmull  vatheter  only  huviug  been  intro- 
(lui:e<I,  the  iustnmien't  may  be  left  in  for  twenty-four  or  f4)rty-eight  houn, 
when  it  will  be  found  that,  however  tightly  gras[>ed  it  had  beeo  originally, 
it  hue  become  loosened ;  a  slight  discharge  being  at  the  same  lime  set  up 
from  the  urethra.  It  may  then  be  readily  whh(lruwn,  and,  when  the  irnta- 
tian  hag  eubajded  at  the  end  of  a  couple  of  days,  u  L-on^idcrubly  larger  one 
mav  be  imrudiiced. 

The  augmciitaLJoD  uf  the  size  of  the  JDatrument  should  b«  very  gradual. 
It  ia  fullv  mifHcieot  to  increase  it  by  one  number  at  each  tJme  of  iotjodae- 
lion.  >fuuy  unithrtfi  will  not  bear  eveo  tbia,  and  it  becomes  ucccmary  to 
pass  the  same  instrument  on  two  or  three  succe»iivc  uccasions  before  a  lareer 
size  can  be  intrnduocd.  Tbo  aiz*  of  the  iuftlrument  may  be  gradually  m- 
crea&od  until  thut  ia  reach(--d  which  tht^  urethral  oriRco  rt-adily  adroit^; 
beyond  this,  the  Surgcou  should  not  go ;  but  so  moix  as  the  full  size,  miually 
No.  12  or  14,  can  b*.- introduced  with  coao,  it  «hould  not  be  paMcd  bo  frc- 
ouftntly  as  before :  once  a  week  or  ton  days,  and  gnulunlly  with  less  frequency. 
But  a  patient  who  ha^  once  ^uHered  from  a  tivht  stricture  should  p«»  ao 
itwtruRient  at  traitt  nnec  a  month  for  the  rcet  of  hio  life. 

If  thft  size  of  the  instrument  be  incrpaned  too  rapidly,  irritation  may  beaet 
up,  and  indammation  of  the  teaticlc?,  and  abscess  in  the  perineum  or  prostate, 
induced.  I  have  more  than  once  had  occaaion  to  regret  bt^infz;  in  Wto  maeh 
bafite  to  increase  the  siz«  of  the  instrument;  and,  by  augmentiag  it  bjr  two 
or  three  numbers  at  one  silting,  have  seen  the  |>atteat  thrown  back  for  week* 
by  the  eufierveutiou  of  some  of  the  affections  ju&l  meutiuued. 

By  gra<lual  dilatation,  properly  carried  out,  most  etricturee  may  be  cun- 
ttiderably  relieved  tn  the  vourse  of  a  few  weektt;  and  the  majority  may  be 
brought  to  the  full  sixe  by  coutinutiig  the  treatment  for  a  euflicieul  leagtn  of 
time.  Some,  however,  cannot  be  cured  in  this  way  ;  it  would  a[jpvar  that  the 
tiwue  uf  which  they  are  eoinpiHfed  h  no  rigid  that,  although  they  may  be 
expanded  up  to  a  certaiu  size — «ay  up  t-j  No.  5  or  ti — it  is  impo«»ible  to  go 
beyond  Ibis.  In  other  caiiee,  there  is  a  great  teudaucy  to  relapse,  and  to  a 
return  of  the  couatnction ;  the  stricture  rapidly  iMMomiug  tighter  so  aonn  u 
the  introduction  of  the  iu»truitient«  is  discontinuetl,  even  though  it  b«  dilated 
to  the  full  tiizc  of  the  uriithra — up  to  No.  12  catheter,  for  inhlani.-e.  In  .-ome 
iDBtancbs  the  relaiitie  iu  ulmifst  iiiKlaiitaneuuu.  micturition  being  at«  rlitHcult  ai 
before  immediately  Llie  catheter  is  vrith<lrawu.  Iu  these  cases  recour&e  must 
be  had  to  other  measures,  which  will  be  desiTilied. 

AcciiiENTS  ATTENniNQ  Catiiktkri*'M. — ^The  introduction  of  instruments 
occasionally  gives  ride  Lo  certain  trouhlesome  and  even  dangEirous  Hef|uences. 
AmongHt  ihtwe,  i;yn<rope  auil  rigors,  hemorrhage,  and  iullamnmtor/  irritation 
about  the  urethra  or  testes,  are  the  mii^t  common. 

HenroBi  Symptoms,  Bigors,  and  Urethral  Fever.— The  auhject  of  urethral 
fever  following  the  uce  »l'  iiiKLrumeiilij  on  the  urinary  orgnn.'^  in  persons 
affected  with  rhnmir  Eubucute  interstitial  nephriui<  han  already  iHwn  di^- 
cuased  at  p.  H8G.  Therr  in  no  clatw  of  cawes  in  which  this  untA-iward  com- 
plication IB  morn  apt  txi  occur  than  in  the  treatment  of  stricture  of  the 
urethra,  owing  no  doubt,  in  a  great  degree,  to  the  frequencr  of  the  occur- 
rence of  chronic  and  potuibly  unsuspected  kidney  disease  m  old  oasea  of 
stricture. 

Various  (logrees  of  constitutional  disturbance  may  be  produced  by  the 


of  ftD  iustniinvul  thruu^'li  n  Mlricture.  lo  aervous  •od  MQsiliT« 
lath,  this  upvraLtoii  is  oftui  aUvudod  Uy  a  sensation  of  finlutnoiB  and 
ehilliuvea  as  lh«  tDStrumi'iit  vatvni  the  Itulb  or  luvnibmioui  portious  of  the 
urvtbra.  Ttiia  Bciisutiuii  is  uut  iluu  eitber  tu  paiu  or  to  fear.  It  is  purely 
reflex,  and  in  mtwt  itxvs  mxm  pawei  off,  heiug  Icm  liable  to  recur  as  the 
■retbra  gti»  awn  aciniiilDined  to  the  use  of  itutrumeiiLt>. 

If  a  jKrsoii  liable  to  tbtee  nervouH  fet'liu^  ix  txpdWNl  lo  a  chill,  a  levere 
rigor  may  roiiie  on  »)me  boure  aflfr  tbe  p»»<aee  of  tbu  ini^lru intent,  nr  the 
■ame  occiirrenrc  may  happen  when  tbcrr  has  \>of.n  iio  pn><lispiiHiii(in  to  jc, 
tkt-  ri^tr  rciiiiin^  on  .tiKideoly  and  without  warning.  This  is  nwre  npt  tn 
bapiH-n  when  the  atricture  »  ttj^bt ;  when  metallic  inftrumenUi  have  Wen 
mmn — presibly  with  some  degree  of  force,  snil.  though  Htirinf;  a  conHderable 
lasgth  of  time — perhaps  in  vain  attempts  to  penetrate  the  uricltire.  The 
rigors  in  these  circumatao<«i  are  very  severe,  so  mueh  so  as  to  resemble  an 
attack  of  ague.  During  the  rigor  the  temperatare  rises  cnoaiderably,  oflen 
to  104'  or  lOS^.  The  subsidence  of  the  rigor  is  marked  by  profuse  sweat- 
ing, aod  i*  UiU&lly  atteniled  hy  great  exhaustion.  This  nccnrrenn-  i«  always 
Terr  alarming,  and,  though  usually  not  alteixk-il  by  pi«itive  i1nngi>r,  leaves 
tlie  naii«Qt  weak  and  exhausted ;  and,  if  be  be  old.  uf  broken  constitution, 
or  the  Mibjectof  chnnic  kidney-diaeiwe,  a  5it«l  result  may  rapidly  on^uv.  In 
tkese  di»treMiiif<  cases,  death  may  i.>ccur  at  diSerenl  |H>ri(><i»  and  in  ditforent 
ways.  Tb«  paniest  period  at  which  1  have  seen  a  fnlnl  tcnuination  has  beeo 
in  nine  hours ;  usually  it  takfs  place  in  fri>tn  'iA  to  49  hours  aller  the  ocoui^ 
rence  of  the  firat  rigur.  The  immediate  cause  uf  death  may  be  coma, 
ttUuusLiun,  or  cardiac  syncope. 

The  CUUM9  of  these  rigors  is  exceediogly  obecure.  Cotistitutioual  nervous- 
seas  ur  timidity  baa  certainly  nothing  tu  do  with  tbeni.  They  occur  io  the 
•tniogest  and  mutt  couraL'eous  men,  and  they  very  rarely  follow  the  use  of 
che  catheter  in  women,  i  have  only  ooce  seen  then  effects  in  the  female,  in 
the  person  of  a  youug  married  Iady,8lroag  and  benlthv,  who  had  a  stricture 
of  tM  orifice  of  the  urethra,  which  1  dilated  by  a  twn-bfadetl  dilator.  Twenty 
hoars  after  the  operation,  »hc  bad  three  most  intenne  rigors  fidlowed  by  pro- 
iMB  sweatings.  In  men,  they  may  occur  afler  dilatation  of  any  {lart  ut  the 
urMhrs,  but  are  much  more  fre<)uenl  alter  dilatation  of  a  stricture  seated  >n 
cIm  bnlb  or  ID  the  membranous  [wrtioD  of  the  canal.  I  have,  howarer, 
heard  of  one  caae  in  which  a  faul  rigor  followett  inctsiou  and  dilatation  of 
the  orifice  of  the  urethra.  I  doubt  whether  severe  rigor?  oci.'ur  unU<ti8  there 
Kawe  beeo  eome  truuinntic  l«sion,  such  a«  abrasion  or  rupture  of  the  mucous 
awcabraae  of  the  urcthm.  Rigors  certainly  follow  the  use  of  metallic 
iii»tru meots  more  frequently  than  that  of  the  soAcr  kinds,  which  are  Ims 
likely  to  produce  such  mischief  Itigors  are  not  prevented  by  the  UM  of 
aoastbetlni.  Some  of  the  worst  eases  that  I  have  seen  have  oceorred  after 
pTDloogecl  instrumentation  under  aaieathctica. 

Tmimenf. — The  rigor  is  l>eiit  prevented  by  gentleness  in  the  use  of  instni* 
■MOla;  by  the  employment  of  soft,  rather  than  metallic  ones;  by  guarding 
■MM  earvfully  against  a  rbill.  the  patient  being  kept  in  a  warm  room  during 
Ibe  whole  of  the  day:  and  by  the  administration  of  a  full  doae  uf  opium  ana 
<)Uinino  before  the  use  of  the  iottrument 

When  a  rigor  has  set  in,  tbe  |>aticDt  should  be  wrapped  up  in  blankots ;  a 
%iam  of  hot  spirits  and  water,  or  tea,  mar  be  given,  to  be  followed  up  by 
miaiot  and  opium.  Tbe  swatting,  wbicli  is  oAeo  so  profuse  as  to  wat 
Umafth  pillows  and  bed-olothoi,  must  be  enooura^ed.  When  it  has  oaased, 
the  patient  should  be  rubbed  dry  and  laid  in  dry,  warm  btankcls. 

ltt]ipTeBsion  af  Urine  is  a  rare  accident  &Aer  simple  dilatation,  being  mora 
attmmon  aftar  the  oiore  seven  methods  of  trcatmrat,  such  as  forcible  dilata- 


J 


105« 


DISEASES   01 


FRETHBA. 


tioo.  The  fl^mploms  arc  at  Unt  tboso  just  i^escribeH,  th«  pAtintt  ralTerhig 
from  a  rigor,  with  rapid  cli^vaiion  of  temperntiire,  dry  ^kio,  and  rnmitini;. 
The  secretion  ol'  iirino  entirely  ccasa-*,  or  at  most  a  few  dn-ips  darkly  swined 
with  blood  e8<?ape.  The  pationt  usually  dies  in  from  two  lu  three  day*, 
unless  the  secretion  returns.  lu  these  casefl,  the  kidnejB  are  usually  foutul 
more  or  lees  extensively  affected  with  chronic  intersLiUal  ioQammalioD ;  bat 
caises  have  been  recorded  in  whtcU  the  niicrot<cn|>e  revealeil  but  little  ofaanee. 
They  are  usually  gorged  with  blood.  The  couditiou  wuuM  ««eni  tu  ans« 
from  retlex  nervous  uiaturbnnce  of  the  kidney,  but  the  exact  iwtholoj^y  uf 
the  nriK'eitf  is  very  obscure. 

The  'IWahnent  consist-i  in  dry  cupping  over  the  loins  and  bot-air  bathe. 
Large  warm-water  enemata,  wilb  a  view  of  "foinentiug  Ihu  kidneys,"  have 
been  suggested.  The  bowels  must  be  freely  opened  by  u  compuumi  jalap 
powder.  Possibly  in  some  cases  pilocarpine  hypuderiuically,  in  axMW  of  ^m 
J>lf  to  1  of  A  graio,  might  he  of  use. 

Hemorrhage,  whicb  is  soraetimee  rather  profuse,  may  follow  the  introduc- 
tiou  of  u  culhcier,  especially  if  the  strtctuni  be  cougestive,  and  the  instru- 
ment employed  small.  It  generally  ceases  of  itself;  but,  if  it  be  troublesome, 
the  applirutioii  of  cold  willcbeck  it. 

The  Inflammation  about  the  urciliru  and  iu  the  testae  that  occasionally 
occurs  during  the  treutiueut  of  stricture,  u  brat  guiinled  a^innt  by  not  uusg 
too  large  catheters,  and  by  directing  tbe  jtatient  to  abstiiin  from  much  eser^ 
oise  during  the  time  of  their  iuLruduutiou. 

False  Passages  are  oecasionud  by  the  iustrumenlpasaing  out  of  the  urethra 
through  its  ciJHttt  into  tht-  Hurrounding  ttmues.  They  are  especially  apt  to 
occar  in  tight  briille-HLritJlurijis,  when  a  small  instrument  is  being  used,  and 
more  eBjiecially  if  llie  dirwtioii  of  the  ctjiiHtrirtioji  be  somewhat  oblique,  so 
that  tiie  point  of  the  sound  is  thrown  against  the  side  of  the  canal  •;  Fig.  021). 
The  extent  and  situation  of  a  fnlse  passiigc  ncceasflrily  vary  according  to  the 
position  of  the  stricture;  find  the  danger  is  usually  in  proportion  to  its 
depth.  Tbe&lse  passage  usually  takes  a  direction  downwards  and  bo  one 
side  of  the  urethra.  If  the  stricture  be  far  forward,  it  may  run  in  the  eorptu 
spongiosum;  but  if  it  be  in  the  usual  situation,  it  may  perforate  the  lateral 
lobe  of  tlie  prostate,  or  run  between  this  and  the  rectum,  being  unable  to 
extend  upwards  on  account  of  the  rigid  nature  of  the  stnicturea  id  this  situ- 
ation. When  the  false  paasage  merely  perforates  the  corpus  spongiosum, 
running  parallel  to  the  urethra,  and  opening  again  into  the  canal,  or  when. 
perforating  a  portion  of  the  prostate,  it  enters  the  bladder,  it  is  not  neoei- 
sarily  attended  wilh  much  danger;  but  when  it  enters  the  areolar  tissue  be- 
tween the  bladder  and  the  rectum,  breaking  up  this  structure  to  a  great 
extent,  admitting  urine  into  the  recto-vesical  space  and  about  tbe  neck  q( 
the  bladder,  then  the  most  serious  oonsequenceo,  such  as  inflnuimation  and 
abaccss  iu  this  neighborhood,  are  apt  (o  ensue,  which  may  not  uulikcly  be 
followed  by  the  death  of  the  patient. 

At  the  moment  when  a  false  paseage  is  made  during  the  introduction  of  u 
instrumeut,  by  the  Surgeon  using  Uh>  much  force  or  preoaing  in  tbe  wrong 
directiuu,  lie  feels  the  point  make  a  sudden  slip,  which  the  plane  of  the  handle 
ahowa  to  be  to  one  side  of  the  urethra.  Tbe  patient  complains  of  severe  pain, 
and  is  often  conscious  of  a  laceration  ;  there  is  a  grating  or  rough  scnsatiun 
oommunicated  by  the  tissues  against  which  the  instrument  has  passed  ;  and 
thCHufa  it  have  entered  deeply,  it  will  be  found  not  to  have  reached  the 
blkdmr.  On  the  Surgeon  introducing  his  finger  into  tbe  reotum,  he  pri>b- 
ablv  fteU  the  jKiint  of  the  instrument  in  the  areolar  tissue  between  the  gut 
ana  the  bhulilcr;  on  withdrawing  it.  it  will  be  found  covered  with  blood, 
and  therv  will  be  free  hemorrhage  from  the  uretbra. 


4 
I 


I 


OOWriWVOUB  dilatatTok. 


1057 


Tlic  Sur^'CuQ  kDOvB  wbi'u  lie  liaa  uutcred  ud  oM  fnlse  pUMge  by  the  cliaoge 

II  takes  place  iu  the  rlireclitm  uf  ;tie  inslrunit^Di.  by  ila  Dot  rencliiag  tlie 

iitJf  r  aad  by  the  rough  sensaliou  c^iiucuuuii-alwi  l»  it,  wry  dilTervDt  Irom 

atlunje«i  by  the  smoDtli  lioiuK  of  ilie  unilbm.    Tlie  fmtieal  ia  aOxa  cuu- 

oi  the  exiBteoce  aud  of  the  eolry  uT  the  ituitruueut  into  the  faJae 

,  and  will  waro  tbu  iTurf^n  of  it. 

[If  the  tMirgtim  be  aware  that  lie  baa  made  a  bke  pisBaf^e,  he  aliould,  if 

Ible,  at  the  time  of  the  arcideut  pass  a  catheter  into  the  bladder,  and 

ive  it  there  lur  a  few  davs  until  the  laceraUoo  is  healed.     If  there  be  an 

fidbe  paasage  be  niu»t  he  careful,  by  keeping  the  point  of  the  instrumitnt 

hj  from  it,  not  to  euter  it,  \t6l  durin;^  the  intr<xluolion  of  the  eatbct«r  he 

with  the  fxtint  of  tbe  iodlninient  the  rnlvular  angle  that  iolerTOoea  b&- 

it  and   the  uretbra ;  every  time  that  this  is  *>peu<->«l   up  it  tend*  to 

the  chanM  of  closure  of  the  tt|>criure,  whiliit,  overlapping  the  urethra, 

;iBlcrfer«d  with  the  ouward  [>aAsa^e  of  the  instrument  into  thu  bladder. 

withdrawing  the  inatrumeot  and  changing  lt»  direction,  the  fahw  paatago 

fcy  often  be  avoided,  and  the  bladder  reached.     Should  there  have  beui 

icb  difticulty  in  iotroiluciuii^  the  catheter,  the  better  plan  will  be  to  oilow 

[to  remain  in  tbe  bladder  lor  two  or  three  days,  when  tbe  falae  cuui  may 

■toibly  cloM. 

Ui  baa  aJraady  b«cn  itated  that,  to  certain  formj  of  stricture,  gradual  dila- 
doM  not  auooMd  in  e&t-ling  a  permanent  cure.  Id  l hew  coses  four 
of  treatment  bare  been  recommended — coniinaoai  ditatatiou,  tlie  de- 
letion of  the  stricture  by  caufttic,  forcible  dilatation,  aud  iu  divisiun  by 
knife.  The:^>:>  inotlnMlit  will  now  be  dsBcribed. 
Ji.  CoDtinQoas  Dilatation  ut  merely  a  modiheaiion  of  the  preceding  mode 
~  Ueatmeut,  and  ia  luefui  only  in  verv  tight  organic  etricturea.  A  amtM 
imeut  ia  6ni  pamod  and  tied  in.  In  Lying  tm  catheter  in,  care  should 
ilak«D  that  it  \iiMX  not  lie  Um  fitr  iu  the  blutlder.  It  dhould  be  pushed 
iwards  and  furwartht  unul  ttie  exact  jwiint  is  lound  at  which  the  eye  it 
le  rafficientiv  to  alhiw  the  water  to  flow,  and  be  fixed  at  this  point.  It 
fhmi  retained  by  toft  thick  ailk  lied  round  the  corona  of  the  f|;land«,  or 
to  the  body  of  the  penin  by  a  piece  of  pla«ier,  care  of  courM*  being 
ken  nut  to  produce  Rtran^uiation.  In  fn>m  twelve  to  twenty-four  hours, 
iiou^h  it  may  at  6nii  have  be^^n  tighrW  unuiped  tbe  catheter  will  be  found 
I  be  quite  Ioom,  and  urine  will  cAcape  tx^Aide  it.  It  must  now  be  cliaoged 
larger  one.  In  doing  this,  the  fresh  inntrumenl  should  be  ready,  so 
It  tbe  mitnient  one  is  removed  the  other  may  ha  intniduoed.  A  neglect 
(hi*  prtx-imliod,  ««pecia1ly  when  W»e  |Hiwage«  are  prewnt,  may  Mriously 
■■  difhculty  of  poMing  tbe  fresh  calhet<T.  By  the  »eouud  day  ft 
■  iiT)^'  will  be  fuund  to  have  been  »et  up  from  tbe  urethra.  The 
qitmrnt  should  bo  continued  till  the  uretliru  reticbea  the  iize  of  No.  5^  or  6, 
Ucb  it  will  do  iu  a  few  days  at  inuel,  aUcr  which  it  is  not  ueoeamry.  tho 
'!)«tcr  may  be  closed  with  aeniull  wooden  plug,  $<>  that  the  patient  cad 
iw  off  bis  own  urine,  or,  belter  still,  an  India-rubber  tube  may  he  attached 
n  as  to  dinin  the  bladder.  In  ouhm  in  whiob  «  guro-elastio  catheter  cannot 
paseed,  a  small  silver  one  may  be  tied  In,  and  replaced  by  a  gum-elastte 
IlUw  Bnt  change.  When  nothing  but  a  filiform  wbalebooe-  or  catinit- 
haa  been  passed,  it  may  still  be  Ued  in,  as  the  urine  will  usually  find 
to  way  beside  It  even  when  it  seems  at  first  to  be  tigblljr  grasped;  and  in 
twelve  hoon  or  a  little  longer  It  may,  in  most  eascn,  be  cfaanged  fur  a  fine 
gntn-elnstlo  catheter.  This  plan  of  irentroeol  Is  at  great  use  in  rsjKS  in 
which  Obosiderable  difficulty  lit  fbnnd  in  intriHludDg  uie  Instrument,  but  it 
has  the  disadvanuge  of  Imidk  extrt^mely  liable  to  set  up  oyslitis.  If  the 
matment  be  ooniinued  beyond  three  days,  the  urine  will  almost  always  be 

TOL.  tl. — fi" 


1058  '  DISE&flKS    or    TUK    UBKTUBA. 

founil  to  b«  ulkiillat; :  aud  litis  is  Bcnrccly  lo  be  woD(l««d  st  «Imb  «v  a» 
aider  the  wuv  iu  wliicli  thv  blaildi-r  is,  as  il  were,  opened  op  lo  iW  lir.  TW 
riak  of  cystilis  ia  inuoli  Uiiuiulelied  bj  (Iraiiiiu);  ibe  bladder,  fir  iW*  m 
urine  U  led  U>  JecumnuBe,  aud  ibo  nierv  cuuta^t  uf  Uie  xiA  imfraaeKL  wA 
the  vralli  of  the  bladder  Keuu  lo  ceuw  but  \htlv  Irritmttfui  by  iMl  U 
ran}  ctucs,  alougliinjE;  uf  the  urethra  may  take  place  ■(  the  m*1  of  tUwtan, 
lidding  to  ]>criiieal  abiMrvsB.  A  cose  uf  ih'ia  kinil  oci-urrvd  Dot  IdOgigBii 
Univemty  College  Ho8|iitaI. 

3,  Caustics. — Id  the  irratmeMt  of  stricture  bj  rauBius,  two  aljKti  m 
endettvorcd  to  be  attain«l ;  lliu  6rHt  U  the  df^lnicii  ->'<tBn:;  iW 

»eoODd,  the  diminution  of  the  st'iisibtlitr  of  tbt^  mir:  :'.--tm  mm^- 

braue,  »•'  that  the-  irritnbiUty  and  5[)ii8m  iiftlie  canal  may  tw  Itm^arA.  XVt 
fallowing  id  tilt!  way  iu  which  the  c(iui»tic  i»  apiijic^l.  A  wax  boOfw,  mI 
oiled,  18  pa»sed  down  Ut.  but  not  (hroiigh.  tlie  slricttirr;  tb«  Pnfj^n  \hn, 
witli  till)  thumb-uail,  makce  h  ntitch  on  thai  [lorliim  of  the  iDtfnmcU  «ff» 
site  to  the  mealua.  Anolher  bougie  of  similar  Ivuglh  and  mm  »  lliaa  trmi 
with  a  niece  uf  putuasa  fiinu  attoul  (he  size  uf  a  i>niBll  pio'*  bfl«d.  pbetd  »■ 
duprceeion  at  it«  end.  A  mark  ia  made  on  it,  at  a  poiat  correspjtidi&f  b>  d* 
DoU:b  OD  ihe  6ni  bougie,  and  it  U  then  puKe«l  mpidl;  down  until  tkn  aaii 
oomw  upi>ueile  to  the  meatus,  and  pnmed  flrtnly  for  two  or  ihtm  mmi0m 
afntiiist  the  stricture,  upon  which  the  ciUMtic  exercUea  its  actMMi.  Tba  ^ffr 
cation,  which  is  followed  by  a  gleety  dbcbarge,  \t  tii  be  rt|Wtwl  aiwi  mmti 
or  third  day  until  a  bougie  of  proper  size  cac  be  totniduecd ;  and  \km  At 
dilntatiou  may  be  proceeded  with  in  the  Ufluai  way.  Tbia  pfneties,  itifaa 
tiz«fl,  not  unjuMtly.  by  ListoD  as  "  m'«t  atrocioaa,"  ba«  Dow  bal  Aw  ad' 


and,  in<l<M-Hl,  iliere  aiipcare  to  be  nothing  anfal  rfbcted  bv  it,  beyeari  abft 
dii<bpii  mut^-h  more  aafcly  and  eafiily  bv  a  cnilmcef  i 


can  hf  iwrnmyVnihefl  mut^-h  more  aafcly  and  easily  by  a  aUMCerori 
an  ordinnrilr  ekilful  hand. 

4.  Forcible  Expaniloa  or  Rupture. — Korcible  and  rapid  dilatatiuni 
the  expansion  and  rupture  uf  the  cincture,  u  a  metbod  ibat,  miiriBaUy  fv* 
posed  and  pra^iioed  many  years  (univ  )iy  Luxmoor,  Aroott,  and  Bac^aiaa. 
of  OlaBcow,  has  of  late  yeam  beiui  ruvivol  in  prf---'-  ■••■  <  ...  ^.-.s^» 
mudiBedin  detail,  by  many  ^urj^ons,  amonzxt  wboii:  >«■■■_ 

Pernive,  Wakley,  llolt,  Tbom)>9oD,  and  Hill  arc  the  iii"-'i  ■  un>jiM-u<fU>.  Hn«> 
ever  varied  the  means  by  which  ntriMurea  arc  lbu4  Irraml.  (be  IBitllisMA 
employed  maybe  arran^eil  in  three  f^roupA ;  a.  Thi«<  1  '  '  «*•!»£■( 
tubes;  6.  Thoae  that  expiuirl  by  a  ncrew  n><yhani>m;  u-.  -e  tluU  act 

ou  the  principle  of  a  weidge. 

a.  Siidinp  Tu^  were  first  eniployud  in  the  traatrnent  uf  atrktun  W 
Doaault  at  the  cluse  of  the  last  •.-«iilury,  Bubtufiui-ntly  by  TarioiM  FrMcft 
Surgeons, and  iu  later  yeara  by  llulton.of  r>'--hl:(>,  nnd  rcry  exteiMTvlf  aid 
saocea^fully  by  Wuktey.     The  int>d«  of  »i  of  these  tuba  u  at  M- 

lows:  A  h'mgcoudurtor  is  iutrvduced  thr-'  >  -iricture  iu'.>>  iht*  bladda, 

aod  over  this  a  catheter,  either  of  gum  or  adver.  is  p«aK-d,  m  '  j  taia 

iQ  W 


is  made  to  aervc  ae  a  conductor  to  a  larj^r  one,  Iu  Wakii. 
the  oooductor,  or"uret)inil  Ktitdc,"conRi(rt'i  of  a  email  nWercmlbeiar,  vfaii^ 
aft«r  being  passed  through  the  stricture,  has  a  long  Oa^  trtd  acre  wad  {mp  11 
Over  this  a  ailver  tube  ia  peaaed,  which  iu  ita  turn  is  made  to  BerTt  ••  a  a«- 
duclor;  and  ihiia  the  stricture  may  he  rapidly  dilated  by  pajntng  *m»  tabt 
orer  anntbcr  until  a  ftill  siie  ia  feocht^l.  The  only  dtSniliy  in  tUi  nn 
iiwanions  nieihtxl — which  is,  howerer,  common  to  it  and  fxtty  oibcr  plan  af 
treatiDg  strinnra  by  dilatation — eonslsta  io  the  firvt  inirMlnecioa  of  tto 
"ur«lbnil  guide;"  when  that  baa  onoe  naaed  through  tli-  M-,iWtahfl 

mufl  lollow  as  a  matter  of  neoeesity.     Tbey  cano4>l  prvn  ^nof'.wti. 

as  no  laceration  nf  the  slriclure  ia,  or  can  be,  eflbdMl  by  tbp  inscramwt,  ji 


FORCIBLE    DILATATION    OF    STRICTURK. 


1059 


appears  to  be  a  peculiarly  saie  means  uf  eniployiog  rapid  dilatation  when 
circumstances  Beem  to  require  it. 

b.  Tlie  methfxl  of  forcibly  expanding  a  fitricture  by  tbe  introduction  into 
it  of  a  small  two-  or  fuur-bladcil  instrument,  fn^hioued  somewhat  like  a  nar- 
row beaked  sound,  and  wbicli,  by  Screw- nierhumi'm  in  the  handle,  admits  of 
being  o|iened  uut  i^o  as  to  stretch  the  siriciuru  to  an  extent  corresponding  to 
the  diatancti  at  which  the  blades  are  screwed  npurt,  htu>  many  advocates ;  and 
various  iugeuious  contrivances  have  been  invented  to  ctlcet  this  object.  More 
than  half  a  century  ago,  Luzmoor  atteni|)ted  it  by  the  uae  of  a  four-bladed 
iiutrunienl.  Subsequently,  Civiale  iuventrtl  a  strioture-ex|>ander;  and  of 
late  years  two-bUuled  inatrumeut:^,  haviu);  this  end  in  view,  have  been  iniro- 
duecd  into  practice  by  Perreve,  Lyon,  and  Sir  11.  Thoniiwon.  The  accom- 
panying tlmwing  '  Fig.  1)2!)  i  is  a  representation  at  the  instrument  used  by 


Fig.  '.W, — ThoiD)is(in''  Siriciure  cx[iknder. 

the  latter  Sui^uu ;  it  answers  admirably  the  intendeil  purpose,  the  cxpan- 
aiun  of  the  blades  being  etf'eeted  by  a  screw  worked  by  turning  the  handle. 
This  should  be  done  very  slowly,  t!eventl  mtdikIs  being  allowed  to  elapee 
between  each  turn  of  the  bundle,  so  that  the  ti^iic  composing  the  stricture 
may  be  gradually  stretched,  and  the  curial  of  the  urethra  at  the  seat  of 
atricture  dilated  beyond  the  full  size,  go  us  li»  be  ovcratretehed ;  the  extent 
of  dilatation  may  be  carrieil  up  to  16  or  IH,  und  is  marked  on  a  scale  attached 
to  the  handle  of  the  instrument.  If  this  operation  be  done  slowly,  little  it 
any  bleeding  results,  and  there  is  no  evidenc>e  of  deep  lantration  of  the  wall 
of  the  urethra  at  the  strictiired  spot.  A  large  guiii-elastie  catheter  mar  then 
be  paueii,  and  the  urine  drawn  utf!  It  is  n»t  usually  nece^nrr  to  leave  the 
catheter  in  the  bladder,  though  there  can  be  no  oI)jectii»n  ta  doing  this  for 
forty-eight  hours,  al>er  which  the  patient  may  hiive  one  passed  occasionally 
in  order  to  maintain  the  dilatation. 

e.  The  rupture  or  .splitting  of  the  stricture  by  an  iu:<trument  acting  on  the 
principle  of  a  M'fdyr,  has  bei.'U  roeommemied  l)y  I\<\vUard,  adopted  bv  Holt, 
and  very  extensively  emp!oye»J  by  the  latter  excellent  Surgeon,  The  instru- 
ment used  by  him  is  repri-seuled  in  the  aei'»mpuuying  li^rl|^e  ;  Fig.  HZO).     It 


¥'i'.  •.':.», — lliitl'ii  l[i«!ruiiii-iil  :.ir  Sj.litiiii^  r:iii''tjre*. 

consists  of  two  gro>>ve<]  metallic  bhides  joined  at  tlie  extri^nity.  Between 
these  a  tube  U  slip|K'<d  ubmg  a  wire,  whieh  in  its  descent  separates  the  blades 
at  a  eonniderable  angle,  iind  thus  t^plit^  up  the  ^ftrieture.  In  this  way  tbe 
eontracte<l  ))art  of  the  urethra  is  at  ouee  eiihirgeil  to  its  uoroml  diameter,  so 
as  to  admit  a  full-sized  catheter,  by  which  the  iirhw  in  then  dniwn  oil'.  The 
lotrtKluction  of  the  catheter  should  be  liad  recoiiri'e  to  at  liriat  on  alternate 
days,  and  ofterwards  at  lonnfr  intervals.  11  »!t  believes  (hat  theetlect*  of  the 
dilatation  lire  entirely  citntiiit-d  to  the  umrbi-l  t-tutraetiDn.the  healthy  jtortion 
of  the  urethra  not  being  injiiri>>nsly  di.ttnrbeil  by  the  expansion  of  the  io- 
■trunicnt. 


1  a  ^BiBBeation  of  the  dilatoni  pirriquslr  in 

K.    He  thiu  describes  il:  "Tlie  uiHni- 

equals  io  calibre  a  No.  2  or  3  catheter. 

I  ka  Bepant«d  hy  poMtng  between  iti«ni  a 

Tke  wedge  i«  p'reventeil,  by  two  dovetail 

t  leaving  the  BouDd  which  Hcte  aa  a  guide 

p  down  the  urethra."     "The  adTaalage* 

^:  mnpJicity  of  ctmHtructiua;   the   central 

tet  needed,  heucR  the  «p]it  souud  oui  be 

Xcxt  had  cbicHy,  diiulDUtiun  of  nsiit- 

immediftte  appliottion  of  Ibe  rupturiog 

■t  Io  he  overcimie.     The  lurce  ueeded  to 

I  vciT  great,  aud  the  attempt  has  bpeu  abau- 

Mtt  broken,  even  in  skilful  bauds,  from  this 

a  cxMsded  on  the  continuous  friction  outeide  the 

^  nJ  innde  along  the  guide.     lu  the  wedge-dila- 

maeei  to  two  dovetail  grooves,  which  together  do 

F«r  ihu,  the  force  rctjuircd  \a  bo  amall  that  (uw 

hm  MMtaoce."    The  inetnirueut  lan,  if  re«uired, 

,  fuch  as  is  described  aAerwards  under  In- 


.  most  efficieut  mode  of  treating  strictuna ; 
It  reelorod  to  its  full  diameter,  and  the  reaok 
«ite  •»  accomplish  hy  simple  dilatation  is  at  onoe  oh- 
K.^  aa  seaiu  devoid  of  daii>:er.  The  urethra  fa  not 
t«tagin»dtnal  rent  iu  the  iiiuctuiii  membrane  is  made 
^HCfc  of  the  stricture.  The  f>h(>ck  produced  bj  n 
»  <^ea  aevere,  and  Buppreeston  of  urine  has  foDowed 
Hk.  !t  baa  also  been  gometimes  followrd  bv  urinary 
w«  W  prxraia.  What  it  gains  iu  rapidity  it  loses 
IS  -J  u  a  universal  mrxle  of  treating  ntricturvs  would 
■M^T  lires  that  might  hare  been  saved   by  geutle 

may  be  practised  either  fttim  teilhin  the 
gh  the  perineum. 
t—Tfce  division /roi/i  ictthin  may  be  performed  iu  two 
•ljlM«gh  the  iitricliire  from  b*tnre  hackwards,  or  by 
t  lafDUgb  it,  and  dividing  it  from  behind  forwards. 
\tt  perforalinft  the  stricture /rom  be/ore  barhmrdt 
a  lancetted  stylet  (Fig.  931)  into  the  stric- 


I 


« 


I 


l^-'^U 


6(>Ut  for  Divbion  oT  SUloint*. 


;  *«(ard8  the  oontH-aled  laDrcr>like  knife,  aUcmptiog 

-^m.    Thil^  plan  is  necfHenrily  attended  by  the  ni^wl 

HnLtf  >*>  Httcuipl  be  made   to 'thrust  a  stylet  through 

»ptid«:  the  probability,  indeed  almost  the  cerlMinty, 

u  ivUing  blade  will    nam  by  the  stricture  and  divide 

-'  afetbra.     It  \s,  indeed,  almost  banished  from  surgi- 

,3(«Ue  with  ttaffity  only  to  those  strictures  that  ars 

.M  urethra  anterior  to  the  tcrotum,  where  the  canal 


INTBHyAL   DHETHROTOHT. 

is  straight.  Iii  the  deeper  and  more  ciirred  parts,  any  attempt  at  perfora- 
tion would  obviously  be  fraught  with  dnnccr ;  for,  as  it  would  of  couree  be 
impoesible  fur  the  HiirgeoD  to  guide  the  stj-let  exactly  in  the  directioa  of  the 
luethra,  it  would  he  more  likely  to  nerfurato  the  valla  of  this  canal  than  to 
pan  through  the  stricture.  In  hard  and  resisting  contractions,  however,  in 
tbe  Straight  portion  of  the  cnnal  anterior  to  the  aerotura.  such  an  instru- 
nent  may  ocoasiounlly  he  uacd  with  advantage.  A  very  convenient  form 
of  cutting  stylet  is  the  one  figured  hero,  which  hfu  a  probe  cod,  that  is  in- 
trodnccd  through  the  striomre,  aud  serves  s\*  a  guide  in  the  blacjc,  which  ia 
project<yl  and  eauaeil  u>  retract  into  its  cylinder  by  the  action  of  a  spring 
?Fig.  931). 

The  other  mode  of  dividing  AtrietnrcB  within  the  urethra  in  by  catting 
Jirom  behind  forwards. 

During  the  last  few  years,  great  improvement  hm  been  made  in  the  itiatru- 
mcut«  employed  in  this  operation,  and  it  has  consequently  risen  much  in 
favor.  Cutting  from  betore  backwardt*  without  a  guide  proved  to  dangerous, 
that  it  had  been  finally  abandoned.  Ou  the  other  hand,  the  operation  of 
cuttiDg  from  behiud  forwards  could  not,  until  recently,  be  performed  uoleai 
the  stricture  was  cnpable  of  ndiuittiog  a  No.  5  at  least.  The  Surgoous  to 
wh<>m  we  are  nio^t  iodebted  for  improvemeut«  in  the  instruineDts  employed, 
are  Van  Buren,  Oouley,  aud  Otis,  of  New  York.  Maiaonneuve,  ol  Parii, 
and  Berkeley  Hill,  of  London.  The  objecta  which  the^  Surgeoua  have  bad 
in  view  have  been,  first,  to  provide  a  safe  nud  certain  guide  for  a  etnall  cut- 
ting iDsirumeat,  and  secondly,  eo  far  to  diminish  the  size  of  the  inatrumentB 


Fig.  B32. — OiV*  Dtlktor  ud  ttrftlhromatM. 

aa  to  make  them  available  for  Rtrictunu  not  capable  of  taking  more  than  a 
No,  ]  entheter.  I^iu^tly,  m  It  wnH  found  that  the  great  mobility  of  the 
urethra  rtndereil  il  difficult  in  many  cai"**  to  divide  the  stricture,  a  oombi- 
uation  of  the  stretching  and  cutting  was  intniduced  by  Otta,  which  greatly 
bciliiatea  the  upf^nitiitn. 

The  guide  to  the  bladder  may  be  obtained  in  two  waya.  A  fine  whale> 
bone  bougie  having  been  pujiseil  through  the  strieliire,  the  nrethrntorae  may 
be  so  constructed,  by  being  tunnelled  for  a  .thort  difitnnce  at  its  point,  ns  to 
■lide  over  this  into  the  bladder.  Rut  a  better  plan  is  the  employment  of 
Mais'iiineuwB  mndu  coirWui^frice,  or  conducting  sound.  This  is  a  very  fine 
gutu>t:-liu>tic  bougie,  provided  with  a  male  screw  at  the  end  (Fig.  033n).  Thia 
u  first  pii««ed  ou  till  it  is  suppoited  to  be  in  the  bladder.  A  small  catheter 
correspoudiug  to  a  No.  1,  liuving  a  female  screw  at  tts  extremity,  is  then 
screwed  ou  tu  it  and  [msswl  onwards,  white  the  conducting  sound  coils  up  in 
the  bladder.  If  the  urine  How,  it  is  then  certain  that  the  conducting  sound 
has  paaaed  in  the  proper  direction.  It  is  now  wiihilrawn  again,  the  con- 
ducting »ound  being  left  in  position^  The  catheter  is  now  replaced  by  the 
urethrotome,  wliIcU  screws  in  the  same  way.  Curkelev  HUl  has  invented  a 
very  ingenious  urethrotome  for  cutting  from  behind  forwards,  in  which  a 
very  fine  knife  can  be  protriuietl  from  an  instrument  not  larger  timn  a  No.  2. 
Another  instrument  invejited  by  the  same  Surgeon  ibr  cutting  frum  before 


1 


1062 


mSlASXS   OF   THE   URKTBRA. 


Iinckwurds  is  r«preKD(cil  la  Fig.  933.  tt  oUd- 
bio«s  tl]«  priuciples  or  sevenil  otbere,  and  h 
been  found  tu  work  moat  succt^nfullr.  It  is  t)i 
employed.  The  comiuctioB  rnund  bivini;  bet-n 
pfiMt^l  Ettid  ascertiiioeii  t<>  he  in  tbe  blndder.  tlie 
fenmle  screw  6  is  applied  tn  tbe  mtite  screw  ti,  aw 
ihe  intitrumeat  poued  tlirougli  llie  stricture.  Tb. 
bliides  1  ftod  A,  wtieo  cloaeo.  about  eijual  n  No.  3 
catheter  in  Mze.  The  point  6  is  about  equal  to  a 
No.  1.  The  instrument  having  been  pawed,  the 
wedec  e,  which  coniaine  a  knife  d  concvalod  in 
sbield  c,  is  now  inserted  between  the  blade*  anu, 
pasaed  st*adily  down.  The  blades  ibna  seporatrf" 
strclL-b  nnJ  eteody  tbe  urethra;  and  ubtn  the 
stricture  ie  reached,  the  shield  c  etnp«  a^iust  it 
and  prevent*  further  proj.'re8».  The  iiuall  coo- 
oeak-d  knife  d  'm  then  pnitrudtvl  by  prcwing  tbi 
button  nt  thA  top  of  the  in-strument,  nnd  aa 
OB  llic  linger  i^  r(>nmved  it  i^  withdrawn  again  br 
the  spring  /.  The  wcdgr  can  tbcn  be  passed  on  ft 
tittle  further,  and  if  it  hitt^h  nfrain  the  knif^  ran 
he  again  protruded.  By  tht<i  means  tbe  urethra  if 
cut  only  at  the  point?  of  Rtridnre,  and  no  moi 
wound  ID  made  than  i^  fth.<iolutcIj  Dftxss^ry.  Thi 
iiK-i)tiiin  ix  alwny.s  made  downwards  toward.^  tbe 
fliwrof  the  nretbm.  This  in.%trument  may  !>e  em- 
ployed in  almost  anj  stricture  that  will  fl<]mit  tbe 
conducting  »onnd. 

In  Itrgtr  elricturee  Civiale's  urethrotome  (Fig. 
*JI]4)  niny  beuttcd.  In  unler  to  use  thie  instrument, 
the  stricture  must  be  dilateil  up  tu  about  N».  3. 
The  end  of  tbe  instrument  is  then  poased  beyond 
it.  and.  the  small  blade  having  bevn  made  tu  pru- 
jeut.  the  stricture  is  divided  or  ootcbwl  du«n- 
wanls  by  firm  nnd  steady  pressure  to  tb*;  extent 
usually  of  about  an  inch.  The  blade  Li  then  fhiii 
into  its  ebcBth,  nnd  the  instrument  is  vithdrown. 
As  this  instrument  d'tes  not  steady  the  urethra* 
the  penis  must  be  pulled  furwBr<l  so  as  to  put  it  on 
the  stretch  bcfnre  the  division  is  nttempteil.  and 
this  should  be  done  by  a  steady  pressure  or  a  saw- 
ing motion  rather  than  br  a  sudden  effort. 

After  the  operation  uf^  intenial  urclhmtomT,  a 
ruU'Bize^i  instrument  should  be  imme^liutcly  pfLdse<l, 
but  it  is  not  usually  mtccuarv  to  tie  it  in.  It 
should,  however,  be  paawd  daily  for  u  few  days, 
and  after  that  cvcrv  secftnd  or  third  day  for  three 
or  four  week*.  AtWr  that,  the  patient  should  he 
taught  to  |>ass  it  for  himself,  and  continue  to  do  ao 
occasinnaliy  for  the  rwt  nf  bis  life. 

The  operation  of  internal  urethrotomy  is,  of 
course,  requireil  only  in  exceptional  caMa.     Thete 

Fig.  *U.-B«rh«tBr  Ulll'i  Dllktor  Md  L'nlbrotoms.  4.  Front  VU«;  s,eM«VI«ir:  c^  Cn- 
dactltiit  SouBit  tritb  ftuftU  nilvKraw  at  o:  ft.  fount  I «  Serva;  e,  ihMik  fareonemliJ  Itath: 
d,  knilo  t"^'^''*'^  t  '■  "vilff*  Tur  tcpBniliDslb«  bta'lo*  i  bdJ  I't  ibt  kDlfv  It  ra  ihe  puatirlvr 
MJivvl  <>(  lb*  nadga;  g,  raJ  f'W  oarrjieg  th»  •••dfo;  /,  nt-I  far  pruiradtng  llie  half*;  k, 
(crow  for  r*nulatlB|t  th«  dUUn«a  to  «bieb  tfa«  heiTc  oui  b«  proiradad  ;  I,  tprlni  la  dr*« 
bMk  tbskDU«andV*«f  il.««itA«B\«A.ci,i»\liiilM(i  tfotrudml  bjproning  Ifaa  balton  ofp*- 
ffH  *  and  «.    (In  y\5- B  A«  ^mVV'in  *\'i\»\i  V»'»*'«Mi««»i*»«Vfc\  %»  &-tyoi«d,) 


^■B 


i^Mi 


EXTKKNAh    URETHROTOMY.  1068 

are  chiefly  resilient  or  very  irritable,  nnrl  some  very  tough  stricturr*.  In 
milient  strictures,  dilatation  tails  because  the  atrirture,  though  admittiog  of 
apansioD,  immediately  relaiwea.  Id  very  irritable  strictures,  the  jmtient 
eaonot  bear  the  pain  of  rlilatation.  In  some  very  tou>rh  strictures,  simple 
dilatatioD  faili*.  and  then  iDternal  urethnitomy  or  torcihle  dilnliition  is  re- 
<|uired.  In  all  these  caxea,  the  division  of  the  stricture  from  within  removes 
ftt  ouee  all  ditficuUy  in  treatment ;  and  I  have  of  late  years  employed  this 
verr  simple  method  in  several  cases  of  this  kind  with  the  most  markeil  and 
permanent  success.  In  fact,  in  strictures  of  the  siTotal  or  penile  jiortions  of 
the  urethra,  where  one  or  other  of  the  above  conditions — resiliency  or  irri- 
tability—j^'enerally  prevails,  I  now  very  commonly  notch  the  constricted 
portion  of  the  canal  by  means  of  Civiale's  urethnitome,  and  thus  at  once, 
•ad  with  great  ease,  obtain  most,  if  not  all  the  space  required. 


Fig.  B34.— CiTi»le'»  Crethrotoma. 

RtimU. — The  risk  attending  the  ofwration  is  not  great,  and  diminishes  as 
the  stricture  approaches  the  orifice  of  the  urethra.  It  ia  not,  however,  abso- 
Infcely  free  from  danger.  The  accidents  that  niiiy  hupt^en  are,  jwriDeal 
abscns,  extravasation  of  urine,  hemorrhage,  and  orchitis;  and  in  some  rare 
eases  it  may  be  followed  hy  py:emin.  If  the  kidneys  be  <lisease<l,  it  may, 
like  any  other  operation  for  stricture,  give  rise  tu  fatal  acute  iuterBtitJal 
nephritis.  Perineal  a!>sci<ffi  usually  results  fnmi  cutting  too  deeply,  so  that 
the  knife  completely  divides  the  corpus  spongiosum.  Such  abscesses  most 
frequently  form  beneath  the  accelerator  urin:c,  and  burrow  forwards,  directed 
by  the  expansion  uf  that  muscle  to  the  root  of  the  penis.  They  contain  a 
mixture  of  urine  and  pus,  but  it  is  rare  to  find  general  extravasation  into 
the  scrotum.  Hemorrhage  also  results  fnmi  cutting  too  freely.  In  rare 
eases,  after  the  operation,  a  {lermanently  bent  condition  of  the  penis  re- 
mains during  erection.  We  possess  as  yet  but  few  trustworthy  statistics  of 
the  results  of  internal  urethrotomy,  and  there  is  every  reason  to  believe  that 
UDtoward  amsequence:)  follow  thii*  ojierulinn  more  frequently  than  some  of 
its  advocates  arc  willing  to  admit.  Stutislics  of  this  o|>eration  done  in 
private  are  worthies.-) ;  those  of  vAea  ncTurring  in  lios))itaI  practice  scarcely 
exist.  In  Universitv  College  IlD-^pital,  where  the  operation  ha.t  been  ex- 
tensively practisetl.  (  find  from  the  Ke]>ort8  of  the  Surgical  Itegietrar  that 
the  results  are  aii  follows.  In  Tfi  cn)>es  operated  on  during  a  iH-ritxl  of  five 
years,  there  were  4  deaths,  1  from  tubercular  disease  of  kidneys,  lungs,  etc., 
1  from  pleurisy ,  1  from  se|>ticiL'n>ia,  and  1  from  suppurative  nephritis. 
Perineal  abscesAm-curred  in  8  cases;  extravasation  of  urine  in  l.aud  epidiily- 
mitis  in  4.  There  was  bemorrbajie  in  •">.  mid  in  "1  the  patientwas  left  with 
permanent  chordee  during  erection. 

(For  tbeetfecttt  pnxbK'ed  on  tlit-  kiiliieys  l>y  .splitting  strictures  and  internal 
urethrotomy,  see  C'liiip.  LXVIl.) 

Sxtemal  Urethrotomy. — Tiie  divi:;iim  of  tl»'  sirieture/rowi  without,  by  io- 
cisiou  thntugh  the  jM-rint'um.  may  be  [M-rfiirmed  l>y  two  distinct  operations; 
the  one  being  applicable  only  to  iIiom-  istri(.'tnri'.s  that  an^'  [tervinuH  to  an  in- 
strument; tlif  other  to  ihi)!'*' which  an-  iui|H-rnieal>lc.  In  the  tirst  rosea 
Soovcl  BtatI  is  passed  throiiL;li  tlit-  stricture,  itnd  (lie  section  is  made  u|Kin 
is.  In  the  second  case,  tin-  Sorgcm  culs  tlir<>ii;r|i  llio  stricture,  withuuk 
any  guidance  except  such  us  his  analoiuiral  knowledge  may  afford. 


1064 


DISIASES   OF   THB   ITRBTHRA. 


Operation  for  Permeable  Stricture. — The  first  of  these  n|>eratioiis.  iotrt^ 
<luc«<J  by  Synie  as  L'relhrotomif,  and  coinmoQly  called  the  Perineal  StWion  ii 
comparatively  »  dimple  procedure.  The  iDetruiueiite  required  for  its  per- 
fomianoe  are  a  BtnfT,  a  No.  8  eilver  catheter,  a  poiotod  scalpel,  and  a  broad 
director.  The  staff  should  vary  in  ^izc  from  No.  1  to  No.  6,nccordiDg  to  the 
tigbtoees  of  the  siriciure ;  it  should  bo  grtjoved  alnnj:  its  convexity,  either 
the  whole  of  the  way,  or  better,  merely  li»r  ihe  lower  third  (F'tg. 
d3o).  The  Acta  is  Binooth  and  of  full  aiev.  and  joins  ititu  the 
lower  gniovcd  part  by  adivlitict  ahoiiUIer,  whi^h.  being  passed 
down  ttH  far  an  the  ftirii-lure,  (unvn  by  iti*  pntjeetiuu  a  guide  to 
that  iiarl  of  ihc  tirothra  rrquiriiig  <livi«ii)ii.  In  those  cawfi  in 
whicn  ihorf!  are  false  pnflBa^cH,  a  hollow  Hlatl'of  the  Rame  size 
iind  Hhapi'  iimy  be  udvatitfif^ouHly  iiHe<I :  the  flow  of  urine 
ihrougii  it  imlinitinj:  with  certainty  its  passage  into  the  poate- 
rior  part  of  the  urfihra. 

Performance  of  Perineal  Section. — The  opemtion  is  per- 
formed as  follows..    The  Mjifi'  haviny  been  passed  well  through 
the  stricture,  fu*  (hat  the  shoultlcr  r^sts  against  the  upper  part 
nf  the  coRStriclion,  the  pntient  is  lied  up  tut  for  lithotomy,  and 
the  Surgeon,  .sealing  him»olfiu  front,  pushes  the  scalpel,  with 
the  back  of  the  hinde  downwards,  into  the  nie«ial  tine  of  the 
perineum  a  little  alwive  the  rectum,  and  cut«  upwards  for  ao 
Fij[.  1I3S.—         '"ch  or  more  into  the  raphe.  The  dissection  is  carried  on  verr 
6b«yiil«re<l  Suff    carefully  exaotly  in  the  mcdiun  line  until  the  staff* ie  reached, 
Ar  P*rinoft[ Sm-     when  the  knifi*  must  Jje  entered  into  its  groove  6«Atn</  the 
tlon.  stricture,  and  (.-iirriud  forwards  through  this.     The  staff,  bar- 

ing been  pushed  ud  to  ascertain  that  all  is  free,  must  be  with- 
drawn, and  a  No.  9  catheter  intn>duccd,  which  ts  to  be  kepi  in  for  forty- 
eight  boure;  it  must  then  be  taken  out,  and  at  the  end  nf  eight  or  ten  days 
the  oretbra  mu^l  be  dilated  by  the  introduction  every  second  day  of  a  full- 
eizod  silver  catheter.  Urine  escapes  for  some  little  time  by  the  perineal 
incision  ;  but,  as  tlits  heale  by  gnuiulaiion,the  How  of  fluid  gradaally  leseeiw 
and  at  lasc  ceases  entirely. 

The  principal  points  to  be  attended  to  in  this  oneralion  are — 

1.  To  (tec  tnat  the  staff  is  fairly  thn>ugh  the  stricture,  and  to  be  especially 
careful  in  determining  this  if  false  passages  exist. 

2.  To  cut  cartfully  in  the  median  line;  where,  as  Syrac  has  observed,  a 
kind  of  septum  exists  even  in  Ihe  deeper  atniirturcs  of  the  perlTieum.  and 
where  there  can  he  no  danger  whatever  of  dividing  any  artery  of  magnitude, 
which  might  happen  if  any  lateral  deviation  of  the  knife  took  place.  The 
only  vessiel,  indeed,  which  is  at  all  endangered,  is  the  artery  of  the  bulb; 
anff  thiH  will  of  course  lie  avoided  by  rai-efiilly  keeping  in  the  raphe. 

ft.  To  enter  the  point  of  the  knife  behind  the  stricture,  and  to  divide  that 
by  cutting  forwards  in  the  groove  of  the  staff. 

4.  Much  difficulty  has  occasionally  arisen  in  the  introduction  of  the 
catheter  into  the  bladder  afVer  the  division  of  the  stricture.  This  may  be 
avoided  by  passing  a  broad  director,  with  the  groove  turned  up.  int<i  ihs 
posterior  part  of  the  urethra  after  the  stricture  has  been  cut,  but  before  th« 
staff  is  withdrawn.  As  the  catheter  is  passed  down  the  canal,  iu  point  will 
infallibly  be  guided  by  this  onwards  into  the  bladder. 

Where  there  are  niure  strictures  than  une,  the  division  of  the  deepest  is 
usually  alone  necessary  ;  the  utbers  may  Iw  dilati-Hl. 

li«e>tll. — The  r««ult  of  the  |>erim-al  eectiun,  s/)  far  as  Ihe  life  of  the  patient 
is  concerue<l,  is  nsuallv  sniisfect^try ;  yet  cases  bavenotunfreuui'Otly  occurred 
in  which  a  fatal  Icnninaiiou  has  been  the  oonseiiueuce,  and  there  b  every 


I 
I 


IMPKRMKABLE    STRICTURE.  1067 

btitoiiry,  will  be  fouod  the  ooly  reitlly  advantageous  treatment.  It  is  prac- 
licftlly  free  from  dauger,  as  riguri*  anil  other  cimstittitional  disturbance, 
icarcelv  ever  follow  o|>crations  on  the  anterior  extremity  of  the  urethra. 

InperiDeable  Stricture. — In  onlcr  to  perform  the  {wrinfal  section,  the 
itricture  muf>t  be  pervious  to  a  gnmved  staff,  however  smnll  this  may  be; 
ind  this,  it  might  be  supposed,  would  limit  materially  the  cases  in  which  the 
spention  can  be  performed.  But  complete  obliteration  of  the  urethra 
mnnot  take  place  except  as  the  result  ot  slouching,  usually  from  injury ; 
indeed,  "impermcnhle"  stricturea,  though  frequently  B])olfen  of,  are  very 
rarely  met  with,  t^yme,  indeed,  denie<l  their  cxistcuw,  and  staled  that,  if 
urine  can  escape  thron^'h  a  stricture,  a  bougie  can  bo  intmduced.  A  Sui^eoo 
tOMj  ot^n  be  foiled  in  his  finit  attempts  in  pasfing  an  inatrurnout  through  a 
very  tight  stricture.  But  I  believe  that,  with  patience,  by  attention  to  cod- 
■titutinnai  treatment,  bo  as  to  lessen  urethral  irritation,  and  especially  by  the 
Administration  of  chloroform,  he  will  usually  at  last  succeed  iu  making  an  ia- 
■InimeDtufBome  kind  pass  through  the  very  worst  strictures.  In  the  first  cage 
in  which  I  perfortiietl  the  perineal  section,  alnioi-t  all  the  urine  had  for  twelve 
yean  been  dischargeil  through  tistiilous  o[)eniugs  in  the  perineum  and  scrotum ; 
and  the  priucipat  portion  esca[>ed  tbniugh  a  large  hole  on  the  innide  of  the 
left  thigh,  only  a  few  dn>[)3  occasionally  passing  out  by  the  li|»  of  the  urethra. 
No  instrument  had  been  passed  for  four  years,  though  repeated  attempts  had 
been  made  by  different  Surgeons,  Being  foiled  in  intrmlucing  a  catheter  into 
the  bladder  the  first  time  I  tried,  I  kept  the  |>atient  in  the  Hospital  for  two  or 
three  weeks,  attending  earefulty  to  his  constituti'inal  con<Ution,  but  without 
making  any  further  effort.  He  was  then  placed  under  chloroform,  when  I 
■neceeded  in  parsing  No.  1.  The  urethra  was  then  dil»te<l  up  to  No.  5, 
b^ond  which  no  instrument  could  be  passed,  when  the  perineal  section  was 
perfiirmeit.  The  patient  made  an  excellent  recovery,  the  fistulous  openings 
dosing,  and  the  urine  being  discharged  by  the  natural  channel,  In  another 
ease,  persevering  attempts  liad  been  made  for  five  years  to  make  an  instru- 
ment  enter  the  bladder,  but  without  success,  the  stricture  not  only  l>eing 
excessively  tight,  but  the  urethra  acutely  scni^itive;  under  chlon>form,  I 
succeeded  in  introducing  No.  i  silver  catheter  into  the  bladder,  and  ^i>cedily 
cured  the  patient. 

The  inllueuce  of  Anto'thi'tics  in  facilitating  the  pa^^ige  of  instruments 
through  apparently  imiiermeable  tttrictures  is  very  marked.  Sliortty  after 
tbe  Intrixluvtion  of  ether  as  an  au:ei«thetic  agent,  Listnn  wu<j  ^oing  to  cut 
through  a  stricture  that  bad  resisted  all  attempt.*!  luiide  hy  hi:j  moxt  dexterous 
hand  at  introducing  an  iustrMmcnt  into  the  bladder;  but  no  sooner  was  tbe 
patient  put  on  the  table  and  rendered  iiisen^^lble,  than  the  Xo.  S  silver 
catheter,  which  had  hcen  pai'SKjd  dnwn  as  far  a?  the  stricture,  and  the  |>oint 
of  which  was  to  serve  as  a  guide  to  the  knife,  8lip|)ed  into  the  hhiddcr,  and 
thus  rendered  a  dangerous  ojieratinn  unnecessary. 

Yet  no  Surgeon  can  doubt  that  casf?  do  occusiunally.  though  rarely,  occur, 
in  which,  in  conseijueiice  of  extrnvniialiiin  of  urine  and  old  inflammatory 
action,  the  urethra  iisw  become  .-<>  tortunus  and  narrow,  anrj  the  |wrineum  so 
thiekene<l  and  indurated,  that  iiii  instrumi'iit  ramiot  be  pas.fed  ihr-iugli.  even 
though  the  urine  pa^  out  readily.  It  must  Ih'  home  in  mind  that  a  stricture 
may  ne  |>ermeable  to  urine,  but  iuipenucable  to  a  catheter,  even  in  (he  most 
dexterous  hands.  It  does  not  follow  necessarily  tluit,  lH>caus4'  a  finid  will 
trickle  out  of  a  narrow  and  tortuous  channel,  a  catheter  or  solid  nound  can 
be  passed  into  it  from  withnut.  In  a  case  <>t'  extravasatinn  of  urine  f'dlow- 
ing  stricture,  coiisei]Ucnt  on  injury  nf  the  [H-rineuni.  under  my  care  at  the 
hospital,  in  which  no  <'atheter  had  been  introduced  for  ei;:lit  years,  it  was 
ibond  after  death  that,  although  the  urethra  had  been  converted  into  a  mass 


10(>6 


DISEASES    OF    THE    URETUBA. 


wbeuever  an  in^lrumcnt  is  passed,  that  ht>  cnnnot  beiir  tlitt  rcppntcfl  mtmduiv 
tiun^  llml  are  nece^stry,  more  [fnrltt'uliirlv  if  the  atriclure  l>e  i-<jm|tltcutvd 
with  (i^Uilie  in  pcriniQi  or  fa\^  |iiL^a^(.-«>,  wliich  render  iu  cun  by  dtlatalioa 
tulious  nml  iilnnut  impracticable.  In  suub  caacs  ue  these  the  8iirge<)ii,  lH.'iii.^ 
unable  to  beneJit  h\a  patient  muterinlljr  bj*  dilutation,  must  cbooee  betwiieD 
the  eniplufment  <>f  pnllifttire  means  or  more  nclivc  incosnrea. 

It  a|>pear9  tu  mc  that  tbert  are  four  claaacfl  of  cab«,  in  vhich  more 
energetic  racaos  tbnn  simple  dilatation  may  not  only  be  advanUigeoiialy 
empluyed,  but  are  aljsuluteiv  require*). 

1.  Very  oU  detuc  cariUagiatm*  Mriciuren,  often  of  traumatic  origin,  whiob 
admit  aa  iuHtrumeut  with  great  dilBculty,  and  cannot  b«  dilated  l»cyond  a 
certain  point,  owing  to  tlie  cmveraiun  of  the  urethral  structures  into 
n  kind  uf  dunte,  fibroun,  iilmiwL  cicatricial  tiMue.  which  neither  admiu  of 
expaoiioa  nor  of  abftorptlon  by  the  preaaure  of  inslrumcnui ;  and  in  which  a 
considerable  extent — half  an  inch  or  more — 'of  ihe  urethra  in  involved. 

2.  The  same  kind  of  htricture,  complicated  \\\t\\  Ji*lultx  in  the  perineum  or 
BOrotuni,  with  pertiaps  considerable  plastic  intiltmtiou  of  tb«se  parts.  In 
both  these  cliteses,  1  think  that  the  perineal  section  or  external  nrelbroforoy 
U  the  preferable  operation. 

3.  Very  tight  tl'ifturei.  accompanied  \>y  ex^enive  ttnaUivenettof  \\w  urethra; 
in  which  each  introduction  of  the  iustrunieut  is  attended  by  inlcns«  sutTering 
and  rigors,  eo  that  the  patient  cannot  be  induced  to  submit  to  a  proper 
ooutse  of  boueies. 

4.  Very  etattie,  though  perlmps  Tiarrow  gtrictttret,  that  can  be  dilatwJ 
nodily  enough,  even  up  tu  the  ndmisaiou  of  full  sited  instruments;  but 
which,  when  the  treatment  is  discontinued,  immediately  began  to  oonlrmct 
again,  so  thai  the  patient  is  never  out  of  the  Surgeon's  hands,  and  kcs  no 
proBpecc  of  cure. 

lu  theso  iHHt  two  (dai<M»i  of  casea,  I  am  4)f  opinion  that  internal  uretbr<:itomy 
or  tht^  forcible  expun.>iion  or  rupture  of  the  Hlricture,  is  the  best  niediod  of 
treatment;  the  perineul  i^ertion  Iwing  too  severe  and  dangerous,  whilst  simple 
dilatation  is  too  feehln  u  meaiiK  of  treutnient. 

Strictore  of  the  Urethral  Orlflca  U  usually  the  cjinsequenoo  of  destrootiaa 
of  tissue  by  a  chancre.     It  is  apt  U>  be  extremely  tight,  and  hne  a  great  teo* 


FIc.  UA.— CirUla'a  Uralbiotam*  fur  ijlriot«i*  uf  tti*  OrlRM,  naodlAad. 


I 


lig.  »3Sa.  — Anottasr  form  i>f  BUtouria  CmM*. 

dency  to  relapjie.  A  tight  stricLure  in  not  uacommuDly  met  with  also  wiihiQ 
an  iucb  of  the  orifice  as  a  consequence  of  an  iutraureihral  chouvre,  and  !«■■ 
oommimly  of  gouorrbtea. 

Theee  strictures  may  be  treated  by  ffrodual  difntation  by  means  of  short 
nail-headed  etylesof  graduated  sixes,  but  this  is  usually  tedioua  and  ineSicienC 
Divition  by  Civiale's  inslrumenl.  introduced  shut,  and  cutting  aa  it  ts  witti- 
drawn  (Fig.  ^36},  or  in  the  absence  of  thb,  by  a  commoo  probe-pointed 


IMPERMEASLS   STBICTl'RE. 


1061 


buuvurv,  will  be  found  the  ontv  really  advaalagcouti  treatment.  It  is  prac- 
lically  froe  from  danger,  nit  rigors  and  ntlier  cnnfitittitinnttl  dtnturltance, 
scar*"cl_v  ever  follow  npcmlion*  uo  the  anterior  eitremity  of  the  urethra. 

Impermeable  Striotare. — In  order  to  perfr>rni  the  perineal  M^ctiim,  iha 
Mrictnn?  must  he  pprvious  to  a  gnioved  HlafT,  however  amall  this  may  be; 
and  thia,  it  might  be  siipptMcd,  wotild  limit  mulerially  the  cii^s  in  whitdi  the 
operation  can  he  pprloritied.  Hut  complete  ohliteriition  of  the  urethra, 
cannot  take  place  except  an  the  result  of  *lounliiiijj,  u*>iiiilly  from  injury; 
indeed,  "impermeable"  strictures,  thongh  frt<nie»tly  tip(.>k«u  of.are  very 
ntrely  met  with.  8yme,  indeed,  deuie<l  their  existence,  and  stated  that,  if 
orine  can  oscam  throiit;h  a.Htr>(.'lure,  a  bougie c^iq  be  iutntdnciiHi.  A  i?urgeoa 
may  ollen  be  lolled  iu  liii*  hret  alCvnipte  in  pasi-iui;  nn  iuetrumeul  through  a 
very  light  slricture.  But  I  believe  that,  with  patience,  by  atteuliou  to  cuu- 
atitutiutinl  treatment,  eo  ae  to  leeaeu  urethral  irritation,  and  vvpeeially  by  the 
admiuistratiuu  of  ehloroform,  be  will  uaunlly  ut  In^jt  succeed  in  making  an  in- 
atrunivnt  of  some  kind  paw  Ihnmgh  the  very  wnnitetriclures.  In  tlie  fimtcuse 
in  whieh  I  performed  the  perineuE  Fucllua,  ulniuet  all  the  urine  had  for  twelve 
years  been  discharged  through  HulniousopeiUDgBin  the  perineum  and  scrotum; 
and  the  prLnin{>al  portion  enoafied  thniugh  a  Targe  hole  on  the  inoide  of  the 
left  thigh,  only  Hle«  dropt;  occasionally  |)afislngoutby  the  li|iKorthe  urethra. 
No  instrument  had  Itcen  passed  for  lour  years,  though  repeated  atleinpts  had 
been  made  liy  diflerent  Surgeons.  Being  foiled  in  iDtrodncing  a  ralheler  into 
the  bindiler  the  6r?l  lime  I  tried,  I  kept  the  patient  in  tlie  Hospital  for  two  ur 
three  weeli!<,  attending  carefully  to  his  couatiliitional  ct>ndilion.  hut  without 
making  any  further  effort.  He  was  then  placed  under  chloroform,  when  I 
succeeded  lu  pacing  No.  1.  The  urethra  wh8  then  dilate^t  up  to  No.  5, 
beyond  which  no  Instrument  could  be  passed,  when  the  perineal  section  was 
performed.  The  jwiticnt  made  an  excellent  recovery,  the  tiatulouh  opening* 
dosing,  and  the  urine  being  discharged  bvthe  natural  channel.  In  another 
case,  persevering  attempt.^  had  been  made  for  tive  yearn  to  make  an  instru- 
ment «nter  the  bladder,  but  without  Nucce»i«,  the  fltricture  not  only  lieing 
excesaively  tight,  hut  the  urethra  acutely  sensitive;  under  chloroform,  I 
succeeded  in  introducing  No.  i  iiilver  catheter  into  the  bladder,  and  speedily 
cured  the  patjpnt. 

The  iuHuence  of  AiKatthfJia*  in  facilitating  the  panage  of  inetniments 
through  apparently  inijieruieable  Htrirture!<  in  very  marked.  Shortly  afler 
the  inlriKUiclion  of  ether  n»  an  anui^thetic  agent,  Listoo  was  i;oing  to  cut 
thrr>ugb  a  stricture  that  had  rewisted  all  attemptH  made  by  his  nioHt  dexterous 
hand  at  introducing  an  iuBtmnicnl  iulo  the  bladder;  but  no  sooner  wus  the 
patient  put  on  the  table  and  rendered  iuseasible,  than  the  No.  y  silver 
catheter,  uhicb  had  beeu  pu£^ed  down  as  far  as  the  stricture,  and  the  point 
of  which  was  to  serve  as  a  guide  to  the  knife.  8lip[>cd  into  the  bladder,  and 
thus  rcndorod  a  claugcroue  operation  uunect-giuiry. 

Yet  no  Surgeon  ean  doubt  that  canes  do  oecusionally,  though  rarely,  occur, 
iu  which,  in  consetjucnce  uf  extravamtiun  of  urine  and  old  inflammatory 
aulion.  the  urethra  baa  bccorni'  ao  tortuous  and  narrow,  uml  the  jicrineum  bo 
thickened  ackd  imiuruted,  that  un  in^^trumeiit  cannot  be  pui>a;d  through,  even 
though  the  urine  \>aai  out  n-H<lily.  Il  iiiut<t  bo  borne  in  niinti  that  a  stricture 
may  be  )iermeabb-  to  urine,  but  tm|H.>rmeahle  to  a  catheter,  even  in  the  most 
dexleroufl  hand?.  It  doett  not  follnw  ner-t^sHarily  that,  becuuHe  a  fluiil  will 
trickle  out  of  a  imrrnw  ami  Inrtuoiiii  channel,  a  catheter  or  Holid  sound  can 
be  pawc^d  into  it  from  withuiit.  In  a  c^me  of  extravaitalion  of  urine  follow- 
ing stricture,  ron-'^eipient  on  injury  nf  the  perineum,  under  my  care  at  the 
hoepital,  in  which  no  catheter  had  been  inlrndnred  for  eight  years,  it  waa 
found  aher  death  that,  nltbough  the  urethra  hod  been  converted  intoa  moM 


1008 


TBS    L'BBTURA. 


of  ciratririal  tis^iiA  at  the  pftrt  injured,  it  was  yet  p^riieatftd  br  a  nanrnv, 
tnrtuouit  passage,  throu};)i  wlitrl)  tlie  urine  had  escatM>«l. 

Hence,  cases  will  occftsinnally  occur,  in  which  th*^  perineal  section  w  not 
prtcticahle.  In  the  evcnl,  therefore,  of  a  stricture  beiu}:;  m  tishl  and  toriu- 
oiie  that  DO  innrumeiil  will  pa«s  tliruugh  il,  or  where,  a  |Mirtion  of  lb« 
urethra  having  ttluughetl  uwuy,  %l»  cuual  U  ublilemted.  neitlier  the  cure  l>y 
dilatation  uur  iirethrotwmy  cau  bo  perfynued,  auti  it  mar  then  l>e  u^ceat&ry 
tti  b»ve  w'course  tti  iuci^inu  of  Ibu  vtricluru  without  a  )!uiilt<. 

Operatiooa  for  Impermeable  Stricture. — In  upvraiing  for  the  relief  of 
ini]>vrtutL-abi(;  Hlriclurv  viirioiiB  ineaiiH  have  bwu  uJupled.  lh&  chief  of  which 
art*:  1,  up«:t]iug  ibe  urethra  bt^hitiil  the  atrioture;  2,  oyivuiag  the  ur»'thra 
buhind  tlie  etrieture  uud  CDttiii^  fi>rwardti  tbmugb  the  ooustriciiou  ;  8,  npen- 
iug  lb«  urctbra  in  fn>nt  and  dividing  the  Ktricture  from  belore  t)iickwardB. 

1.  OpeoiDg  the  Urethra  behind  the  Strietore,  or,  as  it  in  uttcn  called  in 
thin  country,  Cwb'B  operation,  is  thus  ji«rli>rmed  :  The  paliuut  having  bfen 
prepared  as  for  tilbntoiur,  the  operator  intruducc^  bi^  left  lurt-tingt-r  into  the 
rectum.  Hn  then  takes  a  broad,  ehnrp-pointed  knife,  wbicli  ('iwk  advised 
abould  be  double-edged,  and  pnsees  it  towards  the  ajiex  of  the  proetate. 
guiding  its  cuitrge  by  the  finger  iu  the  rectum.  The  knife  musl  be  poaaedat 
one  thrust  to  the  npex  of  the  prustate,  and  great  care  muet  lie  taken  that  it 
keep^  accurately  to  the  middle  lino.  The  externul  wound  is  then  eolarge^ 
aomewhnt  by  moving  the  knife  up  and  down,  till  the  lower  angle  reaohea  to 
about  half  an  inch  {nun  the  anu^.  The  knife  i^  then  withdrawn  aiul  a  large 
pro  be- pointed  director  with  u  handle  is  pu^ed  through  the  praatutic  uiethra 
from  the  wound,  and  along  this  a  female  cutheter.  or  on  in;<Lrument  nf  thai 
shape  fitted  with  ring:*  by  which  it  enn  be  securely  tied  in.  \»  guide^I  into  tbe 
bladder.  The  es;»eutial  puinta  of  tbe  operation  arc  to  keep  accurately  t<}  the 
middle  line  and  t^j  open  tho  urethra  an  it  emerges  from  the  proataCe  gland. 
Should  the  prostate  itself  l>e  notched,  no  bnrm  will  re«ull.  The  inatruineat 
having  been  passerl  a«  above  dvscriberl,  im  tied  in  and  retained  for  some  dora 
or  weekit,  as  may  lie  required.  In  a  verv  tiirge  proportion  of  caaea,  afltr  tM 
irritation  of  the  paMwge  of  uritie  through  tlie  narrow  stricture  baa  been  n- 
moved,  a  certain  degree  of  relaxation  will  take  place,  and  a  few  days  aitw 
tbe  operation  it  frequeiHly  bapijeni*  that  a  catheter  will  poaa  through  the 
atricltire  which  was  formerly  "  impermeable."  If  thi«  does  not  take  place, 
an  effort  may  i^ul>«equeutly  be  made  by  some  further  operwlive  prooeilurs  to 
o^ien  up  a  way  iu  the  natural  line  of  the  urethra;  and,  should  this  fail,  the 
patient  may  pa»*  bia  urine  permatienlly  thn>ugh  tbe  fwtulouR  opening  in  the 
perineum.  This  can  he  kept  readily  open  by  tbe  occatiional  psssage  of  a 
noxiblo  bougie,  wbich  must  Lx:  left  iu  «itu  for  a  few  houra.  C>ck  recorda 
cases  in  which  tbe  patient  pui^aed  his  water  in  this  way  for  tweatv  years  or 
more.  The  opening  lu-iug  well  in  Inrnt  of  the  prostate,  tbe  control  over  the 
ttcapc  of  urine  ia  perfect,  and  tbe  patient'u  mode  of  micturitiuu  ia  oesimiluted 
to  that  of  the  other  sex. 

This  operation  in  best  adapteil  to  thrive  <3ises  in  which  the  patient  ie  saflW- 
ing  from  actual  retentirm  at  the  time  the  Surgeon  ia  called  upon  to  opcratd 
The  objection  to  it  \?  that  it  di^ea  nothing  to  relieve  the  stricture,  unleee  thii 
should  happen  In  yield  aller  the  irritation  of  the  patuuge  of  urine  ta  cut  otT. 

'2.  Opemng  the'Urethra  behind  the  Stricture  and  catting  forwards.— 
This  operation  mav  he  r^'^^irded  na  an  extension  of  the  preceding  method. 
It  is  thuBp<irfnrme<l:  A  N'o.  8  silver  catheter  is  paaami  down  to  the  atricrare; 
the  patient  is  then  tied  un  as  if  for  lithotomy;  and  the  Surgeon,  sitting  in 
front,  pUHhejt  a  bistoury  with  the  hack  inrned  towards  the  rectum  into  the 
raphe  of  the  perinrum  »■<  far  as  the  apex  of  the  prostate,  so  as.  if  piosthle,  to 
open  the  dilated  urethra  beliind  the  slriotnre.    He  then  cut8/(n'war(i«  through 


I 

i 


I 


OPBRATIONS    FOR    IHPBBUEABLK   3TBI0TDR£. 


10«9 


tbe  alrieCure  ou  to  the  point  of  the  catheter,  und,  liaviog  thus  o{)eu<'<l  a  |>ns- 
acp,  cnficsTure  to  poBg  that  iti^trument  on  into  the  biflddcr.  Tbu  upprntion, 
I  mT«  Du  he«itBtiou  in  avitis.  U  one  of  the  mmit  troubtnomc  in  t-nrgciy, 
I  baT«  more  thau  oaeii  iwcn  th«  mMt  akilful  operaUtni  foiled  in  their  en- 
dcarore  to  acroroplinh  it,  and  cotnpelkd  to  rvlinquish  tbs  operation  viihout 
cuncludiog  it.  or  i>U(!ce«l  only  after  protoneed  and  mnst  painful  attennta. 
The  difficulty  conaista  in  fitid'ing  the  t>o«itenor  part  of  tbe  urethra.  When 
the  ti«ue«  of  tbe  perineum  are  hard  and  ^rintly  from  repeated  attacka  of 
intliimmation  and  the  pretence  of  fUtuliv,  it  is  a  mnit  ditticiilt  matter  to 
t  through  Mich  an  altcr«Kl  maas  snd  hit  the  urethra  heynnd  it,  and  the 
illy  in  stilt  further  inrreaaed  by  the  bleedin)^,  which  is  tiilen  very  pro- 
luw.  Vioreover,  should  the  Surt^n  tind  the  p(Mteri>»r  )»irt  *<f  the  urellini, 
and  cut  f'trwarda  fr«m  it  to  tlie  catheter  in  ihe  urethra,  the  chame*  nre  that 
hb  iiu'ifion  will  not  follow  the  line  of  the  urethni.  and  the  tiMuUmti  track  h« 
Citablithef  between  the  |iart  nf  the  urethra  in  front  of  the  stricture  and  that 
btbind  it  wilt  almost  to  a  certainty  contract,  as  tbe  wound  heale,  tu  suvb  aa 
eJtteot  a»  to  leave  the  patient  little  better  for  tbe  oji^ralion. 

',i.  Opening'  the  Urethra  in  Front  of  the  Strictare  and  dividing  from 
Mer«  backwards. — This  ifptratiuu,  Lliough  difUcult  of  perfuruiance  iu  »tme 
caaaa,  gita  better  retulta  tuao  any  olbcr.  Wbeclbuuse  has  lately  inveiitvd 
iafue  ingcniuuB  inatnimeuts  which  gnrntly  facilitate  it«  j>erforuiancu. 

The  opvralion  is  tbuf  [M--rri)ritK>d.  The  patieut  having  been  et-eurtd  in  the 
Ulbut«iiuT  iKN^itiou,  Wheclhouse'a  stair  if  |iai«t'd  down  to  the  Htricturv.  The 
eod  nf  LhiK  is  idvout  the  aize  of  a  No.  K  raihfler ;  on  one  side  it  is  flattened 
■od  grooved,  and  on  the  other  it  forma  a  Knialt  blunt  himk,  with  which  tbe 
■pper  end  of  the  "  bittujn-hole  '*  inci-iion  in  the  urethra  may  be  drawn  up* 
wiraa.  The  staff  being  psned  and  held  with  the  grooved  i«idr  forwards,  tbe 
8ar|{eoD  cats  dawn  upon  it  by  an  incision  aliout  li  inch  lung  in  tbe  median 
Itne  and  opens  tbe  nrethm  just  above  tbe  stricture.  The  staH'  is  now  pushed 
oat  at  the  wound  and  turned  round,  so  that  the  small  book  ia  forwards ;  it  ia 
Uico  drawn  upwards  so  tu  to  catch  in  the  upper  angle  of  tbe  opening,  tod  in 
this  way  the  urethra  is  put  on  (he  stretch  and  steadied.  If  the  special  etaff 
be  not  at  hand,  the  end  of  a  catheter  can  be  cut  down  on  with  aInxDtt  e<]iiat 
•lae.  T)ic  eiljj^es  of  the  slit  in  tbe  urethra  are  then  seieed  in  arlery-forcei>s 
•od  held  ajnrt  ao  tut  to  expoae  tbe  interior  of  tbe  c«nal,  which  can  be  readily 
recogoiwU  by  its  smooth  shining  surface.  It  will  often  be  found  to  be  cou- 
%-euieat  to  pass  a  silk  suture  through  each  side  by  which  the  edges  may  be 
held  apart,  aa  tbe  furoepo  are  rather  apt  to  get  in  tbe  way.  Ooxing  having 
been  allowed  to  ceaae,  the  atwrtuni  leading  tu  tbe  stricture  will  usually  be 
found  without  very  great  dimcully.  The  chief  trouble  in  many  oases  arisn 
from  thecuiu'tant  trickling  of  blotxl  from  the  upper  part  of  the  wound.  Tbia 
may  be  ivrrnied  by  plugging  it  with  a  small  iit>onge.  or  by  the  applicHtiou  oi 
water.at  atcnperstureurabout  MO'^  F.,  which  is  usually  mureeoiL'ient  than 
lee.  Another  difBculty  may  arbe  froui  Uie  urethra  having  been  opened  too 
flur  nbove  the  atrirture,  umler  whiob  drcuiustanoes  tbe  IncaiiDa  must  be  pni- 
kamd  downwanls.  If  a  false  passage  have  been  opened  instead  of  the 
uTTUini.  it  is  rccognir^d  by  the  ahwDce  of  (he  snootb  pink  mncotia  mem* 
brnoe.  Tho  oriHc*'  of  ihr  stricture  must  be  sought  for  with  a  fine  prolw. 
WbeelbiMJse  uses  a  small  [irobc-puintitl  rliredor.  In  some  cxsea  the  ttmall 
director  uscfl  in  sitling  up  the  canaliculus  will  be  fouad  to  pus  when  other 
tnatrumefits  have  fisiled.  In  seeking  the  true  orifice  of  the  stricture  every 
itoweaaion  must  bo  careAilly  exploreit  without  force.  Prrasuro  above  toe 
pahfn  will  often  cause  a  slight  mcnpe  of  urine  by  which  the  proper  ori6iA 
may  be  m-i>gniwd.  When  the  o]H'»iiig  is  found  and  the  [mibe  paMed,  the 
•tncturemust  l>e  divided  aloiigit  with  a  fine  knife  i>r  tenotome.     Wbedhuttse 


1070 


DISEASES   OF   THB    URSTQRA. 


then  (lOfwe  a  small  eorgei  thmugli  lii«  tttricture  ami  along  tliia  a  full- 
cHlheier  can  be  eaeuj  guiik'tl  iulo  the  hlaildcr.  It  niufiL  Itu  lied  in  iDil 
reuiine<l  for  a  few  *lay3.  The  wound  iimy  lie  wijiwl  out  wilh  a  HWoiig  solu- 
tion of  chloride  of  zinc  ami  aftctrwanis  apnnkled  witli  iiKltforni  auil  fillt>cl 
with  iofioforni'Wnol,  which  iiiny  be  led  UDilUlurbeil  till  the  third  day  when 
healthy  grRnulalion  nil)  usimlly  be  found  to  have  commenced.  ThU  o|>en<  ^ 
tion  rci^iuirei!  care  and  putifiice,  but  it  is  easier  and  safer  than  unv  other,  ^M 
General  S«flolts  of  the  Treatment  of  Strictare. — Whether  it  u  or  ts  tiot^ 
possible  periiianenlly  to  cure  a  stricture,  \a  a  question  which  hu  been  much 
debated.  The  a^Ivocntes  of  the  various  modes  of  treatment,  whether  forciblfl 
dilatation,  iuteriial  uretlirotomy,  external  nret  hrutomy,  or  caustics,  have  oAen 
atourted  that  by  the  means  they  adopt  a  alrictnre  can  be  really  cured,  b.i  that 
the  patient  U  rid  of  his  disease  forever,  and  need  toar  no  return.  The  gcD- 
eral  opioiuu,  however,  of  those  who  have  atudit-d  ihi-*  <)ueslioD  carefully,  is 
that  although  a  patient  can  be  put  into  a  [MMiiiiiu  in  which  his  stricturt:  ueed 
never  be  a  source  of  danger  tu  him  if  he  tjccBsioually  paaaea  an  instrument, 
be  ciinnot  be  really  cured — that  ia  to  say,  by  no  ii]«ai»  of  treatment  can  a 
Btrictured  urethra  be  restoreil  tu  its  normal  condition.  Kvery  patient,  there- 
fore, Tvbo  has  once  Hulfered  from  a  definite  organic  stricture,  should  continue 
fur  the  rest  of  his  life  to  pass  a  full-»ized  inatruinvnt  not  I«ai  than  once  a 
month;  otherwise,  gradual  contraction  ia  almost  certain  to  take  place,  and 
the  whole  treatmeut  will  have  to  be  commenced  again. 


\ 


COMPLICATIONS  AIff>  RESULTS  OP  HTRICTUnK. 

Ketr^ttion  01'  UittNR  baa  already  bcon  several  times  dacribcd  ma  arisiDK 
from  ditfurenl  causes.  ThuH,  iu  boyi^.  it  arista  from  the  impaction  of  a  ca^ 
cultM  in  the  urethra;  in  girt.t  it  in  uaually  hy-^u^rical ;  in  old  men  it  is  nlmott 
invariably  the  conseqiictuM!  of  atony  of  the  bladder  or  enlarged  proatale, 
alone  or  combinert.  In  thfwe  of  middle  Rge,  stricture  of  the  urethn  is  Um 
occasioning  cause  in  the  vafft  majority  of  ca^en.  Retention  of  urine  iua  a 
tendency  to  occur  in  all  tight  strictures  from  the  gradual  and  prof^reanve 
contraction  of  the  canal.  It  most  u.'«ually,  however,  takeg  plac-o  in  coosfr- 
qucQce  of  a  congestive  spasmodic  condition  betug  superadded  to  the  organic 
constriction.  It  commonly  happens  that  a  patient  having  a  moderately  tight 
organic  stricture  commits  nn  excess,  or  bceomee  exposed  to  4y)ld  and  wet,  and 
thai  gets  such  a  congested  condition  FUperadded.  that  the  urine  will  not  paa 
at  nil,  or  only  in  such  small  quantity  by  drops,  and  with  so  much  pain  and 
elraiuiitg,  that  th«-  bladder  c-aunut  be  cumplet«ly  emptied.  In  thcM  cwe* 
the  retention  always  eveutually  becomes  complete;  the  bladder  speedily 
&llB,and  rises  abov6  the  puU-^;  lliere  in  much  di«tre«s  and  oonatttutional  dis- 
turbance; and,  if  relief  be  not  Htforded,  the  distended  |K>rtion  of  the  urethra 
behiud  thfii  stricture  will  ultimately  give  way,  aud  extravasation  uf  urisv 
en»ue.  In  these  circnii)i>tHricv«  it  becoroen  imperatively  oeoMnry  to  empty 
tbe  patieat'tt  bladder  »<*  s|H>edily  as  possible. 

lrfaii>\enl. — This  variee  with  the  severity  of  the  symptonu  and  irritabilitv 
of  tbe  [Nitieiit.  If  the  retention  have  not  continued  very  long,  and  if  the 
patient  be  not  very  irritable,  an  endeavor  might  be  made  at  once  to  gire 
relief  by  parting  a  small  catheter  into  the  bladder.  In  this  tbe  Surgeon 
may  oileu  succeed  more  readily  than  might  have  been  expected,  the  stncture 
frequeutly  yielding  liefore  an  instrument  more  easily  when  there  is  retcntiun, 
than  when  this  coudilion  does  not  exist.  Even  if  the  catheter  do  not  cnlur 
the  bla<lder,  its  point  or  that  of  a  aitgut  bougie  merely  being  inlroduccd  well 
into  the  Rtricture,  it  will  generally  luippeu,  us  Brixlic  has  pointed  nut,  thai. 
on  the  withdrawal  of  the  instrument,  the  urine  will  follow  in  a  Aill  atreani; 


1 


I 


TRSATMENT    OF    KKTEh'TION    OF    I'RINE.  1071 

but  if  a  sufficiently  siiiall  catheter  be  ufed  (_ia  many  caees  not  larger  than 
half  of  No.  1  is  adniii»ible),  the  instrument  may  iieually  be  made  lairly  to 
enter  the  bladder.  If  the  iiatient  Iw  very  irritable,  it  is  l)etter,  before  attempt- 
ing the  introduction  of  the  instrument,  to  give  him  an  opiate  ent-ma  ol  a 
dnwhm  of  laudanum  in  about  two  ounces  of  starch,  and  to  put  him  into  a 
warm  bip-batb;  the  introduction  of  the  catheter  may  now  be  attempted, 
and  will  generally  succeed.  Should  it  Rtill  fail,  the  effect  of  an  ana-etnetic 
•hould  be  tried,  when  it  almost  invarial^y  may  be  made  to  pass  without  the 
employment  of  any  great  or  dangerous  degree  of  force.  There  are  no  eases  in 
sui^ry  in  which  aniesthesia  is  of  more  value  than  in  these;  under  its  in- 
fluence  it  is  seldom,  iudeed,  that  the  catheter  will  nut  para.  After  the  instni- 
meot  has  been  passed  into  the  bladder  it  should  be  lelt there,  beingtied  in  by 
means  of  tapes  passing  from  its  riugs  under  the  patient's  thighs,  to  a  band- 
age that  is  passed  round  his  waist.  A  free  purge  may  be  administered  on 
the  following  day,  and  the  jMitient  should  be  confined  to  bed.  The  catheter 
will  be  found  to  be  loosened  at  the  end  of  forty-eight  hours,  when  it  should 
be  withdrawn,  and  the  cure  by  dilatation  proceeded  with  in  the  usual  way. 

There  are  two  conditions  which  in  retention  of  urine  may  eventually  call 
ibr  operative  interference.  The  first  is  the  necessity  for  very  frequent  in- 
troduction of  the  catheter,  owing  to  an  irritable  state  of  the  bladder.  In 
these  cases,  it  may  eventually  be  thought  safer  to  puncture  the  bladder  and 
to  establish  a  direct  opening,  either  through  the  rectum  or  above  the  pubes, 
rather  than  subject  the  patient  to  the  constant  terror  of  repeateil  catheter- 
ism,  which  will  end  by  exhausting  him.  Every  act  of  catheterism  inflicts  a 
certain  shock  to  the  system,  greater  in  some,  less  in  others;  and  if  this  have 
to  be  repeated  every  three  or  four  hours,  lew  danger  will  probably  result 
ftom  puncture  of  the  bladder  than  from  the  frequent  use  of  the  instrument. 
In  these  cases  the  patient  cannot  allow  it  U>  be  tie<l  in  for  the  same  reason, 
that  of  extreme  irritability,  that  necessitates  its  repeated  introduction. 

The  second  condition  that  calls  for  ojieration  is  a  difTerrnt  one,  viz.,  the 
necessity  of  relieving  retention  of  urine.  For  if  the  Surgeon  be  unable  to 
introduce  a  catheter  in  the  ordinary  way  through  the  stricture,  relief  must 
be  given  to  the  over- distended  bhiilder  in  some  other  wav,  lest  it  or  the 
urethra  burst,  and  eztravusation  of  urine  occur.  The  bladder  may  be 
emptied  in  five  ways :  1,  by  Forcible  Catheterism  ;  2,  by  malciag  an  Open- 
ing  into  the  Urethra  behind  and  through  the  Stricture;  ^,  by  Puncturing 
the  Viscus  itself  through  the  Kectum  ;  4,  by  Puncturing  it  above  the  Pubes; 
and,  5,  by  Asinnitioii. 

1.  Forcible  Catheterism  h  a  most  un^'urgicsd  and  dangerous  procedure. 
Iiothing  can  surely  be  more  impn)per  than  to  take  a  xniall,  stiff,  silver  cath- 
ter,  pass  it  down  to  the  stricture,  and  then,  by  muin  force,  attempt  to  drive 
it  on  into  the  bladder.  In  the«e  ca^tei*  the  Surgeon  usually  falls  in  his 
attempt  at  reaching  the  vi:<cu!i,  but  pu.-'hos  the  )>oint  of  the  instrument  into 
the  tiHSUcs  amund  the  neck  of  the  bladder  or  into  the  prostate,  and  thus  in- 
duces great,  and  jierha|iscven  liital,  mischief  in  these  regions.  If  he  should, 
by  some  fortunate  accitlciit,  reach  the  bladder,  it  i^  not  by  any  skilful 
though  forcible  cxpani'i<in  of  the  Htricturo.  hut  mther  by  perforating  the 
urethra,  and  burrowing  thnni^rh  the  corpus  Hininjriosuni  am\  prostate — "  tun- 
nelling," as  it  hoK  )>oon  termed — until  he  aguiu  enter  that  canal,  or  in  some 
such  way  reach  the  neck  of  the  bladder. 

2.  Opening  the  Urethra  behind  and  through  the  Stricture. — In  the  kind 
of  retention  of  urine  that  we  are  now  discui'i'in!;,  the  safext,  though  by  no 
means  the  easiest  motle  of  attord lug  ri'lief  after  the  I'aiture  of  the  catheter,  is  to 
make  an  incifion  into  the  middle  line  of  the  |H>rini-um,  and  to  ojten  the 
urethra  behind  or  through  the  stricture.     In  many  cases  the  simple  o|iening 


1072 


SISIASKS    OP    THB    UKETHBA. 


""-'  rr,, 


of  the  distaoded  sinaa  beyond  the  stricture  will  be  found  ibm  mwA 
mode  of  trcatmeflt,  eepeciftlly  it'  the  uperatioa  hms  to  be  done  in  a  harry 
vithijulnll  the  conveuiencra  which  eiirrouod  tlip  Sargvoo  in  bnfilnl  |Q» 
ticc.  If,  brtwcver,  it  is  nraclicalilc,  it  ie  hotter  to  perform  lb*  optnliin  tea 
twfitrc  the  BLri(7Lure.  ana  thus  Ui  relieve  the  diaeasp  at  tlie  wa*  tiat  ■■  ito 
rctcDtiitn.  i^impte  puncture  of  the  dilated  pouoh  behind  LbeMrirttiai^a 
has  been  already  pointed  out,  eastor  in  caws  of  reteDtion.  M  it  b  tmaSj 
tensely  diatended  and  may  aitain  a  oooaiderablc  munitnde.  Tba  matt  «f 
perfbrmiog  thcM  operationa  have  alroadr  beoo  flufflcirally  dcnefQiad,  mi. 
10S8-1070. 

Another  advantage  of  the  periDefll  inci«ion  in  these  enaen  if,  that 
unfrequeutty  happeoa  that  urinarT  absoeu  has  begun  to  form,  or  Um 
vaaation  of  a  few  drope  of  urine  has  taken  place  Moner  than  Um 
mav  htive  had  any  idea  of;  and  if  bo,  the  lociaion  through  the  [ 
will  aH<>f<l  au  exit  for  any  extranuated  matlen,  at  the  aane  liaaa  Ifcaik 
relieve*  the  patient  from  the  diatrewi  ami  daoffer  of  the  reUBtlon.  SuiaU 
any  mischiei'  of  this  ktod  have  tak^n  place,  it  is  not  Decenary  to  beao  f»t- 
ticular  about  opening  the  urethra  with  the  knife;  [\rr,  »n  apertarv  hariM 
■Jready  been  cetabliflhed  in  it,  the  urine  will  readily  flow  through  the  a(t» 
cUl  chaunel  thus  formed  by  tree  incision  into  the  inflamed  vr  aappunuiif 
perineum. 

3.  Pasoture  of  the  Bladder  throng-h  the  Beotum. — AlVer  eaptyia|  tk 
bowel  by  muauD  of  uu  euvma,  ihu  Surgeon  paeaea  the  left  iutirx-ciogv  viU 

into  the  gut,  feeling  fur  the  pivteriur  maxpu  if 
the  proMate ;  he  then  cutmb  the  trocar  and  a*- 
ula,  which  are  Itng  and  iomawbat  curved,  apa 
this  as  a  guide,  and,  when  the  extcvnitj  af  lb 
instrument  has  reached  ths  poMerior  ed^  Mf  iIn 
{instate,  he  punhai  it  upwards  into  the  fatHUtf 
I  Fig.  !*I7].  The  Mst  uf  thi<  ]ttiDciarB  biiwi« 
hut  in  from  of  the  iireten  is  well  showxi  la  Flf. 
i^37,  which  represents  the  bladder  and  MnctwMl 
urethra  of  a  man  whn  died  aome  daya  aAir  tik 
operation  had  been  i«erformed  for 
stricture.  In  performitijic  this  operalkHi, 
geon  perforates  tlii>  htailner  in  that 
fundus  which  is  un<Hiver^  by  peril>Mir«ta, 
bounded  behind  by  the  rvtlecttfia  of  the 
Qtenibraue,  anteriorly  by  iba  pnaUte,  and  m 
eaob  aide  by  ttie  ve^iculie  N^miaaIM.  In  ordsrts 
avoid  wijuuJiu;:  luiy  nt'  cliose  structure*, 
keen  strictlr  iu  the  matial  linr,  and  pu 
mediately  behind  the  prustate.  In  tv 
tho  inbtrumuDt  into  the  reotum.  th» 
should  wilhiJniw  tbe  point  of  the  tiT«ar 
canula,  m  as  to  avoiil  wounding  tbe  gut, 
posh  it  forwards  until  he  has  tbe  end  nf  the  canula  fUed  agalnit 
where  he  intend?  to  make  the  perforation.  In  making  tJ»  puncture  theln- 
Btrumeut  tnuat  be  directed  forwards  towards  the  umbtlicua.  AfW  withdraw- 
ing the  stylet  and  emptying  the  bladder,  the  canula  should  be  lied  in  by 
means  of  tapes.  It  is  often  difficult  to  prevent  the  oanola  froMi  afimiinr  e«t 
of  the  wound  when  only  tied  in,  and  ibusespanng  the  paticBt  lo  laednffv 
of  urinary  infiltration.  It  mav  be  securely  retained  by  meaiia  of  a  iritdi  of 
silver  wire  passed  ou  either  si<^e  through  the  ^lit  in  the  gtuni  bihI  the  «m- 
tlguous  skin  of  the  nates.    The  canula  should  be  reufaied  tat  a  Aw  dav»— 


nS'  9ST 8ml  of   fonaturs 

tbnwgb    RootilM  in    n  <n(« 
•r  6tnet«r». 


POVCTURK   OP    BLADDSS    THROVeH    RECTCTK. 


1078 


ittl  urine  brgiati  to  pUB  by  ihe  urethra,  nr  until  u  cfltliPler  hu  been  iMUsed 

troagh  tho  •tricLure — when  U  must  be  witbilrawn  and  the  aperture  left  U 

Th«  irritntion  of  the  paauif^  of  the  urine  baTing  been  removed  from 

urethra,  a  catheter  may  often  be  paiKd  n  few  dayn  aAer  the  opemiion ; 

the  stricture  will  readily  yield  to  dihtlation  in  the  ordinary  way. 

Thift  operation  haa  the  advaotage  of  beiof;  far  easier  of  performance  than 

'« laal,  and  may.  doubtless,  occauonally  b**  re<|nir«<l  in  thcmt*  very  rare  omm 

'r*t«ntion  I'mru  stricture  in  which  there  id  no  sign  of  abtceaa  or  extravaja- 

In  th«  perineum,  in  which  the  urethra  appears  not  to  be  dilatetl  behind 

stricture,  ill  which   the  pro«tale  is  oot  enlarged,  ajid  in  w!ii<-':.  under 

lloruturoi,  and  with  patience,  a  catheter  cAonut  be  paaed  iiitn  the  bladder; 

kcombiuatiuu  of  circuni8tance«  that  will  but  very  rarely  indeed  occur  to  a 

Brceuo  skitltfd  iu  the  UM  of  his  iuelrumcnle. 

Ihu  opemtiou  of  puncluru  through  lUc  revluui  is  out  devoid  of  danger; 

eritouitis.  uriuary  iutlttnitioo,  and  pelvic  inliauimation  and  abeoMS,  may 

lit  from  iu 

The  rectu-VGwcal  pouch  of  the  peritoneum  will  sometimeB  dencend  eo  ab- 

rmally  low  aa  to  a>ver  the  baafoTid  of  the  bladder  aa  far  as  the  prostate, 

iving  DO  apace  for  a  puncture  to  be  safely  made.    This  condition  necee- 

rily  cannot  be  delennined  during  life,  hence  tta  great  danger.     I  have 

lown   two  inetancee   in   which  a  double  puncture  was  in  this  way  made 

}Ugh  the  fold  of  the  recto-veucal  pouch,  hall  ao  inch  beyond  an  unen* 

prcBtate,  for  relief  of  retention,     la  both  oasea,  death  from  perituuitis 

The  preparations  are  in  Unirerrity  Oollege  Museum. 

Hi  n  remarkable  cose  that  vras  under  my  care  nt  the  Floopital  (in  16&9), 

m  Aequcnce  occurred  which  I  have  nerer  seen  noticed,  vh.,  the  diffhdon  of 

^     il  tlatus  throof^  the  areolar  tinoe  of  the  pelvis  and  down  the  thighs  and 

itM,  producing  an  emphyaematous  condition  of  theae  parts  and  the  death 

of  the  patient.    The  case  was  brieSy  as  follows :  A  middle  aged  man  had 

ierod  from  traumatic  stricture  tor  very  many  years— ittdeeo,  firom  duld- 

Ue  was  admitte<]  with  retention.     As  no  catheter  ever  had  been  or 

lid  be  passed,  I  punctured  the  bludder  by  the  rectum  in  the  usual  way. 

canula  was   removed  on   the  (ilVh  day,      He   then   paiwed   urine  per 

inland  ooutiuued  to  do  so  up  to  the  time  of  his  death.     The  day  after 

withdrawal  of  the  canula  he  felt  very  ill.  but  without  any  poaittre  or 

igible  complaint.     The  next  day  it  was  found  that  the  bock  and  tuner 

irt  of  both  tbij<hii  wvre  emphysematous  and  cnu-kliug.  evidently  distended 

itfa  gaa.    The  emphysema  extended  downwards  and  also  up  the  flanlu,  and 

~  even  in  the  right  arm.    There  was  no  pain  or  diDOoloratioa.     He 

died  oa  the  following  day,  the  eighth  after  the  puncture.     After  death,  do 

iTBoe  of  (wIviL'  iaSommatioD,  suppuration,  or  urinary  extravmsattun  wag 

Jbund ;  hut  tbcru  waii  much  infillmlirm  of  gns  under  lUo  [Mrlric  peritooeani, 

and  in  the  areolar  tmue  between  the  bladder  and  rectum.     The  gas  had 

probably jMUsed  thnui^h  the  eciulic  nuttihes  into  the  posterior  puis  of  the 

tilighs.     It  waa  firtid,  like  iniestiiml  Hatui^. 

4.  Panotnre  of  the  Bladder  above  the  Pobea,  In  eases  of  retention  from 
ure,  is  but  seldom  resorted  to;  although  some  fiargeooi  of  emioeDce. 
.lly  Voget,  of  Ijeicestor,  have  utrongly  reoommeDded  and  often 
it.  This  operation,  which  bus  been  diacuasod  at  p.  1024,  is  no- 
!attble<lly  easy  of  penbrmaopc,  and  MitBcimtly  aaft,  though  not  free  ftvm 
th*^  dangvr  of  tntillration  of  urine  into  the  iksues  around  the  ponciure.  and 
of  the  ionmvrnii-nce  of  a  Gstuttm*  opi-ning  being  left.  Thr-re  i«  fmr  rlaai  of 
eaoM  to  whirh  it  sppenni  to  bo  especially  applirahir,  and  in  whirh  I  hav* 
^fcnd  oecaaiim  to  practise  it,  vii.,  those  cases  of  ri>teoiion  from  impaitsablo 
HBlriclure  in  whidi  therv  coexists  ao  eolargeotent  of  the  prostate,  rimd«riai( 
^H  n  — 4R 


10T4 


DIBKASBB   or   THB   UBBTHBAT 


puncture  thrnii^h  the  rectum  impoeiiibV,  the  Siirgeou's  finger  notbeintr  khV 
to  reach  beyond  tltc  i-nlargeJ  prosUit*;  and  here  undoubU'HIy  the  safert.  if 
not  tbe  oul)-  counse  to  purouu,  is  the  suprapubic  puucturo.  lu  some  case*  of 
impermeable  tttrtcturo,  Paget  liiis  established  a  permanent  t'lsLulous  opening 
abuTH  tbo  pubc«,  the  patient  wearing  a  tube,  through  which  he  passes  his 
water,  tiir  Ucury  Thoin|isoii  aUo  boa  adopted  a  similar  proceeding  iu  soum 
caaas  of  disease  of  the  bladder  with  ptiiulid  nnd  frequent  micturitiuo,  in 
which  eathuterism  could  nut  be  carried  out. 

Bruinurd  has  suggested  that,  ufler  tapping  above  tbe  pubes,  eepecially  if 
the  cause  of  dilhcultr  iu  passing  an  instrumeDt  haa  been  in  great  part  tbv 
presence  of  fkhie  paasages,  uu  attempt  maj  be  made  topoas  instruments  from 
the  bladder  dnwu  the  urethru. 

5.  The  Employment  of  the  Aspirator  for  the  purpose  of  emptying  as 
over-dii- tended  bladder  19,  however,  upon  the  whole  the  simplest  method  of 
treatment,  uud  should  be  preferred  to  any  of  the  preceding  plans,  in  the  &tA 
jnetance  at  all  events.  The  perforntin^  trocar  of  the  aspirator  should  be 
passed  directly  into  the  bladder  above  the  pubes.  The  operation  is  a  simple 
one,  and  with  a  Httlc  ciira  is  perfectly  aife.  The  chief  points  are  not  to 
thrust  the  needle  too  deeply,  to  direct  it  well  behind  the  nubca,  and  gently 
to  withdraw  it  before  the  whole  of  the  urine  has  eacapea,  so  as  to  prerent 
the  emptied  bladder  from  oollapMng  upon  and  being  wounded  by  its  poinl 
(see  p.  683,  vol.  ii.). 

After  the  bladder  has  been  punctured,  either  through  the  rectum  or  above 
the  pubes,  means  must  be  taken  to  restore  the  calibre  of  tbe  urethra,  to  u 
to  prevent  the  orjtice  of  the  puncture  from  dcffcnerating  into  n  permanent 
fi-;tulouB  opening.  With  this  view,  the  cnnutn  anuuld  be  Ictl  in  the  bladder, 
and  the  urine  allowed  to  discharge  through  it  for  from  four  to  six  days.  At 
the  ezpinilion  of  thii>  time,  should  no  urine  have  pR8»ed  by  the  urethra,  the 
stricture  in  the  canal  will  be  found  to  hn  relaxe<I,  and  a  small  iii-itruaient 
may  usually  without  much  difficulty  b«  introduced  into  the  bladiler,  where 
it  should  be  retained,  the  canula  being  withdrawn.  The  cure  of  the  stricture 
by  dilatation  may  then  be  proceeded  with  iu  the  usual  way. 

In  connection  with  this  subject,  it  may  b«  stated  that  Ptmeivrv  of  til* 
Bladdvr  may  be  required  for  the  following  cooditious: 

1.  Impermeable  stricture  (through  rectum). 

'Z.  Complete  rupture  of  urethra  (through  rectum). 

3.  Enlarged  prostate  (above  pubes). 

JSztravasation  of  Urine  is  uuv  of  the  most  dangerous  and  fatal  r««uttB 
unrelieved  rctcuLion.  Thih  at^^ident  may  occur  in  ooneequcuce  of  rupture  of 
tbe  dilatud  jiortiuu  of  the  urethra  which  is  immediately  behind  the  stricture. 
It  thi!u  oeeurti  suddenly,  the  patieut,  while  auHering  from  retuntiun,  feelini; 
eometliiug  give  way  during  a  viol(>ul  effort  at  micturition,  and  at  the  same 
time  there  vt  a  sense  of  some  relief,  an  if  he  were  emptying  llie  bladder,  fol- 
loweil  after  a  time  by  a  hotand  burning  thmbbtni;  pain  in  tbe  perineum. 

In  other  cttitct4  tliu  proceed  in  mure  gradual,  and  is  preceded  by  the  forma- 
tion of  au  abbccjis  iu  the  immeiliate  neighborhood  of  the  uretbra,  muet 
probably  eommoneing  in  one  of  tbe  lacunie  or  glands  opening  iniu  it.  The 
nbacees  burstit  into  the  urethra,  and  its  cavity  is  subeequently  distended  with 
urine  at  each  act  of  micturition ;  finally  its  walls  give  way,  and  general 
extravasation  takes  place.  In  soroe  coses  It  is  probable  that  the  ahaceas 
ftrises  from  a  very  limited  extramsation  of  urine  into  the  tisBues  in  the 
immediate  neighborhood  of  the  urethra,  conae'|uent  upon  ulceration  of  the 
mucoufi  membrane  behind  the  stricture.  In  the«e  cases  the  signs  of  peri- 
neal nbsoeae,  to  be  presently  described,  precede  the  extravasation  often  for 
some  days. 


I 
I 


Tlic  ]vtn  of  the  urptlim  thnt  gives  way  in  alnimt  invariably  the  men- 
raQoui  portioD  of  the  canal,  just  bctweoD  the  laTrn  of  the  triuiij^iilar  Hg*- 
racnt,  where  it  is  v*iik,  b«iof[ieAat  mipnorted  byiiurmunding  ainioturts.  and 
uaoallr  moac  diUted  and  aUei)oat«d  by  the  prcMure  to  which  it  ha«  been 
aubj<>c'i<»d.  Th«  extr«vaaat«d  urine  afterwards  f^Ddii  itH  may  through  the 
BDtt-rior  layer  of  tbe  triangular  liftarnent,  whore  it  i*  pt-rtorated  by  tb« 
ur«-thra.  and  hi  beneath  the  deep  layer  nf  the  KUiiorticiitl  t'aM-ia  of  ihe  peri- 
neum, by  which  it»  ooarte  is  aAerw&rds  direotcil.  This  fascia  is  firady 
attached  acruea  th«  perioeuiQ  to  th«  (n«  border  of  the  triangular  ligameo't 
and,  alouti  ench  bide,  tu  ihe  ranti  of  the  iKliiiim  mid  piil>M,  h«  far  upwards 
M»  the  puGtc  spioe,  from  which  point  itit  attacliiiieitU  arc  continue*!  outwards 
along  roujiart's  liesmeat  to  the  crest  of  the  ilium.  The  extmvaeatcd  urine, 
tberefore.  uiiiformly  lake«  a  course  forward  into  tbe  jwrtncum  auil  scrotum, 
Kod  upwards  upou  the  extcrnul  orgun  of  gvnerstioa,  the  gniins,  aud  the 
anterior  abdominal  wnll :  eo  that  it  asceuds  contrary  tu  gravity  rather  than 
•oaks  back  into  tfau  more  dependent  parts  of  the  body,  as  it  would  do.  were 
U  not  for  the  particular  connectiona  uf  the  faaoia  that  has  just  been  alludod 
|o.  I  have,  however,  known  the  superficial  fascia  to  give  vbt,  and  the  urines 
Uwo  ffrmviuttng  bnekwartl,  to  give  rtt^e  m  extensive  slunghiog  io  the  iscbio' 
wweMkmiv  and  about  tbe  nateo,  dejiuding  the  rectnm. 

The  toeat  I^eetg  of  Ettwavoiatdd  Urinr  that  has  become  acrid,  decompoeed, 
sod  ooaceotraied  by  long  retention,  are  moet  deleterkMu  upon  the  tisuea 
with  which  it  comes  into  contact.  It  acta  as  a  most  intense  irritant  on  all 
tJurt  it  touches.  The  vitality  of  whaterer  portion  of  nreolar  tisane  it  infil- 
mtw  is  qiiicklr  desU^oycd ;  the  tiuue  beeomiag  oooverte<l  into  a  kind  of 
patrtd  stringy  slough,  iniormixpd  with  and  soddeood  by  n  quantity  of  fetid 
aArk*oo)orea  acrid  pug  and  urine.  Tbe  niTages  of  extravasai£-d  urine  are 
cAen  extenuve;  the  urethra  giving  way  suddenly  behind  the  stricture,  tbe 
fluid  u  driven  with  all  tbe  force  of  the  vital  and  pbyeic-al  contractility  of 
tbe  over-distended  bladder  into  the  |>erineuni.  and  then^  rapidly  &nd* 
iti  way  through  the  aerotum  upwards.  Rapid  twelliug  and  iufiltnUtoo, 
partly  urinous,  partly  iutlammatory,  tak«  place  in  tbe  scrotum  and  penis; 
Iboe  parts  become  euormouslv distended,  ti-dematous,  craekling.  and  emphy- 
■ematous.  The  ekiu  is  speedily  afTecled,  becumiug  of  a  <lu>ky-red  or  purple 
color,  and  then  fnlliog  into  a  state  of  gangrene.  In  this  way  tbe  testo  may 
beoome  denuded,  and  the  cords  exp<jwd.  It  is  n'markable,  however,  if  tbe 
pstient  survive  these  destructive  effects,  with  what  rapidity  repair  guvs  on 
in  tbi«  region.  It  is  seldom  that  infdtrati'ju  exteixis  iiigher  than  the  gn>ins, 
or  tbe  anterior  portion  of  tbe  nbttominnl  wall ;  hut  it  may  rvaeb  the  cueiol 
cftrtilagea  before  pnivtng  &t«l. 

Tbe  OnuLUviiowil  Ofsfitriones  is  ftlwmys  very  great.  At  6nt  there  is  high 
fever,  with  a  rapid  lull  pulse;  but  the  symplomi  ^medily  oaeume  the  form 
Bet  with  in  acut«  septic  poisoning.  The  tuuguo  bectime*  browo  and  dry; 
then  may  be  vomiting  ;  tbe  pulse  l>octmKia  small  and  verv  rapid  ;  muttering 
dnJIriom  sets  in,  ending  in  inM>nailiility.  and  death  quickly  follows. 

Tbe  Treatment  cnnsidts  in  making  a  frro  and  ready  outlet  for  the  urine  as 
tarty  ns  piMsible.  This  should  be  done,  as  soon  ax  extravasation  b  known 
to  have  ocourrcil.  by  n  deep  indaion  into  the  middle  of  tbe  p«rin<>um.  So 
•noD  as  any  pnin  and  throbbing,  with  difTUsnd  •wplling,  orrur  in  thi-  [teri- 
BCSK,  with  rcdncw  and  more  or  Ims  o<«len)a  of  the  scmium,  tlie  patient 
•bould  b<*  drawn  to  the  end  of  the  hnl  and  placvil  in  the  position  for 
Uthnt<imy.  Tbe  Sargeon  ithituld  next  intriMimie  bis  left  iniles-ting«r  into  ibe 
rectum,  MO  that  the  gut  may  not  he  woundeal.  and  then  pushing  a  long  sharp- 
pointed  bistoury  deeply  in  tlie  raphC  of  ibe  perineum,  cut  upwaril  to  a 
•ulBi'ient  rxtvnt  into  tbe  exlravasHtion,  and  in  tbe  direction  of  the  urethra. 


1076 


;asxs  or  tbk  cbktuba. 


A  catheter  should  then,  if  poMible,  he  introilaced,  secured  in  thp  blEdder, 
And  lefi  tinplii{;:ge<l,  with  au  India-nibher  tube  attached;  in  thl»  way  no 
further  extrava&atlon  can  occnr,  an  outlet  will  be  tilforded  to  matK-ni  alreadr 
eflused,  and  the  orealer  yyart  of  the  urine  will  coromoolj  be  found  to  oscape 
&ft«r  A  time  by  the  aperture  thus  made.  Should  tb«  case  not  be  seen  uniil 
extravasation  bae  spread  widely,  a  free  incisioa  should  be  made  not  only  into 
tbe  periueum,  exteodiug  lu  the  aperture  in  the  urettira,  but  also  into  the 
Bcrotuin  on  each  side  oi  tbe  iseptuui,  iuto  the  penis,  aud  wherever  else 
swellJDg  is  observed.  The  sole  chance  of  etirvty  for  the  patient  ti««  In 
making  ihvse  free  iucisions,  through  nbiuh  the  purLs  uiay,  tu  a  certaio  ex- 
tent, eiupty  iheoiBelvev.  However  extensive  the  iulillrutiou  ati<l  serinus  tbn 
uiisehief  nmy  be,  we  need  not  despair  of  tbe  patient  if  a  free  outlet  eau  bt 
obtained  for  tbe  acrid  aud  putreficvut  urine ;  aud  iu  order  lo  s«vure  tbts,  thv 
iuflltruti«)n  must  be  fullowetl  by  incisions  as  high  as  it  extends.  Tbe  parts 
niiJE^t,  ut  the  siime  time,  be  covered  with  some  warm  uud  moist  nutisepUc 
dressing.  The  beel  is  borucic  acid  lint  moistened  with  warm  boracic  acid 
lotion.  If  tills  be  not  at  hand,  the  surface  may  Ih!  greased  with  carbolic  oil 
(I'in  10),  or  terebeneand  oil  and  fomentattuns  made  of  itekum  wrung  out 
of  boiling  water  may  be  applied.  Th<»e  applications  are  cleaner  than 
poultioes,  and  should  always  lie  preferred.  The  patient  will  oftui  exwrienct 
great  relief  fn>m  frequent  hot  hip-baths,  Goody's  fluid  nr  boracic  acid  being 
added  to  the  water.  In  this  way  tho  parts  can  be  mo^t  tborougbly  cleaneii 
without  pain  to  the  piilient. 

If  the  patient  survive  the  immediate  impression  upoo  tbesyBlem  produced 
by  the  gangrene  aud  the  urinary  iniiltralion,  be  must  be  prepared  to  20 
through  a  severe  trial  to  his  con^titnlional  powers,  in  the  eoiMnUion  of  tAB 
sloughs,  the  profuse  discharge,  and  other  sources  of  irritation  that-  are  aet  up. 
During  this  period  he  will  rctjuire  abundant  support — tbe  brandy. an d-«ge 
mixture,  ammonia  and  bark,  with  any  nourishment  that  ho  can  take  ;  a^ 
much  attention  should  be  paid  to  the  removal  of  tbe  slougliR.  lo  providins  a 
ready  outlet  for  discharges,  and  to  keeping  the  patient  as  clean  and  as  free 
from  all  looal  irritation  as  ponible. 

Perineal  Abscess. — By  perineal  abscess  is  meant  a  collection  of  pus  in 
the  perineum  situated  under  the  deep  layer  of  the  superficial  fascia  of  tbil 
region.  It  is  the  confinement  of  the  pus  by  tbe  fascia  which  glTea  ihcM 
abscesaes  Ibeir  ttjiecial  character.  Owing  to  the  attachments  of  the  de^ 
fascia  which  hnvi^  just  been  dei^cribed,  the  pus  formed  in  connection  with  the 
urethra  ii^  shut  off  from  the  iscbio-reclal  fossa,  just  as  extravasated  urine  is. 
If  the  abscess  be  left  unrelieved,  it  may  burrow  widely  around  the  bulb  and 
along  the  urethra  before  it  reaches  ihe  suriace  by  perforating  tbe  fascia.  It 
is  very  important,  therefore,  that  such  abeceases  ibould  be  opened  early. 

Tbe  chief  forms  of  periuenl  abscess  met  with  are  the  following  : 

1.  AtNieeem  arising  from  Suppuration  m  a  Lacuna  or  Follicular  Gland.— 
These  have  already  been  flest-rlLied  as  an  occasional  complication  of  gonor- 
rb<Ga.  They  are  met  with  also  iu  stricture.  Tber  may  jwiut  slowly  towards 
tbe  surface,  without  actually  communicating  wiln  tbe  urethral  canal.  In 
other  cases  they  open  into  tbe  urctbra,  and  then  run  the  sanw  courae  as 
abscenes  oommeucing  from  the  canal. 

2.  Abattsse*  eovtmeneingjroni-  Ulceration  in  the  Urethra  behind  a  ^rifturv. — 
These  arise  in  the  diluted  jiouch  bebitid  a  tight  stricture.  As  before  stated, 
tbe  mucous  membruoc  at  this  part  is  tbickeuod  and  opaque,  and  often  pig- 
mented, showing  evidence  of  chnmic  inflammation.  The  openings  of  loe 
ducts  are  dilated,  sometimes -giving  the  whole  surface  a  reticulated  sppear- 
Anoe.  The  ulceration  commcucts  in  one  uf  the  hollows  thus  formed.  Tbe 
iullammainry  consolidation  of  ibe  surrounding  Ueaues  prevenU general  extra- 


• 


I 


J 


URINARY    FISTUL.E.  1077 

TBsation;  hut  the  prewure  duriog  micturition  nnd  the  coustnnt  preBence  of 
letained  urine  cause  gradual  exteosion  of  the  cavity  till  a  distinct  abscess  is 
formed  discharging  imperfectly  into  the  urethra.  Such  an  abscess  slowly 
extends  till  it  reaches  tne  surface.  It  then  bursts  its  cavity,  contracts  to  a 
DUTOW  channel,  and  thus  a  urinary  fistula  is  formed.  At  any  period  before 
it  bursts  superficial ly,  its  wall  may  be  ruptured  during  a  violent  effort 
•t  micturition,  and  diffuse  extravasation  of  urine  may  result 

3.  Abaeettes  from  Injuries  by  Iminanenti, — Thetie  occasionally  arise  from 
blse  passages  made  with  a  catheter  or  bougie ;  they  may  also  follow  forcible 
dilatation  or  internal  urethrotomy.  More  rarely  they  result  from  inflamma- 
tion and  ulceration  of  the  mucous  membrane  around  an  instrument  tied 
into  a  tight  stricture.  These  abscesses  usually  form  rapidly.  If  resulting 
from  a  false  passage  behind  a  tight  stricture,  they  may  lead  to  extravasation 
of  urine;  but  under  other  circumstances,  as  there  is  a  free  passage  through 
tlie  urethra,  this  is  not  likely  to  occur.  If  the  injury  is  in  the  Dulbous  or 
■poDgy  portion,  the  pus  may  burrow  forwards  along  the  urethra  under 
the  accelerator  urinie,  and  appear  at  the  root  of  the  penis  in  front  of  the 
■crotum. 

4.  Suppuration  of  Cowper's  Oland  is  an  occasional  cause  of  a  perineal 
abscess.  It  may  occur  from  the  irritation  of  a  stricture,  but  far  more  com- 
inoaty  it  ia  met  with  during  the  acute  stage  of  gonorrhoea.  The  gland  can 
at  fint  be  felt  as  a  tender  knot  on  one  side  of  the  middle  line  near  the  bulb. 
This  gradually  increases  and  becomes  more  tender,  and  at  last  fluctuation  is 
felt.  ThiB  form  of  abscess  can  be  recognize*!  if  seen  early  by  its  situation, 
and  by  the  fact  that  it  is  distinctly  on  one  side  of  the  miildle  line.  At  a 
later  periofl  it  may  burrow  widely  nmnd  the  bulb  and  in  the  perineum,  bo 
that  its  exact  origin  cannot  be  determined.  It  usually  causes  some  difficulty 
in  micturition. 

5.  Prostatic  Abtce»»&i  may,  as  before  stated  (p.  1014),  occasionally  point  in 
the  perineum. 

It  will  be  seen  that  there  are  two  dli<tincl  classes  of  perineal  abscesBes: 
those  that  communicate  with  the  urethra,  and  th(.isc  that  do  not.  The  former 
uiually  end  in  urinary  fistula,  the  latter  do  not. 

The  ('buradert  of  a  perineal  abscess  are  those  of  a  hard,  roundeil,  elon- 
gmte<l  or  oviform  maits,  situated  in  front  of  the  anus,  extending  nloug  the 
urethra,  or  perhaps  occupying,  to  some  extent,  one  side  of  the  jwrineum. 
Fluctuation  is  not  Oi  be  felt  so  long  a^t  it  U  bound  down  by  the  8U|)erficial 
fa«cia ;  when  it  burets  beyond  its  limits,  then  that  sign  maybe  met  with. 
But  s»  long  as  it  is  under  the  fascia  the  altsccss  will  l>e  found  to  be  sur- 
rountled  by  so  dense  a  mass  of  iu<)urated  tissue,  and  «>  tightly  bound  down, 
that  fluctuation,  or  even  elasticity,  is  nut  appreciable  bv  tiie  most  practised 
finger. 

Traitmi'nt. — The  usual  routine  trcatnivnt  of  local  seiiativcs.  fomentations, 
and  poultices,  are  of  no  avail  in  these  cuties.  When  once  pus  lias  forme«I  in 
this  sit'jation  it  must  be  freely  evaeuattfl.  No  good  can  possibly  come  of 
delay,  and  everv  possible  harm  nmy  result  from  the  infittnLtionofpuii  among 
the  ini|>ortant  tissues  of  this  region.  The  Surgeon  must  not  wait  for  fluctua- 
tion, but  when  onco  the  lianl  niiu>s  has  fully  formed  must  make  a  free 
incision  into  it.  For  this  purpose  he  niuxl  keep  in  the  mei^ial  line,  or  as  close 
to  it  na  possible  ;  for  in  all  i>erineal  incisions  "  nudio  ttdi^imtia"  must  be  bis 
motto. 

Urinary  Fistnls  eoninxmly  form  in  the  ]K>rinoum  and  scrotum,  as  the 
result  of  abs('<-ss  in  these  p'^jinn-*  eomniunic-ating  with  the  urethra;  ocea- 
•ionally,  however,  tliey  are  met  with  in  other  situations,  as  in  tlie  irroin.  the 
anterior  abdominal  wall,  or  the  inside  of  the  tbigli.     Tliev  usuallv  conimu* 


1078 


DIBKABBB   OF   THK 


ETHRA. 


nicate  with  the  meiuhranouR  portiim  of  the  urt-llira,  but  ■i<Ta*ionaIIy  ooonr 
anterior  to  this.  In  niimliier  they  vary  coimiderably;  vrhen  rkccurring  in  the 
HCrotal  aoif  penile  |>ortions  oi'  the  ui'elhrn,  they  are  usually  singlp ;  hut  wht-n 
in  the  perineum,  they  nre  ofleii  rather  uiinierous,  neveral  MperttiiYa  lieinj; 
occasioually  met  with  abDUt  the  penneuni,  »crotuni,  aad  natee.  In  on«  case 
Civiale  found  ns  many  as  tifty-twu.  Their  size  aleo  diffors  coasiderahly; 
some  admitting  only  the  finest  probe,  whilst  others  are  large  eluacie.  Id  a 
coae  under  my  care,  the  patient  bad  a  tunnel  of  this  kind  ia  the  gnnn  that 
vrotild  readily  admit  three  fingers.  They  .are  usually  tortuous,  elongated, 
and  narrow;  sometimes  conetricted  exteninlty  and  more  widely  dilated 
behind.  The  eurroundiug  parts  are  greatly  condensed;  the  whole  nf  the 
scrotum  and  pcui^  ia  enormously  enlarged,  indurated,  and  almost  cartilngi- 
noDH  in  structure.  The  urine  may  escape  almost  eoUreiv  through  the  fistutx, 
BMtrcely  any  being  discharged  through  the  urethral  ori^cc;  or  there  may  be 
but  a  8]);;hi  exudation  from  the  tlstuTous  opcniogs. 

The  Tr'-atmeiU  of  urinary  fiBlula  varies  accorJiugae  it  is  complicateii  with 
stricture,  nnd  as  it  U  simatcd  in  the  anteriiir  or  the  posterior  t»ort  of  the  canal. 

If  there  be  a  stricture,  thi«,  aft  the  cause  of  the  fistula,  will  require  rcmoral 
either  by  dilatation  or  by  the  perineal  section.  If  the  stricture  be  not  very 
tight  and  hard,  dilatation  commonly  snccecda;  the  instrument  being  iotro- 
ducod  every  second  nr  third  day,  until  the  urethra  ii  dilated  to  it^  normal 
size,  when  the  fistuloun  tracks  will  in  most  cases  eluse.  In  some  instaneea, 
howercr,  the  freiiiicnt  introduction  and  withdrawal  of  the  rotbctcr  is  a 
source  of  irritation,  and  then  it  had  better  be  left  in.  When  this  prneticcis 
adopter!,  a  moderatfi  sizpd  eln<ttir  colhetcr  should  be  used.  If  thin  be  loo 
small,  the  urine  will  tlow  between  it  and  the  sides  of  the  urethra,  and  thus 
escape  through  the  fistula; ;  if  too  large,  it  stretches  the  urethral  orifice  of 
the  nstuU  injuriously. 

If  (he  stricture  be  very  tough  and  irritable,  the  belter  plan  is  to  perform 
urethrvl<.i[i)y  at  oueetas  much  time  and  pain  are  thus  saved.  In  the  majority 
of  instauces,  iutvruul  urethrotomy  with  Civtalu's  instrument  appearv  to  dm 
to  be  the  salc-jst  nud  Biniplesl  procedure,  and  I  have  very  advaotageoualy 
practised  it  iu  suuh  case«t.  But  if  the  Gslulw  be  very  cumeroua,  su  as  Do 
riddle  the  perineum  and  scrotum  in  all  directions,  perba|x9  the  better  plan  is 
to  perform  the  perineal  uectiou.  In  this  way  we  not  oulv  divide  the  striciure, 
and  thus  at  once  remove  all  obstruction,  but  give  a  (ree  exit  to  the  uriae, 
which,  instead  of  escaping  by  tortuous  and  sinuous  pasaages,  finds  its  way  oat 
readily  through  the  new  aperture  that  has  been  made,  antlthis  will  eventually 
granulate  and  hcnl  l)y  the  Ht^cmil  intention. 

The  twtuhi-,  PHp^-cially  if  small  and  rece-nt,  will  aometimes  heal  kindly 
enough  afiT  the  rerimviil  iif  the  ol>struct.ion;  but  if  extensive,  old.  nnd  car- 
lilaginims,  they  are.  of  roiirse,  little  dispo?ed  t.i  take  on  reparative  action; 
an<l  although  the  cause  that  in  the  first  instance  gave  rise  to  them  may  be 
removed,  yet  they  constitute  an  independent  nfiectiun  which  requiru  spedal 
treat  menu 

The  special  treatment  for  urinary  fistula  must  vary  according  to  the  size 
of  the  canal,  but  more  particularly  with  regard  f)  the  part  of  the  urethra 
with  which  it  communicates  ;  whether  it  be  a  Prrinenl,  a  Srrotal,  or  a  Penile 
fistula.  Mut  in  ail  ca^ps,  and  wherever  it  be  situated,  there  is  one  most  Im- 
portiint  point  to  be  attended  In,  viz.,  never  to  let  the  fistula  be  disturbt'd  or 
irritated  by  the  passage  of  urine  over  or  through  it,  or  it  will  never  heal. 
Hence  the  urine  must  always  be  drawn  off  with  the  catheter,  which  the 
patient  should  l>e  taught  to  pass  far  himself. 

If  the  fistula  be  Perineal,  and  of  small  si/e,  a  probe  coated  with  melted 
nitrate  of  silver,  or  a  wire  made  red-hot  in 


I 


I 


n  the  ortltnary  way,  or  bj  the  gal-   fl 


URINARY    FISTULA  —  URETHROPLASTY.  1079 

vmnic  curreDt,  and  passed  down  it  occasionally,  may  cause  its  ccmtrection. 
If  it  be  large,  the  edges  of  the  fistula  may  be  freely  rubbed  with  the  nitrate 
of  ailver,  or  deeply  pared  and  brouj^ht  together  by  quilled  sutures,  after  which 
tfae  urine  should  be  dranu  off,  whenever  required,  by  a  catheter.  If  the 
fittulse  be  large  and  very  uumeroutt,  it  will  be  better  to  pass  a  gnraved  director 
down  the  principal  ones,  and  slit  them  up  so  as  to  throw  the  several  sinuses 
into  the  larger  one. 

When  the  fistula  is  StroUt/,  it  ofleu  re<[uire8  to  be  laid  open,  and  to  be  made 
to  granulate  from  the  bottom,  when  it  may  be  found  to  communicate  with 
lar^e  sloughy  and  ill-conditioned  cavities  in  this  itituation. 

SVhen  Penile,  the  fistula  is  usually  much  moru  tnmblesome  to  heal ;  ita 
«dees  are  thin,  and  the  track  is  short  and  shallow. 

Unthroplasty  may  in  such  cases  be  advantageously  practised.  Opera- 
tions of  this  kind  require  for  their  success  very  careful  management  and 
BlDUte  attention  to  detail;  they  very  commonly  fail  in  consequence  of  a 
mall  quantity  of  urine  or  of  mucus  escapiug  through  the  wound,  and  thus 
interfering  with  union  of  its  Una. 

Id  order  to  prevent  this  accident,  which  id  fatal  to  the  success  of  the  opera- 
tion, the  patient  should  be  taught  to  pass  a  catheter,  and  thus  to  draw  off  bis 
own  urine  after  the  o|>eration  as  often  as  necessary ;  or  an  assistant  must  do 
this  every  third  or  fourth  hour.  Should  this,  however,  not  be  practicable,  a 
full-sized  gu Ri-catheter  should  be  passed  into  the  bladder  and  properly 
secured  there.  It  should  he  left  without  a  plug,  so  that  no  distention  of  the 
bladder  and  consequent  likelihood  of  escape  of  urine  between  the  urethra 
and  the  instrument  may  take  place.  In  onler  to  prevent  urinous  effusion 
over  the  integuments  of  the  penis  and  scrotum,  n  vulcanized  India-rubber 
tube  should  be  attached  to  the  end  of  the  catheter,  by  which  means  the  flow 
of  the  urine  is  directed  away  from  the  patient. 

Urethroplastic  operations  may  he  varied  according  to  the  seat  and  extent 
of  the  fistulous  opening. 

If  the  fistula  be  in  the  perinettm,  the  parts  around  being  thickened  and 
indurated,  its  closure  may  oflen  be  attained  by  freelv  and  deeply  paring  the 
edges,  and  then  bringing  them  together  with  the  quilled  suture,  or  by  Sims's 
button. 

When  the  fistula  is  ticroUd,  the  edges  should  be  freely  pared,  and  the  parts 
nround  widely  disiiocted  up  so  as  to  form  large  and  thick  flaps  of  cellulo- 
eutanefjus  tissue,  which  may  he  brought  aud  held  together  by  metallic  sutures 
or  shotted  clamjie.  In  this  way,  if  union  be  not  obtained  throughout  the 
whole  length  of  the  fistula,  it  may  he  to  a  partial  extent;  and.  after  n  time, 
A  second  or  a  third  o[>emtiou  will  coniplet(>  the  cure. 

When  the  fistula  ia  penilf,  the  difficulties  in  effecting  closure  become 
immensely  incrcat^d.  This  is  owing  to  the  tliiniiei>s  of  the  iutcgumental 
structures  and  the  al)9(.>n('e  of  laubcutaueoux  areolar  tistiiic  in  this  region,  so 
that  there  is  nut  sufiicicnt  thicknt-Hs  of  thi'  parts  for  ready  plastic  union.  In 
these  caf<e8,  the  Surgeon  hn^  a  choice  of  four  o{H>rations. 

1,  X<^lat(in  has  reooni mended  the  following  pr<K'cdure:  The  edges  of  the 
6stula  having  Iteen  partnl,  the  skin  around,  to  the  extent  of  about  an  inch, 
should  he  diitscftcd  up  (lubi-utHneouKlv  througli  an  o{>ening  made  below  the 
fistula,  the  edges  of  which  must  then  be  Itrought  together  by  a  u  few  [M>inta 
of  suture.  The  displaccuicnt  of  the  skin  rovers  in  the  a^wrture  in  the 
urethra  and  causes  granulationj*  to  spring  up,  bv  which  the  fistula  i;:  closed 
(Fig.  938). 

2.  The  edges  of  the  fistula  having  been  pared  and  the  skin  separated 
widely,  lateral  incisions  may  l>c  made  so  as  to  take  off  all  tension,  and  a  slip 


1080 


DISXAB£8    or    THE    DRKTHRi.. 


of  India-nihk^r  mar  then  be  paucd   un<!erneath  the  flaps  of  skin,  id  order 
to  prc'VPnt  contact  with  urine  from  dUlnrhing  the  adheaions  (Fiji.  939). 

3.  Ricord,  rern^ni/inj^  the  fact  thnt  the  occasional  intruaJuQ  of  a  drop  of 
urine  between  the  freshened  edges  of  tlie  integumenlii  brought  together  to 


dp 


© 


-f 


Pig.  03S.— Drattara. 
pl>Bl7.  NflBton'i 
u|>«raliuD :  Pirrt 
H«tha(l. 


tig.  Ite«.— l)r«tkropUatjr. 

NflitoD*!  Opcmllan :  8m- 
(idJ  Ualbud. 


dote  thc'fistulfl  is  the  mo«t  common  cauae  of  disunion,  re<^on] mended  that, 
in  tboM  cii^-^  in  which  a  perineal  or  a  scrotal  fistula  happen?  to  pnexin  with 
a  penile  one,  a  catlioler  should  be  pawed  through  the  fijrraer  into  the  bladder, 
and  led  there  during  the  whole  of  the  operative  procedures  that  are  adopted 


. —  a 


'T-' 


/^•' 


.: — I e 


PIf.  040. — tJrelhroptMt;.     Cltrk'i  Opem- 


J 

Fif.  941.— l'r«thT«|ilMtx.    CUrh'a  Opm* 
tiaa  I  llMORtt  Sui:*. 


for  the  closure  of  the  penile  fistula.  Should  no  fistula  exist  in  the  perineum, 
he  has  pn>pueed,  though  1  btilieve  the  operation  has  never  yet  been  practised. 
to  puncture  the  bladder — which  would  meet  couTeoiently  aud  aafelj  be  done 


URINAKY   VAGINAL   FISTULJI,  1081 

throuf^h  the  rectum — aud  to  keep  it  emptied  in  this  way  until  the  penile  fis- 
tula has  been  closed  bv  one  of  the  preceding  operations,  and  then  to  allow 
the  lower  aperture  to  dose  apontaneously  ;  or,  if  it  were  situated  in  the  peri- 
Deuin,  to  adopt  surf^ical  meana  for  its  occlusion. 

4.  Le  Gro8  Clark  has  recommended  and  euceeaefuUy  practised  the  follow- 
ing ojicration.  Having  ]mired  the  edges  of  the  fistula,  he  makes  a  trans- 
Terse  cut  through  the  integuments  of  the  penis,  about  an  inch  in  length, 
above  and  below  it.  He  then  dissects  up  the  flaps  of  skin  so  bounded,  and 
brings  Ihem  together  by  means  of  clamps  or  the  quilled  suture.  By  this 
operation  a  wide  raw  surface  from  each  side  is  brought  into  contact,  instead 
of  a  mere  raw  edge  of  cut  integument,  and  there  is  conscfjuently  a  greater 
chance  of  successful  union  resulting  (Figs.  940,  941). 

In  all  operations  of  this  kind  union  will  be  promoted  by  keeping  the  part 
ooDStantty  bathed  with  a  concentrated  cold  solution  of  boracic  acid.  In 
this  war  all  decomposition  of  any  mucus  or  urine  that  may  accidentally  find 
its  way  to  the  wound  is  prevented,  and  at  the  same  time  the  lotion  is  so  an- 
irritating  that  it  does  not  interfere  with  union.  The  lotion  is  beet  applied 
by  means  of  a  niece  of  boracic  acid  lint,  which  must  be  frequently  wetted 
and  changed.  If  the  urine  can  be  efficiently  kept  fn>m  the  wound,  a  dry 
dressing  of  iodoform  or  salicylic  wool  will  be  found  the  best. 

Stricture  of  the  Female  TJrathra  is  rare.  When  it  occurs,  it  is  seated  at 
the  ezterual  orifice,  which  will  be  found  to  be  narrowed  and  sharp^ged. 
The  disease  is  usually  the  result  of  gonorrhn-a,  but  may  be  caused  hv  a 
chancre  at  the  orifice.  The  symptoms  are  the  ordinary  one  of  irritability 
of  the  bladder,  frequent  desire  to  micturate,  and  some  difficulty  or  delay  in 
doing  so. 

The  TVeatment  consists  in  the  dilatation  of  the  orifice  by  means  of  a  two- 
bladed  dilator. 

URINARY   TAGIKAL   FISTUL.F,. 

Preternatural  communications  between  the  urinary  passages  and  the  va^na 
commonly  arise  from  injurious  pressure  upon  and  consequent  sloughing  of  the 
anterior  wall  of  this  canal,  to  a  greater  or  let^a  extent,  during  parturition. 
They  may,  however,  occur  fmm  idiopathic  abscess,  or  from  malignant  dis- 
c*ae  involving  those  parts. 

VARiKTit->. — Urinary  vaginal  fistuloearc  essentially  of  two  kinds,  accord- 
ing as  the  communication  is  eslnblished  between  the  urethra  or  the  fundus 
of  the  blad<lcr  and  the  vagina.  Hence  they  may  he  divided  into  Urethral 
and  Vftieal. 

TTrethro-Taginal  Fistnlae  are,  so  far  a^  my  ub!<crvii(ion  goes,  of  most  com- 
mon occurrence;  and  thisi  is  readily  explained  by  the  fiu-t  that  the  urethra 
lies  between  the  vagina  and  piibes  and  is  tliiTefun-  expo^d  to  the  most  severe 
pressure.  These  fi^tula^  are  usually  ol'!>ni!ill  size  and  llTu-ar.  Vesico-Taginal 
fistula  establish  a  coniitiunicution  between  thi'  neck  or  fundus  of  the  bladder 
and  the  vagiua.  They  aro  consei|uenily  Mtuiited  rurtlior  hack  than  the  other 
and  arc  usually  larger  and  more  ragged. 

K&ri.Ts. — The  existeni-c  of  a  uriniiry  fistula  in  the  vagina  is  alwavs  a 
source  of  the  greatest  di^tconifurt  and  di.itrcti.''  to  the  patient.  The  dribbling 
of  urine  thrtiugl)  the  prcteniatunil  nitertureii*  generally  continuouit;  although 
if  this  be  situated  far  back  it  may  be  ^nmfwhat  interiniltcnt.  a  How  taking 
place  as  the  lower  pnrtinn  of  the  bhidder  fills.  The  incontinenro  of  urine 
thus  proflnci'd  givi-s  rise  to  irritnli'in  and  I'xenriatioii  about  the  external 
parts,  and  occasions  a  titrong  aitimnnincal  iKhir  to  hang  alxiiit  the  patient. 

The  prccii>e  scat  uiid  t-xt«-nl  tif  the  fiittulnns  ii])cning  may  bi>  ascertained  by 


1082 


DI8EASK8   OF    TBR    CRITBBa. 


placing  the  patifot  od  tif-r  koecs  op[)Oeite  s  nn-x]  V. 
p<at«nrir  and  lateral  walls  of  the  vagina  with  btii 


bolilisg  I 


itMOlWl 


rior  JUpecl  of  that  cnnai  will    hiivf>  ii  li-miL-ncTr  to   [tr>i;iuilv.  mikI  thntlBM* 


pose  the  tistuln,  at  the  same  lime  that  Ib*^  intriNlurti<>n  of  o  hvflt  prv^^«M(i 
a  <'>:mnle  catheter,  iato  the  urethra,  will  guidv  the  Surgvoa  to  tbm^^KKM 
ojieniue  in  the  ariaarT  pa»age.     lif  means  of  the  dock-bill  wmalflVH^ 
942  ^  tnc  tistula  can  be  brought  into  view  equslLf  tbU   if  ui  paticat  C 
placed  iu  the  lithntomy  positLoa. 

TntLiTML:rr. — When  theapertareuamall.ahuata  liae  or  tw a  iiiwiig, 
and  more  especially  if  urethral,  its  otoBarf  maj  buat  be  tOtetaA  by  iuac^ 
the  edfiefl  of  iho  aperture  with  the  galvanic  cautery  or  »  nd>bot  vifB, ■! 


Kl 


r^wuting  thb  appliention  odco  a  fortnipht  or  three  wlfl»  oUil  % 
elTectfrd  bv  their  gradual  coQlraction.  This  little  opermlktt  m  mmt  _  _ 
Diently  el^oclcd  l>j  placing  ibo  iiaiiout  in  a  knwliog  pnaUira,  and  tliMlhMM- 
ing  ii^ide  the  pMelcrior  aotl  lolvrul  vajfinnl  walla  by  nieana  nf  Ibe  daefc  H 
speculum,  when  the  opening  will  be  fairlr  bmugbt  into  view. 

Wlifn  the  fistula  u  lar;L'cr,  and  eijieciBlly  when  veritml,  iti  eaic  «•  hi 
fl4?conipliithcd  only  by  luiriiig  the  edges,  and  brinj^iog  them  tngetber  «tt 
Buturea,  nud  thus  attempting;  to  procure;  uoiun  by  the  firac  tnwtiaa.  la 
efl'i--ctiiig  this,  however,  two  Hifiiculticflpreiient  Ehenuelvei — the  wtuiet  calhv 
cutting  their  way  out  too  Hoon,  or  the  tnckliog  of  uriDe  betwwn  the  ftcAlf 
pared  fdg<s  interfering  with  adhesion.  In  order  to  uvereone  lbc«e  iMiat 
tic«,  a  variety  of  tngenioii9  conlrivan<-es  have  been  iDtmduc«d  by 
Surgeons ;  amongnt  which  may  be  especially  menttnoed  the  clamp* 
fiiras  and  Bxlcer  lirown,  aud  the  button- nature  of  Ruji^maa.  T»  Si 
cially,  ia  due  the  great  merit  of  having  8uht)lilut4>tl  silver  mttt*  fur  "ilk.  m 
io  this  <>|>vnili(iu,  by  which  the  pnjbabUtliea  of  a 
ceasful  resuU  hnvt;  been  very  grwitJy  tocraaaad. 

Before  (lie  ■>peratiuo,  thw  Utwels  sliouki  bar* 
fVoety  opifued  by  t-Mtor  oil  and  an  eoema. 
formerly  rewmiueodcd  thnt  uo  BDK«tbe(ic  slw 
giveu.  aa  its  adminiatraiiou  iiinkf*  it  difficult  to  plw* 
the  patient  in  the  mnec  cnnvfuim:  pneitiuniM  ihi 
koe«  and  elbows,  with  the  buiti»cks  well  laiKd  od 
the  h««d  tow.  As.  however,  the  opezviiua  fa  icdioa 
and  painful,  it  is  better  to  give  an  aomUielie.  bmI  as 
difficulty  will  be  fuuud  in  performiDii;  the  apecaliia 
with  the  patient  lying  on  her  bark  in  the  \ak 
poeitioD,  if  the  jielvia  be  well  ratsnl  «n  a  nitlnw. 
of  great  moment  that  the  jmrtn  t>h.>uld  m 
pcec*!.  This  is  best  d*ini*  by  means  of  the 
^Iteciiluni  (Fig.  042i.  by  uhirh  the  pnatanoT! 
the  vagina  is  well  dmwn  up  and  i<ul  of  iba 
operator,  and  lit;ht  is  retlectttl  tin  the  Sstatwtt 
The  edges  of  lti<r  aitcrturc-  are  iinw  t>t  be  frwtij 
Thifl  is  bt«t  done  by  seizing  iheti.  Soak-fi*rfisn 

or  a  double  hook,  ami  directing  olT  the  vagiiiitl  niu<  -  nbniDelan* 
extent  of  alkMit  a  quarter  nf  an  inch  all  rniind,  by  mmtu  of  a  60c,  nal 
scalpel  or  migulnrly  set  knives  (  Figs.  U4:i,  !I-I4)  ani)  scismn  pnificrlr  ntrvai. 
Tlie  ilisscciion  should  be  carried  towanls  the  finure.  and  especial  cmn  lakai' 
lliat  t)u-  ungtee  are  well  cleared  of  muooua  laembram. 

Alter  the  edges  of  the  lislula  have  been  freely  parrd.  aad  all  brvt 
etcatrldu]  ojnslrictinne  divided,  sutuna  of  nlver  an  paMid  acraa    ' 
of  (he  wound.    These  wires  niay  most  conveD'Hiatly  bo  p«hkI  by  ■ 
the  hollow  needle  (Fig.  945) ;  or*  if  this  be  not  at  hand,  a  aiik  thnad 


Flg-Vtl— Duvli-liilM 
S|i«<<ittBia. 


OPXRATION    FOR    URINARY    VAGIN/L   FISTUL,*;.       1083 

be  puted  by  a  Dievus  or  corkscrew  needle,  a  full  half  inch  from  the  fresh- 
ened edge  of  the  fistula,  and  brouf^ht  out  through  a  correflponding  point  od 
the  other  side  of  the  fistula,  without  having  transfixed  the  mucous  membraDe 
of  the  bladder.  Aa  many  threads  as  necessary  having  l>een  passetl  in  this 
of  silver  wire  about  eighteen  inches  long  is  attachetl  to  the  silk, 


ly,  a  piece 


Figi.  043  »nd  04-1— Angulu-l^  Carrad  KnirM. 

which  is  then  drawD  out,  leaving  the  wire  to  occupy  its  place,  so  that  its 
centre  corresponds  to  the  fissure,  and  both  ends  hang^out  of  the  vagina. 
Sims  then  paaaea  the  uppermost  free  ends  through  ho^  made  in  a  narrow 
leaden  bar,  on  which  they  are  clamped  by  having  split  shot  fixed  upon  them 


Fig.  D45.— Hollow  Suture  N««>lla. 

in  the  same  way  as  is  done  on  a  fishing  line.  The  undamped  wires  are  now 
drawn  down  until  the  bar  is  pulled  close  to  the  upper  suture  holes ;  and  a 
•econd  clamp  is  then  fixed  to  these  ends  and  is  pushed  up  against  the  lower 
suture  apertures.  In  this  way,  the  edges  of  the  tiatula  are  brought  and  held 
together  on  each  fide  by  a  clamp,  which  mav  be  allowed  to  remain  in  from 
seven  to  ten  days.  The  ctamps  may  then  m>  n-moved  bv  clipping  oflT  the 
flattened  shots  from  the  anterior  one,  which  is  thus  detactied  from  its  bed. 
The  poBteriur  one,  with  the  wires  attachr<l,  may  then  l>e  hooked  up,  pushed 
backwards,  and  lifted  out  of  the  vnginn  with  force])s.  Int^tcad  of  a  clamp, 
Simpson  used  a  splint  made  of  annealed  iron  wire,  which  surrounds  and 
supports  the  tiwues  untmid  the  fistula.  In  ninny  oa«>s,  however,  where  the 
fistula  is  of  but  niudorate  itize,  the  clamp  and  splint  may  be  dii»i>ensrd  with, 
and  the  edgee  of  the  opening  brought  together  with  the  suture-wires  imly. 

In  the  after-treatment,  esppcial  attention  is  retjuirerl ;  and  here  the  great 
point  is  to  prevent  contact  of  urine  with  the  edgei^  of  the  fistula.  With  this 
Tiew,  a  catheter  should  be  introduc-e<l,  and 
worn  in  the  bladder,  so  that  ud  urine  niny 
C!o)lect  in  this  organ.  I'\ir  this  iiurjtose, 
Sims  has  invented  a  very  ingeniiHis  catheter, 
representeil  in  the  annexed  cut  (Kiir.  i'ltii, 
which  may  be  worn  with  nmn-  com  fort,  and  *'"'k-  '■' ip!,- SiBi»>  Cuthei^r. 

with  IcM  chance  rif  i^lipping,  tlinn  thi-  ordi- 
nary instrument.     After  the  [wtimt  has  been  put  to  l>ed.  and  the  catheter 
introducod,  a  fidl  opiate  flxmld  Im>  given,  iin<l  continued  throughout  the 
treatment,  with  a  viow  of  [treventing  Ow  action  «f  the  bowels,  a  )>oiiit  on 
which  Sims  lays  much  strops,  and  to  which  the  success  of  liis  operatinnit  may 


108  i 


DISEASES   OF   THE    URKTSBa^ 


b«  in  n  great  rueaaure  attrihuled.  It  it  very  M>Moni  thmt  U>wt  rvf 
opeiitHi  fcr  ivu  or  fifueu  days,  provided  tb«  patJQDl  b«  k(fK  no  ftmltUf 
diuU  During  tliiii  ucataicoi.  the  catheter  may  b«  nmovad  oooe  or  twit*  • 
day,  in  <in\vr  tu  be  cleaned  and  to  be  kept  free  from  pboaplniie  or  Bwaa 
aauinniiutiniiB;  aud  free  ablutioua  of  the  extcronl  geailjua  by  upoofi « 
Byritigi!  and  warm  wau-r  elioul'l  be  practued  duriofc  the  whole  of  ika  tnfr 
ment.  Ader  tho  removal  uf  the  tiulures,  Siiiu  adviiei  thmt  th»  CiAtfV 
should  be  oautinued,  aud  great  earo  takea  that  the  patient  do  ool  nvnlB 
scmn,  lest  the  weak  cicatrix  be  elraiued. 

A  very  aiin|il(!  and  auceewful  mode  of  cIorJh^  tfane  fbtalv  ba«  Iihi  ih 
Tented  by  Biviwuian,  by  what  he  terms  the  "  button-future."  After  farar 
the  edges  of  the  ftatula,  and  puaeing  silver  wires  acruM  In  tlie  luual  *ar«ki 
«lrav8  the  parts  tiigether  bv  pawing  buth  pods  af  the  wtrv  ihrao^  ■■ 
apertiin*  in  a  Hteel  md,  which  ticiDg  cnrrieil  alon;;  tbt-m  cIchm  the 
A  thin  lfa<Ion  plate,  "  the  button,"  properly  pi^rf-iniut)  dowti  lh« 
then  iflijiprd  iilong  the  wirm  no  na  to  cover  llio  fi^litla  I'Fi^.  947 
«hol  having  been  pushed  along,  their  free  extremitlea  are   p 


BmaBan'*  Ap|wraUia  for  Bultos  9(il«r». 
Pig.  «47.— ApplUailon  <if  PlaU.  ri|.  Mil.— Af  |iJtoUU»  t4 

against  the  button,  the  wires  are  then  properly  nipped,  and  lb^  ap;^ 
letl  un  f(ir  ahimt  ten  days  (Vig.  94Si;  the  sbnt  are  then  cot  c>IT.  the  Waia 
plate  ia  carefully  lifted  off,  and  the  suture  wires,  having  been  etrughtael 
out,  are  withdrawn. 

Whatever  kind  tjC  Hutiire  may  lk«  emplnved,  it  U  alwmrv  of  xroal  ud*#- 
tance  thallheedgi^of  ihe  Miila  l>e  brought  lAgi^thur  frawjwrwy  to  tW  M^t 
axis  of  the  vagina.  Should  the  abnormal  arM-rturu  be  clow  to,  or  ann  (i^ 
plicate,  the  cer\'ix  utt-ri,  thiti  purl  may  )>e  ilrawn  down  and  tnaidbDld 
the  sutures,  thus  abiding  materially  to  tbo  Aiippnrl  uf  Uie  posterior  tip 
6ttur«. 

TtnrOBS  tX  THE  URcrnRA. 

Small  Polypoid  Tumori  arc  not  uofreqiiently  met  with  hiride  the  di 
orifice;.    They  have  oocasiooally  a  gtmorrbir-al  orik'in,  ihnagfa  they  ooai 
arise  irn!8pei>tivety  of  euohduMasc.    They  an'^  always  very  rascolar.  mmI  ' 
most  frequcntiv  met  with  in  or  around  the  fomaJe  uredua,  nbcR  iliey  ^ 
of  a  bright  rivl  color,  have  a  florid  hue,  bleed  freely  wlua  umc&ed,  asd  art 
eompoB^  of  iixtrrrocly  va^rular  pnpillip :  they  are  oomnoalT  coooid^  «^ 
oval,  bordering  the  iirr tliral  orilirc  on  one  aide,  orevan  aocirriiDic  It. 
grow  slowly,  and  Afldom  attain  a  larger  siie  than  that  of  a  nuplxnTT- 

These  vascular  tumors  are  far  tf«i  frequent  in  the  maJ*  tli&n  in  thr 
urethra.     When  tliey  occur  in  men,  they  oatially  cocHtituie  a  vmall 
florid  maM  inside  the  orifice  of  the  canal. 

When  seated  in  or  around  the  female  urethra,  these  tumors  out 

quentlv  give  rise  to  very  great  nnd  cominuotii  irritation  ;  ■ 

and  after  micturition  radiating  ibrongh  the  whole  |»(>lv: 

by  an  admixture  of  tuucus  and  a  litUel>lu(Ml  in  the  urine,  an-j.  in  lact*  i 


DISEASES    OF    THE    PENIS.  1085 

of  the  symptoms  of  stooe ;  so  that  patients  laboring  under  this  affection  are 
often  tounded  on  the  suppoeition  of  the  existence  of  calculus. 

Treatment. — Vascular  urethral  turours  may  be  removed  in  four  ways: 
by  ExcisiuD,  Lifrature,  CausticB,  or  the  Actual  C'autery. 

1.  £xeuion.  W-heu  situated  withia  the  male  urethra,  the  tumors  should  be 
■Dipped  off  by  a  tine  pair  of  curved  scissors.  When  situated  in  or  around 
tbe  female  urethra,  if  of  small  size  and  pedunculated,  they  may  readily  enough 
be  removed  by  the  sci^eors  or  dissected  away  ;  the  canal  of  the  urethra  being 
encroached  on  as  little  as  possible.  This  operation  is,  however,  always 
attended  or  followed  by  very  considerable  and  continuous  arterial  hemor- 
rhage, which  has  even  been  fatal.     Hence,  when  the  tumor  is  large,  and  the 

Satient  weakly,  excision  should  be  practised  with  much  caution.  If  it  be 
one,  tbe  hemorrhage  may  be  arrested  by  the  introduction  of  a  catheter  into 
tbe  urethra,  and  by  firrapressure  on  the  bleeding  surface  by  means  of  a  pad 
of  lint,  supported  by  a  T-bandage. 

2.  Ligature  is  not  a  convenient  mode  of  removing  these  growths  ;  its  appli* 
cation  is  difficult,  very  painful,  and  tedious. 

3.  Ctnufiot,  particularly  strong  nitric  acid  or  potassa  cum  calce,  may  be 
Tery  conveniently  employed  where  the  tumor  is  of  small  size  and  very 
Tucular.  In  applying  them,  the  upper  wall  of  the  canal  must  be  protected 
by  a  broad  director  introduced  along  it 

4.  Tbe  Atiual  or  Galvanic  Cautery  is  the  most  convenient  agent  for  the 
removal  of  vascular  tumors  from  the  female  urethra.  By  it  they  are  at 
once  destroyed  without  hemorrhage ;  and  the  eschar  that  is  formed  protecta 
the  subjacent  raw  surface  from  the  irritation  of  the  urine.  If  they  ne  situ- 
ated deeply  within  the  urethra,  and  of  email  size,  the  galvanic  cautery  or  a 
red-hot  wire  will  most  easily  reach  them ;  but  if  they  oe  at  or  around  the 
orifice,  I  employ  a  small  olive-shaped  cautery.  During  its  application,  the 
Hirrounding  parts  may  be  protected  from  the  action  of  heat  by  a  wooden 
ipooD  having  a  hole  cut  in  the  middle  through  which  the  application  ia 
made,  and  the  upper  wall  of  the  urethra  by  a  director  or  silver  catheter, 
which  should  be  retained  after  the  operation.  Cnre  must  be  taken  not  to 
destroy  more  tissue  than  is  absolutely  necesearv,  leet  a  stricture  of  the  orifice 
be  left. 


ClIAPTEK    LXXIII. 

IllSKASKS  OK  TMK   TKNIS  AND  SCnOTl'M. 
IHsi:a^J>  of  TlIK  I'KNi.-. 

Complete  Arrest  of  the  Development  of  the  Hale  Sexual  Organs  must  be 
of  very  rare  occurrt'iice.  I  have  m'cii  only  out*  iiiiitAnoe  of  it.  This  was  the 
case  of  a  man  xl.  22,  iu  whom  the  ponit!  uiid  scrotum  were  [lerfcctly  formed. 
but  nut  larger  than  the  or^'iiiix  of  an  infant  a  ti-w  months  old.  Xo  distinct 
testes  could  bt-  felt,  but  tht>ri-  wm  mmw  lliiL-ki-nc4l  structure  in  the  scrotum 
which  felt  like  an  unravelled  ti-stis.  The jirepuce  was  long.  There  was 
aome  hair,  but  very  little,  on  the  )iul><'i>.  This  jierson  hud  sexual  desires, 
and,  in  fact,  had  engaged  himself  to  be  married  when  his  condition  led  to 


1066 


OI&fiASSS    OF    TIIK    PENIS   AND   SOBOTDU. 


asut^gical  exuiiinalion.     He  tuld  me  tliat  he  >iri1  erectious.  whea  the  orgu 
bnaa>e  aUxit  an  inch  or  ad  iuch  and  a  hail'  lotiif.  and  ihal  tliere  wat  ncci' 


aiauftl  eoinkia  of  a  };lHirv  Uuid.  Hv  kmis  fair,  fresh-colored,  rtiuQU-t"aco<3,  fat, 
and  hsd  foiooth,  niuiiilt-d  liuih»  more  tike  those  uf  a  alout  dirl  iban  ul'  a  Tousg 
DUO.  His  Toicc  WHS  weak  aud  teminine  in  [one.  He  led  a  eedeutary  indoon 
U^.  bat  »ud  that  he  wait  atruug  aud  caimhle  of  ordiiiury  physical  t'Jiertioi). 

foNutMiAL  Mau-okmati(>.v».  AdJi«sioQ  of  Penis  to  Scrotnin. — I  buTe 
oooe,  and  oooe  oulr,  met  with  a  very  curiuus  lualfurouuioo  of  the  genital 
ocnos.  the  peais  beiog  tied  down  by  ite  under  surface  to  the  scrotum,  so  u 
to  lie  iu  a  deep  sulcus  between  the  testes.  In  tbe.se  cASee  the  raphfi  of  the 
ccrotum  appeared  to  he  continued  in  a  narrow  rsthvr  tiriu  hand  upwards 
to  the  under  surface  of  the  penis,  eo  that  this  organ  was  always  beot 
or  bowed  downwards.  The  palicut,  u  man  of  :J0,  paaaed  his  urine  down- 
wards,  apparently  from  the  under  aurfacc  of  the  srroluin;  iUirin>;  ereriion 
the  peats  ourvcti  up  iu  a  eeniicircular  form,  cht>  mnvexity  upwanih.  tho  >;laoa 
being  tightly  lied  down  to  the  scrotum  t>y  the!  narrow  tense  band  conlioupd 
up  trnm  the  raph^.  Id  fact,  the  oonilitiim  of  tbia  orfl;an  was  very  like  that 
which  is  met  with  iu  the  tongue  wh^n  "tnneiie-tied.  Thi.<)  malforoiatitto 
wA!t  remedied  by  cutting  through  the  t*m>num  which  tied  the  peois  down, and 
thiu  tib<-nttin^  the  organ. 

Hypospadias  coneistji  in  a  cleft  cnndition  of  the  under  mrfaoe  of  the  pcaii. 
Up  to  the  tenth  week  of  intrauterine  life  the  external  organs  of  gcneratino 
are  alike  in  the  male  and  female.  At  this  time  the  urogenital  aperture  forms 
a  narrow  slit  wider  hehind  than  before,  at  the  anterior  extremity  of  whi^  is 
a  Bmall  eminence  representing  the  rudimentary  penis  or  clitori*.  Iu  lb« 
female  the  urogenital  aperture  remains  unclosed  and  the  external  folds  of 
iutegimient  forming  its  Literal  boundaries  enlarge,  forming  the  labia  majors, 
whidi  cuutaiu  the  vueculttr  bulbs  corresponding  to  the  corpus  apongitwum  of 
the  male.  These  reiuuiu  He[inrate  and  distinct,  but  a  soiall  isolated  portion 
beooroee  united  iu  the  uiiddle  liue,  fonuiug  (he  i;lun9  of  the  clitoris.  In  the 
ttinle  the  two  sides  of  the  urogenital  a[H.-rlure  unite  in  the  middle  line,  form- 
ing the  svrotum,  Hud  the  bulbous  and  spongy  portlnns  of  the  urethra.  At 
the  snme  tiiue  the  Mimll  eminvuce,  whicti  iu  the  female  becomes  the  clitoris, 
devetoiis  iuto  the  penis.  The  vKstulur  bulbs,  which  in  the  female  remain 
£«parate  in  the  labia,  unite  along  the  middle  line  in  the  male,  forming  the 
bulb  of  the  curpua  spougioeum.  In  ibt;  female  no  corpus  spon^oeum  exists 
in  the  clitoris,  the  ghms  being  an  isolated  nodule  of  erectile  ttssue.  In  the 
male  the  erectile  tissue  is  contiuuous  around  the  urethra  from  the  bulb 
torwards. 

Hy[Ki!^padia»  confi^itii  iu  un  arrest  of  tiie  union  along  the  middle  line,  and 
iu  pro|x>rtion  Uj  the  de-gn%  ot  the  malformation  the  male  organs  come  more 
clti^ely  lo  resemble  the  lemale  in  appearance.  Hypoepodifls  anpcajs  in  thne 
df-grLt.-)<.  In  the  i^imphvl.  form  the  glans  is  cleft  along  \tt  unoer  surfaoe,  the 
fureekin  alwi  showing  a  correopoudiug  gap.  In  the  second  degree  the  corpora 
uaverooea  and  glnne  are  well  ileveloped,  but  the  urethra  i»  cleft  to  the  root 
of  the  penis  ana  the  corpus  Hpnngioeum  ia  wanting  between  the  bulb  and  Cbe 
glana.  The  penis  thus  rem^mbles  a  large  clitori:;.  The  under  surface  abowi 
a  Airrow  in  the  line  of  the  urethra  ueually  covered  by  a  moist  mucous  mem- 
bnme.  Between  the  glane  nenia  and  the  point  at  which  the  urethra  lermi- 
oalea,  in  the  place  of  the  alwent  conius  apoogioaum  a  firm  den«o  band  of 
fibrous  tissue  is  often  present,  somewhat  mcmhliag  in  bardne«s  and  tennon 
the  cicAtrix  of  a  burn.  In  tfae^  cases  when  erection  ukcs  place,  ibe  organ 
assume*  a  crescentie  shape,  with  the  convexity  upwards,  the  tense  hard  enird 
that  has  just  been  mentioned  stretching  acroM  its  arc  like  the  string  of  a  b>iw, 
(bus  rendering  connection  impoffiiblc,  and  the  sufferer  pra(i.ically  impuleuL 


I 
I 


PHIMOSIS.  1087 

The  third  and  most  extreme  form  uf  hypospadias  is  wheu  the  scrotum  also 
is  cleil  and  the  urethra  opens  iu  the  periueum.  This  is  usually  accompanied 
by  imperfect  development  of  the  penis,  and  most  commonly  by  retained  tes- 
ticles. It  is  this  malformation  that  has  been  erroneously  considered  to  be  an 
example  of  hermaphroditism.  The  cleft  empty  scrotum  resembles  the  labia 
of  the  lemale,  and  the  diminutive  penis  might  readily  be  taken  for  a  large 
clitoris. 

Hypospadias  affects  only  the  parts  in  front  of  the  membranous  portion  of 
the  urethra,  and  consequently  never  leads  to  incontinence. 

ISreatment. — The  first  degree  of  hypospadias  requires  no  treatment,  the 
cleft  glans  being  not  even  an  inconvenience.  Intermediate  degrees  between 
the  first  and  second  require  treatment  only  if  the  urethra  is  so  short  that  the 
aeminal  fluid  will  not  enter  the  vagina  during  connection,  or  if  there  is  a 
tight  band  beneath. 

In  the  second  degree  of  hypospadias,  the  first  step  is  to  dissect  away  the 
firm  fibrous  band  which  prevents  complete  erection.  Some  months  after 
this  has  been  successfully  accomplished,  and  when  the  scars  have  become 
supple,  the  attempt  may  be  made  to  cloee  the  urethra.  In  order  to  do  this 
•uccessfuUy,  it  is  necessar}'  to  provide  an  e|>itheiium- covered  lining  for  the 
new  urethra.  Many  methods  have  been  suggested  for  doing  this,  but  by  far 
the  best  is  that  adopted  by  Anger,  which  is  an  a<laptation  to  hypospadias  of 
Thiersch's  operation  for  epispadias.  It  is  thus  ]>erforme4l.  An  incision  is 
made  parallel  to  the  groove  representing  the  urethra,  and  half  an  inch  from 
its  right  margin,  a  transverse  incision  from  each  end  of  this  is  made  up  to  the 
«dge  of  the  urethral  groove.  The  flap  thus  ntarkeil,  which  we  will  call  the 
right  flap,  is  then  dissected  up,  leaving  it  attache<I  along  the  mar^n  of  the 
urethral  groove.  A  similar  Hap  is  then  raised  nn  the  left  side,  but  on  this 
side  the  incision  is  carried  along  the  lefl  margin  of  the  urethral  groove,  and 
the  flap  turned  outwanis,  ils  attached  eilge  being  in  the  position  correspond- 
ing to  the  free  edge  of  the  right  flap.  The  right  flap  is  now  turned  over  so 
that  its  skin  surface  forms  the  lining  of  the  new  urethra.  A  number  of  fine 
aCitches  are  then  inserted  in  the  following  war.  The  needle  is  first  passed 
through  the  base  of  the  lefl  fiap  from  the  skin  surface,  then  through  the  free 
edge  of  the  right  flap  from  the  raw  surface  lowardit  the  skin,  then  it  is  made 
to  catch  the  lefl  edge  of  the  urethral  groove,  and  finallv  passed  again 
through  the  base  of  the  left  flap.  In  this  way  the  etlge  of  the  right  flap  is 
held  in  position,  and  the  stitches  can  be  removed  from  the  surface.  W^en 
these  have  all  been  pasi^ed,  they  may  be  lightened.  A  similar  number  of 
stitches  are  then  passeil  through  the  free  edge  of  (he  lell  flap,  by  which  it  is 
attached  to  the  skin  of  the  penis  at  the  <»uter  e^lge  of  the  raw  surface  from 
which  the  right  flap  wai<  raised.  The  rnw  surfaces  of  the  two  flaps  are  thus 
brought  closely  into  contact,  and  an  epithelial  lining  formed  for  the  new 
urethra.  During  tlu'  healing,  a  catheter  nmst  be  tied  in,  and  the  bladder 
drainetl.  A  small  fistuli>ui«  o]>euing  will  usually  Ik  left  at  the  lower  end, 
which  muKt  l)e  clicked  by  a  sul)#i'qiit'nt  plnatic  operation.  Several  successful 
casea  of  this  operation  have  l>een  reconled,  and  it  !>eems  to  be  by  far  the 
most  efficient  of  the  many  metbo^ls  ffuggCiited.  The  thirtl  degree  of  hypos- 
padias admits  of  no  treatment. 

Spispadiaa. — The  upi^-r  t>urfa<'e  of  the  peni^  is  Wvs  frequently  fixsured  ; 
only,  I  believe,  in  ciui-:)  of  extrover.<ion  i>f  the  bladder.  This  condition, 
termed  epUjMtiitui,  may  be  ri'me<lied  to  soirii-  extent  by  WikkI's  o}>eration, 
deseribeil  at  p.  !<!I2. 

Phimosis. — The  prepuce  ii*  ni>t  unfri'qiicntly  the  iseat  of  malformation  or 
disease.  The  condition  >>f  it  in  which  it  id  s>\  iiiui-h  t'longateil  that  it  extends 
beyond  the  glans,  anti  at  the  faiiic  time  it  '\^  ^o  much  contracted  that  it  pre- 


1088 


DISK  At 


TUR  PKSld    AND    BOROTCH. 


■nafcia.J^ 


vtiotA  Oxe  proper  expnaure  of  thU  pottiuu  of  the  orgmo.  If  wnntd 
Tbiti  oiay  be  cither  i-oiit^ntml,  or  ncquired  an  iii«  remit  of  iaftua 
dueuv. 

la  Congenital  Phimosis,  the  pcttin  is  niunlly  domcnbat  atroi>hi«l, 
deTeluptuetit  uf  the  glana  in  prtiTrnted  by  the  prcacure  of  tb«  oUTMr 

puce.     The  akin  i»  abundant  and  Inx  ;  bin  tho  miicoiu  UniDa  oT  '^ 

IS  sburt.  cuutracted,  and  undevelopM.     Tho  count  rioting  baud 
the  retractioD  vt'  the  Ibreokin  is  alwsjrii  Jiitual^l  at  the  junctiuo 
and  the  tuiicuuR  mbnibranA.     In   the  tnajuritj  of  csaca  ■   hnk| 
Bixn{ilr  a  wurcv  uf  Jucul  iucuiiveujeiioe  ;  but  it  may  bcr""'- 
eue  from  a  vnn«L,r  <rf  caustt.     Thuft.  iu  ctiildrvn,  reUuK 
•eantiun — "eueguia  preputii"— under  an  clongatMl  ai 
eomea  a  tuarce  uf  Jucal   trritaliou   and   iiiUainmatinn 
The  irritation  thus  kupt  up  (.Fig.  i>4^;,  leads  to  lucal  excKvoicai,  anil  tni 
ihu  dcveiupmcut  of  ihu  habit  of  carijr  maataftettnu  J 
flume  cusvti  the  pruputiut  uritioe  is  m>  tight  a>  tai  iirfin 
uiutcriuily  wiLli  tliu  di^charj^e  of  the  Diine,  wUdb 
from  the  ureiiini  intu  a  kind  of  powah  batweea  iW  {I 
and  prepuce,  dbtends  this  strictare.  aad  iaUiMiBmi 
in  a  fine  jet  ur  in  a  frcuttenxl  RprinkliDK  Mtnaai  titm 
the  narrowed    preputial  oriGue;  uid  urit*hilttf  rf 
bUidder,  oflen   prewoting  sympCoiiM  itamlAtiac 
may  thus  be  aet  up.     CaTcnuMiB  oolunCiaM  ouij 
tweeii   the  glaos  and   the  prepaoe  in  aocfa  BiaeiMA 
and  hare  been  known  to  do  so  m  aufmoni  num 
abaw,  of  Fyzabad,  removed  no  fewer   than 
varying  in  size  from  a  pin's  head  to  ■  small  ( 
Bitualiou  in  the  person  of  a  native  cif  India, 
age,  wbu  came  under  ircaunenC  for  what  api^ 
a  large  tumor  of  the  end  of  the  pemt,  the  true 
which  vAi  not  detected  until  in  retuoving  it   th* 
grated   against    the   contuined   calcaU.      Various   sfTtM-tinn*  nf  the 
urinary  ori:nn»  in  children,  ouch  as  iocontini*iice,  \h-  '  ,«  of 

hiotuaturia,  priapistn,  etc.,  have  been  ahottu  by  Bryi  i^iog  to  I 

genital  phimoeis.  The  stmininf;  in  niictuntiMU  lany  give  riae  abo  to  hcK 
Hydrocele  of  young  children  will  aleu  Im  found  u>  bo  very  frcquasUf  s 
ciated  with  phimoaia.  i:^yre  has  pointed  out  the  important  fiici  that  n 
paralytb  and  various  forms  uf  apa«iic  uontnicti<ins  chiefly  of  the  lower  tti 
arc  duo  to  the  same  cause,  being  readily  curable  by  circuBkclrioii.  In  ai 
iJon  to  these  I  have  seen  general  apasmtxlic  afli-ctJons  in  dillilRii 
chorea,  reenlting  frum  congeuiial  phimtisb.  At  more  adraoocil 
life  I  have  known  it  to  be  a  cause  of  impotence, or  lasbar  aa  fai 
conceptiiiu  In  the  wife,  tho  senoeo  after  emissiosi  being  ivtaiaed 
tight  and  narrow  prcjtuce  untQ  ereetiua  bad  oomplelelfanbi' ' 
uA  phimoeis  cepecially  beoomcs  a  source  of  IncaavanleBM  in 
goDorrhawl  <ir  veucn-al  diecdue  be  contracted,  g»  It  renden  ex 
diaeawd  part  ditlicult  or  imponible,  and  interforee  with  ibe 

In  the  opinion  of  aome  Sarg«<ins,  cancw  nf  the  penis,  if  noi 


rig.   Pt».— (rriia- 
t«<l      CuDgiitllal 

Plll«<Mil. 


oecadoned,  b  at  all  eventa  predispoeMl  lo,  by  ooogenital  phini»*i* 
Acquired  Pbimoait  UMially  rvsulu  from  repeatcj  attacks 

or  of  specific  disease  in  the  part,  giving  rise  to  solid  tsdeiua,-^^  ;■ 

trtiphy  of  the  pr«puee. 
In  elderly  men,  phimosis  will  eomettmes  slowly  come  on  at  a 

of  the  irritation  set  np  by  oracka,  fiaiunw,  or  aujiorticial  nlovratJons  turn 

round  the  preputial  orifioe.  which  befx>mee  turruwed,  su  as  to 


OPERATIONS    FOK    PIIIJIOSIS.  1089 

glam  from  beiDg  uucovered.  It  is  not  uncommuD  in  gouty  subjects  from 
repeated  attacks  of  herpes  preputialis.  The  preputial  mucous  membrane 
bMomes  thickened,  and  can  be  lelt  like  a  broad  band  under  the  loose  and 
pOMibly  slightly  ccdematous  integument  of  the  prepuce.  Thin  condition  is  a 
■ource  of  much  irritation  and  annoyance,  and  requires  relief  by  dilatation  or 
by  circumcision. 

TreatmeiU. — Every  child  who  has  a  congenital  phimosis  ought  to  be  cir- 
ca mcised ;  and  even  those  who,  without  having  phimosis,  have  an  aboor- 
mally  long  and  lax  prepuce,  would  be  improved  greatly  in  cleanliness,  health, 
and  morals  by  being  subjected  to  the  same  ojK-ration  ;  and  it  would  be  well 
if  the  custom  of  Eastern  nations,  whether  it  be  regarded  as  a  religious  rite 
or  only  as  a  time-honored  observance,  were  mure  fretjuent  among  us.  Phi- 
mosis, when  not  congenital,  must  be  treated  in  accunlancc  with  it«  cause  ; 
thus,  if  it  have  rraulted  from  inflammation,  that  must  be  sulxliied ;  if  from 
Tenereal  disease,  that  must  be  remeilied,  when  perhagis  the  cnntniction  and 
elongation  will  gradually  subside.  If,  however,  the  phimosis,  though  ac- 
quiretl,  be  permanent,  it  should  be  subjected  to  operation. 

A  long  foreskin  without  actual  phimnsii>,  if  a  source  of  annoyance  to  an 
adult,  may  easily  be  remedied  by  keeping  it  constantly  dra%vn  back.  At 
first  the  tendency  for  the  prepuce  to  slip  forwards  must  be  overcome  by 
mapping  a  piece  of  dry  lint  round  it,  and  securing  it  by  an  elastic  band, 
vhicn  must  be  just  tight  enough  to  keep  it  in  position.  Aflcr  a  few  weelu 
the  foreskin  will  retain  the  retracted  position,  and  after  a  year  or  so  will  be 
found  to  have  undergone  considerable  diminution  in  size. 

Operatioiu  for  Phimosis  may  be  conducted  on  three  plans;  the  elongated 
and  contracted  prepuce  may  be  dilated,  or  slit  up,  or  circumcision  may  be 
performed. 

1.  Dilatation  of  the  Phimosis  may  be  eflVcted  by  putting  the  patient  under 
chlurofurra,  introducing  a  pair  of  forceps,  and  ojx'uiiig  them  widely,  tearing 
through  the  narrow  preputial  orifice  an<l  tight  fuunel-shaped  mucous  mem- 
brane ;  or  this  may  be  i^lit  up  with  a  uurniw  tciiototuc  on  each  side,  and  then 
dilatation  practised.  Thii^  procedure  may  lie  usefully  adopted  if  the  prepuce 
be  not  very  long  and  tight,  or  if  any  objection  exist  to  circumcision  as  too 
MTerc  an  operation. 

In  the  acquired  phimosis  of  old  men,  cunticqucut  upi)n  contraction  folIoV- 
iDg  cracks  of  the  preputial  margin,  I  have  found  that  dilatation  may  Kntelj 
and  Bi>eedily  be  ctiectt'd  by  the  iutrotluction  of  a  tw<t-bluilcd  dilator,  such  as 
is  use«l  for  the  female  urethra,  which,  l)ciiig  gradually  screwed  open,  causes 
the  indurateil  circle  to  yield. 

2.  Slitting  op  of  the  Prepuce,  wbcthor  upon  its  upper  or  under  surface, 
is,  I  think,  an  objcctitmablc  pniccdiiro,  Kaviiig  the  preiiuce  nf  it;^  abnormal 
length,  and  more  or  let»^  lisrun-d  and  kiiiil)l>ed.  In  all  case.-<  I  prefer  circum- 
cision OS  the  simplest  and  spi-t'die:>t  opcratiiin.  aiul  a*  leaving  the  most  satis- 
factorv  result. 

:t.  Circumcision  for  Congenital  Phimosis  in  Infants. — It  may  be  ^'athercd 
Irom  what  Ims  already  been  ceiled  with  rt'S|H.ct  to  tlie  evil  ellects  n.'^^ultiiig 
fnim  congenital  phiuiii-ii:<,  thai  eireuiiiei.-ion  in  this  i-uudilinn  mar  be  re- 
quiretUoreiuovt'aii  eluniiated  and  picsibly  adlierent  ]iri'puce,  which  ueeusi«ina 
much  hical  irritittinn,  nr  whieh  i.-  the  cxeiliu.!,'  t-iui^v  nf  reflex  and  di.-»iant 
DervouH  di!<turbance  of  a  paralytic  or  Hpaiitie  eharacter.  S)  great  are  the 
evils  resulting  not  only  Inmi  ciin;:eiiital  [ihiiin^iK.  but  f'rniii  uii  almormally 
long,  though  not  phiumlie  prepuee,  that  it  is  only  humane  aud  right  from 
a  nioml  [Kiint  of  view,  to  practii-t-  early  eircunicision  in  all  »nch  cumi).  This 
operation  is  easily  and  caD-ly  ptTforined  iieeording  to  tlic  Hebrew  rite,  which 
I  have  several  timcx  had  uti  opportunity  of  witiiesi^iiig,  and  whicb  is  done  as 

Viil,.   II, — ''•'* 


1090 


DISKAasa    OF    TUS    fENIB    AKD   aOROTVH. 


follows :  The  child  being  held  i>u  the  lap  of  ui  — iwtout,  tb* 
the  forcakiD  slightly  forwanl^.  and  then  grmspa  it  jaal  in  fr««t  of  ifci 
by  drawing  it  through  a  %V\t  in  u  Bilver  guard.  Thw  is  not  haU 
larly  downwards,  but  is  inclined  frrim  abore  aligbtJjr  forw»nii»ad 
BO  u  to  avoid  cutting  the  fnennm  aa  much  as  paoHble.  and  to  dim  if  it 
propuc«  in  au  oblioue  or  quillod  manner.  Tliu  udoDO  bf  o*e  tfntorfa 
oroad,  rouDd-ended  Knife.  The  mucous  mombnuip  is  then  tAin  opiB  tatfVHi 
the  finger  and  thumb  along  the  dorsum  of  tbo  pcnu,  and  b  ismel  tack* 
a«  to  be  brought  into  cootact  with  the  cot  edge  of  iho  skin.  A  auifJi^ 
lint  U  then  twisted  round  the  organ  in  the  sulcui  bebiod  the  fUH.MBk 
keep  hack  the  mucous  membrane,  and  also  to  natraiD  h«DOiTha|*  hy  li 
pressure.  Union  is  perfect  in  n  few  days.  This  oMTAtiaB,  which  ii  pfloW 
on  the  eighth  day  after  birth,  is  very  rarely  attended  br  any  ill  mmm^mm 
I  have,  hovi^ver.  seoD  it  in  one  ease  followed  by  &ul  i-nrnpelaa,  ftMhnt 
heard  of  auotlier  instance  in  which  death  oocurrtd  frnm  hffii-rrhap*. 

CircnmcisioD  in  Boys  or  Adnlts  may  be  ni<Mi  t-on  r''<jtmtim 

the  fiiUowiug  way  :  The  SurgeMii  rualniias  heiuorrhu^>       .  ■iptrlJM 


Vig.  9i9.—Clcm'a  CIrcuaicitlMi  TuuralqiMl 


ri|.  vil.— * 

TlHU 


by  tying  a  tope  tightly  round  th«  root  of  the  penie,  or  by  compniint  ^ 
organ  In  Clorer's  circumcision  toumiqaet  (Figt.  8&0.  USD.  «  sum  mM 
inttniment,  which  can  be  slacked  or  tightenod  at  any  tinw;.     Ha  wot 


ff1(.  tSS. — Initr«n>anl 
for  balding  tb«  ft*- 
pnoa  ID  Circumcl- 
ritm. 


tig.  VU.— ClrwaMtMBP  la  U«  AU 


the  eloiiffntcd  prepucv  slightlv  forward*,  until  tli*  jwriion  iif  it  - 
respondx  m  thu  bni'k  of  ihe  g^ans  is  brought  ju»t  in  fnini  uf  that 
He  then  Beliiea  the  prujeotiag  prepuce  imnediutely  in  irnni  ofiba  ' 


FABAFHIHOSIS    AND    ITS    TKEATHSNT.  1091 

Ik  pair  of  aarrow-bladed  polypus  forcepe,  which  he  gives  to  ro  assistant,  who 
DBUt  bold  them  tightly ;  or  be  grasps  it  and  protects  the  glaos  by  meaDS 
of  a  plate  (Fig.  952),  which  1  have  bad  constructed  for  this  purpose.  With 
DIM  sweep  of  the  bistoury  he  cuts  off  all  that  portion  of  the  integument 
irbicb  projects  beyond  the  forceps,  which  are  then  taken  away  (Fig.  953). 
[t  will  DOW  be  found  that  be  has  removed  only  a  circle  of  skid,  but  that 
the  mucous  membrane  lining  it  still  tightly  embraces  the  glans;  this  he 
llits  up,  by  introducing  the  point  of  a  pair  of  scissors  at  the  preputial  orifice ; 
■ad  then,  trimming  off  the  angles  of  the  flaps,  ho  turns  Iuck  the  mucous 
Boembrmne,  and  attaches  it  to  the  edge  of  the  cutaneous  incision  by  a  suffi- 
tmat  number  of  fine  catgut  sutures.  Before  introducing  these,  he  will  gen- 
erally find  it  necessary  to  ligature  a  small  artery  on  each  side  of  the  penis, 
Mid  one  or  two  in  the  frsenum.  The  best  dressing  in  children  will  be  some 
rimple  ointment,  such  as  boracic  acid  ointment,  or  the  glans  may  be  simply 
•ineared  with  a  Utile  vaseline.  After  every  act  of  micturition,  the  parts 
should  be  well  sponged  with  boracic  acid  lotion  or  Condy's  fluid  and  water. 
In  the  adult,  union  by  first  intention  may  often  be  obtained  by  a  dry  dreas- 
ing  of  iodoform-wool  thickly  covered  witti  collodion,  so  as  to  protect  it  from 
the  nrine.  This  may  be  left  unchanged  for  four  or  five  days.  There  is 
uuftlly  a  good  deal  of  swelling  of  the  mucous  membrane  about  the  fnenum. 
Mid  some  solid  cedema  usually  remains  for  some 
weeka  after  the  operation.  This  gradually  subsides, 
aad  a  linear  cicatrix  remains,  which  causes  the 
■Btient  no  inconveuieoce.  In  some  cases  I  have 
mind  adheaions  between  the  prepuce  and  the  glans ; 
thcae  require  to  be  torn  or  dissected  through,  but  no 
inoonvenience  results  from  this  slight  addition  to  the 
operation, 

If  sloughing  of  the  prepuce  have  occurred,  allow- 
ing the  glans  to  protrude,  as  in  Fig.  954,  circumci- 
non  must  be  practised. 

The  chief  points  to  be  attended  to  in  the  perform- 
ance of  this  operation,  and  on  which  its  atter  success 
ii  most  dependent,  are — 1,  That  too  much  skin  be     FiK.B54.— sionghingoftbe 
Dot  removed  ;  2,  That  the  mucous  membrane  be  slit       prepay,  anj  protrailon 
up  to  the  base  of  the  glans ;  3,  That  too  much  of  it       of  the  uimDi. 
be  not  removed ;  4,  That  all  bleeding  vessels  be  tied 

with  catgut  ligatures,  which  must  be  cut  short ;  o.  That  the  mucous  mem- 
brane be  well  turned  back,  so  as  to  cover  the  gap  left  bv  the  retracted  skin ; 
6,  That  all  sutures  be  of  catgut,  which  will  be  abaorbei),  and  thus  save  the 
pain  of  taking  them  out. 

Paraphimosis. — In  paraphimosU  the  prepuce  has  been  forcibly  drawn 
back  behind  the  glans,  which  becomes  strangled  by  the  pressure  exercised 
by  the  preputial  orifice,  sn  that  the  parts  canuot  be  replaced  in  proper  rela- 
tion to  one  another.  This  accident  principally  occurs  in  boys,  or  in  indi- 
Tiduals  who  have  naturally  a  tight  prepuce,  and  who,  on  uncovering  the 
glans,  find  it  diflicult  to  get  this  part  of  the  organ  back.  This  difficulty  is 
speedily  and  greatly  increased  by  the  swelling  from  congestion  that  is  set  up 
in  the  constricted  glans. 

TreaimenL — This  is  siiflitiiently  simple.  The  Surgeon  should  first  try  to 
reduce  the  swollen  organ,  lie  may  otlcu  siiccccl  in  doing  this  by  seizing 
the  body  of  the  pciuA  between  the  index  and  middle  fingers  of  each  hand, 
and  then  endeavoring  to  draw  the  prepuce  forwards,  at  the  same  time  that 
be  compreeaes  the  glans  between  th(^  two  thumbs  and  pushes  it  back  (Fig. 
955j.     Should  retluotion   nut  bo  effected   in   this  wav,  the  cunstricted  and 


1092 


DISKA9SB   OP  THK    flHIS    AS D    SCAOim. 


iUuufnilftiiiig  prfputial  orifice  must  he  iiiviite>l.     lu  iJiWDU-lliu,  the 
will  .jbetjrve  thai  the  glaus  i»  w'lmralwl  lr>m  ibe  ImkI v  i>l*tlje  prtii».li)f 
and  narrow  sulcus,  which  is  specially  evideDt  <>n  th*r  uj>imt  j^rt  'd  Um 
Thie  aulcus,  which  is  owrlapptU  ou  one  wdc  by  the  [.■'""•  '""1  t*  ifce 
by  a  fold  <•(  intpgunicnt — the  bwoll^u  mucvu*  layer  • 
ipoDiU  to  tlK;  iDnor  tnargio  of  the  preputial  urifloo ;  atj-^  ■ 
of  this,  in  wliicli  the  Mricture  is  eilUHltd.that  tmmcdialo  t- 
This  oi*mlifin  may  rtadily  be  doue  by  drawing  the  gin: 
paMiog  lilt-'  point  of  a  narrow-bliidn!  w-aljud  inln  ilic  puk  '-^ 
of  the  ptuin,  and  nmking  a  pcrpendiciilap  incii!i"u  aht.ui  ■  ?     ;) 
in  l«iigUi  through  tlie  iiitcgumeiitaat  the  Ituttiim  afll-.v  ^! 


.^y. 


Fl{.  •>>• — ttadoedonor  i*Bn4ih)ii>orif. 


tkmUf 


it  <Fig.  9M).     In  conwqacnce  of  the  gmt  »tr«tchuig  of  t^-^  •- 
sioD  nill  immediately  gape  wirlcly :  lo  that,  instead  of  bri 
will  iip[M-Ar  to  be  trauaveiw;  and  Ihtii  rcdaciUMi  of  Uw  ^>ai>t>  nut 
be  ifJiflcd. 

Balanitis. — iDflammaUoo  of  the  prepuce  com  tii'  i  '. 
local  irriliiiioD  from  want  of  cleanluieia,  out  unli 
rfauea.     Wbcu  coDfioed  lo  th«  pn'pucc,  and  coiiBtilui.: 
Uire  is  tiiuch  swolleu,  iufiltrnled,  and  redilfued,  and,  v 
lastB,  continues  in  a  iiUit«  of  pbimusis.     Whro  thu  n>ULt<ii»  iuhuUi 
glans  ta  afiTecu^d  a»  well,  cfnetiiutiug  PoeiAifis,  ihrn'  i^  a  gmxl  dtal 
tioD  and  smarting,  together  with  niuco-puruliml  dbdiargw 

TVeoinwR^ — Tbu  aiiwa«e  mpiirni  tn  be  crrsi«d  oo  onllnarr 
The  continued  appiicuiiun  of  lead  lotion,  with  tbp  inlcmal  adottitatmloa 
salinef.  will  gtuerally  remove  it;  but  in  many  inetnocts  <1>"  ni,-i  .  rT^Lii.! 
plan  will  Im*  found  lo  otinai^L  in  rapidly  sweeping  the  inflr 
aalii'k  of  nilrattf  of  sitwr  [uuenl  dnnn  between  ihcm  uu  ■.».    «.' 
iVivnutii,  and  carriiMl  round  to  die  opfiosite  udn.     If  Uie  pailfst  m  lisl 
rew-nti-tJ  nltnokfi.  rironmcii'ion  i»bonM  be  performed. 

Herpos  of  the  Olans  and  Prepnoe  lji  chnract^'ruK'd  hv  the  fc 
timsll  v<"j*ii"lrt«  nr  pxoiriftt^'d  points  up<^  the  nmcr  n    :        '  .  '    'U 

ntl*-uileil  by  much  AniAriing  and  ilrbing,  and  nc. 
a  gimiy  habit  of  biidy.  with  an  irritable  nj"' 

TrfilmriU. — Tbii*  *liyht  aHtTlion  i*  oft<'n  >  Ct  nvflttimnL    II 

many  innlance*,  local  means  abme  will  not'-  Fattfb^ 

uhtameil  by  powdering  tli«  part  with  the  ox< 
Mtringcnt  and  cool inglot ions,  yet  no  permanent  bcuctit  will  ba  dcxirad 


OANQRKNE    OF    TUE    PEXI3. 


1098 


ooDititutional  treatment  be  adopted,  modified  accordiug  to  the  circumstances 
of  the  case. 

Hypertrophy  of  the  Prepuce  not  unfrequently  occurs  as  the  result  of 
chronic  irritation  or  disease;  it  is  usually  of  limited  extent,  and  requires  no 
apecial  interference  on  the  part  of  the  Surgeon  ;  but  in  some  iustances  it  may 
become  su  extensive  as  to  require  operative  interference.  The  hypertrophy 
is  due  U)  solid  a-dema  of  the  areolar  tissue  of  tlie  prepuce  and  of  the  sub- 
integumental  structures  of  the  body  of  the  penis,  the  organ  being  very 
greatly  enlarged  and  l>ecoming  club-shaped.  In  these  casus  circuniciaioD, 
with  the  excision  of  a  V-shaped  piece  from  the  dorsum  of  the  penis,  will 
usually  be  found  to  leave  a  good  and  satisfactory  result.  But  a  greater 
magnitude  than  this  may  be  attained.  Thus  Vidal  has  related  and  figured  a 
case  that  bad  attained  such  an  enormous  size,  that 
the  organ  reached  to  below  the  knees,  and  was  ns 
large  as  a  thigh.  This  moDstrous  growth  was  suc- 
cessfully excised. 

Warts  on  the  penis  have  already  been  described. 
They  may  attain  a  very  large  size,  as  in  Fig.  9o7, 
Aud  are  best  treated  by  being  snipped  off  with 
curved  scissors. 

Homy  Excrescencet  have  been  oltserved  to 
ipring  from  the  glaus  peniii.  The  most  remarkable 
case  of  this  kind  on  record  ia  one  by  Jewett,  of 
Oinnecticut.  It  was  that  of  a  young  man,  in 
whom,  after  operation  for  congenital  phimosis  and 
the  removal  of  warts,  a  horn  grew  from  the  left 
side  of  the  glans  i)enis,  and  attained  a  size  of  three 
and  a  half  inches  in  length  by  three-fourth  of  an 
inch  in  diameter  at  the  b:tse.  It  could  be  hundletl 
and  cut  without  pain,  and  the  patient  "was  accus- 
tomed to  amuse  the  inmates  of  the  ward  by  light- 
ing the  end  of  the  horn  and  allowing  it  to  burn." 
not  return. 

Fenistent  Priapism,  lusting  for  many  days,  is  occasionally  met  with,  aa 
the  result  in  most  casi-s  <>f  exccs.'tive  vencry,  and  more  especially  of  violent 
coitus  during  intoxiciitlon.  The  crectiim  of  the  penis  is  not  accompanied  by 
any  sexual  desire,  but  i:#  attended  with  great  pain,  a  sense  of  weight  about 
the  perineum,  much  anxiety,  and  condtitutionnl  disturbance.  The  organ  is 
■ingularly  hard  iind  unyielding.  The  patholngy  of  this  condition  is  obscure. 
By  some  it  has  lifen  considi-rcd  ax  the  result  ot'  extntvnsation  of  blood  into 
the  corpora  cavernosa;  by  others,  as  d(.>i>endent  on  itympathetic  or  reflex 
nervous  irritation.  The  t-Hi-ct  of  treatittent  would  lead  to  the  inference 
that  the  latter  view  was  correct.  Incisions  into  the  corpora  cavernosa  to  let 
out  the  blood  supposed  to  be  extntva.>!atcd  havf  lu^ri  |)riMhictivc  of  no  gi>od 
result,  whilst  the  ert-ction  has  rapidly  subsided  under  full  doses  of  the 
bromide  of  |><>la>4<ium. 

Oan^ene  of  the  Penii. — Sloughing  of  the  integuments  of  the  penis,  to 
a  greater  or  lesser  extent,  not  unfrctiucntly  occurs  in  jxTson^  of  bmken  con- 
stitution as  the  rt>sult  of  intlanimat'iry  pliinnuii!!,  simple  or  gonorrhiral  i  Fig, 
9.54 1 ;  <ir  in  coni)e<iueni.'<>  of  tlie  invafi'in  of  syphilitic  phaged:ena,  and,  indeed, 
the  glans  and  body  of  the  <>r;r:in  may  often  hv  extensively  dt-slroyed  by  the 
latter  cause.  These  various  forms  of  the  disease  have  been  <le*cribefi  in  dif- 
ferent parts  of  thi-<  work. 

The  true  iiliopniliir  ^iwirene  of  the  penis  is,  however,  a  very  rare  disease; 
and  Demarquay,  who  has  s|wciully  directed  attention  to  it,  finds  but  few 


FiK-  VJT.— Wart.-  <iii  (he  Olaoi 
nni)  inner  »urf«ce  of  Pre- 
puce. wliK-h  \»  clil  up. 

It  was  excised,  and  did 


1094 


DISEASES    or   TBB    PXNIS   AND  SCROTCH. 


instanocB  of  it  in  tlie  reciirds  of  eui^ry.    It  bai  chiefly  bvMi  mrt 
peoplf  of  nilvanceri  Ago  or  of  brukeo  ouutitation,  wbn.  nhi^ 
Bome  locfli  affection  of  tbo  orgnti,  hare  been   atucket) 
(liwiwe,  such  ait  typhoid  or  ^DiAllimx, or  have  Iwcume  the  Mtbt&cU  *ii  i 
In  80UII.'  cit#m  it  i^  jinyhnbly  emlxiUc.     The  (lt»es»«,  when  wmsiin^  ■ 
of  Ibp  p«nia.  is  iA\en  fatal — [>(»«iblr  bj  hem'jrrhags  no  tli«  ivjmnttioir* 
stough.     When  the  ginna  Duly  i»  Bttack«<],  the  proajMict  ii  boitiu. 
either  case — eBpectaUy  the  former — mutilatioD  of  U)«  orsfta  ta 
extent  miW  result. 

The  IVeahnent  of  gangrene  of  the  peob  preaeut*  oothio^  apectal.  w^l 
exooptioD  of  reslniiniDg  hemorrhage  by  ntetuis  of  ifae  actual  oaalery, ' 

Ereveuting  or  repairing  losEof  sobstaocein  the  arethral  wall,  if  it  beiai 
y  the  ilisease  and  inmtved  in  the  deetruction  resulting. 
'  Fibrous  XDmor  of  the  Penis. — The  penis  may  bo  the  arat  of  filuwl  i 
other  tumors.    The  accompanyitig  drawitig  (Fig.  05H)  ta  aa  Qli 


Flf .  m. — Fibroid  Tnmor  «f  lh«  PmiU, 
SneeeMlnll;  fidiDov*d. 


Pig.  u«— K|.tih«a.i 
•r  ta*  Pnu. 


one  springing  from  the  fibruus  tiEt>iie  of  Uio  corpora  eavcrvuM 
reniOTed  ttotuo  years  ago  from  thf  uiidt,'r  surface  uf  Uic  omB. 

Cancer  of  the  Penis. — The  Ctui  nf  (vnivr  mot  with  to  liM* 
Sqtiamtnu  EpHiirttoma.  It  Uftually  6pring»  fnmi  the  eulcus  bebisd  t&e 
and  lla^uce  invudcii  tbv  neighboring  porUon  (if  tlit-  organ.  It  alwan  o 
mences  in  t\w  anterior  oxtrrmilr  of  tbo  penis,  atTpcliog  the  body  of  the  m; 
only  by  txicnttion  from  the  original  i^tflrticg  ptiint.  It  apjiears  id  twn  fbl 
either  as  u  flat  tubrrcle  or  as  a  distiiu-ily  [mpillary  gruwib.  Whra  it  4 
n)eac««  as  a  tubercle  it  nppean  as  a  hanl.  pale,  recUlub-vbite  mam  Kim 
on  tfae  glans  or  between  tne  prepuce  and  the  glaoa.  This  i 
aiul  extends  deeply  into  the  orf^.  At  last  a  crack  ftirniA 
eerotis  discharge  to  exude  which  usually  becomes  very  fetid.  X 
ra]>idly  takM  place.  Somelimes  the  diseasA  ap|iear»  to  be  very 
localixed  ;  but  afler  its  removal  it  will  usually  be  foun*!  to  infiltraU 
for  a  considerable  distance. 

The  papillary  tVirm  ai  first  presents  th*  sppearatiif  i-f 
959).     It  grottg  rapidly,  and  a  deep-seated  luitorniMl  Iv  ^^ 

it.     Ulceration  Sixiti  sols  in  with  abuudsiit  tV'ni  r, ,,.     ,\i  gnfi 

Unction  fn>m  a  simple  growth  is  nut  easy  It*  :  \\  tb«  flal 

inflllraling  the  glsns  will  usually  indicate  its  nature. 


CAirCKR    or   THE    PKNI8 — TBBATXK.VT. 


1005 


r^Dccr  uf  the  penis  occiirrinj;  untler  a  Iddk  Toreskin  aono  tca<la  to  such 
CBUrgenicot  nf  toe  eIsm  that  the  prepuce  cannot  be  drawn  back.  It  then 
CUMCB  a  globular  rnTart^nipnt  over  which  the  skin  of  the  prcnuce  U  tif^htly 
■trotebed,  and  a  foul  »erf>uji  duobarge  often  tiDged  with  hfood  eacApea  fVotn 
the  on6cc.  FiDally  the  difltendeii  ^>r6Nkin  may  j;ive  way  And  the  tuB^Ung 
cancerous  gmwib  prnject  through  an  uiceratinfj  aperture  io  it.  The  ^and« 
in  the  ^oin  arc  parly  alTecte<l. 

tJbuM*. —  It  has  been  supposed  and  with  some  «how  of  reason,  thai  con> 
Moital  phimoiiiis  oredUiHises  to  tbeatl'ectioD ;  prubabty  b^  confining  th4  wore- 
Booa,  and  thus  Iceepin^  up  irritatioii  of  the  pari.  Uey  fuuod  that,  of  13 
|MU}«itJi  with  thb  dt««fte«  who  came  under  bin  ubeervaliou,  U  had  coogeitital 
phiiiioDtA;  anil  Travtrs  states  that  Jews,  who  are  circuinct»*>d,  are  Mtdom 
■utij<-rt  tt>  lhi«  atltx'tiou.  But  as  they  are  a  limited  cooirouDily  In  tbta 
country,  and  rm  the  diaease  is  mre,  we  cannot  draw  aiiy  coneluoive  iDfereiica 
from  thi«  obM^rvalioa.  It  is,  bontiver,  very  prubable  that  the  papil  lary  fono 
of  the  diseaae  oflen  »ri«e8  from  the  local  trrilatiua  resulting^  frum  tlie  avcuinu* 
latioB  of  the  aecretion  under  a  limg  foretikin.  The  nodular  furiu  of  ibe 
■fcniinn.  however,  may  occur  frequently  in  individual!!!  who  have  nut  suffered 
from  this  aourve  of  irritation  ;  of  this  I  have  »eeo  aevend  inntaiioes  at  Uni- 
venity  College  Huepital. 

IMaynon*. —  Kpilhelinmnof  the  penis  reqtiireflto  bedJagnoaed  frum /tmi;r/ul 
wart*.  Tbifl  may  iit^iially  be  done  readily  enough,  by  oompanng  the  iuda- 
laled  aute  of  the  malignant  with  the  soft  mod  lax  condition  of  the  Don> 
BMUifpiant  aHe<:tion.  Krom  ehanerotu  indmation  of  the  glaus,  the  htatory  of 
tkeeweand  the  way  in  which  it  ia  influenced  by  treatment  will  enable  the 
SornOD  to  effect  Ibe  diagnosis. 

mutmgnl. — The  treatment  of  cuioerof  the  penis  will  niry  according  to 
the  oature  and  extent  of  tht>  malignanl  aflbclion.  If  the  growth  is  limited 
IB  extent  and  especially  if  it  is  papiltarv  in  form  the  Burgeon  mav,  if  he  see 
the  ease  early,  content  himself  with  ditaecting  off  tbe  affected  patch.  SboaJd 
tlie  ptiwth  be  more  extensive  and  exte&d  deeply  into  the  subcUnce  of  the 
penis  the  treatment  must  be  conducted  on  the  priuciplea  tliat  guide  us  in  the 
swaagemeot  of  malignant  affections  wherever  situated  ;  vix..  to  remove  the 
4iee«sed  organ  at  as  early  a  ttage  as  pooaible,  whilst  the  affection  is  Iocalix«d, 
before  the  glands  are  implicate*!  and  the  cuuslitutioD.poisoned.  Id  the  pvais, 
this  may  reediljr  be  doue  by  an  operation  that  is  simple  ■□  ita  execution  and 
oearW  devoid  of  danger.  In  many  cases  a  return  may  take  place,  and  that 
iqiesaily,  either  in  the  iwrt  itself  or  in  the  neighboring  lymphatic  glands; 
jwt,  even  if  this  occur,  it  is  clearly  the  duty  of  toe  Surgeoo  to  rid  the  patient 
of  a  loathsoBw  disease,  aod  to  put  him  in  aalateof  c«>mparative  comfort  for 
some  time  ;  the  more  to,  as  there  is  rvasou  to  believe  liiat,  in  some  iuotitucva, 
the  disease  may  be  entirely  extiriwtetl  fn>ni  the  syrlem,  evincing  no  tendency 
to  return.  Indeed,  I  believe  that  amputation  of  the  penis  for  cancer  is  more 
BOCceasAil  in  Its  results  than  is  the  extirfietion  of  malignant  gntwths  frum 
most  other  situations.  In  some  uf  Hey's  casta,  which  continueii  under  his 
ohsenration,  there  was  no  rBCurrenoeof  the  disease  fiiraerernl  yean.  I  have 
•eea  several  patients  who,  after  a  lapse  of  rix  or  eight  years,  have  continued 
Aee  tnm  a  roeurrence  nf  the  disease ;  and  I  have  also  seen  a  gentleman  who 
had  his  psnis  amtmtaird  for  cancer  more  than  twenty-five  yean  ago,  and  in 
whom  DO  retam  ho*  ukrn  place.  The  fact  is,  that  we  see  and  hear  of  tboie 
OHea  in  which  a  recurrence  taketi  place;  bat  those  patients  who  remain 
free  from  a  nrtum  of  tho  affi>(;tii^n  do  not  ilivnlgr  iheir  iofirtntty  :  and  it  is 
noeedingly  rare  in  hnapital  practice  to  tlnd  a  patient  come  back  with  re- 
enrreat  cancer  in  the  slump  of  the  i>eni»,  which  he  would  cartainly  do  if 
relapse  took  place.     In  those  casoe  in  which  the  operation  b  out  sucoessful. 


1096 


DISKA&ES  OF  TES  TBNtS   AHD   aOROtlTlt. 


it  ha$  iifun1l<r  heen  delayed  too  long,  the  ducttie  hav!n|{  klrfadt  t 
the  lymiibalic  glands  in  the  ktoid,  and  thui  coDtAminatc*!  th«  patt 
fttitutioR. 

Ampatation  of  the  Penis  it  b«sl  perfonuod  with  the  knife,  tki 
£cra«<-ur  may  be  used  U'  preferred.     The  opeimtkw  abould  alwaj* 
formed  luwards  the  root  ot  the  orgao,  so  bs  to  bs  wdl  elvar  of  um 
Before  prooeodiog  Ui  operate  meuia  murt  be  taken  tn  nwtrain 
rbagc.    1\m  is  l^t  done  by  tyiug  a  aarmw  tape  ' 
the  pcuie,  ur  by  cncirclicg  ihie  [mn  by  Clover's  tou  i  r    _ 
as  in  circumcieion,  ouly  ucorcr  to  the  pubca  and  dkot  u^titiy. 

Uon  mav  bo  doue  in  various  ways,  hut  tbe  followinff  is  [irrliflfH  i     ^ 

any.     'the  pt-nis  Wing  rlrawii  well  forwards  a  circular  iDcUi(>D  if  nmie 
it  with  a  bistoury  dit-iding  the  skin  only.     The  mtpnra  ravenit«a  ar 
cut  carefully  tlimufih  from  ibe  doreal  lupcfct.  rtire  bfio^  takr'O  Dot  la 
the  corpus  spongiiwum.     If  Decenenry  a  full  siz^  caihf>i'>r  may  ' 
to  define  more  clearly  the  limita  nf  the  urethra.    The  part 
beyond  the  sectioa  of  the  corpora  cavemoea  being  drvwn  wd 
dimculty  will  be  found  in  Hparating  these  frum  the  rarpoa 
Finally  the  corpus  sponirf'isiirti  is  cvl  through  half  i" 
inch  nearer  the  glnns  than  ihp  Inriftinn  thruojjh  tht>  .'■■r, 
bleeding  in  then  arrested.     There  sre  usually  "  -ii»g 

the  dontales  neiii^,  one  in  eavh  corpui)  caverit  ih* 

In  securing  thf**,  trouble  is  not  unfre(]Hfnlly  ■ 

the  retmclion  of  the  stump  that  i«  l»ft.     The  •' i  ::nfff 

exists  if  the  tape  or  the  tourn'K|iiel  have  bcfa    prwprrly  applied  bcfim 
oporatiou,  ae  every  artery  should  bo  secured  befurv  tha  cnmp. 
vlT.     The  prujectiug  corpus  spoDgiosuni  aud  urethra  ars  tbca 

Eair  of  sciBsors  along  the  durval  aspect.     It  is  tbou  spraad  oat 
y  catgut  sutures  to  the  skiu  below  and  to  the  corpora  caTrmosa 
this  way  the  contraetioa  of  the  urethral  onSce,  which  i«  oftea 

Kuroe  of  inconveuieiiee  and  even  of  danger  to  the  pntit  nt  after  _  _^ 

of  the  peau,  otay  with  certuinty  be  prevented.  UUtoo,  vbo  fint  poieledj 
thenecesBity  of  providing  agiiin!^tlhinRcr)dei}t,rrconim«iidiid  tbattiw 
should  be  @lit  aloug  U»  under  «6|)ect,  but  if  ihia  be  dnnv  the  ori: 
dowDwnrds  between  the  legs  during  minuriLion.  whil«  if  the  alH  bs 
towards  ihc  dorml  aspect  it  ia  often  projected  eonwrwhal  fonrmrd,  uai 
pnticnt  can  thus  make  water  with  less  inconvenienoe.  Is  pcribraiaf 
operation  care  must  he  taken  that  the  skin  isnotdmnedioaBaiidifarvi 
lest  sufficient  covering  be  not  lefL  After  the  npcratioii  is  fiaiihed  tha 
spong)'  tiffluo  should  be  wiped  over  witli  a  solation  of  cfaloride  of  dM  i 
40  to  3j),  and  the  stump  must  he  covered  with  a  piece  of  lint  n 
boradc  acid  or  snme  other  anlise|)tio.  After  pA«iD^  vmter  the  puia 
be  well  bathed  with  some  antiseptic  solution.  In  thu  wajr  Mptie  i 
which  may  readily  occur  in  so  spongy  and  vaacnler  en  orgas^ 
prevented. 

If  the  amputation  be  performed  too  high  Qp,  infiltraiion  of  nriiw 
place  into  thi-  it^roluni.  and  to  prevent  this,  it  may  be  safer  to  in 
elastic  catlit^ler  after  the  operation,  and  leave  h  in  f>>r  a  fern  day*. 

When  the  "icmw-ur  i»  used,  it  19  belter  to  .!■      ■  ftkin  and  I 

8t>ongioeum  with  the  knife,  the  corporu  cavvm     <         ,  being  eut 
the  wire.     There  if,  however,  tittle  if  any  advantafjv  lo  be  gained 
of  this  itistruiiient,  unless  there  is  any  special  reaaon  Tt  nvi>idii)f 
bloud,  as  hemorrhage  is  not  usuallv  a  serious  iroublv  ii  atkm 

If  the  glands  in  the  groin  arv  dUtiuctly,  but  nol  Uiu  b-  — •■  .>  • 


HYPERTROPHY    OF    THE    SCROTUM.  1097 

attempt  should  be  made  to  remove  them  at  the  same  time  as  the  amputation 
of  the  peuis  is  perfurmed. 

Id  a  case  extending  too  far  back  to  allow  tht  performance  of  the  ordinary 
operation,  Pearce  Gould  successfully  remuvt'd  the  disease  hy  dividiug  the 
scrotum  and  dissecting  away  the  whulc  organ  »3  far  back  as  the  crura, 
leaving  an  opening  iu  the  perineum  through  which  the  patient  subsequently 
passed  water. 

If,  after  amputation  of  the  penis,  much  iuuonvenieiice  arif^es  from  the  urine 
being  paused  downwards  between  the  legs,  it  niuy  best  be  avoided  by  follow- 
ing Ambnise  Park's  advice  of  adapting  a  funnel,  which  may  be  made  of 
metal,  or  ivory,  to  the  pubca  over  the  stump,  and  thus  currying  the  urine 
clear  of  the  person. 

Other  Tumors  besides  cancer  are  occasionally  met  with  in  the  penis.  I 
have  seen  Cystt  and  .Yixiii  situated  under  the  prepuce;  and  Fibroiu  Tumors 
may  occur  in  the  corpora  cavernosa.  Such  morbid  growths,  if  small,  can 
readily  be  removed  without  injury  to  the  rest  of  the  organ ;  if  large,  they 
may  require  itA  amputatioo. 

DL<iEA8E8  OF  THE  SCROTUM. 

Inflammatory  (Edema  of  the  scrotum  is  an  erysipelatous  inflammation  of 
tbis  region,  and  derives  its  chief  peculiarity  from  (he  circum!>t»nce  of  its 
giving  rise  to  great  effusion  into  and  swolliiig  of  the  areolar  tif^ue  of  this 
part  and  of  the  penis,  with  a  tendency  to  the  rapid  formation  of  slough  in  it, 
fey  which  the  integument  may  likewise  become  aflected  to  such  an  extent  that 
the  testes  and  cords  siJeedJly  become  denmied.  This  disease  usually  origi- 
nates from  some  local  source  of  irritation,  as  figures,  cracks,  or  urinary 
extravasation.  There  is  a  peculiar  and  specific  form  of  "  inflammatory 
cedema"  of  the  scrotum  and  penis,  which  is  apt  to  occur  as  a  sequence  of 
■mallpox  and  scarlet  fever.  In  this  form  of  the  di^'ast'  rapid  and  exten- 
sive iufittratioD  of  the  parts  occurs,  with  a  tendency  to  s]H>cdy  gangrenous 
diaorganizatioD  of  the  areolar  tissue  and  ekiu  aivering  the  organs  of  genera- 
tion. 

Treatment. — This  consists  in  elevating:  the  scrotum,  fomenting  it  well,  and 
making  early  and  free  incifiona  into  it,  |)articularly  at  the  posterior  and 
dependent  parts  of  the  scrotum  and  penis,  with  the  view  of  relieving  the 
tension  to  which  the  tissue  iit  suhjected  by  the  effui-ion  into  its  meshes,  and 
thus  preventing  the  liability  to  i>l<mgh.  Should  this  occur,  thi*  case  must  be 
treated  on  ordinary  prind|)los,  when  cicatri/.atii)n  will  sjiecdily  ensue,  how- 
ever extensive  the  denudaliou  of  parts  may  be.  Tlic  constitutional  manage- 
ment must  always  he  conducted  in  iiccordanoe  with  those  principles  laid 
down  in  the  first  division  of  this  work,  and  with  s[>eeial  attention  to  the 
maintenance  of  the  patient's  strength. 

Hypertrophy  of  the  scrotum  seldom  occurs  in  this  country,  thou^rh  Liston 
once  had  cu'casion  to  remove  such  a  mass,  wrighinu  44  lbs.;  but  in  some 
tropical  regions,  particularly  India  and  China,  it  [*  of  fre<[uent  occurrence, 
ana  may  go  ou  until  it  attains  an  enormous  bulk,  lorming  a  tumor  nearly  as 
large  us  the  trunk,  and  |>erliaps  weighing  70  or  >^0  tbs..  or  even,  as  in  one 
case  recorded  by  I^arrey, 'iOii  lbs.  Thesi>  fnormous  growths  are  of  simple 
character,  and  constitute  the  dist^ase  tt'rmiil  Klephnntiaxii  Artihum  of  the 
serottiiii.  iSet*  vol,  i.  ]>.  !I44.)  Fig.  'Mi)  ri-j)r»'s*-uts  a  tumor  of  tliis  kind, 
weighing  40  lbs.,  which  was  succcvstully  nni'iviii  Ity  lingers,  of  the  Mauri- 
tius. It  is  taken  froiti  a  photograph  of  the  eas<'.  kindly  sent  lo  me  by  that 
gentleman. 


1096 


VISBASKS   OF    TUE    PKNIS    AVV   SCIl*^ 


It  lias  usuallv  l>eeu  delayed  too  Uinp,  tbe  diKaae  br 
the  lyinpliBtic  glBiida  in  thv  groiu,  aotl  tbui  cvOUl'  , 
etituiion.  JF    2 

Amputation  of  tlie  Penia  ui  bwt  pcmtra^r'     I 
4cra«fcur  umy  be  used  if  pniferrt-d.     Tbo  O' 
formed  towards  the  root  of  the  orgao,  to  r 
Before  pn>coeding  to  operatu  umwub  iniul 
rhagc.     Thu  is  best  done  by  triti^f  ft  or 
the  pcuis,  or  by  encirotin^  tnia  part  hy 
EH  iu  circumcision,  only  tiearcr  to  th' 
tinn  m&v  b«  done  in  mriotu  wavB. ) 
anr.     'the  pt-oU  beioe  drnwn  wel' 
it  with  a  biflioury  dividinp  the  a' 
cut  itard'ully  through  from  tho 
tlie  corpus  spongioBum.    If  n' 
to  defiuc  more  clearly  the 
bevoD<l  the  9vcLiou  of  th« 
di&cultv  wilt  be  found  ' 


bleeding  is  Lhun  arrer        _j  ^^^|^V  -  ^|  Vi 

the  dorsale*  oenli,  0 

Iu  eecurint'  thest, ' 

the  retracii'.tu  of  ' 

axiste  if  the  tap 

opemth)ii.  an  e-         Ftf.  ««u,— mtpbultailioC  tb«8et*l«». 

off.       Vrr    1 

.rmll  iu  1844.    The  patioal  Iving  <ici  hb  hack  and  bar 

.ilioTC  the  level  of  the  bnly  for  an  boor  bafon  tlw  ap 

mny  at  tht.*  Nunc  time  be  banda)^  M  >a  to  compr^ 

^M  empty  them.    This  method  doea  not  prtTwit  die  pna 


K 


mfll  hemorrho^  may  be  prevented  by  oo«  of  tbe  IbUav 


If  ol 

V 

llll- 

eourci- 1 
of  thf 

th'    I 

"biii       ....        ,   , 

^fy    ^£.  ^ipIttAtitiD  of  the  aortic  oomprcvsor. 

^^       '  ^^n-li'a  bnndagf. 

lidLtioiiof  ascrew-comprewor  to  the  ruuC  of  tbv  tunor. 

it  Lbt  other  methotLi  may  Vie  rnnj<>ine<l. 

'».  »!»•  uf  the  compresBor  It  especially  inivi.icated  by  Dr.  Tamer,  a 

^H>ry  at  Sunioa,  who  ha«  bad  vMl  focperieuce  in  tbt*  u|*eratkra, 

,rr>J  D'l  fewer  than  l.'tfi  of  tbp«e  tunion.     The  clamp  iieed  by  DrJ 

^^^f  of  cu'o  |Mirallol  hai-9  of  sufficient  leuiftb.  united  by  twu  long 

^•*  -.> Miked  by  uuLs.     After  tbe  tumor  haa  been  nuanl  and  cmptM 

Ik'  compreMor  is  applied  to  th«  neck  and  scrowad  doBu  ttgflt,^ 

itirm  ia  pn>oeede<l  uilli. 

ffi«:  ilircctioDfl  i^veii  by  Hr.  Turner  for  the  «afe  |MsrfonnaiHi! 

^fix  are  as  follows :  Tbe  patient  having  bc^u  anntbetixed.  Uie  el 

the  tumor  emptied  uf  its  blooil  by  piraiure,  the  damp  Must  1m 

le.     Tlie  tuuior,  if  small,  mar  tbeti  be  raised  by  tbe  bawb  :  if  I 

hooks  sboulit  be  passed  deeply  into  tbe  leatbefy  akin  at 

beiu|{  attached  tu  a  block  and  uit-kle  jixed  to  the  ceiling,  lb«  w 

lUet  be  raised  so  that  its  jiusterior  jutrl  in  bn>ii};bt  into  naw.    A 

ikiu-flape.  about  1)  inch  luu^^,  arc  tncn  made  here  at  li-  '"^-^ 

is  then  lowerod  and  alloweil  U)  fall  forwani.    Two  or  -i 

now  to  be  made  from  the  front  and  aides  of  the  tumor,  t»r  irout  dftprl 


tbe 


'HALPOSITIOlf   OP   THB   TB8TI8.  1099 

■  * 

'■-;.  ''nis  when  Hiasccted  out ;  one  should  be  of  Bufficient 

'^';  ''iteral  flaps  are  intended  to  cover  in  the  testes. 

>).    '',  *  fur.    In  amalt  tumors,  where  it  lies  super- 

.;,.  ■,       '  V         *  "Pr  ones,  where  deeply  buried,  it  is  best 

;v' ',  ■  '"nmgh  which  the  urine  escapes,  goinj; 

_^-»;.  ■  -fctinp  out  the  organ,  which  should 

"H".'     ■        .^  „  ■■•«  are  now  to  be  Bought  for  by 

'",  '  .i  ^  ^^ "  they  must  be  cleared  and  the 

-^        ','..,  '  ;fe  this  mass  is  now  remove*!. 

*'-4,      "'..  *   „  '—may  require  ligature  in  the 

*-^-i.        '■  >.  '     _  iually  looseDed.     Theskin-flapa  are 

s.  ^i  *'*  -,  \  '  .  "•  ^f"^  testis,  and  the  wound  treated  OD 

y-^  H^'  .■'    ,  '    '  \  <iia  object  bi  the  formation  of  skiu-flaps 

—      ^  '  ■*       •  _  .!■  penis  and  testis,  as  tending  to  favor  recur- 

"^''^  '-•/<-  .'-  ^    ■  us  Dr.  Turner  very  truly  remarks,  the  skin  od 

"^'^^    '  „enerally  healthy,  being  merely  dragged  down  from 

i^         '''"»'  .otum. 

^"^  ..dionaUy  affects  the  scrotum  ;  and,  as  it  occurs  principally 

"ti^   ^  ^pen,  it  has  been   appropriately  enough  termetl   Chimney- 

^  >eer.     This  aflTection  appears  to  arise  from  the  irritation  of  the 

iig  ID  the  folds  of  the  scrotum  (vide  vol.  i.  p.  976\    It  commonly 

dces  as  a  tubercle  or  wart,  which  after  a  time  cracks  or  ulcerates, 

ontiog  the  ordinary  characters  of  a  cancerous  ulceration.    It  rapidly 

^mt/in,  tovolving  at  last  the  greater  part  of  the  scrotum,  and  perhaps  in- 

nding  the  testis.    After  a  time,  the  inguinal  and  pelvic  glands  will  be 

|r    aflbcted ;  and  the  patient,  if  deprived  of  his  covering  of  soot,  will  be  found 

['    to  be  cftchectic-looKing. 

r  ^e  H^aimenl  consists  in  excising  widely  the  diseased  portion  of  the 
tewtum,  provided  the  inguinal  glands  be  not  involved,  or  the  patient's  con- 
atftDtion  poisoned.  The  disease  has  a  great  tendency  (o  return,  and  it  is 
■ddom  that  the  patient  long  escapee  with  life  when  once  he  has  been  affected 


CHAPTER    LXXIV. 

DISEASES  OP  THE  TESTIS  AND  COKD. 
MALPOSITION  OF  TUE  TESTIS. 

Tbk  testes  are,  in  the  fcetus,  lumbar  organs  tying  below  the  kidneys,  and 
in  the  normal  condition  d^cend  into  the  scrotum  a  short  time  before  birth. 
"Fnm  some  arrest  of  development,  this  descent  may  be  retarded  on  one  or 
hoth  sides;  and  in  other  instances  it  is  never  completed.  An  undescended 
testis  may  continue  to  lie  within  the  cavity  of  the  abdomen ;  or  it  may  find 
its  way  into  the  internal  ring  ;  or  may  become  engaged  in  the  inguinal  canal, 
lying  above  the  external  abdominal  ring,  or  it  may  project  just  beyond  this, 
Mt  passing  into  the  scrotum.     In  these  several  situations  it  may  remain 

Sicacent;  but  it  may  become  the  seat  of  inflammation  or  of  new  growths, 
sple  or  malignant.    It  may  also,  when  undescended,  as  has  been  stated  at 


1098 


nsEASES  or  rne:  pskis  anl>  sckotu! 


Treaiment. — Tviniore  of  this  kind  necTtuarily  requirp  rxlirpaboD. 
foriniDg  ibis  operation,  two  points  ini|>eratirel7*deinAti>l  ntuoitioti.    Tk*^ 
is  the  avoi<)uuce  of  hemorrhajje,  which  in  90  vOM-ulor  a  refpoa  mijcUj 
b«  fata).     The  otb«r  in  the  preservntion  of  the  penis  aud  bjalc*. 

The  Bvoidnuce  of  hemorrhage  may  He  eftected   by  f»ur  mHlioda,! 
may  b«  employed  eiogly  or  combined.    TbeM  are,  1 ,  by  poviltaD.a* 


=.<- 


Fig.  fM.— Rttf>b>&tlMli  of  lb*8«rataK. 

advocated  by  O'Fcrrall  ia  1844.    The  patient  Irlng  oo  h$>  hmA  and  _ 
the  tuiDor  raided  above  the  level  of  the  body  Jbr  an  hour  befive  the< 
tion.     The  tumor  may  at  the  lamc  time  be  bandaged  lo  aa  to 
TCMeU,  and  thus  empty  tbem.    Tbii  method  doea  not  proreal  the 
bemorrhnge. 

This  proximal  hemorrhage  may  be  prevented  by  one  of  tlie  foE 
methods: 

1.  The  app[it;atioii  of  the  aortJo  compressor. 

2.  I'^niarch's  bandage. 

3.  The  applieation  of  a  Krew-oom  pressor  to  the  root  of  the  tumor.    Thai 
and  either  of  the  other  methods  may  be  conjoined. 

The  use  of  the  compressor  is  especially  advocated  by  Dr.  Tomer,  a 
miniooary  at  Kamoa,  who  has  had  vast  experience  in  this  operatirto, 
removed  no  fewer  than  1!J8  of  these  tumors.  The  clamp  useil  by  [>r. 
OMUtsts  of  two  [>ftrallel  bars  of  sufficient  length,  unitctl  by  two  Iodj;  u] 
screws  worked  by  nuts.  Afler  the  tumor  has  been  mi^ed  and  emptied 
blood,  the  compressor  is  applied  to  the  neck  and  screwed  dova  tigbti 
the  n)>eratioa  is  proceeded  with. 

The  directions  given  hy  Dr.  Turner  for  the  safe  perfimnaDce 
tion  are  as  follows :  The  patient  baviug  been  annstfaatlSHl,  the  <  ' 
and  the  tumor  emptied  of  its  blood  by  praaare.  the  damp  muic 
home.    The  tumor,  if  small,  may  then  be  raised  by  the  bands  :  if  I 
lar^e  hooks  should  he  passed  deeply  into  the  l«aUiery  skin  at  the 
and  being  attached  to  a  block  and  tackle  fixed  to  the  oeiliog,  the  whc 
must  be  raised  an  that  its  posterior  part  is  brought  into  view.     A  o(  . 
ekiu-Aapa,  about  1 1  inch  long,  are  then  made  here  at  iu  neck.     Tb« ' 
is  then  lowered  and  allowed  to  fall  forward.     Two  or  ihrM  dtii 
now  tn  be  mule  from  the  front  and  tides  of  the  tumor,  the  front  flop"' 


XALPOaiTION   OF   THK   TK8TI8.  1099 

intended  to  cover  in  the  penis  when  dissected  out ;  one  should  be  of  sufficient 
nte  for  this  purpose.  The  lateral  flaps  are  intended  to  cover  in  the  testes. 
The  penis  must  next  be  sought  for.  In  small  tumors,  where  it  lies  super- 
ficially, it  is  easily  found.  In  larger  ones,  where  deeply  buried,  it  is  best 
reached  by  slitting  up  the  aperture  through  which  the  urine  escapes,  going 
in  search  of  the  gfans  penis,  and  then  dissecting  out  the  organ,  which  shoulct 
be  held  up  against  the  abdomen.  The  testes  are  now  to  oe  sought  for  by 
eotting  diagonally,  and  with  finger  and  knife  they  must  be  cleared  and  the 
oorda  followed  up.  fiy  a  few  strokes  of  the  knife  this  mass  is  now  removed. 
A  large  number  of  vessels— from  30  to  40 — may  require  ligature  in  the 
■tnmp ;  they  are  tied  as  the  clamp  is  gradually  loosened.  The  skin-flaps  are 
then  brought  together  over  the  penis  and  testis,  and  the  wound  treated  on 
ordinary  priucipfes.  Some  Surgeons  object  to  the  formation  of  skin-flaps 
with  the  view  of  covering  in  the  penis  and  testis,  as  tending  to  favor  recur- 
rence of  the  disease.  But,  as  Dr.  Turner  very  truly  remarks,  the  skin  on 
the  neck  of  the  tumor  is  generally  healthy,  being  merely  dn^ged  down  from 
the  parts  above  the  scrotum. 

Epithelioma  occasionally  affects  the  scrotum  ;  and,  as  it  occurs  principally 
in  <iimney-sweepers,  it  has  been  appropriately  enough  termeti  Chimney' 
noetper'a  Cancer.  This  affection  appears  to  arise  from  the  irritation  of  the 
•oot  lodging  in  the  folds  of  the  scrotum  (vide  vol.  i.  p.  976).  It  commonly 
commences  as  a  tubercle  or  wart,  which  after  a  time  cracks  or  ulcerates, 
presenting  the  ordinary  characters  of  a  cancerous  ulceration.  It  rapidly 
spreads,  involving  at  last  the  greater  part  of  the  scrotum,  and  perhaps  in- 
Tftding  the  testis.  After  a  time,  the  inguinal  and  pelvic  glands  will  be 
mfiected ;  and  the  patient,  if  deprived  of  bis  covering  of  soot,  will  be  found 
to  be  cachectic-looking. 

The  JVeatment  consists  in  excising  widely  the  diseased  portion  of  the 
•erotnm,  provided  the  inguinal  glands  be  not  involved,  or  the  patient's  con- 
■titntion  poisoned.  The  disease  has  a  great  tendency  to  return,  and  it  is 
•eldom  that  the  patient  long  escapes  with  life  when  once  he  has  been  affected 
by  it 


CHArTER    LXXIV. 

DISEASES  OP  THE  TESTIS  AXD  CORD. 
MALPOSITION  OF  THE  TESTIS. 

The  testes  are,  in  the  fcetus,  lumbar  organs  lying  below  the  kidaeys,  and 
in  the  normal  condition  descend  into  the  scrotum  a  short  time  before  birth. 
From  some  arrest  of  development,  this  descent  may  be  retarded  on  one  or 
both  aides;  and  in  other  instances  it  is  never  completed.  An  undescended 
tMtu  may  continue  to  lie  within  the  cavity  of  the  abdomen ;  or  it  may  find 
ill  way  into  the  internal  ring ;  or  may  become  engaged  in  the  inguinal  canal, 
lying  above  the  external  abdominal  ring,  or  it  may  project  just  beyond  this, 
not  paaing  into  the  scrotum.    In  these  several  situations  it  may  remain 

Sicacent;  but  it  may  become  the  seat  of  inflammation  or  of  new  growths, 
iple  or  malignant.    It  may  also,  when  undescended,  as  has  been  stated  at 


1100 


DI3EA3K8    OF    THE    TESTIS    AND    OOnU. 


p.  791,  v»l.  ii.,  become  itinipltnittH]  nitli  i>r  mistaken  for  &  bernift,  am)  msy 
[>r<«eiit  mniiy  iliajriiimtit;  diHirultk't).  JutlaiimiatiDU  of  the  tcstU  retaiu«^  in 
the  canal  will  be  c'ltitiidfrivl  til  |>.  1101.  When  aa  uoileeouuJec)  tetUB  be- 
comes puintiil  iir  the  ecal  of  structural  dii^ease,  it  may  require  removal  frwiB 
the  Ciinal.  The  teati?  niuy  he  met  with  in  other  ahn'trmnl  eittiationa :  tbtn, 
some  time  ago  I  saw  a  case  in  which  one  of  chede  organs  was  uiuatetl  id  the 
perineam,  cioee  bj  the  anus,  having  tippaKntl^  missed  the  8cr"tum;  and 
cases  have  occurr^  in  which  they  have  t>een  met  with  ia  the  iotennr  of  the 
pelvis.  The  organ  mayaometimeB  be  turoetl  himlside  forwards,  being  retro- 
vertetl.  so  that  (he  epididymis  is  placed  in  froul.  In  n  cnsc  of  this  kind 
which  I  had  an  opportunity  of  examining  after  df-ath,  a  fc-w  years  ago,  the 
epididymis  and  vas  deferens  were  coosidernbly  li)r;^or  than  natural.  If  a 
hydrocele  form  in  such  a  ca«c,  it  will  be  seated  behind  the  testis. 

There  is  a  very  important  question  connected  with  lualpoaition  of  the 
testis,  viz.,  Is  the  organ  when  undescended  prolitie?  There  is  rca&on  to 
believe  that  it  is  not.  Such  testes  arc  small,  hard,  and  grnuular  in  sirucLure; 
and,  wlivii  tiiey  Bn>  exatniiied  under  the  microscope,  spermatozoa  are  not 
found  in  them.  AVbeu  only  one  testis  ia  undescended,  the  other  one,  being 
in  it«  pro|>er  position,  carries  on  the  functions  of  the  two  organs;  but  when 
both  testes  are  retained  in  the  canal  or  in  the  abcbmen,  being  nodescended, 
the  individual  who  is  the  subject  of  such  malposition  will  most  probably  be 
sterile,  lie  may  have  the  usual  en>tic  feelings,  full  power  of  erection,  and 
of  emission  of  a  spermatic  fluid  ;  but  the  secretion  will  probably  have  no 
fecundating  power.  In  the  event  of  it  being  necessary  to  determine  this  point 
with  certainty,  the  examination  of  a  drop  of  this  fluid  under  the  microsct^ 
will  demonstrate  the  presence  or  not  of  spermatozoa,  and  so  decide  it. 

Trtalvienf. — In  nio»t  cat^e,  a  misplaced  testis  calls  for  no  treatment,  in 
children,  the  application  of  a  horscflhoe  tras«  above  it  may  aid  id  il«  descent 
when  it  liiis  immediately  outside  the  ring,  but  its  otfcctis  eomcwhal  doubLful. 
Any  attempt  to  bnn»  the  K-iiticle  down  lutu  the  scrotum  would  be  tneilectual. 
for  in  tliese  ca«es  it  will  be  found  that,  although  iho  va«  deferens  u  usually 
long  and  lax,  the  vci^mjU  are  too  short  to  allow  iif  any  further  displacement 
of  the  gland  dnwnu-arda.  A  icstielo  in  the  groin  may,  however,  \m  so  serious 
a  source  of  inconvenience,  as  ui  call  for  eome  opemtion  fur  its  relief.  This 
moat  commonly  arises  when  it  lies  in  the  inguinal  canal.    In  these  ca«es  the 

f^land  may  nncjuionalty  bo  forced  into  the  external  ring  and  jtartly  strangu- 
ated,  causing  intense  {fain  till  it  is  reiluceil.  Under  these  circum-itanceB, 
the  ring  may  bi>  closwtl  by  suture,  ns  in  the  radical  cure  of  hernia,  or  the 
eland  may  be  rerno^-*^.  The  latter  h,  perhaps,  the  preferable  operation,  as 
being  the  more  certoin. 

When  the  testicle  hun  mtnsod  the  scrotum  and  paased  into  the  perineum, 
it  may  be  a  gnuit  source  of  pain  from  the  frequent  injurit^  to  which  It  Is 
exposed  in  fiitting.  As  in  these  case*  the  cord  is  of  Mitfic-ieiit  length,  the 
testicle  may  be  put  into  its  proper  position  without  great  difBcully.  tt  mnst 
be  rlitaefi^^l  .mt,  and  left  attached  hy  th«>  cord  only.  An  tnci«iioti  is  ihefl 
made  into  tho  scr.itiim,  the  testicle  placed  in  iu>  proper  piMlion,  and  s^?<rurrd 
by  a  catgut  stitch.  The  details  of  the  operation  must  nccesMirtly  vary  with 
the  abnormal  position  from  which  the  gland  has  to  he  removed. 


^ 
I 


A'EUiLiLOIA  OF  THE  TE8Tt8. 


A  painfbl  or  irritable  condition  of  the  testicle  may  occor  without  any 
actual  disease  of  the  organ ;  the  pain  being  seated  either  in  the  cpididraiii. 
which  is  the  part  naturally  the  mnnt  tender,  in  the  body  of  the  teotukor 
stretching  along  the  cord  to  the  loins  and  groins.    It  is  usually  paroxyimat, 


J 


INFLAMHATIOy   OF   TU£   TESTIS — SYMPTOMS.  1101 

and  is  accompanied  by  great  teoilenieM,  and  commonly  by  some  fulnees  of 
the  organ,  which  teela  soft  and  flaccid;  but  it  is  difficult  to  make  a  proper 
examination,  on  account  of  the  agony  that  is  induced  by  touching  the  part. 
This  disease  occurs  chiefly  in  young  men  of  a  nervous  and  excitable  tem- 

Serament,  and  is  frequently  associated  with  great  mental  disquietude  and 
Mpondency,  uilen  amounting  to  a  suicidal  tendency. 

1  he  Causes  are  obticure ;  in  many  codcs  the  disease  appears  to  be  connected 
with  a  neuralgic  temperament,  but  in  others  it  is  associated  with  some  dys- 
peptic disorder,  ur  may  be  dependent  upon  local  irritation ;  thus  external 
piles,  or  the  pressure  of  a  varicocele,  will  otlen  give  rise  tu  it. 

The  disease  is  usually  of  a  very  chronic  character.  In  some  instances, 
however,  it  ceases  spontaneously,  atler  having  lasted  for  weeks  or  months. 

Treatment. — When  the  neuralgia  is  depenrtent  upon  constitutional  causes, 
the  treatment  is  extremely  unsatiafactory.  The  administration  of  tonics, 
Bach  as  iron,  zinc,  or  quinine,  the  local  application  uf  sedatives,  as  of  atro- 
pine ointment  or  the  tincture  of  aconite,  may  be  of  service.  In  other  cases, 
oold  bathing  or  douching  will  be  beneficial ;  anil,  in  all,  keeping  the  part 
supported  with  a  suspensory  bandage  will  be  advantageous.  In  the  event  of 
there  being  any  local  irritation,  that  should  be  removed  ;  thus  I  have  known 
the  disease  to  cease  after  the  excision  of  external  piles;  and  when  it  is  con- 
nected with  varicocele,  proper  measures  must  be  adopted  for  the  relief  of 
that  aflTectioQ. 

In  extreme  cases,  Sir  A.  Cooper  recommends  castration ;  but  such  a  pro- 
ceeding is  altogether  unjustifiable  in  a  disease  that  is  either  constitutional,  or 
dependent  on  local  causes  which  are  readily  removable. 

INFLAMMATION    UF   THE   TESTIS. 

Infianunation  of  the  Testicle,  consi<Iering  the  organ  as  a  whole,  may  be 
of  two  distinct  kinds,  varying  as  to  seat  and  as  to  cause.  Thus  it  may  be 
Mated  in  the  body  of  the  organ,  constituting;  OrchitU;  or  the  epididymis 
may  alone  be  affected,  constituting  Epididymiiit.  As  to  cause,  it  may  be 
rheumatic,  traumatic,  or  gonorrhceul,  or  may  occur  as  a  sequela  of  mumps. 

Aoute  Inflammation. — The  Seat  of  the  intlamnmtion,  at  the  commence- 
ment  of  the  disease,  depends  greatly  U]>on  the  cause,  which  may  be  in  the 
urinary  passages  or  elsewhere.  Irritation  iu  any  i>art  of  the  urethra,  iwca- 
■ioned  by  the  passage  of  in8trumeiitj>,  by  the  Icxlgement  of  calculi,  or  by 
gononhwal  inflammation,  usually  causes  the  epididymis  to  be  primarily 
afiectcd,  and  the  body  of  the  or^an  to  be  inflamed  in  a  secondary  manner. 
When,  on  the  other  hand,  the  inflnniniatiou  comt-s  on  from  injuries,  blows, 
strains,  or  other  cimw.-*  acting  on  the  teeitii*  as  n  whole,  the  body  is  usually 
first  afTfCted.  To  alt  this,  however,  exception:*  will  often  occur ;  an<l  orchitis 
may  supervene  as  the  result  of  gonorrho-a,  or  epididymitis  from  a  blow. 
The  orcliitis  in  such  ca^cs  i^  in  all  probability  a  kind  of  constitutional  aflec- 
tion,  intimntely  oi'soc-iateil  with  intlanimation  of  other  tibrous  tissues.  es|)c- 
ciallv  with  gonorrhu-al  rheunintism ;  the  inflamnintion  of  the  epididymis, 
arising  from  gonorrlm-a  or  other  irritation  of  the  urinary  pat.-'age,  apjieuring 
to  result  from  din-ct  extensiim  of  the  morldd  prtn-ess  along  the  vas  deferens. 

SymptomH. — These  neceij«irily  vary  to  a  certain  extent,  not  only  acc»>rding 
as  the  flisease  is  of  an  acute  or  of  a  ehn<nic  chararter.  but  as  it  primarily 
affects  the  b<Mly  erf  the  testi!"  or  the  cpididymi.".  When  it  commences  in  the 
latter  stniutun',  it  is  the  inferior  globii.'i  that  is  conini'mly  first  aOi-cted,  which 
becomes  swollen,  hanl,  anrl  tender.  The  diseaMC  may  t)e  confined  throughout 
to  this  i>art ;  but  most  fre<iuently  it  invmleif  the  wiiole  of  tin*  organ,  which 
becomes  uniformly  enlarged  and  .xomewbut  ovoid ;  it  i:>  frequently  accomj>anied 


1102 


DISEASES   OF   TUE    1ESTI8   AND    COBD. 


br  a  good  deal  of  effusion  into  the  tunica  vngioali!!,  then  coiutiUilinK  tk* 
Amie  Jljfdrocefe  of  Velpeau.  As  Uie  tiitlaiiitimtinn  subttidee,  the  Jilli-Tval 
clinrncters  preeented  by  the  enlargement  of  the  two  eonrtitueotfl  of  the  organ 
Rgaiu  becc-me  apnareat.  The  Bwelling  la  therefore  due  partJr  to  geoeral 
eulargenieut  of  tne  organ,  but  iu  some  cases  to  inflatumabory  effusioo  into 
the  tuiiicn  vaginalis;  and  this  exudation  may  either  be  purely  serous  or 
partly  coagulable. 

The  pain  ia  always  very  severe,  with  much  teoderneei  and  a  senaation  of 
weight,  and  commonly  extends  up  the  cord  into  the  groin  and  loio.  It  it 
generally  greatest  when  the  body  of  the  tcstia  is  affected,  owing  probably  to 
the  eoveloping  librous  tunic  preventing  the  expansion  of  the  organ,  lienoe 
it  is  oiWn  spasmodic  and  paroxysmal,  extending  up  the  course  of  tbe  cord. 
There  arc  usually  considerable  swelling  and  redoes^  of  the  scrotum,  with 
turgeaccace  of  the  scrotal  veins,  and  a  congegtod  state  of  the  oord,  with 
sharp  pyrexia,  nausea,  and  perhaps  occasionar  vomitJog. 

Ab  Uie  diMisse  subsides,  the  body  of  the  toatis  first  resumes  its  DorauU 
character  and  shape,  the  epididymis  often  continuing  hardened  and  enlarnd 
for  a  coQsiderable  period.  In  fiict,  the  induratiou  that  forms  in  the  e|Maid- 
vmid  may  he  permnDouC,  implicating  the  whole  or  a  portion  of  its  cuiTo- 
lutiotu. 

Oosselio  has  shown  that  this  iuduration  of  the  epididymis  following  in- 
jlammaiiou  frcqueutly  cauaca  complete  obstruction  of  the  canal,  and  if  oeeur- 
ring  on  both  Aidva  pruduc-ca  sioriliiy.  In  1  ^J  such  cnaes  he  found  spermatutea 
ab<<ent  from  the  semen,  and  the  paticnui  consequently  incapable  of  proer«a- 
tion,  although  the  appearance  of  the  testes  and  of  their  .<»ecretion  was  scareelr 
altered,  and  the  virile  pnwcns  of  the  patients  remained  imimpairtKl.  Curl- 
ing also  mentions  Bcvcrul  auch  rases,  and  poinU  out  the  nerwAsity  of  cootlnu- 
ing  the  treatment  of  epididymitis  until  the  last  trace  of  induration  hat  dis- 
apfneared.     At  a  later  period,  lr«iitmeut  is  almost  useless. 

SubacQte  Orchitis  ui^onlly  comes  ou  with  the  same  symptoms,  though  in 
a  less  marked  furm  than  in  the  ncute  variety.  The  swelling,  however,  is  oon- 
stderabie,  thuugli  of  a  nutlet  kind.  When  the  disease  is  chronic,  tbe  testis 
otien  becomes  permanently  enlarged  and  hardened,  aoauming  an  oval  shape, 
beiug  smooth,  Jieavy,  and  uuifoimly  expanded,  with  a  eeusatiuu  of  wetsut, 
dragging,  and  severe  |>niu,  and  a  good  deal  of  teuderneeH  uu  preainre.  This 
form  of  orchitis  yccasiuually  occurs  in  old  people. 

Orchitis  may  occur  idiupathically,  without  any  aseigaable  cause  in  the 
way  of  exU;ruat  iujury  or  local  irritation  iu  the  urethra  or  prostate.  This 
form  of  the  disease  is  must  cummou  in  middle-aged  men,  and  more  fsp^ 
cially  in  those  who  are  gouty.  In  fact  the  disease  is  in  all  probability  one 
of  the  many  local  forms  of  gouty  indammation.  It  is  not  very  auute  but 
lingering,  liable  to  rci:urrenoe,  and  to  be  followed  either  by  hydrucele  or 
chronic  indurations  uf  the  epididymis. 

Atrophy  of  the  Testis  as  a  consequence  of  luflammatioii  is  more  liable  to 
follow  the  orchitis  of  mumiiei  in  yiuiig  nieu  nbL>ve  the  age  of  puberty  tbaa 
any  other  inllammutory  atlectioo  of  the  organ.  It  is  remarkable  how  ratiid 
anti  how  complete  the  wasting  of  the  testis  will  be  in  these  cases.  A  rev 
weeko  aller  the  subsidence  of  the  intlammation  the  testis  will  be  found  to  be 
shrunk  away,  so  as  to  form  a  small  6oi\  mass  not  larger  than  a  GlberL 

\truphy  of  the  titiliH  may  sometimes  gradually  ensue  also  ae  a  result  of 
chronic  e]>ididymitis,  and  the  conaequent  induration  of  this  structure.     Stran- 

{;ulatioD  of  the  vascular  supply  to  the  testis  occurs,  and  the  whole  organ  at 
ast  wastes  so  as  to  leave  nothing  but  a  small  hordenetl  mass  in  the  scrotum. 
Treatment, — The  treatment  of  Amteitf  Jnjtamed  TeMidf,  whether  local  or 
ooxiuitulional,  is  eBsentially  antiphlogistic    The  patient  should  be  kept  in 


I 


I 

I 
I 


ISrUAUUXTlOV   OF    TUE    TESTIS— TRIATMXMT.       1103 


MUice 

^1 


witlt  tbe  tMtis  raised  on  a  small  pillow  between  the  ll>i)i;hiL.  anil  hot 

toCioDS  ililigeotly  applied.     Ac  tbe  same  time  tbc  swotleD  glauil  luay 

pamtetl  with  ao  oiottiii*til  compt>w<l  of  equal  partsof  gtyccriiie  and  bella* 

ma.     This  Lreatmeut  will  tuually  be  found  to  give  the  patient  looit  relief; 

t  if  the  ca»e  be  seea  very  early,  before  mucb  swelliug  has  taken  placo,  tbe 

plicatioD  of  cold  br  meana  of  Leiter's  tiibea  (vol.  i.  p.  SIO)  or  Otia'l  ooU 

■7  ■oDietiiuea  cut  the  iuflaiumatioD  short  and  give  immediate  relief.     LoobI 

iood-letUng  is  often  of  great  service  wbeo  there  is  much  pain.     It  is  bnt 

euriad  out  br  puncturing  the  veins  of  the  »crotum — a  far  better  method 

than  applying  leeches,  tbe  bites  of  which  are  apt  to  become  irriutcd,     Tbi« 

little  operation  may  he  very  eflbctually  done  by  directiug  the  patient  to 

atand  up,  and  lo  foment  tbe  scrotum  for  a  few  minuus  with  a  hot  tspunge,  so 

ac  to  dioend  tlie  veiua ;  these  mav  then  be  puuciuretJ  at  various  pitints  with 

a  fine  Eancet,  and  tlio  paru  well  tbmcnied  anerwarda,  ao  aa  to  encoura^  the 

flow  i)f  bl<x>d.     lo  tbia  way  six  or  eight  ounoee  may  be  taken  in  the  course 

of  a  few  minuu« ;  when  enough  has  escaped,  tbe  Airtber  flow  may  be  arreeted 

by  laying  the  patient  dowu  and  elevating  tbe  part. 

If  there  W  much  otfuaion  into  the  tunica  vaginalis,  const  iliiting  acute  hy- 

drooete,  relief  may  tw   sHiirded   by  puncturing  this  mc  with  the  point  of  a 

UtoceL     Puncture  of  the  iratis  ildolf,  which   has  been  recommended,  is  a 

lew  and  dangerous  proceeding.     I   have  known  of  a  case  in  which  it 

followed  by  abaceu  in  tbc  gland,  ending  in  its  complete  destruction. 

Tbe  CoiutUutional  Dreatmetit  during  the  acute  stage  consists  in  the  admin< 

IstraiioD  of  nlioee  and  aotimony,  with  henbane  in  tull  doaes,  eo  a»  to  give  an 

•perieot,  a  diaphoretic,  and  a  sedative  together;  when  tbis  begins  lo  act, 

great  relivf  u  usually  affonled. 

Aa  the  inllammsuon  subsides,  the  treatment  must  be  changed.  Wh«o 
tberv  IB  merely  swelling  and  bardneas  left,  with  but  little  pain  or  tandemoM. 
th«  testis  may  advantageously  be  strapped  with  adhesive  plaster,  so  as  tu 
civc  itom)  support  and  to  promote  abeorption  of  plastic  matter.  Fricke.  of 
Uamburg,  ba»  strongly  reoDoUDended  strapping  in  tbe  acute  stage;  but  I 
«uinot  say  that  I  have  ever  aeco  any  advantage  derived  from  it  at  this 
period  of  tbe  diaeau,  though  I  have  many  limMS  seen  it  tried :  it  has  usually 
Apfieared  to  me  to  iucroase,  sometimes  very  coDsidorably,  the  pain  in  the 
part,  and  the  ^•vnfral  uui^ncn. 

In  Sobaoata  Orchitis  much  benefit  u  usually  derived  from  a  abort  coarse 
of  Dover's  powder  and  calomel,  with  v&rly  strapping  of  the  lestb.  Wbea 
the  organ  has  beoome  eolorged  and  indurated,  as  tbe  result  of  chronic  in- 
flanirantiiku,  ji  may  be  advEatageonaly  strapped  either  with  simple  plaster,  or 
I  wttb  one  composed  uf  equal  parts  of  tbe  omplaatrum  lummoniaci  cum  bydrar- 
I  ijn}  and  soap-plaster;  mercury  in  small  duees,  more  eaperially  the  bichlo- 
kHHKbftUiK  continued  fnr  «tme  length  of  time,  until  the  inOafflmacofj  pro* 
^I^^Vw  abcnrlKil  and  thi>  hBnlnesa  diaanpears. 

^^InBtrappiag  a  Testicle,  the  arrnmm  should  be  shaved,  and  then  dmwn 
tightly  upwardi*  un  tbe  affecteal  aide.  '['h<>  .^urgeoD  should  UfXl  pu»  n  long 
atrip  of  plaaler.  at  I'-il^L  uii  inch  hrttail.  above  the  enlarged  tasliuleand  round 
the  CDrrospondiiig  aidt?  of  tito  scrotum,  *■■  as  ti>  isolate  it,  as  it  were.  Another 
strip  ii  now  paowyl  fn>m  iH'hind,  in  a  lon^nitjdinal  d!n*ction.  over  the  lower 
end  of  the  testis,  and  unwanis  u\Ma  the  anterior  juK  of  the  scrotum ;  and 
tbm,  by  a  succenion  of  horifiutal  and  vertical  atri|is,  noatly  overlanpjag 
and  drawn  tigbUy.  the  oripiu  it>  mmpletely  envclnpexl  and  oompranei).  To  bo 
of  any  service,  tbe  stmpping  must  be  tightly  and  evenly  applied ;  but  at 
thaaamt  time  care  must  be  taken  nni  in  stmni^lato  the  sorotum  by  draw- 
ing down  the  upfwr  strips  of  ptaslirr  1<>o  forcihty.  In  a  case  uf  syphilitto 
"  of  tba  tastia,  in  tt-nich  I  was  obliged  to  ban  nMwane  tn  eoiinuioii. 


1104 


DISEASES   OF   THE   TESTIS    AXP   COBD. 


the  whole  of  tlie  side  of  the  scrutiim  had  sloughed  away,  liaviu^  the 
exposed  ami  iuugatio^,  in  coi)8e(|uenco  of  thn  (iglit  sirnppiiig  which 
been  eiiiplovcil  before  me  case  came  into  my  liaods. 

Aiter  the  eweliiog  has  mbsided,  the  patient  luust  wear  a  suspensory'  band- 
ar for  Bonie  nioDthe. 

The  Induration  about,  thf  Epitlidymts,  vrhich  uniaUy  remains  after  epididy- 
mitis, must  be  treated  by  prolonged  connter-irritalion  with  tincture  of  twjine. 
or  by  the  appliention  uf  the  iodide  of  lead  or  iotline-ointnient.  So  long  as 
any  indiirniioD  i<^  led,  it  is  doubtful  whether  the  seeretton  is  able  to  find  its 
way  through  the  thickened  epididymis. 

Abscess,  lis  the  result  of  inflaraniation  of  the  testis,  is  of  rare  oecurrenoe. 
Sometimes  the  scrotum  inflames  at  one  point,  where  ductuntion  Iwcnnies 
appartnt,  with  thinned  skin  and  evident  signs  of  suppuration :  a  puncture 
should  here  be  made,  and  the  pus  let  out  as  soon  as  formed.  In  true  absccM 
of  the  tc-aticle  the  pus  forms  under  the  tunica  albugioea,  adhesion  uL:es  place 
between  the  testis  and  the  scrotum,  the  fibrous  coat  gives  way,  and  the  pas 
gebi  veut  exleruslly  tbR>ugh  the  integuuient«.  Into  thu  H|>erture  that 
uecesoarily  results  u  portion  of  the  ttecreting  tissue  of  the  gland  sotuetlmes 
projects,  aud,  beixmiing  inllame<l,  Ibrmit  a  red,  granular,  and  fungous  ntasv. 
protruding  through  and  overlapping  the  edges  of  the  aperture.  The  treat- 
ment of  this  condition  wilt  be  considered  when  we  come  to  speak  of  the 
scrofulous  testicle. 

InflammatioD  of  the  Testis  in  the  Ingoiiial  Oanal  may  sometimes  take 
place,  even  iu  adults,  when  the  organ  htw  not  descended  through  the  external 
ring;  giving  rise  to  a  train  of  somewhat  puzzling  symptoms  which  cloeety 
resemble  those  of  sUaoBuluted  incompiete  hernia;  with  which,  however,  it 
must  be  borne  in  mintf  that  it  may  be  aasooiated  (p.  791,  vol.  ii.).  On 
examiimtion,  a  large  irregular  tumor,  in  some  parts  hard,  in  others  soil,  very 
tender  to  the  touch,  and  occasioning  a  sickening  sensation  when  pressed,  will 
be  found  in  one  of  the  groins,  in  the  situation  of  the  inguinal  canal.  There 
aro  usually  a  tendency  to  vomiting  and  some  conelJpation,  with  coliuky 
pains  in  the  abdomen.  On  csannoing  die  scrotum,  it  will  bo  fouod  that  ifac 
teatis  on  tlie  aifectod  side  is  afasout;  and,  on  passing  tbe  finger  into  the 
external  ring,  the  organ  can  be  felt  to  be  lodged  in  the  canal.  In  ooesfr- 
quenco  uf  the  proximity  of  the  peritoneum  to  tbe  inflamed  testis,  this  meio- 
Drauo  occasionally  bccomea  involved  In  the  morbid  prooeea;  and,  as  tbe 
result  of  the  eougtrictiou  of  the  tendinous  and  aponearotie  tiaeuee  in  this 
situation,  idoughiDK  has  occasionally  occurred.  Either  of  Ihcae  cooditiiifls 
may  lead  to  a  mtaftermiDation. 

The  Tymtmcnt  should  be  actively  antiphlogistic.  Lecchea  must  be  freely 
applied  over  tlie  part ;  satinn  with'  antimony  being  at  the  same  time  admio- 
i!iten?d.  und  fonifnlations  diti^ji^ntly  persevered  in. 

Inflammation  and  Abscess  of  tHe  Cord.— In  some  coaca  the  inflammation 
of  the  t^tis  may  extend,  or  the  diaease  may,  from  the  first,  be  limited  to  the 
arefilar  tisaue  of  the  cord,  giving  Hrc  to  tumefaction,  with  a  good  deal  of 
pain  and  tenderne.<«  along  it,  and  rvcntunlly  ab«^c«s,  accompanied  by  the 
usual  signs  of  nuppuration.  The  7Vf:atmr.i>t  of  such  a  case  must  be  con- 
ducted on  ordinary  principles,  early  discharge  for  the  pus  being  SccuretL 

Chronio  Orchitis  of  a  persistent  character  constitutes  a  distiiict  disease  ot 
the  testis,  «f  chisely  allied  to  some  forms  of  tumor  of  thii  organ  in  il« 
character  and  pathology,  that  it  will  be  more  convenient  t>i  consider  il 
with  tbe  Sitreocflen. 


I 


I 


• 


HTDROUELK    OF    THE    TUNICA    VAGINALIS. 


1105 


HYDROCELK  ASI>   H.EMAT(K:ELE. 

By  Hydrocele  is  meant  an  accumulation  of  serous  fluid,  formed  in  connec- 
tion with  the  testis  or  cord.  Most  frequently  the  fluid  occupies  the  sac  of  the 
tunica  Taginalis,  const itutiiif?  a  true  dro^tsy  of  it ;  in  other  instances,  it  appears 
to  be  formed  in  distinct  cysts,  situated  either  in  connection  with  the  testis,  or 
upon  the  cord.  Hence  hydroceles  are  commonly  dirided  into  those  that  aflect 
the  Tunica  Vaginalis  and  the  Encynted  variety. 

Hydrocele  of  the  Tunica  Vacsixalis  may  occur  as  the  result  of  acute 
orchitis  ;  the  inflammation  of  the  testis  causing  the  efl'usion  of  a  quantity  of 
fluid  into  its  senms  investment  (p.  1102i.  This,  however,  is  not  the  kind 
of  hydrocele  that  is  commonly  met  with  ;  the  fluid  so  poured  out  as  the 
raBuit  of  active  inflammation  becoming  alnorbed  as  the  parts  recover  their 
normal  condition.  The  ordinary  hydrocele  occurs  as  a  chronic  disease, 
without  any  signs  of  inflammation  of  the  testicle,  or,  at  most,  with  but  slight 
tenderness  of  that  organ.  It  is  must  frequently  met  with  in  individuals 
nbout  the  middle  period  of  life,  commonly  without  any  evident  exciting 
cause,  either  constitutional  or  local.  It  is  very  common  in  men  who  have 
lived  long  in  warm  climates,  and  Sir  J.  Fayrer  considers  it  in  some  cases  to 
have  a  malarial  origin. 

In  young  infants,  hydrocele  is  not  unfrequently  seen,  and  in  them  it  may 
nffect  two  n)rms:  either  the  ordinary  one,  similar  to  that  which  occurs  in 
adults  in  whom  the  tunica  vaginalis  constitutes  a  closed  sac  filled  with  fluid; 
or  a  leas  common  variety,  in  which  the  accumulation  of  fluid  in  the  tunica 
Tagioalis  communicates,  hy  the  peraititence  of  a  canal  in  the  funicular  pro- 
longation of  the  peritoneum  investing  the  cord,  with  the  general  cavity  of 
that  membrane.  This  form  of  hydrocele  is  Congenital;  and  the  fluid  in  it 
oooupies  the  same  position  that  intestine  does  in  a  congenital  hernia.  It  may 
readily  he  recognized  by  the  fluid  heing  matie 
to  flow  back  into  the  general  peritoneal 
cavity,  on  raising  or  squeezing  the  tumor. 
But,  although  this  may  be  considered  to 
be  the  true  congenital  form  of  hydrocele  in 
in&nte,  the  other  variety  of  the  disease  also 
occurs  in  them  when  but  a  few  days  old,  and 
TCry  possibly  even  at  the  time  of  birth. 

S^ptomt. — The  symptoms  of  hyiirooelc 
are  tolerably  evident.  The  disease  begins 
with  a  degree  of  swelling  and  weight  about 
the  testis:  the  swelling  may  at  first  besots, 
but  afler  awhile  becomes  hard  and  teniae; 
or  it  may  be  st>  from  the  commencement. 
There  is  no  impulse  in  it  when  the  patient 
coughs.  Whatever  its  nriginul  condition, 
the  tumor  soon  Itecomcrt  oval  or  pyriform 
in  shape,  being  narrowed  above,  nuinded 
and  broad  below  :  it  it-  siiiootli  and  uniformly 
tense  and  hard;  it  ii.^ually  fluctii:ite.-<  Aii- 
tinctly,  but  may  have  merely  a  iiemieliistii' 
ftel.  It  n-uchcs  upwordti  along  *tli(>  cDnl, 
towards  the  external  abdoiiuMal  rin<;,  wliicli 
may  in  some  rare  cases  Ik^  (V\)^.  W>\  >  invmlrd 
by  it,  but  the  cord  i«  iisuiilly  distinrlly  Id  U- 
felt  above  the  upper  niar^'in  of  ttif  tunmr. 
ftom  that  of  a  hen'.x  c-g>^  to  a  small  cofnanut 

VOL.  II.^TO 


4^ 


Fit!.  '■''''I. —  Doiibis  HjrJravete  Cun- 
<-[ri>'ti,''l  <)|,|iii.iie  Hxlcrnil  Ab<Jt>inl- 
n.Al     liini;     >ii>l     thin    Situulsling 

.Mn.'t  comnmnly  the  size  varies 
but  soniutimcd  It  may  attain  a 


llWf 


i;iSBAfiKs  OF  ran  testis  axd  cord. 


c»mii(1prAhly  ffrt^aler  mAgnitude  (hao  tbig,  ani)  wU)  tben  cHUtv  iiiucb  iocon- 
venieoce,  as  it  reachca  up  close  to  tbo«xt«rnaI  ring,  anil  drags  over  (be  l^eoio, 
duiaing  thai  organ  to  be  buried  iu  it,  so  us  to  interlert*  witb  micturitiun. 
Gibbon,  the  historiau,  had  an  enormous  byttrocele,  wliicli  w«a  lapped  by  Clitte, 
who  drew  off  ux  quarts  of  lluid. 

Tlie  luost  cbaracturiiitic  eigu  of  hydrocele  is  its  tranelueeucy  by  tnuismitted 
ligbt  This  luay  always  hv  dctuvt^  by  tbe  Surgeou  grasping  the  poaterior 
part  of  the  tumor  with  one  hand,  eo  as  to  put  tue  iut«gumeuls  of  the  fore- 
part ou  thu  Btrt-tcli,  theu  plauiiag  ihv  edg«  ot  the  other  hand  aloDg  the  moat 
pruriiiu(<iit  part  of  tht;  ewi^Iliug,  and  having  u  lighted  candle  held  close  behind. 
On  matciug  this  exam  i  out  ion,  the  tumor  will  appear  trun&luceut :  if,  however, 
tlie  walla  of  the  eac  be  thick,  or  the  fluid  dark,  the  transmitieion  of  light 
through  it  may  not  be  perceived  unless  the  examiaatiou  be  conducte^l  in  a 
darkened  room.  Anotner  very  simple  and  eihcient  method  of  deteriainiug 
the  transluceucy  i»  by  putting  the  end  of  a  stethoacope  againat  the  tumor, 
and  looking  dowa  the  tube  ngainet  tbe  ligbt.  It  mufil  not  l>e  forgirtteo  that 
iu  iuffinia  a  hernia  uiay  be  traosluoeat  on  account  of  the  thinoeaa  of  tbe 
Btnictures  at  that  age. 

We  have  already  seen  that  tbe  ordinary  hydrocele  of  the  tuoien  vsgtoaliB 
may  vary  as  to  size:  It  may  also  ditl'er  as  to  shape;  in  some  comb  bdag 
globular,  in  others  constricted  in  the  middle,  or  of  an  hour-glaiB  shape 

The  quantity  of  liquid  varies  considerably ;  there  are  usually  from  mx  to 
twelve  (ir  twenty  ounces,  hut  I  have  known  a  hydrocele  to  conlnin  more  than 
one  hundred  and  twenty  ouneea.  Tbe  6uid  is  gencrnlly  clear  and  limpid, 
and  of  a  straw-eolor ;  but  iu  very  large  and  old  hydroceles  it  may  bccomp  of 
a  dark-brownish  or  chocolate  hue,  owing  to  the  admixture  of  disintegrated 
blood ;  and  it  will  then  be  found  to  contain  dakes  of  cbolesterine.  The  sac 
is  UBUatIv  tlitn  ;  but  in  some  old  cases  it  becomes  thick  and  dense,  lined  by  a 
kind  of  iaW  membrane,  and  divided  by  septa  or  bands,  occasionally  to  such 
an  extent  as  almost  to  sepamtf  it  into  ilistinctcorapartmenlH.  When  the  sac 
ie  thick,  and  the  fluid  opaque  and  turbid,  there  may  be  considerable  difficulty 
iu  detecting  tbe  translucency. 

The  testis  is  oflen  somewhat  enlarged,  e«p<%iatly  alwut  the  epididymis, 
and  frctiuenlly  i«lightly  tende-r,  more  particularly  in  the  early  stagea  of  the 
comj>laiiit.  It  is  almost  invariably  situated  in  the  p<^l«rior  part  of  tha 
sue  (Fig.  !)62),  but  may  sometimes  be  found  louarilK  its  anterior  part. 
When  this  is  the  case,  tbe  epididymis  will  be  found  turne<l  towards  th**  front, 
owing  to  the  organ  being  retro vert4.-il.  If  tbe  hydrocele  is  of  any  size  and 
tense,  the  tcaticre  is  lost  in  iL  Its  situation  cao  then  be  recognize^i  by  some 
puin  elicited  by  pressing  on  it.  and  by  tbe  opacity  of  the  tumor  at  that  poioL 

A  peculiar  form  of  hydrocele  is  occasionally  met  with  which  extends 
through  the  external  abdominal  ring  forming  n  large  tumor  in  the  region  of 
the  inguinal  caual,  between  ivhicli  and  the  scrotal  swelling  fluctuation  can 
be  folt.  There  is  iu  this  form  u  distinct  impulse  on  coughfne.  It  occurs  in 
tliofio  cases  iu  which  the  |>roc(Ksus  vaginalis  testis  has  been  oblitarBled  ouly  at 
the  internal  abdotuinal  ring,  remaining  patent  below.  Such  cases  are  very 
rare  and  iimy  resemble  hernia,  but  tuey  are  easily  distinguished  by  their 
tnuisluceuey,  their  irreduoibility,  their  absolute  dulness  on  pcrcuasion,  and 
their  distinct  flm-tuation. 

The  (hferint/n  of  a  hydmi^elo  are  the  same  as  thtise  of  the  testis.  Besides 
the  integuniental  slnictnrea,  aponeurotic  prolougatioDS  fntm  the  inter- 
columnar  and  cremasteric  fasoin  may  be  traced  over  the  snrfaoe  of  the 
Bwellitig  (.Fig.  963). 


I 


I 
I 

I 
I 


HYDROCELE    OF    THE    TUNICA    VAGINALIS. 


1107 


Trentmenl. — The  treatment  of  hydrocele  is  divided  into  the  Palliative  and 
C^traUve.  By  the  palliative  treatment  the  Surgeon  seeks  simply  to  relieve 
the  patient  of  the  annoyance  induced  by  the  bulk  or  weight  of  the  tumor; 
but  the  otra^iVehas  far  its  object  the  permanent  removal  of  the  disease. 


Flf.  MS.— Hydrocele  of  tb«  Tunioa 
VaginftlU  1*1  d  open. 


Fig  903— DiiieolioDOfa  ll7droe«1«, 
•howiag  iti  coreriDgf, 


The  PalliatiTe  Treatment  consists  in  the  use  of  a  suspensory  bandage  and 
cooling  lotion,  or  in  tapping  with  a  fine  trocar.  These  simple  means,  how- 
ever, will  sometimes  succeed  in  effecting  a  radical  cure.  Thus,  in  infants  it 
will  happen  that  the  application  of  evaporating  and  discutient  lotions  may 
remove  the  effused  fluid ;  and  indeed  it  is  seldom  that  any  other  plan  of 
treatment  than  this  is  required  in  young  children.  The  beat  lotion  ior  the 
purpose  consists  of  one  compoeetl  of  ^  of  chloride  of  ainmoniun},  ^j  of  spirits 
of  wine,  and  .^viij  of  water ;  with  this  the  scrotum  shuuld  be  kept  constantly 
wetted ;  and,  if  there  be  a  communication  with  the  peritoneum,  a  truss 
should  be  kept  applied  over  the  external  ring.  In  adults  it  occasionally 
happens  that  simple  tapping  of  the  tumor  has  effected  a  radical  cure.     Some 

J  ears  ago,  a  geutleman  from  Cuba  consuIte<l  me  for  u  small  hydrocele  which 
ad  been  forming  for  several  months;  I  tap]>ed  it  with  ii  fiue  trtfcar,  and 
drew  off  about  five  ounces  of  Huid.  Thiin  was  followed  by  a  radical  cure. 
This  case  bears  out  a  remark  made  by  Brodic,  that  the  few  instances  in 
which  he  baA  known  simple  tapping  to  pnHluce  a  radical  cure  occurnNi  in 
Weat  Indians.  I  have,  however,  several  times  seen  hydroceles  disappear 
after  having  l>een  tapped  a  few  times,  without  auy  other  treatment,  in  persons 
who  had  never  been  in  hot  climates.  This  simple  operation  is  not  altogether, 
however,  destitute  of  danger;  I  have  known  an  old  man  to  die  from  io- 
flammatorv  a-dema  of  tlit^  i>crotum  at\er  having  been  tnppeii,  and  tetanus 
mlsu  has  followed  this  o|K<riition.  AAcr  tapjiiiig,  it  usually  happens  that  the 
hydrocele  slowly  forms  again,  iittnining  its  former  bulk  at  the  end  of  about 
three  months.  Occosiomilly  it  will  be  found  ihat  the  hydrocele  returns  more 
and  more  slowly  afWr  each  tapping ;  so  that  by  rci>eatiug  this  simple  process 
■t  intervals  of  three,  then  six,  then  twelve  niontns,  the  disease  will  fia&ll'^ 


1108 


DISEASES    OP    THE    TBBTI9    AND   COSII^ 


disappear.    Thiti  kimi  uf  progrcmvu  cure  br  ^tinplp  (afiiiiii^  I  h»*s| 
tlmf«  Be«n,cKieHy  in  old  men.    Wbcn  a-  congenital  hvdrrxvtc liiu  I 
the  ucsoon  till»  Afcnin  by  drainage  into  it  triitn  itir  pcritDOeain; . 
in  Biicli  a  cue  the  fluid  of  an  ludte*  bas  been  drawn  otf  by  Uppe 
vacinatis. 

In  lAppiiif;  a  hydroMie  a  few  prfcautiona  are  afoemMry,  tb«  prinoit 
to  avoid  puncturing  oae  of  the  «crotal  veim.  or  injuriofr  tb»  tMtiK.^ 
nmjortly  of  ca»eft  tbe  testis  is  Aituated  at  the  hack  iff  (! - 
MXjiieiiily  »ltf^tb«r  out  of  tbft  way  of  the  tnioir.      i 
however,  always  he  dftttfrniiiitit  In-fore  thtr  i>jienili'>n.     'Ihu  .-iiay' 
done  by  pressing  with  tbe  linger  liniily  on  liKIen-nt  points  of  lb* 
i-eesiuu.     The  patient  will  ueunlly  Ixt  able  at  ••□«  l«  t«ll  wbco  Uic 
is  jirvwed  uptja  bvlhe  iivculiur  "(raticularseusiitiuD,"     llreccAt  of  ll 
lutiy  be  further  Jeterminvd  by  tbe  waat  of  tranBlucvney  at  Um  spot  i 
it  t»  i>ilualed. 

Tbe  o{x:rattou  is  iben  performed  ae  follows :  1.  The  trocar  sboold^ 
greuH-d  with  aniifleplic  nil.  2.  The  [laiicnt  should  be  raadv  to  Iw 
sit  ou  a  chair,  leet  he  U'cnme  faint,  -i.  The  Hurgeon.tbrn  gtacpisf  tlHbj 
oclo,  draws  the  scroium  back  5o  as  to  make  the  coverings  on  tu  •nterter  | 
of  tho  tumor  as  thin  and  tmooUi  as  pomible.  4.  He  then  tdwtiai 
little  below  the  middle  of  the  tumor  w'h«.<re  no  vein  ur  bloodTMBcl  ii 
and  there  tapa  tbe  liydrocete.    o.  The  croi-nr  &huuld  not  be  thmttia^ 


y^ 


Ftg.  VSl.~Ta|>ptii£ln  Ilydrneclt;  a.  Intfudaotiuii  of  TrvMr;   4-  Pa«ia««  ' 

Budden  iiluuge — this  is  alwnyi)  jiainftjl  to  and  startlH  cbr 

be  Bteaully  pushed  fiiruardB.  the  tumor  at  the  Mtne  Ume 

\W  point.     In  this  way  the  operation  ii>  almoet  painlc-y- 

taken  In  avoid  hloodveteels  and   their  accnmnnying  i; 

to  be  pttsbed  in  directly  backwards  (Ftg.  ft'>1,  ai,  but  b»  sooo  m 

withdrawn  the  cnnula  should  be  inclined  obliquely  upwnr^l*.  •< 

the  chance  of  presBure  against  the  testis  i  Fig.  964,4).     t       ■  aH 

has  escaped,  the  cnnula  »  sluwlv  withdrawn,  tbe  edges  -  '> 

preswd  together  and  covered  with  a  bit  of  plaster,  or  a 

collodion.    A*UBpcn»f>ry  bandnge  should  be  th^n  nut  •■it.  nii-i  ir-t 

for  a  few  boura.    The  fluid  eometimes  escnpea  witA  a  pulsatory  id< 

apparently  cr)niiiniiiiciite<l   by  tbe  arteries  f>f  tht<  cord.     If  tbe 

been  found  in  Irnnt,  the  hydn>cele  should  be  lapped  at  tb«  ride  gr 


Before  using  the  trocar,  it  is  well  to  soe  that  Ine  cauala  fits  ^«saly  !■ 
the  neck  of  the  stylet;  and,  above  all,  tbnt  tbe  itkttnjiiMat  has  Kit  bio 
rusty  by  having  been  caroleatly  put  aside  silcr  us«  oo  ft  previotta 
the  cnnula  while  still  wet  hsving  been  put  on  the  troear. 

The  Cnrativ*  Treatmeot  has  for  its  obpeot  tb*  cxdtjUiun  i>f  s 
degree  of  inflammation  in  the  tunica  vaginalis  to  r«aiAr«  tbe  bst 
bttvcca  BOGrcl\on  %nd  «hW»viioa;  bat  it  b  not  nrasiwry  that 


THE    R&^DICAL    CUKE    OF    HYDROCELE.  1109 

cavity  should  be  obliterated  br  adhesions  between  its  opposite  aides,  though 
these  Dot  unfrequentlv  form.  "The  means  by  which  the  Surgeon  sets  up  this 
inflammation  are  either  throwing  a  stimulating  injection  into  that  cavity 
after  tapping  it,  or  the  introductioD  of  a  small  seton  into  the  tunica  vaginalis. 
Whichever  plan  is  adopted,  a  certain  amount  of  inflammation  ought  to  be  set 
up.  This  is  always  attended  by  considerable  swelling  of  the  testis,  and  by 
the  effusion  ol  a  fresh  quantity  of  fluid  into  the  tunica  vaginalis.  As  this  is 
•beorbed,  the  part  gradually  resumes  its  normal  bulk,  and  the  disease  will 
probably  not  return. 

In  order  that  the  radical  cure,  in  whichever  way  undertaken,  should  be  safe 
and  efficient,  it  is  necessary,  in  the  first  instance,  that  the  disease  should  have 
been  allowed  to  attain  a  chronic  condition,  more  particularly  if  the  hydrocele 
have  been  of  rapid  growth.  In  order  to  prevent  its  att«iniug  too  large  a  size, 
it  will  be  well  to  adopt  palliative  tapping  once  or  twice  before  attempting  the 
radical  cure.  Care  must  be  taken  to  remove  all  inflammation  ana  tender- 
ness about  the  testis  also,  before  having  recourse  to  this  means  of  treatment. 
If  attention  be  nut  paid  to  this,  recurrence  of  the  hydrocele  will  probably 
ensue.  After  the  proper  amount  of  inflammation  has  been  set  up,  it  will  be 
well  to  treat  the  patient  as  if  he  were  suffering  under  an  ordinary  attack  of 
orchitis,  confining  him  to  the  bed  or  couch  for  a  few  days;  indeed,  care  in 
the  after-treatment  ia  of  very  considerable  importance  in  securing  a  favorable 
result 

The  treatment  by  Injection  is  that  which  is  commonly  employed.  It  con- 
sists  in  tapping  the  tumor  in  the  usual  way,  and  then  throwing  a  suflicient 
quantity  of  stimulating  fluid  into  the  tunica  vaginalis  through  the  canula,  so 
as  to  excite  a  proper  amount  of  inflammation  in  it.  Port  wine,  or  a  solution 
of  the  sulphate  of  zinc  of  the  strength  of  ^j  to  .^xij,  were  formerly  employed, 
but  their  use  has  been  entirely  abandoned  since  the  introduction  of  iodine 
for  the  purpose. 

Injection  of  Iodine. — The  injection  of  tincture  of  iodine,  originally  intro- 
duced by  Sir  J.  R.  Martin,  whilst  practising  at  Calcutta,  is  now  always 
preferred  as  a  more  certain  and  safer  mode  of  treatment  than  anv  other, 
Many  Surgeons  prefer  the  liquor  iodi  to  the  tincture,  believing  it  to  be  more 
certain  in  its  effect.  The  quantity  of  tincture  of  iodine  injected  should  vanr 
from  two  drachms  to  half  an  ounce,  according  to  the  size  of  the  tumor.  It 
maybe  used  pure  or  diluted  with  an  equal  quantity  of  water.  After  injection, 
the  Surgeon  should  rub  the  scnitum  gently  over  the  testis,  so  as  to  diffuse  the 
injection  equally  over  the  surface  of  the  sac.  One  half  the  quantity  thrown 
in  should  then  W  allowed  to  escaitc,  the  canuhi  reniove<l,  and  the  puncture 
clo!>ed  with  a  piece  i>f  plaster.  The  canula  used  for  this  purpose  should  be 
made  uf  platinum  and  not  of  silver,  which  in  apt  lo  I>ecimie  corrftded  and 
made  brittle  by  the  action  of  the'i<idine.  A  good  dcnl  of  inflammation,  with 
fre^h  efluRi'in  into  the  wu",  will  usually  be  set  up,  nn  the  gultsidence  of  which 
a  cure  will  be  found  to  have  lieen  efft-ctcd. 

Useful  as  the  iodino  injection  i:*,  it  soriietinu-s  ftiils  in  pnxlucing  a  radical 
cure  of  hydriicele.  Thia  is  nttributiiblc  to  two  causes:  the  first  is,  thai  in 
Some  cases  snflii-iont  inflammation  in  not  net  up  to  induce  tlint  condition  of 
the  tunica  vaginalis  whicli  is  nc-ccssary  for  a  radical  cure.  It  is  wi^ll  known 
that,  when  a  hydrocele  is  nutically  cured  by  injection,  it  is  so,  not  l>y  any 
adhesion  Uikin}:  place  between  the  twn  <ippo!»itc  surfaces  of  the  tunica 
vaginalis  and  a  con-ipqueut  oblitt-mtion  of  its  cavity,  but  by  the  inflammation 
that  is  artiftcially  itxliiccd  cxoitiu}:  such  a  nifxlification  of  this  membrane  as 
to  restore  the  balance  between  tin-  secretion  und  abtmrption  of  the  fluid  by 
which  it  is  naturally  luhricatf^l.  Now,  in  some  cases,  sufficient  inflammation 
u  not  induced  by  the  intrtnluction  of  the  irritating  fluid  to  restore  the  natural 


1110 


D1SBASE8    OP    THE    TEaxiS    AND    C0R1>. 


balance  betweea  tbese  two  fuoclJoDs  of  tbc  menibraiie ;  and  thi-  lunica 
Dslis  ^^niduaily  fiile  ngain  iiflGr  the  iojecliou,  as  it  nould  ui'lcr  tbe  sioi^c 
operatiuu  of  (appiog.  It  occatioiiallv  Iiappene  tlml  ibc  [)atit!iit  may  tuvkt 
excrucinliug  a^ooy  at  tbc  lime  uf  iLc  injiH:tioii,  fmiti  thu  couUiU  uf  tin 
Htiniulaiing  Quid  with  tbc  eurfaco  of  tbe  leatit^,  uutl  yet  lilUc  tir  no  ioflaio- 
matioii  mar  be  cxviccd.  Tbo  amount  nf  sutleria^,  tberefore,  at  the  time  of 
tbc  operation  'u  by  do  means  pruporlinoate  to  ibe  amnnnt  nf  consecutiro 
iDflaoimation  wbicb  ful]<iW8.  ImiIclhI,  the  revenw  nnubl  appear  to  bo  tbe 
case  in  many  iuslanocs ;  anil  I  bavv  uflcn  olieer%'e<l  that,  in  those  vases  which 
progremi  moiit  ateadlEy  t»  a  rmlical  cure,  there  U  but  a  moderate  amount  of 
pain  experienced  at  the  time  of  the  injection. 

There  is  a  second  way  in  which  injectionn  wontd  appear  (o  fail :  a  cun- 
8i(!erable  nmntinl  nf  inflamniatinn  is  excite<I,  and  effusion  lakes  place  intft 
tbe  tunica  vaginalis,  which,  in  the  course  nf  three  or  fmr  daya,  becomes  dis- 
tended to,  or  almost  to,  the  5anie  size,  that  it  bad  previonsly  to  the  operation : 
but  this  effused  fluid,  insleud  oP  being  absorbed  by  the  cnil  of  the  second  ur 
third  week,  remaitis  uucbaugcd  in  bulk,  or  absorption  gDes  on  to  a  certain 
point,  uud  tbou  aeenia  to  be  arrested;  llic  tuuica  vaginalis  remaining  dm- 
tended  with  a  cerlain  quantity  of  fluid. 

A  ihini  way  in  which  the  tailure  arisea,  is  in  cousequeuce  uf  the  walU  of 
the  NIC  being  so  thickened  that  they  canuut  colIa|Me. 

The  pro]K>rtion  of  caws  in  which  tbe  iodine  injection  fails  to  bring  nbout 
■  radical  cure  of  tbe  hydrocele  is  variously  Mt!roate<l  by  different  Surgeons. 
ThuB,  Sir  J.  It.  Martin  states  that  in  India  the  fHtlures  scarocly  araounl  to 
1  per  cent. ;  Velpeau  calcutateii  them  at  3  per  ceut.  1  am  uot  aware  that 
any  stativtics  of  ibis  mode  uf  Ireatiueut  iu  this  country  have  been  collected  ; 
but  the  general  opinion  of  Burgeons  would  appear  to  be  decidedly  in  its 
favor,  as  being  the  most  successful  as  well  as  tbe  safest  plan  of  treatment 
that  hoa  yet  been  iiitrnduccd.  Id  this  opinion  I  fully  ctjincide  :  yet  it  is  by 
no  menus  improbable  that  tbe  success  of  the  iodine  injection  in  this  country 
would  prove  to  be  not  quite  so  great  as  is  generally  believed.  1  have  peen  a 
crm»i(lcrablc  number  of  cases  of  simple  hydrocele  of  the  tunica  vaginalis, 
both  in  bo«|ii[Hl  and  Id  private  praclJoc,  in  which  a  radical  cure  bad  not 
been  eifectcd,  nltbougb  recourse  bad  been  had  to  the  iodine  injection  by  some 
of  tbe  mitst  careful  and  skilful  Surgeons  of  tbe  day,  as  well  as  by  mj-^lf.  It 
is  especially  apt  to  fail  in  men  advanced  in  years.  In  them  there  is  either 
nut  suflieient  inflammation  excited,  or,  if  it  Ite,  tbc  fluid  that  is  a^  a  coose- 
qniiii-c  ellbscd  into  tlie  Luuiea  vaginalis  is  not  reabsorbed. 

SetOD.— The  cure  by  the  introduction  of  a  soton.  though  formerly  mneb 
employed,  is  seldom  practised  at  the  present  day,  chiefly  on  aecoiini  nf  the 
danger  of  exciting  too  much  inflammation.  It  may,  however,  conveniently 
be  employed  in  tbc  truu  hydrocele*  of  children,  and  in  some  of  those  cases  in 
which  the  injection  fails,  if  prnctiaed  in  the  manner  that  will  immediately  be 
described.     There  can  be  no  doubt  that^  &&  a  flret  remedy,  tiHlinc  injectiim  is 

E referable  to  the  scton.  in  the  treatment  of  hydmoele;  but  when  injection 
na  failerl,  and  thin  from  no  want  of  care  on  the  part  of  the  ■Surgeon,  or  of 
attention  to  the  atler-treatment  of  the  case,  but  apparently  fn*ni  iusntficieiit 
inflammatii>n  having  been  set  up  in  the  tunica  vuginalis,  tbe  setoo  will,  I 
think,  be  foumt  to  be  the  most  certain  mean.4  of  accomplishing  our  object* 
It  is  true  that  several  objections  may  be  urged  to  the  use  of  the  setou ;  it 
requires  much  watching  and  care,  and  is  occasionally  apt  to  excite  a  danger* 
OUft  amount  of  inflamnialion  in  the  areolar  tissue  of  the  scrotum  ;  and  tliMS 
objections  are,  to  my  mind,  sufliclently  valid  to  prevent  our  employing  it  as 
tbe  oniinary  trejitment  tor  the  radical  cur«  of  hydrocele.  Rut  it  must  be 
remembered,  that  Uie  particular  cases  to  which  I  am  uuw  alluding  are  those 


« 


4 


^ 


THS    RAOICAIi    CUKE    OF    UYUROCKLS.  1111 

in  which  ordinary  means  have  proved  insufficieat  to  excite  proper  action, 
ftod  in  which.coDsemieutly,  it  would  api^ear  as  if  a  greater  amount  of  irrita- 
tion could  safely  be  borne.  Indeed,  nothing  is  more  remarkable  than  the 
difference  in  the  intensity  of  the  inilaniniatiim  that  is  set  up  in  diflerent 
iodividuals  by  the  means  that  are  commonly  em]>loyed  in  the  treatment  of 
hydrocele.  In  some  cases  the  most  irritating  injections  may  be  thrown  into 
the  tunica  vaginalis,  or  a  seton  may  be  drawn  through  the  scrotum  and  left 
there  for  days,  not  only  without  giving  rise  to  any  injurious  inflammation, 
but  without  Betting  up  sufficient  to  bring  about  a  cure  of  the  disease ;  whilst 
in  other  instances  simple  tapping  may  effect  a  radical  cure,  or  may  give  rise 
to  such  an  amount  of  irritation  as  to  terminate  in  a  fatal  sloughiug  of  the 
■crotum. 

The  seton  that  I  employ  in  these  cases  is  composed  of  one  or  two  threads 
of  dentist's  silk.  It  may  be  intrr>duced  by  means  of  a  nievus  needle,  the 
fluid  of  the  hydrocele  being  allowed  to  drain  away  through  the  punctures 
thus  made;  or,  far  better,  by  tapping  the  hydrocele,  and  then  passing  a 
needle,  about  six  inches  long,  armed  with  the  seton,  up  the  canula,  drawing 
it  through  the  upper  part  of  the  scrotum,  and  then  removing  the  canula, 
cutting  off  the  nee<lle,  and  knotting  the  thread  loosely  (Fig.  96,  vol.  i.). 
The  thread  should  not  be  removed  until  the  scrotum  swells  am)  becomes  red, 
with  some  tenderness  of  the  testis  and  effusion  into  the  tunica  vaginalis. 
When  these  effects  have  been  pnxluced,  it  may  be  cut  and  withdrawn,  and 
the  case  treated  in  the  same  way  as  when  the  radical  cure  has  been  attempted 
br  iodine  injection,  viz.,  by  rest  and  antiphlogistic  treatment  The  length 
of  time  during  which  the  seton  must  be  left  in  before  sufficient,  or  even  any 
inflammation  is  produced,  varies  very  considerably.  In  most  instances,  the 
proper  amount  of  inflammatioo  is  excited  in  from  twenty-four  to  thirty 
nours;  but  in  other  cases  the  seton  may  be  left  in  for  ten  or  twelve  days, 
giving  rise  to  but  little  inflammation,  although  a  radical  cure  may  result. 

The  Antiseptic  Kethod  has  been  successfully  applied  to  the  treatment  of 
hydrocele  by  Volkmann,  and  Reyher,  of  Dorpat.  The  sac  is  incised  along 
its  anterior  aspect,  and  the  fluid  evacuated ;  the  tunica  vaginalis  is  then 
attached  to  the  skin  by  a  tew  points  of  suture,  and  the  parts  dressed  anti- 
septically.  This  treatment  is  said  to  be  more  certain  and  less  painful  than 
that  by  the  seton.  It  would  be  especially  useful  in  old  cases  with  thickened 
walls,  in  which  the  injection  had  failed. 

Acnpnnctiire. — 8mall  hydroceles  in  elderly  men  may  sometimes  be  dis- 
persed by  simple  acupuncture,  in  an  almost  painless  manner.  The  scrotum 
nmving  been  put  upon  the  stretch,  the  hydrocele  is  punctured  at  two  or  three 
points  with  a  large  darning-needle,  introduced  slowly  by  being  rotated 
iMtween  the  ffnger  and  thumb.  From  the  punctures  thus  made  the  serum 
■lowly  escapes  into  the  cellular  tissue  of  the  scrotum,  whence  in  two  or  three 
days  it  is  absorbed. 

This  mode  of  treatment  will  be  found  also  the  safest  and  most  cflTectual  in 
the  hydroceles  of  younff  children,  in  whom  it  would  he  extremely  dangerous 
to  attempt  a  cure  by  injection  of  iodine.  It  may  always  be  safely  employed  if 
the  application  of  the  lotion  l>efore  mentioned  tails  to  cure  the  disease. 

It  IS  not  always  prudent  to  have  recourse  to  the  radical  cure  in  the  treat- 
ment of  hydrocele.  In  {>erHon8  advanccti  in  yean),  or  of  feeble  and  unhealthy 
ooDStitutiou,  the  inflammation  excitetl  in  the  tunica  vaginalis  by  any  of  the 
means  just  dctaile<l  may  run  on  to  such  an  extent  as  to  give  rise  to  iuflamma- 
toiy  oedema,  and  even  simighing  of  the  scrotum,  with  great  danger  to  life. 
In  these  subjects  it  is  much  safer  and  usually  sufficient  to  temiwirizc  with  the 
hydn>cele,  and  only  to  tap  as  occasion  arises  from  the  increasing  size  of  the 
•welling. 


1112 


tllSEASKS    OF    TUB    TESTIS    AW    COBl). 


Enctstep  HYDROcnr-E. — In  iJ»ih  variety  of  the  liisea-w  the  fluid  docs  oi 
lie  iu  Uie  tuuica  ragritialiit,  but  is  Cfintaineil  in  a  eyrt  which  projectK  troiu  tJie 
eurfiu-^  of  tl)«  epididymis  or  testis,  and  pu9h«s  the  serous  investment  of  the 
glaad  before  il. 

ThCT*!  cysts  are  inucb  more  frequently  found  connected  with  tlif  i^pididjrmii 
than  with  the  body  of  the  tfirticle.  Indti^d,  C'uriiug  huo  pointed  out  tiie  fad, 
that  Bmall  pedunculated  cyBtn  about  llie  »ize  of  cumuita,  «od  composed  of  a 
fine  serous  metubraue,  liovd  witli  teH^ellult'd  epitbeliuin.  arv  very  fr^tjurotlr 
found  beneath  the  vixceral  tuuicu  vngiualis  coveriog  the  epididymis.  They 
are  delicate  in  structure,  contain  a  clear  limpid  tiuid.  and  are  very  liable  to 
rupture.  They  are  met  with  at  all  agee  ufler  tbut  of  puberty.  Act'onliag 
to  titnselin,  after  the  age  uf  forty,  Ihcy  occurred  in  at  Iea«t  twoihirdJi 
of  the  testes  examined  to  ascertain  their  prcEvuce.  Such  cyeL«  iw  tbna 
may  remain  stationary,  of  firaall  aize,  uudiscvruible  during  life;  they  may 
rupture  into  the  tunica  vagiDaliu;  or  they  tuHv  enlarge  uud  become  dev«> 
oped  into  tumora  of  coDiiderable  nmguilude. 

The  fluid  of  these  cvsts  poeseteee  the  rpmarkable  cbaracteriBtic,  diacorend 
bjr  LiatOD,  of  containing  Hpermntozoa  {V\ir.  965'i.     Thougti  t^jK-rmatuztfa  do 

not  alwaym  exint  in  this  tluid,  yut  lliey  ant 
UBunily  met  with,  Honietinies  in  limall  qiiau- 
tiliea,  ai  others  so  abundantly  as  to  f^ive  it  a 
turbid  or  o|>alescent  apjiniranoe.  This 
admixture  of  spermatozoa  witb  Ibe  clear 
fluid  of  the  cyat  is  probably  due,  ae  pointetT 
out  by  Curling,  to  the  acc?iiiental  nipture 
a  e«niiual  duct  into  an  ulreHdyexiMiu^cyEi. 
Spermatozoa  have  also,  but  very  rarely, 
been  found  in  the  fluid  of  an  ordinary 
hydrocelu  of  the  (untca  vaginalis  ;  and  then 
probably  tbeir  presence  was  due  to  the  rup- 
ture of  one  of  these  cysts  into  the  luntca 
rujpnalia.  Hence  their  presence  in  the 
fluid  of  hydrocele  tiiav  in  most  cases  be 
considered  a«  chamctcrUtic  of  the  encrsted 
variety  of  the  diseiue. 
The  Signs  of  encysted  hydrocele  dilfer  in  lome  respects  fh>m  those  pr^ 
s^nled  by  hydrocele  of  the  tuuica  vasinaliB. 

The  tumor  is  snialler,  more  irregular  in  shape,  and  docs  not  envelop  tb< 
testis  completely,  but  is  situated  behind  uud  above  il,  rather  in  couoecltoul 
with  the  epididymis. 

The  Diagnona  from  ordinary  hydrocele  of  the  tunica  vaginalis  may 
made  by  observing:   1.  That  the  testis  is  below  and  in  front,  and  not  covered 
in  by  the  encysted  form  of  the  disease ;   2.  Thnt  the  tumor  is  more  globular  ot 
irregular,  and  leas  pyriform ;  3.  When  tapped,  the  fluid  will  oeunlly  be  found 
to  be  opalescent. 

The  Treatmrnf  consists  in  injecting  the  sac  with  tincture  of  iodine,  or  <>tfl 
inciting  the  tumor  and  allowing  it  to  granulate  from  the  Iwttom.    The  injec^-fl 
(ion  by  iodine  is  not  so  frequently  8Uccc&<rul  in  this  as  iu  the  last  variety  of 
the  disease,  but  dcBeiTes  a  trial;  if  it  tiul,  incision  of  the  tumor  will  always 
effect  a  cure. 

in  encysted  hydrocele,  the  iodine  injection  should  not  be  so  strong  as  that 
which  is  used  for  injecting  the  tunica  vaginalis.  It  should  be  diluted  with 
two  or  three  parts  of  water,  as  it  comes  mure  directly  into  rehitioo  with  the 
structure  of  the  teelis. 


yip 


IIS 

ar  — 
■71 


« 


ytg.  9Si.— 5pana>iuiD»  Truiu 


H^MATOCELE^CHABACTEKS.  1113 

Hydrocele  of  the  Cord. — This  disease  is  charncterized  hy  the  presence 
of  a  round  or  oval  tumor,  situ&ted  od  the  cord,  below  or  within  the  inguinal 
canal.  It  b  smooth,  elastic,  and,  if  of  sufRcient  size,  may  show  semi- 
transnarencT  on  examination  by  transmitted  light.  It  can  be  pushed  up 
into  tne  alxfomen,  unless  the  testicle  be  drawn  tirmly  down  ho  as  to  put  the 
cord  on  the  atretch,  when  the  cyst  becomes  fixed.  It  receives  no  impulse  on 
coughing,  and  does  not  alter  in  size  on  being  steadily  compressed.  Occa- 
sionally more  than  one  cyst  may  be  met  with.  It  appears  to  be  due,  in  some 
cases,  to  imperfect  closure  at  one  or  more  points  of  the  funicular  portion  of 
the  tunica  vaginalis,  and  to  distention  by  fluid  of  the  unclosed  portions; 
though  i(  is  possible  that  in  other  instances  it  mav  arise  as  a  distinct  cystic 
jfTOwth.  These  tumors  may  occur  at  all  a;ree.  i>ut  are  met  with  chiefly 
in  the  young,  and  are  not  unfrequent  amongst  children. 

The  fluid  of  a  hydrocele  of  the  cord  is  lighter  in  color  than  that  of  one  of 
the  tunica  vaginalis. 

Treatment. — The  obliteration  of  the  cyst  is  best  conducted  hy  passing  a 
acton  through  it,  or  by  making  an  incision  into  it,  treating  it  antiseptically, 
and  letting  it  granulate  from  the  bottom. 

Diffused  Hydrocele  of  the  Spermatic  Cord  consists  in  the  infiltra- 
tion of  the  cord  with  serous  fluid,  contained  in  rather  distinct  spaces,  and 
ipiving  rise  to  an  oval  or  oblong  irregular  circumscribed  tumor,  extending 
below  an<)  into  the  inguinal  caual. 

The  TVeatment  consists  in  the  application  of  blisters,  or  of  counter-irritant 
plasters.  Should  the  disease  prove  very  tmublciiome,  an  incision  might  be 
made  down  to  and  into  the  swelling,  su  as  to  let  out  the  tiuid  and  allow  the 
cyst  to  become  consolidated. 

H.i'iMATOCKLE. — By  Hcrmatoctle  is  meant  an  accumulation  of  blood  in  the 
tunica  vaginalis,  distending  that  sac,  and  compressing  the  testis.  It  is  of  two 
kinds,  Traumaiie  and  Spontaneous.  The  Traumntic  is  the  most  common  form 
of  the  disease,  usually  arising  from  a  blow  on  or  a  squeeze  of  the  testis,  bv 
which  one  of  the  veins  ramifying  on  the  surface  of  the  gland  is  ruptured, 
and  btnod  is  poured  into  the  tunica  vaginalis.  It  may  arise  also  in  tapping 
a  hydntcele,  from  the  point  of  the  trocar  being  pushed  t(M)  directly  oaek- 
wanls  and  puncturing  the  testis,  ur  wounding  a  vessel  in  the  conl.  Sponta- 
neoua  Hematocele  is  a  disease  of  rare  occurrence,  arising  apparently  from  the 
rupture  of  an  enlarged  spermatic  vein  into  the  tunica  vaginalis.  It  attains 
a  larger  size,  and  is  altogether  a  more  formidable  aflection,  than  the  trau- 
matic bn^matocelo, 

Cii'iracter;). — In  whatever  way  occurring,  a  ho'matocele  slowly  but  gradu- 
ally increases  in  size  until  it  attains  about  the  magnitude  of  a  duck's  egg,  or 
even  that  of  a  cociHinut.  It  is  sehlnm  that  it  lu'cumes  larger  than  this :  but 
cases  are  recorded  in  which  the  tumor  has  attaine<t  an  enormous  magnitude. 
I  once  operated  in  a  case  in  which  ns|x>ntnneoUi<  h:eni:itocelc  had  existed  tor 
BIX  years ;  it  was  os  large  a."  a  good  size<i  moI<iu,  iiml  C'-utaineil,  besides  about 
a  quart  of  dark  thin  blond,  a  handful  of  partially  dt-colorized  ami  tough 
fibrin,  the  greater  portion  of  which  was  finidy  a'lhenut  to  the  insiile  of  the 
greatly  thickened  tunica  vaginalis  in  filarnrntary  and  laminated  niass(>t<,  with 
here  and  there  nodulcB  interspersed.  The  wliole  of  the  interior  of  the  tunica 
vaginalis  ctoM-ly  reseinblcl  an  aneiirismal  sar. 

The  fluid  contiilni'il  in  the  h;eiii:iioi.-i>U',  when  the  disease  is  recent,  eonsista 

of  pure  bloo<l.    The  bl i  so  eltiiseil  will  cnuliiiue  fluid  fir  years  ;  but  at  last 

it  may  decompose  and  set  up  liitul  iiilhimrnatory  niiThief;  in  some  rare  in- 
stances the  tumor  ln'come«  partly  soli-iitiod  hy  the  di'posit  of  masses  of  fibri- 
Dous  coagulum  lining  the  interior  of  the  tunica  vairinalis,  which  are  some- 
tiroes  decoiorizt'd  anil   arran;:ed,  n.->  in  the  case   jiisl   referred   to  and  in  one 


11V4 


niSBASBS    OK    TICK    TKSTIS    A  N  tl    COHn. 


recorded  by  Bowmnii.  iu  a  lauiiuatctl  maimer,  like  (he  cuDteoU  of  an  udm- 
romal  sac.  When  the  hematocele  is  of  nlil  ataadiug,  ch»ti^t!4  t&ke  plaw 
both  in  the  efUi^ed  blood  and  in  \h*^  i^c.  The  bliHxl  ia  uli|  iiu;iiiatocel«A  be- 
oonieit  at  tint  dark  uud  treaviy.  As  cliemica)  changed  advance  further  it 
becomea  converted  into  a  dirt^'-browuieli  tluid.  lull  of  nbreJs  i»f  partially 
decolurized  librin  and  crystals  of  cbolesterine.  The  tunica  Ta^inalls  b&> 
comes  thickened  and  iadural«d,  aud  in  exceptional  cases  may  undergo  calci* 
fication.  Tbid  change  I  found  in  a  puti«ot  whose  dUorgaoized  te»tis  I 
reniwved  for  a  btumatocele  of  nearly  forty  yeara'  standing. 

Hympiotrut. — Thei!«  are  genernlly  sufiicieQtly  obvious.  The  occurrence  of 
the  tumor  suhaecjuetitly  to  a  blow,  strain,  or  injury  when  traumatic,  ila 
gradual  increase  in  size,  ib)  somewhat  beary  but  wmi-elasuc  or  ob^urely 
tliicttmling  feel,  and  the  absence  of  translucency,  form  the  moat  iiuyiortaDl 
signs.  Its  shape  is  somewhat  uncertain.  When  recent  it  may  bave  the 
pyrifbrni  shape  of  a  hydrocele,  but  an  old  hiematocele  is  always  mure  or  itat 
oval  or  rounded  in  form  and  smooth  on  the  surface,  and  thus  comes  doacly 
to  rosomble  a  solid  tumor.  Except  in  very  old  casts,  in  which  atrophy  of 
the  testicle  from  prcieiire  hns  occuiTcd.  the  peculiar  "  testicular  sensation'* 
will  be  ])L'reeiv(.'d  by  the  patient  it'  the  site  nt  the  glaud  li  prc^seil  upon. 

Diannasi)!. — I  [it-niatoec-lc  may  be  mistaken  for  hydrocele,  horuin,  and  other 
scrotal  ^^rclliugs.  The  mode  ot  distinguishing  it  will  be  described  at  the  end 
nf  ihia  chapter,  with  the  diagnosis  of  Bcn)tal  tumura  in  general.  It  is  raoAt 
frequently  confounded  with  solid  tnmors  of  tho  testicle ;  and  upon  ibis  fact 
is  iViundcd  the  excellent  rule  nf  practioe  never  to  remove  a  doubtful  tumor 
of  the  tetttis  without  fir»t  ascertaining,  by  an  inciaion  into  its  substauee,  that 
it  ij)  not  a  hematocele. 

Treniment. — -This  must  vary  with  the  sixc  and  duration  of  the  tumor 
When  it  is  small  and  recent,  and  has  fluid  contents,  the  Surgeon  may  try 
tlie  effect  of  tapping  il ;  it  in  pixttible  that,  afler  the  evacuation  of  the  blood, 
closure  aud  obtiierati^iu  of  the  tunica  vaginalis  will  take  place.  This  ha|f>- 
pened  in  a  case  under  my  care,  in  which,  though  the  disease  had  exi-nteol  for 
threw  years,  a  complete  cure  f'jilowed  the  operation  ^f  tapping.    8uch  wimple 

treatment  as  this,  however,  caunot  he  depeiio«d 
u[>«>n ;  aud  it  usually  beconies  necessary  to  lay 
the  aac  0|>en,  treat  the  wouutl  autiseptically,  and 
to  cause  it  to  contract  aud  to  granulate  from  the 
bottom,  when  the  obliteration  of  the  cavity  of 
the  tunica  vaginalis  necessarily  resnlt«.  If  the 
tumor  were  of  wry  largo  sise,  and  tho  tuuica 
vaginalis  much  thickened,  hardeni'd,  aud  parch- 
nifiit-like,  with  adherent  anil  laminated  tlbriu. 
castration  might  ptnu^ihly  Ire  rctjuired.  \a  ttie 
instance  to  whic-:h  I  have  alriiidy  rcfurrvd,  and 
which  is  represented  in  Fig.  *Kiti.  this  was  ren- 
dered necessary  in  conHi'tjueuce  of  these  cntnUi- 
tiont^.  !Uid  wii«  KUt'crcsfully  dime. 

Hematocele  of  the  Spermatic  Cord  has  been 
observed  liy  Pott,  ( 'urling,  Bowiitau,  and  othen; 
it  iii  a  rare  disease,  and  usually  iK'cure  in  the 
form  of  a  tumor  of  considerable;  niagnitu<le,  sud- 
denly arising  nfler  a  strain  oraorae  violent  exertion,  giving  rise  to  rupture  of 
a  varlcoae  spermatic  vein.  It  coinmenreti  iu  the  inguinal  canal,  ancl  thence  ex- 
tends duwnwartU  along  the  course  of  the  cord,  thrnugh  the  alxlomlnal  ring 
into  the  scrotum  ;  but  it  di»<^  not  surround  or  im]dicAtc  the  teslin,  which  can  be 
felt  free  and  movable  at  it^  lowest  pBrc  On  incbing  such  a  tumor  as  thu,  a 
quantity  of  blood,  partly  Kutd  and  partly  coagulated,  has  been  found,  aone- 


VIg.  neo.  —  lla^nulaeala  frlUi 
Tbiekencd  Tnoicn  Vftginalb 
anJ  »ilh«Tnni  Fibria. 


A 


VARICOCELE.  1115 

times  contained  in  a  cavity,  occaBioned  bv  the  laceration  and  separation  of 
the  tissues  of  the  cord  and  scrotum.  I'he  most  remarkable  case  of  this 
kind  on  record  is  one  related  by  Bowman,  in  which  the  tumor,  after  existing 
for  ten  years,  had  attained  so  enormona  a  size,  that  it  reached  to  the  patella, 
and  was  so  heavy  as  to  require  both  hands  and  a  considerable  edbrt  to  raise 
it  from  its  bed.  In  this  case,  death  appears  to  have  resulted  from  decompo- 
sition of  the  coDlents  of  the  tumor. 

DiagnMis. — In  its  early  stages,  hematocele  of  the  cord  would  run  consid- 
erable risk  of  being  cimfounded  with  an  inguinal  hernia.  The  more  diffused 
character  of  the  swelling,  however,  its  regular  feel,  its  semi-fluctuating  bco- 
sation,  and  the  imjKissibility  of  reduction,  might  enable  the  diagnosis  to  be 
made  (p.  787,  vol.  ii.).  H»?matocete  of  the  cord  may  always  be  distinguished 
from  an  accumulation  of  blood  in  the  tunica  ragimdis.  hy  the  testicle  not 
being  implicated  in  the  former  cnse,  but  surrounded  by  the  fluid  in  the 
latter  instance. 

The  TTeatmcnt  of  this  disease  must  in  the  earlier  stages  be  of  a  jmlliative 
kind  ;  consisting  in  rest,  support  of  the  tumor,  and  the  application  of  evapo- 
rating lotions.  Care  should  be  taken  not  to  incise  it  at  this  period,  lest  the 
loss  of  blood  from  the  ruptured  vein,  after  the  evacuation  of  the  contents  of 
the  tumor,  become  uncontndlable.  In  one  instance  I  have  known  fatal  con- 
sequences from  this  cause  to  ensue  in  half  an  hour  afler  making  an  incision 
into  the  tumor  and  turning  out  the  coagula.  When,  however,  the  disease 
has  reached  a  chronic  stage,  and  is  no  longer  increasing,  it  may  be  incised  ; 
and,  its  contents  being  turned  out,  the  cavity  may  be  allowed  to  suppurate 
and  granulate. 

VARICOCELE. 

Varix,  or  Enlargement  of  the  Spermatic  Veiuf,  is  a  disease  that  is  com- 
monly met  with  from  the  age  of  puberty  to  about  the  thirtieth  year,  seldom 
commencing  later  than  this.  It  usually  occurs  in  feeble  individuals  having 
the  scrotum  lax  and  [tendulous ;  and  in  some  coses  appears  to  have  been 
brought  on  by  venereal  excesses.  The  spermatic  veins,  extending  as  they 
do  from  opposite  the  lumbar  vertebra:  to  the  plexus  pampiniform  is,  whicn 
constitutes  the  base  of  the  pyramidal  tumor  formed  by  a  fully  developed 
varicocele,  are  necessarily  subject  to  considerable  tension  from  the  weight  of 
so  lung  a  column  of  blood  as  that  contained  within  them,  to  which  they 
eventually  yield,  becoming  much  dilated  and  tortuous.  The  left  spermatic 
veins  are  tar  more  frequently  aAected  than  the  right ;  owing  partlv  to  their 
compression  by  feculent  accumulations  in  the  t<igmoid  flexure  of  t^ie  colon, 
and  possibly  in  part  to  the  obstacle  at  the  mouth,  occasioned  by  their  {xmring 
their  contents  into  the  letl  renal  vein,  at  right  angles  to  the  current  of  blood 
flowing  through  that  vessel  into  the  vena  cava.  The  right  9[>ermat)c  veins 
are  rarely  aflected  ;  and  never,  I  believe,  without  those  on  the  leA  side  par- 
tici|>nting  in  the  didonse.  In  thei^c  cases  of  double  varicocele,  the  lefi  is 
almoat  invariably  the  more  seriously  :ifrecte<l ;  hut  I  have  seen  exceptions  to 
this  in  one  or  two  instances,  in  which  the  veins  on  the  right  side  formed  the 
larger  tumor. 

Symitoms. — Thesymptnins  of  varicocele  consist  of  a  tumor  of  pyramidal 
shape,  having  a  soil  knotted  or  knoltlied  feel,  owing  to  the  irregularly  swollen 
aoa  convoluted  condition  of  the  veins,  with  its  base  uj)on  the  testis  and  the 
apex  stretchiug  up  to  the  external  ring.  The  swelling  iucrenM.>s  when  the 
patient  stands  up,  if  he  take  a  <h'e[>  inspiration,  cough,  or  make  any  violent 
exertion.  Ilf>  size  varies  fmiii  flight  fulness  of  the  veins  to  a  large  mass, 
several  inches  in  eirfuinference  at  the  base.  AVhen  the  patient  lies  down,  it 
goes  u]>  to  a  certain  extent,  hut  inimeiliately  returns  to  its  former  magnitude 


1116 


DISEASES   OF    THE   TESTIS    AXD   CORD. 


when  he  sbimlA  ti[>.     Tl  ie  attended  by  n  HO?ation  nf  wpi^lit  and  sntnetiin 
of  patD,  whicli  is  occ!»«ii>nHlly  very  acute,  of  a  severe  and   neiimlgir  ch» 
acter,  even  iti  llie  &crol.uin,  tlic  RroinB,  and  the  loim,  more  pnrlicularly  whea 
the  lunjor  i»  unsupported.     This  pain  \s  greatly  increased  on  thf  paticn' 
walking  iir  ridiu|;;  so  much  bo,  that  in  pome  caaes  he  it  aliaoAt  debarr^  1t«>: 
taking  uec(»s»ry  exercise,  and  is  prevented  from  fiillnwioK  any  active  occu 
paLii>n.     Uvbililv  of  the  •^tfucrfttive  or^itus,  with  a  t<*ndeocy  to  setnina)  etni' 
sious    anil    raucfi    ineutttf    dvpresetoD,  freijuenlly    nccunpaniefi    variooce' 
Alropliy  uf  the  itMticle  i»  ttomelirnes  fuiiod  aaociated  with  varic^icele,  and  1 
believt-d  to  be  deiiemlenL  upon  it.     The  rupture  of  a  varicocele  niay  ficni 
from  exu-rnnl  injury,  giving  rise  lo  ao  cnomioiis  extravasation  of  bhiod  in 
the  nn!i>lHr  liwue  of  the  »crfjtuni.     Of  this  P<ilL    relntea^  a  case.     I    ha 
known  the  Hccident  to  be  aHi'Uilcd  with  fatal  coniwpjueucee.     A  man  who. 
Use  hi:^  own  expn.esiou,  "  hftd  Ix-eii  romping  with  bis  wife,"  rttfived  n  bit*' 
<iD  a  varici)ee)e,  when  an  enormous  uxtr:tviis4itioa  of  blood  rapidly  fi)riiiedii 
the  Scrotum  and  ihe  coni,  for  which  he  was  miinitlcd  into  the  Ilixjpilal.  Tin 
tumor  woe  iiicised,  and,  Inrgo  tnasnet)  uf  eo^^ihi  wi-re  turut^d  out.     Th 
patient  shortly  ullvr,  in  the  abwnoe  of  tu-Hutlunce,  fudrlenly  bevBme 
and  died  of  venous  hemorrhage.     The  bleeiting  wob  found  tuhave  pi 
from  a  nipturvd  spermatic  vein. 

DlAriNOHlfl. — ^Tne  diagnonis  uf  varicocele  i»  always  anfliciently  eary; 
peculiar  convoluieil  feel,  il«  Imiad  base  and  narrow  apex,  the  manner  in  wht 
It  goes  U|)  when  the  patient  til's  down,  and  returiu  ngnin  when  he  (>lJind3  u 
Ore  sutlinient  to  dit^tingiiisli  it  from  nil  other  scrotal  tumors.     From  inrfuin 
hernia  the  diaeaHe  may  be  distinguished  by  attention  to  the  test  deecribed  al' 
Pl  787,  vol.  ii, 

Tki:atmknt. — Tlie  treatment  i>f  varicocele  mu3t  be  conducted  with  refei^ 
ence  (/>  the  severity  of  the  eymptoms  occasioned  by  it,  and  to  the  extent  of 
the  diseoBe.  When,  ns  i.^  usiinlly  the  ca^e,  it  gives  ^i«^  to  but  slight  incoD* 
venience,  natlinlivc  ireAtment  w  fully  sufficient;  but  if,  as  occasionaUy 
happens,  the  disease  be  a  source  of  very  intense  sutlering,  or  tend  to  the  in- 
duction of  atrophy  of  tho  testis,  or  to  generative  debility,  with  much  mental 
diiiquietudc  or  tiypochondrin^is.  then  the  Surgeon  may  te«1  dispoMd  to  «&• 
denvor  to  cure  tlie  varicocele  radically. 

The  PaltiaUve  Treatment  of  varicocele  msoItm  itself  into  means  of  vario 
kinds,  having  for  their  object  the  support  of  the  testis  and  the  diminution 
the  length,  and  of  the  consequent  pressure,  of  the  colnmn  of  blood.  This 
uaualtj  moat  conveniently  done  by  supporting  the  scrotum  in  a  welhmsdi' 
Buapensory  bandage ;  or  pressure  may  he  made  u)>on  the  )>«rt,  as  well  as  (tup> 
port  given,  by  encluiiing  the  testis  in  »n  elastic  bag.  In  other  cmmm.  Mijtpoi 
way  be  afTonled  by  drawing  the  lower  portion  of  the  scrotum  on  thtf  atitx-t' 
side  through  n  ring  made  of  luift.  metal,  covered  with  leather,  or,  better  tti 
through  a  small  vulcanij'.ed  India-rubber  ring,  so  as  to  shorten  thr  coni, 
And,  with  the  same  object,  excision  of  the  lower  portion  of  the  corotum  hsa 
been  recommended ;  so  that,  by  the  contraction  of  Ihe  cicatrix,  the  testis 
may  be  pressed  up  against  tbe  ring,  uod  the  cord  thus  ihortene<l.  This  plao. 
however,  is  ramewbot  severe ;  and  though  it  might  be  attended  by  tompomry 
beuetit,  the  a<lvnutage  accruing  is  not  Ukely  to  be  very  continuous.  Tbi 
jireeeure  of  the  |)ad  of  a  truss  on  the  spermatic  cord,  as  it  issues  from  tb 
external  riug,  will  break  the  length  of  the  column  of  blood  in  its  veins,  and 
might  thus  be  uf  service.  But  many  patients  cjinnot  bear  the  irksome  pre*- 
sure  of  iho  iuatniment ;  moreover,  it  must  aliM  be  I'emembered  Uiat  it  nill  at 
the  ^mc  time  ubslruct  tlio  return  of  blood,  and  coDsetjuently  in  all  proba- 
bility do  OK  much  Imrm  us  goml. 

In  addition  to  these  merhanieal  means,  the  part  may  be  brBccd  by  oold 


KADICAL   CDHE   OF    VARICOCELK  1117 

douchiDg,  sea-bathing,  and  the  general  strength  improved  by  the  administra- 
tion of  iron. 

The  Sadical  Gore  of  Taricoeele  consists  in  the  obliteration  of  the  en- 
larged veins,  on  the  same  principle  that  guides  us  in  the  maosgenient  of 
varix  in  other  situations. 

The  circumstances  for  which  operation  may  be  and  has  been  practised  in 
this  disease  can  be  arranged  in  the  following  categories. 

1.  When  the  existence  of  a  varicocele  disqualihes  the  sufferer  from  adnils- 
non  into  the  public  services,  there  is,  in  my  opinion,  a  perfectly  legitimate  rea- 
■on  for  operating.  One  uf  the  cases  in  which  I  have  efTecleu  a  radical  cure 
was  that  of  a  man  in  the  prime  of  life,  who,  wishing  to  enlist  in  the  Marines, 
was  refusetl  solely  on  the  ground  of  having  a  small  varicocele.  This  I  cured 
by  operation,  and  the  man  aflerwards  entered  the  service. 

2.  Id  some  cases,  the  presence  of  a  varicocele  of  inordinate  size  causes 
a  distressing  sense  of  weight  and  pain  in  the  loins  and  groins,  and  ot^n 
inability  to  stand  or  walk  for  any  length  of  time.  Here,  when  the  patient 
is  in  continual  discomfort,  or  more  or  less  prevented  from  pursuing  his  ordi- 
nary avocations — in  fact,  quite  crippled — it  is  perfectly  justifiable  to  resort 
to  operation. 

3.  When  atrophy  of  the  testicle  is  a  consequence  of  the  pressure  of  the 
blood  in  tbe  veins,  an  operation  may  be  performed. 

4.  Cases  not  uncommonly  occur  where  the  pressure  of  the  enlarged  veins 
CD  the  spermatic  nerves  produces  repeated  attacks  of  spermatorrhcea.  These 
cases  are,  however,  more  frequently  met  with  out  uf  hospitals,  than  in  indi- 
viduals of  the  class  who  apply  to  such  institutions  for  relief  In  fact,  young 
men  of  the  more  highly  educated  classes  are  very  subject  to  varicocele,  espe- 
cially thoee  who  haoitually  lead  a  sedentary  and  studious  life,  as,  for  instance, 
joung  clergymen  and  lawyers.  In  these  persons  a  peculiarly  hypochondriacal 
■tale  la  brought  on  by  the  tendency  of  the  mind  to  dwell  on  the  condition  of 
tbe  genital  organs,  ami  the  patient  is  constantly  fidgeting  about  the  local  and 
tansnble  disease  he  observes  in  them. 

The  radical  cure  of  this  condition  may  be  produced  by  exciting  inflamma- 
tory  thrombosis  of  the  spermatic  reins,  through  an  iippHcation  of  the  sameprin- 
ciple  which  sets  up  that  process  iu  the  veins  of  the  lower  extremitv.  There 
are  several  different  ways  of  doing  this ;  some  are  very  objectionable.  The 
twisted  suture,  as  applied  to  the  veins  of  tbe  leg.  induces  too  great  irritation 
in  tbe  scrotum,  and  there  its  introduction  is  otton  followed  by  violent  in- 
flammation or  sloughing,  or  by  an  opening  up  of  the  areolar  tissue  of  the 
•crotum  with  u-dema,  and  even  purulent  infiltration.  It  is  better,  I  think, 
not  to  use  this  method  here;  indeed,  I  have  twice,  in  the  practice  of  others, 
ieen  it  followed  by  death.  The  plan  I  have  adopted  for  mtnic  years  is  that 
■uggested  and  prncti::eJ  by  Vldal  de  CW^iiii,  and  is  0:^  follows :  The  vas 
deferens,  readily  distinguished  by  its  niuiid  cord-like  fi-el,  is  tin>t  separated 


i'l/i.  'Ji'-7.  —  Ir-'ii  I'm  fur  TiimIim  lit  "f  Viirii'Ui'i-lc. 

from  the  veins,  &n<l  intrti^ted  to  uii  ut<iiii<t:int :  next,  an  iron  pin  bori'd  with  a 
hole  at  each  end  i.Fig.  M~),  is  parsi-d  botwivn  tlif  vas  and  the  veins,  and 
brought  out  at  the  point  of  jxTlonuiim,  tin-  scroUim  bving  tir>t  nnti-hi'd  with 
a  Bcal|H.'l ;  then  a'^ilvtr  wire,  ilircaik-d  on  a  needle  si>  i.-oiii;trueIed  that  the  wire 
■hall  follow  it  without  eiiteliing  i.Fi}:-  W"^  .  is  pikN^.d  in  ut  tbe  ajierture  of 
entry  of  the  pin,  ami  earrieil  iK-tweeii  the  iiitt'^uiiit-nt  of  tbe  laemtum  and  the 
veins,  tbe  wire  twin;;  bmui^bt  nut  at  the  meouit  puncture  i  l-*ig.  W.i).     l^ch 


H18 


UI8SASBS    or   THB   TXSTfS   A7VP   CORI>. 


end  of  Uie  wire  is  novr  pw(««d  ihrougli  tbe  correapoadiag  hole  of  the  pin. 
which  is  twisted  n>uur|  aud  round  repeatwlly,  each  turo  causiag  ihe  wire  to 
be  r<.)lli>d  nrouud  tbe  pin,  and  eo  lightetll^l,  till  the  veias  are  firmly  compresved 
betweeu  tbe  pio  behind  and  the  loop  of  wire  in  front  (.^ig.  970).     Br  this 


Fig.  0«S.— Split  »««<l)«  lliresJcd  wllti  SilTar  Wlm. 

means  the  scrotum  is  quite  free  and  unoDrnprejased,  and  there  is  no  daoger  of 
exeilin;;  itidamuiatinn  or  unlema.  The  ivire  should  be  tightened  from  any  to 
day,  as  it  psuhoi  iilceratifiii  in  the  veins  until  it  hiw  completely  cut  ihruugli, 
which  reeulu,  ueually,  in  about  a  week  or  ten  days.    Meauiwbile,  there  u 


Pig.  VOV.— Vldal'*  OpxfftUon  for  V«rko. 
Mlej  Needlai  and  Wlra  ippllBd. 


ittU«<l  u|>. 


mueh  inflnmmatioD  arouud  the  vcinit;  this  finally  contracts  and  oblitcrAla 
their  ehonnets.  This  mvthud  produces  an  eflectuoJ  and  permanont  care 
(Fi«.  971). 

Of  late,  I  have  been  in  the  habil  of  eniploying  a  simpler  method.     I  sepa- 
rate the  van  deferens  in  the  usual  way,  and  then  make  a  small  iucisitin,  abuul 


Fig.  8T1.— Vldftl'*  0(iont(oD  ;  AppwraUM  of  N<»ll«  •nJ  Wire  vhan  rtanvad. 

half  an  inch  long,  in  the  front  and  back  of  tbe  scrotum ;  afterwards  I  put 
a  needle  armed  with  silver  wire,  as  before  deH<.-ribe<l.  between  the  vas  and  lh« 
veins,  bringing  it  out  behind ;  I  then  r^jtiim  the  ueetlle,  hut  this  time  carry- 
ing it  in  fri>ut.  between  tbe  veins  ami  the  ekiu ;  and  thus  the  veins  are  included 
in  a  loop  of  wire,  without  implicating  the  scrotum.  Tbe  loop  is  then  tightly 
twisted  together,  so  as  to  constrict  the  eucloeed  vessels.  This  plan  has  a 
similar  effect  to  that  of  the  wire  and  pin  combined;  by  repeated  tighleuin|n 
the  wire  gntdually  elTects  a  paivage  by  ulceration  tbrougu  tbe  vcimt,  wbini 
are  obliterated  by  the  wirae  nrocew. 

It  has  been  ot)Jeele<t  to  this  and  similar  operations,  that  atrophy  of  the 
testis  may  take  plaire,  from  the  spermatic  artery  being  included  ttwclher  with 
the  veins.  Kxperieace  shows  that  there  is  no  risK  of  this.  Even  if  the 
spernialic  artery  were  obliterated,  the  artery  ol'  the  vn&  deferens,  the  cremas- 
teric, and  other  branches,  would  enlarge  and  take  its  place.    In  must 


CBROKIC    INFLAMMATION   OF"   THE   TKSTIS.  1119 

however,  it  probably  escapes,  beiog  held  out  of  the  waj  with  the  vas  deferens, 
but  observatioDs  od  the  dead  body  show  that  this  is  not  always  the  cnse. 

Since  the  introduction  of  the  antiseptic  treatment  of  wounds  the  risk  of 
pyeemia  following  ligature  of  a  vein  is  so  completely  abolished  that  the  opera- 
tion of  exposing  the  enlarged  veioa  and  tying  them  may  be  safely  under- 
taken. It  is  thus  performed.  A  small  incision,  one  inch  in  length,  is  made 
over  the  spermatic  cord,  commencing  about  one  inch  below  the  external 
abdominal  ring.  The  skin  and  superficial  fascia  are  then  dissected  carefully 
through,  until  the  cord  is  ex|K)8ed.  An  assistant  then  graape  the  cord  imme- 
diately above  and  below  the  incision,  and  squeezes  it  forwards  till  it  projects 
from  the  wound.  The  veins  are  then  isolated,  and  a  double  ligature  of 
carbolized  catgut  or  silk  is  passed  under  each  by  means  of  an  aneurism- 
needle.  The  veins  are  then  divided  between  the  ligatures,  which  are  cut 
flhort,  and  dropped  into  the  wound.  If  the  incision  is  made  hi^h  enough  up, 
two  or  three  veins  at  most  will  require  ligature.  The  wound  is  then  oloeed, 
a  smalt  drain  being  laid  in  its  lower  angle,  and  an  antiseptic  dressing  is 
applied.  It  is  dressed  at  the  end  of  twenty-four  to  forty-eight  hours,  and 
the  drain  removed.  At  the  second  dressing,  which  should  be  at  the  end  of 
a  week,  the  small  wound  will  usually  be  found  to  have  united  by  the  first 
intention.  The  operation  has  the  great  advantage  of  causing  no  pain  during 
the  afler-treatment,  and  it  is  certainly  as  safe  as  any  other.  It  has  been 
repeatedly  performed  in  University  College  Hospital  with  the  best  results. 
Pearce  Gould  has  also  operated  eucceesfully  on  a  considerable  number  of 
cases,  by  dividing  the  veins  with  a  galvanic  cautery,  the  wire  being  passed 
round  them  from  a  small  puncture  in  the  skin. 

SOLID   ENLAItOKMENTS   OF   TlIK   TKSTIS. 

All  tumors  of  the  testicle  were  formerly  classed  together  under  the  generic 
term  of  Sareoeele ;  and  when  they  were  conjoined  with  fluid  accumulations 
in  the  tunica  vaginalis,  they  were  termed  Hydro-iarcocelfl.  The  term  is  of 
little  use ;  but  so  long  as  it  is  understood  that  it  means  no  more  than  a  solid 
enlargement  of  the  testicle,  there  is  no  barm  in  using  it.  Solid  enlargements 
of  the  testicle  may  be  divided  into  the  Simple,  the  Syphitilic,  the  Tubercular, 
and  the  true  Tumors  of  the  Tenticte. 

Cheonic  Orchitib. — Simple  Sarc-ocklf.  is  a  chronic  enlargement  of 
the  testix  resulting  from  inllummati>ry  mischief  in  the  organ,  not  arising 
from  syphilis  or  deposit  of  tuburcle.  It  is,  in  fiict,  chronic  orchitis.  IJotn 
tbe  epididymis  and  the  body  of  the  gland  are  uiitinlty  alfected.  The  testicle 
fieels  hard,  sm<K)th,  solid,  thuu^'h  |ierha[>s  slightly  elastic  at  points:  it  is 
'ovoid  in  shape,  and  usually  about  as  large  as  n  duck'tt  egg.  It  id  heavy  and 
but  slightly  painful,  and,  exce])t  in  very  nl<)  ca^'s,  the  |>cculinr  sensation 
ibit  on  squeezing  a  testicle  is  present.  The  c<>rd  is  usually  somewhat 
thickenetl,  and,  as  well  a^  the  gniiu,  is  the  sent  of  paiu  of  a  dragging 
character.  The  tunica  vaginalis  nccasionally  contains  serous  fluid  lying  in 
front  of  and  olwcuring  the  testis.  The  scrotum  is  always  henllhy.  and 
usually  one  testicle  only  is  affected.  Occa-^imially  simple  chronic  inllamma- 
tioD  may  slowly  give  rise  to  suppuration,  and  one  or  more  alujcessfs  may 
fi>rm,  especiallv  in  strumou-i  subjects.  In  tlwr^c  circumstances,  a  part  of  the 
iodurateil  testicle  enfleiis  and  becomes  nrnniiiient,  the  skin  becomes  rcii, 
sbining  and  thinned,  and  adliesioii^  form  l)(>twt>en  it  and  the  gland  l>eneath. 
At  last  the  abscei^s  burxts  nn<l  a  fistulous  n|>oniug  is  loft.  Thniugh  this 
aperture  a  funpiis  i  heruiit  tf»tis,  or  benign  fiMigus  of  the  testicle)  si>eeitily 
protrudes,  which  grows  .«<>metime!<  .■^hnvly,  }<oinetinics  rapidly,  |KThu|).'i  uttain- 
ug  a  very  considerable  size  {  Kig.  \.1~2).     As  the  fungus  increases,  the  organ 


1120 


DI8£AaBS   OF   THE    TSSTtS    XXD   COKO. 


•  i». 


fig.  &::.  '  iiiMiitv 

Dvttlgti    Funga*    "t     ill* 
TutioU. 


ap|>«ttr«  U>  atrophy,  but  io  r«ftlily  ta  preaied  out  of  thv 
inU)  tbu  fuugu«.    TliU  fungtia  u  ooi  ■  oev  gruwth.bui  ii 
tubuU  tc«iis  aud  iuflaoimaionr  products.    It  u  ia  ihefbraof  ft 
yellow  gnuiular  oibm.    If  small  and  firm,  it  msj  bveon* 

complolDt:  butifUnn.  rapidly gnvin^od 
^  textured,  it  speodtly  deslruTi  lira  MontiBg  Mn 

'f^()  of  Lb«  leBliSr  leaviQ)^   Doibing   but   ■  lU 

epididfutu  aad  a  coQtiacted  %ai  ibraDkaa 
albugiuca.  It  is,  liiiwi!v»,  »urpruui|;  ham 
fuucliuua  of  this  orjpui  will  DooUaue, 
tinuo  is  ill  a  ^reoi  moasura  dflttnmd,  ukI  tli  i 
ture  intvcneu  by  luppuimtiiig  natula.  Ia 
cases  no  tuaens  appears  but  a  ftiuiloiw  tadi 
be  Wit,  It^diu^  U)  ao  impetfeetiy  draianl  t 
surniuiiilMl  by  iodurnti'd  llwua,  aiul  liui. 
main  unhcaliHl  for  montha  tv  «vea. 
«nnftlly,  inftt^ad  of  himtinj;  and 
fiiii^Mif.  ihf!  abflccM  may  become  to 
Atfitsf  fibroid  tissue  and  remain  atatiotiary,  aa 
dtiiiM^  wall  has  b^d  known  to  rnloify. 

Simple  chronic  nrcbitta  cad  usually  be  dlM 
Attributed  to  a  blow,  Bquevsc-,  or  iMtnt  iDJa 
which  iiidanimation  hu  hem  «X'--'-'' 
Structure. — On  makiog  a  kcUod  of  a  taticle  aSectcd  > 
ioflamiuatioD.  tk«  tunica  vagiualittwill  be  fi>uDd  to  be  nioiv  •>! 
and  perhaps  eeparated  from  tbu  tunica  albugioca  in  part*  by 
tioQs  oi'  tluid.  The  tunica  albugioi^a  is  thickened,  oKca  prcMa 
external  surface  a  seriea  of  tirui,  g-lietcnioii  laveiv.  The  MDta  «f 
are  seen  to  be  thickened,  rt;ndvriu(r  the  nhulc  organ  hara  and 
giving  it  a  bluish-gray  appears  not;,  in  ibu  mitUt  of  Ihiv,  mA  o|>*<|W 
Bputs  may  be  teen.  These  have  been  mislukeu  for  tubercle,  but  on  i»  i 
maaea  of  chronic  inflamraat4)ry  protluvta  that  bare  uadL-rgone  fiuty  del 
tjun.  The  microeoope  shows  that  the  chronic  inflamiBaliao  euaiy) 
the  inlertubular  fibrous  tissue,  but  in  many  oaaes  thh 
catarrhal  overgrowth  of  the  fpilhetiuni. 

Proffno»i*.—-Bimale  chronic  orchitis  usoallv  u-rminalca  fai   

the  organ  may  be  lefl  somewhat  enliirged  anif  indurated,  or  to  oiker 
may  undergo  atrophy  as  the  inflammobiry  pn>dDrl»  become  abaorfaed. 

jVeatmenL — {^trapping  and  (he  admiiii»tnition  of  an  alu-rative 
pcrcfaloride  of  mcrourr  may  be  tried.     If  the  tifgan  do  out  dtmhitab  la  i 
these  means,  or  if  it  V  a  source  of  much  EiwooveflMBCe  U>  tbc 
mast  be  removed.   If  accompanied  by  hydrocele,  the  tunics  vaginal* 
lapped,  hut  on  no  account  ihoulJ  injection  of  iodin*-  W  mctftid 
nbaoesus  form,  they  mast  be  ojtcned.     When  a  fnng^ 
one  of  the  fistnlou*  apertures,  roeau«  mu«t  l«e  taken  '■ 
lest  It  go  on  to  complete  destruction  of  the  testis.     I- 
best  plan  will  be  to  spiinkle  ii  with  rod  oxide  of  tr 
tightly  down  with  a  piec«  of  lint  aud  strapping.     If  it  bo  lar^itf,  if 
iihaved  off*,  aud  the  cut  surface  then  drvmd  with  thv  ointmaut  ef 
oxide  of  mercury:  oar«  being  taken  during  cicatrization  tu  rvpreHtte 
latiooa  below  the  level  of  the  surroundLng  in(cgum«it  br  stm 
preeeure.    Syme  has  recommaaded  that  the  pnoanin  stuMild  be 
the  inl^picDent  of  the  port;  an  ulliptical  iadsioD  boiiif 
fungus  and  tiie  edges  of  the  opening  in  the  skin  through  w. 
|ifti«d  ftway,  tba  acrotal  integoments  are  freely  seipuatail  by 


TUBEHCULAR    TE3TICLK.  Il21 

their  eubjacent  coDnections,  aod  brought  together  uver  the  protruding  uibbb 
and  secured  by  sutures.  This  operation  I  have  'practiseil  with  eucceea. 
Should  the  fungus  be  of  very  larf,re  eize,  so  as  to  include  within  itself  the 
whole  or  greater  part  of  the  structure  of  the  teiitis,  it  may  not  be  possible  to 
Bsve  any  of  that  organ  ;  and  in  these  circumstances  it  is  better  to  remove 
the  whole  gland  ;  if  left,  it  could  never  be  of  any  service,  and  would  continue 
alowly  to  suppurate. 

Tubercular  Testicle,  Scrofulous  TEi^TirLK,  or  Tubercular  Sar- 
COCELK. — This  disease,  although  occasionally  met  with  in  individuals  appa- 
rently strong  and  healthy,  usually  occurs  in  those  of  a  febrile  or  cachectic 
constitution,  most  frequently  in  early  manhood;  and,  although  commonly 
associated  with  phthisis,  may  occur  without  any  evidence  of  tubercle  in 
other  organs.  It  is  very  common  to  find  both  glands  affectetl,  but  the  disease 
is  usually  more  advanced  in  one  than  in  the  other.  In  some  cases  it  arises 
apparently  as  a  sequence  of  gtmorrhteal  epididymitis,  or  there  may  be  a 
history  of  some  injury  to  the  testicle.  The  disease  almost  invariably  com- 
mences in  the  epididymis,  either  at  the  globus  major 
or  niinor,  which  becomes  swollen,  indurated,  and 
■lightly  tender.  As  it  progresses,  it  spreads  upwards 
along  the  vas  deferens  until  it  may  reach  the  prostate 
and  ve«iculie  seminalee,  and  tbrwarde  through  the 
corpus  Highmorianiim  into  the  body  of  the  testis. 
In  some  rare  cases,  it  ie  said  to  commence  in  the 
body  of  the  gland.  The  progress  of  the  diseaM>  is 
usually  slow,  but  it  may  go  on  rapiilly  to  almost 
complete  destruction  of  the  testis.  In  a  well-marked 
case  the  Ibllowing  conditions  will  be  found :  The 
testicle  is  moderately  enlarged,  but  ou  examination 
this  enlargement  will  be  found  to  be  chietly  in  the 

epididymis,  which  can  be  felt  as  an  irregular,  craggy,  

nodulated  mass,  half  surrounding  the  btxly  of  the  FiE.o;.i.— TubercuUr  Tm- 
gland  in  the  form  of  a  crescent  situated  at  its  jxn)-  tide,  Pbowing  tb«  dU- 
tenor  aajwct  (Fig.  973).  In  the  hard  mass,  which  e»#ed  Epi.iidjia(B  form- 
often  considerably  exceeds  the  b<><ly  of  the  glami  in  ing  »  cre^emia  drm 
bulkfSpotsof  sohening  may  he  felt.  The  gland  itself  pkrtuiij^nrroundingtfa* 
may  seem  soft  and  natural,  or  a  nodule  or  two  may  healthy  body. 
be  felt  in  its  eub^itaiice.    The  affection  is  scarcely 

ever  complicateil  by  hydrocele,  and  in  the  earlier  Plages  the  scrotum  is  un- 
affected. The  s]>eniiaii(-  cord  will  usually  present  no  general  thickening, 
but  the  vas  deieren^  is  enlarged.  In^tea<l  of  feeling  like  a  piece  of  whipcord 
l>etwecn  the  finger?,  it  may  i>e  as  large  as  a  quill.  If  the  diseasi-  have  ex- 
tended to  the  vesicuhe  seminales,  these  can  he  felt  enlurgctl  and  hardenetl  by 
intrtKlucinp  the  (in^'r  into  the  rectum.  Tliere  is  little  or  no  pain,  and  on 
squeezing  the  gland  the  onlinury  st-tiiiations  »ill  Ih'  jH-reciveil  by  the  patient 
except  in  a  very  advanced  stage  fd'  the  dii^nse.  A«  the  di^'ase  advances, 
one  of  the  craggy  n<Hlulcs  xottens,  un<l  the  i>kiu  lu'comes  adherent  over  it. 
This  procetts  is  ui'mmpanifd  by  iii<in>  acute  intlanimation,  usually  causing 
ninrkeil  increase  of  pain  iind  tendernof^.  The  adherent  skin  becomes  retl 
and  shining,  and  finally  t:ive8  way,  and  tlio  tuberculous  alwcefs  discharges, 
leaving  an  unhealthy  cavity  yielding  thin  pus  mixcil  with  soft,  jihreddy, 
whitieli-yellow  sloughs.  In  soiiie  favoriihle  case!?  the  cavity  may  granulate 
and  close  completely,  ur  have  merely  a  tisiulmis  opening  discharging  small 
quantities  of  senms  lltiid.  In  uidsI  caH.-s,  however,  the  process  of  sottening 
extends,  other  nnduU-tt  break  down,  ami  h  gn'al  part  <>f  the  testicle  may  be 
deatruycd.  If  an  iil>s<-(Si'  t>h<iiild  liirm  in  the  biKly  of  the  gland,  a  hernia  or 
VOL.  II,-  71 


1122 


DISEASES    or    THE    TESTIS    AND    CORD. 


fangiini  tPBtis  mnj  ft>ll(>w,  an  In  (»iiii[>le  clir'mic  tircliilts.  On-iisi'iDiillv  rxtt* 
beraot  gmtiiilationti  may  eiinjul  nut  I'rmn  the  regitJii  of  tlic  ujiitlidyiniD,  utoeuly 
reeemblinj;  ttie  true  fungus  t«etts.  Tb«  geiierul  health  suflHrs  ^renlly,  aod 
at  a  coraparalively  early  eta^e  <jf  the  aise  tubercular  diaesse  of  tbe  lungs  i« 
almost  certain  t»  make  its  appearance.  lu  the  great  majority  of  caacs,  the 
opposite  testicle  ala<>  beonmes  affeoted.  Death  usually  results  from  th« 
disease  of  the  lungs,  but  may  occur  from  acute  general  tuberculosis  with 
tubercular  meningitis.  Occasionally  the  dbease  may  extend  to  the  urinary 
tract,  and  terminate  fatally  from  tubercular  disease  of  the  kidneys. 

In  some  ca»e3  of  pbthi^s,  in  which  the  testicles  enlarge,  and  yei  give  but 
liltle  trouble,  the  whole  organ,  both  body  anil  opididymifi.  may  be  fuund 
converted  into  n  uniform,  Bni\,  cheeky  mass.  A  specimen  of  two  such  icsti- 
ctea.  from  a  paticut  who  <lied  from  diacnse  of  tbe  lungs,  is  in  the  Museum  of 
Univerdity  College.  In  cases  of  acute  general  tut)ercutii9is,  gray  graaula- 
tious  have  becu  t'ound  in  tbe  testicles. 

Struetttre. — On  making  a  Bectir.n  from  before  backwards  thrtiugh  a  typical 
specimen  of  tulxTcitUir  ilisHue  of  the  l^nttcle,  the  following  (tinditioutt  will 
he  fiiuud.  Th«  tunica  vaginalis  m»y  be  perfcctly  healthy,  or  m:iy  be  iiere 
and  there  adherent  to  the  tunica  albugineu.  The  tunica  albuginen  will  be 
Dormsl  in  appearance,  except  in  the  immediate  neigh btirhocKl  of  a  tubercular 
growth,  wbere  it  will  be  thickened.  That  part  of  the  body  of  the  gland 
Dearest  the  surface  nmy  b^  perfectly  healtliy  in  appearance,  ther«  is  no 
thickening  of  the  septa,  iiml  tbe  tubules  can  be  teased  uut  under  water  as  in 
a  healthy  testicle.  As  we  approach  the  orpus  Uigbmurianuni,  tbe  gland 
becomes  studde<l  with  small,  hani  nodules,  not  growing  in  the  aeptn,  but  in 
tbe  glandular  substance  of  the  testia.  In  their  earliest  sUige  tbeae  are  mer«ly 
hard,  semi-traosparent  granulations;  but  they  soon  show  signs  of  undergoing 
fatty  degeneration  in  the  centre,  so  thai  the  majority  have  the  appearance 
of  Hujall  bodies  about  ihe^izeof  a  millet-seed,  having  a  yellow,  opaque  centre, 
antl  iL  delicate,  grayish,  semi-trnniipareul.  growiug  margin.  StitI  nearer  the 
c(tr|ius  HiglimoriaQum  these  yellow  spots  coalesce,  and  form  a  solid,  cheesy 
sulMtance.  coutinuoua  with  a  still  larger  mn^  of  tbe  same  kind,  which  repre- 
sentH  the  epididymis,  and  half  surronuds  the  body  of  the  gland  in  tbe  shape 
of  a  crescent.  In  this  lar»iir  mas^,  patches  of  eofteniug  are  found  forming 
the  tubercular  absceestt  above  described,  and  these  may  extend  into  lbs 
body  of  the  gland.  On  making  irausvente  sections  of  ilie  vas  deferens,  its 
walk  will  1k9  eeeu  to  be  ibickcned.  and  its  conlre  filled  up  with  a  yellow, 
oheeey  material.  If  the  disease  bo  further  advanced,  the  whole  g^aod  may 
be  converted  into  a  single  ohecsy  mass,  in  which  sottening  may  oe  taking 
place  at  various  parts. 

The  exact  nature  of  the  change  (hat  takes  place  in  the  production  of  tbe 
condirinn  above  doacribed,  has  given  riRc  to  much  difference  of  opinion; 
enine  authors  maintaining  that  the  primary  change  eonsiKts  in  an  overgrowth 
of  the  opithi'Iiuro  of  the  tubuH  sirminifcri  and  epididymis,  which  aflcrwanli 
undergi>es  fatty  degeneration  ;  and  others  asserting  that  the  primary  growth 
takea  place  between  tbe  tubuli,  and  that  the  changes  in  the  epithelium  are 
secondary. 

The  accompanying  drawing  (Fig.  974)  represents  a  section  of  one  nf  tbe 
small  outlying  nudules  in  tbe  body  of  the  gland,  as  described  above.  It  will 
be  seen  tliat  the  change  consists  ohietly  in  an  accumulation  of  smalt  round 
cells  in  a  more  or  lew  perfect  reticulate  stroniB  l>etween  (lie  tubules,  separat' 
iug  them  from  each  other.  At  the  samv  time  the  walls  of  the  tubule*  have 
Qodergtuie  a  cbunjce,  being  InfiltrHted  with  cells  in  tbe  same  war  as  tbe 
rounding  parts.  The  inbulev  alei^  are  choked  with  epillieliuni,  which  in ) 
parta  of  the  same  testicle  was  found  to  be  undergoing  faity  degeneratton. 


1 
i 


I 


in  »nrae    ^| 

J 


TRKATHSNT    OF    TUBERCULAR    TESTIS. 


1128 


Towards  the  centre  of  the  Dodule  the  intertubular  growth  also  becomei 
caseous.  'Scattered  through  the  new  growth  are  tnuny  large  masses  of  proto- 
plasm cootainiug  many  nuclei,  the  so-called  giaut-celU.  It  is  moBt  probable, 
therefore,  that  the  change  commences  in  the  lymphatic  tissue  in  the  walls  of 
the  duct  of  the  epididymis  and  between  the  tubuli  semiuiferi,  and  gives  rise 
to  secondary  proliferation  of  the  epithelium;  both  tbe  intertubular  growth 
and  the  proliferated  epithelium  atlerwards  nndei^>ing  fatty  degeneration, 
•Dd  forming  cheesy  masses. 

Prognom. — The  prognosis  of  tubercular  disease  of  the  testis  is  extremely 
bad.    Treatment  is  of  little  if  any  avail,  and  the  patient  almost  invariably 


Fig.  VN,— Tuberculnr  Tostii.     a.  Tubul!  feiuinircri  ;  h.  Ui»Dt-ee1l9  {4"  dinm.]. 

diee  sooner  or  later  of  disease  of  the  lungs,  from  peneral  acute  tuberculosis,  or 
from  extension  of  the  disease  to  the  bladder,  pnwtate,  and  even,  in  rare  cases, 
the  kidneys.  In  some  cases,  however,  afler  the  abscesses  have  bunt,  the 
cavities  may  heal,  and  the  testicle  remaiu  withered,  but  free  from  active 
disease. 

Treatment. — The  more  I  see  of  this  disease  ilie  more  convinced  I  am  that 
the  sooner  the  diseased  organ  i^  romovfd  the  better  will  be  the  patient's 
chance  of  prolongation  of  life.  The  dan>;or  of  infection  of  the  system  by 
acute  tuberculosis  from  a  tubercular  teelis  is  so  preat  that  when  once  the 
diagnosis  has  been  made,  ciistration  should  not  be  delayetl.  In  most  cases, 
however,  the  oporatiou  is  at  bt'i-t  ralcidated  to  fjivc  the  patient  only  temporary 
relief,  as  the  <Iiseai<c  usually  extends  along  the  vas  liefvrcns  l)eyond  the  reach 
of  the  knife,  and  wilt  continue  to  prDgro^  in  the  vesiculie  serainaira  and 

finistate,  unless  the  patient  suecuinb  early  from  tuliercular  disease  of  the 
ungs  or  brain.  Before  undcrtukinp  it,  the  urine  must  be  examined  for  pus, 
and  the  state  of  the  prostate  and  vesieulsp  eeminales  ascertained  from  the 
rectum,  as  the  t>|)cr«tion  wouhl,  of  course,  be  useless  if  the  affection  of  the 
testicle  were  merely  a  part  of  tubercuIosii>  of  the  whole  pen i to- urinary  tract. 
Should  the  patient  decline  to  submit  tn  the  ojMTaliim.  or  hiii  healtli  l>e  so  bad 
that  its  performance  is  not  advisable,  the  tn-unnent  mu^t  l>e  conducteil  on 
general  principles;  alteratives,  tonics,  esjH-cially  the  i>Klide  of  iron,  with 
cod-liver  oil,  and  general  hygienic  mean:>  eiiU-ulnted  t<i  imjirove  the  health, 
must  be  steadily  persevered  with,     liocal  applications  are  of  little  avail. 


1124 


DISEASES   OF   THE   TESTIS    AND   CORt>. 


The  absMBBfes  must  be  opeutx!  vihen  they  form.  The  caviir  ^ould 
iboroughhr  Bcrsped  out  with  &  sharp  epoon  and  tlrcasetl  with  todofirm. 
Under  iliw  trcitmcnt  it  sometimes  hcala  rapidly,  hut  the  cut*  is  rarclr  po^ 
iimoeuL  If  fungus  form,  it  is  of  Itttic  use  tu  try  tu  treat  it  br  the  methods 
baforc  described :  if  the  body  of  the  testis  be  deeply  infiltrated  with  tubercle, 
no  good  oould  result. 

SvpiituTic  Obchiti-i,  SYPnri.iTTC  SAEC<yEi.r_^Sypliili(ii,:  di«jfl<e  of  tb* 
testicle  appears  utxler  two  loruii).  a  simple  iuBamtuuttiry  and  a  |;Ut»mat0Ul. 
The  latter  vim  formerlv  conlounilvd  with  tal>ercl6.  under  the  name  of  tuber- 
culo-ayphilitic  8urcoc«le.  Tb«  «rrur  arov«  before  the  exact  nature  of  ^M 
»yphilttic  ^umnm  w-'ui  iinderetood.  Hyphilitic  orchitii)  of  Ixith  furms  may 
4tccur  either  a»  the  result  t>t  inherited  syphilis  in  infanta  or  of  aoqiiirM 
syphilis  in  adults.  It  \»  UHUfllly  one  of  the  later  Rianiftstatiom  of  the 
diaeatie. 

The  Simple  Inflammatory  Form,  which  ba«  been  accurately  described  by 
Virchow,  <-ontii8ls  esiivulially  of  a  chronic  luflaminatory  overgrowth  of  the 
connective  tissue  between  the  tubuli  ifcminifcri.  The  disease  may  uuifortuly 
aFect  the  whole  gland  or  hn  limited  to  localized  patebes.  If  the  whole  gland 
be  allectcd,  the  oi^u  slowly  enlarges  to  perhapa  mure  ibao  double  ils  natural 
size.  The  eulurgemcut  will  be  found  to  alTuct  tlie  IxkIv  of  the  gland,  tbe 
epididymis  uudcrguing  but  little  if  any  change:  in  iiict,  it  may  be  w 
far  concealed  by  the  thickening  round  it  as  to  be  scarcely  recognizable. 
Tbe  cord  and  vas  deft^ren't  are  unaffected.  The  body  of  ihc  gland  feeli 
bard,  alniuat  cant lagi nous,  and  the  surfiace  is  aniooth  or  perbapa  slightly 
irregular.  There  is  nu  ])ain,  excflpl  u  dragging  Beusation  in  the  gruln  due  to 
the  iucrciuusd  weight  of  the  tpeticle.  There  la  little  or  no  teoderueaa,  and  io 
the  more  advanced  etagra  the  })eciiliar  nensation  caUHsd  by  aquoezing  B 
healthy  teeticle  i»  abM>nt.  There  is  no  tendency  to  sottenitig*  or  to  tlie  forma- 
tion of  Hbsoess.  The  diacaae  is  alniogt  always  accompanied  by  hy<ln>c<>le.  but 
nt  the  same  time  adhenons  nay  exist  at  various  parts  hetwc-en  the  parietal 
and  Tisceral  layers  of  the  tunica  vaginalis,  diviaing  the  fluid  into  two  or 
more  portions,  or  limiting  it  to  a  small  part  of  the  surBice  of  the  testicle. 
Most  commonly  only  one  testicle  is  affected,  but  both  may  be  attacked.  In 
the  localized  form  the  induration  is  limited  to  one  or  more  poruons  of  the 
gland,  (he  remainder  being  soft  and  healthv. 

Structure. — On  making  a  section  from  *betbre  backwards,  the  following 
appearance*  are  found.  If  hydrocele  exist,  the  tunica  vaginalis  will  be 
opaque  and  thickene<l,  and  probably  adherent  at  various  points  Ut  the  suHace 
of  the  te«ticle.  If  no  hydr(.'K:e)e  l>e  present,  the  tnuica  vaginalis  may  be 
Uniformly  adherent.  The  tunica  albuginea  will  always  b«  found  greatly 
and  irregularly  thickened,  and  from  it  proc««<l  opaque  white  dense  fibroid 
proceases  into  the  subtttHnce  of  the  gland.  Theee  may  in  extreme  casea  be 
so  abundant  that  no  healthy  glaad-substance  can  b«  aeen  between  Uiem  ;  in 
lees  severe  caaee,  patches  ot  healthy  tubular  substance  are  round  at  various 
naria  of  the  organ.  A  process  of  <»ca{riclal  contraction  takiu):  place  in  tlienc 
fibroid  prt^ceoeeH  may  lead  to  a  ditopling  of  the  surface  of  the  orgnu.  The 
niicro^etipe  ohows  that  the  change  is  duo  to  an  inflammatory  small  round* 
celled  growth,  which  afterwards  undergoes  a  development  intoHilvuai*  fibroid 
tissue,  situiited  in  the  connective  tissue  between  the  tubuli  seminiferi  ^Fig. 
976).  The  new  growth  separatee  and  presHS  on  the  tubule^  and  may  cause 
their  destruction  in  large  areas. 

The  Oammatoiu  Form  ia  an  aggravation  of  that  just  de»cribe<I,  and  pr^ 
scute  the  eame  symptoms,  with  the  addition  of  those  vau^  by  the  pruaeuoe 
of  the  gummata.  Tho^e  form  hani  craggy  nodules  on  the  surface  of  th* 
gland,  the  irregularities  so  pn>duced  being  mudi  greater  ibun  thoite  arising 


\ 


4 


^ 


SYPHILITIC  TESTICLE  —  SYMPTOMS  AND  HISTOLOGY.      1125 

from  simple  fibroid  i ml ii ration.     The  pummiitu  have  little  tendeocy  to  soften, 
aud  discharge  extcrually;  yet  in  rare  cases  they  may  do  m. 

Structure. — On  making  a  section  of  a  gland  in  this  condition,  more  or  less 
of  the  fibroid  induration,  above  describeil,  will  alwuvs  be  found  combined 
with  thickenin<r  of  the  tunics  c)f  the  testicle.  The  gummnta  vary  in  size, 
from  a  pea  to  a  hazet-uiit.     They  arc  of  an  r>pni)uo  vc-llow  color,  irregular 


Fif .  975. — S<r|'bllitie  Qaiuiuatit  of  tbe  Tcillv.     n,  L.  liuiiimata  cut  u(.to»i<  ;  r.  ^ceti'in  uf 
Glgbui  minor;  knd  d.  Curd. 

flhane,  and  dense  leathery  hardness.  They  may  be  toienibly  sharply  circum- 
scribed to  the  naked  eye,  but  are  usuallv  surrounded  by  a  zone  of  tibrous  in- 
duration of  an  ouaiiue  white  color.  The  microscoiMj  shows  around  them 
the  ijame  small-colled  growth  above  described,  situated  between  the  tubulca. 
Nearer  the  centre  the  tubules  arc  found  to  be  pressed  upon  and  destroyed,  and 
the  cells  of  tbe  new  growth  commence  to  undergo  degeneration  ;  until  in  the 


yellow  part  of  th- giimiiin.  iMtluiii:  but  gnuitiliir  dObiis  h  to  bo  recnguized. 
The  guiiimiira  inav  lio  di-nii;:iii.-h<'d  tnun  tnbon-h'  by  tlieir  jrroati-r  tuiighiieM 
and  nion-  opjiipic  vollmv  <■■•]' it.  Tubt-n-lo  i^-  ran-ly  limited  tn  the  buly  of  the 
testOf  ;  gummata,  i>n  iho  i-iIht  !i:ind,  nin-ly  :iH!(t  the  rpiilitlymifl. 

I*rnffiioiiiii.- -It'  t\u'  dij'fiisi'  be  ri'ooL'iiizi'd  and  mated  enrly,  mniplote  re- 
C«)very  mav  bi-  ciiilid.  uily  tn'pi-il  f-tr:  ;illli"UL:h  rolap-es  are  of  frequent 
occurrence.     In  the  mon-  atlvaneod  siagon,  the  i>rogni»«is  is  not  so  ho])eful, 


U2e 


UISBAUKB    OP    TUK    TB3TIS    AXU    CORD. 


for,  although  iin'Ier  proper  treatnicul  tlio  new  growth  moT  be  abaorbed,  Ihe 
glanil  will  i-eiiiatu  lilii-uiikou,  {luckeiv^l,  and  indurated.  This  it  but  what 
would  be  expectfi :  nathctuhuli  tn'iniiiiiVri,  as  above  -Lflltii.  Wfoiiie  more 
or  lees  exteu-'iveiv  tlwtruycd  by  Lhc  prcswure  of  Uie  ii«w  growth  lu  ibe  Uter 
itues  of  the  digciise. 

The  TSKtihnrr.t  h  that  laid  down  in  Chapter  XXXVI.  for  cnoBtllutional 
sypbilii).  Lncally.thu  hydrocele  may  be  tapped  (butoa  no  aocouDt  injected), 
and  pnasure  may  l>e  appliprl,  hy  Htrapnin^  over  sitniL'  ^l^^c^^ia!  oiiilnient. 

Diagnosis  of  the  Simple,  Tiibercular,  and  Sypbilitic  Sarcocelei. — The 
diug;nTiigit<  nf  tli&fle  aflVciiolis  ts  in  nimw  (viws  ea»ty,  iu  nthers  very  diffltiuh. 
Whatever  the  f(»rni  rtf  disease  may  be,  if' it  be  roniplicatetl  by  hydniceic,  this 
miiHt  firsl  be  tapped  in  onler  that  the  gland  may  be  art-urali^ly  examined. 
The  hydrocele  in  these  cases  may  not  be  translucent,  an  the  tunica  vaginalis 
is  often  thickened.  It  must  be  rememlM-re<l  that  hydrw^ele  'u  a  wry  nn 
coinplicatiun  uf  cancer,  or  nf  cystic  sarcoma;  it  ia  rare  with  lubercular 
snrodcele;  less  rare  with  i^imple  chronic  orchitis,  and  very  common  with 
eypliiiitic  disease.  Prom  lia^nintooclc  And  tiitiiorg,  thedia^Mis  may  he  mode 
by  fttloiilion  to  the  rule*  laid  down  on  p.  113'2.  It  having  been  determined 
that  thexwelliiit;  is  due  to  one  of  ihe  three  above-mentioned  catiMS,  it  remains 
Ui  aecvrtjiin  which  it  ts.  This  may  be  done  by  attention  to  the  following 
puiutn.  The  cord  is  often  thickened  aud  teuder  in  simple  chronic  orchitis; 
lu  tubercular  »ftrcocelp,  the  vtm  deiereng  aloou  ts  alVecled,  being  frequently 
ctioitiderably  fular^-d;  in  iiy|ifaili«  the  cord  'a  perfectly  h^Allhy.  In  simple 
chronic  orchitis,  theepididymt»  muy  be  ewidlen,  but  the  chief  en largenient  is 
in  the  body  ;  iu  tidierculiir  diseiute,  the  epididymis  i«  MliiK^t  always  the  gtart* 
ing  jwint  of  tho  diHi;:u)v,  mid  is  enhirged  morv  tbau  the  l>o«Jy  ;  in  RypfaiHtic 
wrfocvlif,  the  btnly  i»  first  and  almiist  exclusively  attectcd.  In  chronio 
orchitis,  the  enlargement  ia  usually  uniform  and  itao-Ah,  and  fluctuation  is 
rarely  present;  in  tubercular  sarcocele.  the  enlarged  epididymis  is  oragsy 
and  noduiur,  and  spots  nf  softening  may  be  felt;  in  PVphilitic  sarcocele,  tne 
boity  of  the  gland  is  greatly  indurated,  olten  nodulatetl,  aud  softening  is 
very  rare.  The  tcHtictc  is  usually  painful  and  tender  in  chrouic  orchitis ;  iu 
tabercutar  sarcocele  it  is  aomctimes  tender,  seldom  painful ;  iu  eyphiHiic  dis- 
ease, it  is  almuet  invariably  perfectly  painless,  and  free  from  tendemvta. 
The  constitutional  condition  ot  the  patient  shoulil  also  be  carefully  inquired 
into.  Chrouic  orchitis  uaunllv  arises  as  n  sequence  of  injury,  or  perhaps 
^iinorrboia,  in  patients  )K«i>ihry  Btrumou?,  gouty,  or  rheumatic;  tubercular 
disease  occurB  almost  always  in  cnchectic  subjects,  with  a  tulieroulnr  hislory 
and  a  tcudi-ucy  To  phthi^ia.  The  ]uu};b  iihould  therefore  be  carefully  ex- 
amineil.  In  syphilitic  sarcrtccte,  the  ordinary  sympioms  of  constitnimnal 
ayphilis  may  be  present,  or  a  syphilitic  history  may  be  obtained.  In  tuber 
cutnr  sarcocele,  the  vusiculcc  semiualea  may  often  ho  felt  to  be  enlarged 
thrauj^h  the  rectum. 

CS-sTic  DisRA-^E  OP  Tnr:  Testis,  on  Cyhtio  Sabcoma  of  the  Tk-^tis,  ob 
CvfTic  SARCOCia,E.— In  this  disease  the  ic«i»  bcconii^tt  enlarged,  indurated, 
of  a  yellowuvh-whito  opnqtie  appearance,  and  studded  with  a  multitude  of 
cyslis  that  van,'  in  size  from  a  pin's  head  to  a  cherry,  containing  clear  amber* 
colored  or  hri.«ni_«h  Hind  (Fig.  1)77).  The  disease  may  run  a  simple  or  a 
malignant  course.  The  enlarge*!  lealicle  may  reach  a  very  great  size,  with- 
out showing  any  signs  of  general  ninlignancy.  In  the  simpler  forms,  the 
diseJitfu  somewhat  r«aembte«  the  fldeno-Mmimn  of  the  mauima.  The  new 
growth  is  found  to  be  compos*^]  of  a  stroma,  const^tinfi  of  various  modifier- 
lioua  of  connective  ti>4ue  in  all  blitgeti  of  groivUi,  in  the  midnt  of  which  are 
spaces  liued  willi  epitheliuin.  Die  iilnmm  »how«  great  irregularity  of  vtruo 
ture.     Iu  the  sauies[>ecinieu  may  be  found  libroid  tissue,  cartilage,  myxoma- 


■ 


I 


CVSTIC    DISEASE    OF    THE    TESTKLE. 


1127 


Fig.  VTT — Cjrttiu  ^Areonk 
of  th«  Twiic1«. 


twuo,  spiiKllr-cclled  and  roiind-oellei)  sarconia-tieeue.     Paget  lins  found  the 

cartila^  tu  be  arranged  in  beaded  lirancliiug  liiit-s,  rettembling  the  course 

and  8lia|)e  of  the  lymphatic  vcesela,  and  hatt  i^hdwii  tliat  itactually  lifs  within 

them.     The  epithelial  B|>aces  are  irregular  iu  shape  and  size.     It  i«  tliflicult 

to  say  whether  they  represent  the  remains  tif  tuhuji 

•emiuiferi  or  not.     The  cysts  are  formed  by  dilatation 

of  these  spaces,  and  are  lined  by  an  irregular  cubical 

epithelium.     lutracystic  growths  may  be  found,  as  iu 

the  mamma,  projecting  into  the  cysts.     The  disease 

uay  assume  a  malignant  form,  becoming  gcneralize<l 

in  the  internal  organs  like  a  sarcoma;  or,  according 

to  Kindfleisch,  actual  cancerous  transformation  may 

take  place,  the  stroma  assuming  the  form  of  a  cancer- 

atroma,  and  the  epithelium  of  the  spaces  taking  on 

the  active  growth  of  the  cells  of  a  true  carcinoma. 

According  to  Curling,  cystic  disease  of  the  testicle  is 

the  result  of  morbid  changes  in  the  ducts  of  the  rete 

testis. 

Diagnona. — ^This  affection  has  been  carefully  stud  led 
by  Sir  A.  Cooper;  who,  with  great  justice,  adverts  to 
tbe  difficulty  of  ilistingulshiug  it  from  other  diseases 
of  this  organ,  more  esi^cially  from  hydrocele.  The 
pointa  to  be  especially  attended  to  in  distinguishing 
tbe  cystic  sarcocele,  are  its  want  of  translucency,  the 
more  globular  ahajie  of  the  organ,  its  weight,  and  tbe 

eolai^^Ml  and  varicose  state  of  the  veins  of  the  cord.     If  there  be  any  doubt, 
an  exploratory  puncture  will  resolve  this,  and  should  always  lie  practised. 

Treatment. —Cystic  sarcocele  requires  early  removal  of  the  diseased  organ. 

Sarcoma  of  the  Testicle. — Pure  sarcoma  of  the  testicle  without  the  pres- 
ence of  the  cysts  just  described  is  of  rare  occurrence.  It  is  indistinguish- 
able from  cancer  lietore  removal,  presenting  the  same  rapid  growth,  and 
■otlness  of  structure,  giving  rise  to  a  smooth  elastic  globular  or  oval  enlai^e- 
ment  of  the  testicle.  It  i^  usually  met  with  in  younger  suhjects  than  cancer, 
■onietimes  even  in  young  children. 

Its  microscopic  structure  varied  in  different  oases.  Small  round-celled 
■arcimia,  and  myxo-sarcoitia  with  large  spiudlc-cells  intermixetl  with  it,  have 
been  described. 

The  Treatment  conHsIs  in  earlv  removal  of  the  gland  by  castration. 

Enehondroma  of  the  Testicle.— Cartilage,  as  before  state<l,  is  almost 
always  present  in  the  cystic  sarcoma  of  the  testis.  It  may,  hi>wever,  appear 
alone,  in  larger  or  smaller  no<luli\-<.  or  infiltrating  tlie  ginnd.  It  usually 
oumraences  in  the  btxty,  but  may  invade  the  epiilidvmis.  .\i.-conlini;  to 
O^rnil  and  Kanvier,  whenever  it  ri'ach<.>s  any  c>m.«identl)le  size  it  isuo  longer 
purely  cartilaginous,  but  is  mixed  with  sarcoma- tissue  and  complicated  with 
cysts,  so  that  botli  clinii'ally  and  patbologicnlly  it  merges  into  the  disease 
just  dest'rilx.'d  as  ry-itie  sarcoma. 

Cyita  Containing  Colored  Matters.— Occasionally,  cystic  tumors  of  the 
testicle  are  met  with,  in  wliich  the  sii)>^tuiice  of  the  organ  is  atrophied  or 
absortwd,  and  its  yUuf  occupied  by  'me  or  mure  hirgi>  thin-walled  sacculi 
containing  fluids  of  ditrerent  colori>  and  consistence,  dark  and  fatty.  One 
of  the  most  renmrkiibk'  of  tlicsc  luionialouti  tumors  of  the  testis  that  I  have 
•een  wan  under  the  c.-ire  i>t'  my  ciilli<u;:ne,  Marshall,  :it  the  Imspital.  The 
dtieased  organ,  which  \v:is  Hlimit  the  si/.f  ol'  im  ot^tricli's  egtr,  and  felt  partly 
solid  and  |>artly  tluiil,  was  f'linid  after  reinnval  to  be  com)Hised  of  a  large 
oyat  tilled  with  an  oily  fluid,  like  melted  butter,  which  soIidifie<l  on  i>o(diug. 


1128 


UI8EA8S8   OK   THB   TSBTIii   X»b   CORU. 


AAer  remfival  Ma.ralinl1  found  that  ihc  »ac  ooniii'i  ■ 

WM  doubtlMB  of  an  einbryoDic  cliaracwr.     Tli 

thirty  yean  of  age.  hml  beeu  affected  with  iIip  c  It 

CiNCKK  OK  THE  TesTICLK,  or  MaUO^IaST   t^A  I  i    II 

ocean,  aad  almost  iuvariably  auunkCB  Ibe  eDOeplmiuKi  obanwlv. 
deed  a  qQettinti  uheihernDv  utber  form  of  cuicer  ova  ovcun  la  ifaitai 

Olar^cfcrf.— <.!aDcer  uf  tbe  testicle  iiiucL  oommoolr  ucean  in  ibati 
etaoce  in  the  buiJy  of  that  orgsu,  rarelj.  if  ever.  auectiDg  iha  cnidi 
iirioiBnl^.  The  ordioitry  characters  of  cacephalold  mtr  Klwrnys  waU  a 
m  tblH  affection  ;  uDd  the  luraor  vveatuully  luugaiw.  ^-  ■  "       " 

and  [lulpy.    The  mam  un  eectjon  ia  Bofl,  piuk  iu  <-  i 

pateum  of  fatty  dcgenerntioD  acatlereil  tbruugb  it.     il.*  mi 
orokan  down  in  jwrt^  by  beniorrhage.    Ii  U  inipotaible  la  A 
from  a  soft  parconm   without  microicopio  eiauituulii>o.      The 
Blruclurfi  ie  that  uf  enoepliubtid  cauoor.    TbeiLroma  iit  i>miill  id 
encloses  ^pncL-e  of  great  ^m:  filled  with  large  cells  of  '  r  tvm. 

A  muligiiant  t«8tiolc  may  rapidly  Attain  a  very  c<  <>  mafa 

bcconiing  m  largo  as  a  cortunnut  in  ii  few  vti^'lcK  nr  m<itiili».  Wbn  4 
aixo  it  is,  of  course,  iibundantly  supplied  by  bi<i<>clvrsarlfi ;  c^iOM^iO^ni 
spermatic  artery  and  mTiiiii)Miuriiig  vcimi  will  ht>  found  a  fcw-^  I 

The  lymphatic  glnmls  in  ibe  ijeijfhliorh<H^i  iipee«iily  Wct>n»«  €t;  .>  _  .. 
in  the  iliac  t'lssa  e,')pe<;iiilly,  ta  niay  be  ascertained  by  dwp  ()rv9Mtn- 1| 
flank.  The  inguinal  gland*  do  not  in  general  become  nffeclca,  until  tM 
baa  become  implicatcil  by  the  prosrcn  of  the  di»e»e.  It  ia  then  klad 
the  cancerous  cachexy  rapidly  de\"elope  itM-If.  1 

The  Sifinptoms  oreiictfpUaloid  of  the  testicJe  are  usually  eotuewbal  1M 
in  tb«  early  staged,  alth^^ugh  tboy  beo^nit*  clearly  and  distiuctty  dcfvclai 
the  dia««8«  pr<>gre«De».    It  u  ukwI  cuniiouidy  met  nith  after  ntjddle  Hh, 
patient  fint  complains  of8<.>iue  degree  of  dragging  ]i4iiu  ai'  '  to  i 

the  testes,  which  on  examiuatiuu  will  Iw  fuuud  U>  beiudui  .  call 

tbutigh  {ire>*erviug  its  normal  Flia|ie.  The  eulargutiU'nt  oiuiiuuo  unt 
teatirln  nltain^  iibimt  (lie  siuj  and  Fibafx;  of  a  duuk'n  t-gg,  In-iug  •••im 
ten»e  ami  elastic,  but  smmilb  and  heavy.  Aa  it  tmireasM  in  *itr.  vfa 
ueually  dues  vritb  rapiililv.  it  Ih-co rites  riiuoded  and  90QH>vfiat  d»qgl 
pulpy  in  iMrtc,  where,  imfi-cii.  it  may  Hlmi«L  be  !>i-mi-du<'  \um 

others  it  coulinuea  bard  and  knobbed.     Tbia  allenuioa  in ,ant 

to  softening  of  the  aultslance  of  the  Uiniur,  and  [mrtly  u>  ita  making  i 
through  the  tuni(:a  nlbiigiuen.     The  scMttim  is  much  di-'  :-- 
and  puriilish,  and  becomes  citrered  bv  n  uetwfirk  of  torli; 
may  liecome  somewhat  enlarged,  hard,  and  knotty.    A»  tbr  <ii» 
the  scrotum  becomes  adherent  at  vnae  of  ihesjjftened  parts, uloai 

filaM,  and  h.  fuugos  prajccia,  which  pre^uts  nil  tl:r   ' '  nmiti 

unguB  hiematodes;  itdo<-«  not comm'jnly  liapjM-ti.ho'n  itbft< 

allowed  to  go  so  far  as  tbii!  belbrc  removal.    The  jmiu  i*  tiut 
firet,but  after  a  time  aasunit«  a  lancinating  cbumrti^r,  extend 
and  into  the  loins.     Scomdary  iufc^llriu  <■!  the  t^vittfm  tnkc* 
the  medium  of  the  tiimbiir  and  iliac  glaodf  in  which  the  a 
testir  terminate.     In  (-•ni'er  of  the  Krniun<,juel  as  in  the  aone 
(he  penis,  the  inguinal  glands  become  socDdarily  afleciad. 

Jrmiment, — The  onlv  trentm«Qt  of  anv  avail  in  cnevpluUriid  nt 
is  the  removal  of  the  liiseaaed  organ.     This  opuntion  is  '--'    ■-' 
much  with  the  view  of  cruriog  the  patient  of  his  iliaiiaai.  m 
return  io  the  lymphatic  glauda  nr  iu  s<uue  internal  organ,  &•   >'t 
tenipnniry  relief  trom  the  BUtI):'ring  and  incumlimuoe  nf  lh<>  ra 
licte.     It  is  therelunt  an  optTKtiun  of  cxpedleney.  attd  afaauld  b« 


OPERATION    OF    CASTRATION.  1129 

in  those  cases  in  which  the  disease  ia  liiniteH  to  the  testicle,  the  cord  heing 
free  and  the  glaods  not  evidently  involved ;  so  that,  it'  recurrence  takes 
place,  it  may  not  be  a  very  speedy  one. 

An  TJadescended  Testis  may  become  the  seat  of  a  tumor,  just  as  it  may  be 
afiected  by  jnllamniation.  The  combiDAtion  of  malposition  of  the  oi^d  and 
a  tumor  is  necessarily  rare.  But  its  possible  occurrence  must  be  borne  in 
mind  bv  the  .Surgeon,  as  it  may  lead  t<i  the  necessity  of  an  o]>eration  for  the 
removal  of  the  diseased  mass  fnira  the  inguinal  canal.  Cases  of  this  kind 
are  recorded  by  Storks  and  J.  >[.  Arnott.  The  tumor  in  the  tirst  case  was 
aa  large  as  a  cocoanut;  iu  the  second  a?  a  man's  fist.  Both  were  medullary. 
The  ojwration  consists  in  eiposinf;  the  tumor  by  a  free  incision — if  necessary, 
carried  thnmgh  the  tendon  of  the  extcrunl  oblique — opening  the  tunica 
vaginalis,  enucleating  the  mass,  and  tying  with  care  the  shortened  spermatic 
ooi^,  which  would  probably  be  the  most  difficult  part  of  the  operation.  The 
possible  coexistence  of  a  congenital  hernia  must  be  remembered.  But  it  is 
remarkable  that  peritonitis  does  not  ap|>ear  to  be  the  chief  danger  of  this 
operation.  In  neither  of  the  cases  above  referred  to  did  it  occur,  the  patient 
dying  of  erysipelaa  in  Arnott's  case;  of  recurrent  cancer,  a  year  al^r  the 
operation,  in  that  of  Storks.' 


OPERATION    OF   CASTRATION. 

This  operation  may  be  required  for  the  vari<iU3  non-malignant  affections 
of  the  testicle  that  ba%-e  resisted  ordinary  constitutional  and  local  treatment, 
and  have  become  sources  of  great  annoyance  and  discomfort  to  the  patient; 
in  the  early  forms  of  malignant  disease,  also,  it  may  be  advantageously  prac- 
tised. The  operation  ia  performed  in  the  following  way.  The  patient,  hav- 
ing had  the  pubes  shaved,  should  He  upon  his  back  with  the  legs  and  thighs 
hanging  over  the  end  of  the  table.  If  the  tumor  l>e  of  large  size  and  vas- 
cular, an  India-rubber  tourniquet  may  be  applied  (Fig.  10,  vol.  i.  p.  73). 
The  Surgeon  should  then  take  his  stam'l  in  front  of  the  patient  Itetween  his 
legs,  and,  grasping  the  tumor  at  its  posterior  pitrt  with  his  let\,  hand,  make 
the  scrotum  in  front  of  it  tense.  If  the  mass  to  l)c  removed  be  of  small 
aize,  he  makes  a  longitudinal  incision  over  its  anterior  surface;  if  of  large 
use,  or  if  the  skin  be  implicated,  two  curved  incisions,  encl(H?iug  u  portion 
of  the  scrotum.  The  incision  should  commence  oppr'site  to  the  external 
abdominal  ring,  and  be  carried  rapidly  down  to  the  lower  part  of  the  scrotum. 
By  a  few  touches  with  a  hroud-bladed  ?ciilpel  or  bi^jti.ury,  wliiUt  the  skin  is 
kept  upon  the  stretch,  the  tumor  is  scpanitod  from  its  acnttal  attachments, 
and  left  connected  merely  by  the  curd,  which  must  then  be  <iivifled.  In 
some  cases,  it  will  be  found  advantageous  to  expose  and  divide  tht'  cord  in 
the  first  instance,  befiire  (lisf>ccting  out  the  tumor  froiu  the  i>crolum,  as  in 
this  wav  a  better  cmimnnd  over  it  is  obtained. 

The  division  of  the  Cord  constitutes  the  most  iiii]><iM:ii)t  jmrt  of  the  opera- 
tion, whether  this  Im  done  first  or  last ;  iis,  unless  care  be  inkon,  the  cord 
may  be  retracted  through  the  iibd"iiiiii:il  riuj;  iiiin  the  in^'uinal  canul,  where 
it  is  extremely  difheult  to  f.illuw  it.  suul  wliere  tin-  ftump  may  bleed  very 
freely,  pouring  out  blooil  into  lis  own  arenlur  tissue  so  ;is  in  swell  up  rapidly 
and  form  a  large  extnivasiuinn  ul'blii..d,  ami,  ii  iiut  properly  secured,  ;;iviug 
rise  to  eztent'ivc  and  even  fittiil  iiitlltr:kti'<n  iiit"  :iiiil  between  the  muscles  i)f 
the  part  and  into  the  tlitnk.  This  Eiecident  m:iy  be  jireveuted  by  sejianiling 
the  conl  cleanly  from  the  slu'ath — nmre  e-peeially  from   the  cremasteric 

'  T  wi'Ulfl  ri'f-r  tli"-''  ulm  wi-li  iVr  t'irili>T  iiir^rninli"!!  on  tlii-  iut-j-'ft  t"  Curling'* 
excullunt  work  i-n  ilif  'I'-'-ii-. 


1130 


1>1SEAS£S   OF    THE    TESTIS   AND   CORD. 


fibres  whicK  rtro  the  chief  caiiSM  i>('  Llie  retrai'tioo.  Il  mav  ihtMi  tie .  _ 
wilh  a  pair  of  clainp-fiircciw.  or  tiwl  lichily  wfilh  a  iu|»«-*  i  Ki^.  !I7S  i.  l\i§' 
very  filiiipcry.  nuii  npt  to  slip  thnm^h  itio  nssiitUkiil's  tin>^rB,  itcucfs  the  un 
of  :liu  cmmp  or  tape.  It  rany  thc-ti  ho  cut  ucnuut  boliivv  lhi«,  and  the  arteria 
lied  HL-purntciy.  Tltc  veinn  tiiiist  lie  tifvl  as  well  on  the  arleriea.  The  anerifs 
r^iiuiriii^  li^'atiire  are  iiiiunlly  Lho  Hpenualic,  the  cretuaM^riti.  and  the  arury 
of  Llie  VHS  (Ictereiu.  Tlio  aiierrnBlic  artery  will  h<-  t'nUuJ  at  iu  ailMrior  pan 
— the  arlery  nf  the  vns  liel'viviis  bt>hiati.  When  all  iha  vesaolti  arc  wciutd 
the  tape  or  chimp  niiiiil  be  ivinoved. 

W  ilif  Surgeon  has  iiyt  a  very  reliable  asmtaot,  it  is  Mifer  to  lie  the  eord 
a»  ft  vrhule.     This  U  iloue  by  pHeylug  a  piece  ol  stnmg  carbuliiwd  mIIc  iiDder 


y  f 


^ 


Fix.  lire.— iii> 


CoiA  la  CutntioB. 


the  cord,  and  tying  the  whnle  of  tliiastrucLurG  very  tightly  before  dividing 
it.  la  thi«  way  hemorrhage  is  most  effectually  restrained :  and  the  lignbire 
separaics  about  the.  eighth  day,  ur  raay  heal  into  the  iround  if  cut  abort, 
pronded  offieient  nnti»:ptic  treatment  ia  carried  out. 

Jn  caitraiioD  fortubercuhr  testicle  it  is  better  Ui  separate  the  vaadcfereni 
frnni  (ho  other  constituents  of  the  cord  and  to  divide  it  separately.  If  it  be 
fouuil  discAiied,  it  may  be  drfl\vti  down  and  a  further  piece  removed  in  ti» 
hope  of  gctlinj;  aliove  the  disease^ 

A  large  number  nf  vesselA  usually  require  ligature  in  the  Bcrotum.  AH 
bleeding  from  thLt  source  miisl  he  very  thoroughly  arrested,  olherwiM  the 
loose  lieAues  nf  ihe  .scrotum  may  become  digteiidod  with  exirava«ited  blnod 
and  very  troul>Ieiionie  auppurattnn  result.  At^er  the  operation  tbc  woand 
must  he  artrurately  closed  with  auturps  and  a  good  sized  drainage-tDbt 
inaerictl  at  its  lower  end. 

To  caneer  of  the  te^licle,  it  is  of  f;reat  coiuterjuence  to  divide  tlie  eurd  aa 
high  up  ng  puft^ible,  for  ohvioitH  ren^omi.  It  will  mrf,  however,  be  u.fo  to  do 
this  oppw^ile  the  abilomitial  ring  in  the  way  that  hao  jtiHt  been  described,  aa 
there  would  not  be  sufficient  «|tav«  for  the  ni*»i«tant  to  bold  the  cord  abow 
the  part  to  be  divided.     In  cases  of  this  kind,  I  have  found  it  a  gucKi  prafr- 


M 


GENERAL   DIAGNOSIS   OF   SCROTAL    TUMORS. 


1131 


tice  to  expi«e  the  ©ml  bv  diaeeotion  up  to  the  alxluminal  ring ;  then  t()  draw 
it  veil  down,  an<l  tu  include  thu  whole  in  a  strong  ligature,  tied  round  it  as 
tightly  as  poBuible.  The  section  ia  then  made  a  (juarterof  an  inch  bulow  this, 
■ml  the  i)|)eRition  is  completed  a^  iii^ual ;  the  ptump  of  the  cord  niiiy  retract 
into  the  nigtiinal  canal,  hut  cannot  bleed  it' properly  tied,  an<l  will  ill  ways  be 
□nder  command  by  drawing  upon  the  ligature.  This  plan  of  tying  the  cord 
en  tmiif<«  was  ut  one  time  generully  adopteii  in  all  cases  «t'  cii^trntion,  but  is 
not  Dow  commonly  employed.  The  objection  to  it  \»,  that  by  comnrei<8ing 
tbe  uPTves  of  the  «)ni  with  the  ligature  the  aller-pain  is  iucreiised;  out  this 
certainly  does  not  alwara  happen,  for,  in  the  instances  in  which  I  have  done 
it,  but  little  pain  was  complained  of;  and  the  iiractioe  in  malignant  disease 
of  the  testicle  hus  the  advuntngc  of  enabling  the  .Surgeon  to  divide  the  cord 
at  a  higher  i)oint  than  he  otherwise  could  ;  which  advantage  is  still  further 
iDCrea^d  by  the  parts  within  and  below  tbe  ligature  i<loughing  away,  and 
thu?  eventually  carrying  the  section  to  a  level  with  the  point  tletl. 

There  is  one  danger  that  may  occur  in  cai-tration  in  young  children.  It  is 
that  in  young  flubjects  the  processus  vaginalis  testis  may  not  be  obliterated, 
sod  tliat  thus  the  peritoneum  may  be  o]>enti<l  up  into  the  wound  (>n  dividing 
the  c(trd.     In  one  case  I  have  knowu  this  cunditinn  to  lead  to  tutul  {teritonitis. 


lii:NJ:RAL   DIAGNOi'IS   OF  SCROTAL   TfMOR-i. 

The  diagui^is  of  scrotal  tumors  is  not  only  of  considerable  importance,  but 
is  oflen  attended  with  very  great  dlfHculty:  the  more  ho,  sxa  they  are  fre- 
quently associated  with  one  auother.  so  that 
much  tact  and  caro  are  re<iuire<l  to  discriminate 
their  true  nature.  Thus  it  is  not  tincomnion  to 
find  a  hydrocele  and  a  hernia  ;  a  bydmcele  and 
a  varicocele  ;  op  these  aHecllons  coexisting  with 
a  e4>lid  tumor  of  the  testicle.  In  other  cases, 
again,  as  in  the  annex(>d  llgure  1 970  i,  an 
encephaloid  tumor  may  coexist  vvitit  a  hydrocele 
of  the  tunica  vaginalis,  and  wrih  an  encysted 
hydnwele  of  the  conl ;  and  thediti'erent  forms  nf 
hydrtK-ele  may  occur  together. 

Tumors  of  the  scrotum  miiy,  from  a  dlaj- 
Dostic  point  <'f  vit-w,  be  divided  into  two  diitiuct 
classes:  1,  the  Kcducibic;  and,  2,  the  Irrc- 
dnciblo. 

I.  nKiir(ii[i,K  TiMdi;*. — Tln'M'  arc  II<-riiiii. 
C'ongt-nitat  llydriii'cic,  DiHiise  Hydrocele  of  tlu' 
Copi.tuni  Variciicele;  in  all  of  wldrh  theswfll- 
ilig  can  Ih'  made  !>>  ilisapiH-ar  inon-  or  h'ss  com- 
pletely  by  pressure  and  by  the  |iaticiit  lying 
down:  reap|H'aring  on  the  rciiioviil  of  the  pn>sure,  or  on  bis  assuming  the 
erect  poj-lnre.  Tbe  mode  in  whii-h  tin-  tumor  dij-appcai-s.  tend.-*  greatly 
to  t:-labli;<h  ils  (Iiuj:n<i!.is  ;  tlnni;:!,  ili^-  general  rliaradcr  I't'  (be  swelling,  and 
the  hi-l'>rv  iif  tlif  ca^e.  aHlinl  im|i<>rtant  c<>llatt-ral  cvidiiicc  "n  tiii;'  p'tiiU. 

a.  Ill  Hernia  the  re  aie  the  oriliiiary  ►igns  i-f  I  his  atfeclion.  tudi  as  impulse 
on  coughing,  etc.  On  n-dui-ini:  lln-  iiniior,  it  will  be  I'lnnd  that  ii>  return 
into  the  abdomen  is  ac<-i>iiipiiiiit'd  by  :i  giir;:lli)g  n--ise,aiid  by  the  ludden  slip 
upwards  iif  an  evidently  s'>11d  body.  In  tin-  oMin-  nihieihle  tumors,  i be 
diniiinilion  and  eventual  disappeanwiee  under  |)ressure  are  more  gradnul, 
and  there  Is  »<>  re.luctii'n  of  the  ma's  as  a  wli-ile. 

b.  The  gradual  sijueezing  out  uf  the  contents  of  a  Congenital  Hydrocele, 


V^i|>m:ili''  iiU'I  I'f  tlicCiiril. 


1133 


DisKAsxs  ot  •vb: 


B»TT8    AXV   0< 


I 


i 


tiigvtfaer  willi  ite  tninitttj«*iiry,  snrl  tin-  early  «ffe  at  which  it  occurs,  will' 
ertabluh  ita  Iruo  chnnicLer.  It  nnwl  Im.*  rvnieniiivred,  however,  that  li'ivniio 
in  very  rouag  iDlants  may  Iw  trutisluciml  iC  the  gut  contitips  little  or  oo  fecal 
matter. 

r.  In  tlieDiffoae  Hydrocele  of  the  Cord,  there  U  a  tinirnrm  semi-flurtaaiing 
■welling  in  nii'l  ucur  tlie  riug  ;  \u  vrhiuh,  haw4;ver,  there  is  no  gurgliog.  etc., 
DO  complete  re<liicti':iD  nor  sudden  dUappeit ranee  as  to  hernia.     It  is  nuo  It 
deHneil.  and  has  a  less  dletiuet  ini]>ul5e  pq  coughing. 

tl.  Varioooele  roav  alwnys  he  [ii.«tinguished  by  it«  pyramidal  shapo,  ood  , 
its  knotted,  soft,  and  irregular  feel.  After  being  reduced  Trhcti  the  |intient  H 
liod  down,  it  will,  when  he  etaridfj  up,  fill  a^iiin.  even  though  the  Siire^oja  H 
c»ni|ireai  the  external  rini;  with  his  lingers.  Thi?  eign,  which  dittiuguisha  ~ 
it  fnmi  a  lieruin.  occure  iil'-"  in  I'ongenital  hydrocele ;  fruni  which,  however. 
th«  vHrir')i-cle  ntay  he  disliof'ui.she'l  bv  the  alisence  uf  traiialuoeacy,  tbci 
vunl  of  llut'iuntioQ,  nnd  the  general  fed  of  the  tumor. 

2.  Ikrrducibli:  ^ctu^TAi.  TuMOitt^  are  of  mrious  kinde ;  euch  as  Omeuul 
Hernin,  Hvdrotele,  Hieraarocele,  the  vnrioiiB  fibrins  of  ^arcocele.  und  Ccmoer 
of  the  Te«1iele.  Tht»e.  minora,  though  preseniing  reriniu  chnmctcra  in  com- 
mon, yet  difTer  Homcwhat  in  the  predo  mi  nance  of  particular  aigna.  Thai, 
the  shape  of  the  luroor  ia  usually  pyrifortn  in  hydrocele,  globular  in  hiEinato- 
cele,  and  oval  in  mrc-^ccle;  though  this  h  auhject  to  much  vurinttou.  Tbe 
weight  i."*  least  ia  hydrocele  and  greatest  in  sarcocele,  ])ni|)oriionHt(--ly  to  the 
siste  of  the  tumor.  The  characters  of  the  surface  prcaeut  conridemble  differ- 
enoes,  being  smnoth  and  teneo  in  hydrocele  and  hiomatocelc  ;  often  irreguUr, 
hard,  or  knotted  in  the  other  varieties.  The  rapidity  of  the  formatioti  of  the 
turoor  in  greatest  in  hn-inntocele. 

n.  IrrodaoiWe  Scrotal  Hernia  may  be  reoognizcd  by  its  irregular  feel,  hy 
its  ini|H3l«*  ou  coil;;! I  in ^,  by  ii.n  urcupyiiig  the  canal,  and  concealing  tbe  cord, 
and  bv  the  toti'le  lii-int'  ilixtiii'lly  ['i-rreptibte  hehiw  it. 

b.  Hydrocele  of  the  Tnnica  Vaginalis  in  nH^i><<ni/jihle  hv  it*  tnuigluc«ncy; 
8ud  the  amount  of  opacity  i-onjniued  with  ihts  vcill  enable  the  Surgeon  to 
distiouuifih  the  ilegree  of  eiilargeiaent  of  the  testis,  and  how  far  there  a  a 
aaroocele  coujoiikmI  with  it. 

«.  In  Hematocele  the  tmoor  is  of  audJeo  or  rapid  formation,  somewhat 
globular.  i>pa<iue,  but  not  very  heavy  ur  liar<l,and  smooth  Ui>>^n  the  surface. 

rf.  lu  Sarcocele  generally  the  tumor  in  heavy  for  il«  »\7A.',  frenueiitly 
globular  or  irr<*giilnr  in  ttliape,  s<jnietinie«  knobbed,  and  ueutilly  attended  by 
m  good  deal  of  dragging  puin  in  the  gniin,  and  fretfucutly  by  iMOje  cnlor^ 
nieiil  of  ttie  eonl. 

In  thei-e  three  iiimi*  <if»7r>ilal  tumor,  virjiylroct'le,  hseaiiit'K'ole,  aud  tmt- 
oocele,  the  diagnosis  can  always  be  made  at  oui-e  fn>in  hernia,  by  the  Surgeoo 
Ibotiiig  ill''  coni  Tree  above  \hv  lumor. 

Tbe  jKiint  of  most  inip»rlanre  in  iho  diagnosia  of  solid  enlargemeutanf  the 
testicle  i&  U*  ilixtin^iii^li  the  nialiguitnt  lumore,  sanMtuia,  and  eancvr,  fram 
other  foriiu)  of  diwac'e.  In  inalignanl  tumors,  rapidity  of  growth.  pufUKs 
and  elaalieiiy  of  the  niaas,  the  iin|ilicntioii  of  utio  lestlc  only,  and  the  early 
xtilargenieDt  of  the  cord,  with  its  indurated  and  liDobhefJ  euudilion,  are 
ioip'irtaot  stgnn;  ecipeeially  if  the  iliaerue  occur  in  ynung  men.  Ia  a  more 
•ilTaored  rnndition.  the  sf)IWuing  of  the  swelling  »t  p»r1a  with  a  tulieroos 
«Mditi»n  of  the  real.and  the 'vcciirreiiw  of  fungiifl  with  niwedy  cousUtuttnoal 
OM^iy.will  fioint  to  the  maJigiiMnt  nature  of  the  tiitnor.  In  caaeeofniueh 
^Hbt  and  illHii-Ldty.  an  explorah.ry  jmnrtore  may  he  made,  when  tbe  OD- 
«B0  .  •"  "  ve  in  the  m-cdle  or  of  ihe  fine  raiiuin  will  pn^liablv  dett-rniine 

^0  ^  -'  the  growth.     In  niurtt  than  one  iiislnniv,  in  whieh  there 

«B  »»i-ji  ubseurity,  I  have  wen  the  true  nature  of  the  dtae«ac  cleared  up 


TRUE   SPEBHATORKHCEA,  OR    SSMINAL    FLVX.  ]133 


SFEKMATURRHmA  AND  IMrOTENCE. 

Various  forms  of  debility,  of  loss  of  power,  or  of  irregularity  of  action  in 
the  geaerative  organs  of  the  male,  are  conlbunded  together  under  the  terms 
SpennatorrhiBa  and  Impotence.  These  conditions  require  a  more  careful 
consideration  on  the  part  of  the  educated  Surgeon  than  they  have  hitherto 
received,  as  their  exitttence  is  a  source  of  the  deepest  mental  deprestiiou  and 
diatrers  to  the  sufll-rer.  They  are  certainly  one  cause  of  conjugal  unhappi- 
new,  leading,  perhaps,  to  infidelity  on  the  part  of  the  wile,  and  occasionally 
eveu  to  suicide  of  the  husband.  These  alll-ctions,  which  are  of  extreme 
frequency  amongst  all  classes  of  the  community,  having  f<carcely  as  yet 
Feceived  that  atteutlon  on  the  part  of  the  profeifdion  generally  that  their 
importance  deserves,  the  unfortunate  suflerers  from  them  are  too  ollen  driven 
into  the  hands  of  those  pestilent  quacks  who  fluurish  in  the  metropolis,  and 
infest  almost  every  town  in  the  country,  by  whom  they  are  not  unfrequently 
ruined  in  health  as  well  as  in  purse. 

The  Sexual  Melancholia  that  accompanies  these  conditions,  is  one  of  their 
moat  striking  chantcteristics.  The  patient  is  languid  in  manner,  depressed 
ID  spirits,  his  countenance  is  pale  and  haggard,  eye  dull,  expression  listless, 
and  devoid  of  all  energy.  He  takes  no  interest  in  the  ordinary  affairs  of 
life,  his  whole  thoughts  are  concentrated  on  his  own  condition,  and  he  feels 
himself  degraded  as  being  unfit  for  that  duty  which  is  alike  the  first  aud  the 
lowest  of  man.  This  state  of  mind  is  commonly  the  result  of  some  local 
irritation  or  disease,  reacting  on  a  morbidiv  sensitive  nervous  system ;  and, 
on  examination,  the  Surgeon  will  commonly  find  some  local  condition  that 
has  been  the  starting-point  of  the  mental  malady.  Balanitis,  phimosis,  or 
varicocele  in  the  male,  are  the  common  occatiioning  causes.  But  the  most 
frequent  direct  exciting  cause  is  undoubtedly  that  pernicious  and  disgusting 
habit  alike  destructive  of  bodily  vigor  and  of  mental  pr>wer,  which,  heed- 
lesslr  contracted  in  youth,  lays  the  fuuudatiou  for  an  effete  and  im)>otent 
manhood,  aud  for  pn-mature  senility  in  the  one  sex,  and  entails  hysteria,  in 
its  most  aggravated  and  intractable  forms,  in  the  other. 

We  may  recognize  at  leo^t  three  distinct  varieties  of  generative  debility 
in  the  male,  of  whom  I  alone  si>eAk,  wliicb  may  in  some  cases  amount  to 
actual  impotence  :  1,  True  Spermatorrhn-a,  or  Seminal  Flux  ;  2,  Spasmodic 
Spermatorrhwa,  or  Siwrmaspasmos ;  and,  3,  that  arising  from  Want  of 
Seminal  Secretion,  or  Asperma. 

1.  True  SrFKMATORRinEA,  or  Seminai,  Flux,  is  a  rare  disease  and  is 
met  vith  chiefly  in  young  men,  usually  from  the  ages  of  eighteen  to  thirty. 
It  is  commonly  the  ci*n.icquL>nce  of  that  hideous  ?in,  eugonikret]  by  vice,  and 
practiseil  in  solitude,  which  alike  enmsculato^  tlie  Ixidy,  ent'ctblcs  the  iiiiud, 
and  degrades  the  moral  nature  of  its  }>erj>elrator,  or  of  debility  of  the  gi-n- 
erative  organs  induced  by  gonorrbu'a,  or  of  the  continued  ^it^lggIe  to  repress 
the  natural  sexual  <Iciiire.-'  by  a  life  of  forced  or  unavoidable  continence.  In 
this  form  of  the  discudt.'  there  is  a  mixture  of  irritahiliiy  and  of  deliilily.  The 
generative  organs  are  excited  by  slight  eiiioiinuul  causes,  or  by  trivial  and 
ordinary  jdiysical  t-tiinuli — a  thought,  a  look,  a  word,  the  movements  of  a 
carriage,  the  etli)rt  of  straining  at  t-liHtl,  will  excite  the  secretion  of  the  te>ted, 
which  the  debilitated  state  of  the  |>arts  allown  to  e(-ea|»e  with  a  I'wblc  cjacula- 
tory  effort,  or  in  a  kind  of  leakage  of  a  lew  drojB:  IVuni  the  urethra.  In  the 
slighter  cases,  and  in  the  earlier  stages  of  the  nuilady,  these  emissions  take 
place  but  itccasionally — three  or  lluir  times  a  week.  cliicHy  in  the  morning, 
10  the  mill  state  iK'lween  wtiking  and  slt-c)>ing,an<)  are  preceded  by  an  erection. 
Id  the  more  advanced  stages,  the  emishiuns  occur  once  or  ■itU-ner  in  the 


1134 


L'lsBAaES  or 


'KSTIS    A»U    COKO. 


twenty-four  liours  without  iii)  crcrtion ;  the*  lienteii  at  last,  wlicti  discharged, 
HowiDg  liflck  iiitn  ihc  neck  of  the  bladder,  eecapini^f  with  each  iliM'hargeof 
the  urine,  or  lieing  squccjied  out  after  defecation.  The  patient'i  physical  rad 
mental  8lfite  Ih^cdiiil-h  ftcriniisly  impliaited  in  thcfle  ninre  advance^l  cajm  of 
true  spcrmatorrha'n.  Ilis  countenance  h  pallid,  ana<mic,  and  aaltow;  bit 
features  are  drawn,  their  expre»>ifiu  i«  listl«#8;  hiA  eyei  lileteH;  hi*  ■pint* 
deprea»ed,  often  to  the  lowest  depihadt' despondency  and  despair.  CoDiiectiotk 
i»  ini practicable,  as  the  dischai^  of  semen  takes  plac«  eiUier  b«ibr«  erecti»a 
oociirn,  or  withiml  its  occurrence- 

Dla^nosls. — The  first  |>oinl  in  making  a  dia}^nc«i8  ie  to  ascertain  that  Ihere 
is  SOU] e  real  diseaNe,  and  that  the  jiHtienl,  i«  mtl  merely  the  xuhjecl  of  byp>- 
cboni)ria!«i^  or  sexual  melancliotia.  VariouM  couditiooB  are  nii«i|akeii  for 
8I»erni:tlorrIifea  by  a  nervous  pali^itit.  The  white  disvbnrge  uC  pluwphawi 
occurrin};  nt  the  end  of  uiictnrilinii  ( [>,  '.)03),  when  the  urine  i«  nikaiiur  ic 
some  loruis  of  dy#pe[Mtia,  is  ofU*u  believed  by  the  iHilieut  to  Iw  seiuiDti)  fluid, 
and  a»  this  conditiou  w  frenueully  nceimipuuied  by  the  languor  ofdytju-jwia, 
and  U  ciinnuoii  in  limec  who  eit  up  tiHi  late  at  tiighi  and  overwork  themsrlvee, 
thJH  harridiifio  condition  may  give  riw  to  the  <lee)>eHt  mental  depretwion. 

Prostatorrliiun  \  p.  lOld,  vol.  li.)  is  very  apt  to  he  cimfounded  with  Bper>^ 
nuitorrhit-a;  but  the  rliagnuHi«  may  always  lie  effected  by  a  microscopical 
exaniiuatiiin  of  the  discharge. 

An  occasional  involuntary  eruiiwion  is  not  spennatorrhipa.  It  is  commoa 
to  young  menof  uu  ardent  and  excitable  temperament,  ai<d  ii>  otten  the  occa- 
Btou  nf  much  grovmdiees  alarm,  [t  occurs  at  thai  iwriod  of  life*  n-beo  t&e 
geuemlive  power  and  &exual  feeling  are  at  their  highest  point  of  deveJop- 
ment.  It  ia  eimply  the  result  of  b  hr|)cn'ecretion  of  the  testes  and  overflor 
of  the  ^enien.  For  its  repree^ion,  moral  advice  and  tnedicinni  ogvnu  m 
equally  nnueoessary  ant!  unavailing.  For  it,  early  and  congenial  marrius 
is  llie  only  remedy.  Unlc«*  this  be  adopted.  Nature  will  assert  herself— us 
ia  indifferent  to  social  cousiderationa — she  will  enforce  her  rights  in  spile  of 
all  rcstrainL    "Katiirnm  cxpcllas  furcA;  inracn  usque  rocurrct."' 

The  escape  of  a  small  quantity  of  seminal  6uld  from  the  vosiculn  semi* 
nalcs  while  ^training  at  stool  is  uf  common  occurrence  in  young  men  lettdinc 
a  continent  life,  and  need  cause  no  auxifity,  and  requires  no  treatment  bejood 
a  {Mirjic  and  a  cold  bip-hath. 

Frequent  norturnnl  emiMions  in  many  cases  arc  merely  a  symptom  of  djrs- 
pepaia,  the  languid  feelingH  of  which  the  patient  coniplains  being  very  often 
due  to  thiii  much  rather  than  to  the  lum  of  semen.  The  lews  of  ."emeo  by  U 
involuntary  emiwinn  causes  no  more  depression  limn  a  cor re«jM)n ding  lg» 
during  coition,  and  if  occurring  not  more  than  twice  a  week  has  no  evil 
eSect.  It  is  the  contitipation  and  dyspepsia  accompanying  it,  that  are  the 
rest  source  of  the  symptoms  omplained  of. 

Trtalment — The  curative  treatment  of  true  spermatorrbon  should  cooBit 
iu  giving  tone  to,  and  in  leseeuing  the  irritaliitity  of,  the  ^ivuito-urinaiT 
organs.  In  these  ca&es  it  becomes  neeessary  to  maintain  and  impn>ve  Hit 
tone  of  the  system  by  remedies  calculatcil  to  remove  the  ana-niia  and  Iw 
stimulate  the  nervous  energies.  With  this  view,  the  preparations  uf  iroo, 
phoapborus.  nux  vomica,  ana  caotharid(»  will  be  found  tiio  most  effective. 
The  evruii  of  the  phuspliato  of  iron  and  strychnine,  or  the  tincture  of  tbe 
perchforideof  iron,  in  combination  with  those  of  dux  vomioiand  cantharidrs, 
will  be  found  of  rhc  greali-sl  service.  But  under  any  form  uf  treaum-ni  the 
cure  will  be  sli>w,  and  long-iimtinued  tiersever.iuii^  in  the  use  of  rvmedlrs, 
local  and  cimstitutiouu),  is  iniperatively  nec««»nry.  In  nddiiion  t^i  th«a 
means  tbo  cold  bip-lmth  ehonld  be  aKsiduounly  emplnyi'<l.  Thii'  the  iiatient 
should  use  every  night  and  morning;  remaining  in  it.  at  lirst,  for  about  thns 


I 


8PASU0DIC   SP£R1IAT0HRH(BA.  1135 

miDutea,  but  gradually  increafling  the  time  of  immcrsioD  to  ten  or  fifteen. 
The  patient  must  sleep  un  a  hard  mattress,  be  lightly  covered,  and  eat  no 
•upjier.  Some  satisfactory  mental  occupation  should  also  be  provided,  or 
travelling  if  possible.  In  some  cases  the  cold  shower-bath  appears  to  give 
more  tone,  and  then  shouhl  be  preferred.  These  means,  useful  as  adjuncts, 
will  not,  however,  cure  the  patient.  For  this  purpose,  the  local  irritability 
must  lie  removed  by  the  application  of  the  nitrate  of  silver  to  the  prostatic 
juid  bulbous  portions  of  the  urethra.  It  will  usually  be  found  that  there  is 
*  good  deal  of  tenderness  in  these  situations,  felt  on  pressing  upon  the  peri- 
neum, or  on  passing  an  instrument  into  the  urethra,  when,  as  the  point  enters 
the  bulb,  the  patient  will  suffer  much  pain.  The  continuance  of  this  irrita- 
tion certainly  keeps  up  the  seminal  emissions,  aud  thus  maintains  the  debility 
of  the  genital  organs,  and  the  nervous  irritability,  that  are  so  characteristic 
of  these  cases.  It  may  most  effectually  be  remeilied  by  the  application  of 
the  nitrate  of  silver,  as  originally  recommended  by  Lallemand;  and,  if  this 
be  done  in  a  proper  manner,  a  cure  will  usiiallr  be  accomplished.  For  many 
years  past  I  nave  employed,  with  much  ailvaatage  in  such  cases,  the  instru- 
ment  here  figured  ( Fig.  980).     It  consists  of  a  silver  catheter,  having  about 


Fig,  9^0. — SjriDge-CAtbetor  for  ap(ilyin)(  Cnuitie  to  the  Urethrk. 

•  dozen  minute  apertures  near  the  end.  In  the  interior  is  contained  a  slender 
piece  of  sponge,  about  two  inches  long,  fixed  to  the  expanded  end  of  h  firm 
stylet  that  moves  within  the  catheter.  The  instrument  is  charged  by  filling 
the  sponge  with  some  solution  of  nitrate  of  silver  by  withdrawing  the  stylet. 
It  may  then  be  well  oiled,  and.  being  passed  down  to  the  spot  to  be  cauterized, 
the  solution  is  forced  out  of  the  aperture  by  pushing  down  the  rod,  which 
compresses  the  spouge.  I  have  found  this  syringe-catheter  far  safer  and 
more  manageable  than  Lalleraand's  or  any  other  porte-caui^fitiueii  that  act  by 
protruding  a  spoon  or  sponge,  which  is  apt  to  be  grasped  by  the  spasmodic 
action  of  the  muscles  of  the  part,  often  being  returne<l  with  difficulty  into 
the  shafl,  and  not  without  risk  of  lacerating  the  mucous  membrane.  I 
generally  use  a  solution  of  the  strength  nf  .-^  of  the  nitrate  to  an  ounce  of 
water;  though  sometimes  onlv  a  half  or  n  thini  of  this  strength  can  be 
borne.  The  application  usually  occasions  a  giHHl  deal  of  irritation  for  a 
time,  sometimes  even  a  muc<vpurulent  diiichfti^.  and  can  be  repented  only 
at  intervals  of  from  ten  t\ay/  to  a  fortni<;ht.  Any  undue  amount  of  irrita- 
tion, particularly  afler  the  application,  must  be  subdued  by  onlinary  anti- 
phlogistic treatment.  Alter  the  nitrate  of  pilvtT  has  In-en  used  two  or  three 
times,  the  treatment  may  be  atlvantageously  foiuinuo<l  by  pawing  twice  a 
week  a  similar  instrument  charginl  with  giyc4-riue  of  tannin.  This  acts  as 
an  admirable  a-otringeut,  and  suits  many  people  lK>tter  than  the  nitrate. 

2.  SpAsMonto  SpT:BMATnKitn<i:.\,  or  Si'KitMAsrA!»Mn5,  more  fre^iucntly 
occun  between  the  ages  of  i\vcnt_v-fi%'c  and  fiirly.  It  is  frequently  pre<litH 
posed  to  by  residence  in  a  wiirin  cliinato,  or  by  tht>  pxiatencc  of  some  disease 
about  the  generative  organs:  such  a."  etrictiire,  varicocele,  neural;:ia  teutis. 
etc.  In  these  ctisfs  there  is  ni»t,  pri'iH>rly  !«[K-akiiiK.  a  Keminiil  tlux  ;  but 
complete  connection  cannot  ho  ctFi-ctcd,  ii»  erect  i<tn  and  cjiu-ulntion  are  either 
simultaneous  acti*,  or  the  erection  parliHlly  fubdidr:*  before  the  emis-ijon  lakes 


1186 


DISKASKS    OF    TUB    T£!JT1S    AXD    CORD. 


I 


place.     Tbis  form  of  ({tiiierative  debility  is  oAeo  wa  niucli  dei>eotleut  i 
or  moral  a»  ou  inirely  pliysical  cau»«t. 

TrwtnicHt, — This  is  a  condition  of  irritnhilitT  ratlier  than  of  debility. 
otlen  occurs  is  etrouf;  and  ollicrwise  hcnltby  iii»*ii,  accustomtd  to  tie!ii-*[i<) 
aud  oiit-of-door  exerci*ei».     There  h  uo  cvideDcw  of  HU»-mia  or  of  duhilify 
any  kind.    Hence  tonics  are  not  uect-osary ;  uor,  indeed,  vouid  Ibey  l^t! 
BDV  way  useful. 

The  miuedy  most  to  be  relied  upon  ia  the  bromide  of  poUusium  in 
of  20  to  30  graiu),  with  local  cold  bathing,  aud,  perhape,  wheu  there 
urethral  irritation,  blislerv  to  ibe  perinuum  aud  along  the  peuis,  with  bel 
donna  to  the  iuteriur  of  the  urethra.    In  additioa  to  these  means,  it  U  of 
firtil  importuuce  U}  eujoiti  tuoderation  in  food  and  drluk,  and  ubove 
avoidauue  of  alcolioltc  stiiuuli ;  for,  in  mauy  of  these  caseii,  it  will  be  fou 
that  abdominal  plethora  eoexitiU,  and  exercise  au  injurious  iuflueiicu. 

3  Imi'utkkcj:  urisitij;  from  absence  of  all  sexual  desire  <ir  jHmer.  or  from 
premature  decay  of  tliat  power,  ia  not  unfrequenily  met  with,  and  often  i^B 
individuals  who  are  ntherwiee  strung  and  healthy ;  sometimed,  inde«d,  t^| 
thaw  characierized  by  great  muecular  power,  and  much  given  to  athletic 
exercises.  This  want  ut  pexuni  desire  may  be  looked  ujiou  in  many  iD!«t&oreb 
as  a  natural  <l(:f]eit-i)r.y  in  the  organiKation  of  the  individual,  for  which 
medical  or  surgical  trentmeut  can  do  little.  In  other  cases  it  aritie«  from 
exhaustion  of  the  ncrvoua  ayatem  by  habitual  phpical  or  ineutal  exertion, 
by  excessive  sexual  indulgeuec,  over-training,  or  ittudy  carried  to  too  great 
and  injurious  a  degree.  Complete  aliscnce  of  seminal  accretion — A^>crma 
— except  iu  cases  of  atrophy  or  abBcnoe  of  the  testes,  must  be  eapeciallj 
rare.  In  a  iMitient  of  mint-  who  dieii  at  54  years  of  age,  and  who,  according 
lo  his  own  and  his  wife's  account,  had  been  enmplttfly  impoleut  for  the 
twenty-four  preceding  years,  spermatozoa  in  con^id^nible  quantJtieii  were 
after  death  tound  in  the  te«t«,  which  wer*  carefully  examined  with  the 
view  of  ascertaining  whether  they  ever  eecreted  «emen.  Retention  of  bolt 
testicles,  or  atniphy  of  both  glands  from  mumps,  will  of  course  cau»e  ii 
potence.  Temptirary  impotence  fn>m  nervousness  is  not  unwimnionly 
with  iu  young  men  immediately  alter  marriage.  In  tbese  cams  the  b 
iiieut  recommended  by  >Sir  A.  Coojier,  of  ordering  borae  harmleas  naedtc 
aud  forbidding  the  patient  to  attempt  connection,  will  usually  be  elledual. 

BTEfttLrTY  in  tli«  male  is  a  condition  that  has  attracted  some  aiu»unt  < 
attention  of  late  years.  It  is,  of  couree,  not  uufret|ueully  ormueete*!  witll 
aud  probably  dependent  ou,  the  same  coudilioiu  that  give  rise  to  the  variol 
forms  of  BQXual  debility  that  havo  juel  boon  de(«-ribc<L    But  il  may  uc 

independently  of  auv  of  thusc  staKJf,  iu  individuals,  indeed,  who  arc  . 

of  u  very  considerablu  amouut  of  sexual  dt«ire  and  vigor.     It  would  upf 
to  be  due  to  aouic  morbid  condition  of  the  Heminai  lluid,  in  couaequeuea  ' 
which  the  spcruialuz<M  aru  either  abiieni,  or  are  jKuusussed  of  insuffioient 
vitality    to  elleet   impregnation.      The  cauites  of  Inia  oinditiou    are  very 
obscure;  but  over-tiiiiulgeiiiH.*  iu  sexual  intercouree  appEare  to  Ih:  amuuusl 
the  miiHt  Imittent.     It  wouhl  m^em  tut  if  each  inrlividual  were  endowed  nil}' 
a  certain  amount  of  pmcrvutive  power,  whicJi.  if  early  exliRUc>tud,  or  babil 
uolly  wattted  in   indmerimiualu    inler(.Nmr»e,  cannot  be  reslon:d.      HeOf 
potygamists  in  the  ['jist.  or  their  Wenteru  conguners,  do  not  ])ro|*ogale  aei 
rule,  more  than  the  averagu  number  of  children.     Amongat  organic  caue 
of  tbia  state,  chronic  epididymitifi  appearn  to  be  the  most  fre<iuent  (p.  llt^| 
The  only  Treatinent  that  can  be  adoptwi  with  any  prospect  of  Fucctiw.  la  " 
tlie  one  case  prolonged  avoidance  of  sexual  excitement,  and  in  the  othrr 
n>moval  of  local  disease  existing  in  the  urethra  or  tesils,  sucli  aa  i^tricture, 


J 


INTRODUCTION    OF    INSTRUUENTS.  1137 

or  thickeDing  or  condetiBatioD  of  structure,  by  the  loog-coDtinued  un  of 
•faaorbent  remedies  on  general  priuciples.    Tunics  are  valueless  io  such  cases. 

SterilitT  arises  also  from  malfonnation  of  the  penis,  such  as  completa 
hypospadias,  and  more  rarely  from  the  size  of  the  mole  oi^^  rendering 
complete  coition  impossible. 

In  conclusion,  I  need  scarcely  say  that,  in  the  treatment  of  that  general 
melancholia  or  hypochondriasis  that  accompanies  these  various  affections, 
much  good  may  be  effected  by  means  that  directly  influence  the  spirits  and 
the  mental  condition  of  the  patient.  He  should  be  encour^^  to  travel,  to 
occupy  himself  with  healthy  outdoor  pursuits  and  amusements,  to  take 
rqpilar  exercise,  to  avoid  alt  enervating  habits ;  and,  above  all,  his  mind 
■hould  be  cheered  by  the  hope  of  eventual  cure.  Should  there  be  any  local 
disease,  such  as  balanitis,  phimosis,  or  varicocele,  that  should  be  subjected  to 
treatment  or  operation. 


CUATTER    LXXV. 

DISEASES  OF  TUE  FEMALE  GEN'ITAL  ORGANS. 

Some  of  the  more  important  surgical  aflTections  of  these  organs,  such  as 
Tcwco- vaginal  and  recto- vaginal  nstulie,  lacerated  perineum,  etc.,  have 
already  been  discussed.  The  remaining  affections,  implicating  the  Vagina, 
the  Uterus,  and  the  Ovaries,  are  of  considerable  practical  interest;  but,  as 
their  full  consideration  would  lead  me  far  bevond  the  limits  that  can  be 
assigned  to  them  in  this  work,  and,  indeed,  belongs  to  another  department 
of  Medicine,  I  must  content  mjrself  with  a  brief  indication  of  the  principal 
mrgical  points  deserving  attention. 

INTRODUCTION    OF   INSTRUMENTS. 

Speculum  Vagina. — Vaginal  specula  of  various  shapes  and  matenab 
are  commonly  used  by  Surgeons.  When  the  os  and  cervix  of  the  uterus 
zequire  exploration,  the  most  convenient  instrument  is  certainly  the  cylindri- 
oai  reflecting  glass  siieculum  (Fig.  981) ;  which,  being  coated  with  a  layer 
of  tinfoil,  covered  by  India<rubber,  always  presents  internally  a  mirror-hke 
■ar£sce,  by  which  a  stning  body  of  light  is  thrown  into  the  bottom  of  the 
tube.  It  has  the  additional  advantage  of  being  very  cleanly,  and  not  stained 
by  any  caustics  that  may  be  used  in  it.  These  specula  should  be  of  different 
sises,  and  may  be  sometimes  advantageously  bevelled  off  at  the  inner  end. 
When  the  wall  of  the  vagiua  requires  examination,  as  in  some  operations 
for  fistula,  a  bivalve  speculum  (Fig.  98X',  one  with  expanding  blades  (Fig. 
962),  a  cylindrical  one,  provideii  with  a  sliding  side,  or  the  "duck-billed" 
■peculum  (Fig.  942 1  may  advantageously  be  used. 

Introdnction  of  the  dpeculum  may  readily  Ik-  effected,  without  any  ex- 
posure of  the  person,  under  the  dress  or  bed-ctutbes.  There  are  two  posi- 
tions in  which  the  patient  may  conveniently  be  placed  for  this  purpose.  Id 
the  first,  she  lies  upon  her  back,  with  the  nates  well  raised  or  brought  to  the 
edge  of  the  bed  or  couch,  her  legs  separated,  and  hor  feet  resting  on  two 
chairs;  the  Burgeon,  standing  or  sitting  in  front  of  the  patient,  introduces 

VOL,    II. — 7"J 


1138        DISKASES   OP   THK    FEUALE    QENITAL   ORGANS. 


the  fore  anti  midille  Hngera  of  his  leA;  hand  into  the  vngina,  dilates  ite 
panes  the  6iK-<.^uium,  well  greased,  geotly  and  steadil}'  between  and  ander' 
tliem,  exerting  any  pressure  that  may  be  required  backwards  on  the  poii- 
neum.  Thie  po<<itiou  is  the  most  cionvcnicDt  when  caustics  require  to  b« 
appLieil,  but  is  often  objectionable  to  the  patient,  as  it  appeora  to  entail  much 
exposure,  though  In  reality  it  noed  not  do  so.  Another  mode  of  intriKluo- 
ing  the  Bpeculum.  which  should  nlvays  be  adopted  vhen  practioable.  coDaiM 
in  placing  the  patient  on  her  left  aide  across  the  bed,  irito  the  knc««  drawn 
up,  and  the  nates  near  the  edge ;  the  inMrumeot  i^  thco  introduced  io  th« 
same  way  as  before,  the  Sutton  silting  by  the  patient's  ude.    In  wbicberer, 


Pi(.  981.— Cylindri- 
cal Spwuluta. 


ytg,  WS, — Blvtir*  8p««ahiMi. 


iHtm*' 


way  tbe  ipecuhim  is  used,  no  fnrce  should  be  employed  ;  tbe  patient 
be  placed  oppr«ite  a  good  light,  and  care  should  be  taken  tLaC  the 
meat  be  introduced  fuirly  to  the  uteruit,  the  ]io)ution  of  which  may  bare  been 
previously  ucertained  by  tactile  examination. 

Fkmale  Catheter. —The  u»e  of  tlie  female  catheter  ia  oAen  required  in 
various  diseases  and  operative  procedures  about  the  genilo-urinary  orgaoi  of 
vromeu.  It  iliould  be  introduced  without  exposure,  bv  the  aid  of  the  toueh 
alone.  This  may  readily  be  done,  as  the  patient  lies  in  bed,  under  the 
clntlieb.  The  Surgeon,  standing  on  her  leil  side,  pasKs  bis  lefl  index-finger 
di)TrDwardt<  between  the  nymphie  until  he  fecia  tbc  projection  of  ibe  lueatiia 
urinarius,  immediately  above  the  entrauce  into  the  vagina ;  keeping  bis  finger 
juH  Ik-'Iovv  this,  he  uses  it  as  a  guide  to  direct  the  point  uf  the  catheter  into 
the  canal.  Or  the  rtiverso  wav  may  be  adopted ;  tbc  Surgeon,  pusiog  hu 
finger  just  iuUi  the  orifjco  of  too  vagina,  feek  tbc  urethra  like  a  cord  under 
the  arch  of  the  pubo.  He  carries  it  along  this  until  the  urethral  uritioe  is 
reached,  when  the  cuthotcr  iis  olipjiod  iu.  ThiM  iiielbod  has  the  advantage 
that  the  cHluris  is  nut  tuucbed,  a  lualter  of  importance  in  hrslerJcal  females. 

DieRASre  OP  THE  eXTBRNAL  OROANS  AKD  VAOtNA. 

The  vulva  in  the  seat  of  numerous  morbid  conditions,  cnmiiiting  prind* 
pally  of  hypertrophy  or  of  warty  growths,  or  the  formation  of  cy»t«- 

HvrKKTROPBY  OP  THE  Ladia  to  a  limited  extent  is  not  unfrequentty  met 
witb,  one  labium  bunging  down  couiiderably  below  the  other.     In  these  cases, 


^ 


IMPERFORATE    HYMEN    AKD   ITS   TREATMENT.         1189 

it  will  oflen  be  found  that  the  enlargement  is  due  to  a  kind  of  solid  <Bdema, 
ori^ally  dependent,  perhaps,  upon  a  fiaeure  or  ulcer  of  the  part.  In  other 
caaei,  large  nbro-cellular  tumors  form  as  outgrowths  from  the  natural  struo- 
turea  in  this  region  ;  these  mar  require  removal  by  excision. 

Large  Condylomata  or  Verbucje  are  oftan  met  with  here  as  the  result 
of  gonorrhteal  or  syphilitic  disease,  forming  at  last  irregular  pendulous 
masses  which  require  extirpation,  either  by  luiife  or  scissors.  I  nave  had 
occasion  also  to  remove  a  large  Ncevus  by  ligature  from  this  situation  ;  and, 
in  fact,  any  growth  that  occurs  in  the  akin  or  cellular  tissue  may  be  met 
with  here. 

Cystic  Tumors  are  not  unfrequently  met  with  in  the  labia,  and  may 
sometimes  resemble  rather  closely  the  ordinary  forms  of  inguinal  hernia; 
with  which,  however,  their  incompressibility,  irreducibility,  and  the  absence 
of  impulse  on  coughing,  will  prevent  their  being  confounded.  These  cysts, 
which  require  removal  by  a  little  simple  dissection,  usually  contain  a  dark, 
turbid,  or  sanguineous  fluid,  and  sometimes  atheromatous  matter.  Tolerably 
free  hemorrhage  may  follow  their  removal,  the  vascular  tissues  of  the  labia 
being  cut  into.  This  may,  however,  always  be  arrested  by  Paquelin's  or 
some  other  form  of  cautery,  or  by  firm  pressure  by  means  of  a  T-bandage. 
Occasionally  they  project  from  the  inside  of  the  vagina,  and  then  require 
removal  by  dissection  or  ligature,  as  can  be  best  practised. 

Imperforate  Vagina  is  occasionally  met  with  in  young  children,  and 
occasions  a  good  deal  of  anxiety  to  the  parents.  This  condition,  however, 
mar  always  be  very  readily  and  speedily  removed  by  tearing  open  the  canal, 
OS  It  were,  by  dragging  open  its  walls  in  opposite  directions,  and  breaking 
through  the  adhesions,  which  are  little  more  than  epithelial,  with  the  thumb- 
nail, a  blunt  prube,  or  the  handle  of  a  scalpel,  and  then  introducing  a  small 
pledget  of  greased  lint. 

Imperforate  Hymen  is  occasionally  met  with,  causing  great  inconveni< 
eooe,  and  even  danger,  by  the  retention  of  the  menstrual  secretion,  which 
may  accumulate  to  an  immense  extent,  and  become  converted  into  a  kind  of 
chocolate-colored  grumous  fluid.  This  malformation  does  not  usually  attract 
attention  until  the  age  of  seventeen  or  eighteen.  When  the  menstrual  flux 
baa,  however,  not  appeared,  notwithstanding  periodical  constitutional  dis- 
turbance, an  examination  is  instituted,  and  the  cause  of  the  obstruction  is 
revealed.  In  these  cases  the  hymen,  which  forms  a  dense  elastic  membrane, 
is  pushed  down  between  the  labia,  and  the  uterus  distended  by  accumulated 
secretion  may  generally  be  felt  as  an  elastic  fluctuatiug  tumor  above  the 
pubes,  reaching  sometimes  nearly  to  the  umbilicus. 

The  Treaiment  consists  in  puncturing  the  hymen  with  a  trocar,  enlarging 
the  opening  with  a  probe- i>oiD ted  bistoury,  and  thus  discharging  the  retained 
fluid,  which  may  be  in  very  laree  quantity.  This  operation,  unless  performed 
with  antiseptic  precautions,  is  by  no  means  free  from  risk.  Before  any  inci- 
UOD  be  made,  the  parts  should  be  thonjughly  cleansed  with  a  5  per  cent 
■olution  of  carbolic  acid.  The  cavity  left  after  complete  evacuation  of  the 
fluid  must  be  well  washed  out  with  carbolic  lotion  or  a  strong  solution  of 
iodine,  af^r  which  a  pnd  of  iodoform  gauze,  or  other  efficient  antiseptic 
dressing  should  l>e  applied  and  retained  in  place  by  a  T-bandage.  Daily 
syringing,  with  renewal  of  the  drestsing,  in  to  be  practi:<ed  at  first  until  all 
danger  of  septic  mischief  be  over,  the  urine  meanwhile  being  ilrawn  off  as 
required  by  menus  of  the  catheter.  In  (i|K>niiig  the  nicnibrane,  it  neetl 
scarcely  be  suid  that  wound  <>f  the  urethra  ohituld  be  carefully  guanled 
against;  and,  with  care,  that  caniil  may  ulwiiys  be  avoided.  I  have,  how- 
ever, seen  one  cum  in  whicli  it  had  liceu  silt  up  by  the  Sturgeon  who  puDo* 
tured  the  membrane. 


1140         DISEASES    OF    THK    FEMALE    GKMTAL    ORQANS. 


OocaaioDally  tim  Surgeon's  a<lvice  may  be  sought  by  Diarried  women, 
a  rigid  and  only  partiaUy  perforate  hymen;  wlieu  iucisiou  with  a  pp>b«- 
poinled  bistuury  or  forciblAiiitittatioQ  may  b«  rei^uired.  Impn*gualioD,  bow- 
ever,  le  possible,  er«n  though  the  hyitieo  be  not  ruptured;  au<l  it  maj  be 
BCoeeaarv  ilurlng  parturitiou  actu»]ly  to  cumpletu  the  tiivision  of  thai  cdmd* 
braoe,  U'  thickened  and  uurupturud,  though  in  moat  cases  it  gives  way  under 
the  pressure  of  the  fffital  head. 

It  may  happen  that  surgical  aid  is  needed  to  Bupplement  ooojugal  effort* 
in  the  coDsuiutnation  of  the  uinrriage  ritt*.  In  these  io>cftlIed  "  delicate" 
cases,  aniBsthe«ia  having  boeu  induced,  the  Surgeon  tntruduceti  a  small 
bivalve  speculum  shut  (Fig.  983),  or  an  ordinary  "glove-stretcher,"  and, 
expODding  the  blades,  ruptures  the  h^njen,  and  dilates  the  vagina  to  the 
iMniiiiwij  extent  as  he  withdraws  the  mstrumenL  When  severe  apasniudic 
pain,  of  the  clmracter  known  as  vaginismus,  is  babitunlly  caused  by  coiLiuo, 
il»  origin  may  occasionally  be  traceij  to  u  hvperaslhccic  condition  of  the  re- 
uiuine  uf  the  hymen.  In  such  cose^,  excisiou  bv  moiine  of  curved  sciivure 
of  u  compk-tc  ring  of  the  sensitive  tissiio  seated  immciliately  within  the  en- 
tritncc  of  the  vaeino,  uso&lly  serves  to  cure  the  atfcction  ;  and  this  all  the 
more  surely  if  fiillowed  by  loroible  dilatation  of  the  part  and  the  introduc- 
tjan  nf  a  firm  pluj;  of  irxloform  gauze,  which  should  be  allowed  to  remain 
tft  situ  for  several  daj's. 

Abbbnce  or  rnu  utruob  akd  Ovadies,  with  imperforate  vagina,  is  occa- 
sionally met  with  ia  women,  othcnviso  perfectly  welt  formed:  tnc  external 
organs  of  generation,  labia,  and  nymphm  being  present,  and  the  breasts 
developed.  In  such  cases,  it  is  remarkable  that  sexual  desire  usually  exists. 
The  true  couditinn  may,  however,  he  detected  by  an  examination /)*rnwh(ia, 
and  especially  by  the  introduction  of  a  catheter  into  the  bladder  whilst  the 
finger  is  in  the  rectum,  when  the  two  cavities  will  he  found  to  be  in  close 
aplMjeition  without  the  intervention  of  uterus  or  ovaries,  the  point  of  the  ia- 
atriitneul  being  fiill,  thinly  covered,  through  the  gut.  In  twoof  tbo  cases  of 
thia  kiud  in  which  1  have  been  consulted,  there  bad  been  monthly  epistaxis. 
No  surgical  iiUerlereuce  can  be  of  any  avail  iu  such  cases  ;  and  on  attempt 
to  reulorv  the  vagina  would  oecei^aarily  lead  to  fstiU  results  by  o[tetiiiig  the 
peritoueal  cavity.  Occasionally,  if  the  woman  has  l>een  marrie«i,  the  fruit- 
less attempt  al  coition  on  the  [wrt  of  the  husband  has  caumd  dilatation  and 
expausiuu  of  the  urethral  orifice  to  such  ao  extent,  that  the  index  finger 
may  be  introduced  into  the  cavity  of  the  bladder.  I  have  knowa  this  ex-- 
pauded  urethra  mistaken  for  the  vaginal  aperture,  coitus  effected  into  it. 
and  the  existence  uf  the  lualfurmalion  for  a  long  time  completely  uvertuokcdL 
SimuUaneota  vesical  and  rectal  exploration  will  always  clear  up  Che  iroe 
nature  of  the  case. 

HyrEicTitoriiY  of  tiii:  Ci.rroKrfl  is  oncasionatly  met  with ;  this  urgaa 
becoming  enlarged,  vIongattHi,  anil  jienduIouH,  aurl  in  some  cases  mitaimag 
au  enurmous  size.  Hargra%'0  nieutions  an  instance  where  it  was  fuuo<l  aAcr 
removal  lo  constitute  a  tumor  weighing  five  noitiidii  and  a  half.  When  the 
clitoris  ia  vulai^d.  it  may  give  rise  to  a  gouu  deal  of  irritation,  and  require 
excision,  an  operutiim  that  is  often  followed  by  rather  troublesume  hemor- 
rhage, requiring  tiie  use  of  the  actual  cautery  for  its  arrest.  The  clit^irte 
may  also  ocaisittnally  be  the  seot  of  epithelioma;  which,  however,  ia  raon 
Cfimmnnly  met  with  HtTecting  the  labia  minora  and  the  orifice  of  the  vagina. 
In  either  situation  excision  By  means  of  Paquelin's  cautery  knife  is  the  raoac 
efTeclual  mode  of  treatroent- 

Seaoval  of  the  Clitoris,  even  though  not  enlarged,  was  some  years  ago 
recommendod  nnd  extensively  practised  as  a  means  of  care  in  some  forms  of 
epilepsy  and  of  erotomania.    This  is  an  operntion  as  unscientific  as  it  wonM 


I 

4 


\ 


^ 


PROLAPSE    OF    THS    VAGINAL    WALLS.  1141 

be  to  remove  the  glsDs  peoiB  for  the  cure  of  f^imilar  afffctions  id  the  male,  aod 
one  that  the  experience  of  the  profeseion  haa  proved  to  be  aa  useless  in  its 
reaults  as  it  is  unscientific  in  its  principle. 

TxTMOBB  of  various  kioile  are  met  with  in  the  interior  of  the  vagina, 
springing  from  its  walls.  These  may  be  of  a  Cystic  character ;  but  occasion- 
ally true  Macoaa  Polypi  are  found  dependent  and  projecting  from  the  side  of 
this  canal.  These  may  most  readily  be  removed  by  traustixing  their  base  by 
a  double  whipcord  ligature,  and  then  strangling  them.  In  performing  this 
operation,  however,  when  the  tumor  grows  from  the  posterior  wall,  care  must 
be  taken  to  ascertain,  by  proi>er  digital  rxaminatiou,  that  a  portion  of  the 
rectum  has  not  lieen  dragge<l  down  into  its  base. 

Vaginal  Hemokrhoii>s  are  occasionally,  though  rarely,  met  with.  They 
occur  chiefly  towards  the  anterior  part  of  the  vagina,  or  about  the  lower  wall 
of  the  urethra,  as  roundecl,  smooth,  purple  masses  of  enlarged  and  congested 
veins.  In  one  case  I  have  seen  a  mass  of  this  kind  in  an  old  lady  give  rise 
to  permanent  incontinence  of  urine  or  dysuria,  by  keeping  the  urethral 
aperture  patent.  Destruction  by  Paqueliu's  or  the  galvanic  cautery  is  the 
beat  method  of  treatment,  care  being  taken  not  to  touch  the  healthy  mucous 
membrane,  which  must  be  protected  by  a  bone  speculum. 

Prolapsus  of  the  anterior  or  the  posterior  wall  of  the  vagina  may  occur, 
living  rise,  in  the  lirst  instance,  to  protrusion  of  the  bladder,  or  Cyitocele; 
in  the  other  to  a  Eectocele.  In  either  case,  but  especially  iu  the  flrst,  it  occa- 
sions very  serious  and  troublesome  consequences,  amongst  which  chronic 
irritation  of  the  mucous  membrane  of  the  bladder,  with  perhaps  phoephatic 
deposits  in  the  urine,  are  the  most  marketl.  These  protrusions  may  be  sup- 
ported by  the  use  of  properly  constructed  belts  or  pessaries  combined  with 
the  use  of  astringent  injections. 

In  some  cases  the  Surgeon  may  feel  disposed  to  undertake  plastic  opera- 
tions, in  order  to  narrow  the  vaginal  orifice  by  freely  paring  op]>08ite  portions 
of  its  wall,  bringing  togetlier  the  freshened  surfaces  by  mesns  of  the  silver 
suture,  and  thus  procuring  narrowing  of  the  cunal  and  permanent  support  to 
the  protruded  part.  The  success  of  such  o|>erative  proceedings  wilt  grt-atly 
depend  on  attention  to  detaili<.  The  mucous  membrane  at  the  orifice  of  the 
vagina  should  be  dissected  ofl"  from  about  half  an  inch  below  the  meatus  on 
one  side,  to  a  corresponding  part  on  the  other,  in  a  strip  about  an  inch  and  a 
half  wide;  the  dissection  l>eing carried  well  up  posteriorly  in  the  fourchette. 
Two  or  three  deep,  and  as  many  sui>erficial,  sutures  should  be  passed ;  the 
deep  being  left  in  for  about  five,  the  superfiinal  for  seveu  days.  Great  atten- 
tion should  be  paid  to  cleanliness,  the  patient  lying  on  her  side  with  a 
catheter  in  the  bladder  communicating  with  an  India-rubber  tube  to  carry 
off  the  urine  ;  and  the  bowels  uhoutd  be  cimtined  by  opium. 

Vabioi'h  r)l.'«cnAi»Ji:s  connected  with  the  female  organs  of  generation  &11 
under  the  olwervatiun  of  the  Surgeon  ;  tlii'se  may  otriir  from  the  external 
organs,  from  the  niucous  nicndirnue  covering  the  cervix  uteri,  or  from  the 
intierior  of  the  cavity  of  that  organ.  These  diseharges,  when  proceeding 
fn>m  the  mucous  membrane  covi-ring  tlie  external  organ,  or  lining  the 
vagina,  are  frequently,  thougli  nut  neces.<'iirity,  of  a  g'jnorrhieal  character; 
and  then  require  to  be  treated  in  the  way  that  lias  been  mentioned  at  p.  1042, 
vol.  ii.  When  tlioy  are  of  a  simple  nature,  proceeding  from  mere  excessive 
secretion  of  these  parts,  u.-tringeni  injections,  and  attention  to  the  general 
health,  will  UHually  succeed  in  t-fll-cting  a  cure. 

VAorsAL  I)isfri.\i:<ii>  of  a  purulent  cluimctcr  not  unfrequently  occur  in 
young  female  cliihlren,  iu<  the  re.-«ult  of  coniiiitutional  debility  or  strumous 
derangement.  0('oa.»iiinHlly  i<ueh  discharges  lead  to  the  suspicion  of  the 
child  having  been  iniprii{K>rIy  tamiwretl  with;  und,  although  they  may,  of 


1142        DISEASES   or   TBX    FKHAI.K   OBNlTAU  DBOJL5S. 


courae,  be  oceasioiii'cl  hy  aome  vi'^If  tic?  inflirlcd  od  the  ^roitmls,  or  i 

gonorrbival  iufectioo,  it  must  be  burue  in  miml  iKat.  irr  tlif  jrroit 

inntanceB,  thfj-  certainty  arist  from  c"ni*tiluliiinul  vt-o 

ill  DO  way  referHble  to  external  eauBcs.    Thv  jyvatin-r-  ati 

tocleanlineits,  ibe  use  of  warm  lead-lotions,  aad  imprvvcuteol  of  Ibv  gmml 

henlth. 

Diechargvgi  ilepeudeul  upon  unbealtbv  eoDdilioDS  of  ttie  cerrix  wmI  Bonf 
menibnine  of  the  uterus  usually  require  unccial  tre«ltD«til.  for  th«i' 
wbicb  tbe  reader  may  be«l  rt;fer  lo  works  ifevotctl  U>  tb«  IKwbm  of 
wbere  a  conaideraliou  of  tbe  nature  and  Diaiiageiiieut  of  uteriD* 
meut&  also  will  be  fuuud. 

TVMOK»  OV  THE  rTEBU*. 

The  Ro-called  Fibroid,  or,  more  cnrrectly,  Fibro-mjrDiniitiws  grovtfa*,  i 
etitule  by  far  tbe  most  oninnioD  form  of  uterint>  tumor.  Tbne  nccarddv 
siogly,  or  as  multiple  formationg  affecting  chiefly  tbtv  ftmdos  sad  bndj  if 
the  uterus.  As  a  rule,  they  develop  slowly,  and  in  the  majoritr  of  iaMnn 
give  ris«  to  no  Bymptnms  calling  for  surgical  tr«atmcot;  but  ceemitudtf 
active  interrereoce  is  neeenltalcd  in  coD»er)ueor«  of  Hangrr  tu  IU«  uwbf 
fetttn  one  or  more  of  the  fi)llovring  ci>tiditi(>ns,  vie,  pcrsittent  and  udoMw 
lable  uterine  hemorrhage ;  rapid  increaw  tn  tbe  aizc  of  the  tum»r  '•oomAw 
due  to  oystic  degenemtinn)  ;  or  constant  end  Mvere  pain  cansrd  bv  prasK 

The  ordinary  clatwiJication  adopted  of  subpfriloneal,  iDtramunl.  aodlib' 
mucoua  gr<>wti)ti,  may  cmiveniently  be  followed  in  conaMleruig  tbe  Mf|tia) 
trealriient  of  tbene  tumors. 

1.    The  mbprritoncni  variety,  when  unac^  '  by  roaeh  ooHdMOl 

eotargenient  of  the  uterine  bo<ly,  \«  not  unc>>:  mi^i  ailh  aa  a  mm* 

Jen  distinctly  pedunculate*!  grv)Wih  sprin^n^'  Imni  tiit<  fuudu*.  If  of  wd- 
erate  8iz«.  Ibis  may  readily  be  rvmuvcd  on  abdyDiinul  m-ittoo  by  ftcuriBfll* 
pediciv  wrili  a  trantilixing  ligature  of  ttiout  n\k  prt<vir>u8  todiviMttt.attiltfc<i 
Buturiug  tb«  cut  edges  ol'  its  peritoneal  ioTcslmeut  acroM  iIm  aarfiKV  of  0* 
stump.  lu  cases,  however,  tn  wbicb  a  tumor,  often  of  vtrj  larRt  mr,^ 
cnmp4iM.-d  of  a  multiple  ma»  of  subperitoneal  ouigrowtha,  toTulvioit  tUv^S 
tbe  tiieriuo  body.  Lbo  operation  of  hyetcn!vl'juiy  is  to  be  had  ncotamU 
Thi»  pn>(»durc,  involving  the  ablation  oj'  the  entire  nuus  of  ibe  tn*'. 
inclu(ling  the  body  of  tbe  uterus  together  with  the  ovaria  antl  Uibei.te 
recently  oomu  to  be  rt-gnrded  an  tbe  moat  satiBfaotory  moda  of  JwHifl'fc 
such  CHses.  The  oiM-raiifin  is  p^rfiirme<i  an  follows:  The  tnmor,  barbie bA 
turned  out  of  the  abdominal  cuvity,  is  held  up  by  an  arairtant.  Triiflf  ** 
Burgeon  encirclen  the  uleruK,  umirIIv  at  about  the  level  of  the  jnnctlcai  af  l)< 
body  and  rervix,  with  ii  fuift  iron  wirt^  eonnecle«i  with  a  smalt  emtrar 
known  B9  Knrberl^'B  eerrf-aaruft.  Whenever  poeeihle,  lh<<  ovarita  ami  laW 
should  he  included  in  ihe  li^>p;  while  care  ifi  rp^piirfd  that  oopattioaif 
intejiine  be  nippe<l  by  it,  ami  that  tiie  bladder  be  fcrpt  r.iii  -.f  lianu'*  way  ii 
front,  Tbe  wire,  having  been  properly  secured,  is  i. 
Ibe  spiral  »crew  of  lbo  serre-rtfrurf  suHirtetillv  to  prc^'i.  . 
rhage;  nod  a  sl"Ut  8t«el  pin  i«  then  patneil  timmgb  ihf  (■  ' 

above  the  cynJtrieting  hwo,  before  cutting  away  'f     • 

been  done,  Ibe  abdotninni  incision  is  carefully   < 

Wbicb  19  iDainlaiucd  in  position  externally  by  the  m- 

(he  wire  is  agitiu  tigiilene<l  by  a  lorn  or  two  ol' tbe  scr< 

thorriughly  tanned  by  menus  of  the  Kilid    >< 

dresHog  is  applied.     If  all  go  well,  the  win 

16lb  t»  tbe  20th  day,  leaving  a  cavity  which  huil*  by  ^rtuiui«i*ua. 


riBKO-HTOMATA    OP    THE    UTERUS.  1148 

2.  The  intimmiiral  varietj  of 'fibro-mjoma  occurs  in  ooe  of  two  forms. 
Thefirri  of  these  may  be  described  as  a  more  or  lees  uoiform  hypertrophy  of 
the  uterine  tissue,  coDstituting  the  tumor  commonly  known  as  a  tojl  fibroid. 
This  enlargement  is  usually  accompanied  by  profuse  uterine  hemorrhage, 
which  may  occasionally  necessitate  active  surgical  interference.  In  such 
cases  either  one  of  two  operations  may  be  performed  for  the  relief  of  the 
patient,  viz.,  removal  of  the  uterine  appendages  (ovaries  and  tubes)  with  a 
view  to  arresting  hemorrhage  and  promoting  atrophy  of  the  growth  by  pre- 
mature induction  of  the  menopause ;  or  else  the  above-described  operation  of 
hysterectomy,  which  is.  on  the  whole,  the  most  satisfactory  mode  of  dealing 
with  these  tumors.  The  tecond  form  of  intramural  fibro-myoma  consists  of 
localized  hypertrophic  growths,  which,  as  a  rule,  are  distinctly  eocapsuled. 
When  multiple,  these  may  occasionally  give  rise  to  a  considerable  tumor, 
requiriDg  the  same  treatment  as  the  above. 

3.  The  iubmuooat  variety  of  fibro-myoma,  when  occurring  as  a  more  or 
IcH  senile  growth,  projecting  into  and  dilating  the  uterine  cavity,  may 
occasionally  demand  surgical  interference  in  consequence  of  alarming  and 
pentstent  hemorrhage.  If  the  cervix  be  expanded  over  the  protruding  mass, 
&  free  incision,  made  through  the  capsule  of  the  presentmg  portion,  will 
oiable  the  operator  to  shell  out  the  tumor  by  a  gradual  process  of  enuclea- 
tion, while  firm  supra-pubic  pressure  is  maintained  by  the  hand  of  an 
SMStant,  in  order  to  facilitate  the  extraction.  This  operation,  often  a  very 
■evere  and  difficult  one  if  the  growth  be  of  any  size,  should  be  undertaken 
ooly  for  the  relief  of  most  urgent  symptoms,  since  all  submucous  growths 
have  a  natural  tendency  to  bea>me  polypoid  in  character,  and  thereby  mora 

sily  removable. 

Toe  ordinary  fibroid  polypus  is  usually  met  with  as  an  oval  or  pyriform 

us,  attached  to  the  posterior  aspect  or  fundus  of  the  uterine  cavity  by  means 
of  a  more  or  less  distinct  pedicle.  Such  growths  not  uncommonly  give  rise 
to  repeated  and  dangerous  hemorrhage,  ouen  altogether  disproportiouate  to 
their  size.  The  most  efficient  mode  of  treatment  consists  in  removal  by 
means  of  a  wire  ^raseur,  of  which  the  loop  is  passed  round  the  pedicle  and 
gradually  tightened  until  division  is  effected.  Unless  the  growth  be  pro- 
truding through  the  cervix,  preliminary  dilatation  of  this  structure  will  be 
tequired  in  order  to  permit  of  the  necessary  niaDipulations. 

Two  other  varieties  of  uterine  polypi  are  met  with,  viz.,  the  glandular  and 
the  cellular  polyp.  These  usually  grow  from  the  cervix  or  its  immediate 
neighborhood,  and  their  removal  by  means  of  the  wire  ^raseur,  or  by  simple 
torsion,  if  of  itmall  size,  commonly  presents  no  difficulty. 

It  is  an  iniiMirtant  rule,  af^er  nil  operations  iuvolving  the  uterioe  cavity, 
ireely  to  ttpply  pure  tincture  of  iodine  to  the  interior  of  the  womb,  in  order 
to  avoid  the  risks  of  septic  mischief  otherwise  liable  to  ensue. 

Xalignant  disease  of  the  uterus  may  occur  in  any  one  of  the  three  follow- 
ing forms,  viz.,  as  glandular  carcinoniii  (usually  of  the  medullary  type)  ;  as 
epithelioma  ;  or  wry  rarely  as  sarcoma. 

1.  Olandolar  carcinoma,  which  is  much  the  mo^t  common  form  of 
malignant  diacHse  here  met  with,  cunimeui'es  us  a  hanl.  somewhat  nodular 
hypertrophy  of  the  cervix,  with  a  toixlency  s[H>eilily  to  affect  the  neighboring 
tissues  of  tlie  broad  li^ameiitu,  thereby  lending  to  early  impairment  of  the 
natural  mobilitv  of  the  iitt'r)ii>.  As  the  diticuse  progresses,  innltration  rapidly 
extends,  until  tlic  iwlvir  organs  ure  found  coni])letely  fixed,  and  surntundea 
by  the  new  growth.  ]Vstriu*tivc  <'bangt>s  next  take  place  in  the  ti^ues 
implicated,  usually  accoiiipanied  by  fetid  dim-harge,  and  by  (»ccat<ional  attacks 
of  facmorrhage.     The  uninmit  of  pain  compluined  of  varies  in  different  cases, 


1144        DISEASBS   OP    THI    PSHALE  OB51TAL  OBOAXS. 


but  it  18  ofton  of  »  most  severe  <dMraoter.'  GeoenU  coHttttatiaaBl  i 
ensucA,  ftiid  the  pntieot  dies  exhfuiated. 

TKtitrtietU  ID  advuDoed  cwee  must  neaeaMiilT  be  pareljr  pallinn^tli 
chief  indicationa  being  to  control  liemorrhoge,  relieve  puD,  sod  anada  ika 
patient's  Btrengtfa  hy  5uitable  nourishmcDL  In  the  euiier  mamt  if  tk 
Rffection,  before  there  i»  nny  appareni  implicatjoa  of  neiyfchnwf  fMtL 
attempts  are  occaNooally  made  to  arreat  the  disean  etlber  Of  titMm  ui 
the  use  of  the  cautery,  or  olm  by  roorting  Ui  tbe  aolfvnc  prapenia  «l  a 
strcmg  bromioe  salutioD  iujeci«d  into  ibe  diseocod  tuauea.  eoch  cnaUMM. 
although,  perhaps,  jiutitiable,  cao  be  of  little  um  in  reurdin^  lb«  pnfna 
of  the  malady. 

Complete  extirpatioD  of  the  utenu,  pntitiMd  per  vaginan  or  br  abdeaiMl 
•ection,  iaa  prooedare  which,  unleai  reaoriad  to  in  the  very  cariieai  Aafi if 
the  diaeaae,  when  the  nnoortointy  of  diagnods  mnai  render  it*  adopcian  hanly 
juitjfiflble, CAOOot  poaribly  holdout hopeaof  prolcai|;intr  Uf*^  The  ImmtStH 
resultA  of  the  operation  have  so  far  proved  moat  diaakirotw  in  Uii*  cxMBtry; 
vbile,  iu  the  rery  few  exceptional  caaea  where  tbe  jmlii-iit  has  wirrinw, 
rei-urr«uc«  uf  tbe  diiaue  has  invariably  taken  plaw  witfato  iba  ooonaoTa 
few-  uiDtithB. 

'2.  Epithelioma  of  the  ulcnis,  oominuiDly  known  aa  e«liiiflnr«r  «Ban»- 
eence,  LMmmeiicefl  as  a  riApillotnalom  ^frowth,  aAectiDg  tbe  naDeeoi  llaiaf  «f 
the  cervix,  which  rapidly  (Spreads  to  a  soU  lungatiug  mass,  nilfa  a  tcaaMCf 
to  implicate  oeighboriog  parts. 

While  still  coDfiucd  to  the  U»u»  of  the  cervix,  th«  dtseaae  may 
cuted  by  removal  with  the  ^-rswur,  or  br  fVce  exdaion  ;  but.  a 
broad  ligameots  have  be«n  invaded,  nipiu  infiltration  takea  pUm, 
affection  inevitably  prove*  fatal. 

3.  Sarcoma  ol'  the  uterus  ii  of  very  rare  occurranee,  bring  nH  with  tUar 
un  a  liicalizod  Kubmuct)iM  growth,  or  Mill  more  mrelv  aa  a  oiAmr  mShnliaB 
of  the  uterine  wall.  The  projcnoeis  ia  always  unJiivonible.  Alibaudh  Im 
si)eeflilyBO  than  in  the  rii^u  uf  the  (.-ancer.  When  confiopd  to  Um  nuidB^ 
tne  remnvnl  of  the  projeotinj;  firowtha  may  occastoDally  btt  aflWaid  aiir 
dilatation  of  the  cnrvical  ranal,  by  meann  of  the  coraCta  or  sharp  fpoo^ 
followed  by  the  nppllcatioo  of  strong  nitric  acid.  The  ooly  other  ti  lalianN 
likely  to  prove  emeCual,  is  extirpaooa  of  the  entire  oienta,  aa  reCiml  it 
above. 


tcaaiwf 
^4 


TUH0B8  OP  THE  OVABT. 


Si 


For  clinical  purpiMm,  may  be  broadly  classed  in  two  ouUii  groapt, 
and  solid.  The  (iroL  of  these,  includinj;  thuse  in  which  orstHMnlDM 
the  most  marked  feature  of  the  gruMth,  i-nn  Im:  Kubdividad  ■■  ftUoiiB:  L 
Uniliicular  cysts;  ti.  Moltilo€«jlar  cyet*  ;  •^.  Dermoid  cyt^:  4. Oollosd  eyik; 
5.  Cyeto-sarcomula.  The  secotiJ  group,  consisting  of  tbe  iDora  or  Imb  soU 
fomiatiuuif,  would  iuclude:  1.  SarL-oma;  '£.  Kibnima;  3.  CarouMBMk 

or  thvsv  growths,  thiwv  includes]   to  the  first  group  oooatiiMta  a  laifl 
usjority  of  tbe  ovariau  tumors  met  with  ;  the  mohilocalMT  vwriatj'  bwv (• 
the  vhole  the  miiFt  common,  while  ilermmd  cpts  and  ojrsta  wiili  wlkrid 
tenlfi  are  outrip«rattvcly  rare.    Tbe  wliH  tumore,  rnferrad  lo  in  lb* 
group,  ocoor  very  much  le«  frequently  tlian  any  of  tbe  nboTC. 

Tumors  of  the  ovary  may  develop  at  almost  any  age.  btinc  onaiiannUy 
net  with  in  quite  young  cbildrco,  and  nut  very  unoomrooaly  m  mHn^  «ba 
have  long  passed  Uie  menopause ;  but  the  largcat  pnponioa  ot  tmmm  oesw 
between  ibe  ages  of  twenty  and  tiftv.     Ooc  or  both  omriea  BMy  be  mWretti, 

If  nninterfered  with,  the  disoaso  mvariably  proreslalAl  after  n  ifeotar  cr 
longer  interval,  usually  within  two  or  three  yeaia  from  the  first  d 


DIAOKOSIS  AN~1>  TBBATUENT  OP  OVARIAN  TCUOB.      1145 

at  ma  abdomioal  tumor,  death  occurring  from  gradual  exhaustion  due  to 
iDterfereDce  with  the  fuuctiona  of  neighboring  viscera.  But,  in  the  great 
majority  of  iostances,  an  earlier  fatal  termination  is  liable  to  result  from 
■ome  iDtercurreDt  complication  or  accident — such  as  rotation  of  the  pedicle, 
ill6ammation  of  the  cyst,  rupture  of  its  wall,  etc.,  conditions  which,  unless 
pmmptly  dealt  with  by  operation,  must  inevitably  hasten  the  patient's  death. 

DiAONOflis.  —  The  differential  diagnosis  of  ovarian  tumors  from  the 
Dumerous  abdominal  eolargemeot«  which  may  simulate  them  is  too  extensive 
m  subject  to  be  treated  of  here.  The  following  may,  however,  be  enumerated 
as  coDditi<ms  possibly  requiring  elimination  before  a  definite  diagnosis  of 
ovarian  disease  can  be  arrived  at.  1.  Obesity,  oMlema  of  the  abdominal 
wall,  tonic  spasm  of  the  recti  muscles  with  hysterical  tympanitis  (phantom 
tumor).  2.  Stercoraceous  accunuilalion,  distended  urinary  bladder,  retained 
menstrual  fluid,  distended  gall  bladder.  3.  Tumor  of  liver,  spleen,  or  kidney, 
nrcoma  of  the  abdominal  glands.  4.  Peritoneal  hecmatocele,  abdominal  or 
pelvic  abscess.  5.  Normal  pregnancy,  hydraronios,  extra-uterine  pr^nancy, 
uterine  fibro-myoma,  uterine  fibro-cyst,  hydro-  or  pyivsalpynx.  fi.  Hydro- 
Dephroeis,  hydatid  cysts,  subperitoneal  cysts,  parovarian  cvsts.  7.  Simple 
ascites,  encysted  dropsy  of  peritoneum,  peritoneal  cancer  with  ascitic  fluid. 
The  conditions  enumerated  in  the  last  three  of  these  groups  are  perhaps  the 
most  likely  to  mislead  in  forming  an  opinion. 

In  all  cases  of  abdominal  tumor,  the  patient  should  beexaminetl  undressed 
and  lying  upon  her  back  with  the  shoulders  somewhat  raised  and  the  knees 
drawn  up.  After  carefully  noting  the  salient  points  in  the  history  of  the 
case,  such  as  the  duration  and  rate  of  growth  of  the  enlargement,  its  apparent 
seat  of  origin,  the  past  and  present  condition  of  the  menstrual  function,  etc., 
the  Surgeon  should  proceed  to  determine  the  nature  of  the  tumor  by  the 
systematic  employment  of  the  following  means  :  1.  Itupertion :  Condition  of 
tjie  abdominal  wall ;  amountof  distention  ;  shape  and  contour  of  the  swelling, 
whether  symmetrical  or  not,  prominent  anteriorly,  or  bulging  laterally  ;  ex- 
tent of  downward  movement  visible  on  deep  inspiration.  2.  Peraution : 
Position  and  extent  of  resonance,  whether  strictly  limited  or  diffused,  altered 
or  not  by  change  of  position  on  the  part  of  the  patient ;  presence  and  nature 
of  fluctuation,  whether  limited  (encysted),  or  gvneral  (free  fluid).  3.  Pal- 
ftUicn:  Size,  outline,  and  consistence  of  the  tumor;  itx  relative  mobility; 
solid  or  with  fluid  contents;  presence  of  ntnlular  outgrowths.  4.  Atuvulta- 
tion:  Presence  of  the  ftetal  heart  iu  case  of  suspected  pregnancy;  uterine 
souffle.  5.  By  Vaginal  or  Jtectal  examination  may  bo  determined  whether 
the  tumor  have  a  pelvic  connection  or  not;  and  if  so.  whether  it  be  uterine, 
tubal,  or  ovarian. 

Tapping  or  aspiration  of  a  fluctuant  abdominal  tumor  of  doubtful  origin 
is  occasionally  resortetl  to  with  a  view  to  ascertain  its  nature  by  examination 
of  the  fluid  withdrawn  ;  and  of  late  years  an  explonitory  inoisiitn  has  lK>en 
recommended  in  obscure  coses  as  a  more  definite  iiirans  of  clearing  up  the 
diagnosis.  This  lai^t  pnx-cdure,  although  com  pant  lively  finfe  if  performed 
with  all  due  precautions,  should  by  no  meanii  be  rn.xhly  undertaken  ;  but  if 
practised,  the  operator  must  Iw  prepare*!  at  once  to  jtroc^-cd  to  the  removal  of 
the  tumor,  should  such  a  step  be  found  adviiiable. 

Treatment  of  Ovarian  Tomor. — 1.  Jit/  MriUcal  meann.  These  cannot 
possibly  exercise  any  curative  influence,  tir  in  anyway  materially  retanl  the 
progress  of  the  diseane,  ^^ppcific  treat iiu>nt  by  incrcury  or  iodine  only  hiuitens 
the  progress  of  the  malady,  by  breaking  down  the  cot)»tituliimal  powers  of 
the  patient;  and  attempti*  at  proini)fin<;  the  absorption  of  the  fluid  by  purga- 
tives, diuretiea,  etc.,  are  invurial)ly  unsui-iH-sffiil.  The  utmost  that  can  be 
done  by  medical  treattnent  in  ovarian  disease  is  to  attend   to  the  general 


1146 


niSEASBS    OF    TBB    PBUALK    GBIflTAL  OKOA^IS. 


healtli,  and  to  eiippori  tbo  patient'i  itreogth  by  tooka.  pmi^ng  U* 
of  tbf  tumor. 

3.  Ttippitiij  in  nvariao  drup&T  wiu  firmcrW  rKomBModed  m  %  ^atlbltw 
miniti  of  iroatiiient,  occa»iooally  rwuliiDg  ui  a  cun.  ThMi  thmmmffambij 
fulhiw  iu  the  case  of  a  uDitocular  wnmt  oyit  of  Uw  bniad  li^UMM,  m 
Joubt  am  be  pnicrlaine*);  but  experience  ha*  abown  thai  after  vitUMal 
of  the  fluid  fiMoi  a  true  ovarian  cyat,  rcaecunmtatirio  iorariablj  labfli  plM, 
neces«iuitiog  more  anil  inuro  frequent  repetiiiun  of  the  tappiiw.  if  ikt  Haft 
ment  Ite  pcrxistrd  in,  until  tht^  putieut  finally  dies  exhautfec.  The  fmniii^ 
theffion;,  D(it  only  hfiid«out  ui>  pr(Mf>ecl  ctf^cure;  but,  aa  a  bmIUt  <a  itA.'» 
adoption  U  usually  the  precunmr  of  a  more  rapidly  fatal  Urmittaiiiia  l»lfe» 
caae  than  would  otherwiMi  occur.  Fur,  in  addtlion  la  Ibr  tuotv  immiA^ 
riaks  attendant  upon  the  procedure,  such  as  wound  n(  a  ve*vl  in  th«  abilflt 
oal  wall,  In  the  tiubjacent  omentum,  or  in  the  eyst-<*all  tls^f;  poartwrnf 
adherent  inteitlliie  or  urinary  bladder ;  escape  of  irritatjftc  orariao  flHUj 
the  peritODeal  uavity,  etc. :  tap[itii>r  enbitlii  also  certain 
reufler  iu  adoption  of  very  questionable  adr&Dla^ce  U-  ;  'crat, 
UDdertalcea  as  a  mesas  of  temporary  relief.  FureOMm  maxmg  tlMk 
meatiooed  adhesive  peritonitis,  infiammatiuu  uf  tlie  e7K>nll.  raptiBi 
its  oonteuLs — cuudiltoos  which,  if  not  rapidly  fatal,  niutt  wry  — minatf  9m-' 
plicate  any  future  attempt  to  extirpate  Uie  tumor.  F.wd  tbo«^  wtamtt 
tbcae  untoward  uveuta  should  result,  yet  tbeuperaiiuo,  uulras  parfarwd  %iA 
the  strictest  aiiliMptic  prvcauttous,  is  always  liuble  to  induor  saficic 
nation  of  the  cyai-fluiih),  a  Ktate  tif  things  which,  althoogli  mA  meamanij 
leading  lo  any  obvious  trouble  ut  the  time,  will  surely  tanil  in  dlMinii  iia 
patieat'8  chance  nf  recovery  from  a  subsequent  aTsriDtcBiy  by  expofa^lir 
to  the  risk  of  sepitcTmia.  Finally,  tho  puiicturr  in  tbr  t;ysl-wall  «ay  6iM 
some  cause  or  other  remain  uneealfMl,  ibun  ntloKing  free  racape  cif  a 
fluid  into  the  |H>rltoneal  cavity  with  all  iu  nitendnnt  dangera,  aa»a|[ 
not  the  leiui  19  that  uf  malignant  infection  of  the  iNrriiuaevm  fnmapc*' 
truding  iiapillomaUiu:^  growth. 

The  above  etium^ratlon  of  the  danger*  incurred  thrauyh  ta| 
cysts  ifi  in  accurdanoc  with  the  ex)»eneDre  of  tboae  8ur)teoaa 
the  (iilleat  opportunities  of  judging  of  (he  ratului  of  i)k'«  nr»< 
is  not  too  much  to  say  that  the  pri>ce«lure  \»  (Oie  t" 
but  very  rarely  be  had,  only  when  rendered  justiBablc  ..^  ^  * 
stancea. 

As  a  means  of  relieving  urgent  dyspno-a.  tappng  i» 
only  to  unilocular  cy»ts,  or  to  thuee  muUtlucular  lumora 
cavity  largely  prudoniiuatL-s  iu  fize  over  ita  n-'ighlion.      V' 
called  fur  with  Ibis  view,  (he  ojivratioD  fhould  invariMhlt 
the  strictest  anljiieptic  precauliuus,  including  thv  um  it  n  < 
in  order  lo  ubviato  the  risks  of  wptic  iiilrrlinn  uf  tli       1 
puncture  may  be  made  tlirnugh  the  linen  alba,  ui  in  tt< 
nftcilea;  but  not  unfrequtollv  ibe  tumor  pn-»cnta  roor*    :  ^  _ 

other  part  of  the  abdominal  wall,  and  the  point  tehmtod  outy  b* 
accnnlini^ly.  cam  being  taken  always  ti>  cbiHM)  a  apot  rnv  fmni 
monancc,  and  sufficiently  remote  fr>im  the  pubcs  to  ■-.  p<Mbi[ity« 

puncturing  the  blaildcr  which  may  Iw  drawn  np  in  fi-;..  .l   :.iM  ta«nr. 

Incision  and  Drainage  is  a  method  of  treatment  nirwitwallj  appUcaU 
with  advanta^'e  iu  oxceptiona)  aises  of  univerMllr  adbnvm  tappvimtin 
c^sts,  when  attempted  exiir|)ation  of  (ho  tumor  would  enuil  exirene  mkt 
life,  owing  to  the  probability  of  rupture  of  the  ryM-waU  durins  ill 
— an  acciticnt  most  likely  to  prove  fatal,  as  invoIiiB^  ihe  eacmpe  of  i 
septic  matter  Into  the  peritoneal  cavity.    The  oponUkB  in  each 


TRBATHRNT  OF  OVARIAK  T0HOBS — OVARIOTOMY.      1147 

InvoWefl  a  short  incision  in  the  usual  Bituation,  of  sufficient  extent  to  enable 
the  SurgenD  to  judge  of  the  closeness  of  the  parietal  adhesions,  and  by 
puncture  of  the  uyat  to  determine  the  putrid  nature  of  its  contents.  After 
thorough  evacuation  and  spooging  out  of  the  cvst-cavity  with  a  strong 
solution  of  iodine,  a  glass  drainage>tubc  should  be  inserted,  and  the  incisioD 
elowd  by  means  of  sutures  cnnoecting  the  cyst  with  the  margins  of  the  open- 
ing in  the  abdominal  wall.  The  subsequent  management  of  the  case  involve 
frequent  withdrawal  of  fluid  from  the  tube  by  means  of  a  suitable  syringe, 
and  the  use  of  some  efficient  antiseptic  to  prevent  putrefaction  of  the  dis- 
charges. Under  this  treatment,  the  cyst-cavity  rapidly  contracts,  and  Anally 
oloMs  entirely. 

Other  meant  of  dealing  with  unilocular  ovarian  cysts  have  from  time  to 
time  been  suggested,  all  aiming  at  the  same  principle,  viz.,  that  of  inducing 
gradual  contraction  of  the  cyst  and  cohesion  of  its  walls.  But  of  the  pro- 
cedures advocated,  that  above  described  is  the  only  one  to  be  at  all  recom- 
mended,  and  that  only  in  the  exceptional  instances  alluded  to.  No  operation, 
however,  short  of  complete  extirpation,  can  be  looked  upon  as  surely  cura- 
tive, since,  even  after  incision  and  drainage,  followed  apparently  by  complete 
contraction,  it  not  uncommonly  happens  that  secondary  cysts  develop  in  the 
wall  or  base  of  the  original  tumor,  and  eventually  a  multitocutar  growth 
may  be  substituted  for  what  was  apparently  in  the  first  instance  a  unilocular 
cyst.  These  measures  have  consequently,  wherever  possible,  given  way  to  the 
m£eT  and  far  more  certain  procedure  of  ovariotomy. 

Orariotomy  is  probably  the  greatest  triumph  of  modern  Surgery  in  ita 
operative  department.  In  its  original  cnnception,as  in  its  ultimate  perfection, 
it  reflects  the  greatest  lustre  on  the  British  School  of  Surgery. 

Its  history  is  curious.  Its  progress  was  slow,  and  was  marked  by  those 
oadllations  in  the  judgment  and  tbe  favor  of  the  Profession  which  frequently 
precede  the  final  establisbment  of  a  great  advance  in  practice.  The  operation 
ma  originally  proposed,  and  its  practicability  discussed  in  1762,  by  William 
Hunter.  It  was  strongly  advocated  and  its  practicability  taught  by  John 
Bell,  at  a  later  period.  It  is  said  to  have  been  performed  in  France,  by 
L'Aumonier,  in  1782,  in  a  case  of  "scirrhous  disease  with  abscess"  of  the 
orary,  tbe  patient  recovering.  A  pupil  of  John  Bell — McDowell,  of  Ken- 
tucky, who  is  the  father  oi  ovariotomy — first  performed  the  operation  in 
America  in  1809;  and  in  all  operated  thirteen  times.  In  1828,  Lizars 
0|)erated  for  the  firpt  time  in  this  country.  But  the  operation,  though  several 
tinHs  repeated,  fell  into  discredit,  in  a  great  measure,  owing  to  the  imper- 
lection  of  the  diagnosis  of  the  cases  in  which  it  was  done,  and  was  not  revived 
until  1836,  when  Jeaffrcson,  of  Framlingham.  practised  it  successfully  through 
a  small  incisinn  an  iuch  and  ii  half  long  only.  From  this  operation  we  must 
date  the  revival  of  ovariotomy  in  Great  Britain.  Tlija  n|wration  was  fol- 
lowed by  others  performed  by  King,  of  Saxmundham,  Criep,  of  Ilarli'Ston, 
and  West,  of  Tonbridge.  The  example  of  these  provincial  Surgeons  was 
followed  by  their  brvrhrcn  in  London,  and  the  oi>erati<in  was  practised  by 
many,  eapecinlly  by  Wiilne,  F.  IJinl,  and  Baker  Bniwn.  bvit  with  very  dis- 
couraging results;  for  of  162  cases  collected  by  Robert  Lee,  in  60  the  disease 
could  not  be  removed,  and  of  thcfc  19  died  ;  whilst  of  the  remaining  102.  42 
terminated  fatally.  Not  only  did  these  unfiivornhle  results  discourage  the 
I^feasion,  but  a  growing  iH'licf  spmng  up  that  this  nmrtality,  great  as  it 
was,  did  not  by  any  ineniiH  rcprt^rnt  tlie  whole  extent  of  tlie  fatal  cases,  and 
notwithstanding  that  C.  ( 'iiiy,  of  Manchester,  continued  to  operate,  ovariotomy 
waa  in  great  danger  .if  (iilliii;;  intn  cuch  disrepute  n»  to  he  excluded  from 
ordinary  surgical  pnicticf.  In  1H.'>7  appeant  for  the  fimt  time  in  connection 
with  ovariotomy  the  name  of  a  Surgeon,  who  was  not  only  destined  to  revive 


1U8        DI8EABKS   OP    TBS    FEMAtK    OKNITAti  OBOAVft. 


KNI  oA>n»,  £(  di»4 


orarlotomv,  but  to  rejf^caliliiiii  it  firmly  aod   tIefiuEirly  ftrooniprt  Uw  pni 

opttrationB  in  surgery;  for  in  Deoemlier  of  tbit  y----  -'■cnoer  WdU  ptr- 

formod  bin  firnt  itppratioii  of  thia  kiml.     Tlii*  en  r«i  ttf  ■  Miia  tf 

1000  ca«e«  Ihsl  Kp  hnd  (>erf'-.rnnHl  up  Im  the  Vt-ar  !  -  iE  «f  A« 

operAtion.     In  SirSju^iHVr  WVIIu'h  liand-,  i>vari'ir 

itt  poH'orinftiicc  wa«  Biii'l'-d  by  ili-litiiit'  niU-*.  i 

fully  worlswl  lail  aiul  cv'itematiW'fl,  and  th"  n 

TIm-  rf^iilu  obtain*^)!  >»lioWBd  n  ^riuiiiallv  iiii-r 

M-rien  of  100  <'iW4.ii  published.  ^4  enoet  uiwl  nij 

Maries,  2H  difd  nud  72  rftouvervd ;  uf  the  tbin 

recovered  ;  while  of  the  luM  lUO,  complHio^;  bis  lOOO  cKsrm  imly  11 

89  ri.<c()v«rc<l ;  this  ruprtMeoLing  in  l^SO  a  morUility  lr«9  (ban  a  Ufi 

rccordeil   in  ItHiO.     Tfauie   results,  odmirablo  u  ibry  luv,  kaw 

further  irnpnived  upon  during  law  years  by  nl-ber  well-known  workva  ia  (Is 

field  i>f  Surgery :  und  the  praoedare,  fiirmtirly  ra  fatal  oc  hi  be  ^ramiimamd 

unjuBttliablt;,  ts  now  the  miwt  succesful  of  all  gr«at  ffnrgiisil  aparati(ilL 

In  vompBriuc  ibc  decnmscd  ranruUlty  nHer  ovarii^tuoiy  at  tha  jwemmiitj. 
with  that  which  olttaincvl  even  so  recently  ok  ten  yean  ago.  then  an  mr 
important  factors  connected  with  thp  opi^nUion  kb  now  prnciiMd  mhiA  naM 
he  taken  into  account:  tl}  ihf  diminution  in  tho  number  of  (»■■  vhiA 
have  been  tapped  prcvioas  In  npi-rstiun  :  {2)  the  inmem  of  rtrafiMy  af  tks 
peritoneal  cavity ;  i'i)  the  geocrnt  adoptioD  of  the  mtrftpiiritaMal  umaaml 
of  the  pedicle;  (4)  tbe  systematic  employment  of  anUwpdoa  in  ahrfwaiwi 
Bureery. 

With  regard  to  the  firet  of  tlic«e,  thcrv  can  be  no  d-jubi  iJiat  the  ptaete 
of  tapping  ovarian  cyats.  formerly  co  commonly  in  vo^^e,  had  naicli  i» 
answer  fur  in  retarding  the  progreM  of  ovariotony.  The  dioaatruut  ooi^ 
quencea  of  the  procedure  failed  from  some  oanu  or  other  suffidenily  m  oa- 
preaa  the  mind  of  the  profcMion  at  large;  and,  until  within  the  ip4 
years,  tapping  wu  looked  upon  oi  the  proper  preliminair 
Noommending  abdominal  section.  That  each  a  contae  shnuM  haw 
justifiable  in  Uie  etrly  tiroes  of  ovariotomy,  when  ibf    '  '' 

disease  was  compHratively  in  itt<  infaiRT,  i»  n"t  titMn-' 
wnl  day,  when  trie  study  of  ainlotninal  tumor-  ..'neaiiy 

the  fact  that  tapping  is  an  ojieratiuii  lu  be  li*-  <.  th»  grtatt' 

trust,  \»  daily  becoming  more  generally  rt-o'giiucd ;  and  this  beuef  has  toh 
doubre<ilT  ciintributetl  to  the  succew  of  ..variiii..mv. 

Th<-  tecond  factor  alludeil  to,  viz.,  dniiiiage  of  tlie  at»lo(uiual  cmvHy,  prsfr 
Used  by  the  insertion  at  the  lower  extremity  of  the  abdumtnat  indtina 
glass  tube  reaching  to  the  bottom  of  Duucltia's  pouch,  has  cartainlr  u 
share  in  reducing  the  mortality  alWr  the  oi>c-muim.  Tba  value  «f 
metboil,  as  a  means  of  preventing  the  accumulaliou  in  the  paritMiaal  aviiy 
of  fluids  liable  to  undergo  septic  ebanges  is  uuitoiibituDy  imai ;  but  itsaa- 
ployment  ncvenbeie^  involves  certain  ditadraiuni*vs  which  must  miC  be  btt 
eight  of.  Furemojt  among  these  are  the  risk  of  mtry  of  the  rainc  of  nUi» 
faction  aiiiug  tbo  track  of  the  tube ;  the  iios^iblo  trritatloa  cwitBJ  hf  lis 
preseore,  iuvolvitig  th»  danger  of  inu^titial  nl»9truftt<m  from  the  imMMH 
of  lymph  nrouml  its  extremity;  thr  ton-lcncy  to  subse^neai  WMfcaaiofaf 
the  cicatrix  at  the  seat  of  lt«  initrrtion  ;  and,  finally,  the  incnnvcniMieft  la 
the  patient  csnaetl  hy  the  frequent  dre»in^  neceadtattd  by  lis 
which  in  some  •legrec  prevent  that  ahftoliilc  quiet  m  beocAcial 
convalraconce  after  ovariotomy.  In  view  of  inpar  objeetintM,  It  ts 
that  the  anlitepttc  nystem,  by  the  protertion  which  it  afRirds  Sgat 
now  enables  the  .Surgeon  to  difl)»en»e  with  drunage  to  the  grwu 
iostuioes  where  its  niw  would  formerly  have  be«a  justly  dwmail 


OVABIOTOHT — FRKPARATION    OF    THE    PATIENT.      1149 

The  third,  fiDd  perhaps  the  moet  important,  factor  id  the  increased  success 
of  ovariotomy,  has  been  the  general  adoption  of  the  intraperituueal  method 
in  the  treatment  of  the  pedicle,  as  opposed  to  the  extraperitoneal  method, 
by  means  of  the  clamp,  which  was  formerly  used  to  a  very  large  extent. 
l!ne  disadvantages  of  the  clamp  are  now  so  self-evident,  that  it  is  difficult  to 
nnderBt&Dd  how  it  should  so  loDg  have  held  its  ground  against  the  ligature. 
Oertaioly  the  practice  of  tying  the  pedicle  with  a  silk  thread,  cutting  the 
ends  short  off,  and  returning  the  stump,  is  the  simplest  and,  if  properly 
managed,  the  safest  plan  of  treatment ;  and  it  is  now  universally  adopted  in 
dealing  with  ovarian  tumors.  The  use  of  the  actual  cautery,  either  alone  or 
more  commonly  combined  with  that  of  the  ligature,  is  still  continued  by 
■ODie  few  operators,  but  appears  to  possees  little,  if  any,  advantage  over  the 
more  usual  method,  even  in  cases  where  the  condition  of  the  pedicle  is  moet 
fiivorablc  for  its  employment 

The  iaii,  but  by  no  means  the  least  important,  of  the  facton  mentioned  as 
hmving  of  late  years  influenced  the  mortality  after  ovariotomy,  is  the  appli- 
oatioD  of  the  antiseptic  system  to  abdominal  surgery.  Although  the  utmost 
importance  had  for  long  been  attached  by  all  operators  to  the  employment 
of  the  strictest  hygienic  measures  both  during  and  after  the  performance  of 
ovariotomy,  it  is  only  within  the  last  five  or  six  years  that  the  antiseptic 
treatment  has  been  systematically  applied  to  the  operations  of  this  nature. 

The  extent  to  which  it  is  necessary  to  carry  out  uo-called  strict  Llsterism, 
may  still,  possibly,  be  a  matter  for  discussion,  but  of  the  now  well-established 
value  of  antiseptics  in  these  operations,  as  shown  by  published  results,  no 
doubt  can  be  entertained. 

The  advocates  for  the  use  of  the  strictest  antiseptic  precautions  in  ovari- 
<rtomj,  recommend  their  employment  on  the  following  grounds,  viz. :  that, 
since  their  introduction,  the  rate  of  mortality  has  diminished ;  the  after- 
treatment  is  simplified  ;  recovery  is  more  rapid  and  complete  ;  and  drainage 
can  be  dispensed  with,  thus  obviating  the  liability  to  ventral  hernia  as  a 
result  of  the  operation. 

Those  who  object  to  the  use  of  antiseptics,  base  their  practice  on  the  fol- 
lowing statements :  that  they  are  unnecessary — the  diminution  in  the  rate 
of  mortatitv  being  due  to  circumstances  other  than  the  employment  of  anti- 
septics, such  as  increased  pergonal  experience,  the  diminution  in  the  number 
of  cases  which  have  been  tapped  before  operation,  the  general  adoption  of 
improved  methods  of  hygiene  and  cleanliness,  and  the  employment  during 
the  operation  of  special  means  for  cleansing  the  norituneal  cavity. 

The  true  estimate  of  the  relative  value  of  tlit'i^'  conflicting  statements 
may  be  safely  left  to  time;  but  meanwhile  the  fact  remains,  that  the  em- 
ployment of  antiseptics  in  abdominal  surgery  K  rapidly  gaining  ground,  as 
the  beneficial  effects  of  the  method  are  becoming  more  widely  recognized. 

In  the  days  when  the  results  of  ovariotomy  were  much  less  go<xl  than 
they  DOW  are,  the  opinion  generally  hvld  watt  in  favor  of  piist|K>uing  any 
surgical  interference  »»  long  as  the  patient  was  tnlerably  free  from  pain  and 
able  to  move  about.  Of  late  vcars,  however,  the  iucreuuing  .-uccefs  uf  the 
operation,  together  with  the  fuHer  recoguitiut)  of  the  serious  risks  entailed 
by  delay  in  such  cases,  has  led  to  the  belief  that  an  ovarian  tumor  should  be 
removed  so  soon  as  its  nature  and  cimiiections  i.<nn  l>c  clearly  ascertained,  and 
its  presence  is  beginning  in  any  wav  to  afTtfi-t  the  patient's  well-being. 

Preparation  of  the  Patient. — M^o  sjwciul  mcilicai  treatment  is  as  a  rule 
necessary,  beyond  attending  to  the  state  of  the  btiwels.  In  the  ca^,  how- 
ever, of  a  very  large  tumor  of  long  standing,  when  the  urine  is  scanty  and 
highly  concentrated,  depositing  tjuantities  of  mixed  urates,  benefit  will  be 
derived  from  the  ad  in  in  i!«t  rat  ion  of  full  doses  of  citrate  of  potash  or  iithia 


1150 


DISKASKa    OF    THK    PKHALK    OKNITAL   OBOAl 


iluring  the  forty-eight  hours  jirccoding  operatino,  combined  wUk  tb>j 
ment  of  a  hot  hath,  nhouM  the  i^kui  bo  habitually  dnr  and 
acL.     Kiually,  a  full  dose  of  castor  uil  ur  soom  equiTaleni  aperiat  ■ 
f^vtok  the  ev^DiDg  before,  to  be  fulluwed  by  an  enerua  adouDlMfend  oa 
tnnrning  of  iht?  ojicratiou,  U*  miurt:  thnmu^h  «TBcualJiiu  of  Lbe  l>i««r 


-.-,,,1 


The  room  seluctotl  for  the  operntinn  bdiI  for  huIi«-' 
f>atieiit,  must  bo  thorotighly  clean,  airy,  ftrnl  well  ■. 
tin  o|)ea  lire-plflce.     A  trustworthy  and  c<iai|wt«ni 
use  of  the  female  catheter,  and  to  the  pviiig  of  nii; 
choeeii  to  take  iiote  char^^  of  the  ca«e;  she,  as  wvli   n#  .ui 
operation,  ought  to  l>e  coniplptely  free  from  any  Uiat  of  r- 
tntuinHtion. 

All  itiHiiigei)  and  instrumeots,  previously  well  cltianaed,  muM 
iu  a  warm  2i  |>er  cenL  solution  of  i-nrbolic  acid,  sad  pUoed 

reach  of  the  operatorV  hand.     Thtrwlk  «mploy«d  for  UgaUuva,     

should  be  thoroughly  purified  by  Boaking  iu  a  D  per  ceat.  anlatfaa 
a<:id  for  aa  hour  or  tvri>  before  b^ng  used.  It  ia  an  importaot  raie,  Ar 
viuus  reasoasicarofully  to  cjuut  the  spoograaod  artery -force  [j*  iii  hi  Inn 
diately  before  commvucing  ihu  upuratiou,  bo  as  Co  prevent  toe  poaAiUiy 
any  subsc(]Ut>ut  doubt  as  tu  their  numl>er. 

Afttr  thv  bladder  baa  beeu  emptied  by  meatts  of  the  catbetrr,  tim 
in  her  nigbt-droes  aad  wearing  a  Hatmol  bed-jacket  and  wana 


utsmwy 


u 


sr» 


yit.  BSt.— t>lafnB  ikawlBt  ilit  iDaMoai  ia  Ui«  (o1t*«iat  vfm»Mmm  x  Xtm.  wA  Sn. 
«f  Bxtenml  IIIm  •«M>nl>n|  to  Ab«ni*ib/  Md  M«ar41itc  tv  C««|>«r.    L.  IIHiMliiit  SI 
ivetomj'.     O.  OrartotDinj.     S.  tlsitnxtanjr. 

placed  upon  the  operating  table  with  h«r  head  and  sbo't'i-~  --i 
ported  by  pillows.    Ann^thfsia  having  bec-n  induce*!,  thtr 
ill  a  blanket  are  secured  by  abro«dttnipbut;klwl  acr<3ai  ju-t  no 
whil«  ber  baoda  are  fastened  on  cithi^r  si-Je  of  the  table.    A  tbtn 
sheet,  large  enougb  eutirely  to  cover  the  patieut  r<         '  <    Tibou) 
Mnrda,  oi^  having  an  opening  in  the  centra  four  in.  <..  eoalad 

with  adhesive  material,  is  next  applieil  i'  -.  whieh  iIm 

prfviiiu.ilv  well  cleansed  with  aoep  and  u.       .  'Ogcd  «rer 

carbolic  fotion  before  luroing  on  the  spray.    The  duqj«Mi,  itaiwHi^ 


PKBFORUANCE   OF   OVARIOTOMY.  1151 

ri^t  side  of  the  patient,  is  faced  by  his  assistant  oo  the  oppoeite  side  nf  the 
Ubie. 

Operation. — No  defioite  rule  can  be  laid  down  as  to  the  length  of  the  inci- 
«0D,  beyond  stating  that  while  necessarily  proportionate  to  the  size  and 
nature  of  the  tumor,  it  should  in  all  cases  be  as  limited  as  possible.  A 
wnall  cut,  two  to  three  inches  long,  extending  in  the  mid-line  to  within  an 
inch  of  the  pubes,  will  suffice  for  the  removal  of  any  simple  cyst ;  and,  if 
necessary,  may  readily  be  prolonged  upwards.  All  hemorrhage  from  bleed- 
inr  points  in  the  abdominal  wait  having  been  arrested  by  the  application  of 
Wetls's  pressure- forceps,  the  peritoneum  must  be  divided,  care  being  taken  to 
open  it  fairly  ;  for,  if  adherent,  it  may  readily  be  mistaken  fur  the  cyst-wall, 
and  so  stripped  off  the  under  surface  of  the  abdominal  muscles. 

On  exposing  the  tumor,  any  soft  parietal  adhesions  in  the  immediate 
neighborhood  uf  the  incision  may  be  separated  by  the  Surgeon's  finger. 
The  growth  if  cystic,  should  then  be  tapped  with  WelU's  trocar,  care  being 
taken  to  avoid  the  escape  of  any  fluid  into  the  abdomiual  cavity  by  fixing 
the  edges  of  the  puncture  with  uie  trocar-clamiis,  which  enable  the  operator 
to  extract  the  gradually  collapsing  cyst.  Should  this  prove  impracticable 
owing  to  the  multilocular  nature  of  tlie  growth,  the  trocar  must  be  carefully 
vithdrawn  after  applying  Nclaton's  forceps,  and  the  puncture  in  the  cyst- 
wall  sufficiently  enlarged  tu  permit  of  the  Surgeon's  introducing  his  hand 
for  the  purpose  of  breaking  down  the  contents  of  the  tumor.  If  still  unable 
to  extract  it,  he  roust  prolong  his  incision  upwardu,  and  carefully  separate 
any  parietal,  omental,  or  intestinal  adhesions  which  may  be  present,  apply- 
ing  pressure-forceps  as  required  to  all  bleeding  points.  Immediately  after 
the  extraction  of  the  tumor,  a  flat  sponge  squeezed  thoroughly  dry,  should 
be  introduced  for  the  purpose  of  protecting  the  intestines  and  preventing 
their  protrusion. 

The  pedicle  is  now  examined  and  ita  connection  with  the  uterus  clearly 
defined.  As  a  rule,  it  is  most  convenient  to  tie  it  before  cutting  away  the 
tumor;  but,  if  desirable,  it  may  be  temporarily  secured  with  strong  pressure- 
forceps  during  division,  and  then  dealt  with  subsequently.  The  following  is 
an  efficient  method  of  procedure :  a  single  thread  is  first  passed  at  a  point 
just  internal  to  the  large  plexus  of  veins  in  the  outer  edge  of  the  pedicle, 
and  securely  tied  so  as  to  include  the  plexus,  together  with  the  ovarian  artery 
which  runs  along  this  border.  The  pedicle  is  next  transfixed  centrally  with 
a  double  ligature,  and  tied  in  equal  nalves,  care  being  taken  that  the  loops 
interlace  at  the  seat  of  puncture.  Pressure- forceps  art'  then  applied  to  either 
border  on  the  distal  side  uf  the  ligatures,  and  the  tumor  is  cut  away.  Fin- 
ally a  single  lt>op  of  stout  sltk  is  tied  firmly  nmnd  the  stump,  either  exactly 
in  or  tmmediatelv  behind  the  groove  formed  by  the  previous  ligatures.  All 
the  threads  should  be  cut  short,  and  the  ))edicle  he  returned,  without,  how- 
ever, removing  the  pressure-forceps,  whicii  are  left  on  in  order  to  facilitate  a 
final  examination  of  the  stump  lH.'ftjre  closing. 

The  condition  of  the  remaining  ovary  should  next  be  ascertained ;  and  if 
diseased,  it  should  1h-  removed. 

Parietal  adhesiono,  unleM>  of  long  standing,  do  not  as  a  rule  require  liga- 
ture, temporary  compreivion  by  forcfps  usually  sufficinp  for  the  arrest  of 
hemorrhage.  Should  there,  hnwover,  he  general  oozing  from  a  somewhat 
extensive  surface,  the  application  of  a  )^[Kinge  moistened  with  strong  Liq. 
Ferri  Perchloridi  will  iwrvf  rvndily  to  ci»ntrol  it.  Bands  of  jtelvic  adhe- 
■ions  must  alwavs  be  titnl  txn  near  im  [xiwihlc  to  their  scat  iir  origin,  and  cut 
abort.  Omental  and  inti'ilinal  ndlieitiom*  need  careful  managenii'iit ;  the 
former  should  be  dt-alt  with  fithcr  by  transfixion  an<l  tyin^'  off  in  Mections, 
or  else  by  separate  ligHture  of  bicetliug  vc^ft-lt> ;  the  latter,  if  extensive,  may 


1162        D1SBA&K8   OP    THB    FEMALE    08N1TAL  OHOAIHl. 


require  to  be  laoed  by  a  fine  continuuus  suture  involving  only  tkc 
cwat  of  Lbe  intestine. 

Tbe  peritonf.'al  cnvity  should  now  b«<  tLorou^lily  and  eyflemalicaDyi 
out,  carrf  being  especially  directed  to  the  uleiiuc  puucbiv.  aud  lotiwUiMJ 
lumbar  regioos.     The  pedicle  a  again  examine  to  mak«  cxrUun  tkil  i ' 
leA  Bocuro ;  tb«  tbrc«pB  holding  it  are  leuiovod,  nod  it  ia  di 
siuali  flnt  spoD^  ia  then  introduced  lor  the  purpow  of  pr 
tinea  during  the  ioenrtion  of  the  luturus,  for  which  no  b^tcr 
enipluyL-d  than  fineeilk,  jioased  at  intcrvaU  of  abuut  balf  an  iuefa.    Ta 
a  sati&faclury  cicatrix,  each  alitch  should  include  the  r<tgw  of  the 
the  rectuu  niuaolee,  in  addition,  of  counw,  to  tho  |>erlU)Deum,  vhi 
inmt  i[up4)rtaDt  layer  of  auV  in  the  wall.    Bcfun!  eloiiog.  mil  af 
fnn'e|s  ure  otrefully  counieif  lo  make  eura  that  uune  are  mMiag. 

Hhoiild  dnuiinge  be  deemed  adviKable.  a  glase  tuho  of  the  rM)nl 
it)  inlriHluci-d  u>  the  buUom  of  DnuglaB's  fiourh  fnim  the  lower  aadj 
nbiloitiiiial  ini-iiiiou.a  !!uture  thread  being  leltuntieil  at  thr  p<>ini| 

fut  as-  Ui  permit  of  suhetequcnl  cloiiure  of  the  opening.     Tbc        

rubber  sheet,  perfnratf^l  in  the  centre  ao  as  to  fit  closely  tvand  tbf 
tbe  tube,  will  jfreatly  tacililate  the  afler-manngement. 

Finally  a  dry  dresaing,  preferably  of  carbolic  gnuxe,  u  appliod  and 
in  place  by  bri>ad  straps  of  adheftive  pliuter,  over  whicii  a  ttatinel 
fastened  securely  round  the  patient's  fkbdonien  before  placiDg  b«r  in] 

AJUftreatmcnt. — On  recoverv  from  the  aniefltliel)t\  an  opiatff  •' 
once  be  admintstered,  either  in  the  form  of  a  hypotlcrmic  JDjectioii  of  i 
or  perbape  more  ciiuvenieutly  a»  the  ordinary  Li<j.  Opii,  of  wt 
drops  may  be  given  by  lbe  bowel,  and  repeated  as  re(]uir«i, 
every  six  hours,  for  the  firat  three  or  four  daya.    Should  nckiraM' 
some,  nothing  ueed  be  given  by  the  niuuih  for  (he  fint  tvealy-lbar  or 
six  huum  beyond  a  little  iee,  plain  soda-water,  or  brandy  and  water; 
wliicb  milk  and  water  may  b<3  tried,  to  be  aucoeeded,  U  retained,  by 
breud  Rtid  milk.  J 

III  the  mean  time  nutrient  injectiouA  of  b«ef-tea  with  or  witbuot  iWa^ 
tion  of  a  tableapuonful  of  |>ori  wiue,  administered  evury  three  or  Cw  hct 
will  probably  be  of  service :  the  nurae  being  directed  to  iatiDdoee  ■  tn 
tube  before  each  itijeetiou  in  «irder  to  facilil&le  the  aoape  of  flatiML    1 
urine  slioutd  be  drawn  ufT  by  the  catlieler  four  times  daily  for  ttie  (fallj 
dttvs,  or  until  the  [tatient  be  able  l*i  puaB  it  naturally.    If  all  be  doing  < 
ordinary  light  diet,  auch  as  mtlk-puuding,  fish,  or  t-hicken,  may  Im  aU« 
on  the  third  or  fourth  day.     tShould  there  be  much  hxcx  at  any  tlnkr, 
application  of  an  ice  bladder  to  the  head  will  aootbe  and  tnuwjvilii 
|wtient,  and  promote  reduction  of  the  lemperatnm.    A*  a  mlir,  u»e  T 
may  be  left  undiaturbed  until  thev  show  some  inelinalioo  to  ad,  when 
may  be  aasiated  by  an  enema.     Finally  the  stitches  ah««ild  lw> 
the  seventh  or  eignth  day,  and  the  patient  ma v  be  all  '  '  ava 

at  the  end  of  the  sct-ond  week,  wearing  n  i)uita(>le  ahd".  u 

AAer  recovery  fmm  ovariotomy,  the  cure  is  uaunlly  amjiUtK. 

Herkia  of  thf,  Ovart. — It  may  happen  that  the  Dvary»  oa  owi 
sides,  becomea  dinplaced,  and  esoapes  from  the  pelvis  thraogh  noe 
openings  which  give  passage  to  inteetinnl  hernia.    In  Oavt^mttht 
recorded  cases  (twenty-aeven  out  of  thirty-eigbt.  aocoffdlDg  to 
Vienna)  the  dispiaoemcDt  bos  been  inguinal.    Inn^rlTotifrl 
it  was  congenital ;  all  these  were  instances  of  ingninnl  aii 
the  instances  of  double  ovariaa  hernia  were  inguinal  sa 

The  CoiMMof  thcdbphtoement  in  the  adult  are  not  easUyi 


HERNIA    OF    THE    OVARY.  1153 

the  congenita)  cases  it  would  Be«m  as  if  an  abnormal  descent  of  the  ovarj 
took  place,  analogous  to  the  descent  of  the  testis  in  the  male. 

Sympiome. — Congenital  ovarian  hernia  is  nearly  always  irrettucible ;  while 
in  most  cases  of  acquired  diaplaceoient  of  the  ovary,  it  has  been  possible  to 
return  the  tumor  into  the  Abdomen.  The  swelling  is  generally  pyriform  in 
the  inguinal  region,  rounder  in  the  femoral.  There  is  no  constant  diagnostic 
aymptom  ;  but  in  several  instances  it  has  been  noticed  that  the  hernia 
became  more  tender  on  pressure,  and  larger,  during  menstruation.  At  this 
Ume,  also,  inflammation  of  the  ovary  may  take  place ;  and,  being  attended 
with  vomiting,  mar  lead  the  Kurgeon  to  imagine  tnat  the  case  is  one  of  strao- 
giilated  hernia.  The  diagnosis  here  is  not  easy ;  indeed,  according  to 
Englisch,  of  twentv  cases,  in  which  symptoni^of  strangulated  hernia  were 
present,  a  correct  diagnosis  was  made  in  seven  only.  The  difficulty  of  diag- 
nosis would  be  much  iocreaeeil  if  an  intestinal  or  omental  hernia  were  present 
with  the  ovarian.  Abscess  or  sloughing  of  the  displaced  ovary  occasionally 
occurs. 

l^reatment. — 80  long  as  the  hernia  presents  no  special  symptoms  there  ta 
little  or  no  occasion  for  interference,  beyond  the  wearing  of  a  properly  fitted 
trusB.  If  inflammation  occur,  the  case  must  be  treated  on  onlinary  princi- 
ples ;  and  if  the  ovary  suppurate,  the  abscess  should  be  opened.  When  the 
ovary  is  very  painful,  or  has  become  cystic,  extirpation  may  be  practised. 


TOL.  II. — 7.T 


APPENDIX. 

CORRf>SlVK  SUBUJUTE  AS  AN  ANTISfJTlC. 
|Pa(ies  21 1-216.— Vol.  L] 


SlNTK  the  early  part  of  tlie  present  edition  wiw  revised,  Corrosive  Subli- 
mntc  liH9  coinc  extensively  into  use  as  an  antiseptic  in  surgical  practice. 
Attention  was  first  directed  to  it  by  Koch,  who  showed  experimentally  that 
even  in  the  extreme  dilution  of  one  part  in  20,000  of  water  it  is  capable 
of  killing  the  spores  of  the  bacillus  anthracis.  the  most  resisting  of  all 
known  organisms.  The  results  of  tho«e  experinionts  cannot,  however,  be 
applieil  without  modification  to  the  prevention  nf  decomposition  in  albu- 
minous fluids,  for  corrosive  sublimate  fonn.s  with  albumen  a  compound 
known  as  "mercuric  nllmminate"  which,  although  not  inert,  possesses 
far  less  active  properties  than  the  watery  solution.  Thus  Mikulicz  found 
that  the  addition  of  o7io  part  of  corrosive  sublimate  to  2000  [mrts  of  a 
mixture  of  e<|ual  parts  of  blood  and  water  entirely  failetJ  to  retanl  putre- 
faction and  the  development  of  bacteria ;  when  a<Me<l  in  the  proportion  of 
1  in  1000  these  processes  were  retanled.  but  not  prevented,  and  It  was  not 
until  the  proportion  of  1  in  400  was  readied  that  the  decomposition  and 
the  development  of  hacteriu  were  completely  excluded.  Sir  Joseph  Lister 
hhs  further  demcmstnited  by  a  series  of  most  interesting  experiments  that 
the  mercuric  albuminate  is  precipitated  from  blootl-seruni  by  the  addi- 
tion of  cornisive  sublimate,  is  soluble  in  excess  of  serum,  and  the  solution 
thus  fonncJ  is  powerfully  nntiseptie,  while  at  the  same  time  its  irritating 
properties  are  greatly  diminished. 

Frc»m  these  observations  it  is  evident  that  although  a  weak  watery  solu- 
ti(»n  is  thoroughly  efficient  for  ck-aning  sponges  ;  di'^iidlvting  the  Surgeon's 
hands  or  the  skin  mund  an  operation  wound,  and  for  irrigation  during  the 
performance  of  nn  iipenition.  n  much  stronger  preparation  is  rwjuire<l  to 
prevent  putrefaction  in  the  albuminous  discharges  which  soak  the  dressing. 

The  strength  gciienillv  agretil  n{>on  as  the  best  for  the  watery  solution 
is  I  in  I'HUl,  or  H'J  grains  to  the  ]»int.    The  solution  may  be  conveniently 


1166 


APPENDIX. 


prepared  »»  Tillows :  take  2  \mrv,  (bv  wci'tibt)  of  cornwtva  wbljmiiia 
powder  and  add  U  to  3  parts  [by  weight)  uF  glycerine;  plaee 
warm  place  and  shake  it  occ&sionallj  till  iwtlution  i.i  complete.  One  fluid- 
drachm  of  this  added  to  four  piota  of  water  gives  a  solution  of  1  in  1000, 
Corrosive  subUmntc  in  this  strength  vanttot  be  used,  to  disinfeet  metal  in' 
strumenls,  (la  it  act^^  powerfully  upon  thcni.  This  muAt  therefore  be  dan 
fts  already  described,  in  a  solution  of  carbolic  acid. 

Sillc  for  siitureii  or  ligatures  may  be  prepared  by  soaking  it  in  1  pi*i 
ccuL  solution  of  the  sublimate  for  two  hours,  aAvr  which  it  muy  W  kepi 
in  the  1  in  1000  solution.  Catgut  may  be  prepared  by  soaking  it  fi 
twelve  hours  in  a  1  in  1000  watery  wilution,  after  which  it  uiay  Im*  kepi 
in  a  1  in  400  alcoholic  solution  to  which  one-lenth  pan  of  glycerine 
adde<l. 

The  sublimate  dressings  have  been  very  vurioiu;.  but  all  are  composed 
sunie  absiirbent  mutcrial  impregnated  with  mercuric  chloride  in  varyin 
proportions.  Spnn-glaas,  gauze,  jute,  ahsorbcnt  cotton-wnol.  peat,  saw- 
dust, moss,  ashes,  ^nd,  and  a  variety  of  other  substances  have  been  tha» 
prepared.  The  following  may  be  given  tut  it  lypiail  specimen  of  a  sohli- 
roatc  drosaing.  One  part  of  corrosive  sublimate  iit  dia^dved  in  224 
water  and  25  of  glycerine,  forming  a  Holution  of  the  strength  of  1  in  2oO, 
Jute,  gauze,  or  absorlient  wool  is  thou  sraiked  in  the  Mlution,  sifUcc-zed  f( 
oildy  in  a  presB  to  gel  rid  of  the  excess,  luid  then  allowed  to  dry  as  far 
the  glycerine  will  permit.  Bnms  haa  ueed  as  the  basis  a  material  kno 
as  '' woo<l-wool "  prepared  by  grinding  pine  wood,  and  sawduKl  may  bal 
equally  well  prepared  in  the  same  way.  These  and  other  similar  prepa- 
rations are  applied  in  bags  of  the  prepare<I  gauze. 

Sir  Jaseph  Lititer,  as  the  ruiiuU  uf  the  exfwriments  above  ijuoted^  was  1 
to  ftuggcflt  the  use  of  corrosive  sublimate  dissolved  in  hlood-eorum  obtauue 
from  shiaghter-housefi  as  the  material  for  impregnating  the  ganw,  the  mo 
curie  albuminate  possessing  comparatively  si  Ight  irritating  properties.    U 
has  found  that  gauze  impregnated  with  a  pre|mration  containing  1  of 
limate  to  100  uf  serum  is  |)erfectly  unirriiating  and  in  fact  mo^t  si 
can  bear  1  to  50  without  inconvenience. 

The  results  obtained  by  the  use  of  oorrosive  sublimate  hare  been  m 
very  satisfactory  :oi  regards  the  prevention  of  wpticwmia,  pysemia, 
erysipelas.    The  wounds  seem  to  unite  well,  primary  union  being  obtain 
in  tlie  minority  of  cases,  especially  when  the  sublimate  preparaiiuns  have 
l*on  used  us  **  lasting  dressings."     These  good  results  have  not,  however, 
been  universal.     The  ordinary  preparations  are  frequently  very  irritatin; 
and  eczema  has  been  a  common  consequence  of  their  application.     It  wi 
to  avoid  this  that  Sir  Joseph  Lister  devised  the  non-irritating  sero-subl 
male  dressing,  but  it  remains  to  be  aeen  whettier  it  will  fully  attain  th< 


APPKSDIX.  1157 

desired  object.  Salivation  and  diarrhoea  have  been  but  rarely  met  with, 
but  it  must  be  remembered  that  in  empluying  mercuric  chloride  we  are 
dealing  with  a  very  dangerous  drug.  The  maximum  metlicinnl  da-^e  is 
containeil  in  about  4J-  drachms  of  the  1  iu  1000  solution  and  it  is  evident 
therefore  that  ;:rent  caution  must  be  used  in  syringing  out  wounds  or  clean- 
ing the  jwritoneal  cavity  with  sponges  wrung  out  of  the  mercurial  solu- 
tion,— in  fact,  more  than  one  fatal  ca^e  of  mercurial  jnisoning  ha.t  already 
been  recordeil  as  resulting  from  the  use  of  sublimate  dressings. 

Another  important  [wint  suggested  by  Mikulicz  also  remains  to  be  de- 
tenuiueil  by  time,  and  that  is  what  effect  the  constant  dabbling  in  strong 
mercurial  solutions  will  have  upon  the  health  of  the  Surgeon. 

Among  the  advantages  of  the  sublimate  dressings,  I'siK.'cially  in  military 
practice,  must  be  included  the  cheapness  of  the  materials,  the  concentrated 
form  in  which  it  can  be  carried,  and  the  ease  with  which  almost  any  ab- 
sorbent substance  can  be  impregnated  with  it  without  the  employment  of 
any  special  apparatus. 

So  far  as  the  evidence  goes  at  present,  it  may  be  said  that  mercuric 
chtoritle  has  been  proved  to  be  a  most  powerful  and  efficient  antiseptic  and 
to  be  capable  of  being  safely  used  in  the  treatment  of  wounds,  but  as  with 
all  other  really  potent  antiseptics,  it  is  locally  irritating  and  generally 
poisonous  and  :l9  it  possesses  these  pro|x>rties  in  a  higher  degree  than 
most  others,  a  corres* ponding  degree  of  caution  is  necessary  in  the  prepa- 
ration of  the  solution  and  dressings  and  in  their  use. 


INDEX  TO  VOLUME  II. 


ABDOMEN,  cancer  in,  242 
dingnosfs  from  ineuritm,  242 
diieacea  of,  786 
tapping  the,  826  * 
Abdominalnorta.     See  Aorta 
operations,  shock  aflpr,  787 
eeneral  rules  in,  787 
Hemorrhage  In,  78? 
parietes,  changes  of,  in  hernia,  74 
tumors,  diagnosis  from  aneurism,  242 
viscera,  operations  on,  S26 
Abernethy's  method  of  tying  the  external 
iliac  artery,  245 
symptoms  of  tetanus,  68 
Absce«s  {abseeiio,  I  go  away),  diagnosis 

fhim  aneurism,  186 
AB8CX88,  anal,  862 
of  anlnjm,  573 
of  areola,  696 
atheromatous,  111 
in  axilla,  diagnosii   from   aneurism, 

185,222 
of  bone,  chronic,  286 

treatment  of,  287 
necrotic,  802 
of  breast,  696 
chronic,  700 

diagnosis  from  cancer,  720 
of  bursa  patellsp,  478 
dorsal  427 

follicular,  in  external  meatus,  683 
in  frontal  sinuses,  661 
in  groin,  catxes  of,  428 

diagnosis  from  anfiiriem,  136, 242 
from  hernia,  480,  786 
from  psoas  abscess,  428 
of  gums,  668 
in  Dip-disea»e,  440 

acetabular,  453 
anhritic,  461 
femoral,  402 
diagnosis  from  abscess  near  hip, 
456 
from  spinal  abscess,  429 
iliac,  diagnosis  of,  480 
ischio- rectal,  851 
of  lirer,  829 
lumbar,  428 
near  Joints,  diagnosis  from  arthritis, 

888 
near  larjni,  668 


Abscess  {eontinued). 
mammary,  696 
cases,  696 
milk,  696 
in  neck,  diagnosis  from  carotid  aneo* 

rism,  190 
ID  noee,  541 

diagnosis  from  polypus,  646 
pelvic,  aeerly  seatea,  1016 
pericecal,  aiagnoeis  of,  429 
perineal,  10T6 

forms  of,  1076 
treatment  of,  1077 
perinephritic,  diagnosis  of,  429 
popliteal,  diagnosis   fh>m    aneurism, 

257 
postpharyngeal,  648 

dysphagia  from  648 
prostatic,  1014,  1077 
psoas,  from  spinal  disease,  427 

diagnosis  from  other  abscwses  Id 

groin,  430 
diagnosis  from  aneurism,  480 
from  empyema,  429 
from  fatty  tumors,  480 
from  femoral  hernia,  480,  796 
from   serous  collections  and 
hydatid  tumors,  480 
retro- pharyngeal,  486 
SBCro-illac,  440 

diagnosis  from  spinal  abecess,  440 
of  spermatic  cord,  1104 
in  spinal  disease,  426.     See  AbscMl, 
psoas 
course  of,  426 

diagnosis  fmm  saero-iliac  abacwa, 
440 
submammary,  6Wi 
supremammary,  696 
of  testis,  1104  ' 
of  tongue,  620 
Abscesses,  scattered,  in  kidney,  878 
Absorbents.     See  Lymphatics 
Acetabular  coxatgia,  468,  464 
prognosis  of,  454 
treatment  of,  4-'')7 
Acetabulum,  exciiion  of,  464 
AcupreMure    (nitu,    a    needle;    prrmo,    I 

presv)  in  aneurism,  IRT 
Acupuncture  in  aneuritm,  171 
in  hydatids  of  the  liver,  880 


^H                                      ^^^^^^^^^^INDB^^^^^^^^^^^^^^^^^^B 

^^H              Actipunccur&  [eoatinueii). 

Allarton'i  operation  of  medUn  llthotAmy , 

^^H                        ID  hydrocele.  UOS 

944 

^^H                        is  EcJKlicu,  40 

AllbuU,  palhgiogy  of  t«luiua,  Cfi              ^M 
Anio(;bana's  clamp,  86fl                                  ^M 
AlternitltnK  caiculu*,  905 

^^H               Xdam^'fl  oiieration  for  ankrlotb  uf  hip* 

^H                         Join^  473.  474 

^^H                      tKUtment  of  dieital  contractidn,  MS 
^^H                Adama  and  Trcvea.TiguUin;  uf  caratid  and 

AlLhaiiH,  Dr.  Juliufi,  ga1vMno>put)iCtUf«  is 

aneuruiu,  1(19 

^^H                  tubcUvian,  1S& 

Alrwlar  prooewoa,  dlwasw  of.     Set  Jaw* 

^^H               Adolreann,  von,  cMts  of  taul  reaioval  of 

AhpctjLTIOH  (ampuia,  I  lop  ott)  tat  uaa- 

^^H                   ftc«|iul«,  380 

tiiiii,  147.     Sre  wUo  AoeurLun         ^| 

^^H               Adoao-Sbroma,  790 

aakvlosU,  861                                  ^^H 

^^H                      diaf^noMs  from  cnncfiroiii  groTth,  707 

cartas,  300                                      ^^H 

^^H                         Irealnii^iiL  of,  707 

JoinL^iMaM,  414                           ^^^^| 

^^H               AdeD<rid  (JlA?i>,  a  gland ;  tlSo(,  (otm)  CAOcer 

oiortaliljr  after,  41S                 ^^^| 

^^1                          of  roGtum,  840 

malignant  diBMue  of  bone,  82A         ^H 

^^H                       lutnor  uf  br«ut,  70& 

iniucular  tumort,  488            ^^^H 

^^1               AdVDoma  [&6>iv,  a  gland)  of  breoat,  TOfi 

necroiU,  80S                                ^^^| 

^^1                       of  ullvarr  glandi,  68Sl 

of  breaO,  727                                 ^^H 

^^H                       of  ikin,  4& 

mortality  tflar,  781               ^^^^| 

^^H                       of  aofl  |uilate,  M 1 

of  panlR,  1096                             V^H 
atthouMar-joiaL  In  axillary  anauf^^^l 

^^H               Ad«ac>*myxo-urcoma,  706 

^^H               Adeao-tarvunia,  70C 

284                                               ■ 

^^B                       treMtuifiut  of,  707 

la  luK-lavJan  aneurUm,  330        ^M 

^^H                Adlimiiini  in  liernial  uie,  741 

of  thigh,  fur  liiiMJi>na»<:,  471                 H 
fur  |>uplii«al  aneuri»ni,18fl,3ft7,3n  ^ 

^^H                               loanagoHionl  of,  771 

^^M                    o(  penli  toAcrutiim,  1086 

renilu  of,  46H 

^^H               Adheelve  nrteriti*.  106 

Amiuaafa  u|icration  fnrartiflcukl  aniU,BS] 

^^H                Age,  in  r«lallon  u>  anouriiiu,  123,  HO 

In  child r«o,  886,  837 

^^H                       arwrinl  dta«u«,  118 

Aowthallca  tn  oompr«i4lon  for  anauriUD, 

^H                       calculiu,  90U  • 

160 

^^H                              L>[ieratliiii  for,  077 

tn  vofU|>reMlni;  abdominal  »vrU,  IN 

^^M                              slaviitlcs,  WJ 

In  upemtioDf  on  p«Ul«,  616 

^^M                         oanoar  ul  |>r<'»*l,  717,  72S 

in  lithulrily,  969 

^^H                       chronic  vndHrlQrilu,  IIS 

in  tlriclure,  1067 

^^H                       «xciiiii>n  of  joinb,  869 

Anat  dilator,  Mn 

^^^B                          hcniiirrhniil*,  8M 

An«l's  operation  for  an«ur>sm,  148 

^^H                       liornin,  743 

Amkurwu  (dwi,  through ;  nptvw,  I  vUb| 

^^1                                  femoral,  7!i6 

in  gtnerat,  122 

^^1                          lilhotoniy,  MO 

acoidvnlf  aftwr  Ii|;atiir9  for,  146 

^^M                       UUivtrily,  077 

acupuncture  in,  171 

^^H                       luput,  87 

amputation  for,  147 

^^H                       ntonm,  301 

for  gsngrpnoKftwr  ligHlurvof,  Ifil 

^H                      pilw,  8» 

for  racurrt'oi  puhaMion,  161 

^^H                      pRMUtlic  ciitargentcnt,  1016 

for  tuppnrntion  of  lac  of,  163 

^^m                         nnkifta,  SIS 

l)j  aoai(toni<uii,  f>2 

^^H                       «pinal  ourvnLuro,  4!)t 

in  looguv,  f/lii 

^^H                          xtrictnre  of  iirethn,  1046 

diagnoainffom  ordinary  an«iiriiiii 

^^H                       totnouc,  GO 

92 

^^H                                      1116 

ftom    matignanl    rtliioain  t$ 

^^H                Agus,  din|pi(Ni»  tVom  ■uppurativB  itepltH* 

bone,  837 

^H                   lit,8S« 

from  )>uUatiag  aareaou,  83T 

^^H                Air-lampon,  Urownc's,  0S7 

treatniftot  of,  V^                                    ^ 

^^H                 Air-tuba.     St*  Ijarynx  and  TTachea 

arterio-Tonoti*,  173                               ^M 

^^H                       opvralions  on,  669.  &«  LaryogoUioijr 

of  bono,  t2&.    See  On«u- uu> uriim     H 

^^H                           and  Tmche-jUim; 

bruit  in,  182                                          H 

^^H                Aitkon,  lypliili*  a  (-anna  of  atlieroma,  118 

cauMuof,  133,  1-J4                                    ■ 

^^H                Ala  nati,  rwloraUun  uf,  50i> 

circ'umwrilwil ,  127                               ^M 

^^H                Albrficbt,    Atatisltc*    of    tuborcutosu    in 

*yn^ptiiin*  of.  182                          ^H 

^^H                      ciironic  Hrthrilin,  A5S 

cl«Mili>'nti<in  of,  134,  ISS                       ^M 

^^V               Albaminuria    in    rolaUon    U>  lillwtotDT, 

clolin,  13t>,  143                                   ■ 

^H                                       tl41 

dealli  frocD,  ti-iw  produced,  13B          ^H 

^^M                               to  lilfaotritf,  679 

dfflnition  of,  1-'3                                  ■ 

^^H               Aicholio  excaea  a  prvdiapotiac  eauM  of 

dia^o*li  of,  18j                                   ^M 

^^1                       pilei,  SAC 

^^H                 Alexander,  IlKaturo  of  v«rlabnt)  ftrtwy  h 

from  aW«u,  186                           S 

fW>nt  nuilignant  iiimwi  of  boM^fl 

^^M                  u  cur«  for  epiUptjr,  22) 

827                                               ■ 

IHDBX. 


1161 


AXXDXIBU  {eontiNueti). 

diagnoeii  of,  from  neuralgia,  186 

from  o(teo-aneurisni ,  330 

from  pultating  bronchocele,  191 

from  puUatingtumorsof  boQfl,S8l 

from  rheumatism,  186 

from  tumors,  134,  190,  881 
diffused,  127 

■ymptoma  of,  133 
diucctinfr,  117,  127 
dunilion  of,  132 
extracranial,  200 
faUe,  127 

circumscribed,  1*27 

diffused,  127 

sacculated,  127 
formation  of,  129 
fusiform,  12-1 
gBDgrene  in  diffuted  form  of,  184 

after  ligature  for,  154 

from  pressure  of,  131 
^ec^raphical  distribution  of,  128 
impeded  circulation  a  cause  of,  124 
muscular  strain  a  cause  of,  128 
number  ol,  131 
preeeure-effecis  of,  130 
pulsation  in,  132 

recurrent  pulsation  in,  147,  149,  150 
i^imcn  in,  139 
rupture  of,  138 
aacculated,  125 
■econdary,  149 
Spontaneous  cure  of,  186 
structure  of,  120 

suppuration  and  sloughing  of,  187,  152 
surgical  treatment  of,  141 
symptoms  ol,  182 
terminations  of,  I3(i 
treatment  of,  188 

by  actual  cautery,  158 

by  acupressure,  107 

by  acupuncture,  171 

bv  compression    br    instruments, 
153,  155,  15« 
dumtinn  of  treatment,  161 
i-latistics.  Iti2 

constitutional,  138 

by  digitiil  coriipn-ssion,  142,  1(>4 

by  KBmHrch'n  method,  llJa 

by  flexiiin,  lii'i 

bv    gnlvtino-puiicture,    142,    169, 
*17'.',  211 

by  injii'tixn  of  ergntin,  171,  211 
(if  jK'n'hlorideof  iri>n,  170,  210 

by  lignluTv,  142.     .V«  Ligature 

local,  140 

by  muiiipulution,  1i>7 

by  vnriiiu>  tiit-chunii-al  means,  171 
true  sacculati-d,  125 
tubulur,  124.  l;>j 
varicose,  172 
AVXDRIBM.-',  Spkcial,  17^ 

of  abdomen  and  lower  extremities,  241 
of  aorta,  abdominal.  241 

diagnosis  of,  242 

from  iliac  abscess,  430 


Aneurisms,  Special  (eontiniud). 
of  aorta,  symptoms  of,  241 

treatment  by  comprewion,  242 
of  aorta,  thoracic.     S^  Aneuriun,  in- 
trathoracic, 173 
of  arm,  forearm,  and  hand,  237 
of  axillary  artery,  221 
aniput^tiou  for,  234 
compreasion  in,  223 
diagnosis  of,  222 
inflamed,  233 
ligature  for,  228 
suppuration  of,  230 
symptoms  of,  222 
Ueatment  of,  223 
basilar  artery,  201,  202 
brachial  artery,  238 
biachio-ceplinlic  artery,  180.    Ste  An- 
eurism of  innominate  artery 
carotid  artery,  common,  188 
diagnosis  of.  189 
digital  compreasion  in,  191 
dysphagia  from,  648 
ligature  for,  149,  191 
spontaneims,  188 
symptoms  of,  189 
treatment  of,  19! 
internal,  200,201,206 
treatment  of,  201 
cerebral  artcr^-,  anterior,  201 
middle,  201.202 
poeteriur,  201 
femoral  artery,  255 
deep,  256 
superOcial,  257 
treatment  uf,  257,  258 
gluteal  artery,  254 
in  hand,  2^17 

of  iliac  artery,  comprea-ion  in,  261 
external  iliac,  244 

diucnoHis   from  absccai,  480, 
7W> 
inU.-rnal  iliac,  254 
inguinal,  244 

diagnosis  from  Hbscees,  244 
pyniptoms  of,  244 
treatment  of,  244 
of  innominate  artery,  180 
diagnosis  of,  182 
dysphagia  fmm,  182,  648 
dyspna'a  from,  182 
ligaturt'  f'lr,  of  carotid,  184 
.if  subclavian.  4R."t 
and  carotid,  184 
pain  in.  IH] 
pn.'>surc-eft'eclj'  of,  181 
prognosis  <>f,  182 
IiuNc  in,  Ii*I 
rvmptnms  of,  180 
t'rehtmenl  of.  IS.I-188 
intracraniul.  201 
causes  of.  201 
denlh  fr.ini,  201 
path..loi:y  iif,  20i 
pre>Mire-t'trfct-  of,  203 
rupture  of,  itl.'i 


t\ 


1162                                                       INDKX. 

ANEiiRiaMs,  Spkcial  {eoiitinued). 

Anktlo 

intracranial,  sympUmis  of,  208 

diag 

trentmetit  of,  206 

36 

intraorbital,  206 

of  el 

causes  of,  207 

digital  compression  in,  210 

patholopy  of,  208 

fibre 

|.rognosia  of,  207 

in  h' 

symptonts  of,  207 

treatment  of,  209 

intrathoracic,  173 

auscultatorr  Hignn  of,  173 
dysphagia  from,  I7ti 

inco 

dyspntpa  from,  l?^ 

of  jt 

gal vano- puncture  in,  179 

of  k 

ixdeina  from,  176 

osse< 

pnin  in,  174 

treal 

presiiuro-etfectR  of,  173 

Annandi 

pulsation  and  liimor  in,  177 

Annular 

rational  siirns  of,  173 

Annulus 

tracheotomy  fop,  180 

Antisept 

trcBtmont  of,  177 

oste< 

of  ophthalmic  artery,  206 

treat 

of  popliteal  artery,  257 

compression  in,  16S 

Antisept 

dingnoais  of,  185,  257 

diffused,  13IS,  265 

amputation  for,  136,  266 

double,  265 

ASTRDM 

ligature  for,  258,  268 

dent 

of  external  iliac,  265 

drop 

of  femoral,  common,  258 

superflcial,  269 

poly 

rupture  of,  267 

aupf 

secondary,  264 

symptoms  of,  267 

tumi 

treatment  of,  164,  161,  166 

Amits,  al 

piidic  arterj-,  254 

abse 

radial  arlery,  237 

artif 

sciatic  artery,  L*54 

subclavian  arlery,  210 

ampiitiition  for,  220 

compression  for,  211.  219 

diagniisis  of,  2t  i 

ligature  of  linicliio-ccphalic  artery 

for,  212 

of  siibcliivian,  216,21ft 

!<yinptoins  of,  211 

trontmont  of,  211 

tibial  arteries,  2(i8 

ulnar  iirtery,  237 

vertebnil  aricry,  201 

cane 

Aneurismiil  dtHthesis,  131 

closi 

varix,  24fl 

of  jugular  vein,  188 

Angeioleuciti?,  68 

cong 

Angular  ankylosis  of  elbow,  882 

flSfilt 

of  hip,  472 

flstu 

of  knee,  517 

imp( 

curvature  of  fpinc,  410 

mo  is 

Sayre's  ta-atment  of,  432-434 

proli 

Ankle,  excisiim  of,  35 

weak,  529 

proti 

AsKYLOsiM  (d-M/of,  crooked),  359 

spaiti 

amputation  for,  361 

SO 

complete,  350 

ulcei 

INDKZ. 


1168 


AoBTA,  abdominal,  anetirifm  of,  241  | 

diagnufU  of.  'i42,  4.10  , 

symptoms  of,  241 
treatment  uf,  24*2  I 

aibcruma  of,  113 

compres^ioD  of,  242  i 

ligature  of,  252  | 

thoracic  aneurUm  of,  173.     See  Aneu- 
rism, intrathoracic 
Aphonia  (d,  nogatire;  fM-^,  voice),  650      i 
Areola,  inHammation  and  abecesa  of,  695, ' 
69r>  I 

Aku,  anetirixro  of  vo§8els  of,  287 
ankyliwis  of,  straight,  504 
contraclion  uf,  601  I 

of  muscles  of,  504 
deformities  of,  501 

gangrene  of,  after  Ugalure  of  arteries,  j 
233  ! 

Amdt,  ligature  cf  brachio-coihalic  artery, ' 
218  I 

Arteries,  anetirism  of.     See  Aneurism 
■theromnuf,  110-114 
calcification  of,  117 

contraction  of,  1111  , 

degenerations  of,  116 

a  cau<e  of  aneurism,  117 
diseasca  of,  108,  109  , 

earthv  matters  in,  114  I 

embolism  of,  120  I 

fatty  degeneration  of,  116  I 

gangrene  from  obstruction  of,  120 
^janular  degeneration  of,  117 
inflammation  of,  108.    Ste  Arleritii 
ligature  of.     See  Ligature 

in  elephantiasis,  71 
occlusion  of,  by  disease,  119 
oasiecation  of,  111,  118 
pressure  of  aneurism  on,  131 
rupture  of,  spontaneous,  119 
thrombus  in,  11R-I21 
ulceration  of,  118 

wounds  of,  in  hcmia-i>peration8,  774 
in  lithotomy,  U3.'> 
Akteries  or  Artery,  axillury,  aneuri-'m 
of,  221.     Sfc  Aneurism 
ligature  of,  220,  T^-'t 
basilar,  aneurism  of,  201.  202 
brachial,  aneurism  of.  238 

ligature  of,  238,  3:11 
brachio-cephalic.   Ve  Artery,  innomi- 
nate 
of    bulb,    wound    of,    in     lilhotnmv, 

937 
Cftrotid,   common,    aneurism    uf,    IHH. 
See  Ani'urisui 
■  neuriiimal  varix  of,  188 
ligature  of,  for  aneurism  of  aorta, 
178 
of  i-arolid  arter.',  191 
i>finni>miiiHieHrtrry,  184 
intraorbital,  2<*ti 
on  diiial  ^idc,  l»w 
fItecLs  of,  on  brain,  194 
ipu  lungs.  r.i8 
internal,  aneurism  of,  21K),  20ti 


ABTERIEB  or  ARTEBT  (continued). 
cerebral,  anterior,  aneurism  of,  201 
middle,  201,  202 
posterior,  202 
dorsal  of  penis,  wound  of,  in  lithotomy, 

98ti 
epigastric,  relation  b)  femoral  hernia, 
794,  788 
to  inguinal  heniia,  784,  785 
femoral,  aneurism  of,  2o5.     See  Aneu- 
rism 
ligature  of,  common,  2>>8 
superficial,  259 
for  elephantiasis,  71 
accidents  after,  262 
relation  to  femoral  hernia,  794 
of  foot,  ligature  of,  271 
forearm,  aneurism  of,  287 
gluteal,  aneurism  of,  254 
hemorrhoidal,  inferior,  wound  of,  lo 

lithotomy,  936 
of  hand,  aneurism  of,  237 
iliac,  common,  ligature  of,  249 
external,  aneurism  of,  244 

ligature  of,  for  elephantiasis, 
72 
for    inguinal    aneurism, 

245 
for    popliteal    aneurism, 

2fi.') 
results  of,  248 
internal,  aneurism  of,  254 
ligature  of,  2.'>4 
innominate,   aneurism  of,   180.      See 
Aneurism 
ligature  of.  212 
intracrauial,  aneurism  of,   201.     See 

Aneurism 
lingual,  ligature  of,  f.27 
obturator,  relation  to  femoral  hernia, 

794 
ophthalmic,  aneurism  of,  20lt 
palmar,  aneurif-ni  of,  237 
perineal,  «ound^of,  in  lithotomy,  935, 

946 
peroneal,  ligature  of,  271 
plantar.     S^e  Arteries  of  f  n>t 
p(>|)liteal, aneurism  of,2o7.    See  Aneu- 
rism 
pudic,  aneurism  of,  2»4 

internal,  wound  of,  in  lithotontv, 
936 
radial,  ant-uri^m  of,  2^7 
ligature  of,  240 
sciatic,  aneunsm  of,  2fi4 
ligature  of,  2->4 
subclavian,    aneurism    of,    210.      See 
Aneurism 
eoniprefsion  of,  219 
ligature  of.  for  aneurism  of  axiU 
Ury  artery,  224 
of  inniiminaiearier}',  183 
of  siil>clavian  Hrterv.  2111, 
224,  226 
accidents  afl<T,  227 
dii-tal,  219 


llt>4 


INDEX. 


Artekies  or  Artery  (continued). 
thyroid,  ligature  of,  665 
tibial,  uncuriBm  of,  '2<j8 

anterior,  ligature  of,  270 
posterior,  ligature  of.  269 
uliiur,  anGurlsni  »f,  S3T 

ligature  of,  239 
vorlebrul,  anouri-iu  of,  201 
ligature  of,  221 
Arterio-capillary  fibrosis,  113 
Arterio-vunous  aneurism,  172 
Arteritis  (m-ieria,  an  artery  ;  itu,  deaot- 
ing  inllainniation),  10*8 
acute,  lOH 
deformans,  IIO,  114 
embolic,  109 
hyperplastic,  116 
obliterans,  115 
prolifenins,  116 
thrombosis  from,  109 
traumatic,  108 
Arthritic  coxalgiu,  449 
prognosis  of,  454 
treatment  of,  467 
Arthritis  {updpov,  a  joint;  ilia,  denoting 
inflammation),  336 
acute,  336,  692 

causes  and  varieties  of,  341 
diagnosis  of,  338 
in  infants,  344 

trcatmeni  of,  348 
infective,  341 
pathology  of,  838 
pyitniic,  341 
repair  after,  344 
rheumatic,  343 
senile,  344 

treatment  of,  348 
septic,  341 
symptoms  of,  330 
treatment  of,  345 
chronic  rheumatoid  of  hip,  356 
diagnosis  of,  367 

from  sciatica,  49 
pathological  changes  in, 
35(5 
of  lower  jaw,  357 
of  shoulder,  358 
deformans,  353,  503 
polyarticular  rheumatoid,  354 
puerperal,  341 
rheumatoid,  303,  503 
chronic,  354 
causes,  355 
symptoms  of,  35 
treatment  of,  355 
strumous,  348 

patliok'gical  changes  in,  350 
symptoms  of,  348 
treatment  of,  352 
tubercular,  348 
Arthromeningitis,  acute  cruupnus,  342 
Arthropathy  of  paraly/.ed  limbs,  368 

of  atitxic  patients,  358 
Artificial  anus.     Sire  Anus,  artificial 
Ascitic  fluid  ill  hernial  sac,  742 


Ashhurst,  cases  uf  Bbdominal  section  for 

intussusception,  818 
Aspcrma  (a  negative;  irirfp/ui.seed),  1136 
Aspirator,  use  of,  in  exploration  of  kidney, 
896 
in  hydatids  of  the  liver,  830 
in  retention  of  urine,  1074 
in  strangulated  hernia,  782 
in  tapping  chest,  688 
Astragalus,  excision  of,  409 
Atheroma    (addpa    or    adrjpjj,    porridge    of 
meal)  in  arteries,  110-114 
influence  on  aneurism,  122 
nature  and  causes  of,  112 
syphilis,  influence  of,  113 
thrombosis  from,  115 
Atheromatous  abscess,  110 

artery,  microscopic  examination  of.  111 
ulcer,  111,  115 
Atlas,  disease  of,  436 
Atony  of  bladder.    See  Bladder 

of  rectum,  861 
Atrophy  (a,  negative;  rpi^,  I  nourish)  of 
bone,  313 
of  prostate,  1026 
of  testis,  1 102 
Attitude  in  hip-joint  disease,  443 
Aubrey,  intraorbital  aneurism,  208 
Auscultatory  signs  of  aortic  aneurism,  173 
Automatic  retractor,  67G 
Aveling's  talivert,  524 
Axilla,  aneurism  in,  221 

tumors  in,  783 
Axillary  artery.     See  Artery,  axillary 
glands, implicated  in  mHmmarv  cancer, 

removal  of,  729 
lymphadenoma  of,  733 
strumous  disease  of,  733 
Axillo-mammary  cancer,  731 
Axis,  disease  of,  436 

Ayrea's  operation  for  extroversion  of  blad- 
der, 991 


BABINGTON'S  glotliscope,  654 
Bahcr,  Morrant,  connection    between 
ranula  and  Whartonian  duct, 
640 
India-rubber  trachea-tubes,  680 
necrosis  without  suppuration,  302, 

304 
statistics  of  cancer,  723 
Balanitis  (,.')a?^voc  un  acorn,  also  the  glans 
penis;     itia,     denoting     inflammation), 
1092 
Bandages,  plaster-of-Pari?,    in    disease   of 

spine,  432-434 
Banks,  operation  for  hernia,  750 

results   of    operations    for    cancer    of 
breast,  723 
Barbadoes  leg,  70 
Barker,  A.  £.,  acute  arthritis,  692 

itntis>.-ptic    osteotomy     of     metatarsal 

hone  for  bunion,  483 
diseases  of  tongue,  022,  626,  638,  639 


INDEX. 


1165 


Barker.  A.  E.  (eoulinned). 

exploration  of  kidnrv  by  Rfpiralur,  805 
hyiJCTtrnphy  of  toiifriic,  61ii 
wound  of  obturator  in  hem  in- opera- 
tioirn,  799 
Birlow.  cases  of  rickets,  Rifl 
Bkron,  intrai'rbttiil  aneurism,  208 
Bartiey,  ligature  cif  ftbnontial  obturator  in 

hemia-4>peration,  7!t9 
Barton,  operation  fur  ani^ulttr  unkvlosi-''  nf 
hip. '472 
i>f  knee,  &17 
Banrell.  liipiture  of  cHmtid  and  Eubclnvian, 
185 
treatment  of  aneurism  bv  comprcesion, 
163 
Basilar  artery.     .See  Artery,  basilar 
Baudons,  etatisticf  of  excision  of  shoulder, 

878 
Bell,  Sir  C,  ligature  of  femoral  artery  for 

popliteal  aneurism,  144 
B«ll,  John,  median  operation  of  lithotomr, 

944 
Bellingham,  regimen  in  aneurism,  140 

treatment  of  aneurism  by  compression,  i 
163 
Bellocqs  sound,  .'>44 
Benign  polypus,  &44 
Bent,  J.,  excision  of  cariotis  head  of  hu-  ^ 

merus  fordisease,  367 
Bergmann,   ligature  of  carotid  and  sub- 

cMvian,  186 
Biceps  muscle,  contraction  of,  602 
Bicker^tetb,  eicision  of  head  of  humerus 
for  G.TOstosis,  874 
ligature    of   bractaio-cepbalic   artery', 
213,216 
of  car\itid  and  subclavian,  185 
Bifurcation  of  the  hand,  605 
Bigetow's  eTacuati>r,  066 
lithotrite,  9r,i> 

operation  of  lithotrity,  05<>,  965 
Bigg's  apparatus  fur  contracted  knee,  514, 
515 
for  wry-neck,  601 
Bilateral  ftorget,  962 

lilhotumy.  943,  950 
Bilharsia    hspniatobia,   hematuria    from, 

1012 
Billroth,  nature  of  atheroma,  112 
caries,  295 

chronic  arthritis,  350 
endarteritis  proliferans,  115 
excision  of  pylorus,  828,  829 
extirpation  o\  larynx,  667 
Injection  of  iodine  in  cases  of  simple 

hypertrophy,  '^'A 
ligature  of  both  carotid*.  \Wt 
osteoplastic  periostitis,  274 
removal  of  tumor  of  bladder,  1010 
results  of   o|>erations   for   cancer  of 

hreNSt,  723 
white  Rwetling,  850 
Birkett, eases  of  fujierniimerary  breasts,  692 
age  fi)r  oocurrvnc*"  "f  cancer  of  the  i 
hrcaM,  717 


Bistourie  cachee,  106B 

Blackman,  ligature  of  both  carotids,  196 

Bladder,  atony  of,  1001 

danger  of,  in  lithotrity,  972,980 
incontinence  of  urine  from, 1005 

treatment,  of,  1006 
retention  of  urine  from,  1003 
diagnosis  of,  1008,  1021 
results  of,  1003 
symptoms  of,  1002 
treatment  of,  10O4 
cancer  of.  1011 
caUrrh  of,  996 

treatment  of,  996 
conditionsuf,  unfavorable  to  litfaotritT, 

979 
congenital  malformation  of,  990 
cysts  of,  1007 

difficulty  of  entering,  in  lateral  lithot- 
omy, 980 
in  median  lithotomy,  948 
dtlaUtion  of,  875 
dilatation  of   neck  of,  id  litbolomy, 

980 
diseases  of,  990 

induced  by  calculus,  916 

by  enlarged  prostate,  1019 
by  stricture,  1048 
pn>ducing  irritation  of,  998 
distention  of,  with  overflow,  1006' 
exploration  of,  afier  liihotrity,  963 
extroversion  of,  990 
false  membrane  in.  982 
fasciculated,  876,  982 
fistulous  openings  into.  846 
foreign  bodies  in,  calculi  formed  on, 

986 
hemorrhage  from,  1012 

into,  al^er  lithotomy,  941 
hernia  of.  743 

treatment  of.  789 
hypertrophy  of,  875 

cfiect  in  kidney-diiease,  876 
inflammation  of.  acute,  998 

treatment  of,  994 
gonorrhceal,  1036 
after  lithotomy,  941 
after  lithotrity,  974 
chronic,  994 

complicating  lithotrity,  980 
diagnosiK  from  enlarged  proa- 

Uto,  1021 
pathological  changes,  994 
symptoms  of,  996 
trf'Htmeni  of,  y!>6 
irriuble,  '.»98 

cause*  of,  99H 
in  b<.y»,  1000 

complicating  lithotrity,  978,  979 
diagnoi'is  of,  9l>9 
in  gonorrhoea,  1036 
in  gout,  908 
treatment  of,  99!* 
in  women,  1000 
irritation  of,  by  calculus,  910 
by  lithotrity,  964 


^H                      ^^^                          ^^^^^^^^^H 

^^H               Blaudkr  (e-antiauttl). 

llONK  [rvfttinntit).                                          ^^^B 

^^H^                      l>Hin(iil  coDditiuni  of,  1007 

itiiili^uaiiitltteMoof,  litmtlofuor.RS^ 

^^^^^               pArntv^it  of,  dinf;nmis  friiii)  cn!arg«d 

IreatmeBl  of,  KiT                   ^M 

^^^^H                  iiro«rut«,  lOl'l 

myeloid  lumon  of,  82!!                         ^M 

^^^^H              puncUirt  nbuve  imbes,  1024,  1078 

nocnsii  of,  278.     Set  Kvcroib            H 

^^^^H                        througli  riy.-Uini,  1026.  WVJ 

{lulMliDg  lumoK  ofj  SSK.     Set  OMBft-S 

uneuristn                                             ^M 

^^^^H              vMiouli  of,  870,  DI 4,  f^&,  too? 

^^^^^H                        coini>lic-Hltn;>  Ijtlvnti-ity,  QiV) 

ramoTttlof  nMrn>««d  pelvic,  4d4         ^M 

^^^^^^B               tcvoiidary  murbii]  ouiiOitii^nk  of,  876, 

repair  of,  nflvr  ctciiion,  870                 ^M 

^^^H                    <J1& 

after  necroeis,  304                          ^H 

^^^^^H             sounding  tlip, 

nc-irrbiit  of,  SStI                                     ^H 

^^^^^^H                       crfurt 

i>clero»i*  or  hardening  of,  813       ^^^H 

^^^^^^P              rpaimi  of,  comiilk'sLlae  lithotomy, 982 

torofuluui  diteate  of,  2H1               ^^^H 

^^^^^H              EU)n«  in,  IHJkV     .Vn-  Calculus 

ftoftening  of,  219                                ^^^H 

^^^^H              tubercle  of,  1007 

ipindlerelkd  *an-onia  of,  8SS             ^U 

^^^^H              lutnoK  of,  1008 

itructura)  cbaitce*  in,  81l!             ^^^H 

^^^^^H                     diBcriMla  fnnienlftrved  iiroslBtd 

suppu  ration  of,  278                        ^^^^| 

^^^H                          1021 

diffute.                                        ^^H 

^^^^^                wuhiDg  ibe,  Bfier  lUboirity,  96S 

iru)>biiiin);  of,  268                         ^^^^| 

^^H                      iroiind*  of,  in  Ijthatoniy,  vAh 

liiben-le  of,  283                                 ^^H 

^^H                Bland,  lltmtiire  of  bractiio  toiiliiilic  iirwrv. 

luiMon  of.  319                               ^^^^1 

^■^ 

malignant,                              ^^^H 

^^^^^^          BUia',  Sir  <>.,  irritaLion  of  br«in  lijr  anea- 

trBHlmenl  of,  827                      ^^^^^ 

^^^^B 

ulceration  of,  277 

^^^^^f               BMUalicfi  of  iGlanui,  iI2 

Bonei,  iiaMl,  lldlulous  Dpcotngv  in,  flOC         , 

^^^^^          BlHn)iHro|>lH.')ty      {i^fi^apev,     «u      6^' el  id ; 
^^^1                   TA<i9ti(j,  I  form},  &9> 

Bo.w,  |>erfori(iance  of  iraftiAubiiny,  674 

BoUiiii,  exiirpalion  of  larynit,  liiI7 

^^H                Blind  Atttibi  in  sno,  &&i 

BouffipJt  f  >mrliaure,  1052 
l>ullx>u*,  10&2 

^^^1                       pil^.  8(>7 

^^H               Bloud-L'yit,  oOO 

vatuut,  1002 

^^^1               Blood  iti  bifinniooele,  HIS 

mtforni,  I0r>2 

^^^1                 Bluwk,  Hiii^iirliiu  PnUuMJ  by,  124 

i<>d»ririii  and  eucalyptus  for  goatu 

^^^1               Buvk,  CAWt  of  ktiock-knev,  -M 

rWa,  1032 

^^^1               Bokiki,  inomiUlion  with  microoocoi  fraui 

BowniAn,  inlrnorhilat  aneuridin,  206 

^^H                     KonurrbtKMl  pii*,  IffZS 

Boys,  circioinci»ii.ui  in,  1090 

^^K               BuKE.  ftb^evM  of,  cbronfc,  2S7 

itupBLtion  of  calculus  in  uretltra  of,  91 

^^^^^^^                        *yni|iti>JiiK  Mnd  lri-»tm«nt  of,  S87 

latvral  lilliolomv  ln,l'2!< 

^^^^^^B                anruHiiii 

difflvultiM  in,  !)80 

^^^^^^1                      ligHturo  i>f  nmin  iirwry  in,  SSI 

marlality  of,  1<89,  &40 

^^^^H 

BoEeman'xoporation  for  urinary   vagina 

^^^^^^1                cancer  of,  B29 

fliluln,  1094 

^^^^^^1               cariOM  of,  2f  1.    Ac  Curies 

BniuLial  arWry.     Stt  Artery,  brachial 

^^^^^H              cyilio  tiim^innf,  R2I 

BrHchio-oophHlic  erWtry.     .S«  Artery,  In- 

^^^^^^1                        trvntni^nt 

nominal*                                                         A 

^^^^^^1               dead,  M|>itrniioii  of,  3(M 

Bkaik,  anvuri«m«  of  v«ue]i  of,  201        ^H 

^^^^^^1              tlefonniiiO'J       tK-k«i*,  914 

i.-oni;onital  horninofmemkranasor, AM^H 

^^^^^H               diiMFc    in,  disMi«e  of   ckrtllage  do- 

elffct  of  ligature  'jf  varjlid  on,  I1>4  ^H 

^^^^^H                 pendftnt 

|>«ralysi«  froRi  com(iraulaD  or  injurj" 

^^^^^^B                d>ieM«>  of, 

of,  67 

^^^^^^1               vffKt  of  Hiieuriini  on,  131 

Bralnaid,  excition  of  liwd  of  buni9rui,87^^ 

^^^^^H              etirhund  roma  of,  820 

ojicmtion    fur  angular  ankyloelfl  i^H 

^^^^^^1              «pith(>l)oni«  of,  9^\ 

knw,  &n                                       ^1 

^^^^^^B              «roeli(o  ^P>n'lt)R  in,  329, 

Drvdot'a  operation  for  noeuritm,  143      ^M 

^^^^H              ciEro)i«tiori  of.  n08 

Bbkast,  alucM*  of.  GW                               ^M 

^^^^^^m 

clironic  diir<i«»d,  7U0                     B 

^^^^^^t                  BbroillH         420 

eocyilvd,  700                                ^1 

^^^^^^B               ^rowiti        arrntled,  !118 

■h<enr«  of,  A^<2                              ^^^M 

adfiiitid  lufoor  of,  Tdo                    ^^^^H 

^^^^^H                faypcrLn))iby 

■mpulBtion  of,  727                        ^^^H 

^^^^^H                      liitlammntory, 

morlHliiy  nfl«f.  731                       ^M 

^^^^^^M                inflnniinalion        '2''2,  278 

anoniiilies  of  davelnpnient  of,  OM^^H 

^^^^^F               Unelh  of,  inciviMod,  313 
^^^^^                  maflgnanl  dlscMC  of,  .S'JI 

of  tecrcitioo  of,  694               ^^^H 

cancvr       712                               9HI 

^^^^K 

axillnrr  ulanda  BflWt«(|  |n,  TI^^^ 

OBuaei  ofTin 

^^^^^H                             diignojif  of,  324 
^^^^H                             perTphornl,  822 

catulict  in,  722                              ^A 

INDSX. 


1167 


Bkxabt  (continued). 

cancer  of,  colloid,  716 
comprenion  in,  721 
conBtitutionsl  cachexy,  71& 
development  of,  710 
diKgnMit  of,  718 
duct-cancer,  716 
duration  of,  716 
encephaloid,  716 
in  male,  7S2 
operation  for,  722 

•election  of  caMi  for,  726 
■Utiilici  of,  728 
paiu  in,  714 

pathological  structure,  716 
retraction  of  nipple  in,  714 
return  of,  after  operation,  727 
icirrhuB,  712 

in  male,  783 
■kin  implicated  in,  718 
treatment  of,  720 
Tillout,  716 

vitcera  affected  in,  714 
cystic  sarcoma  of,  705 

diagnosis  from  cancer,  718 
tumors  of,  701 

treatment  of,  704 
diseases  of,  GV2 

in  male,  732 
fcetal  remains  in  tumors  of,  712 
hydatid  cysU  of,  703 
hydrocele  of,  703 
hypertrophy  of,  Q9Z 
innammatiun  of,  69u,  696 
chronic,  698 
treatment  of,  696 
lacteal  tumor  of,  U94 
neuralgia  of,  698 
painful  tumor  of,  707 
recurrent  flbruid  tumor  of,  710 
sanguineous  cvKts  in,  711 
sarcomata  uf,  710 
serous  cysts  of,  703 
Bu|>ernumerBry,  092 
syphilitic  disease  uf,  701 
tubercle  of,  701 
tumors  of,  707 

nun-malicnHoi.  701 
Bridle  strictures,  1047 
Broca,  structure  of  aneurisms,  ViU 

ligature  of  ^uUUvian  for  innominate 
aneurism,  IR'l 
Brodie,  Sir   11.,  t-allI^l1'  of  sucL-ess  In  lith- 
otomy, HSN 
method  of  seizing  »tone  in  lith»tritv, 

960 
treatuieiil  i>f  (.'miccr  of  hreast,  724 
of  enlnnnil  ["rin-talc,  1023 
Bronchi,  prefsurv  of  niieurlNm  on,  176 
BEOscHm'Ki.E    (,)fKi;  lof,    thi!    windpi|iei 
Ai^/.iV,  n  tumor),  iVil 
acute,  '<»v'i 
caui>(.-»  of,  6'>2 
coniiiressioii  in.  'i*'A 
cystic,  .VfS 
Ckciriuii  in,  -jO') 


BhomCBOCELZ  (eonituwd). 
fibrous,  563 
iodine  in,  664 
iron  in,  564 

ligature  of  thyroid  arteriea  in,  665 
pulsating,  603 

diagnosis  from  carotid  aneurism, 
191 
seton  in,  664 
simple  hypertrophy,  662 
■ymptomH  and  vsinetiea  of,  662 
U-eatment  of,  668 
Browne,  Buclcston,  air-tampon,  937 
Browne,  Langley,  ligature  of  carotid  and 

subclavian,  186 
Bruit  in  aneurism,  182 
Bryant,   statistics    of   excision   of   knee, 
401 
statistics  of  intestinal  obstruction,  809 
tracheotomy  in  laryngeal  disease,  668 
Bryk,  cysts  of  lower  Jaw,  688 
Buccal  operation  for  excision  of  tongue, 

686 
Buchanan's  operation  for  restoration   of 
lip,  613 
rectangular  staff,  945 
Buenger,  ligature  of  both  carotids,  197 
Bulb  of  urethra,  arteries  of,  wounded  in 
lithotomy,  935 
wound  of,  in  lateral  lithotomy,  987 
in  median  lithotomy,  947 
Bullen,  ligature  of  subclavian  arterr  for 

axillary  aneurism,  281,  232 
Burns  a  predi»|MMing  cause  of  tetanus,  61 
Bunion,  482 

treatment  of,  482 
Burow's  plastic  oiMiratiun,  697 
i  BuBSA  PATELL.C,  diseases  of,  478 
;  enlargements  of.  47'.* 

inflammation  of,  478 
sloughing  of,  479 
I  Buppiimtiim  of,  478 

disease  of  |wtella  from,  479 
tumors  of,  480 
[  Buna>,  diseases  of,  476 

enlargemcuts  of.  476,  47»-4tt2 
siluatiunf'  of,  47i> 
treatment  of,  478 
Bunal    tumors   in    ham,  diaf;nosis    from 
aneurism,  4'*2 
in  fli>or  of  moiiili,  •V4I 
Husch,  naso-orbital  tumor,  6-'>l 
Kui-h,  distal  ligaitire  of  i-arutid,  WtU 
Biifbe's  needle,  8'>7 
Hulcher'p'  chw,  :571 
Uullin.  ca><eit  of  ^Hrcoiiia  of  bone,  326 

glanilulnr  oy^U  uf  breast,  702 
Hultoij.^iiture,  1084 


tiACIlKXY,  influence  of,  on  nnourism, 
I     12:i 
I'n-cal  hernin,  74-"' 

ln-Hlii>eiit  ..r,  7M» 
('slii)'iir  li'iiii  in  ii-ianus,  (>7 
Caiinneuui,     .Vr  ii*  eaki* 


IIGG 


INDEX. 


Bladdkr  feotHinued). 

iminfiil  conditions  of,  1007 

paralysiB  of,  diagnosis  from  enlarged  i 

prostate,  10-21 
puncture  above  piibes,  1024,  1073 

tliroiigh  rectum,  1025,  1072  \ 

sacculi  of,  870,  914,  995,  1007 

complicating;  lithotrity,  080 
secondary  morbid  conditions  of,  876, ' 

915 
sounding  the,  912 
errvn  in,  915 
EpasmH  of,  complicating  lithotomy  ,932  ' 
stone  in,  90o.     See  Calculus 
tubercle  of,  1007 
tumors  of,  1008 

diagnosii  from  enlarged  prostate,  ' 
1021 
washing  the,  after  lithotrity,  963  . 

wounds  of,  in  lithotomy,  938 
Bland,  ligature  of  brnchio  cephalic  artery,  i 
212,  215  I 

Blane,  Sir  (i.,  irritation  of  brain  by  aneu- 1 
rism,  200  j 

siHtisiics  of  tetanus,  132  I 

BleptiaroiiluHty      (^Ii?.e^fjov,      an      evelid ;  I 
^?Aaou,  1  form),  697  i 

Blind  flstula  in  ano,  Soi  i 

piles,  857  i 

Blood-cyst,  5f)0  i 

Blood  ill  hii'imitocelc,  lllS  ■ 

Bliiws,  aneurism  cnuscd  by,  124 
Bock,  cu<e4  of  knock-knee,  508  | 

Bokai,  inociiliitiun  with  micrococci  from 

gonorrlio'al  juiii,  102'.(  I 

Bone,  abscess  nf,  chronic,  287 

symptoins  jiiid  treatment  of,  287 
aneurism  of,  329 

ligature  .>f  main  urtery  in,  331 
atrophy  of,  313 
cancer  of,  329 
caries  of,  204.     Sre  Caries 
cystic  iiimor*  of,  S21 

treatment  of,  Slil  I 

dend,  sepiirniion  of,  303  . 

def'Tiiiitic-  in  ricketis,  314  I 

disease    in,   disease   of    cartilage   do- 1 

jiendetit  im,  339 
diti'HSPs  of,  272 
elTccl  of  aiicuri!:iii  cm,  131 
enchiindriiiiiii  of,  'I'lO 
C|>ithL'lii>iiia  >•(,  329 
erectile  s;ritwtbs  in,  329 
cxfoliutiLiii  of,  303 

('Xl':fto^is  of.  319 

llbr..iiiu  of.  320 
growlh  of.  urrc-ted,  313 
hydatiO,-  in,  :'.2I 
hypertro|ihy  of,  312 

intlammatury,  312 
inflammation  of,  272.  278 
length  of,  increased,  312 
malignant  disfeasc  of,  321 

central,  822 

diagnosis  of,  326 

peripheral,  822 


Bonk  {roHthiued). 

malignant  disease  of, «' 
treatmeot  c^. 

myeloid  tumors  of,  8*. 

necroaiaof,  278.     Set 

pulsating  tumor*  of 
aneurism 

removal  of  necro«. 

repair  of,  after  ezc 
after  necroali. 

BcirrhuB  of,  1129 

sclerosis  or  barde 

scrofulouB  disear 

softening  of,  27! 

Bpindle-cellfld  e^ 

structural  chsi 

suppuration  of 
diffuse,  2" 

trephining  of 

tubercle  of,  t 

tumors  of,  8 
malign! 
treatm< 

ulceration 
Bones,  naaal,  f 
Boso,  performs 
Bottiui,  extir- 
Bougies  for  si 

bulboni, 

catgut, 

filiform 

iodofur 
rh(E 
Bowman, 
Boyi,  cin 

impn 

late' 


Mitdi: 


Bozem- 
flalu^ 

Bracli 

Bracl) 
not 

Bra 


.-t 


■  ■■  lielioma 
iciioD  ftanii  809 

ii 


Bi 


>,  546 
.-na,  561 
:gluid,fi67 
lOM 
:iimMi  0^1006 
^lata,  I(M 
turn,  MO 
rotnm,  HIS 
estte,  11» 

f  iHnM.  1148 

pnm  {IM.  hmA  turnsd  to  om 


INDKZ. 


1169 


Carbonate  of  lime  calculus,  904 
Carcinoma,  glandular,  in  ulerua,  1148 
Caribs  {Lat.  ruttenneu),  294 
cause*  of,  :^94 
dry,  28'2,  29C,  420 
fungalintc,  282,  295 
necrotic,  282,  296 
open,  296 
operations  fur,  298 
relative  frequency  of,  296 
situation  of,  297 
spinal,  419 

structure  of  bone  in,  296 
ivmptotns  of,  297 
sVphilitic,  276,  295 
traumatic,  282 
treatment  of,  297 
in  femoral  coialfcia,  448 
of  Irochanter,  469 
■  if  vertebrfe,  419.     See  Spine 
Carmichan,  lif^ature  of  carotid  forelepben- 
tiasia,  197 
ligature  of  femoral  artery  in  elephan- 
tiH»i!i,  71 
Carotid  artery-.     See  Artery,  carotid 
Carpue,     Intlian     rhinuplaitic    operation 

introduced  hv,  600 
Carpus.     See  \Vrist 
Carta's  compressor  for  aneurism,  157 
Carter,  nature  of  calculi    in   India  and 

England,  909 
Cartilaoeh,   det-tructioD    fmm   synovial 
direase,  439 
fn>m  diwafe  <if  bime,  339 
repair  afier,  344 
inflammation  or  ulceration  of,  343 
of  larynx,  necrosis  of,  663 
ItKxe,  in  Juints,  361 
diagnoiii),  362 
■ymptoms  uf,  362 
treatment  of,  363 
Caulli,  extirpation  of  lar\-nx,  667 
Caatration,  1129 
Catarrh,  chronic,  640 
of  ear,  536 

acute,  simple,  536 
pupilent,  536 
chronic  non-purulent,  536 
purulent,  636 
treatment  of,  637 
vesical,  lymploms  of,  WH 
treatment  of,  «9<1 
Cathiter    (mru,     down  :    iii/u,    1    send), 
effect  of  retention  and  repeated  use 
of.  1005 
Bigelow'K,  9<i7 
elbowed,  HI22 
female,  1I3H 
fur  liibotritv,  'M'>S 
Sims'i,  1083' 

use  of,   in   retention   from    enlarged 
prusUte,  1024 
from  gonorrhiea,  1037 
trom  stricture,  1052 

accidents  attending,  1064 
Catbeter-fcver,  8^7 
TOL.  11  — 74 


Catheter-life,  1004 
Catheter  &  cuiido,  1022 
Catheterism,  forcible,  1026 
Cauliflower  growth  of  rectum,  841 

of  uteme,  1144  ■ 
Caustics  (xaf'u,   fut.  ;    naitju,   I   burn)   in 
cancer  of  breast,  722 
in  lupus,  S9 
I  in  nievus,  96 

in  piles,  869 

in  stricture  of  urethra,  1058 
urethral  tumors,  10ti6 
.  Cautery,    actual,    in     hemorrhage    froa 
aneurism,  163 
in  hiemopbilia,  107 
in  lupus,  89 
in  nsevus,  96 
'  in  urethral  tumor%  1085 

galvanic,  in  urethral  luroon,  108o 
Cavernous  na^vi,  94 
Cellular  exostusii,  319 
Celsus,  resection  of  bone,  866 
Central  malignant  disease  uf  bone,  822 

necrosis,  801,  303,  807 
Cerebral  artery.     See  Artery,  cerebral 
'  Cervical  spine,  disease  of,  435 

treatment  of,  436 
'  Chancres  in  the  navel,  832 
Chancrous  induration,  diagnosis  from  epi- 
thelioma, 1095 
Charcoi  and  B<iuchard,  periarteritis,  116 
Chaaot's  disease  of  joints,  858 
Chassaignac's  drainage-tubes,  686 
6craseur,  632 

treatment  of  loose  cartilages,  863 
Cbeek -com  pressor,  609 
Cheeki>,  diseases  of,  651 
fluures  of,  612 
nipvi  of,  101 

tumoro  and  ulcers  of,  661 
Cheiloplasty  (^''>^,  a  lip;  iT>.amu,  I  form 

or  shape),  612 
Cheselden,  statistics  of  lithotomy  in  chil- 
dren, 9T7 
Chest,  inflammation  of  contents  of,  after 
ligature  of  subclavian,  229 
tapping  the,  683 
Cbeyne  Watson,  ligature  of  the  vertebral 
in  cases  of  epilepay,  221 
treatment  of  gonorrhoea,  1032 
Children,  conRenital  malformations  in. 
See  Congenital  Malformations 
colotomy  in,  835 
fetid  nasal  discharge  in,  641 
incontinence  of  urine  in,  1006 
irriuble  bladder  in,  1000 
lithotomy  and  lithotrity  in.    See  Boya, 

Lithotomy,  and  Lithotrity 
matfonnalions  of  anus  in,  834 
nervous  affection  of  larynx  in,  064 
Pott's  disease  of  spine  in,  424 
stone  in,  911 
tracheotomy  in,  680 
umbilical  hernia  in,  800 
vafiinal  discharges  in,  1042,  1141 
Chimney-sweeper's  cancer,  '099 


IXDEX. 


..-Hi-  a  ■:"  lip.  412 
i      ■SfO 


L-i.  k   sk;»«  <f  luieuriiiii, 


I  Golotoniy 
Colton  de : 
■      199 
Columna  i 
!  in  Inc 

I  Complete 
i  QBtula 

j  inguii 

COMFBKHB 

I  in  ani 
b 
b 
b 


cifoc, 


1. ,-.  1.    ■  lily.  ;i'mv,  '.'51 
,      ;^^itw.  Ml 
...      --  %-^Me  '.iiholomy  and 

■  ■,.      "t    :t.W3.  lOtMi 
-.:a^'!»  .;'.  ".a  ovariotomy, 

■  .r^cbs'plasty,  1081 
,.x  >■".  vathi'li^y  of  tola- 

si^-.  -vai  Ji*l,H;alionof,649 


^      -  .  :■.  ■:•.  liard  palate,  C!  7 
^  1    n'.^w.  tilo 
■  -..  ■<■•;» 

^.     ..   .■»  aiu>iiri!ti)i ,  123 
,   ,  -     -.    ■:.  UW 

.i) 
.  >  '.-fc.'!  ,-.-  sowit)  in  necrosed 

,     ■     .;iil»»r  roijion,  802 

^^ii»  -i',-  wa^^bini;  out  b!«d- 

..!--V,iWU 

^    ...iu-(iiq"tft,  low 


_^  ^        vrri'wtiori  i>f  larynx,  1)67 
,■».  I.CU*  k'lir*  ol'  inlruurbiial 

■.:w  ■  I    •■  "'  hs'iiiojihilia,  '.07 

i,    .>-»,Ti:v'»l'ne;  lidoc,  form) 

■   ,.    ^.......S4i 

\^  ..  ^t.A*: 

*.»    .,    »    *»!.'f  oll-itriU'li"!!,  fjl4 

'"  •  -.  .iw  kvSoii ;  Ti'in-tj,  I  fm). 


of  abi 
iit  axi 
of  bn 
on  bn 

in  brc 

in  oar 

in  car 

in  fon 

In  ilin 

in  ing 

in  ini 

in  po] 

in  rer 

in  Hilt 

in  vai 

Comiirft^Si 

Uoncrotioi 

il 

Ciindylom 

niif 

in  Inb 

Connenitn 

derm  I 

Bssun 

herni. 

d 

il 

(I 

bydn 

d 

liypoi 

luuiru 


)>bim 
,  C"ngeitt:( 

Congt^ptiv 
('I'lijiniL'ti 

C'ullSlTVUl 

C'lU.'lipal 

stn 

a  jire 


INDEX. 


1171 


CoHTRACrrtoN  of  arm,  501 

of  arteries,  from  disease,  119 

in  feiDom)  coxalgia,  4&6 

of  fingera,  603 

of  forearm,  602 

of  knee-joint,  611 

of  li]i!,  congenitu),  562 

of  tiiiitclea,  497 

spasmodic,  of  sphincter  ani,  861 

of  steriio>niastoid  muscle,  499 

of  tiies,  629 
CiKiper,  Sir  A.,  ligatureof  aorU,  262,  25S 

duniti<<n   of   life   in   sciirhus  of   tbe 
breast.  715 

dysphagia  from  dislocated  clavicle,  649 

lacteal  tumor,  694 

ligature  of  external  iliac  artery,  246 
of  subclavian  artery,  226 

results  of  operation  for  hernia,  779 

serous  cyst  of  breast,  703 
C<<o[ier,  Bransby,  lithotomy,  939 

obturator  hernia,  804 

treatment  of  irreducible  hernia,  752 
Cooper,     lif>;aturo     of      brachio- cephalic 

artery,  213,  214,  216 
Copaiba  in  gonorrhcpa,  1032 
Cord,  B|ierniBtic.     S^f  l^|>crmatic  cord 
Corley,  wound  of  obturator  in  hernia  op- 
eration, 790 
Cornil  and  Ranvier  on  acute  endarteritis, 
110 

on  duct-cancer,  716 
Corns,  46 

treatment  of,  47 
Corpus  spongiosum,  danger  of  wounding, 

in  lithotomy,  937 
Corrosive  sublimate  as  an  antiseptic,  1166 
Coulson,  dilated  artery  di>ubled  upon  itself 
simulating;  aneuntm,  190 

lithotomy  at  various  ages,  909,  940 

mortality  from  lithotomy,  940 

statiMics  of  lithoiriiy,  977 
Couptand,  cases  of  chronic  intestinal  ob- 

atructiuu,  809 
Coxalgia  {ciia,  the  hip;  ii>.;or, pain),  462. 

&«  Hip  disease 
Cracked  nipple,  695 
Cracks  in  tongue,  623 
Cranial  bonei",  necrosis  of,  810 
Cred6,  ca:>p!<  of  extirpHtion  of  spleen,  881 
Cripps,  excii^ion  of  |H>riii>n  t>f  tlie  rectum, 

843 
Crisp,  ancuriKHi  with  regard  to  sex,  123 

femoral  and  popliteal  aneurisms,  266 

mortality  in  liKHtiirt;  nf  larger  arteries 
for  aneurism,  147 

results  of  ligature  of  fenmrHl,  201 
Crufl,  reisults  <<f  fxiiNion  of  liip-j<'int,  4GH 
Croft   and    (iri'ciillflit,    niicri>iH.iipi('Hl   a[>- 

pearanc<'i«  in  chmnii'  arthritis,  3'il 
Crotse,  iiiltiii'nc**  <'f  «ixi>  of  oalcuhis  xn  re- 
sults of  lithiitiiriiy,  tM^t 
Croup,  lipasmi^ic,  Wl 
Cubeos  in  i;i>iiiirrhii'n,  10112 
Cuboid  Ihui'-,  ■■xci-ii'ii  <•{.  41.1 
Cuneiform  l>"ni-E,  (.'xcision  ■■i",  4i;j 


Curling,  hydrocele  of  hernial  sac,  741 
spermatozoa  in    encysted    hydn>cele, 
1112 
Curvature  of  spine,  angular,  419 
lateral,  489.     See  Spine 
Cussck,  puncture  of  subclavian  aneuriam, 

227 
Cutaneous  erupti>ms  in  gonorrhoea,  1041 
Cuticle  of  ear,  thickening  of,  >t3S 
Cystic  (Ki'OTic,  a  cyst  or  oladdcr)  broncho- 
cele,  6<i8 
cancer  of  breast,  718 
hygromata,  569 
sarcocete,  1126 

diagnoeia  from  hydrocele,  1127 
sarcoma,  706,  718 
of  testis,  1126 
Ctstic  Tt'HOHs  of  antrum,  674 
of  bone,  321 

of  breast,  701.     Hee  Breast 
of  cheeks,  661 
of  groin,  removal  of,  888 
of  labia,  1139 
of  lipa,  668 
of  lower  jaw.  687 
of  mouth,  640 
of  muscles,  486 
of  neck,  669 
of  ovary,  1144 
of  part>tid  gland,  666 
of  penis,  1097 
of  testis,  1126 

containing    colored    matters, 
11 '27 
of  tonf^ue,  624,  640 
of  vagina,  1141 
Cystine,  calculi  of,  !K>4 
Cystitis  (jcfarjc,  the  bladder  ;  Hit,  denoting 
intlammation),    993.      See    Bladder,   in- 
flammation of 
Cystocele  {niwrff,  the  bladder;  w/?./),  a  tu- 
mor), 743 
in  females,  1141 
Cy St o- Sarcoma  of  breast,  70o 
Cvstotomv  iMT-it,  the  bladder;   riitvu,   I 
cut),  KKK) 
supra- pubic,  1010 
Cysts  ill  bladder,  1007.    See  Bladder 
dentip-rous,  .'i7«"i 
hydatid,  ■'*» 
in  iifck,  .ViO 
in  omentum.  77:t 
in  prostHtf.  H'27 

in  thyroid  IhhIv,  diagnosis  from  aneu- 
rism, 1!(1 
C/.ennuk.  tlu-  l«rynKO!<ii[.enpplt(d  by,  666 
Czcrny,  ligature  of  the  aorta,  263 


UAVIE,  excision  of  sternal  end  of  clu vi- 
de. .IHI 
l)avio>-t,'oni'y,    treatment     of   congenital 

tJili[Mii  i-ijuino-varur',  t>26 
Ihivy,  exiiniiai  of  kiip'-joint,  WJ 

treninicni  of  ('<>iit,'i'iiiUil  talijies  e<^uino< 
varu».  ■"■24 


^M                     ^^^                      ^^^^^^^^^^^B 

^H             I>MflM«.^3q 

Dolbeau.  perinoni  lilhoiri^,  07S           ^^^| 

^^H                   tktoa  intra-cniniiil  Biicuriiii),  2<M 

l>ouble  hiirvlip.  tlOO                                     ^^^1 

^^H                   B«rToui,  638 

operalion  fur,  MM                         ^^^| 

^^H            Dkfokhitik*,  489 

Iteniiu,  T40                                        ^^^H 

^^^^^_            of  inn  ud  bund,  GOI 

ini;uiiuii,                                    ^^^^| 

^^^^H         ^  "'^  ***^  atek,  499 

l>nlnage-tubw  In  empyema.  QM           ^^^H 

^^^^m          pf  log  ana  fool,  MS 

Drill  fur  anh^Iuaetl  joint,  617                    ^^^^| 

^^^^^1           of  neck  and  limlw,  405 

I>ropey  of  aDtnim,  674                                    ^H 

^^^^^P           of  »pine.     •*!««>  Spine 

dlagn(i4ia  Ttom  tumors  of  Jaw,  &T7    ^M 

^^^^^^     l>ec«na  rati  (111  of  Briertiil  thau«,  116 

ovarian,  treatia«nt  of,  1 146                         ^M 

^^H                   K  c»u»e  of  iiD«urlim,  12^ 

Dublin  iurjfcni,  •.-ouipt^tfiou  of  ueurua     H 

^^H            U«Uhn;c,  mesial  Ruuiv  of  ufiper  ll|i,  ROlt 

introdueed  by,  IA2                                        ^| 

^^H             I>el«iiu,  intraorliifal  aiieuri^m.  'iO^ 

Duoliaunay,  caaea  of  inliiMuaceptiait,  Sift     ^M 

^^H            Delon,  tFcninient  of  menu  vnteum,  &0j) 

Duvbenne,  hollow  claw-fool.  &24                   H 

^^H            I>c(iimr>,  liifitul  li^atura  of  cunnjil.  IHU 

rheumatio  peralvsis,  AR                            ^H 

^^H             Tht  SlorgHii.  (1niiiiH){«  ill  emjiyiMTi*,  t^'> 

Duck-billed  ipeculum,  1082                            V 

^^H            I>eLi  tlt'croui  cyfts,  STS 

DucL-canL-er  of  breMt,  71(1 

^^H            Jientiiial  uimure,  6T& 

Ilufour,cnuiprea5ion  of  artery  in  plepban- 

^^H             Drntition  to  rii-kelfr,  S\& 

tiaxiii,  71                                                               ^ 

^^H            DrprttriiMl  n(K«,  opcnitton  for,  A<H 

Dul1e«,  Rtaititica  nt  lupmpulilc  lUhotioiiiy,  ^| 

^^H             D<i»>nn<^uux,  j^mnulnr  iimllintis,  1030 

964                                                                        ■ 

^^^H            Dolitvliwl  portloQH  oT  h'Mly,  rcstomtion  ot. 

Duncan,  electitt-punuiure  of  onpurimi,  109   ^M 

^^B 

Ihipuvlren.  ncoident  in   ligBtur«  of  tub-   H 

^^H            Diii|>hriigtnalic  hemui,  )itOA 

'clAviim,  227                                                 ■ 

^^^^^^     X>iATEiiutii»  i>Mfif(T(t>iimngcmenl  vrdi*t>o- 

biUlc-nil  lithi't(iniy.{>GO                            ^M 

^^^^^K               4ltlon),  unourisniiil,  181 

contnictlon  uf  flngen;,  608,  60fi               ^M 

^^^l^^f             lii>[tiiiiTliU);ir,  lOo 

entrrntonio,  777                                             ^H 

^^^^^     DIckiiuon,  (-«uiu.4  uf  mcutc  lupiinntive  na- 

ligaiurv  uf  iLKillart-  artery,  3S0               ■ 

^^H                        phritii-,  SM 

of  btAciilu-cvphallc  iirt«r7,  SIS        ^M 

^^H                      jwMuilii.tcv  nf  (elanni,  6& 

of  ranilMl,  IWI                                        ^ 

^^H            Didot,  tr^iitirienluf  wvlibed  Ui)u[p»,  507 
^^H            I)ieiiluft<y,  U|i]>in^  th4>  |v>ricaTdliiiu,  691 

uf    oilioluTinii    fur    innominate 

nnHirinni,  IKS 

^^H                   iwjiimtoi'.     Sir  A.'i<inilor 

lilhotonic  iriivlif,  Mai 

^^^^^     DilTufcil  iibfi'ud  of  l>K-»>t,  700 

Hum  malcr,  fungii«  of,  6M 

^^^^^K             Hnciiniim,  127, 

Diirbant.ligalurvofrubcliiviuiandeaivUd, 

^^^^^^B            hrdToc^lf  "T  (iiinuHtio  I'urd,  1113 

185 

^^^^^H          iiiutnUtiiil  iicphHtU,  B7d 

Dysphagia  (dt^,  badly ;  faytir,  to  cKt)  tram 

^^^^H            polvir  r^ilutttiA,  V41 

aortic  anruiisni,  171 

^^^^^             phl«t>iU>,  K4 

from  camtid  nn"?iiri»m,  048 

^^^r           Digiuil  oonipfcsoion  tii  Aiieurism,  16-1 

from  (liilunttcil  cUiTii-'lc-,  449 

^^^^^_^                  in  iisitUry  nncuriam,  T2H 

from  fuirjf:n  hoilii^*  in  eiillH.  MU 
fVom  inniminiHit  uniiinum,  lft2 

^^^^^^H                            cMrotiU  aiK-urbm, 

^^^^^V                       iiitrHi^rbitut  Kni.-urirtri,  20U 

fhMii  inlntllioractc  anvurisni,  176 

^^^f                          in  aiibclarian  aneurism,  t^II 

from  irdeina  of  the  larynx,  OGS 

^^^L           IMIalatioii  of    pri>*tut«  hi  litliotuiuy,  925, 

CftUBM  of,  04B 

^^^K 

DyspaoDN.  n'if,   bfidly  j    Tvtu,   I    ItrmtlM) 

^^^^^^P          crf  urethra  farcalculu*  In  feiiuilc,  9^7 

from  norttc  Hni'Mmm,  17& 

^^^^                   in  Urlctiire,  lOGI,  l(f57 

fVom  iiinoniinataanvurittn,  IK 

^^m           Dlplilfaeria,  mv 

from  intmthomcic  nncnrlftn,  17tt 

^^H                   diA;;uMiii  fmu)  tousfllilh,  11-12 

Dyniria  (iln,  bndly;  alpatr,  uriu«),  lOW 

^^H            IMkcI  irtfiiilniil  li»uiH,  783 

^^^^^^     IHsHrticuWioii  nt  shoulder -Join  I  for    In- 

^^^^^K               flftmetl  nxilltiry  niif^unaTii,  234 

UAK.  bloody  tnroon  of,  G»                 ^^B 
Hi    boib,  ^3                                            ^^^1 

^^^^^^V            for  BubclKvinn  Htii>uri«iii,  22U 

^^^^^     DisobBrgp,  fetid,  from  ear,  6S7 

concntlou  In,  688                          ^^^H 

^^H                          frcm  n(«c,  61! 

di»M»M  of,  «!xt«nud,  688                   ^^^H 

^^H             I>iaehHr);e*,  iitr-i-ovnj'ina],  1H1 

middlv.  534                                ^^H 

^^^           DislocalioD  ardiivicte,  dysphogiit  from,  649 

cniarrb,  686                        ^^^H 

^^^^^_             of  femur  in  htp-disMse,  44' 

ecr^Mna,  688                                           ^^^H 

^^^^^M          of  libia,  bacltwHrds,  in  contracLlDii  of 

exostoMi,  684                                  ^^^| 

^^^^^V               tence-jriint, 

fetid  diichAt;^  tVod),  687                   ^^^1 

^^^V            l>i»cctini;  HiictirJim,  117,  127 

flbroiu  hiiiiorx  of,  rtfl8                           ^^^H 

^^^L^^     Dktal  lijintiire  for  ttneurism,  I4C 

routy  concntioiu  In,  fiSV                  ^^^H 
nyp»itn^]jby  of,  oK8                           ^^^^M 
innamniiitio]!  of,  i%83                           ^^^^H 

^^^^^L                  rnrcsniidaneiin^m,  198 

^^^^^^H                    for                        iiueurijtin,  194 

^^^^^^K                 for  Bubdnviao  an«urlim.  219 

malfonnaiiona,  688                         ^^^H 

i  >■  D  E  X . 


1178 


EaB  {eoniinueil). 
]M)h-pi  in,  537 

tbickoning  of  cuticle  ot,  533 
EHr-Hclie,  o38 

£crucur  (French,  ieraseur,  to  cruah),  re- 
inuvnl  (if  [)ilc»  liy,  Pilft 
of  tongue  by,  (531,"  1132 
galvnnic,  rutiiovHl  of  penis  by,  1096 
removal  of  tongue  by,  G:i2 
Ec7.eni&  of  external  ear,  5S3 

of  nipple.  fi!«,  717 
Elbow,  ankylosis  of,  382 

excision  of,  S^l 
Electricity  in  treatment  of  wneuriani,  142, 
168 
deformities,  497 
Elephnntiasis  arabum,  70 

ligature  of  arteries  for,  71 
of  aciutum,  70,  1(W7 
EUii,  lisature  of  IkhH  (.'Hn>tid9,  196 

limit  of  pelvi«.  1""J4 
Elongation  of  uvula,  64'2 
Embolic  arteriti*.  tOU 
Embolism,  82 

of  arteries,  120 
Emprosthotonoj  i  iKrr,ciofti-,  forwiird  ;  m'lti, 

I  atrcti-h),  C3 
Enipveinu  [h;  in;  iriov,  pus),  drainage  in, 

"  im 

treatment  of,  CSo 
Enc^phalocele  {i-iu^>oi;  the  brain  ;  k//}ji, 

a  tum<>r|.  &:)2 
Enccphaloid  ihjtaoa/'ii;  the  brain;    t'lAof. 
s\m\k),  dittgniRiiA  of,  from  aneurism, 
134 
of  breast,  7ir> 
of  parotid  gland,  658 
of  rectum,  841 
of  te«tia.  1127,  1128 
of  tonsil,  1)45 
Encboxdboma  (i);  in ;  v''''^/'"<  cartilaeej, 
320 
of  jaw,  570 

upper,  67 fi 
of  muiK'le,  487 
of  testicle,  1127 
E'lcveteil  1M-,  in;  *i<rr/f.  a  bliidder  or  sac) 
absce*»  of  brca^,  700 
calculus,  012,  UU,  '.I30.  032,  080 
hernia  of  tunica  vaginalis,  783,  700 
hydrtNX-le,  1112 

diHgnoKi."  tViiui  hernia,  787 
tumon.     S^r  t'yi-Uv  tumors 
EndarteritM,  10S 
acute.  110 

cbnuiic,  110,  112,  114 
eir>ilKof,  114 
Endo- laryngeal  firci-pD.  tifi'i,  6W 
Knemata  in  hernia.  7tiO 
EBtvrectomy,  827 
Enteritis,  acute,  after  reduction  of  hernia, 

7li9 
Enterocele     (m  ri,>"i-,     iiiti-'tirn' ;     ki/^'i,    a 

tumor),  740 
Entero*epipli>ofle  (iirrii^v.  inh^iitine;    i-ri- 
i:?jiov,  the  aiul ;  i.',/',.  a  luuiori,  741,  742 


Enterotome    {irrifior,    intestine;    ri/ti-u,    I 

cutj.  Dupuytrcn's,  777 
En tero- vaginal  HhiuIb,  84<» 
Eiitero-vcaii-al  flKtula,  848 
Epididymitis  (fVi,  on  ;   Aifii/to^,  a  testicle: 

itis,  denoting  inflammation],  1101 
Epiga.«tric  pulMttion,  diagnosiit  from   ab- 

doniinat  aneurl.<ui,  242 
£pi)e|isy,    ligature  of   ihe    vertebral  as  a 
ineun^  of  curing,  221 
{  Epiphysitiii,  acute,  343 
i  Ifpiplocele    {!vi^?Mii;   the   caul;    n///^,   % 
1      tumor],  741 

Epiploitis  {irri^/jxit;  the  caul;  Hit,  denot- 
I     iiig  inflammation),  773 
I  E|ii)ipadias  (iTi,  over ;  (nrriilur,  an  eunuch), 
I     flOl,  1087 
I  Kpifltaxis  ((Ti,  on  ;  UTaCu,  I  drop),  542 

treatment  of,  .>13 
I  Epithelioma  of  antnim,  57C 
,  of  anus,  841 

of  bone,  329 
I  of  floor  of  mouth,  039 

of  gum.  570,  587 
of  liirvnx,  6tt7 
of  ]ip!>,  553 

of  naso-orbilal  r^ion.  &48 
of  nose,  .'.39,  548 
I  of  <Lt4ophagii!>,  651 

of  peniii.  1094 

diagnosis  frxm  fungoid  warta, 
1095 
of  pharynx,  647 
of  rectum,  840 
of  scn)tum,  1099 
of  tongue,  022,  023 
of  ton:iil.  045 
of  up(>cr  jaw,  570 
'  of  nlerns,  1144 

diaguiisis  of,  from  lupiu,  ,38 
from  pileii,  803 
from  rodent  ulocr,  41 
Kppner,  cases  of  elephantiasis,  72 
Ei-L'Lis  (j'ri',  on  ;  ni'/m;  the  gum),  5*19,  o8T 
malignant,  570 
simple,  50 0 

treatment  of,  500 
Kreclile  tumor*  i-f  Iwine,  329 

diagmtsis  from  malignantdii- 
easo  of  btine,  326 
of  lip.  443 
Krgotin,    siiU-utuneous    injection  of,     In 

aneurism,  171 
Kruptions.  gonnrrho-al,  1041 
Kryi'iiX'las,  diagniKiin  uf,  from    inflamma- 
tion of  lymphatio*.  09 
Krysiiielatout  arleriti*.  108 

pharyngitis,  040 
K-marcliV     bloodless     method,     puplitMl 
aneurism  (reate<l  by,  165 
o]>onition  for  cliwun"  of  ihejaws,  593 
H'sults  of  removal  of  umter  jaw,  586 
Kvans.  ligature  of  carotid  for  innominate 

aneurism.  184,  18il 
Eve,  F,  S.,  origin  of  cvjt»  of  lower  jaw, 
588 


^H                                                       ^^^^^^^^^^^^^H 

^^H           Excision   {fjrirto,  I  cutout),  of  «c«Ubu- 

EXOIAtoy  {rontinUfH).                                   ^^^^M 

^^K                      lum  Rnd  nolvic  bonce,  444 

of  i(.'it)>iilii,  iMMiHt,  370                    ^^^H 

^^^^H 

of  Ahould«r-joint,  878                       ^^^^| 

^^^^H 

for  diot^M,  ATX                          ^^^^1 

^^^^^H           of  wRtrn^lii".  4(t& 

injury,                                  ^^^H 

^^^H                  result,  410 

operation,  S74                               ^^^^| 

^^^^^H          of  branobocDLe,  585 

r«niU,                                         ^^^B 

^^^^^H           for  caric*,  209 

of  tanal  1».-nM.  4<K,  418                  ^^H 

^^^^B 

hUuiry.  4(H                                   ^^H 

^^^^H 

indK'Miion*,  405                         ^^^^| 

^^^^^^H            cubiijii          113 

tibia.  4(IS                                      ^^H 

^^^^^^H             of  cuD'^il'ortn  koiiPA,  4K1 

t(>M,                                                          ^^H 

^^^^H                ulWw, 

of  lon^U'U,  6Sn                                  ^^^B 

^^^^1 

uccidctiti  arter  A|)Pmtla4i,  697        ^H 

^^^^H                    indicnlion*  Tor,  382 

nftfr-ln-ndneiit.  tt.*l7                             H 

^^^^^H                 (^peroilou, 

bv  buc'viil  opvrplton,  fi3'j                    ^B 

^^^^^H 

compnri.'Win  ••>'  m^thi>d&  itf  oponiW  ^B 

^^^^^H 

ing,  638                                              ■ 

^^^H           of  (Ibuln,  40» 

b;  divitioti  of  lower  J««,  ft!}0        ^B 

^^^^^B 

•ntir*.  C,H\                                      ^^^M 

^^^^^B                            l)-<nia>or,  -103 

bv  gitlvanic  {vnueur,  ilS2         ^^^H 

^^^^^H            of            IvDiie*  iif,  :iTi 

ni»i\u,  ffVtt                                ^^H 

^^^^H            of  hi|>-j»int. 

«|H>i-ch  ullrr,  «:»                                      ^B 

^^^^^B 

l>r  ^ubnirtiuil  ojicmiiun,  G34     ^^^B 

^^^^^H                    KAtiiliif, 

nf  brtMih,  G44                                   ^^H 

^^^^^^H             of  intriliiii!.  p>jrCi<>n*  of,  K:j7 

of  ulflK,  Hfil                                          ^^H 

^^^^H 

of  uppvr  JBW,  cumplctc,  5St            ^^^H 

^^^^^^B                  «rinditl»ni  I'f  hkcpm,  ZHH 

pnrtiul,  />K0                                    ^^^B 

^^^^^^^r 

moitts,  5tSa                                    ^^^^H 

^^^^^^^^B                                   ftrr,  SQ8 

of  nreUirvl  tumor*,  1083                 ^^^H 

^^^^^^^^^L           InatnifliOEitj) 

of  nrUl, 388                                     ^^H 

^^^^^^^^^B              0]>Cl'Htioil 

LlRbir'a  opcmlion,  889            ^^^| 
ruault,  382                                  ^^H 

^^^^^^^^V           repKir 

^^^^^^V                  •cicondnry,  878 

SicurvBtion  of  cpioa,  treatnient  of,  494 

^^^^H 

Kxfidintion  (ez,  out;  /oliuim,  n  loaf)  of 

^^^^H                 otMrnUon, 

bone,  808 

^^^^H                  ntiitl 

ExomphBliis  (i;,  out  of;    ififmStif,   tba 

^^^^^^m                  tclpctinn  of  cttt»,'40O 

iiiivc!),800 

^^^^^H                                     TrST 

EsophttiAlmicgoitro,  M7 

^^^^^^1              of  lowor  j«w,  iiSS 

ExontOxifl  (ii,  from  ;  iarfw,  U  bou«),  SID 

^^^^^^1                   fornin-rwiv,  571 

ivorv.  :llf> 

^^^^^H 

ipon'py,  819 

^^^^^H           for  niAligiinnt  dlMftw  of  bone,  828 

•>'inpti<nH  of  820 

^^^^^^H 

trcatmrnl  of,  ViO 

^^^^^^1           of  mcUicarpHl  boiit«,  3D3 

Bxt«nsii»   KDd   Mipinnioff,  mnlysii   of. 

^^^^^^1            af  mr-tJit«r»Hl  b<>n4>«,  414 

»08 

^^^^^^1            of  uipruti. 

£xtaTn»l  inpT'iinnl  koruik.  788 

^^^^^H            for  nccrneji,  309 

jiilos.  Sft7.  t^iO 

^^^^^^1                    r>l«vmnnTi,  <1K8 

uivttin'Uiniy,  lOM 

^^^^^^1           of  oruvntuiii  in  hvmiii,  773 

Estirpntioa  of  mflninvd  Ijmpbitio  kIrdJi, 

^^^^^H                OS  eilris, 

7fl                                                                1 

^^^^^^P                    op^alimi,  407 

of  ktdn«y,  mi                                                   fl 

^^^^H                  rctuU,  400 

of  Jurrni.  6«7                                    ^^M 

^^^^^^1                  ■iihp«riri«t^nl,  opemtion,  408 
^^^^^^1            for  Q«tfim-anoiirT*m,  ^31 

of  splrcn,                                          ^^^H 

of  ntcniJi,  1 144                                     ^^^^| 

^^^^^^H           of  jNirutid  uiiind,  559 

Extravrniiiiil  nti'.'uni<tii,  200                      ^^^H 

^^^^^H           of  pile*, 

Extnipclvic  'iKi\u)1iuc  iib>i-<««,  440               ^H 

^^^^H 

Kxtravii*ailiuii  of  iiruiis,  107*                             ^^ 

^^^^^B 

Sxtrovonioii  (gxtrorttim,  ouLwurdJ :  winio. 

^^^^^H            of  ivolum,  partiiit,  848 

1  tum^  of  bladder,  flW) 
Btx,  oHfct  of  tntinorbitiil  ■nriiri*m  oo, 

^^^^^^H            of  MiTVoinatn  of  brpiiKl,  711 

^^^^^H          of  (caphoid  bonr,  41S 

207                                                               1 

^^^^^^1                  KapitU, 

^n<in'bo>til  inflMmmation  of,  108V         ^H 

^^^^H 

Brclid*,  nrnvi  nf,  KM                                          ^B 

^^^^^H                opention. 

plastic  toTptry  of.  507                      ^^^^B 

INDSX. 


U75 


FACE,  deformities  of,  499 
DB>vi  of,  100 
parmlysif)  of,  from   intrmcmnial  aneu<  | 

riMii,  204 
plaitiu  Mii^ery  of,  604 
Fftceuof  cMlculi,  907  I 

Facial  neuraluia,  54  { 

Fse«t,  exci«iun  of  portion  of  the  rectum, 

84S 
Fmg^,  cases  of  intefitinal  obstruction,  806  ; 
FalksuD,  cVBt^  of  lower  jaw,  0H8  ' 

False  aneurism,  127 

membranes  covering  calculi,  032 
pasaa^e«,  1006 
Fucia,  planur,  cimtraction  of,  627 
propria  of  femoral  hernia,  703 

of  inguinal  liernia,  7H8 
recto- vesica  I,  importance  of  lithotomy, 
924 
Fkfciculation  of  bladder,  »~(>,  932  , 

Fatty  degeneration  of  arterien,  116 
Fattt  TDMORit,  in  crural  canal,  diagnosis, 
from  femoral  hernia,  706 
ingrotn,diagnosiBfromab$cess,429  i 
in  mouth,  ilol 

in  neck,  'iW,  -VJO  \ 

on  s|M.Tintttic  cord,  diagnosis  from  i 

hernia,  787 
on  tongue,  641  ; 

Fayrer,  pathology  of  oeteo-mvelitis,  289     | 
Feam,  ligature  of  carotid  and  subclavian, ' 

186 
Fecal  fli^tula,  77'>,  77r>  1 

impaction,  800,  815 
Feces  in  transvttr»e  C'llon,  diagnosis  from  , 

aneurism,  242 
Female  caihetor,  1138  ' 

FlHALKs,  calculus  in,  086 

diseases  of  genital  organs  of,  1137 

Eonorrho'u  in,  1041 
emia  in,  74:i 

congenital,  703 
femoral.  7!H) 
intiuiiml,  78o 
irritability  of  bladder  in,  UXHI 
lithotomy  in,  088 
lilhoirity  in,  989 
stricture  of  urethra  in,  lOSl 
Femoral  artery.     Srn  Artery,  fc-moral 
coxalgia,  447,  4'il 
carie-  in,  448 
pwgniifis  of,  4.'i4 
treatment  of,  4M) 
hernia,  ~'M.     See  Ui-rnia 
ligauK'Ot,  707 
Fiutra,  di-lixalion  of,  in  hi)>-di sense,  447 
division   of   neck    of,   lor    ankvbwi^, 

473 
excision  iif  head  of,  4<>1 
methiHl  i>f,  4f>'i 
rmults  of,  4t'A 
F«rgus*on,  Sir   W.,  excision  of   bead    of 
femur,  :t67 

f;ng  for  o[M'ration»  "n  tongue,  ti29 
igitturc   uf   i-tiriitid    for    innominate 
aneurism,  1K4 


PergUKSon,  Sir  W.  {eontinutd). 

manipulation  in  aneurism,  167 
in  subclavian  aneurism,  21 1 

mannerof  holding  knife  in  lithotomy, 
922 

operation  for  double  harelip,  610 

partial  excision  of  upper  jaw    680 

Btapbyloraphy,  61o 

treatment  of  projecting  intennaiillary 
bone,  610 

uranoplasty,  618 
Fever,  urethral  or  urtemic,  886 
Fibrin,  degiositof,  in  aneurism,  129 

in  arteries,  100 
Fibro-angioma,  547 
Fibro-cystic  tumor  of  muscle,  487 
Fibroid  tumors  in  prostate  impeding  lith- 
otomy, 983 

in  uterus,  1142 
Fibroma  of  ttntrum,  578 

of  lower  jaw,  588 

of  mamma,  705 

of  parotid  gland,  557 

of  skin,  4-^ 

of  upper  jaw,  576 

molhiscum,  530 
Fibro-myomata  of  uterus,  1142 
Fibrous  ankylosis,  859 

of  hip-joint,  472 
Fibrous  stricture  of  cesophaicus,  660 
treatment  of,  G61 
of  rectum,  838 
Fibrous  tumor  of  axilla,  7S3 
of  ear,  583 
of  lower  jaw,  569 
of  penis,  1094,  1097 
of  tongue,  624 
Fibula,  excision  of,  403 
Filiform  bougie,  1052 
Filkin,  exoi»ion  of  knee-joint,  36? 
FlNOERS,  congenital  deformities  of,  606 

contractions  of,  503 
trentmeTit  of,  o04 

exci>ion  of,  :{93 

supernunterarv,  505 

webbed,  .VW 
Fischer,  Rtat  sliisofflexion  in  aneurism,  167 

caise.o  of  gluteal  and  scintic  anenrism, 
254 
FiBstTRE  of  anus,  849 

of  cheeks,  612 

of  lip,  5.'>2,  tMU.     Stf  Uarclip 

uf  nin'e,  539 

uf  palaie,  614,  617 

of  toniiue,  023 
FiBTULA  [Lat.  a  |>i))e^  in  ano,  85A 

complete,  853 

incomplete  or  blind,  8-'r4 

n|wration  for,  854 

treatment  of,  8,'>4 

entero-vaifinal,  846 

en tenw vesical.  M48 

ffcal,  775.  77(1 

penile,  1079.  1080 

perineal,  1078 

rectal,  84<: 


^H                       ^^^»                        ^^^^^^^^^^^^ 

^^H         FurruLA  (^nfia^ed). 

Frli^tion  in  tbc  irMUnent   of  tl^formtty, 

^^H                  recto-YHgiiml,  M7 

487 

^^H                         cQinplimted     with     a    UcoraUd 

Frontal  »]nuMa>,  diHuw  vf,  r>&l 

^^H                             [X'tinAiini,  S47,  S48 

Fungoid  VATU  •.>(  pcnl*.  dm^nuiU  ot  «fi- 

^^H                   racb>-v«Kioiil,  840 

Uifliomn  from,  H)1W> 

^^H                 mIIvu-v,  ool 

Fungu»  |J^a(.  r  uiu*lmoai]of  dursmatOT, 

^^H                   AL-rolal^  1079 

5.10 

^^H                   iiailitlirst,  8S:i 

of  skull.  Ml 

^^H                   un.tlirt>-va!;iuiil.  U>9I 

Furner.  Knouriim  of  botb  RXiIlRry  Rruriei, 

^H                    iiriRftry,  m-^,  £077,  l(»81 

221,  232 

^^H                    v«feiro-viii;inHl.  1061 

Fusif'>fm  (/Kw«,R(p[ndl«;  /orma,ahmpK) 

^^H          Fistulip  in  cnrios,  Sd7 

aneuriun,  I2i 

^^H                   of  nutiil  )>i<nM,  008 

^^H                  of  neck,  $59 

^H          FUl-foot,  51'ri 

riAG,  Smitli'i.  0)6 

U     (tnUcVHclc.  »194.  702 

^^H          Fl«»h]r  pil«»,  8<i0 

^^B                 |H>lypii«,  544,  647 

4>iiUct»r'*liii>>  i/oXa,  g*n.  >^><wn>rT  milk; 

^^H          FlBurr,  UcMtiDt'rit  of  •neuriam  by  flexion, 

^t>.  I  flowi,  SM 

^^1 

GslUblftddT.  di»c»««t  of  the,  t»3l 

^^H          FlexiuD  in  Rneurhm,  ino 

tiulranic  vHiit«ry,  in  nKvu»,  9tl 

^^H                 In  pwpliMal  ancuriaot,  258 

rt^nioTivl  of  urctbml  tuinon   by. 

^^^B          FIdid  hccui&uIaUoii  in  mntrum,  diatcnoali 

1086 

^H 

OalTaiiic  (cnueur,  mnoval  of  p«nU  by, 

^^H          FiEtul    rotnHins,    M-currARM   of,    in    tlic 

1090 

^^^B               breiut,  71'^ 

removnl  of  tnnguA  by,  *132 

^^H          Fotticulnr  liy|ifi-iru(ttiT,  S40 

Itulvano-punvturv  in  «m.'itri*iii,  108 

^^H           Forilanelic,  nu-vj^  uf,  100 

in  aortic  anMiriam,  17'.< 

^^^1           Foot,  conge  nil  til  h_v[i<^rtro[ihy  of,  <>29 

in  intrai'rbital  uti'-uriim,  210               ^k 

^^H                 conHrvsliv«  Eun;(ir,V"f,  404 

it]  inlralhonicic  iiiKviri«m,  170           ^^^^| 

^^^1                   deforniilJMiif,  fi08 

in  subclaviitn  anGuriini,  211              ^^^^| 

^^^1                   «xci«jnn  of  Iiohm  of,  i(U 

^^^^1 

^^H                 ganRliotiic  luuiurs  uf,  4^5 
^^^B                 perroraling  ulcer  of,  47 

QmofcHon  (;<7}7>j(n-,  ■  knot),  -488              ^^^H 

foot,  485                                              ^^^1 

^^^H                 •jrnovUI  raembranei  uf,  40Q 

In  hard,  484                                        ^^H 

^^H          FoitCEpa,  bone,  S07 

Qakorrkx  {}ayjfiiu>-n,  from  /i*^.  I  n^^^H 

^^m                 Konga,  29B,  DOS 
^^1                 tlthotomy,  917,  018 

tode),  from  nilcrial  •>lntn>L'lion,  121       ^M 

of  arm  after  ligaUiro  of  Brivri«w,  £tK        H 

^^m                        niKnl|>ulaUun  of,  'J2A,  94R 

of  Intealtne  in  hi-rnia,  7&5,  770                ^M 

^^^k                   Kisaon,  642 

inanajtouienL  uf,  770                    ^^^H 

^^H                 urethral,  970 

after  lij^aturc.  IA3                               ^^^H 

^^^^^^  Forcible  cnlbolerUm,  10S6 

of  External  iliac,  1&4,  248          ^^^H 

^^^^^K                 «xpftntion  ur  rupture  of  ttricture 
^^^V                     by,  tOM 

of  feiijural  aru-ry,  2M2,  368               ^M 

of  iubcUvian  artery,  288                  ^M 

^^^^^    FoRR&RU,  Biiouri«bis  In,  237 

lr«atment  of,  164                                ^| 

^^H                  vottlriicliuo  uf  iniiic-l(B  uf,  002 

of  penit,  1093                                                 ^H 

^^H                 deforcuiUM  of,  AOI 

from  prewttre  of  anenriatn,  181               ^H 

^^H                •xelilon  uf  bonra  of,  S66 

Qirrod,  rheumatoid  arihrilit,  858,  856          ^M 

^^B                 ItgsUir*  of  KrteriM  of,  238 

Ouiro-«iitertaU>iny,  829                                   ^M 

^^^1                  parnljrtU  of  nuitcle^  of,  WH 

Oatiroaiomy    yaffnu,  tli«  HomRcb;  irHm*     H 
a  mouth),  0G2                                         ^| 

^^^^^   FoREmMHODieititi  bliuliier,ci(l(-u)i  fiirmod 

^^^^■l 

■Utittlct  of,  054                                          H 

^^^^^f                 In  (T^iHei,  dysphftt;l&  from,  64^1 

Gafitrotomy  (yaarip,  ihe  itoiiiReb;   rifmv     ^M 

^^^^^^^                     III  heniml  hkc,  742 

Icut),  ftlf>,S20                                              ■ 

^^^y          FoulU,  cxlir)«tion  of  lurynx,  008 

Gay,  InviaioD  in  lupjturatliii;  Jolnta.  847        ^H 
Oelatinoui  [lolyput,  M4                                    ^| 

^^H                  mnlictinnt  tumor  of  lon^ll,  S10 

^^H            Fok,   Wilftuii,  luliercular  NrthrittK  of  faip 

Geuilrin,  inlraurbilal  ancurhm,  208                ^M 

^^H                in  childri?n,  4i>2 

OenltsI  organi,  female,  di»Mi*««  of.  1187         ^M 

^^m           Fmc-ture  >•{  cklcului,  907 

Oenlto-urinury  or^ane,  diHitiMis  ot,  8i&          ^M 

^^H                             difficullT  in  llUxrlOiny  from,  llSfi 

OenBoiil,  excision  of  upper  jaw,  Ml               ^M 

^^^1            FrarUire  of  ueck  nf  femur,  diKgnotii  from 

Genu  valjjum  (L'lt.  bowed  kn«e|,  .'iOS             ^M 
Q«ographi<'Al  diitribniinn  of  aneuriini,  128     B 

^^B               rheumatic  nrthntls,  Hb7 

^^H           FrAgililM    oMiuoi    {Lai.    brittlsnaM    of 

ofcaU-uluK.tKK)                                       ■ 

^H               bonMj,  917 

^^1          FriBUu'i  nual  cpeciilum,  TM 

Glonpl,  <;urD  of  intraorbiul  Ractirlain  by     ^M 

d  f;ltal  compr^^ion,  'J09                               ^H 

^^H            FntHr,  Dr.,  cAlvBoii'itiiiiclnre    in    ttneu* 

Gland,  mHoiniarv.     Set  Bi«aBt                          ^H 

^H            HMD,  109 

|>aroUd.     Sfe  l*nr>tid                                    ^H 

INDXX. 


1177 


Gland,  tbyroid.     See  Thyroid  Gland 
GUDds,  effect  of  pressure  of  aneurigm  on 
ISl 
lymphatic.     See  Lvmphfttic  Glaodi 
tumiirt  of,  diafjnoflia  from   aneuriem, 
135,  190 
Glandular  growths  in  neck,  oiK) 
carcintioia  of  uteriif,  1143 
cysr«  in  breast,  TOtl 
prolifemuA  cvBta,  TOti 
Glans  penie.     Nee  Peni* 

calculi    between,    and    prepuce, 

1088 
chitncrDiiB  iiidiiration  of,  1096 
herpeR  of,  10»*i 
Glazed  red  tungiie,  *!"il 
Gleet,  1030 

treatment  of.  1034 
Globular  pile*,  801 

Glowitis   {■}>uaaa,   the  tongue;    Uia,    de- 
noting iitflammHtion],  621 
chronic  fuperflcial,  621 
cases  of,  ti23 
treatment  of,  G'2'2 
Olottiicope   ()?*(rrif,  the  gluttiH  ;    UKOTrfu, 

I  view),  ti54 
Gluteal  artery,  aneiiri!>ui  of,  2-S4 

injection   of  jierchloride  of  iron 
in,  170 
Gmelin,  degenerative  change!!  in  arteries, 

114 
Godlee,  case  of  obturator  hernia.  804 
excision  of  parotid  gland,  5S9 
operation  fur  hvdatids  of  the   liver, 

83t 
treatment  for  musciilar  tic,  S7 
tubercle-bavillus  in  ulcer  of  toneue, 
623  ^ 

Goitre.     See  Brnnchocele 

exophthalmic,  ACT 
GonococcuH  the  probable  virus  of  gonor- 
rhoea, 1020 

GOHOBBIUKA    (V^I'r>t,  ECmcn  ;    /Vu,    I    flow), 

1028 
cause  of,  102H 
character  <»f,  1029 
chonleG  in,  1030,  103o 
complicatii>n«  of,  lO^u 
cystiLtB  in,  103r> 
in  fematet,  1041 

treatment  of,  1042 
hemorrhage  from  urr-ihra  in,  1037 
incubative  ■tat;*',  1029 
inflammation  of  tyinphatioi  in,  1035 
injections  in,  11)33' 
irriUble  bladder  in,  1036 
protUtilis  in,  1036 
pyelitis  and  nephritis,  rare  oomplica- 

'tionsof,  1036 
of  rectum,  1040 
retention  of  urine  in,  lt)37 
sequenri-M  of.  JOSW 
iUges  of,  1029 
(yniptom*  of,  1029 
treatment  of,  1*>31 
urethral  abtces*  in,  KK17 


GoKORRBtEAL  Conjunctivitis,  1089 
treatment  of,  1039 
cutaneous  eruptionx,  1041 
epididymitis,  1038 
induration  of  penis,  1038 
inflammation  of  eves,  1039 

of  n.«e,  1040' 
pya'min,  1041 
rheumatism,  1040 
Bcleroliti!-,  104(P 
stricture,  1038 
warts,  1038 
Ooodharl,    causes    of    acute    suppurative 

nephritis,  884 
Gore,  lii^Hture  of  brarh in-cephalic  artery, 

212 
Gorjiet,  bilateral,  9:>2 
I         Smith's,  928 
Wood's,  952 
'  Gouelin,  encysted  hrdrocele,  1112 
results  of  epididvmttis,  1102 
Gouge- forceps,  298, 1(08 
Gould,  Poarce,  obliterative  arteritis,  115 

Esmarch'N   bandage  in  treatment  of 
'  aneurisms,  165 

I  Ooni,  irritable  bladder  in,  998 
Gouty  concreiioiis  in  ear,  l>33 
phlebitis,  84 
I  Gowan's  osteotome,  467 
Grufe,  ligature  of  brochio-cepbaUc  artery, 

212,  215 
Granular  dej:eneration  of  arteries,  116 

urethritis,  1031 
Gravel,  889,  899 
Greatrex,  digital  compreisinn  in  aneurism, 

164 
'■  Groin,  abscess  in,  causes  of,  427 
'  diagnosis  of.     See  Abscess 

I  dise»>es    in.   diagnosis    from    femontl 

hernia,  796 
pulsatini;  sarcoma  in,  diagnosis  from 
I  uneurism,  244 

'         tumors  in.  diagnosis  of,  833 

treatment  of,  833 
Gross,  ligature  of  subclavian  fur  axillary 
aneurism,  231 
prostatorrhcea,  1016 
'         pulsating  tumors  of  bone,  829 

removal  of  the  whole  scapula,  378 
sarcoma  of  bone,  822,  327 
'  Growths.     S^e  Tumors 
Guersant,  lithotriiy  in  children,  977 
Gucgenbuhl,  curt-  of  bronchocele,  563 
Gull,   Sir  W.,   Brterio-capillar%'    flbrosis 
118 
intracranial  aneurism,  201 
Gullet.     See  (Ksophagus  and  Phary*nx 
Gulliver,  ol>crvaiion«  on  atheroma,  112 
Gumboil,  568 

Gum-elastic  tut<e  in  lithnlomy,  927 
Gumma,  syphilitic,  in  mamma,  7Ul 
in  testis,  1125 
in  tongue,  623 
Oummataef  spine,  437 
Gums,  diseases  of,  .')'i8 
Gunshot- wounds,  tetanus  after,  61 


^^^       H78               ^^^^^^fll 

^^^^^^^^^^^1 

^^H                UuiUt/ir}- nerrp,  dlvUlon  of,  In  cancer  uf 

Ueatti,   C,    Ruupunetnrs    tn    sabclxTliB 

^^H                      tongue,  tl27 

■  ueuri<iTn,  171 

^^H                 Gutbrl«,  cjritotoniy  In  trril«bl«  bladder, 

adenotDB  iif-iolt  |>«)hI«>,  ti-ll 

^H                            1000 

unipuUiLioii  at  eb'iitldor-Joinl  for  tiiV 

clavian  arif^urJam.  1i2i                       ^h 
bellailoina  in  iyini'lintiKUi*.  €9         ^M 

^^H                        iDlrMorbiul  aneurUm,  20(t 

^^H                 Guyou'*  iiij«ciur,  1064 

^^H 

denti^iM'nuB  cy»U  In  Jawa,  &76            ^| 

^^^H 

«xciMon  uf  upiwr  jaw,  oMI                    ^M 
tongue  fur  t-uncGr,  HSS                 ^| 

^H                If^^^^^i  W.  &.tfbm«r«iiveNricrUU, 

operation    for   closure  of    tba  Itn, 

^^H                   H^MATocKLBfiilin,  blood:  itiilf,  a  Lumor), 

MM 

^H                    ins 

prolapius  of  tongue,  $20             ^M 

^H                      Mood  In,  1118 

removal  of  cjini'er  of  lip,  566              ^H 

^H                               diKRmMiU  ur,  TBf).  IIU,  11S2 

latoral  liibuioniv  in  Uuyi,  MO           ^| 

^^H                        ofncckifitiO 

UaiiORRBJtoB    (u^Hi,    b)<ui«l;    Mi'v^i.  ^| 

^^H                        orsiiannaiic  ctnl.  1114 

brenk  fonhj,  from  bladdi^r,  1012  ^M 

^^^1                                   diai^nujii*  iir.  787,  lllo 

ill  nbdutiiiiial  u|H-rAUuna,  7S7              ^H 

^^H                        i|iuiiian«<>ui  iind  trauiuacic,  U18 

in  cathcicrUiii,  10<>1                      ^^^M 

^^H                        tr«atnieni  i>f,  1114 

in  cxriunn  of  lnneu»,  tSS7          ^^^^| 
from  kidney*,  1012                      ^^^H 

^^H                 HiuDinV'iriu  (a'ifta,  blood),  fiSS 

^^H                 Hinntaturtn(iuuii,  ttlmxl;  eifiov,  urino),1011 

In  lateral  li'ihoiDmv,  1)86             ^^^^| 

^^1                               trnitmant  nl,  1013 

ntlarinl,                             ^^^H 

^^H                 IIiviiKip^iliti  [fu/m,  blood ;  pt?Jv,  I  am  woni 

Rvcundnry.  All                 ^^^| 

^^H                          tndii],  lOo 

vrnoiiK,  nSi                     ^^^^1 

^^^B                   llnlin,  n>-phn>*raphy,  69n 

median  Itiholunir,  MS            ^^^^| 

^^H                 Itiilritby'ii  ctii-vit  cumprvttvr,  OOO 

iiiunl.     Sre  EpUlRxii                     ^^^^| 

^^H                 KhII,  Ui:utiir«  of  braehlo-caphalic  artcrr, 

from  hilM,  tiitil                              ^^^^| 
diagiKHii  of,  1^44                      ^^^^| 

^H 

^^H                 Hhii),  viilariivmcnt  uf  biinar  in,  49'J 

fh)Ri  nn>*lKti>,  1012                       ^^H 
•eeondary,  «tt«r  Ugattirofor  anaiirw^H 

^^H                   FlnmiUnn,  li^itKire  »rhoth  rtirolld*,  IH6 

^^^B                   Hnmntrint:  ti>n(]i>n»,  rontrii,rtiuti  nnddivi- 

^1 

^^H 

of  «xt«m»l  iliac.  249             H 

^^H               Hanct>c-k.  muscular  itructun  of  urethra. 

of  lubclflviab.  2X2                H 

^H                         1043 

of  itijwrlloiBl  fentnral,  391    H 

^^H                        suti«ti<!s  ofesciaion  nf  afitmcalus,  410 

gangrano  frum,  IM                      H 

^^^^^^           IIaitd.  tini^tiriim  uf  vMseU  uf,  2S7 

»n«r  MDiotomy,  t>4l                        H 

^^^I^^L                 birnrc^tion  of,  505 

after  axciMon  of  tonguo,  6117       H 

^^^^1                 clubbed,  fi03 

from  Buppuratin;;  anuuriain,  l&^H 

^^^^^B                 deformitiM  of,  501 

in  Irachnot^my,  B7C                               ^H 

^^^^^H                deformttin*  oT,  voneenhal,  SOS 

from  urethra,  lOU                              ^M 

^^^^^H                       from  muMutar  ounlrHcMoo,  602 

in  Ri>n"rrtiii>a,  lOS?              ^^^H 

^^^^^^1                                 of  boTiiM  uf,  392 

Ueroorrbaijic  diuili>:ti«,  106                  ^^^^| 

^^^^^^1                 gantrlion 

piitliolitcy  <.f.  llW                    ^^^H 

^^^^^H               gnn(>r<-iio  of.   after  lipitur«  of  *ub- 

LreHtmt^ot  of,  107                        ^M 

^^^^^F 

Ueniorrhtniln  (aiua,   blood:    ^'u,  I   fi>>'*|^| 

^                          HiiMimntoiil  iirthritie  of,  d 

^^m                Uarkmi',  ij5'2,  601 

HafiytA  {ifarti:,  n  branch),  789                   ^^ 

^^B                       n^>  for  op«rslion  In,  100 

cau«e«  of.  743,  744                                ^M 

^^B                       dtfublo,  000 

chloroform  In  reduction  of,  761          ^| 

^^^B                                  operniion  for,  609 

complete,  744                                        ^H 
viindltlun*  prA'eiitcd  by,  T44               ^H 

^^^B                          aimple  mture  in,  610 

^^H                       *in[^le,  fiO& 

i-ongeiillal,  74:j.  lUO                        ^^^H 

^^H                               operation  for,  noi 

contents  "f,  7411                               ^^^^| 

^^H                Rflrrin,  ■uti*t>c«  of  rmpbret^toiuy,  WO 

duilt>l«,  740                                        ^^^H 

^^H                Biirr,  flt.-xion-lr«Minienl  of  iiDourtim,  146 

diagnoais      from       BtrKnguUt^H 

^^H                  Ilav«n,  caspfof  iitlruuiiK-eptcori,  818 

bcmia,  768                                   ^H 

^^H                 linwkins,    Cwfar,    stntlilict   of   nrtificUl 

emmata  in,  760                            ^M 

^^m                  nnui,  B25 

Inoarcoraied,  7A2                                 ^M 

^^H                 Head,  JisoaMs  «f.  TiSO 

incomplel^,  744                                ^^^^H 

^^H                        Uppiric  the,  032 

Influence  of  ngv  on,  7iS               ^^^| 

^^H                 Ho&ring,  aOrcouid   by   Intracranial    anmi- 

of  oci^upation,  744                  ^^^^M 
748                             ^^H 

^^H                    iiiici,204 

^^H                Ucari,  influence  of  acUon  of,  on  produc- 

internal,  dinfinotis  of,  807           ^^^H 

^^^1                           ttnii  of  itnniiriint,  I2lt 

IntMtiiial,  742                                ^^^H 

^^^ft                       dbplitcifd  (ir  wnWneiMl,  (iptgnxIriG  piil- 

irrvdwibU,  744.  T&l                     ^^H 

^^^^_                     MUon  from,  212 

caiuea  of,                               ^^^^| 

INDEX. 


1179 


ISBKIA  {continued). 

irreducible,  dinffno^tk  uf,  1132 

fnim    fltrangulttted     hernia, 
768 
inAamed,  7fi2 
omental,  74'J 

operation  with  opening  »c,  763 
accidents  attending,  768 
after-treatment,  767 
artiflcial  anu<  after,  77S 
division  of  stricture,  765 
exposure  of  sac,  768 
fecal  fistula  after,  776 
management  of  adhesions,  772 
of  congested  intestine,  769 
of  constricted  intestine,  770 
of  gangrenous  intestine,  771 
of  omentum,  778 
opening  sac,  764 
peritonitis  afler,  768 
reduction  uf  intestine  and  omen- 
tum, 766 
sloughing  of  sac,  77S 
treatment  of  the  sac.  766 

of  the  wound,  767 
wounds  of  arteries,  774 
of  intestine,  774 
operation  without  opening  »ac,  778 
objections  to,  778 
performance  of,  780 
results  of,  779 
radical  cure  of,  746 

Si>an(on's  operation,  7fiO 
Wood's  operation,  748 
Wuizer's  operation,  747 
reducible,  744 

treatment  of,  745 
wc  of,  7»9 

adhesions  of,  741 
asc-itic  fluid  in,  742 
contents  of,  740 
double,  740 
fluid  in,  changed,  7nS 
foreign  bodies  in,  742 
hydrocele  of,  741 
sujipiiration  in,  755 
signs  of,  742 
strangulated.  744.  7'>3 
aspiration  in.  7S2 
consliiuli'Hiiil  >vn)ptoms  of,  756 
diagnosis  nf,  T'iS 
gangreni^  in,  7>>4 
inllaiiiniation  of  gut  after  relief 

of,  IW 
local  efTccUt  of,  754 
local  signs  of,  7r>i) 
mechanit^m  of,  7r>3 
operation  for,  76.'i.     Sff  above 

results,  7*)7 
reduction  of,  760 

in  mass,  76'J.  'KO 
porhistence  of  ^vni[>loms  after, 

761 
In-atment  of,  7f*2 
seat  of  stricture  in,  7.>4 
•jmptoniM  of,  756 


Hkrxia  (cotiiinued). 

stranguUt«(l,fvni[it<>ms,modiflcatioii> 
"  of,  867  ■ 
taxis  ill,  75U 
treatment  of,  766 
structure  of,  739 
truss  for,  745 
BsBiriA,  t^pKriAL  FoRMd  of,  783 
of  bladder,  748 

treatment  of,  789 
of   cerebral    membranes,  coDgenital, 

682 
cscal,  743 

treatment  of,  789 
of  colon,  749,  807 
diaphragmatic,  805 
femoral,  793 

contents  of,  795 
diagnosis  of,  295 

from  abscess,  480,  799 
fascia  propria  of,  798 
opening  sac  in,  798 
operation  for,  797 

hemorrhage  in,  799 
relati«ns  of,  793,  798 
signs  of,  795 
treatment  of,  796 
inguinal,  78.3 

complete,  788 
congenital,  783,  793 

in  femalf,  793 
diagnosis  of,  786,  1115,  II31 
direct.  788,  784 

coverings  of,  784 
relations  of,  78i'i 
sympioms  of,  786 
double,  78'> 
eucvDted,  783 
esternal,  783 
fascia  propria  of,  783 
incomplete,  788,  785 

operation  for,  789 
infantile,  783.  793 
interstitial,  78.) 

symptoms  of,  785 
large  intestine  in,  740 
oblique,  783 

coverings  uf,  78;i 
relations  of,  784 
symptoms  of,  785 
operation  for,  788 
sent  of  striiMun-  in,  789 
signs  of,  785 
treatment  of,  788 
vnrii'ties  uf,  783 
obtiiratur,  8(t;i 

treatment  of,  808 
of  ovary.  1152 
pelvic,  k)3 
perineal,  80.') 
pudendal.  806 
sciatic,  805 
SCroUl,  783 

diagniniis  of,  1132 
totis,  1119 
of  tnnica  vaginalis,  790 


1180 


INDXX. 


I! 


Bkbkia,  Sfscial  Forms  of  {continued). 
or  tunica  vitginatis,  encysted,  798 
BigiiB  ftnd  diagnosis,  7&1 
treatmeDt  of,  792 
umbilical,  800 

operation  for,  801 

antiGCptics  in,  802 
Birnnffulated,  801 
Taginal,  K06 
ventral,  8U2 
Herpes  of  penis,  1002 
Hey's  ligament,  797 
High  operation  of  lithotomy,  943,  952 
Hill,  Berkeley,  axillary  aneurism,  151 
dilatation  of  strictured  ureihra,  1060 
ligature  of  subclavian,  failure  to  cure 

disease,  233 
treatment  of  gleet,  1035 
urethrotome,  I0C2 
Hilton,  division  of  gustatory  nerve,  627 
HiP-JOiNT,  unkylosisof,  44*8,  471 
operations  for,  472 
chronic  rheumatoid  arthritis  of,  856 
excision  of,  394 
neuralgia  of,  364 

diagnosis  from  sacro-iliac  disease, 
440 
shape  altered  in  sacro-iliac  disease,  489 
Birumous  arthritic  of,  451 

HiP'JOINT,  DISKASE  OF,  442 

acetabular,  453,  464 

excision  in,  468 
acute,  diagnosis  fmrn  perityphlitis,  466 
anijiutation  for,  470 
ankvliwis  in,  449.  471 
artliritii',  44!i.  4')0 

roiills,  4.V1 

trt'jitinfnl  uf,  457 
attitude  in,  44.'3 
cross- lci;i,'od  doforniily,  475 
diH^iiii^i-'  iif,  4'i(i 

fniiti  cHric*  of  si'ine.  429 

frniii  rlu'Uiti:ilii-in.  456 

from  siicro-iliiic  di^eai-c,  441 
di'liH-utiiin  ill,  447 
f<.'iiii>nil,  44:1,  4r>l 

cxci^jiim  in,  402 

trcHtniciU  of,  1^.31 
fi)rm>  iif,  44:! 

liniiljilinn  of  Tiiovemenl,  44ti 
nmdes  <if  ii])*Tnting,  4';;") 
]>nin  ill,  4-lo 
piiihiiloirv  iiiiil  svmptomsof  the  various 

r-)riii,-  ,',t',  4V.>]  4.y2 
plu-iiciiDfiiii  "f,  448 
jiri^u'iiiwis  of,  454 
Miiyn-'s  Hj>j>rtnilus  for,  460 
RiiHi>.t-i  in.  447 

siLppiinitinn  in,  440.     See  Abscess 
TIi'>iiiii>''s  iijipiinitu'i  for,  45'J 
tri'iitinciil  lit',  457 
UippiHTHlcs,  r<.'.-.i'ction  uf  bones  mentioned 

by,  ;i66 
Histrinnii-  siirisni,  57 

ilodf;!'.^,  stjili-tii's  of  excision  of  shoulder, 
377 


Hodgkin's  dis«&se,  Tt> 
Hodgson,  sacculAtcd  aneuruius.  IS-'* 
sponUaeoue  can  •<{,  IK 
duration  of  aneumnu,  13:! 
Uoffacher,  reunion  of  sep^rvied  («uu.  i 
Bolden,  amputation  at  tboulder-joiu 

subclavian  aneurism,  '221 
Hollow  club-foot,  ol*e 
Holmes,  ligature  uf  carotid  and  MibcliT 
for  innominaie  aneurum.  \^ 
statistics  uf  camtid  aoeuritm.  18^ 
of  comfireEaion  trfatment  <'f  u 

rum,  163,  Iffl,  233 
of  excisiun  of  kne«-j'>iDt.  401 
of    ligature    of    femoral    am 
261 
Holt's  treatment  of  stricture,  1059 
Horny  excrescence  on  giant  |ieni>.  I<M 
Hospitals,  hygiene  of.  768 
Houseoiaid's  knee,  47ti,  477 

true,  479 
Howse,  H.  G.,  oesiScalion  of  arterisi.  I 

incision  in  gastrostomy,  S54 
Howship's  lac.mse,  276,  277.  282,  28fi 
Hueter,     micnMcupical      appeataaea 

chronic  arthritis,  351 
HuMKBDM,  disaniciilatinn  of.  for  axill 
aneurism.  2M 
for  subclavian  aneuriwi, ' 
excision  of  head  of,  373 
tumors  of  head  of,  diagnosis  from 
eurisin,  222 
Humphry,  fibro-sarcoma  of  bladder.  1( 
statistics     of    supra  pubic     lith  'I"! 
955 
Hunter,  o|>eration  fnr  ligature.  141.  It 
Hunter's  c.4nnl,  204 
Hutchinsiin.  gustnitiimv  in  intu<!'a!c»p'. 
818 
ligature  of  carotid  for  innomioti- 

eurifm,  184 
result'  iif  removal  of  tpulie.  571' 
results  of  rem-ivnl  uf  upper  jaw.  ' 
trcHtment  of  enlarircd  pi^^tate.  1" 
Rutin,  litriilure  of  brachio-cephalic  art 

212 
Hydatids  in  bone.  321 
in  breast,  703 

in  gf^^'^t  diacnosis  from  ali-ces*.  4 
in  liver.  830^ 
in  muscles,  487 
in  neck.  5*10 
Hydrarthrosis  (iAj/),  water:  ^('■.■■i.a jcj 
833 
treatment  of.  334 
Htduocelk  (iiLif),  water:  *-',^-'.,»  t"" 
1105 
acupuncture  in,  1 1 11 
acute,  1105 
encysted,  II 12 

diagnosi.s  fr.m  hernia,  ~^\ 
treatment  of.  lll'J 
of  hernial  sac,  741 
of  neck,  481 
of  spermatic  cord  .1113 

diaicnosi^  fr»>m  hemta.  7* 


INUKX. 


1181 


Htdrocili  ieonlinittd). 

of  »|H!riiiHtic  cord.  dilTufed,  1113 

diagnosis  of,  1182 
of  tunicK  vaein'liBi  110& 

antiseptic  treattnenl  of,  1111  ' 

complicating  herniii,  787 
congenital,  TlOu 
covering  of,  1106 
diagnosis  of,  1132 

from  cystic  sfircoc«le,  1 126 
from  encysted  hydn<cele,1112 
rrom  hernia.  787  i 

injections  in,  11(K)  ! 

seton  in,  1110 
symptoms  of,  llOo 
tapping  in,  1107 
treatment  of,  1107 
HydrDcephalus  (tAjfi,    water;    kI^j/,   the 

head),  tfip|>ing  head  in,  632 
Hydrops   pericardii   {/wi/.   dropsy   of   the 

pericardium),  tapping  in,  691 
Hydrosarcocele  (iAjp    water:  crn/if,  fle»h ; 

«;/i7,  a  tumor),  1119 
Hydrothorax    {v&jf),    water;     Oiifxi^,    ihe 

chestj,  tapping  chest  in,  683 
Hygiene  of  hi«pitals,  768 
Hymen,  imferfiTate,  1139 

partially  perforate,  1140 
Hyperplastic  indimeritis,  116 
Htpkrtrofuy    {i-iii,   beyon^;    rptou,    I 
nourish)  nf  bladder,  87u 
causes  of,  87ti 

influence  on  kidney  disease,  87<> 
of  bone,  812 
of  breast,  693 

in  male,  732 
of  clitoris,  1140 
of  external  ear,  633 
i>f  gums,  6CH 
of  labia.  1138 
of  lipa,  (>62 

of  lymphatic  glands,  73 
of  no«e,  540 
of  prepuce,  1093 
of  scnitum,  1097 
of  thyroid  gland,  562 
of  toe-nail,  36 
of  toe«  and  f.iot,  529 
of  ton(;iie,  019,  024 
of  toni-iU,  643 
Hypochondriue  ivpon,  hernia  in,  802 
Hypodermic  injwtion  of  ergotin  in  aneu- 

nsra,  171 
Hypofpadias  {i'o,  under;  crTmiui',  an  eu- 
nuch), lONO 
Hysterical  contraction  of  knee,  Sit 

retention  and   incontinence  of  urine, 

10U6 
stricture  of  ti-sophagus,  660 
treatment  of,  651 


ICHTHYOSrS  of  t.mguo,  621 
Idio[Mthic  gangrene  of  i>eni8,  1093 
phlebitis,  M 
tetanus,  t'lO 


iLtAC  ABSCKM,  diagnosis  uf,  4S0 

aneurism,  244 

arterv.     .See  Artery,  iliac 

incision  in  imperforate  anus,  83S 

region,  hernia  in,  802 
Image,  naivus  of  tongue,  624 
Impacted  calculus  in  urethra,  969 
Imperforate  anus,  834 

hymen,  1139 

vagina,  1189 
Impermeable  stricture,  1067 
operation  for,  1068 
Impetigo,  diagnosis  from  lupus,  88 
Impotence,  1133,  1186 
Incarcerated  hernia,  752 
Incifion  of  suppurating  jointj,  847 
Incumpleie  ankylosis,  369 

fistula,  8'>4' 

hernia,  744 
Incontinence  of  urine,  1005 
Incubative  stage  of  gonorrhcea,  1029 
Indian  rhinoptastic  operation,  600 
Induration  of  penis  alter  gonorrhtea,  1038 
Infantile  hernia,  783,  798 

paralysis,  496 
Infants,  acute  arthritis  in,  344 
iKFLAMMATioy  of  aneurism,  137 
after  ligature,  162 
axillary,  283 

of  areolar  tissues  of  pelvis,  941 

of  arteries,  108.     See  Arteritis 

of  bladder,  998.     See  Bladder 

in  disease  of  urinary  organs,  874 
after  lithotomy,  941 
after  lithotrity,  971 

of  bone,  272 

scrofulous,  281 

of  brain,  after  ligature  of  carotid,  197 

of  breast,  696 

of  buna  patelliv,  478 

of  bursa?,  478 

of  cartilage,  843 

of  conjunctiva,  gonorrhceal,  1039 

of  par,  633 

of  epididymis,  1101 
gonorrhuea),  1038 

of  eye,  eonurrh<ral,  1089 

gonorrhd'al.    See  Uonorrhoea 

of  hip.     See  Ilip-Joint,  disease  of 

of  intestine  in  hernia,  76*> 

of  irreducible  hernia,  762.  ~'>8 

of  joints,  332.     See  Arthritis 

of  kidneys,  cause*  of,  882 

diffuw  imcTititial,  878,  884 
suppurative,  879.  885 

of  knee,  contraction  from,  612 

of  lar^'nx,  66*}.    ^^e  Laryngitis 

of   lungs,    after    ligature   of   camtid 
artery,  198 

of  lungs  and  pleura,  after  ligature  of 
suK-lavian,  22<.t 

of  mamnmry  gland,  696 

of  medullary  membrane  of  bone,  278 

of  niii.''c1i.>ii.  485 

of  n<-rve*,  48 

of  nipple  and  areola,  696 


^^^^^1182^^^^^^^^^^^isi>iX^^^^^^^^^^^^^^B 

^^H                      iKFLAMUATtDV  {confintt't } . 

iKTKltTtXAL  UOsmCf^lON  (etmttiuifil).       ^H 

^^^^^               uf  aose,  gonorrluBul,  1040 

Kouta,  ii|n:nitini)  for,  817               ^M 

^^^^^L              of  inrotid  Kl'U>d,  6b& 
^^^^M                oT  penii,  1092 

treuliiicnl  of.  Aid                     ^H 

AmiitwNt'f  operAliitn  for,  81A,93l^| 

^^^^^H              of  periocUuin,  'j^'i,  28X 

belludcnnii  in,  817                         ^M 

^^^^^^B              of  pt^ntontiunt.     Set  I'eritnnitia. 

CnllitcD't  opeivtiun  for,  B21         ^M 

^^^^^H                   phnpi-DX,  M<i 

cbronio,  WKi                           ^^H 

^^^^^^1               nf  pro|iiicB,  10!>'J 

tmairnHnt       Hiw            ^^^H 

^^^^^^1              ot  intMlnlc, 

colotomr  for,  S2I                      ^^^^| 

^^^^^^1                of  toloraticj^narrlKMil,  1040 

diasnucf»  of.  811                            ^M 

^^^^^1               of  slicstlit  of  tcadoni!,  484 

duration  of  cnnitipBlion  In,  818    H 

^^^^^^1                ■j'philitic.     ^««Sypbilis 

encRiiila  in.  817                                  ^M 

^^^^^H               01  synotiw]  m«inbninw,  SS2 

exannnstton  of  revtiim  in,  ijU     H 

^^^^H              uf  tfiflUa.  1 

gaiitnmiiny  in,  830                           ^M 

^^^^H                     •/philitic. 

p'neral  o<'Ddiliu»  uf  {ntieut,  819>^| 

inBalioii  in,  819                              V 

^^^^^H                     uadowviided,  797,  791 

^^^^H          of  tunguo,  sua 

inversion  in.  SI"                                ■ 

^^^^H           of  u>D<ii»,  044 

Liltro's  oporutioii  fur  82 1 ,  B|^^^H 
niod«  of  iovuiou,  812           ^^^H 

^^^^^H                   iirwthm,  1037 

^^^^^^P                          L-Atlictftrism,  ItKM 

pain  it),  SIS                             ^1^1 

^^^^^V              of  utenw,  chronic,  1141 

phvticMl  eiamioatioD  of  bvHf^^H 

^^^^^P              of  veini. 

813                                                   M 

^^^^^         Inflantmatory  oedoma  of  tcKAxim,  1097 

prrviouti  bi*(ory,  812                       ^M 

^^^H                            ost«opnrosiB,  !i!?7 

puncture  of  in(V«tine  in,  817        ^M 

^^H               Inflation  of  oMnictod  intestine,  9X9 

tent  of,  801)                                 ^^^1 

^^^1                 In^'i'^tui;  i>r  rttiils,  34 

^^^H 

^^^^^^          lujtuinul  HiKtiri'iii,  244 

vuniitinK  iu.  818                       ^^^^| 

^^^^^B                      dingiiMu  from  abaows.  821 

IsTEK T J N K,  adbcdions of,  ia  hemi*,  741 , 72^H 

^^^^^P               oololomy. 

niAtiS}];cmi*nt  of,  772                             ^H 

^^^^^V                      ounipxrMl  with  liinib»rcolotomr, 

calHrrhitl  inllnniiTiKiion,  ncul*,  fitUown^H 

inf;  r>^duction  of  bcmia,  770            ^M 

^^^F                    hcmiA.  7H8.     .SV«  li^rnin 

congMlcd,  in  h^^mia.  764                      ^M 

^^H                I  i\liuluUoti  of  pu«'dt>red  intrut«  of  silver, 

nianMcemeRt  of,  770                     ^H 
contirictiHi,  in  hemin,  mana^ttineiil  «(^| 

^^1 

^^H^               Injections  of  solution  of   nitnt«  of  ailver 

770                                                      H 

^^^^^                   into  liirvnx.  OAI 

C«Df;renaiu,  in  b«niiit,  764,  ''iH,  i,l  ^M 

^^^^^H              in  eonorrbcpn,  1033 

roana^roeni  of.  T7t                       ^M 

^^^^H                     livdnKi'Itt.  1109 

b«mori^nji«  Trom,  diagtiotin  trvm  idlrt^l 

^^^^^^1 

8U4                                                       ■ 

^^^^^P                  varis,  no 

bi-miii  of,  740.  748                                 ■ 

^^^^^^                 tubeuUiUPoui.     Set  Subcutuieoiu  in- 

inllHm Illation  of,  in  bertiia,  7K&            ^H 

^^H                          j(wtii>[is. 

larKc,   di»e«iM«  of.    t<34.      Sm  Asuf^| 

^^H                Injury,  a  cau&e  of  caawr  of  brnHt,  717 

I'ilca,  and  Kcctuni                     ^H 

^^H^               lunmninateartery.  AWArtcrj?,  Innoininalo 

malformationti  of.  ^4                   ^H 

^^^^^—       IffaTKiTMSKTs  forcomprauiou  in  unvuriiin, 

removal  of  portions  i-f,  827                 J^| 

^^^^^ 

woundf  of,  in  openiiion  for  hernia,  7r^H 

^^^^^H              for  «xpiaion,  871 

Intmcnininl    fintrn,    within;    upoviw,  ^k^H 

^^^^H               for  lithotouy,  016 

ckuU)  Hiifuriiiin,  301                               ^H 
[Mtrn'>rbilul    (iwlm,   within ;    orAtM,   U>^| 

^^^^P                for  HtboLHty,  9h0 

^^^^^^^                 for  removing  diflcSMKl  tninn,  3t07,  808 

nrbit)  aneiirifiii,  tAM                                         ^H 

^^^1                 Inlcrmuxiltury  lionet  in  hnrvlip,  UOj 

liilrapt'lvk- -iifr'>'iliarBliM<««B,  440              ^H 

^^^1                                 iimiiHK'iiienL  of,  GOO 

lutratlioracii.-  (•■■frit,  within;    K/prnf,    tb^| 

^^H                I'ltuniol  hi>mlB,  diuenoeii  of,  807 

a]he>t)  Nnoiiri'in,  17^                            ^H 

^^^^^           piiH,  tc67,  (>eo 

Uinwrs,  d\>pliai;iu  frrim,  &48               jH 

^^^^^H                UK^bnilomv.  lOOO 

IntUHusLvjitioii  {mtiu,  within;  »uaeifio,^M 

^^^^V                        mtiiU, 

n^rptvp),  810                                           ^H 

^               InUro-i'itt'rtiul  iiile-,  867 

diat;iiii^if  of,  811                                        ^H 

^^K^         liilT'nlUiBl  Ix^min.  783,  78G 

opcnilidii  fur,  818                                     ^^t 

^^^^^^^               iiiUuuiKiuiiiiii  tif  Lbo   hrvwft,   obronlo, 

ctAli«tir«  of.  818                         ^^^M 

^^^^^H                            din^iifeia  from  r«ti<H>r,  i2U 

■ymptoiris  nf,  KIO                              ^^^H 

^^^^^^H 

Ir^Blmpnt  of.  818.  8in                      ^^^H 

^^^^^B               mutttiii,  chivniu,  n?^ 

Inynijirialion  'if  rr^^iiiin.  87!1                         ^H 

^^^^^r                      InMitincDt  of.  ^t"! 

Invrr-iun  in  intvatiital  olietnKltmi,  817     ^M 

^^V                      iiupbriti-,  KT»,  mi,  1004 

Invoiutioit-cvDla,  702                                       ^H 

^^H^^            IHTUTlNAl.  OlISTilUGTIDH,  tWl 

lodido  of  noiowiiim  in  anvitrinn,  140  ^^^| 
lodini'  in  (iniiirbiKwIn.  BM4                   ^^^^| 

^^^^L                      nevte,  807 

INDEX. 


1188 


ludine  (eonliiiuril). 

injection  of,  in  hvdnirlfarneii,  886 
in  hvdtveek'i  1109.  111*2 
In>n,  perrhloride  of.     See  IVrchloride 
In«duciblc  hernia,  744,  7-'i].    See  Hemift 

tumult  uf  ^niin,  888 
of  licrutuni,  1182 
IrriUbte  bladder,  098.     See  Bladder 
Itchio-iTcUl  ab»ceM,  851 
Ivor^  exostosis,  Slfl 


JAMKS,  ligature  of  abdominal  aorta,  262 
Jaw,  lower,  cv»U  of, .687 
dlKasea  of,  687 

excision  of,  complete,  681,  688 
necrosis  of,  diagnoeis,  !>!} 
periostitis,  acute  suppurative,  687 
reproduction  of,  after  necroais,  672 
rheuniHtic  arthriti*  of.  857 
tumors  of,  MO,  670,  687-589 
upper,  diseases  of,  673 

excision  of,  complete,  581,  588 
partial,  680 
re^ulU,  685 
operations  on,  579 
osteoplastic  section  of,  680 
tumors  of,  676 

diMgn(«is  of,  577 
treatment  of,  578 
Jaws,  ankylosis  nt,  502 
closure  of,  698 
dentigerous  cysts  in,  675 
di«ea»e0  of,  5'i8 
necrosis  of,  571 

treatment  of,  571 
Jeffreson,  ovarintomv  performed  by,  1147 
Jenner,  Sir  W.,  syphilis  and   rickety  chil- 
dren, 813 
trai-heotomv  in  mcmbranoua  larrngi- 
til,  670 
Jewett,  horny  excrescence  on  penis,  1098 
Jubert,  effect  of   ligature  of   carotid  on 

lungs,  198 
Johnson,  Dr.  U.,  eausM  of  acute  suppura- 
tive nephritis,  888 
the  larvngoivoiM)  In  aortic  aneuritni, 
176 
JotXTH,  amputalion  in  disea-*e  of,  414 
ankylosis  of,  850.     Set  Ankylosis 
CNUtcriMition  uf.  84'> 
chani;e'  in  {'Hrtiltiirf  of,  .144 
chronic  rlifuniatii-  diM-H^e  of,  856.     See 

Arthritis 
diseuoi  of.  ZT2 

excision  "f.  ."Hit;.     Se^  Kxciition 
6uid  <vill<'cti'>n>  ill,  8:t:t 
incUioiis  int".  347 
inflaiDrimiii'U  i>f,  :i.t2      .S>e  Arthritis 

of  <tyn<iviiil  incin limner  >if.  832 
liHMc  <-iirtilH^(->  in,  8iil 

treatnii-nt  of,  :it;5 
neuralgia  <'f,  8t>4 
chum-h  <if,  Sin:, 
Fv  III  I'll  111  ■■>  of.  ;ti>4 
tn^ntnirnt  >>l',  "I'u, 


JoiKTS  [continued). 

repair  after  disease  of,  844 
stiff,  359.     See  Ankylosis 
strumous  disease  uf,  848 
suppuration  in,  887 
Jones,  Wharton,  treatment  of  gonorrbcMl 

conjunctivitis,  1089 
Jordan,  F.,  buccal  opention  for  removal 

of  tongue,  635 
Jugular  vein,  aneurismal  varix  of,  188 

wound  of  external  in  ligature  of 
subclavian,  227 
Juillard,  results  of  removing  gangrenous 
gut  in  hernia,  771 


KAUFFMAN,  cases  of  malignant  tumor 
of  thyroid  body,  667 
Kelser,  results  of  operation  for  cancer  of 
■      rectum,  845 
I  Key,  lij;atiira  of  carotid  for  innominate 

aneurism,  184 
,  KiDNBT,  abscessea  in,  scattered,  879 

calculi  formed  in,  906 
^  calculous  pyelitis,  890 

careiiiouia  of,  893 
I  treatment  of,  894 

!  diseafie  of,  induced  by  calculus,  915 

by  hypertrophied  bladder,  87G 
by  pressure,  877 
by  stricture,  1048 
I         fistulous  ci>mmunications,  894 
I  floating,  795 

gouty,  113 

hemorrhage  from,  1012 
hydroncpiirusis,  893 
inllamnmtion   of,  diffuse    intentitiiil, 
878,883 
I  suppurative,  879,  886 

cuiisea  of,  882 
reflex,  >*8-_' 
influence  of  disease  of,  on  lithotomv, 
!I4I 
on  lilhotrity,  979 
I  irritable  bbidder  fVom,  900 

I  morbid  conditions  of,  877 

polvj*  of,  .■iix^indarj-  disease  of,  877 
r  M-ptic  timttcr  in,  788 

'         pyonephrosis  of,  893 
I  sarcoma  of.  H03 

'  treatment  of,  894 

stone  in.  88'.» 

treatment  of,  800 
fiurf;iciil  operations  on  the,  889 
I  a'piration  of.  K95 

:  exploration  of,  8'.l-'> 

j  nephrectomy  of,  897 

'  abdominal.  898 

resiilUof,  899 
nephro-litbotumy,  895 
i  lu'pliro-rHphy,  t*;i5 

neiibnitoniy,  8H7 
tuben-ular  or  M-niAilout,  891 
lunmrs  of,  893 
Kin|;d<>ii.  »tH:i>tiei>  of  hernia.  744 
KNtE-JoiNT.  iinkvl«'i>  of,  517 


1184 


IN  UBS. 


Kkkk-joikt  (eontin-iot). 

OMntrHclioB  of,  ^11 
chronic,  i\'2 

rroiii  consotidaled  tiganicDk,  o\2 
frpm  concrxct^cl  («nu<>n>,  615 
exteniioa  in,  &13 
trvta  inflnmnution,  518 
with  Ulend  displiu:«nt«nt,  510 
Oxiin  Donoiu  irritution,  -ill 
treatment  of,  613 
varieties  of,  ill 

ilefonnities  of,  608 

diwMM  of,  diftgno«i>  ttota  bip^UesM, 

fexeiriun  of,  S94 
rwult  of,  400 
Knight,  digital  cocnpreaaioit  in  Rnmirwm, 

164 
Kniv«f,  liiToin,  7Si> 
Ilthoioniv.  fll7 

method  of  bolding,  022 
Knock -kiiev,  oOS 

MacEweo's  ifperaUon  for,  SIO 
Koch,  itatUtiu  of  lijfiature  t^  subdavian 

artery.  230 
Kocher,  ciolsion  of  tonfcue,  fiS.VCSS 
ri'itulU  of  exdsion  at  kn«(^juinl.  401 
of  thyroid  body,  .'06 
Konhvrli'a  Hrro-iioBud,  114^ 
Kohlcr,  i<?nuiu  throrubosis,  78 
KvniK,  pTMenoo  of  *lubeivle  in  itnimoua 

aitbriUs,  8&L 
Kuhl.  tigaturc  of  both  carotids,  IflC 
Ktwl«r,  rotilu  of  ufomtlooa  fur  oaoeer  of 

l)rww.t.  728 
lCypho>is  {M<^,  I  iK-nd),  4)10,  494 

LABIA,  condyloiiiiiU  of,  1189 
cy»tic  tumon  of,  1189 
hy[icrinkjihy  uf,  IIHK 
Divrtu  111,  104 
Lnrtalc  of  m-u,  iujeoUuD  of.  In  iolraorljiuil 

iinoiiri«ui,  210 
Luctrn]  KocreLioii,  abnoraial,  094 

tolliimuLBtloii,  influence  ou  cancer  of 

brmU,  TIT 
tumor.  6i"4  ' 

LiLQiborl,  dUlitl  liuiaiiin)  of  carotid,  1119       | 
LHiuinar  cntriliciiLii'n  iu  artenM,  I  I'J 
Luie,  dieul  ligature  of  <mrotid,  199 

li^atoro  of  citmtid  and  lubclaTian,  185  ■ 
LliDge)>bM-k,ptilh»|[>gii:HlincT«NWuf  length 
of  bonw.  312 
cMteoplnrtiofK-tion  of  iifiperjnw.  6Sr> 
|riiofpboru^iHcr<»ti'  of  Juwit,  TiT  I 
■uboutaneous  injuctiuii  of  vntotiii   in 
uidiiriun,  171,  211 
Laparotomy,  820 
Laiyngpal  phthiAiftt  60S 

•yring«,  "11 
LnrTOf;i>ctwiii.v,  007 

Lartsoitih  [j-Mitvii,  tlio  lap>nK;  ««,d»- 
notinic  ihllanintniton),  6&7 
acute  cniarrbul,  457 

tnrmbninoiif ,  mcbeutoiny  In,  909 


LARYKOtTtS  \et>nttainj\ 

Ki'iite,  <(<detiiato'i«,  4w7 
ohrooic.  fiimpie.  6iv 

rotuplienttom  of,  663 
*ypliililic,  im 
traumatK,  61^9 
LubeicuJar,  008 
L4iryn^>K<op»(><ipi'if,  tbe  laiyax;  vkmSH 
I  Tiew).«64 
use  of.  in  aortic  aDeimcin,  176 
Labtsuoiomt  {'ffii,  lh«  Larynx  [  rigvn, 
I  cut),  WU.  G72 
afler'tr«Htiii«Dt  of,  682 
in  Honii;  aneurism,  IW 
oo«p«ri?d  with  tracheotomy,  >;^ 
indications  for  performance  of,  ^7^ 
LitryneoirxcheaHooiy,  472.  676 
Labymx.  abeccacM  near.  KAft 

ooaditiuci*  of,  produdi^  dy*pb«gta,M7 

diMuea  of,  054 

»lirpalH>n  of,  tlOi 

iiidamniatlon  of,  R&O.     Snp  L«ryn^^ 

il^ection  of  nitrMte  of  silver  into,  i'  " 

malifiimni  tumors  of,  MW 

necru'.is  of,  tWia 

nervous  al)i'GtJ->nd  of,  604 

paralyiis  i.f,  '«4 

tutnoni  in,  <i*l4 

ireuitmeRtof,  M& 
Lateral  cunature  of,  4piD«,  481*.   Sm  «pin« 
dltplncenwnt  of  knw.  «17 
Ittholoiny.     Set  Lilhotomy 
LAt«ritioue  depoftiu  in  tirine.  'AOO 
Laugkr,  ligHtureof  «uU-lavian  forinnomi- 

nnl*  iin4>iiri*in,  tiJS 
XiMutvniMT,    Z.,   hurnla    of    tnenibnuiM    of 

bruin,  682 

LairrtM.o^',  Sir  W.,  suiUiUoior  bcrnla,  74S  ; 
ventml  bvniln.  V02 
t«moviil  of  nawil  polvpl,  '•47 
casAinf  woundof  urtf'rvln  bnniioioDiTr ' 
774 
Lawtoii,  coupr«wioa  in  iDcuiaal  aiwoilun, 

159 
Lead,  acetate  of,  injected  in  Mni^rrfaiMi, 

IMS 
Lm,  U.,  MibcutaocoiM  divinlan  of  rein  in 

Torix,  91 
Lee,  R.,  utaiiatla  of  ovariotomy.  1147 
Lao,  defomiiUi^  of,  60ft 

tlviiiiin  of  boiiet  of,  408 
L«^.  hnrnioiAllla,  106 
Iicurink,  •taLislloiof  eaciaion  of  hip-jotDin 

408 
Lonkoplftkla,  );2I 
Lii'h'^niiid  of  the  tunRue,  622 
Liilvll,  nt-Liri'Uia  of  Mptio  n«tv«,  59 
Llganientd  of  j<>inu,  diMste  in,  Vt6 

of  kuee,  Li>nM>lidatioB  of,  612 
LtoATtTKE  iliov,  I  bind),  roil  AyKtmiaH,  i 
14'^,  1(15 
Kbori^  kud  lielow  Mc,  148 
accideula  after,  147 
An^^lN,  142.  143 
l(r»Kiur'«  142 
uomiwrcd  with  oompnnloa,  162 


INDKX. 


1186 


JOATVU  TOB  AXIOKIBM  (continutd). 
gangrene  after,  iM 

treatment  of,  164 
bemorrhnge  after,  152 
treatment  uf,  l&S 
Hunter's,  142,  143 
etfeclBof,  144 
indicHtioni  antlcuntra-indications 

of,  145 
morUlily  after,  147 
on  oirdiacaide,  148 
on  diKtal  aide,  14u 
statiatica,  145 
recunvnt  puUation  after,  147 

treatment  of,  160 
■econdar)'  ancuriam  after,  149 
■uppuration  and  aloughing  of  aac 
after,  loi 
irwtmentof,  163 
of  ftorta,  abdominal,  2r>2 
of  arteria  doraalis  pedia,  271 
of  axillary  arterj',  2S& 
of  bnu.-bial  artetr,  238,  331 
of  bracbio-cepbalic  arten-,  212,  218 
of  carotid  arterr,  149,  lo'l 

on  both  aitfefl  of  neck,  196 
on  diatal  aide  of  aneuriam,  198 
effect!  uf,  on  brain,  194 

on  lungs,  198 
for  aortic  aneuriam,  177 
for  elephantiasia,  71 
for  innominate  aneuriam,  184 
with  §ubclarian,  184 
for  intracranial  aneurism,  2(H) 
for  intraorbital  aneurism,  210 
suppuration  of  sac  after,  194 
at  dorsal  artery  of  foot,  271 
of  femoral  artery,  common,  258 

in  the  middle  of  the  thigh,  264 
superficial,  2ri!t 

accidents  after,  262 
for  elephantiasis,  71 
ganerene  after,  263 
reaultB  of,  261 


;  LiQATUSK  (eontinutit). 

iliac  artery,  external,   tetaniu  after, 
i  248 

internal,  254 
'         of  lingual  artery,  627 
I  of  peroneal  artery,  271 

of  radial  artery,  240 
of  subclavianartery,foraxlltary«neu- 
I  riam,  228 

behind  acalenus  anticus,  228 
in  third  part,  224 
for  innominate  aneurism,  188 
with  carotid,  184 
for  subclavian  aneuriam,  216 
on  distal  aide,  220 
on  tracheal  side,  217 
statistics  of  operations,  217 
accidents  after,  227 
gangrene  after,  2S8 
for  inflamed  aneurism,  288 
infiammation  of  cont«Dts  of  chMt 
after,  229 
I  resulu  of,  229 

secondary  hemorrhage  after,  232 
auppuration  of  sac  after,  280 
of  thyroid  artery,  666 
of  tibial  artery,  anterior,  270 

poaterior,  269 
of  ulnar  artery,  239 
of  vertebral  artery,  221 
in  aneuriam  by  anastomosis,  98 
in  cancer  of  tongue,  627 
in  osteo-aneuriam,  381 
of  nwvua,  97-99 
of  pedicle  in  oTarlotomy,  1149 
of  plies,  STA 
of  polypus  of  noee,  546 

of  uteruf ,  1 148 
of  prolapsus  anl,  872 
'         of  tumors  of  rectum,  846 
of  urethra,  1086 
Limbs,  deformities  of,  496,  601,  608 
Lindemann,  treatment  of  hydatida  of  liver, 


880 

return  of  pulsation  after,  264    Lines  aemilunar«»,  hernia  In,  802 
eccondarj-  ancuriam  after,264    Linear  ostent^mv,  28^ 
aecondary  hemorrhage  after,  .  Lipoma  (?j:roc.  /at)  of  breast,  704 


2t>2 

wound  of  vein  in,  262 
of  eluteal  artery,  2.>4 
of  Uiac  artery,  cumnum,  249 
results  of,  2.".0 
external,  24.'> 

Al>em(>thy'!t  method,  240 
CiH)piT's  meth»d,  24<> 
fi>r  aneuHsmal  varii,  249 

combined    inguinal   and 
p-<{>litful  anfuriBm,249 
IK)plitcAl  aneurism,  266 
gangrene  aftt-r,  248 
practical  |H)ints  n-garding,247 
n-cum-nt  (luUHtiun  after,  24K 
results  i.f,  248 
aecondarv  hcniurrhage  after, 

248 
suppuration  after,  248 
TOL.  It  — 7.'> 


of  nose,  538 

nnvoid,  104 

Lips,  cancer  of,  556 

congenital  malformations  of,  662 

contraction  of,  552 
diseases  uf,  6'>2 

encysted  and  erectile  tumors  of,  6A8 
epithelioma  of,  563 
operation,  664 
fissure  of,  ;Vi2 
>         hypertniphy  of,  552 

malignant  disease  of,  658 
nKTUs  of,  102,  658 
plastic  surgery  of,  604.    See  Harallp 
I         reHtoraiion  of,  618 
I  ulceration  of,  562 

'         warty  growths  of,  &-*>3 
'  Lisfranc,  excision  of  p-'rtion  of  tht-  rectum, 
843 


1186 


Ltiur,  Sir  J.,  aortic  toum{iiu«l,  243 
openttion  for  excWon  »>f  vfrbi,  889 
for  hernia,  TM) 
LUton,  nneiirism  of,  136.  ISB 

arrar  in  Hpttura  ^f  mibelnvlui  227 
ligKlurv  in  na>vii",  1*7 

of  carotid  mnd  tubel»rt*a,  218 
metbod  of  boldiug  knife  In  llUiotomy, 

opentiMt  for  ftteUion  of  upper  Jrw, 
680,668 

Rtatisaoi  of  titholomj,  f)89 

treHUDcnl  of  wunua,  60 
Litlicctn«7     {f^Att,    a    ftoao;     itriaic,    a 

streiching),  yffT 
Litliic  Buid  i^lcull,  DOO 

dftpoiila,  000 
LlthoUpKKj-,  OM,  9lM> 
Uthoinvicr  tound,  9SA 
Lltbotome  atchi,  li&l 
IiiTUOTOMT  {}AKt,m  tton*;  riypu,  1  out], 
916 

ohoic«i  of  Mpcrntion,  ^1 

ooinipttr«d  with  IJtlxXriiy,  976 

ia  BgMl  p«f0uni,  077 

ID  cbildrvn,  077 

is  f«mRl««,  988 

^n)-«lfiAtiR  tube  ill,  827 

Hulrttim-nLi  fur,  916 

prepHfaliun  i-f  p&tienl  for,  918 

neumociiot  culcalus  nfter,  981 

tMulU  of,  081 

BILATK&AL,  MS,  NO 

accidenlB  i3iirin|{,  DS£ 
after-troutmetit  of,  D28 

ID  b0V9>.  ll^U 

dilHu^uItiM  in,  9S9 
morlnUiy  In,  940 
brttUing  and  OTer<di«tentioii  In, 

cyititU  nfier,  941 
dftiig'T'  atwfidinic,  988 
ditlBciiltitu  ill,  0;tO 

frvui  encj'fUid  caloulua,  980, 

982 
In  Dotaring  bUdder,  9S0 
In  finding  aion*,  910 
from    fracture    uf  calculoi, 
936 
piMiUon  of  stone,  991 
prualatic     lumon,     931, 

938 
richflU  of  paWlc  boD«i, 
988 
iu   toizlng   and    «ktracllng 

■tono,  981 
from  uliapa  and  me*  of  >ton«, 
933 
rpoim  nT  bladder,  982 
ilitTuM)   indammation  after,  941, 

dilalalion  of  priuuteand  neck  of 

bladder,  926 
AXlraciian  of  (tone  In,  921) 
difllcuUie*  of,  981 


LlTBOTOUr,  I.ATKKAL  (mtttint&t). 

faemurrhaE^  after,  911 

dutin^i  USA 
iiicidon,  external  in,  930 

in  pruiuie,  l>23,  981 
inllitence  .if  ■>)••<  >.n,  W40 

of  ihixV  on.  940 

of  slate  of  ktdnejra  on,  Ml 
lilholi'ii.e  f'-r,  il27 
luiitini*  urctlin  in,  937 
rooriaiily,  l»8y,  WO 
imritotijli*  after,  943 
]KK]tl->u  <yr  knife  In.  922 

of  [4Ueni  In,  91U 
prolonfjeil.  danger  of,  941 
pjwDiia  and  'eptlcvnla,  caaM 

of  death.  MS 
romoval  iif  large  calculua  tn,  931 
tl<>ui;1iini:  after,  948 
unn\4it>n  fitrtUmf  in,  91S 
MaiUtic*  ■>f,  1139 
wtiiriil  •>(  arterir^  In,  93fi 

uf  bladder,  938 

of  bulb,  UST 

of  notum,  988 
untAN,  948 

conifiared  witb  laUral,  946 
dlfflmiltieii  In  extracting  itoae  la. 
948 

In  i>nt<?riiic  blad'lor  In,  948 
eaae  and  Aitr|>lirltj-  of.  ;•« 
for  pmslnlic  ruliulu*.  W<1 
for  urethral  calLiiiiu,  (tSi,  98G 
bcinorrhaEV  in,  Olfl 
hi«lory  flV»43 
indicatiuni  for,  940 
ojirration,  '.'<4 

proatalo,  lr««tmvn|.  of,  WJ^t 
wound  of  balb  in,  947 

of  rectum  in,  147 

IfXDIO-HII.ATKajlL,  9^1 
1IBD[0-LATBU.L,  948 
BBCTO-VKAirai.,  948.  9&2 
auraAruKic,  'JK,  9&2 

In  feinalee,  988 

operation  of,  953 

vauMi  of  daagar  in,  OM 

OBXTIIHAL,  B6S 

in  feinalo,  087 

VAOINAL,  988 
l.itbo-lripiie  lithotomy,  B7S 
Litbotrite  (iJ6a(,  a  stone;  rptffu,  1  grit 
9fiO 

Sigolow'a,  MS 

Oivialf'*,  967 

T!u>inp«on'*,  958 

urethral,  970 

Wein'*,  9G(S 
LiTBOTRiTT  {}Mis,  a  >tan* ;  rp/^,  1  grii 
955 

accidvnu  in,  9Bfi 

anmtlielica  in,  MS 

at'inr  "f  the  bladder  aflari  978 

brv'aking  ifne  In,  OSl 

Cnttiittvr  fiT,  9^ 

eo»)parcd  with  lillMlumy,  UTS 


INDEX. 


1187 


LiTHOTBlTY  (conUnued). 

cumplicated    by    eQl«rged     prostate, 

970 
conditions  influenvinK  choice  of,  977 
age  of  patient,  977  ! 

nature  of  calculu*,  978 
state  of  bladder,  979 
of  kidneys,  979 
of  prosUte,  980 
of  urethra,  9S0 
constitutional  disturbance  from,  972 
cystitis  after,  971 
danger*  in,  971 

exploration  of  bladder  after,  963  I 

history  of,  955  | 

impaction  of  fragments  of  stone  in  ! 

urethra,  969 
in  children,  977 
in  elderly  people,  979 
in  feinalet,  989 
instruments  for,  956 
introduction  of  lithotrite  in,  959 
irritation  of  bladder  after,  WA 
morulity  in  liifpital  practice,  977 
operation  of,  '.*o'3 
before  1878.  ornl 
subsequently  to  1878,  965 
perineal,  073 

preparation  of  patient  for,  958 
recurrence  of  calculus  after,  981 
seizure  of  utone  in,  960 
Brodie's  methM,  960 
Uiviale's  method,  961 
statistics  of,  975 
washing  out  bladder  after,  968 
Little,  ligature  of  carotid  and  subclavian, 

186 
LHtre'i  n|teration  for    intestinal  obstruc- 
tion, 821,  836 
Litzmann,  mollities  ossium,  316 
Liver,    operations    on,    for    abscess    and 

hydatids,  829 
Lizars,  ligature  of  brachiocephalic  artery, 
212,  215 
ovariotomy  performed  by,  1H7 
Lock-jaw.     See  TeUintis 
LongitudinnI  piles,  860 
LoDgmore,  ligature  of  both  carotids,  197 
Loose  cartila^^^  in  joints,  361 

treaiment  of,  363 
Lordosis  (?Mpd6i,  bent  or  ci^rved),  490 
Lorinser's  case  of  obturator  hernia,  804 
Lower  extremity,  am-iiriim  of,  241 

conservative  »urg«ry  of,  404 
deforniitic'i  of,  o08 
Lucas,  crosft-lcgced  deformity  in  ankylosis 

of  hip-juint,  475 
Lucifer-muU-h  di^ea^e.  671 
Luke,  statitttics  r>f  strangulated  hernia,  759, 
761,  779 
Petii's  o|>eraii<>n,  77« 
Lumbar  incititm  for  itrtiHcial  anus,  821 
in  I'liililfn,  f*37 
(■"iiipHn-'i  with  ini;uinat 
vcl"tiimy,  82.J 
region,  hernia  in,  K02 


Lund,    treatment    of   congeniul    tallpei 

equinovnrus,  524 
LiTKOB,  effect  of  ligature  of  carotid  on, 
198 
pressure  on,  by  aortic  aneurism,  175 
by  axillarr  aneurism,  230 
Lupus  {^Lat.  a  wolf),  35 
causes  of,  37 
diagnosis  of,  38 

from  ini|>«tigo,  88 
from  rodent  ulcer,  41 
from  squamous  epithelioma,  88 
erythematosus,  3d 
exedens  or  exulcerans,  87 
non-exedens  or  non-utccratire,  87 
of  nose,  539 
scraping  in,  89 
situation,  37 
structure  of,  86 
svmptoms  of,  87 
treatment  of,  38 
ulcerative,  37 
vulgaris,  36 
Lymphadenitis,  72 

symptoms  and  treatment.  74,  75 
Lymphadenoma  [l^mpha,  lymph  ;  &A^,  a 
gland),  76 
of  axillary  ^land^,  733 
Lymphangioma  of  tongue,  620 
Lymphangilis,  68 

diagnosis  and  treatment,  69 
Lymphatic  gland*  of    axilla,  lymphade- 
noma of,  733 
cancer  of,  714 
strumous  disease  of,  788 
bronchial,  enlarged,  compreasioD 

of  cBsophagus  Dy,  648 
chronic  inflammation  of,  73 
of  groin,  enlarged,  diagnosis  from 

hernia,  796 
of  neck,  enlargement  of,  560 
strumous  disease  of,  74 
Lymphatic  vcswls,  indammation  of,  68 
causes  of,  6M 
diat;iii>si*  of,  69 
morbid  anatomy,  68 
rt>'iilt!t  of,  69 
symptoms,  R8 
treatment  of,  69 
Lymphatics  of   p«ni«,  indammation    of, 

"1035 
Lvmphorrhica    {lympAa,    lymph ;    /tiu,    I 

'd'.w),  72 
Lvnn.  lithotouiv,  939 


MCCAKTIIY,   lii^Hture  of    carotid  for 
innominalf  aneurism,  185 
Mi'Dowcll,  E.,  ovariotomy  performed  br, 

1147 
MacEwen,  acupuncture  in  popliteal  *n«u- 
ri«m,  171 
ojM-ration  for  knock-knee,  510,  619 
traii»|ilantati'>n  uf  l>one,  370 
Macgtll,  tiKHtup-  of  both  carotids,  196 
McGuire,  ligatureof  abdominal  aorta,  263 


^^r                                                                                    IKDKX.      ^^^^^^^^^^H 

^^^^H                           UackcDKie,  cyphililic  luryneiUi.  (Ht2           i  Median  fljMir*  of  Up,  404           ^^| 

^^^^H                                   tnatm«at    of    ttilMrculxr    Iknrngitb, 

lilbotooiy,  MB.     .Sm  liiMlV^ 

^^^1                                      668 

Modio-bilaiura)  litbotomy,  9SI 

^^^^H                                re»u)u  of  ihyrotomy,  t66 

Med  In- lateral  litbotAtsf ,  9U          ^   , 

^^^^H                            WBoro-{EloMi«t  019 

U«dultary   iiionibraiM  of  boaa.J^H 

^^^^H                         MMiMtoou,  £52 

tivn  of,  278                         ^^M 

^^^^1                            HadclunR,  c««a  of  onUrectofny,  ^27 

tumor  of    hnmcruSf  "*E^^H 

^^^^^1                            Mal*onQflure'>  •ondoconductricF,  10(11 

Blitlary  anavrUm,  St7    ^^H 

^^^^^1                            Malar  boni^,  tumon  growing  fruui,  51Q 

Melancholia,  laxual,  lltt          ^H 

^^^^H                            Malformatii^n,  congoblul.  Set  Congentui 

MeUn<^tl«  MMoma,  44                 ^^M 

^^^^^1                                        Mnir^rmnliun 

Malon-wwd  bodiw,  Ml                 tM 

^^^^^1                            Ual^icnv.  ligaturu  of  carotid  bdiI  tab- 
^^^^^1                                       clfiviun  for   tnnnmtrialo  anturUm, 

Mvmbra&M  of  bnun,  haraii  </.  10'] 

M«nlngoc«la  Ijiit/ffi,  mrnnbru^n;  m 

^^^1                                       18fi 

tumor),  M2                                        ] 

^^^^H                                   mortalilf  from  lithotrily  in  hutpital 

Moreurr,  bicblorid*  ot,  m  am  tmtitt 

^^^^^H                                       pra^lioc, 

I1&&                                            ^^ 

^^^^^H                                       ctali'tic*  "f                  (4<S 

llwsint;,  rruulljt  nt  »xran<n  "f^^M 

^^^^1                            Malbarbv,  unithral  fever,  686 

(irmt^d  i»tiii--'r.ii,~i»Tir     mi     ^^H 

^^^^^H                            Ualignant  <li(ea*«  ft  bon«,  1121 

MelacarjMl  !                                      ^^M 

^^^^P                                           uf  tomil,  645 

Mctalafltl  1'   '                           '      'l^l 

^^^^^1 

Mt^yer,  follkular  lay  iMrrtxo^Uiy  d^^H 

^^^^^1                                   nasal  tiiniori,  MS 

Micr(iC>cci  in  (rnnAr rtirv^l  pu*.  ^^H 

^^^H                                   potvp.  M6 

in  IMiS  >>f  Mrr                   <',  S^^^l 

^^^H                                   sarcocole,  1128 

^^^^^H                                   Btriolun  of  CMnphagui,  651 

Military-  «urg«rv,  ivianu*  in,  91 

^^^H                                       of  rwtun,  MO 

Milk-a&K'«w,<de 

^^^^^1                                   tumon  of  ihymid  body,  S07 

Milk,  abstriiM  afid  eioMt  oC  94 

^^^^^1                               Hiillooli,  excUion  nf,  414 

»ecr«>llon  of,  by  ih«  maW,  TV 

^^^^M                           MalpofiJiion  of  leetiH,  1009 

Miller,  offnct  uf    liga4ura  Jl  mtttji 

^^^^H                                HamoMi,  o>*to-»arcon>B  of,  708 

luDfc*,  198                                  ■■ 

^^^^1                                 diacnoau  of  farcoma  of,  from  ad«no- 
^^^^H                                    flDTDaaand  Adeno^areoma,  711 

Miner's  elbow,  476,  4«t              ^M 

Miscarriaga  complKsting  b«r«l^^| 

^^^H                                    fibroma  of,  706 

M6U«r,  l)sat4>rc  of  both  oaiolid^^H 

^^^H                                    syphilUlo  diMa»»  of,  701 

MolM,  4«                                      ^^ 

^^^^H                          Mammary  ■hweM,  B06 

MoLLtnn  oMimt  i  Imi.  •uftaaaof  M 

^^^^H                                            treatment  vf.  697 

817                                ^^J 

^^^^B                                        gland.     See  Br^a't 

oaoaa  of,  818                   ^^| 

^^^^H                                    tumor,  chronio,  TOS,  720 

dl^;iM«la  of,  819            ^H 

^^^^H                                            painfVit,  707 

•cat  of,  818                             ^ 

^^^^1                          Manipulation  in  aovurhm,  167 

structural  «1uhm!w  {»,  tl},  J 

^^^^H                                        in  iDlMliDsl  obatritttlon,  814 

syciptoo  -                        ^H 

^^^^H                                    in  (ubclavian  nnmiritm,  *J11 

traataif"                          ^^| 

^^^^H                             Mnpothor,  coroprauion  in  iliu-fomoral  an- 

urine  In,                        ^^M 

^^^^H                                 euriitn, 

Montei^>.  li)^liLr«iif  ■t>l-itnliial^^| 

^^^^H                             Marian  operation,  944 

M'>ntc •    '-tit]  Usatun^eM^ 

^^^^H                             Manball,  aoupoaotut*  in  aortic  aneurism, 

Moor-'.                     :  cvMttloCTMn*, 

till              <           rin^uttofBt  jOt 

^^^^H                                     ))«rformanM  of  trachet'tomy,  674 

Moral  caWu  vf  «nlarf«d  proetala.  1 

^^^^1                                     air«lchin^  tho  £«ialte  nervs  in  fcialiai. 

^^^H                                         rMulu,  60' 

^M 

^^^^H                                     tr«aim«nl  of  emp^iDB,  686 
^^^^1                              Manball's  mteoiritfi,  299 

Morri                   .-i«qri«in,  l&l.  ^^H 

nu«<ii  iiiruotc  uUaMlBali4^^| 

^^^^1                              Manh,  Howard,  lUtittJc*  of  caMi  of  hip- 

800                                      ^H 

^^^^H                                 disMMt!  in  childhood,  406 

Ifortoft    ;..;;-(■. .r,  ..r  i.^iit,.  >.,  ^H 

^^^H                              Martin,  t^jr  J.  It.,  jnjection  of  lodlna  in 
^^^H                                 brdrocele,  HUD,  1110 

'1                                             ^1 

HvAi-r                                                       H 

^^^^1                              MaiiBolr,  Ilexlon-tr«aintent  in  anmuisiDi 

Mott,aaci*ltmui                   Hi         1 
llgalim  of                   '   r    in^M 

^^^1 

^^^H                                 MaxilU.     SeeJtvi 

.^H 

^^^^M                             May,  Bonnttl,  »li:in«  In  kidnny,  896 

iH 

^^^^M                             Mayo,    axillar;    aneuriuu     prcaaing    on 
^^^^1                                  piaura,  280 

uf  bc4h  ct»ru:i««.   tvn         ^^% 

of  br«cbio-a«iJi»lte  an«*^J 

^^^^1                            U»tns  audttnriua,  conerctton*  Int  US 

214                            ^J 

^^^H                              Mrcbankal  mMm,  various,  fur  traaUnant 

at  DMBBon  iliac  for  •n^^H 

^^^H                                   aoeuriiu). 

HeOTV,  dtMa««  ef,  4IV             ^H 

^^^H                            Meob«l,  nir«  form  of  barallp,  n06 

flfAouror,  T8»             ^M 

lyDKX. 


1189 


MoTTTH,  plwtic  surgery  of,  594 
MoxoD,  embolic  enterilia,  109 

pAtholo^y  of  atheroma,  111-118 
Mocoiu  nual  polyp,  545 

diftgnotis  snd  treatment  of, 
646,546 
Mulberry  calculus,  902 
Multitocular  cy*Xa  of  lower  jaw,  588 
Mumps,  666.     See  Parotitis 
Murray,  ligature  of  abdominal  aorta,  262 
Murray,  W.,  comprewion  of  abdominal 
aorta  for  aneurism.  169,  242 
division  of  posterior  tibial  nerve  ia 

teUnus,  66 
gravid  uterus  in  an  umbilical  hernia, 
800 
Mdsclks,  diseases  of,  485 

of  forearm,  disorders  of,  601 
inSammation  of,  485 
syphilitic  disease  of,  486 
tumors  of,  486 

treatment  of,  488 
Muscular  action    a   cause    of   aneurism, 
128 
a  cause  of  stricture  of  urethra, 
1044 
Musculo-spiral  nerve,  paralysis  of,  68 
Mussey,  ligature  of  lx>th  carotids,  196 
excision  of  the  whole  scapula,  878 
Myeloid  (^?j6t,  marrow ;  tldo;,  form)  sar- 
comaU  of  bone,  827 
of  lower  Jaw,  587 
of  upper  jaw,  576 
Myomata  of  bladder,  1009 
Myzoedema,  605 

Myxoma  (//^(o,  mucus)  in  parotid  giftnd, 
667 


N^^VOID  (nienu;  t'lioc,  form)  lipoma, 
108 
Njtus  (Lat.  a  mole),  93 

capillary,  94 

structure  of,  94 

treatment  of,  95 

venous  or  cavernous,  94 
VMTva  of  cfaeek,  101 

of  extremities,  101 

of  eyelids,  100 

of  face,  100 

of  fimunelle,  100 

of  labia,  104 

of  lips,  101' 

of  neck,  104 

of  nose,  101 

of  penis,  103 

of  scalp,  100 

of  tongue,  108,  024 

of  trunk,  104 

of  vulva,  104 
Na-vus  in  bone.  3.10 
Nails,  diseues  of,  33 

hypertrophy  of,  35 

indammation  of  matrix  of.  88 

ingrowing,  84 

•ypfailitic  disease  of,  84 


Nasal  bones,  fistulous  openings  in,  603 

necrotis  of,  542 
cavity,  afibctions  of,  689 
douche,  640 
foesie,  calculi  is,  642 
speculum,  639 
tumors.     See  Nose 
Naso-orbilal  tumors,  549 

diagnosis   from  naso- pharyngeal 
tumor,  649 
Naso- pharyngeal  tumors,  646 
Navel,  epithelioma  of,  882 

ulceration  of,  832 
Nkcx,  abscess  of,  diagnosis  from  carotid 
aneurism,  190 
congenital  flstuln,  669 
crsts  of,  669 
deformities  of,  496,  499 
diseases  of,  559 
enlargement  of  lymphatic  glands  in, 

660 
hydatids  of,  560 
hydrocele  of,  659 
nnvus  of,  104 
tumors  of,  659,  660 

congenital,  661 

diagnosis  from  carotid  aneurism, 
190 
Necrosis  (vn(p6t,  dead),  278,  800 
acute,  292,  306 

diagnosis,  298 

pathology,  298 

prognosin,  298 

results,  293 

symptoms,  292 

treatment,  294 
amputation  in,  809 
causes  of,  300 
characten  of,  801 
centra),  301,  303,  307 

treatment  of,  807 
cranial  bones,  310 

results,  810 

treatment  of,  311 
cloacs  in,  804 
exfoliation  in,  808 

iostniments  for  removing  bone  in,  807 
peripheral,  301,  307 

treatment  of,  807 
quiet,  302 
repair  in,  804 
resection  in,  809 
senile,  301 

separation  of  bone  in,  308 
sequestrum  in,  801 

removal  of,  306 
symptoms  of,  801 
syphilitic,  300 
treatment  of,  806 
toul,  801 

without  suppuration,  302,  304 
NicROflis  of  cancellous  tissue,  288 
of  cranial  bones,  310 
of  law,  671 
of  larynx, 668 
of  nasal  bones,  642 


Hi 


IJfDBI. 


MxCKOHtK  (fOHtiriMfd). 

of  patvllB,  811 
of  poIviB,  464 
of  nbii,  SI  I 
y«donil,  tiiberciilKr  ulcer  of  lungue,  628 
NcwIIm.  iirrMl  of  hnmorrhiige  by  pKMurfi 

f'f.     iV«  AciiprVMun.i. 
N^lttlon,  cvxlic  tuiiiur*  of  Soup,  it21 
operMion  fat  pHninl  hsrflip,  0O9 
for  pntiUd  flotitia,  1079 
XepbritU  (tffp6(,  n  kitlnoy;  itis,  dooottng 
InSbmiiiiilifin),  nctitc  diFfiiiod  intor- 
»tiU«l,  $70,885,  918 
nutw  of,  682 
with  ttwecMM,  $»&,  sal 
cbroiilc,  dUgtiMiii  from  tpinnl  OBriiM, 
420 
X(ret,  lultcUvfAn  •n«uriiiii  rommuaicaU 

ing  Willi  lung,  231 
Nkrtkh,  rifccu  tif  Ahourifin  on,  121 
flfth,  MTtion  of,  54 
gtiCulory,  Keutiou  vf,  in  nncer,  627 
InOaminutifln  of.  Hi 
plininir,  injury  of,  in  Lignture  of  sub> 

(.'kvinn,  'J80 
pnniiinognKtrie,  prMturc  of  nneurinn 

en,  I7r> 
ncumnt  InrynEOMl,  prcuura  od,  176, 

180 
Miction  of,  in  n«ijriOgia,  EiZ-fi6 

in  leUinuR,  66 
BlAtc  of,  in  t«lftiiu*,  6(> 
sIretcliinK  of,  50 
tatnp»  on,  68 
Ncrvou*  iiffoctions  of  Inrynx,  RM 

Irrilfttinn,  ctiiitrai-ltoii  of   lfD«6-Joint 

from,  611 
contrHclion  of  idurc1«s  from,  4B7 
ayiDptoms  froni  culhet^ricm,  lOM 
syxtcRi,  dbi-MM  of,  II  caUEC  of  defom]- 
ily,  496 
fljtUEALtiiA  [vfiifioi',  a  i]«rv«;  JUjtf,  pain], 
eaui«B  of,  61 
diagnoif*  iif,  fniii)  ac^uritm,  13S 
from  intliinKntiliun,  62 
from  r>rf;anic  di^fJL£e,  62 
from  flpin«l  cnriw,  428 
&ciial,  64 

eociion  of  nerves  in,  68-66 
■itnalion*  of,  61 
BtreU-biii^  ulTovied  nerve,  6S 
•ymptoni*  of,  frO 
IreDimcDt  of,  o'2 
of  bladder.  10C>T 
of  breuit,  (lUH 
of  litp,  diugnoiis  tKta  Moro-Uiao  dia- 

ea»o,  440 
of  joinU,  SM 
of  tv«ti>,  II 10 
N«Mriti«ti'n')Xii>,B  nerve;  i'/m, denoting In- 

flammitlinu],  48 
NcuroTna  ii-ri'pov,  a  nerve),  88 
tniuniAtic,  60 
UftHtmont  "f,  10 
KicBti,  ran  fonn  of  bni«lip,  606 
2<ippte,  cracked,  (lt*6 


NippU  (conlinut^). 
ocaenia  t-f.  rtiW.  717 
intlnmmntion  nf.  fll*6 
n^lruL'tion  iif,  in  ranitT,  714 
supvrriijiiirrary,  <lit2 
Xocht,  «r<-«liiiii;    the    tciAiic    nvrra   fa 

»c'iati«'«,  •tiiti»lic»,  .V> 
X(>Ii-m&-Uiiit;c(v,  3U 
Normnn,     ligaturv     of     brae1iio-c«pliitllt 

Hrt<>ry,  212 
Kon-it.'slatiMka  of  compntieion  In   aooo- 
ri»Tn,  IC2 
■Uatitlici  of  ligaltira  of  «xtvnuil  itH 
i!48 
NOHB,  abfMH  of,  &1I 
acni.'  roHHcvn,  5SR 
abi  I'f,  n.»tor<^.  mt 
btM:-ding  from,  642 

trvatnH-nt  I'f,  643 
caleuii  in,  642 
catArrh,  chronic,  640 
column*  of,  trvton-d,  608.  608 
coliimitarpApilloina,  6&I 
di'iiH-ucil,  op'THtion  ftrr,  004 
di)".'n«M  ijf,  08* 
tpi'.hrti.inia  uf.  63B 
rxti-ma)  xRatrtioiW  of,  688 
fotid  di^bargit  fit'in,  641 
flMiilcitt*  oprniiig*  Into,  608 
fnltioiilar  bytwrtrupby,  ft40 

fviiurrtiwal  infliminntiun  (>f,  IMO 
Iponift  of,  AS8 

li)pu«  of,  639 

niitlignant  lumonof,  618 

nirvii"  iif,  101 

n..>«niiii»  of  Ixino*  of.  642 

pliutic  mirgrriF-  of,  608 

piilypj  of,  fKJO'.     Nre  I'olyplts 

rcJit  Drat  ion  of,  &!)H 

M-uluin,  iloriatiun  Ttf,  640 

Ihickenine  nf  nMrobninc  of,  641 

ulcwn  and  ttivtirra  or,  ail'.* 

waten'  (liecharvr  from,  MO 
Nueleui  of  calctih.  5»<*6 
Kannalvr,  intmorbilal  Bnirurinni,  IfOS.f 

upcration  for  reniovul  »f  tougWf 


OBLK^ITK    inguinal   hernia,   7a&    Sm 
Hamia 
Ohri't  case  of  obturator  bemia.  904 

trachM-tubc,  Q79 
Obatniction,  inicwtinal,807.    St*  IntMtinal 

Ob«tnicUoD 
Obturator  arterr      See  Arlny  | 

bomi^  808  1 

Ocdutivn  of  artvn<^.  119.     S*t  ArtCfim 
Oocupaiion,  inltiimci-  of,  r.n  hernia,  744 
(Ed«rna  (otiMu,  1  *wcllt  from  mirtic  anr 
rinn,  HS 
from  innnminalr  aneurism,  181 
of  larynx,  drxi-bagia  Tmm,  tJftT 
inflanmiBtury,  of  tcrotum,  ItMT 
OVb'TtiAiitii*  Ui^n^ltla, '167 
O'Gndy,     Irgutura    uf     bncbio-capbalia 
arUry,  213 


1 

J 


IN^DEX 


1191 


<Bbofbaou8.  dygjihiigia  from  foreign  bodies 
in,  n49 
dy^phapa  from  pressura  on,  648 
atricturc  of,  tj47 
citncorous,  60 1 
dia(;nu(iis  of,  6fiO 
fibrous,  fi50 
pastrontoiny  for,  fioS 
brstcricHl  or  sptk^iiiodic,  650 
treatment  of,  651 
(Ktlingen,  intraorbital  aneurism,  208 
Olecranon,  excision  of,  HHS 

enUr);ement  of  bursa  over,  481 
Ollier's    experiments   on    bone-producing 
power  of  periosteum,  ROl.  370,  409 
operation  fur  rhimiplai'ty,  <>03 
removal  of  naso-pharyn^^eal  tuaior,&17 
OuiHTuu  in  hernia,  741,'  74'2 
cyata  in,  773 

excision  of,  in  hernia,  773 
raanajrement  of,  773 
saca  or  apcrturt-s  in,  773 
Onychia,  34 
simple,  34 
syphilitic,  34 
Open  piles,  857 

Ophthalmic  artery,  ancuriiim  of,  206 
Opisthotonos  [b:riaSe,  backwards;  nivu,  I 

stretch),  63 
Optic  acuritis  fi-om  intracranial  aneurism, 

204 
Orbit,  aneurism  in,  206 
Orchitis  (bpx'^,  <^  testicle ;    UU,  denoting 
inflammation),  1101.    See  Testis,  in- 
flammation of 
syphilitic,  1124 
Organic  stricture  of  ce^^pha^us,  650 

of  urethra,  1043,  104o 
Ortbopiedic  (opWf,  straight ;  nat^eia,  educa- 
tion) surgerr,  498 
Os  calcis,  excision  of,  406 
OiMous  ankylosis,  1)60,  361,  472 

of  kne«,  61? 
OsTXiTis  [oorioi;  a  lH>n«  ;  iiig,  denoting  io- 
flammatii>n).  276 
affecting  cancellous  tissue,  280 

compact  tissue,  270 
chronic,  284,  286 

symptoms  i>f,  285 
treatment  of.  2><5 
defonoan^  -'85,  312 
osteoplastic,  283 
patbologv  of,  274 
rarefying,  275.  280,  302 
scrofulous,  2Kl 
treatnifntof.  riC.) 
OVTXO-AVEL-KIHM    .ooriin;  a  bone;    arieu- 
riam),  32il 
characters  i>f.  329 
diagnosis  of,  330 
ligature  in,  331 
of  humerus,  diitgn.>si-  fnmi  unourism, 

222 
situation  of,  330 
symptoms  nf.  ;';!il 
treatment  of.  3::i 


Osteo-cancer  (btnimi,  a  bone;  eaneer),  821 
Osteo-cephaloma  {bffriov,  a  bone;  nt^c},^,  % 

head)  321 
Osteoclasts,  270,  277,  288 
of  antrum,  576 
of  breast,  705 
Osteomalacia  (harinv,  a  bone ;  fUi?MKi(,  toft), 

317.     Sm  Mullities  ossium 
Ost«o-mycliti4(u(m(n',  abime ;  /A«A^,[mai^ 
row;  Hit,  denoting  infiammation), 
278 
acute  ditfiisc,  2711 
diffuse  septic,  289 
syuiptoms  of,  290 
treatment  of,  2yO 
idiopathic  infective,  279 
pathology  of,  278 
simple  acute,  278 
Osteoplastic  {oarim;   a   bone ;    trUoow,  ^I 
form)  osteitis,  283 
periostitis,  274,  284 
section  of  upper  jaw,  586 
Osteophytes,  274 
Osteoporositt   (oeriov,  a  bone;  srdpof,  paa- 

sage),  277 
Osteo-rhinoplasty  (o<rr^ov,  a  bone ;  />c'v,  th« 

nose;  TrJjiotnj,  I  form),  603 
Osteotonie,  Gowan's,  467 
Osteotomy  ^inrrim:  »  bone;  rifint,!  cut), 
antiseptic,  509 
linear.  28o 
Osteotrite  {o<TTiov,  a  bone;  rpi'ptt,  I  grind), 

299 
Otis,  eracuator  invented  by,  968 
internal  urethrotomy,  1061 
treatment  of  prx>long«d  gleet,  1085 
urethrometer,  10-X),  10t>l 
Otitis  (ott.  genitive  ur6i,  the  ear;  )/ts,^de- 

noting  inflammation)  externa,  588 
Otorrboea  (oiVi  genitive  iirog,  the  ear ;  fiiw, 
I  flow),  537 

OTA&IA.N  TCMURS,  1144 

diagnosis  of.  1145 
excision  of,  1147 
incisiiin  and  drainage  in,  1 146 
medical  treatment  of,  1145 
tapping  in,  1146 
treatment  of,  1145 
Ovaries,  al>scnce  of,  1140 

hernia  of,  1152 
Ovariotomy  (nr/jrium,  an  ovarv  ;  rimw, 
I  cut),  1147 
antiseptic  precautions  in,  1149 
mode  of  pcrformlni;,  1151 
after- treatment,  1152 
preparation  of  patient,  1I4'.> 
results  of,  1147 
Overflow  of  urine,  1006 
Oxalate  of  lime  calculi,  902,  906 
lithrotritv  in,  978 
deposit*  of.  ;«>» 

treatment  of,  903 
Oza'na  [i^u,  I  Mnell),  rr40 
sim|>le.  541 
stniniciu>,  541 
syphilitic,  541 


1192 


PACHYDERMATOUS  tomob  of  Bcaln, 
MO 

Paj|;el,SirJ.,  I)>>iiitn>  imdinnlignanl  tumore 
of  bone,  8^7 
daniiou  of  life  in  Kirrhus  of  Uiit  breast, 

716,728 
iDorened  l(^^gOl  of  Ihirm,  %12 
rtati>tic4  of  cnnc«T  ol  brcMt,  728 
Mtoltfs  dpformuni,  28G,  SU 
quiot  nwrosia,  SOS 
watery  dischnr^o  from  dom,  MO 
Pain  in  ancurUm  of  Bonn,  174 

of  innnniiniitc  utury,  181 
in  caIcuIu*,  9]0 
in  cBiiror  of  brw«»t,  714 
in  bip-joint  ditcasc,  448 
in  iiitrwcniniiil  uneun»in,  204 
in  ■jicn>-iUu(;(Lijit-aM.',  4.18 
PniiifUl  (;(inditionu  of  hl.idder,  1007 
lnnnim«rv  lumnr,  "1)7 
tubcuUDCDUi  tuticrcle,  SO 
Palatx,  hud,  flf4t]rt«  of,  617 
nncrvwi*  of,  (Wl 
pcrfunttvn  of.  419 
pUulic  fur^r^  of,  614 
aoft,  Auorasnf.  fJU 
Panonwlic  wrooma.  70ft 
rspillomatn  of  bladder,  1U07 
of  larynx,  fifi4 
ot  roctuui,  84u 
of  »kin,  4)t 
of  tnHKUe,  '1'24 
PfcmuuitGais    (t;apn,    liejroiul ;    avrhi,    I 

pierce).     See  Tapping 
Piini1.v«Uof  tiladd<>r,  1021 
of  faoial  norvp,  67 
of  larjux,  6«4 

of  muscles  of  limb.  re<l«x,  S38 
deformiij-  from,  40(1 
from  ititracraiibl  an«urinii,  204 
infunlik,  4^6 
theumaiic,  AS 
traumntic,  ti7 
pA.UArtiiuoBiH    (to/m),   beyond;   pif^,  » 
miiEzlo),  1091 
treatiuenl  r.f,  1001 
Pnraplei^iii  from  cunaturo  of  epiao,  426 
pAmsitk  cvBt  of  brmst,  703 
Park,  cxcUion  of  ths  knr«<joint,  8Q7 
Pfuker,  lit*atiireur  botb  c&rvlida,  lOQ 
Parker,  H.  W.,  nneurism  in  voung  enfa- 
jecU, 123 
automatic  retnotor,  fi7a 
CM<*  of  Cttric»  of  opine.  4'24 
Parker,  Itu*btnn,  cwxiiitHivcv  of  adanoma 
and  I'sjvmunia  in  ibu  aame  br«ui, 
71B 
embolic  nrteriti*,  lOU 
»mcbea-tubo,  680.  fl82 
Parotid  (jlavu,  diticawsor,  &&& 
exciBi'in  of,  My 
JDlliiinmaiiiiii  nf,  656 
tuiuun  of,  66G 

dinifDocb  of,  557 
niHlijjuanl,  65* 
Lrentioent  of,  6fl8 


PnrvtittG  (nup£/Tt^,  tbe  parotid  gland ;  Wa, 

donolitij>  inflatnmuionl,  666 
I'atki.i.a,  di*<>«M  of,  4*8 

dittafie  vC  buna,  478 

ncci-o*!*  of,  an 
I'atiliiK  .1{)>ineUi.  reaction  ot  bono*,  ft 
Pcncock,  esperimenU  on  utorMB,  LIS 

Moculalcd  aneurism,  TM 
\'6aa,  exeUion  of  pylorus,  SW 
Pfldiclo  of  ovarian  tumor,  manaMSient  > 

1)49 
ri!l1i<tnii,  niK^urinmal  tumon,  182 
Pelvic  !icrtii!i>,  803 
I'KLTiB,  ditfut«  cfllluiitis  of,  U4I 

diaenositt  from  saorO'lUae  dt»- 
MPO,  441 

in  hip-joint  cli««aM,  454 

nccriMii  of,  4<i4 

ricki't>  cf,  a>iiiplicatin^  litlintuiny,  < 
I*«lTis  vi  kidney,  «eo:>i>dury  di«>e«s>B  of,  ' 

M'plic  mutter  in.  ^^3 
PoBi^ru,  rtariftio  of  eiciMon  of  knee, 
Penile  liot'ilm  lOTB,  1080 
Pk^u,  adliofion  of.  to  Minium,  It 

Am  puliation  nf,  lOWt 

cfto<:er  wf,  10!t4 

disearca  of,  1085 

ftncyftrd  tumor*  in,  1089 

eiiil  lieliorim  of,  1095 

fibruus  tumor  of.  lOM,  1097 

Itittulaiii.  lOTIt,  1080 

giitign'n<."  nf,  ITOS 

eunorrhii'ul  imlumlioa  of,  1088 

Yierpfa  of,  10»2 

humy  excresveooea  oo,  1093 

indamTiiatioD  of,  lOOS 

uialformalions  of,  H)60 

nwvufi  of,  103,  10l"7 

nmoral  of.  by  c^lnuue  finrawm,  1( 

warU  oQ,  1098 

wounds  of  doiml  utcry  of.  In  ttlb* 
otomy,  dSft 
Popper,  l)r.,  tapping  pulmonary  cavity .CBO 
P«rchlvrid«  of  iron/  inj(<ctiaa  r»f,  in  aaea- 
TiMn.  170 

in  eluieal  aiMiiTiRB,  2M 

in  hemorrbocWdiatiieiia,  10? 

in  intraorbital  aneurism,  210 

in  nvTiu,  M 

in  varix,  00 
I*ercu<.MoD  in  iiiinttinnl  i>h>tructkin,  B14 
Perfontiona  in  pnlale,  CI9 
Poriarteritis,  118 

a  cauM  of  apoplcxT,  IIQ 
Poricardiiini,  tiippiiic  thv,  flSl 
Purinuuin,  Iiiwnili'in  of,  with  nctn-VMBBal 
B»liiln.  848  

wound*  uf  ■rtiTMTO  uf,  9S5,  M 
Puringa)  aliscui,  I07ft 
forms  of,  107A 
tretttmiml  of,  1077 

fl'tiila,  U>;8 

brntia,  tWi 

incikion  in  impvrforata  ■Tins. 

liilitilritr.  b'.i 

npi^lrahillty  nf,  fl74 


I 


INDKX. 


119S 


Perineal  lithotrity,  ronulu  of,  974 

»cctii>n  for  stricture,  1084 
Perinephritic  abpc««a,  429 
Periimeiirn,  inflammHtory  pri>c<^8es  in  the, 
•>:•>,  273,  283,  304 

rrgenenition  of  bone  by,  304 
pRBlOoTITIs  { pfrioateiim ;    ifig,   denoting 
inllnmmation),  273,  2B3 

nsiwipln-itic,  274 

Btmplo  aculo,  273,  283 

sitpptinttirc,  273 
rhr>mic,  275 

typbililic,  276 

BymptoniB  of,  283 

treatment  of.  284 
Peripheral  necmsiB.  801,  307 

nervouB  irritation,  deformity  from,  496 
PerilyphliiiB,  diagnuBis  of,  from  acute  bip- 

disease,  456 
Peritoneum,  prolongation  of,  in  descent  of 
testes,  i90 

wound  of,  in  lumbar  colotomy,  829 
PemTOSiTis  {peritoneum;  itiB,  denoting 
inflammation),  with  hernia, 750,  757 

after  abdominal  operations,  735 

after  hernia  operationi,  768,  7ti9 

after  lithiitomy,  943 

diaiznosig  from  intoivtilial  nephritis,910 
Perknw#ki,  treatment  of  twteo- myelitis,  291 
Petit'*  operation  in  hernia,  778,  779,  780 
Pharvni;otome     {^ipf}^,     the     pharj'ni; 

r^,in«j,~^I  cutl,  047 
PHA.RTNX,  aluiceM  behind,  646 
dyBpha^^ia  from,  648 

disMBeB  of,  64fi 

epithelioma  of,  647 

inflammation  of,  046 

polypi  in,  647 

aysphacia  from,  647 

tumors  of,  C47 

behind,  dysphafria  from,  648 
pHiuositi  i^/itK.  a'  muzzle),  1087 

acquired,  HW8 

conirenital,  1088 

circuni(.'i>tion  for,  1089,  1090 

dilaUtion  in,  1089 

Bliitin);  prepuce  for,  1089 
Phlebitis  (ft^'V',  a  vein;  His,  denoting  In- 
flammation], 83 

causes,  8.1 

diacnoni*  from  Irmphangitis,  69 

diftiiw,  H4 

idiopathic,  84 

pathi>lo);ical  anatomy,  84 

(ipreoilini;  pfptic,  8'i 

Bymptumx  of,  K4 

traumatic,  83 

tn-utmont  "f.  8'> 
Phosphatic  calculi,  903 

favorable  for  lilhotrity,  978 

dep««iu<,  '.K13 

treatment  of,  904 
Phnsiihorus,  ne<'P>Hia  of  jawn  from,  571 
Phthisis  omplicatine  R«tuln  in  ano,  8r>5 

with^tru[ni>o>j<<inti',amputationin,415 

laryngeal,  Ci:3 


PiLfts,  blind,  857 

caufie*  of,  exciting,  8r>9 

predispoding,  857 
caustics  in,  8t>9 
coagulation  in,  8<i3 
complications  of,  868 
constitutional  management  of,  864 
crushing,  808 

dangers  attending  operations  for,  869 
diagnosis  of,  8<i8 
excision  of,  866 
external,  857,  860 
fleshy,  860 

galvanic  ^raseur  in,  868 
globular,  861 
hemorrhage  from,  861 
diagnosis  of,  864 
treatment  of,  864 
internal,  657,  660 
intero-esternal,  867 
ligature  of,  866 
longitudinal,  860 
open,  8'i7 

removal  by  fralvanic  ^raseur,  868 
sphacelus  of.  SIJS 
structure  of,  859 
subsidence  of,  863 
suppuration  of.  863 
symptomf  of,  861 
■    terminations  of,  863 
treatment  of,  864 

local.  86.-, 
vaginal,  1141 
PilE,    statistics    of    ligature    of    carotid, 

195 
Pimbet,  cases  of  obturator  hernia,  803 
!  PinigofT,  lisature  of  carotid  for  innomi- 
I  nato  aneurism,  184 

ligature  of  both  carotids,  196 
;  Piston -trocar.  ^84 

[  Flaster-of'Paris  bandage  in  spinal  disease, 
j      432-434 

Plastic  (^/liaau,  I  form)  sUHaERT,  694 
of  evelid*,  'i»T 
of  face,  594  • 
j  of  ]}}•»,  604 

of  ni.se,  51*8 
{  of  palate.  614 

of  vagina. 1141 
Plxitra,  inllamniation  of,  after  ligature 
of  PulH.-liivian,  227 
tappini;  ihv.  I1H3 
PIpuro»lhol'>no*.  63 
Pliers,  cuttini;,  3(17 
Plugging  noiitrils.  644 
,  Pnci'mosia,  conite*tive,  after  ligature  of 

canitid  artery,  19H 
I  ot  subclavian  artery,  230 

Polaillon,  rcrults  of  exciiion  of  oa  calcia, 
409 
'  Poland,  cure  of  subclavian  aneurism  by 
I  digital  compression.  211 

sUtistics  of  subclavian  aneurism,  210, 
'  216 

I  statistics  of  tetanuK,  61,  62 

I  Politzer's  bag,  634,  537 


1194                                                              INDEX. 

Pollock,  ligature  of  carotid  and  subclaviaa. 

Pbolapbu 

186 

of  ton 

operation  for  ataphyloraphy,  617 

of  va^ 

removing  piles  by  crushing,  868 

PB08TATB 

Polypoid  tumora  in  urethra,  1084 

St 

POLYPOS  of  antrum,  576 

CI 

of  bladder,  1009 

CI 

in  ear,  637 

di 

fleshy,  54j,  546 

in  frontal  sinuses,  651 

in  larynx,  665 

di 

oasal,  545 

flbrouB,  546 

di 

malignant,  548 

ei 

mucouG,  544 

removal  of,  546 

pharyngeal,  647 

dysphagia  from,  647 

of  rectum,  845 

diagnosis  from  piles,  864 

uterine,  1143 

in  vagina,  1141 

Foore,  treatment  of  ozicna,  641 

Popliteal,  aneurism.     See  Aneurism 

Porta,  mortality  after  ligature  of  arteries. 

147 

Portal  circulation,  retardation  of,  a  cause 

fil 

of  piles,  859 

Posthitis  {Trdodt!,  the  foreskin  :  itia,  denot- 

h< 

ing  inflammation),  1092 

in 

Pott's  disease  of  spine,  419 

di 

in  adults,  425 

in 

in  children,  424 

Pregnancy  complicating  hernia,  768 

effect  of,  on  cancer  of  the  breast,  726 

mollities  osi^ium  during,  318 

strangulation     of     umhilical     hernia 

si 

during,  802 

tu 

Peepdce,  circumcision  for  disease  of,  1089 

tu 

herpes  of,  1092 

hypertrophy  of,  1093 
inflammation  of,  1092 

Prostatic  c 

cathet 

slitting  up,  for  phimosis,  1089 

Prostatitis 

Pressure  in  aneurism.     See  Compression 

indi 

Pressure- effects  of  aneurism,  130 

in  gon 

of  aorta,  173 

Prostatorr 

of  innominate  artery,  181 

101  f 

of  inlrhcraniHl  aneurism,  ^3 

diagni 

obstructions  to  flow  of  urine,  877 

113^ 

Preston,  li(^ature  of  both  carotids,  196 

Pruritus  a 

Priapism  from  calculus,  911 

870 

persistent,  1093 

Pseudo-pa  1 

Price,  statistifs  of  excision  of  knee,  401 

Psoas  absc 

Probang  for  larynx,  IJ60 

di 

Probe,  Savro's  vertebrated,  297,  447 

Proctotomy,  843 

Prolapsus  {Lot.  a  falling  forth)  of  anus, 

tu 

870 

Psoriasis  o 

from  calculus,  911 

Ptosis  {rrr€. 

causes  of,  870 

aneurisn 

diagnosis  of,  871 

Pudendal 

from  piles,  804 

Pudic  arte 

ligature  of,  872 

Puerperal 

treatment  of,  871 

Pulmonar; 

of  reciLini,  872 

ope  rat 

of  tongue,  (iiy 

trocar 

IKDBZ. 


1195 


Puluting  bronchocele,  668 

diagnusi*  fVom  carotid  an«uriam, 
191 
tumors,    diaKnoais    from     aneuriim, 
134,  381 
of  bone,  320.    Set:  Oateo-aneurism 
dmt^nosis,  030 
situation,  830 
srmplom.t  of,  880 
treatment  of,  831 
of  groin,  diagnoais  of,  833 
Pulsation  of  aneurism,  182 
of  aortic  anenrism,  177 
recurrent,  aft«r  operation   for   aneu- 
riam,  147,  150,  151 
Pula«  in  innominate  aneurism,  181 
Puncture  of  bladder  above  pubes,  1024, 
1078 
through  rectum,  1025, 1072 
PuTKBtivcs,  piles  caused  b;  habitual  use 

of,  869 
Pynmia  (rfiw,  pua ;  aliia,  blood),  arthritis 
from,  341 

fonorrhceal,  IMl 
iagnosis  from  interstitial  nephritis  886 
in  urinary  diaenres,  874,  8B8 
Pyelitis,  calcuiou',  890 

diagnosix,  894 
Pyelo-nephrilia,  879 
Pyloru*,  excision  of,  for  cancer,  828 
Pyonephroais,  891 


nUINST,  642 


RABE,  Btatistics  of  ligature  of  eiternal 
iliac,  248,  249 
Race,  influence  of,  on  hernia,  744 
Kadial  artery.     Ste  Artery,  Radial 
Radical  cure  of  hernia,  74ft-761 

of  varicocele,  1117 
Radius,  exctfiion  of,  .187 
RansohoflT,  removal  of  tumor  of  bladder 

by  lateral  cystotomy,  1010 
Ranula.  fi40 
RecUl  fistula.  846 
Rectangular  Riaff,  945 
Rect'>cele  I rr'-Zum,  the  straight  intestine; 

t^yjj,  a  tumor),  1141 
Recto-vaginal   {rectum,  the  straight  intes* 

tine  ;  vapiiia)  fistula,  84T 
Recto-vesical    Irretum,   the  straight  intes* 
tine  ;  vesiftt,  the  bladder)  fistula,  84G 
lithotomy,  943,  9r>2 
Rectum,  absence  i>f,  835 

arrangpnient  uf  vuina  of,  857 
atony  of,  8.11 
cancer  of,  840 

excision  of  lumor,  848 

results  of  optrration,  84-5 
treatment  of,  842 
cauliflower  growth  of,  841 
fistulous  opening!)  into,  846 
gonorrbopa  of,  1(M0 


Rectou  (continued). 
invagination  of,  878 
malformations  of,  834 
occlusion  of,  by  septum,  834 
opening  into  other  canals,  637 
papillomata  of,  845 
piles  caused  by  disease  of,  859 
polypi  of,  845 

diagnosis  from  piles,  8G3 
prolapsus  of,  878 

treatment  of,  873 
puncture  of  bladder  through  the,  1026, 

1072 
•arpomat*  of,  845 
stricture  of,  flbroua,  838 
treatment  of,  889 
malignant,  840 

treatment  of,  842 
syphilitic,  840 
wound  of,  in  lateral  lithotomy,  988 
in  median  lithotomy,  947 
Rectum-dilator,  839 
Recurring  sarcomata  of  breast,  711 
Reducible  hernia,  744.     See  Hernia 
tumors  of  groin,  833 
of  scrotum,  1131 
Reflex  irritation  of  kidney,  882 
Regnoli's   operation   for  excision  of  the 
tongue,  634 
-  Reid,  treatment  of  popliteal  aneurism  by 
bloodless  method,  165 
Renal  calculus,  889 

tumors,  diagnosis  of,  898 
Repair  of  bone  after  excision,  870 
after  necrosis,  ,304 
of  jaw  after  removal,  572 
in  divided  tendons,  499 
in  joints  after  destruction  of  cartilage, 
344 
I  Resection.     Se/'  Excision 
Retention  uf  urine.     See  Urine 
Retention -cysts  of  breast,  702 
Retraction  of  nipple  in  cancer,  714 
Reynolds,  ligature  of  carotid,  196 
Rheumatic  arthritis,  437 
acute,  342 
chronic,  853 
paralysis,  ■%8 

treatment  of,  58 
I  synovitis,  treatment  of,  844 

.  Rheumatism,  diagnosis  of,  from  aneurism, 
136 
from     caries    of    spine, 

428 
from  hip-dtsease,  456 
'  from  osteomalacia,  819 

I  gonorrhfpal,  1040 

I  Rhinolitha  in  the  nasal  fosssp,  542 
;  Rfainoplastic    operationa    {ftiv,   the    nOMj 
T?.ii(iffu,  I  fnrml,  698 
modiflcatioiis  of,  603 
'  Ribs,  necrosis  of,  811 
RiCKETtt,  313 

cause*  of,  318 
j         dentition  in,  815 
'         diagnosis  from  osteomalacia,' 31 9 


1196 


IKDEX. 


RlCEKTS  {eontinuftl). 

of  pelvii!   lii>n«i,  cotnplicstiog    lUh' 

otoniy,  962 
patbt>]ug;v,  3iS 
|)rt))(r«M  «nd  |ir<)KniHti,  316 
Bj'inpt'imd  of,  Hi 
IrfBliiionLof.  810 
Rickety  rooury,  $14 

Rlrard,  treattn«ni  n(  urinary  fistula,  1060 
Jti|;ori  frotii  calh«teriiiu,  1064 
Uihui  varxJonicDB.  OS 

Kivingt'tfi,  cMefl  of  intranrbita)  aneurUm, 
207,  2m 
digilai   com  pros  ion    ami    lit^iLuro   of 
cotDint'O    carotid    in    intraorbital 
■iietiriiui,  210 
Robort,  ligature  uf  both  cnrotid*,  196 
Bobinaon,  period  of  uL-curronco  uf  i«tsnui, 

0*» 
Bodoot  ulcer,  89 
diagnofla  of,  41 
(lalhnliijjy  of,  41 
■ymptoou  of,  40 
trMtm«ni  of,  42 
"Rouge  of  lAuianne,  diicilal  cooiproeitoo 

in  carotid  aneurism,  IM 
Roiix.  atiipu[atK>n»  in  i>«u>oniyeliti<,  291 
UurrCKK  of  Kiieuri*m,  188 
axillaiy,  :^1 
intrafrnnial,  205 
|i<ifi1l»al,  'iA7 
art«riGs,  Bpoiitaneouc,  119 
Bjrdjgier,  encislon  of  pjloruf ,  S28 


SAC  of  bernia,  739 
luoltic  fluid  in.  743 
changea  of  diiid  in,  766 
expuaurauf,  7(13 
foreign  bodies  in,  742 
hydrocele  Af,  741 
(HkenioK  tbe,  T04 
■Touglilue  vt,  775 
suppuration  in,  766 
lreHliiienl.of,  7li« 
SuxmlMod  iinennini.  i'i'i 
■"    blftddcr.    Sef  llludder  and  Lilhotomy 
Sack,  rMulto  of  aniit«|ilio  ireatmeai  after 

'flxeiskiH  of  knM,  401 
SaoO'Iliac  joikt,  diicase  nf,  437 
diaKnoflii  of,  44i> 
pathology  of.  i'-il 
prcignuais  of,  440 
uTinptom*  ofj  438 
treaiin^nt  of,  ii'i 
Smv  In  om^ntlln1.  778 
Salirar7  calculi,  »4I 

Cilutn,  ^'<1 
8&ii^i>lne<>uR«<ysU  of  breaM.  711 
Santuii,  ru4!ti>-re«iral  lithotomy,  952 
Saphena  vein,   varix  of,   diagntiEis  fyom 

femoral  bcrnta,  TIM 
SAKochCKi-X  {oap{,  flwh;  «(>v,  a  tumor), 
lllv 
critic,  1126 
<nKKnu«>>or,  112S,  1IS2 


8aiicocki.ii  (MittmMd). 
malisnant,  H!28 
iimpTe,  1119 
ayphihtic.  Ill».  1124 
tuUrciitar,  I  UN.  1121 
Sarcoiu  tffApf,  fleali),  alvfeolar,  of  •Ub,  ' 
44 
nf  antrum,  57C 
of  axilla,  784 
ofbliwlder.  1009 
of  biraxt,  710 

irMtmBttlof,  711 
central,  nf  Ixine,  Ki9 

tliugnwiFf"""  '■l>">nicoat«itii! 
uxi  :  ■-,  926 

fttjiii  .1  ,  327 

cyttio,  of  br«ut,  7o6 

iimgnttit  from  cyatic  caBCW, 
7I« 
of  tmtii.  1126 
in  mutolc,  487 
tnelaoMic,  44 
nycloid,  in  bonm,  827 
of  lower  jftw,  ISH 
of  naso-nrbtUI  rpgion,  bSO 
of  noso,  548 
of  upper  jaT,  bid 
of  ubenm,  1144 
uf  parotid  slawJ,  557 
puhfltin^;,  diainioxis  trom  anenriim  at] 

ilinc  nrtprv,  244 
pcrioGtoiiI.  325 
■cooDdarr,  of  bf>n«,  329 
of  tmb,'ll27 

Mft,  diagiuuis  from  aneurism,  184 
apiiidleK:«ll(>d,  in  hou«t,  312 
Iti  ikin.  44 
Baranmaiou^  P^'yPt  ^'*^ 
Saw,  ltiitrbiT%,  3.1 
for  iiwnrti*,  SOT 


Sayre,  nppamiiu  for  bin-joint  dfaeaM,  4G0 
diviiiiiiti  nf  neck  or  t«inur,  473 


exte'iiion  aflvf  divifion   of   tendons, 

499 
indicAtiona    for  dividing    lendoB 

Qwoia,  840 
operation  for  angular  aakyloab  of  Up, 

478 
plaatar-trf- Parts  bandae*  in  stnoal  di»> 

nue.  432-484 
BtAllitics  of  «xci»ion  of  hip,  4*^8 
verlebntcd  probe,  297,  447 
Scalp,  diieasca  of.  630 

nwTua  of,  100 
Scftlpeb  for  litbowmT,  917 
Bcaplioid  bohp,  ciciaion  of,  418 
ScAPCi-A,  excUlon  of,  878 

necMfts  of,  878 
Scar     .*Mr«  Cicatrix 
Scortot  lever,  arttiriti«  in.  841 
ScHrmmtixm,  diRiul  compreMiOD  in  lab*- 

orbilitl  aticuriiini.  210 
Sobneiderinn  in«iRbrano,  UiiokcniiijE  of  iba, 
641 
din(;i>o«i«  fh>ni  poljrpoi,  H 
Sciatic  artery,  aneurism  of,  354 


'4 


INDEX. 


1197 


Sciatic  (eontinued). 

hernia,  803 

nerve,  strerchiiig  the,  in  sciatica,  00 
Sciatica,  48 

diagnosis  from  Mcro-iliac  disease,  440 

treatment  of,  49 
Scirrhous  wart,  44 

SciRHBUs    (cr«'j'/>of,  «  hard    swelling)  of 
breast,  711.     .See  Breast 

of  prostate,  ICJG 

of  rectum,  841 

of  tongue,  62o 
Hciis<ir-1  egged  dcformitr,  47a 
Sclenisiit  (oK/j/fiof,  hnrd)  of  bono,  812 
Sclerotitis,  gonon-hwa),  1040 
Scoop,  lithotomy,  918 
Scult,  dressing  of  inflamed  joints,  8-16 
Scraping  in  lupus,  39 
Scrofula  a  predisposing  cause  of  necrosis, 

800 
Scrofulous  kidnev,  891 

osteitis,  281 

t*-sticle,  1121 
ScroUl  Ustula,  1078,  1079 

urethroplasty  in,  1079 

hernia,  788 

tumors,  general  diagnwis  of,  1131 
Scrotum,  adhesion  of  penis  to,  1086 

diagnosis  of  tumors  of,  1181 

diseases  of,  1097 

elephantiasis  of,  70,  1097 

epithelioma  of,  1099 

hypertrophy  of,  1097 

innammatory  oedema  of,  1097 
Scurvy,  rickets  and,  816 
Searcher,  lithotomy,  918 
Secondary  aneurism,  149 
popliteal,  '26') 

rest^tion  of  jnints,  378 
Sedentarr  life  a  prediepxsing  cause  of  piles, 

858 
Sfdillot,  excision  of  tongue,  686 

gaolrostoniy,  6il2 

operation  for  staphyloraphy,  6o3 
Sediments,  urinary,  90U 
Seminal  flux,  1133 
Senile  arthritis,  344 

gangrene,  120 

necrosis,  301 

osteoma  iHkia,  933 
Septica<mia  after  alKlominal  operations,  73o 

in  urinary  diseases,  87.'i,  88^ 
Septic  matter  in  pt^lris  of  kidney,  efiects 
of,  »m 

pneumonia,  a  cau«o  of  death  in  exci- 
sion of  tongue,  638 
Septum  cninile,  rtrlation  to  femoral  hernia, 

.98 
Septum  of  norc,  aliscesa  of,  diagnoi^is  f^om 
polypus,  546 

lateral  dr-viation  vf,  'A<t 
Sequestrum  {/,af.  a  thing  deposited),  301 

removal  i>f,  l>y  natural  process,  SOU 
by  ii[)cniti<in,  306 
Sero-cystic  sariM-inu  of  breast,  706 
Serous  cysts  of  tirt'a>t.  7(K) 


Serous  collections,  diagnosis  fVom  spinal 

abscess,  430 
Seton  in  bronrhocele,  564 
in  hydrocele,  1110 
in  varix  of  lymphatic  vessels,  70 
Sex,  infiuence  of,  on  aneurism,  128 
on  calculus,  909 
on  cancer  of  breast,  717 
on  hemorrhoids,  858 
on  hemia,  743 

femoral,  706 
on  lupus,  37 
on  mollitiea  ossium,  318 
on  piles,  8.'>8 
on  spinal  curvature,  491 
Sexual  melancholia,  1188 

treatment  of,  1186 
Shock  a  cause  of  death  in  abdominal  operv 

tions,  737 
Shoulder-joint,  dry  chronic  rheumatic 
arthritis  of,  358 
excision  of,  373 
Sibley,  statistics  of  cancer  of  braast,  728 
Sight  affected  by  intracranial  aneurism, 204 
Silver,  nitrate  of,  in  laryngeal  disease,  660 

in  spent) atorrhtea,  1135 
Simon,  Oustav,  extirpation  of  kidney,  897 
Sims's  catheter,  1088 
Sinus,  frontal,  disease  of,  5oI 
in  caries,  297 
in  hip-di'ease,  447 
Siphon-tmcbar,  685 
Skin,  diseases  of.  35 
cancer  of,  44 

implicated  in  cancer  of  breast,  718 
gonorrhrpal  eruptions  of,  1041 
transplantation  of,  595,  598 
Skull,  disease*  of,  TiSO 
ftmgus  of,  .'»30 
necrosiH  of,  310 
Slouobiko  of  aneurism,  187,  162 
of  bursa  patella.',  479 
of  hemial  rac,  775 
after  lithotomy,  948 
Sloughy  ulceration  of  gums,  568 
Smallpox,  arthritis  in,  341 
Smith,  U.,  operation  for  piles,  868 
clamp,  868 

seat  of  urethral  stricture,  1046 
Smith,   J.    L.,   cases    of   intussusception, 

818 
Smith,  >'.  K.,  lilhottime,  927 
EJniith,  K.  W.,  intracranial  aneurism,  202, 
20;i 
rheumatic  arthriti*,  3.Vi,  357 
unprecedented  case  of  neuroma,  '>9 
Smith,  T.,  acute  arthritis  of  infanu,  344 
gag  for  operations  on  mouth,  615 

WihkI's  modification  of, 
615 
Smyth,   ligature  of  brachio-ccphalic  and 

vertebral  arterie*,  151,  218,  215,  221 
Softening  of  bone,  279 

of  hrain  fmm  intracranial  aneurism, 205 
Soft  poiypuD.  544 
S>rc  throat,  clergyman's,  659 


1198 


INDEX. 


Bounding  for  stone,  912 

errors  in,  916 
Bounds  for  lithotumv,  912 
for  lithotrity,  9-^6 
for  urethral  stricture,  lOoO 
Bouth,  ligature  of  abdominal  aorta,  252 
Southey's  drainage  trwar,  8:^6 
Bpanton,  ankylo«ig  of  jaw,  592 

operation  for  hernia,  760 
Spasm  of  bladder  in  lithotomy,  982 
Spasmodic  contraciioo  ofsphiDcterani,  861 
croup,  fS64 

sperniatorrhcea,  1135 
stricture  of  a»ophaguB,  650 
of  urethra,  1048 
Bpeculum  ani,  84'J 
duck.billed,  1082 
nasal,  539 
vaginip,  1137 
Speech  after  removal  of  tongue,  689 
Spence's  amputation  at  ahoulder-joint,  875 
for  subclavian  aneurism,  220 
Spermaspasmos     (oztpiia,    seed;     inrda/wt, 

contnii^tion  or  spasm),  1135 
B7ZBUA.TIC  CORD, division  of,  incaatration, 
1129 
h  hematocele  of,  1114 

diagnosis  fVom  hernia,  7f)7 
hydrocele  of,  1113 

diagnosis  from  hernia,  787 
difl'used,  1118 

diagnosis  of,  1132 
inflammation  and  abscess  of,  1104 
relation  of,  to  hernia,  784 
vnrix  of,  1115 
Sperm atorrlicea  {(j^ep/ia,  genitive  OTripfiarot, 
seed  ;  ,Vt<J,  I  flow),  1133 
BpHsmodiu,  1135 
true,  1133 

dingnusi^  of,  1134 
treatment  of,  1134 
SpermiitoKOH  in  fluid  of  encysted  hydro- 
cele, 1112 
Sphacelus  (o^i«/j3f,  gangrene)  of  piles,  863 
.S|ihen"id  bone,  tuiniirs  growing  from,  586 
Sphincter   mii,  spasniodic  constriction  of, 

8ol 
Spina  bifida  [L'lt.  cieft  spine),  416 

venlosji,  321 
Spinal  cord,  |)aral_vi-is  from  injury  of,  57 
patln^logy  111',  in  lotaniis,  65 
treaUneiit  of,  417 
SriNK,  ni)giilnr  ctirviituni  of,  41'J 
caries  vf,  ■H'.i 

«lJ^t■(■ss  in,  426 
diaiiiiiisis  uf,  42S 

IVi'iii  .■^aoro-iliac  disease,  441 
panipletiia  I'ruii),  42il 
piillic>l.i;:_v  .if,  419 
liri'irnnsis  of,  4^50 
fyiiipl.iiiis  nf,  424 
tn-uiiiUTii  (jf,  4:il 
disiiws  (if,  4!';,  437 

in  ciTvii'iil  reirion,  43."! 
)ilii--t'T-iir-]'ai  is  baiiilnirc  in.  432- 
4:14 


Spimx  (eontinued.) 

lat«ral  curvature  of,  489 
causes  of,  490 
diaj^nusis  from  bip-di*a 
mechanical  contrivaiu 

494 
mechanism  of,  490 
signs  of,  491 
treatment  of,  492 
posterior  excurvation,tr«kUtMni 
incurvation,  treatment  of. 
Pott's  disease  of,  419 
strumous  osteitis  in,  424 
tubercle  in,  42u 
tumors  of,  487 
Splay  foot,  525 
Spleen,  extirpation  of,  831 
Spongy  exostuiiis,  S19 
hypertrophy,  312 
ulceration  of  gunu,  508 
Spontaneous  aneurism,   rarity    of, 
axilla,  23T 
htematocele,  1113 
Squamous  epithelioma,  44 

of  carotid  arterv,  166 
of  penis,  1094  ' 
Square's  operation  for  loose  cartilag 
Staff  for  Itihotomy,  917 

rectangular,  945 
Slaphyloraphy  (oto^j^,  a  bunch  of; 
the  tonsiU;  pdirru,  1  sew),  til 
Fergusson'a  operation,  tilti 
Pollock's  operation,  617 
SMillot'a  operation,  617 
;  Sterility  in  the  mule,  1136 
Stevens,  ligature  of  internal  iliac,  : 
Stimson,     ligature    of    carotid     am 

cittviaii,  1S5 
Stocks,  protrusion   of  ovarian  cyst 

anus,  f74 
Stoker,  ligature  iifHUlominalHuria,: 
Stone,     Dr.    \V.     II.,    pre»suiv-«lfi 

aueuriam^,  130 
Stone  in  bladder,  vO'i.     See  C'alculu 
congenital,  90y 
in  kidney,  Sf-'J 

dia^iioris  of,  from  caries  ol 
428 
Storks,  tapping  pulmonarv  oavilv. 
Strangulated  hernia,  7.".3.'   See  iier 
Strangulation  removal  of  ti>ni;ue  b> 
Strangury     ^or^;,-,    drop  :     oi,mi  , 
9'J3 
in  gonorrha'a,  103<'i 
Strapping  the  testicle,  110:i 
Stkictukk,  an»>sthi-ii(»  in,  li>iT 
bougies  for,  ]i.).j2 
in  hernia,  754 

of  w:4opbagus.     See  iH>ophai;ui 
of  reetuni,  837 

of  urethra,  1042,     Se£  Urethrs 
caustics  in,  1058 
Strumous  arlhritis,  348 
of  hip,  451 
constitutions,  caries  in.  294 
diseases  of  axillnry  i;lands,  738 


INDEX. 


1199 


Strumous  oznnt,  541.     See  Scrofuloiu  en- 
largement of  gUnds 
Styptics  in  hnmuphilia,  107 
Subclavian  arterv.  &«  Artery,  subclavian 

vein.     See  Vein 
Subcutaneous  injection  of  ergotJn  in  aneu- 
rism, 171 

injection  in  neuralgia,  62 

nKvi,  94 

section  of  neck  of  femur,  472,  478 
of  tendons,  498 

tubercle,  painful,  59 
Submammary  abscess,  69G 
Submaxillary  tumon,  removal  of,  561 
Submental  excision  of  tongue,  634 
Subperiosteal  excision  of  os  calcis,  408 
Supernumerary  breasts,  692 

fingers,  oOo 

nipples,  692 

toes,  riL>9 
Supinator  muscles,  paralysis  of,  506 
SurPDBATiOM  of  aneurism,  137,  153 

in  axillary  aneurism,  230,  338 

after  ligature  of  subclaTian,  280 

in  carotid  aneurism,  194 

in  iliac  aneurism,  '2iS 

in  antrum,  573 

of  bone,  273 
diffuse,  278 

of  breast,  696,  700 

of  bursa  palelln,  478 

of  buraic,  478 

in  bernial  sac,  756 

in  hip-joint  disease,  446 

in  joinu,  337 

of  kidney,  879,  885 

of  piles,  8<;3 

in  sacro-iliac  disease,  489 
See  also  Abscess 
Supramammary  abscess,  696 
Suprapubic  lithotomy,  948,  952 
in  women,  988 
indications  for,  981 
Surgical  sole,  526 

Sutton,  arterio-capitlary  tlbrosis,  118 
8tjtohb«,  button,  1064 

ID  harelip,  608,  610 
Swain,  results  of  excisions  of  It  nee-joint, 401 
Symc's  disarticulation  at  ankle-joint,  404 

operation  for  contraction  of  lip,  613 

ojicration  for  stricture,  1064 
SynoTJal  membrane,  disease  of,  47ft 

destruction  of  cartilage  from, 
246 
of  foot,  505 

inflammation  of,  832 
Stkotitim  (fynovial  membrane;  iHt,  de> 
notini;  inflammation),  332 

acute,  8.13 

cause*  of,  332 

chronif,  'A'AA 

pathology  of.  3.12 

rheumatic,  33'> 

symptoms  of,  883 

torminatixn*  uf.  :{33 

treatment  of,  334 


Syphilis  as  a  predisposing  cause  of  athe- 
roma,  113 
of  necrosis,  800 
Stpbihtic  caries,  277,  295 
gumma  in  tongue,  628 
diagnosis  of,  628 
treatment  of,  624 
laryngitis,  662 
necrosis,  300 
orchitis,  1124 
onychia,  34 
ozicna,  541 
sarcoeele,  1124 

diagnosis  of,  1126 
stricture  of  large  intestine,  840 
synovitis,  treatment  of,  885 
tumors  of  muscle,  486 
I         ulceration  of  tongue,  diagnoeis  of,  626 
Syringe,  laryngeal,  661 
for  lithotomy,  917 
for  lithotrity,  966 


TAGLTACOTIAN  opkration,  695,  699 
Tait,  Lawson,  removal  of  impacted 
I  gall-stone,  831 

I  Talipes  (talus,  an   ankle;  pet,  a  foot), 
I  519 

calcaneo- valgus,  519,  525 
calcaneus,  519,  521 
equino-varus,  519,  528 
equinus,  519,  520 
pathological  changes  in,  520 
valgus,  519,  525 
valgus,  spurious,  525 
varus,  519,  522 
Talivert,  Aveling's,  524 
Tanchou's  apparatus   for  compreMion  of 

mammary  tumor,  708 
Tappinq  the  abdomen,  826 
the  chest,  688 
the  head,  582 
hydrocele,  1107 
ovarian  tumon,  1146 
the  pericardium,  691 
the  pleura,  688 
I  Tarsus,  articulation  of,  405 
'■         disease  of,  406 

excision  of  bonei  of,  406, 418 
I  Taxis  {T&aau,  I  put  in  oiiier),  769 

in  obturator  hernia,  808 
!  Taylor's  spinal  support,  480 
'  Teale's  excision  uf  encapsuled  nsevi,  97 
:  Teevan,  urethral  injector,  1084 

on  tumors  of  muscle,  486,  488 
Tendu  Achillis,  division  of,  521 

disease  of  bursa  beneath,  482 
I  TiMDONR,  diseases  of  sheaths  of,  488 
inflammatiun  of,  484 
division  of,  498 
I  repair  after,  499 

I         hamstring,  contraction  of,  515 
Tenesmus  from  calculus,  911 
Tenosynovitis  (r/iw,  a  tendon;   syfioriol 
membrane;    tii»,    denoting    tnflamma- 
I      tion\  4K4,  4Wo 


1200 


ixbxx. 


TAootomy  (r^MW,  a  tendon ;  r<vpw,  I  cut),  | 

498 
Tmtib,  ib«CMa  of,  IIM 

■trophy  of,  1 102 

cmDC«r  qT,  I12S 

cyMlo  dlfeucB  of,  1127 

int^  ot,  vm 

effect  of  rvoiuTirift  tonriU  on,  645 
«nc«ph«lnhl  of,  1 129 
enclmndrtiinft  of,  1 127 
eummaU  in.  11*24 
iDllMnmntton  of,  tu^ute,  1 101 
chronk,  I104,  tlMl 

ueainieiiL  uf,  1120 
gonarrhiDal,  VKW 
lu  inguinal  CMiml,  1104 

dikicnutli    from    berni>, 
TH7 
■ubttcol^,  1102 

ireatment  of,  1103 
lrvttliii«nl  of,  1102 
mKlpositiuii  of.  1090 
B«iinlg)sof,  1l()0 
rvlMtmn  Ui  ioKuimil  hnmift,  TM 
noKival  vt,  1123,  1120 
Mrcomnof,  1127 
■omfulouB,  1121 
■olid  •inluvvfnents  uf,  1119 
■tritpping  tne,  1103 
iyubiliticdiuiKMi  of,  1134 
lubcreuUr,  U21 

trOKtmxnt  of,  1123 
tatngn  of,  III  y.     .Sc»  SarcDcel« 
diAgno«U  from  hernia,  TfSS 
UndMOOndL-d,  dikKM'jaiK  frum  oongsnU 
tal  hvmiK,  T^ll 
from  inguinal,  Td7 
diauMin,  1129 
TetMin  {riritvt,  Hnin,  tomJon),  60 
ft  cAuM  of  d«ath  in  o|>er«li<>ii>,  fli 
ft(t«r  ligklura  of  ext«ntal  ilmc  mrurs, 

248 
Cftuie*  of,  60 
rormi  of.  02 
idiopfttbic,  CO 
In  military  prftcUoe,  dl 
pfttbologVi  ^ 
period  of  ooourrence,  62 
aymptomi  of,  03 
trauoiatic,  00 
treatment  of,  GO 
Thierry,  lreatm«utof  mnaummhj  flaxJOD, 

166 
Thigh'bone.    See  Femur 
ThuRiw'i  a|)linl  Cor  bi|»-di«MM,  4S4 
kntw-ftpllnt,  39S,  39% 
ireatment  of  intMllnal  obtlrucLion,  RIO 
TbompaoD,  Sir  U.,  Impiuvod   eTKcustor, 
968 
lllhotrit«,  0.'>H 
lilbotrity  Bt  ■  (InKle  »IUlDg,  960,  076 
prnetate  tumors,  1017 
alalia  tic*  of  calculi,  909 
ctatittlci  of  lliholcniv.  940,  976 

lilliouily,  97ft 
tlono  in  v)d«r)y  man,  ftit 


Tliomfwr   ■'■'  "     turtimmtiy 

itrict  .i..r,  liMO 

urvitir  '  ,  tanllMi  partM 

sion,  lUliJ 

TboropMU'i  cipbon  trvoar.  MUi 

ThooHoa,  A.  T.|  tatncrwiul  an 

308 
ThinntoD,  W.,  Iljcmliir*  of  tnoi 

arlrrv,  2)S,  21K 
Tboru.     Sn  Chat 
TliromliocLi,  vMtvua,  77 
oaiiMS  of,  77 
aer«cU  of,  81 
pKMSi*  of,  79 
«ytnpl(>ma  of,  M 
tnatiiiBnt  nt.  M 
Tbumb.  i<     '    . 
Thyroid  ^ 

ch.f  .^ 
maliunant  lura--n  uf,  W7 
•woliinin,    diac&oaii 
191 
Tbjrruiomy  (ti0fi(,  ■  abield 

bko;  Tifim.  I  rut),  555 
TiuiJi,  dulij^'fttlon  of, 

eioiiiian  of,  408 
Tibial  arwry.     St<  Artery. 
Tic,  mwciitnr,  rj 
Timhmann,  ocolualon  of  arMrJai, 
TiAld,  tre«im«nt  of  taUnut,  fil 
TiXvUktl,  hypertrupby  of, 

Ingrowing  of,  M 
ToRA,  conlrxction  o€, 

«i«i»ion  of,  414 

exlontioa  of,  ni>p«nUnt 

bypartrophy  of,  KW 

■Uprrnmi'irarv  and  wnbi 
ToinM,  il'  vtM  in 

ToKoCE,  ,  iiao 

anciuitoj  by  tiiuMU'm«Mu 

cancer  iit,  625 

di<i!)<^>n  "f  Ungual  nrnr*' 
ligaturo  of  linriial  aflarj 
IraatiuMil  of,  (120 

diHUM  of,  019 

epitb-lt'^n"'  -f.  <I2£ 

epitit'  iiiw 

tlbroui  tuuora  of,  KU 
(Uauraa  or  orndL*  uf,  Q38 
elawd  rttd,  ASI 
DvriertmpbT  and  pnilaMiM 

-.jf.asi 

■  an  (if, 
i..f.  BIS 

r.  lot 

r.i  oft  R28 


lulB.i 

1  nvrr*] 

1 


[..ill..  I 
oprnii  I 
prul  I. 
p««r 
ram 


".1 


byg»..-. 


INDEX. 


1201 


ToSGVK  {continued). 

reninvHl  hy  Jordan'l  operation,  88A 
by  Kiicher'a  operation,  685 
by  !iK"ture,  630 
by  Kunneley'»  opention,  682 
by  Kegnoli's  or  submental  opera- 

"tion,  634 
by  S4dillot's  operation,  686 
by  AVhitehead'*  operation,  633 
methuds  of,  compared,  638 
results,  638 
scirrhus  of,  625 
bDeccb  after,  63!) 
plouguing  ulcer  of,  620 
»y)iDilitic  gumma  of,  623 
diaicnoflis  of,  fi'26 
tumors  of,  624 
ulceration  of,  623 
limple,  623 
aypLilitic,  6*23 
tubercular,  623 
warts  on ,  624 
Tonsil-fiuillt^tiiie,  644 
ToDgillitis,  642 

diagnosis  of,  642 
ToN'Hiiji,  attfceM  of,  siinulated  by  aneu- 
Tttia  of  internal  <.'arotid,  100 
diseases  uf,  642 
hyiMsrtrophy  of,  648 
indnmniatiun  of,  643 
malif;nant  disease  of,  64.'i 
removal  uf,  644 
Tophi  (Lat.fRiid  or  gravel-stone)  inear.-ViS 
Torticollis  [toriua,  twisted,  from  tor^ieu,  I 
IwJHt;  eotlum,  the  neck),  409 
division  of  spinal  acc«ssory  nerve  in 
clonic,  'iT 
Trachia,  opvrHtions  on,677.  See  Laryn- 
giitomr  and  tracheotomy 
pressure  on,  by  aortic  aneurism,  IT'i 
Tracbea-hooks,  67< 
tampon,  '>82 
tube*,  677,  678,  1179 
Tracheotomy  (TfHi^fia,  thetracbca;  rr/nv, 
I  cut),  1169,  673 
after-treatment  of,  dSS 
in  <.'hildri>n,  680 

clili>n>form  in,  67'> 
conkjiared  with  laryng<>t<'my,  680 
in  Iaryi)i;cal  disease,  663 
difficulties  and  accidents,  675 
hemorrtiage  in,  676 
indications  fur,  672 
in  inimthoracic  aneurixm,  180 
in  membranous  laryngiii*,  669 

results  of  operation,  670 
"jieratii-n  of,  674 
Tran«plantatinn  of  skin,  695,  598 
TkaL'Hath*  {rpai'iut,  a  wound)  caries,  282 
diaptirafimatic  hernia,  8Uti 
bs'matoccle,  1113 
laryri(;itis,  659 
necriiKi*,  301 
neuromata,  ■'>'.> 
parulyi>is,  '>7 
phlebitis,  88 
TOL.  II. — 76 


Tradmatic  tetanus,  60 

Travels,  accident  in  ligature  of  subclavian, 

227 
Trendelenburg's  trachea* tampon,  282 
Trephining  bone,  288 
Trismus  neonatorum,  60 
Trocar,  for  Upping  chest,  690 
Trochanter,  great,  caries  of,  469 

cnlargeniflnt  of  bursw  about  the, 
481 
Trunk,  n»vi  on,  104 
Trusses,  application  of,  74-'t 
Tdbekcli  of  bladder,  1007 
of  bone,  288 
of  prostate,  1026 
painful  sutkCutaneouB,  59 
Tubercular  arthritis,  848 
laryngitis,  <i63 
kidney,  891 
'sarcocele,  1129 

diagnosis  of,  1125 
testicle,  1121 

treatment  of,  1128 
ulcer  of  tongue,  628 
Tubular  aneurism,  124,  156 

calciHcation  of  arteries,  117 
Tufnell,  compression  in  aneurism,  168, 159 
TcMOR-i,  abdominal,  diagnosis  frutn  aneu- 
rism of  aorta,  242 
of  alveoli,  ■')69 
of  antrum,  577,  686 

treatment  of,  578 
in  aiilla,  733 
of  bladder,  1008 

diagnosis  from  enlarged  prostate, 

1021 
treatment  of,  1010 
of  bone,  321 
of  breaxt,  701 

diagnosis  from  oancer,  720 
malignant,  712 
non-malignant,  701 
of  bursa  patellR,  480 
of  bundle,  480 
of  cheeks,  551 
cystic,  "f  bi'ue,  821 
deiitinHl,  575 
i>f  liura  instor,  530 
of  ear,  533 
of  groin,  833 

diagnof  iit  from  ilia<-  aneurism,  244 
from  hernia.  79ti 
from  iliac  and  psoas  abscess, 
430 
treatment  of,  833 
of  gum.>,  5<>9 

entctile,  94 
hemorrhi'idBl.     !>fr  Piles 
intra  pel  vie  .intestinal  obstruction  fnmi, 

819 
of  humerus,  diagnosis  from   axillary 

aneuri>io,  '."J'J 
intrathoracic,  dysphagia  from,  648 
of  jaw,  lower,  587 

UppiT,  fi7''i 

iH-hind,  '*Mi 


1202 


INDEX. 


Tumors  (amtitmed). 
of  labia,  1189 
keloid,  of  ekin,  46 
lacteal,  694 
of  kidney,  893 

diagoosis,  893 
of  larynx,  664 
of  lips,  663 
of  malar  bone,  578 
of  muscles,  486 
naso-orbital,  649 
naao-pbaryngeal,  646 
non-pulBating,  diagnoeis   &om   aaeu* 

riem,  136 
of  neck,  659,  660 

diagnosis  from  aneurism,  190 
dysphagia  from,  648 
of  nose,  538 

malignant,  648 
of  ovaries,  1144 
pachydermatous  of  scalp,  580 
of  parotid  gland,  556 
of  penis,  1094,  1007 
of  pharynx,  647 

dysphagia  from,  64T 
in    popliteal    space,    diagnosis    from 

aneurism,  135,  268 
of  proBtat«,  simple,  1017 

obstruciing   lithotomy,    98!, 
933 
pulsating,  diagnosis    from   aneurism, 

184,  331 
of  rectum  (papillomata) ,  845 
of  scrotum,  1097 

diagnosis  of,  1131 
of  skin,  45 
of    spermatic    cord,    diagnosis     from 

hernia,  1115 
of  spine,  437 
of  testis,  1119 

di^DO!-Js  from  hernia,  788 
of  thyroid  body,  667.     See  Broncho- 

cele 
of  tongue,  624,  640 
of  tonsil,  malignant,  645 
of  urethra,  1084 
of  uterus,  1142 
of  vagina,  1141 
Tdnica  vaginalis,  hH;matocele  of,  1113 
diagnosis  from  hernia,  788 
from  hicmatoceleof.cord, 
1U5 
hernia  in,  790 

encysted,  793 
hydrocele  of,  1105 
diagnosis  of,  1132 

from     cystic     sarcocele, 

1127 
from     inguinal     hernia, 
786 
Tunnelling  the  prostate,  1026 
Turntr,    clamp    used   by,    in    removal   of 

tumors  of  scrotum,  10!'8 
Typhoid  fever,  arthritis  after,  341 
Typhoid  fever,  diagnosis  from  suppurative 
nephritis,  886 


ULCSR  of  anus,  849 
atheromatous.  111 
of  cheeks,  551 
rodent,  89 

of  foot,  perforating,  47 
of  gums,  568 
of  Tips,  552 
of  nose,  639 
of  skin,  cancerous,  44 
of  tongue,  628 
Ulceration  of  arteries,  118 
of  bone,  277 
of  cartilage,  348 
Ullman,  ligature  of  both  carotids,  196 
Ulna,  excision  of,  387 
Ulnar  artery.     See  Arterv,  ulnar 
Umbilical  tiatula,  832 

hernia,  800.     See  Hernia 
in  adults,  800 
in  children,  800 
Umbilicus,  diseases  of,  882 
U nem ic  (oi'pw,  urine;   aifia,  blood)   fever, 

886 
Uranoplasty  (uraniaeus  an  old  term  fur  the 
palate,  from  oiipm-df,  the  sky  ;  Trkaaau,  I 
form).  617 
Urate  of  ammonia  calculus,  900 
Ureter,  dilatation  of,  877 

secondary  disease  of,  877 
Ubkthra,  abscess  of,  1018 
in  gonorrhoea,  1037 
bulb  of,  wounded,  935 
calculus  in,  983 

impacted  in,  969 
in  children,  986 
dilatation  of,  in  calculus,  915 

in  removing  calculus  in    female, 

987 
behind  stricture,  1048 
in  treating  stricture,  lOol,  1057 
oft'ect  of  enlarged  prostate  on,  1018 
examination  of,  in  stricture,  1049 
false  passages  in,  105*1 
fistula  of,  1077 
hemorrhage  from,  1013 
after  catheterism,  1056 
in  gonorrhoea,  1037 
inflammation  of,  1027 

specific.     See  Gonorrhtea 
in  treatment  of  stricture,  1056 
missing  the,  in  lithotomy,  938 
opening  the,  in  retention,  1071 

in     stricture,     1060,     1068.       See 
Urethrotomy 
plastic  operations,  1079 
rectum  opening  into,  837 
tumors  of,  1084 
Urethra,  Strictcbk  or,  1042 
age  at  which  it  occurs,  1046 
catheterism  in,  1060 

accidents  attending,  1054 
ana?sihetic8  in,  1067 
forcible,  1058 
complications  and  results  of,  1070 
congestive,  1043,  1046 
treatment  of,  1045 


INDEX. 


1208 


Ubkthra,  STKirTi'RE  OF  (cnntinutd).         \ 
constrictiiin  in,  1048 
detection  of,  104U 

diagnosiH  froiii  enliir{|;ed  prottatQ,  1021 
dilKtntiun  of,  continuous,  106T 

forcible,  1058 
examinfttinii  of  (lutient  for,  1049 
exiTHvasHtion  of  urine  in,  1074 
in  females,  lOSl 
«fter  gonorrhrea,  103S 
forms  of,  1043  ' 

impedes  lithotrtty,  980 
imperni€AMe,  10*17 
(ipenttions  for,  1008 
mcclianical  rtwnlte  of,  lOuS 
muscul&r,  t04H 
orgiknic,  1043,  UMr. 
ptttholoirical  iip|>earance«,  1040 
at  orifice,  lOtiO 
permeable,  1064 
relent  nn  of  urine  from,    1070.    Ser 

Urine 
rupture  of,  forvible,  1058 
■eat  of,  104f; 
S|.ia<niodic,  IM^t 

treatment  of,  1044 
symptoms  of  conicfslive,  104ft 
or(;anic,  1047 
spasmiidic,  1044 
treatment  of  coniteatire,  104-'i 
organic,  lOGt 

Ly  <-KUstiea,  1058 
by  dilatation,  1051,  1058 
by  dirifion,  lOGO 
by  forcible  exjiansiun  or  rupt- 
ure. 1058 
general  results  of  treatment, 

1070 
methodj  of,  comparetl,  1065 
of  Sfiasmodic,  1044 
Urethral  fOTer,  886,  lOiH 
forceps,  970 
lithotomy,  984 

in  femiile*,  987 
lithotrite,  ii70 
Urethritis  {uretha :  itit,  denoting  inflam- 
Diulion),  1027 
RFsnular,  1031 
Uretliromcter  (urffhra  ;  /a'P"",  *  meuurc. 

1050,  lOfil 
Urethroplasty  {urfihrn  ;  t>jJ(«tu,  I  form  or 

fashion),  1(179 
Urethrotome  (wreMrn  ;  riunt,  I  cut),  1061 
Urethrotomy  {urelhni;  rf/im,  I  cut),  by 
median  perineal  incision,  1010 
im  inqwruieabie  strictiirt-,  llhiH 
for  i>ermi-'ablo  Mriclure,  10i;4 
external,  1063 
internal,  1003 
f<ir  urinary  flutiilH,  1078 
subcutaneous,  lU*i5 
Urrthro-vaKinal  fl«lula,  lONl 
Uric  acid  calculi,  900,  1KI7 
dcposiu,  'MO 

treatment  of.  1>0I 
Urinarj  calculus,  8'J9.     Sr^  Calculus 


Urinary  {continued). 

diseases,  pviemia  and  sapticnmi*  In, 

875 
fistula,  832,  1077 
organs,  operations  for,  1079 
effect  of  calculus  on,  915 

of  enlarged  prostate,  1016 
secondary  diseaMS  of,  from  sur- 
gical causes,  874 
states  of,  influencing  propriety  of 
operation,  979 
vaginal  fistulie,  1081 
Urine,  albuminous,   in   relation  to  lith- 
otomy, 941 
to  litbotrltr,  979 
blood  in,  1011 

in  calculus,  911 
deposits  in,  900 

CRrbonate  of  lime,  904 
cvftine,  904 
oxalate  of  lime,  902 
pbxsphatic,  903 
uric  or  lithic,  900 
eztiavasation  of,  1074 
effects  of.  1075 
treatment  <>f,  1075 
flow  of,  impeded  by  calcului,  911 
incoiitinence  of,  1005 

from  calculus  in  the  female  blad- 
der. 987 
hysterical,  1006 
morbid,  in  irritable  bladder,  998 
mollitics  ossium,  318 
vesical  catarrh,  996 
overflow  of,  1006 
quantity  of,  in  intestinal  obatruction, 

815 
retention  of,  from  atony  of  bladder, 
1003 
from  c<<iii;estive  stricture,  1046 
from  enlarged  proaute,  1020 
^>m  catbeterism,  1065 
fn>m  puncture  above  pubet,  1024 
through  rectum,  1025 
'  tunnellint;  prostate  in,  1026 

retention  of,  from  eonorrfa<ea,  10S7 
I  hyflcrical,  lOOii 

I  from  organic  stricture,  1070 

fnim  aspiration  in,  1074 
from  forcible  catheterism  in,  1071 
from   puncture  above  pubea   in, 
1073 
through  rectum,  1072 
urethrotomy  in,  1071 
from  pr\>i-tatiti)i,  1015 
from  spasmodic  stricture.  1044 
,  Utebcs.  absence  of,  1140 

affections  of,  exciting  piles,  859 
oauliflowcr  excrescence  of,  1144 
chronic  discharges  from,  1141 
gravid,  in  umbilical  hernia,  800 
h        malignant  di»ea*ea  of,  U43 
polypi  of,  1143 
sarconia  of,  1144 
tumorw  of,  1142 
'  l*  vi'LA,  elongation  of,  642 


1204 


INDBX. 


V  AGIST  A,  discharges  from,  1141 
in  children,  1042,1141 
diagnosis  of,  1042 
flstuloua    openings   into,    1061.      See 

Fistula 
imperforate,  1139 
prolapBui  of,  1141 

irritable  bladder  from,  1001 
tumors  of,  1141 
Vaginal  hemorrhoidB,  1141 
hernia,  805 
lithotomy,  988 
speculum,  1187 
Valsalva's  treatment  of  aneurism,  189 
Van  Buren,  ligature  of  carotid,  196 
Van  Ercklens,  statistics  of  colotomy,  825 
Vanzetti,   digital    pressure   in   aneurism, 

142,  164,  210 
Varicocele  {yarix;  xfih],  a  tumor),  1115 
diagnosis  of,  IIIG,  1132 

from  hernia,  78T 
compression  in,  1116 
radical  cure  of,  1117 
symptoms  of,  1115 
treatment  of,  1116 
Varicose  aneurism  in  neck,  188 
Varix,  avkurisual,  172 
in  neck,  188 

diagnosis  from  carotid  aneurism, 
190 
in  groin  result  of  ligature  of  external 

iliac  for,  249 
of  jugular  vein,  188 
of  lymphatics,  70, 

of  saphena  vein,  diagnosis  from  her- 
nia, 796 
of  veins,  appeantnce  and  symptoms, 
88 
causes  of,  86 
locality  of,  87 
morbid  anatom'y  of,  87 
progress  and  effects  of,  88 
structure  of,  87 
treatment  of,  89 
Vascular  tumors  in  antrum,  676 
upper  jaw,  576 
in  urethra,  1084 
Vbins,  diseases  of,  77 

hemorrhage   from,  during  Uthotomv, 

946 
inflammation  of,  83 

diffuse,  84 
pressure  of  aneurism  tm,  131 
femoral,  wound  of,  in  operation,  262 
jugular,  aneui'iemal  vanx  of,  188 
of  neek  and  arm,  enlarged  in  innomi- 
nate aneurism,  181 
pulmonary,  pressure  of   aortic  aneu- 
rism on,  176 
of  rectum,  arrangement  of,  predispos- 
ing to  piles,  857 
saphena,  vurix  cif,  diflgnosis  from  fe-< 

mora)  hernia,  796 
spcrmntic,  varix  of,  1116 
Vclpeau,  hernia  in  tunica  vajfinalis,  790 
ligature  of  both  cnrolids,  196 


Venoi 
tl 
Ventr 
Verru 
Verte 
Vertel 
Vertel 

Vesiw 
Vesici 
Vidal 
111' 
Villoi 

^3 
ti 

Virch. 

P 

Viscei 
ing 
Visioi 
Vitrit 
Voice 
Volkr 

ti 
Vomii 
Vomii 

St 

Von  1 
Vulse 
Vulvs 


W^ 


Warn 

K 
Ul 

Wart 

g« 

01 
01 

ot 


ot 

Wart) 

ee 

Watei 

uf  h 

Watso 

en 

w 
Woav 
Webb 

to 
Webei 

ti< 
Week. 


INDEX. 


1206 


Weir,  ligftturfl  of  carotid  tnd  lubclaTiao,  i 

185 
WeiM't  lithotrite,  956 
Wells,  Sir  Spencer,  ovariotomy,  performed 

br,  1U6 
Whsrton'd  duct,  relation  to  ranula,  040 
Whmhaw,  removal  of  preputial  calculi, 

1088 
Whit«,  excision  of  juinb)  for  diseasa,  867, 

461 
White  swelling,  848,  487 
of  hip,  451 
treatment  of,  362 
Whitehead's  gag,  630 

excision  of  tongue,  6311,  6S8 
Wickham,  ligature  of  carotid  and  sub-  j 
clavian  for  innominate  aneurism,  185      I 
Willett,  results  of  excision  of  knee,  401 
Williams,  C,  statistics  of   lithotomy  in 

Norwich  Hospital,  939,  982 
Winiwarter,  von,  endarteritis  proUferans,  I 
115 
gaatru-entorostomy,  829 
Windpipe.     See  Air-tube 
Wolfe,  plastic  surgery,  695,  598  I 

Women.     Se«  Females  i 

Wood,  John,  operation  for  hernia,  748 
statistics  of,  748 
for  extroverted  bladder,  992 
Wood,  J.   R.,  distal  ligature  of  carotid,  i 
199  ' 


Wood,  lifcature  of  both  carotids,  197 
Wood    (New    York),    bilateral     gorget, 

reproduction  of  lower  Jaw  after  re- 
moval for  necrosis,  572 

Wound  of  arteries.    See  Arteries 
of  bladder  in  lithotomy,  938 
of  bulb  of  urethra  in  lithotomy,  985 
of  intestine  in  hernia  operation,  774 
of  joints,  arthritis  from,  886 
of  rectum  in  lithotomy,  938,  947 

Wrist,  excidion  of,  888 

Sir  J.  Lister's  operation,  889 

Wry-neck,  499 

apparatus  for,  601 
treatment  of,  500 

Wutzer's  operation  for  hernia,  747 

Wyeth,  cases  of  ligature  of  carotid  for 
vascular  growths  above  clavicle,  98 


XANTHINE  or  Xanthic  oxide  calculi, 
904 
X-kne«,  508 


ZAIIN,  experiments  on   the  proceaa  of 
thrombosis,  79 
Zinc,  aceUte  or  sulphate  of,  injected  in 
gonorrhoea,  1033 


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Lea  Brothers  &  Co^  Xo*.  706  and  708  Sansom  Bt^  Fhiladeliihia. 

* ,  *  Communioations  to  both  theee  periodicals  are  inrited  from  gentlemen  in  all  parta 
of  the  country.  Original  articled  contributed  excliisirel;  to  either  periodical  are  Ubcnllj 
pkid  for  upon  publication.  When  necessary  to  elucidate  the  text,  illostratiotu  will  be  ftir- 
nished  without  cost  to  the  author. 

Alt  letters  pertnining  to  the  Edilorial  Dtpartnmt  of  The  Meotcal  Newb  and  Tub 
AnEicAN  JouBXAL  OF  THE  McDicAL  SciEKCSB  shouM  be  addressed  to  the  Editobxai. 
OmcEP,  1004  Walnut  Street,  Phihtdelphia. 

All  letters  pertaining  to  the  Biuineet  Department  of  these  journals  shoold  be  addrened 
«xWiiinW/y  to  L.£A  BROTHEBa  &  Co.,  706  and  708  Sansom  Street,  Philadelphia. 


HAItTSHORNB,  HENRY,  A,  M.,  Jtf.  i>., 

Lnlaiy  ProftttoT  of  Byyi«in  •»  the  Vnii-trnt)/  of  Pti*ntylcania. 

A  Conspeotus  of  the  Medical  SoienoeB;  Containing  Handbooks  on  Anaton;, 
PliTfiologT,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics. 
Second  edition,  thoroughly  reriF^d  and  greatly  improved.  In  one  large  royal  12mo, 
Tolume  of  1028  |tnge«,witb  477  illutttratioos.    Cloth,  f4.2d;  leather,  95.00. 

The  object  r>f  Ihh  miuiiiftl  l!<  til  •ffWrrl  •conven-  IndufiliT  and  enrrsy  of  Ita  able  vdlbir. — Boltan 
lant  work  of  rafareoce  in  t>tud«DU  durinji  the  hriHl  MeduiUnnd  SuroiaaJoarmU,  8«pL  S.  181*. 
mocaPDt^  kl  ilieir  comTnand  while  ia  Klteodanre  We  cui  xaVi  with  the strlclert  iriitn, (hat  [t  I*  the 
upon  medii'kl  lecturer.  It  In  k  (aTorkble  r\ga  that  |  bent  work  of  Ihe  kind  with  which  we  ■reacqualut- 
tt  baa  been  found  ne<f>«9ary,  in  »  short  «pace  of  ed.  It  emtkullp*  In  a  condenMd  form  all  recent 
time,  u>  issue  a  new  and  carefully  revised  edition,  contributionii  to  practical  tnedlrlnc,  and  1b  thera- 
ThB  illuotralion*  are  TCry  numerou:i  and  unusu-  fore  u^ieful  to  eTery  buny  prartltlnner  throughont 
allT  clnir.  and  each  part  neems  lo  hare  recelTCd  our  counli^,  be<>ides  being  admirably  adapted  to 
tiB  due  xhareof  allentlon.  We  can  con  eel  re  such  the  une  of  xIiideQla  of  medicine.  The  book  Is 
a  work  to  he  uvehil,  not  onl^  to  students,  but  lo  Uthfiilty  and  ably  ezeeutad.— CAarUitoa  MtUtai 
practitionerii  ad  well.    It  reflects  credit  upon  the    JuurniU.  April,  W.h. 

STUDENTS'  SERIESOE  MAKVALS. 

A  Serict)  of  Fifteen  Munualo,  for  the  use  of  StudenU  and  Practitionera  of  Medicine 
and  SurgePi',  written  by  eminent  Teachers  or  Exaniinere,  and  inued  in  pocket-fliu 
12mo.  volumes  of  ;f00-o4U  puges,  richly  itlustnited  and  at  a  low  price.  The  folfowlng  vol- 
ame>  are  now  ready;  (iorLD'3  Surgiral  Dimjnoxu,  KoBEBTSOS's  Physiologieid  I^j/tics, 
BKrCE'a  Materia  Mediea  and  Iiemi>eiitie*,  PoiVEU'i*  ILiBinii  Phyxiolngy,  Cl.ARKe  anrl 
IXX^wooD'fi  Diuvrtonf  Afanval,  Kai.FE's  Clintail  ChanUlry,  TKEVEa"  SurgUal  Applied 
AMOtointj,  Peppek'm  Surqieid  Vathifoijy,  -ind  KleisV  KIrmeTiU  of  Hintolo^.  The  following 
are  in  pr«# :  liEl^LAVY^a  Operative  Surgery,  Bell's  0>mpttratire  Phyitoiogy  nnrf  Annlomy, 
Pepper's  ForennU  Medicine,  <ind  Curnow's  Medirul  Apjtiied  Anatmny.  For  separate 
notices  see  index  on  last  page. 

SERIES  or  CLINICAL  MANUALS, 

In  armnging  fur  thifi  Series  it  hau  lieen  the  de»i(;n  «f  the  publishers  to  provide  the 
profession  with  n  tNiIlection  of  authoritative  monograplis  on  important  clinical  subjects 
in  a  chcEip  and  portable  form.  The  vulumca  will  contain  about  o-JO  pagea  and  will  be 
freely  iltu.-'lniutl  by  cbniitui-Iithogr-.t|ihs  and  wondcutf.  The  following  volumes  are 
JDA  readv:  Trei'ES  on  fntrMiniU  Oiutmetion;  and  Savage  on  Ituanity  and  Allied  Neu- 
rotet;  T}ie  fidlowinj;  nre  in  active  prcparBtinu :  IIi'Tciiisso.v  on  Si/fifiiliA;  Bbvast 
on  the  Brnul;  Morris  on  Sinijieid  Dinenne*  of  the  Kidn-y;  BKuADBExron  the  Palte; 
Bttlin  iiu  tlie  T'lii'jnt:;  HWEN  on  Suryieal  IH*fwn  of  Childrrn;  LufAS  I'O  JH*ttiM*  oj  Ihe 
Urethra  ;  Mar.''!!  on  lH*^i*fi>  of  ihr  Jointu,  PiCK  nu  Praelun*  antl  Dixloeatioiu,  and 
Ball  on  tlic  Rerfun  nnd  Ann*.    For  separate  nolicvs  see  index  on  In^it  page. 

NEILL,  JOHN,  M,  i).,   and  SMITH,  F.  G.,  M.  I)., 

Ln't  SHriii-iii  U>  Iht  I'f  una,  H'-tyilnl.  I'nif.  o'  thr  hithtult4  '■/  Vfd.  in  (Ac  (/nir.  of  fuum. 

An  Analytical  Compendium  of  the  Various  Branches  of  Medioal 
BoiencCt  fcr  the  uxe  and  exuiuination  of  .'^tndenU.  A  new  e<littun,  revised  and  improved, 
loonelnrueniyul  linvi.  volume  of ',174  page*,  with  S71  wiinlcuiii.    Clolh.  f4;  leather,  (4.75. 

LUDLOW,  J,  i.,  M.  D„ 

A  Manual  of  Examinations  uiNm  .\nHtoiny,  Physiolt^,  Surgery,  Practice  of 
Medicine,  ( >bsletric!i.  Materia  Mwlicji,  (.'hemistry,  Phnrinacy  an<l  Therapeutics,  To  which 
!■  adde<l  a  Medical  Formulnry.  Third  edition,  thoniughly  revised,  and  greatly  extended 
umI  enlarged.  In  one  handwime  roval  12mu.  volume  of  ^16  large  pagea,  with  370  illus- 
ttstlons.    (.loth,  $iiM^ ;  leather,  tA.'h. 

The  arrangement  of  this  volume  in  the  form  of  iiuculion  and  .inswer  render*  it  espe- 
cially RuilnMe  for  the  office  examination  of  iitudcnta,  and  for  thooe  \i[e\iarin%<<ff  (st»A>s»i.^s«i- 


Lea  BBOTUBas  &  Co.'e  PuBUCAnoiia — DlcttvoarieK. 


nUNOLISON,  BOBLET,  Jf.jf)., 

Lett  pTx^empr  of  Jnttltulu  cf  Mtdi^^  in  th*  Jtfetten  Utdual  CbtUgt  tf  J'kitodtlifMm, 

IiEEDICAL  LEXICON;  A  DlctionaiT of  MeiUcal  Science:  Cbn; 

a  oonci.'O  f'.;[))liuiiiti'iii  ui  the  ^'srliniR  Siibjoru  anil  Tenn»  of  AnaUmT,  Phyilolaer, 
flgy,  Hy^eiie,  TherjiwiitiM,  PharroscolojcT,  PhnrnuKy,  Sun^ery,  ObMetriea,  Meoiabl  J 
pnidenoe  lud  l>»[uiR-,.\'oiic«»>}f  C1inui»nod  of  Mineral  Uaten,  FocmuliP  for  OSc 
Enpiricol  ouJ  Dietetic  Preioiaticme,  with  the  Accentuation  nod  EtTmolooT  of  the '~ 
and  the  French  and  oltier  Synooyiuea,  m>  as  to  cooMilDle  n  I'retioli  as  welD  w  ai    ~ 
Medical  Lexicon.    iiAlited  by  Kiuilaad  J.  DtixauBO't  M.  !>.     In  one  repr 
hmuLwuic  royal  ocuto  Tolume  of  1130  V*Sf*-    CUtth,  frS^O;  lMUli«r,  raised  huida,' 
vety  liaiuUuiue  b&lf  Kusua,  raised  baoda,  (8. 

The  object  of  tiie  author,  fram  the  outMt,  hafi  not  been  to  make  tlie  irork  a  mer«  lui- 
coo  or  di(!Unnary  of  lerms,  l»it  to  afiord  under  each  word  &  ooodeaaed  viev  of  ita  variooi 
tii«NU£al  relatiinu,  uid  tiiua  to  render  the  work  on  eijitome  of  ili«  piiatiim  cooiitiuo  «f 
ni»Iical  adeooe.  HtartluK  with  thla  vi«w,  ibe  Initucase  demaod  which  baa  exiated  tor  the 
work  haa  enabled  hiin,  in  repeated  rerisionSj  to  augment  ils  oontpletCDeHB  and  uaefulaei^ 
until  at  leugth  il  bu  atlaict^  the  pooition  of  a  nxogoiited  and  standard  autliurity  whennx 
the  language  is  ajKiken.  Special  pains  have  bwo  token  In  the  prapaniiton  of  the  piawnt 
editioo  to  maintain  ihia  enriafale  npuiiitioii.  The  additions  to  the  vocb1ni1«7  are  toon 
DUinercKiB  than  in  any  previoiia  reviiaon,  and  particular  attention  baa  been  boBtowed  ea  lb« 
aooentimtioo,  which  will  be  found  marked  on  every  wun).  The  tyjiogrnphiciil  arranf;wMat 
ha.1  been  (rreatly  improved,  renderin^^  referenoe  much  more  eoOT,  and  every  csre  baa  bees 
taken  with  the  mechanical  exeoution.  The  volnme  now  containa  the  matter  of  at  Itait 
four  ordinary  octavos. 


A  book  of  irlileb  erery  AnMrtrao  oajtbt  lo  \m 
proud.  When  the  l<«niad  anUMr  at  ilia  wort; 
pasBodaway.I'Wbahlrallof  owfcfd  \*K  thahi>ol: 
should  not  irmlctaln  ita  plK«  la  the  advaaclnit 
Mlaaoe  wh>MH  u>nu>  !l  iIoRd*!!.  Pnrtucalaili',  Dr. 
Bleluutf  ].  DuagllMD,  havfag  aMiMMl  bia&tber m 
It)*  rvTlilnn  of  oaToral  adtlii)ni>  of  thti  work,  aad 


ir<irk  hu>  baan  «*11  known  Ibr  about  limy  jaMt, 
aad  n*d»  uo  wonla  of  prriMon  our  oart  lo  rMocn- 
mand  It  to  lb*  (nambon  of  Uia  mcdual,  aiiil  Uk*- 
wt<«  «t the phanaaceBtlwl, prmesslon.  TbaMiar 
oupadally  at*  la  naod  of  a  wortc  wMob  glvaaiaady 
■Bd  retisDk  talOmatlM  « tbousands  of  mbjaa 
aod  l«mi*  which  tbey  ara  Uabia  to  •neoiintar  la 
"'  "  .tpBlwlthwblciiUW- 


hatrlDK  boeo,  therefore,  trained  in  the  rnethuda    ptir^ukDrtbelrdaliymoailOD^bai  wltb  whlcIiUiiy 

and  linhni>d  vlth  tba  spirit  nf  iha  book,  ban  1»od     imatuit  ba  cipeetod  to  b«  (amlllar.      Tha  vora 

at^  lo  edtt  It  ac  a  wwk  of  iho  kind  fhould  be    "   "  "  " 

•dllad^oearry  Itoa9itaadlly,irlthoa(jar  or  intet^ 

rapUon,  idoof;  the  Knw*«a  or  thoavbt  it  Dai  trav- 

•liad  daring  iia  Ilfatlme.    To  abow  Ibe  magoltude 

erthe  iMk  ahl<:-h  Dr.  UudkIIboii  hat  usumed  and 

earrlvd  Uirouffh,  It  la  only  naeaHUwy  to  atato  tbat 

■Dore  thait  aiz  thocifand  new  miWeeta  Uara  bean 

■diM  bl  tha  prtta*nt>d)llon.— fUlbtUMM  WaKnal 

n«««,Jan.a.ie;4. 


Aboat  th«  fli9t  book  parchasdd  by  the  rr-edleal 
•UldMll  I*  iho  Mi'dl'Pal  I'lottoaar?.  Tha  loxlnon 
eKplanaiory  of  lei^htileal  terms  le  aimplv  a<ii»e  911a 
wm,  la  a  MitentM>  no  niiennU*  uid  with  raob  eol- 
latarel*  b>  madiclne.  It  L<  4a  modi  a  aeeeaslty  also 
CO  tha  pMOttaIng  pbralnlan,  Tomeet  th«  mmtii  of 
eUulaaM  ud  most  phjnleuuu  ■>>«  dioiionarr  miut 
be  oondaaaod  while  oomprahenilte,  uid  pr*cti«al 
while  perspiMeloaF.  It  wa*  l>ecauM  DUDCIlaon> 
mat  thaaalndloall'iti*  Ibm  It  bacama  at  oooa  the 
dietioaanr  ofgMioriii  uw  wbararar  ntdtdaa  wee 
■tadtod  in  the  EoKlinh  Uufuaca.  In  no  Awmer 
rerialon  hare  the  aiteradoiw  and  addltWaa  been 
au  paat.  The  ehlat  (erma  have  been  mi  Id  black 
latler,  <rhlla  the  derlratlTee  follow  In  waall  aapii 
ananan«inaat  wbjeh  Kreatly  facitllate*  refrreaca. 
— OadMHin  /.AKel  aafOtiM,  Jan.  Id.  mi. 

As  a  Maodard  owk  of  retoreae*   DuD^taoo** 


fXK  puniisii«a  lor  loa  ouaj  t>r*cuuaaBr,  at  »eea- 
Jna  mfnrtnatloa  npoa  aTafT madloal  aittjaot,ta 
fom  far  ready  aoMM,  and  wtth  a  brarinr  at  ad- 
ibaUa  aa  It  la  praottoaL— .S^iiM  rm  Jfodtiwf  Am>»< 


beferc  ua  (UllyrappUae  thte  wani.-^i»wr*ow  .^tw- 
>mI  ef  FkormiKi/,  Kb.  U74. 

Partlcalar  cara  has  been  de*at«d  lo  darliMloa 
and  aeoentuatk>a  of  lertna  Witb  r«m<d  to  ibe 
tni:«r,  Indoad,  tli«  praaani  adlUoa  muF  ha  e«a*Id- 
ered  a  eoeaplete  "PronoaneiBa  Dletlonan-  tt 
StadlfaJ  SolBooa."  It  1*  perhafia  tha  aaoat  ralhUa 
v'K'k  puhli«ii«d  f6r  the  biwy  pnetiUoaar,  aa  lif 
laina  mfi 

al 

mbaUai 
Pah.  mi. 

A  vBloabla  dictionary  of  tha  tanu  emalayad  li 
laadloln*  and  tha  alllsd  adaooea,  and  of  lb*  raW 
daiu  of  tha  tntrfaeta  iraatsd  under  each  baaA    ~' 
veil  deaarraa  Um  aMthorllrand  potMbulnr  ' 
oMalnad.— ArttM  JVad.  Jnrr.,  Oot  if.  IRi. 

rewwork»  aCtMa  etaai  exblblt  a  naadet  1 
meat  of  pBilent  raaaaccb  and  of  (clentUlo  1 
lA'ufcn  L<iit*t,  Uay  la.  inii. 

DuoifliHnl  rietlonaryti  taealenlabty  ralaau^  ' 
and  IndlfpaiMBble  to  avacy  praotJIlonar  of  nadl- 
rine,  pharmaoM  and  daatfaL— tVaHim  Zi>w< 
Mareb,  IST*. 

It  baa  tlM  rara  nierli  ihailiecnainlr  tia*  Bontet 
lathe  Easllah  taa(UMt*foraMut«c]FandeaMDlaf 
rehrencOB.— Jt«iur<m  Jfidwal  OawCta. 


&raW 
rltb^ 


itertfl 


SOBLiy,  BICITARD  ]>.,  M.  D. 

A  Dictiouai*y  of  tUo  Terms  UBed  io  MediaiuQ  and  the  CoUat 
Boienoes.     ReriHed,  with  numerous  additions,  l>y  Lsaac  IIay!^  M.  t>,  late  editor  f€ 
The  American  Joiimal  of  tlie  Meilical  Scimoea.     In  one  large  ro>-al  ISnm.  toIuid«  of  fiSO 
double-coluained  pages.    Cloth,  11.50:  leathirr,  (2.00. 

It  lilhitltrn  ^n^Tl^  rf  rtiflnltlnni  irn  bannral  nntlil  alweji  in  Iwi  mmn  Ih^  imdnil'i  tahti     aaiftni 
MtdUol  and  Smt^gUci  Jwntat, 

BODWBLL,  G.  F,,  F.  B,  A,  S„  F,  C,  8,, 

t-tttwrtr  on  iraturat  S(v>m<  at  tSiflan  OoOtg*.  Bngb—d. 

^  A  Dlctionai?  of  Boienoe :  CompriainR  AetnoomT,  Qtemlflti?,  Tfynamics,  Klee- 
_       ii-_.    t«_  1..  J  .1.1  ..      .«•  Mechnnit*,  Aleteurriloay. 

,M.A..  F.CS^  WUUam 

_  . .. — .,  ..  .^..,^   .  .™„.»_  ^u.«..,^  «.4..,  . ...  ^.,  «.  «.  proctor.  B^-  FJtA.fl 

G.  F.  Rodwoil,  Editor,  Charles  Tomlinaon,  F-BA,  F.CA,  and  Richard  Womcll.  ->H 
BSc  Preceded  by  an  Eaaay  cm  the  fTirtoty  of  the  Phyaical  Sdencea.  In  one  haadmn 
OCteTO  Tolume  u1  .0%^^ta,w\v\t  V\^\\V%tw.\nicA.    Cloili,  $S>.00. 


Lka  BaoTHEBa  &,  Co.'s  Pitblications — Anatomy.  5 

OMAT,  HJEKRY,  F,  R.  S., 

Lteturer  on  Analomji  al  St.  Qeargt't  HoMpitatf  London, 

Anatomy,  DoBcriptive  and  Surgical.  Tlie  Drawings  Iit  H.  V.  Cabter,  M.  D, 
and  Dr.  WEarMAcorr,  The  difleections  joinllT  bv  the  Author  and  Dr.  Carter.  With 
ao  Introdiictinn  on  General  Anatomy  anH  Devcloitmenl  hvT.  floLMB^  M.  A.,  Surgeon  10 
St.  George's  Hdepital.  E<lite<l  by  T.  Pickering  Piclt,  F.  R.  C.  S.,  Surgeon  to  and  Lecturer 
on  Anatomr  at  nt.  George's  Hospital,  London,  Examiner  in  Anntomr,  Rnval  College  of 
Soi^eonB  o(  England.  A  new  .\merican  from  the  tenth  eidarged  vii  improved  London 
edition.  To  vhich  is  addcl  the  second  American  from  the  latest  English  edition  ot 
IiANDMARK.'s  Mkdical  AND  SfRoicAL,  by  LimiER  Hoi.DEX,  F.  R.  C.  S.,  author  of 
*'  Human  Oslei>lopr,"  "  A  Manual  of  Dissections,"  etc.  In  one  imperial  octavo  volume 
of  1023  pages,  witn  564  lame  and  elaborate  engravings  on  wood.  Lloth,  $(1.00 ;  leather, 
$7.00;  very  handsome  half  Rnseio,  raised  bands,  $7.50. 

'This  work  covers  a  more  extended  range  of  siibjecta  than  is  customary  in  the  ordinary 
text-bookSj  givine  not  onlv  the  details  necessary  for  the  student,  hut  also  the  npjilication  to 
those  details  to  tne  practice  of  medicine  and  suifrery.  It  thus  forms  ttoth  n  guide  for  the 
learner  and  an  admirable  work  of  reference  for  the  active  practitioner.  Tlie  engravings 
fbrm  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nesLrly  all 
original,  and  having  tlie  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in 
place  of  figures  of  reference  with  descriptions  at  the  foot.  They  thus  form  a  complete  and 
■plendid  series,  which  will  greatly  assist  the  student  in  forming  a  clear  idea  of  Anatway, 
aind  will  also  serve  to   refresh  the  memoir  of  those  who  may  find  in  the  exigencies  of 

Sractice  the  neceasity  of  recalling  the  details  of  the  dissecting-room.  Combining,  as  it 
oea,  a  complete  Atlas  of  Anatomv  with  a  thorough  treatise  on  systematic,  descriptive 
and  applied  .\natomv,  the  work  will  be  found  of  great  service  to  all  physicians  who  receive 
students  in  their  oAces,  relieving  both  preceptor  and  pnpil  of  much  labor  in  laying  the 
groundwork  of  a  thorough  medicnl  education. 

Ln^iTuirkg,  .V«rft>n/  and  Siirffiftd,  by  the  distinguished  Anatomist,  Mr.  Lnther  Holden, 
has  been  appended  to  the  present  edition  as  it  was  to  the  previous  one.  This  work  gives 
in  a  clear,  condensed  and  systematic  way  all  the  information  by  which  the  practitioner  can 
determine  from  the  czlemal  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  worli,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by 
type  and  illustration  in  anatomical  study. 

Thii  well-known  work  come*  to  ua  •*  the  iMeat '  There  !•■  pr<>h«)itj  no  work  ilaed  K>  uafverMlly 
American  from  the  tenth  Bucliah  rdlllon.  Ae  It*  by  ph  vriicluii-  snd  medical  student*  »■  thU  oae. 
UUe  ladlQaWH,  It  ha-i  pssied  through  many  hands  It  i*  deaerTiii);  of  the  confidence  that  they  repOM 
and  ha*  recelTed  man^  additiooit  and  reTlaion*.  tn  JL  If  the  pri-nrnt  edition  UoompMrediHthtbai 
Thawork  1b  notBUBceplibleof  mor»  ImproremenL  laaued  two  fttara  axo,  one  will  rekdiJ}'  see  how 
Taking  it  all  in  all,  its  *ize,  manner  of  make-up,  mtich  It  ha.<  bfi'n  tinprored  In  that  time.  Many 
Its  ohaJKOter  and  tllii^lrstloDs,  ite  general  aocui^    pagen  hare  h<vii  added  lo  the  text,  eepeolally  la 

SMST  of  d<>*«riptloa,  It*  practical  aim,  and  Ita  pei^    those  parts  thM  tri-at  nt  hliilologr.  and  manv  new 
lenllx  of  Ktylc,  It  Is  thv  Anatomy  best  adapted  to    cuts  hare  been  introdnc«d  and  old  ones  modlAed. 
t  wauta  of  tae  student  and  pracllllonor.—JuaJicaJ    — J'lumil  of  th<  Aiitrriam  ilfliciU  AMoeiatiint,S«ft. 
Jltford,  Sept.  15,  tSS3. 1.  liwq.  _ 

Also  for  bale  sspakatb — 
MOLDENf  ZUTHEB,  F.  B.  C.  5., 

Surgeon  lo  SL  BartkoUmem'i  and  tht  FotmHIing  Hotptlnlt,  London. 

LandmarkSj  Medioal  and  Surnoal.     Second  American  from  the  latest  revised 

English  edition,  with  adilitions  by  W.  W.  Kek.v,  M.  D.,  Professor  of  Artistic  Anatomy  in 

the  Pennsylvania  Academy  of  the  Fine  Arta,  formcrlv  Lecturer  on  Anatomy  in  the  Pnilt' 

delphia  School  of  Anatomy.     In  one  handsome  I'imo.  volume  of  148  pages.    Goth,  91.00. 

This  little  book  Is  all  thai  can  be  desired  within  almost  lo  learn  It  by  heart.   It  leathei  dUcnoefa  by 

It*  scoM,  and  Its  contents  will  be  found  simply  in-  external  examination,  ocular  and  palpahle,  of  the 

valuatile  1i>  the  young  surgeon  or  phj'sloiaa,  sini.'e  t>odv,  with  such  anal-'mlcal  aud  phyalolngieal  fiMrls 

they  bring  before  him  sucTi  data  a-*  he  requires  at  as  directly  bear  on  the  subject     II  l»  emlneatlj 

•rary  ezamlnallon  of  a  patient.     It  Is  written  In  the  studeut'o  and  young  practltloDer'ibook.—/'lky. 

laagtiage  ao  clear  and  conclae    that    one    ought  $ieinmtnd  Siirgton,  Snr.  liSl. 


WILSOir,  ERASMUS,  F.  B,  8. 

A  System  of  Human  Anatomy,  General  ant  Special.  Edited  l>v  W.  H. 
GoBREC'HT,  M.  D.,  Profemur  of  fiencral  and  .surgical  An.itomy  in  the  Medical  College  of 
Ohio.  In  line  large  and  handsome  octavo  volume  of  B16  pages,  with  397  illustrationa. 
Ooth,  ?4.00;  leather,  $-">.00. 

SMITH,  m  ff.,  M.D.Tafuf  HORNER,  WM.E.,M,D., 

RmtrilHM  Prof.  »/  Surgtty  in  thi  fair.  <if  /Vnnn.,  tie.         Lnle  Pn,f.  of  Anat,  in  tht  Viin.  of  Ptntta, 

An  Anatomical  Atlas,  Illustratire  of  the  Structure  of  the  Human  Bodv.  In  one 
large  imperial  octavo  volume  of  SOU  pages,  vith  t>34  l>eautiful  figure*.     Cloth,  ^50. 

CLELAIfD,  JOHX,M.Ik/f,R^sZ~ 

Prt^tmar  of  AmaUmnif  aitd  Phyiulogy  in  Qmmi'i  OAUgt,  <3nltM)i. 

A  Dlreotoiy  for  the  Diaseotlon  of  the  Human  Body,  tn  one  12mo. 
▼olnme  uf  178  pages.    Cloth,  <1.'29. 


6 


Lea  BaoraKBS  &  Co.'s  Fi;bucatioh»— Auatomjr. 


ALLEN,  HAnRTSOy,  M,  J>„ 

A  System  of  HumaQ  ADatomy,  Inoluding  Its  MocUcal  and 

ficliLtionH.     Fur  the  111K-  of  I'rai-liliuiicn  and  l!^t<Hltnu  of  Mediciur.     \\'ltli 
(itictiiry    .--cition  on  llisloli.pj'.     Itv  K.    O.    ^llAl!»<r)'-MtE,    M,    D..    <>|>htluilni(i1 
the  I'hilMlelpliut    lloapital.      louiprMJiy;  8KI   i!'»iililt-«i!iiinnf<i    i(iiiirU>  pM)(«*, 
illuatrations  on  IT'S  full  pi\gv  lltliuuruplilo  t'tnlctt.  miuir  vf  vrhicb  arc  iu  tulon, 
cnf^viiun>  in  the  toxl.     In  t*ix  StUuins,  r-noh  in  »  pooioliit.     Becllon  I.  Hi?; 
y««i"n  n.    BoMW   AM'  Jois*p«-     twiiini  HI.   Mr*ci.ia   anh  Fa«i^, 
Ainuu^  Veik8   asd    I/YMTIIatic*.     SocUvm  V.   XBRroct'   EtvnxM.     Sec-ii<3a 
OitOAN^  OF  SessB,  OF  biOB«Tios    ASD  ttEN-rro-I'tirJ  *BT    Ohoashs    EiniBroi 

t>KVICIX>FMI9'T,  TkRATOI/XIY,   SlTfRllKJCIAl.   AjJAT<l»Y,  P(JM'-MoKTE3«    F^XAMISATIC 

amdGknehal  akdCunk'alIaiiEXES.  jtui  rtiuiv.  Prik.«|'vr^'tii>n,vM:h  in  a  IiaiuUki 
port/olio,  $3.iiD;  abw  ImhiimI  In  cme  rolutnc,  cUiUi  $23.IX>;   rfwy  luuKUrme  haif  Ri) 
mbed  bands  uul  opt«  liuck,  $2&fH).     For  mlr  f/y  luhiimiiltmi  only.     Appiy  tti  iht  PiMiti 

Extract   (ron   loUQduCtloa. 

II  ■•  ihedni^  (if  this  liook  tu  |imi-iit  ili>-  Inclsof  hrimnn  uummjin  the  ni&nner  l«at 
suited  U>  tint  nrquinnnvnU  of  tho  vtudwot  uid  thv  pnutitiuiwr  of  niMliciuv.  Tbcr  autlMr 
beUcTC*  ibM  nicb  »  book  k  needed,  inunudi  u  no  ifttliM,  u  fu  u  be  kn<m,  uunl&iDs,  ia 
■dxlltlon  to  llie  len  dftwripttre  of  tlt«  aibject,  •  trreteniatic  prcMnution  of  sudi  onatomkil 
facia  aa  nui  t)e  3i>|)Um(  li>  imcUcv. 

A  book  whirh  will  )icatonMaceumt«  in  Matetnent  tind  ooodfle  internui;  which  vlUfai 
an  arct^ptaMc  iu[ittiaii)n  nf  the  [in-arnl  ntnt^of  tbc  Mncncti  uf  amilorujr ;  which  will  exeJode 
D'tthiiijt  l)int  vnn  be  nimlv  ii{>['liiiil>lv  U>  tbi.-  itiviiiMt]  Mtt,  and  «)iidi  will  thiM  «cQl>Tac»aU 
of  Bui^iml  bnportaniT.  wiiile  I'Diiitinx  iv'ihin^  of  raloo  to  clinicnl  metlidne, — wnuld BpiiMr 
to  have  an  excuse  fur  i'xi.->l<>nii-  in  :i  riniiitrv  «rb«re  n)<«t  Marjpictu  ate  gt-ncml  [>nfUtu»en, 
and  where  Iheie  arv  ft;n  gcueial  t'l^^-'^i'^^'neiv  who  bare  no  iniereM  !ii  niTfiery. 

can,  and  an  Mmplr  Mip«rbL    Tb*Mt  ui  ■•  mndi 

i>r    pni^kal   MtiiTr^'iiin   -if  alial>i|iiii  nl    i-ilt)!.'   M_ 

Ui«  trury-ils, 

ti»  tb»«  ri   ■ 

KoB^ral  rnt-'  >' 

f<Noline  rtf   >uiitii*<:\l   £1- 

Klntti,  ciMif^rotng  wEi:' 
DUfhl  twfbrv  iirv  »o  wli  *        h4 

(Ktoratlon.    ]i  l«  a  «mrk  hi,:..-ii  u  'icmui* 
th*  btiBt  of  Ha  kind  Id    any  Muiciuut*i.— JT* 


It  tt  M  h*  wa»ld«F«<l  n  ^tndyarivplkdaiuUMBr 
la  Ita  »l<lMt  ■case— a  *ystefDa(Jc  prMaalaUMi  of 
■ach  itiitu»mtcal  Omiu  ai  van  be  appllod  to  tbf 
prartkv  nf  idkUcIiiv  •«  well  ^  of  nirnrr.  Dux 
kiith"-  !■>  rr.TK'iMi^  aecuiato  mid  prutt^al  la  Mo 
■1b  '  "  '  <l   nuFored*  iidiiilrahly  in  inPi^laii 

an  I'  ilio  Mudyof  viiKi  I"  K'-nnntHv  r'fi' 

•iil<  iil>Jv«t.    Tlt«  •lofianiiM'nt  of  fliMul- 

os;  !-■>  ironicil  to  a  niwlvrlv'  maanar,  aad  ih« 
croufKl  b  traTHliyl  ovvr  by  one  tlioroaghljr  bintl- 
Ikr  Willi  U.     Cbf  UlMnirMUitip  are  madawtia  fr«ai 


CLAIiSE.W. B.fF.n^CS.  tit  LOCK WOOI>,V.B.,£'.It,C- 

Dmunuemlartaf  AmUcmjiat  St.  jg4r(Aatr,wM*i  Aoi^raf  UaliaU  StJiaitl,  tvoAn. 

The  Disacctor'8  Manual.  In  ont*  pockrt-*i«  lano.  Tolnme  nf  396  V^voK  *■ 
49  IlIiMtniliunB.  Unip  diAli,  red  «dgm,  fl.fta  Jwf  ran^.  Bv«  ShidnU^  Strfm 
Mantiois,  I«(Ce  3. 

Tbii  li>ari!r]r  rXi'HIcnt  maiiiiat  (i>r  iheu^of  Uie    jiart, are aiMil  and  laatrortfve.    Tba  bmli  !• 
Mii<t«nt  wlKxlMiro- Iu  i<^ni*aai«Bi>.  TtiAmetb-    and  eoawtetiL    Wo  am  Klad  U>  neommeBd 
odtofdviriouilialion  r'ppm  liiuarerjr  (aUiiduitory.     Acubnt  Jtfcdkof  itadSurTUiet  ^itrnal,  Jan.  t^ 
Tl>«t«  ar*  many  uwmIciiU  nMob,  for  ibe  inaal ' 

TREVES,  FREJyEniVK,  K  B.  C.  *, 

Sursical  Applied  Anatomy.    In  oue  Kicke(-«iM  ISmo.  roInnl(^  of  &4<l 
with  ni  inu^t^lti(>nB.    Limp  rloUi,  n-O  «<lgM,  $£.01).     Jnit  r«W^.     8««  $>ii</«ajU'  Stri^ 

jU'onn-'Tit,  (lam'  3. 

H"  !i«'  i'iV'iIti'-('d  B  work  whlrli  nill  ramiiiatiil  ■    iiuk'tt«n«d  tiy  lUHr  xttr-  mi  «  '  '  prartt- 

tar|ivrrli'>1u  iif  rrailt-n  ihiui  (li<*  ftiu'<  tr<r  '-rtili-U  ti    doner,  hoa  onabruil  our  auth''T 
WM  willloii.    TliJ>  odIud  of  ■  Ihormifli.  |jraeli«>l  i  which  It  aualj  t>«a  iNcldtRli  •<••  <v>, 

hrofmtor  111  A  mUemg  it  &'•>■/•  CUtspf,  />)iy«wiiin  at  A'in|;'i  UtCf^^  Mtuj'lUL 

UecUoal  Applied  Anatomy.    In  ont  jwdui-vlM  t^o-  vohuue. 
See  Studenit'  Sfrifs  of  .Vnni.<i/<<,  ]>ng^  3. 

BELLAMY,  EUWARV,  JF,  R.  C  *, 

The  Student's  Ouide  to  Sargical  Anatomy:   Being  a  l'^  of 

nuiet  ImpiM'iatit  ^Idruicai  KenQnaof  thelllunan  Ihxlv,  and  inlondcd  a*  nn         l     .  .'iloal 
operative  Surgerf.    In  one  l^no.  volume  of  dOO  pa^  wilh  50  illuKtmUona.    Ciuth,  VL^ 


ttABTSHORKn-H  nASDnCxlK  tip  AMATOUr 
ANt>  fUY^IuLOiiV.  Stcani  feJitlan,  rcTiwa. 
1b  od*  loyal  Isno.  mlutpn  of  SUt  p«Ri>«,  vlih  SW 

veodaota.  otMb,«v.-n. 


ROttNER'SSPECULASATf-:  ' 
QGV     ElKbUi  Bdtuoa,  axtct, 
■nodlAad.    In  twa  oatam  voh  ' 
wilt)  3»  woodeuta   OlotlbVjLU. 


Lea,  Bbotheks  &  Co-'s  Pcblications — Anat.,  Pbyslcs,  Physiol. 


DALTON,  JOHN  C,  M.  />., 

PrufOKir  fnwHttM  (/  Pkyioliigy  in  tht  CliU*g*  q^  Phi^ntiaiu  oarf  Suryawu,  Xtw  York, 

The  Topoq;raphical  Anatomy  of  the  Brain.    In  three  very  h&ndaome  quarto 

TolumcH  comprising   \~S   pagw  of  descriptive  text.      Illustrated  with  furtT-eight  fall 

page  phitukgraphic  plates  of  Bruin  Sections,  with  a  like  number  of  outline  ezplanatoiy 

ptiUea,  afl  well  as  many  careful  ly-exeeuied  woodcttte  through  the  text.     Price  for  the  oom- 

{)let€  work,  $30.    Jwt  rtad^.    For  arUe  by  lubKription.    Aa  but  few  »f  the  ojpic*  reeerred  ■ 
nr  this  country  now  remain  unsold,  gentlemen  desiring  the  work  will  do  well  to  apply  to 
the  publishers  at  an  enrty  date. 

Tbla  tn  one  of  the  moHt  maRiiiflrent  work*  on  precise  mad  mcciimte.  and  the  methods  bj  which 
anatomy  that  han  appeared  durlDg  the  proxent  the  MCtioDH  werv  mu/W  and  tlie  KprcimcQ*  re- 
generation, and  irlll  O'lt  only  lapemede  all  its  produced  are  KlTenTfryiilalnly  loan  Introductory 
predeoesnorv  on  the  lopouraphical  anatomy  of  the  chapter,  wtiii'li  caiiDot  (all  to  bt'  of  the  graaleat 
brain,  but  make  any  further  work  ou  Iho  Mime  value  lu  any  one  dciairous  of  malclngiilinllar  prep- 
Unea  unneonn^ry.  It  contains  torty-elght  ex-  aratioUB.  CrlMcUm  on  vuch  a  work  is  super- 
qalslte  tllu«trailons  of  the  brain  en  miu*t  and  In  tliioui.  Wc  can  only  conRraliilate  Dr.  Dalton,  his 
eectlnn*.  Ni>t  only  ha*  perfect  accuracy  been  awlatania,  and  the  iiiilillpher*  on  the  energy  they 
»«eured,  but  one  or  the  flne*t  and  moet  artistic  hare  shown  In  iindeiiaklDB  ruch  a  work,  and  the 
work*  <-f  recent  tlmeti  has  lieej)  iireseDted  to  tlie  lUccaM  wlUi  irhich  they  hare  overcome  a  taak 
medical  piihllc  It''  Tatue  an  a  work  of  ivfereoce  pre-^ntinK  so  many  meohanteal  dlfflcnltlea.  We 
1>  considerably  lnc.Tea.<ed  by  the  very  carpful  >'Lit-  tary  our  Americaa  confreres  the  authorship  and 
line  sketches  which  aecompany  ilie  platoi  and  execution  of  .ao  l>«'autirul  and  useful  an  addition 
which  enable  thera  to  bo  easily  followed  and  to  medical  llterstura.  Much  light  Is  thrown 
understood.  These  itketches  are  reiy  complete  on  soroB  obacure  relations  of  part*  of  the  brain 
and  accurate,  and  hare  been  reproduced  from  which  have  nerer  befora  been  seen  in  oorraat 
tracing*.  The  descriptions  by  the  author  are  clear,   Jnztaposltion.~-/.oiido)i  Laitctt,  April  IB.  IMS. 

BY  THE  SAME  AUTHOR, 
pootrines  of  the  Ciroolation  of  the  Blood.    A  History  of  Physiologicsl 
Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.     In  tme  handaouM 
12m(>.  Tohime  of  293  pages.    Cloth,  %%    Jtat  ready. 

In  the  pnigretis  of  physiological  study  no  fact  few  years  by  American  physicians.  Itlsinserenl 
was  <if  greater  moment,  none  more  completely  resp^t*  the  most  complete.  Thi-  Tolume,  though 
revolution  lied  the  thcorie:<  of  teachers,  than  tho  small  In  stse.  Is  one  of  the  moat  credltMHe  e<HW 
discover)'  of  ihc  clrciilatlun  of  the  blood.  This  trlbutlons  tmm  an  American  pen  to  tnedlnl  hi*- 
•splajn*  the  extraordinary  int<>rest  It  has  to  all  tory  that  lias  appeared. — Meditnt  and  Suryiral  fie- 
medical  historians.  The  volume  before  us  Is  one  porter,  Dec.  6,  IS84. 
of  three  or  fonr  which  hare  been  wrtitan  within  a 


BLLI8,  GEORGE  VINER, 

Emtrttu*  /VitftiSiw  of  Analomi/  in  Vnirertity  OAUgt,  London. 

DemonBtrations  of  Anatomy.  Being  a  (.iuide  to  the  Knowledge  of  the 
Human  Body  by  Dissertion.  Fn>m  the  eighth  and  revised  Iy>ndnii  edition.  In  one  verr 
bandaume  octavo  volume  of  71(t  giages,  with  249  illustrations.   Clutli,  F4.25;  leather,  ZoJia. 

ROBERTS,  JOHN  B.,  A.  M.,  M.  J>., 

I'ruf.  "f  Applial  .inal.  niul  0}-er.  Ifiiry.  in  Phila,  f\>(iiclinif  ami  CM.  for  Oradualei  in  Jftdictru. 

The  Compend  of  Anatomy.  For  um  in  the  dissecting-room  and  in  preparing 
for  examinations.     In  one  Itlmo.  voluuie  of  l!>f>  pact's.     Limp  cloth,  To  cents. 

DRAPER,  JOHN  C,  Jf.  />.,  XX.~  I>., 

ProfMiuir  of  ClumiMtni  in  rA«  Vnirertilv  "/  IS*  tlfv  of  .Vcir  Turk. 

Medical  iPhyaios.  .\  Text-boi>k  for  students  ami  Pructitioners  of  Medicine.  In 
one  rictavii  volume  of  alNHit  TiHI  pngw,  with  :t7i>  wnodcutK  mut^tlv  original.  In  a  I'ef  dayK 
The  iiliitH't  of  the  uuthiir  has  lievn  to  prt.'M'nt  in  n  clenr  iin<I  concise  manner,  without 
uiiiliie  t(^-hni(':ilitii>s,  the  nKwt  modem  views  of  phvsit'n  in  their  s|>ecinl  Ivearing  on  medical 
ecifU'V.  ruiuiliiirity  with  the  lawn  :in'l  |irini'i|>k-^  which  Kovem  tlic  rclatinns  of  force 
and  iiiiittcr  if  miiiwjtrv,  ti-H  only  in  :i  i'k-:ir  ciuiiprehcii-ion  of  phviinli^-y,  but  is  an  ines- 
timable aid  1(1  the  pnyficiun  iind  surKeon  in  their  ilaily  practit'c;  yet  the  sulject  is 
Strangely  neglected  in  prottWonnl  educiition  anil  \>  one  lor  which  the  me<li(iU  student 
has  no  !>i)e('inl  lext-lstok.  ThiK  wuni  I'mleseor  I>ni[>vr  bits  enileavored  to  supply,  and  his 
diiilintfiiisbeil  rejiiiLiliiin  >;ii;iriiiitee!<  Mtch  n  nrcseiitutioii  of  the  subject  that  the  work 
will  l>e  net  only  c-ssi-ntiMl  Id  the  sii:>lent,  but  of  inii>ortiince  Ut  the  pmcttlioner. 

ROBERTSOX,  J.  McGREGOR,  M.  A.,  M.  B., 

llutrl.ettil  thtmn-tttrntur  uf  Ph'itifJifjfi,  t'nntrnttj  f/  (Jlntyjv. 

Physio  logical  Physics.  In  one  12nio.  volume  of -VIT  ti.iet.it,  with  219  illiistrm- 
tioiu.     fanip  clcth,  tlJ.CO.     ,/iij"/  rcti/y.     Sec  Sluiirntii  Srri>*  of  .l/'rriKn/ji,  psige  S. 

The  tlilp  of  thl-  w<  rk  siiflli-ii'irily  eTplainn  the  meiito.  It  ulll  )>e  found  of  great  value  to  the 
naturi-  <>r  t(^  <'.'[iI'>iiIh,  Ii  i*  iI-''Iki>i  "I  a-  a  mnn-  iirwtiClonfr.  li  in  a  I'srvfully  prt-pared  bo>ik  of 
Hal  for  ilie  "Iii-li'iil  of  ttieilo'iiie,  an  auxiliary  u-  ri-f-Trin'e,  euni'iM-  ninl  ai-cursti-,  and  ai  'Ueh  ws 
bl<lext.)'i<ik  inpliy^loloKy.and  it  would  ln'imrtlcu.  I,i  srtitv  r-'<-oiiiiiiend  it.— ./■''! rimf  vf  tht  Amtnean 
larly  uiehil   a- a  giilds  to  Ills  lal— rat'ir>-  expert-     .l/rrliml  .4u""'iri<in,  tier.  I'l.  InM. 

BELL,  F,  JEFEREY,  M.  A., 

pr'ifyntr  of  Cimparritirf  Annltimy  at  Kin;)''  0>"'fjf,  Ijyn'f-''. 

Comparative  Physiology  and  Anatomy.    Sliorily.    ixe  ^uitmif'  Serira  of 

MaHmnt*,  |>age  'A. 


S       Lka  Brothxrs  ft  Co.'6 


nSmONs — PbTstoloffyt  Ctaeml 


i>AZTo:y,  JOHN  a,  m,  j>., 

prTfftuor  9f  Pti^fiHovf  In  tilt  OtttUft  at  Pftytteinni  mid  Amvwm.  A'm  r«rlt,  Ht. 
A  Trcattso  on  Human  Physiology.     I»eiitgncH  for  th*  nae  of  Stodenu  i 
Pr)ictitiiini.'r)i   of  M^lidni'.     Srvvmh  iirlitidn,  Iborniighlv  Tv%'i«pil  Knd  rei*rilt«n,     In< 
Tcnr  buidKHuo  wtaru  vulumv  uf  722  vs;vv,  iritli  252  bcauUAil  vnmriogs  oq  wood.   CIq 
Ift.OO;  iMther,  $6.00;  Tcr^p  handwime  half  RusbU,  rabwd  tmnds,  fC.M. 

'    Tb»  nwrltt  ot  Pnfewor  IMHeB'a  tl^xt'boo1e,  his  mon  compact  forai,  jrM  lu  d^lfghirtil  «liarai  bi 

■nootl)  m4  pI*m4d«  dtrlty  tfaa  r««nul:i>Ue  cUtiT-  Ulnod,  anxl  no  mMwot  !•  Uirown    Into  obacoi' 

su*  of  hli  dtMrtptidoi,  wblcl)  !«*««•  not  ■  e)i>pt#r  Altosftlbcr  Ibu  editlOB  te  ht  In  •rfTane*  »f  i 

lAiaan,  hl>  (i>nilou>  jDilfp»"nt  "^'l  <l^'  gcjioral  pi«(tou*  ono.  Mid  *>lll  WimI  to  kiHip  ih*  pru 

eORwiBMs  Of  hfs  fHtn,  are  perltMnlr  known.  Tb^  pmEmI   u  io  ifce  moat  kmdI  »d4ttlOD« 
bar*  mad*  Mo  t«xt4>aok   tli*  on*  inort  bnlllw 
U  Am»neaa  Httdt»ta.—Mtd.  Bttard,  March  4,  IKS. 


to 


C«rtfi]Blr  BO  pttj-aloloKloal  noTk  baa  arar  tlBa«d 
from  tba  prawthat  prMantad  Iiji>t]bjMit>niaurTr  tn 
a  eltam  and  mon  aunutirs  HrIii.    Alm<-«  aT«T 

of  tba    axliBUallte  lexinittt 

Tbe  mataritl  In  pIvTad  In  a 


phyalofogloBl  knowladBa'~i''>cA«9a"  M»iiMi  S 


BIC*  bawv  •rtdanea  of  tba  axliBUallte  ibtIiIiii) 
tat  haa  lakan  plaM. 


prU.18a. 

Ont  eaa  Manaljr  (tpes  a  Mli«f«  «ataJ< 
doaa  not  hara  mMUTon  or  fallon't  P' 
iha  t«MminMi<l«d  last  m  coomltattos 
Amviioui  nudimt*  tr*  iroold  onnuiarvmnjr 
mead  Dr.  Dal laa'a work.-  Va.  ifad.  JVoilJUy, ' 


JF08TER,  MICHAEL,  H.  Z>.,  J*.  JJ,  &, 

Text'Book  of  FfayBiolo^.    Third  Amfricai)  trom  tbe  Touilh  EdsIuUi  •ditioi^ 

witb  Dotca  and  additions  b)-  E.  T.  Kkiliiert,  M.  D.    Io  one  bandsoiBe  royal  fSUMLToIinM 

ofovar  1000pii£e«,<rilliiiboiitS00  illiisiratiooM.  Clotli,  $3.25;  Wth«r,  |3.i5.   ia  a/wdoya, 

A  notint  of  toe  previous  ciiiioD  b  npjMittded. 


A  m&t*  compacLaad  "-lFTitin<^  «r.rk  on  rl>y*in4'  <  »taUoo  (ha  lat«  dlaMt«i1ea  In  phniologUsti 

omy  hM  navfr  b^fn  pit>ill'--ri{<^,  r.tiri  wiwitorii  our    talryat>dUi««zp«rlin«nl«lnln«auBaUoB»f  I 
•anaaoM  l    :  unit  tlint  li  hai  ,  aodot:  ""  ■  *  *" 


fin  rithll'--f5{'il,  Ktirl  wvlwltoni  utir- 
iiriK  tllBl  U  hai 

Riow  ba*n  : 
In  whiRh  It. 

WOlk  «0«lffiiri'"  li'  1^1 

aad  eoniF«miTo  aiMUmy,  and  lahM  laia  eaam 


:  iriK 


'iS 


"l"'ki-n,    Tl 

I  ii.->i<.-i>r''hi-alntotooloeT 
MM- 


'aodtliaaz;, 

41]«r«.  Tha  amtiK«in«&t  foll«ir«d 
to  ra«id«r  Iho  wliola  lubjevl  liield  and 
BMlad  la  tt*  Tartoue  parW.— Uioaira  JTi 
not  awl  JEsnvdicr,  Augual,  un. 


JPOWEHf  HEyjiT,  M.  B„  JF,  Jf.  C  &# 

Aaaitarr  M  Jtn^U/toatr,  Rofal  OtUtft  of  Sur^fecm  of  KiflMd.  

Htunon  Physiology.      In  onp  hnndsome  podcet^iu  t2no.  volnme  of  396  pagck 
with  47  illiiMCTiiiiniii'.     *  !>ith,  $1  -iD.     i^e  Sltilentif  Stria*  ^  Manuait,  p«f«  S. 

Th«  protnttHBloliaraetcr  of  tlila  work  tt)  thai  of 
JudMoua  coadeBullon,  ia  which  an  able  Mid  >uc- 
Maaftl  «A)rt  appcara  to  hara  he«n  cnadf^  hy  iu 


aeeotnptUkad  authtir  h>  taaah  tbn  grcatm  numttor 
of  tKia  In  Uia  f«waet  pa*#lbl«  trwda.  Tb«  rasuli 
la  a  (fMclman  of  oonRaatmtwd  lni«lUctna]  pabu- 
lum aaMon  ■urpawad,  which  oocbi  to  b«  e«r»- 
Aillf  Innrtod  and  dtaetitad  \y  mrmxy  praMillonBr 
Who  daalrac  lo  kaap  Klmaalf  well  tnfotniod  apc>a 
thli  OM»at  pr<igr«*il*a  of  tb>  medical  icl«nc«'- 
TbOTOlamo  liofiewhlehwaooTdlattrrcBommand 


naj  if  ike  Unileal  Setmem,  Cictotvr,  IMt. 
Tbi*   1111)0  work   If  dMorrfitf   <>f  'h^   hl^MA 


nnlia,  aiMl  «•  oui  hardly  ooncr  i 
Wte  (If  ihlft  Mience  Miald  lwt«  > 
cr  cDnolMljr  rtaCvd.    T1i«  iwl««  o: 

M  toplaHli  wtibtBtbareaob  t-Taii.  uruir      

a^«Uan«B  of  its  taxt  will  DanalDly  ircure  for  ll  tncat 
fkTOtaUe  oounMBdattOB  — OM^iwMb  Xoiurt  aad 
rtMff,  Fab.  b^  leN. 


rorathfll 


C^JBPJEiVTEJJ,  TOT.  B.,  M*  />.,  jF.  JJ.  &,  Jl  G.  A>  Jl  X. 

Prinoiples  of  Human  Physiology.    Editeit  Ify  Hbkrt  Powm,  M.B^ 
F.F.CSt  Hxaniiisi-r  iu  NntuwlStiMKi-!.,  L'ltivfikiijr  of  OxroTcl,    A  n«w AiDeriem  froin 
ei([hlh  revUcd  and  enlaiitederiitioii,  wttli  rioie^aodaddittoDF  hr  FttAXCUG.Smrn,  M.Dn 
late  Pffifefiwir  of  the  Institutes  erf  Mwlit-inc  in  the  Cnivmiiyof  Pennaj^lrRuia.     Iao«w 
very  lar](«  nad  liaiidaom^  octave  volume  of  1083  I>agcai  with  two  pl»t*n  ami  373  illuf-, 
timtiooB.    Cloth,$&&0;  leBth«r,$6.oO;  half  BnanSfST. 

FOTTXES,  GEORGE,  Ph.  D. 

A  Manual  of  Elementary   Chemistry;    'nic»wtic»]   nml  Prartirxl.    B*> 
vised  by  H^xitv  Waitv.  B.  A..  K.  K.  B.     >'cw  AtueriEnn  edition.  Iti oii«  latiitm>yil  ISm 
voUmw'of  ortr  IW)  pnccv.  with  S^>0  illtistratioos  on  wood  and  a  eolond  [>Ut«.     L' 
$2.7&;  leatlwr,  SH,-J."<.     Tn  piyj*. 

A  notice  of  lbs  prvviuus  edition  is  appoaded. 

Tlw  book  opeciB  with  n  tnailar   < 
Phnl«.  IndVdiBK    UaM.  Ugtit,  M. 
naetr1olt}>.     Thea*  niMect*  af«  i-  >  >y 

and  brleflj'.bnt  MtOOcti  In  Kl**n  (<■  •'■'it'''-"  I'.c  -in- 
dani  to  ooTDprebcud  the  beta  and  law*  of  CbonUa- 
trr  propar,  ll  UUio  (kvlitoonf  lata  iNiim  to  omit 
tttoao  toiplci  frain  wcirka  on  ohMSlatry,  but  |]i«lt 
otBlnlau  la  not  10  ti»eomrn«ndBd.  A*  waa  r*(]Blr«d 
by  Ibe  freal  adTuMo  In  lbs  actaaea  of  Cbatalatfy 


« 


~i     ofl: 


of  lata  jraar*,  1 1 
ufClHnloal  r: 
l«o.    TIm  I«'< 

le>MM,  ale.  ai»  riPiU]-,-  ftr.,i  tii.  ■■ 

laMadiUim  <■  Bgroatlnipr«v«ni-' 
oawora,  wtikh  ll  uyiii^  nat  klii:. 
haa  Racked  It*  iweltUi  adlitoti.—  < 


W6hler*8  Outlinoe  of  Organic  Chomlatry.    Edited  bjr  Frtno.    TnaaUiad 
by  iRA  KrMiTW.  M.  r».,  Ph.  D.     In  one  I'liaa.  Toiome  nf  MO  paft*-    Cloth,  tS. 

pAU-nWAVa  QUAUTATIVE  ANaLTSIS.  flaw  i  CASPEKTEn-SPniEB  BSSAV  ON  TnCCaBAM) 
MUtlm.  ABoaaaiP  Ammuo  Liovoaa  t«  Ui^Ltw  a«e  Vi* 

L.EHMAyS'S  MXin^Kli  OT  (m'U\Cli.tt  PRTS>  I      uaKWIIliexplnirtSunsDrHilattllflowanIa  Snwll 
lOIXXiY.    In  ou«  ncvaio  T<Aiun«  cA  VCl  va«M.\    \ttM.  'ttWtMta.  Cloth, 60  oanu. 
wUh  u  iHuauaUoft*.   Q«i*i.^aas-  \ 


Lka  Beothkrs  &.  Co.'8  PuBLioATioirs — Ctaemlatry.  9 

ATTFIELn,  JOHN,  Ph.  D., 

Prnfa»or  qf  FraetUai  Chemittry  to  Hit  Phamaeeutieal  8ofi*ty  of  Ortat  Britaiii,  *U, 

Chemiatry,  Oenerol,  Hedioal  and  Pharmsoeutioal;  Including  the  Cbem- 
'taUj  or  the  U.  S.  Phaxmacopoeu.  A  Maniul  of  the  Oensral  Principla  of  the  Science, 
tad  their  Applicatioo  to  Medicine  uid  Phumacy.  A  new  American,  from  tbr  tuitb 
English  edition,  specially  renaed  bj  the  Author.  In  one  handsome  tojbH  12ma  Tolume 
of  f2S  pagtM,  with  87  illustrationa.    Cloth,  92.50;  leather,  $3.00. 


A  tast-book  which  pftioes  tbroogb  tan  •ditlons  f  to  put  hlmaelf  In  the  •tadant'i  plae«andta»ppi«- 
in  »lst«en  yvtn  must  have  rood  aukllUaa.  Thts  i  alWte  faU  MaU  of  mind. — Amtnem  Ck*mcat  Joitr' 
remark  la  certainly  applicable  to  Attfletd'a  Chem-    not,  April,  ISM. 


letrr.  ■  book  which  U  •o  well  known  that  It  li       It  i«  a  hook  on  which  too  much  pralw  cannot  ba 
hardly  naceeaary  to  do  more  than  note  the  app«r-bOTtowed.    As  a  taxt-book  fbr  medical  aohoota  it 


Mioaof  thUnewaodlraproTededltlon.  ItaMiUB, :  la  muiarpawable  In  the  preaent  i<tat«  of  ehemlnl 
however,  dMlrable  to  point  out  that  haWr*  of  the  i  .cleace,  and  baring  been  prepare!  with  a  ■pMila] 
book  which.  In  all  prohah  Iltr,  has  made  It  ■©  i  vjew  towards  medicine  and  pharmacj.  It  ia  aUke 
popalar.  There  can  "be  lltUe  doubi  that  It  la  its  '  indispensable  to  al!  perwms  engaged  in  thoaa  <to- 
thoKKuhly  practical  ebaractar,  the  expraaalon  '  p«rtinentB  of  aelence.  It  Includes  the  whole 
balnansed  In  its  bast  sense.  The  anther  undei-  '  chemistry  of  the  laBtPharTOaoop(B!a.—A«(*;*«*. 
■tan*  what  the  student  ought  to  laam,  and  la  able  l  eal  and  /iHgrlaU  J-wmol,  Jan.  IsSt  ^^ 


BLOXAM,  CHARLES  X., 

Pn/Mtor  c/  OumUtrw  t»  Kim^t  CblUf,  Lcmkm. 

Chemistry,  Inorganic  and  Organlo.  New  American  from  the  fiilh  Lon- 
don edition,  thoroughly  revieed  and  much  improred.  In  one  verr  haodacMne  octSTO 
volume  of  727  pages,  with  292  illustrations.    Cloth,  $3.76 ;  leather,  $1.75. 

Comment  from  us  on  this  Rtandard  work  Is  al-  '  the  best  manual*  of  ganrral  chemlstrr  tn  the  Bog- 
most  iuperfluouB.  It  ditT«r«  widely  In  scope  and  '  lish  language.— D«troJ(  LaneA,  Feb.  ISM. 
aim  from  thai  of  Attfleld,  and  In  Us  wi^  ise<iually  The  general  plan  of  this  work  remain*  tba 
beyond  criticism.  It  adntits  the  most  direct  meth-  same  a*  to  prerlous  edllions,  the  exident  objaei 
ods  in  titating  the  principles,  hypotheses  and  facts  being  to  gire  clear  and  concise  deeerJMIons  of  all 
of  the  sclfnce.  Itn  laiiBUsge  Isso  terse  andhicld,  known  elemaDts  and  of  their  moit  Important 
and  Its  arranxement  or  matter  so  logical  In  »e-  \  onmpounds,  with  eiplanatloni  of  th«  ohamloal 
qnence  thst  the  stadvnt  nsTer  has  occasion  to  '  laws  and  principles  tnrolTed.  We  gladly  repeat 
complain  that  chprnlftry  is  a  hard  ntudy.  Much  now  the  opinion  we  azpreasad  abont  a  former 
attention  Is  paid  to  experimental  illu^tratlnns  of  edition,  that  we  regard  Blozam'*  Chemiatrr  as 
chemical  principles  and  phenomena,  and  the  one  ol  the  best  treMlses  on  general  and  q>plfad 
modeof  conducting  these  experiments.  The  book  chemistry.— Ji»«rie<inJoHr.ofPhars«aeiy,  Deo.  IKS. 
maintains  the  poaitTon  it  has  always  bald  as  one  of 


8JMON,  W.f  Bh.  D.,  jr.  J>., 

PnfettoT  c^  Ckamutry  and  TbtkoUtgy  ti*  tA«  Oilltg*  of  J%t«HiM  and  Sitrgtont,  BMiman,  and 

Profmtor  of  Oboilitry  in  tAs  Matytand  OatUgt  of  Pliarmaey. 
Manual  of  Chemistry.  A  Guide  to  Lectures  and  Le)x>rator7  work  for  Beginners 
in  Chemistry.  A  Text-book,  specially  adapted  for  Students  of  PharmaOT  and  Medidne. 
In  one  8ro.  vol.  of  410  pp.,  with  16  woodcuts  and  7  plates,  moMlf  of  actual  deposits, 
with  colors  illustrating  56  of  the  mnct  important  chemical  reactions.  Cloth,  $3.00;  also 
witliout   plates,   cloth,  $2.50.     Jiuf  rtatiy. 

This  bonk  supplies  a  want  Ion*  felt  by  iiudanta  '  plates,  beautifully  exccut»d,  iltnsttatlng  precipl- 
of  medicine  and  pliarmscy,  and  !■  a  concise  but    tales  of  rarlotis  raactloon,  form  a  noTcl  and  nlu- 


thorough  treatise  on  the  subject    The  long  expe-  ,  able  feature  of  the  book,  and  cannot  bil  to  be 


rience  of  the  author  as  a  teachar  In  schools  of 


.Tp 


<  predated  by  both  student  and  teaoher  as  a  halp 
medicine   and    pharmacy  l«  coospicnrius   In  the    orer  the   hard  places  of  the  aclenee.— Jftrvfona 
perfect  adaptation  of  tliework  toihesMclal  needs     --  -      ■   ■ 
of  the  student  of  these  branehen.     The  colored 


FRANK!.  AND,  E,,  D.C.X.,  F.  R,8.,  &JAPP,  Ph,  !>.,  F.  I.  C, 

Prefator  of  ChtmUtry  in  tht  Xomai  School  Atut.  Pro*,  of  ChemUtry  in  tJn  Kortnat 

of  Srienri,  London.  Sehaol  of  Sritnee,  London. 

Inorganic  Chemistry.  In  one  handsome  octavo  volume  of  600  pages,  with  61 
woodaits  and  2  lithographic  plates.    Cluth,  $:}.7a;  leather,  &4.7o.     In  prett. 

This  work  on  t'lementarr  chemintty  ia  tmaed  upon  prLncij>le!<  of  olanitiuation,  noiuen- 
clature  and  notation  which  have  been  proved  by  nearlT  twenty  vears  experience  In  teaching 
tn  im)>art  must  readily  a  sound  and  accurate  knowledge  of  the  science. 

REMSEN,  IRA,  M.  I}.,  Ph.  J>., 

ProftMor  of  Ckvnisfrjf  (n  tht  Jotint  Hopl!in4  Unntriity,  Ballimorr. 

Frincil>le«  of  Theoretioal  Chemistry,  with  special  reference  to  the  Constita- 
tion  of  Chemical  Com|iuunds.  S«v<)nd  and  reriaed  edition.  In  one  handsome  royal  liina 
volume  nf  240  pages.     Cloth,  $1.75.     JvM  ready. 

The  book  f  s  a  raluable  eontrihnilon  to  Iha  eheml-  of  chemiatry.  The  high  repntatloa  of  tlia  author 
eal  lltaratura  of  inatniction.  That  In  so  few  yaan  assures  Ita  aceuraer  in  all  maUara  of  fhet,  and  tla 
a  second  edition  haa  baan  called  for  Indicates  (hat  tudldous  eonaerratlam  in  mattera  of  theory,  corn- 
many  chomkal  lewihera  hare  been  tbund  ready  bined  with  the  tbineaa  with  which.  In  a  small 
to  andoraa  lla  plan  and  to  adopt  Its  mathoda.    In  compasa,  the  |>raaent  attltada  of  chemical  aelanea 


thla  edition  aaoBBldarabla  pniportlon  of  the  book 

haabaan  rawrittan,  much  new  matter  baa  bean  »•«•~w,K••«>>»1w■Iu^Bl«v>I^>l»w>K■K~ 

•Mad  and  Iha  whole  liaa  baan  brought  up  to  data,  to  th«  aienM  ta&tAMDtu  cA  \&»  Juq^A' 

ir««araa*l()'<MaaafldthlabooktoaTai7atudant  Joamal  <^  £ianca,lfca>«ti,UM. 


towvda  Iha  eonalttatlon  of   eorapoands  ia  ea» 
a  Idarad,  (iTaa  tta  vaLna  nvKlti^ian  tA^^kvUk  wstortaA 


Lba  BEomnu  k  Co.'s  PiTBUCAnoNs— Cliciflist>7. 


CHARLES,  T.  CBAySTOVN,  M.  i>.,  F,  C.  S.,  M.  A, 

Permtrly  Ami.  Prvf.  ami  ftmnnnt.  of  CJirmnfry  ind  f*<™..  l^ftw*»  CMtayt,  St^MM. 

The  Elementa  of  Physioloeical  and  Pn-  al  Chomfalry.    A 

Hntiiihfmlc  frir  Moilimi  StiiHt^ntM  and  Primhionere.      (.■,i:i,..nii;K  »  ^renvml  ftc«tNint 
Niitritiuit,  F'xJ*  find  Digtalioii,  «mi  ihc  Cliemiatry  of  the  TUsues.  Orcnns,  RpcT«innf 
Eiccjeiifw  iiC  the  IWy  in  Hcnlth  ond  in  I>tsea«e.    ToRCthw  with  lli*  lurtliiidn  ' 
|)Arin^  or  Mfinriitiiig  their  chirr  mnKlitiipnW,  a«  abo  Tor  their  examtiiMion  id  d 
an  OQiUiie^lluliUBurniinutii-uU-uurwof  inEtnictkororBtudcntB.  In  one  huidaania' 
TOltime  of  463  i<ngt^  with  S^  woo<)riit«  nrul  1  colored  plate.    Cloth,  $3.50. 

Tb«  *ork  i>  Ihcfougfalr  traiivtorUiy,  juid  to-  |     Dr.  Cbu-tM*  tnuiutl  adnlimbljr  Aimif  Kd  In' 
ftnmod  Uiroii|;liiKit  Inr  a  g*niiiu«  ■oknllGo  ■vlrit.  '  tloa  of  flHiig  hit  naden  on  th«  <mf-  ~ 
The  mUuj.*  'I'-aIo  ii-ith  Ui««b*mutrT  o(  th*  dlite*- 1  tavy,  compNbmslve  but  T«mu-k*t< 
Itf*  McrailnuB  in  ■  >]r*temalic  lOBiui^f,  wlilcli    Ihe  mom  of  beta  In  Ihe  aelencva  * 
iMtrcit  iK'Uiiax  to  b«  d«j<ln)4,  and  In  raiutty  *up-  i  comr  indu>p«u«bl*  to  t)i«  phyician  :  mxy  od 
Itllitii  a  «>□!  in  Etiiilfiii  !ll«rstur».    Tbo  book  «(-  '  u4li«r  haiMl,  of  b  ayslein  of  pranlpal  (il>w4JMia 
pMrtiu>u>lol>*M  '>D'^  full  and  KirmiinAttc,  and  ,  tnlnute  tbMaa>}jrMaon«aaeiuid*n»l  Mml' 
10  ihon  a  liulBfipr«al»tiou  of  Um  i«UU*a  tuiiKirl-    may    ba   juamied   bf   any  Inlalligent 
oaoo  of  tha  vbrlooi  suMeeu  dealt  wlih.— £nrut    ArrMvt*  vf  MMtmt,  I>m.  UM. 
Voiintt  /puma/.  NorcmUr  tt,  UM. 

HOFJr3lANy,  F.,  A,M.,  jP/i.7>.,  *  POWER  F.B.,  Fh,. 

PuM^  AnalyH  loft'Staltof  Sm  York.  prf/f.cf  A^utl.  Citm.inlh*  pKH.  OAi.of  fh^ir^a 

A  Manual  of  Chemical  AnalysiB,  u  applied  Xo  the  Exaiaiimtioo  of  MedicU 
< li^mif^'l''  and  their  rrcjuinlions.    IWlne  n  Ouiilr  fonhe  I»pl«rmiDati<>D  of  their  id« 
■od  Quality,  and  for  th«  rk-talion  of  lni|Hiriti<s  and  .\dult«nituiinu     For  lli« 
PhanuacUla,  PtijFsidanK,  Dmwintj  itnil  Muiiufiictiiring  ChtiuiHa,  and  Ph a/am.'w aticml  i 
Mcdiral  StiidMtte.     TIiIrI  wlili(in,  witirely  r«writl«»  and  mm-ii  ailapp?<L     lo  oneteiy 
handacnir  fwliirii  mlutiip  "f  <ii!l  jmRr-r,  with  179  illiisiralinn*.    ftolh,  (4  2A, 

W»  eoDKTKi"!.-''    'I -  ■  ■     .  -LL    M»rvov«T,iiJ 

of  Uia  Ihinl  ccii'  'iiliicklamm. 

BmUmoln"  :k'04Iiu|  It  Ki 

tba  lnflM:i :  ii"  inaBU&Suntirl 

axttnsit''  :  Micalv— ZriMtdm 

cwanfori'  >nt(w>nt,  U8H. 
CM  of  Wllli;li  U  Ip-ni'.  1'  -ii't-lliTii  luui  II...  H-.(-r(j- 

Srmar  ShiiK* iliulrr  a!  Mr  U<i'  r.iwflr-uirlrr-l.-jmt,  *l(. 

An  Blemontary  Trcatii^r  i    uctical  Cbomistry  and  Oimlitativs 

Inorganic  AnalysiB.    8)>c\-iatly  ailn|it(-(l  for  mtc-  in  thn  Labon.' 
Coll^w  niid  i>r  iLirKiom-rs.     Thinl  Ain«rii-»ii  in^ta  tlic  futirth  and  ir\  .  . 

In  ooti  TL-ry  IttuulHiuut  ru>al  IStnu.  volume  vS  about  400  pti^H,  wiUi  uUmI  U)  tUu^iMi 
dolh.  $"i.oO.     /n  a  /em  (/rijw. 

The  demand  fi-r  iwir  editions  of  lhi»  wiu-k  prove!-  the  nuvnt-nf  PmBoanor  <~1. 
10  i'^>vidf  n  Hiiu)>le,  (vinciiir  and  ini«twcrthy  Ktitdv  to  i^niilitativv  analyain.     'i 

Jrr[Kimli>'n  i-f  Niii-fimtim,  nnd  ihv  dirciii<'n(>  for  Wirkiny  hnvr  betn  «>  lully  ami  >  K-an* 
piailcd  thill  thi-  ui-ik  ie  Mlmiicahlr  adapl<.tl  not  •■nly  (•>  rL-Jicvr  the  Uwhef  of' 
XaUt,  Uit  nlm  to  nn^vft  all  th«  rrqHirTnicnu  nt  »t<lf>inMnicti<>ii. 

RALEE,  CUARLES  IL,  M. D,,  F.R^C.F,, 

.Itt'i.'pin.'  /'Ayorina  nl  (Jtr.  Jondna  Hoipilat. 

Clinical  Chemistry,     In  one  pt*^krt-»it  I?m<»  mlnmf'  (*f  SH  l»p».  with 
lUuttlratluiiK     Uiiup  cloth,  i«d  ed^i^%  ^l^olr. 
Thb  t*  <>[>«  ^  <!><*  *DMt  Inttnicllvp  lildc  vrr-iMt 

UmI  ••tin""'  ^-  ■  •  ■^  ■>'■■  '•    M  ' ■  -  n-r.    Tin-  nullurT 

laartv"  '''^"  '*'  O  ^''*^II^* 

M,eMI*<-'  'iBllfifdly  ti-«c- 

UMl.Mli>l>K  ■"■    IJ'.'-- J'"    -''"It  h«o««littc 

kaM).  of  fM  apflimiioni  <ii  dyaoiiattjt  in  tnedl- 


8w.^' 

ti'Iri;  - 

•nd  'ii 

nsodcru    -..^ .^    l....;^ 

Btetrd,  Fctiniai7  «,  loat. 


UMl.Mli>l>K    ■"■■    IJ--.-- 

■  apflimilon 

CLASSEN,  ALEXANDER, 

■lemontary  Quantitative  Analysis.    Tmiulated,  with  notv  i 

KwiAB  F.S.'iiiTii.  I'b  n..  Aiuintaiil  Proferwir  of  CJhemistryin  thbTont  : 
X^iri^ty  vi  i'tiaiiu.     Ill  "iiv  1 2iu».  voluiue  t>f  31M  pu|^,  mth  39  niHH. 


n  !■  nnfabtj  tka  lw*t  ii>niiiini  «I  >ii  i^lmeaiaiy 

■XMlt    HtMBtoll  Ik*  il>  [ii''llio-|i  nr*  thn 


and  Uiea  adfaiiiMna  toili*  anatr>l«af  mliicraliaaJ 
muih  nrttAaet*  an  aiw  toai  vlA  la 


^uaa*  Bxivii    m»"wr...  1--  ■■-  ■-  —  — I "'tk  'a  ajifiliad  rhvaiw- 

^^   li  wMha*  br  axamiiJ**.  contaieaMac  vltii    t^.    it  la  au  ladupwaUa  bosk  far  atodaaia  )a 
SkcU  JaMrmtaailOBa.  Mkmtd  hf  aafatatloa^  '  irhciiilitfjr— Acaliaii/ovnial^  CktHUfeihOaLUn- 

^mES?f£.  WTLLIAM  ff.,  3f.  J>., 

j^  >■  r  Medical  Chemistry.    Fortht  iiw  nf  S'lndi-nlt.    Raft«l  «j     ' 

^^-■^  %  i-.l-lry,   Ifl  HUB  rJmo.  vi-ltimi;  of  310  poRi*.  with  T4  illua.    C'ln 
!»-.  ^*:«M!.-  T'liM*  iwjudiwl  t«in.    the  wcoratil-B  .11  nimp«ua4*  ilu*  u.  (* 

woavw.  ,[Yot  vVi«\i«>^iM*V)<K>a>    uAdWSttDs.    The  dMccUan  <4  pnlMWa 

»,"*^**"-;  .,,,,iiift\4»*ilftAV*T.*w*-    ■•Wtv^'iKiiiAin.i.WVm-fctaHhapurwwa  qfUiail 


Lea  Beqtbehs  &  Co.'s  Publications — Ptaarm.,  MM.  Med.»  Therap.  11 


PABBI8H,  EDWARD, 

Late  I'riifeuor  of  t)u  Thtory  mid  Prattiet  0/  Pharmacy  in  lltt  rhiladtlphia  OMtgt  of  Pkamutty. 
A.  Treatise  on  Pharmacy :   ilesiKned  u  a  Text-book  for  the  Student,  and  u  a 
Guide  for  the  rhyucioD  and  Phaniiaceiitisi.     With  manv  FormulK  and   Prescript iona. 
Fifth  etiition,  thoronithlT  revised,  by  Thomas  8.  Wifoaxd,  Ph.  G.     In  one  handsome 
octavo  vnlume  of  109S  pages,  with  2-^  illustrations.    Cloth,  $5;  leather,  $6. 

No  thoronKhKnlnRpharniKclBtwlIt  fkll  tapOM«H«  '  Th<p  well-known  wnrk  pi^sent*  lUelf  nowbaawl 
hlmveir  of  »o  uMfiil  *  guide  to  pncilea,  and  qo  npnn  th«  recenttr  rerised  n*w  PharroacopcBla. 
physician  who  properlv  eitimaU^n  Che  rtlat  of  an  Each  page  beam  «Tidenc«  of  th«  eara  beslowad 
accural*  bnowledgo  of  the  remedial  a^Dtn  em-  .  upon  it,  nod  ^'iiTeyi  Taluable  iDforniallon  t^m 
plojed  bv  hlro  In  dally  practice,  so  far  aa  their  ■  th»  rich  store  of  thp  edllnr's  eifurience.  Id  taet, 
mincibiliiy.cnmpaillilHty  and  mostefTectlTe meth-  all  ttiai  rrlat^s  to  practical  pharmacy— appaiatua 
ods  of  poiiibinatloD  arc  concerned,  can  alTord  to  prooesteii  sud  divpi^D sing-- liar  been  arraugad  ana 
Icare  this  work  out  of  the  hat  of  their  works  of  described  with  clearness  fn  It*  rariou*aBpectn,sa 
r«[arence.  The  country  practitioner,  who  roust  .  as  to  afford  aid  and  adrlee  alike  to  the  studentand 
always  be  In  a  measure  hiM  own  pharmacist,  will  to  the  practical  pharmacist.  The  work  is  JtuU> 
And  tc  indispeusable.— X>otiksrU(s  Medical  .Vciri,  clously  Illustrated  with  good  woodcuts — jJnssHsaa 
March  29, 18M.  Journal  of  Pharmae}/,  January,  1884. 

BRVNTOXf  T.  LAUDER,  M,D., 

Ltcturer  on  Mnltria  Hedi(a  aiid  Thcmp«utiet  at  St.  BarHtolomauft  HoipUal,  London,  tte. 

A  Text-book  of  Pharmaoolosy,  Hateria  Medioa  and  Therapeutios. 

Id  one  handaoine  octavo  volume  of  nlioiit  \000  j'Sges,  with  over  200  illustrations.    Cloth, 
$5.50 ;  leather,  Sd.-'JU.     /n  press. 

It  is  with  peculiar  pleasure  that  the  early  ap|iearani.-e  of  this  long  expected  work  is 
umoiinLtHi  hy  the  pubhsliers.  Written  by  the  foremost  authority  on  its  subject  in  Eng* 
land,  it  fornu>  it  com|>cndiouB  treatise  on  materia  medii'a,  pharmacology-,  pharmacy,  a^ 
the  pntcticnl  use  of  medicines  in  the  treatment  of  diiieaye.  .Space  lian  been  devoted  to  the 
fiia<iiimeiitul  (w.-ienceii  of  chemistry,  physiologj-  and  jHitholopj',  wherever  it  seemed  necenaij 
to  ehiciihite  the  prtijHT  subject-matter  of  the  book.  A  ewneral  index,  an  index  of  diseaaes 
and  remeilies,  and  an  index  of  blbliogTuphy  close  a  Toluiue  whicli  will  undoubtedly  he  of 
the  highest  value  lo  the  student,  pnctitioner  and  pharmacist. 

HERMAiry,  Dr,  X., 

Pru/r-mor  of  Phyiol'jgy  in  the  Vniitrtity  of  Zurith. 
Experimental  Fbarmacology.  A  Handbook  of  Methods  for  Determining  the 
Physioli^cal  Actions  of  Drugs.  Translated,  with  the  Author's  permission,  and  with 
ezt«nflive  additions,  by  Robert  Meade  ti.viTi[,  M.  D.,  Demonstrator  of  Physiology  in  the 
University  of  Pennsylvania.  In  one  handsome  12mo.  volume  of  199  pages,  with  32 
illustrations.    Cloth,  $1.50. 

ProC  Hermann's  handbook,  which  Dr.  Stnllh  has    plains  the  Tsrious  methods  and  iDsLrumenw  used 


translateii  and  enriched  with  many  Taluable  addi-  and  points  out  what  lines  of  InTestlgation  are  to 

tlons,  will  lie  Riadiv  welcomed  by  tnoseeiifnifccd  In  be  pitn>aed   for   sludyinf   different   phraomeaai 

this  deparimenC  oi  physi<>logy.     It  is  an  eicelleat  and  also  how  and  what  partlcalarly  to  obaerra.— 

little  book,  full  of   concise    Information,  and  It  Ameriean  Ji,urnal  if  the  itflieal  Sncntt*,  Jaa.  m^ 


MAISCH,  JOHNM,,  Bhar.  !>., 

pTKifator  lif  ilattria  JJedica  aiul  Botany  ia  tkt  PhiiaJelpliin  Ooltrgt  of  Pharmacy. 

A  Manual  of  Organio  Materia  Medioa;  Being  a  Guide  to  Materia  Medicm  of 

the  \'egetahle  and  Animal  Kingdoms.  For  the  use  of  Students,  Druggists,  Pharmacists 
and  Physicians.  New  (second)  edition.  In  one  handsome  royal  ISmo.  volume  of  550 
pages,  with  242  illuatrations.     Cloth,  $3.00.     Juat  rtady. 

This  work  contains  the  substance, — iitt  prnttiral  etcelli-nt,  being  rery  true  to  nature,  and  are  alone 
"kern-l  of  the  mil"  picked  out,  >o  that  the  piu-  worth  the  prlceof  the  book  In  the  student.  Totlie 
dt^nt  ha-  no  xuperduou^  lalicr.  He  can  contidcnlly  praciicat  physician  and  pharmaoini  ii  iss  raluable 
accept  what  this  work  places  liefore  him,  without  w<irk  for  handy  reference  and  for  keeping  fresh 
any  fear  thai  the  kIsI  uf  the  matter  Ih  not  in  It.  In  the  memory  the  knowledKc  <<f  materia  medica 
Another  merit  is  that  the  drugs  are  placed  l>efore  and  botany  already  acquired.  We  can  and  do 
him  in  such  a  manner  as  U>  simplify  reiy  much  heartily  recommend  IL— Jfsrilcol  and  Siryititl  Rt- 
the  study  of  lliem,  enabling  <he  mind  to  grasp  fHirrer,  Feb.  II,  IsSj. 
them  miTG  readily.    The   llliislrattons  are   most 

BBUCE,  J,  MITCHELL,  M.D.,  F.  R.  C.  P., 

PKi/tiCiin  ami  Lfffurrr  an  Mntrna  Mtdiea  and  Ttieraprvti<t  al  CAnrtnj  O-MI  Hotpxtaf,  Lfmden. 

Materia  Medioa  and  Therapeutios.  An  Introduction  to  Rational  TrMt- 
ment.  In  one  pocket-siie  l^mo.  volume  of  bah  pages.  Limp  cloth,  $1.50.  Juti  ready. 
See  StiidenW  Serie»  q^  Manuaia,  page  3. 


One  of  the  rery  latest  works  upon  Materia  recommend  II  as  one  of  the  Tery  best  for  either 
Medica  and  Therapeutics,  replete  wUh  informa-  medical  student  or  piaetllloner  of  msdlctn*. — 
lion    abreast    of    tlie    times,    we    unhesitatingly     f>itctnsn(i  Mnltnif  A'nrs,  Aufust,  IBM. 


QBLFFITH,  BOBEBT  EG LE8 FIELD,  M,  D. 

A  Universal  Formulary,  containing  the  Methods  of  Preparing  and  Adminis- 
tering (Officinal  and  other  Medicine*.  The  whole  adapted  to  Physicians  and  Pbarmaceat- 
ists.  Third  edition,  thoroughly  revised,  with  uumenxis  additions,  1^  John  M.  Maisch, 
Pbar.  D.,  Profeasor  of  Materia  >Iedica  anu  Botany  in  the  Philadelphia  Coltwe  of  Pbannacr. 
In  tme  ocUro  volume  of  775  page*,  with  38  illustrations.    C'lotn,  $4.50;  leather,  $6.50. 


12        Lea  Brothbbs  Jk  Co/s  Pttsucationa — Mat.  Med<»  Tlier«p. 


8TLLLE,  A.,  JIT.  J).,jLX.D.,  *  afJJSCfff  J.  M.,Ffiar,D., 

ProfmfBmrrUttnfVitnco'yatdPnif.  fVnf.n/ IW.  jrodLoMl  BodMy  tentfa 

tiet  vf  Mtdirln*  mtvf  dfiiroi  St»i*nn4  O^Owa^l'tonMM.Ai^toOMjM^ 

The  National  Dispeiisatory :  CosuiiiiiiR  ihe  yftturml  Uistoir^'heinlstfT,  H 
DuicT,  Actions  uiil  Uks  of  StedictneEi,  indiuUni;  ihoK  recognited  in  tbePhumao»|    * 
the  Unilci)  .States,  Ur«iit  Briioia  luid  0«raiaii7,  iritb  niunerotu  rofeT«n««  to  the 
Codex.     TliirJ  edltioD,  ihoroudily  nrvued  and  Krentlj'  alluded,     la  «me 
imperial  octavo  volume  of    Ii67  pn^aa,  irith  311  boc   ennaTiag&      Cloth,' 
leather,  93.00;  ImlfKuMJn^  open  Inck.  ^.00.    Whh  Denitorrm  "K«ac^  Reference  led* 
d.OO  in  RddiucQ  lo  juice  m  any  of  above  stylw  of  liindlog.    Jurt  rtwift. 

la  the  present  rcvUk>D  the  aiitbon  have  Inbored  incnwiiitljr  with  the  view  of  noldat 
the  ihinl  edition  of  Tue  Xatiosal  iMPPEKSATORy  an  ^i-n  lu  - 
tative  or  the  pliarmacculic:!)  itoil  ihoi-nwiitic  roienct;  of  1;?S4  tliun  ' 
that  of  lt>79.     F<tf  ihifs  Luiiplv  mnierial  hns  l«en  nf!br'Ir<I  m>(  uu'. 
States  Phanmunpanii,  Ixii  by  ibivc  <  if  (jiennauT  uid  Frniioe,  it  hicli  1 . 
and  have  been  incorpfirjitii  in  tlic  LKsjtcninKin',  loycibo-r  with  a  In; 
offidutl  temedteH.    It  if  thus  nrndered  tb«  rvi)rcsent.-iltveof  tbe  iikjm  (i>u>iii<-<->i  i 
Americao,  English,  French  ami  Gemiin  phnriD.ico1og>'iind  iberapcuili;*.    The  vn^il  i 
of  new  and  itn|Hirlnnl  mntcHnl  tliiio  iiilroihiC*'!  may  W  KUtbtred  frftni  ibp  fml 
■dditiims  to  Urn- edition  atD<juiilintbi;:iuvl%~«  tut hv  mutt L-rufiin  oniiimr^'  fuU-ci/nl 
volume,  rendering  the  work  Inrccr  l;y  lircntT-fivt  per  ctnt.  tbttn  lh«^  I.   •      '  * 
Tberapeiilic  Indpx  (n  feitiire  ppnili:ir  tn  this  work  ],  w  "Dgitiwtivft  and  c 
prarlitioni.T,  n'titiiins  16O0  mon-  n-fcrvnccs  tban  tbv  liwl  i>diliot»--'tlit.    _'^:.  : 
STOll  more,  moking  the  total  nwml-cr  of  refwcncfs  *JL',31K>.  irhUe  the  Hk  oi'  illr 

has  I'vm  iiiCTvtiDvA  liy  80.     Every  rlfnrt  bun  Iwen  ruiutc  t/i  prevent  nndne  etlan; 

the  ivlumc  hv  biivlne  En  U  uolhiog  that  txHild  be  rCKaid»1  u  Hiperfluoiu,  jrei  ati« 
hoen  taken  tliat  nothing  dhoiild  be  omitted  which  a  phamuimt  or  phyaldwa  conM  i 
to  find  in  it. 

The  Dpiwajwoce  of  the  work  hi»  been  delayed  by  nearly  a  year  in  coflMi)u«iice  uT  I 
determlnatinn  of  the  ambon  tbnt  It  rfiould  attain  as  near  an  apprcac!-  •    -'  -  !itte  j 
cnmc^  M  ia  btimaiily  pOHsiijle.     With  tbi.i  view  an  pUibnrnte  and  hi' 
examinntions  ami  tefU>  have  been  made  to  verify  or  correct  the  sitnteinentF>    .  .an 

ro|Ki-ta,  and  very  ntimennin  tvirrei'tionii  hare  been  fouthl  neceanr^.    It  baa  ifaua  been  m- 
(ietcil  indiHpeiiKible  to  nl!  wht>  rciunilt  lliv  PbarraaonpciHa. 

Tlie  work  L»  ihercAjre  pnwented  In  ibo  fidl  expectation  that  it  will  mnint 
po*]ti(>[i  iiniverxilly  nocirilMl  to  it  an  the  Htaivflitrd  autboHtr  in  all  mattera  t>erti 
ila  inilijecl,  a*  reglsiterin^  the  fiirtbe«l  adrnniv  of  lb«  wcieure  of  the  day,  ana  a» 
inK  in  a  Nbape  for  eouvenieiit  rcfetvu^  tbe  ri-^vmlvd  tctulu  of  human  experienod| 
laboralorr,  in  the  dispensing  roivni,  and  nt  the  bed>«iile. 

CamaTeh^DeiTe  Id  ««oi»e,  vast  Id  dtHlsa  an4inplOd««.  Tha  w«tfe  hM  been  T*t7  w»U 
*p1«tiilld  In  oiecail'iiLTh*  KalkiiMit  Ma pn main ry  I  taiga  tmtebar  of  eitrji-iil<ii.-nLSoo]iail«i  n 
maybejQBiiyracardaauthviDMilmMrtaDtwM):   tmTiacl>««Dad<R<ir  -ittaae4  tii  pnrinu 

of lla  kind  oxtant— ikwinlKs  VtHoia  .V(v>,  D«e.  '  odmaa*.—lmdom  !  r:,  IttM. 

*,  l*t  1u  eoRipMeae*'  ■   *'"  .-(■"■ff-^-*- 

n^A  hate  rauctipleMure  Id  rcoardlnitlhp  appear-    eiTaaua  of  Ito  d*i>'- 
aiic*  of  a  third  cditltia  of  Ihb  picvUrnt  voik  of    dph  of  tbo  ttvalni  > 

r«fcr«aM.    II  Una  adralrabl*  ab«traei  c(  all  thai  JFafHIlclBg  tAa  dcti...  .-  :.^ ;  ..-:  .■~%x\-.-^ 

reljktel  to  otismlilrj,  pliarmacj',  maMria  mcdlca,  I  fot  whlrli  tiiah  a  w-iit  i*  iivrilml.  itinks  ihi*  >'»- 
pharnii>«ilnKV  rmI  i)irra[««t(lc!i:  It  may  be  re-  I  am»  a  inaJ^al  "f  9XKt\\ft»tj—Fhimmat0mttmi  Kr 
gard«da*ciabud>-lii|;  (h«  PharmncopalM  of  tti«  ranl,Auc- 1\  10M. 
cirlltEed  DaUaoa  of  ih*  wMld,  all  twlof  broll()il  i 

FJMQVJaUMSOX,  BOBJEBT,  Sf,  !>,, 

Lttitrtr  OR  Materia  Mtdien  it  St  Monft  BotpUal  Mtd^at  S*IkhH, 

A  Gttlde  to  Therttpeatics  and  Blatoria  Medica.  Third  American  ediil 
epectnlly  reviiied  by  tbo  .\iitlii)r.  KnlarL'<->!  and  adapted  to  the  U.  S,  Phanancopoila 
FltA*<K'  WoODnLTty,  M.  D.     In  cme  hiiniUime  12nm,  Toltiuie  uf  6M  pegf*.     Cloth,  f 

Dr.  Fnti( II ha »'>□'•  Thorapoutlca  b  MOMruc^tvd  umaod  paua^-on*  «lii»euiitatnlD||(b«  r»eqptla*J 
ilpuuaplan  whlcK  brlCit*  t>«rwt  tli»  n-aJor  all  the  ptiyekil<^K'^aI  aciUtnof  Ui«IDedIelnei,«B4tb«Mlitr 
(■•vnUal  |>niota  with  rvtimvev  la  ili«  prup pttton  vt  the  dl*aa>i>  in  itMrh  nbaamir*  fwho  ara  naariv  >^ 
•lnir»-  )■  ImpreMoa  thea«  upe-a  him  Id  mieh  aaajr  tnyv  m«atUiB*d)  have  oMainad  fMm  ttfotii  t*- 
aalo  eaabla  him  to  tak*  a  ch-ar  *I«w  uf  (boaclkui*  aufia— male*  a  vvfr  good  arrangvimanl.  TliaaadT 
nt  mpdti'iDe*  and  iIm  dlnordared  roivdlllonii  \a  cliapl«r  cootalnlaa  rahMfar  pnacttbtBg  taaaeah 
whlcli  liter  mux  pr«T«  uaetaL    Tlw  doable-col-    luot.— OimuAi  JtfntTaiiiSary.  Aarwaii;  Dml  Utt 

8TILLB,  AJJFBEJ>,  M,  J>.,  LL^., 

PrvSMVjm}  Tltturymi  Pmttitt  tf/  3itd.  cimf  t^r  C'.nuii/ Jkfott  to  fA#  Vnit.  of  Fmma. 

TherapeutioB  and  Uateria  Iffcdica.    A  Syneustic  Treatiwoo  th«  Ac 
Utea  of  Medidnal   Agentfi,  inrbidin^-  iln-ir    Ifewriptlcin   and   Ilisinrr.     Fourth 
reviaed  and  enlarged,     in  two  larite  ami  biu>il«niie  tictavo  %oluiu«a,  containing  1936  f^gflf 
Cloth,  llO.i.K):  leather,  $12.00;  very  handMue  half  Riosia,  ni»ed  bands,  %\€m. 

Wr  t».n  l>MdlT  admit  liiai  '^  F  »•  ■  r^ial  to  tl>«    in  "  '>rii  >.  ..tvii»nttM.biit  aa  brdu' themoMi 
mnlUtiide  ot  tla  cttaUmr  -  ■■•«*  rf  iw    •  ■  tire  clink*!  and  fmedMl 

re»emrch  Inui  cllnfcri  Wtf-  i,^i«i*«\w.  .)!.-.b  Jfi*ea(  aiwiayrftoal  J 

ti  a  plaee  li»  the  abyejriai.  ^  , ,  V-ilir^t^'i. 


b  editioiS 


LSA  BftOTHBRS  k  CO.'B  PtTBLIOATIOHB — ^Pathol.,  Hlstol.  13 


COATS,  JOSEPH,  M,  !>.,  F.  F,  F,  8,, 

PnthologUt  to  th*  OUugow  Walem  Ir^rmani. 

A  Treatise  on  Pathology.    In  oae  very  huiiUome  octavo  volume  of  829  f»gm, 
with  339  beautiM  illustrations.    Cloth,  $5.50 ;  leather,  $6.d0. 

Th«  work  befon  us  tre»w  the  lubjnct  of  Path-  coDdltloD  elTecied  in  itructurM  by  dliaw,  and 
ologf  moTV  extcnsUHy  than  It  li>  ufiuatl;  treatod  polnta  out  the  chanf  terlBttcs  of  Ttrioua  morbid 
In  Bimtlar  worki.  Msdlcal  aludeDts  ai  meU  as  ageticle«,«ol>ialth«'y»Db«>a*11]rr«cofl:nlMd.  But, 
phyaiclBDiu  »hn  desire  a  work  for  «tudy  or  rafei^  iiot11mll«dtoTnorblcli(n*tainr,ltezplaluflillTh(W 
•nee,  mat  treats  the  !>iibjects  [ii  the  various  de-  the  funcllnQaororKaaK  are  disturbed  by  abnormal 
partroems  in  a  very  thorough  manner,  but  without  condition*-  Thrr?  Is  nnthiof  balODKlnKto  lt«  d»- 
prolixtty,  will  r^iialnlv  give  thlf  one  the  prefer-  paitmentot  medicine  that  la  not •■  fully  alaoldatcd 
•nee  to  any  with  which  we  are  iu!'qiiaint«d.  It  sets  ax  our  pre<>eDt  knowledge  will  admit.— Clndnnati 
forth  the  most  recent  d<BcoTPrie<i,  exhlbltn.  In  an  Xedicai  .Vttrf,  Oct.  IS83. 
IntarestlDg  manner,   the  chanites  fttim  a  normal 


OREEN,  T.  HENRY,  M.  I}., 

Ltetiirtron  Pathotogii  irul  Murbid  Annlomit  at  Chnring-Crnu  Hotpital  MtdUal  School,  LtmdiM. 

Fatholosy  and  Morbid  Anatomy.      Fifth  American  from  the  sixth  revised 

and  enlai^ed  English  edition.     In  one  very  himdsome  octavo  volume  of  482  pages,  with 
160  tine  engrnvingu.     Cloth,  t'2.50.     Jutt  ready. 

The  fact  that  this  vrell-known  lr«atlfie  ha*  eo  '  No  work  In  the  Engllah  languaKe  la  ao  admlmUr 
rapidly  reached  Ita  sixth  edition  In  a  tiirong  e*i-  adnpted  to  the  wants  of  the  studeot  and  praetl- 
dence  of  lt>  popiilarltv.  The  author  Ii  to  be  con-  tloner  as  thU,  and  we  would  rocommend  Ic  moat 
rratulatfd  upon  the  thorouKhneio  with  which  he  earneslly  lo  e»ery  one.— -VatAniW*  Joitntal  of  Mtit- 
nas  prepared  thH  work.  Itl.i  thomiighly  abreast  ctne  and  Sur^jery,  Xo*.  18S*. 
with  all  the  most  recent  adranc^e■  In  pathology. 

WOOJOHEAn,  O.  SIMS,  M.  JO,,  JF.  R.  C.  F.  E., 

tiemnfittralrrr  of  Pathology  in  M*  Ctiicermfy  nf  flUinburjA, 
Practical  Pathology.    A  Mamml  for  Students  and  Practitioners.     In  one  be«n- 
tiful  octavo  volume  of  497  pages,  with  136  exquisitely  colored  illustrations.    Cloth,  $6.00. 

It  form-i  a  real  guide  for  the  student  and  praotl-  The  author  merltH  all  praise  for  having  produced 
tloner  who  \»  Ih. 'roughly  In  earnest  In  his  en-  a  valuable  work.— JfeiHCfW  Accord,  Hay  81,  ISSi. 
dearor  to  <iee  for  him-'elf  and  do  fur  himself.  To  It  Is  manifestly  the  prodnctof  one  who  tias  hlm< 
the  l■)]«^Kto^^'  titiideni  it  will  be  a  helpfol  com-.  eelftraTelledoTerthe  whole  Qeldand  who  Isaklllad 
panlon.  and  ali  tlio'e  who  may  wish  lo  lamllUtrize  not  merelv  In  the  art  of  histology, but  In  the  obner- 
th«mMlfe3  with  modem  methods  of  examining  lallon  and  interpretation  of  mwiidehangaa.  The 
morbid  iiMuee  are  strongly  urved  to  provide  work  Is  sure  to  command  a  wida  cirvulatioo.  It 
themselves  vlth  this  manual.  The  numerous  should  do  much  (o  encourage  Uie  pursuit  of  path- 
drawing*  are  not  fancied  pictures,  or  merely  ntogy,  since  such  advantajMs  In  hbtoltwlcal  atady 
•chematic  diagrams,  but  they  repreeeni  fidthfully  hare  never  bafora  baen  Mnrad.— TIM  Ijamttt,  Jan. 
th«  actual  Images  seen  under  the   microecope.  0, 18M. 


CORNXL,  F.,  and  RANTIER,  L., 

Prof,  in  (A«  FaetUty  of  Mid.  ofParit.  Prof,  in  th4  OMtgt  of  France, 

A  Manual  of  Pathological  Histology.  Translated,  with  notes  and  additions, 
bv  E.  O.  SoAKESPKARE,  M.  l5.,  PathoIo«st  and  Ophthalmic  Surgeon  to  PMUdelphia 
Hoepital,  and  hy  J.  Henry  C.  Simis,  M.  D^  Demonstrator  of  Pathological  Histolo^  in 
the  iTniversit;  of  Pennsylvnniiu  In  one  very  handsome  octavo  volume  of  800  pages,  with 
360  illustrations.    Cloth,  ^.60 ;  leather,  $6.50 ;  half  Russia,  raised  baode,  $7. 

One  of  the  most  complete  volumes  on  pathotog-  Thns  side  by  side  physiological  and  pathologtaal 
Icalhlstologvwe  haveever  aaen.  The  plan  of  study  anatomy  go  hand  in  hand,  aflbrdlng  that  iMatof 
embraced  within  its  pages  1*  easentially  pracUeaL  all  processes  in  demonatratloaa,  oomBarlaoct.  The 
Normal  tissues  ar«  discussed,  and  after  their  thor-  admirable  arrangementof  thaworit  MTbrds  BMUUy 
ough  demonstration  we  ara  able  to  eompare  any  In  the  study  of  any  part  ot  tha  human  aoonoaiy^ 
pathological  change  which  has  accarred  In  them.    iVneOrteaiu  Jfcdico^andSbryiaiJ/avmaliJaiiaAM. 

KLEIN,  E.,  Jf.  2).,  F.  R.  8., 

Joiitt  Lt€twtr  on  0«a«^  Aitat  and  Phj/t.  in  lAs  Mtd.  Schoot  of  St.  BartJtolomme't  Bo»p.,  Ltrndion. 
Elements  of  Histology.  In  one  pockct-aizel2mo.  volume  of  360  pages,  with  181 
illuB.    Limp  cloth,  red  edges,  l|l.50.    See  Sludtnttf  Seria  of  J/anuois,  page  3. 


Although  an  elementary  work,  it  is  by  no  means 
sDperfldal  or  Incomplete,  for  the  author  present* 
la  ooncise  language  nearly  all  the  fundamenlaJ  facta 
regarding  the  mlcroecopio  structure  of   tissuea 


The  illostratlons  are  numerooa  and  •zeeliaat.  Wa 
commend  Dr.  Klein's  SsaMafs  moat  heartUj  ts 
the  student.— Vscficat  Bttord,  Dm.  I,  UI3. 


FEFFER,  A,  J.,  M.  B.,  Jf.  8.,  F.  R,  C.  8., 

Atryeon  and  l^eturtr  at  SL  Marjft  Botpilal,  Lomfcrn, 
Surgical  Pathology.     In  one  pocket-eixe  12mo.  volume  of  511  pages,  with  81 
illustrationit.  Limpcloth,rMedgM,$2.00.    See  Studml^  Serin  of  Ma*tiaU,j»gaS. 

It  la  not  pratantloua,  but  it  will  serva  exeaad-  '  llluatrmtad.  Th*  Mndant  will  flod  In  It  aothlas 
ln(ly  wall  a*  a  book  of  reference.  It  amtMdlea  a  that  U  nnnscswary.  Tha  list  of  rablMti  Mivan 
pit  deal  of  matter,  eilandtng  over  the  whole  tha  whole  range  of  surgery.  Tba  book  >nppUaa  s 
Said  of  surgleal  pathology.  Ita Ibrm  la  praetleal,  *  very  manlfasf  wast  and  shoold  maat  wflh  nt^ 
ita  langnag*  la  elaar.  and  the  InformaUoo  set  cess.— A«w  Fork  MtdiaU  Jwwaal,  May  n,  UM. 
ftarth   is   wwU-arraafad,  well-ladexed   and  well- 

aCHAFSR-8  PRACTICAL  RISTOLOQY.    In  om  I  COY.    TraaslaMd  by  J«M«  Iabt,  M.  D.    la  oaa 
handaoraaroyalUno.  Tolnraaofaupages,  wltbl  Tolama,  t«r)   Uiia   VrnigwAi^   oioa^A. '^Nd^  Vb 


0LUamV  A7XA9OrPArHOIX>OICALHlSTOL-|0rKuv«\atia(<viMa.   CMCli.VI» 


Lbjl  BBOrnsBS  &  Oo.'a  Pdbuoa 


or  Med. 


vuarr,  austin,  m,  j>,, 

mf.  tf  tht  iVfncfHfc  -xd  Prttic*  cf  Xt<L  anrf  of  CKn.  Mil.  in  J(Rm<im  HmsHM  JMmmI  Colh0^  Jr.  T. 

A  Treatise  on  tho  PrliioiplG«  and  Practice  of  Medicine.    DwigMd  far 

the  iiMof  t^ud^ntHniiil  IVartitionor*  of  Mtvtirine.     With  an  AppcmJix  «d  tli«  Re 
of  KocliiUnl   thvlr   UNuiDi;;   uu  lb«  Elinlogy,   Tutiiolagv,  Dumoeia  and  Ttvat 
PhtliisB.    Fiftli  ulitiuti,  revised  and  largely  rewritt«D     In  one  lii^ge  sod  clcMelj- 
octuro  volDiaacif  IliiU  pngM.    C1olb,|6.60;  lMth«r,$6^:  hnlf  Itunin,  $7. 

KiKh'e  dUmrerv  of  the  faooilliiB  of  tubercle  ^ves  promUe  of  being  the  „ 

boon  ev«r  CAnferred  by  iciene^  on  humanilv  nirpuninit  «v«n  vkcrinxlifin  in  il«  t>^ne1itt '. 
taankind.  In  the  sppeudijc  to  hib  uoik^  ProfesMr  I'unt  dcslBwllb  the  Enbjeci  Jromi 
pmctioO  suiadpoint,  duNniffiing  iu  bcnnngs  on  the  eiioloi?,  patholoev,  ducnoeu,  prof- 
ntMia  and  trealnicnl  of  pulmttDnri-  phthuis.  Tbiu  enUi^ged  ana  cooij)l?t«<l,  tftu  atandard 
work  will  bw  ninrp  ilian  ever  a  aVcwnity  lo  the  pbTstdan  who  fhily  appreciaU*  tin  n- 
Bpon&ibility  of  his  «<nlting. 


A  w«tI'knoirn  irriur  ftod  leaiurcr  oo  Ri«dlctD«  [ 


Thl»  work  i*  ■«  wldalj-itoowa  aod  xwyi*^  m 


recenlly  «x)>reMrd  mu  oiiiDluu,  In  lbs  hlgheal  do-  ■  l)i«  beft  AiuerkiNU  t*xl-buok  of  Itio  pmuin  *f 
n««  cotni/HaienlaiT  uf  the  admirable  iRnll»«  of  in(!4lctnp  ihnt  li  would  tr*m  hardljr  worlli  vltU*!* 
Dr  Fllal,  niid  lii  »uloft«iii|[  il,  he  ileiicrllx^  H  ai>    (i*a  Ihb,  Itia  fift>>  -  'M  ■•    ...>•'. in-  -■■—  rhuii 


euratoly  w~r<;«itabk  aud  r«lUbl«."  Nowxt-book 
Is  taoTv  •■*k-iilsl«il  to  oticlMla  (h*  Inwiwtl  of  ttic 
•tudvDt,  anil  none  beii«r  vlaMldc*  tho  mvlUladl- 
uoua  aiiiijf^-u  [nHiiii<>il  In  It.  11  hm*  alrvady  wt  Car 
Trnn  Iia  «^  !□  Engtaaj,  thai  no  lncon*iaerabl« 
niinilvr  nf  niHi)  iimo  Ii  aliirio  in  ihr  <i<ii1y  <>f  |.-iii* 
mc41(ln(';  and  wc  eon  ."»)'  ■^'I'  "  t*!**  'I  I'  '"  ^Tery 


aalion   »twiiri>  Oike  rnrn 

thaa  arvTlacd  edit.o... ,  ^^., :..[  acaa 

work  throlif  tioiit,  Tlilntmiiw  >iU  tiuijoutn«4Ij 
contlnii*  to  bold  the  Br«t  place  ia  th»  estlnattra 
of  AmBrtcan  iiliyalcten*  amt  MudMiU.  \u 
our  m«dtc«l  uTiUr>  apircnaehe*  pTofeaaai  FItat  I 


«ajr  ailBiiIrd  lo  H<r»<,  ant  unl^  i<iiai'Miit[i'tH(HK'i''l*i  r.Inuniua  of  ■ItPltim,  Invadth  of  tWit,  andi  whal 
but  abo a«  an  ample  lD><ttiioivr  ic  Ihr  »Llunr«'  and  '  r«KaH  of  traaMcadeat  tinportanM,  rational  « 
prariloa  of  mwllLiliin.    Tiiv  •ivli>  nf  I>t-  t'Uni  la    mjtiA  of  ih»  rain*  at  ramwllal  aaaau.     It  U  U: 


prariloa 

aJwajTi  poli*ti«d  and  cDmittnK. 


la  paiwjiiounn*  •ipluiallnn.  and  la  a  mom  (aluabla 
tast-boak  of  ncdiclDc " 


I  la  a  mom  wi 


a^aat 

ouflily  p'ortital,thtr«ton  jm-aulatntly  tJu 
for  AnaariCBB  t«mi»n.—SL  Loiti*  CNh.  Awv,  Uar. ' 


HARTSHOBNB,  HENRY,  M.  J>,,  XX.  J>., 

EBBontinls  of  tbo  Frinciplos  and  Practice  of  Medicine.    A   Handl 
forSluiipnt- aini  Pnui-ilitmen.      Kiflli  edition,  tliomiiglil/ rt^viii-d  miii   rewritten-     In 
rojal  I'ioM.  volnsw  of  069  p*^^  with  144  Ulustrationii.    (.'loth,  $2.75 ;  haif  bound,  93.00. 
Wttliln  Iha  oiRiiiaaa  of  MS  pagM-  It  Irnalji  (iflh^    l>il*on*i  aad  prohaht^  nnt  nae  v-iitPT  In  our  4v 
hUtory  ct  OMdleuft,  MaerM  patholojc  seneral    bad  ab«tt«roaip«viii<  itrttlume  |m 

>rinplomalotocy.andfIi/ricaldlatniM>l*(ini!liidlng    coadonidBgali  Ut<-  >  iTacUilnaMi 

taf7DBoiwope,opiit1iariaMQOp«,  etc.).  Hwneml  tti«>r-    fnioaismo.    Tti*  ><  >i»ni«  wtU 

aacutlOd  noMloB^,  and  BDeolal  paihdlc*^  and  prao- 
two.  Tiiar«  U  a  wouilernil  anioutii  i>f  iiLfdrniaikin 
oonlatawd  in  Ihl*  work,  and  It  la  ntm  nT  the  bost 
of  Ita  kind  Ihai  w»  Imit*  »«ml — Oiiwyi'm  jfrWiml 

JdWiiMf,  Nov.  lAHlL 
An  llidl*p«aMlb1e  book.    Xo  work  "mr  aiht1)li«d 


rcry  lUeAli  li>  atDdcnti 
'  '  I,  M  tha  MtRia 
^r«ede  th«  tesl-1 


tlala,  M  tha  nama  aii|Kn>u<.  am  i^nt  in 

■UMntede  th«  tesl-hooki  •>! 

hut  tl-py  am  tha  nnat  valuaMa  In 


lly 
a    I 

riittt  and 


meaoB  ta  soi^  at  a  glanM  tlM  «lu>l«  Ut«.  _ 
ilfwaM>,aDd  111*  moat  «alaabi«traaltniu»: 


abaMravoragacf  aetaalpraotfcaltTMiUaentthaii  i  Utikau  Jottntai  and  Bmninfr,  April,  I 


BfiJSrOITE,  JOHN  8YBR,  Jf.  />..  Jl  .B.  C.  J>., 

/^WtMan  aaJ  JoM  Xacfww  on  Jf(4U»iM  ai  St.  IAo«m'  .ffofrifo'. 

A  Treatise  on  tho  Practice  of  Medicino.    .Set«>nd  Americin  uilitioa, 
by  Lbe  Autbtir.    EiUtMl,  with  a^tditioiu,  hr  Ja.mi:>-  II.  IIiti'IIIX^ik,  >[.r<.,pbyEiiiiui  l» 
P«anivlvania  HMcuital.     In  nn^  hnndMimo  octavo  volumo  d'  1Ik<-t  pnjr*«,  arith  illitairaui 
Clolh,'(5.O0:  leatbor,  $0.00;  very  handwm*  b^BiwlsL,  vmkA  IoukIs,  f3.50. 


Tha  rcadrr  will  finil  prury  cflor ■■! 
ooaoaoUid  wi<li  iht-  practice  of  m>"i 
wnHd,  In  i>  ■tvii  nt  odm  utaar,  n 
oonciap.    Thr  additiun*  made  hj  hi 


,.-id 

lutHM) 


ar*  approprlnl»  lUul  )w«ptk'«l,  and  giaalti  aM 
II*  UMtbiliiM*  W  AmaMcan  rvadan.— BH/nia  M^ 
mil  nnd  Siit^irai  Juunutl,  Manili,  tWt. 


WATSON,  SIR  TUOXASf  M.  I)., 

Ijtt*  Fhi/ttrinti  •«  Ordinary  Id  tXt  Qtiwn. 

Iioctitres  on  the  Prlaoiplea  and  Practice  of  Physio.    A  luw  .\idi 
frviu  t)iv  fifi!)  Eofiliah  edition.     Edltwl,  vlth  odditioiw,  and  190  UfaHlndon»  by  Hxkbt 
iluininoRNr.,  A.  M.,  >!.  T).^  Iat«  Profenor  oi*  EysieDe  in  the  UniTerriftef  Pcon^l      " 
Id  Iwu  lai|[e  octeTo  rolumea  of  1840  iiages.    Cloth,  f9.00 ;  leather,  (11.00. 


i«ria^^ 


LECTlUlia  C'.V  TUe  Sl'UDY  OF  FEVER.  By 
,  A.  UrcpoM.  M.  D.,  M.  R.  1.  A.  tn  no*  ocUto 
r  volDina  of  am  |iagoi.    ClAih.  SUtx  ' 

BTOESir   LBCTURB8  ON   FEVER.    EdK*d  br 
jQha  Wllllam  •UoorvM.  ij..  F.  K.  Q.  C.  P.    In 


3 

^»H 


on«  octavo  voluma  of  wo  pasoa,    (' 


riitih. 


tLOCt. 


A  TREATiaC  ON  FEVER.    By  Bousr  IX  L 
E.  C.  C.    tnqaelTi>.TaLarSHpp.    ChMlvt 

LA  ROCHE  OK  TELLOW  FEVEB.  Mi»M«>4  ja" 
Ita  HWorlMl.  Pathatopral.  Btkttoglcat  and 
Tlwtapvuicai  R«Juil«i*.  In  i*olarBaaad)uiid- 
MMnendavo  tolDmeaofUOBpp.    CMh.fIjOa 


la*  A  CEMTtm  OT  ABtERICAN  HKDICHnE.  ITTtt— tfflS.    B7  Dr*.  S.  B.  Cuax^  IL  i 


Lka  Bbothkrs  a  Co.'8  Publioationb — System*  of  Ued.  16 

For  Sate  by  Subscription  Only, 


A  System  of  Practical  Medicine. 

BY  AMERICAN  AUTHORS. 

Edited  by  WILLIAM  PEPPER,  M.  D.,  LL.  D., 

PBOTOfiT  AND  FKOFEaSOB  OF  THE  TH20BT  AND  PBACTTCE  OP  XEDIdTB  AKD  OF 
CLIKICAL  MEDICINE  IS  THE  USIVEB8ITY  OF  PEirNSn.VANIA, 

Aaaisted  b^  Louis  Stars,  )I.  D.,  Clinical  Profeaeor  of  the  Diaeasea  of  Children  in  th* 
Hospital  of  the  Uoiversitj'  of  Fennsylvaaia. 

h  fae  imptrial  odaro  wlwttet,  eontainmgah<nU  1100  poget  taeh,  mih  UltutnOum:    Price  per 
rviume,  doth,  $5 ;    Italher,  f6 ;    half  Jfusna,  mij«i  band*  and  open  back,  $7.      VoUtne  I. 
(Genenl  Pathology,  E^itary  Science  and  Ueneral  Diseaaee)  eoniaint  1094  paff«9, 
m'/A  24  Uiuttraiion»  and  is  jutt  ready.      Volume  II.  ((.Jeneral  Diseases  [con- 
tinued] nnd  Dieeaiiteii  uf  the  Digestive  S>->iteiii)  wui  be  ready  June  Itt, 
and  the  ndtteqiient  tolunet  at  interval*  of  four  months  thereafter. 

The  publishers  feel  pardonable  pride  in  announcing  this  ma{pific«ot  woA.  For 
tbr«e  years  it  has  been  in  active  preparation,  and  it  is  now  in  a  sufficient  state  of  fiffmid- 
ncaa  to  justify  them  in  calling  the  attention  of  the  profession  to  it  as  the  woA  in  which 
far  the  tiret  time  American  medicine  is  thoroughly  represented  by  its  worthiert 
teachers,  aod  preaented  in  the  full  development  of  the  practical  utility  which  ia  its 
preeminent  characteristic.  The  most  able  men — from  the  East  and  the  West,  from  the 
!North  and  the  South,  from  all  the  prominent  centres  of  education,  and  from  all  the 
hospitals  which  afford  special  oppoKunitiee  of  study  and  practice — have  united  in 
generous  rivalry  to  bring  together  this  vast  aggregate  of  specialized  experience. 

The  distinguished  editor  has  so  apportioned  the  work  that  each  author  ha*  had 
asatgoed  to  him  ihe  subject  which  he  is  peculiarly  titled  to  discuss,  and  in  which  his  views 
will  be  accepted  as  the  latest  expression  of  scientilic  and  practical  knowledge.  The 
prmctitioner  will  therefore  find  these  volumes  a  complete,  authoritative  and  unfailing  work 
of  reference,  to  which  he  may  at  all  times  turn  with  full  certainty  of  finding  what  he  needs 
in  its  most  recent  aai^ect,  whether  he  seeks  information  on  the  general  principles  of  medi- 
cine, or  minute  guidance  in  Ihe  treatment  of  special  disease.  So  wide  ia  the  scope  of  the 
work  that,  with  the  exception  nf  midwifery  aiid  matters  strictly  surgical^  it  embraces  the 
whole  domain  of  medicine,  including  the  departments  for  which  the  physician  is  accustomed 
to  rely  on  special  treatises,  such  as  diseases  of  women  and  children,  of  the  genito-urinarj 
orgaiia,of  theHkiu,of  the  nerves,  hvgiene  and  sanitary  science,  and  medical  ophthalmology 
ai^  otol<^.  Moreover,  authors  fcave  inserted  the  formulas  which  they  have  found  most 
efficient  in  the  treatment  of  the  various  affections.  It  may  thus  be  truly  regarded  aa  a 
CoxFLETE  LiBRABT  OF  PRACTICAL  MsDlciHE,  and  the  general  practitioner  poMeering  it 
may  feel  secure  that  he  will  require  little  else  in  the  daily  n>und  of  ^rofemoiul  duties. 

In  spile  of  every  eflort  to  condense  the  vast  amount  of  practical  Information  fur- 
nisbed,  it  has  been  imposdible  to  present  it  in  leas  thnn  5  large  octavo  volumes,  containing 
alx)iit  o-'HHI  beautifully  printed  pages,  and  embodying  the  matter  of  about  15  ordinary 
octavos.     Illustrations  are  introduced  wherever  thev  serve  to  elucidate  the  text. 

As  material  for  the  work  is  substuDtially  compfete  in  the  hands  of  the  editor,  the  pro- 
fession muv  confidently  awslt  the  appearance  of  the  remaining  volumes  upon  the  dates 
above  specitie<l.  A  detailed  prospectus  of  the  work  will  be  sent  to  any  adoreas  on  appli- 
cation to  the  publishers. 

It  i<  ■  larK^  iiixI'TiakinK,  hut  t]uii«  juctlfisble  in  Ihl*  country  m  anlhiritiei  on  lh«  part Icalar  topics 
th*  cjt"*  of  *  piogresBivi-  nation  liltp  ihf  I'nited  on  which  tfi*)-  di'sl,  whilst  iho  oth»r«  show  by  tlia 
8tai«K.  Ai  any  rate,  \{  we  may  'jadge  of  (uttire  way  they  have  hanJlutl  th»lr  subject*  that  thsjt 
ToliimiM  trt-m  th»  liixt,  it  will  n>  JiiHllfled  by  tli»  are  tUlly  fi|u»I  to  ih«  ta^ik  they  had  undertal[«n. 
rsaiiU.  We  tiave  n<'lliin|{  but  praiM  to  braluw  •  *  ■  A  work  which  w«  eaonot  doubt  will  make 
upou  till-  wr>rk.  The  articles  are  the  work  if  a  lasting  reptitation  for  itrvlL—Lomdon  Maheat 
writ«T»,  many  of  irli..m  are  alrfa>iy  recognited  In     TiniM  on.f  <iaztttr,  Mny  ',',  18t-'i. 

REYNOLDS,  J.  RUSSELL,  M.  I>., 

Priiftisor  of  Iht  Prineipla  ntul  Pntrtitt  of  Mtdieine  in  Uiar^rtity  CbUtfft,  Loitio^ 

A  System  of  Mediotue.  With  notea  and  ailditions  by  Henby  IlASTaHOBH^ 
A.  )[.,  M.  r>.,  late  Pniferwir  i;f  Hygiene  in  the  University  of  Pennsylvania.  In  thrf«  large 
and  handsome  octavo  volumes,  containing  306t>  double-columned  juigat,  with  JIT  illustra- 
tium.  Pric^jwr  volume,  cloth,  to.OO;  sheep,  $6.00;  very  handsome  half  Ruatia,  raised  banda, 
$6.dtl.     Per  set,  cloth,  t\h;  leather.  $trt;  half  Russia,  $19.00.     Sold  on/y  by  ti^rription. 

There  \a  do  mi^dlral   work   wlilch  we  have  In  hfoiMlf  in  neod  of.    In  order  that  any  daftcleacies 

ilmea   part  mora  frequently  and  fUMj  consulted  may  be  !<iipplle<l,  tha  publlaherm  have  commtttad 

when  p^rpl'S'il  by  doubt*  a*  to  treatment,  or  by  Ihe  preparuinn  of  the  bonk  tor  t)ie  preea  to  Dr. 

bavlDB  uniiiual  or  apparently  inexplicable  lymp-  Henry  Hartshome,  whose  Judicious  notea  dlatr1l»- 

lo«nf  preMBted  to  n«,  than  "^  Reynolds'  Syvtem  of  nt*d  thmushont  the  volunie  affwd  ■faan.dan.'t.  a^V- 

Medl'-ine."    It  contain*  Junl  that  kind  of  Informa-  donee  ot  xtia  VboTWii^Avaa  <A\.\i«TW^9ta^.— kiMW' 

Hem  whleh  tb*  hatjr  pnelltloner  frequently  finds  ieaa  JowriMl  oj  tK«  Xc&lnl  8e^cnMM^l^B.>»^ 


Cholera:   lU  Origin.  Histocy.  Cbnsotioti,  SyiaptmuA,  Prrremloa  and  TnatufR 
In  one  hiiu(L«>n)C  tSmo.  volumo  of  anoat  176  ini^i^  wiUi  a  dixrt.    doth,  $I.S&.    JUdrfk 

'Hie  threnleimi  iiitjxirtstioo  o£  cholera  inlo  the  euiintrv  tvoden  |)eculiAr1v  limnV 
this  vork  of  an  uuthorit^  so  enuneat  as  Profewor  Stilli'.     The  Itistoi^  of  prenoua  "-' 
dcmio,  their  tnodM  of  pro|<agalion,  lh«  vaM  recent  adilitJoiui  to  oar'kixnvle  ' 
cun&tioii,  prevenuoD  una  treutiueDl  of  llie  diwove,  all  hare  beea  hAocUed  ki 
to  pratcDt  with  brevity  the  infanuatioD  which  ereiv  {iraetitioftcr  ahould  i» 
wMxxe  of  it«  Tisluition. 


FLrST,  AUSTIN,  M.  D. 

Clinioal  Medicine.    A  Sysiemalic  TresilK  on  tb«  DbgOMb  and  Tnuistat 
Dbeuea,    Deaijped  for  Students  iad  PrartitionATB  ot  Mnlicine.     In  nne  large  mkI  baod- 
«nu«  octavo  TMume  of  799  pages.    CU>lh,  ^iJiO;  Wther,  9&^;  h^lf  Ruana,|&00. 

Tib  h*r«)l>*i III* > kill Mnd  kaniliiK cf  th*  grwil  i  (burBtly  wtlli  brtTlljr  aad (riaar&(MM,  lh«  dittnmt 
eUnletan  an  dlnilftjred.  Ha  hu»  cItoii  ut  ■  tuwe-  vubjeeta  Btid  their  MToral  parts  f«MlTtac  Ai 
lioiLMvf  Riwdlcaf kuMwtadfa,«iMllonlfcr (hcitii- 1  Blientli»i  irlileh,  T«laU*«l]F  to  tli«lT  bnpanHLO^ 
d«nt,  ooDTMilMil  for  Uto  pnctlllofKr.  th«  rMttli  of  aiadlcal  opinion  elaUniferth«iB,  la  atlU  SMradiA' 
•  Inaa;  Itf*  c<r  tlw  zattH  (UthlHI  rllnlcal  work,  col-  I  ctili.  Tltti  (mIi,  »•  fbd  bound  lu  mty,  ha*  bM* 
l«el«3 by  ati  •B«Tsr  h  *lg)laiii  and  •^'■MntMC  w>  i  ex«cut»d  with  mun  than  parttal  nii  riw  br b- 
unllrlns.  »iul  valjlhtd  by  ajnilsinoot  nal«a*clc«     Hlnl,  wlimw  nuuo  1*  altwai^  ^*"'>'w  to 


I  Inai;  Itf*  of  tlw  rocwt  (UthM  rllnlcal 

>lihi 

tlun  hii  cb»«rrat(oB  IceloM.— <ir<JUrH«f  JMMif, 
D««.  IKS* 


of  adruwd  laadieUi*  IntnM  oopitliT  aa  Utal^af 


ibo  auilkor  of  loo  wo^u  gf  afal  taaril  oa  i 


To|U«>Niad*nuii<»Hnitui»'r'.i1rnT»pH4uaofth«(  MtWMU.aad  olnaaiCMUpapen  aahlblEtncBnca 
a«cn*iT6B»ldolnio<ierBcUuic*lmt4lclu«Uata«kl<>r'S'a»J'iT  •ndMtao»I»»  f*M»r*h— Tfc»  thMt 
of  noonllnarjrdlRIciilijr,  ()i;iiom«M-TnplUt(Uil>M>o>  >  J9tmm,D*e.  WTfc 

By  the  Same  Author. 

EasaysoD  Conaorvative  Uedicino  and  Kindred Topfos.  loooerer^l 
eome  rofaf  ]2ma  voUiin«  of  210  imgcs.     Goth,  tl.iVi. 

BROAJ>BJB2<rr,  TT.  ~n7,  m  !>.,  it.  sl,  c.  p., 

Pht/tMim  to  (wd  l,^tKTtr  im  MtdMmt  at  Si.  M»r)f*  RoapUoL 
The  Ptllse.     Id  one  lllmo.  Tolnm«.    S«e  Seria  of  Ctinieal  JtannaU,  page  S. 

SCHRFABEJi,  VltTjOSETH, 

A  Manual  of  Treatment  by  MEtesage  and  Hethoctioal  BEosole  Ex- 
erolse.      Tnnalated  br  Walter  MKltDfiUOir,  M.  I).,  nf  New  York.     In  one  hnn>lAiima  1 
octaro  x-olume  uf  about  300  paf!«a,  with  about  IS-?  liiw  eiifmving*.     I'^ri/uriny 

IFXNJLAYSON,  JA3LE8,  m7j>,,  £ditar^ 

Clinical  Diagnoaia.    A  Haudbook  for  StudentB  and  Practhtonen  of  U«di 
With  Chapt«t«  bjr  Prof.  Grurdnt-r  oa  the  Phjrno^^ouy  of  DiieaM ;    Pmf.  St«]ih< 
Diaeu«B  oi  the  Fvmala  Organs;    Dr.  Bobertwn  on  Innuiiiy ;   I>r.  Oemmell  on  Phvilod 
DiumoriB;  Dr.  Coauun  Ijiiypguaooinr  anil  Poet-Mnrtetu  Examinationi^  and  by  th«  £dtlar'^ 
OQ  nanfi  tdViitg,  Fnniily  Ilijton-  and  bympuima  cif  Diaoixler  in  the  Vsnoua  i^yat«ni».      In 
one  handaoina  \'haf>.  volume  nf  MO  |»gw,  with  l4-i  illustnitions.    Cloth,  RiLOS. 
ThUliooBOltliaraallr  (W«ful  boolu.    It  1*  at-    bal)i:«r  T^iumot:  ml  frriiiiiTT  rf  Iti  ■rnniimiaM 

and  coinpMo  Ind^i  It  b  unamallf  coBTcaiflBf  Alt 


traoUte  Crom  pni&oc  lo  th«  flcal  vwc,  ud  ouchi 
>  Afi  «r«r]r  ofllfw  lanlo.  lMV*a#>' II 


im  pma 
tobe|^T«nK]>law..u<i.i<>/  .™».^  —■.■..,  .-,--™«n.. .. 
CWialai  In  a  oondantad  forai  all  ilui  I*  TatuaU* 
In  MfnololoDt  ud   dlaanoMlM   lo  Iw  Icund   lu 


Pl'  .  _    - 

qtilck  rt'Mreai'*  in  auv  emenieiicj'  tlial  auf  4 
uptw  lb*  baav  »ra^Uan«r-— A'.  C   JM.  Aara, 
Jan.t«». 


The  Student'a  Guide  to  Hedioal  DiagnoslB.    Fnnn  ilw  thfaJ  iwliiit  i 

enlitrgrd  Ku^liali  edition.    In  oDe  vet7  haodaoniti  rc^  12nui.  Mlmne  «f  SR  pa^a^  ■ 
87  iliuHtratioQa  oo  wood.    Cloth,  t3.2S. 

OUaVTEB,  TnOMAfTnAWKBSTWiy, 

A  Manual  of  Climcai  Hcdicino  and  Pbysioal  Diagnosis.  Third  Aineric 
from  the  second  I/nidou  viUtion.    Ki.'vu'.i]  :ind  i-nlariE^d  by  TlxauBT  Fox,  H.  D.,  Phy-' 
flieian  to  the  Skin  Depattmrat  in  T7niv<-n>iiT  f'nllt^v  Ifmpitnl,  London,  etc.    In  on*  small 
I2mo.  volumt,-  of  362  |wg«8,  witli  illuxtmUoun.    CMh,  $1.40. 

FOTHEBGLLli,  J.  M.,  M,  D,,  Edin,,  M.  B,  C  P.,  ZAfnd,, 

Pl^a(eidi»  to  Uu  Oljy  tf  Lotion  BotpiMfar  DUmm*  t^  Ot*  OuM. 

Tho  Practitioner's  Handbook  of  Treatment;  Or.  The  Prindtte  flfTlMea- 
p«aticB.  N«w  edition.     Tn  on«  ocIato  to1iiiu«.     Prtpunug. 

STURGKa*  lETrRODUCTIOH  TO  TUE  STUDY 
OF  CLIMCXL  UED^tnttE.  naVntaOi^to 
tba  Intaat^fallon  of  DVMaaft.   \&  om  ^a&Aawim 


lUAVlS'  CLWIOAL  LECTI'IUB  0!f  VUUOn 
V  lUFOBTAITT  DISBASZS  Bj  N  0.  D»t^ 
)\    'A.U.lAaM.^Y«icsiU..DLrB,  K.D.  teaou 


LiA  BmoTBSu  &  Co.'s  Pdbuoatioms — Hygiene.  Electr.,  Pract.       17 
BICSAMI>80X,  B,  W.,  M.A.,  M*D,,  LL.  I>*,  F.B*8„  F.8,A. 

FrerentiTe  Medicine.    In  one  oct&vo  volam«  of  729  p«g«>.    Cloth,  $4;  leather, 
96 ;  y^Tj  huidsome  half  RuMia,  raised  bands,  $5.50. 

Dr.  RlehkrdtOD  hfts  ■uoeeaded  In  producing  k  '  th«qu«at<oQof  dlMaBalieoiapMhen«lTa,iiUBt«rlT 
work  which  Is  eleralvd  In  coacepllon,  vomprehen-  |  uid  fult7  abrWftst  with  the  latait  and  bMt  knowf- 
■Ira  Id  neopa,  HclpiitiHa  in  chkranter,  syitematlc  In  edga  on  tha  (ubjMt,  and  thajpT«TeDtl*ame«*uraB 
arraDgamenl,  and  which  ia  written  in  a  clrar,  con-  adrlftcil  are  accnrata,  explicit  and  rellabla. — Tk* 
elaaand  plaaaant  manner.  II0  i?T<nceH  the  happy  ^mcHtax  Journal  of  tin  MtdUatSelMem,Afiil,'lSM. 
faculty  of  extracrlnK  Che  pith  or  what  la  knuvn  on  ,  This  U  a  book  that  will  BUraly  find  a  place  ootha 
the  lobJectiaDdor  prcfientlng  il  in  a  mont  5!mple,  table  of  ererr  pmgraaiilTe  physlclao.  To  the 
intalligant  and  practical  form.  There  isperhapa  '  medicalprofeatlon,  whoaednty  laanllaaamuehto 
no  lim liar  work  written  for  the  general  public  prerent  aa  tocurealBaase,  thebooK  will  baaboon. 
that coDtatnn  such acomplete.rrllablF  and  Instruc- 1  — Bo4ton  Mtdieal  and  Surgxeal  Jountal,  Har.  6,  UH. 
tlTe  collection  of  data  upon  the  dipeanc!*  common  The  treat Ive  eontaln*  a  Tairt  amount  of  eoUd,  TalD- 
lo  the  race,  their  orlginB,  cauaev,  and  the  measure*  ,  able  hyglenlo  loformatfon.— ^edtM/  and  Surgieal 
tot  their  pre*eDtlOD.  Tne  descrlpUonii  of  dlMase*  BtporiT,  Feb.  23,  ISM. 
ara  dear,  obaate  and  eoholarly;  the  dlscusBion  of  i 


BAMTHOLOW,  SOBEBTS,  A.  M.,  JT.  J>.,  XX.  »., 

f¥o/.  of  ifof cria  JfaHM  and  Qmeral  rAtropMtie*  to  (At  J^«raon  Jfal  CbU.  0/ PhUa.,  tU. 

ICe^Oal  £leotrioity.    A  Practical  Treatise  od  the  Appllcationa  of  Electricitj 

to  Medicine  and  Sui^gerr.    Second  edition.  In  one  veiy  handsome  octavo  yolome  of  292 
page*,  with  109  illostrationa.    Cloth,  $2.50. 

The  aaooad  edlilon  of  thin  work  followina  eo  A  moM  azoallant  work,  addreaead  by  a  pracli- 

aoon  Qpon  the  Brsi  would  In  itself  app«ar  to  be  a  ttoner  to  blj  fellow-praciltloDera,  and  Iberefora 

aaBcient  announcement;    □eTe^thele•^  the  test  thoroughly  practloaL    The  work  now  bafora  as 

ha*  been  so  considerably  reTised  and  condenited,  has  IJie  ezoepUonal  merit -of  elaarly  pofntiaa  out 

and  m  much  enlarged  by  the  addition  of  new  mat-  where  the  beneDta  to  ba  derifad  bom  alactrletty 

tar,  that  «a  cannot  fall  to  rvcognlie  »  Tart  Improve-  muat  come.     It  eontaliu  alt  and  a*eiTthiDg  thid 

tnent  upon  the  former  work.    The  authnr  has  pre-  the  praetlttoner  naads  In  ordar  to  underataad  In- 

parad  his  work  for  etudentH  and  pracUtlunera — for  talllnntly  the  nature  and  law*  of  the  went  ha  la 

tbote  who  haio  never  acquainted  ttiemselTee  with  making  use  of,  and  for  Ita  proper  appltcatlon  In 

the  subject,  or,  having  di>ne  so,  find  that  after  a  praotlce.     In  a  condensed,  practical  Tom,  it  pra- 

timethelrknowledKeneedsrefreehing.    Wethink  sents  to  the  physician  all  Inat  he  woold  wish  to 

ha  has  accomplished  this  object.    The  book  is  not  remeinberafterparuslngawhotelibraiTonmadlcal 

too  TolumlDoua,  hut  is  thoroughlv  practical,  sIm-  electricity,  litcludlnK  the  rasntta  of  the  latast  In- 

pla,  complata  and  oomprehensible.    It  Is,  mora-  *astlgations.    It  is  ua  book  for  the  practitioner, 

OTar,  replete  with  nnmerous  Illustrations  of  lostni-  '  and  tne  necessity  for  a  saoond  adltlon  prores  that 

mants,  appllanoea,  etc— JTsdicn/  Bteord,  Norember  It  has  been  appraolated  t^  tha  praftaaIon.'-/'i^fi- 

U,  ISBl.  I  aon  and  Surgmm,  Dao.  1882. 


THE  TEAB-BOOK  OE  TREATMENT, 

A  Comprehensive  and  Critioal  Beriew  for  Praotttionera  of  Hedi- 
Oine.     In  one  12ino.  Tolume  of  320  pagrea,  botind  in  limp  cloth,  with  red  edges,  $1.25. 

This  work  present»<  to  the  practilioner  not  onl^  a  complete  classified  account  of  all 
the  more  important  advances  made  in  the  treatment  of  Disease  during  the  year  ending 
Sept  30,  18fi4,  but  also  a  critical  estimaie  of  the  same  hv  a  competent  authority.  Each 
department  of  practice  has  been  AtUv  nod  conciselv  treated,  and  into  the  consideration  of 
each  subject  enter  such  allusions  to  recent  pathological  and  clinical  work  as  bear  directly 
upon  treatment.  As  the  roediitd  literature  of  all  countries  has  been  placed  under  contri- 
bution, the  references  given  throughout  the  work,  tt^'ther  with  the  sejtarate  indexes  of 
subjects  and  authors,  will  serve  as  a  guide  for  those  who  desire  to  inre^tigate  any  thera- 
peutical topic  at  greutcr  length. 

The  contributions  are  frt>ro  the  pens  of  the  following  well-known  gentlemen: — J. 
MrrciiELL  Bri-ce,  M.D.  ;  T.  Lavdkb  BarNTOK,  M.D.,  F.R.S. ;  Thomas  Bryast,  F.R. 
C.9. ;  F.  H.  CiiAMpKKYs,  M.B. ;  Alfred  Cooper,  F-K.C.S. ;  Sidnbt  Cocplasd,  M.D. ; 
Dyce  Duckworth,  M.D.;  Oeobgr  P.  Field,  SI.R.C.S. ;  Rbgisald  Harrisos,  F.B. 
C.S, ;  J.  Wahrivotos  HawarI),  F.R.(\S.  ;  F.  A.  Mahomed,  M.B. ;  Malcolm  Morris, 
F.R.C>?„  Ed.  ;  Edmisd  Owes,  F.R.C..S. ;  R.  Douglas  Powell,  M.D. ;  Hesey  Povteb, 
M.B.,  F.R.C.S.;  C.  H.  Ralfe,  M.D. ;  A.  E.  Sassom,  M.D.;  Felix  Semos,  M.D.; 
Walter  G.  Smith,  M.D.  ;  J.  Ksowslet  Thorstos,  M.B.;  Frederick  Treves, 
F.R.C.S. ;  A.  DE  Watteville,  M.D. ;  John  Williams,  M.D. 


HABEBSHON,  S.  O.,  M,  -D., 

Smtor  /^ytifinn  to  ltd  lats  Lwl,  on  Printipi**  and  FraetU*  qf  Med.  at  O^*  HotpiXaL,  London. 
On  the  Diseaees  of  the  Abdomen ;    Comprising  those  of  the  Stomach,  and 
other  partsof  the  Alimentary  Canal,  (Esophagus,  Caecum,  Intestines  and  Peritoneum.  Seoood 
American   Irnm  third  enlarRed  and  rerised  English  edition.    In  one  baodsome  octaro 
Tolume  of  664  pages,  with  illustrations.    Cloth,  ^.60. 

PAVT-8  TREATISE  ON  THE  FUNCTION  OF  DI-    ^i^h^.y^tv^^w^ii^J'XiI^^hrn*^?''^^-™ 

0E8TI0N;  lu  DUordars  and  thair  TraaUnent.       S^^'^J^  J^'**  ^*^^^^'£\I-  ^'^^ 

From  the  eacood  I»ndoo  edition.    Inonaoetaro       "■"■    "**'•'"*-,*'?•  ™*...„2r'^ri„«   ,. 

volume  of  ISSiiaaas.    Cloth  tLoa.  TODD'S  CLINICAL  LECTURES  OS  CERTAIN 

"  .     ACUTE  DISEASES.    In  on*  oetaro  volume  of 

CKAMBElUrHANVALOFDIETANDREOIMEN  I     S»  pagaa.    aoth.«Ua 
IN  HEALTH  AND  SICKNESS.    Ia  ona  hand-    HOLLANDS  MEDICAL  NOTES  AND  REPLEC- 
KHDaoetaTo*olumaor•l)Sp^    C)««h,|lTe.  TIONS.    1  toL  tro..  pp.  KB.    Clolh,tSJO. 


COTTEXf  J.  SOhlS,  M.  »., 

l.ffinra  m  I/trjnK/wfopji  aihl  l>iitaK±  i>/  Out  Jhroal  tmtA  Ohtit  in  th*Jtffm»Qm  3f»tlatt  CbBipt 

Biaeasas  of  the  Throat  and  Nasal  PaasageB.  A  Guide  to  tb«  XKBg&onftnd 
TrMtmf^m  of  Atfbotionsof  the  E'h&nrnx.  <Ksi')jhA||[[ua,TrKchea,  JMrynx  and  tfMTtm,  TUd 
ediiioD,  ttiomiighly  reritted  an<]  rewritWu,  with  a  Urg«  ouniber  ni  new  iUustnUoiv,  h. 
OOP  vorr  liandBoms  oclaro  volume-.    Preparinff. 

8EILER,  CARL,  M.  7>., 

A  Handbook  oi'  DiaKUOBifi  «nd  Treatment  of  Diaeaaes  of  the  Thrott,  [ 
Nose  and  Naso-Pharynz.    SmvnkI  edition.    In  ono  bitMbome  rajal  I2tiia. 
of  294  page*,  witb  77  iUii&imiioiia.     Clotli,  (I.To. 

th«  •M*ollftl>  of  itliMMwls  ftBd  lr«>ta&«ot  ta  • 
e^*»  of  tha  thrual  iid  mmw.    Th«  *rt  of  I 


It  la  oBA  or  t^*  htm  at  Ihc  practtcal  t«xi-Ui>ik» 
OB  tKU  *uhje«l  wltli  wlihih  wo  mn  K^uklaled.  The 

eniaentlr  pmctlckl  abuibcler  tut*  hocn  tnalu- 
t«ln*d.  Muiy  aoa  IHiiHiraikKii  har*  alw  lwii:i 
lDin>«liic«(l,  *  c«»«'rv4Kird  tlie«t  bu  bvro  acUled. 


PMI 


ipv,  iha  Rawiomynf  the  throat  And  no*»  aarf 


....»...■.«<.,  .  v-n-.vw.u  ......V.  u_  wu  »».».  (UMI7  lllittliw«a,  exc«U  In  muiv  a«Mailal 

and  lliora  »ro  »  rnliuiMfv  MI>ll>>|[Ta|ihr  and  a  (ooii  un>«,  aiHl  doavrroa  a  plac«  Id   Ina  otOoa  a. 

lDd«x  »t  th«  vlivlc.    Fur  nay  qdo  whv  wUhv*  to  praolltloncr  «bi>  wmild  iDforra  tilnivcir  Mk  (»  Ua 

nwka  hlm*a)f  fainlllar  wilti  lli*  firaotli^l  n>nna|p>-  nalatv,  dlac"***'*  '^'^  tr«atnt«(it  nf  m  cim 

ni«iit  ofeaMavfUiroMt  and  novvdlwwefthe  book  Ma««  •Iroart  Uiae<paritltl«  frotn   MDerMt 

vLD  b»  totad  ofcraat  T«tii«.— .Viw  r«ri  Jf«lienl  imMioa.    Willi  adxaaiMdaiadMitBlhabank 

AurmK,  Jina  ».  ISO.  ha  vm  popnlftT  an  aooiNut  of  it*  vandaBaM 

Th*  workb*fi<r«(i*l«aoiin«lMhandh(Mk  npon  —tomtt^l'  Mtdifol  Xa»t,Jaamat,  Utt. 


patlKtloKT  of  tb«  Kinooas  m<i»bnut«  ar«  dlitiuaii 
wiUi  w;4K^U«nwMi  and  ^>illl7.    Th*  ««k  la  w* 

otOM  of  U>a 
(n  Ua 


madM I 


BROVmnE,  LEMyOX,  JP,  M.  C.  A,  Sdln,, 

Snnor  S^rgntit  In  Ikt  CnifrnI  If-aJ/t  TIknnI  unit  Bnr  BitpUnl,  tic 

Tho  Tliroat  and  its  DiacaaOft.  Srivitil  Amwican  tmai  tli«  aeoond  iJKgliA  «£• 
ttoo,  UiunniBlilj  nviaed.  With  l(n}  lypicut  iUuntntlDOU  in  colon  Mtd  60  wood  «iigmTiafk 
dcufnwl  aiM  exeoiiicH  I17  t)ie  Aiitbur.    In  otw  vvrj  huulmme  imperial  ocutq  vohme  tt 

FLINT,  AUSTIN,  M.  />., 

Pt^fttmu  at  thi  l\inf%pt*d  onrf  fVncUM  q<  MtdUSM  M  A)Bm*M  flMjiMaf  JfaAeaf  OUIapa,  JT 

A  Manual  of  Auscultation  and  Perousaion;   Of  i1m>  Plt.vuiml  IMigoad* 
OtieaMaofUie  LunfilsiUKi  Heart,  and  of  Thoradc  AneurisRi.  Thitd  edition.   In  ooe  banl* 
'■■M  royal  I21&0.  rolame  of  240  pag«a.    Cloth,  t\M. 

It  la  (al*  K>  aajr  that  ihvr«  la  not  In  Uia  BomIMi  |  tlw  nanlU  ol  Ma  oafoftil  atndr  and  amjAm  «' 


«^4l^ 


taoKuase.  ei  any  oth«r,  tlM  equal  Hittoiiai  of  ciaar, , 


•xaci  ana  oompralieBtlbl*  In  formal  ftn  toitetiliu| 
■■■■"■■■  iial 

proclw  and  iiimple,  DOOTe^ng  wxth^mt  duhioty 


iha  pbj-aloal  etnjatailon  of  Uir 
Dumbot  of  wordn- 


hitst,  In  an  o<|iii 


erieoM  tn  Kieh  wIm  tbai  Uia  young  will  find  tttba 
•ti  ... 


aoBroo  oif  tnitnietjoa,  aad  th»  a4d  tho  mmt 
(iloaaaal  raoMU  of  raTlvUv  an^  BomjpIemMllat 
()i«lr  knowlvdsa-— jt"w^MK  JVnanftewar,  Jurna, 
IfMS. 


Bi'  TUB  SAXa  AUTltCiB. 

niysioal  Exptoratiou  of  the  Iiungs  by  Bleans  of  Auscultation  an 
Percnnaion.     Three  lerlureA  delivered  bcront  iho  Ptiilnd<.-l[tliut  (>>ii:it7  Molical  Swim, 
1882-83.     Ill  one  lionliunie  amall  12uk>.  votiiiiic  uf  8»  pngr^.     1.:io(h,  tl.W. 

A  Practical  Treatiao  on  tho  Physical  Exploration  of  the  Ohest  asd 
tho  Dia«Do«i8  of  BiMases  Affeottng  the  Bespiratory  Organa.  Baeood  and 
revised  cflitiun.    In  one  bandaonM  octaro  roiiune  of  •^01  pa(ca.    Clotb,  U^^ 

FhthJHiH:  Its  Morbid  Anatomy,  Stiology.  Symptomatic  JSvcntit 
Complications,  Fatality  and  Prognosis,  Treatment  and  Physical  Di 
noais:  lo  a  series  of  Cliaical  iSuidlea.    In  one  Itaodanniv  octavo  voIuomi  of  442 
Clirth.  t3.50.  

A  Practical  Treatiao  on  the  Diagnoaia.  Pathology  and  Treatment 
Diaeases  of  the  Heart.    Second  rerMeaaiid cdWr^I tilition.    In  rmo ocUcro  volnBie 
of  MO  pagGu,  wilh  a  pluie.     Cloth,  $4. 

GROSS,  S.  D.,  M.D.,  LL.I>..,  I>,C.L,  Oxo»..  LL.2>*  Cantab. 

A  Practical  Treatiae  on  Foroign  Bodies  in  tho  Air-pasBagea.    Is 
octavo  roll ime  of  4-VJ  pnges,  «rilh  5fl  ilhiWratirai".     I'loth,  ?-.7rt. 


J 


A 


FULLER  OM  UISKASBS  OK  THS  Ln.VW  AKD 
Aia-PASSAOES.  Ttictt  Patli>.d'>«7,  Phy-ioal  fl- 
agnoala,  tsrtn  rtom*  and  Trt«mi«at.  Prom  Um 
aMraqid  and  roTistKl  Englhh  nllUon.  In  one 
octavo  foloma  of  r.b  pajtci.    Clinb,  tQ.fi(i. 

BLADE  OS  DIPRTBERrA;  ll»  NaK.roandTfPai. 
tnaai,  with  an  aeooanl  of  Iho  tllMoir  of  ilB  ]1*> 
*alsnc*  to  variotisCotmtric*.  BMVMKraadraiUi^ 
•dltUn.    la OM IXmo. veL, p^ US.  Clinh.fi,3& 

WALRRRON  TIIKT>t9EAIi|»09  TRK  REART 

ASlir.REAT  VESaF.US.   ThW4  Ma*rt(»o  edl- 


SMlTaONCOSSUMPnON;  H«  Barlr  aad 

<l<a><I«  HUsaa.    I  ToL  4*0..  pt>.  JTO,    Oath. 

I.\  kiMEtK  OK  pmnmOKlA.    I  vat  t*9. 

!)•«-.     Cl.-jtfl,«11>. 
WIIJ.IAMB  !■  - 
so    Xnmrr 
aiialv'U  uf    I 
dtinittofL   in  ^dcsTo.  ("1- i>[Air.  [^  u 

JOSESCUNtCAL  OBSERVATIOSS 
TIONAI.  XERVOUa  DUORDRRa.     . . 
«riA»n  i-dition.   la  one  liaailaoine  oeta«« 


ufN* 


Lka  Beotbxbs  &  Co.'b  Pcblications — Nerr.  and  Ment.  Dls..  etc.      19 


MITCHBLL,  8.  WEIR,  M.  D., 

PSynaoH  to  Orlhopadic  HotpHal  md  l/it  InSmtary  for  IhttatM  of  lh4  TTtrvoui  Sytttm,  FhUa.,  tie. 

Iiectures  on  Diseases  of  the  Nervous  Syetem:  Eepecially  in  AVomen. 
S«ooD(t  edicinn.    In  one  12iDn.  Toliiiue  of  283  pages.    Cloth,  $l.i5.    Jtut  rtady. 

So  Rfcat  have  been  the  achievements  of  the  syslem  perfected  by  the  author  for  the  treat- 
ment of  hviitencat  and  nervons  disease)  that  the  profession  will  welcome  the  second  edition 
of  a  work  which  gives  in  detail  the  methcMls  of  entorced  rest,  massa;^  and  systematic  feedinjr 
OD  which  thin  mixle  of  treatment  is  bnse*l.  Manv  of  the^e  lectures  are  origina!  stndiet  m 
well-known  di.it'iises,  and  others  deal  with  subjei-ts  which  have  been  hitherto  slighted  in 
medical  literatnre  or  which  are  almost  uaknown  to  it.  The  present  edition  contains  sevenl 
new  lectures,  notably  those  on  the  difficulties  of  diatpiosis  in  hysterical  diseases  of  joints,  on 
the  relations  of  hysteria  to  organic  disease  of  the  apine.  and  on  hysterical  disordera  of 
the  rectum. 

HAMILTOTf,  AJLLAN  McLAN^,  M.  !>., 

Alttndiitg  Phy4ieian  at  th*  Hotpitatfor  EpiUpttt  and  Prtralytie*,  KadaetWt  JHvd,  X.  T. 
Nervous  Diseases ;  Their  Deecriptinn  and  Treatment    Second  edition,  thoroogfalT 
TeviBed  and  rewritten.    In  onem-tavo  volume  of  o98  pages,  with  72  ilhistrationa.    Cloth,  $1. 
When  the  flr«l  edition  orthio  good  book  sppearvd     ehararterlied  this  book  sn  the  l>e*t  of  Its  kind  In 


wa  g^Tf  It  our  emphatlo  endonemeat,  and  the  any  languaae,  which  Is  a  handiHime  endorssmaat 
pr*A«n(  edition  enhaneea  our  appreciation  of  the  tmm  an  exalted  source.  The  ImproTementa  Id  the 
book  and  Its  author  as  a  safe  guide  to  )<tudeDts  ol     oew  edldoc,  and  the  addlliuns  to  It,  will  Inatl^  Ita 


Dreneni  edition  enhaneea  our  appreciation  of  the  tmm  an  exalted  source.  The  ImproTementa  Id  the 

book  and  Ita  author  as  a  safe  guide  to  )<tudeDts  ol  oew  edition,  and  the  addiliuns  to  It,  will  ' 

■llalcal  neurology.     One  '>f  the  best  and  moat  purcha.*e  ereo  bj-  those  who  posMss 

critical  of  Englli<1i  neurological }ou mala.  Brain,  ha*  AtianUI  tnd  Saurotogut,  April,  ISBX. 


TUKB,  DAJS^EL  MACK,  M.  !>., 

Joint  AutXoT  of  Tkt  Manual  vf  Piythuiogital  Maticint,  t(t. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 
and  Disease.  J>esigned  to  elucidate  ibe  Action  of  the  Imagination.  New  edition. 
Thoroughlv  revised  ana  rewritten.  In  one  liitndsome  octavo  volume  of  487  page«,  with 
two  colored  plates.    Cloth,  $3.00. 

It  Is  lmposi>ibla  to  peruse  these  In  teres  ting  chap-  method  of  interpretation.    Guided  by  an  enlighl' 

t*n  without  being  conrlnced  of  the  authorV  per-  eut-d   deduction,  the  author  has  reclaimed  for 

(i>et  ■incerlty,  linpartiHtiTy,  aud  thorough  meuial  science  a  most  interesting  domain  to  paycholcoj, 

sraep.      Dr.  Tuke    ha*   exhibited   the    requisite  preTiousIy  abandoned  to  charlatans  and  emplrlu. 

amount  of  scleatiflo  addresH  on  all  occiuians,  and  This  b<M)k,  well  coneet*ed  and  well  written,  must 

the  more  intricate  the  phenomena  the  more  firmly  oommend  itself  to  every  thouahtful  understand- 

haa   he  adhered  to  a  physiological  and  rational  Ing.— .Vne  I'^fntJfeduo/ JoHmoJ;  September  (^1884. 


CLOII8TOX,  THOMAS  S.,  M,  D.,  F,  B,  C.  P.,  i.  B.  C.  A, 

Lttlurer  on  Mmint  Diicoau  in  tkt  Cni\-trtitfi  of  Bdinhurgh. 

Clinical  Lectures  on  Mental  Diseases.  With  an  .\ppeDdix,  containing  aa 
Abstnut  of  the  Statutes  of  the  L'niteii  States  and  of  the  Several  States  and  Territoriea  re- 
lating to  the  CiiNtody  of  the  Insane.  By  Cuaklk  F.  F01.8011,  M.  D.,  Assistant  Profeanr 
of  ^lental  Diseases,  Medical  Deparlinent  of  Harvard  University.  In  one  handsome 
octavo  volume  of  &41  pages,  illustrated  with  eight  lithographic  plates,  focr  of  which 
are  beautifully  colored.     Clotn,  $4, 

The  practitioner  as  well  as  the  student  wilt  ae-  the  general  practitioner  in  guiding  him  to  a  dlag- 

cept  the  p1ain,practlcal  leaching  of  the  author  a*  a  noeis  and  Indicating  the  treatment,  especially  m 

fbrward  ptep  in  the  literature  of  Insanity.    It  Is  many  obeeure  and  ili'iiblful  eacer  of  mental   dla- 

refre^hinic  to  find  a  phy^ili'lan  of  Hr.  Cloust'in's  ea^ie.    To  the  American  reader  I>r.  Ptdsom'e  Ap- 
ezperlenoe  and  high  reputation  glTlng  the  bed-  ,  pembx  add»  grestly  to  the  value  of  the  work,  and 

side   notes  upun  which  his  experience  haa  l^eeu  will  make  It  a  desirable  addition  to  every  library, 

founded   and   his   mature  judjimeut   eMabll'ihed.  —Ameriean  P.MhologiaU  Jtmrmil,  iaiy,imt. 
Such  clinical  otMerTatloua  cannot  but  be  useAil  to 

M^Dr.  t'DUmi's  Ab»lmd  may  ulsii  be  obtained  seiKinitely  in  one  octavo  rolume  of 
1  OS  page-.     Cl'ith.  $l.*>it.  ' 

SAVAGE,  GEORGE  S.,  Jtf.  !>., 

Ltflurrr  on  M'niitl  l>iittuti  at  Otn/'t  Hotpitai,  Lorff-m. 

Insanity  and  Allied  Neuroses,  Prattical  and  Clinical.  In  one  12mo.  vol- 
ume of  ool  pages,  with  IS  typiflil  iUustratiuns.  Cloth,  $2.00.  <^u«f  readif.  See  Seria  ^ 
Cliniinl  MnnualK,  page  3. 

As  a  handbook,  a  guide  to  practitioner*  and  atu-  common  sense  I.*  eTerywhere  apparent.    We  re- 

deals,  the  book  fuints  an  ailmlrable  purpoai'.  The  peal    that   Dr.  Sarag^   has  written  an   excellent 

many  fortti"  of  Insanity  ar-^  di^^cribed  with  char-  manual   fur  the   practitioner  a=d    «tiident.— ^Jas- 

acierlKtir  rl'-arnes-',  the  111ri*tratlT«  i-a<e>  arc  care-  mean  Jmirtiai  •■<  Jn-anit\,,  April,  lil&'j. 
ftitlj  selected,  and  ae  regards  treatniant,  sound 

PLAYFAIB,  W.  8.,  M.  U.,  E.  B.  C  P., 

The  Systematio  Treatment  of  Nerve  Proetratlon  and  Hyitaria.    In 

one  hanttsome  small  12mo.  volume  of  97  pages.    Cloth,  $1.00. 

Blandford  on  Insanity  and  its  Treatment:  Lectures  on  th«  TrMtnent, 

Medical  and  Legal,  of  Insane  Patients.    In  one  vary  haadsontaoete^oi^wn*. 


GSOHH,  S,  AA,  Jf.  J),,  i£.  2>«  />.  C  X* 


.TW  wvft  M  »  ««irf«  mamd»  m  . 


rifM*   •(Mq^T' 


AHHnVRHT,  JOSS,  Jr„  Jf-  Z>^ 

Tba  Prtnciptoi  ud  Fractiee  of  Borgaw 
tiirbri.    lann  lM|«ind  haadManacnfemhoBVfl 


tUOTi 


OOVJAh  A.  PEABCB,  JC  JS>,  IC  B.,  J".  JS.  C 

Slsncnu  of  Surgical  DlMBoala.    !■ 

ClMl^«3Liyi.    J.ufrn.'V        H*t>ab,dmM  Sirtmif 
MMtaM  M4    HMUiliof    will    fln<l  Um  '  and  tf 


Ml  mifc  vMl  in  ammrrfmn  *>t)>iKv  aiml-    twnw— m  bwvR  I*  *•  ^v  •*  aiAMriltaf  »m 
Anntd  h«r«  * wfr  1o  ttnij  *in1a§  *h»}MlMrnlt,  \  tit  fmpmi^^-afttmmmt  M^md  Jlm^ im^wm- 

GIBJfEY,  r.  P,,  Mrih,  " 

Oithop»diii  aurt«ry.    For  Uw  »m  uf  Pnrtltk«m  tmi  Ormti  ■!<>. 


IjuiHTtr  in  A-MUmif  rani  (m  OtmUUt»  Afrftry  at  O*  /WtaJH^pUa  ft*w*< 

Th«  Friooipl«i   and  Praotloo  of  SurcMT*    Far  tk*  om  of 

rrnattian^'nt  of  MedidiM  uul  tfiinc«i7.    In  dim  tnjhmtOBK  ortxfo  mbtas  cf 
(MfH^  wIUi  nmn/  {UtMnUiam.    fytparing. 

BELLAMY,  EDWABD,  JP.  if.  C.  «., 

OparattTO  Surgery.    Sioriiy.    Sn  Simtmi^  £Vrv«  «<  JfasMO^  pii^*  x 


STIMHON,  LKWJS  A.,  B,  A.,  M,  I>,, 

A  MuDual  of  Oporntivo  Surgery.    In  une  verv  bandaotDe  n7>l  l&ao. 
of  477  pagt^  With  »S2  llliMtnauiu.    Cloth.  Ti-W. 
.  Tlilirolun«Ud«T«to4«ailnilylooMr*UTeHir'    eTdrx  itudent   dboutd   poww  a»«.    Tbli  «orK 
lt«nr,  mad  Im  InUndMl  to  (kmlllMlu  l)t»  Mudviii    •loea  srar  wlUi  Um  naottMllgr  «(  pMidwiaf  «nr 
«llh  til*  4«UII»  of  opArailonii  wid  th«  ■llireroni    UrK«r  wAricion  anmrr  IbraM^rtptlPUAC  ofwl- 
niodM  of  patribrr^lni  thani,    TIid  oork  !■  Iiuid-    tlcm^^i  li  praaaate  la  •  nntobell  what  la  vaatad 


■•Ir  JIIuMMML  UI<I  tb«  dtaMlMlou  ««  oImt 
ui4  walMnwn.    IllaKitlanrattiriiMftilTotanMi 


tlcinLM  li  praMOte  la  a  nut 

br  tb«  largwa  withvat  la  •UbomM  Mwnk  u 


ilod  It— JTonrlaiaJ  JTirffent  J«wi»<  Ai^iM^un. 


.  _,_I«l»»U'i      I.  ma 

TOllIlM  «r  m  t-uc^  ntUi  tn  ::uta.    Cl'^Ui,  tt.in. 

MiLi.Bitvranioin.iBsortuitoEBr.  pMiniil 

AnarioMt  IVofn  llMtlilrd  EdlnMrgb  adlllou.    In  t 
on*  no.  vol.  of  uo  pagaa,  villi  HO  lllu»ir>tJotu. 
ao*h.  CI.TA, 

Mii.t.KU-B  I'HArncK  or  buhokry.  rouriii ' 

Wd  raTliad  Ainorinui  lr*in  (b*  Ual  Edlbberfrh  , 
cation,  to  oiia  Wn  t:iixTQ\.D|Mtuc*B,ii(lh  ' 
Ml  tVluMmiOUL    Ctbttk.lft.'tk 


prHHli  M1IM,R3   JOID   PRACTICE  OP 

i3i'i:  ""i  hf  ivmm  tXwax,  M.  D.    U 

onn  -■  1  i>p  wilhMa  niO*.     CtMh,RT3- 

coopr-u^  LKiTLKHa  oy  THE  PHiirnFLW 

AM>  CKArTirEOPSt'ROERT.  Id  an*  Ira  rol 
of  TC7  paet*.    Clolli,  CUM. 

aSEr-B  OPEKATIVE  9UR«BfiyinoMf«t.»>a- 
of  on  piwa>.  i*l(h  81  wooilcaU,    CtoUi.  PJB. 

(lIlWtN'H  INSTITUTES   AW    PIUCTICE   0» 
"irit'^GRT   Clghlh  adlllAik    In  two  ooM*1>«•b■ 


Lka  Brothkes  &  Co-'s  Publicatiohb — Sm^ry.  21 

BRlCnaBN,  JOHN  £.,  F.  R.  5.,  F,  JR,  C.  5., 

froftator  of  Surgery  in  Uturar»Hy  Cillegt,  London,  itr. 
The  Science  and  Art  of  Sur^erv ;  Beinj;  a  Treatise  OD  Surgical  Iiyuries,  Dia- 
eases  and  OperalionB.     Fmnt  the  eighth  and  enlarged  English  edition.    In  two  large  and 
beautiful    octaTO    volumeB  of  2-llb    psgee,    ilhistrated    with  9S4  engraving  oa  wood. 
Cloth,  $9;  leather,  raised  bands,  (II ;  half  Russia,  raised  hands,  $12.     Just  ready. 

After  the  profenslon  hui  placed  \ti  approTiJ  npon  miii^h  to  he  raid  tn  the  yivj  at  comment  or  crltl- 
a  work  to  the  ezlentof  purctiwiDK  aeven  edition*,  eitra.  That  it  sttll  hiildd  Ita  owd  goee  without  say- 
it  does  not  Deed  to  b«  Introduced!  Simultaneous  i  ing.  Tlii"  author  infuBi-n  iDto  it  his  lar|(o  eipen- 
wlth  the  appearnni^e  of  thi''  edition  Atmnnlalion  '  enre  and  ripe  Jiiclfcm^nt.  Wedded  to  no  itchool, 
la  being  made  into  It^ian  nnd  Spanish.  Thus  committed  to  no  theoiy.  biassed  by  no  hobby,  he 
this  bToriM  text-book  ou  surgery  holdri  In  own  tn  .  imparts  an  honepi  persotialltv  In  his  olwer  rat  tons, 
•pice  or  DumerouD  rirals  at  the  eud  of  tlilrly  years.  .  and  Iii«  teachings  are  the  rulings  or  an  Impartial 
it  U  a  grand  l>ook,  worthyof  theart  In  the  lnt«r«st  '  Judge.  Such  men  are  alwavfl  ^afe  guides,  and  their 
of  which  It  in  written.— Dttfoirixuicef,  Jan.  10, 1885.    works  "land   tho  tests  of   time  and  ezperlenoe. 

.Afier    tving   Vfire    the    profession   for  thlrtv  i  S-uch  an  author  In  Erlchs*n,and  such  awork  Ishto 
years  and  mainiainlnK  during  that  period  a  re-    SiiT(iery.~:s!oli(al  Ruard,  Feb.  SI,  188S. 
putatioD  a-  a  leading  work  ou  nurgery,  there  Is  not 


BJfl'AiVT,  THOMAS,  F.  R.  C.  S., 

Surgaon  and  Lttturer  on  Surgery  at  Ouy's  Ho^Aial,  London, 
The  Practice  of  Surgery.     Fourth  American  from  the  fourth  and  revised  Eng- 
lish e«lition.     In  one  large  and  rerv  handsome  Imperial  octavo  volume  of  1040  page*,  with 
727  iUustrattons.     Cloth,  $6.-50;  leather,  $7.50;  half  Russia,  $8.00.    Jiutreadi/. 

The  treatl-e  lakes  In  the  whole  Held  of  surgery,  '  This  most  magnificent  work  upon  snrgery  has 
that  of  the  eye,  the  ear,  the  female  organs.  orthc>-  reached  a  fourth  adition  tn  thU  country,  showing 
p«dies.  Tenereal  diseases,  and  mlllUry  surger.v,  the  high  appreciation  in  which  It  Is  held  t)y  tha 
as  nell  as  nii>re  c<immi>n  and  general  topics.  All  American  profession.  It  comes  ftvsh  from  the 
of  the^o  ail'  treated  with  cleame>-s  and  with  pen  of  the  author.  That  It  is  the  very  best  work 
tnfflcient  fulncs  to  suit  all  practical  piirposc'i.  '  on  siirf:ery  for  medinal  students  we  think 
The  Illustrations  arf  numerous  and  well  jinuied.  there  can  benodouttt.  The  author  aeams  to  have 
We  iln  not  d,iu)ii  that  liii:-  new  edition  nil)  ci-n-  -  under^C'>od  Just  what  a  student  needs,  and  has 
tlmie  to  iiiftlnlain  the  piipiilnriiv  of  this  -laiKlard  !  prepared  the  work  accordingly. — Ctnetnnati  JfaiinlJ 
work.— .U( '/iMf  o'ld  ^"r;;t«ii  Ht'p'irtrr.  Feli.  H,  'W.  |  Afira,  January,  ISgA. 

By  the  same  Author. 
Diseases  of  the  Breast.   In  one  l^mo,  volume.   Pr^ytriag.  See  Serut  of  Ciwwol 
itanMtiii,  pag»  3. 

E8MARCH,  Dr,  FRIEI>RICH, 

Profettor  ot  Surgery  at  tha  Univertitfi  of  Kiel,  ttt. 
Early  Aid  in  Injuries  and  Accidents.     Five  Ambulance  Lecturea.    Trans- 
late«l  by  H.  K.  H.  Prixce^  tHBDrriA:).     In  one  handsome  small  I2mo.  voluow  of  109 
pages,  with  24  illtiBtntion:^.    Cloth,  75  cents. 

The  course  of  Instruction  Is  dUlded  Into  Are  '  the  methods  of  affording  Brat  treatment  Id  eaaes 
sections  or  lectures.  The  Hr^C,  or  Introductory  of  fr<i«t-bit<?,  of  drowning,  of  snSticaUon,  of  loaa  of 
lecture,  glies  a  brief  account  of  the  itructurii  and  coosciouxiieaii  and  of  poisoning  ars  tlaacTllMd; 
organization  of  the  human  body,  illustrated  by  and  the  fifth  lecturo  leaches  how  Injured  persona 
clear,  suitable  diagrams.  The  second  leaches  how  may  b«  most  safelv  and  easily  transported  to  tlialr 
to  giTe  Judicious  help  in  ordinary  Injuria*— contu-  homes,  to  a  medical  man,  or  to  a  boapHaL  Tha 
•ioDs,  wounds,  hemorrhage  and  poisoned  wounds,  lllusiratloni  In  the  book  ara  dear  and  goad.— Jfsdj- 
The  third  trtats  of  flnit  aid  In  csbcb  of  fracture  [  Mi  Timet  and  Oaittte,  No*.  4,  I8BS. 
and  of  dislocBliouB,  In  sprains  and  in  bums.    Next, 

TREVES,  FREnERickTE^'CTsr, 

Attittant  Surgeon  to  nnd  Lecturer  on  Surgery  at  Ui4  London  BotpitaL 

Intestinal  Obstruction,  In  one  pocket-«ize  I2mo.  volume  of  522  pages,  with  60 
illustrations.  Limp  cloth,  blue  edges,  $±00.  Jiut  rtidy.  See  Seritt  of  Clinital  liannolM, 
pages. 

A  I'landard  work  on  a  siitiject  that  has  not  been  Justice  to  the  author  In  a  few  paragraptis.  /nt«s- 
•o  comprehenslTely  treated  DT  any  contemporary  ,  tmaT  Odtrmrtfon  Is  a  work  that  will  prove  of 
English  writer,  lis  completeness  renders  a  full  oqnal  value  to  the  practitioner,  Itie  atadeot,  the 
review  difficult,  since  every  ohapier  deKvrves  ml-  pathologist,  the  phjrslclau  and  the  oparallag  for- 
nute  attention,  and  It  Is  Impossible  to  do  thorough    geon.— Sn'fttA  Sfidieat  Joimtal,  Jan.  Si,  1SS6. 

BALL,  CHARLES  B.,  M,  Ch,,  JDub,,  JF.  R.  C.  8,  E., 

Surgeon  and  Trnfhrr  at  Sir  P.  Dun'i  lloepttat,  DubttK. 

DiaeaaeB  of  the  Beotum  and  Anns.    In  one  I2mo.  Tolnme  of  650  pag«a. 

Preparing.     See  Seria  of  t'/imcoi  AlanuaJs,  page  3. 

BUTLJJff,  HEXRY  T.,  F.  R,  C.  8., 

AtttttmU  Sitrfon  to  St.  BarthoUmeit't  BotpUal,  London. 
Diseases    of   the    Tongue.      In  one   12mo.   volume.      See  Senei  tf  CUmaai 
J/anuu/s,  page  3.     Shortly. 

DRUITT,  ROBERT,  M,  R.  C.  «.,  eU, 

The  Prinoiples  and  Praotioa  of  Modem  ChirfiBT^.    ?vn.  i^  sa^<i^ 
toadoo  edltioa.    Jd  one  8to.  volume  of  687  pagea,  «it.h  4^^  \\V».  WdCI^V>^^»■<fit»»^V»• 


22 


&  Co.'s  Pci 


HOZXE8,  TlMOTHYf  Jf.  A,, 

JhrgMii  Md Littff-1  UK  .S'iii7<r«af  51.  Qaor^'t  Haipitai.  £oni4'in. 

A  System  of  Surgery ;  Theoretical  and  Practical.     IV  TKEV  TISES  B 
VAKloCfj  .\UTJH.iKS.     AxciticAH  edition,  thohoiohlv  uevi¥ki>  a...  m-rtinv 
hv  John    IL  I'ArKARD,  M.  D.,  Hnixcxn  to  the  Eni»-"[>n]  uml    .St.  .Ti>-  ^ittK 

l'hit«iIelpliiK,  HMi^linl  by  a  corn*  uf  tliirtr-(tirc«  nf  iW  iirnsl  *iuini?nt  _\t  ,  -£snBL 

lu   liiree   IttiK^   Slid    very  hnudsonie    iiiip«riiU   vcuvu   voliituvoi  cun.  i'«dd^ 

cnlnmnet)  r>ugns  iritli   979  illuMratl'ms  on  irooA  niul  13  UUirtcrntjil.  tUtOy 

Diiloni!.     I'rk*  {>crv<>luiito,  i-totli,  pfl.OO;  Ic-allior,  $7.U0;  half  KuwU,  t  >    ''j.      I'cr  >rt,diih, 
Clii.Ou ;  U'slher,  j^JI  .OM ;  iiilf  KiiMia,  j^ii^.oO.     S>Ai  only  l/f  wWr^Mm. 

Volume  L  L-Linuine  GEXKKAt.  Pathoi-ooy,  Mobiiii>  PnoiiBSBt,  l?rJt'Bn»  ts  G 
KRAL,  tom-ucATioss  OF  IsJvuiHA  ASD  iMjrum  or  Hegioss. 

VoLtHK  II.  crintnina  Diskju'EM  uy  OKUAmur  ^i-eclal  HenfX,  CtMcat-ATOax S 
TEM,  DmernvB  TuAt-T  and  GKsrro-UjirsARY  OauAifi 

VoLUwx  ill.  <x>ntaiDB  UueAKK  OF  TI1E  KnpnuTORT  Oboaki,  Bostes,  Jonm 
MLnscLi?*,  Di6KAsj»  ov  TUB  Nkkvouh  Sv^ncM,  GuinsuoT  WoUKLis,  Opkhativ* 
MiHoa  SuKTiBUV,  ANu  MiMKLLANBor^  SirBJHDn  (incliidrng «a  wa^v  on  ntwrriAt^! 

Ttiifl  great  wM-k,  UKiiAi  ^me  voira  oince  in  KnjelMiu),  liitA  won  Riieh  uairecaU 
ileui^  irh«rever  the  luiiguuMi^  i^  *|H-ikeu  Umt  lU  rei>iil>liciiLiiN]  here,  la  ■  farm 
tli<iniu|t;hlr  adsipWd  lo  the  wauts  of  the  American  [  .-.  hit-t  Keiut^l  lo  Iw  &  ivSJ 

owing  to  Uie  pniifMBon.    To  occomikliiih  this,  esi-'h  :i  --en  jilai-iNl  in  tli<-  hAOil*  u4 

ageutlenuiD  K(>e<-iatlv  <.i:>]upelent  to  iivut  JL^subjiK.-l,  -.:> -.  i,  -<r  lui^  W'vu  %i^Tvi  i"  Ifioc 

euik  ooe  u)i  lu  tho  forvmtwl  level  of  the  ttine^  and  to  aditpt  it  ditirtiuKh Iv  t->  the  |irA<-ti-> 
of  the  country.  In  ocrluin  en^es  this  hsti  rt-udereil  net-aaary  the  Miti^titulioii  (if  an  ctitTn-tt 
new  casar  Tor  the  oriitiiiil.  lu  in  the  cue  "f  the  &rticlm  on  Skiu  Di»eaMw,  un  Dtoti— o  d 
the  At>»rl]ent  li-yMGoi,  &iid  ou  A[iiB>chcliiK.in  the  uw  of  which  Amvrinn  [malce  dlflai 
(torn  that  of  EuKlaud-  The  Mme  mr^dil  and  conseientioiu  roraioa  hiu  been  pur«o<  ~ 
throuj^ioul,  leadiog  to  an  incrvsM  of  ni>Arly  (iiiF-fourlh  in  tustlvi,  uhile  tlie'  «vrie« 
illuatrntioiw  has  been  nearly  trebled,  and  the  wliuhi  is  preeoticd  as  a  complete  expr 
of  British  ftDd  American  Sitr^irii',  adiiplol  to  the  daily  DMda  of  the  working  firai-titioi 

In  order  tobrina  il  uHlhiu  ttia  reach  trf  every  tnember  of  the  prf'-i--    'lii*  fire  twI-' 
tunes  of  the  original  liavc  Wen  ooammev^  iniu  thrvu  by  em^'tyiu.  ' L-aalamneil 

ro^AloctaTDpoge.andin  thisimproTcdformit  i^olTcrod  nt  trmthnnniK  [irioeoftlw 

original.  Il  in  iirint«il  nud  iHxinil  touinli'h  in  «v<>ry df-tail  with  Rernnlito'  ^^vrimii  iif  M 
cine.  The  worb  will  be  liold  hy  siilwcription  only,  and  in  duo  lime  oveiy  oiMubei  nf 
profMBion  will  Iw  cnllod  upon  ami  uReml  an  o{ip<irt unity  to  iinbMTit<c. 

Tba onthon of  tb« orteliMil  BnglUh  Bitittoii  ara  thwlilirarynf  uij'nMdtnJrMUi.  Itla 
nenvrUwftODtTank  tnBacUii4andDr.  PhChard 
ha*bai»D  fomioala  In  Hciiiing  on  lili  Aiii'-iiriui 
eoaOfnton  mirh  men  u  Bwihotow,  Hrde,  JUtni, 
CiMiDar,  SltnuMin,  Hortoa,  HaJKen,  Jewell  ano 
ttiair  ctllvacuMu  A»  a  wbota,  th«  wofk  will  be 
aolld  and  nilielanUKi,  anil  a  Taltiab)«  addltloo  to 


:3 

on 

)d*u4 
Mi.* 

lilTtt 

•loeea 


aodiDoniiaeftil  tl>aaUwEnc]l>b'*iUllMi,i 
Its  oointMBlud  wnrk— "Rcynolif 
elao  "—will  w«ll  rcproaenf  ttw  i 


Its  oointMBlud  wnrk— "Rcynolda*  Bjvltmx  i 
elao  "—will  w«ll  rcproaenf  ttw  preaeat  at 
Kiivoca.  One  wbu  fa  CainllfBr  wfUi  ttiaa*  I 


will  b«  lUrhr  well  mmtfbed  Miad-wlM  aik4 
<■!>«.— 71l«  3t«di€at  Kfn.  Jan.  T.  lUS. 


8TIMS0K,  LEWIS  A,,  B.  A.,  JIT.  JO., 

JVdtea9r<^i\itAaJie#faat4»MiMur«(U«  (MtwMCu^  thtary  of  ffw  For^DMvMiMirfi 
to  Btltmm*  Bo*pitaty  Smfmm  to  Ott  PrtAtftmnn  JTiMpifnl,  !ftv  Tort,  ttt. 

A  Fraotiofll  Treatise  on  FracttLres.     In  one  very  handmaic  octaro  rolniM 
fii98  pBgee,  with  360  benuttriil  UliiKtmiuuu.     Cliith,  14.75;  loother,  (5.7&. 

Itia  •utc^09  ta  IViIl  prarOMi.— iV.    O.  MrMeal  aa4 
SitrsievI  Journal,  |fan->i,  )«>». 

The  author  sttwe  In  eiwir  lanKUMv  oil  Uucik' 


Tli«  author  ho*  givea  to  the  medtcol  prolawwn 
In  thla  lr«aU>a  on  frwlure*  nhat  U  tlkaly  lo  li»- 
comaaataiulanlworkon  tbamtjeot  tt  la  certoiiil; 
DOl  mrpaiMifiJ  hy  any  word  wrilcan  !ii  tlut  F^ngllan, 
(ir.  Tot  iliat  inMtar,  nny  olhi>T  UoKuait^  Tli«  au* 
Ihor  Inlla  an  Inanhort,  oonol**  and  aomprohaolTa 
n„P_,..  -K-k-r '<<knoiriial»3tithl»*ubjact.  There 
[»  III  '     i>T  »iiMiinrl«1  about  It,  a*  In  niwl 

oltn  n  ttif 

<}Uf(fi     ^  iH.-  ■  ii,.f.iB./iion 

treatment  ihow  him  not  onlr  to  bo  a  prcfduod  tta- 


hractiic«:,  itclr  nti'-iocy,  rytnpinma.  ptooeM**  «( 
naioB.  and  traatmeDl,  oocordtag  lo  u>*  laJMat  4^ 
ivlvpneaie.    Ua  U»  Mlaof  mMhaalealaaatfata 


I»ynri«iatK.utit.a.inm™i     u^  ^u.^,  aewKatoIr  Ki4  clearly  •■plalaa  Uw 
■."'"^ll^^I  ,i;!iJ^l! -"J,'    me'hoaarri.^.atiheprcperAhgiioai.iBdaata^ 

gl«.    01.twrfeoftr^mMt«fiR*dlftrtotrrKV    ^SoS*liXiSf  >A^iSS  iSiK  _ 
ur«alaamln*ntl/«>iiuclaiid(,mrll<-al    ^to.v.n»l-Jcr    „»   iqliin  ftir  rrrry  matillllnnfrr      fhahirfMiilf 
thl*  work  ftoa  of  the  bom  on  rr*fltir*s  -.  and  It  will     ainrlntt.  Kav  "TX™""""""— '^i  '" 
ha  wJmMoad  nol  onW  a«  a  (oiUbook,  but  alio  by  ,  '-«^"'»^  "»»'  •»•  "*•■ 


MAJRSJT,  HOWARD,  F.  R,  C  A, 

Srmar  AaUiami  Surgtrrtt  ta  aad  Lteturtr  at  Jaatonfr  at  SL  Bitrikatemuft  Itotptjol, 

Diaeaaes  of  the  JoinU.  In  <hw  ISoio.  Toliunei.  Pivpaniuf.  5e«  An'nt  of  i 
Manual*,  page  3.  

j»jcic;  T.  :picsji!sryGf  f,  b,  c.  a, 

Amv*C"  '«  '"d  ijtftniMr  on  Awytry  «t  «)k  (?Nwy<'i  i/ovr^/.  I«»laa. 
FractUTM  and  Dialooationa.    In  one  ISma  voliunr.    iVyiiy. 


Lka  Bbothibs  a  Od.'h  Publications— Frac.,  Dlrtoc,  Opbtlial.     23 

A  Praotioal  Treatise  on  Fractures  and  DislooatlonB.  Seventh  edition, 
thoroughly  revued  and  much  improved.  In  one  verv  handoome  octavo  volume  of  998 
pages,  with  379  illiistrations.  Cloth,  $o.60 ;  leather,  ttf.oO ;  verj  handsome  half  BuniB, 
open  back,  |7.00.     Jiut  ready. 

Hsmll(oi)>  KTciit  eip«rienee  and  wide  acqQklnt-  '  «(h«r  lan^ia^, — Jltdual  Rtcord,  Jaaaarj  3^,  UH, 
anoawlihthenteTBtureofthesuhiect  baT»pn»bted  With  lu  flnt app«araDCe  In  UM,  thio  work  look 
him  to  eomplrte  the  labors  of  Halitalgne  and  to  rank  among  the  ctamiiCB  In  medical  lltcralarr, 
place  the  reader  In  ponseaiilon  of  the  adTancas  and  ban  ever  nince  been  quoted  by  ■nrgeons  the 
made  during  thirty  years.  The  edltloni*  hare  fol-  world  oTcr  a"  an  authority  upon  the  topic*  of 
lowed  each  other  rapidly,  and  they  Introduee  ub  which  it  treatn.  The  HUrgeon,  If  one  can  be 
to  the  meth[>dR  of  practice,  often  »o  wi*e,  of  hla  '  found  who  doe-i  not  already  know  tha  work,  will 
American  cotlengiie^  More  practical  than  Mai-  Hnd  it  vcicnlilic,  forcible  and  scholarly  to  text, 
|nigne>  work.  It  will  oerTe  a*  a  raluable  guide  to  .  exhau^clTe  in  detail,  and  exer  marked  ^  a  'P''''* 
n. ,., ,_  .L J   — .1 jjj  ^^^    conserTatlnm.— Lout5ri(/e  MtdiM   Hfttrt, 

Jan.  10,  ISSA. 

For  a  quarter  of  a  eentury  the  author  bai  beeo 
Then'  i-  no  longer  any  necea'tlv  for  reTlewlnc  elaborating  and  pcrfe«tlaK  his  work,  ■«  that  tl 
this  admirable  work.  It  ha-<  Irliimphantly  atT- 1  now  MandK  as  the  best  oi  it*  kind  Id  any  Ian- 
Tanevd  to  lis  xev^nth  edition,  its  venerable  and  {  gnage.  As  a  text-book  and  m  a  book  of  reference 
talented  author  atlll  keeps  abreast  of  the  time*,  .  and  guidance  for  praetltlooarait  la  alinply  InTalu- 
and  ft  Is  still  the  moHt  eiliaiistlTe  practical  trea-  '  able. — .Vnr  OrleaM  Sttdicat  and  Surgitai  Journal, 
tlse  on  fractores  and  dialocations  In  this  or  any  ',  Kovember,  1B84. 


ibe  praclllloner  In  the  numeroim  and  embarrasa- 
Ing  ca*'?'-  which  come  under  his  obeerTailon, — 
Arftiirf  GtntralfS  lit  .VMcftnt,  Paris  Kot.  IHM. 


JVLER,  HENHY  E.,  E.  R,  C.  8.f 

Srnior  At4't  Surgeoii,  Aoydi  Wnlmttvier  OpMJuilmie  Ho*p. ;  taU  OMenl  At^t,  JToofjUUi,  Londatt, 

A.  Handbook  of  Ophthalmic  Science  and  Practice.  In  one  handeome 
octavo  volume  of  4i<U  ]>:iee^,  with  1--''  woodciita,  27  colored  platea,  and  Belectioni  Eroiu  the 
Test-types  of  Jneijier  ami  Snellen.     (  loth,  $4.50 ;  leather,  $-i.oO,     JvM  rmdy. 

This  wi-rk  Is  ili>tiii((u;)<hvd  hy  the  creiU  niim-    and    typical    illuMrallons    of   all    Important   eve 
ber  of  cvilored  plaleii  wlncti  appear  In  it  for  lllii.*-  '  alTections,  placed   in   Juztapoaition,    ao  ai  (o  be 


traling  TariotiH  )'Htli"l«)Eical  i-ouditions.  Tlii-r  are  '  Kra>)n'd  at  »  ilance.  Beyond  a  doubt  11  la  the 
»ery  IieaiitifiLl  in  appi-nranre,  and  hate  been  besi  1 II ii -it ratea  handbook  of  ophthalmic  aelence 
executed  with  great  care  a*  to  accuracy.  An  ex-  which  has  ever  appeared.  Then,  what  U  atlll 
aminatlon  of  Tlie  work  !<tii<iT->  It  ta  l<e  <iiie  of  IiikIi  )>Fi(t>r,  these  lllusiraiionK  are  nearly  all  original. 
standing,  one  ihiit  will  Iv  reimrited  an  an  authority  We  have  examined  this  entire  work  with  great 
atiii'iig  i>|ihthalin<'liiKi!'l<.  The  treainieoi  rt'cimi-  care,  and  It  repreiteiiis  the  commonly  accepted 
Blended  in  such  as  the  auih^r  ha*  tearnod  from  riew*  of  advanced  ophthalmologtota.  weoaamoet 
actunl  experience  to  be  the  best. — Ci'ieinnati  Mttli-  heartily  commend  Inia  book  to  all  medical  atu- 
c<i'  .Vr"-*,  I>e<>.  |4^t.  denta,    jiraciitlonera    and    •peelallaU.  —  Detroit 

It  present*  to  ttie  student  coiiclae  det>crlptlona  '  LoiiKf,  Jan.  188A. 


WELLS,  J.  80ELBEBG.  F.  B,  C.  «., 

Pr->ftntdf  nf  Oj-Hlhnhif.liyy  in  fkiny'i  OMtiie  IlotpiItU,  Lundi/n,  ttt. 

A  Treatise  on  Diseases  of  the  £ye.  Fourth  American  from  the  thin]  London 
e<liti«ii.  Thomiighlv  rcviiwtl,  with  copious  nddition.i,  br  CtiARLEA  8.  BrLL,  M.  D.,  Surgeon 
and  PiHhol<i>,'isi  to  tfie  New  York  Eye  and  Ear  Infirmary.  In  one  large  octavo  volume  of 
S2"-  i>atr«>,  with  'I'tl  ilhi^t  rat  ions  on  wotnl,  six  0)lored  platen,  and  selections  from  the  Teet- 
types  <<f  JiieKLT  nnd  Snellen,    (loth,  fo.lM):  leather,  t<«t.i.H>:  half  Riisaia,  ^.oO. 

The  preTM>nt  eillllon  appears  In  le-u  than  three  show-  the  fidelity  and  Ihoroughneiu  with  which 
years  since  ilie  piiliMcBitoD  of  the  la-t  Amerlc.tn  the  editor  hai  accomplNhed  his  part  of  the  work, 
edition,  aiiil  yet,  mim  t\\v  numenius  rfuenl  IntcH-  The  illtiatrationa  throughout  are  good.  Tbla  edl- 
tlfiati'm-'  thai  lia*e  tiexn  made  in  iIiIm  bnuich  uf  tloD  enn  be  recommended  to  all  as  a  complete 
niediciiie.  many  change:*  unil  ailditious  hare  tweu  treatUo  on  diiea-^!<  of  the  ejre,  than  which  proba- 
re^TiiroJ  lo  iiieci  the  (ireseut  -.-ope  I'f  knowledge  bty  none  better  exUta.—Jf*diaiJ  JIanfrd,Aug.l8,'S3. 
upon  thi-  ■•iil..jeci,    A  rritical  examlnatinn  at  oni« 

NETTLESHIP,  Ei>WAIib,~E.  B.  C.  S., 

Opti'liiihitie  Sirf.  ant  Lert.  on  Ophth.  Stiry.  at  St.  Thomat'  ifuipitaJ,  Londioa. 

The  Student's  Guide  to  Diseases  of  the  Eye.  Set-ond  eiiition.  Withacha^p- 
ter  on  ihf  I)ele('tii>n  fi  1  (ilor-niindnefti.  hy  William  TiiuUi^n,  .M.  D.,  Uphthalmulugist 
to  the  .IcAcrson  Mvdii-ul  College.  In  one  royal  I2mo.  volume  of  416  pagea,  with  138 
illiifllratioii-i.    Cloth,  f-*.W. 

Thin  Rdmlratile  guide  bid*  fair  to  become  the    and  well  chosen.    This  book, wlthlntheiihorteom- 
faroriti'  (•■ii-l>->k  •.inophihalmlosdrgerv  with  siu-     pass  of  about  400  pages,  conialna  a  lucid  axpoaltlon 
dent"  and  iceueral  pra<-titlonera.   It  bears  through-    of  the  modem  BApfCt  of  ophthalmle  aelenea.— 
out  the  Imprint  of  ixiund  Judgment  aimlilued  nltli     XtJitat  Rtct/rd,  June  23, 1883. 
Tasl  experience.    The  llfu"lrati<m«  are  numerous 

BROWXE,  EDGAR  A., 

.s'linjwm  (o  Ikt  tiV'TptfJ  Evf  nnd  Ear  Infirmary  ami  tn  tht  t>i*ptn»ary  for  Skin  DIamtu, 
How  to  Use  the  Ophthalmoscope.     Beini;  Eleroentarv  Instructions  in  Oph- 
thalniotKiipT.  arruntced  for  the  iiiw  of  Stiidenta.    In  one  nnall  rojal  12ma  volume  of  118 
IMgeo,  with  :{.'■  illiislrationa.    Uoth,  $1.00. 

I.AW>:i>N  <i\  I.NJl-RtF^l  Tn  THE  BYt:.tlKBIT        tlitonera.    Second  edition.    Id  om  oetave  vol- 
AM>  1^:VKI.I1M.   I'heir  Imniudiaie  and  Uen.ulu  ,      iime  of  .-.';  pagea,  with  AS  llluat.    Cloth,  ttTft. 

Effe.(-,    *  r...,  Vt  pp..  .-.•  ill,,..    CI.,,!,.  SI.'-.  CARTER't*  PRArriCAI,  TBEATIBB  0l»  DISBAS- 

LArHE.V'E   4Mi   >iniiN.t   HAM'Y   JMH>K   '>K         E--*  i>F  TIIE  EYE.    Edited  by  J«a»  OaMW,M.l». 
OPHTHALMIC  ^UlUiKRY.  fi.r  (i.a  uow  ol  l'ra>'-         \u  one  ban&wtcaa  oc^fo ^iJra^^iM. 


24        LiA  Baotbbiu  &  Co.'s  Pi'bucations— Otot.  Urin.  Dl«.,  Dent. 


1 


BVRlfBTT,  CMARLES  H„  A,  M^  Jtf.  V„ 

The  Bar.  It*  Anatomy,  Physiology  and  Disdasea.  A  Piwiinl  Trmm 
lot  th«  uM  of  Medical  Siuiieiit"  nuii  rraoiUinuerA.  N«w  (tccoud)  Mlition.  Iikiim  humlcaw 
ocMvo volnme of  6S0  pafw,  with  107  illuelratioru.  Clolh,$4.00;  leather,  $5.00.  J^Mfrnt^ 

oarrlvd  out,  aad  marti  nvr  mtMmt  iiddaA  Dl 
Batncn'a  work  murt  i-e  nvard^l  mo  m  rMf  wlQ* 
bit  ouirlbutloB  to  AnntT  ■iirgmr.  *t°*  n^^*  ■■ 
kocoijntor  lU  camiiTfbt-uitTviirM.  bul  WcMHftll 
ooatAiur  UiAMsnltaoT  itic  c«f  «ful  F«noa»l  <Ami«» 
Uan  knd  «xp«rl«iiM  of  tlib  «ni  tnaat  lumJ  •urfMC 


We  note  wlU)  ptauon  lh«  ■ppMnaMofm  eoconil 
«<lltlon  of  Ihtii  laliudilfl  «wrk.  Wlwo  it  flnt  cwue 
out  It  WW  uovpwd  br  Uw  proPMHoD  u  ona  of 


(It*  fiandu-il  wotIcm  da  modern  mani  Nurgetrin 
tb«  EatlUb  UuRiuuKi  ud  tii  tils  MXKind  rdllloa 
Dr.  Burnitt  h>s  (utly  maliitkliiMt  lila  repat«tlan, 


.  bt  ttie  book  Ic  r«plM«  witk  TAloftblo  infonsMlon 
«nd  Kintaatlaii*.    Th«  rerblon  tin*  bnan  carafuUy 


POLITZER,  ADAM,  1 

}mp€riai-}ioffal  Prof,  of  AumI  Tirrap,  In  (Ao  Vmi:  ^  llniul. 

A  Text^Book  of  tho  Ear  and  it<  Diseases.  Tmiwlflied,  at  the  Authw^  » 
qiwal,  bar  Jahk  Pattebwh  Casselus  M.  D.,  M.  R.  C  S.  In  ope  tuuidsome  ocuvn  tod- 
umeof  000  pa««^  with  '267  original  Illustmti'tnif.     CIntb.  %hM. 

Tha  wnrtc  lunlf  <ro  do  not  )wMlt»i«  to  prooMiDO*  i  iMcilaii,  mud  ihfi  iig>iD  bjr  th«  pvUioliaKiekl  ptmf 
tIi«tMuitu|xinlhDBUb|Mi<3rMiT«I  Uin^MM  wMoli  olaKy,«tiu-nu|c«tn«i)l<'ttlehMrv«»lok«toiipVM 
hu  avar  appovwl,  nf  noniiitia  u-lthoui  batng  um  |  Incarad  iif  th*  Btudeat  bjr  ■kotrlna;  th*  <lu«al» 
dliiuM  An  etiMileto  «Dbi«ciit,  anil  emlo«nt|r  pnic-  pllMti<>n  or  wh*t  b»e  proo<d«d  M  tM  Hii4t  of  w 
llMl  In  arnrvwDM.  TIm  aiatuatnlosl  d«rafipiloiiii  •»«•.  Th»  »rlK>l»  »ork  p»n  b«  rwconiiMomxl  •>  * 
of  WKl)  Mp>nrt«  dlrinttia  of  the  ear  itre  admirBblis  nluhli'  sti{d«  to  tti«  pt>1il«nl.  Mid  Mt  •AetoBt  *94 
and  p««AimIt  tllu(tra(4(t  b^  uroodoui*.  Tbvyu*'  toth*  pnwiltlooor  ia  lite  tre«uaeat^— SMCn  Jfi* 
foUov«d   lrom<H)U(el7  by  Ihp  plij^'oiog/  of  tbe  .  ipst  tn^  ^ibrjitdlJ'OMfWf,  Jllli«  T,  '  — 


i 


ROBERTS.  WILLIAM,  M.  JD„ 

A  Practical  Trontlso  on  Urinary  and  Ranal  Dtfleaaes,  Inoluding'^ 
nary  Dopoaita,     Fuitrtli  AuK-riuui  fr"iu  ihe  r<.>urtli   London  ediUoa.     In  onm 
lome  ocbiro  volume  of  abotit  i>50  |Mg«e,  with  SI  llluvtmian^    Cloib,  $3.50.    Jwt 

ChROSSf  S.  JD.,  JV.  7>.,  LL.  D.,  ».  C.  X..  e/^r. 

A  Pi-aotical  Treatine  on  the  Diseases,  Ipjurioa  and   UaLformatioiu 
of  the  Urinary  Bladder,  tbe  Prostate  Oland  and  tho   Urethrtt.    'I1ni'~ 
Mitir.n,  iln.rciiighly  reris^d  liy  !^A«n:i,  \\'.  tina'K,  M.  D.,  Prafcawr  of  ibe  IVtociitltti 
Surgery  and  of  CUoiL-aJ  Surgerv  in  the  jFiierw>»  Medical  Coll*^  Philadelpluo,      In  ai 
ocuvo  rolume  of  674  padres,  wub  170  illiuurHiloi^    Cloth,  ¥4.50. 

MORRIS,  SEXRr,  M.  B„  J*.  R.  C\  S.,  '  ^ 

Surgtoal  Diseases  of  the  Kidney.    Tnoov I2iiu>. Tolum*.    J^tfHwhtf.   Sm 

Saia  q/  CUnifal  ilamials,  pagu  3. 

LUCAS,  CZRMByrTMrB.,' B,  8,f  F.  R.  C,  «.,  M 

Srniior  At^titnt  Swr^mn  to  Oufft  SoipUai,  London.  ^B 

ptoeasefl  of  tho  Urethra.     In  one  ISmo.  TOlanu.     Prtparittff.     See  Sen* 

THOMPSOy,  SIR  ^EyRT,  fl 

Surgeon  aitd  Pinfauor  of  CUnifiU  Buryery  to  Vnir^tilg  OtOtft  HnupUal,  £oi»Axi. 

IieoturOB  on  Diseases  of  tbe  UriDary  Organs.    SmmxI  American  treax  tht 
third  English  vdition.     In  on»  H-vn.  volume  or  200  p|i^  with  S5  illntlrxtiona.     Cloth,  fS^ 

By  the  Same  Author. 
On  tho  Pathology  and  Treatment  of  Stricture  of  the  Uretlira  and 
Urinary   PistTllfle.     Pn*ii   the  third   Kii;;liHlt  edition.     In   <n»  <iciai-o  vuliuue  of  369 
I>uffv6,  mill  47  cuu  kikI  3  phites.    Cloth,  $3^.  " 

COLEMAy,  A,,  L.  R.  C.  P.,  K  R,  C.  S„  BxatH,  i.  I>. 

Senior  Omt.  Surg.  0114  leri.  on  Otnt.  HUrg, at  BL  Bnrthalommi^$  /fotp.  OhI  IA*  Amf.  Botj; 

A.  Manual  of  Dental  Surgery  and  Pathology.    TlKwotythl?   re*b«U 
adapted  to  the  uoc  of  Aiun-ioan  SiudcinU.  by  Thomas  C.  !:trBlJ.WAokN,  M.  A.,  \t  U, 
D.  f>.  S.,  Vto(.  of  FhyHiology  at  the  Pbilodelphui  Dental  College.    In  otie  haii<hiuiu«  octavo 
Toltum  of  iI2  lagos  with  S31  illuatratinoo.    Cloth,  $3.25. 

Thit  ToUuno  d«*«rt»a  lo  rank  amoug  lb«  ninl 

tmiMrtHit  atfnovnt  eoDtrlbatJmato  danial  Iltora-  ,..__, 

tur*.    Hi.  Colaiaav  haa  pr«*Mui«d  hi*  moUtodi  of  I  d«BTOi«d  lotoac&loattionaU  UultetiMaafinad 
practice,  IM  tli»  moil  part,  Is  a  plain  and  eonelM  .  bjr  bt>«ini«b*eTV«tk>(ia)»>l*ip«fla«««.    TbatMok 


of  praatlo*  Ibr  Iba  loilroetigB  of^lfaoM  aojnnnc- 
Inc  a  rrolMalonal  earwr,  and  b*  baa  Minnlqr  aa> 


luaanar,  wd  Um  MArit  nf  lb*  iKMrl'-ao  edrior  hu    daaarvM  a  plai-c  In  ih*  tOmiTOI  »ntf  dtalM. 
baea  G«DaokBtlau«lrparlana*d.  He  haaerldontlj 
{■tMfdtoynaatint  hb  mDTtcUoatoftha  bwi  inodaa 


BiSHAU    ON   flEKU.  DUCIAVftv  h  QUaioal   I  one  Umo.  toL  Of  KH  pac«^  with  Zl  UliuiniMu 
Guide  to  tbe\t  tiUgaMte  aiu^  TtmUkmUi.  \'a  \  ^i^^.mm 


LiA  Bbotbxbs  &  Co.'b  PoBLtCATiovB — Venereid,  Impotence. 


2S 


BWMSTEAI>,  F.  J., 

Jtf".  !>.,  Xi.  J>.f 

LaU  ProUMor  of  Vtntrtal  DiMntm 
at  Ih4  (JMtg*  of  Phynttatu  eutd 
Surgtont,  A*»o  Tort,  etc. 


and  TATLOR,  R.  W., 

Surytim  to  Charity  HotpitttL,  ir«w  Tork,  lYof.  oj 
VtnvtA  and  SIdn  Dimatm  <a  U«  (MMniiy  ^ 
VtemunI,  Prt*.  q/"  tJu  Am.  Dtrmatotagical  AtM'n. 


The  PatholoKjr  and  Treatment  of  Venereal  Diaeases.  Includiiw  the 
rasnlu  of  recent  iavestigationB  upon  the  tnibject.  Fifth  edition,  revised  uid  iKrgdr  re- 
written, by  Dr.  Taylor.  Id  one  \&Tfe  and  huidaome  octaro  volume  of  698  niges  with 
139  illuMmtions,  and  thirteen  chromo-litliographic  figures.  Cloth,  (4.76 ;  leather,  $5.75 ; 
Tery  handsome  hntf  Russia,  (6.25. 

It  la  *  nilanilid  record  of  honest  labor,  wld«       The  character  of  ihli  atandard  work  Is  ao  well 
r— larch,  /tut  coroparlaoo,  careful  KniUny  and    known  that  it  would  be  mperfluoa*  here  to  paM  In 
Orlfinal  axperlenoe,  which  will  always  be  held  as    rerlew  Its  general  or  special  paints  of  exeeilenoA. 
ah^hcredit  to  American  medical  literature.  This  ...... 

la  not  only  the  best  work  in  the  English  language 
noon  the  subjects  of  which  It  treats,  but  alsu  one 
wnloh  has  no  equal  In  other  tongues  for  its  clear, 
eomprehenslre  and  practical  handling  of  Its 
themes.— i4fa«ncan  Joumai  of  the  XtdicalSeimctt, 
Jan.  ISM. 

It  Is  certatoiy  the  best  single  treatise  on  *«□•- 
fsal  in  our  own^aod  probablj  the  best  In  any  Ian- 


rat 


.—Botton  Mtdital  aad  Sia-gic^  Journal,  April 


The  verdict  of  the  prolisaslon  baa  been  pa  wad;  It 
has  been  accepted  aa  the  most  thorough  and  com- 
plete exposition  of  the  pathology  and  treatment  of 
renereal  diseases  in  the  language.  Admlrablsaaa 
model  of  clear  description,  aa  exponent  of  eoand 
pathological  doctrine,  and  a  guide  for  ratlona)  and 
snooess1\il  treattnent,  Itlsaaoraamenttothe medi- 
cal literature  of  this  countir.  The  addlUons  made 
to  the  present  edition  are  eminently  Judldooa, 
from  the  standpoint  of  u«ctlcal  atlllW.  JoMiiai  qf 
OtfoMota  and  vttfrtaluittatM,  Jan.  ink. 


BUTCHINSOy,  JONATHAJS^,  F.  R.  S,,  JF.  R,  C,  8., 

Cbntoltta^  Stirgom  to  tin  London  Botpital. 
Syphilis,    la  one  12nio.  Toliune.   Prepnring.   See  Seria  o/0inie<d  if<mual»,T?»gaZ. 


CORNZL,  r., 

Profator  la  th»  Faadty  of  Jtadieina  of  Parit,  end  F^ytirUm  to  tht  Lourtitu  HotpUoL 

Svphllis,  its  Morbid  Anatomy.  Diagnoaia  and  Treatment.  Spedallj 
revised  oj  the  Author,  and  translated  with  notes  and  additions  by  J.  Hiai&Y  C.  Sims. 
M.  D.,  DemonMrator  of  Pathologioil  Histology  in  the  University  of  Pennsylvania,  and 
J.  Wii.i.!A>[  White,  M.  D.,  Lecturer  on  Venereal  Diseases  and  Demonstrator  of  SurgeiT 
in  the  University  of  Pennsylvania.  In  one  hamtsome  octavo  volume  of  461  pages,  with 
84  very  beautiful  illustnitions.     Cloth,  $3.75. 

The  anatomical  and  htstologlralcharaclenof  the  '  the  whole  volume  Is  the  clinical  experience  of  the 
bard  and  soft  »ore  ere  admlrahly  deM?'rlbed.  The  author  or  the  wide  acquaintance  of  the  trustaloi* 
naltlform  cutaneous  maul  fen  Utlonv  of  the  dixea^  with  meillcal  literature  more  evident  The  anal- 
are  deelt  vttb  hlito logically  In  a  masterly  way,  as  omy,  the  histology,  the  pathology  and  the  cHnleal 
wa  should  Indeed  expeoi  (hem  to  be  and  the  fretun-sof  nyphllTsarereprveented  in  this  work  In 
iceompaoylngilluBtratlons  are  eieciileil  carefully  their  be»%  most  practk'a]  and  meet  Inetnactite 
and  well.  The  Tarioua  nerroii*'  tesloos  which  are  fomi,  and  no  one  will  rise  from  ita  perusal  without 
the  reoognlted  outcome  of  [ho  Kvphllitlo  dyscraKla  the  feeling  that  his  grasp  of  the  wide  and  lmpor> 
are  treated  with  care  aiid  ctin^iderattuD.  SyphlUtlo  tant  iiubject  on  which  It  treat*  is  a  etroDger  and 
•pllepey,  paralyls,  cerebral  syphilU  and  locomotor  surer  one. —  TV  London  Prattitiotter,  Jan.  18SS. 
alaxlaaresubjectefullof  inierest:  and  nowhere  in 

GROSS,  SAMVEL  W.,  A.  M.,  M.  D., 

Proftitor  of  Ik*  PrintipU*  of  Surgtry  and  of  Ciinieat  Stirgrry  in  tha  J^rrton  Mtdieat  CoUag*. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disorders 
of  the  Male  Soxual  Organs.  SciMnd  e^Ution,  thoroughly  revised.  In  one  very  hand- 
some octavo  vohinie  of  ins  i»ge^  with  IB  illuHtniti<.>na.     Clo'th,  $1.50. 

The  author  of  this  monograph  Is  a  man  of  po^i-  This  work  will  derive  value  from  the  high  stand- 
tlve  iMiniclionK  aiiU  vlgoriiiMslyle.  Thin  Is  lustl-  Ing  •••I  its  author,  aside  from  the  fact  of  li«  c«Ming 
fleil  liv  liU  exi>er<enc<>  end  l<y  lil>»tudy,  whicli  has    iii>  rai>i<l!y  into  lis  !>eeond  edition.    Thlii  i^lndee<I, 

roe  nand  in  Hand  with  bis  experience.  In  regard    a  book  that  every  physician  will  be  glad  to  place 
the  varioii*  orimnlc  and  hincllonal  dliwrder*  of    In  hi>.  lihrar;'  to  he  read  with  profli  lo  himself 
the  nialr  jjenerative  apparatus,  he  hns  heil    ex-    and  with  Ineali^ulable  benefit  lo  his  milent.    Be- 


eeptlonal  opuirtunlile*  Tor  iilMeri  ailnn,  and  his 
book  Hlii.ws  tnat  he  has  not  neglected  (u  mmnre 
his  own  vtewi-  with  ihoee  of  oihiT  suthori.  The 
reeult  i>  a  work  ahieh  enn  lie  saXely  n'ennmieuded 
to  both  physloiant  and  siirKeom  aH  a  Ki'ide  In  the 
treatmi^nt  of  the  dl»(urbauces  il  refers  to.  It  i.< 
the  best  treatise  on  the  sublect  with  urltleh  wa  are 
acquainted.— TAs  Jtflieai  Sttra,  Sept.  I,  IMjS. 


sides  the  Mibjects  embraced  In  the  title,  which) 
treated  of  in  (heir  varlnos  forms  and  degrees, 
■permstorrhcea  and  pntslatorrhoa  are  also  fully 
mnsldered.  The  work  l><  thoroURhly  prartlcal  la 
eharaeler,  and  will  be  esHclalty  uaeAil  to  the 
Kem-ral  praeliKoaer.- Jfttfirai  Kaeonl,  Aug.  IS, 
1883. 


CULLERIER,  A.,  &  BUMSTEAJD,  F.  J.,  M.D.,  LL.I>., 

Airjreon  to  Ih*  HipHal  du  J/idi.  Lata  Prnftmtrir  '-f  Vtntrtal  Oiatntia  tn  tha  OjlUgt  nf  Phyaieiant 

lud  Surftona,  Xtte  York. 

An  Atlas  of  Venereal  Diseases.  TranKluteil  and  edited  by  Fbxem a»  J.  BVK- 
STXAD,  M.  D.  In  one  imperial  4to.  vilume  of  Z'2&  pag^  douMe-columns,  with  26  plates, 
ooDtaining  almtit  TV)  figures,  l>eautifullr  colored,  many  of  them  the  size  of  life.  Strongly 
bound  in  cluth,$17.0(),    A  qiecinien  of  tlieplatcu  and  text  sent  hy  mail,  on  receipt  of  26  ct*. 

HILLONSTPHIMS  AND  LOCAL  CO.VTARlOfS    FOBMR    OF    LOTAL    DISEASE    AFTECTISO 

DlSORDEBa.  Inon»Bvovol.uf«73p.  Cloth.P.a.    PRINCIPALLY    THE    ORT.AHS    OF    GENERA- 

LSrS  LECTURES  ON  STPniLlS  AN*D  SUME   Tin:<.    Vuo&e  t.'<o.to\.  at  Vfc '«•«».   C«ji^^(LXk 


S6 


Lu.  Bhoticebs  &  Co.'b  PuBuoATiONe— J>lsea8at  «f  ttkin. 


2n7>JS',  J.  yTsrrys,  x  jit.,  jt.  j>., 

I'rtiftfor  tf  0dm«rolo^  qkI  f«H«r«aI  DIttmn  >n  KutA  Jl«l»nl  CWlcpe,  Ckutgo. 

A  Practical  Treatise  on  Siseaaaa  of  the  Skin.    For  Ui«  om  of  StudMti 
PrM-iilinnvn.     In  iMie  Iuu)d»me  octavo  volunM  (/f  oTO  pn^cB,  iritfa  M  bcaotifUl  athl 
ornt*!  ill'iFimtloiiH.    Clolh,  ^4.2-^ ;  lealher,  ?5.-26. 

Th«  snthar  hu  Klvea  Um  ■tudent  and  practt-    vlaa  in  wilv*  pnMlM.    In  dMttlDg  vtUi  lhm» 
UoiM-r  t,  work  aitnilrabl/  Kdaptod  to  the  irkiitK  of    ^nf-ttfoKi'  Ui«  MitlMir  )«>*«■  noliilDf 
oMli.    We  CAD  hMrtlly  contmeod  tbo  tiook  w  a  ,  Miiiivd  kim<rlo«lK«  of  tb»  ivadvr,  tnu 


Vk)>ut>'n  aiMltlon  m  our  lltoTMuTn  and  «  rellalils 
gnld«lA*tiMlcn(aBadpraolHloiiarf'ln  tlictrnudJM 
and  |inuiil«M.— j4a.  Jovm.  a/  Jf<iL  &-i-,  July,  lUS, 

EBpooially  10  ha  pralMd  ara  Iti*  praotlul  (ug- 
ipwtlrina  an  to  wliBl  nuqr  ba  onll«d  the  commoD- 
MBM>  tr«atmpnl  irf acMKiK  It  1»  (|"lt«  ImpC'ii'ilMc 
to  BXaKEoralo  Uiv  JudivlouiCPi''  uith  Hliirh  tht? 
Itmauut  for  Ihn  ext«rival  trvatmam  nt  eruaitt  tirr 
aaloetod,  mud  what  i>  nf  pqiul  Iitiportani^r.  iliv  Mi 
UdclMT  Itl'lnirllona  for  lliclril»«. — twl-^n  Mtdi- 
*al  JSmman-l  troi<r.-<  Jul/  2g,  nta. 


uaghtj  tnlo  Ibr  nioil  nlluiit«  deaicript 
ons  li  n.iit  nnlT  lold  irtlil  ■hottld  b«  ' 
1-  '-■((<  lilt  it  k« 

t  .-0  "»  privrticiJ  .  _ 

T    .L.  .  -   I'--,  a  rIaiicT  a)  tli«  tiidu.  I 

wiLl  ,hi>i:,— Jfjrvta^d  M-lical  Joi-rno',  Jiily  T,  IBW. 

I'tcrfc'^'f  HyJe  li&a  Innn  b<7*iti  kninati  k>  "B*  of 

tjT«>< 

coutri' 
hata 


•I  Tiawi  anil  utnt'ir,  Jiii/  n  mn.  nata  jlk.li  ..     i 

Tta  work  of  [*r,  llyda  itlil  be  awarded  t.  htsti    e«refa1,  <kmu«Iwii1«u«  aB>l  oiuIukI  oL*«rr< 


pofltloa.  T1>«  RlndpDt  (>r  crnvdlcSiiP  wilt  flud  H 
paeullailr  adapted  to  hi»  vaata.  ?<oi«ltlifUDdlDK 
tlia  a:iU>tit  nt  wf  iKiti]4oe  to  vliji^h  It  In  r!«T(i|vd, 
yai  It  la  lluilloil  to  a  iitaKle  and  ooi  v<>rr  lor^ a  rol- 
nni*.«llhniil  omitting  a  [irnjict-  dlwuMii'ti  ')f  tha 
toDlEW.     Tlie  «anci»eii«M  of  the  niiunic.  and  the 

■■Mlnfi  tatth  of  tiXtif  whal  Ciui  !■#  lolil  ii*  Tallin  vlll 


nrnarkalilo  adraoo**  nuMla  In  our  fcu 
dUea»«9  of  the  akin,  «*p«el*lly  from 
[.iriiit    .if    nalFinloiclral    li(»l"li,p5y    ma<] 
owtJiyd"  or  iTcatinvat.  ti *(*.■•» iiat«  a  re 

Ih*  .Milor  tPXl-tHk'V**)  •hurl  till 
brluK  Ihfva  up  lo  lh>-  -landjj^'i 
maivri  at  arl*np«i.    1l<i«  la-i 


aiRO  mtkt  It  acc«pt«Ua  togetiorai  practlik>n<'ni.    Ilyda  I*  an  «if«f1  In  tbU  dL- 


Th*  aim  of  the  withor  tuM  been  to  preMnttoht* 
Toadam  a  work  not  only  axpniiodliiK  tli"  nia*l 
m«dvrD  «iDo*pltima  of  Hit  tublact.  bat  pronentliiK 

what  laafMandatiliallJ*.     Ilnliaa  roar*  aapK^taJly 

deT«i«d  Ha  f*Kif»  to  lh«  trektutaat  nt  diMwe.  and 
b)-  hf>  dalailsd  daaeriptton*  of  thDTapoutlf!  iBaa» 
xat^  hH  adapted  tham  (« iho  &««(]*  of  the  phy^ 


(•hipMd,  a*  ha  Intbrmii  dh.  Ih*  itvA  uf  (m  i.n... 
In  a  <!Ondena«d  fona  Um  rc*ulta  o(  ibe  laleat  < 
■vrraUan  and  opariauoa.  A  f-an>ftil  asafnlaadaaJl 
Df  the  work  conHnce-  u*  MitX  he  hu  aeecmplMiari 
hi*  uwk  wliti  pain>Uikinji  fldalitjr  and  wUb  a  na^ 
lUbie  rwolt,— ^*i>™al  ef  CWaiWMM  anrf 
OiMaMsJuatMl. 


n^Ui'tn  far  AiauM'a  of  (Ai  fitm  (o  Mr 


An  Epitome  of  Skin  Diseases.    With  FormxUie.    For  Stiidenu  uul 
tilionen.    Third  edition,  r«Ttsed  and  uilnrget).    Id  one  very  hsadeonie  12bio. 
of  238  jngea.     Cloth,  |].2a 

The  Ihtrd  edlttoa  of  thU  conveitlcnt  1uiBd)v>ok 
eall*  ft>r  iuill«onwliic  ti> Ilia rwrtiiiaii  and  ('Xiwndiiii 
wh>p!i  ii  'i»*  unHatitOtW.  Th'?aniKiir'"i'Mitor»U!B 
dl"'  ■  it>nil«»lixdi  i:' iTH'thi-il 

of  •'  '    itd'>i>t«d  lu  I  "'uonivK  a 

Sl'^JI  ,      t^   Ui   the    Ntlj   I'  >■  Imok    |a 

D«  wUlPlt  «*  «aa  ttftOKly  HH.-Piiiiupud,  ri'.t  oulw 
loatadantafaut  alaa  topnnllllLidvi-  ulu)  rviulrii  ■ 
•ompaBdlouf  iummarv  of  iht>  prvvfiit  miiIv  lI 
darmaUiloay.— A^lM^  AfnUra^  J<MiFndr.  .Tiilv  L>,  litsi 
We  rnrdlalli'  raoiinimaiid  Fwi".  A>.i/,,.iv,  lu  iLobc 
whom   lime   la  HmltMl  and  whu  wl>h    a    liaiKly 

MORRIS,  MALCOLM,  m7d7, 

/.Ml  return  <A  rmnmaiolcav  «(  -Si.  .Vaiy^  HowplM  JfadUal  Abol.  £<«A7a. 
Skin  Diseases ;  Indadinc  tbvir  rhetliiiii»t».  SrmptoiiK.  Ifin^daiii,  Prognosiai 
bid  AiuUomT  aisd  Treatutenl.    A  Mnniul  for  Htmlviita  nod  rnictiiicaera.     Id  ww  ISSba' 
mtnme  of  310  jiu^es,  wiili  UluBtratioiw.    Cl'>lli,  $1.70. 

To  phv»l(-lariii«)iowuii]il1lkaloka<»«MnethhiK  t»r  oimifnaaa  of  asfvaaatoa  ai: 

abwii  iklu  diaeMva.  ND  tliat  when  a  fiatUiot  pr<v  laiigntnanllab^iaradafited  ki  i 

aanta  lilnnMlf  far  r«IUtf  th»y  >«n  loaka  n  tvirrael  poiic-iriiikta  of  dtrouMan^— •  t 

diMttoala  and  p(«acrib«  a  nuioiuJ  treaim^ni,  wa  dlSlr  nit  and  pamlazltig  t<>ttM  br^uiiri-.- 

unliaattatltvty  ranimmaDil  (hi*  lliil*  )>-iii  or  I>r.  Cbunrr  of  U*dkm»,  Ajail.  IMW>, 


mantial  to  Ila  upon  tka  table  ftirtBrff««ur»L.. 
lt*ali>hati«tJcml  arntnK«Bi«Bt  braltad  to  lid* 

fof  all  one  liv  to  fcBr,«  i.  ih-  n»mc  «r  m. 
BiiH  lier"  atr  [In  it 
treatniant  ai  iian.l 

tlim      Tti<'  t>li-*«DI 
rei-Ued  luid  a  ouiut^t    ■. 
i.iTilM'.|.  ii)ill»  n^iAt  «f    t' 
di-;nial  iliBmpeuiic*  find  'i 

l»ry  at  Uin  nnd  "(  the  boiik  !.•>• 
a»)iui«illvd.— 7^  JtfeJiMJ  .V*u  , 


MofTla.  The  a(Fa«tloa*  of  tlie  aktn  are  doeiilicd 
fn  M  larM,  ■□eld  inannsr,  and  thitlr  pfToral  otiaraiu 
lariMicn  ID  pialDly  »h  forth  thai  dia«ti09tii  will  he 
a«>y.  Th*  uaatracnt  Id  tuu^h  c*iw  fa  aiirli  aa  Ilia 
ttpattnM  of  Um  inoaietnlDeBl  danaatolMDi'ta  ad- 
Tbaa^-ChdNMttl  JIaifeal  .T>ki,  Apvll,  UM. 

Thia  la  atnphallGally  a  iMrnaKa  boaki  far  w* 
ran  aafely  aa>',  thai  In  Iha  whola  nuigB  of  mtdleal 
ltt»nUitT*  lh*r*  h  ivo  hnek  of  a  Ilka  >anp*  whlnli 


Tbuaiita«lkaiio«ttaliityKlt*ii  tnainuJteoiDt 

*  larce  anxxiiii  of  areii-ri>n>rlled  *  nf*-ftriatlM j  awJ 
hi*  lliitahnok  oom|«ri-->  favitiilij  with  — yawat 
whieli  hai  amanalcd  from  Emtaiul,  whUatoe 

Clnia  he  haa  •maclpatvd  hihiHilf  ftrnmUivi 
mly  adh«rcd  U>  ttrf/r*  of  othera  if  hi*  om 

man.     There  la  eertaJnljreioelleiit  material  I  

book  which  vUl  well  re;;^^  p#ru«L— ihataa  JM 
mil  Swnr  7aurv  March,  IMD. 


tba-a^H 

oMiaO^H 
laliBO^ 


WILSOX,  KRASJfVS,  F.R.8. 

Tho  student's  Book  of  Cut&noous  Modiclne  and  Diseases  of  the 

Tn  imt>  luuuUiTite  nmjtll  cu-tnrn  vuluiiitt  uf  53-'i  i>aK««.     Cloth,  (SjM. 

HILLSKR,  THOMAS,  M,  V., 

Handbook  of  Skin  Diseases;  fur  Studeitu  nnl  Pnrtiiioatmt.    &mk«kI  AiNri* 
can  ediliuQ.    \n  on«  \1.ui".  tuVwut^  t.i  'i'i5  vinr™,  with  pbkiei^    Clr-ili.  $2,2rSu 


LiA  Bbothirs  k  Co. '8  Pvblicationb — Dls.  of  Women.  27 


.AX  AMEBICAy^  SYSTEM  OF  OTA'^COZOGT, 

A  System  of  O-ynaBcoloCT,  in  Treatises  by  Various  Authors.  Edited 
by  MATTnEw  I),  Mans,  M.  I>.,  Pmfeswtr  of  Obstclrini  and  (Jj-nsecologr  in  the  I'ni- 
Teisity  of  BiifTalo,  \,  Y.  In  two  handsome  octavo  ToUioieB,  richly  illustrated.  In  aetiv* 
prrparation. 

LIST  OP  CONTRIBUTORS. 
FORDYCE  BARKER,  M.  D.,  CHARLES  CARROLL  LEE,  M.  D., 

ROBERT  BATTET,  M.  ».,  WILLIAM  T.  U'SK,  M.  D., 

SAMUEL  r.  Bl'SET,  M.  D..  MATTHEW  D.  HANN,  M.  D., 

HENRV  F.  CAMPBELIj,  M.  D.,  ROBERT  B.  MAITRT,  M.  D., 

BENJAMIN  F.  PAWSON.  M.  P..  C.  D.  PALMER.  M.  D., 

WILLIAM  GOODELL.  M.  U.,  WILLIAM  M.  POLK.  M.  D.. 

HENRY  F.  GARRir.UES.  M.  D..  THAPDErs  A.  REAUT,  M.  D.. 

SAMrEL  W.  GROSS,  M.  P.,  A.  I'.  ROCKWELL,  M.  D., 

JA.ME3  B.  HU.NTER,  M.  D.,  ALBERT  U.  SMITH,  M.  D., 

WILLIAM  T.  HOWARD.  M.  I>,,  R.  STAN8BVRY  Sl'TTON,  A.  M^  H.  D.. 

A.  REEVES  JACKSOX,  M.  D.,  T.  GAILLARD  THOMAS,  M.  D., 

EDWARD  W.  JENK5.  M.  D.,  CHARLES  8.  WARD,  M.  D., 

WILLIAM  H.  WELCH,  M.  D. 

THOMAS,  T,  GAILLABdVm,  D.,      ~~ 

Fruftuor  of  Diitatu  of  Wowttn  in  tht  CoUtgt  nf  Phiitifinnt  and  Surytont,  A'.  T. 

APractical  Treatise  on  the  Diseases  ofWomen.  Fifth editino, thoroughly 
rerised  and  rewritten.  In  oae  lur^e  and  handsome  octavo  volume  of  SIO  ptwefl,  with  266 
illustrntions.     Clnth.^j.OO;  leather,  $t>.00 ;  very  hand«)ine half  Hiwiia,  nufle<rbandti,f6.50. 

The  wordA  whinh  rollow  "fifth  «illtlnn"  uc  In  *iouH  oat.    An  a  book  nf  referuace  for  th#  bu«jr 

thli  ewe  no  mere  rorniiU  ttnninnoemeDt.    The  pnciitloner  it  In  uDeqnalled.— BMton  Jfattiml  any 

•IterWionsanrlndililtoDBwIiiph  hsrc  been  mad*  are  Surgkni  Jiurrmt,  April  7. 188a 

both   numenmi  And   imj>orti»nL      The   ntiracllon  It  ha..*  been  enWK''d  and  careftillr  rerlMd.   It  U 

and  the  petmnneni  phurncter  of  this  hook  lie  In  «coD(1eii."ed  eno>-eTop<edtaof  pTiwpoIoglp*!  medl- 

the  oleune^r  Hnd  truth  of  the  rlinip&l  de*criptloni<  r[ne.      The  Myle  of  amnftempiit,  the  maelerij 

of  dloeKHei:  the  firtllity  of  the  Kiithur  in  thera-  miuiner  in  whtrh  e*ch  pnhjei-t  if  treated,  and  the 

Siutlc  rPMtiircen  uid  tlip  fiilnei<!i  with  which  the  honcot    fonvlctlonH   derived    from    pmhablj  tha 

etaJIe  of  trpalim-nt  are  dei"-Htvd:  Iho  definite  largei-l  clinical  eiperieooe  in  thai  apeelaltj  nfan^ 

character  of  Ihe  li'ai'hiiii;:  and  la^l,  t)ii(  not  leaiit,  in  thin  cuuntrv,  all  vervp  to  commend  It  la  Iha 

tha  evident  i-anJor  wlik-li  itrrailcB  It.    We  would  hiDhesI  term*  to  the  practltlooer.— AotAtilt*  Jum'. 

alao  partlculariie  (he  niliieM  with  whleh  the  hii^  of  Jfnl.  an^SUr?.,  Jan.  1881. 

torj  of  the  »uh|e.t  U  g..iie  Into,  which  make*  thf  That  the  prerloUB  edltton*  of  the  treallw  of  Dr. 

booTc  aiiditloimlly  intfre-.ilnK  and  elver.  It  value  at>  Thomas  Here  thouaht  worthy  of  tmni-lailoa  Into 

a  work  of  reffren.-c,~£'i».l„T   MolUnl   Ttma  niul  c-iumn.  Fr,-ii.-h.  llalian  an.f  Ppantsh,  1^  enough 

Oiii4tlf,  July  -Jii,  Mix\.  tonive  t(  th«  ^tamp  of  epnutne  merit.    Ac  hotne  It 

The  determination  of  the  author  to  keep  hli>  han  made  its  way  into  the  lihrnry  of  every  obrtet- 

book  forenioRt  In  the  rank  of  worku  ■•n  (t>-niecolo)ty  riclan  and  (t>'nnMV(|(iKl»t  m  tM^e  guide  to  practfc*. 

la  roott  imttifyins-     Rei'oiculEiiiK  the  fart  that  Ihi!!  No  Hniall  niimhiT  of  additions  have  been  made  to 

eaa  only  1*  aci-oinpllshed  by  ti-equent  and  Ihur-  the  piVHem  cdiii.in  to  make  It  correspond  to  n- 

nQKh  revision,  he  ban  •pared  no  pain*  lo  make  the  cent  Improvemenie  in  treatment. — J'ofijlr  Af«ltral 

preaeiit  edition  more  (fesirable  even  than  ihe  pre-  ami  Sumintl  Jnurnnt,  Jan.  1881. 

EDIS,  ARTHUR  W.,  Jf.  J*.,  to»rf.,  F.R.C.P.,  3I.R.C.S., 

A-i-.Al.  O'u'rtrir  l''.t,tifinn  In  MuiiUuti  II-^)iitnl,  htte  Phviimm  lo  Brililh  Lyiitg-ai  HiMpitaL 

The  Disoases  of  Women.  Including  their  Taih"l(^,  CawMti<in,  STmiit*.ima, 
Piagiiofifi  nntl  Treatment.  \  Mnminl  for  t>tiidenl«  and  I 'null  tinners.  In  one  fianilaome 
octavo  volume  of -"iTli  {uige^,  with  14X  illimtnitiiin^     (loth,  $;i.l.Kl;  leather,  J4.00, 

It   i"  a  f<|i'a~iiri'   (  '  read   a  )>o>>k  ^'>  <h'>r<>ii)Ehly  The  ^r>'aie!<i   |iainii  have  been  taken  with  tha 

gooil  a*  ttii«  •inc.     The -.jvecliil  .[tialltie^  which  ure  iieclinri"  relali'iK  to  treattnenl.     A  lil>era]  i<eIpctJoa 

eonK)'l"ii<>ii-    Are    (li<>t<>iiiitiiii'»    in    er.ventit;    ihe  ••!  reniedie*   I-  Kiven  for  each  m'.rhid  condition, 

whr-lr    KOiitid,  c1<  HMieii.i  of  ileicription  and  con-  the  ^treiicth,  ii.oilc  if  application  and  other  drtaila 

el^nVK'  of  Male  met  It.     .\nother  marked  feature  of  lieinji  fiilli  ex^-lnlned.     Tlie  dencrtptlou.!  of  ftynn- 

the    bi-'k  i^  the  allentiou    [lald  to  the    delail.i  uf  I'ok'Kli'al    niaiiii'iiialioiii'   and   i.ii>erati»n*  are  full, 

many  mlii'ir  siiiyical  "{"'raOonn  and  priH'edurc-,  eh-ar  an^l  | Tactical.    Much  care  hac  also  been  ba> 

aa,  for  ln"i»nce,  the  ii-«  "f  tentu,  applii'ation  of  -towed  .'n  the  (*»•  r.f  the  tvok  which  drat  with 

lee<-ht— .  and  nw  of  hoi  water  iiij-ctinii-.     These  di»i:ni-i — m-  ii^'te  e-|*cially  the  i^^a  dealing 

are  aiui'iiK   the  iiutc  cumnion   tiieili<Bl.>  of  treat-  uiiii  the  di:[creni:ati»n,  i-ae  from  another,  of  the 

meni,  and  vei  very  llltk'  Ih  >kIi1   iiI>>ui   them  in  ditT-Tent  kind-  of  at<dominal  tuniorK    Tlie  I'rac- 

manyof  the  iexi-U«ik-,    The  l-o.>k   I-  i>iie  in  he  titloiicr  will  thercf-ire  t)nd  in  thin  l«ok  the  kind 

warmly  reeoniineniled  ehpei-ially  lo  Miiileni*  and  i>f  kn^'wledec  he  nioft  needn  in  hin  daily  work,  and 

general  )intciiii"iier-.  »h<>  nei-d  a  cj-ni-iiu'l)iitc>>m-  he  a  ill  \k  pleam'd  with  tlie  clearneM  and  fLilnesa 

piete  r/jcim/  nf  the  «  hole  Rubject.    hpeehUliita,  !•».  of  the  inCirmatlon  there  given.— T"**  Praetitioitm', 

will  Hitd  many  uiwful  hlnia  in  It*  i>agef-. — ZtMtoii  Feb.  It^'i, 
litfl.  and  .^iirr;.  Juurn.,  March  'i,  ll<»2. 

BARXES,  ROBERT,  M,  D.,  F.  R.  C.  P., 

Olftrtrir  /'Aj/dciin  fu  St.  nirnuu'  lU-*p\>iil,  London,  lU. 

A  Clinical  Exposition  of  the  Medical  and  Surgical  Diseasea  of  Women. 

In  one  hnmlaume  i)i-(.ivo  vohiii)«,  with  niiiiti-niiiB  illiintniiinna.    New  editiun.    J^eparimg. 

WEST,  CHARLES,  M.  />. 

Lectures  on  the  Diseases  of  Women.  Thinl  American  fnim  the  third  Lon- 
don edition.     In  'mextavo  volume  ni  'tA'A  pairea.     t'loth,  (3.7^;  leather,  $4.75. 

CaUKCHlLL  t'.N    THE    I'lKRPEBAL   FKVKR     MKI'.f  «.»>"  THE  NATV^RILJi-Vr.Vft  kXM -^^tiCt. 
AMU  OTHER  DISEaBEH  PECULIAR  TO  W'l-       MKMT  0¥  VTHWAjV.^vTY'S.'^t'*.-  Vsi  »»*W». 
JfJCV'.     /oonexro.  ro/.  of  f^-lpagee.    Cloth,  K.Su.        vi>\>ui\e  uf  M^  vaV"-    C\aVti.\L,«.V 


38 


TfKA  BBOTaiR&  &  Co.'e  FvBUCATiOKs — Dis-  of  Wutueti,  ail(tvr(>-. 


SJOMET,  THOMAS  JJ>I>I8,  M.  J).,  X£.  !>., 

fluryafla  1«  f Ac  H'oman'f  BatpiC''lt  A'nr  IVA,  c/c 

Th»  Principlefl  and  Practico  of  OTiueoology ;  For  the  ngc  <4  Stndeau  i 
PnctiUoneraof  Mwlkiae.  New  (iliird)  edition,  tliorouKhir  r*ri«^.  In  onp  )>mai>d  w 
haDdKHne  OCUto  volume  of  SSO  pigee,  with  150  iUuEiniliuic     Clutli,  ^-j;   iMthct,! 

(lAuf  retuqF-) 

Excerpt  from  the  Author's  Preface  to  the  Second  Bditioo. 

80  fireot  KoTe  be«n  the  luSmnco  and  change  of  vitw«  (Uirine  the  p«ft  taar  ri 
(rymeooTogy,  thni  the  prcpnmtKm  tit  thi*  nlitioo  has  ocovMiUtrcl  utoiairt  ««  roodi  Ijlnri 
to  liftvo  Kwritieo  ihe  volume.     Ever}'  )x>nioii  hu  bcco  Uiot^iughlv  reTited,  n  grctt 
hu  been  Irft  out,  und  much  ntrtv  mnttT  aiMi:'*). 

The  cliuplera  on  th«  nUtiim  of  «(luutti'>ii  mii)  «oc!iil  canditum  to  de%-eloi»nvnt.  tb 
on  [K'lno-clliilllii,  the  diMUHMof  theoran,' nnd  od  OTuriotoiuy.  t4>g«ther  yrlth   tasi 
itooo  in  thp  hlndder,  hnv*  he*n  nenrty  revritt«n. 

Th«  ('lin|itiTii  on  ntolaiiM;  of  |Ii(>  vn|[ii)al  wullw  and  tsc«nitioiu  ttf  tht^  vnginal  uotlat, 
Iho  ineihwU  of  purtiid  iin>i  complete  retnovfil  of  the  utenb  far  tonUeiuuil  dut-aar,  tbt 
BiiTffind  treatTMcnt  of  flhrmiii  tiimoK,  dUeuea  nf  tht-  Fallnjiian  tubes,  and  the  rtitriwir  rtf 
the  uretlirK,  nre  ementinlly  niMv,  with  iJie  ri«»-i>  and  «xj>erienoe  of  lli«  itittluir  ia  a  torn 
whlcl)  hu  Doi  been  preaunted  to  the  profeMtiii  before.  To  thue  ehnpten  sot  lot  than 
one  hundred  and  neYenly>fiv«  pA|^  of  new  mateml  hire  IwcD  added. 
Tli«  work  moj'  now  be  aid  fkirly  to  reprciHinl  it  ti  i««i>ii<l  10  oooe  o;':  • 
th«  prffctil  iMMttlon  of^nrntBCoIojiy    in  AnorieiL,    £»rart  withoat  [-laMur 


audi*  uQ«oitb«b««t,  Ifiiot  th«  boil,  in  the  Eng 
li»h  tooKuac*.  Itr*inaln«  a  vr'>rth>-  «K)ioiieiil  of 
•  lift  d«TMed  te  iho  ■liiitr  au<l  prsdlce  of  eyiMi)- 
MlofiT;  ft  boob  thai  will  m  of  ln)m«n>«  rain*  to 
tb*  prufesalon  at  larga,  and  va»  which  will  ba  a 
aUmnliis  to  b«U*r  work  whrrvKT  it  In  rAsd.— 
Battvu  iTidiml  nitdStryieal  JmrwnJ.  Jan.  »,  ]XM. 
Aay  worti  nn  ajimtuAotr  hy  Binmci  maxi 
«ial  iiiteruat 


It  f*  wtth  a  tF<«1lii$of  i>lm>iir 
*  work  00  iJi««Mii»  of  woman  1  ■ 
evnnwv.lnirMl  *•  !)T.  FmniM.      /' 


n«  oaa  mat 
3  and  mac 

UMBt  * 


alwo}'!  ba'a  vapecT 


Laudvaluo.    Ht-  hia 


foriaanv  yMrs  hoaa  an  ascti'dinsir  buxy  fiac 
illlan»r1it  till*  daparlinviit.  F*w  ineii  )ia*B  had 
htii  nxperlanea  and  opportunkUMi.  A*  a  cntda 
*ll)i4rT  for  th«  Kanarai  |irauil(li>n«r  <n  dpfclslLu, 


inn,  wcnui  ■■ 

l<l<-ii',  trr'li 

it  wrll(«ti  la  n   ciraTniu^ 

thi>  llorarv  rtrauiMtOM  "' 


[n-'«  otih* 

«    tba   net 

-"Btd4»aiui 

'>iirnui'I.      1b  pM> 
'<!IU>WIlh   <wiittil 

'(•<i(t>ra<illc«,IM 
'    1r,  wonkr  <t 
■m    Wd  O  * 
r  vb.  tWV 


J>VN€A2f,  J.  MATTSCEWB,  M,1>„LL.  D,,  F.  S.  5.  J?.,  tftf 

Clinical  Iieotttree  on  the  Diseases  of  Women:  DvIivcnMl  in  Suae  Bar- 
tholomi'w'H  Kiurpttal.     In  one  hnndwime  orUro  voluniu  of  176  pugn.    Clnth,  (1.>V). 


Thar  are  la  etMy  way  worthy  of  iheir  author ; 
ln4aM,  wn  look  upon  iham  a>  amaiiK  the  moat 
▼aluabfa  of  hU  cMtrlbiitloBB.  Xtney  an  all  opoo 
matwini  of  gtvat  InlBrvit  lo  tba  Keneta)  praetiltuoar. 
Soma  of  thfiD  doal  with  Huhjeete  that  ar*  not,  a*  a 
mlo,  adeqiouol*  haadlad  In  tha  iaxt>booka;  other* 
Of  than,  while  Martngr  opoo  lopICA  thai  an  n>tia)lr 
traa(«d  of  si  Ivaglh  in  inch  worki,  yet  b*«r  aucli  a 


aUktria  nf  Indli  Idnaltly  thai.  If  » 
04>rta)nlj  daa^rrw  <«  ba,  Uwy  iM' 
wliolcaonia  rmiratnl  iipOD  Uii.-  .  . 
wiih  whteh  many  youiiji  pltyviciaa* 
upiH)  following  tba  wild  wa^htnga  «t>lel 
tna  nnnoologv  of  (tiB  nrwnaat  4Mf. — JV. 
Joanat,  Uanh,  UHL 


nODGE,  UCOUL,,  M,  J>., 

J^arT>;M  Fnftafir  of  OMetria,  <!c^  in  Ike  Univtriilf  of  PlMM^bwiMk 

On  Diseases  Peculiar  to  Women;  lui^'lu'iinj;  DUplAfcmeDls  of  the   C7t«m 
Second  «ditiou,  rfivivvd  aud  eiilar)(«il.     la  one  beautifatlv  {iriulad  octavo  voliu&e  of  Si$_ 
pages,  with  original  illuHtrationa.    Cloth,  (4.60. 

By  tho  Same  Attthor. 

The  PrinoiplOB  and  Pi-actico  of  Obstetrioa.  Illu»inued  with  harge 
graphU-  ptui»  ciinUiining  1IS9  tistirts  front  oriKiital  photographs,  aad  trith  niimeroras 
cuts.  In  one  Urue  uiiartu  voluine  of  M2  double<olnian»d  p^ea-  t^^trongljr  boc 
cloth,  $14.0fi. 

*  a  *  Specimen  of  tlie  pLite»  and  letter-press  tvlll  he  forwarded  to  no j  adilrea%  fr««  hr 
awil,  on  receipt  of  aix  cent*  In  poata^ e  stamps. 


1 

Jtaim 


TARNTER,    8.,    atul    CHAXTREUlLf    O, 

A  Treatiae  on  the  Art  of  Obstetrios.     TmiuUied  fWua  the  FrcDcb. 
two  iaegt  octavo  rolumea,  ridily  il  lust  rated. 


Bi 


RAMSBOTHAM,  FRANCIS  H,,  M.  J>. 

The  Principles  and  Practice  of  Obatetrio  Medioine  and 

In  i«fere»ix>  (o  iboT'iTK'm'ot  I'lirturiiioD.  A  nnw  awl  eidarRed  viitiou,  tlionoughl^  i 
bf  the  Author.  With  ulditioiu  b.v  AV.  V.  K  eatino,  M.  D-  ProfMaor  of  OhatcMn,  etc. 
in  the  Jcfleraon  Mc<li(«l  CoIIfkc  of  Philadelphia.  In  one  Urn  *aA  haadaome  (lapmil 
octavo  mhinia  of  MO  pagca,  with  64  niII-«Rge  pUtea  nnd  43  woodcttU  in  the  XmxV,  ruotaia- 
in^  in  all  atau\j  200  bawjtuUl  CiitircK    dtronsly  bound  in  lestlivr,  with  raiaed  lawda,  fT 


ASHWELL'8  VUfcCTlCM.  T^tK-VWE  uS  THB 
D18BME&  PBC«UA«.  to  "Sf^itV.S.    TtArt. 


American  from  tii*  third  and  rvf\m4  ttfadsa 
aU>\<KL.  \ii <yM sio. Tol., ppkCaa    GhMh,|Ua 


Lka  Bbotbibs  St  Co.'8  PuBLiOATiONa— Midwifery.  29 

:PXiATFAXRf  W.  8.,  M.  D.,  F.  R,  C  J»., 

PriiftuoT  of  OtttUtrit  Mtdietttt  in  King'*  OoUtge,  Loitdon,  tfc 

A  Treatise  on  the  Soienoe  and  Praotioe  of  Midwifery.    New  (fourth) 
American  edition,  revised  bj  the  Author.    Edited,  with  additions,  b;  Kobbbt  r.  Har- 
ris, M.  D.      In  one  handnouie  octavo  vohime  of  nliout  700  pagee,  with  183  illustrations 
and  3  plates.    Cloth,  (4 ;  leather,  $d ;  half  Busaia,  $.5.uO.    Just  reathj. 
A  few  notieex  of  the  jirevtuiis  edition  are  apjtendcd: 
Ths  medical  profMtlon  liu  dow  th«  npponuntly  !  cbooae   PlaffKlr'n.    It  Ih  of  caDTenlPiil   >U«,  bat 


of  MldliiK  to  their  stock  of  etandard  memcat  works 
on*  of  tno  best  Tolume^  dd  nildwirery  erer  piib- 
lUhed.  The  lublect  Is  tnkea  up  wltli  %  mMt«r 
hADd.  Tbe  p*rt  deTol«d  to  laborlo  ell  ita  TArioua 
pneentatlon*,  tbe  manMemeot  and  renulta.  Is  kd- 
mlrablr  aRange<L  aod  the  rievrs  ont«rt«lned  will 
b*  found  eaeentlally  modeni,  and  the  opiaioiu  ex- 
praaved  trustworth;.  The  vork  abounds  with 
plUeii,  llluBtrstiDK  variou''  obaletrlcal  po.«ltlonii ; 
th«r  are  admirably  wrought,  aod  afford  great 
■■■Utaiice  to  the  itudeDt.—A.  O.  Medical  andTSur- 


what  Is  of  chief  importance,  its  treatment  of  tfaa 
TarlouH  subjecin  Is  coDcliie  and  plain.  While  the 
diacaseloay  and  de»onplioni> are mfflclently  elabo- 
rate to  render  a  rery  intelliglhle  Idea  of  them,  vet 
all  details  not  necessary  for  a  fall  andaretaDdlu 
of  the  subject  are  omitted. — OMfinnoti  Xmiieal 
Stitt,  Jan.,  l(tM. 

It  certainly  in  an  admirable  expoeillon  of  tba 
scleaec  and  practice  of  mtdwlfery.  Of  eourae  the 
ftddltloDS  made  by  the  American  editor.  Dr.  R.  P. 
Harris,  who  never  utters  an  Idle  word,  and  whoea 


pteol  Journal,  March,  tSSO.  i  studious  researches  In  smne  special  departroenta 

If  loquired  of  by  a  medical  aludent  what  work  |  of  obetetr[<^  are  so  well  koown  to  the  proteftltw, 
OD  obatebrieR  we  shotild  recommend  for  him,  par  .  are  of  great  Talue.— TAe  jlswricaa  iVactitiofwr, 
wrcsJIfwes,  we  would  undoubtedly  advl»e  him  to  \  April.  1^. 

Knro,  A,  F,  A.f  JIf.  JD,, 

ProftMOT  of  Obttetrie*  nnd  Dutaitt  of  Women  m  tkt  Mtdieai  Dtparlment  of  tht  Columbian  Vnirer- 
•ity,  Washington,  D.  C,  and  in  Ihs  Unircrtittf  of  Verwuint,  ttc. 

A  Manual  of  Obstetrics.  New  edition.  In  one  very  handoome  12mo.  volume 
of  331  pages,  with  59  illustrationfi.     Cloth,  $'2.00. 

In  a  series  of  short  paragraphs  and  bv  a  con-  correct  Idea  of  tbem.    The  general  practitioner 

denaed  alyle  of  composition,  tne  writer  lias  pre-  will  also  And  It  very  usenil  (or  reference,  for  the 

a«nt«d  a  grvat  deal  of  what  it  is  well  that  pvery  purpose  of  refresbing  the  mind.    We  can  confl- 

obatetrician  should  know  and  be  ready  to  practice  deutly  assert  that  It  wilt  be  found  to  be  the  beet 

or  preeorlbe.    The  fact  that  the  demand  for  the  cla.>a   I«xl-tiook    upon    obstetrics    that    lias    been 

volume  has  been    such  as  to  exhaust  the   first  ispued  from  the  pres.*.— CVmnnofi  Medical  Ann, 

•dltlon  In  a  lltils  over  a  year  and  a  half  speaks  March,  IBM. 

well  for  Its  popularity.— A  m<rifan  Journal  of  the  it  must  l«  acknowledged  that  this  is  Jui>l  what 

Medical  SeUnet*.  April,  ISM.  It  preteud*  to  bo — a  sound  giiide,  a  portable  eplt- 

Thla  tittle  work  upon  obstetrics  will  be  highly  ome,  awork  in  which  ouly  indispensable  matter 

valued  by  medical  students.    We  feel  quite  sure  has  been  presented,  leaving  out  all  ijadding  and 

that  It  will  be  in  great  demand  by  them,  w>  suited  chatf.  and  one  In  which  the  student  will  Sndpure 

U  It  to  their  wants.    Of  a  siie  that  It  can  be  easily  wheat  orcondeneed  nutriment. — .Y«irOrriaHr  Jfstl- 

earrlsd,  yet  it  contains  ail  of  (he  main  points  In  ifil  and  Si-r'iireU  Journal,  .May.  16S4. 
obatatrica  sufficiently  elaborated  to  glre  a  full  and 

BAMNFS,  ROBERT,  M.  D.,  atid   FAJf COURT,  Jtf.  JE>., 

Pkf».  to  tXt  Oeneral  Lyinff-in  Hotp.,  Land.  ObtUlrie  Phf/t.  to  St.  Thomtat'  Botp.,  Lotd. 

A  System  of  Obstetrio  Medicine  and  Surgery,  Theoretioal  and  Clin- 
ical. For  the  Student  and  the  Practitioner.  Tbe  Section  on  Embryolt^v  contributed  bv 
Prof.  Milnes  Maraball.  In  one  handsome  ocuvo  volume  of  aliont  1000  pages,  profusely 
illustrated.    Cloth,  $6 ;  leather,  ?6.      In  prett. 

BARNES,  FAJf COURT,' Mr~j57, 

Obttstne  PkytKian  to  St.  Thomat'  Hotpital,  London. 

A  Manual  of  Midwifery  for  Midwives  and  Medical  Students.    In  one 

royal  12mo.  volume  of  197  paj^es,  with  oO  illustrations.    Cloth,  $1.25. 

FARVZ^r,  THEOFHILU8,  M.  D.,  LL.  D., 

Prafefor  of  Obetelrta  an-l  the  Di»<a*4t  nf  iromon  and  Children  in  tAc  Jeferton  Meditat  Oaltege. 
A  Treatise  on  Midwifery.     In  one  very  handsome  octAvo  volume  of  about  650 
pages,  with  numerous  illustrations.     In  /trcM. 

FARRY,  JOHX  8„  m7^„ 

Obttetrieuin  ia  the  Philadelphia  Hoepital,  Wite-Prtident  of  tht  Obttit.  Soritty  of  l^uladtiphia. 
Extra -Uterine  Pregnancy:  Its  Clinical   History,    Dianiosis,  FrogDosis  and 
Treatment.     In  one  hand.'wme  octavo  volume  of  272  pages.    Cloth,  $'2.50. 

TANNER,  THOMAS  HAWKE8,  M.  D, 

On  the  Signs  and  Diseases  of  Pregnancy.  First  American  from  the  second 
English  edition.  In  one  handsome  octavo  volume  of  490  pages,  with  4  telored  plat«s  and 
16  woodcuts.    Clotli,  $4.25. 

WINCKEL,  F. 

A  Complete  Treatise  on  the  Pathology  and  Treatment  of  Childbed, 

For  Students  aixl  Praciitionera.  Translateil,  with  the  consent  of  the  Author,  from  the 
■eeoitd  German  edition,  bv  Jamb:  Read  Chadwick,  M.  D.  In  one  ocUvo  volume  or  484 
pagfs.    Cloth,  HOO. 


ao 


Lka  BBorraBos  &  Co.'«  Publioatiohs— Midwfy.,  DU.  Ctitktn. 


ZMTSSXAJSr,  WIZLTAW,  ItF.  I)., 

ASystem  of  BCidwif^ry,  Including  the  Diaeason  of  Pregnancy  and 

Puerperal  State.     Thini  Ann-ncan  cfiilinr,  tevifi«<l  br  the  AiilJior,  with  Dilditioai 
JotOS  S.  Parry.  M.  h.,  Oljutetrtcian  lo  lh"»  I'liiln"lel(ihia  ^lomMlsl,  e(c.     In  cop  largu 
TCiT  hutfUome  ocuvo  volume  of  740  jKigc-s,  vUh  200  illustratigos.     Cloth,  ^.-30;  IcstWr, 
$5J^0 :   very  liiiivb-nic  hnlf  liiLwiii.  miM^  hiindss  W.OO. 


onwHw  hrtffly  tin-  c<iin|i«niii»B  luialoniy  of Ihe  pel- 
Pl>  and  lliv' ini>)>lllty  <rt  ''i*  |>nlil<'  orflniiiiilnn*- 
Th«  ■econd  i-ti«(.l«'i  Is  ilfttou^i]  M^pFcioIlv  lo 
in«taidy  I'f  the  (vlvlx,  whito  In  t)»>  itrlrif  Ihs 
bniklc  'iirf»n»  of  fem-ntlnn  trt  lnlr«4<K«d- 
T^i«  ttn'.niiirn  >n-]  >UT*InpmBni  of  iho  (inim  ■ra 
«Jmu-»My  <l•^»l■llt■■■■l  Tlj-ri  T'^IErvir  i^hAptAn  UIWTI 
If)*  v«rlnuii  nifii' '  <  <        I'd  In  iha  ■mdyof  mid- 

inf#rr     T1*eJ<  rMistMQtUiewark  wft 

fil«ln  anil  |iImi>1[..  < i  tAcIant to  tUa*  thkt  In 

hl«,  Ui«  tut  »dltl'^  T)  «r -hi-i  w«IMcoowB«wrk,eivnr 
rwMit  adHtnvMnvnt  In  iMii  flvld  h««  bown  binaglil 
'fenrftrd.— i'AyfbAiit  andSury^-^  Jon.  l8Wi 

Wc  RlAdly  nleoiine  the  n«w  edltlos  of  thia  rs- 
o«l1siirtaxt4NMk  of  laldiritr'tT.  Tha  foraitir  odl- 
tlona  h4t«  b««D  mOM  hrnrabl^  rttitUtA  tijr  the 
ptahaaiqa  oo  tioth  •IdsB  otf  tbs  Atlmtln.    Id  tb« 


miMB  au«h  •Jl^rKiioni  %t  Hit  pt<'>^^erM  vf  obMim- 
p«I  uianMi  Mvm*  m  («<  i^  •■'  »«nnoi  tal 

bimire  ibe  ntrilily  whit    .  --^Ii  Km  b»«B 

Crfi'rmmt    W«   oonclili"  Ji'ilimUa  Mt^ 

ok  Inr  ttnilettU  doriac  tli^li  m^cn^ 
iBnlntttn,  and  h**a  ft'**'  pWnniw  1b  n 
injK  ft.    Ah  an  expdOMil  of  tbt>  mUmtt  . 
IVMmit  day  II  ha«  nn  wparior  In  th*  Kni 
mMn.— OuMda  Lametl,  Jan.  UfiU 

Ta  ttM  Aawrlnaa  ntadent  (h«  wurk 
inniKpTDVBaiJntrablvadapiad.  Oan>plMA| 
MrU.  MMDUaily  DiM«m  m  Ita  UMotiloaw  ■ 
demaavtralloiis  tioMd  for cl— ma»  and  p) 
It  «1U  nlii  le  hvw  and  be  mooirnlMcl 
at  itwiilBnl   nMiil.    Thw  work  eannnC 
MTUlar  aad   I*  cordlaltr  r«<wmm«nd« 
jr«r.  amd  S*ry.  Jborm,  Uanli,  IMA 


SMTTHt  J,  LEWIS,  Jf.  !>., 

OAiira!  Pntfmmr  o/  />i«taict  i^  CMMren  «■  lAt  S^Otra*  HotpMat  it«H^  CoOtgt,  It.  T. 

A  ComplGte  Fractioal  Treatise  on  the  Hisoases  of  Children. 
Ailition,  thomiigblj  reviMHt  Atfl  rewritten.     In  onv  tiniulsomc  octavo  Tnlmnc  vt  HS6  ya 
with  illiiHtrntion*.    Cliilh, f 4JiU ;  l>-jillii!r,?>Vr}4l ;  vorjr  hiuiilanniv  half  !{■ 

TbI*  U  cno  tt  iti9  nam  l>i>ok»oulh«  Kiibjori.  villi    whlcb  w«  vnaairt  to  ml>' 
wbieti  w*  liara  ni^t  and  ooe  Itisl   ti«,»  civfi:   tt-     f>i'''fln  .frutmnl  i^  Midioi' 

•rtl^fiwllotl  tin  BVOty  OCfllMlotl  GTi  '    .  T"  !■^  fr)Ok  puWl'ti'^l  'iri  I'ln  •Pijj-r"  m 

eoonulMd  II,  cUtira  ax  l"  illncn"-  <l-  IrenU  tti>I  is  ita  eqiul  In  tallM  U 

II  It  DOW  to  lu  lltUi  Mtllon  an-l  li  WiiK?  v,"  ha>  Mid  }q»I  aonngti  t* 

fs  a  TDnr  admuato  rvpreMi'i  i''  .       i    *  I  by  gcnond  pnclf- 

tnat«riTMaipr«*eaCundvr  "Ivlvcr,  patlwl'^ 

MibloMof  luhnt  hytt«n«  U  .        .  ,i  mfrr  aMralhio 

aaffy  portion  of  tlieiii»W.  i'l-n-'vn  i 
work  Is  apr-'*?!''"''''?'  ^"rotf.i  U:  ihv  . 
laracey  and  childhood.      Wo  would   ro 

•ay  ona  In  nued  iiT  iDforritHtiini  un  ttit<  "nnjii't  i"    '  lainiiy  pii^'tm^ian-.  — in   .i/ui.  .uoiiiAiu,  Pal 
proeur*  tlt«  work  aod  lorin  bit  own  oplmoo  oa  lu  I 

JTE^  rryc,  johnm.,  mKi       '~ 

The  Uother's  Gtiide  in  the  Management  and  Feeding  of  Infttnts. 

(me  hnml-'in'i-  )?pii'..  vi.iuiiie  uf  IIS  pagca.     l-l<rtli.  91. IX). 


Worki  "  will  dill  thn  phy«lot*n  lm>  ' 

menial}-,  r  '!..■  limr  he  IsonnMaaliyKi^ 

lug  hli'  ;ii  i.>irMetln|i  t>i*n>  od  Iha  Rob- 

iaci<  li«ri:  uvidi  Liih.u  no  tUorongtily  and  brao- 
UOally  I>r.  RnatfnK  hw  wrllMtiapnuHlaal  booh, 
bu  ear«rulh  tv.  1.1.:. I  iii.n<..>Mittfyf*p«lifioJl,aDi] 
•oenaMiril.  -  matharlDitiolidatall' 

of  lh«  trr  'I  I  Oft  AenAt*  upon  bi>r. 

Hp  ha«  -'   ■  ■'    I  jdTlDg  pcpfcrlpUoiw, 

and  Idnlniir  '.he  muUicr  «lt«n  tO  call  upoD  Ihs 
dwtot.aD  bU  dnttoaat*  WUlIf  lUftlnci  froRi  ti«n. 

J>r.  Kfn''  ■    i-ion  fciJtt 

nf  workt'  '  duUna  of 

IbBinoU)":  p.    Tlifi* 

!•  tha  TtDg  tiC  i^OitaMi  <UD>e  la  Ihu  roniarki  about 


iha  ■mpliivmani  of  a  wM-nnrMi,  about  (It* 
food  for  a'Duraini;  mother,  about  Ihe  lonlocflli^ 
uf  a  tiiiih,  iiUint  (ha  pat*lnbcilatcir  iwfi»j  u>^| 
■I'  i>  many  oiber  subjM-ta   4^a 

*  'I  l!lo  mtKhi  ■aj',  "mirvdf  thla 

'   iu'h«Kp«rt«WWl«*Cli*att9a4«^ 
ih-  iMng>ii«adwdlobnfauilMwl  ituoi>,  with  t 
BAwellaa  Ibepoor.— £'<Ml>'a/iOB(vi..raoiiaf7,3 
A  book,  small    n  'if.  >iir<ll«u  lu  plraiuuit  *t/1>sl 

laaKUHffavi< adlly  oadMHtood  W  alir 

moUcT.  and  .  ladlcal  «ad  Mif* ;  In  brt 

a  boo)>    r  "I    "  "<'   bp<-<:i    Wiillins    a  lau 

llnip.  t  'iiBiand 

lo  m-."  ^  I";** 

Jtabn,  .  I     !    Una. . 


It  •»!*  WH 


ow£y,  EjyjujryD,  jmt.  j?.,  jp.  ».  e  &» 

S^rgnjf  Ui  "S'  CAil'trcn'i  Itr^lUti,  OrHtt  Orw-wl  .It.,  fiiWilft. 

Surgical  Diseases  of  Children.    lu  ooe  ISbb.  tiglinne.    Pr^ariug.    8ee  i 

q^  Climair  Manualt,  [M^^  S.       

IFJS:«T,  CllABLES,  M.  »., 

Lectores  on  the  Diseasos  of  Infancy  and  Childhood.    Killh  Ai 

from  rtlh  KnslipJi  eitition.    In  i.iifi  .>-taVi>ri>liiriiei)f  t>?M;  p,i;,'cs.   tlolh,  (4/&D  ;   Icailter.j 

By  the  Same  Author. 

On  Borne  Disordera  of  the  Norvous  Byateoi  in  Childhood.    To  one  rmU 
ISaio.  Tflliime  of  127  pagcft.    Clotb,  11.00. 

00lilHE"B  PRAirnt:*.!-  trkaiisk  on  rati 
-~  ~    •   —  -•     •■-•       .\ 


DISU&iESO?CEU.T)A'K:!>.    (SVxW  cA\vVm,t<»-\    'r»-ijM«;t%.    (?lniOi,V.U)  laallMr.^U. 


rl»«d  andaajpiaiUviL.  In  <w<  oc<*n>  *ulni: 


] 


LiA  Bbothxrb  &  Co.'s  Publications — Med.  JnriH.»  Miscel. 


31 


TIDT,  CBAMLE8  MBTMOTT,  M,  J?.,  JF.  C.  A, 

Pmftfor  of  Ckamittry  <Md  «f  fumtie  XtHeint  and  PiMU  Hmdth  at  tka  London  BotpUat,  Ut. 

laOgal  Hedioine.  Voluue  II.  Legitimacv  and  Paternity,  Pr^nancj,  Abor- 
tion, Rape,  Indecent  Ezpoeure,  SodomT,  Bestiality,  Lire  Birth,  Infanticide^  Alqibrzii, 
Drowning,  Hanging;,  Strangulation,  SiiJrocation.  >[aking  a  rerr  haodaome  imperial  ocy 
tavo  Tolume  of  d20  pagea.    Cloth,  ^.00;  leather,  S7.<K). 

VoLrHE  I.  Containing  664  imperial  octavo  pages,  with  tiro  beantiful  colored 
plates.    Cloth,  9^.00 ;  leather,  rz.OO. 


Th«  NUlsAwrtloD  expniiBed  with  the  flrtt  portion  i 
of  thl*  work  is  tn  dd  wl.ie  leBseoed  by  a  peruaal  of 
tha  •Foond  Tolume.  We  find  ft  characterised  by 
tb*  HUn«  fulnciiv  of  detail  and  cleameti'  of  ex- 
pr«**ioD  which  we  had  ocoaslon  lo  highly  to  com-  ' 
mead  la  our  former  notice,  and  whton  render  It  m> 
valaable   to   the   medical   Jurlit.      The  copionn 


table*  of  i-ases  appeoded  to  each  dlvbilon  of  tha 
subject,  muHt  have  cont  the  author  a  prodlgloaa 
aroouni  of  labor  and  renearch,  bot  ther  contutute 
one  of  the  most  raluable  feature*  of  tha  booli, 
eepeclatiy  for  reference  tn  medioo-legal  triala — 
Atncriran  Journal iif  titt MtMealSeieiutt,  April, IMt. 


TAYLOR,  JlLFREI>  8,,  M.  i>., 

Larturir  on  XedinU  Juritprudtme*  and  OumUtry  in  Ouy't  Botpilal,  London, 

A  Manual  of  Hedical  Juriaprudence.  Eighth  Americanfrom  the  tenth  Lon- 
don edition,  thoroughly  revised  and  rewritten.  Edite«lDy  Johk  J.  Reese,  M.  D.,  ProfieMor 
of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania.  In  one 
large  octavo  volume  of  937  pages,  with  70  illustrations.  Cloth,  $5.00;  leather,  96.00;  half 
Bussia,  raised  bands,  |6.60. 

The  American  edttloni  of  this  staikdard  manual 
have  for  a  long  time  laid  claim  to  the  attenlioa  of 
the  profenalon  in  this  country:  and  the  eighth 
Mcnea  before  un  aa  embodying  the  latest  thoughts 
and  emendatlonn  of  Dr.  T^Ior  upon  the  tttibject 
to  which  he  devoted  his  life  with  an  assiduity  and 


•neeesn  which  made  him  JaeiU  jrrint^p*  among 
English  writers  on  medical  Jariaprudeoce.  Both 
the  anthor  and  the  t>ooli  have  made  •  mark  too 
deep  to  be  affected  by  crltlciim,  whether  it  be 
eansure  or  praise.  In  this  case,  however,  we  should 


only  hare  to  seek  for  iaadatory  tarms. — Jiavteaa 
JoumrU  of  tKt  Medital  SeimtM,  Jan.  ISSL 

This  celebrated  work  han  been  the  standard  an- 
thorlty  In  Its  department  for  thlrty-eeven  year^ 
both  In  England  and  Amerlra,  la  both  the  protki- 
nionx  which  It  concern^  and  It  Is  Improbable  that 


It  will  be  superiieded  In  many  years.  The  work  Is 
dimply  iDdl^peDKabletoeverypnysiciaa,  and  nearly 
so  to  everj-  llt«rall}'-edneatedr  lawyer,  and  w« 
heartily  commend  the  present  edition  tc  both  pro- 
fess Ions.— ^fboay  Xow  Jottmal,  March  m,  1881. 

By  the  Same  Author. 

The  Frinoiples  and  Practice  of  Medical  Jurisprudence.  Third  edition. 
In  two  handaome  octavo  volumes,  containing  141ti  pageit,  with  lS8  illustrations.  Cloth,  $10; 
leather,  $12.     Jtut  rtadg. 


For  years  Iir.  Taylor  wan  the  highest  authority  ' 
Id  Enitland  upon  the  subject  to  which  he  gave 
•special  attention.  Hlii  experience  was  Tai>l,  his 
Indgroent  •'icellent,  and  hid  skill  beyond  cbtII.  It 
la  therefore  well  that  the  work  of  one  who,  as  Dr. 
BteTen^on  i-ays,  had  an  "enormous  gnap  of  all 


matters  connected  with  the  subject,"  shoaid  ba 
briiughl  up  to  the  present  day  and  continued  In 
its  BiilhnritallTc  position.  To  accomplish  this  ra- 
suit  I>r.  !?teTi-n<iou  ha*  siihjected  it  to  mostcarafot 
editiiift,  brlneinx  It  well  up  lo  the  times. — Atntn- 
fnn  J'iurnil  o/  the  ilrtlical  Seitnets,  Jan.  1S84. 


By  the  Same  Author. 

Poisons  in  Belation  to  Medical  Jurisprudence  and  Medicine.  Third 
Ameriuin,  from  the  third  and  revibcit  English  edition.  In  one  lai^e  octavo  volume  of  788 
pages.    Cloth,  $5JiO ;  leather,  $6..VI. 

PEPPEB,  AUGUSTUS  J.,  M.  8,,  M.  B.,  F.  B.  C.  S., 

Exininrr  in  Firrtn»ir  Uatieint  at  the  Vnirertily  of  L<'n-l'in. 

Forensic  Medicine.  In  one  |>ocket-ttize  rJnii'.  v'>hime.  Preparing.  S^e  i^udtnttf 
Strifi  nf  Maniialf,  page  3. 

LBAyHENBYC. 

Superstition  and  Force :  Essays  on  The  Wager  of  Law,  The  Wager  of 
Battle,  The  Ordeal  and  Torture.  Thirrl  revi^f.!  and  cnlnrged  edition.  In  one 
handiMiitip  n>yiil  l^mo.  viluuie  of  •'i.Vi  jiagea.     Clutli,  S!J..~il'. 

This  valuable  work  is  lu  reality  a  hi<l'iry  of  cIt- 
IllSBlloneiiliiierpreted  by  the  prngre'^nf  Jiirispra- 
denpp.  .    .    In  "Superstillnnand  Force"  we  hate  a 

Ehtloeophlc  -um-y  of  the  Innjt  period  ItiterTening 
ttweeii  pHmltlTe  turbarlty  and  ciTlllzed  entiiiht- 
•nmenu    There  is  not  a  chapter  In  the  work  that 


shmiM  nut  lie  ino^t  ritreftiliy  studied:  and  however 
well  vi-r-eit  (he  failcr  may  l-e  in  the  sclenoB  of 
Jurl>|>rii'li.iic>-,  he  will  And  much  In  Mr.  Lea's  vol* 
lime  tif  which  he  was  previously  Ignorant.  The 
h.><.|<  1^  a  raltinbte  ail'lilfon  in  the  literature  of  so* 
ciat  -rii'Ti.'M,—  WrtimoMttT  Rtvirvr,  Jan,  1S80. 


By  the  Same  Author. 
Studies  in  Church  History.    The  Rise  of  the  Temporal  Power— Ben- 


efit of  Clergy— Excommunication. 

octuvo  volume  of  'J<>-')  i>itgi.t>.     Cloth,  $'J.''>0. 

Thea'ithorl!-|'r«-emlnently  a  scholar.  He  takes 
tip  ever)'  ixjiic  allied  with  the  lea<llnK  ihcme,  and 
traces  it  oui  t<i  tin-  Tiilnule-t  detail  with  a  wealth 
of  knowledge  and  Imiiarllallty  nf  trcntnienl  (hat 
Com[-e|  adiiilmilon.  The  amount  of  information 
eom)ir*ssed  inbi  the  book  Is  ai(rai<rillnar>.  Inuo 
other  aingle  volume   i"   the  deti'l<>|<iiLi-nl  -t  thv 


NiH  *-liii"ii.     In  one  very  handrome  royal 

prliiiitive  church  traced  with  so  much  clearness, 
and  Willi  (■"  .li'Onlte  a  perception  of  complex  or 
ciHiflli'ilngj-ourci'-.  The  fifty  |ia«e"  on  the  growth 
of  ttie  paiMwy,  tor  Instance,  are  ailmirable  fur  coD- 
ci-eiie-!i  ami  freefliuu  from  prejudice, — Bi>*(vn 
T-.'n-Mrr,  May  :i,  IMO. 


AmiMlckii  Jon  nial  crib*  M«#al&(MBOW 
Amvrtcan AyaMmofOTiUDcaUiffy    . 
Atuortcui  njMMn  uf  t%BCt1c>l  aMIcnw 

•AAfabvnt'l  MfKWT      .... 

A«biiT«lJ  m  Ulitiiw  of  Woiaui 
Attile]il'iiCli«mMry     .... 

SRll  nn  itic  lluMum  nnd  Anna 
u1  uK'i  pnti'i  111' of  Mv>Urli>t> 
Boram'  MidwifciF        .... 
■Band  ou  IMMHMa  of  Wdimd 
UMT  ^MMD  of  Ubslctftc  Medltdna 
Uialow  Dii  EIt«lricily 
_tuuD  on  Rcnnt  DIhmm    . 
11*1  (.'o'liiHiratlv*  Pri^-diilogj  antl  Admudv 
Bellvuy  K  Opentl  v«  Hutmnr 
BfllAimy  ntiiinikkl  AtiaXuaiiy  , 

Blftn4runl  a»  tvaaaXtj 
Blox»iit'*  CbcmUIiT     .... 
BQWWkti'K  PntoUou  Cbamkiirr 
•Bftolowv  ■  PnctlW  or  MwiMM    . 

Btowoc  an  Ilir  UchUuUlIMMOfM      . 
Brun'tic  iiij  it>r  Tlitiml  , 

BiQcv  ■  Klaicita  MmUo  mai  TbcmpMiUai 
llriiii  I  u>>  •>  M  (^ivrla  BlfdUft  BiMl  Ttianitvutloi 
Birnni  ''H  <&»  BrMCl    .... 
■2i>*aiir«  I'rMMke  orsunHiT        . 
tSniuM.iuI  i>i>  Vcnncol  DtaMM   . 
•BHrnnt  un  tliv  pjir      .... 
BUtlll]  oa  UtflToiijina   .... 

CkrpwitcToa  lii«  0wK04  AtnMof  Alooliol 

'CttnKOMr'i  HnBikn  PtvOoIen'   . 

QkrirT  on  Ibe  Sre         .... 

Omtury  of  AaMclout  MMIbdD* 

Cbamton  oa  U«  UM  nwunen 

Otawln'  PbrHAiocleal  mm  rktholiifloU  Oti«m. 

Ojiwviblll  on  f^orpwal  Forof 

CIcTliv  mill  Lockwood'a  DnMctOis'  tbmtutt 

ClaMM-"' >J'i»^i'utlva  Anatyxla 

ClOlantl  ■  VbmvQViT         .... 

Clouaton  OB  Iumdiiv    .... 

Qg*M'  Palbutqav  .... 

Ooban  ou  tbn  'niTtM    .... 

DWtta  «n  DlaMM*  of  Cttiulrwi 
r'al.Miiurvi  on8«iifi7 
dlouf^yphlllfl        .... 

nil  uijrriuiivlrT'*r»lhol«1aBl  tUaUioKT 

Oollvr^nr'*  Atlitf  ct  V«n«KaI  DlMaaa* 
CnriKiu'*!  Uivtk.«I  AiikliJiuy 

IW114D  ou  tin  ClrruUiLon 
•lujun'a  IIiuEuuiI'hralolocy 
IM^'a^^uiumplilMl  AiMtotty  OfUM  Brain 

t  Medial  ?li!^ca 


lUMIJ 


praltri  UoCsrn  Botnn- 
DnMan  on  UIimiw  of  woinea 
•Saa|1liMii-aM«]ln<  nteur 

'DMOOiiMfviTDtnof  Anaiony 

-«■■  orn*wi»«y„ 

JitBD'cSnien  ofsurat/r 

jtrcb'*  ]{«i|t  AM  tn  InliiilM  »nd  Acd^'ia 
__4llb>nuii'lTliHnpentlciuHtU>(.  Mad. 
7*iiwtolt'i>  Madtcal  Dlaonndu 
rtnlKyaun'aCUiilvalDUvriaala  . 

piii.t-...  .1  <iu.aitnUoci  ADd  PvKOMloti 


.  ili-al  RaixInraUtin  of  Ui*  L«asi 
>Mui  till  iiii(ll«irl 


I'lmi 


I  Kiixl 
otjf  D. 


inmi* 


•PUni'f  CUalcniatedlcUie      . 

niAl  s  E^sAya      ....  * 

•Vtlul'i  PiucLtoe  of  UNtkdM 

Vbiaim)'*  law*  of  V.  a.  on  Ctulodj'  at  latitat 

nUTk  JIUdtlOOlE  OfltMUMBt      . 

3enir[iMrv  cimnlMry     , 
t  on  ll>w««a  of  lilt  wititt  . 

Undiiii'i  J*i>]'i>Irion|MiloCbMnlsir7 
on  lbs  Lump  «»>•)  AJr  Pmm(w    , 


_  tAMftiyina 
ir'aOrtbcuMaicSurgaiy         ,         . 
J^Bunrfy         •        .        .        . 


QiMiW*  MkUmI  Ch«o]4ibT  ■ 


QH«p^  MhAlocr  Ml  Moftld  A  uriomy 
GruBtfa'a  Uttfrtnu  Pontiulftrr 

OfO«0«i  PanUn  BodlM  lii  Alr.pMi 

Oroaioa  >tnr-ciim<«BD4Bi«rtUl7   . 
Oiwa  no  Urlanry  U*VMia 


B|b«nban  od  lb»  AhdnsMo 
*HainnEo(i  on  Fnwumm  anO  Inwooittoiiia 
BmbUCoo  on  Svrvuiu  ur 


HIUM   , 

BatflVOU  Wotncn 


orifMUain* 

■1  nuunUKoIccr 


^-- iktHi  rowM"* CSMuifaal  ABkljA 

37  HoMea'a  t«odi)uuka    .... 

11  H>>)luid^MeiU«alKM«MUtIl«AMdaai 

»  •HolmM'RrnaBorvncstrr 

a  BoiBBrt  jmiomy  md  iDiioJao 

9  nurti.li  tin  FMYH  .... 

'-'■  >->>noas}i>Ull* 

J  .  [!>•  DteMUHncf  ihaSkto    . 

HanOltoU)  om  :(«rv«iM  DHoMlw* 

:.,  ..vxT  <■  •Ji^MiwjialoSclaBn  Md  PneUot 

»  ]keaiiiif  Ml  Iniiina      .... 

a^  Ia  llncb*  un  Piw^MnnU.  MjOaite,  M»    . 

S,3»  LnUodicon  YellvivFariB'   .  . 

«  Lannae*  *Bd  Mooa'a  Ophtb^linlo anmii 

10  lAiiTKin  ixi  111)-  Ry».  OrMt  aiud  nr«l1d 

ft  t.«i'«  8ludl«  In  Autcb  ItlatotT 

V  Lot'  I  itiiMnll  I  Ion  »oA  FtaM 

14  L,v«  on  tfyyWU 


■•S  i£SffiS2J-3aS!S9i^*l""  :     :     :    iS 

)H  Li*«uooI>lHuw^CbeTTnl2m  .  .    US* 

11  Ludlow's  Mkanal  of  KnulOMJiO**  I 

II  LjotaornVvtit  ......      u 

"■s  fei'oiEmisrr'"r** :    :    ;  ^a 

»  KedlnlNMP 1 

M  Steteon  CblMbed IVvM      .         .         .         .      S 

1,31 ,  wiTvnptMtionafauMir.       .       .       .     » 

"  MillWiniiMlpMaallMiaJiT         .         .         .      W 

*  MitcboU'i  Xarrooi  Mmum  of  Wonu  .  a 

•a  SoirUMinMAaNOfiSendMT*  .  &M 

14  srorrlaomaktalllMMM  .  ,  .  .  S 
IT  Nr!  1 1  Kod  flnJUi^  Oxnnmdlinii  tttbO.  Sd.  .  I 
IV  ^p'.UvaiiipooElaHMioribaSr**  •  Si 
37  iini-n on litiwmia of CbUdwai                               .   %,m 

i  ■ruiiah'*  I'nmcnl  rfakniUMT       ...       II 

10  PoTTT  on  Kxirft'TTiacinii  Franaiicy  9 

»  Mn-WiMI'lolCbr}- S 

■•  t^vroikDimntuaaadiHlMwiilH*  n 

lU  I'cppM'*  FeraaMe  McdJctn*  .  .  3.D 

15  p»i>t«#'»SMi«iralPnt)Kilan-  .  >.» 
IS  flckoti  PraciumMidniloeMIoui  .  .  LS 
34  Pliria'ii  itfiruiu)  of  SntV^  ....  IB 
s>  ptarfcU  on  K«rv«  PTwraUun  »Dd  KnMtto  .  V 
W  "PlfcyAlCaMMwliteiT  .„      .         .         .         .      J» 


at    PnJU*p(  nn  ID*  btf  and  tn  1 

U    Pcrwer*!!  Iluinan  rbntotocy  .... 
ffi    Italfn'D  t'JInlcul  CIwinlatrT     .... 
S,<  '  Iliui»i>utCuiiu  un  l>ailarllkM 

T  '  RMiweD'i  llitorvUaU  (.KOUMUT    • 

f  ,  ■it«7ii»l(ia-g]rUcmorM«lHiliw  . 

T    Kir/Minuait'*  PnrvMiUra  MadldiM 
IC    llobertii  DO  L'riowy  IMibmiw  j 

r    ItiA«ru'piladpl«RndPnclloaofSBa«7 
21    R<it<cnac>a'|  Pb7*k)laslaLi  ytrnUt 

t    ^rctnl'i  MiMor  hnirUIIKaiy  Hurtcfty     . 
TT    Siranon  in^nitj-.  iDcIuilltic  Ilyiivria  . 

r    sicliAftir'M  HUtolagr 

n   rrlinllinr  nn  TlauMff 

H    iMI»fuqi)M'niroU.XoMUMl9aM-rbkr7ex 
n    ScnnorCUBSralUnnual*     .         .  .  . 

i:    HiriiMi'a  Uatiiait  at  CbanMtT 
M    HKagr'aOPonuvaBorginy 

U   MladuoaraptaUiMU 

14    -ir.i.i^  .  r/^'n'i.riiionOsinaaBtniOB  - 

'  w3  iiMiMi^  Xokunk*!  AU** 

..   on  <1ilUliCD 


[  ii     hi  Tailiiiial  rriijiMaiiiij 
riictapeutia  abd  Mimu  U«<tica 
11  nacMtva  ..... 
u    .-..•..-..» kfifictaitvaMarf«ry 
Iw    (Moksaon  nvcr  . 
•   WniMuu' Serial  of  MAoiwia  . 
U '  «un«'  LUahMt  MediciAa     ,  .         . 

a   TteoM-ronnnMatHt  niaaaiMorpmiiMicT 
M    TkniM'r'iMaiiaalufCnipdokllCcadliM     . 
«    Tanili.-ri(WlrtMiitr«uIl'^OIi««Crtca 
U    Taylirr  im  Polaona         ..... 
K    TarLcni  MedtotJ  fnrllpifdMW*   . 
s  l^'W«riiitandPMi4«faiM.Jarl«raldaM 


.  imaa oiiDtoi—  (« WodUi 
U    TliomproDOM  Rirlcnir* 
>,  X)    Tli<iiti)<Kin  (in  l,'riiiai7')t"(i* 


W  I  tOdit  op  JEcuM  blaMH 

S,  Trev<^ADti[ 
Tnvn  OB  ui 


ott  Ilia  Budy 


XM  TiikCOa  "^p"  In.tiiiniJ^ut 

Ill  WMIK-C  ■  '    ■■'  ' 

31  'WHlll.i-: 

t;  Well  on  1I1-4.-IUW-IDI  tnlMliaod 

21  \Vv*t  an  IKwaaw  of  WoBcn 

lu  wiMoii»«rvoa>nMrd<nliiCbUdbM)d 

a  willlALu  on  CoMominWi    .... 

a  WllMiM'aHM«nx»kof<>auiM««M«UalM 

II  Wliif  kai  on  roiKit.  aait  Tnialntaal  oTf^IUbad 

»  U'(ili]i<r^OrwuiteCbnBi'wry 

ao  Woodbaad-afneilcKi  mbologr   , 

Books  iBuked  *  mn  tlao  bomid  in  hnlf  RtMaia. 


LEA    BROTHERS   &  CO.,    PhilAdelpbla. 


LANE  MEDICAL  UBRART 


To  avoid  line,  tbla  book  ihotild  be  returned 
on  or  before  the  date  last  stamped  below. 


i  See  ^^Jcji^^ 


^tr^^ 


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